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OtherPractice

Omega-3 supplements for dry eye

Joey Ton and Christina Korownyk
Canadian Family Physician November 2018, 64 (11) 826;
Joey Ton
Knowledge Translation Expert with the PEER (Patients, Experience, Evidence, Research) Group in the Department of Family Medicine at the University of Alberta in Edmonton.
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Christina Korownyk
Associate Professor, with the PEER (Patients, Experience, Evidence, Research) Group in the Department of Family Medicine at the University of Alberta in Edmonton.
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Clinical question

Does oral omega-3 supplementation improve symptoms of dry eye disease?

Bottom line

The evidence for omega-3 is inconsistent. The best quality RCT found omega-3 supplementation does not improve dry eye symptoms or function. Smaller RCTs suggest statistically significant benefits in symptom scores that are not always clinically relevant. At best, omega-3 improves symptoms about 3.9 points more than placebo on an 18-point symptom scale.

Evidence

Eleven RCTs of omega-3 (with both eicosapentaenoic acid [EPA] and docosahexaenoic acid [DHA]) reported patient-oriented outcomes.

  • The best quality RCT examined 535 patients (mean age 58) with moderate symptoms of dry eye disease taking omega-3 (2000 mg and 1000 mg of EPA and DHA per day, respectively) versus placebo. At 1 year there was no difference in symptom scores, patient function, objective measures, or adverse events.1

  • An RCT studied 105 patients (mean age 57) with moderate meibomian gland dysfunction taking omega-3 (1680 mg and 560 mg of EPA and DHA per day, respectively) versus placebo. At 3 months there was statistically significant improvement on the 100-point Ocular Surface Disease Index2:

    • - There was an approximate 17-point reduction with omega-3 versus about 5 with placebo. The difference was likely clinically relevant (minimal clinically important difference was 7 to 10) but the baseline score was higher in the intervention group.3

    • -A limitation was that the study was industry funded.

  • In 4 RCTs of 256 to 518 patients, taking omega-3 ranging from 325 to 720 mg of EPA and 175 to 480 mg of DHA, outcomes were examined at 1.5 to 6 months4–7:

    • - There was a statistically significant improvement of 2.0 to 4.6 points versus 0.2 to 0.7 for placebo on an 18-point symptom scale; this might be clinically relevant.

    • - These articles were written by the same lead author and they used a non-standard scale created by the authors that assessed symptoms but not function.

  • Smaller RCTs report statistically but not clinically significant improvements with omega-3.8,9

Context

  • Guidelines suggest artificial tear lubricants (about $11 per 30-day supply depending on usage), hot compresses, and environmental changes, such as increasing humidity, for management of dry eyes. Omega-3 was suggested but dosing was not discussed.10

  • Cost of omega-3 supplementation is about $60 per 90-day supply (based on a daily dose of 1800 mg and 900 mg of EPA and DHA, respectively).

Implementation

Prevalence of diagnosed dry eye is about 7% in the United States and has been reported to be as high as about 19% in patients older than 75.11 The cause of dry eye disease is often multifactorial; therefore, questionnaires such as the Ocular Surface Disease Index can help clinicians determine triggers and severity of the symptoms.10 A systematic review of 43 RCTs (3496 patients with dry eye) concluded that over-the-counter artificial tears are safe and all options are similarly effective (low level evidence).12

Notes

Tools for Practice articles in Canadian Family Physician are adapted from articles published on the Alberta College of Family Physicians (ACFP) website, summarizing medical evidence with a focus on topical issues and practice-modifying information. The ACFP summaries and the series in Canadian Family Physician are coordinated by Dr G. Michael Allan, and the summaries are co-authored by at least 1 practising family physician and are peer reviewed. Feedback is welcome and can be sent to toolsforpractice{at}cfpc.ca. Archived articles are available on the ACFP website: www.acfp.ca.

Footnotes

  • Competing interests

    None declared

  • The opinions expressed in Tools for Practice articles are those of the authors and do not necessarily mirror the perspective and policy of the Alberta College of Family Physicians

  • This article is eligible for Mainpro+ certified Self-Learning credits. To earn credits, go to www.cfp.ca and click on the Mainpro+ link.

  • La traduction en français de cet article se trouve à www.cfp.ca dans la table des matières du numéro de novembre 2018 à la page e486.

