Thursday, July 12, 2018

Conjunctivochalasis and Its Treatment



Conjunctivochalasis (CCh) is a condition characterized by multiple folds in the conjunctiva, the clear covering of the white part of the eye (called the sclera). After years of eye rubbing, aging, genetic risk factors, the conjunctiva no longer adheres closely to the sclera and the conjunctiva becomes loose with redundant conjunctival folds. These folds sometimes do not cause symptoms but often cause foreign body sensation due to their presence and/or due to tear distribution [123].  This condition is also characterized by bloodshot eyes, subconjunctival hemorrhage (popped surface blood vessel), chronic tearing (ie, epiphora), dry eye, and corneal ulceration [124]. It can also cause tear meniscus disruption, impaired tear distribution, and punctal occlusion (ie, the whole that drains tears to the nose). [14].

Treatment (Reference 7):

Medical therapy

The goal of medical therapy for CCH is to improve tear film stability and suppress inflammation by lubricating the surface to prevent mechanical friction making the CCH worse. 
1. Topical lubricants: ie, eye drops and ointments may be used. 
2. Non-steroidal drops to decrease inflammation: Xiidra, Restasis
3. Autologous serum eye drops further achieve a more functional tear status Reference 8). Furthermore, a prospective unmasked study showed that an artificial tear containing isotonic glycerol and sodium hyaluronate can in fact reduce the severity of CCH.43 Additionally, there are ongoing double-masked clinical trials on safety and efficacy of a sodium hyaluronate eye drop (LO2A) for CCH (clinicaltrials.gov, NCT02810119 and NCT02804191).
4.Topical corticosteroids: nonpreserved 1% methylprednisolone 3 times a day for 3 weeks leads to subjective (83%) and objective (80%) improvement, as well as resolution of DTC (87%). 
5. Eye patching at nighttime: For patients with severe CCH associated with nocturnal lagophthalmos.
It is important to remember that CCH is frequently associated with other common ocular surface disorders such as aqueous tear deficient dry eye and meibomian gland dysfunction, which may not only contribute to its pathogenesis but also produce symptoms similar to those caused by CCH. Thus, these conditions need to be treated as well.

Surgical treatment

1. Laser Treatment with Argon: Red or Green Argon. The laser work at a wavelength of 532 nm and tries to shrink redundant conjunctiva and possibly to promote conjunctival fixation to the underlying tissue. The recovery is short and minimal risk of side effects. Repeat treatment may be needed. 

2. Conjunctival cauterization: also tries to shrink redundant conjunctiva and possibly to promote conjunctival fixation to the underlying tissue. (Ref 9). The advantages of conjunctival cauterization include short operating and healing times and the elimination of suture-related complications. (Ref 10).

Conjunctival cauterization has been shown to be effective in treating refractory cases of mild-to-moderate CCH. Although different techniques have been used for conjunctival cauterization, a complete or significant improvement in ocular symptoms and signs, as well as shrinkage of conjunctiva, have been found after this procedure. (Ref 11). Importantly, cauterization does not result in removal of normal conjunctival tissue, significant scar formation, or motility restriction. 

3. Conjunctival excision with or without tissue graft with or without Sutures (more painful) or Glue (less pain). 

Conjunctival excision with Fibrin Glue: This is the most commonly performed procedure for CCH after Argon laser as it involves no suture and a quicker recovery time. The risk of complications is very low. The success rate depends on the extent of CCH. 

4. Scleral fixation of the conjunctiva: fixation of the redundant conjunctiva to the sclera with 3 6-0 Vicryl stitches 8 mm posterior to the inferior limbus. Benefits of the scleral fixation technique include firm conjunctival adherence to the sclera from the ability of Vicryl thread to induce focal inflammation and the lack of conjunctival resection, avoiding inferior fornix shortening or ocular motility restriction.6

5. Other procedures

a. high frequency radiowave electrosurgery,92 
b. conjunctival ligation,60 
c. conjunctival semiperitomy combined with subconjunctival cauterizarion,78 
d. laterosuperior traction of the inferior lid, and 
e. conjunctival Z-plasty or Y-V plasty.255059

 2018 Jul 10. doi: 10.1007/s10792-018-0963-6. [Epub ahead of print]

Investigation of conjunctivochalasis histopathology with light and electron microscopy in patients with conjunctivochalasis in different locations.

