ODs recommend omega-3, omega-6 supplements for managing dry eye

A: Omega-6, DHA, EPA

Jeffrey Anshel

Jeffrey Anshel, OD: I do not treat dry eyes with omega-3 supplementation. I use a combination of omega-6 and docosahexaenoic acid (DHA)/eicosapentaenoic acid (EPA) fish oils. While omega-6 fatty acids have been given a bad rap in the press, it is necessary for proper mucous tissue maintenance.

It is true that the typical American diet is overloaded with omega-6 linoleic acid (LA) from vegetable oils, which are added to nearly all processed foods. Many pantries are far too full of overly processed crackers, chips, cookies and cakes and the omega-6 oils that oxidize too quickly and become pro-inflammatories.

However, good health also depends on omega-6 gamma-linolenic acid (GLA), which is a metabolite of omega-6 linoleic acid and is found in sources such as black currant seed oil, borage oil and evening primrose oil. This compound is a necessary component in the metabolism of omega-6 fatty acid to the series one anti-inflammatory prostaglandins (PGE1s), which are associated with healthy mucosal tissue and healthy tear film.

Omega-6 fatty acids that are successfully metabolized or those that have the metabolic advantage of containing GLA reduce inflammation after further metabolizing to dihomo-gamma-linolenic acid (DGLA), which also blocks, when appropriate, the pro-inflammatory arachidonic acid conversion.

I most often recommend BioTears (Biosyntrx Inc., Lexington, S.C.) for dry eye patients. Just two gel caps twice daily provides the balance of omega-3 EPA, DHA and omega-6 GLA, along with the specific nutrient co-factors vital for optimal metabolism to the type of anti-inflammatory that affects the ocular surface tissue.

BioTears includes a natural COX-2 inhibitor to further control the inflammation associated with dry eyes. BioTears contain lactoferrin, an iron binding protein that inhibits viral and bacterial growth on the ocular surface.

Omega-3 fatty acids alone do not begin to appropriately address the entire scope of issues associated with dry eye syndrome. BioTears usually takes up to 1 month to be effective, but I have had several patients notice a difference in 2 weeks or less.

For more information:

• Jeffrey Anshel, OD, has written numerous articles regarding nutritional influences on vision, stress factors that affect visual performance and computer vision concerns. Dr. Anshel is the principal of Corporate Vision Consulting, where he addresses the issues surrounding visual demands while working with computers. He has published several books, including “Smart Medicine For Your Eyes” and his latest, “Visual Ergonomics Handbook.” He also offers on-site consultations and seminars to corporations related to visual stress in the workplace. Dr. Anshel maintains a private practice in Carlsbad, Calif. He can be reached at Corporate Vision Consulting, 842 Arden Dr., Encinitas, CA 92024; (760) 944-1200; e-mail: eyedoc@adnc.com. Dr. Anshel is a member of the advisory board for Biosyntrx Inc. Dr. Anshel has no direct financial interest in the products he mentions in this article, nor is he a paid consultant for any companies he mentions.

A: One thousand milligrams twice a day

James E. Stafford

James E. Stafford, OD: Many dry eyes are a result of long-term inflammatory processes, which explains the popularity of using omega-3’s anti-inflammatory action. Our goals are to change the character of the tear film and make our patients comfortable.

I discuss natural food sources and the omega-3 supplements found in our local stores. Fortunately, sources that are known to have inaccurate labeling are not found in our local outlets.

Most patients are started at dosages of 1,000 mg taken twice each day toward the end of or after a meal. If I know that the patient will be shopping where the capsules come in 500 mg, 700 mg or 900 mg, the dosages will be adjusted to keep the dose between 2 grams and 3 grams per day.

I will prescribe 3 grams or more in severely dry eyes if the patient’s current medications do not include anticoagulants or if the patient is not experiencing a bleeding or bruising disorder.

Regarding the choice of fish or flaxseed oils, patients with fat metabolism problems are advised to use fish oil, because EPA and DHA already exist in the fish oil. Flaxseed oil is recommended for all others, and its alpha-linolenic acid (ALA) is used to synthesize DHA and EPA.

If another member of the family is currently taking an omega-3 supplement for cardiac, dermatologic or rheumatologic problems, I advise them to start sharing the family supply rather than add another bottle to the vitamin cabinet.

