The role of oral long chain omega-3 supplements for treating dry eye disease

© 2017 Laura Adelaide DeinemaDry eye disease (DED) is a highly prevalent multifactorial eye condition. While traditional therapies, such as ocular lubricants, provide symptomatic relief for dry eye sufferers, they do not treat the inflammatory overlay found in DED. Omega-3 (ω-3) essential fatty acid (EFA) supplements show promise as a potential treatment for DED. The major aim of this thesis was to compare the efficacy of two forms of long chain ω-3 EFAs, stored primarily as either triacylglycerides (fish oil) or as phospholipids (krill oil), for treating DED. In this regard, a randomised, placebo-controlled, double-masked, three-arm, parallel- group clinical trial was conducted. Sixty participants with clinically significant DED-related symptoms were enrolled for a three-month study. In addition this thesis aimed to determine the effects of elevated tear osmolarity on central corneal thickness (CCT) and corneal reflectivity. In a cross-sectional study involving 38 participants with hyperosmolar tears and 10 age-similar controls with normo-osmolar tears, anterior-segment optical coherence tomography (OCT) was used to detect subtle corneal microstructural changes that occur in association with tear hyperosmolarity. This study aimed to examine the effects of elevated tear osmolarity on central corneal thickness (CCT); and to measure the effects of elevated tear osmolarity and corneal reflectivity. Central corneal thickness (CCT) of participants with severely hyperosmolar tears (defined as eyes in the upper quartile for tear hyperosmolarity, 539.1 ± 7.4 µm) was found to be less than those with mildly hyperosmolar tears (defined as hyperosmolar eyes in the lower quartile for tear hyperosmolarity, 622.7±5.8 µm, p<0.0001) and control eyes (583.1 ± 15.0 µm, p = 0.02). Central corneal reflectivity (45.1 ± 0.3 versus 48.1 ± 0.6 greyscale units, p = 0.02) was relatively lower and peak tear film reflectivity higher (by 4.8% ± 3.5%, p = 0.04) in eyes with hyperosmolar tears than eyes having normo-osmolar tears. In order to test the relative efficacy of two forms of long-chain ω-3 EFA supplements over a three month intervention period, a randomised, placebo-controlled, double-masked, three-arm, parallel-group clinical trial was conducted. Sixty participants with clinically significant DED-related symptoms (Ocular Surface Disease Index Score (OSDI) score of 18-64) and tear hyperosmolarity (≥ 316 mOsmol/L) were randomly allocated (1:1:1) to one of three groups: triacylglyceride ω-3 EFAs (1000 mg/day eicosapentaenoic acid, EPA + 500 mg/day docosahexaenoic acid, DHA), phospholipid ω-3 EFAs (945 mg/day EPA, + 510 mg/day DHA) or placebo (1500 mg/day of olive oil). Primary outcome measures were: mean change in tear osmolarity and OSDI score from baseline (Day 1) to Day 90. Secondary outcomes included: mean change in key clinical signs of DED (ocular surface staining, ocular redness, meibomian gland integrity, anterior blepharitis, tear stability, tear production and tear volume). Fifty-four participants completed the study. Tear osmolarity was significantly reduced from baseline in both the triacylglyceride (fish oil) [n = 19, -19.8 ± 4.5 mOsmol/L, p < 0.001] and phospholipid (krill oil) [n = 18, -18.6 ± 4 mOsmol/L, p < 0.001] groups at Day 90. Only the krill oil group showed a significant reduction in OSDI symptom score [-61.4% ± 5.2%, p = 0.009] relative to the placebo group [n = 17, -32.4% ± 9.6%] at Day 90. Secondary outcome measures of ocular redness, meibomian gland capping, tear stability and corneal staining, were all significantly improved with long-chain ω-3 EFA treatment at Day 90 compared to baseline. There were no significant inter-group difference in tear production, tear volume, corneal thickness, corneal transparency, peak tear film reflectivity or Symptom Assessment in Dry Eye (SANDE) questionnaire scores relative to baseline. These two studies give insight into both the corneal micro-structural changes that occur in association with tear hyperosmolarity and provide evidence that moderate daily doses of long-chain ω-3 EFA supplements, in either predominantly triacylglyceride or phospholipid form, significantly reduce key clinical signs and symptoms of DED, compared to placebo over a three-month treatment period