EW CORNEA124

by Clifford Salinger, MD

+ Lomb, Bridgewater, New Jersey) twice a day, AzaSite (azithromycin, Akorn) to be applied to the outside of both the upper and lower lids at bedtime, and to continue using preservative-free artificial tears as needed.

Shortly after beginning the new regimen, the patient called with complaints about Lotemax and dis-continued use. At her 1-month fol-low-up appointment, she reported a moderate level of improvement, but was still experiencing irritation and other dry eye symptoms. A tear os-molarity test demonstrated improve-ment from 340 to 302 mOsm in the right eye and 355 to 306 mOsm in the left eye. We performed LipiFlow treatment (TearScience) 1 week later, and the patient continued all other therapy as prescribed, plus the addition of 0.1% fluorometholone eye drops once daily and exclusion of Lotemax.

At the 10-week follow-up appointment, the patient reported a 50% improvement in symptoms compared to her initial visit. The examination revealed a more stable TBUT, less punctate keratitis along the inferior cornea, and less punc-tate conjunctival staining in the interpalpebral area. The patient was instructed to continue the pre-

Dr. Salinger presents a case study on this disease that is gaining awareness

Our understanding of the etiology and treatment of dry eye has grown expo-nentially in the last few years, but a quick and

easy fix has yet to emerge. There is overwhelming evidence demon-strating the efficacy and viability of nutritional supplements when combined with comprehensive care; however, both patient and doctor must exercise patience and allow sufficient time before seeing measur-able, clinical results.

Nutritional supplements, lid hygiene, and hot compresses serve as the foundation of our treatment plan for dry eye patients. Additional treatments or pharmaceuticals are added or subtracted as needed be-yond this essential infrastructure. Al-though the treatment takes time and requires some adjustments along the way, we have had great success with this approach, as is demonstrated in this case study.

Case historyA 62-year-old patient presented with complaints of burning sensation, irritated eyes, and intermittent blur-ry vision. The initial examination revealed:• Moderately early tear break-up

time (TBUT)• Mild superficial punctate kerati-

tis on the inferior aspect of both corneas

• Mild to moderate conjunctival punctate staining

• Mild to moderate redundant conjunctival folds

• TearLab Osmolarity Test (TearLab, San Diego): 340 mOsm right eye, 355 mOsm left eye

• Lipid content (LipiView, Tear-Science, Morrisville, North Caroli-na): 74 ICU right eye, 88 ICU left eye

• Inflammation detected using InflammaDry (Rapid Pathogen Screening, Sarasota, Florida)

At the time of examination, the patient’s treatment regimen included the use of preservative-free artificial tears and three TheraTears Eye Nutrition gel caps (Akorn, Ann Arbor, Michigan) per day. One week prior to the exam, the patient had ceased taking fexofenadine and reported an increase in irritation as a result.

A long history of failed pharma-cological and surgical interventions included Restasis (cyclosporine, Allergan, Dublin), wherein the patient described worsening symp-toms, and punctal plugs, which be-came dislodged. The patient under-went laser punctal closure; however, the puncta had slightly reopened, leaving a pinpoint opening in both lower lids.

New treatment protocolThe patient was instructed to im-plement a new treatment protocol including: two HydroEye gel caps (ScienceBased Health, Houston) twice a day (discontinue use of TheraTears), daily administration of a hot compress and OCuSOFT lid wipes (OCuSOFT, Rosenberg, Texas), Lotemax drops (loteprednol, Bausch

scribed lid hygiene routine, reduce 0.1% fluorometholone eye drops to PRN usage, and to discontinue taking AzaSite after finishing the remaining supply.

The patient has consistently continued treatment as directed, rarely employing the use of the steroid eye drop, without any other prescription medications. Over the course of the next several months she reported a noticeable improve-ment in symptoms. She was very pleased with the overall improve-ment, with only occasional episodes of mild discomfort.

