Efficacy of a new prescription-only medical food supplement in alleviating signs and symptoms of dry eye, with or without concomitant cyclosporine A

Effect of aerobic exercise alone or combined with Mediterranean diet on dry eye in obese hypertensive elderly

BACKGROUND

Lifestyle modification is a newly recommended complementary treatment for dry eye (DE) disorder.

OBJECTIVE

To investigate the effect of a 6-month high-intensity interval aerobic exercise (HIIAE) (conducted 30 min, 3 times weekly) alone or combined with a caloric-restriction approach, the Mediterranean diet (MD), on DE parameters in obese hypertensive elderly.

THE DESIGN, SETTINGS, PARTICIPANTS, AND INTERVENTION

This is a randomized controlled trial included sixty obese hypertensive elderly with DE based on university-based hospital recruitment. Elderly were randomly assigned to the experimental group (n = 30 elderly received HIIAE plus MD) and control group (n = 30 elderly received only HIIAE). Besides anthropometry (abdominal circumference, body weight, and body mass index) and blood pressure (measured in systole and diastole), DE parameters (tear film break-up time, DE scoring system, ocular surface disability index questionnaire, Schirmer's test, and Oxford grading system) were evaluated.

RESULTS

Significant improvements in anthropometry, blood pressure, and DE parameters were higher in the experimental group than in the control group.

CONCLUSION

Aging-related DE symptoms and signs can be prevented and/or treated with HIIAE alone or combined with MD in obese hypertensive elderly with DE disorder.

Bilberry-containing supplements on severe dry eye disease in young and middle-aged adults: A 3-month pilot analysis

Purpose

To explore the effect of bilberry and fish oil combination supplement on a small clinical sample patient-base with severe dry eyes.

Methods

Twenty-four subjects were recruited with twelve randomly assigned to the intervention and control groups, respectively. Inclusion criteria included severe dry eye symptoms determined by scores >33 from the Ocular Surface Disease Index (OSDI) questionnaire. The intervention group was instructed to take an oral supplement with key ingredients of 600 mg bilberry extract and 240 mg docosahexaenoic acid-refined fish oil once daily for 3 months. The control group did not take any supplements. Mean changes in OSDI score, non-invasive tear break-up time (NITBUT), phenol red thread test (PRT), and percentage of meibomian gland openings were used as outcome measures. Testing was done at baseline, 1-month, and 3-month follow-up. Comparison between the treatment and control groups, and the younger adult and middle-age groups were performed.

Results

The mean baseline values for the treatment and control groups were not clinically different. The OSDI score, NITBUT, PRT, and percentage of meibomian gland openings improved after taking the supplements for 3 months. The OSDI score, NITBUT, and PRT showed clinical improvements between the intervention and control groups. These improvements were consistent between the two age groups.

Conclusion

This study suggested preliminary improvements in signs and symptoms of severe dry eyes that were independent of age after taking dietary supplementation of bilberry extract and fish oil for 3 months. Further studies using more device-based measures and a placebo supplement are warranted.

Effect of Oral Choline Alfoscerate on Patients with Keratoconjunctivitis Sicca

Keratoconjunctivitis sicca (KCS) or dry eye is a disease characterized by ocular surface symptoms. This study aimed to investigate the effectiveness of oral choline alfoscerate (CA) administration as a treatment for KCS. The medical records of dry eye patients who were refractory to topical eyedrops and then took oral CA were reviewed. Results of tear break-up time (TBUT), fluorescein ocular surface staining score (FSS), and tear secretion by the Schirmer test (STT) were analyzed. The results of the ocular surface disease index (OSDI), visual analog pain score (VAS), reporting of the severity and frequency of symptoms, and the modified Standardized Patient Evaluation of Eye Dryness (SPEED) questionnaire were also analyzed. The records of 47 patients were analyzed for this study. The mean age was 62.8 ± 9.3 years, and the patients included 9 males and 38 females. TBUT, OSDI, and VAS significantly improved after CA administration compared to before (p < 0.05, paired t-test). After CA administration, symptom frequency and impact on life improved (p < 0.05, paired t-test). No significant change in photophobia or FSS was identified. In conclusion, oral CA administration was effective in improving tear stability and alleviating symptoms of KCS.

