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Artificial tears

Artificial tears are over-the-counter lubricant eye drops formulated to mimic the composition and function of natural tears, providing essential moisture and lubrication to the ocular surface to alleviate symptoms of dry eye disease (DED).^[1]^[2] They serve as the first-line therapy for DED, a common condition characterized by insufficient tear production or excessive evaporation, leading to discomfort, inflammation, and potential damage to the cornea and conjunctiva.^[3]^[2] Artificial tears have a long history, with ancient Egyptian texts from around 1550 B.C. describing eye pastes for dry eye relief, evolving to saline solutions in the 19th century and modern polymer- and lipid-based formulations in the 20th and 21st centuries.^[4] The primary causes of dry eyes that artificial tears address include aging, environmental factors such as wind or smoke, medical conditions like Sjögren's syndrome or rheumatoid arthritis, certain medications, and post-surgical effects.^[1]^[3] Formulations typically contain active ingredients like carboxymethylcellulose (CMC), hyaluronic acid, or polyethylene glycol (PEG) to enhance viscosity and stabilize the tear film, along with electrolytes, osmoprotectants, and sometimes lipids to target the tear's aqueous or lipid layers.^[2] They are available in various types, including preservative-containing drops for occasional use, preservative-free single-dose vials for frequent application in moderate to severe cases, and thicker gels or ointments for nighttime relief, though the latter may temporarily blur vision.^[1]^[2] Beyond DED management, artificial tears play a role in promoting corneal abrasion healing, reducing inflammation in conditions like conjunctivitis or keratitis, rewetting contact lenses, and aiding post-operative recovery.^[2] Clinical evidence shows they improve symptoms such as stinging, burning, and redness within one month of regular use (typically four times daily), with objective signs like tear film stability enhancing over several months, though up to one-third of patients may require alternative therapies if unresponsive.^[2]^[3] Selection should consider usage frequency and severity, with consultation from an eye care professional recommended for persistent symptoms to avoid irritation from preservatives or overuse.^[1]

Introduction

Definition and purpose

Artificial tears are over-the-counter lubricating eye drops, gels, or ointments formulated to mimic the composition and function of natural tears, providing relief for ocular surface dryness.^[1]^[5] Their primary purpose is to supplement deficient tear production, stabilize the tear film, lubricate the ocular surface, and alleviate symptoms associated with dry eye disease, also known as keratoconjunctivitis sicca (KCS).^[2] By replenishing moisture and protecting the cornea and conjunctiva, artificial tears help maintain ocular comfort and prevent irritation from environmental factors or underlying conditions.^[5] The natural tear film consists of three main layers: an inner mucin layer produced by goblet cells for adhesion to the ocular surface, a middle aqueous layer secreted by the lacrimal glands containing water, electrolytes, and proteins for hydration and antimicrobial defense, and an outer lipid layer from meibomian glands that prevents evaporation.^[6] Artificial tears replicate these functions by delivering a balanced mixture that hydrates the aqueous component, enhances viscosity to mimic mucin, and provides a protective barrier akin to the lipid layer, thereby restoring tear film stability without addressing underlying production deficits.^[7] Common forms include liquid drops for frequent daytime use, thicker gels that offer prolonged retention on the ocular surface, and ointments designed for nighttime application to provide extended lubrication during sleep.^[8]^[9]

