This article is more than 5 years old. Information may no longer be current.
Should premium surgeons consider DREAMing when optimizing the ocular surface?
Practitioners may want to continue their use of omega-3 therapy for dry eye until there is more evidence against its use.
Click Here to Manage Email Alerts
When performing refractive and/or refractive cataract surgery, premium surgeons must pay attention to the ocular surface in order to achieve premium outcomes for our patients. With the pathophysiology of the underlying ocular surface disease being so complex, advanced diagnostic and treatment algorithms, such as the TFOS DEWS II and CEDARS publications, should be followed in order to have a good game plan both preoperatively and postoperatively. Both of these algorithms and many other publications have suggested nutraceutical omega-3 and GLA supplementation to be an integral part of treatment and maintenance of a healthy ocular surface.
Recently, the multicenter Dry Eye Assessment and Management (DREAM) trial, published in April in the New England Journal of Medicine, came to the conclusion that omega supplementation is not really helpful to our ocular surface disease patients. In my opinion, there are many flaws to the DREAM study, and premium surgeons should not quite abandon omega therapy for their surgical patients so quickly.
DREAM trial was not well controlled
The participants in both arms (active supplement and placebo) were permitted to remain on their existing dry eye therapies, such as Restasis (cyclosporine ophthalmic emulsion 0.05%, Allergan), Xiidra (lifitegrast ophthalmic solution 5%, Shire), artificial tears, warm compresses, lid scrubs, immunosuppressants, corticosteroids and additional omega-3s (up to 1,200 mg), to simulate “real-world” conditions. The use of these additional therapies was not controlled, with 75% of participants in the active group and 78% in the placebo group reporting a change in their treatment regimen over the course of the study. More importantly, the placebo (olive oil 5 g daily compared with the 3 g of omega-3 — 2 g EPA and 1 g DHA daily) utilized was not neutral and actually contains a known ingredient with well-documented anti-inflammatory properties.
DREAM trial was not a true dry eye study
The inclusion criteria were broad, making it more a registry vs. a true dry eye study. It did not focus on true dry eye patients as defined by TFOS DEWS II; the DREAM trial did not include hyperosmolarity as a criterion, and only 6% of patients had tear osmolarity of 312 mOsm or higher in one eye and mild meibomian gland dysfunction in both eyes.
DREAM trial confirmed the benefits of omega-3 supplementation
The primary outcome of dry eye disease symptoms, measured by the Ocular Surface Disease Index (OSDI), improved in both treatment groups. The mean change from baseline for OSDI scores was 13.9 points in the omega-3 group, which was only slightly better but not statistically better than the mean change of 12.5 points in the placebo group. Overall, 61% of the omega-3 group and 54% of the control group achieved at least a 10-point reduction in the OSDI score — a reduction considered sufficient for noticeable symptom improvement by patients.
DREAM trial did not use the best omega supplementation
The DREAM trial did not use pure re-esterified TGC omega-3, with studies showing that this formulation is associated with a statistically significant improvement in tear osmolarity, OSDI symptom scores, tear breakup time, MMP-9 positivity and omega-3 index levels. Also, the DREAM study did not assess efficacy of the fatty acid gamma linolenic acid (GLA) in addressing ocular surface disease. GLA is a known anti-inflammatory that has shown to improve dry eye signs and/or symptoms. GLA (alone or along with modest amounts of EPA and DHA, known as HydroEye from ScienceBased Health) was evaluated in a study that showed suppression of known inflammatory markers HLA-DR and CD11c of conjunctival inflammation.
In summary, premium surgeons can stop DREAMing about omega supplementation and should continue to use these products until better randomized controlled studies show otherwise. My patients continue to have better ocular surface optimization and outcomes by continuing the use of re-esterified or GLA omega supplementation.
- References:
- Dry Eye Assessment and Management Study Research Group, et al. N Engl J Med. 2018;doi:10.1056/NEJMoa1709691.
- Epitropolous AT, et al. Cornea. 2016;doi:10.1097/ICO.0000000000000940.
- Gibbons A, et al. Clin Ophthalmol. 2016;doi:10.2147/OPTH.S114890.
- Gorzynik-Debicka M, et al. Int J Mol Sci. 2018;doi:10.3390/ijms19030686.
- Jones L, et al. Ocul Surf. 2017;doi:10.1016/j.jtos.2017.05.006.
- Milner MS, et al. Curr Opin Ophthalmol. 2017;doi:10.1097/01.icu.0000512373.81749.b7.
- Sheppard JD Jr, et al. Cornea. 2013;doi:10.1097/ICO.0b013e318299549c.
- For more information:
- Mitchell A. Jackson, MD, can be reached at Jacksoneye, 300 N. Milwaukee Ave., Suite L, Lake Villa, IL 60046; email: mjlaserdoc@msn.com.
Disclosure: Jackson reports he is a consultant for ScienceBased Health.