December 2018


Good habits for healthy eyes
Value of omega-3 supplementation

by Ellen Stodola EyeWorld Senior Staff Writer/Digital Editor

Slit lamp photo of corneal keratitis secondary to dry eye disease

Premature tear breakup time seen with evaporative dry eye disease and MGD
Source: Alice Epitropoulos, MD

Corneal keratitis secondary to dry eye disease. Omega-3s have been suggested as a primary treatment for dry eye disease and can be used for other ocular conditions.
Source: William Trattler, MD

Experts discuss omega-3 and nutrition in dry eye disease

Nutrition can play an important role in dry eye disease. Alice Epitropoulos, MD, Columbus, Ohio, and Michael Gross, MD, Blue Bell, Pennsylvania, discussed the role of omega-3s in dry eye disease and shared their experience, information on dosing, and how omega-3s can be used for other conditions.

Role of omega-3s in dry eye disease

Dr. Epitropoulos said there has been a paradigm shift in using good quality omega-3 nutritional supplements as a primary treatment in dry eye patients. “High quality oral supplementation of omega-3 fatty acids in the appropriate dose changes the fatty acid composition of the meibomian gland secretions, preventing the blockage and stagnation of meibomian glands,” she said. “In the Tear Film & Ocular Surface Society Dry Eye WorkShop (DEWS) I and II reports from 2007 and 2017, nutritional therapy is listed as first-line treatment for even mild dry eye disease.”
Dr. Gross discussed how the role of omega-3s in dry eye disease has evolved. He said that “it had been and still should be the basis for adjunctive therapy for dry eye disease.”
He also noted that DEWS I and II said that the foundation of dry eye therapy should begin with omega-3s. Dr. Gross agreed with Dr. Epitropoulos that the foundation of all therapies should be to address diet and how this impacts whatever disease a patient has.
Dr. Gross said that there are many different treatments for dry eye disease, and physicians rely on a combination of many of them rather than just one.

Differences among sources of omega-3s

Dr. Epitropoulos said there are substantial differences in the various omega-3 preparations that are available commercially. “These preparations vary in their purity, efficacy, and quality,” she said.
Fish is contaminated by mercury and carcinogens, making it risky to consume the amount we need. “Most commercial fish oil manufacturers use alcohol [to] detoxify these compounds,” Dr. Epitropoulos said. “However, the addition of alcohol makes it an ethyl ester compound, which is more difficult for the body to absorb.” Re-esterification is a costly, time-consuming process that removes the alcohol to create a clean yet natural form of omega-3 that is not only better absorbed than omega-3 in the ethyl ester form but better tolerated, Dr. Epitropoulos said.
Most over-the-counter omega-3s are in the less desirable ethyl ester (alcohol) form or in the uncleansed triglyceride form. “It’s also important to distinguish that the most beneficial omega-3s are EPA and DHA,” she said. Research has suggested that plant source omega-3s have minimal impact on meibum composition.
Dr. Gross also commented on the different sources of omega-3s. He said that there are a number of products out there, but some are not as effective as others.
He pointed to past research using plant-based omega-3s in high doses. If you use plant-based omegas, no matter how high the dose, the body can’t convert it.
Dr. Gross said you also have to “draw a line” between products that patients buy over the counter, particularly those labeled as “fish oil.”
Dr. Gross noted that the recommended dose is 2.24 grams of EPA/DHA in a 3:1 ratio.
He said the most available form of omega-3s is the form that appears in food, and most of the omega-3s that people get are in chemical or unpurified form.
Dr. Gross said that the Physician Recommended Nutriceuticals (PRN, Blue Bell, Pennsylvania) product is not sold directly to consumers and must come through a physician’s recommendation.

Role of omega-3s in other conditions

Inflammation lies at the heart of dry eye disease, Dr. Epitropoulos said, and when associated with omega-3 deficiency, it can be associated with multiple other systemic diseases.
“There is a high prevalence of patients in the western world with dry eye disease who also have age-related macular degeneration,” she said.
The omega-3 index measures the omega-3 level on red blood cell membranes as a proxy for omega-3 levels in all cells, she said, and once the omega-3 index level reaches >8%, we maximize the ocular, cardiovascular, rheumatologic, and neurologic benefits from these nutritional supplements. “The optimal omega-3 index value of 8% is known to be cardio-protective,” Dr. Epitropoulos said. “Achieving a significant serum level was noted in a study to reduce the risk of sudden death from myocardial infarction by 90%.”1 Studies have also shown a reduced risk of diabetic retinopathy with highly concentrated DHA by 48%,2 she added.

Evidence of omega-3s as useful in ocular disease

Evidence for benefits of nutritional supplementation has continued to strengthen over the years, Dr. Epitropoulos said.
Both of the DEWS reports recommended nutritional therapy as first-line treatment for dry eye disease. A poster presented at the 2011 American Academy of Ophthalmology Annual Meeting compared three different omega-3 supplements and showed PRN achieved desirable therapeutic levels of 8% after 1 month of use in 44% of patients.3
In a study published in Cornea in 2016, Dr. Epitropoulos and colleagues analyzed the effects of re-esterified triglyceride EPA and DHA omega-3s. Results demonstrated a statistically significant improvement in tear osmolarity, Ocular Surface Disease Index symptom scores, tear osmolarity, MMP-9, and omega-3 index levels. They saw significant improvement in tear film stability as evidenced by improved tear break-up time.4
Data shows that supplementation with high-quality omega-3 fatty acids, in the proper dose, is a primary therapy for treating dry eye disease.5


1. Harris WS, Von Schacky C. The omega-3 index: a new risk factor for death from coronary heart disease? Prev Med. 2004;39:212–20.
2. Sala-Vila A, et al. Dietary marine omega-3 fatty acids and incident sight-threatening retinopathy in middle-aged and older individuals with type 2 diabetes: prospective investigation from the PREDIMED trial. JAMA Ophthalmol. 2016;134:1142–1149.
3. Kislan TP. A comparison of omega-3 RBC saturation for PRN-Dry Eye Omega Benefits versus Thera Tears Nutrition versus Nature Made. Ophthalmology. 2011;82:357.
4. Epitropoulos AT, et al. Effect of oral re-esterified omega-3 nutritional supplementation on dry eyes. Cornea. 2016;35:1185–91.
5. Faulkner WJ. The role of omega-3 essential fatty acids in dry eye disease. Int J Clin Exp Ophthalmol. 2017;1:055–059.

Editors’ note: Dr. Epitropoulos and Dr. Gross have financial interests with PRN.

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