Historical development

The use of artificial tears dates back over 3,500 years to ancient Egypt, where remedies for eye conditions were documented in the Ebers Papyrus around 1550 BCE. This ancient text describes various eye salves and washes, including honey-based solutions mixed with ingredients like human brain or other natural substances to lubricate and treat irritated or dry eyes, reflecting early attempts to mimic natural tear functions for ocular comfort.^[10]^[11] In the 19th and early 20th centuries, artificial tears emerged in Western medicine through commercial products promoted in traveling medicine shows. A notable example is Collyrium, introduced around 1899 by Wyeth Laboratories as a boric acid-based eye wash delivered via cobalt blue glass bottles with eye-cup applicators, aimed at relieving eye strain and irritation from environmental factors. These early formulations marked the transition from homemade remedies to standardized, accessible ocular lubricants.^[10]^[12] Mid-20th-century advancements deepened the understanding of tear film dynamics, leading to more effective artificial tears. In 1973, Frank J. Holly published research elucidating the critical role of mucin in stabilizing the tear film, which inspired the development of polymer-based demulcents to enhance lubrication and prevent evaporation. This was followed in 1975 by the introduction of autologous serum tears by Ralph et al., a biological alternative derived from the patient's own blood serum to closely replicate natural tear composition, particularly for severe dry eye cases.^[13]^[14] From the late 20th century into the 21st, artificial tears evolved toward preservative-free formulations to minimize irritation in frequent users, with single-dose vials becoming common in the 1980s and multidose options emerging later. Commercial innovations included Systane, launched by Alcon in 2003 as a lipid-enhanced formula using hydroxypropyl guar for prolonged relief, representing a shift to advanced, multi-layered tear substitutes that address both aqueous and lipid deficiencies in the tear film.^[10]^[15]

Composition and Formulations

Key ingredients

Artificial tears are formulated with a variety of active and inactive ingredients designed to replicate the lubricating, moisturizing, and protective properties of natural tears. The primary active components are demulcents, which act as lubricants to form a protective film over the ocular surface, thereby reducing friction and preventing corneal damage during blinking. Common demulcents include carboxymethylcellulose (typically at concentrations of 0.25% to 1%), hyaluronic acid (typically at 0.1% to 0.4%), hypromellose, polyethylene glycol 400, polyvinyl alcohol, povidone, glycerin, and propylene glycol, each contributing to viscosity and retention on the eye surface.^[7] Emollients and viscosity agents are incorporated to mimic the lipid layer of natural tears, which helps prevent evaporation and ensures prolonged contact with the ocular surface. In ointment formulations, mineral oil and lanolin serve as key emollients, providing a thicker barrier for extended lubrication, particularly suitable for nighttime use. These agents enhance the overall stability and duration of the tear film substitute. Other additives play crucial roles in maintaining physiological compatibility. Electrolytes such as sodium chloride and potassium chloride are added to approximate the osmolarity of natural tears (around 300 mOsm/L), preventing cellular swelling or shrinkage on the corneal epithelium. Osmoprotectants such as L-carnitine and erythritol are also included to protect ocular surface cells from hyperosmolar stress associated with dry eye. Buffers, often based on phosphates or borates, stabilize the pH to approximately 7.4, aligning with the eye's natural environment and minimizing irritation.^[16] Formulation variations allow artificial tears to address different needs for ocular lubrication. Aqueous solutions provide rapid, short-term relief with low viscosity for frequent daytime application, while viscous gels offer longer-lasting coverage through higher molecular weight polymers. Ointment bases, primarily composed of petrolatum, deliver sustained release for overnight therapy, though they may cause temporary blurring of vision. Preservatives may be integrated into multi-dose aqueous formulations to prevent microbial growth.

Preservative systems

Artificial tears formulations often incorporate preservatives to prevent microbial contamination in multi-dose containers, ensuring product stability and safety during use. The most widely used preservative is benzalkonium chloride (BAK), a quaternary ammonium compound typically present at a concentration of 0.01%, which provides broad-spectrum antimicrobial activity against bacteria, fungi, and other microorganisms.^[17] BAK is employed in approximately 70% of preserved ophthalmic solutions, including many artificial tear products, due to its effectiveness in maintaining sterility.^[18] As a milder alternative to BAK, polyquaternium-1 (Polyquad) is utilized at a lower concentration of 0.001%, offering comparable antimicrobial protection with reduced potential for ocular surface disruption.^[17] This preservative is found in several commercial artificial tear brands and is preferred in formulations aimed at minimizing irritation while preserving multi-dose usability.^[19] Vanishing or oxidative preservatives represent another category designed to enhance ocular safety by decomposing harmlessly upon instillation. Purite, a stabilized oxychloro complex, breaks down into water, sodium chloride, and oxygen gas upon instillation into the eye, thereby eliminating residual antimicrobial activity after delivery.^[20] Similarly, sodium perborate degrades into water and oxygen via peroxidase enzymes in the tear film, providing temporary preservation in the bottle without persistent exposure to the ocular surface.^[20] These agents are integrated into specific artificial tear products to balance efficacy and biocompatibility. Preservative-free formulations address concerns related to cumulative preservative exposure, particularly for patients with frequent dosing needs or sensitive ocular surfaces. These are commonly delivered via single-use vials to prevent contamination without chemical agents, or through innovative multi-dose systems such as bottles with sterile filters or spray mechanisms that maintain purity.^[17] Such options are essential for individuals prone to preservative-induced discomfort, allowing sustained use without compromising safety. In terms of market prevalence, most multi-dose artificial tear products contain preservatives to extend shelf life and reduce costs, while preservative-free options comprise a significant and growing segment, holding approximately 55% of the market share in 2024.^[21] This shift reflects increasing emphasis on preservative-free delivery for optimal ocular tolerability, often in conjunction with lubricating agents like carboxymethylcellulose.^[21]

