Omega 3 for Dry Eyes, Blepharitis and MGD with Dr. Alice Epitropoulos
Omega-3 is an essential fatty acid that has been a topic of conversation in the dry eye space for the last few years. Many eye care practitioners recognize the importance of taking omega-3s, but there has recently been a study (the DREAM study) stating that there was no benefit to taking it. However, most of the peer reviewed research out there does indicate a benefit to taking omega-3s, not only for dry eye disease but also for cardiovascular health and improvement of cholesterol, triglycerides, joints and other muscular disorders. Recently, the American Heart Association came out with a report showing that the risk of cardiovascular events was reduced by about 25% when taking omega-3s.
The Importance of Omega-3 for Dry Eyes
Patient Selection for Omega-3 Supplements
Dry eye disease is a very common reason for patients to enter their eye doctor’s office today, and 85+% of all dry eye disease patients have a component of meibomian gland dysfunction (MGD), which results in dysfunctional lipid production and evaporative dry eye disease. MGD may also be a sign of hypercholesterolemia, and omega-3 supplementation has been recommended for nearly all dry eye patients according to many dry eye algorithms. Oral supplementation of omega-3s changes the composition of the oil component of the meibomian gland secretions and the tears. This means that, instead of hardened oil, you’re going to get an increase in the amount of unsaturated fatty acids which are in a liquid state at body temperature. This prevents blockage and stagnation of the meibum in the glands. Omega-3s may reduce tear evaporation in this way, since a healthy oily layer of the tear film prevents evaporation.
There are not many contraindications to taking an omega-3 supplement, however they do have the ability to thin the blood (especially if the supplement contains vitamin E). Some surgeons will have their patients stop supplements such as this before surgery. If a patient is predisposed to gout or has gout, a liquid form of omega-3 may be recommended because the outer coating of omega-3 supplements can sometimes be problematic for these people. However, the most common reason people cannot take omega-3s is due to issues with the GI tract.
What Makes a Great Omega-3 Supplement?
It’s important to take a medical grade omega-3 supplement, which are re-esterified triglyceride omega-3 supplements. This means that an extra process has been taken to remove the alcohol from the substance, making it more tolerable and more bioavailable. As a note, the majority of the omega-3 supplements on the market are ethyl ester vs. triglyceride based, meaning they may not be absorbed as well as triglyceride based supplements (and they have a greater likelihood of disrupting the GI tract).
An omega-3 index level test is available as a quick finger prick test which can check a patient’s omega-3 level in their blood. An omega-3 index level of 8 or higher has been shown to give benefits, and those with lower index levels will likely not be experiencing as great of a benefit.
Study: Oral Re-esterified Omega-3 Supplementation and Dry Eyes
Dr. Epitropoulos recently published a study assessing the effect of oral re-esterified omega-3 supplementation on tear osmolarity, MMP-9, tear break-up time, OSDI score, corneal staining, Shirmer score, Omega-3 index, and other indices in subjects with dry eye and confirmed MGD. This was a multi-center, prospective, interventional, placebo-controlled, double-masked study.
Subjects were randomized to either 4 softgels containing 1680 mg of eicosapentaenoic acid/560 mg of docosahexaenoic acid (the omega-3) or a control of 3136 mg of linoleic acid (omega-6), daily for 12 weeks. 3:1 ratio of EPA:DHA has been shown to help with dry eye disease and was used in this study. After completion of the study, a statistically significant difference was shown in tear osmolarity, omega-3 index levels, tear break-up time, MMP-9, and OSDI symptom scores. This is great because omega-3s were shown to improve nearly all areas studied.
What about the DREAM Study?
Despite the negative results of the DREAM study, patients in both the omega-3 (3 grams) and olive oil placebo (5 grams) group had improvement in OSDI symptom scores. 61% of the omega-3 group noticed improvement of OSDI by greater than 10 points, compared with an improvement of 54% in the placebo group. However, this was not considered statistically significant. Basically, both the omega-3 and olive oil worked well in these patients.
There has been a lot of debate around the design and interpretation of this study, and many other variables in this study were uncontrolled. Study subjects were able to add, delete, or change their dry eye therapy during the study. Olive oil is also known to be a natural anti-inflammatory, so this may not have been the best placebo oil to choose.
A recent meta-analysis was done looking at 17 qualifying, randomized trials including the DREAM study and Dr. Epitropoulos’s study and the mean indices looked at were greatly improved in the omega-3 group vs. placebo groups.
22:50 - Vanessa Hofheins - What are they doing to find a cure for this disease?
24:14 - Ali Ali - Best omega 3’s they recommend?
25:23 - Sylvie Morin - Does the source of Omega 3 make a difference? (ie: krill? salmon? mackerel? herring? anchovies? cod? plants?)
26:21 - Nadine Nehme - What’s your experience treating people with accutane? Do you typically see improvement?
27:25 - Tina Capello-Silvestri - If your glands are atrophied, do omegas help?
28:35 - Karen L. Torgerson - How do you know if you're absorbing Omega-3, and how can I go about trying to absorb it if I'm not?
29:35 - Sarah Wes - Is fish oil, flaxseed or sea buckthorn best, or a combination of all 3?
If you’d like to contact Dr. Epitropoulos, visit her website or give their Columbus office a call at 614-221-7464.
About Dr. Epitropoulos
Dr. Alice Epitropoulos is a Columbus, Ohio, native passionate about improving the vision of her Columbus neighbors. Her highly personal, hands-on approach to preoperative evaluation and measurement enables her to provide an unmatched level of care, and unusually low re-treatment rate. She is proud to be one of the cofounders of The Eye Center of Columbus, an innovative affiliation of more than 70 ophthalmologists. The Eye Center is one of the largest dedicated Eye Care Centers in the United States and is located in the Arena District of downtown Columbus.
Alice T. Epitropoulos is a board certified ophthalmologist who specializes in refractive and cataract surgery.
She has been performing laser vision correction since 1995 with excellent results. She is also offering femtosecond laser cataract surgery with premium lens surgery for her cataract patients. In addition to operating a private practice, Dr. Epitropoulos serves as a clinical assistant professor at the Ohio State University. Currently Dr. Epitropoulos has a patent of a medical device known as the EpiGlare Tester to measure visual disability from oncoming headlights in cataract patients. There was a multicenter clinical trial to validate the device, and recently signed a license agreement to manufacture, market and distribute the device.
Dr. Epitropoulos received her bachelor and medical degrees with Honors from The Ohio State University. She completed her internship at Riverside Methodist Hospital and returned to The Ohio State University for her residency in ophthalmology where she served as Chief Resident. She is a Diplomat of the American Board of Ophthalmology. Several of Dr Epitropoulos' articles have been published in ophthalmic journals, and she has presented numerous papers at prominent national eye meetings.
You can read more about her study on omega-3s for dry eye diseasehere.