Abstract

PURPOSE:

To investigate changes in conjunctival tissue of conjunctivochalasis (CCh) patients and to determine the relationship between pathological findings and localization of loose conjunctiva.

METHODS:

Our study included nineteen eyes of 19 patients who were referred to Cukurova University Ophthalmology Department based on ocular surface symptoms and CCh detected in ocular examination. Amniotic membrane was applied after conjunctival excision as surgical treatment. The control group was formed with five eyes of five patients who are similar in terms of age and gender distribution with our study group. Tissue samples obtained from the study and control groups were investigated with light and electron microscopy.

RESULTS:

Results of pathological examination of conjunctival tissues revealed increased inflammation in 13 patients (68%), lymphatic ectasia in 12 patients (63%), and loss of goblet cells in 17 patients (89%). Destruction of elastic fibers was detected in all cases by staining with elastic van Gieson. After semiquantitative assessment, varying degrees of light microscopic findings were noted considering the localization of CCh. No statistically significant relationship was observed between light microscopic findings and CCh location (p > 0.05 for all). Electron microscopic investigation revealed increase in intercellular spaces, increased cytoplasmic electron density, and the presence of slight vacuolization in cell cytoplasm, and heterochromatin clumping in nuclei of cells in conjunctival samples.

CONCLUSIONS:

Mechanical and inflammatory factors induce development of CCh, and signs associated with these factors can be detected with light and electron microscopy of conjunctival tissue. No relationship was observed between CCh localization and pathological changes in tissues examined in our study, and large-scale case series are required to evaluate the possible effect of CCh localization on pathological findings.


References:
  1. 1.
    Youm DJ, Kim JM, Choi CY (2010) Simple surgical approach with high-frequency radio-wave electrosurgery for conjunctivochalasis. Ophthalmology 117:2129–2133CrossRefPubMedGoogle Scholar
  2. 2.
    Fernández-Hortelano A, Moreno-Montañés J, Heras-Mulero H, Sadaba-Echarri LM (2007) Amniotic membrane transplantation with fibrin glue as treatment of refractory conjunctivochalasis. Arch Soc Esp Oftalmol 82:571–574CrossRefPubMedGoogle Scholar
  3. 3.
    Erdogan-Poyraz C, Mocan MC, Bozkurt B, Gariboglu S, Irkec M, Orhan M (2009) Elevated tear interleukin-6 and interleukin-8 levels in patients with conjunctivochalasis. Cornea 28:189–193CrossRefPubMedGoogle Scholar
  4. 4.
    Erdogan-Poyraz C, Mocan MC, Irkec M, Orhan M (2007) Delayed tear clearance in patients with conjunctivochalasis is associated with punctal occlusion. Cornea 
  5. 5Nainiwal S, Kumar H, Kumar A. Laser conjunctivoplasty: a new technique for correction of mild medial ectropion. Orbit. 2003;22(3):199–201. doi: 10.1076/orbi.22.3.199.15619. [PubMed] [Cross Ref]
6. Naval CIN, Cinco PR, Yutangco RA, Dinglasan JL. Argon Laser Modified. Conjunctivoplasty for Bullous Keratopathy,European journal of Implant and Refractive Surgery. 1995;7(5):pp. 279–284
7.  2018 Jul - Aug;63(4):554-564. doi: 10.1016/j.survophthal.2017.10.010. Epub 2017 Nov. Conjunctivochalasis: a systematic review.
8. J. Murube
Characteristics and etiology of conjunctivochalasis: historical perspective
Ocul Surf, 3 (1) (2005), pp. 7-14
 2013 May;32(5):574-8. 
9. T. Kashima, H. Akiyama, F. Miura, S. Kishi
Improved subjective symptoms of conjunctivochalasis using bipolar diathermy method for conjunctival shrinkage
Clin Ophthalmol, 5 (2011), pp. 1391-1396
10. K. Gumus, C.H. Crockett, S.C. Pflugfelder
Anterior segment optical coherence tomography: a diagnostic instrument for conjunctivochalasis
Am J Ophthalmol, 150 (6) (2010), pp. 798-806
11. Di Pascuale MA, Espana EM, Kawakita T, Tseng SCG. Clinical characteristics of conjunctivochalasis with or without aqueous tear deficiency. British journal of Ophthalmology. 2004;88:388–392
 2018 Mar 1;8(1):3863. doi: 10.1038/s41598-018-22204-0.

