Michael P. Lange OD, CNS, 05/31/2013 updated 4/21/18
Nutrition for dry eyes is an area gaining a strong foothold in eye care centers around the globe.
Dry eye conditions are one of the most common problems that optometrists and ophthalmologists see on a daily basis. Patients come into the office with eyes that feel sandy, gritty, burn, tear, itch and sometimes are quite painful. Traditionally in the past eye doctors would prescribe topical and oral medications along with artificial tears for this condition. Many eye care providers are now taking a more natural approach. Proper nutrition will help the patient suffering with dry eye dramatically. The majority of dry eye sufferers will notice a significant improvement in dry eye symptoms when the correct dietary and lifestyle modifications are implemented. Dry eye is a nutritionally responsive condition and this article will discuss how proper diet and supplementation may improve subjective and objective signs and symptoms of dry eyes.
The majority of the public, whether they are over weight or under weight, are nutritionally compromised. Most people are not of ideal body weight, medication free and on a truly healthful diet. As a clinician, I know at the first glance of my patient and a brief discussion how critical a dramatic adjustment in their diet is going to be to their overall health and their dry eyes. Proper nutrition is one of the most important single factors in maintaining the health of our patients. Most people in today’s society are not getting the required vitamins, minerals and essential fatty acids from the foods they are eating. We have become a society living ‘life on the go’ that is fueled by junk food and fast food. Convenience has become our main concern instead of quality. A diet that is caloric dense and nutrient deficient is becoming main stream. Americans consume a diet that is unbalanced—with too few omega-3 fatty acids and way too much omega-6 fatty acids—leading to increased inflammation and disease in the body. This is associated with increased levels of cytokines, proteins that trigger inflammation. Inflammation is one of the root causes of dry eye syndrome (keratoconjunctivitis sicca) and many other systemic diseases. Our foods are overly refined and processed, sugar- and salt-laden, filled with trans fats, hydrogenated oils, synthetic dyes, high fructose corn syrup, chemicals and artificial sweeteners. These poor nutritional habits combined with a sedimentary lifestyle are why the health of the American people (our patients) is becoming compromised. America is home to the most obese people in the world. According to the CDC (Center for Disease Control and Prevention) obesity in adults has increased by 60% within the past twenty years. A staggering 70% of American adults are overweight or obese and obesity related deaths have accelerated to more than 300,000 a year, second only to tobacco related deaths.
Dietary modifications and lifestyle changes
Most nutritional experts recommend 10-13 servings of organically grown fruits and vegetables a day. Americans are falling short of this amount and are becoming more and more nutritionally compromised. 70% of adults are not even consuming half the recommended amount of fruits and vegetables daily. The population that consumes the least amount of fruits and vegetables are at a greater risk of developing disease and illness. If you are nutritionally compromised you are more prone to develop free radical damage in your eyes and entire body. This is the group of people that will have an increased risk of dry eyes, cataracts and retinal disease. In my twenty one years of clinical practice in Florida I have seen the positive effects dietary modifications and lifestyle changes can have directly on ocular health and total body health.
I have finally come to the realization that patients who follow a combination of a gluten free Mediterranean, Paleo or hunter gatherer type of diet, and follow a regular exercise routine and get proper sleep benefit significantly. This is a diet that consists of organically grown fruits, vegetables, seeds, nuts, whole grains, proteins, lots of water and a few other beverages. I recommend that my patients avoid water in plastic bottles and to try to drink spring water that is in glass bottles due to the potential for bisphenols leaching into the water from the plastic. Bisphenols cause endocrine disruption which could compound a dry eye problem. Not only can you find bisphenols in plastic bottles but they are in canned foods as well. F, D and C red, yellow and blue dyes can also cause endocrine disruption and so should be avoided. Dyes are in just about everything we consume these days, so I teach my patients to be proactive in their health and read labels. I recommend patients to try to consume half their body weight in ounces of a good quality water daily. Try not to drink to much distilled or reverse osmosis water due to the acidity and low mineral content. Spring water is the safest especially if it is stored in a glass conatiner. I also recommend a few glasses of coconut water a day to help hydrate the body and eye. Coconut water is high in potasium and their is a link to low potassium and dry eyes. I also advise patients to try to substitute their morning coffee with organic green tea and lemon. The antioxidant and anti inflammatory effects of green tea and lemon have significant health benefits and many people will notice an improvement in their dry eyes from this one simple step. I advise my patients to try to eat 10 to 13 servings of fruits and vegetables on a daily basis. I recommend a specific group called “the dirty dozen” fruits and vegetables be only organically grown due to the high amounts of pesticide found inside this specific group. Most of us have an accumulated build up of pesticide exposure in our bodies due to numerous years of exposure. This “chemical burden” leads to a variety of serious health issues that may potentiate a dry eye condition. The protein in this particular type of diet should always be free range, organically raised or wild, not farm raised! Try to eat fish at least three times per week to improve the omega three to omega six ratio in the blood. The fish that are highest in omega three and lowest in potential contaminants are sardines, anchovies, herring, mackerel, wild rainbow trout and wild Alaskan salmon. Many people will follow these directions precisely; however the majority is going to wander off of these specific recommendations. This is why supplementation with good vitamins and omega-3 fatty acids is so crucial.