All of the supplements should be refrigerated. The possible laxative effect, the aftertaste and fishy body odor of fish oil, and the possible allergic reaction to flaxseed oil are discussed with patients. The patients leave with a card explaining why they are using omega-3 supplements and what their dosage should be.

For more information:

• James E. Stafford, OD, can be reached at 28 Clara Barton St., Dansville, NY 14437; (585) 335-8812; e-mail: eye2eyedoc@yahoo.com. Dr. Stafford has no direct financial interest in the products he mentions in this article, nor is he a paid consultant for any companies he mentions.

A: A high-quality omega-3/fish oil with EPA, DHA

J. Mathis Dixon

J. Mathis Dixon, OD: I ask my patients to reduce their consumption of synthetic, hydrogenated oils to help restore a proper balance. They should also increase their intake of cold-water fish, such as wild salmon. Then I recommend daily supplementation with a high-quality omega-3/fish oil product that contains EPA/DHA in a 2:1 ratio. I consider a good daily dose to be 400 mg of EPA and 200 mg of DHA, although higher concentrations may be needed for a more therapeutic effect.

Inexpensive brands should be avoided, because quality is imperative for this type of product. Preferred products are pharmaceutical grade and do not contain lipid peroxides, heavy metals such as mercury or other impurities. The product must contain vitamin E as a preservative.

The best products have been independently tested for purity and concentration. Two products I feel meet these criteria are TheraTears Nutrition (Advanced Vision Research, Woburn, Mass.), three capsules per day and Omega-3 (Nordic Naturals, Watsonville, Calif.).

Patients are educated that quick results are not expected. Supplementation is a long-term process. It could take months to correct a severe EFA deficiency; however, it is worth the effort, because omega-3 supplementation has been shown to help many conditions, including heart disease.

For more information:

• J. Mathis Dixon, OD, can be reached at Advanced Eyecare, 1105 Morningside Dr., Perry, GA 31069; (478) 987-2020; fax: (478) 988-4628; e-mail: jmathisdixon@windstream.net. Dr. Dixon has no direct financial interest in the products he mentions, nor is he a paid consultant for any companies he mentions.

A: One gram twice a day

David W. Nelson

David W. Nelson, OD, MBA: It is difficult to overstate the importance of fish oils for the human body. They are essential for the proper functioning of many organ systems due to the primary components of anti-inflammatory EPA and neuro-protective DHA present in fish oils.

In a cross-sectional study of 32,470 women, Miljanovi and colleagues concluded that women who had a higher dietary intake of fish per week expressed a significant reduction in dry eye syndrome. Even though this was one of the first large-scale studies to show significant benefit from consuming fish, most consumers find it difficult to ingest sufficient quantities of fish for a therapeutic benefit without risk of polychlorinated biphenyls (PCBs), mercury and dioxin.

Farm-raised fish present an even greater problem, as the beneficial EPA and DHA are significantly reduced by these production methods. Flaxseed containing ALA is inefficiently converted to EPA by the body and is not primarily recommended by our office.

Because of dosing and contamination problems of consuming large quantities of fish, our practice has established a protocol of placing dry eye syndrome patients on pharmaceutical grade fish oil gels such as ProOmega (Nordic Naturals, Watsonville, Calif.). Fish oil quality standards do not exist in the United States. Nordic Naturals adheres to Norwegian Medicinal Standard and the European Pharmacopoeia Standard for all products. These standards guarantee quality by setting maximum allowances on peroxides, heavy metals, dioxins, furans and PCBs.

The dosing depends upon the patient’s symptoms and health history. For most general patients exhibiting dry eye symptoms, including those wearing contact lenses complaining of dry eye, we prescribe 1 g twice per day of the omega-3s with EPA quantities of 325 mg/gel and DHA of 225 mg/gel. We have the patient take the gels with food. Some prefer a liquid version; however, those products require refrigeration.

For postmenopausal women or for those with systemic inflammatory diseases that result in dry eye, we will recommend a 4 g/day dose, 2 g twice per day. We tell the patient of the early potential of mild gastric disturbances and that the use of blood thinners, such as Coumadin (warfarin, Bristol-Myers Squibb), is a contraindication for taking the products.

For more information:

• David W. Nelson, OD, MBA, can be reached at 7428 Mineral Point Rd., Madison, WI 53717-1710; (608) 833-4242; fax: (608) 833-4248; e-mail: AMOPTBDDWN@aol.com. Dr. Nelson has no direct financial interest in the products he mentions, nor is he a paid consultant for any companies he mentions.