Effectiveness of Mediterranean Diet Implementation in Dry Eye Parameters: A Study of PREDIMED-PLUS Trial

The purpose of this study is to evaluate the effect of a Mediterranean diet supplemented with extra virgin olive oil and nuts on dry eye parameters. The participants in this study were randomized into one of the two interventional arms: (1) a standard intervention group, a Mediterranean diet supplemented with extra virgin olive oil and nuts; and (2) an intensive intervention group, based on a hypocaloric Mediterranean diet and an intensive lifestyle program with physical activity and weight-loss goals. In both groups, common dry eye tests were conducted at baseline and after six months: the Ocular Surface Disease Index (OSDI), the Dry Eye Scoring System (DESS), tear break-up time (TBUT), the Schirmer's test, and the Oxford staining grade. Sixty-seven eyes were examined. After six months, dry eye parameters improved in both groups; differences between groups were favorable for the intensive intervention group. The implementation of a Mediterranean diet pattern was beneficial for the selected patients with dry eye, and could be beneficial for patients with dry eye in general. Behavioral support for diet adherence and the promotion of healthy lifestyles (exercise) and weight loss (calorie restriction) have an added positive effect.

Association between vitamin D and dry eye disease: A systematic review and meta-analysis of observational studies

PURPOSE

A number of studies have examined the association between vitamin D and dry eye disease in different populations, but findings are inconclusive. Herein, available observational studies were systematically reviewed to elucidate the overall relationship between vitamin D and dry eye disease among adult population.

METHODS

PubMed, Scopus, Google scholar and ISI web of science databases were searched until January 2020 for studies assessing the association between vitamin D and dry eye disease. The Newcastle-Ottawa Quality Assessment Scale was used to examine the quality of each study.

RESULTS

A total of 14 studies out of 252 met the inclusion criteria and were included in this systematic review and meta-analysis. Serum 25(OH) D3 was lower in dry eye disease subjects compared to healthy ones (WMD -5.93; 95 % CI, -7.47 to -4.40; P < 0.001) with evidence of significant heterogeneity (I² = 94.6 % p < 0.001). Also, in final analysis, vitamin D correlated significantly with ocular surface disease index (Fisher's Z: -0.26; 95 % CI, -0.48 to -0.04; P = 0.018), with significant heterogeneity between studies (I² = 59.3 %, P = 0.043).

CONCLUSION

It was found that serum vitamin D had a significantly lower level in dry eye disease patients, and correlated with ocular surface disease index but no other dry eye disease parameter. The findings add to the existing literature supporting the concept that nutrition especially vitamin D plays an important role in human eye health. Prospective studies are needed to confirm this relationship.

Omega-3 and omega-6 polyunsaturated fatty acids for dry eye disease

BACKGROUND

Polyunsaturated fatty acid (PUFA) supplements, involving omega-3 and/or omega-6 components, have been proposed as a therapy for dry eye. Omega-3 PUFAs exist in both short- (alpha-linolenic acid [ALA]) and long-chain (eicosapentaenoic acid [EPA] and docosahexaenoic acid [DHA]) forms, which largely derive from certain plant- and marine-based foods respectively. Omega-6 PUFAs are present in some vegetable oils, meats, and other animal products.

OBJECTIVES

To assess the effects of omega-3 and omega-6 polyunsaturated fatty acid (PUFA) supplements on dry eye signs and symptoms.

SEARCH METHODS

CENTRAL, Medline, Embase, two other databases and three trial registries were searched in February 2018, together with reference checking. A top-up search was conducted in October 2019, but the results have not yet been incorporated.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) involving dry eye participants, in which omega-3 and/or omega-6 supplements were compared with a placebo/control supplement, artificial tears, or no treatment. We included head-to-head trials comparing different forms or doses of PUFAs.

DATA COLLECTION AND ANALYSIS

We followed standard Cochrane methods and assessed the certainty of the evidence using GRADE.

