Compendium of the most significant studies with reference to properties, intake, effects.

Seino S, Takada Y, Saika S. Effects of Benzalkonium Chloride in Ophthalmic Eyedrop Medications on Corneal Epithelium. Yakugaku Zasshi. 2021;141(1):35-39. doi: 10.1248/yakushi.20-00177-1. 

Abstract. Eyedrops often contain additives other than active pharmaceutical ingredients, such as preservatives. The most frequently used preservative is benzalkonium chloride (BAC). When the ocular surface is exposed to eyedrops, the active pharmaceutical ingredients and additives can cause corneal epithelial disorder. Particularly in clinical settings, there is great interest in corneal epithelial disorders resulting from the use of glaucoma eyedrops, which is inevitable when instilled for a long period of time after the onset of disease. At the authors' institute, glaucoma is treated with consideration of reducing corneal epithelial disorder while ensuring the effect of lowering intraocular pressure by the appropriate choice of eyedrops. In this review, we show the examples of the retrospective studies. Sodium hyaluronate eyedrops are prescribed for corneal epithelial disorders such as superficial punctate keratitis associated with dry eye. Prescribable concentrations of sodium hyaluronate in Japan are 0.1% or 0.3%, and the 0.3% formulation does not contain BAC. The authors' study showed that 0.3% sodium hyaluronate pretreatment reduced the cytotoxicity of BAC in cultured corneal epithelial cells, whereas an in vivo study in mice showed that a 0.3% sodium hyaluronate instillation was suggested and that the drug may enhance the cytotoxicity of separately administered BAC. It is suggested that sodium hyaluronate prolonged the retention of BAC on the ocular surface. However, there have been no reports of this problem in the clinical setting. It is important for ophthalmologists to understand the properties of additives other than the active pharmaceutical ingredients in eyedrops.

Goldstein MH, Silva FQ, Blender N, Tran T, Vantipalli S. Ocular benzalkonium chloride exposure: problems and solutions. Eye (Lond). 2022 Feb;36(2):361-368. doi: 10.1038/s41433-021-01668-x. 

Abstract. Preservatives in multidose formulations of topical ophthalmic medications are crucial for maintaining sterility but can be toxic to the ocular surface. Benzalkonium chloride (BAK)-used in approximately 70% of ophthalmic formulations-is well known to cause cytotoxic damage to conjunctival and corneal epithelial cells, resulting in signs and symptoms of ocular surface disease (OSD) including ocular surface staining, increased tear break-up time, and higher OSD symptom scores. These adverse effects are more problematic with chronic exposure, as in lifetime therapy for glaucoma, but can also manifest after exposure as brief as seven days. Multiple strategies are available to minimize or eliminate BAK exposure, among them alternative preservatives, preservative-free formulations including sustained release drug delivery platforms, and non-pharmacological therapies for common eye diseases and conditions. In this paper, we review the cytotoxic and clinical effects of BAK on the ocular surface and discuss existing and emerging options for ocular disease management that can minimize or eliminate BAK exposure. © 2021. The Author(s).

Kabashima K, Murakami A, Ebihara N. Effects of Benzalkonium Chloride and Preservative-Free Composition on the Corneal Epithelium Cells. J Ocul Pharmacol Ther. 2020 Nov;36(9):672-678. doi: 10.1089/jop.2019.0165.

Abstract. Purpose: Benzalkonium Chloride (BAK) is reported to have the potential to damage the cornea. We developed a composition with broad-spectrum antimicrobial activity without preservatives by combining trometamol, boric acid, and ethylenediaminetetraacetic acid (TBE). This study aimed at evaluating the corneal damage caused by TBE and comparing it with that caused by BAK. Methods: SV40-immortalized human corneal epithelial cell line (HCE-T) was treated with BAK or TBE, and the cell viability was measured. The exposure time that caused 50% cell death (CDT50) was calculated. Transepithelial electrical resistance (TEER) was measured before and after treatment with BAK or TBE. Occludin was detected with immunostaining and Western blotting after treatment with BAK or TBE. The effect of BAK or TBE on membrane-associated mucins was evaluated with rose bengal (RB) staining. Results: In the BAK group, cell viability decreased in a dose-dependent manner. The viability of the TBE group was significantly greater than that of the BAK group. The CDT50 of the TBE group is greater than that of the BAK groups. In the BAK groups, the recovery of TEER was delayed in a dose-dependent manner, whereas in the TBE group, the recovery occurred earlier. Localization of occludin was disrupted, and the amount of occludin was significantly reduced among the cells exposed to BAK. The area stained with RB in the BAK groups increased, whereas that in the TBE group did not increase. Conclusion: These results suggest that the application of TBE would be useful for developing preservative-free ophthalmic preparations that offer both sufficient safety and antimicrobial activity.

