Millions of Americans are affected by dry eyes, making up 8.1% of the US population.1 Its widespread presence has grown so much that you can almost expect to diagnose it daily as a professional eyecare provider. More often than not, dry eye syndrome interferes with the everyday lives of patients, even impairing work functioning.2
With the impending prevalence and chronicity of the condition, our approaches in preventing and treating dry eye have drastically changed, whether it be novel technologies or personalized situational changes.
Here we will piece together the role of nutraceuticals in healthcare, as well as within eyecare, as therapeutics that improve overall health, including that of the ocular surface in dry eye patients.
Be in the know: Nutraceuticals
Originating in the 1980s, the term “nutraceuticals” combines both nutrition and pharmaceuticals.3 Nutraceuticals are biologically active therapeutics that can modulate immunity to provide optimal benefits to overall health.
Although they are not considered “alternative therapy” to pharmaceuticals, they play a role in preventative healthcare and supportive therapy to minimize side effects or symptoms, typically coming with a good safety profile.
Figure 1 highlights how nutraceuticals, which are comprised of biologically active nutrients, herbal substances, or dietary supplements, sit at the intersection of nutrition and pharmaceuticals.
Nutrition therapy research
Elements of functional nourishment are utilized after establishing clinical relevance. The nutritional bio-active components of nutraceuticals include but are not limited to herbs, vitamins, proteins, minerals, fat, fiber, and amino acids.4
Studies have shown how biologic molecules in nutraceuticals have:4
- Lowered cardiovascular disease complications
- Allowed for healthier low-density lipoprotein (LDL) ratios
- Suppressed inflammation in conditions such as asthma, atherosclerosis, rheumatoid arthritis
- Provided better vibrancy of skin texture and properties
Research has also been proven successful in benefits for diabetes, hypertension, sleeping disorders, and depression.5 Certain nutraceuticals have therapeutic properties that have been effectively preventing and controlling malignancies as adjunct therapies in cancer treatments of chemo- and radiotherapy. The anti-carcinogenic properties not only improve outcomes of treatment but also diminish side effects.5
Developments in nutraceuticals for ocular health
Research and development regarding nanotechnology has been advantageous for the nutraceutical industry. Nanomolecules accommodate improved chemical stability and bioavailability while minimizing side effects to achieve better performance and outcomes.5
The role of nutraceuticals in consumer health is surrounded by the importance of having evidence-based studies due to their medical effects.
Nutraceuticals and dry eye
Dry eye may occur with irregularities in quantity or quality of the tear film, causing injury to the cornea, conjunctiva, and surrounding glands. Poor blinking function, dysfunction of meibomian glands, or unstable tears may cause an imbalanced ratio of fatty oils, water, mucus, and proteins which are necessary for the appropriate anterior segment health.
Learning how we can keep a fortified ocular surface with the use of nutraceuticals is worthwhile to ensure we provide the best treatment and management options for patients.
Anti-inflammatory nutraceuticals and dry eye
There are four key nutraceuticals that have been researched in regard to dry eye disease (DED):
- Antioxidants
- Omega-3 fatty acids
- Vitamins
- Minerals
Studies have been completed to determine the benefits of using antioxidants and essential polyunsaturated fatty acids (EPUFAs) in the realm of dry eye. In one study, patients with non-severe dry eyes were provided with both antioxidants and EPUFAs for 3 months.6 Results showed how this joint treatment lowered immune response mediators in the tear levels-altering interleukin and vascular endothelial growth factor expression.
In fact, subjective improvements in symptoms were noteworthy due to benefits to quality of life in non-severe dry eye patients as well as non-dry eye patients. Further an improvement of 50% or greater was reported in the following: visual fatigue, ocular heaviness, and improved eyelashes, nails, hair, and skin.6
Among the nutritional ingredients analyzed in the study was a combination of omegas (docosahexaenoic acid [DHA] 350mg and eicosapentaenoic acid [EPA] 42.5mg). These nutraceuticals with antioxidants and EPUFAs herein provide a space in dry eye management as a possible conjunction therapy.
Table 1 is a breakdown of the oral nutraceutical formulation provided to patients in the aforementioned study.6
| Nutrient | Amount |
|---|---|
| DHA | 350mg |
| EPA | 42.5mg |
| Vitamin A | 133.3μg |
| Vitamin C | 26.7mg |
| Vitamin E | 4mg |
| Tyrosine | 10.8mg |
| Cysteine | 5.83mg |
| Glutathione | 2mg |
| Zinc | 1.6mg |
| Copper | 0.16mg |
| Manganese | 0.33mg |
| Selenium | 9.17μg |
| Docosapentaenoic acid (DPA) | 30mg |
Table 1: Courtesy of Pinazo-Duran et al.
