Eyeworld

EW FEATURE 40 Good habits for healthy eyes • December 2018 AT A GLANCE • The recommended dose is 2.24 grams of EPA and DHA re-esterified triglyceride in a 3:1 ratio. • Both of the DEWS reports recommended nutritional therapy as first-line treatment for dry eye disease. • Re-esterification is a process that removes the alcohol to create a cleaned, natural form of omega-3 that is better absorbed and better tolerated than omega-3 in the ethyl ester form. by Ellen Stodola EyeWorld Senior Staff Writer/Digital Editor gas, 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, par- ticularly those labeled as "fish oil." Dr. Gross noted that the recom- mended 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 reach- es >8%, we maximize the ocular, omega-3 preparations that are avail- able commercially. "These prepara- tions vary in their purity, efficacy, and quality," she said. Fish is contaminated by mercu- ry and carcinogens, making it risky to consume the amount we need. "Most commercial fish oil manu- facturers use alcohol [to] detoxify these compounds," Dr. Epitropou- los said. "However, the addition of alcohol makes it an ethyl ester compound, which is more difficult for the body to absorb." Re-esterifi- cation 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 import- ant to distinguish that the most beneficial omega-3s are EPA and DHA," she said. Research has sug- gested 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 ome- ity omega-3 nutritional supplements as a primary treatment in dry eye patients. "High quality oral supple- mentation of omega-3 fatty acids in the appropriate dose changes the fatty acid composition of the meibomian gland secretions, pre- venting 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 Experts discuss omega-3 and nutrition in dry eye disease N utrition can play an important role in dry eye disease. Alice Epitropou- los, 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 qual- Value of omega-3 supplementation 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

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