Blood chemistry testing
How do you know the specific nutritional status of your patients without testing them? The only accurate way to test for these deficiencies is through blood testing. At the Lange Eye Institute in The Villages, Florida, we will routinely do three special blood tests to gain valuable insight into the nutritional health of our patients. A SpectraCell intracellular blood test, vitamin D 25 OH and an omega-3 index test will help determine our patient’s nutritional status and if they have nutritionally modifiable risk factors for ocular conditions like dry eyes. The vast majority of the patients we test are deficient in antioxidants and omega three. Many of these patients will also have elevated CRP, homocystein, triglycerides, cholesterol and arachidonic acid. The majority of these blood chemistries can be positively impacted through proper nutrition. The poor results on these tests can help motivate patients to make crucial dietary and lifestyle modifications that will positively impact their overall health. After reviewing the results of these tests, patients will finally understand the benefit of proper supplementation. Realistically, because these tests are not being covered by Medicare or other medical insurance, not everyone will be able to have these tests done due to cost. Fortifeye Vitamins and Lange Eye Care have actively been researching the bio-availability of vitamins and omega -3 supplements by using these blood tests in a clinical setting. Let’s now review the specific protocol that is working extremely well with the dry eye population.
Omega-3 fish oil
The majority of large clinical studies that have documented the positive health benefits of omega-3 fatty acids have utilized fish or fish oil consumption. There are many positive studies supporting the beneficial health aspects of a higher consumption of omega-3 from fish oil or fish. The medical community has readily embraced these positive health benefits and is prescribing and recommending fish oil supplements to their patients. The increased public awareness regarding omega-3 fish oil has created an omega-3 explosion. Consumers that are in tune with prevention and wellness are becoming proactive in their health and are practicing prevention by consuming more fish or purchasing fish oil supplements from the drug store, health food store or through the Internet. However, one must be careful with consuming too much fish because of the potential contaminants that are in particular types of fish. With all of the contamination in the oceans it is becoming more and more difficult to recommend consuming large amounts of fish. The consumer or patient must also be aware that all fish oil is not created equal! The health care professional should be educating their patients on the benefits of proper omega-3 supplementation.
Ethyl ester and triglyceride forms of fish oil
Omega-3 fish oil has two readily available forms, ethyl ester fish oil and triglyceride form fish oil. I recommend purchasing the triglyceride form fish oil over the ethyl ester version of omega-3 fish oil for a variety of reasons. The ethyl ester form of fish oil is highly unstable and therefore it can oxidize and become rancid quicker than the triglyceride form of fish oil. Many of the ethyl ester fish oils may become rancid before you purchase them. This is one of the reasons many people get a nasty aftertaste or have problems burping up an unpleasant fish taste from the ethyl ester form of fish oil. Studies also indicate that the triglyceride form omega-3 fish oil absorbs much faster and more efficiently therefore increasing bio availability. Most fish oil that is being sold OTC or as a prescription in the United States is the ethyl ester version because it is significantly less expensive to manufacture. The final phase in the purification of a triglyceride form of fish oil requires the ethyl ester molecule to be cleaved off and replaced with a triglyceride molecule, thus making it a more natural omega-3 fish oil than the ethyl ester version. The triglyceride form of omega-3 fish oils are extremely pure and concentrated making them the ideal choice. If you do not know if your fish oil is an ethyl ester version or triglyceride version you should call the customer service department on the back of the bottle. You can also squeeze the contents of your fish oil into a Styrofoam cup and watch for the chemical reaction. If the cup begins to dissolve after 10 to 20 minutes, then you have an ethyl ester form. However, some fish oils with very low concentrations of ethyl ester fish oil may not melt the cup.