Dry eye and omega-3 nutraceuticals
A prospective dry eye study was completed to consider the nutraceutical benefits of omega-3 fatty acids, vitamins, minerals, and antioxidants with a 12-week analysis.7 Dry eye patient signs varied from mild conjunctival injection to moderate to severe dryness.
The study concluded that the use of oral omega-3 fatty acids significantly diminished the need to use artificial tears, ameliorated dry eye symptoms, and resulted in better Schirmer scores and tear breakup time (TBUT) findings.7 They found that omega-3 fatty acids promote a better equilibrium for the tear film, blocking pro-inflammatory particles such as eicosanoids and reducing cytokines.7
Nutraceutical compound benefits
Table 1 lists the demonstrated health benefits of various nutraceuticals.4,5,8,9
| Category | Nutraceutical | Demonstrated Health Benefits |
|---|---|---|
| Fatty Acids | Omega-3 polyunsaturated fatty acids (EPA, DHA) | Appetite, reduces chemotherapy toxicity, regulates ocular surface inflammation |
| Monounsaturated fatty acids and polyunsaturated fatty acids | Reduces chance of coronary heart disease | |
| Vitamin/Macro- or Micronutrient | Vitamin A | Skin, mucus membranes, vision, anti-cancer, antioxidant, regulates ocular surface inflammation |
| Vitamin C | Wound healing, antioxidant | |
| Vitamin D | Calcium absorption and regulates ocular surface inflammation | |
| Folic acid | Formation of red blood cell (RBC) | |
| Inositol | Movement of K and Na, transport of amino acids | |
| 2-fucosyl-lactose | Tear film stability | |
| Minerals | Zinc | Wound healing, child development |
| Calcium | Bone strength, glandular function | |
| Plants | Aloe vera | Acute dermatitis |
| Seaweed | High-density lipoprotein (HDL) cholesterol | |
| Coenzyme Q-10 | Skin | |
| Ginseng | Skin homeostasis | |
| Echinacea | Antidepressant, anti-anxiety | |
| Collagen peptides | Bioactive collagen peptide | Significant decrease in the eye-wrinkle volume |
Table 2: Courtesy of the author.
Omega-3 fatty acids for dry eye and ocular health
Diving into the anti-inflammatory mechanisms of omega-3 fatty acids, we should consider the root causes of our dry eye patients. Many times, it is notable to have components of both evaporative and aqueous deficient dry eye findings.
Benefits to meibomian gland dysfunction (MGD) have been established as advantageous by improving the quality of meibum composition, TBUT, and patient symptoms.10,11 Among the aqueous deficient population, Sjögren’s disease patients have higher inherent tumor necrosis factor alpha (TNF-α) levels, and omega 3 suppresses TNF-α production.12,13
Although it is important to note that genetics plays a role, studies found that there were better responses to certain lymphotoxin alpha (LT-α) genotypes compared to others.12 Overall, the use of omegas in dry eye has subjective improvements, better Ocular Surface Disease Index (OSDI) scores, and higher TBUT values.10
Deeper dive into vitamin A and vitamin D
Essential vitamins are organic nutrients that can be obtained in the diet. In eyecare, vitamin A is typically at the forefront of common knowledge for ocular health, containing retinol and carotene. Vitamin A plays a crucial role in dry eye due to its presence in tears as retinol, by sustaining the kerato-conjunctival junction, and by repairing conjunctival goblet cells.14
Vitamin D receptors are found in many ocular structures including the cornea, lens, ciliary body, and retina).15 On the ocular surface, vitamin D preserves the ocular surface osmolarity and is anti-inflammatory—therein a great target in patients with abnormal tear hyperosmolarity.15
Vitamin-rich foods that are beneficial for eye health
The list below outlines vitamin-rich foods that are especially important for optimal eye health.9,10,11
Foods rich in vitamin A:
- Shrimp
- Sweet potatoes
- Carrots
- Pumpkin
- Mango
- Broccoli
- Red pepper
Foods rich in vitamin D:
- Salmon
- Swordfish
- Tuna
- Sardines
- Raw oysters
- Oranges
- Portabella or morel mushrooms
Food rich in both vitamins A and D:
- Cod liver oil
- Beef liver
- Egg
- Fortified milk, dairy, juice, or cereal
- Cheese
- Spinach
Implementing nutraceuticals into clinical practice
When recommending the appropriate over-the-counter (OTC) therapeutics, we tend to consider the appropriate artificial tear viscosity, avoid ocular redness drops, and preservative-free options. Other therapies may include warm compresses, eyelid scrubs, and sleeping masks.
