Dry Eye

Dry Eye Care is Whole Body Care

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Integrating lifestyle changes with customized medical care is imperative for success.

By Laura M. Periman, MD

When we consider the updated definition of dry eye disease (DED) from 2017 TFOS DEWS II, we often focus on the first section and perhaps less on the second section, which contains a key term: neurosensory compromise. The committee wrote, “Dry eye is a multifactorial disease of the ocular surface characterized by a loss of homeostasis of the tear film and accompanied by ocular symptoms, in which tear film instability and hyperosmolarity, ocular surface inflammation and damage and neurosensory abnormalities play etiologic roles.”1

The brain regulates tear film composition based on constant signals and feedback it receives. Based on that incoming information, the brain sends out commands to the lacrimal functional unit, telling it what it needs to do to orchestrate a physiologically complete tear. Ideally, the system functions like a perfectly elegant rheostat, constantly and seamlessly controlling the “temperature” or in this case, the components of the tear film to maintain homeostasis. In the setting of DED, that rheostat malfunctions—maybe it was ripped off the wall, or the wires were cut, or the air conditioner is broken.

A variety of pathways can be involved in damaging the apparatus, and that includes higher-level cortical function problems such as stress, anxiety, depression, and sleep disturbances. In other words, biopsychosocial function has an impact on the lacrimal functional unit resulting in a loss of homeostasis. It also works the other way, with chronic pain as a response to corneal damage causing stress, anxiety, depression, and sleep disturbances. A vicious circle indeed, as that ripple effect, in turn, has an impact on the entire person—mental health, the ability to perform at work, engage with family, and enjoy life.

How to Address Whole Body Wellness
When addressing patients’ whole body health as part of a comprehensive approach to regaining tear film homeostasis, physicians should strive toward mindfully initiating nuanced conversations. I believe we must be sure to honor patients’ suffering and their experience of symptoms, taking care not to be dismissive. Treating the mental health aspect of ocular disease requires dignity and compassion in addition to frank discussion.

A meaningful discussion can start with a pause, a deep breath, and physicians pulling their chair up alongside their patients. This simple act is dignifying and compassionate, signaling to patients that they have been heard and that their doctor is on their team. It says, “I hear you, I’m here to help, and I am on this journey with you. Let’s do this together.”

I explain that the pathways to the most effective relief from DED—a multifactorial disease—require that we address their situation with a multidisciplinary approach. Therefore, we need to consider all the factors that create this problem of homeostasis loss. One crucial risk factor is a lack of nutritional support; therefore, I talk about diet, I recommend the Whole 30 Program, for example, proper nutraceutical supplements; and adequate hydration. I let patients know that focusing on lifestyle and self-care with regard to getting enough sleep and working to reduce the stress in their life as best as they can is paramount. I counsel patients that if these excellent self-care measures are not enough, a visit to their primary care doctor to explore pharmacologic assistance with anxiolytics and/or anti-depressants may help. I empower patients by advising them, “you deserve to be your best self and it is okay to create time and space to address these things.” Sometimes patients need permission from their health care providers to put themselves first. Sometimes they cry in relief in feeling heard and their struggles having been seen.

Once these aspects of self-care are in place, there will be a shift in the disease state.2,3 For example we know that improving water intake helps tear osmolarity. A better diet has benefits in terms of sleep, anxiety, and depression. The whole biopsychosocial model is a constant expansion and micro-manipulation process like a spider web with separate strings supporting the entire structure. Anxiety and depression are important components to address so that they do not destroy the web.

 Recommending Supplements
The omega fatty acid gamma linolenic acid (GLA) is an anti-inflammatory omega-6 shown to play an important role in modulating the inflammatory response.4 Unlike the pro-inflammatory omega-6 arachidonic acid, which is over abundant in the Western diet, GLA is a unique omega that is lacking in fish or flax and is not found at meaningful levels in our diet. GLA is present in mother’s breast milk and is naturally produced in the body via conversion from other omegas. This conversion, however, becomes less efficient as people age, which means that some older adults may not be able to obtain sufficient levels in their bodies.

