This article is more than 5 years old. Information may no longer be current.
Personal knowledge, experience often guide recommendations regarding supplements
Click Here to Manage Email Alerts
Nutritional supplements and their role in preventing or mitigating systemic or ocular disease remain for me an area of much confusion.
This is a topic where I have had more than a passing interest for decades. I was a consultant for Storz Ophthalmic when Ocuvite (Bausch + Lomb) was conceived and participated in early clinical trials that seemed supportive of a beneficial effect in retarding the progress of dry age-related macular degeneration. The AREDS and AREDS2 clinical trials have confirmed this finding for a select class of patients with moderate dry AMD. I also worked with Peter La Haye when ICaps (Alcon) were first developed and looked at cataract progression using a special Swiss “lens densitometer.” Early findings suggested that antioxidant vitamin supplementation did benefit dry AMD and delay nuclear cataract progression, as measured by this instrument. The studies on Centrum multivitamin supplementation also suggest that progression of nuclear cataract is retarded with vitamin usage.
Of course, we know that severe vitamin deficiency, such as night blindness with vitamin A totally absent from the diet, scurvy from lack of vitamin C or rickets from severe vitamin D deficiency, can cause severe disease, but the benefit of adding any vitamin or omega-3 supplementation to a typical advanced country “normal diet” remains unconfirmed. On the other hand, advancing knowledge suggests that the diet of most Americans does not meet the minimum recommended standards for many nutrients, especially consumption of green leafy vegetables, fruit and fish. In addition, when blood tested, most Americans’ lipid profiles and omega-6-to-omega-3 ratios are far from ideal in the typical 50-plus-year-old patient. So, what are we to do in the absence of solid level 1 evidence?
As always, we must use our best judgment and practice the art of medicine. It is to be expected that every physician and ophthalmologist will interpret the present evidence in a different manner, and when the science is soft, this is as it should be.
So, to the bottom line, what do I personally do and recommend to my patients? I personally take a multivitamin every day and also 2 g a day of omega-3s extracted from pelagic fish because I have mild meibomian gland dysfunction (MGD) and evaporative dry eye (PRN brand). Every year I eat more fish and white meat, I have added more fruit to my diet, especially at breakfast, and I eat a salad with mixed greens for lunch every day. I exercise through tennis, golf or walking every day, enjoy a glass — but never more than two — of red wine 3 or 4 days a week, and take a baby aspirin each day. I am happily married, have an enriching career, have two children and five grandchildren living within 20 miles of my home, and have a strong network of friends. I am, according to my wife, a delusional optimist and definitely not depressed. Most important, I control my blood pressure in the 120/75 range and do not smoke. I do not take antioxidant supplements because my maculas are normal, and neither of my parents, who died at age 80 years and 94 years, had any evidence of even the mildest dry AMD at their death. But the first fundus examination I have that shows any retinal pigment epithelium (RPE) dispersion or drusen in my macula, I am starting on the AREDS2 formulation of vitamin supplementation while continuing my multivitamin and omega-3s. If my parents had both demonstrated severe AMD before their death, I would be taking the AREDS2 formulation today despite a normal macula.
I am impressed that omega-3 supplementation improved my mild MGD and evaporative dry eye symptoms of burning, so I have been recommending it to patients. I believe it is important to use enough, 2 g a day, and the right form of omega-3 extracted from pelagic fish.
I recommend the PRN or Nordic Natural brand. I am impressed it is helping many of my patients as well, so my level 1 therapy for dry eye, especially in the face of MGD (80%-plus), now includes lubricants, lid hygiene and omega-3s. My former fellow, S. Gregory Smith, MD, has been able to measure increased omega-3s in the meibum after 3 months of therapy with 2 g a day of the PRN brand of supplement.
In regards to AMD, I offer the AREDS2 formula to all my patients who demonstrate any RPE dispersion and/or drusen, rather than waiting for the patient to develop more significant disease as studied in AREDS and AREDS2. Now that the beta-carotene has been removed, I believe that this is a safe formulation for those who can swallow the tablets.
When a family member with parents or siblings with significant vision loss from AMD asks me if there is anything they can do to lower their risk, I suggest green leafy vegetables, exercise, management of obesity and no smoking. I also discuss the AREDS and AREDS2 trials, being clear that there is no data that they work to prevent AMD, but one on one, when asked, I advise them that if I had a very strong family history of AMD, I would take supplements.
So, it comes down to the age-old axiom: What do you do for yourself and what would you recommend to your family and closest friends? For every physician and ophthalmologist, the answer will be different, but I sleep well at night when I can look my patients in the eye and say, based on my current knowledge and experience, this is what I do and recommend to my family and close friends.