Dry eyes: An integrative clinical approach from a holistic health perspective

Patient education is a critical component of managing expectations and communication is paramount. Before initiating treatments, provide the tools for patients to evaluate at home. Then, when they return to the office, you will have additional answers to allow a deep dive into dietary patterns, home environment, and other factors that may be significant contributors to symptoms. (Adobe Stock / Viacheslav Yakobchuk)

As the prevalence of dry eye disease continues to rise, we have an opportunity to influence healthy lifestyle habits while recognizing the key impact of balanced nutrition on disease prevention. The Merriam-Webster Dictionary defines nutrition as “the act or process of nourishing or being nourished.” Nutrition encompasses the holistic contributions from internal and external factors for whole body balance. This balance represents a vital component of tackling dry eye disease.

To begin, how do we change the mindset of patients to link holistic wellness with dry eyes? No daily activity has more ability to change our biology than choosing what to eat. As frequent repetition aids in the formation of a habit, we must provide patients with consistent education about holistic solutions to support healthy eyes. And it makes sense to combine approaches: from the inside, through targeted dietary adjustments or additions, as well as from the outside, through prescriptive treatments and reduction of toxic contributors. This holistic approach is doubly important because chronic disease is prevalent among patients presenting with dry eyes.

We should consider the contributions to dry eyes from a number of internal factors, such as gut dysbiosis, hormone imbalance, poor nutrition, and chronic diseases including diabetes, autoimmune conditions, thyroid imbalances, and vascular diseases, to name a few. In addition, consider the known adverse effects from common medications prescribed to mitigate these health conditions. Lastly, there are external factors such as environment, allergies, product use, stressors, and sleep quality. Making these multilayered, symbiotic, organic connections helps patients grasp the complexity of dry eye disease.

We have turned a corner in health care and now find a larger contingent of patients who want to feel empowered with health solutions. To take advantage of this, we should aim to include patients in developing treatment options and planning around lifestyle demands. Let us discover multitargeted strategies to guide patients on a holistic journey to relieve symptoms of dry eyes.

These strategies can include the following:

• Increasing water intake

• Managing a balanced environment

• Improving diet via nutrition or adding supplemental care

• Avoiding toxic offenders in products, including cosmetics and household products

• Referring to specialists for further testing such as vitamin deficiencies, autoimmune or skin conditions, and more)

Water intake

Because water makes up approximately 50% to 70% of our body weight, it is a crucial component of survival. Lack of fluids can lead to dehydration, a precursor to dry eyes. Approximately 20% of daily hydration is derived from food; the remaining 80% must come from fluids. Factors that demand additional fluids are exercise, a hot or humid environment, fever or illness, pregnancy, and breastfeeding.

There are varying recommendations regarding the ideal daily fluid intake, which can be derived from water, other beverages, and food. As a general guideline, 8 glasses of water a day is recommended; of course, this varies by person. Good indicators that fluid intake is adequate include (1) rarely feeling thirsty and (2) urine that is colorless or light yellow.¹

Environmental factors

Where do we begin when considering external factors? Office space, sleep conditions, humidity levels, stress—all of these could play a role in the development or severity of dry eyes. Inquiring about these possible culprits helps patients become more aware of the complex contributors to dry eyes.

When I ask patients about their office setup, the answers may involve a vent above the desk, poor placement of multiple screens, dry radiator heat, and more. Send patients out on a self-discovery search for solutions after opening the door with questions about their home and work environments. This is a beneficial project that pays dividends upon a scheduled return visit.

Nutrition

When directing attention toward primary nutrition, we typically focus on omega-3 polyunsaturated fatty acids (FAs) to combat the inflammatory component of dry eye disease. These FAs are not synthesized by the body, so they must be obtained through a balanced diet.^2,3 Clinical studies have shown improvements in tear stability and tear secretion in patients with meibomian gland disease after the use of omega-3 FAs,⁴ which include docosahexaenoic acid, eicosapentaenoic acid, and α-linolenic acid, in balance with the omega-6 FA γ-linolenic acid. The ideal omega-6 to omega-3 ratio in the diet should be less than 4:1⁵ in order to lower the overall inflammatory state of the body. Therefore, with such a strong connection between nutrition and dry eye success we can lead patients towards the necessary steps for improving dry eye symptoms.