Clinical Applications

Indications

Artificial tears are primarily indicated for the management of dry eye disease (DED), a multifactorial condition of the ocular surface characterized by tear film instability and symptoms such as burning, itching, and discomfort.^[22] This includes both evaporative dry eye, often due to meibomian gland dysfunction leading to rapid tear evaporation, and aqueous-deficient dry eye, resulting from reduced tear production by the lacrimal glands.^[22] In the United States, DED affects approximately 20 million people, with prevalence estimates ranging from 5% to 50% globally depending on diagnostic criteria and population demographics.^[23]^[24] Secondary indications encompass relief from transient ocular irritation caused by environmental factors, including wind, prolonged screen use, and air conditioning, which can exacerbate tear film disruption.^[5] They are also recommended for post-surgical lubrication following procedures such as LASIK or cataract surgery to alleviate discomfort and support corneal healing.^[25] Additional uses include mitigating contact lens-related discomfort and addressing age-related reductions in tear production, which become more common after age 40.^[26]^[27] Particular patient profiles at higher risk for requiring artificial tears include older adults, due to age-associated declines in tear secretion, and postmenopausal women, who experience elevated DED prevalence compared to men.^[27] Individuals with autoimmune conditions, such as Sjögren's syndrome, represent another key group, as up to 10% of DED cases are linked to this disorder, often presenting with severe aqueous deficiency.^[28] Dosage guidelines typically recommend instilling 1-2 drops into the affected eye(s) four times daily or as needed for symptom relief, with preservative-free formulations allowing more frequent use—up to every hour in severe cases—to minimize irritation while maintaining efficacy.^[29]^[5]^[2]

Therapeutic effects

Artificial tears exert their therapeutic effects primarily by mimicking the natural tear film's structure and function, thereby addressing the multifactorial nature of dry eye disease (DED). They supplement the aqueous layer of the tear film to restore volume and hydration, particularly in aqueous-deficient DED, where viscosity-enhancing agents like carboxymethylcellulose (CMC) or hyaluronic acid (HA) increase tear retention and improve ocular surface wettability. Additionally, certain formulations stabilize the lipid layer to reduce tear evaporation in evaporative DED; for instance, lipid emulsions or nanoemulsions incorporate oily components such as mineral oils or liposomes that reinforce the meibomian layer and enhance overall tear film stability. These actions collectively protect the cornea from mechanical abrasion and hyperosmolar stress by forming a protective barrier, promoting epithelial healing, and mitigating inflammation through osmoprotectants like trehalose.^[7] Evidence from systematic reviews supports the efficacy of artificial tears in alleviating DED symptoms. A 2023 systematic review of 64 randomized controlled trials (RCTs) found significant improvements in symptoms such as irritation and burning within one month of regular use (approximately four times daily), with objective measures like tear breakup time (TBUT) and ocular surface staining scores also enhancing over longer periods. Polymer-based formulations, such as those containing polyethylene glycol (PEG), demonstrated superior TBUT prolongation compared to CMC or hypromellose (HPMC), while combination therapies (e.g., CMC with HA) yielded better reductions in corneal staining. Lipid-emulsion types, including nanoemulsions, proved particularly effective for evaporative DED by increasing lipid layer thickness and sustaining symptom relief for up to six hours post-instillation.^[2]^[30] Despite these benefits, artificial tears offer primarily symptomatic relief and do not address underlying tear production deficiencies or cure DED. They are most effective as an adjunct to targeted therapies, such as cyclosporine for inflammation or punctal plugs for tear retention, and may not benefit all patients—up to one-third show limited response, necessitating alternative interventions. In post-LASIK care, they aid in transient symptom management but require integration with other modalities for optimal outcomes.^[2]^[31]

