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Omega-3 reduced dry eye (computer related) by 3X - RCT June 2015

Journal of British Contact Lens Association DOI: http://dx.doi.org/10.1016/j.clae.2015.01.007 |
Rahul Bhargava, Prachi Kumar, Hemant Phogat, Avinash Kaur, Manjushri Kumar
Highlights
•Schirmer's test was abnormal in 33% symptomatic computer users at baseline.
•Tear film break up time was abnormal in 55% symptomatic computer users at baseline.
•Dry eye symptoms scores improve after dietary intervention with omega 3 fatty acids for 3 months.
•Omega 3 fatty acids decrease tear evaporation rates.
•Conjunctival goblet cell density increases after omega 3 fatty acid treatment.

Purpose
To assess the efficacy of dietary consumption of omega-3 fatty acids (O3FAs) on dry eye symptoms, Schirmer test, tear film break up time (TBUT) and conjunctival impression cytology (CIC) in patients with computer vision syndrome.

Setting and design
Interventional, randomized, double blind, multi-centric study.

Methods
Four hundred and seventy eight symptomatic patients using computers for more than 3 h per day for minimum 1 year were randomized into two groups: 220 patients received two capsules of omega-3 fatty acids each containing 180 mg eicosapentaenoic acid (EPA) and 120 mg docosahexaenoic acid (DHA) daily (O3FA group) and 236 patients received two capsules of a placebo containing olive oil daily for 3 months (placebo group). The primary outcome measure was improvement in dry eye symptoms and secondary outcome measures were improvement in Nelson grade and an increase in Schirmer and TBUT scores at 3 months.

Results
In the placebo group, before dietary intervention, the mean symptom score, Schirmer, TBUT and CIC scores were 7.5 ± 2, 19.9 ± 4.7 mm, 11.5 ± 2 s and 1 ± 0.9 respectively, and 3 months later were 6.8 ± 2.2, 20.5 ± 4.7 mm, 12 ± 2.2 s and 0.9 ± 0.9 respectively. In the O3FA group, these values were 8.0 ± 2.6, 20.1 ± 4.2 mm, 11.7 ± 1.6 s and 1.2 ± 0.8 before dietary intervention and 3.9 ± 2.2, 21.4 ± 4 mm, 15 ± 1.7 s, 0.5 ± 0.6 after 3 months of intervention, respectively.

Conclusion
This study demonstrates the beneficial effect of orally administered O3FAs in alleviating dry eye symptoms, decreasing tear evaporation rate and improving Nelson grade in patients suffering from computer vision syndrome related dry eye.

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Study is reviewed at http://www.nutrasource.ca/ifos/post/research-on-our-radar--summer-edition

  • 'For the study, researchers recruited 478 people with dry eyes who were using computers at least three hours daily for at least one year, and randomly divided them into two groups.
  • The first group received daily omega-3 supplements (360 mg per day EPA and 240 mg per day DHA) while the second received a placebo for three months.
  • The group taking omega-3s saw significant reductions in dry eye symptoms. In fact, when compared to the placebo group, 70% of patients were totally symptom-free compared to only 14.9% in the placebo group

A randomized controlled trial of omega-3 fatty acids in dry eye syndrome ~3X (2013)

Int J Ophthalmol. 2013; 6(6): 811–816. Published online 2013 Dec 18. doi: 10.3980/j.issn.2222-3959.2013.06.13
Rahul Bhargava,1 Prachi Kumar,2 Manjushrii Kumar,3 Namrata Mehra,1 and Anurag Mishra1

AIM: To evaluate the role of dietary supplementation of omega-3 fatty acids in dry eye syndrome.

METHODS: A prospective, interventional, placebo controlled, double blind randomized trial was done at two referral eye centers. Two hundred and sixty-four eyes of patients with dry eye were randomized to receive one capsule (500mg) two times a day containing 325mg EPA and 175mg DHA for 3 months (omega-3 group). The omega-3 group was compared to a group of patients (n=254) who received a placebo (placebo group). There were 4 patient visits (at baseline, 1 month, 2 months and 3 months). On each visit, recording of corrected distance visual acuity (CDVA), slit lamp examination and questionnaire based symptom evaluation and scoring was done. A symptomatic score of 0-6 was mild, 6.1-12 moderate and 12.1-18 severe dry eye. Response to intervention was monitored by routine tear function tests like Schirmer I test, tear film break-up time (TBUT), Rose Bengal staining and most notably, conjunctival impression cytology.

