Why have ophthalmologists been spineless in dealing with BAK?

[Sisyphus]

Every medication I've ever been prescribed for my MGD, blepharitis, conjunctivitis, etc. contains BAK. I seriously need allergy medications such as Zaditor for relief from itching, burning eyes but use it only infrequently because these medications also contain BAK. It has been well documented that BAK is harmful to people with dry eyes. Yet, where is the outrage from the ophthalmological community with regard to BAK's presence in nearly every prescription or OTC medication currently in use? Where is the outpouring of letters, petitions to the FDA for replacement of BAK? After years of this nonsense, I have come to the conclusion that BAK contributes so much to the bottom line of ophthalmologist and optometrists financial status, that they would prefer that it not be removed from the market. What else can I believe, given the profound lack of action by the community that is allegedly in charge of our eye health?

[Rebecca Petris]

Hi Sisyphus,

I think you're vastly overestimating how much eye doctors know about this. They just don't. Dry eye specialists are the most sensitized to the issues. Glaucoma doctors are becoming more sensitized to it because glaucoma medications are the biggest offenders and the issue is gradually becoming better know. Many of the specialists I know are working hard to get more and more studies published to put more pressure on the industry. But another thing you have to realize is that they're all looking for evidence base. The evidence that's been published is almost entirely about glaucoma medications, because they are daily-use drops and historically were all preserved with BAK. Most doctors, even the dry eye specialists, are frankly not going to be concerned about a short course of steroids or antibiotics that is preserved with BAK.

I had a friend with dry eye visiting from Canada recently and I was really surprised at how many preservative-free options they have, that we don't. We need PF options... so badly. Especially allergy drops and steroids, which dry eye patients who are at the most risk from BAK often need.

[Sisyphus]

Five minutes on pubmed will show that the evidence is there. Although there are more current articles that further demonstrate the cytotoxicity of BAK, I will use this one excerpt from a 2010 article to summarize what is repeated in many studies and articles:

"The most frequently used preservative, benzalkonium chloride (BAK), has consistently demonstrated its toxic effects in laboratory, experimental, and clinical studies. As a quaternary ammonium, this compound has been shown to cause tear film instability, loss of goblet cells, conjunctival squamous metaplasia and apoptosis, disruption of the corneal epithelium barrier, and damage to deeper ocular tissues." Prog Retin Eye Res. 2010 Jul;29(4):312-34

The very fact that BAK is used in clinical studies to INDUCE dry eyes should make it obvious that BAK should not be in solutions applied to the eyes. The damage is shown to begin within one hour (J Ocul Pharmacol Ther. 2009 Oct;25(5):415-24) and potent damage by two weeks. So how can doctors not be concerned with a "short" course of steroids or antibiotics preserved with BAK? There are stuidies going back to the 1970s (American Journal of Ophthalmology, vol. 84, 2 Aug 77 169-171) testifying to the harmful effects of BAK on the cornea, so I have no sympathy with the "don't know much about this issue" argument. Individuals with DES every day consider suicide, or have already followed through with it. Millions of lives are made miserable and less effective daily for endless years. Some of the worst affected don't even find relief in sleep. So I damn well will not excuse the ophthalmologic community for not pursuing at least this one identifiable path to possibly making the lives of people with DES a little less complicated; a little easier. Instead they shrug and say "Well, it can't be helped" while they flood our eyes with BAK preserved medications after every eye procedure, and hand out prescriptions designed to make our lives easier in the short term, yet screwing us in the long term.

[farmgirl]

When I go to any eye specialist and they aim at my eye with a bottle I inquire as to what it is preserved with. It happened just today and when I informed the Dr that I do not tolerate anything with BAK he promptly cracked open a mini vial of preservative free drops, so they have it you just have to ask. What really picks me is that if I get preserved Lotomax for example which costs about $35 per bottle my insurance will cover that but if I need the non preserved stuff which is about $85 I get nothing, not even a $35 discount....that is discrimination.

[Rebecca Petris]

Sisyphus, I'm sure you realize you're preaching to the choir here... I've been writing about BAK for many years. Maybe you could point some of your energy towards how to help bring about change? Change happens slowly. Demonizing the medical community isn't generally the most effective way to encourage them to change their behavior. And I stand by my claim that many doctors don't know what we know about BAK. I know an ophthalmologist in New Zealand for example, where there are no BAK free glaucoma medications available at all. For the doctors there that "get it" it is in fact a yearslong uphill battle to prove to their colleagues and the national insurance that this issue matters and that they need to make PF glaucoma meds available.

http://forum.dryeyezone.com/forum/tf...onium-chloride

[hannsho]

Hi Sisyphus,

Thank you for highlighting the BAC problem. I'm grateful for the information you and Rebecca Petris provided, because I have just discovered to my horror that the cyclosporine 0.05 eyedrops that are made up for me by a pharmacy, and which I have already used twice daily for 4 months, contain BAC. The special formula was prescribed to me by an ophthalmologist who said, that it was basically the same as Restasis and that I could use the drops indefinitely. I immediately stopped using these eyedrops and hate to think what might have happened if I continued using them. Thank you!

[Sisyphus]

Rebecca, I do realize I'm preaching to the choir. I also still don't feel empathy any more, for doctors who are not aware of BAKs harmfulness, and even less empathy for those who are aware and haven't complained to the FDA, held sessions at conferences, in short, haven't done anything to turn the tide of use of BAK in the solutions they prescribe, including OTC. I'm not sure what else I can do to bring about change, other than what I have done - complain to my doctors, post on various forums. In a couple of cases, directly emailed doctors who have written articles pointing out the harm of BAK. Should I be carrying signs, holding protests outside offices? How about someone from the medical community, someone who might actually be believable, starting a movement, instead of someone like me, an average person who's done research, who will be more than likely shrugged or even laughed off, The pharmaceutical companies are certainly not going to do anything about it. Only the communities involved directly with eye health can bring enough pressure to get them to come up with an alternative to BAK.