EyeWorld India March 2018 Issue

55 EWAP PHARMACEUTICALS March 2018 Beyond prescription medications by Maxine Lipner EyeWorld Senior Contributing Writer continued on page 56 Chronic meibomian gland dysfunction with thickened opaque meibum Source: Edward Holland, MD Natural therapies for Meibomian gland disease F or patients with Meibo- mian gland disease today, practitioners often reach for natural remedies, which would have been unheard of in the past, according to Edward Holland, MD, professor of oph- thalmology, University of Cincin- nati. “Five years ago, it was pretty uncommon,” he said. “I think there has been a lot of clinical evidence on the value of omega-3 and the importance of nutrition in treating dry eyes, and I think many clinicians are now aware of it.” In addition, patients are now often asking for practitioners’ opinions on this. Omega-3 supplements have become one of the main remedies practitioners are pointing patients to. “Unfortunately, our diet is filled with the wrong fatty acid,” Dr. Holland said, adding that patients tend to ingest too many omega-6 fatty acids, while there isn’t enough omega-3 in the diet. People can obtain omega-3 from raw nuts and fish. “But most experts don’t recommend eating fish 7 days a week because of the potential toxins,” Dr. Holland said. “So, the only real way to ingest significant omega-3 is with supplements.” Why omega-3 works Laura Downie, PhD, senior lecturer, University of Melbourne, Australia, explained that it has been well established that inflam- mation plays a key role in the pathogenesis of dry eye disease. “The major mechanism through which omega-3 supplements are considered to be therapeutic in dry eye is through modulating the inflammatory status of the eye by altering systemic cytokine produc- tion,” Dr. Downie said. While both omega-6 and omega-3 fatty acids are needed in a healthy diet, people commonly get too much omega-6. “The ratio of consumed omega-6 to omega-3 is a determinant of the overall inflam- matory status of the body,” she said. “While the omega-6 pathway mostly produces pro-inflammatory mediators, the omega-3 pathway biases prostaglandin produc- tion toward the generation of anti-inflammatory mediators.” In modern Western diets, the ratio of consumed omega-6 to omega-3 is typically 15 to 1, whereas an ideal ratio is about 4 to 1. “By increasing systemic omega-3 EFA levels with dietary supplements, we can lower the omega-6 to omega-3 ratio, with the intent of yielding anti-inflam- matory benefits,” Dr. Downie said. Omega-3 supplements may also directly alter Meibomian gland li- pid secretions. “It has been shown that the level of omega-3 intake is associated with differences in the polar lipid pattern of Meibomian gland secretions in women with Sjögren’s syndrome,” Dr. Downie said. “In addition, supplementation with short-chain omega-3 can alter the composition of Meibomian gland secretions, with correspond- ing improvements in gland block- age and tear stability.” John Sheppard, MD, presi- dent, Virginia Eye Consultants, Norfolk, Virginia, pointed out that the underlying function of the Meibomian glands is to produce a healthy mixture of lipids to pre- serve the ocular tear film through prevention of evaporation. “The organic health of those secretions depends on nutritional intake of the correct essential fatty acids,” Dr. Sheppard said. He stressed that the effect of the fatty acids is anti-inflammatory throughout the body. In addition, the awareness that a pill bought over the counter can be as effective as expensive prescription medication hits home for many, he finds. The evidence The evidence for using omega-3 fatty acids is growing. Dr. Shep- pard cited two landmark studies. One published by his group looked prospectively at the use of a com- bination of polyunsaturated fatty acids that showed a significant improvement in several parameters in patients after 6 months. 1 “Our study showed that patients had stabilization rather than worsening of two ocular surface inflamma- tory markers seen in the placebo control group,” Dr. Sheppard said, adding that it also showed an improvement in the Ocular Surface Disease Index as well as some of the irregular astigmatism markers from corneal topography. “A subsequent multi-center, placebo-controlled, masked, pro- spective, randomized study was published looking at re-esterified Omega-3 essential fatty acids,” Dr. Sheppard said. “This trial showed that those concentrated supple- ments, assumedly through their improved bioavailability, improved a wide variety of parameters in patients with dry eye.” 2