Johnson NF. Pulmonary Toxicity of Benzalkonium Chloride. J Aerosol Med Pulm Drug Deliv. 2018 Feb;31(1):1-17. doi: 10.1089/jamp.2017.1390.

Abstract. The available toxicity data of benzalkonium chloride (BKC) clearly shows that it is toxic; however, the weight of evidence favors the view that at doses encountered in nasally and orally inhaled pharmaceutical preparations it is well tolerated. The adverse toxicological data predominantly come from in vitro and animal studies in which doses and exposure periods employed were excessive in relation to the clinical doses and their posology and, therefore, not directly applicable to the clinic. The conflict between the in vitro and animal data and the clinical experience can be reconciled by understanding some of the physicochemical properties of BKC, the nasal and respiratory tract microenvironments, the doses used, and the posology.

Rasmussen CA, Kaufman PL, Kiland JA. Benzalkonium chloride and glaucoma. J Ocul Pharmacol Ther. 2014 Mar-Apr;30(2-3):163-9. doi: 10.1089/jop.2013.0174.

Abstract. Glaucoma patients routinely take multiple medications, with multiple daily doses, for years or even decades. Benzalkonium chloride (BAK) is the most common preservative in glaucoma medications. BAK has been detected in the trabecular meshwork (TM), corneal endothelium, lens, and retina after topical drop installation and may accumulate in those tissues. There is evidence that BAK causes corneal and conjunctival toxicity, including cell loss, disruption of tight junctions, apoptosis and preapoptosis, cytoskeleton changes, and immunoinflammatory reactions. These same effects have been reported in cultured human TM cells exposed to concentrations of BAK found in common glaucoma drugs and in the TM of primary open-angle glaucoma donor eyes. It is possible that a relationship exists between chronic exposure to BAK and glaucoma. The hypothesis that BAK causes/worsens glaucoma is being tested experimentally in an animal model that closely reflects human physiology.

Romanowski EG, Yates KA, Shanks RMQ, Kowalski RP. Benzalkonium Chloride Demonstrates Concentration-Dependent Antiviral Activity Against Adenovirus In Vitro. J Ocul Pharmacol Ther. 2019 Jun;35(5):311-314. doi: 10.1089/jop.2018.0145.

Abstract. Purpose: Adenoviral conjunctivitis is the most common cause of conjunctivitis worldwide with no approved antiviral treatment. Benzalkonium chloride (BAK) is a common preservative in ophthalmic medications and is the active ingredient in some skin disinfectants and hand sanitizers. BAK is known to be effective in killing bacteria and enveloped viruses; however, its activity against ocular types of nonenveloped adenoviruses (Ads) is unknown. The goal was to determine whether BAK is an effective antiviral agent against common human ocular types of adenovirus in vitro. Methods: The direct inactivating activity of BAK was determined by incubating several human adenovirus types with BAK concentrations of 0.001%, 0.003%, 0.005%, 0.01%, 0.1%, and 0% for 1 h at 33°C. Resulting adenovirus titers were determined after treatment. Decreases in titers of ≥3 Log10 were considered virucidal, while decreases in titers of <1 Log10 were considered ineffective. Results: BAK 0.1% was virucidal for Ad3, Ad5, Ad7a, Ad19/64, and Ad37, while it reduced titers >1 Log10, but <3 Log10 for Ad4 and Ad8. Decreases in titers >1 Log10 were demonstrated for BAK 0.003%, 0.005%, and 0.01% for Ad5 only. Decreases in titers for the other adenovirus types for those concentrations were ≤0.53 Log10. 0.001% BAK produced minimal decreases in titers for all types. Conclusions: BAK, at 0.01% or less was not consistently effective as an antiviral against adenovirus, but higher concentrations, such as 0.1%, should be further investigated as a possible topical treatment for adenoviral ocular infections, providing ocular toxicity is not an issue.

