Eyeworld

29 EW CORNEA January 2018 Currently there are two differ- ent forms of omega-3 fatty acids, Dr. Holland said. There are re-esterified and non-esterified essential fatty acids. The non-esterified omega-3 is the cheapest formulation but can have drawbacks. "It's not absorbed through the GI tract very well, it gives some patients indigestion and has a fishy taste," Dr. Holland said. "The advantage of using a re-es- terified triglyceride omega-3 fatty acid is that the omega-3 maintains its natural triglyceride structure, which can be easily metabolized and absorbed. They're more expensive, but they're more advantageous for patients." To equal one tablet of the triglyceride omega-3, you'd have to take many more of the ester alco- hol-based ones. Dr. Sheppard would like to see an ideal combination of re-esterified and selected traditional essential fatty acids as well as the anti-in- flammatory gamma linolenic acid (GLA) from the ScienceBased Health (Oak Ridge North, Texas) formula. He recommends that patients take only clearly labeled mercury-free, pharmaceutical-quality essential fatty acids if purchasing on their own. He makes the ScienceBased Health formula available in his office, as well as online or by direct mail from the company. "We give patients access to the literature, en- abling them to formulate decisions themselves," he said. "But I think patients prefer one-stop shopping and become compliant when they see the benefits." Possible precautions Not everyone can take all omega-3 fatty acids. "If a patient has a fish allergy, it becomes much more difficult," Dr. Sheppard said. "But they can take various sources of GLA like black current seed oil, primrose, borage, and they can take flax seed, which is the vegetable form of ome- ga-3." This is a bit less bioavailable but is far better than nothing, he said. "We have numerous patients on warfarin or other prescription anti-coagulant therapies taking fish-based supplements safely and successfully, working in conjunction with their internist." Even for those without this issue, some precautions should be taken with the use of omega-3 sup- plements, including taking the pa- tient's general health into account, Dr. Downie advised. "There are several general health contraindica- tions, including liver disease, atrial fibrillation, and bleeding disorders," she said, adding that in these cases medical advice should be sought prior to beginning supplementation. Although it remains conten- tious, some think ultra-high doses of omega-3 EFA intake of greater than 3,000 mg per day of combined EPA and DHA may cause height- ened risk of bleeding, Dr. Downie said. She recommends that prior to beginning such supplementation, those with hematologic disorders seek medical advice. Keeping dosage amounts in mind is important. "The Food and Drug Administration suggests an upper daily limit for omega-3 fatty acid consumption of 3,000 micro- grams, which includes omega-3s de- rived from foods and supplements," Dr. Downie said, adding, however, that this refers to the amount of omega-3 fatty acid content, rather than the size of the supplement capsule. Many 1,000 mg fish oil cap- sules only contain 180 mg EPA and 120 mg DHA. In such cases, only about 30% of the content of the fish oil supplement capsule will be long- chain omega-3 fatty acid. Use of krill oil is gaining some attention as a natural remedy for dry eye. "Our groups' recent study is the first to demonstrate the therapeutic potential of krill oil supplementation for modulating ocular inflammation in dry eye," Dr. Downie said, adding that while the clinical findings were similar to fish oil, there were differences. 4 Among these was the differ- ential modulation of tear IL-17A, which suggests that the anti-in- flammatory effects are not entirely the same. Investigators also found that after 3 months of treatment the improvement in symptoms was marginally better with krill oil compared with fish oil. "Krill oil has the advantage of fewer gastrointesti- nal side effects, although we did not observe any specific difference in this adverse effect between groups in our trial," Dr. Downie said. One downside to the krill oil is that this is more expensive than fish oil supplements. Mechanical methods There are also mechanical methods that may help. Dr. Holland is a big advocate of thermal pulsation ther- apy. "Diseased meibomian glands have thickened static meibum that is hard to express and with the nor- mal blink meibum is not released to the ocular surface," he said. "Nor- mally, when you blink, you have a very microscopic contraction of the muscles around the gland and the glands release meibum." However, if there is stasis of the gland or these are partially obstructed, the thick- ened meibum oil is never released, Dr. Holland explained. He finds that one way to reset the gland is to heat the meibum and with pulsation express it. "This allows the patient who's on maintenance therapy, such as omega-3s and doxycycline or azithromycin, to now have a new, healthier meibum in the gland," he said. "At this time, it appears that the best way to deliver the heat and pulsation is posteriorly." For this, he finds LipiFlow (Johnson & Johnson Vision, Santa Ana, California) works best. This heats the glands up and massages them to express the heated oil, which flows better because it's at 104 degrees F. "There are devices that heat anteriorly that can have some effect, but the glands are po- sitioned posteriorly, so the heat di- rectly on the posterior gland shows the most efficacy," Dr. Holland said. Probing the glands can also be useful in meibomian gland disease patients. "There are some patients in which the glands are capped, so uncapping the gland makes sense," Dr. Holland said. "Any time we do a LipiFlow treatment, we'll uncap any keratinization." For this, you could use the Maskin probe or the tip of a needle, he explained, adding that you can do mild expression of the oil to prepare the gland for LipiFlow. Practitioners are much more likely to realize that meibomian gland disease is a large part of dry eye these days. "In the past, if you said 'dry eye,' clinicians and patients would automatically think aqueous tear deficiency, and many of them still do," Dr. Holland said. "But meibomian gland disease is a much more common form of dry eye than aqueous deficiency." Practitioners are finally now realizing the impor- tance of meibomian gland disease and the strategies for treating this, he said. Neurostimulation therapy (TrueTear, Allergan, Dublin, Ire- land) was recently approved for the improvement of tear production in patients with dry eye. The hand- held, external, low voltage device produces signals through the ante- rior ethmoidal nerve that emulate natural afferent trigeminal stimuli for the constitutive production of all three major components of the tear film. Because neurostimulation is neither surgical nor pharmaceu- tical, it provides a novel, unique, and potentially synergistic modality for dry eye patients utilizing other regimens, Dr. Sheppard said. Ultimately, each individu- al patient will require a targeted evaluation by an inquisitive eyecare provider to determine the best com- bination of treatments for his or her condition. Dry eye is a multifactori- al disease, necessitating a carefully orchestrated and often multimodal therapeutic attack directed by con- sistent visits to the same managing ophthalmologist or optometrist, Dr. Sheppard said. EW References 1. Sheppard JD Jr, et al. Long-term supple- mentation with n-6 and n-3 PUFAs improves moderate-to-severe keratoconjunctivitis sicca: a randomized double-blind clinical trial. Cornea. 2013;32:1297–304. 2. Epitropoulos AT, et al. Effect of oral re-es- terified omega-3 nutritional supplementation on dry eyes. Cornea. 2016;35:1185–91. 3. Jones L, et al. TFOS DEWS II Management and Therapy Report. Ocul Surf. 2017;15:575– 628. 4. Deinema LA, et al. A randomized, dou- ble-masked, placebo-controlled clinical trial of two forms of omega-3 supplements for treating dry eye disease. Ophthalmology. 2017;124:43–52. Editors' note: Dr. Downie has finan- cial interests with Alcon (Fort Worth, Texas), Allergan, and CooperVision (Victor, New York). Dr. Holland has financial interests with Physician Recommended Nutriceuticals (Blue Bell, Pennsylvania). Dr. Sheppard has finan- cial interests with Johnson & Johnson Vision and ScienceBased Health. Contact information Downie: ldownie@unimelb.edu.au Holland: eholland@holprovision.com Sheppard: jsheppard@vec2020.com

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