Almost 2 years after initiating treatment, she began wearing con-tact lenses comfortably all day. Prior to this treatment, she could only wear contact lenses for a very limit-ed amount of time because the irri-tation rendered her unable to read, work on the computer, or engage in any long-term visual tasks. The patient’s conjunctivochalasis has not progressed, nor has it resolved. This was not a significant contribut-ing factor to her discomfort as her symptoms improved in spite of the continued presence of the chalasis.

Alternative solutionInflammation comes from many factors, including hyperosmolari-ty; the friction caused by elevated, redundant conjunctival folds in con-junctivochalasis; T-cell lymphocyte infiltration of the lacrimal glands; and other sources. It is essential to bring inflammation under control as quickly as possible as it can cause irreversible damage to the ocular surface.

Supplemental omega fatty acids have been shown to reduce inflam-mation and improve the overall quality of tears. There is a significant and growing body of evidence that shows that the unique anti-inflam-matory omega-6 gamma-linolenic acid (GLA) is highly effective for treating patients with dry eye.1,2,3,4

When combined with well-known omega-3 fatty acids such as eicos-apentaenoic acid (EPA), they create a powerful effect of decreasing pro-in-flammatory arachidonic acid and prostaglandin E2.5,6 A well-designed, randomized, placebo-controlled study showed that nutritional sup-plements containing GLA and EPA reduced inflammatory biomarkers,

Battling dry eye with nutritional supplements

Clifford Salinger, MD

October 2016

125EW CORNEAOctober 2016

Editors’ note: Dr. Salinger is medical director at V.I.P. Laser Eye Center and The Dry Eye Spa, Palm Beach Gardens, Florida. He has financial interests

improved corneal surface smooth-ness, and improved symptoms of dry eye.7

In our case study, the effects of the nutritional supplements clear-ly helped to improve the patient’s symptoms sufficiently enough to avoid surgery, despite the presence of conjunctivochalasis. Once her dry eye symptoms were relieved, the conjunctivochalasis by itself was not bothersome. Although relief and healing was not instant, the improvement is obvious when observed over the long term.

Nutritional supplements used in tandem with a comprehensive care plan can offer many patients a long-term, natural way to manage dry eye and their symptoms. Although not a cure, reduced inflammation and the improved quality and quantity of tear production can provide patients suffering from dry eye more freedom within their environment, their daily activities, and a better quality of life. EW

References1. Creuzot-Garcher C, et al. [Efficacy assess-ment of Nutrilarm, a per os omega-3 and omega-6 polyunsaturated essential fatty acid dietary formulation versus placebo in patients with bilateral treated moderate dry eye syn-drome]. J Fr Ophtalmol. 2011;34:448–55.2. Barabino S, et al. Systemic linoleic and gamma-linolenic acid therapy in dry eye syndrome with an inflammatory component. Cornea. 2003;22:97–101.3. Brignole-Baudouin, et al. A multicentre, double-masked, randomized, controlled trial assessing the effect of oral supplementation of omega-3 and omega-6 fatty acids on a conjunctival inflammatory marker in dry eye patients. Acta Ophthalmol. 2007;89:e591–7.4. Kokke KH, et al. Oral omega-6 essential fatty acid treatment in contact lens as-sociated dry eye. Cont Lens Anterior Eye. 2008;31:141–6.5. Barham JB, et al. Addition of eicosapen-taenoic acid to gamma-linolenic acid-sup-plemented diets prevents serum arachi-donic acid accumulation in humans. J Nutr. 2000;130:1925–1931. 6. Viau S, et al. Polyunsaturated fatty acids induce modification in the lipid composition and the prostaglandin production of the conjunctival epithelium cells. Graefes Arch Clin Exp Ophthalmol. 2012;250:211–222.7. Sheppard JD, et al. Long-term supplemen-tation with n-6 and n-3 PUFAs improves mod-erate-to-severe keratoconjunctivitis sicca: a randomized double-blind clinical trial. Cornea. 2013;32:1297–1304.

with Bausch + Lomb, Rapid Pathogen Screening, ScienceBased Health, TearLab, and TearScience.

Contact informationSalinger: drsalinger@VIPLaserEyeCenter.com

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