RESULTS:

  • Sixty-five percent of patients in the omega-3 group and
  • 33% of patients in placebo group

had significant improvement in symptoms at 3 months (P=0.005). There was a significant change in both Schirmer's test value and TBUT values in the omega-3 group (P<0.001), both comparisons. However, there was a larger drift in TBUT values in omega-3 than the placebo group, in comparison to Schirmer's test values.
The mean TBUT score was

  • 2.54±2.34 in the omega-3 group and
  • 0.13±0.16 in placebo group, respectively.

The mean reduction in symptom score in omega-3 group was

  • 2.02±0.96 as compared to
  • 0.48±0.22 in placebo group (P<0.001).

Despite a slight increase mean score, the Schirmer scores did not correlate well with symptomatic improvement.

CONCLUSION: Omega-3 fatty acids have a definite role for dry eye syndrome. The benefit seems to be more marked in conditions such as blepharitis and meibomian gland disease. The role of omega fatty acids in tear production and secretion needs further evaluation.

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Omega-3 and dry eye - Oct 2012

Omega-3 and dry eye
by Vanessa Caceres EyeWorld Contributing Writer
http://www.eyeworld.org/article-omega-3-and-dry-eye

Looking at science and clinical experience
Omega-3 fatty acids seem like a cure-all for just about anything that ails patients nowadays. They're hailed for promoting better heart health, reducing inflammation, providing more lustrous hair and skin, and even promoting better mood. The question is, how beneficial are omega-3s for dry eye patients? "We're in the infancy stages of understanding what this is and what it does for dry eye," said Robert Latkany, M.D., founder and director, Dry Eye Clinic, New York Eye and Ear Infirmary, New York.
Right now, ophthalmologists are using the fledgling research that is available along with their clinical experience to decide whether or not they will recommend omega-3 supplementation to dry eye patients.

The research
Some recent research has tried to pin down the specific effects of omega-3 supplementation on dry eye. In a pilot, double-masked study published in March 2011 in Cornea, investigators gave patients various doses of fish oil and flaxseed oil (TheraTears Nutrition, Advanced Vision Research, Woburn, Mass.) for 3 months. Investigators measured patients' subjective symptoms and tested for tear breakup time and corneal staining as well as performing other tests.

Of the 36 patients included, 70% of the patients receiving treatment became asymptomatic. In the placebo group, 37% of the symptomatic patients became asymptomatic. Schirmer's testing and fluorophotometry seemed to indicate that omega-3 use increased tear secretion, according to investigators. Although those results are promising, they only begin to reveal how omega-3 might help dry eye and which patients would benefit the most, Dr. Latkany said.

A study presented at the 2012 Association for Research in Vision and Ophthalmology (ARVO) meeting in Ft. Lauderdale, Fla., and sponsored by ScienceBased Health (Houston) focused on omega-3 and gamma-linolenic acid (GLA) therapy (HydroEye) taken for 6 months by 38 postmenopausal women who had keratoconjunctivitis sicca. The double-blind, placebo-controlled, prospective, randomized, multi- center trial found that patient self-reported symptoms by OSDI (Ocular Surface Disease Index) as well as conjucnctival impression cytology CD11c and HLA-DR inflammation biomarkers statistically significantly improved after the study duration, said lead investigator John D. Sheppard, M.D., professor of ophthalmology, microbiology, and immunology, Eastern Virginia Medical School, Norfolk, Va. The study did not seem to detect differences in corneal staining or tear breakup time, but topographic corneal surface regularity stabilized significantly with the study supplementation compared to placebo. At the 2012 ASCRS•ASOA Symposium & Congress, Frank A. Bucci Jr., M.D., founder, Bucci Laser Vision, Wilkes-Barre, Pa., presented the results from a study sponsored by Physician Recommended Nutriceuticals (PRN, Plymouth Meeting, Pa.), which makes PRN Dry Eye Omega Benefits. The multicenter, blinded, randomized study randomized 60 patients to receive the PRN product, a Nature Made omega-3 product (Pharmavite, Northridge, Calif.), or TheraTears Nutrition. Investigators measured red blood cell membrane saturation of the omega-3 products at baseline, 1 and 3 months follow-up. Investigators found that red blood cell saturation was significantly greater for the PRN product compared with the other two products.