Near-infrared laser thermal conjunctivoplasty.

Author information

1
Casey Eye Institute, Oregon Health and Science University, 3375 SW Terwilliger Blvd, Portland, Oregon, 97239, USA.
2
Ocular Surface Center, Cullen Eye Institute, Baylor College of Medicine, 6565 Fannin NC205, Houston, TX, 77030, USA.
3
Casey Eye Institute, Oregon Health and Science University, 3375 SW Terwilliger Blvd, Portland, Oregon, 97239, USA. liga@ohsu.edu.

Abstract

Conjunctivochalasis is a common cause of tear dysfunction due to the conjunctiva becoming loose and wrinkly with age. The current solutions to this disease include either surgical excision in the operating room, or thermoreduction of the loose tissue with hot wire in the clinic. We developed a near-infrared laser thermal conjunctivoplasty system. The system utilizes a 1460-nm programmable laser diode system as the light source. At this wavelength, a water absorption peak exists and the blood absorption is minimal, so the heating of redundant conjunctiva is even and there is no bleeding. A miniaturized handheld probe delivers the laser light and reshapes the laser into a 10 × 1 mm2 line on the working plane. A foot pedal is used to deliver a preset number of calibrated laser pulses. A fold of loose conjunctiva is grasped by a pair of forceps. The NIR laser light is delivered through an optical fiber and a laser line is aimed exactly on the conjunctival fold by a cylindrical lens. Ex vivo experiments using porcine eye was performed to investigate the induced shrinkage of conjunctiva and decide the optimal laser parameters. It was found that up to 45% of conjunctiva shrinkage could be achieved.


List of Drops with 

Product

Packaging

Active ingredients

Inactive ingredients (preservative highlighted)

