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February 2011 June 2013 Presbyopia (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 tears—I 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 lipidcontaining 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. EW FEATURE 39 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 oilinduced 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. EW 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 Poll size: 295 EyeWorld Monthly Pulse EyeWorld Monthly Pulse is a reader survey on trends and patterns for the practicing ophthalmologist. Each month we send a 4-6 question online survey covering different topics so our readers can see how they compare to our survey. If you would like to join the current 1,000+ physicians who take a minute a month to share their views, please send us an email and we will add your name. Email daniela@eyeworld.org and put EW Pulse in the subject line—that's all it takes. Copyright EyeWorld 2013