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Optometric Management

Article

When Vision Fluctuates, Look to the Tear Film First

Should tear substitutes be called “artificial tears” or “lubricating drops”?

By: Pamela E. Theriot, OD
Optometric Management May 1, 2026 Vol 61, Issue May-June 2026 Page(s): 24

During a refraction, your patient reports that the letters are drifting in and out of focus. You ask them to blink a few times. Suddenly, clarity returns. This familiar and sometimes vexing clinical scenario highlights the critical role that spontaneous blinking plays in maintaining tear film stability and visual quality.1

Blinking stabilizes the tear film and optimizes visual performance by creating a smooth refractive surface and reduced optical aberrations. The tear film also provides antimicrobial defense and supplies oxygen and nutrition to the avascular corneal epithelium.2

Lubrication Beyond Blinking

Sometimes midrefraction, we suggest using an artificial tear to help patients to clear their vision when they struggle with maintaining a clear image even after blinking. This intermittent blurry or fluctuating vision is a hallmark of dry eye disease caused by inadequate tear production, poor quality tears, or both (Figure 1).3

Figure 1. Patient imaging of unstable tears that lead to unstable vision, using Haag-Streit Imaging Module IM900. Photos courtesy: Austin Lifferth, OD

Artificial tears have been shown to clear vision to a level that patients were capable of achieving prior to tears breaking up on the ocular surface.4 Therefore, lubricating with a drop is a quick way to get our patients to perform through their refraction. If you’re looking for a lubricating drop to stabilize the tear film, reach for one that includes hydroxypropyl guar (HP Guar) in the ingredient list. HP Guar adheres to damaged and dehydrated corneal epithelial cells. Drops containing HP Guar will provide protection to the cornea, prevent further dessication, and encourage epithelial cell repair and regeneration.5

Renaming Artificial Tears

Recently, there has been a discussion about renaming artificial tears to lubricating drops,6 and I’d like to include my support for this change in moniker. Artificial tears are a misnomer for labeling tear substitutes. Complex components including electrolytes, proteins, lipids, growth factors, and anti-inflammatories comprise natural tears.6 Basal tears are a mixture of more than 2,000 components,7 and a delicate balance of aqueous, mucins, and lipids is required to stay in homeostasis.8

A stable tear film from natural production protects the epithelium, reduces inflammation, and maintains optical clarity,9 and ophthalmic research over the last few years has emphasized the importance of natural tear stimulation over synthetic lubricating drops.10 Rebranding “artificial tears” to “lubricating drops,” therefore, sets realistic expectations because lubricants provide symptomatic relief without mimicking homeostasis.6 Be sure to catch my accompanying video discussion next month, which will cover pharmacologic neurostimulation with varenicline solution nasal spray (Tyrvaya; Viatris) and acoltremon ophthalmic solution (Tryptyr; Alcon).

Call to Action

Our patients deserve the best vision possible. The next time a patient presents with difficulty refracting due to fluctuations in vision and you want to reach for a lubricating drop to get them through the refraction, take it as a clue to dive a little deeper into the quantity of their tear film and the quality of their ocular surface.OM

References

  1. Cruz AAV, Garcia DM, Pinto CT, Cechetti SP. Spontaneous blink activity. Ocul Surf. 2011;9(1):29–41. doi:10.1016/s1542-0124(11)70007-6
  2. Chang AY, Purt B. Biochemistry, tear film. [Updated June 5, 2025]. In: StatPearls. StatPearls Publishing; 2026 Jan-. Accessed March 9, 2026. https://www.ncbi.nlm.nih.gov/books/NBK572136
  3. Guo LW, Akpek E. The negative effects of dry eye disease on quality of life and visual function. Turk J Med Sci. 2020;50(SI-2):1611-1615. doi:10.3906/sag-2002-143
  4. Ridder III WH, Tomlinson A, Paugh J. Effects of artificial tears on visual performance in subjects with dry eye. Optom Vis Sci. 2005;82(9):835-842. doi:10.1097/01.opx.0000177803.74120.6f
  5. Christensen MT, Cohen S, Rinehart J, et al. Clinical evaluation of an HP-guar gellable lubricant eye drop for the relief of dryness of the eye. Curr Eye Res. 2004;28(1):55-62. doi:10.1076/ceyr.28.1.55.23495
  6. Abbott KS, Pucker AD. It’s time to retire the terms artificial tears and rewetting drops: a call for accurate terminology and updated clinical usage in eye care. Ocul Surf. 2026;39:46-48. doi:10.1016/j.jtos.2025.08.010
  7. Pflugfelder SC. Tear dysfunction and the cornea: LXVIII Edward Jackson Memorial Lecture. Am J Ophthalmol. 2011;152(6):900-909.e1. doi:10.1016/j.ajo.2011.08.023
  8. Dogru M, Tsubota K. Pharmacotherapy of dry eye. Expert Opin Pharmacother. 2011;12(3):325-334. doi:10.1517/14656566.2010.518612
  9. Jones L, Craig JP, Markoulli M, et al. TFOS DEWS III: management and therapy. Am J Ophthalmol. 2025;279:289-386. doi:10.1016/j.ajo.2025.05.039
  10. Malik FS, Naveed F, Khan A, Fatima M. Acoltremon and the TRPM8 frontier: a new chapter in dry eye disease therapy. Ann Med Surg (Lond). 2025;87(10):6256-6258. doi:10.1097/MS9.0000000000003763
Pamela E. Theriot, OD

Pamela E. Theriot, OD is the clinical director of the Dry Eye Relief Center at Lusk Eye Specialists, a multispecialty practice in Shreveport, Louisiana. In 2021, she was appointed to the public awareness committee of the Tear Film and Ocular Surface Society. In January 2025, she gave a TEDx Talk titled “Seeing Clearly in a Screen-Filled World: 3 Tips to Preserve Your Vision.”