Dry Eye Disease Management & The Importance of Nutrition and Hygiene
Dry eye disease (DED) is a multifactorial disease of the ocular surface system whose chore mechanisms are tear film instability, inflammation, tear hyperosmolarity and epithelial damage.
In recent years, novel therapies specifically targeting inflammation and oxidative stress are being investigated and used in this field.
Therefore, an increasing body of evidence supporting the possible role of different micronutrients and nutraceutical products for the treatment of ocular surface diseases is now available.
The effects on ocular surface of omega-3 fatty acids, vitamins A, B12, C, D, selenium, curcumin and flavonoids and among these, the efficacy of omega-3 fatty acid supplementation in ameliorating DED signs and symptoms is supported by robust scientific evidence.
The anti-inflammatory and antioxidant benefits of many nutrients are key to the long-term preservation of ocular health.
Chronic inflammation and oxidative stress are the hallmarks of much age-related eye disease such as glaucoma, AMD and dry eye.
In dry eye, these contribute to degradation in both the quality and quantity of tears, ultimately leading to chronic injury to the ocular surface.
It is not surprising, therefore, that a healthy diet rich in antioxidant vitamins and minerals provides the best natural means to prevent, delay or even treat this type of ocular disease.
Ocular lubrication and lid hygiene are obvious ways to manage dry eye. However, they usually provide temporary relief and do not necessarily target the root causes of the problem.
Dietary guidance along with targeted nutritional supplementation may offer a much better long-term solution that can significantly enhance patient outcomes.
Essential nutrients cannot be synthesised by the body and need to be sourced through a healthy diet, so that they can carry out a range of important functions in the eye.
These include the omega-3 and omega-6 fatty acids which are of particular interest in the management of dry eye given their role in the production of meibomian secretions, anti-inflammatory effects and other properties.
There is accumulating clinical data demonstrating a beneficial influence of omega-3 and omega-6 on tear stability, conjunctival inflammatory markers, signs and symptoms of ocular discomfort and tear evaporation rate.
Dry eye disease can be overwhelming, but addressing 3 patient categories—nutrition, hygiene, and neural stimulation and visual performance—can help clear up the condition, according to Laura M. Periman, MD.
Periman is the founder and director of dry eye services and clinical research for the Periman Eye Institute in Seattle, Washington.
Nutrition Antioxidants and reactive aldehyde species inhibitors have a role in preventing innate immunity activation, and more research is being directed toward these preventative mechanisms, Periman said.
Although omega-6 fatty acids found in corn, safflower, and sunflower oils are thought to be less than beneficial, the nuances are important.
Hygiene and Prescriptions
Treating the inflammation preoperatively improves accuracy of the intraocular lens calculations and enhances the postoperative refractive result.
Periman showed that when lifitegrast (Xiidra, Novartis) was administered twice daily for 28 days preoperatively to 100 patients with confirmed dry eye who were undergoing cataract surgery, improvements were seen in accuracy, higher order aberrations, and speed.
Likewise, when cyclosporine 0.05% was administered twice daily to 42 patients with dry eye before LASIK surgery, accuracy and refractive predictability improved. A highly beneficial, broad-spectrum impact of chronic dry eye disease pathophysiology is seen with cyclosporine.
Additionally, confocal microscopy studies show that cyclosporine improves the corneal nerve subbasal plexus, epithelial cell density, and the keratinocytes. “These are ultrastructural effects that cannot be viewed during the examination,” Periman said.
“When our patients describe their dry eye symptoms and you don’t see much fluorescein or lissamine green staining, recall that these ultrastructural consequences of chronic inflammation may very well may be occurring.”
Inflammation also interferes with normal nerve healing after LASIK, PRK, and SMILE treatments, when neuropathic pain can develop. The adaptive immunity of chronic dry eye disease has 4 phases: initiation, amplification, recruitment, and damage/self-perpetuation,” Periman said.
And this is where the immunoregulating therapeutics come in to address the vicious cycle: cyclosporine, lifitegrast, steroids, and intense pulsed light affect all 4 phases of chronic dry eye disease, she said.
Periman also noted that aqueous and evaporative dry eye are no longer considered separately. CDED is an interrelated double vicious cycle of inflammation where decreased tear production and meibomian gland dysfunction [MGD] contribute to and are negatively impacted by inflammation.
Periman reminded physicians of the American Society of Cataract and Refractive Surgery’s preoperative recommendations to look, lift, push, pull on the eyelids to examine patients for myriad ocular surface disease coconspirators such as rosacea of the face and eyelids, floppy eyelid syndrome (heavily associated with obstructive sleep apnea), eyelid malposition, and incomplete lid closure (particularly relevant during sleep).
Incomplete lid closure should be addressed with approaches such as a silicone mask (Eyeseals 4.0; Eye Eco) to prevent ocular surface desiccation at night.
Lid hygiene remains a standard recommendation, but avoiding surfactant-based cleansers is important in the meibum-deficient patient.
Deep cleaning of the lids is achieved with in-office ZEST kits (Zocular) that utilize manual debridement using okra-based polysaccharide gel (anti-inflammatory).
Patients report symptom score improvements and effective home maintenance with mechanical eyelid cleaning and meibomian gland–stimulating devices such as NuLids (NuSight Medical). Patients should also be asked about prostaglandin use.
Neural Stimulation and Visual Performance
The goals are to create high visual performance under all conditions. For surgical patients, this means protecting the corneal surface preoperatively, postoperatively, and over the long term to produce a healthy tear film, healthy lacrimal functional unit (LFU), and healthy wound healing response.
Controlling inflammation leads to improved homeostasis. Neural stimulation in the postoperative patient is a great strategy to support the LFU as the corneal nerves recover from the surgical insults of cataract surgery or refractive surgery.
Neural stimulation definitely has a role. An external vibration that stimulates the meibum and an intranasal chemical device are expected to receive FDA approval soon, she explained. “Leveraging all these strategies together can create real healing for your dry eye patients,” Periman concluded.
