EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.
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38 EW FEATURE February 2011 2013 Presbyopia June Surgeons step cautiously toward dry eye supplements by Rich Daly EyeWorld Contributing Writer AT A GLANCE • Well-controlled prospective, randomized, and masked studies clarifying the extent of the benefits of fish oil supplements are few. • Both the International Dry Eye Workshop and the International Workshop on Meibomian Gland Dysfunction recommend including omega-3s in dry eye patients' treatment plans. • There is a wide range in quality and price of omega-3 supplements. The lack of definitive data on effective clinical uses of dry eye supplements has led ophthalmologists to take varying approaches S upplements 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, and—depending on their diet—oral 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 supplements—including the possibility that they could prevent dry eye—have 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. Monthly Pulse T he EyeWorld Monthly Pulse survey for May focused on presbyopic correction. A slight majority of responders (51.7%) said they prefer implanting multifocal IOLs for presbyopic correction, while 36% prefer monovision, 6.6% opt for accommodating IOLs, and 5.6% don't offer any presbyopic correction. Maintaining a healthy ocular surface before surgery is key. Fifty-eight percent of respondents said they recommend fish oil supplements, while 18.9% recommend flax seed oil and 3.1% recommend krill oil for omega 3 supplementation. Nearly 20% (19.9%) do not recommend omega 3 supplements at all. A majority of respondents (44.1%) said they don't personally take omega 3 supplements. A majority of respondents believe that macular drusen with good vision is a contraindication for a multifocal IOL (63%), while 29.9% don't agree. Finally, most (62.2%) would offer a multifocal IOL to a cataract patient who has diabetes with no retinopathy, while 29% wouldn't. Meibomian gland plugging is the most common cause of evaporative dry eye. Source: Gary Foulks, MD "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 Keeping a Pulse on Ophthalmology