Eye Drops Preserved with BAK
What is BAK?
Benzalkonium chloride, a preservative commonly used in eyedrops.
Why should I care about BAK?
#1: It's in most prescription eye drops, and many over the counter eye drops.
#2: It's known to cause or exacerbate dry eye in multiple ways.
Benzalkonium chloride (BAK) is a common preservative that is believed to be damaging to the eyes in up to seven different ways, according to TFOS DEWS II's Iatrogenic Dry Eye Report (see ssection 4.2.3.1). This preservative is used in most prescription eye drops and it is also used in many over-the-counter eyedrops without any warning on the label that mentions the preservative. Consumers sometimes use drops every day for years without any idea of the long term side effects, on the assumption that if it is sold over the counter, it must be safe. Consumers who are taking prescription eye drops on a daily basis for long periods are often similarly unaware of the ocular surface risks involved.
How (not) to use this information
Don't: Please don't stop taking a drug your doctor prescribed just because it's on this list!
Don't: Assume that if it's not on this list then it's OK. These lists are not exhaustive. Check the label to be sure.
Do: Look up your eye drops to see if any of them have BAK.
Do: Bear in mind that while I have included active ingredients so that you can find equivalents and generics, equivalents and generics may be different from the original name brand - they may have a different preservative, or have a different concentration of the preservative.
Do: Have a conversation with your eye doctor to see if there is an alternative that is either preservative-free or contains a less harmful preservative.
A conversation may seem like a small thing. IT'S NOT SMALL. Our collective conversations are our most powerful tools to influence the eye care professions and the industries that cater to them and us, which can change the future of eye care and reduce the incidence of preventable dry eye caused by preservatives.
So please, talk, ask questions, and keep the conversation about preservatives flowing.
Over-the-counter eye drops with BAK
This list contains popular lubricant drops, allergy drops, redness relievers and combination drops. Unfortunately, in some cases the manufacturers refused to provide BAK concentration details. If we're missing a product sold in the US, please contact us so we can add it.
| Eyedrop | Company | BAK |
| Zaditor (ketotifen) | Alcon | 0.01% |
| Patanol (olopatadine) | Alcon | 0.01% |
| Pataday (olopatadine) | Alcon | 0.01% |
| Lastacaft (alcaftadine) | Allergan | 0.005% |
| Naphcon-A (naphazoline hydrochloride, pheniramine maleate) | Alcon | 0.01% |
|
Alaway (ketotifen) NOTE: Alaway PF is now available! |
Bausch & Lomb | 0.01% |
| Children's Alaway (ketotifen) | Bausch & Lomb | 0.01% |
| Lumify (brimonidine tartarte) (1) | Bausch & Lomb | 0.01% (1) |
| Opcon-A (naphazoline, pheniramine maleate) | Bausch & Lomb | ? |
| Advanced Eye Relief Dry Eye Lubricant Eye Drops (glycerine, propylene glycol) | Bausch & Lomb | 0.01% |
| Soothe Long Lasting Hydration (povidone) | Bausch & Lomb | 0.005% |
| Visine Original Redness Relief (tetrahydrozoline) | Johnson & Johnson | Won't say |
| Visine Advanced Redness and Irritation Relief (tetrahydrozoline, dextran, povidone, polyethylene glycol) | Johnson & Johnson | Won't say |
| Visine Maximum Strength Redness Relief (tetrahydrozoline, glycerine, hypromellose, polyethylene glycol) | Johnson & Johnson | Won't say |
| Visine Totality (tetrahydrozoline, glycerine, hypromellose, polyethylene glycol, zinc sulfate) | Johnson & Johnson | Won't say |