Choi SM, Roh TH, Lim DS, Kacew S, Kim HS, Lee BM. Risk assessment of benzalkonium chloride in cosmetic products. J Toxicol Environ Health B Crit Rev. 2018;21(1):8-23. doi: 10.1080/10937404.2017.1408552.

Abstract. A risk assessment of benzalkonium chloride (BAC) was conducted based upon its toxicological profile and exposure evaluation. Since 1935, BAC has been used in a wide variety of products such as disinfectants, preservatives, and sanitizers. It is well-established that BAC is not genotoxic nor does it display tumorigenic potential, but safety concerns have been raised in local usage such as for ocular and intranasal applications. The Foundation of Korea Cosmetic Industry Institute (KCII) reported that in a hair conditioner manufactured as a cosmetic or personal product in South Korea, BAC was present at concentrations of 0.5-2%. The systemic exposure dosage (SED) was determined using the above in-use concentrations and a risk assessment analysis was conducted. The Margin of Safety (MOS) values for hair conditioners were calculated to be between 621 and 2,483. The risk of certain personal and cosmetic products was also assessed based upon assumptions that BAC was present at the maximal level of regulation in South Korea and that the maximal amount was used. The MOS values for the body lotion were all above 100, regardless of the application site. Collectively, data indicate that there are no safety concerns regarding use of products that contain BAC under the current concentration restrictions, even when utilized at maximal permitted levels. However, a chronic dermal toxicity study on BAC and comprehensive dermal absorption evaluation needs to be conducted to provide a more accurate prediction of the potential health risks to humans.

Wu JH, Wang TH, Huang JY, Su CC. Ocular Surface Disease in Glaucoma Patients Randomized to Benzalkonium Chloride-Containing Latanoprost and Preservative-Free Bimatoprost. J Ocul Pharmacol Ther. 2021 Oct 4. doi: 10.1089/jop.2021.0071.

Abstract. Purpose: To investigate the influence of benzalkonium chloride (BAK) on ocular surface disease (OSD) in glaucoma patients receiving ocular-hypotensive agent. Methods: Patients were randomized to receive BAK-containing latanoprost (Xalatan) or preservative-free bimatoprost (Lumigan PF). Intraocular pressure (IOP), basal Schirmer's test, noninvasive keratograph tear-breakup time (TBUT), conjunctival redness score (R score), OSD index (OSDI), and corneal Oxford staining were recorded and compared between the 2 groups at 1-month and 4-month visits. The influence of BAK was analyzed by a generalized estimating equation model. Results: We enrolled 74 and 76 eyes treated with latanoprost and bimatoprost, respectively. The IOP decreased in both groups, although greater reduction was observed for latanoprost (13.95 vs. 15.42 mmHg, P = 0.0264). There was a significantly negative association between tear flow and latanoprost use (β = -0.763, P = 0.0243). The first and average TBUT did not show intergroup differences, but the area with unstable tear film increased with latanoprost use and showed marginal significance at 4-month visit (9.33% vs. 5.94% P = 0.055). In both groups, OSDI decreased, whereas Oxford stain increased over time, and R scores showed improvement after transient increase in the first month. The bimatoprost group had significantly worse conjunctival hyperemia, whereas a negative association with conjunctival hyperemia was revealed for latanoprost use (R score-bulbar nasal: β = -0.045, P = 0.0423). Conclusions: BAK-containing latanoprost was associated with decreased tear secretion and may be associated with tear-film instability, whereas bimatoprost was associated with worse conjunctival hyperemia. Ocular surface side effects should be considered when prescribing BAK-containing medication to glaucoma patients.