Refresh Classic
(Allergan)
30 PF vials (0.4 mL)Polyvinyl Alcohol 1.4% Povidone 0.6%Purified water, sodium chloride. May also contain hydrochloric acid and/or sodium hydroxide to adjust pH.
Refresh Tears
(Allergan)
15mL bottleCarboxymethylcellulose SodiumOxychloro complex, Sodium Borate decahydrate, Sodium chloride, Potassium chloride, Calcium chloride dihydrate, Magnesium chloride hexahydrate, Boric acid, Sodium hydroxide to adjust pH and Purified water. 
Refresh Plus
(Allergan)
30 PF vials (0.4 mL)Carboxymethylcellulose sodium 0.5% Calcium chloride; magnesium chloride; potassium chloride; purified water; sodium chloride; and sodium lactate. May also contain hydrochloric acid and/or sodium hydroxide to adjust pH. 
Refresh Optive
(Allergan)
30 PF vials (0.4 mL)Carboxymethylcellulose sodium 0.5%, Glycerin0.9%Boric acid; calcium chloride dihydrate; erythritol; levocarnitine; magnesium chloride hexahydrate; potassium chloride; purified water; sodium borate decahydrate; and sodium citrate dihydrate.
15mL bottleBoric acid; calcium chloride dihydrate; erythritol; levocarnitine; magnesium chloride hexahydrate; potassium chloride; purified water; PURITE® (stabilized oxychloro complex); sodium borate decahydrate; and sodium citrate dihydrate.
Refresh Optive Advanced
(Allergan)
30 PF vials (0.4 mL)Carboxymethylcellulose sodium 0.5% Glycerin1% Polysorbate 80 0.5%Boric acid; carbomer copolymer type A; castor oil; erythritol; levocarnitine; purified water; and sodium hydroxide.
10mL bottleBoric acid; castor oil; erythritol; levocarnitine; carbomer copolymer type A; purified water; and PURITE®(stabilized oxychloro complex). May also contain sodium hydroxide to adjust pH.
Refresh Optive MEGA-3
(Allergan)
30 PF vials (0.4 mL)Carboxymethylcellulose sodium 0.5% Glycerin1% Polysorbate 80 0.5%Boric acid; butylated hydroxyl toluene; castor oil; erythritol; flaxseed oil; levocarnitine; pemulen TR-2; polyoxyl 40 stearate; purified water; sodium hydroxide; trehalose.
Refresh Celluvisc
(Allergan)
30 PF vials (0.4 mL)Carboxymethylcellulose sodium 1%Calcium chloride, potassium chloride, purified water, sodium chloride, and sodium lactate.
Refresh Optive Gel Drops
(Allergan)
10mL bottleCarboxymethylcellulose sodium 10mg in 1mL, glycerin 9mg in 1mLBoric acid; calcium chloride dihydrate; erythritol; levocarnitine; magnesium chloride hexahydrate; potassium chloride; PURITE® (stabilized oxychloro complex); sodium borate decahydrate; sodium citrate dihydrate; purified water.
Refresh PM ointment
(Allergan)
3.5g tubeMineral Oil 42.5%White Petrolatum 57.3%Lanolin alcohols
Refresh LacriLube
(Allergan)
3.5g tubeMineral Oil 42.5%White Petrolatum 56.8%Chlorobutanol and lanolin alcohols.
Refresh Liquigel
(Allergan)
15mL bottleCarboxymethylcellulose sodium 1%Boric acid, calcium chloride, magnesium chloride, potassium chloride, purified water, PURITE® (stabilized oxychloro complex), sodium borate, and sodium chloride.
Systane Ultra
(Alcon)
25 PF vials (0.7 mL)
60 PF vials (0.7 mL)
Polyethylene Glycol 400 0.4%, Propylene Glycol 0.3%Aminomethylpropanol, boric acid, hydroxypropyl guar, potassium chloride, purified water, sodium chloride, sorbitol. May contain hydrochloric acid and/or sodium hydroxide to adjust pH.
10mL bottleAminomethylpropanol, boric acid, hydroxypropyl guar, POLYQUAD* (polyquaternium-1) 0.001% preservative, potassium chloride, purified water, sodium chloride, sorbitol. May contain hydrochloric acid and/or sodium hydroxide to adjust pH.
Systane Balance
(Alcon)