Omega polyunsaturated FAs are precursors of potent lipid mediators termed eicosanoids, which play an important role in the regulation of inflammation,^6,7 and can befound in the following foods: salmon, mackerel, tuna, herring, sardines, evening primrose oil, black currant seed oil, hemp seed, seaweed, flax seed, walnuts, chia seed, avocado, and safflower oil.^3,6,9,10

Because of its strong connection to eye health, a balanced diet should be encouraged. Additionally, many omega-3 FA–rich foods are included in most restrictive diet plans, including plant-based, Mediterranean, and others. Science continues to show positive benefits of omega-3 FAs in patients with chronic inflammatory diseases.^7,11 We can start small by promoting the addition of 1 new food in this category with the goal of improving adherence and yielding faster results.

Let’s be honest; no one enjoys taking pills, whether medication, vitamins, or otherwise. However, supplements that promote eye health remain a foundational component of combating dry eye disease. Ensure that your advice considers patients’ lifestyle demands or food sensitivities. Empower patients to think about eye health on a holistic level, including immediate regimens and long-term maintenance as part of the nutrition plan for enhanced overall health. Then consistently aim to shift patients towards healthier habits at home which could lead to improved dry eyes. Many people associate an improved diet with weight loss alone. By making the connection to eye health, as well as whole-body wellness, you may witness better patient engagement.

Toxic offenders

Do not be quick to assume all eye care products are in the best interest of patient care. Many products are developed (often by big pharmaceutical companies) to offer fast relief of dryness and redness. But when thinking about long-term solutions, ingredients do matter.

As you consider in-office product sales or making specific brand recommendations in your treatment plan, support products that contain only “clean” ingredients. What does “clean” mean? Such products avoid potential offenders that may contribute to eye irritation, allergic responses, or skin reactions. Remember, not all patients have reactions to such “toxic” ingredients, but toxicity builds in the body over time.

Consider this short list of “toxic” ingredients:

• Sodium lauryl sulfate—binds to oils, potentially stripping the skin of moisture; contributes to dry skin, redness, dermatitis, and edema¹²

• Formaldehyde (also known as quaternium-15, imidazolidinyl urea, diazolidinyl urea, sodium hydroxymethylglycinate, bronopol, DMDM hydantoin)—apreservative and known carcinogen; may lead to erythema, edema, vesiculation, or hives, as well as a sensation of irritation in the eyes with burning, itching, redness, and tearing¹³

• Retinyl palmitate/retinol—a nutrient that may damage DNA and speed the growth of skin tumors when used topically¹⁴

• Coal tar dyes (or known as P-phenylenediamine)—found in pigmented cosmetics such as mascara and lipstick; derived from petroleum and composed of many different chemicals; recognized as a human carcinogen¹⁵

• Mineral oil—coats pores, attracts toxins (though nontoxic, could increase the risk of congested meibomian glands)

• Petrolatum (a mixture of mineral oil and waxes)—seals but does not add moisture; nontoxic but could increase the risk of meibomian gland congestion and acne

Another tip is to consider use in the home of products such as cleaning supplies, laundry detergent, and cosmetics. Guide patients to discover alternative, safer cleaning products by recommending easy-to-use apps such as Think Dirty, EWG Healthy Living, and Yuka. These apps allow users to scan or search products for toxic ingredients while explaining why each ingredient is considered toxic. Educate patients by guiding them toward the best and safest products on the market that will help minimize the risk of dry eyes.

Further testing

When is the right time to refer a patient for further testing? There is no definitive answer to this question. Dry eye disease is multifactorial; therefore, if symptoms persist after the patient has followed your office’s dry eye guidance, chances are that something beyond our scope of practice is contributing to their dry eyes. At this point, you can use this as an opportunity to share a report with a primary care physician or functional medicine practitioner while also building your referral network. In doing so, you may help the patient find the relief they seek while creating a base of patients who will continue returning with friends and family.

