Ocular benzalkonium chloride exposure: problems and solutions

[helvella]

Many here need, or have needed, to use various eye drops and other treatments, often due directly to thyroid issues. Whether for simple dry eyes or other underlying issues.

Most threads end up with at least one member pointing out the importance of using preservative-free products - especially when they need to be used long-term.

This paper, from Nature and only published about a year ago, identifies that the most widely used preservative, Benzalkonium Chloride, can start causing damage in as little as one week.

(My personal experience was that I went from occasional use of drops to using them more and more frequently as they seemed less effective. Seems pretty obvious that I had gone from being able to tolerate them to needing to avoid. Preservative-free worked for me.)

Very pleased to know of this paper as it backs up what has often been said here. (By me as well as many others.)

• Review Article

• Open Access

• Published: 14 July 2021

Ocular benzalkonium chloride exposure: problems and solutions

• Michael H. Goldstein,

• Fabiana Q. Silva,

• Nysha Blender,

• Trung Tran &

• Srilatha Vantipalli

Eye volume 36, pages 361–368 (2022)

Abstract

Preservatives in multidose formulations of topical ophthalmic medications are crucial for maintaining sterility but can be toxic to the ocular surface. Benzalkonium chloride (BAK)—used in approximately 70% of ophthalmic formulations—is well known to cause cytotoxic damage to conjunctival and corneal epithelial cells, resulting in signs and symptoms of ocular surface disease (OSD) including ocular surface staining, increased tear break-up time, and higher OSD symptom scores. These adverse effects are more problematic with chronic exposure, as in lifetime therapy for glaucoma, but can also manifest after exposure as brief as seven days. Multiple strategies are available to minimize or eliminate BAK exposure, among them alternative preservatives, preservative-free formulations including sustained release drug delivery platforms, and non-pharmacological therapies for common eye diseases and conditions. In this paper, we review the cytotoxic and clinical effects of BAK on the ocular surface and discuss existing and emerging options for ocular disease management that can minimize or eliminate BAK exposure.[/I

Open access available here:

nature.com/articles/s41433-...

[DippyDame]

Goodness...a coincidence!

Thank you helvella

My eyes, historically, are not too healthy!

I've been suffering with sore eyes and blurred vision for a number of weeks, and on and off for much longerThought it might be hay fever...

Tried antihistamine tablets

No!

So tried OTC drops for dry eyes...

No luck.

Decided my left eye AMD was getting worse

Or my right eye cataract was getting worse

Optician won't refer me to specialist yet, for a cataract op on my right eye, because my left eye has little vision and they can't risk any loss of sight in my right eye if anything goes wrong

( I'm getting to the point!!)

Had enough and phoned my optician' s practice...an appointment the next day!

Very thorough exam, scans etc

No change in sight since March

Me....well something is wrong because I can't see and my eyes are on fire

Yes....you have Blepharitis!

(It clearly wasn't picked up in March....or before!)

It's chronic....

I have no idea if it's thyroid related....but with me most things seem to be!!

So ...

A moist heat mask and prescription for eye drops

The eye drops are Preservative and Phosphate free and for long term use!

I'm glad I was seen by this new, young optician, and didn't persist with the readily available OTC drops

It's early days... but feeling positive!

PS

I'm using Hylo-Forte and discovered I can buy them on the Internet from " you know where"!!

[helvella in reply to DippyDame]

I don't pretend to understand whether it would cause any issues, but my feeling is that Benzalkonium Chloride should be banned from eye-care products.

It is also present in many things like hand disinfectants. Where it can cause dermatitis. (What a surprise!)

(I think that the EU, at least, is looking at restricting its use - but such things can take years to be agreed.)

[TSH110 in reply to helvella]

And we might not get that protection now. I think they like to call it red tape when it’s actually our safety at stake.

[LindaC in reply to helvella]

Checked one of mine out - YES, it's there in a very small amount - I had asked GP for the preservative free version of it, said not available... THIS is now gone, THANKYOU!