GLA is a precursor to the anti-inflammatory prostaglandin PGE1, which promotes tear production and fights inflammation. GLA has been validated for improving dry eye symptoms in a variety of clinical trials that have studied its efficacy in post-PRK patients, those with Sjogren syndrome, contact lens wearers, postmenopausal women, and others.5-11 This non-dietary omega-6 is the primary component of HydroEye, a patented dry eye nutritional formulation. Along with GLA derived from black currant seed oil, HydroEye (ScienceBased Health) includes other omegas in a specific balance to provide dry eye relief. This patented formula also contains nutrient cofactors to fatty acid metabolism such as vitamins C, B6, and magnesium, that work in concert to support the three layers of the tear film. This approach offers more targeted and comprehensive support than using fish oil omega-3s alone.

I recommend HydroEye to my patients because it has such significant data validating the formula’s efficacy for relieving dry eye symptoms. A randomized clinical trial in post-menopausal women found HydroEye improved symptoms, lowered levels of two inflammatory markers (HLA-DR and CD11-c), and resulted in smoother corneas (SAI; surface asymmetry index, measured with topography).11 My patients have had remarkable success, and I find that by recommending a supplement that is also affordable, patients understand that I am their ally on their journey.

I like to create lightness and use some humor when I provide patients with information about the foundational importance of nutrition and the use of nutraceuticals and supplements. Food is medicine, I tell patients, Grandma was right; you are what you eat. You must eat anyway, so make it work for you, not against you. Once patients’ whole body health and wellness habits are dialed in, medical and pharmaceutical interventions can work better. Just one aspect of therapy is not enough to battle DED. There is no such thing as a silver bullet in dry eye—full stop—and patients that lean into nutrition and lifestyle as foundational lifelong process are generally more successful in their recovery.

Laura M. Periman, MD, Director of Dry Eye Services and Clinical Research, Periman Eye Institute, Seattle
Contact: [email protected]; Twitter, Instagram, and YouTube @DryEyeMaster
Financial disclosure: Dr. Periman is a consultant to ScienceBased Health.

1. Craig JP, Nichols KK, Akpek EK, et al. TFOS DEWSII Definition and Classification. Ocul Surf.

2017;15(3):276-283. doi: 10.1016/j.jtos.2017.05.008.

2. Walsh NP, Fortes MB, Raymond-Barker P, et al. Is whole-body hydration an important consideration in dry eye? Is whole-body hydration an important consideration in dry eye? Invest Ophthalmol Vis Sci. 2012;53(10):6622-6627. doi: 10.1167/iovs.12-10175.

3. Pellegrini M, Senni C, Bernabei F, et al. The role of nutrition and nutritional supplements in ocular surface diseases. Review Nutrients. 2020;12(4):952. doi: 10.3390/nu12040952.

4. Kapoor R, Huang YS. Gamma linolenic acid: an anti-inflammatory omega-6 fatty acid (Review). Curr Pharm Biotech. 2006;7:531-534. doi: 10.2174/138920106779116874.

5. Barabino S, Rolando M, Camicione P, et al. Systemic linoleic and gamma-linolenic acid therapy in dry eye syndrome with an inflammatory component. Cornea. 2003;22(2):97-101. doi: 10.1097/00003226-200303000-00002.

6. Macrì A, Giuffrida S, Amico V, et al. Effect of linoleic acid and gamma-linolenic acid on tear production, tear clearance and on the ocular surface after photorefractive keratectomy. Graefes Arch Clin Exp Ophthalmol. 2003;241(7):561-566. doi: 10.1007/s00417-003-0685-x.

7. Aragona P, Bucolo C, Spinella R, et al. Systemic Omega-6 essential fatty acid treatment and PGE1 tear content in Sjogren’s syndrome patients. Invest Ophthalmol Vis Sci. 2005;46:4474-4479. doi: 10.1167/iovs.04-1394.

8. 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. doi: 10.1016/j.clae.2007.12.001

9. Pinna A, Piccinini P, Carta F. Effect of oral linoleic and gamma-linolenic acid on meibomian gland dysfunction. Cornea. 2007;26(3):260-4. doi: 10.1097/ICO.0b013e318033d79b.

10. Brignole-Baudouin F, Baudouin C, Aragona P, 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. 2011;89(7):e591-7. doi: 10.1111/j.1755-3768.2011.02196.x. 

11. Sheppard JD, Singh R, McClellan AJ, et al. Long-term supplementation with n-6 and n-3 PUFAs improves moderate-to-severe keratoconjunctivitis sicca: a randomized double-blind clinical trial. Cornea. 2013;32:1297-1304. doi: 10.1097/ICO.0b013e318299549c.