Choosing the best fish oil in triglyceride form
When shopping for the best triglyceride form fish oil, look for high levels of EPA and DHA. I recommend finding an omega-3 fish oil supplement that has an EPA between 400-450 per gel cap and a DHA around 250-300 per gel cap. These are the levels I have studied using the latest in omega-3 blood testing and I have found that the consumption of two gel caps a day of this concentration can increase your omega index to a desirable level over 8%. This omega-3 index measures the concentration of EPA and DHA as a percent of total essential fatty acids in the red blood cell membranes. Recent research is proving that the desirable level for cardio protection is an omega index over 8%. This research claims that levels greater than 8% correlate with a 90% reduction in the potential for a fatal heart attack. The vast majority of Americans have an omega index closer to 4%.
Best sources of omega-3
My research team and I have tested a variety of omega-3 oils from flax, krill and ethyl ester fish oils and have not found nearly the improvements in the omega index with these other types of omega-3 fatty acids. This demonstrates why it is important to remember that all omega-3 supplements are not created equal! Most of the inferior brands of fish oil and krill oil you can purchase OTC have no therapeutic value and won’t move the omega index very much. Many of the OTC fish oils are also filled with higher than the acceptable amounts of contaminants like PCB. Is this something you want to be consuming? After years of study, a lot of trial and error and a one month research trip to Norway I developed a highly purified triglyceride omega-3 fish oil concentrate with an outstanding 1600mg of omega-3 (EPA 860mg, DHA 580mg) in just two gel caps called Fortifeye Super Omega. The teams at Fortifeye Vitamins and the Omega 3 Test have been actively studying the influence of two daily capsules of this concentrated formula on blood levels of omega-3 and the results have been astounding! After just thirty days, mean blood levels of omega-3 have increased from 4.2% to 9.1% with some patients as high as 11%! The results are a true testament to the benefits of proper levels of omega-3 supplementation with Fortifeye Super Omega. These are the levels that have produced positive results in our dry eye population. Most patients do quite well on two per day dosing of these levels and will start to experience symptomatic relief in one to three months. If the patient is over 250 lbs or has a significant dry eye problem I would recommend doubling the dosage. We have positive results using these levels of omega-3 fish oil with meibomian gland dysfunction patients, those with recurrent hordeolums, conjunctivitis, chronic low grade uveitis, blepharitis and we are even seeing a positive impact on our diabetic maculopathies and macular degeneration patients. Based on the current worldwide research available, combined with the ongoing research being done at Fortifeye Vitamins and Lange Eye Care and Associates, I feel the primary eye care provider should be making omega-3 recommendations to all of their patients.
Chemical reactions of omega-3
EPA (eicosapentaenoic acid) and DHA (docosahexaenoic acid) are the two principal EFAs (essential fatty acids) found in fish known as omega-3 fatty acids. The current research suggests the anti-inflammatory effects of fish oil may help with dry eye syndrome. EPA generates the anti-inflammatory eicosanoids prostaglandin E3 and leukotriene B5. If the concentration of EPA is high enough the EPA blocks the delta-5 desaturase enzymatic step that stops the conversion of omega-6 EFAs to the inflammatory cascade of arachidonic acid (AA). This allows more conversion to anti-inflammatory prostaglandin E1 (PGE1). PGE1 then binds to EP2 and EP4 receptors to activate adenylate cyclase and increase cyclic AMP (adenosine monophosphate) which in turn stimulates a healthier tear production. DHA also decreases production of pro-inflammatory eicosanoids and helps to balance the body’s response to inflammation. Both EPA and DHA contribute to reducing inflammation in somewhat different but complementary mechanisms. The increase in omega-3 EFAs have also shown to improve dysfunction in the meibomian gland with a much thinner and clearer meibomian gland secretion, thus helping with meibomian gland dysfunction. The increased consumption of a triple molecularly distilled and concentrated triglyceride form omega-3 fish oil will help to get the balance between omega-6 and omega-3 in better harmony and allows for less inflammation in the body and eyes. Americans have too high a percentage of pro-inflammatory omega-6 in their diet. The addition of some good omega-3 fish oil is the start to a healthier body and visual system.
