EyeWorld India March 2018 Issue

56 EWAP PHARMACEUTICALS March 2018 Still, as Dr. Downie pointed out, there is no consensus yet. “As summarized in the recently published Tear Film & Ocular Sur- face Society Dry Eye Workshop II (DEWS II) Management and Ther- apy Report, 3 the role of omega-3 and/or omega-6 supplementation for treating dry eye disease and Meibomian gland disease is not yet completely understood,” Dr. Downie said, adding that although a sizable number of studies have been conducted, some have been relatively short and there have been a number of contrasting find- ings. What’s more, there are few high quality randomized trials to help practitioners determine what an optimal protocol may be. Currently there are two differ- ent forms of omega-3 fatty acids, Dr. Holland said. There are re- esterified and non-esterified essen- tial fatty acids. The non-esterified omega-3 is the cheapest formula- tion but can have drawbacks. “It’s not absorbed through the GI tract very well, it gives some patients indigestion and has a fishy taste,” Dr. Holland said. “The advantage of using a re-esterified triglyceride omega-3 fatty acid is that the ome- ga-3 maintains its natural triglyc- eride structure which can be easily metabolized and absorbed. They’re more expensive, but they’re more advantageous for patients.” To equal one tablet of the triglyceride omega-3, you’d have to take many more of the ester alcohol-based ones. Dr. Sheppard would like to see an ideal combination of re-esteri- fied and selected traditional essen- tial fatty acids as well as the anti- inflammatory gamma linolenic acid (GLA) from the ScienceBased Health (Oak Ridge North, Texas) formula. He recommends that patients take only clearly labeled mercury-free, pharmaceutical- quality essential fatty acids if pur- chasing on their own. He makes the ScienceBased Health formula available in his office, as well as online or by direct mail from the company. “We give patients access to literature thus enabling them to formulate decisions themselves,” he said. “But I believe patients prefer one-stop shopping and then become compliant when they see the benefits.” Possible precautions Not everyone can take all omega-3 fatty acids. “If a patient has a fish allergy, it becomes much more difficult,” Dr. Sheppard said. “But they can take various sources of GLA like black current seed oil, primrose, borage, and they can take flax seed, which is the vegeta- ble form of omega-3.” This is a bit less bioavailable but is far better than nothing, he said. “We have numerous patients on Coumadin (Warfarin) or other prescription anti-coagulant therapies taking fish based supplements safely and successfully, working in conjunc- tion with their internist.” Even for those without this issue, some precautions should be taken with the use of omega-3 sup- plements, including taking the pa- tient’s general health into account, Dr. Downie advised. “There are several general health contrain- dications, including liver disease, atrial fibrillation, and bleeding disorders,” she said, adding that in these cases medical advice should be sought prior to beginning sup- plementation. Although it remains conten- tious, some think ultra-high doses of omega-3 EFA intake of greater than 3,000 mg per day of com- bined EPA and DHA may cause heightened risk of bleeding, Dr. Downie said. She recommends that prior to beginning such sup- plementation, those with hema- tologic disorders seek medical advice. Keeping dosage amounts in mind is important. “The Food and Drug Administration suggests an upper daily limit for omega-3 fatty acid consumption of 3,000 micrograms, which includes omega-3s derived from foods and supplements,” Dr. Downie said, adding, however, that this refers to the amount of omega-3 fatty acid content, rather than the size of the supplement capsule. Many 1,000 mg fish oil capsules only contain 180 mg EPA and 120 mg DHA. In such cases, only about 30% of the content of the fish oil supplement capsule will be long-chain ome- ga-3 fatty acid. Use of krill oil is gaining some attention as a natural remedy for dry eye. “Our groups’ recent study is the first to demonstrate the therapeutic potential of krill oil supplementation for modulating ocular inflammation in dry eye,” Dr. Downie said, adding that while the clinical findings were similar to fish oil, there were differences. 4 Among these was the differ- ential modulation of tear IL-17A, which suggests that the anti-in- flammatory effects are not entirely the same. Investigators also found that after 3 months of treatment the improvement in symptoms was marginally better with krill oil compared with fish oil. “Krill oil has the advantage of fewer gastro- intestinal side effects, although we did not observe any specific differ- ence in this adverse effect between groups in our trial,” Dr. Downie said. One downside to the krill oil is that this is more expensive than fish oil supplements. Mechanical methods There are also mechanical meth- ods that may help. Dr. Holland is a big advocate of thermal pulsa- tion therapy. “Diseased Meibo- mian glands have thickened static meibum that is hard to express, and with the normal blink meibum is not released to the ocu- lar surface,” he said. “Normally, when you blink, you have a very microscopic contraction of the muscles around the gland and the glands release meibum.” However, if there is stasis of the gland or these are partially obstructed, the thickened meibum oil is never released, Dr. Holland explained. He finds that one way to reset the gland is to heat the meibum and with pulsation express it. “This allows the patient who’s on maintenance therapy, such as omega-3s and doxycycline or azithromycin, to now have a new, healthier meibum in the gland,” he said. “At this time, it appears that the best way to deliver the heat and pulsation is posteri- orly.” For this, he finds LipiFlow (Johnson & Johnson Vision, Santa Ana, California) works best. This heats the glands up and massages them to express the heated oil, which flows better because it’s at 104 degrees F. “There are devices that heat anteriorly that can have some effect, but the glands are positioned posteriorly, so the heat directly on the posterior gland Beyond - from page 55