Reference:

• Miljanovic B, Trivedi KA, Dana MR, et al. Relation between dietary n3 and n6 fatty acids and clinically diagnosed dry eye. Am J Clin Nutr. 2005;82:887-893.

A: An increase in fresh, ripe, raw fruits, vegetable salads

Benjamin Clarence Lane

Benjamin Clarence Lane, OD, FAAO, FACN, FCOVD: While all vitamins are equally important for a healthy, well-functioning human and an excellent tear film, the tear film in dry eye syndrome requires more of some specific nutrients than is being supplied by diet alone.

The research community consensus on the importance of the omega-3 fatty acids is valid. It is far from an adequate explanation, or there would be many miracle cures. There are at least several dry eye syndromes with different etiologies. Omega-3 therapies produce better results when we mitigate other risk factors.

Overweight people are less likely to have dry eyes and dry skin; total body fat less than 10% by weight increases the risk of dry eye.

I reported research as early as 1984, both to the Federation of American Societies in Experimental Biology and to the American Academy of Optometry, noting that patients with defective tear films were more likely to be deficient in potassium. The best food sources of potassium are fresh fruit and fruit-like vegetables, including tomatoes.

In 1986 I reported to the American Public Health Association annual meeting the effects on the tear film of excessive protein, dietary fats, alcohol, medications and depressed potassium. Dean E. Hart, OD, co-authored this report.

In 1987, Dr. Hart and I co-authored our study, “Spoilage of hydrogel contact lenses by lipid deposits: tear-film potassium depression, fat, protein and alcohol consumption,” featured on the cover of Ophthalmology. As part of this study, we showed the importance of several ratios positively associated with tear-film breakup time when elevated:

• sucrose intake/food-folic acid intake as from raw salads
• sucrose intake/food potassium intake as from fresh fruit
• sucrose intake/vitamin C intake as from raw fruit & salads

The most significant vitamin deficiencies found in dry eye victims compared to normals are two B-complex vitamins, specifically folic acid and pyridoxine (vitamin B6) and vitamin C. It is interesting that in 1978, Ned Paige, OD, reported on the effectiveness of vitamin B6 supplementation for dry eye sufferers.

The primary value of omega-3 supplementation is delivered when the therapy is normalizing the putative desirable balances as can be revealed by a blood test variously called a plasma phospholipid essential fatty-acid profile (PPFAP). Excessive omega-3 intake can increase the risk for hemorrhaging. Too little omega-3 compared to omega-6 concentration in the blood increases the risk for clotting.

In clinical practice, we request the PPFAP, the erythrocyte glutamic-oxaloacetic transaminase test as a functional test for vitamin B6 and a diet and supplement history rather than a 24-hour urine FIGLU test for folate or a white-blood cell test for vitamin C (except for research interests). With the aid of these test results, we design a supplementation strategy and request retesting.

Fish consumption and fish oil intake are more universally effective than flaxseed oil supplementation alone, except for vegetarians. Intake of the more popular larger marine fish must be limited because of the high natural mercury in larger, older fish. Too frequent intake of tuna or farm-raised Atlantic salmon, if fattened on fishmeal, increases the risk for methylmercury-induced cataracts. Sardines, mackerel and herring do not have a mercury problem but need to be supplemented with B6, folate and B12 and lesser amounts of other B complex vitamins if they are obtained as canned fish. We recommend a generic formula known as Maxi B-caps (Country Life, Happauge, N.Y.), which contains 64 mg of B6; 800 mcg of folate; 500 mcg of B12; 25 mg of B1, B2; 50 mg of B3; and 200 mg of pantothenate. This should be taken at the time when ingesting the over-processed canned proteins.

The most effective therapeutic measures for these syndromes are an increase in the intake of fresh, ripe, raw fruits and vegetable salads, with a decrease in the intake of refined or highly processed foods rich in calories, but deficient in vitamins and essential minerals. An increased intake of small fish such as sardines, mackerel, herring, Alaskan or Canadian sockeye or chum salmon, should also be advised.

For more information:

• Benjamin Clarence Lane, OD, FAAO, FACN, FCOVD, can be reached in New Jersey at (973) 335-0111; fax: (973) 335-2882; or in New York at (212) 759-5270. Dr. Lane has no direct financial interest in the products he mentions, nor is he a paid consultant for any companies he mentions.