This document discusses the role of diet in ocular surface disease. It notes that 14-33% of the US population has dry eye, and while aqueous deficiency accounts for 34% of dry eye cases, 95% of products on the market treat evaporative dry eye which accounts for 65-86% of cases. Dietary changes, hormonal effects, aging population, electronic device use, and better diagnostics all contribute to rising dry eye rates. Treatment options discussed include cyclosporine, steroids, nutritional supplements containing omega-3s and GLA, and procedures like LipiFlow. The document emphasizes the importance of addressing underlying inflammation and meibomian gland dysfunction in dry eye treatment.

1. The Role of
Diet in
Ocular Surface Disease
Peter J Polack MD FACS
Ocala Eye
Ocala FL

2. Ocala Eye
est. 1971
13 Providers
140 Employees
4 Locations + ASC
100,000+ Patient Encounters

7. Dry Eye
in the US
14 to 33%
Of The Population
Has Dry Eye
Dry Eye Disease: The Clinician’s Guide to Diagnosis and Treatment. P Asbell

8. Why Are We Seeing So
Much Dry Eye?
Dry Eye Disease: The Clinician’s Guide to Diagnosis and Treatment. P Asbell
 Dietary changes
 Hormonal effects
 Aging population
 Awareness
 Electronic devices
 Better diagnostics
 Treatments are
now available

9. Ocular Surface Disease
Dry Eye
Disease
Aqueous
Deficient Dry Eye
Evaporative Dry
Eye
Other
Non-Dry Eye
Disease
Lid-related
Disease
MGD
Anterior
Blepharitis
Other
Other OSD
Allergic
conjunctivitis,
Chronic infective
and non-infective
Keratoconjunctivitis,
Post-refractive
Prodromal
States
Symptomatic

10. Dry Eye
in the US
Aqueous Deficiency:
34% Of Problem But
95% Of Products On The Market
2012 Annual Report on Dry Eye Diseases, Contact Lens Spectrum

11. Dry Eye
in the US
Lipid Deficiency:
65-86% Of Problem But Only
5% Of Products On The Market
Lemp MA, et al. Distribution of aqueous deficient and evaporative dry eye in a clinic-based
patient population. Cornea, 2012; 31(5):472-478

12. Symptomatic Dry Eye
52.7%
Contact Lens
Wearers
14-33%
General
Population
Scaffidi RC, Korb DR: Eye Contact Lens. Jan 2007

13. Why do we care
about Dry Eye ?

14. Rheumatoid Corneal Melt

17. Tear Osmolarity
Performance of tear osmolarity compared to previous diagnostic tests
for dry eye diseases. Versura et al. Curr Eye Res 2010 Jul;35(7):553-64

19. Acne Rosacea

20. Blepharitis

23. Lacrimal Gland System

24. Tear Film Layers

25. Blink Blink
Cycle
Repeats
TFBUT
Tear Protected
Ocular Surface
Unprotected
Ocular Surface
Time (Seconds)
Ocular
Discomfort
Staining
0 1 2 3 4 5 6 7
COURTESY OF
OPHTHALMIC
RESEARCH
ASSOCIATES, NORTH
ANDOVER, MASS.

26. Meibomian Gland Evaluator™(MGE)
Grade Secretion Characteristics
3 Clear liquid oil
2 Colored / cloudy liquid
1 Inspissated (toothpaste consistency)
0 No secretion (includes capped orifices)

27. Meibomian Glands Yielding
Liquid Secretion (MGYLS)
DRY NOT DRY
0 - 4 5 6 7 8 – 10+
1. Korb DR, Blackie CA. Meibomian gland diagnostic expressibility: correlation with dry eye symptoms and gland location. Cornea.
2008;27(10):1142-1147.
2. Blackie CA, Korb DR. Recovery time of an optimally secreting meibomian gland. Cornea. 2009;28(3):293-297.
With Symptoms1
(n=133) Asymptomatic
healthy eyes2
(n = 24)Severe Symptoms
Moderate
Symptoms
Minimal Symptoms
Symptom Score,
SPEED
questionnaire
(0-28)
≥10
(14.39 ± 0.69)
6–9
(7.26 ± 0.17)
≤5
(2.30 ± 0.23)
0
Number of MGYLS
for entire lower
eyelid
4.14 ± 0.56 5.14 ± 0.41 6.25 ± 0.35 10.6 ± 2.6

28. “Lipid layer thickness correlates
to MGD and can be measured
with Interferometry”
Donald Korb OD

30. LipiView®
Report

31. Intense Pulsed Light (IPL)
Therapy
Treatment Area:

32. Meibomian Gland Expression (Post-IPL)

34. LipiFlow® Mechanism of Action
Activator
Applies
intermittent
pressure to the
outer eyelid
Inflatable air
bladder
Shields eye from heat
and
vaults above the
cornea to prevent
corneal contact
Heats comfortably
to liquefy the
Meibomian gland contents
Lid warmer
Applies directional
heat to inner eyelid