However small, any risk with eyes... if it's one in a million... if you're that one it's 100+%!

[helvella in reply to LindaC]

Just wondering - how do you know it is a small amount?

(I appreciate all preservatives will be in fairly small amounts! But does it tell you how much there is?)

[LindaC in reply to helvella]

Husband just checked it out... that's enough for me, right now - not well at all - freezing on one of the hottest days. Sorry helvella - I'll ask him later.

[pennyannie in reply to LindaC]

I can't control my temperature well in weather like this and choose to stay in with black out blinds way down - still in socks and a couple of tops and ski pants !!

[helvella in reply to LindaC]

Never need to apologise!

That certainly doesn't sound very nice at all.

[LindaC in reply to helvella]

Ah, it's 0.00.1% - Hmm!? What does that equate to?

Thank you, helvella - you're a kind soul.

[helvella in reply to LindaC]

If you meant 0.001% - that is ten parts per million. (Sorry - not meaning to be pedantic - just trying to make sure I am interpreting correctly. )

I didn't realise that level of detail was available!

Goes to show if a low concentration can have such an impact.

[LindaC in reply to helvella]

Seems it is that - on box as that - 1:100,000. And nooo, nothing pedantic at all - wished damned docs has some clue enough to pass comment Thank you helvella. Hope I've accurately reported/depicted this... cataracts now!

Yes, this particular product is 'Systane - Gel Drops - Overnight Dry Eye Relief' - there are other types of this brand and one is without preservatives. My original choice has always been HYLO-TEAR, which is very good and preservative + phosphate free.

[TSH110 in reply to DippyDame]

I have it quite badly and like you suspect it is thyroid related. I get darn demodex mites causing it 😳 it’s worse in winter. I clean away all the debris around the lashes with a cotton bud dipped in sterile saline solution, using a magnifying mirror, some use really powerful ones so they can see the mites… I’d rather not 🤣🤣🤣 mine is 6x I think. It really helps improve it. Every day if necessary. I use a different bud tip for each eye so I’m not spreading anything from one to the other. Once it’s under control the eyes feel loads better. I have always been told to use preservative free eye drops hycosans are the ones I was advised to use. They are instant eye relief!

Hope the heat mask etc soon helps

☘️🍀☘️

[Timetraveler67 in reply to DippyDame]

Hi I was given hylo drops on prescription but I can’t use them as they irritate my eyes, I’ve tried lots of different brands also spec-savers sold me some Expensive drops for dry eyes and they ended up in the bin as I had the same problem as all the others. I’ve gone back to Using optrex now even though I know it’s not preservative free as it’s the only eye drops that give me any kind of relief. I have cataracts coming also dry eyes And my eyes are puffy underneath now too but when I mentioned it when I had my eye test I was told to see my Dr as they only look at the eyes themselves

[pennyannie]

Thank you for this :

Initially I was prescribed through my doctor and then an eye consultant who diagnosed blepharitis explaining that I wasn't cleaning my eyes well enough.

He continued to prescribe the self same ointments and I found out for myself about the necessity to be using Preservative Free products :

[helvella in reply to pennyannie]

It's been known for at least fifteen years! And that's just what I know without looking anything up.

[pennyannie in reply to helvella]

Yes, I'm not surprised any longer, just disappointed and alarmed that nothing seems to change - maybe it's got everything to do with that Tamar bridge and still waiting to be levelled up and caught up with the rest of the country

[Miffie in reply to pennyannie]

That there bridge does cause problems. This county is several decades behind others. Even the younger medical professionals seem to be absorbing the need to penny pinch re health. Perhaps we can get together blow up the bridge and increase knowledge flow down a wider more open A30! 😏

[pennyannie in reply to Miffie]

Yes, it does seem so - we seem tightly " stitched up " down here -

It could be ' me ' but when I looked at the CCGs prescribing printout SD kindly linked us into on here last week, didn't even see Kernow - in any listing - did you ?