Yamashiro C, Tokuda K, Kobayashi Y, Higashijima F, Yoshimoto T, Ota M, Ogata T, Ashimori A, Kobayashi M, Hatano M, Uchi SH, Wakuta M, Teranishi S, Kimura K. Benzalkonium chloride-induced myofibroblastic transdifferentiation of Tenon's capsule fibroblasts is inhibited by coculture with corneal epithelial cells or by interleukin-10. Sci Rep. 2021 Aug 9;11(1):16096. doi: 10.1038/s41598-021-94852-8.

Abstract. Benzalkonium chloride (BAC) is used as a preservative in eyedrops but induces subconjunctival fibrosis that can result in failure of glaucoma surgery. Tenon's capsule fibroblasts in subconjunctival tissue interact with the corneal epithelium through tear fluid. With the use of a coculture system, we have now investigated the effect of human corneal epithelial (HCE) cells on myofibroblastic transdifferentiation of human Tenon fibroblasts (HTFs) induced by BAC (5 × 10-6%). Immunofluorescence and immunoblot analyses revealed that the BAC-induced expression of α smooth muscle actin (αSMA) in HTFs was suppressed by coculture of these cells with HCE cells (p < 0.01). The concentration of interleukin-10 (IL-10) in culture supernatants of BAC-treated HTFs was increased by coculture with HCE cells (17.26-fold, vs. coculure, p < 0.001). Immunofluorescence and immunoblot analyses also showed that exogenous IL-10 (300 pg/ml) suppressed the BAC-induced expression of αSMA by 43.65% (p < 0.05) as well as the nuclear translocation of myocardin-related transcription factor-A (MRTF-A) by 39.32% (p < 0.01) in HTFs cultured alone. Our findings suggest that corneal epithelial cells may protect against subconjunctival fibrosis by maintaining IL-10 levels and preventing the MRTF-A-dependent transdifferentiation of HTFs into myofibroblasts.

Benzalkonium chloride: properties, uses, pros, cons, safety

Benzalkonium chloride (Alkyldimethylbenzylammonium chloride) is a member of the quaternary ammonium salts (“quats”), in practice a mixture of alkyl-benzyldimethylammonium chlorides with alkyl chains of different lengths. In cosmetics it is used mainly as an antimicrobial preservative and, in some formulations, as a cationic surfactant with an antistatic effect (especially on hair). It is effective but has a “strong” profile: the formula must be designed to minimize irritation and avoid contact with mucosa/eyes.

Presented for the first time as antimicrobial agents by Domagk in 1935.

The name describes the structure of the molecule.

• Benz- indicates the presence of a benzene ring, which is a six-membered cyclic structure with three double bonds.
• alkonium indicates the presence of a quaternary ammonium group, which is a nitrogen atom with four substituents and a positive charge.
• chloride refers to the chloride anion (Cl-) that balances the positive charge of the alkonium cation.

Definition

From a chemical-functional standpoint, benzalkonium chloride is a cationic surfactant: the quaternary ammonium moiety provides a permanent positive charge, which interacts with microbial membranes and negatively charged surfaces. Because it is a mixture of homologues, it does not have a single absolute formula/molecular weight valid for all grades, even though some databases list “representative” formulas.

Production process

Industrially it is obtained by quaternization (formation of the quaternary ammonium salt) starting from tertiary amines and benzyl reagents, followed by purification and standardization (assay, chain-length distribution, residuals). For cosmetic use, critical points are purity, control of impurities, and definition of the commercial grade (active content, solvent/vehicle, viscosity).

Key constituents

The functional component is the mixture of alkylbenzyldimethylammonium chlorides (C12–C18 homologues in variable proportions). Trace components (within specification) may include solvents/water of the commercial grade and process residues. Performance (antimicrobial and sensorial) depends mainly on assay, chain distribution, and compatibility with the surfactant/polymer system of the formula.