10mL bottlePropylene Glycol 0.6%Boric acid, dimyristoyl phosphatidylglycerol, edetate disodium, hydroxypropyl guar, mineral oil, polyoxyl 40 stearate, POLYQUAD® (polyquaternium-1) 0.001% preservative, sorbitan tristearate, sorbitol and purified water. May contain hydrochloric acid and/or sodium hydroxide to adjust pH.
Systane Complete (Alcon)10mL bottle (1/3 fl oz)Propylene Glycol 0.6%Boric acid, dimyristoyl phosphatidylglycerol, edetate disodium, hydroxypropyl guar, mineral oil, polyoxl 40 Stearate, POLYQUAD(polyquaternium-1) 0.001% preservative, sorbitan tristearate, sorbital and purified water. May contain hydrochloric acid and/or sodium hydroxide to adjust pH.
Systane
(Alcon)
28 PF vials (0.4 mL)
Polyethylene Glycol 400 0.4%,
Propylene Glycol 0.3%
Boric acid, calcium chloride, hydroxypropyl guar, magnesium chloride, potassium chloride, purified water, sodium chloride, zinc chloride. May contain hydrochloric acid and/or sodium hydroxide to adjust pH.
15mL bottleBoric acid, calcium chloride, hydroxypropyl guar, magnesium chloride, polyquaternium-1 as a preservative, potassium chloride, purified water, sodium chloride, zinc chloride. May contain hydrochloric acid and/or sodium hydroxide to adjust pH.
Systane Nighttime ointment
(Alcon)
3.5g tubeWhite petrolatum 94% Mineral oil 3%Anhydrous Liquid Lanolin 3%.
Systane Lubricant Eye Gel
(Alcon)
10gHypromellose (0.3%)Carbopol 980, phosphonic acid, purified water, sodium perborate and sorbitol. May contain sodium hydroxide to adjust pH.
Systane Gel Drops
(Alcon)
10mL bottlePolyethylene Glycol 400 0.4%, Propylene Glycol 0.3%Aminomethylpropanol, boric acid, edetate disodium, hydroxypropyl guar, POLYQUAD® (polyquaternium-1)0.001% preservative, potassium chloride, sodium chloride, sorbitol and purified water. May contain hydrochloric acid and/or sodium hydroxide to adjust pH.
Systane Day & Night
(Alcon)
Two 10mL bottles (Systane Gel Drops and Systane Ultra)See Systane Gel Drops and Systane UltraSee Systane Gel Drops and Systane Ultra
Systane Sport
(Alcon)
Two 10mL bottlesPolyethylene Glycol 400 0.4% Lubricant Propylene Glycol 0.3%Aminomethylpropanol, boric acid, hydroxypropyl guar, POLYQUAD® (polyquaternium-1) 0.001% preservative, potassium chloride, purified water, sodium chloride, sorbitol. May contain hydrochloric acid and/or sodium hydroxide to adjust pH.
Systane Contacts
(Alcon)
12mL bottledextran, hydroxypropyl methylcellulosesodium chloride, potassium chloride, with edetate disodium 0.1% and POLYQUAD® (polyquaternium-1) 
Genteal Mild
(Alcon)
15mL / 25mL bottleHypromellose 0.2%Boric acid, calcium chloride dihydrate, GenAqua (sodium perborate), phosphonic acid, potassium chloride, purified water, and sodium chloride
Genteal Moderate
(Alcon)
15mL bottleDextran 70 0.1%, Glycerin0.2%, Hypromellose 0.3%Boric acid, calcium chloride, glycine, hydrochloric acid and/or sodium hydroxide (to adjust pH), magnesium chloride, POLYQUAD® (polyquaternium-1) 0.001% preservative, polysorbate 80, potassium chloride, purified water, sodium chloride, zinc chloride.
Genteal Gel (Severe)
(Alcon)
10g tubeHypromellose 0.3%.carbopol 980, phosphoric acid, purifed water, sodium hydroxide, sodium perborate, and sorbitol
Genteal ointment
(Alcon)
3.5gWhite petrolatum 93% Mineral oil 4%anhydrous liquid lanolin
Genteal Tears
(Alcon)
Previously Tears Naturale Free
36 PF Vials (0.9 mL)Dextran 70 0.1%, Hypromellose 2910 0.3%Potassium Chloride, Purified Water, Sodium Borate, Sodium Chloride, May contain: Hydrochloric Acid, Sodium Hydroxide
Bion Tears
(Alcon)
28 PF vials (0.4 mL)
Dextran 70 0.1%, Hypromellose 2910 0.3% 
NOTE: Are you looking for Tears Naturale (discontinued). Bion Tears has the same active ingredients but some slight differences in the inactives. 