MAIN RESULTS

We included 34 RCTs, involving 4314 adult participants from 13 countries with dry eye of variable severity and etiology. Follow-up ranged from one to 12 months. Nine (26.5%) studies had published protocols and/or were registered. Over half of studies had high risk of bias in one or more domains. Long-chain omega-3 (EPA and DHA) versus placebo or no treatment (10 RCTs) We found low certainty evidence that there may be little to no reduction in dry eye symptoms with long-chain omega-3 versus placebo (four studies, 677 participants; mean difference [MD] -2.47, 95% confidence interval [CI] -5.14 to 0.19 units). We found moderate certainty evidence for a probable benefit of long-chain omega-3 supplements in increasing aqueous tear production relative to placebo (six studies, 1704 participants; MD 0.68, 95% CI 0.26 to 1.09 mm/5 min using the Schirmer test), although we did not judge this difference to be clinically meaningful. We found low certainty evidence for a possible reduction in tear osmolarity (one study, 54 participants; MD -17.71, 95% CI -28.07 to -7.35 mOsmol/L). Heterogeneity was too substantial to pool data on tear break-up time (TBUT) and adverse effects. Combined omega-3 and omega-6 versus placebo (four RCTs) For symptoms (low certainty) and ocular surface staining (moderate certainty), data from the four included trials could not be meta-analyzed, and thus effects on these outcomes were unclear. For the Schirmer test, we found moderate certainty evidence that there was no intergroup difference (four studies, 455 participants; MD: 0.66, 95% CI -0.45 to 1.77 mm/5 min). There was moderate certainty for a probable improvement in TBUT with the PUFA intervention relative to placebo (four studies, 455 participants; MD 0.55, 95% CI 0.04 to 1.07 seconds). Effects on tear osmolarity and adverse events were unclear, with data only available from a single small study for each outcome. Omega-3 plus conventional therapy versus conventional therapy alone (two RCTs) For omega-3 plus conventional therapy versus conventional therapy alone, we found low certainty evidence suggesting an intergroup difference in symptoms favoring the omega-3 group (two studies, 70 participants; MD -7.16, 95% CI -13.97 to -0.34 OSDI units). Data could not be combined for all other outcomes. Long-chain omega-3 (EPA and DHA) versus omega-6 (five RCTs) For long-chain omega-3 versus omega-6 supplementation, we found moderate certainty evidence for a probable improvement in dry eye symptoms (two studies, 130 participants; MD -11.88, 95% CI -18.85 to -4.92 OSDI units). Meta-analysis was not possible for outcomes relating to ocular surface staining, Schirmer test or TBUT. We found low certainty evidence for a potential improvement in tear osmolarity (one study, 105 participants; MD -11.10, 95% CI -12.15 to -10.05 mOsmol/L). There was low level certainty regarding any potential effect on gastrointestinal side effects (two studies, 91 participants; RR 2.34, 95% CI 0.35 to 15.54).

AUTHORS' CONCLUSIONS

Overall, the findings in this review suggest a possible role for long-chain omega-3 supplementation in managing dry eye disease, although the evidence is uncertain and inconsistent. A core outcome set would work toward improving the consistency of reporting and the capacity to synthesize evidence.

The Effect of Periocular Fatty Acids and 0.15% Hyaluronate Eye Drops Application on Keratoconjunctivitis Sicca in Dogs: An Exploratory Study

The aim of this exploratory study was to evaluate the efficacy of a periophthalmic cream of a pool of fatty acids (FAG®) in association with 0.15% hyaluronate eye drops in alleviating the clinical symptoms of keratoconjunctivitis sicca (KCS) in a case series of dogs. The study was conducted on 10 dogs diagnosed with idiopathic KCS. All dogs had been previously treated with topical tobramycin alone, which had been ineffective in improving clinical signs. The affected eyes were treated with 2 applications daily of a periophthalmic cream of FAG® and 1 drop 3 times a day of 0.15% of hyaluronate eye drops for 8 weeks. Schirmer tear test I (STT I) values were recorded and ocular signs (conjunctival hyperemia, ocular discharge, corneal opacity, vascularization and pigmentation, and discomfort level) were collected, scored on a 3-point scale (grade 0, grade 1, and grade 2). Differences between scores and STT data recorded at baseline and at 8 weeks of therapy were statistically analysed. The effect of treatment was pronounced (increase in STT values by more than 4 mm/min, no signs of inflammation) in 8/18 eyes; moderate (increase in STT values of 3-4 mm/min or mild improvement in signs of corneal/conjunctival inflammation) in 3/18 eyes; and unsatisfactory in 7 of 18 eyes. Median of STT values significantly improved compared with baseline levels, while statistically significant decreases in clinical-sign scores of conjunctival hyperemia, ocular discharge, and discomfort were recorded. However, in moderate and advanced stages, reduction of neovascularization or corneal pigmentation was not observed throughout the treatment period. No noticeable adverse reactions were recorded. Preliminary results indicate that the application of periocular FAG and topical 0.15% hyaluronate eye drops may be a suitable treatment for KCS in dogs in selected cases. A larger comparative study is necessary to further confirm these findings.

