In 2017, The FDA approved brimonidine tartrate ophthalmic solution 0.025% (Lumify, Bausch + Lomb, Bridgewater, New Jersey) as an over-the-counter eye drop for ocular redness.
The agent uses a lower dose of brimonidine tartrate. Brimonidine was first approved by the FDA in 1996 for reducing IOP in glaucoma patients.
Unlike popular OTC eye drops like Visine and Clear Eyes that claim to "get the red out", Lumify does not result in a "Rebound Redness" effect well known to occur with the chronic use of Visine and Clear Eyes.
Visine and similar drugs work by constricting blood vessels in the eye via the eye’s alpha-1 receptor. Lumify also constricts blood vessels, but it acts on a different receptor called the alpha-2 receptor which avoids the rebound redness effect.
Lumify has a much lower concentration of a long-standing, FDA-approved, prescription glaucoma medication called Alphagan which decreases eye pressure by constricting blood vessels. Lumify is four to eight times the strength of Lumify so it is considered relatively safe by the FDA as an OTC drop.
The issue with Lumify (as well as all preservative containing drops) is its preservative. It is unclear why they chose Benzalkonium Chloride (BAK), but this preservative is particularly irritating for many patients.
The Dangers of Benzalkonium chloride (BAK)
Benzalkonium chloride (BAK), a common preservative that has been used in ophthalmology since the 1940s and found in up to 70% of eye drops, is a quaternary ammonium compound which acts like a detergent, lysing cell membranes, and killing microorganisms.
Preservatives are used in eye medications because they help make the drops more cost-effective: a large bottle of eye drops can last a month or more when a preservative is added compared with preservative free (PF) counterparts--which come in small, slighly frustrating, vials where you cannot put the top back on.
Many animal and human studies have shown that BAK is toxic to the ocular surface cells, particularly the cornea and conjunctiva (REF 1-6). Studies show BAK stimulated an apoptotic response to corneal cells and may even damage Meibomian Gland Cells. Some studies have also shown that at a molecular level, dose-dependent DNA damage is associated with BAK.
Preservatives are used in eye medications because they help make the drops more cost-effective: a large bottle of eye drops can last a month or more when a preservative is added compared with preservative free (PF) counterparts--which come in small, slighly frustrating, vials where you cannot put the top back on.
Many animal and human studies have shown that BAK is toxic to the ocular surface cells, particularly the cornea and conjunctiva (REF 1-6). Studies show BAK stimulated an apoptotic response to corneal cells and may even damage Meibomian Gland Cells. Some studies have also shown that at a molecular level, dose-dependent DNA damage is associated with BAK.
Preservative-Free Lumify would be lovely but that is NOT available yet.
A patient asked, "if a patient is allergic to Lumify, can they use diluted Alphagan?"
Answer: theoretically diluted Alphagan could be used as the preservative is Purite which is less toxic according to some studies compared to BAK (but Purite is still a preservative); however there is a risk of contamination in diluting the Alphagan which could lead to a corneal infection
A patient asked, "if a patient is allergic to Lumify, can they use diluted Alphagan?"
Answer: theoretically diluted Alphagan could be used as the preservative is Purite which is less toxic according to some studies compared to BAK (but Purite is still a preservative); however there is a risk of contamination in diluting the Alphagan which could lead to a corneal infection
Six studies involving a total of approximately 600 participants reported a low risk for rebound redness with Lumify. The longest of these studies lasted about seven weeks; the effects of the drops, when used four times a day in the studies, lasted about eight hours.
Can You Use Lumify in Kids?
Can You Use Lumify in Kids?
Lumify's label says it is safe for patients over the age of 5, however, the FDA trials only included adults. I would avoid using Lumify in kids: it is imperative to find out why the child's eye is red as it can be due to meibomian gland loss which can lead to significant issues in the future if left untreated.
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Reference
1. Horsley MB, Kahook MY. Effects of prostaglandin analog therapy on the ocular surface of glaucoma patients. Clin Ophthalmol. 2009;3:291-295. Find Full Text [Context Link]
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2. Kastelan S, Tomic M, Metez Soldo K, et al. How ocular surface disease impacts the glaucoma treatment outcome. Biomed Res Int. 2013;2013:696328.
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