A functional medicine approach to the dry eye patient

Photo Cred: Marina Vitale/Unsplash

By Heather Skeens, MD, CFMP

I have treated countless patients with dry eye syndrome (DES). It can be disruptive and significantly decrease quality of life. Patients often complain of red eyes that burn and sting, a feeling of sand in the eyes, itching, pain, and blurry vision. Blurry vision, along with vision that fluctuates throughout the day, or temporarily improves with blinking, is a common complaint. Symptoms tend to worsen as the day goes on, and with prolonged computer use or reading. Patients can feel they are “going blind.” However, this condition is completely reversible when root causes are uncovered and targeted. 

All chronic diseases, including dry eye, are rooted in inflammation. In fact, inflammation of the tear- and oil-producing glands around the eyes and eyelids underlies abnormal functioning of these structures. Normally, the tear film consists of several layers that include an aqueous and an oil component. While dry eye can arise from alterations in either layer, it is most often a combination of alterations in both. Hormone fluctuations, a proinflammatory diet, and biofilm accumulation on the eyelids, contribute to alterations in the tear layer.

I often prescribe topical ocular pharmaceutical agents, which can provide temporary relief, while I am investigating root causes to target with nutrition and lifestyle-related strategies. Autoimmune diseases such as rheumatoid arthritis, psoriasis, Crohn’s disease, ulcerative colitis, fibromyalgia, and Sjogren’s syndrome,  are often associated with dry eye. 

A history of treatment with chemotherapeutic agents is a culprit on many occasions. Patients who have undergone radiation treatments to the head and neck, or trauma to the face, can have an altered blink reflex. Neurodegenerative disorders, such as Parkinson’s disease, are associated with a decreased blink rate, which leads to evaporative dry eye.

One of the ways I may help a patient is to simply stop the use of preserved medications on the ocular surface, including those that have been prescribed. Patients are almost always using an over-the-counter tear substitute, and bottled artificial tears contain preservatives, which are very drying to the ocular surface. Preservative-free tears are a much healthier option. Drops that are advertised to “get the red out,” will dry the ocular surface greatly, and should not be used.

Antihistamines, anti-hypertensives, antidepressants, and antipsychotics are the largest classes of systemic medications associated with DES. While these medications cannot be stopped immediately, patients should be educated on their contribution to dry eye symptoms and reminded that treating the root cause of illness may allow them to decrease or stop the use of these medications in the future.

A thorough review of systems should question gut issues including diarrhea, constipation, gas, and bloating, as well as inquire about skin rashes and joint pain.     

Bacterial biofilm formation on the surface of the eyelid is causative of DES. Like most mucous membrane surfaces of the body, the eyelid margin accumulates bacterial biofilm, and removal is imperative for dry eye management. This biofilm builds up over the lifetime of the patient, and commercial eyelid cleaners are not effective at removing the biofilm. A rotary cleaning brush, designed for the eyelid, can be used by a trained professional to effect biofilm removal. I often describe this technique to patients as equivalent to going to the dentist and getting the plaque removed from their teeth. The procedure needs to be repeated two to three times per year. 
Labwork to identify the root cause of the dry eye should be ordered based on the history and review of systems.  When indicated, an autoimmune panel, complete blood count with differential, comprehensive metabolic panel, high sensitivity c-reactive protein, fasting insulin, hemoglobin A1c, fasting glucose, vitamin D, vitamin A, a thyroid panel, including antibodies, and a celiac disease panel, with HLA typing, should be considered.

The cornea is a vitamin D powerhouse, capable of synthesizing vitamin D, converting inactive to active, and possesses abundant vitamin D receptors. Vitamin D has been shown to inhibit inflammation on the ocular surface that leads to dry eye. There are also measurable concentrations of vitamin D metabolites in the tear fluid, and inside the eye, which can be altered with oral vitamin D supplementation. Patients reporting dry eye symptoms should have their serum vitamin D measured, and optimal levels maintained via vitamin D supplementation. 

Vitamin A deficiency is also associated with DES.  Alcoholism and malnutrition are associated with vitamin A deficiency. Supplementation with oral vitamin A should be recommended if deficient. 

Unless a contraindication exists, I always recommend high-quality omega-3 fatty acids, 4,000 milligrams per day. The 2005 Women’s Health Study published in the American Journal of Clinical Nutrition, involving over 32,000 women described an association between a low dietary intake of omega-3 fatty acids and DES in women. The study reported a 30 percent reduction in the risk of DES with each additional gram of omega-3 consumed per day. 

I have the benefit, in my clinic, of a licensed dietitian certified in functional medicine. I refer my dry eye patients for education on an anti-inflammatory diet. I also recommend staying well hydrated, along with the use of an infrared sauna three times weekly to detoxify body tissues.

