EyeWorld Asia-Pacific September 2018 Issue

51 EWAP CORNEA September 2018 LipiView (Johnson & Johnson Vision) image of a 31-year-old male with emergency presentation of pain and blurring of vi- sion in both eyes. Tear osmolarities were OD 339 and OS 347, In ammaDry test (Quidel) was positive OU. He was diagnosed with MGD with OSD and DED. LipiView image of MGD and DED patient who was started on preservative-free arti cial tears, re-esteri ed oral omega-3 liquid 1 teaspoon per day with food, a Bruder microwaveable heated mask, li tegrast OU BID, and a short course of lotep- rednol etabonate OU BID with no re lls. He was rescheduled to return for a LipiFlow treatment. Source: Cynthia Matossian, MD of previous dry eye research, in which all participants—both ac- tive and placebo groups—obtained improved outcomes. In addition, she noted that in DREAM placebo patients only received one teaspoon of refined olive oil per day, not extra virgin olive oil that is high in the polyphenols thought to provide much of the anti-inflammatory effect associated with olive oil. Fur- ther, red blood cell analysis showed no change in oleic acid, the major constituent of olive oil. “There is no evidence that the small amount of olive oil had any biological effect on subjects.” “Our study is similar; both groups got better but were not sig- nificantly different,” Dr. Asbell said. “It’s hard to recommend anything from this trial because they both got better with no significant differ- ence in many measures of signs and symptoms.” Clinical impacts Despite the significance of the results, it is not clear how much they will affect ophthalmologists’ clinical practice. Dr. Matossian said the “less- than-ideally controlled arms of the DREAM study” meant it would not impact her clinical approach, which includes a “starter triad” of preservative-free artificial tears, re-esterified oral omega-3s, 5 and a microwaveable heated mask. After that, Dr. Matossian moves to prescription medication eye drops and an in-office vectored thermal pulsation procedure. Similarly, Dr. Sheppard did not see the DREAM study impacting his dry eye approach, which includes the use of a black currant seed oil supplement, a source of gamma- linolenic acid (GLA). His research on GLA with other polyunsaturated fatty acid (PUFA) supplements found significantly improved dry eye signs and symptoms among post-menopausal female patients. 2 “Many of us in the field have a concern that the placebo effect will cause some practitioners to refrain from using all forms of PUFAs, including the GLA, that do benefit patients with dry eye,” Dr. Sheppard said. Even Dr. Galor doubted much clinical impact from the research because she views omega-3s as part of a holistic approach to dry eye. “I talk to patients about dietary factors and the importance of a healthy diet, not just with omega-3s but with vegetables, fish, and foods with high antioxidant qualities,” Dr. Galor said. “I mention that supplements have been shown to improve dry eye symptoms and signs in smaller studies, and I don’t think we should discard the results of those studies.” EWAP References 1. Asbell PA, et al. n-3 fatty acid supplemen- tation for the treatment of dry eye disease. N Engl J Med. 2018;378:1681–1690. 2. Sheppard JD Jr, et al. Long-term supple- mentation with n-6 and n-3 PUFAs improves moderate-to-severe keratoconjunctivitis sicca: A randomized double-blind clinical trial. Cornea. 2013;32:1297–304. 3. Kimura Y, et al. Restoration of tear secretion in a murine dry eye model by oral administration of palmitoleic acid. Nutrients. 2017;9. 4. Basu A, et al. Dietary factors that promote or retard inflammation. Arterioscler Thromb Vasc Biol. 2006;26:995–1001. 5. Epitropoulos AT, et al. Effect of oral re- esterified omega-3 nutritional supplementa- tion on dry eyes. Cornea. 2016;35:1185–91. Editors’ note: Dr. Matossian has finan- cial interests with Allergan (Dublin, Ireland), Bruder Healthcare Company (Alpharetta, Georgia), Johnson & Johnson Vision (Santa Ana, Califor- nia), Physician Recommended Nutri- ceuticals (Blue Bell, Pennsylvania), Shire (Lexington, Massachusetts), Sun Pharmaceuticals (Mumbai, India), and TearLab (San Diego). Dr. Galor has financial interests with Shire and Aller- gan. Dr. Sheppard has financial inter- ests with TearLab, Quidel (San Diego), Allergan, Bausch + Lomb (Bridgewater, New Jersey), Topcon (Oakland, New Jersey), and Novartis (Basel, Switzer- land). Dr. Asbell has financial interests with Santen Pharmaceutical (Osaka, Japan), Shire, Novartis (Basel, Switzer- land), MC2 Therapeutics (Copenhagen, Denmark), Valeant Pharmaceuticals (Laval, Canada), Allergan, Oculus, CLAO (St. Paul, Minnesota), and Vin- dico (Thorofare, New Jersey). Contact information Asbell: penny.asbell@mssm.edu Galor: agalor@med.miami.edu Matossian: cmatossian@matossianeye. com Sheppard: docshep@hotmail.com