  • Copyright© the College of Family Physicians of Canada

References

  1. 1.↵
    1. Dry Eye Assessment and Management Study Research Group
    . N-3 fatty acid supplementation for the treatment of dry eye disease. N Engl J Med 2018;378(18):1681-90. Epub 2018 Apr 13.
    OpenUrl
  2. 2.↵
    1. Epitropoulos AT,
    2. Donnenfeld ED,
    3. Shah ZA,
    4. Holland EJ,
    5. Gross M,
    6. Faulkner WJ,
    7. et al
    . Effect of oral re-esterified omega-3 nutritional supplementation on dry eyes. Cornea 2016;35(9):1185-91.
    OpenUrl
  3. 3.↵
    1. Miller KL,
    2. Walt JG,
    3. Mink DR,
    4. Satram-Hoang S,
    5. Wilson SE,
    6. Perry HD,
    7. et al
    . Minimal clinically important difference for the Ocular Surface Disease Index. Arch Ophthalmol 2010;128(1):94-101.
    OpenUrlCrossRefPubMed
  4. 4.↵
    1. Bhargava R,
    2. Kumar P
    . Oral omega-3 fatty acid treatment for dry eye in contact lens wearers. Cornea 2015;34(4):413-20.
    OpenUrl
  5. 5.
    1. Bhargava R,
    2. Kumar P,
    3. Phogat H,
    4. Kaur A,
    5. Kumar M
    . Oral omega-3 fatty acids treatment in computer vision syndrome related dry eye. Cont Lens Anterior Eye 2015;38(3):206-10. Epub 2015 Feb 16.
    OpenUrl
  6. 6.
    1. Bhargava R,
    2. Kumar P,
    3. Kumar M,
    4. Mehra N,
    5. Mishra A
    . A randomized controlled trial of omega-3 fatty acids in dry eye syndrome. Int J Ophthalmol 2013;6(6):811-6.
    OpenUrlPubMed
  7. 7.↵
    1. Bhargava R,
    2. Kumar P,
    3. Arora Y
    . Short-term omega 3 fatty acids treatment for dry eye in young and middle-aged visual display terminal users. Eye Contact Lens 2016;42(4):231-6.
    OpenUrl
  8. 8.↵
    1. Deinema LA,
    2. Vingrys AJ,
    3. Wong CY,
    4. Jackson DC,
    5. Chinnery HR,
    6. Downie LE
    . A randomized, double-masked, placebo-controlled clinical trial of two forms of omega-3 supplements for treating dry eye disease. Ophthalmology 2017;124(1):43-52. Epub 2016 Nov 3.
    OpenUrl
  9. 9.↵
    1. Oleñik A,
    2. Jiménez-Alfaro I,
    3. Alejandre-Alba N,
    4. Mahillo-Fernández I
    . A randomized, double-masked study to evaluate the effect of omega-3 fatty acids supplementation in meibomian gland dysfunction. Clin Interv Aging 2013;8:1133-8. Epub 2013 Aug 30.
    OpenUrl
  10. 10.↵
    1. AAO Cornea/External Disease PPP Panel, Hoskins Center for Quality Eye Care.
    Dry eye syndrome PPP - 2013. San Francisco, CA: American Academy of Ophthalmology; 2013. Available from: www.aao.org/preferred-practice-pattern/dry-eye-syndrome-ppp--2013. Accessed 2018 Jun 28.
  11. 11.↵
    1. Farrand KF,
    2. Fridman M,
    3. Stillman IÖ,
    4. Schaumberg DA
    . Prevalence of diagnosed dry eye disease in the United States among adults aged 18 years and older. Am J Ophthalmol 2017;182:90-8. Epub 2017 Jul 10.
    OpenUrl
  12. 12.↵
    1. Pucker AD,
    2. Ng SM,
    3. Nichols JJ
    . Over the counter (OTC) artificial tear drops for dry eye syndrome. Cochrane Database Syst Rev 2016;(2):CD009729.
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Canadian Family Physician: 64 (11)
Canadian Family Physician
Vol. 64, Issue 11
1 Nov 2018
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Omega-3 supplements for dry eye
Joey Ton, Christina Korownyk
Canadian Family Physician Nov 2018, 64 (11) 826;

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