This article was originally published in a sponsored newsletter.

Dry eye disease (DED) is a multifactorial condition that affects millions of people in the United States. In fact, a recent survey shows that 150 million Americans have dry eye symptoms.¹ Considering that ODs perform around 88 million comprehensive exams every year per the AOA,² these patients are already coming into our offices. The symptoms they experience—such as fluctuating vision, discomfort, dryness and even end-of-day fatigue—have a significant effect on their vision and reduce their quality of life and productivity. Interventional methods and topical prescriptions alongside lubricating drops play a vital role in managing symptoms and disease, but what about treating the whole patient from the inside out? Nutritional approaches offer a complementary strategy that not only promotes overall health, but also focuses on the underlying mechanisms that contribute to dry eye to prevent and treat it.

Omega Fatty Acids

One of the most-studied nutritional interventions for DED is the supplementation of omega fatty acids, primarily eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA). Newer formulations that have been studied specifically in DED patients also contain gamma linolenic acid (GLA), which is found in black currant seed oil. GLA and EPA are effective precursors of anti-inflammatory compounds and have been shown to be beneficial in reducing the inflammation associated with DED. Studies have shown that regular intake of omegas including GLA can improve the lipid layer of the tear film and overall tear stability, and reduce tear evaporation.^3-9 Sources of omegas include fatty fish such as salmon, mackerel and sardines, as well as flaxseed, chia seeds and walnuts.

Antioxidants and Vitamins for Oxidative Stress

An imbalance between free radicals and antioxidants in the body can lead to cellular damage due to reactive oxygen species, both in the eyes and on the ocular surface. Antioxidants play a critical role in neutralizing these free radicals and protecting both the ocular surface and the macula from this oxidative stress. Vitamins A, C, D and E, plus lutein, zeaxanthin and zinc, are powerful antioxidants that have been studied for their protective effects on eye health.¹⁰

Vitamin A is crucial for maintaining a healthy ocular surface and normal tear production. Deficiency can lead to a condition known as xerophthalmia, which is characterized by severe dryness of the eyes and can progress to corneal ulcers and blindness if untreated. Patients often present with Bitot’s spots.¹¹ Foods rich in vitamin A include liver, carrots, sweet potatoes and dark leafy greens. A topical ointment containing Vitamin A has been particularly useful in my patient population with DED.

Vitamins C and E, both potent antioxidants, help protect the eyes from oxidative damage and support the health of blood vessels in the eyes. Vitamin D has natural anti-inflammatory effects, but many Americans are deficient in it. Curcumin, a compound found in turmeric, has anti-inflammatory effects as well. It’s not typically absorbed, but micronized curcumin improves the bioavailability of newer vitamin D formulations. One newly available formulation that showed improvement in DED symptoms and signs combines Vitamin D, curcumin, lutein, and zeaxanthin.¹²

Role of Hydration

Adequate hydration is fundamental to maintaining the body's overall health. In eye health, dehydration can lead to reduced tear production and exacerbate the symptoms of DED. Be suspicious of Sjogren’s when a patient consumes water constantly. Their water consumption may be indicative of dry mouth and DED combined with joint pain.¹³

Emerging Nutraceuticals

These supplements should be part of your armamentarium in managing and treating DED, but be sure to thoroughly vet products with evidence-based information to make recommendations.

Conclusion

Nutrition plays a critical role in the management and prevention of DED. Omega fatty acids, antioxidants, vitamins and adequate hydration are key components of a diet that supports eye health. As research in this area continues to evolve, nutritional strategies may become increasingly integrated into the standard care for DED to offer a holistic approach for managing this common and often debilitating condition.

References:

1. Calculated from Gallup Multi-Sponsor Surveys, 2022. Incidence of Dry Eyes in US Adult Population. N = 1,039.
2. Wilson FA, Stimpson JP, Wang Y. Inconsistencies exist in national estimates of eye care services utilization in the United States. J Ophthalmol. 2015 Aug;435606. doi:10.1155/2015/435606
3. Sheppard Jr 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 Oct;32(10):1297-1304. doi:10.1097/ICO.0b013e318299549c
4. 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 Mar;22(2):97–101. doi:10.1097/00003226-200303000-00002
5. Macrì A, Guiffrida S, Amico V, Iester M, Traverso CE. 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 Jul;241(7):561-566. doi:10.1007/s00417-003-0685-x
6. Aragona P, Bucolo C, Spinella R, Giuffrida S, Ferreri G. Systemic omega-6 essential fatty acid treatment and pge1 tear content in Sjögren's syndrome patients. Invest Ophthalmol Vis Sci. 2005 Dec;46(12):4474-4479. doi:10.1167/iovs.04-1394
7. Kokke KH, Morris JA, Lawrenson JG. Oral omega-6 essential fatty acid treatment in contact lens associated dry eye. Contact Lens Anterior Eye. 2008 Jun;31(3):141-146. doi:10.1016/j.clae.2007.12.001
8. Pinna A, Piccinini P, Carta F. Effect of oral linoleic and gamma-linolenic acid on meibomian gland dysfunction. Cornea. 2007 Apr;26(3):260-264. doi:10.1097/ICO.0b013e318033d79b
9. 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 Nov;89(7):e591-597. doi:10.1111/j.1755-3768.2011.02196.x
10. Choo PP, Woi PJ, Bastion M-LC, Omar R, Mustapha M, Md Din N. Review of evidence for the usage of antioxidants for eye eging. Biomed Res Int. 2022 Oct 3;2022:5810373. doi:10.1155/2022/5810373
11. Das S, Chandra A. Bitot spots: a pathognomonic sign of vitamin A deficiency. Am J Med. 2023 Oct;136(10):e195-e196. doi:10.1016/j.amjmed.2023.05.020
12. Giola N, Gerson J, Ryan R, et al. A novel multi-ingredient supplement significantly improves ocular symptom severity and tear production in patients with dry eye disease: results from a randomized, placebo-controlled clinical trial. Front Ophthalmol (Lausanne). 2024 Apr. doi:10.3389/fopht.2024.1362113
13. Bjordal O, Norheim KB, Rødahl E, Jonsson R, Omdal R. Primary Sjögren's syndrome and the eye. Surv Ophthalmol. 2020 Mar-Apr;65(2):119-132. doi:10.1016/j.survophthal.2019.10.004