A relatively new nutrient used in supplements that comes from the micro alga Haematococcus pluvialis, astaxanthin is proving to have a variety of incredible health benefits. The super carotenoid astaxanthin is the reason lobsters, shrimp, crabs and wild salmon have a reddish color. Astaxanthin is an extremely potent antioxidant and anti-inflammatory. Clinical studies have now proven that 6mg of astaxanthin can improve the blood flow to the eye and actually aid in accommodation (focusing) and in reducing eye fatigue. Astaxanthin reduces inflammatory markers such as C reactive protein (CRP), nitric oxide synthase (NOS), prostaglandin E2 (PGE2) and tumor necrosis factor (TNF). Astaxanthin is documented with high potencies for neutralizing oxygen radicals. For example, it is 550 times more powerful than vitamin E and 40 times more powerful than beta-carotene against singlet oxygen radicals. These remarkable aspects of astaxanthin are the reasons why Fortifeye Vitamins and The Lange Eye Institute are involved in some ongoing clinical blood studies to look more carefully at the anti inflammatory properties of astaxanthin. Early data shows when combined with high quality triglyceride based omega-3 fish oil (EPA 860 and DHA 580) 6 mg of astaxanthin is lowering arachidonic acid levels more than the fish oil alone. Studies also indicate that astaxanthin may help in muscle recovery and reduce muscle fatigue. Many patients that have been taking supplemental astaxanthin have also noticed the sun block properties this powerful antioxidant exhibits. Astaxanthin has also been linked to healthier skin, showing a reduction of fine lines and wrinkles after taking astaxanthin for a few months. Astaxanthin is a truly unique nutrient with some incredible health benefits. I have been very impressed with the potential ocular and overall health benefits of astaxanthin.
Dry eyes and computer vision syndrome
Dry eye and eye fatigue often go hand in hand especially in computer vision syndrome (CVS). The numerous patients who come in complaining of eyes that feel tired, fatigued, dry, sandy and gritty after working on the computer for prolonged periods of time are the ones that will benefit from adding 6mg of astaxanthin to their supplemental regiment. CVS is effecting more and more of our patients these days. The combination of omega-3 and astaxanthin will reduce the typical symptoms related to CVS. I will usually start these patients on a combination of 860mg of EPA and 580 mg of DHA from fish oil (Fortifeye Super Omega) and 6 mg of astaxanthin combined with a little lutein and zeaxanthin (Fortifeye FOCUS). After three months many of these patients’ symptoms have resolved or improved significantly. These patients will also report an improvement in many other areas: less joint pain, healthier skin, improved energy, improved muscle recovery, more endurance, improvement in focusing and many more. I have seen a synergy in my dry eye population taking Fortifeye Super Omega and Fortifeye FOCUS. If patients are not experiencing the relief they are looking for on omega-3 supplementation alone I will add 6 mg of astaxanthin and see the patient back in three months for follow up. I have been amazed at the positive feedback I have received from these patients. Not only are these patients improving subjectively but their objective signs of dry eye are also improving. I think astaxanthin has a place in eye care especially for the patients that are looking for a more natural approach to help with their dry tired eyes. Just about everyone these days is experiencing some form of dry and fatigued eye symptomology throughout the day. Patients are searching for ways to help solve their complaints without recommending surgery or medication. I highly recommend the combination of Fortifeye Super Omega and Fortifeye FOCUS for this group of people.
