One of the biggest misconceptions about chronic dry eye disease (DED) is that a single strategy is sufficient to remedy the problem. The notion that if one treatment does not work, then none will is a common fatalistic outlook among our colleagues. However, chronic DED is not linear like a simple bacterial infection that can be eradicated with a week of antibacterial drops, and it should not be treated as such. Rather, chronic DED is a multifactorial disease that requires a multidisciplinary approach. This mindset can be challenging for surgeons. But we are also physicians, and returning to our roots of listening, caring, and considering overall body health can improve our satisfaction and effectiveness in treating this complex chronic disease.
‘FARM-A-CY’: EMPOWERING PATIENTS THROUGH PROPER NUTRITION
Human physiology is complex, and a simple one-and-done treatment modality will not cure chronic DED. This disease is, by its very nature, a different beast, and its multifactorial character responds best when the entire physiological system is healthy. To this end, I typically speak with my patients about “farm-a-cy.” What we eat matters. Promoting good nutrition to combat chronic DED is simply adding a holistic, elemental approach to the treatment plan.
My patients are given an instruction sheet that includes a checklist of what they need to do: prescriptions I have determined are needed based on DED severity and concomitant, contributing diseases as well as practical pearls for success. Among these are tips for work environment modification, cosmetic ingredients to avoid, and dietary recommendations. I advocate following the Whole30 plan, developed by Melissa and Dallas Hartwig.1 Encouraging patients to follow the book to the letter is a cheap and efficient way to discover which foods their bodies may not tolerate and which foods make them thrive.
For patients, taking control of the nutritional aspect of their health is powerful and creates an atmosphere of enthusiastic involvement along with enhanced compliance. To treat the disease, you put the mind at ease, and one of the ways to do this is to give patients the confidence to know they can be proactive in their own health care, rather than passively reactive. That shift in mentality is also healing.
THE BENEFIT OF COMBINING NUTRITION AND NUTRACEUTICALS
In addition to limiting proinflammatory foods through the Whole30 or other approved diets that promote overall body health, nutritional supplements are a vital component of a balanced dry eye treatment strategy. Supplements that contain ideal ratios of omega fatty acids not only naturally address the inflammatory burden of chronic DED; they also help to provide the raw material building blocks for quality meibum production, which is necessary to keep the ocular surface healthy.
Reliance on supporting scientific evidence and clinician vigilance in directing quality and correct dosage is paramount; however, Americans tend to have the mentality that if some is good, more is better. This is not always the case, particularly when it comes to vitamins such as B12 “energy” injections, as doses higher than the daily recommended amount may cause severe issues. Patients may unwittingly contribute to their chronic DED.
QUALITY OVER QUANTITY
I prefer supplements that have a scientific rationale and clinically demonstrated benefit. HydroEye (ScienceBased Health) is one that I recommend for this and a variety of other reasons. This supplement contains gamma-linolenic acid (GLA), an anti-inflammatory omega-6 fatty acid, along with eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA), which are the beneficial fatty acids found in fish oil. In particular, the plant-based GLA has been shown to be effective in relieving symptoms of DED2 and has a unique property in directly stimulating lacrimal gland activity. The combination of these omegas serves to synergistically suppress proinflammatory mediators and promote the production of antiinflammatory mediators, making it exceptionally beneficial for dry eye.3 In my clinical experience, I have seen this supplement used as a monotherapy and result in a moderately positive matrix metalloproteinase 9 (MMP-9) presence converting to negative in as few as 8 weeks.
Once a diagnosis of chronic DED has been established, I build a so-called foundational therapy plan for my patients, which recommends a lifestyle/diet; a peer-reviewed, high-quality omega; and an immunomodulator such as cyclosporine ophthalmic emulsion 0.05% (Restasis; Allergan) or lifitegrast ophthalmic solution 5% (Xiidra; Shire). Further add-on therapies are prescribed for higher levels of chronic DED as based on consensus guidelines. Identifying and addressing comorbid conditions such as rosacea and allergy is also important.
As the patient improves, the add-on therapies are peeled away, but the foundation therapy remains for the long term. Together with a conscious nutritional diet, the physiological systems, including the eyes, improve. In other words, the treatment goal of physiologic restoration of the lacrimal functional unit is based on addressing the severity and contributing diseases with appropriate treatments and nutrition.
Physicians must remember that the miraculous eyes we see every day are part of a whole person. A mindful shift of focus to a broader understanding that dry eye is a multifactorial disease that deserves a multidisciplinary treatment has enhanced my clinical care satisfaction and outcomes. As a practicing clinician, I view the nutritional and nutraceutical aspects of dry eye treatment as important, foundational pieces of managing chronic DED. Combined with a proactive patient mindset, we move closer to physiologic restoration and healing.
1. Hartwig M, Hartwig D. TheWhole 30. New York, NY: Houghton Mifflin Harcourt; 2015.
2. Kokke KH, Morris JA, Lawrenson JG. Oral omega-6 essential fatty acid treatment in contact lens associated dry eye. Cont Lens Anterior Eye. 2008;31:141-146, 170.
3. Creuzot C, Passemard M, Viau S, et al. Improvement of dry eye symptoms with polyunsaturated fatty acids [in French]. J Fr Ophtalmol. 2006;29:868-873.