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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 22  |  Issue : 2  |  Page : 97-102

Effect of omega-3 fatty acids on dry eye following phacoemulsification


1 Department of Ophthalmology, Mataria Teaching Hospital, Cairo; Department of Ophthalmology, Beni-Suef University, Beni-Suef, Egypt
2 Department of Ophthalmology, Beni-Suef University, Beni-Suef, Egypt

Date of Submission27-Aug-2020
Date of Decision12-Dec-2020
Date of Acceptance20-Feb-2021
Date of Web Publication24-Jun-2021

Correspondence Address:
MSC Mahmoud M Kesba
Department of Ophthalmology, Beni-Suef University, Kornish Elnile, Faraskour, Damietta 34611
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/DJO.DJO_64_20

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  Abstract 


Purpose The aim of this study was to evaluate the efficacy of omega-3 fatty acids on dry eye after phacoemulsification.
Patients and methods This is a randomized controlled clinical trial which included 50 patients who developed dry eye symptoms following phacoemulsification. They were randomly allocated into two groups, with 25 patients each. The first group received an omega-3 dietary supplementation of 1000 mg in addition to the conventional treatment (artificial tears and anti-inflammatory eye drops) for 3 months. The second group received only artificial tears and anti-inflammatory eye drops. Both groups received treatment from September 2019 to March 2020, and they were followed up for 3 months. All patients had the same diagnostic tests (Schirmer test, ocular surface disease index, and tear break-up time), postoperatively.
Results There was no statistically significant difference between the two groups in the demographic data. However, a significant difference was noted in the tear break-up time test scores (11.08±3.29 and 9.20±1.87 s) in the treatment and control groups, respectively. In addition, the ocular surface disease index showed a statistically significant difference between the treatment and control groups (19.41±9.69 and 31.23±11.66, respectively) after 3 months. No significant difference (P=0.186) was noted in the Schirmer test between the treatment and the control groups (9.16±2.72 and 8.12±2.76 mm, respectively).
Conclusions The study showed that the addition of omega-3 fatty acid supplements after phacoemulsification can reduce the incidence of dry eye and improve both the objective and subjective measurements of dry eye.

Keywords: cataract surgery, dry eye, omega-3 fatty acids, phacoemulsification


How to cite this article:
Kesba MM, Saif MY, Saeed MA. Effect of omega-3 fatty acids on dry eye following phacoemulsification. Delta J Ophthalmol 2021;22:97-102

How to cite this URL:
Kesba MM, Saif MY, Saeed MA. Effect of omega-3 fatty acids on dry eye following phacoemulsification. Delta J Ophthalmol [serial online] 2021 [cited 2021 Sep 22];22:97-102. Available from: http://www.djo.eg.net/text.asp?2021/22/2/97/319183




  Introduction Top


Dry eye is a chronic multifactorial disorder. It is characterized by ocular surface inflammation and inadequate production of tears [1]. Dry eye is the most common ophthalmological presentation in daily practice and has been considered a major public health concern [2]. It is also considered a significant complication of intraocular surgeries such as phacoemulsification [3]. Dry eye can lead to unsatisfactory postoperative outcome such as burning sensation, itching, red-eye, photophobia, discomfort feelings, or even temporary blurring of vision [4],[5].

There are many factors that are responsible for the development of dry eye after phacoemulsification, such as the long-term use of antibiotic-steroid eye drops, decreased tear film break-up time owing to surface irregularity at the site of the incision, decreased mucin production from the conjunctiva secondary to incision placement, and decreased corneal sensation owing to the surgical incision, which disrupts the cornea-lacrimal gland loop, leading to reduced tear secretion, poor tear film production and stability due to surgically induced ocular inflammation, and exposure to light from the operating microscope [6]. Dry eye symptoms may temporarily affect the quality of vision and the quality of patient life [7].

Omega-3 fatty acids (FAs) and omega-6 FAs are essential for normal growth and development. Omega-3 FAs and omega-6 FAs compete for the same enzyme to eventually be converted into anti-inflammatory prostaglandins 3 and less inflammatory leukotrienes and into pro-inflammatory prostaglandins 2 and more inflammatory leukotrienes, respectively [8],[9].

