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In which patients or for what conditions would you consider recommending re-esterified omega-3s as first-line therapy for treating ocular surface disease?
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Omega-3s as an adjunct
I am a big believer that proper functioning of the lids and meibomian glands is critical for managing ocular surface disease (OSD). When examining an OSD patient, I pay particular attention to the eyelid margin and look at the expressibility and quality of the meibum and the overall tear quality. I find that MGD is present in the majority of dry eye patients; however, it is often overlooked and underemphasized in most treatment protocols. To that end, for all of my OSD patients I have them start warm compresses with lid washes along with re-esterified omega-3s — this is in addition to preservative-free artificial tears and/or lifitegrast or cyclosporine (depending on severity and testing results). It is very common for patients to ignore the recommendation and try an omega formulation that they get from a big box store. They generally opt for the non-esterified version because of cost. However, when looking at the amount of actual bioavailable omega, the re-esterified formulations are more cost-effective. In many of these patients when they do switch to the re-esterified omega-3s, we note an improvement in their symptomatology and quality of their tear film. I generally recommend either the PRN formulation or Nordic Naturals, which are both re-esterified.
Sumit Garg, MD, is vice chair of clinical ophthalmology, medical director and director of technology at the Gavin Herbert Eye Institute, University of California, Irvine. Disclosure: Garg reports he is a consultant and speaker for Shire and Allergan.
Drops first
I believe that with the exception of patients who have a contraindication to omega-3 supplements — allergy, for example — omega-3s can be added as a first-line therapy. They are particularly beneficial in patients who have meibomian gland disease, which makes up the vast majority of our dry eye patients, but they can also benefit any dry eye patient.
In general, as a first line, I start with an artificial tear. I like to add an anti-inflammatory, such as Restasis (cyclosporine ophthalmic emulsion 0.05%, Allergan) or Xiidra (lifitegrast ophthalmic solution 5%, Shire) very early in the course as well. I occasionally add a steroid early, depending on how inflamed the eyes appear. None of these treatments affect my ability to add the omega-3s.
Kenneth A. Beckman, MD, is director of corneal surgery at Comprehensive Eyecare of Central Ohio in Westerville and is an OSN Cornea/External Disease Board Member. Disclosure: Beckman reports he is a consultant and speaker for Allergan and Shire.