Knowing how well an omega-3 product can be absorbed in the body is crucial in ensuring it will provide key health benefits to the eyes and elsewhere, Dr. Bucci said.

Although there have been other studies related to dry eye and omega-3 supplementation, there has yet to be a large-scale clinical trial that pinpoints how omega-3 fatty acids work to treat dry eye and what kind of dosing is appropriate. Penny A. Asbell, M.D., professor of ophthalmology, director, Cornea and Refractive Services, Department of Ophthalmology, Mount Sinai School of Medicine, New York, hopes to find those answers via a clinical trial slated to get under way with the National Eye Institute. "With omega-3 and dry eye, we have small trials but little in the way of double-masked, randomized, controlled trials," she said. The trial she is working on will look beyond the claims of omega-3 benefits for general health to show how the supplementation can benefit dry eye. "It behooves us to find out how this works," she said. The trial should also reveal more information on the epidemiology of dry eye, Dr. Asbell added.

Clinical experience
Despite what research may find, what is key is how patients respond to omega-3 use. "It's all meaningless if patients don't feel better," Dr. Latkany said. Certain types of dry eye patients seem to benefit more than others from omega-3 supplementation. "I recommend fish oil mostly for evaporative dry eye," said Esen K. Akpek, M.D., associate professor of ophthalmology, and director, Ocular Surface Diseases and Dry Eye Clinic, Wilmer Eye Institute, Johns Hopkins University, Baltimore. "I have the clinical impression that it might work."
At Dr. Latkany's practice, which specializes in dry eye, he routinely recommends omega-3 use. Of those who take it, he estimates that 70% become asymptomatic. However, this occurs along with the use of other treatments, such as Restasis (cyclosporine ophthalmic emulsion, Allergan, Irvine, Calif.), punctal plugs, or environmental changes. "Very few patients notice a big difference from omega-3 use alone. It would be in the single digit percentage," he said.

Dr. Latkany recommends omega-3 use the most to Sjogren's syndrome patients—who typically might have dry eyes, hair, mouth, and skin. He often finds his patients have already heard about omega-3 benefits, perhaps not specifically for dry eye but for general health.
Because of the general health benefits, Dr. Sheppard recommends omega-3 fatty acids for virtually all patients. "The American diet is notoriously deficient in the high-value foods. Rather than becoming a dietitian, I just recommend it to everyone. It can't hurt, with the exceptions of seafood allergy and coagulation deficiency conditions," he said. Additionally, patients can use omega-3 both to help treat dry eye and help prevent other eye conditions such as age-related macular degeneration—a condition where there is even more solid research regarding omega-3 use and prevention of disease, he said. Dr. Sheppard typically recommends 1,000 mg of omega-3 twice daily in addition to GLA supplements, although he will encourage patients to take more if they are willing and able. That dosage amount provides both eicosapentaenoic acid and docosahexaenoic acid— better known as EPA and DHA, Dr. Sheppard said.
However, Dr. Sheppard also noted that patients with evaporative dry eye seem to yield the most consistent benefits. The study he presented at ARVO intentionally focused on postmenopausal females as they represent a fairly homogeneous subpopulation that could benefit significantly from supplementation, he said.

What product works best?
Practitioners seem to have personal preferences regarding specific omega-3 products. "No single study shows yet that one product works better than the other," Dr. Latkany said. "Any well-known company that purifies its product, you'll be fairly safe with it."
However, Dr. Sheppard steers patients toward pharmaceutical-grade, mercury-free supplementation. "With a cheaper version, there's more risk for contaminants. We're recommending this at a high dose, so it's essential to be safe," he said. Dr. Bucci prefers a higher quality omega-3 product that absorbs more quickly in the body, comes from fish sources versus flaxseed, and does not contain alcohol.
There has been recent talk in the popular press about krill oil as an omega-3 source that can be better absorbed by the body, Dr. Latkany said. He has seen some of his patients successfully use krill oil.
In the rare instances where a patient does not like fish oil, is allergic to it, or has another physician concerned about its use because the patient takes anticoagulant therapy, Dr. Sheppard recommends the use of flaxseed oil, which the patient can obtain as a gel cap or even sprinkle in powder form on food.