Safety and Precautions

Side effects

Artificial tears are generally well-tolerated, but users may experience temporary blurred vision shortly after application, particularly with thicker gel or ointment formulations due to their increased viscosity.^[32] This effect typically resolves within a few minutes to 10 minutes as the product spreads and absorbs.^[33] Mild stinging, burning, or redness can also occur upon instillation, often attributable to differences in the product's pH or osmolarity compared to natural tears.^[34] Allergic reactions, though uncommon, primarily stem from preservatives such as benzalkonium chloride (BAK) and may manifest as contact dermatitis or allergic conjunctivitis, affecting approximately 1-5% of sensitive individuals with frequent use.^[35] Symptoms include itching, increased redness, and swelling, and switching to preservative-free formulations is recommended for those affected.^[1] As explored in the section on preservative systems, BAK's role in these reactions underscores the need for tailored product selection. Rarely, overuse of artificial tears can lead to dependency, where natural tear production diminishes, potentially causing rebound dryness that worsens symptoms over time.^[36] Chronic exposure to BAK in high-frequency users (more than four times daily) may also result in corneal toxicity, including epithelial disruption and nerve damage, increasing vulnerability to further irritation.^[37] Management of side effects involves discontinuing use if irritation persists beyond a few days or intensifies.^[38] Users experiencing ongoing symptoms, such as persistent pain, vision changes, or severe redness, should consult an ophthalmologist promptly to rule out underlying issues and adjust treatment.^[39]

Recalls and contamination risks

In 2023, the U.S. Food and Drug Administration (FDA) initiated multiple recalls of artificial tear products due to manufacturing defects and contamination risks. The first major recall occurred in February 2023 for EzriCare Artificial Tears and Artificial Tears Lubricant Eye Drops, prompted by positive tests for Pseudomonas aeruginosa, a bacterium linked to insanitary conditions at the manufacturing facility. This was followed by a March 2023 recall of Delsam Pharma's Artificial Eye Ointment, also due to potential microbial contamination from inadequate production practices. By October 2023, the FDA expanded recalls to 27 over-the-counter eye drop brands, including generic products sold at CVS, Walmart, Rite Aid, and Target, after inspections revealed unsanitary conditions such as non-sterile equipment and water systems that tested positive for bacteria. These recalls highlighted significant contamination risks, including the potential for severe eye infections such as endophthalmitis, corneal ulcers, and permanent vision loss. The Pseudomonas aeruginosa outbreak associated with EzriCare products led to 81 infections across 18 states, 14 cases of vision loss, and 4 deaths as of November 2023.^[40] Such risks underscore the vulnerability of multi-use eye drop bottles to microbial growth if preservatives fail or manufacturing hygiene is compromised. Following the 2023 incidents, additional recalls occurred in 2024 and 2025. In December 2024, Alcon Laboratories voluntarily recalled one lot (Lot 10101) of Systane Lubricant Eye Drops Ultra PF, single vials on-the-go (25 count), due to potential fungal contamination identified during routine testing.^[41] In May 2025, AvKare issued a recall for multiple over-the-counter ophthalmic products, including artificial tears solutions (e.g., NDC# 50268-043-15), affecting approximately 75,000 units shipped between May 2023 and April 2025, due to deviations in manufacturing processes that could compromise sterility.^[42]^[43] No adverse events were reported for these specific 2024-2025 recalls as of November 2025, but they reflect intensified FDA oversight. To mitigate these dangers, consumers are advised to check lot numbers against the FDA's recall database and discontinue use of affected products. Proper storage at room temperature, avoidance of touching the dropper tip to the eye, and discarding any solution that appears discolored, cloudy, or past its expiration date are essential precautions. Following the 2023 incidents, regulatory scrutiny of over-the-counter eye drop manufacturing has intensified, with the FDA emphasizing stricter current good manufacturing practices (cGMP) compliance. This has accelerated a market shift toward single-use, preservative-free unit-dose formulations to reduce contamination potential.