Recent advances of medical foods in China: The opportunities and challenges under standardization

Malnutrition with high incidence in hospitalized patients in China has brought a significant burden of disease. Although many clinical studies have demonstrated the importance of nutritional for patients with malnutrition, the application of medical foods in China is still restricted. For the classification, limits, production and registration of medical foods, the Chinese government newly enacted a series of regulations. In this review, comparing the policy, researches, and product variety of medical foods in China with other countries, although the current status of the development of medical foods in China is still far behind that of developed countries, some of regulations are stricter than those of many other countries or organizations. The medical foods in China are divided into four categories, the nutrients and environmental contaminants are limited to ensure the safety. As a prospect, the development of medical foods in China is expected to get out of the predicament of lack of emphasis, shortage of supply, backward of local processing technology and the imperfect management system. After all, in view of the huge population and the increasing demand of nutrition in China, there must be a very good prospect for the future development of the medical foods industry in China.

Efficacy of nutritional supplementation with omega-3 and omega-6 fatty acids in dry eye syndrome: a systematic review of randomized clinical trials

PURPOSE

To critically appraise scientific evidence regarding the efficacy of nutritional supplementation with omega-3 and omega-6 fatty acids for the treatment of dry eye syndrome (DES).

METHODS

A systematic review of randomized clinical trials was performed. Two independent reviewers selected and analysed the scientific papers that met inclusion and exclusion criteria. Objective and subjective efficacy outcomes were assessed.

RESULTS

The trials involved a total of 2591 patients in fifteen independent studies. All studies were published between 2005 and 2015. The supplements used were mostly omega-3 and omega-6 in different proportions. Subjective improvement was measured using mainly Ocular Surface Disease Index (OSDI) test and Dry Eye Severity Score (DESS) test: significant differences in favour of the experimental group were found in seven of the studies. The objective amelioration was assessed by lacrimal function parameters: Tear break-up time (TBUT) significantly increased in nine studies and Schirmer's test in four studies.

CONCLUSION

We observed a discrete improvement in the parameters of tear function. Scientific evidence is not strong enough to systematically recommend the use of omega-3 and omega-6 fatty acids as a standalone treatment of DES independently from its aetiology. However, they could be considered as an effective alternative to topical treatment in patients with DES secondary to certain pathologies.

Comparison of Topical Cyclosporine and Diquafosol Treatment in Dry Eye

PURPOSE

To compare the treatment effects of topical cyclosporine A (CsA) and diquafosol sodium (DQS) for the treatment of moderate to severe dry eye disease (DED).

METHODS

This prospective, nonrandomized, comparative study involved 60 eyes of 60 patients with moderate to severe DED who were treated with topical CsA 0.05% (group 1, 31 patients) or DQS 3% (group 2, 29 patients) in addition to artificial tears for 3 months. Before treatment, and at 1 and 3 months after treatment, the Ocular Surface Disease Index, tear breakup time, Schirmer score, tear clearance rate, and corneal and conjunctival staining scores were compared.

RESULTS

Significant improvements in Ocular Surface Disease Index score, tear clearance rate, and corneal staining score were observed 1 month after treatment in group 2 (p = 0.014, p = 0.002, and p < 0.001, respectively), when compared with group 1. However, no significant differences were observed between the two groups 3 months after treatment (p > 0.05). Tear breakup times were significantly higher in group 2 compared with group 1 for the duration of the study (p < 0.001). Three months after treatment, Schirmer score was significantly higher and conjunctival staining score was significantly lower in group 1 compared with group 2 (p < 0.001).

CONCLUSIONS

Both topical CsA 0.05% and DQS 3% are effective in patients with moderate to severe DED. However, the timing and degree of therapeutic effects on tear film and ocular surface parameters, as well as symptoms, can be different between the two treatments.