| Visine A.C. Ultra Itchy Eye Relief (tetrahydrozoline, zinc sulfate) | Johnson & Johnson | Won't say |
| Visine-A Multi-Action Eye Allergy Relief (naphazoline, pheniramine maleate) | Johnson & Johnson | Won't say |
| Visine Dry Eye Relief (glycerine, hypromellose, polyethylene glycol) | Johnson & Johnson | Won't say |
| Clear Eyes Redness Relief (4) (glycerine, naphazoline) | Prestige Consumer Health Care | Won't say |
| Clear Eyes Maximum Redness Relief (4) (glycerine, naphazoline) | Prestige Consumer Health Care | Won't say |
| Clear Eyes Maximum Itchy Eye Relief (glycerine, naphazoline, zinc sulfate) (4) | Prestige Consumer Health Care | Won't say |
| Clear Eyes Triple Action (4) (polyvinyl alcohol, povidone, tetrahydrozoline) | Prestige Consumer Health Care | Won't say |
| Clear Eyes Cooling Comfort Redness Relief (4) (glycerine, naphazoline) | Prestige Consumer Health Care | Won't say |
| Clear Eyes Cooling Comfort Itchy Eye Relief (4) (glycerine, naphazoline, zinc sulfate) | Prestige Consumer Health Care | Won't say |
| Rohto Cool Max (5) (naphazoline HCI, polysorbate 80) | The Mentholatum Company | Won't say |
| Rohto Cool (5) (naphazoline HCI, polysorbate 80) | The Mentholatum Company | Won't say |
| Rohto Digi-Eye (5) (hypromellose, tetrahydrozoline HCI) | The Mentholatum Company | Won't say |
BAK-free alternatives to consider:
- For dry eye: There are so many that there is absolutely no reason why anyone would ever knowingly choose a BAK-preserved dry eye drop. Please see our lubricant eye drop ingredient list. All preservative-free lubricants are marked.
- For allergy: The first preservative free allergy drop in the US, Alaway Preservative Free, is expected to become available in spring of 2021.
- For redness relief: Clear Eyes Pure Relief Multi-Symptom. But please bear in mind that while it is preservative-free, it is a vasoconstrictor which is associated with a 'redness rebound' effect. Lumify is the only redness reliever on the US market believed not to be associated with redness rebound, however, it is preserved with 0.01% BAK.
Prescription eye drops with BAK
These lists contain commonly prescribed prescription eye drops Our sources are the FDA and the manufacturer's websites. Please note that these lists are not exhaustive. Please contact us with any additions or corrections.
1. Glaucoma eye drops
| Drug | Company | BAK |
| Betagan (levobunolol) | Allergan | .004% |
| Alphagan (brimonidine tartrate) | Bausch & Lomb | .005% |
| Istalol (timolol maleate) | Bausch & Lomb | .005% |
| Lumigan (bimatoprast) | Allergan | .005% |
| Cosopt (dorzolamide) | Merck | .0075% |
| Trusopt (dorzolamide) | Merck | .0075% |
| Azopt (brinzolamide) | Alcon | .01% |
| Betoptic S (betaxolol) | Alcon | .01% |
| Timoptic (timolol maleate) | Merck | .01% |
| Rescula (unoprostone isopropyl) | Ciba Vision | .015% |
| Travatan (3) (travoprost) | Alcon | .015% |
| Xalatan (latanoprost) | Pfizer | .02% |
Glaucoma eye drops without BAK:
- Travatan Z (travoprost 0.004%) is preserved with sofZia
- Alphagan P (brimonidine tartrate 0.1%) is preserved with Purite
- Zioptan (tafluprost 0.005%) is preservative-free
- Cosopt PF (dorzolamide hydrochloride and timolol maleate) is preservative-free
- Timoptic 0.25% and 0.5% in Ocudose (timolol maleate) is preservative-free
2. Allergy eye drops
| Drug | Company | BAK |
| Bepreve (bepotastine) | Bausch & Lomb | 0.005% |
| Elestat (epinastine) | Allergan | 0.01% |
| Alomide (lodoxamide tromethamine) | Alcon | 0.007% |
| Zerviate (cetirizine) | Nicox | 0.01% |
| Optivar (azelastine) | Meda | 0.0125% |
Allergy eye drops without BAK
There are no preservative free prescription allergy drops on the US market to the best of our knowledge. See Alaway PF (OTC).
