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EW CORNEA 58 December 2016 by Ellen Stodola EyeWorld Senior Staff Writer Dr. Epitropoulos added. There was statistical significance found in tear osmolarity, as well as in the second- ary endpoints. "We consider this game-changing." Dr. Epitropoulos said that an elevated tear osmolarity is one of the mechanisms thought to contribute to damage to the ocular surface, inflammation, and tear film insta- bility. "Overall, the results of this study support the recommendation that re-esterified omega-3s should be included as primary therapy for dry eye disease," she said. Dr. Epitropoulos thinks there is always room for more study and research on the subject. "We know that MGD is a chronic disease that can be progressive if not treated," she said. A longer-term study could be done to evaluate if meibomian gland atrophy is reversible. She added that the paper concluded that visual changes on meibomian glands will need longer follow-up. Omega-3s are the foundation of every cell in the body, according to Dr. Epitropoulos, and the greatest concentrations of DHA are in the brain, heart, and retina. The lipid layer is crucial to the health of the tear film, and omega balance needs to be maintained to help prevent inflammation. Dr. Epitropoulos acknowledged the contributions of all the authors on the paper, including Eric Donnenfeld, MD, Zubin Shah, MPH, Edward Holland, MD, William Faulkner, MD, Cynthia Matossian, MD, Stephen Lane, MD, Melissa Toyos, MD, Frank Bucci Jr., MD, Henry Perry, MD, and Dr. Gross. EW Reference 1. Epitropoulos AT, et al. Effect of oral re-ester- ified omega-3 nutritional supplementation on dry eyes. Cornea. 2016;35:1185–91. Editors' note: Drs. Epitropoulos and Gross have financial interests with PRN. Contact information Epitropoulos: aepitrop@columbus.rr.com Gross: mgross@prnomegahealth.com the OSDI and staining that other studies have used as endpoints, but also tear osmolarity, MMP-9, and TBUT. Dr. Epitropoulos stressed the importance of the inclusion of re-esterified omega-3s in treating dry eye disease. There are substantial differences that exist in omega-3 preparations that are commercially available, Dr. Epitropoulos said. Fish oil manufacturers add alcohol to clean the many toxins and mercury that can be found in fish. However, the addition of alcohol (ethyl ester form) induces a chemical change in the fish oil, which makes it more dif- ficult for the human body to process and absorb. The majority of fish oil on the market is in the ethyl ester form. The re-esterification process, she said, removes the alcohol and creates a more natural form of ome- ga-3s (re-esterified) that are better absorbed and better tolerated. Dr. Epitropoulos thinks this is one of the biggest studies on dry eye to come out. "I think that many are not aware that the average American is deficient in omega-3s," she said. "There have been studies for years, but we didn't understand that all omega-3s are not equally effective." It's important to supplement them in the same form as what's found in nature, she said. The therapeutic value found in the study is tremendous news, our knowledge of dry eye disease matures, it has become more evident that the lipid layer of tear film needs to be addressed for long-term health of the ocular surface," she said. The purpose of the study, Dr. Epitropoulos said, was to assess the effect of oral re-esterified omega-3 fatty acids on several endpoints. The primary endpoint was tear osmolarity, and other endpoints included tear break-up time (TBUT), OSDI, corneal staining, Schirmer test, MMP-9 testing, and omega-3 index. "We wanted to complete a study that addresses the underlying pathophysiology of evaporative dry eye disease," she said. Dr. Gross has been working with omega-3s for more than a decade. Although his medical background is not in ophthalmology, he became involved in the specialty with his work at PRN and omega-3s. He said it's important to emphasize that "we're not trying to replace any- thing." Nutrition is important, but it "doesn't work quickly." It deals with the problem from the inside out, Dr. Gross said, so using other treatments like drops and scrubs are still key to the treatment regimen. He likes to consider omega-3s as a therapy alongside the therapies that physi- cians are currently using. This study is significant and widely read, he said, because it addresses not only Study measures the impact of oral re-esterified omega-3 nutritional supplementation on a number of endpoints D ry eye disease is a common ocular problem that affects many patients. Although it may not be well known, nutrition can play a large role in dry eye and meibomian gland dysfunction (MGD). Omega-3 fatty acid supplements have been recom- mended as a therapy to help improve the problem. A paper published in Cornea in September looked at this. The paper, "Effect of Oral Re-ester- ified Omega-3 Nutritional Supple- mentation on Dry Eyes," discussed a study assessing this clean form of omega-3s for various endpoints. Alice Epitropoulos, MD, the Eye Center of Columbus, Ohio, lead author of the study, and Michael Gross, MD, senior vice president and chief medical officer, Physician Recommended Nutriceuticals (PRN), Plymouth Meeting, Pennsylvania, spoke to EyeWorld about the study and what it means moving forward. It was a multicenter, random- ized, double-masked, placebo- controlled interventional study with 105 patients randomized to receive either the re-esterified omega-3s (EPA and DHA) or placebo for 12 weeks. In the re-esterified omega-3s group, patients achieved statistically signifi- cant improvement in tear osmolarity and TBUT, a decrease in ocular MMP- 9 positivity, an increase in omega-3 index levels, and statistically signif- icant improvement in ocular symp- toms evidenced by Ocular Surface Disease Index (OSDI) questionnaire. These results help to demonstrate a correlation between omega-3 levels and dry eyes. "I think that it's nice to have this study out so that people can realize how important nutrition is," Dr. Epitropoulos said. There have been several studies that have previously shown effectiveness of omega-3 consumption on dry eye, but the ocular benefits were un- known until several years ago. "As Study examines value of omega-3s for dry eyes Example of dry eye Source: William Trattler, MD

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