Efficacy and Safety of Topical 0.05% Cyclosporine Eye Drops in the Treatment of Dry Eye Syndrome: A Systematic Review and Meta-analysis

A systematic review was performed to evaluate the safety and efficacy of topical 0.05% cyclosporine in treating patients with dry eye syndrome (DES). Twelve qualified randomized-controlled trials incorporating 1367 patients were analyzed. In comparison to controls, patients who were on topical 0.05% cyclosporine eye drops had lower Ocular Surface Disease Index scores (mean difference [MD]=4.10, 95% CI: 0.25-7.96, P=.04), longer tear film breakup time (MD=2.30 seconds, 95% CI: 0.75-3.86, P=.004), improved Schirmer I scores (MD=2.77 mm/5min, 95% CI: 1.63-3.91, P=.00001), reduced corneal fluorescein staining (standardized mean difference [SMD]=0.61, 95% CI: 0.07-1.15, P=.03), and higher goblet cell densities (SMD=1.68, 95% CI: 0.54-2.81, P=.004). However, there were more adverse effects in the cyclosporine patient group (odds ratio=1.64, 95% CI: 1.17-2.30, P=.004). Topical 0.05% cyclosporine eye drops twice daily significantly improved both the objective and subjective outcomes in DES patients. The study limitations in the clinical, methodological and statistical heterogeneities are discussed.

Essential fatty acids in the treatment of dry eye syndrome: A myth or reality?

Dry eye is a common condition that can severely impair the quality of life. Systemic and topical omega-3 fatty acids and omega-6 fatty acids have been used as treatment for patients with dry eye disease and showed promising results. Further multicenter randomized controlled trials are required in order to establish a standardized protocol for the treatment of dry eye syndrome with those essential fatty acids.

Red blood cell fatty acid analysis for determining compliance with omega3 supplements in dry eye disease trials

PURPOSE

To evaluate pill counts and red blood cell (RBC) membrane fatty acid profiles as measures of compliance with oral omega3 polyunsaturated fatty acids (ω3 PUFAs) and to compare the two techniques.

METHODS

Sixteen dry eye disease subjects were given oral ω3 PUFA or placebo for 3 months. Compliance was measured by pill counts and blood tests at baseline and 3 months. The Wilcoxon signed-rank tests and rank-sum tests were used to compare changes from baseline and the difference between the two groups; Spearman correlation coefficients were used to assess the relationship of pill counts to changes in blood FAs.

RESULTS

Pill counts for the ω3 (n=7) and placebo (n=9) groups showed a mean consumption of 4.39 and 4.76 pills per day, respectively. In the ω3 group, the median change from baseline was +1.46% for eicosapentaenoic acid (EPA) (P=0.03), +1.49% for docosahexaenoic acid (DHA) (P=0.08), and -1.91% for arachidonic acids (AA) (P=0.02). In the placebo group, median changes in all measured FAs were small and not statistically significant. The difference in change in FA levels between the two groups was significantly greater for EPA (P=0.01) and AA (P=0.04). The correlations between pill counts and changes in EPA (r=0.36, P=0.43) and DHA (r=0.17, P=0.70) were not strong.

CONCLUSIONS

RBC FA analysis can be used to measure compliance in the active group and also monitor the placebo group for nonstudy ω3 intake. Low correlation of pill counts with blood levels suggests that pill counts alone may be inaccurate and should be replaced or supplemented with objective measures.

Involvement of pigment epithelium-derived factor, docosahexaenoic acid and neuroprotectin D1 in corneal inflammation and nerve integrity after refractive surgery

Alterations in corneal innervations result in impaired corneal sensation, severe dry eye and damage to the epithelium that may in turn lead to corneal ulcers, melting and perforation. These alterations can occur after refractive surgery. We have discovered that pigment epithelium-derived factor (PEDF) plus docosahexaenoic acid (DHA or the docosanoid bioactive neuroprotectin D1 (NPD1)) induces nerve regeneration after corneal surgery that damages the stromal nerves. We found that PEDF is released from corneal epithelial cells after injury, and when DHA is provided to the cells it stimulates the biosynthesis of NPD1 by an autocrine mechanism. The combination of PEDF plus DHA also decreased the production of leukotriene B4 (LTB4), a neutrophil chemotactic factor, thereby decreasing the inflammation induced after corneal damage. These studies suggest that PEDF plus DHA and its derivative NPD1 hold promise as a future treatment to restore a healthy cornea after nerve damage.