3. Steroid eye drops
| Drug | Company | BAK |
| Pred Forte (prednisolone) | Allergan | 0.004% ?? (6) |
| Lotemax suspension (loteprednol .5%) | Bausch & Lomb | 0.01% |
| Lotemax gel (loteprednol .5%) | Bausch & Lomb | 0.003% |
| Lotemax SM gel (loteprednol .38%) | Bausch & Lomb | 0.003% |
| Maxidex (dexamethasone) | Alcon | 0.01% |
| FML (fluorometholone) | Allergan | 0.004% |
Steroid eye drops without BAK
- Durezol (difluprednate) is preserved with sorbic acid
4. Antibiotics
| Drug | Company | BAK |
| AzaSite (azithromycin) | Inspire Pharmaceuticals | 0.003% |
| Ocuflox (ofloxacin) | Allergan | 0.005% |
| Ciloxan (ciprofloxacin) | Alcon | 0.006% |
| Polytrim (polymyxin/trimethoprim) | Allergan | 0.004% |
| Zymar (gatifloxacin) | Allergan | 0.005% |
5. NSAID eye drops
| Drug | Company | BAK |
| Acular (ketorolac) | Allergan | 0.01% |
| Xibrom (bromfenac) | Ista | 0.005% |
| Nevanac (nepafenac) | Alcon | 0.005% |
Sources
Our sources are almost exclusively manufacturers and the FDA (see links). If we had to request BAK concentrations, notes of the outcome are below.
(1) Lumify: July 24, 2018 tweet from Bausch & Lomb's Twitter account replying to question from @dryeyezone. BAK concentration data is redacted from Lumify's FDA documentation.
(2) We requested information on BAK concentrations in Visine brand eye drops. Here is their reply, dated 2/6/2019:
Dear Emily,
Thank you for contacting VISINE®. We appreciate your interest in our company. We are very sorry, but our company policy prohibits disclosing this type of information. Most of our research, marketing and sales information is proprietary, as is information regarding our ingredient percentages and formulations of individual products. Information that can be made available to the public may be found on the web site listed below, in our Annual Report, or through other literature that may be available online through the Johnson & Johnson corporate web site at www.jnj.com Again, thank you for your interest in our company. Should you have any comments or questions in the future, please contact us via our website or by calling our toll-free number, 1-888-734-7648. Our specialists are available Monday through Friday, 9:00 a.m. - 5:30 p.m. EST and will be happy to assist you. Sincerely, Erin, Consumer Care Center
(3) Note that the company's more recent product Travatan Z does not contain benzalkonium chloride.
(4) We requested information on the BAK in the Clear Eyes product line. Here is the response we received on 2/7/2019:
Dear Ms. Petris, Thank you for contacting us in regards to your recent experience with Clear Eyes Maximum Itchy Eye Drops, Clear Eyes Redness Relief Drops, Clear Maximum Redness Relief Drops, Clear Eyes Maximum Itchy Eye Drops, Clear Eyes Triple Action Drops, Clear Eyes Cooling Comfort Redness Relief Drops, and Clear Eyes Cooling Comfort Itchy Eye Drops. The amount of benzalkonium chloride is proprietary to our formula and is used a preservative. The percentage cannot be shared. If you have other comments, or questions, we are available by calling our toll free number, 877-274-1787, or you may contact us electronically through our website. Thank you for being one of our valued consumers. Kind Regards, Laura Clear Eyes Consumer Care Center 000765051A
(5) We requested information on the BAK in the Rohto product line. Here is the response we received on 2/7/2019:
Dear Rebecca, Thank you for contacting The Mentholatum Company, USA. We are sorry we can not answer your question. This information is proprietary. If we can be of further assistance, please let us know. Regards, Consumer Affairs Administrator, The Mentholatum Company, USA Toll Free: 1-877-636-2677
(6) This information was redacted from Pred Forte's MSDS and I have not found the concentration on any US sources. I have found package inserts for Canada stating it is 0.004%, and it seems reasonable to assume it's the same for the US but I don't have a source saying so. Also, I was interested to note that Omnipred has 0.01% BAK.
Additional reading
- TFOS DEWS II Iatrogenic Dry Eye Report (A comprehensive review; Gomes et al, The Ocular Surface, 2017) - Contains extensive references prior to 2017
- The Eye Drop Preservative Benzalkonium Chloride Potently Induces Mitochondrial Dysfunction and Preferentially Affects LHON Mutant Cells (Datta et al, IOVS, April 2017)
- Glaucoma therapy: preservative-free for all? (J. Thygesen, Clinical Ophthalmology, April 2018)