Integrating nutraceuticals may be an effective therapy to maximize your dry eye treatment. The anti-inflammatory modulation can be the push to provide relief to symptoms and tear film stability—especially if you infer that the patient is proactively health conscious.
There are four biologic molecules associated with DED, including:
- Omega-3 (EPA, DHA): Blocks proinflammatory factors in imbalance tear film.6,7,10,13
- Vitamin D: Improves regulation of disrupted ocular surface.9,15,16
- Vitamin A: Promotes corneal and conjunctival health.14,18
- Bioactive Collagen Peptide (BCP): Possible integumentary and corneal benefits.8
Example patient conversation on dry eye nutraceuticals
“What would I feel if I got dry eyes?”
Dry eye symptoms vary greatly from patient to patient and can include redness, foreign body sensation, burning, eyelid heaviness, transient blurry vision that improves with blinking, or episodic tearing with dryness.
Approaching dry eye from various therapeutic angles may assist in establishing a healthy ocular surface structure.
“Why do I have dry eyes?”
Dry eye is typically more prevalent with age, especially over 50, but with increases in digital device demands, even younger patients are facing signs and symptoms that can begin with eye strain and ocular fatigue.
It can be exacerbated by ocular surgery, abuse of contact lens wear, poor environmental conditions, certain medications, and underlying medical, hormonal, or autoimmune disorders.
“Are there any everyday habits I can change?”
Reviewing how behavioral practices can improve dry eye symptoms can lead to impressive results. Be sure to highlight appropriate blinking habits, such as the 20-20-20 rule with prolonged near-work.
Staying hydrated and cessation of smoking are vital. In addition, anti-inflammatory dietary changes are helpful. The addition of a humidifier may be recommended, and it is also advisable to advocate for wearing sunglasses to avoid allergens and wind as well as for ultraviolet (UV) protection.
“What are nutraceuticals and how can they help?”
Nutraceuticals are a type of therapeutic composed of bio-active nutrients such as vitamins, herbal, or dietary supplements, that provide a health benefit.
They can boost immune function by nurturing a healthier ocular surface. Certain nutraceuticals are anti-inflammatory, and this is the goal we target for supportive therapy in dry eye, as well as being a preventative measure of tear film stability.
“Are there any side effects to nutraceuticals?”
The broad safety profile and tolerability are great compared to customary pharmaceuticals. It may be advised to get clearance from the patient’s primary care provider and pharmacy to avoid any potential drug interactions or harmful effects.19
“Should I continue using my dry eye prescription with the nutraceuticals?”
Generally speaking, using nutraceuticals is an additive therapy. Although it depends from patient to patient, continue treatment as directed by your eye doctor.
Certain concurrent therapies may include but are not limited to cyclosporines such as Restasis, Xiidra, and Cequa, even Tyrvaya or FDA-approved treatments such as OptiLight that promote meibomian gland stimulation and regression of unhealthy vessels.
“What nutraceutical ingredients could benefit eye health?”
Overwhelming research shows how omega-3 (EPA, DHA) proves to be anti-inflammatory. Vitamin D is effective in ocular surface improvement for dry eye patients, and vitamin A keeps corneal epithelium and conjunctival goblet cells in harmony.20
Bioactive collagen peptides may be a future area of promise due to the restorative corneal and ocular adnexa benefits found in current research.8
“How exactly can I get these ocular nutrients in my diet?”
The Mediterranean diet is high in naturally occurring fatty acids and includes vitamin A benefits. It thrives on whole grain foods, fruits, vegetables, legumes, nuts, and fish.11,21
Being cognizant of anti-inflammatory options can promote healthier ocular health, especially in rosacea patients by avoiding refined sugars and alcohol.22
Choosing dietary supplements or sources with a great profile of nutritional value is helpful. Among many, some options to consider are HydroEye, Pro-Omega, or DE3.
Key takeaways
Nutraceuticals allow us to be proactive about the prevention of pathological disorders. They are not necessarily novel therapeutics but a remarkable tool we can use to target dry eye syndrome’s multifactorial causes.
In your dry eye practice, whether nutraceuticals are an adjunct therapy, a possible consideration in pregnant patients, or certain patients who need high safety profile options, they are making a footprint on how we treat and care for our patients.
Consider nutraceuticals for:
- Adjunct dry therapy
- Health conscious population
- Immunocompromised patients
- Pregnant patients
Staying well-rounded on dry eye treatment is imminent with how widespread the syndrome has become. We have to understand that patients are more health-conscious now and are welcome to learn about lifestyle changes they can make to be healthier and to live their lives with minimal effects on quality of life.