Omega-3 FAs supplementation may alleviate blepharitis and the resulting  Meibomian gland More Details dysfunction and dry eye symptoms by two hypotheses. The first hypothesis is that the breakdown of omega-3 FAs results in the production of molecules that suppress inflammation. Conversely, the breakdown of omega-6 FAs results in the production of molecules that can lead to inflammation. The second hypothesis involves the composition of the tear film. It has been suggested that an unstable tear film results from abnormal Meibomian gland secretions and can result in evaporative dry eye. Supplementing the diet with high amounts of omega-3 FAs is likely to change the FA composition and therefore the properties of Meibomian gland secretions. This change may be beneficial in tear stabilization and may prevent the inflammation from blocking the Meibomian gland ducts and meibum stagnation [8],[9],[10]. Several studies had reported that omega-3 is beneficial to dry eye disease treatment.

This study aimed to assess the effects of omega-3 FAs on dry eye that occurred following phacoemulsification at Mataria Teaching Hospital and the Ophthalmology Department of Beni-Suef University.


  Patients and methods Top


This study was approved by the Scientific and Ethics Committee of Beni-Suef University and adhered to the tenets of the Declaration of Helsinki. A written informed consent was obtained from all patients to participate in the study and for publication of data, before the commencement of the study after a thorough explanation of the study objectives.

A total of 50 patients who developed dry eye symptoms (in the form of foreign body sensation, red-eye, itching, burning sensation, photophobia, or blurring of vision) following phacoemulsification were randomly allocated into two groups (each of 25 patients) over the period extending from September 2019 to March 2020. The first group (treatment group) received omega-3 dietary supplementation (omega-3 plus 1000 mg; SEDICO, 6 October City, Egypt) in addition to the conventional treatment (artificial tears and anti-inflammatory eye drops) for 3 months. The second group (the control group) received only artificial tears and anti-inflammatory eye drops for 3 months as well.

The study included patients with postoperative clear cornea and uncomplicated phacoemulsification.

Patients with preoperative dry eye disease, previous corneal refractive surgery, previous intraocular surgeries other than phacoemulsification, intraoperative complications, autoimmune diseases, eye trauma, entropion or ectropion, uveitis, or glaucoma were excluded from the study.

Patients were asked about symptoms of foreign body sensation, burning, itching, red-eye, photophobia, or blurring of vision after phacoemulsification. Objective clinical measures were obtained including tear production (Schirmer I test without anesthesia) and tear film stability [fluorescein tear break-up time (TBUT)]. Subjective clinical measures were obtained by the ocular surface disease index (OSDI).

The Schirmer test was performed without anesthesia. The strip was placed in the conjunctival sac at the junction of the lateral third and the medial two-thirds of the lid margin. Patients sat in the dark with both eyes closed for 5 min. The strips were removed, and a measurement (in mm) of the wet area of the strip was made.

Fluorescein TBUT was performed as a functional measure of tear film stability. A fluorescein strip (Ophtechnics Unlimited, Haryana, India) wetted with a single drop of Benox (EPICO, Tenth of Ramadan City, Egypt) was applied to the lower bulbar conjunctiva. Participants were asked to blink several times, and the ocular structures were viewed with a slit-lamp biomicroscope using a broad beam of the slit lamp with a cobalt blue filter. This was done before any manipulation of the eyelids or installation of other drops. The time-lapse between the last blink and the appearance of the first randomly distributed dry spot on the cornea is the TBUT. The appearance of dry spots (fixed spots) in less than 10 s was considered abnormal. This procedure was repeated three times, and the average value in seconds was recorded for each eye.

The OSDI was performed as a subjective measure. The patients filled the standard questionnaire for OSDI, which is an instrument to quantify the severity of dry eye symptoms (normal, mild to moderate, and severe) and their effect on vision-related functions. The OSDI questionnaire was scored from 0 to 100 (100 being the most severe disease). All measurements were done by a single person, and the physician in charge of collecting outcome data was kept blinded to the allocation ([Figure 1]).
Figure 1 Ocular surface disease index score.

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Statistical analysis

The recorded data were analyzed using the statistical package for social sciences, version 20.0 (SPSS Inc., Chicago, Illinois, USA). Quantitative data were expressed as mean±SD. Qualitative data were expressed as frequency and percentage. Independent samples t test of significance was used when comparing between two means. The Mann–Whitney U test was used for two-group comparisons in nonparametric data. χ2 test of significance was used to compare proportions between qualitative parameters. The confidence interval (CI) was set to 95% and the margin of error accepted was set to 5%. So, the P value less than or equal to 0.05 was considered significant and if less than 0.001 was considered as highly significant and if more than 0.05 it was considered insignificant.


