Nutritional considerations for dry eye syndrome symptom management

By Kellie Blake, RDN, LD, IFNCP

Nutritional intervention in the management of chronic disease is well-established and commonly recommended. However, using nutrition related strategies to manage the symptoms of eye disease is less well-known and often overlooked. Eye health is intimately related to the health of the entire body. In fact, the eyes provide valuable information and can help to detect the early stages of diseases, like diabetes and heart disease. Effectively managing eye disease requires a comprehensive approach that addresses the health of the entire body. 

Dry eye syndrome (DES) is one of the most common eye diseases and typically affects middle age and older adults. It can cause a variety of symptoms including blurred vision, burning, redness, pain, and can significantly reduce quality of life and lead to vision loss.

Under normal circumstances, the cornea is continually coated with tears that protect it from the outside environment. But, with DES, there is a breakdown in this system. While a functional approach includes a determination of root causes and a comprehensive plan to reverse symptoms, DES is complex in that it may have more than one cause. One proposed root cause that has been gaining traction in medical research is oxidative damage, a key factor for many chronic diseases.

Nutrition can be used to reduce this oxidative burden and improve the body’s antioxidant defense system.  Omega-3 polyunsaturated fatty acids (PUFAs) play a key role in keeping the mitochondria healthy and can be a valuable tool in treating DES. PUFAs are important in the development of cell membranes and influence genetic expression. One type of PUFA, docosahexanoic acid (DHA), reduces pro-inflammatory mediators and increases anti-inflammatory factors. This process ultimately helps to maintain the antioxidant defense system, reduces the oxidative burden in the body, and can protect the delicate tissues of the eye.

Extra virgin olive oil, an omega-9 fatty acid, has also been shown to reduce overall inflammation.  According to a 2017 study in the journal Molecular Nutrition & Food Research, the polyphenolic components in olive oil inhibit the production of reactive oxygen species (ROS). Since ROS are implicated in damaging mitochondrial DNA, olive oil can also be considered an option in the management of DES symptoms. 

Low vitamin D levels are associated with DES. The cornea contains vitamin D receptors and a high concentration of vitamin D. When vitamin D levels are inadequate, managing DES symptoms becomes even more difficult. Vitamin D can be a valuable weapon against DES due to its immunomodulatory, anti-inflammatory, and antioxidant properties. According to a 2016 study published in the journal Scientific Reports, intramuscular injection of 200,000 international units (IL) vitamin D3 in patients with diagnosed vitamin D deficiency and DES, increased tear secretion, reduced tear instability, and decreased inflammation of the ocular surface.

DES is a reversible condition. Along with conventional treatments, nutritional considerations can provide symptom relief and significantly improve quality of life. Adding 3,000 milligrams high quality omega-3 fatty acid and two to four tablespoons of extra virgin olive oil per day can be very effective in managing the symptoms of DES. Checking vitamin D levels and supplementing based on the level of deficiency is also beneficial. Aim for a vitamin D level of 50 to 80 ng/ml. 

In addition to the supplements, overall nutritional quality of the diet must be addressed. Poor nutrition increases the oxidative burden and can lead to DES. When highly processed foods are consumed, inflammation increases, and oxidative damage occurs. Mitochondrial health suffers and the cascade of events leading to conditions like dry eye is initiated.

When it comes to nutrition, there is not a one size fits all approach. A thorough evaluation of current dietary habits is crucial in determining which nutrition-related changes will produce the greatest benefit for DES patients. When relief is quickly realized, further nutrition changes are easier to implement. A full elimination diet for at least four weeks can provide much symptom relief and information to help fine-tune maintenance nutrition recommendations. In general, a long-term nutrition plan for DES patients are plant-based and organic to maximize antioxidant and phytonutrient intake. A variety of vegetables, including leafy greens, should be consumed. 

Healthy fats and fermented foods like apple cider vinegar, sauerkraut, miso, and kimchi should be encouraged. Adequate protein should be consumed from primarily plant-based sources like legumes, nuts, and seeds. If animal proteins are desired, suggest organic free-range or grass-fed sources. When it comes to grains, gluten-containing options may need to be eliminated if gluten-sensitivity is suspected or confirmed. High-fiber grains like quinoa and brown rice can be enjoyed in moderation. Items to eliminate from the diet to reverse DES symptoms may include dairy, sugar, refined and gluten-containing grains, excessive fruit, most processed foods, inflammatory oils, and caffeine.

