June 2013





Surgeons step cautiously toward dry eye supplements

by Rich Daly EyeWorld Contributing Writer

Meibomian gland plugging

Meibomian gland plugging is the most common cause of evaporative dry eye.

Source: Gary Foulks, MD

The lack of definitive data on effective clinical uses of dry eye supplements has led ophthalmologists to take varying approaches

Supplements aimed at treating dry eye have garnered increasing attention from ophthalmologists, but spotty data has limited their use.

Omega-3 fish oil supplements have worked their way into the standard preop surgical regimen of Gary Foulks, MD, professor of ophthalmology, University of Louisville, Louisville, Ky. For most dry eye surgical patients, Dr. Foulks prescribes at least a month of therapy including lid hygiene, topical lubricants and topical cyclosporine, anddepending on their dietoral omega-3s.

"The literature supports the strategy to treat meibomian gland dysfunction and dry eye preoperatively to give the best visual results post-surgery," Dr. Foulks said.

Such benefits stem from the anti-inflammatory effects of fish oil to help reduce ongoing ocular surface inflammation that occurs in dry eye cases.

Robert A. Latkany, MD, associate professor, New York Medical College, New York Eye & Ear Infirmary, said patients may benefit from purified wild salmon oil preop to optimize the surface, but he has found most of his patients are already taking a supplement long before surgery. Reports of the clinical benefits of fish oil supplementsincluding the possibility that they could prevent dry eyehave increasingly appeared in the research literature and consumer press. But well-controlled prospective, randomized, and masked studies clarifying the extent of their benefits are few.

Conflicting clinical findings in the published data led Esen K. Akpek, MD, director, Ocular Surface Disease and Dry Eye Clinic, Wilmer Eye Institute, Johns Hopkins University, Baltimore, to decide not to recommend supplement use for dry eyes.

"When patients ask for this type of treatment, I tell them that it probably won't hurt, but I also tell them that the evidence is conflicting because the types, amounts, and durations of treatments are all over the place," Dr. Akpek said.

However, both the International Dry Eye Workshop and the International Workshop on Meibomian Gland Dysfunction recommend including omega-3s in dry eye patients' treatment plans.

Dosages vary

The nonspecific recommendations have led dosages to vary by practitioner. Some follow the guidelines recommended by the American Heart Association, which include a 4 g maximum daily dosage (divided doses) and to watch for contraindications such as coumadin therapy.

Dr. Latkany said he typically starts dry eye patients with 1 g of fish oil and reassesses them after a couple of months. Usually, the drier a patient's eyes, the higher the dose.

"Sometimes that is sufficient and other times I may increase the dose," Dr. Latkany said. Alan N. Carlson, MD, professor of ophthalmology, Duke Eye Center, Duke University, Durham, N.C., has found good results for his dry eye patients using one teaspoon daily of cod liver oil. The supplement generally offers improvement for his evaporative dry eye patients, particularly those responding poorly to Restasis (cyclosporine, Allergan, Irvine, Calif.) or AzaSite (azithromycin, Merck, Whitehouse Station, N.J.).

"If patients are fairly confident that they are getting some benefit from a specific agent, it makes good sense to keep them on it provided there are no long-term risks," Dr. Carlson said.

He has found the liquid cod liver oil treatment especially effective among patients with evaporative dry eye in comparison to those with tear production-deficient dry eyes.

The ability of fish oil to help stabilize the tears present in many dry eye patients, he said, is what makes it a valuable addition to other forms of treatment. "These patients might be making plenty of tearsI think they are the majority of patients who have dry eye; they don't have a problem with production of tears as much as they have a problem with stability," Dr. Carlson said.

Meanwhile, Dr. Foulks relies on the treatment recommendations published in the MGD Workshop Report. Those recommendations include: Mild MGD: patient instruction, lid massage following application of warm compress daily, supplement diet with omega-3 if there is dietary deficiency, use lipid-containing artificial tears Moderate MGD: all of the above, topical azithromycin, possibly oral doxycycline, omega-3 supplements, possibly LipiFlow (TearScience, Morrisville, N.C.) therapy if available and at reasonable cost, Tears Again Advanced Eyelid Spray (Ocusoft, Richmond, Texas) Severe MGD: all of the above, topical steroids/cyclosporine, expression of the meibomian glands in the office setting LipiFlow is a potentially valuable treatment for MGD and evaporative dry eye, Dr. Foulks said, but it continues to lack the published prospective clinical trials demonstrating the effectiveness claimed in early published data.

Although the anecdotal results suggest LipiFlow could be a good adjunct therapy for dry eye, its high cost and questionable reimbursements may make it a poor fit for the average ophthalmologists, he said.

"It is likely it will find a place in therapy, but I am not sure every practitioner will opt to buy the expensive equipment," he said.

Potential complications

Among the complicating factors stemming from the use of fish oil supplements are the wide differences in both the quality and price of omega-3s, as well as variability in patient tolerance and acceptance.

As reports have spread about the wide range of potential benefits from fish oils and as numerous manufacturers have begun to produce them, variations in quality have appeared. Notable developments in the cost of deriving such benefits include research identifying some similar benefits to fish oil in flaxseed and krill oil.

"Due to the high cost of some of the others, I recommended flax seed oil," Dr. Foulks said.

Dr. Latkany warned that although there has been a surge of information on krill oil, its benefits have not yet been directly compared to another source of omega-3 fatty acids in dry eye patients.

Among fish oils, Dr. Latkany usually suggests Barlean's (Ferndale, Wash.) and Carlson Laboratories (Arlington Heights, Ills.) brands, but when patients are concerned about the cost, he encourages them to find a purified supplement from a large manufacturer, such as Costco.

Dr. Carlson recommended cod liver oil in conjunction with LipiFlow. He also monitors patients' progress with a LipiView Interferometer (TearScience), as well as their objective and subjective clinical changes.

"What I'm looking for is improved lubrication, patients reporting that they are less aware of their eyes, less of a feeling that they have to blink to rewet the surface," Dr. Carlson said.Dry eye supplements article summary

Patient impacts

Among potential complications that Dr. Carlson warns fish oil users about are that some oils and supplements can increase their bleeding time during major surgery due to an effect on platelets, particularly the supplements with high amounts of vitamin D. Additionally, he limits his patients to one teaspoon a day to avoid hypervitaminosis.

Similarly, Dr. Latkany limits oil intake to 1 g daily in high-risk patients to avoid the danger of fish oil-induced increased bleeding and lowered immune systems.

Among the more manageable challenges that arise with the use of fish oil are patient objections to their taste or texture. Dr. Latkany suggests enteric-coated pills for difficulty swallowing and noted some patients report less of an aftertaste with liquid versions. A simple fix Dr. Carlson found for patients who do not enjoy the taste of cod liver oil is mixing it with lemonade or limeade.

Editors' note: Dr. Carlson has financial interests with TearScience. Drs. Foulks, Latkany, and Akpek have no financial interests related to this article.

Contact information

Akpek: esakpek@jhmi.edu
Carlson: alan.carlson@duke.edu
Foulks: foulksgary@gmail.com
Latkany: relief@dryeyedoctor.com

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