Case Study

Lora is a 48-year-old female that presented complaining of dry, achy eyes that are sensitive to light. She is concerned that her vision has changed, and she maintains headaches that she thinks come from eye strain. Her referring physician has been treating her with artificial tears without relief. She has a history of repeated corneal abrasions associated with dry eye.

Lora takes medication for a thyroid disorder, along with metformin for diabetes. She has a family history positive for autoimmune disease. 

Examination of Lora’s ocular surface reveals severe biofilm accumulation on the eyelid, and no oil expression from the glands. She has redness of the conjunctiva, along with severe dryness of the cornea bilaterally, and areas of scarring consistent with the previous abrasions. There are filaments on the corneas, representing areas of dead epithelial cells and mucous, from the severe dryness.

Lab work was ordered, and was abnormal with a fasting glucose of 120, fasting insulin of 18, and hemoglobin A1c of 6.2, elevated liver enzymes, vitamin D deficiency at 31.6, extremely elevated thyroid antibodies, very elevated rheumatoid factor and Sjogren’s antibody, with positive antinuclear antibody, high sensitivity c-reactive protein near 7, and high sensitivity homocysteine of 9. 

Lora was referred to a functional nutritionist, and her primary care provider was notified of the lab findings. A celiac panel, along with HLA typing was ordered secondarily. Topical ocular immunosuppression, 0.05 percent loteprednol and 0.05 percent cyclosporine, was initiated, along with oral omega-3 supplementation of 4,000 milligrams per day, and oral vitamin D of 10,000 international units per day. Biofilm removal from the lid margin was performed.  Preservative-free artificial tears were recommended a minimum of four times daily. The use of an infrared sauna three times weekly was recommended, along with a minimum of eight, eight-ounce glasses of water per day.

At her one-month follow-up visit, Lora reported a resolution of many of her symptoms, along with improvement in her visual acuity. Her topical immunosuppressive agents were decreased in frequency. She declined nutrition counseling initially but said she was highly considering it given the positive changes she experienced. She remains optimistic about her ability to reverse her chronic disease.

References

Alanazi, S. (2019) Effects of short-term oral vitamin A supplementation on the ocular tear film in patients with dry eye. Clinical Ophthalmology. Retrieved from: https://doi.org/10.2147/OPTH.S198349  

Jee, D., Kang, S., Yuan, C., Cho, E., and Arroyo, J. (2016) Serum 25-Hydroxyvitamin D Levels and Dry Eye Syndrome: Differential Effects of Vitamin D on Ocular Diseases. Plos One. Retrieved from:  10.1371/journal.pone.0149294

Jones, L. (2017) TFOS DEWS II Management and Therapy Report. The Ocular Surface. Retrieved from: https://doi.org/10.1016/j.jtos.2017.05.006

Miljanovic, B.,Trivedi, K., Dana, M., Gilbard, J., and Buring, D. Schaumberg. (2005) Relation between dietary n-3 and n-6 fatty acids and clinically diagnosed dry eye syndrome in women. American Journal of Clinical Nutrition. Retrieved from: https://doi.org/10.1093/ajcn/82.4.887

Rynerson, J. and Perry, H. (2016) DEBS – a unification theory for dry eye and blepharitis. Clinical Ophthalmology. 10, pp.2455-2467. Retrieved from:   https://doi.org/10.2147/OPTH.S114674

Sethu, S. (2016) Correlation between tear fluid and serum vitamin D levels. Eye and Vision (Lond). Retrieved from:  10.1186/s40662-016-0053-7

About the Author

Heather Skeens, MD, CFMP

Heather Skeens, MD, CFMP, is a cornea, cataract, and refractive fellowship trained ophthalmologist with 15 years’ experience in her field. She is the founder of her practice, the West Virginia Cornea and Cataract Center of Excellence, PLLC. She performs all types of cornea transplantation, state-of-the art cataract surgery, and bladeless LASIK as well as PRK for the correction of refractive errors.

Other areas of surgical expertise for Skeens include anterior segment reconstruction in eyes that have undergone chemical or thermal burns, corneal collagen cross-linking for disorders such as keratoconus, induced ectasia, and pellucid marginal degeneration, pterygium removal, and stem cell transplantation for limbal stem cell deficiency induced by genetic abnormality, autoimmune disease, or injury. Amniotic membrane therapy for stem cell deficiency, as well as dry eye is available. Medically, Skeens specializes in the treatment of advanced ocular surface disease, dry eye disease, contact lens related cornea issues, and cornea ulcers.

Skeens’ outside interests include spending time with her two boys, ages 7 and 9, as well as yoga, golf, hiking, and taekwando. She is certified by the Korean Taekwando Association as a second degree black belt and is studying for her third. Skeens founded Almost Heaven Yoga and Sauna Services in Summersville, WV, where she teaches yoga in her spare time.