Patient education is a critical component of managing expectations and communication is paramount, Before initiating treatments, provide the tools for patients to evaluate at home. Then, when they return to the office, you will have additional answers to allow a deep dive into dietary patterns, home environment, and other factors that may be significant contributors to symptoms. Provide encouragement and continue to personalize a holistic plan so that patients develop confidence in our abilities as providers and the rewarding journey on which they are about to embark.

References

1. Mayo Clinic. Water: how much should you drink every day? Mayo Clinic. October 12, 2022. Accessed May 17, 2023. https://www.mayoclinic.org/healthy-lifestyle/nutrition-and-healthy-eating/in-depth/water/art-20044256

2. Poteet J. From alpha to omega: how fatty acids fight dry eye. Review of Optometry. May 15, 2017. Accessed May 17, 2023. https://www.reviewofoptometry.com/article/from-alpha-to-omega-how-fatty-acids-fight-dry-eye

3. National Institutes of Health Office of Dietary Supplements. Omega-3 fatty acids. Updated July 18, 2022. Accessed May 17, 2023. https://ods.od.nih.gov/factsheets/Omega3FattyAcids-Consumer

4. Oleñik A, Mahillo-Fernández I, Alejandre-Alba N, et al. Benefits of omega-3 fatty acid dietary supplementation on health-related quality of life in patients with meibomian gland dysfunction. Clin Ophthalmol. 2014;8:831-836. doi:10.2147/OPTH.S62470

5. Simopoulos AP. Essential fatty acids in health and chronic disease. Am J Clin Nutr. 1999;70(suppl 3):560S-569S. doi:10.1093/ajcn/70.3.560s

6. Wall R, Ross RP, Fitzgerald GF, Stanton C. Fatty acids from fish: the anti-inflammatory potential of long-chain omega-3 fatty acids. Nutr Rev. 2010;68(5):280-289. doi:10.1111/j.1753-4887.2010.00287.x

7. Calder PC. n-3 polyunsaturated fatty acids, inflammation, and inflammatory diseases. Am J Clin Nutr. 2006;83(suppl 6):1505S-1519S. doi:10.1093/ajcn/83.6.1505S

8. Whelan J, Rust C. Innovative dietary sources of n-3 fatty acids. Annu Rev Nutr. 2006;26:75-103. doi:10.1146/annurev.nutr.25.050304.092605

9. Panahi Y, Darvishi B, Jowzi N, Beiraghdar F, Sahebkar A. Chlorella vulgaris: a multifunctional dietary supplement with diverse medicinal properties. Curr Pharm Des. 2016;22(2):164-173. doi:10.2174/1381612822666151112145226

10. Ambrozova JV, Misurcova L, Vicha R, et al. Influence of extractive solvents on lipid and fatty acids content of edible freshwater algal and seaweed products, the green Microalga Chlorella kessleri and the Cyanobacterium Spirulina platensis. Molecules. 2014;19(2):2344-2360. doi:10.3390/molecules19022344

11. Saini RK, Keum YS. Omega-3 and omega-6 polyunsaturated fatty acids: dietary sources, metabolism, and significance - a review. Life Sci. 2018;203:255-267. doi:10.1016/j.lfs.2018.04.049

12. Sodium lauryl sulfate, ICSC 0502. International Chemical Safety Cards. International Labour Organization. April 2008. Accessed May 17, 2023. http://www.ilo.org/dyn/icsc/showcard.display?p_lang=en&p_card_id=0502

13. Occupational Safety and Health Administration. 1910.1048 App C - medical surveillance - formaldehyde. Accessed May 17, 2023. https://www.osha.gov/laws-regs/regulations/standardnumber/1910/1910.1048AppC

14. Mukherjee S, Date A, Patravale V, Korting HC, Roeder A, Weindl G. Retinoids in the treatment of skin aging: an overview of clinical efficacy and safety. Clin Interv Aging. 2006;1(4):327-348. doi:10.2147/ciia.2006.1.4.327

15. National Toxicology Program. Coal tars and coal-tar pitches. Rep Carcinog. 2011;12:111-113.