Identification data and specifications

Physicochemical properties (indicative)

Functional role and mechanism of action

As a preservative, it primarily acts by interacting with microbial membranes, altering permeability and viability. As a cationic surfactant/antistatic, it can adsorb onto surfaces (hair/skin), reducing electrostatic charges and contributing to a “conditioning” feel in some haircare formulas. In practice, its efficacy may decrease if the formula contains high levels of anionic surfactants or anionic polymers, which can inactivate it or cause incompatibilities (haze/precipitation).

Main uses

Cosmetics
Typical in:

• products requiring an antimicrobial preservative function (at low levels, within applicable limits)

• selected haircare products with antistatic/conditioning aims (carefully checking compatibility with surfactants)

• certain “hygienic”/specific cleansers where a quat is compatible with the overall design

It is a restricted ingredient  V/54 and III/65  as a Relevant Item in the Annexes of the European Cosmetics Regulation 1223/2009. Substance or ingredient reported: Benzalkonium chloride, bromide and saccharinate

INCI Functions

Antimicrobial agent. This ingredient is able to suppress or inhibit the growth and replication of a broad spectrum of microorganisms such as bacteria, fungi and viruses by making the stratum corneum temporarily bactericidal and fungicidal.

Antistatic agent. Static electricity build-up has a direct influence on products and causes electrostatic adsorption. The antistatic ingredient reduces static build-up and surface resistivity on the surface of the skin and hair.

Deodorant agent. When substances that give off an unpleasant odour are included in cosmetic formulations (typical examples are methyl mercaptan and hydrogen sulphide derived from garlic), deodorants attenuate or eliminate the unpleasant exhalation.

Preservative. Any product containing organic, inorganic compounds, water, needs to be preserved from microbial contamination. Preservatives act against the development of harmful microorganisms and against oxidation of the product.

Surfactant - Dispersing agent. Surfactant ingredient with cleaning properties that acts as a dispersing agent, capable of creating a barrier between particles by dispersing them and improving the separation between particles during the dispersion process. The particles undergo wetting, separation and then stabilisation of the suspension.

Pros and cons

Pros
Effective antimicrobial/preservative in suitable systems.
Can provide a useful antistatic contribution in some hair products.
Relatively easy to standardize as a process ingredient (known assay, controllable quality).

Cons
Potential skin/eye irritation: requires cautious formulation and appropriate target use.
Often critical compatibility with anionics (risk of efficacy loss or instability).
“Strong” sensorial profile in some bases (may feel stripping or poorly tolerated in leave-on if not well balanced).
Particular attention needed to avoid eye contact.

Safety, regulatory, and environmental aspects

Safety profile (practical)
Benzalkonium chloride is an effective biocide but can be irritating; finished-product safety depends on concentration, product type (rinse-off vs leave-on), application area, and the formulation system. In the European Union it is included among permitted preservatives with specific use conditions; additionally, for “non-preservative” functions, dedicated entries/limitations apply.

Allergen
Not a typical fragrance allergen. Reactions reported are more often irritant in nature or contact sensitization in predisposed subjects, especially with repeated exposure or inadequate concentrations.

Contraindications and cautions
Use caution on very sensitive skin, compromised barrier, periocular area, and high-frequency use products. In formulation: verify stability, compatibility with anionics, and reduce the likelihood of eye/mucosal contact (instructions for use, product design).

Conclusion

Benzalkonium chloride is a cosmetic ingredient whose primary role is antimicrobial preservation, and secondarily antistatic in some contexts. It is technically effective, but requires rigorous formulation to limit irritation, ensure compatibility, and meet applicable use conditions.

Studies

Benzalkonium chloride solutions for hospital use tend to be neutral to alkaline, non-corrosive on metal surfaces, non-staining, and safe to use on all washable surfaces. Is also added to drug products as preservative for multiple dose containers (1).

Benzalkonium chloride (BAK) is used as a preservative in several ophthalmic antiglaucoma agents. There are numerous reports on the effects of BAK on corneal epithelial cells in vitro (2).

Safety

In the package leaflet of a widely used eye drops, Visumidriatic, in the Warnings and Precautions it is written: Benzalkonium chloride can also cause eye irritation especially if you have dry eye or discomfort to the cornea (the uppermost transparent layer of the eye). If you experience an abnormal feeling in the eye, burning or pain after using this medicine, talk to your doctor.

