BLOG: Dissecting DREAM Part 4: Why all the fuss?

ByDarrell E. White, MD

Boy, has there been a lot of noise about the DREAM study, or what?! I mean, come ON! We’re talking about fish oil here. Not some life-saving treatment that took years to develop and costs $80,000 per month. Nope. Fish oil. And not any fancy fish oil like the stuff they’re peddling over in the REDUCE-IT or VITAL studies. Uh uh. This is stuff you can get from Amazon for goodness sakes. Why all the fuss?

I think I figured it out.

While sitting on stage at the inaugural Cornea 360 meeting in Arizona, I had an epiphany as Dr. Penny Asbell opened the Great Omega Debate against Dr. Alice Epitropoulos. In her introduction, Dr. Asbell expressed surprise that there had been such strong reactions to the DREAM study and the authors’ interpretation of the results. Why, she asked, was everyone so upset by the findings of a study designed in 2013 that found adding re-esterified fish oil to the treatment regimen of moderate to severely symptomatic DED patients did not improve symptoms?

Have you ever had one of those “time stands still” moments? It was all I could do to keep myself from going all Lucy on the stage and shouting, “THAT’S IT!” Seriously, only the thought of making Marguerite McDonald, who was sitting next to me, tumble off the stage like Schroeder in “A Charlie Brown Christmas” kept me in my seat.

Nobody uses fish oil as a late-stage treatment for moderate to severe dry eye symptoms.

For all of the times I read that darned study I admit that I just stone cold missed this. Perhaps the use of re-esterified fish oil as a treatment for DED was much less well known in 2013 when DREAM was conceptualized. When it was published in 2018 fish oil was definitely a first line, foundational aspect of a comprehensive DED treatment program. I’m not sure if the DREAM protocol was ever “real world” as I understand it now, but for sure it doesn’t represent the real world of DED care now. The authors were extrapolating from a non-existent clinical world, not the “real world” they’d hoped to emulate.

Re-esterified fish oil (or the seed oil found in ScienceBased Health’s HydroEye) is a first-line treatment for symptomatic DED. As I’ve said multiple times, DREAM shows us that adding fish oil as a part of intensifying care in those patients who remain symptomatic despite other accepted treatments results in a decrease in patient symptoms. A multimodal treatment regimen that includes fish oil improves the symptoms in patients who have moderate to severe symptoms. It turns out that DREAM does not represent the real world of present day DED care at all. Omega-3 fatty acid supplementation with fish oil is an early treatment that has been shown to be effective in multiple studies that evaluate it as such.

And that, my friends, is what all the fuss is about.