I gave up around 5years ago now - and think Thyroid UK should get my NHS budget :

[helvella in reply to pennyannie]

Have a look here - where I have selected liothyronine in Kernow as an example.

openprescribing.net/analyse...

Liothyronine prescribing (red) in Kernow (background of rest of England).

[pennyannie in reply to helvella]

Thank you - Helvella, This is so kind of you :

when I originally looked at the analysis in around 2017 we were the top prescriber in the country and I surmise why no new prescriptions were being written.

I'm self medicating on NDT which is even more difficult have to prescribed and minding my own business as I was so disgusted by the way I wasn't treated :

Though I shall revisit the SD link last week just to see what bits of the Nice guidelines Kernow are now said to be following.

[pennyannie in reply to helvella]

Just another thought - I wonder if the demographics or percentage to population within these CCG areas is every considered -

either way - it's a pretty much a rum deal down here - though this analysis shows us in historic fine fettle :

[helvella in reply to pennyannie]

Cornwall being, as we all know, a major part of the rum economy - now and in the past!

[pennyannie in reply to helvella]

Arrgh - Aye

[Miffie in reply to pennyannie]

I see helvella has kindly posted a screen shot.However when I saw the ‘Speciality Lead’ allegedly known to prescribe T3 last year. He told me in under a minute he ‘could not’ prescribe T3 due to cost. I didn’t even want that! I wonder if it’s because my surgery has zero patients on T3. Or a general cutting down on prescriptions.

My current personal gripe is lack of treatment for low ferritin/ low iron.

‘ No you don’t need an iron panel’ just ferritin over 10. If you can’t take oral iron we will give you another infusion when ferritin drops below 10 again’

Add to this incredible statements that any blood test within spitting distance of being in range is ‘fabulous!’ I was particularly delighted to learn that when my kidney function moved from ckd stage 2 to one point away from ckd stage 3 the diabetes nurse told me that my kidney function was now ‘excellent’ rather than impaired as it has been for years.

I have also had a remarkable recovery from Barrett’s oesophagus, the ‘tail’ is now a zig zag and cannot be measured, therefore it must have been ‘cured’.

The hiatus hernia and gastritis remain however are no worse after ten years of medication so that’s also ‘excellent’. Ido agree that no decline is great. Just not sure how a BO can be ‘cured’.

The left ventricular hypertrophy, eptopic heartbeats and diastolic disfunction found on an echocardiogram along with tachycardia pulse 100 and BP of 132/ 110 all indicted my heart health is perfect.

If never had such good health as I now have.

I just appreciate that they do agree that a scan showing a very little thyroid gland over a decade ago and given its sixty plus years since diagnosis might suggest that as yet the hypothyroidism has not been ‘cured’.

Blimey what a rant!

As you can tell I can’t rate Kernow CCG any too highly.

Stay strong and keep looking after yourself!

[LindaC]

THANK YOU SO MUCH - helvella. I have to use these products - always perfect eyesight until hypothyroidism ++ - I'll be scrupulously checking now. Much appreciated.

[Anthea55]

Thanks for posting - that's very interesting.

I had my first cataract op on Wednesday. The eye drops they gave me are Pred Forte 1 drop 4 times a day for 4 weeks and Chloramphenicol, 1 drop 4 times a day for 2 weeks. The Pred Forte contains prednisolone acetate 1.0% with Benzalkonium Chloride 0.006% and a few other things.

It seems that this is their standard issue. They said that Pred Forte is a steroid, which I queried as I've had problems with steroid cream before, but they had no other suggestions to make. I'll try asking for preservative free drops when I have the other eye done. Meanwhile I'll have to keep my fingers crossed that I don't develop problems while I use the drops this time. 0.006% seems a very small amount so hopefully I should be OK.

I'm currently on T4 +T3.

[helvella in reply to Anthea55]

What a crazy world - one lot telling us that benzalkonium chloride causes eye problems, while the other lot are prescribing eye drops that contain it!

I just looked and couldn't readily find any preservative-free prednisolone eye drops - but I didn't spend much time looking as I wanted to reply. I suspect they are telling you exactly how it is.