Calcium chloride, magnesium chloride, potassium chloride, purified water, sodium bicarbonate, sodium chloride, zinc chloride, hydrochloric acid and/or sodium hydroxide and/or carbon dioxide to adjust pH.
Soothe XP
(Bausch & Lomb)
15mL bottleLight mineral oil (1.0%), Mineral oil (4.5%)boric acid, edetate disodium, octoxynol-40, polyquaternium-1 (preservative), polysorbate 80, purified water, sodium borate decahydrate. May contain hydrochloric acid and/or sodium hydroxide (to adjust pH).
Soothe Long Lasting Hydration
(Bausch & Lomb)
15mL bottle Povidone (2.0%)benzalkonium chloride (0.005%), boric acid, edetate disodiumdihydrate, purified water, sodium borate, sodium chloride, tyloxapol. Hydrochloric acid and/or sodium hydroxide may be used to adjust pH.
Soothe Hydration
(Bausch & Lomb)
15mL bottle Povidone (1.25%)boric acid, potassium chloride, sodium borate and sodium chloride;preserved with edetate disodium 0.1% and sorbic acid 0.1%
Soothe Preservative Free Lubricant
(Bausch & Lomb)
28 PF Vials (0.6 mL)Glycerin (0.6%) Propylene Glycol (0.6%)boric acid, hydroxyalkylphosphonate, purified water, sodium alginate, sodium borate
Soothe Night Time Ointment
(Bausch & Lomb)
3.5g tubeMineral oil (20%), White petrolatum (80%) 
None.
Note - this is one of the only lubricant ointments on the list WITHOUT lanolin alcohol
(6/14/18)
Advanced eye relief dry eye rejuvenation
(Bausch & Lomb)
15mL bottleGlycerin (0.3%) Propylene glycol (1.0%)benzalkonium chloride (0.01%), boric acid, edetate disodium, potassium chloride, purified water, sodium borate, sodium chloride. Hydrochloric acid and/or sodium hydroxide may be used to adjust pH
Oasis Tears
(Oasis Medical)
30 PF vials (0.3 mL)Glycerin (0.2%)Hyaluronan, sodium chloride, sodium phosphate dibasic, sodium phosphate monobasic, water.
Oasis Tears Plus
(Oasis Medical)
30 PF vials (0.3 mL)Glycerin (0.2%)Hyaluronan, sodium chloride, sodium phosphate dibasic, sodium phosphate monobasic, water.
FreshKote
(Focus Laboratories)
15mL bottlePolyvinyl pyrrolidone2.0%, Polyvinyl alcohol 2.7%Boric acid, Disodium edetate dihydrate, Ethanol, Glycerin, Lecithin, Polixetonium, Polysorbate-80, Potassium chloride, Purified water, Sodium chloride
Retaine MGD
(Ocusoft)
(Equivalent to Cationorm which is sold in Europe)
30 PF vials (0.4 mL)Light Mineral Oil (0.5) Mineral Oil (0.5%) Cetalkonium chloride, glycerol, poloxamer 188, tris hydrochloride, tromethamine, tyloxapol, water for injection.
Retaine HPMC
(Ocusoft)
10mL bottle
(preservative free)
Hypromellose 0.3%Citric acid, sodium citrate, sorbitol, water for injection.
Retaine CMC
(Ocusoft)
30 PF vials (0.6 mL)Carboxymethylcellulose sodium 0.5%Calcium chloride, magnesium chloride, potassium chloride, purified water, sodium chloride, sodium lactate. May also contain hydrochloric acid and/or sodium hydroxide to adjust pH.
Retaine PM
(Ocusoft)
5g tubeMineral oil (20%) White petrolatum (80%)none
TheraTears dry eye therapy
(Akorn)
30mL bottleSodium Carboxymethyl Cellulose (0.25%)Borate Buffers, Calcium Chloride, Dequest, Magnesium Chloride, Potassium Chloride, Purified Water, Sodium Bicarbonate, Sodium Chloride, Sodium Perborate, Sodium Phosphate
32 PF vials (0.6 mL)Borate Buffers, Calcium Chloride, Magnesium Chloride, Potassium Chloride, Purified Water, Sodium Bicarbonate, Sodium Chloride and Sodium Phosphate.
TheraTears nighttime dry eye therapy (gel)
(Akorn)
28 PF vials (0.6 mL)Sodium Carboxymethyl Cellulose (1%)Borate Buffer, Calcium Chloride, Magnesium Chloride, Potassium Chloride, Water (Purified), Sodium Bicarbonate (Baking Soda), Sodium Chloride, Sodium Phosphate
Contact lens comfort drops
(Akorn)