The moderate to marked dry eye patients may need one additional nutrient in conjunction with the omega-3 and astaxanthin to maximize the nutritional approach for dry eyes. Gamma-linolenic acid (GLA) is an essential fatty acid (EFA) in the omega-6 family that is found mainly in plant seed oils. The three most common plant seed oils where GLA are found are borage seed oil, black currant oil and evening primrose oil. GLA is broken down in the body to dihomo-gamma-linolenic acid (DGLA) and arachidonic acid (AA). DGLA competes with AA and prevents the negative inflammatory effects that AA would otherwise cause. Adequate amounts of magnesium, zinc and vitamins C, B3 and B6 help to promote the conversion of GLA to DGLA rather than AA. It is fairly rare that our patients will have deficiencies in these areas if they are eating the appropriate foods. However many of our patients are not getting the appropriate nutrition in their diet and must supplement with a good whole body antioxidant. Running a SpectraCell nutritional blood panel may to help find many surprising nutritional deficiencies. Researchers in Japan have shown that astaxanthin may suppress the cyclooxygenase enzyme and decrease the amount of pro-inflammatory PGE2 produced. Once the AA pathway is blocked the DGLA is free to convert to anti-inflammatory prostaglandin E1 (PGE1) and an improvement of tear production may occur. Recent studies suggest that oral GLA supplementation improved dry eye both clinically and subjectively in patients with dry eye syndrome. Studies also show that patients who take a combination of linoleic acid (LA) and gamma-linoleic acid (GLA) prior to and after refractive surgery may have better tear production and less dry eye complications. Studies utilizing GLA and omega -3 fish oil have shown an additive anti-inflammatory effect with no elevation in arachidonic acid. Due to the extremely high amounts of omega-6 in most diets I began studying different ratios of omega-3 and GLA and have decided to use a ratio of approximately 10 to 1 omega-3 to omega-6 (GLA) to maximize the anti-inflammatory effects and gain full advantage of both types of essential fatty acids. If the ratio of omega-6 (GLA) to omega-3 is too high in the omega-6 direction then the possibility of more inflammation exists. Currently for my more advanced dry eye cases I have been using 1600 mg of triglyceride form omega-3 (Fortifeye Super Omega), 160 mg of GLA from black currant seed oil, 6mg of astaxanthin (Fortifeye FOCUS) and a good whole body antioxidant (Fortifeye Complete One-a-Day) with great results. I recommend finding an antioxidant supplement without any vitamin A (retinol). Vitamin A deficiency is rarely found in groups of people that consume plenty of fruits and vegetables along with animal sources of protein. Supplemental vitamin A (retinal) blocks vitamin D absorption and a vitamin D deficiency may indirectly aggravate an existing dry eye condition. It will take three to four months to fully realize the potential improvements that you may get. You may not only experience ocular health benefits, but you may also notice many general health benefits as well. It is time that both optometrists and ophthalmologists start to utilize the power of proper nutrition to help their patients. It is a win-win for everyone involved.
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The power of proper nutrition for dry eyes cannot be under estimated. I hope this article will help many of the people out there that are suffering from dry eyes. My advice is to find a good eye doctor that is in tune with nutrition and follow his or her advice carefully. Hopefully this article has educated you on the possible positive benefits you may experience through proper nutrition and life style modifications. This should not take the place of an eye examination. Here’s to your health! Fortifeye Vitamins is located in Ocala, Florida, and the phone number to call is (866) 503-9746, or visit www.fortifeye.com.
Michael P. Lange OD, CNS
Certified Nutrition Specialist
Syndicated Daily Talk Show Host (Ask the Doctor)
CEO of Lange Eye Institute
CEO of Fortifeye Vitamins
CEO of Lange Nutrition Centers
Dr. Michael P. Lange is a Board Certified Optometric Physician and a Certified Nutrition Specialist who started Lange Eye Care and Associates in Ocala, Florida, in March 1993. Lange Eye Care has grown to 13 locations throughout the state of Florida with three surgery centers. The Lange Eye Institute at The Villages in central Florida is home base for many of the nutritional studies that Fortifeye is involved in. Dr. Lange is one of the first doctors in the industry to utilize intracellular blood tests and blood absorption studies to improve the Fortifeye vitamin line. Dr. Lange travels the world for nutritional research gathering valuable information to continuously improve Fortifeye vitamin formulations, and is actively involved in the clinical practice of eyecare. He is a guest lecturer, contributing author to many eyecare magazines, and a daily syndicated talk show host of ‘Ask The Doctor’ which broadcasts daily from Tampa Bay or Gainesville on radio stations throughout the country and video streaming all over the world via the Internet.
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