Maintaining the quality of life for patients while reducing the harmful impact of preservatives in topical glaucoma therapies remains a fundamental challenge in daily practice. Although selective laser trabeculoplasty (SLT) continues to play a valuable role—supported by the favorable outcomes of the Laser in Glaucoma and Ocular Hypertension (LiGHT) trial1—there is a place for incorporating preservative-free, fixed-combination compounded drops into a treatment strategy. These formulations represent an alternative that is easily attainable, reasonably priced, and generally well tolerated without sacrificing therapeutic efficacy.
Preservatives Cause Problems
Patients with glaucoma often require long-term topical treatment, and unfortunately, preservatives like benzalkonium chloride (BAK) are known to cause significant ocular surface issues. As both a preservative and a surfactant, BAK disrupts tear film integrity and induces inflammation, leading to corneal epithelial cell damage, nerve toxicity, and meibomian gland dysfunction.2 Chronic exposure has been associated with goblet cell loss and reduced mucin secretion, aggravating ocular surface disease. Moreover, BAK has demonstrated cytotoxic effects on trabecular meshwork cells and contributes to conjunctival inflammation and fibrosis, which may undermine surgical success.2 Clinically, these effects manifest as dry eye symptoms, redness, tearing, blurry vision, foreign body sensation, and hypersensitivity reactions, which negatively impact patient comfort and adherence. Additionally, some individuals experience true allergic responses to preservatives, reinforcing the need for preservative-free alternatives when feasible.
Advantages of Preservative-Free Compounded Drops
Preservative-free compounded fixed-combination drops present an effective and often preferred solution for many patients with glaucoma. For those with preexisting dry eye or compromised ocular surfaces, avoiding preservatives helps reduce irritation and inflammation. These customized formulations are especially useful when commercial preservative-free options are financially burdensome, unavailable due to formulary restrictions, or require stepwise insurance approval.
Patients who require multiple IOP-lowering medications may be especially good candidates for fixed-combination compounded therapy, particularly if their medication costs exceed $38 per bottle or $78 per month in total. Additionally, compounded drops offer advantages for individuals lacking insurance coverage, those who run out of medication before insurance permits refills, and patients with difficulty adhering to complex, multibottle routines. Because these formulations often contain a longer-lasting supply and do not require insurer-defined refill timing, they reduce interruptions in therapy.
These drops also offer practical benefits. Travelers appreciate that many compounded formulations do not require refrigeration and that a single bottle can replace multiple medications. Home delivery simplifies access for patients with limited mobility or those residing in long-term care facilities. In such settings, reducing the number of drops and frequency of administration minimizes confusion and potential errors. Postoperatively, compounded drops help streamline regimens, improving both compliance and clarity for patients.
From the provider’s perspective, compounded drops also reduce administrative burdens. They eliminate the need for prior authorizations and minimize communication with insurers and pharmacies, freeing up time for clinical care.
Integrating Compounded Therapy
Offering a preservative-free combination drop at initial diagnosis can help preserve ocular health throughout lifelong treatment. For clinicians focused on optimizing glaucoma care, integrating preservative- free compounded therapy into routine practice is straightforward and impactful. Consider the following implementation steps:
1. Explore Available Formulations. Begin by visiting reputable compounding pharmacy websites to learn about their combination glaucoma drops, and by becoming familiar with the available agents, pricing structures, and prescription workflows. Examples of compounding pharmacies offering combination glaucoma drops include ImprimisRx and OSRX Pharmaceuticals.
2. Identify Suitable Candidates. The following are some examples of patients who may benefit most from this approach:
- Those who are prescribed more than 1 IOP-lowering medication;
- Those who exhibit signs or symptoms of dry eye or ocular surface sensitivity;
- Those who are initiating medical therapy for the first time; or
- Anyone in the situations listed above.
3. Prescribe Electronically and Facilitate the Process. Submit the electronic prescription (eRx) directly to the compounding pharmacy. Provide the patient with the pharmacy’s contact information so they can confirm delivery details. The process is typically quick and straightforward: the patient simply provides their mailing address and payment information to the pharmacy, with no insurance-related delays.
4. Evaluate and Reinforce Success. At follow-up visits, patients generally present with stable IOP and report increased comfort and satisfaction due to simplified regimens. This improved experience supports ongoing adherence and frequently leads to word-of-mouth referrals.
5. Support a Patient-Centered Model. Transitioning to compounded drops can minimize treatment-related side effects, reduce financial strain, and enhance ease of use. Making these options available reflects a broader commitment to improving patient quality of life alongside clinical outcomes.
Compounding Pharmacy Options
Over the past 18 months, I have incorporated preservative-free compounded medications into my glaucoma practice. Examples of medications I often prescribe include preservative-free bimatoprost, preservative-free timolol-brimonidine-dorzolamide, and preservative-free timolol-brimonidine-dorzolamide-bimatoprost. This approach has proven especially beneficial for patients with advanced disease, reduced dexterity, or known preservative sensitivities.
Even the most effective, side effect–free medication is worthless if the patient can’t afford to refill it. Many of my patients are on Medicare and don’t qualify for manufacturer coupons or co-pay cards. Therefore, predictable costs from the compounding pharmacy (some as low as $38) allow me to have an honest conversation with the patient: “Can you afford $38 per month?” If the answer is yes, I know we can move forward without delay. This simplicity in prescribing is rare in glaucoma care, and I value it immensely. Many of the recurring issues we encounter—such as poor adherence, cost barriers, and ocular surface complications—are closely linked to multidrop regimens and preservative exposure. These compounded drops have proven to be a practical, patient-focused solution.
Meeting Unmet Needs in Glaucoma Care
Preservative-free compounded glaucoma drops address key barriers to effective treatment, including regimen complexity, intolerance, access to medication, and cost. Compounded drops let us initiate treatment quickly without denials, phone calls, or faxes. Still, not all patients will choose this route. Some decline due to a preference for “free” or cheaper medications covered by insurance—even if those drops require multiple bottles and cause ocular discomfort. Others may be discouraged by out-of-pocket payment if the expense does not apply to their insurance deductible. However, compounded formulations are often competitively priced, and patients can use their HSA or FSA to pay for the medication. Some patients also express reluctance toward mail-order fulfillment, but home delivery remains a significant advantage for many, especially those with transportation challenges.
Ultimately, it is our responsibility to guide patients toward treatment options that offer not only effective IOP control, but also minimize symptoms, reduce medication burden, and support adherence. Offering compounded preservative-free drops aligns clinical goals with patient-centered care. GP
References
1. Gazzard G, Konstantakopoulou E, Garway-Heath D, et al. Laser in Glaucoma and Ocular Hypertension (LiGHT) trial: six-year results of primary selective laser trabeculoplasty vs eye drops for the treatment of glaucoma and ocular hypertension. Ophthalmology. 2023;130(2):139-151. doi:10.1016/j.ophtha.2022.09.009.
2. Kahook MY, Rapuano CJ, Messmer EM, Radcliffe NM, Galor A, Baudouin C. Preservatives and ocular surface disease: a review. Ocul Surf. 2024;34:213-224. doi:10.1016/j.jtos.2024.08.001.