Eyeworld

I WHAT YOUR PATIENT IS TAKING AND ITS EFFECT ON THE EYE N FOCUS 50 | EYEWORLD | JANUARY/FEBRUARY 2020 by Vanessa Caceres Contributing Writer Although there is not a clear-cut omega-3 dosing recommendation for the general public, the American Heart Association recommends patients with documented heart disease con- sume 1,000 combined milligrams of eicosapen- taenoic acid (EPA) and docosahexaenoic acid (DHA) daily, preferably from food. EPA and DHA are two types of omega-3 fatty acids. Registered dietitians generally advise consuming fatty fish for omega-3s but say that a supple- ment may be used if that is not possible. There is a caveat The ophthalmologists interviewed for this story said omega-3 fatty acid supplementation pro- cessed in a specific way has the most benefits for ocular health, with fewer side effects. "I tell patients that not all omega-3s are the same," said Cynthia Matossian, MD, who was a coauthor of the study led by Dr. Epitropoulos. When fish are caught for omega-3 process- ing, their oil is squeezed out, but that oil also contains heavy metals, such as mercury. Most processors of omega-3 supplements take the oil and add alcohol to process it, Dr. Matossian said. Then, they extract heavy metals through a processing called ethyl ester. "Most cheaper versions of omega-3 let the product cool to room temperature and then they encapsulate it," Dr. Matossian said. How- ever, the gastrointestinal (GI) tract does not rec- ognize this version as fish as it's been chemically altered. "As a result, absorption is not as good. The omega sits around in the gut and leads to fish burps, embarrassing gas, and stomach issues. A lot of people discontinue it because of GI effects," she said. A process called re-esterification extracts the heavy metals but then converts the product back to a triglyceride fish form, so the body recognizes the omega-3 as salmon or tuna. It helps absorption and reduces GI issues, Dr. Matossian said. Brands mentioned by the physicians inter- viewed for this article include DE3 Dry Eye Omega Benefits (Physician Recommended Nu- triceuticals), HydroEye (Science Based Health), and Ultimate Omega (Nordic Naturals). O phthalmologists normally focus on medication when treating patients with ocular surface disease, age-re- lated macular degeneration, and other conditions or pathologies. However, nutraceuticals are also considered by some physicians. Omega-3 fatty acids in particular come out strong in the discussion about nutraceutical use within ophthalmology. The scoop on omega-3s Omega-3 fatty acids have been both touted and debated in the literature for a variety of health benefits. Research on omega-3s and dry eye has found that re-esterified omega-3 supplementa- tion can lead to a statistically significant im- provement in multiple endpoints including tear osmolarity, omega-3 index levels, tear breakup time, symptom scores, and matrix metallopro- teinase-9 inflammation, said Alice Epitropoulos, MD, who was lead author of a study on the topic. 1 The buzz over omega-3s for dry eye led to a "real world" randomized clinical trial known as the Dry Eye Assessment and Management (DREAM) Study. This study was published in 2018 and compared patients randomly assigned to receive supplements containing 3,000 mg of omega-3 for a year vs. those getting a placebo of olive oil. 2 Patients in the omega-3 and the placebo arms experienced improvements in the Ocular Surface Disease Index score and in conjunctival and corneal staining, however, researchers did not find a statistically significant difference in those receiving omega-3 supple- mentation with those who received the placebo. Nevertheless, these results have not dis- couraged anterior segment surgeons who rec- ommend omega-3 supplement use. If anything, they found it supported what they already follow. "Both olive oil and omega-3 fatty acids worked," said John Sheppard, MD. "That's en- couraging because we're always hearing how the Mediterranean diet is good for the eyes." The Mediterranean diet encourages fish and olive oil, in addition to vegetables and whole grains. Nutraceuticals: Benefits to ocular health and importance of product selection At a glance • Nutraceuticals can play a role in bettering ocular health. • Omega-3 fatty acids pro- cessed in a way to produce a higher-quality product can help patients with MGD and dry eye. • If recommended dosing of omega-3 fatty acids is too expensive or cumbersome for patients, less frequent dosing still provides benefits. • Nutraceuticals taken for other, non-ocular health benefits can have inadvertent effects on the eyes.

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