Veterinary and Specialized Uses

Applications in animals

Artificial tears are commonly employed in veterinary medicine to manage ocular dryness in animals, particularly in cases of keratoconjunctivitis sicca (KCS), a condition characterized by inadequate tear production leading to corneal and conjunctival inflammation. In dogs, breeds such as Bulldogs and Shih Tzus are predisposed to KCS due to genetic factors affecting lacrimal gland function, resulting in chronic dry eye that can progress to corneal damage if untreated. Artificial tears serve as an essential adjunct to primary therapies like cyclosporine ointment, providing lubrication to flush debris, protect the corneal surface, and alleviate discomfort during the healing process.^[44]^[45] In cats, dry eye often arises from conformational issues such as brachycephalic facial structure or lagophthalmos, where incomplete eyelid closure exposes the ocular surface to excessive evaporation and irritation, particularly in breeds like Persians. These lubricants mimic natural tears to maintain ocular hydration, reduce friction from blinking, and prevent secondary complications like ulceration in affected felines. Administration typically involves topical drops applied 4-6 times daily for optimal coverage, while ointments are preferred for longer retention in non-cooperative or nocturnal animals to ensure sustained protection overnight.^[46]^[47]^[48] Equine applications focus on conditions like recurrent uveitis, where inflammation and associated dryness exacerbate ocular discomfort; artificial tears help by stabilizing the tear film and shielding the cornea during flare-ups. Canine studies demonstrate that hyaluronic acid-based artificial tears, when used adjunctively, yield modest improvements in Schirmer tear test scores (from 5.42 ± 3.50 mm/min to 6.19 ± 3.86 mm/min) and enhance overall ocular surface health, while also reducing the incidence of corneal ulceration by minimizing abrasive exposure. In horses, similar lubricating formulations prevent ulceration progression in dry eye cases, supporting corneal integrity alongside anti-inflammatory treatments.^[49]^[50]^[51]

