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#219 Omega-3 Supplements for Dry Eye: Fishy evidence or a big catch?


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

BOTTOM LINE
RÉSULTAT FINAL
 The evidence for omega-3 is inconsistent. The best quality randomized control trial (RCT) found that 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 will improve symptoms about 3.9 points more than placebo on an 18-point symptom score. 


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EVIDENCE
DONNÉES PROBANTES
 Eleven RCTs of omega-3 [with both eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA)] reporting patient-oriented outcomes: 
  • Best quality RCT, 535 patients, mean age 58, with moderate symptoms of dry eye disease. Outcomes at one year:1 
    • Omega-3 (2,000/1,000 mg EPA/DHA per day) versus placebo. 
    • No difference in symptom scores, patient function, objective measures, or adverse events. 
  • One RCT, 105 patients, mean age 57, with moderate Meibomian gland dysfunction. Outcomes at three months Omega-3 (1,680/560 mg EPA/DHA per day) versus placebo:2 
    • Statistical improvement on the 100-point Ocular Surface Disease Index: 
      • Attained score (lower better): 16 with omega-3 versus 22 with placebo.  
        • Difference likely not clinically relevant (minimal clinically important difference 7-10).3  
        • Ocular Surface Disease Index is the only assessment tool that includes symptoms, vision-related function and environmental triggers related to dry eye. 
    • Limitations: Industry funded.  
  • Four RCTs, 256-518 patients. At 1.5-6 months:4-7 
    • Omega-3 used ranged 325-720 mg for EPA and 175-480 mg DHA. 
    • Statistically significant improvement of 2.0-4.6 versus 0.2-0.7 points (placebo) on 18-point symptom scale. 
      • Maybe clinically relevant. 
    • Limitations: All written by the same lead author. Used a non-standard scale created by the authors that assesses symptoms but not patient function. 
  • Smaller RCTs report statistical but not clinically significant improvements with omega-3.8-12 
Context: 
  • Guidelines suggest artificial tear lubricants (~$11 per 30-day supply depending on usage), hot compresses, and environmental changes, such increasing humidity, for management of dry eyes.13,14 
  • There are no omega-3 dose recommendations for dry eyes provided in the guidelines. 13,14 
  • Cost of omega-3 supplementation is ~$60 per 90-day supply (based on a daily dose of 1,800/900 mg EPA/DHA). 

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Author(s)
Auteur(s)
  • Joey Ton PharmD
  • Christina Korownyk MD CCFP

1. Dry Eye Assessment and Management Study Research Group. N Engl J Med. 2018 May 3; 378(18):1681-90.

2. Epitropoulos AT, Donnenfeld ED, Shah ZA, et al. Cornea. 2016 Sep; 35(9):1185-91.

3. Miller KL, Walt JG, Mink DR, et al. Arch Ophthalmol. 2010 Jan; 128(1):94-101.

4. Bhargava R, Kumar P. Cornea. 2015 Apr; 34(4):413-20.

5. Bhargava R, Kumar P, Phogat H, et al. Cont Lens Anterior Eye. 2015 Jun; 38(3):206-10.

6. Bhargava R, Kumar P, Kumar M, et al. Int J Ophthalmol. 2013 Dec 18; 6(6):811-6.

7. Bhargava R, Kumar P, Arora Y. Eye Contact Lens. 2016 Jul; 42(4):231-6.

8. Deinema LA, Vingrys AJ, Wong CY, et al. Ophthalmology. 2017 Jan; 124(1):43-52.

9. Wojtowicz JC, Butovich I, Uchiyama E, et al. Cornea. 2011 Mar; 30(3):308-14.

10. Kawakita T, Kawabata F, Tsuji T, et al. Biomed Res. 2013; 34(5):215-20.

11. Olenik A, Jimenez-Alfaro I, Alejandre-Alba N, et al. Clin Interv Aging. 2013; 8:1133-8.

12. Malhotra C, Singh S, Chakma P, et al. Cornea. 2015 Jun; 34(6):637-43.

13. American Academy of Ophthalmology. Dry Eye Syndrome. Available from: https://www.aao.org/preferred-practice-pattern/dry-eye-syndrome-ppp--2013. Last Accessed: June 28, 2018.

14. Canadian Association of Optometrists. National Dry Eye Disease Guidelines for Canadian Optometrists. Available from: https://opto.ca/sites/default/files/resources/documents/cjo_dry_eye_supplement_2014.pdf. Last Accessed: June 28, 2018.

Authors do not have any conflicts of interest to declare.

Les auteurs n’ont aucun conflit d’intérêts à déclarer.