36. Restasis (Cyclosporine 0.05%)
 Improves ocular surface health
 Increases goblet cells
 Improves LASIK & Premium IOL
outcomes
 Good safety profile
 Decreases artificial tear use

37. Adapted from Holland EJ. Ophthalmol Times. 2007;32:3-11.
Lotemax® QID
(loteprednol etabonate
Ophthalmic suspension 0.5%)
Lotemax® BID Lotemax® prn
Restasis® BID
(cyclosporine ophthalmic emulsion 0.05%)
Thereafter
The Asclepius Panel:
Recommended Treatment Model
for Ocular Surface Inflammation

39. Nutritional Content of Oils. E Bender: Univ of California at San Diego

40. A review of fatty acid profiles and antioxidant content in grass-fed and grain-fed beef, CA Daley et al, Nutr Jour, 2010 9:10

42.  Contains unique omega (GLA) – clinically backed in
6 controlled dry eye trials
 Not found in diet/flax/fish. Provides other
omegas, nutrient cofactors
 Stimulates tear production, eases inflammation
 Effective for almost any Dry Eye (i.e. contact
lens, post-refractive, post-menopausal, allergy-
related, Sjögren's, other types)
 Guaranteed relief within 60 days or money back;
works for 80-85% of users
HydroEye®
Oral Supplement

43. Essential
Fatty
Acids
Delta-6
desaturase
Elongase Delta-5
Desaturase
COX
18:2w3
Alpha linolenic
(ALA)
18:4w3
SDA
20:4w3
ETA
20:5w3
EPA
20:6w3
DHA
Omega-6
18:2w6
Linoleic Acid
(LA)
18:3w6
GLA
20:3w6
DGLA
20:4w6
Arachidonic
Acid
Series 3 (“good”)
Prostaglandins
Series 2 (“bad”)
Prostaglandins
Series 1 (“good”)
Prostaglandins
Omega-3
Flaxseed Oil
Black Currant
Seed Oil
Fish Oil Fish Oil
(Parent)
(Parent)
Black Currant
Seed Oil
Black Currant
Seed Oil
Only 15-20% of ALA
converts to EPA
Rate-Limiting
Delta-4Desaturase
Anti-inflammatory Fatty Acids

44. Essential
Fatty
Acids
Delta-6
desaturase
Elongase Delta-5
Desaturase
COX
18:2w3
Alpha linolenic
(ALA)
18:4w3
SDA
20:4w3
ETA
20:5w3
EPA
20:6w3
DHA
Omega-6
18:2w6
Linoleic Acid
(LA)
18:3w6
GLA
20:3w6
DGLA
20:4w6
Arachidonic
Acid
Series 3 (“good”)
Prostaglandins
Series 2 (“bad”)
Prostaglandins
Series 1 (“good”)
Prostaglandins
Omega-3
Flaxseed Oil
Black Currant
Seed Oil
Fish Oil Fish Oil
(Parent)
(Parent)
Black Currant
Seed Oil
Black Currant
Seed Oil
Only 15-20% of ALA
converts to EPA
Rate-Limiting
Delta-4Desaturase
Anti-inflammatory Fatty Acids

45. Supplemental GLA: Controlled Trials
Significant Improvement
• Dry Eye patients GLA vs placebo (n=26)
– Dry Eye Symptom Scores, Lissamine Green,
Ocular Surface Inflammation (HLA-DR
Expression).
• PRK patients GLA vs no treatment (n=60)
– Subjective Symptoms, Schirmer 1 test,
Fluorescein Clearance Test
• Sjögren's patients GLA vs placebo (n=40)
– Tear Anti-Inflammatory PGE 1 levels, Dry Eye
Symptoms, Corneal Fluorescein Staining
1. Barabino S et al. Cornea 22): 97–101, 2003.
2. Macri A et al. Graefes Arch Clin Exp Ophthalmolol 241:561-6, 2003.
3. Aragona P, et al. Ophthalmol Vis Sci 46:4474-9, 2005.

46. HydroEye Clinical Trial
• ARVO 2012: Multi-center, randomized, double-blind, placebo-
controlled, prospective trial, 38 postmenopausal women with Dry
Eye Syndrome.
• Investigators:
• Findings: HydroEye improves symptoms & signs of dry eye and
impedes progression of ocular surface inflammation significantly
better than placebo.
John D. Sheppard MD MMSc
•Eastern VA Medical School.
Stephen C. Pflugfelder MD
•Baylor College of Medicine

47. Speaking of
Inflammation

48. Fasano A Physiol Rev 2011;91:151-175 ©2011 by American Physiological Society
Physiological Reviews
Mechanisms Of Gliadin-induced Zonulin Release, Increased
Intestinal Permeability, And Onset Of Autoimmunity.