Editors' note: Dr. Akpek has no financial interests related to this article. Dr. Bucci has financial interests with PRN. Dr. Latkany has financial interests with Alcon. Dr. Sheppard has financial interests with Alcon (Fort Worth, Texas), Allergan, Bausch + Lomb (Rochester, N.Y.), Lux Biosciences (Jersey City, N.J.), Merck (Whitehouse Station, N.J.), ScienceBased Health, and Vistakon (Jacksonville, Fla.). Dr. Asbell has no financial interests related to this article.

Akpek: esakpek at jhmi.edu, Asbell: penny.asbell at mssm.edu, Bucci: buccivision at aol.com, Latkany: relief at dryeyedoctor.com, Sheppard: jsheppard at vec2020.com


Omega-3 for Dry Eye Relief Dec 2015

Snips

  • "While omega-3 deficiency isn’t considered a direct cause, a deficiency of omega 3 fatty acids raises the risks of experiencing dry eye syndrome. A 2005 study published in the American Society for Clinical Nutrition found that those with a high omega-3 intake had lower rates of dry eye syndrome. On the reverse, those with a low intake of omega-3 had higher rates of the syndrome. The reason for this is due to inflammation. Dry eyes are often accompanied by the red and puffy hallmark of inflammation, but inflammation is not only a symptom of dry eyes. A few recent studies have shown that inflammation is actually a cause as well."
  • "Omega-3 was seen to counteract this in a 2011 study, where tear production was increased. Seventy percent of the study participants were experiencing no symptoms by the end of the study period."
  • " In one study, almost every symptom of dry eyes -including burning, stinging, dryness, and the sensation of a foreign object in the eye – was reduced with omega-3 supplementation. Some symptoms were reduced by as much as fifty percent."

References

  • Brignole-Baudouin, F., Baudouin, C., Aragona, P., Rolando, M., Labetoulle, M., Pisella, P., . . . Creuzot-Garcher, C. (2011). A multicentre, double-masked, randomized, controlled trial assessing the effect of oral supplementation of omega-3 and omega-6 fatty acids on a conjunctival inflammatory marker in dry eye patients. Acta Ophthalmologica, 89(7), e591–e597
  • Caceres, V. (2009, June 1). Ocular Surface & Dry Eye: Linking inflammation and Dry Eye. Retrieved November 14, 2015, from http://www.eyeworld.org/article.php?sid=5009
  • Hasson, M. (2012, April 10). New insights advance diagnosis, treatment of inflammatory dry eye. Retrieved November 14, 2015, from http://www.healio.com/ophthalmology/refractive-surgery/news/print/ocular-surgery-news/{886dd792-d1cb-47b9-acc9-b90afb735fb2}/new-insights-advance-diagnosis-treatment-of-inflammatory-dry-eye
  • Kaercher, T. (2010). Dry eye syndrome and omega-3 fatty acids. Acta Ophthalmologica, 88(S246), 0-0.
  • Kangari, H., Eftekhari, M., Sardari, S., Hashemi, H., Salamzadeh, J., Ghassemi-Broumand, M., & Khabazkhoob, M. (2013). Short-term Consumption of Oral Omega-3 and Dry Eye Syndrome. Ophthalmology, 120(11), 2191-2196.
  • Macsai, M. (2008). The Role of Omega-3 Dietary Supplementation in Blepharitis and Meibomian Gland Dysfunction (An AOS Thesis). Transactions of the American Ophthalmological Society, 106, 336–356-336–356.
  • Miljanović, B., Trivedi, K., Dana, M., Gilbard, J., Buring, J., & Schaumberg, D. (2005). Relation between dietary n−3 and n−6 fatty acids and clinically diagnosed dry eye syndrome in women. The American Journal of Clinical Nutrition, 82(4), 887-893.
  • Wojtowicz, J., Butovich, I., Uchiyama, E., Aronowicz, J., Agee, S., & Mcculley, J. (2011). Pilot, Prospective, Randomized, Double-masked, Placebo-controlled Clinical Trial of an Omega-3 Supplement for Dry Eye. Cornea, 30(3), 308-314.

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