Benzalkonium chloride (BAK) is the most commonly used eye drop preservative. Benzalkonium chloride has been associated with toxic effects such as “dry eye” and trabecular meshwork degeneration, but the underlying biochemical mechanism of ocular toxicity by BAK is unclear. This study propose a mechanistic basis for BAK's adverse effects (3).

This 2020 study by Jingyi Wang et al. warns of the toxicity of benzalkonium chloride to the epithelial cells of the Meibomian gland, which secretes, via its ducts, the human tear film, a major source of lipids (4).

This study from 2022, although written by employees of a private company, is well documented and reaffirms that Benzalkonium Chloride, used in approximately 70% of ophthalmic formulations, is well known to cause cytotoxic damage to conjunctival and corneal epithelial cells, resulting in signs and symptoms of ocular surface disease (5).

The most relevant studies on this ingredient have been selected with a summary of their contents:

Benzalkonium Chloride studies

• Molecular Formula: C₁₉H₃₄ClN
• Linear Formula C₆H₅CH₂N(CH₃)₂RCl (R=C₈H₁₇ to C₁₈H₃₇) 
• Molecular Weight: 311.938 g/mol
• CAS:  63449-41-2   68391-01-5   68424-85-1   85409-22-9  
• EC Number: 264-151-6    269-919-4    270-325-2    287-089-1 
• MDL number MFCD00145757
• Beilstein Registry Number 4062599

• Alkyldimethylbenzylammonium chloride
• Alkyl dimethyl benzyl ammonium chloride
• Benzyldimethyldecylammonium chloride
• Benzenemethanaminium, N-Decyl-N,N-Dimethyl-, Chloride
• Benzenemethanaminium, N-decyl-N,N-dimethyl-, chloride
• N-Capryl-N,N-dimethylbenzylammonium chloride
• Quaternary ammonium compounds, benzyl-C8-18-alkyldimethyl, chlorides
• Benzyl(decyl)dimethylammonium chloride
• Benzenemethanaminium, N-decyl-N,N-dimethyl-, chloride (1:1)
• C8-18-Alkydimethylbenzyl ammonium chlorides
• Benzyldimethyl(mixed alkyl)ammonium chloride
• decyldimethylbenzylammonium chloride
• Alkylbenzyldimethylammonium chlorides, benzyl-C8-18-alkyldimethyl
• decyldimethylbenzyl ammonium chloride
• N-Benzyl-N-decyl-N,N-dimethylammonium chloride
• benzyl-decyl-dimethylazanium chloride
• Ammonium, alkyl(C14-16)dimethylbenzyl-, chlorides
• benzyl-decyl-dimethyl-ammonium chloride
• Roccal

References_________________________________________________________________

(1) Ahn Y, Kim JM, Lee YJ, LiPuma J, Hussong D, Marasa B, Cerniglia C. Effects of Extended Storage of Chlorhexidine Gluconate and Benzalkonium Chloride Solutions on the Viability of Burkholderia cenocepacia. J Microbiol Biotechnol. 2017 Dec 28;27(12):2211-2220. doi: 10.4014/jmb.1706.06034.

Abstract. Chlorhexidine gluconate (CHX) and benzalkonium chloride (BZK) formulations are frequently used as antiseptics in healthcare and consumer products. Burkholderia cepacia complex (BCC) contamination of pharmaceutical products could be due to the use of contaminated water in the manufacturing process, over-diluted antiseptic solutions in the product, and the use of outdated products, which in turn reduces the antimicrobial activity of CHX and BZK. To establish a "safe use" period following opening containers of CHX and BZK, we measured the antimicrobial effects of CHX (2-10 μg/ml) and BZK (10-50 μg/ml) at sublethal concentrations on six strains of Burkholderia cenocepacia using chemical and microbiological assays. CHX (2, 4, and 10 μg/ml) and BZK (10, 20, and 50 μg/ml) stored for 42 days at 23°C showed almost the same concentration and toxicity compared with freshly prepared CHX and BZK on B. cenocepacia strains. When 5 μg/ml CHX and 20 μg/ml BZK were spiked to six B. cenocepacia strains with different inoculum sizes (10⁰ -10⁵ CFU/ml), their toxic effects were not changed for 28 days. B. cenocepacia strains in diluted CHX and BZK were detectable at concentrations up to 10² CFU/ml after incubation for 28 days at 23°C. Although abiotic and biotic changes in the toxicity of both antiseptics were not observed, our results indicate that B. cenocepacia strains could remain viable in CHX and BZK for 28 days, which in turn, indicates the importance of control measures to monitor BCC contamination in pharmaceutical products.