Hope the op went well, and you are seeing better and the healing is going as expected.

[Anthea55 in reply to helvella]

Further to the Pred Forte eye drops, quotes from the package leaflet...."Warnings and precautions. Talk to your doctor before using Pred Forte if ....... You have had surgery for cataracts" Yes - I've been given it because I've just had cataract surgery....

"If you use this medicine for more than 10 days, your doctor may ask you to have check-ups. This is to make sure that your medicine is working properly and that the dose you are taking is right for you. Your doctor will check your eyes for: an increase in pressure : cataracts : infection" But my instructions from the hospital are to use it for 4 weeks. Post op cataract clinic 4-6 weeks - by which time I've stopped taking the drops anyway.

As you say, it's a crazy world!

[Mlinde]

I too have a dry eye following a botched cataract op but I use a gel that contains carbomer (0.2%) at night and another lubricant, Hylo-Forte that contains sodium hyaluronate also 0.2% during the day, they work, kindof. It's also important bathe the eye with water.

[helvella in reply to Mlinde]

I used to use ViscoTears carbomer - but had to get the single-dose units. The bottles contained preservative!

[Mlinde in reply to helvella]

Well, my bottle of Hylo-Forte says 'preservative free, phosphate free'. I also use the Viscotears or Ocufresh, apparently the same thing.

[helvella in reply to Mlinde]

I think that came out after I stopped needing them. But I was just pointing out the need to check the specific product!

The bottle of ViscoTears lists:

2.0mg/g Carbomer (polyacrylic acid).

Excipients: 1 gram of gel contains 0.1mg of Cetrimide (see section 4.4.)

Cetrimide, sodium hydroxide, sorbitol and water for injections.

I do not know if they have changed the preservative - can't remember if it was always cetrimide. But I'd not wish to use ones with any preservative.

[Mlinde in reply to helvella]

I also use Celluvisc, it comes in small, single dose sachets, again it's simply hydration. It contains carmellose sodium.

[pennyannie in reply to helvella]

Ditto that preparation:

[RedApple in reply to Mlinde]

'dry eye following a botched cataract op '

Mlinde, that's very unfortunate Do you know what went wrong and why?

[Mlinde in reply to RedApple]

Yes, I think so. I'm extremely short-sighted in my left eye, which means the eyeball, instead of being a sphere, is more like rugby ball! I was informed before the op that my eye should have been 'prepped' in some way as when they do the procedure the eyeball swells and in my case, it banged into the back of eye, damaging it! I'm sorry I ever had it done (BTW, they never did anything to prep my eye). And then, the replacement lens started to cloud over so I had to have laser surgery to let the light in! And the op damaged the lubrication holes on the edges of both eyelids, so they don't work properly (dry eye). A complete balls-up.

I might add that the way it's setup, it's like an assembly line! And funnily enough, just as I was about to get the op, they told me I could pull out any time! They obviously knew something that I didn't!

[RedApple in reply to Mlinde]

' the replacement lens started to cloud over'

Oh crikey! I didn't know that could even happen. The consultant I spoke to seemed to imply it couldn't. He said once you have it done you'll never need it doing again.

[Mlinde in reply to RedApple]

Yeah right! That's why Moorfields hospital have a bunch of lasers to fix the problem that doesn't exist.

[Mlinde in reply to Mlinde]

If you want the technical answer it's:

YAG laser treatment for posterior capsule opacification (PCO). According to the NHS PCO is a relatively common occurrence after cataract surgery. It's actually not the lens itself but something called the lens capsule that seems to sit on top of the replacement lens that goes opaque. So, I don't know where your consultant hangs out, it's obviously not Moorfields Eye Hospital.

[DeeD123]

Just checked mine and thankfully it’s not in the ingredients. Will need drops for life due to ted so it was a relief

[Alice70]

Thank you helvellyn interesting read ,just looked at ingredience in celluvisc ,I don't think it has BAK in it unless under a different name ,I have appointment with optician in one hour so I'll let you know what he says ,must go