The Preservative Freedom Coalition (PFC) is a group of leaders in eye health and care focused on raising awareness about the potential harms of preservatives in topical ophthalmic treatments and promoting the benefit of preservative-free alternatives for patients. Preservatives like benzalkonium chloride (BAK) are often used in eye drops to prevent bacterial contamination. However, research has shown that long-term use of preserved eye drops can cause ocular surface damage and lead to inflammation, particularly in patients with glaucoma and other chronic conditions who require lifelong treatment. The coalition, founded in May 2023, represents several major organizations in glaucoma, including the Glaucoma Foundation, the Intrepid Eye Society, the National Medical Association’s ophthalmology section, Real World Ophthalmology, Dry Eye University, and Thea Pharma Inc. 

To better understand the PFC’s mission, Glaucoma Physician recently spoke with 2 of the group’s representatives. Elena Sturman is president and chief executive officer of the Glaucoma Foundation. Monique Barbour, MD, a comprehensive ophthalmologist and glaucoma specialist, is the medical director of Clear Vue Eye Center in Lake Worth, Florida, and the Chair of Membership for the National Medical Association’s ophthalmology section. During our conversation, which has been edited for length and clarity, they discussed the mission and goals of the PFC, the benefits of preservative-free medications for patients with glaucoma, and ways that physicians can get involved with the organization.

Glaucoma Physician (GP): Tell us a little about the PFC and its goals.

Ms. Elena Sturman: The Preservative Freedom Coalition started around 2 years ago, and the focus was to start a dialogue with patients and physicians about preservative-free options and patients’ ocular surface health. This is a group that is promoting important conversations between patients and physicians. Educating patients is a very important part of the Coalition’s mission. We feel that if the patient is a good advocate for his or her own ocular surface health, they can bring it to their doctor’s attention and ask, “Do you have a preservative-free option for this particular drug?”

A few years ago, the Glaucoma Foundation did an amazing webinar with a Danish physician, Dr. Miriam Kolko, who is president of the Danish Glaucoma Society. Thanks in part to Dr. Kolko’s research, in 2023 Denmark passed a law that makes it illegal to substitute the generic version of an eye drop containing BAK when a patient is prescribed a brand-name eye drop that does not contain BAK. They also offer more preservative-free alternatives for all medications. I’m hoping that eventually changes like this will happen in the United States as well.

GP: What inspired you to become involved with the PFC?

Dr. Monique Barbour: I’ve been practicing for 20 years, and throughout my career, I have been seeing patients with severe glaucoma. For most patients on multiple medications, at some point during their treatment, they will present with redness and irritation, tearing eyelid edema, and other symptoms. Most of the time this is due to the preservatives in the topical preparations, which can be toxic. So [being involved with the PFC] has been a real stimulus for me to try to make changes and put patient safety first.

GP: How is the PFC working to raise awareness about preservative-free topical ophthalmic medications? 

Ms. Sturman: In the last year, we’ve shared a lot on social media about preservative-free drops and included information during public events and symposiums where possible. The Glaucoma Foundation, together with the Preservative Freedom Coalition, is preparing a patient survey that will ask questions to gauge patient knowledge and understand their experience around preservative-free medications and eye health. Glaucoma is a lifelong disease, so preservation of eye health is also lifelong. We try to bring awareness to this among the public and with physicians.

Dr. Barbour: Creating a presence at upcoming local and national ophthalmology meetings is just as important to the coalition and we plan to present at a variety of meetings. Also, I will be attending the Palm Beach County Optometric Society meeting and I will have some of the promotional materials from the PFC to share with my optometric colleagues. 

GP: Are preservative-free glaucoma medications widely accessible to patients? Are there barriers, such as cost or awareness, that need to be overcome?

Ms. Sturman: There are several  available preservative-free medications on the market. They are more expensive than medications without preservatives, but the benefits really outweigh the price. The PFC has been considering some ways to make these medications more affordable to patients through advocacy. Cost is an issue that hasn’t been resolved yet, but we hope that it will be.

Dr. Barbour: I have a direct connection to pharmacies through my electronic health record system, which I use to submit orders for patients. There are places within the software that I can leave comments, informing the pharmacist that the patient has previously experienced adverse effects to topical medications, and that a preservative-free medication is preferred going forward.

Sometimes it has to go a little further than that, where we must get involved with the prior authorization process. This process allows me to expand on my experience with the patient and advocate for the patient’s safety. If the [preservative-free] medication is medically necessary, the insurance company may allow coverage even though it’s more expensive.

GP: For glaucoma patients, who often require lifelong therapy, what are the long-term advantages of switching to preservative-free formulations in terms of ocular surface health and treatment adherence?

Dr. Barbour: There are so many advantages. The patient experiences more comfort when they’re using their eye drops. They may not have that initial burning and stinging that some preservatives cause. Redness and general ocular irritation is certainly reduced. Preservatives like BAK are responsible for blurred vision or fluctuations in vision, and may even cause episodic eye pain or excessive tearing. At times it’s hard to put a finger on the problem, because the drop is working, the pressure’s lower, but the patient is experiencing all these other side effects. 

As a physician, I can see the benefit [of preservative-free medications] when I examine the patient. For example, tear break-up time is improved when we remove the preservatives. Tear production is also affected by preservatives, so we see an improvement in tear production. The cornea suffers the most from a lot of these preservatives, and we can see corneal staining when the patient is on drops that contain benzalkonium and borax. So, the corneal staining is reduced. This is the key: once the toxicity of the preservatives takes over the ocular surface, the efficacy of the drug goes down. Our patients’ improved tolerance of medications without preservatives leads to improved clinical outcomes. 

Compliance is a real challenge, especially when patients are struggling with side effects. They are likely to quit the drug within the first 2 to 3 days after having experienced redness, pain, irritation, and so forth. As clinicians, we don’t find out about this until the patient returns for their follow-up appointment, which is usually in a month or 6 weeks. Removing preservatives improves compliance.

GP: What advice would you give to glaucoma specialists interested in joining your campaign to advance the use of preservative-free therapies?

Ms. Sturman: Doctors can have a conversation with their patients and explain the benefits of preservative-free medicines. They can make sure that their patients know there is a preservative-free option where possible.

Dr. Barbour: I agree they should start by educating their patients. If a physician is prescribing a topical glaucoma medication, they should be aware which ones have benzalkonium or borax and what that means to their patient. If a patient is already suffering from dry eye disease or another ocular surface disorder like Stevens-Johnson or ocular pemphigoid or graft-vs-host, they should be aware that the glaucoma medications or other topical medications can further worsen the condition. If you educate the patient, you can have a win-win situation.

I would also refer doctors to the Preservative Freedom Coalition’s website so they can learn more. If they want to get involved, there is a link to fill out to create a connection with the coalition and join the movement. GP