(2) Berdy GJ, Abelson MB, Smith LM, George MA. Preservative-free artificial tear preparations. Assessment of corneal epithelial toxic effects. Arch Ophthalmol. 1992 Apr;110(4):528-32. doi: 10.1001/archopht.1992.01080160106043.

Abstract. Scanning electron microscopy was used to evaluate the corneal epithelium of rabbit eyes after administration of two preservative-free ocular lubricants, preservative-free artificial tear-1 (Hypotears PF) and preservative-free artificial tear-2 (Refresh), and 0.02% benzalkonium chloride. Animals were randomly assigned to either mild or exaggerated use regimens. A quantitative rating system was used to assess epithelial damage. With mild use, scanning electron microscopy revealed normal epithelial morphologic characteristics for both preservative-free artificial tear solutions (mean relative damage score, solution 1, 0.75 +/- 0.16; solution 2, 1.02 +/- 0.23), which were not significantly different from eyes treated with phosphate-buffered saline (1.38 +/- 0.38) or a mild dosage regimen of 0.02% benzalkonium chloride (1.20 +/- 0.12). Exaggerated use with preservative-free artificial tear solutions (solution 1, 1.31 +/- 0.21; solution 2, 1.35 +/- 0.08) induced minimal damage that was not different from control eyes treated with phosphate-buffered saline (1.26 +/- 0.13). Compared with an exaggerated use of 0.02% benzalkonium chloride (4.0 +/- 0.16), both preservative-free artificial tear solutions induced significantly less epithelial damage (P = .0001). These results suggest that with frequent-dosage regimens, preservation-free artificial tear solutions-1 and -2 are free of the toxic effects associated with preserved solutions.

(3) Datta S, Baudouin C, Brignole-Baudouin F, Denoyer A, Cortopassi GA. The Eye Drop Preservative Benzalkonium Chloride Potently Induces Mitochondrial Dysfunction and Preferentially Affects LHON Mutant Cells. Invest Ophthalmol Vis Sci. 2017 Apr 1;58(4):2406-2412. doi: 10.1167/iovs.16-20903

Abstract. Purpose: Benzalkonium chloride (BAK) is the most commonly used eye drop preservative. Benzalkonium chloride has been associated with toxic effects such as "dry eye" and trabecular meshwork degeneration, but the underlying biochemical mechanism of ocular toxicity by BAK is unclear. In this study, we propose a mechanistic basis for BAK's adverse effects....Conclusions: Benzalkonium chloride inhibits mitochondria of human corneal epithelial cells and cells bearing LHON mutations at pharmacologically relevant concentrations, and we suggest this is the basis of BAK's ocular toxicity. Prescribing BAK-containing eye drops should be avoided in patients with mitochondrial deficiency, including LHON patients, LHON carriers, and possibly primary open-angle glaucoma patients.

(4) Wang J, Liu Y, Kam WR, Li Y, Sullivan DA. Toxicity of the cosmetic preservatives parabens, phenoxyethanol and chlorphenesin on human meibomian gland epithelial cells. Exp Eye Res. 2020 Jul;196:108057. doi: 10.1016/j.exer.2020.108057. 

(5) Goldstein MH, Silva FQ, Blender N, Tran T, Vantipalli S. Ocular benzalkonium chloride exposure: problems and solutions. Eye (Lond). 2022 Feb;36(2):361-368. doi: 10.1038/s41433-021-01668-x.