15mL bottleCarmellose sodiumBorate Buffer, Sodium Chloride, Potassium Chloride, Sodium Bicarbonate (baking soda), Calcium Chloride, Magnesium Chloride, Sodium Phosphate, Sodium Perborate stabilized with phosphonic acid
NanoTears TF
(Altaire)
15mL bottle
30mL bottle
Polyethylene Glycol 400 0.4%
Propylene Glycol 0.3%
Boric acid, castor oil, gellan gum, glycerin, hydroxyethylcellulose, polyoxyl 35 castor oil,polysorbate 80, sorbitol, tromethamine, Vanish (stabilized peroxy complex as a preservative) and purified water.
NanoTears TF PF
(Altaire)
32 0.6mL vialsPolyethylene Glycol 400 0.4%
Propylene Glycol 0.3% 
Boric acid, gellan gum, glycerin, hydroxyethylcellulose, polyoxyl 35 castor oil, polysorbate 80, sorbitol, tromethamine, and purified water.
NanoTears XP
(Altaire)
10mL bottlePolyethylene Glycol 400 0.4%
Propylene Glycol 0.3%  
Boric acid,  castor oil, gellan gum, glycerin, hydroxyethylcellulose, polyoxyl 35 castor oil, polysorbate 80, sorbitol, tromethamine, Vanish (stabilized peroxy complex as a preservative) and purified water. Sodium hydroxide or hydrochloric acid may be added to adjust the pH.
BlinkContactsLubricating Eye Drops
(10mL) bottle
Polyethylene Glycol 400 0.25%
Boric Acid; Calcium Chloride; Magnesium Chloride; Potassium Chloride; Purified Water; Sodium Borate; Sodium Chloride; Sodium Chlorite (OcuPure Brand) as a Preservative; Sodium Hyaluronate.
BlinkTears Lubricating Eye Drops
15 mL bottle
Polyethylene Glycol 400 0.25%
Boric Acid; Calcium Chloride; Magnesium Chloride; Potassium Chloride; Purified Water; Sodium Borate; Sodium Chloride; Sodium Chlorite (OcuPure Brand) as a Preservative; Sodium Hyaluronate.
Blink GelTears
Lubricating Eye Drops 
10 mL bottle
Polyethylene Glycol 400 0.25%
Boric Acid; Calcium Chloride; Magnesium Chloride;Potassium Chloride; Purified Water; Sodium Borate; Sodium Chloride; Sodium Chlorite (OcuPure brand) as a preservative; Sodium Hyaluronate.
BlinkTears Preservative Free Lubricating Eye Drops0.4 mL PF Vials
Polyethylene Glycol 400 0.25%
Boric Acid; Calcium Chloride; Magnesium Chloride; Potassium Chloride; Purified Water; Sodium Borate; Sodium Chloride; Sodium Hyaluronate.
Puralube Ointment3.5g tube
85% white petrolatum
15% light mineral oil
n/a
Note: This is one of the very few ointments that do NOT contain lanolin alcohol.
Clear Eyes Pure Relief for Dry Eyes"240 drops" PF multi-dose bottleGlycerin 0.25%Boric acid, purified water, sodium borate, sodium chloride, sodium hyaluronate
Clear Eyes Outdoor Dry Eye ProtectionBottle
Polyvinyl alcohol 0.5%
Povidone 0.6%
Benzalkonium Chloride, Dextose, Edetate Disodium, Potassium Chloride, Purified Water, Sodium Bicarbonate, Sodium Chloride, Sodium Citrate, Sodium Phosphate (mono- and dibasic)
Clear Eyes Natural Tears LubricantBottle
Polyvinyl alcohol 0.5%
Povidone 0.6%
Benzalkonium Chloride, Dextose, Edetate Disodium, Potassium Chloride, Purified Water, Sodium Bicarbonate, Sodium Chloride, Sodium Citrate, Sodium Phosphate (mono- and dibasic)
Visine Dry Eye Relief15mL bottle
Glycerin 0.2%
Hypromellose 0.2%
Polyethylene glycol 400 1%
ascorbic acid, benzalkomium chloride, boric acid, dextrose, disodium phosphate, glycine, magnesium chloride, potassium chloride, purified water, sodium borate, sodium chloride, sodium citrate, sodium lactate
Visine Tired Eye Dry Eye Relief15mL bottle
Glycerin 0.2%
Hypromellose 0.36%
Polyethylene glycol 400 1%
ascorbic acid, boric acid, dextrose, glycine, magnesium chloride, polyquaternium-42, potassium chloride, purified water, sodium borate, sodium chloride, sodium citrate, sodium lactate, sodium phosphate dibasic

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