Research and emerging developments

Recent clinical trials from 2024 and 2025 have highlighted the efficacy of nanoemulsion-based artificial tears in enhancing tear film stability for patients with dry eye disease (DED). A prospective cohort study protocol published in May 2025 outlines the evaluation of Systane COMPLETE Multi-Dose Preservative-Free (MDPF), a nanoemulsion formulation, for dry eye symptoms, quality of life, and objective measures such as tear breakup time after regular use over three months.^[52] Similarly, a retrospective analysis in August 2025 demonstrated that lipid-containing nanoemulsion artificial tears led to greater enhancements in tear film stability and ocular surface outcomes compared to non-lipid formulations in patients with combined DED and meibomian gland dysfunction (MGD).^[53] These findings underscore the role of nanoemulsions in mimicking the lipid layer of natural tears to reduce evaporation.^[54] Ongoing research is exploring immunoglobulin-based eye drops as a novel biologic approach for DED management. In May 2025, the U.S. FDA cleared Grifols' investigational new drug application for a Phase 2 trial of GRF312 Ophthalmic Solution, an immunoglobulin formulation, which is set to commence in the third quarter of 2025 and enroll 100 patients to assess safety, tolerability, and efficacy in treating DED symptoms and signs.^[55] Preliminary data from prior studies supporting this trial indicated significant reductions in DED signs and symptoms after eight weeks of twice-daily use.^[56] Emerging technologies are advancing personalized and sustained artificial tear therapies. Artificial intelligence (AI)-integrated diagnostics are enabling tailored tear replacement strategies by analyzing multi-modal biomarkers such as tear film dynamics and ocular surface imaging to recommend customized formulations.^[57] A September 2025 review emphasized AI's potential to revolutionize DED diagnosis and support personalized medicine through objective, rapid assessments that guide therapy selection.^[58] Innovations in "smart" tears incorporate sustained-release polymers, such as thermo-responsive hydrogels, to provide prolonged lubrication and drug delivery on the ocular surface.^[59] These systems achieve extended release profiles, with one formulation demonstrating 86% drug liberation over 24 hours in simulated tear environments.^[59] Lipid-based innovations specifically target MGD by restoring the tear film's lipid layer; a 2024 review highlighted nanoemulsion drops with mineral oil that improved lipid layer thickness and reduced evaporation when used daily for 28 days.^[60] In veterinary applications, emerging research includes the use of amniotic membrane extract eye drops as an adjunct therapy. An August 2025 study evaluated commercial amniotic membrane extract eye drops in promoting the healing rate of superficial chronic corneal epithelial defects (SCCED) in dogs, demonstrating efficacy in combination with lubricants like artificial tears.^[61] The global artificial tears market is experiencing steady expansion, valued at approximately USD 3.21 billion in 2025 and projected to grow at a compound annual growth rate (CAGR) of 5.4% through 2033, driven by rising DED prevalence and demand for advanced formulations.^[62] In the United States, the dry eye disease treatment market, which includes artificial tears as a dominant segment, was estimated at USD 2.45 billion in 2024 and is forecasted to expand at a 6.0% CAGR from 2025 to 2030.^[63] Current research identifies key gaps in artificial tear development, particularly regarding long-term efficacy beyond one month and integration with biologics. Studies comparing preservative-free artificial tears to autologous serum eye drops (ASED) in 2025 revealed that while artificial tears provide short-term relief, ASED offer superior improvements in tear breakup time and symptom scores over extended periods, highlighting the need for hybrid formulations that combine synthetic lubricants with biologic components for sustained benefits.^[64] A September 2024 analysis noted that blood-derived drops like ASED outperform conventional artificial tears in severe DED but require further investigation into scalable integration to address preparation challenges and long-term stability.^[65] Additionally, calls for better-designed trials emphasize evaluating lipid-based drops' durability in MGD beyond initial weeks to establish clinical relevance.^[66]

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Ophthalmic drug discovery and development using artificial ... - Nature
Sep 25, 2025 · AI-assisted multi-modal ocular biomarkers may improve treatment monitoring and support personalized medicine. Integrating AI shortens ...
[51]
Artificial Intelligence in Clinical Diagnosis and Treatment of Dry Eye
Sep 18, 2025 · AI has the potential to revolutionize the diagnosis of DE and recommend personalized treatment strategies. This review summarizes existing ...
[52]
Recent Advances in Smart Polymers-Based Therapeutics in ...
Sep 25, 2025 · This formulation facilitated a sustained drug release of 86% over 24 hours, ensuring extended therapeutic effects. Furthermore, the gel ...
[53]
Lipid-based eye drop formulations for the management of ...
A phase IV clinical study with dry eye patients found that these eye drops containing a nanoemulsion of mineral oil when used once a day for 28 days produced an ...Lipid-Based Eye Drop... · 5. Conclusion · 3. Tear Film Lipid Layer And...
[54]
Artificial Tears Market Size, Share & Growth Forecast by 2033
The global artificial tears market size is projected to grow from USD 3.21 billion in 2025 to USD 4.89 billion by 2033, exhibiting a CAGR of 5.4%.
[55]
U.S. Dry Eye Syndrome Treatment Market Size Report, 2030
Eye drops / solutions led the market and accounted for a share of 35.9% in 2024. Eye drops, especially artificial tears, offer rapid relief from dry eye ...
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Comparative Efficacy of Platelet-Rich Plasma, Autologous Serum ...
Sep 22, 2025 · This review aimed to evaluate the efficacy of blood-derived eye drops, AS and PRP, in comparison to PFATs and conventional artificial tears for ...
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Autologous serum eye drops for patients with dry eye disease
In this study, ASEDs had been shown to enhance tear secretion, extend tear film break-up time, mitigate corneal epithelial damage, ameliorate OSDI scores, and ...
[58]
Better designed clinical research needed on lipid-based eye drops ...
Jul 15, 2024 · Eye drops containing omega-3 fatty acids were associated with stabilizing the tear film in patients with meibomian gland dysfunction, indicating ...