Case Study

Ally is a 29-year-old female referred in January 2019 due to severe dry eye symptoms. She had lasik surgery at age 25 and was unable to wear her contact lenses. She reported eye redness, pain, and poor vision. She also complained of low energy and reduced strength.

Her main goal was to wear contact lenses for her upcoming wedding. In addition to the DES, Ally was diagnosed with fibromyalgia, chronic pain, anxiety, and attention deficit disorder. Initial dietary recall indicated inadequate water intake, very limited vegetable intake, and a diet high in processed foods and caffeinated coffee. Vitamin D testing was completed and was found to be inadequate at 41 ng/ml.  Suspecting stress as a major contributor of her fatigue and low strength, a salivary cortisol test was completed, and she was found to be in stage 3 adrenal fatigue. 

Ally was placed on a four-week elimination diet and was instructed to add the following supplements daily: 

• Omega-3, 2,400 milligrams
• Vitamin B complex
• Buffered vitamin C
• Adrenal formula,
• Multivitamin (including 2,000 milligrams vitamin D3)
• Magnesium
• Inflammatone

She was to consume two to four tablespoons of high-quality olive oil and drink at least 64 ounces of water each day.

In addition to the elimination diet and supplements, Ally began meditation techniques, worked toward recalibrating her circadian rhythm, and created a healthy sleep routine.

Ally had an initial symptom score of 111. At her follow up at the beginning of April 2019, her symptom score had decreased to 75. Ally reported she was feeling much better, but she was still unable to wear contact lenses. She continued with her lifestyle modification and nutritional supplements and was given the additional goal of aiming for nine servings of vegetables per day with at least one serving being a cruciferous vegetable. She was also switched to a mitochondrial/detoxification meal plan for maintenance to enhance mitochondrial function. 

At the end of April, Ally reported, regarding her DES, “I’m not red, hardly at all, no pain, I’m pretty comfortable.  It’s not perfect, but I’m so much better.  Maybe the diet is helping.”   

And at the beginning of May, “Today I’m wearing contacts for the first time in FOREVER.” 

Addressing the health of her entire body allowed for reversal of her DES symptoms. Ally continues with her lifestyle and nutrition recommendations and has been discharged from the care of her ophthalmologist due to significant symptom improvement.

References

Bae, S., Shin, Y., Kim, H., Hyon, J., Wee, W., and Park, S. (2016) Vitamin D Supplementation for Patients with Dry Eye Syndrome Refractory to Conventional Treatment. Scientific Reports. Retrieved from: 10.1038/srep33083

Gouvinhas, I., Machado, N., Sobreiria, C., Domingues-Perles, R., Gomes, S., Rosa, E., and Barros, A. (2017)  Critical Review on the Significance of Olive Phytochemicals in Plant Physiology and Human Health. Retrieved from: https://www.ncbi.nlm.nih.gov/pubmed/29144445

Jee, D., Kang, S., Yuan, C., Cho, E., and Arroyo, J. (2016) Serum 25-Hydroxyvitamin D Levels and Dr Eye Syndrome: Differential Effects of Vitamin D on Ocular Diseases. Plos One. 

Sacca, S., Cutolo, C., Ferrari, D., Corazza, P., and Traverso, C. (2018) The Eye, Oxidative Damage and Polyunsaturated Fatty Acids. Nutrients. Retrieved from: 10.3390/nu10060668

Serra, G., Deiana, M., Spencer, J.,and  Coronia, G. (2017) Olive Oil Phenolics Prevent Oxysterol-Induced Proinflammatory Cytokine Secretion and Reactive Oxygen Species Production in Human Peripheral Blood Mononuclear Cells, Through Modulation of p38 and JNK Pathways. Molecular Nutrition & Food Research. Retrieved from: 10.1002/mnfr.201700283

Yoon, S., Bae, S., Shin, Y., Park., Hwang S., Hyon, J., and Wee, W. (2016) Low Serum 25-Hydroxyvitamin D Levels Are Associated with Dry Eye Syndrome. Plos One. Retrieved from:10.1371/journal.pone.0147847