49. Known or Suspected Autoimmune Diseases
That Also Present With a Leaky Gut
Disease Tissue/Organ Citation
1. Allergies Various Liu et al. Acta Paediatrica 2005, 94, 386-93
2. Ankyllosing Spondylitis Skeletal system Vaile JH et al. J. Rheumatol. 1999, 26, 128-35
3. Apthous stomatis Mouth Veloso FT et al. Hepatogastroenterol. 1987, 34, 36-7
4. Asthma Lungs Benard A et al. J. Allergy Clin. Immun. 1996, 97, 1173-8
5. Autism Nerve/Brain White JF. Exp. Bio. Med. 2003, 228, 639-49
6. Autoimmune gastritis GI Tract Greenwood DL et al. Eur. J. Pediatr. 2008, 167, 917-25
7. Autoimmune hepatitis Liver Terjung B Clin. Rev. Allergy Immunol. 2009, 36, 40-51
8. Behcet’s Syndrome Small blood vessels Fresko I et al. Ann. Rheum. Dis. 2001, 60, 65-6
9. Celiac Disease Gut Schulzke JD et al. Pediatric. Res. 1998,43, 435-41
10. Chronic Fatigue Synd Multiple Maes M et al. Neuroendol. Lett. 2007, 28, 739-44
11. Crohn’s disease Gut Caradonna L et al. J. Endotoxin. Res. 2000, 6, 205-14
12. Depression Brain Maes M et al. Neuroendocrinol. Lett. 2008, 29, 117-24
13. Dermatitis herpetiformis Skin Kieffer M et al. Br J. Dermatol. 1983, 108, 673-8
14. Diabetes, Type 1 Pancreas Sapone A et al. Diabetes 2006, 55, 1443-49
15. Eczema Skin Hamilton et al. Q. J. Med. 1985, 56, 559-67
16. Gut migraine children Gut Amery WK et al. Cephalalgia 1989, 9, 227-9
17. Hashimoto’s Thyroiditis Thyroid Sasso FC et al. Gut 2004, 53, 1878-80
“Dietary Mechanisms of Autoimmunity”, Loren Cordain, PhD, Christiaan Barnard Memorial Hospital, Jan 24, 2013

50. Known or Suspected Autoimmune Diseases
That Also Present With a Leaky Gut
Disease Tissue/Organ Citation
18. IgG Nephropathy Kidney Rostoker G et al. Nephron. 1993, 63, 286-290.
19. Intrahep cholest pregnancy Liver Reyes H et al. Hepatology 2006, 43, 715-22
20. Juvenile Arthritis Collagen/joints Picco P et al. Clin. Exp. Rheumatol. 2000, 18, 773-8
21. Lupus erythematosis Multiple Apperloo HZ et al. Epidemiol. Infect. 1994, 112, 367-73
22. Multiple sclerosis Nerve/Brain Yacyshyn B et al. Dig. Dis. Sci. 1996, 41, 2493-98
23. Pemphigus Skin Kieffer M et al. Br J. Dermatol. 1983, 108, 673-8
24. Primary Biliary Cirrhosis Liver Di Leo V et al. Eur. J. Gastro. Hepatol. 2003, 15, 967-73
25. Psoriasis Skin Hamilton et al. Q. J. Med. 1985, 56, 559-67
26. Rheumatoid arthritis Joints Smith MD et al. J. Rheumatol. 1985, 12, 299-305
27. Rosacea Skin Kendall SN. Exp. Dermatol. 2004, 29, 297-99
28. Schizophrenia Brain Wood NC et al. Br. J. Psychiatry 1987, 150, 853-6
29. Scleroderma Connective tissue Caserta L et al. Rheumatol. Int. 2003, 23, 226-30
30. Sclerosing Cholangitis Liver Terjung B Clin. Rev. Allergy Immunol. 2009, 36, 40-51
31. Spontaneous abortion Uterus Friebe A Int. J. Biochem. Cell Biol. 2008, 40, 2348-52
32. Ulcerative colitis Gut Caradonna L et al. J. Endotoxin Res. 2000, 6, 205-14
33. Urticaria Skin Buhner S et al. Allergy 2004, 59, 1118-23
34. Uveitis Eye Benitez JM et al. Eye 2000, 14(pt 3A), 340-3
“Dietary Mechanisms of Autoimmunity”, Loren Cordain, PhD, Christiaan Barnard Memorial Hospital, Jan 24, 2013

53. “Heart Smart” Diet

54. “Are we as physicians merely
treating the effects of the
consumption of wheat?”
William Davis MD
Author of “Wheat Belly”

55. Blepharitis Checklist

57. Why is an
Eye Doctor
telling my
patients
what to
eat?!!

58. Pre-
Treatment

59. Post-
Treatment