  Results Top


The study was conducted on 50 patients who had dry eye symptoms after phacoemulsification. The patients were randomly assigned to two groups, with 25 patients each. Females constituted 76% of the control group and 68% of the treatment group. The mean age of the patients in the control group was 60.44±9.15 years (range: 42–79 years), whereas it was 61.32±10.68 years (range: 39–78 years) in the treatment group ([Table 1]). There was no statistically significant difference in the Schirmer test results between the treatment and control groups. However, a notable difference was observed in both the TBUT and OSDI between the treatment and control groups.
Table 1 Comparison between the control group and treatment group according to demographic data

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The mean pretreatment TBUT improved significantly in both groups after treatment. However, the TBUT drift was significantly higher in the treatment group in comparison with the control group at the final visit postoperatively (11.08±3.29 and 9.20±1.87 s, respectively, P≤0.017, [Table 2]).
Table 2 Comparison between the control group and treatment groups according to the tear break-up time

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The mean pretreatment OSDI improved significantly in both groups after treatment. The OSDI was significantly higher in the treatment group in comparison with the control group at the final postoperative visit (19.41±9.69 and 31.23±11.66, respectively, P≤0.001, [Table 3]).
Table 3 Comparison between the control group and treatment group according to the ocular surface disease index

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The mean pretreatment Schirmer test value improved significantly in both groups after treatment. However, there was no statistically significant difference between the control and treatment groups regarding the Schirmer’s test at the final postoperative visit (9.16±2.72 and 8.12±2.76 mm, respectively, P=0.186, [Table 4]).
Table 4 Comparison between the control group and treatment group according to Schirmer test

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  Discussion Top


Dry eye after eye surgeries can affect the quality of life by causing eye discomfort, burning, itching, red-eye, photophobia, or even temporary blurring of vision [5]. One of the most important mechanisms for postsurgical dry eye is postsurgical inflammation [11]. Omega-3 is considered an essential FA that should be supplemented in diet and cannot be produced in the body as long-chain FAs modulate the inflammatory process and reduce the inflammatory response [12].

In this study, the OSDI and TBUT showed significant improvement in both the control and treatment groups, but this improvement was significantly higher in the treatment group in comparison with the control group. These results illustrated that supplementing the diet with high amounts of omega-3 polyunsaturated FAs decreased the dry eye symptoms after phacoemulsification and increased the tear film stability. However, there was no statistically significant difference between the treatment and control groups according to the Schirmer test results. Mohammadpour et al. [13] examined 61 eyes of 48 patients complaining of new-onset dry eye symptoms after cataract surgery. They observed the same results for the OSDI, TBUT, and Schirmer’s test. The OSDI improvement was significantly higher in the treatment group than in the control group (P=0.026). The TBUT improved in both the control and treatment groups after treatment (P<0.001). However, the TBUT was more significantly affected in the treatment group compared with the control group (P=0.038). In addition, the posttreatment Schirmer test results between the two groups were not statistically different (P=0.155).

Kangari et al. [14] showed that adding omega-3 supplements to the standard treatment in nonsurgically induced dry eye syndrome would significantly improve the OSDI, TBUT, and Schirmer’s test results. In the current study, the OSDI and TBUT showed a statistically significant difference between the two groups, whereas there was no statistically significant difference between the two groups in the Schirmer’s test results. It seems that omega-3 supplementation has positive effects on tear film quality rather than its quantity in surgically induced dry eye syndrome. It could be explained by the more important role of inflammation in surgically induced dry eye. Although inflammation could lead to decreased production of tears, studies demonstrated conflicting results of anti-inflammatory medication in the improvement of Schirmer’s test results.

Wojtowicz et al. [15] conducted a study investigating the potential effect of dietary supplementation with omega-3 FAs on the lipid composition of meibum, aqueous tear evaporation, and tear volume in patients with dry eye. It showed no significant effect on meibum lipid composition or aqueous tear evaporation rate. On the contrary, the average tear production and tear volume were increased in the omega-3 group, as indicated by both fluorophotometry Schirmer testing and Schirmer testing. Similarly, Miljanović et al. [16] did a large cross-sectional study that observed a lower incidence of dry eye symptoms among women who took a higher dietary intake of omega-3.

Goyal et al. [17] did a study on the effect of omega-3 FA supplementation in laser in situ keratomileusis-associated dry eye. The OSDI scores increased comparably in both groups (1.9±0.6 increase in the treatment group compared with 2.8±0.5 in the control group, P=0.267). Compared with the baseline levels, the TBUT decreased significantly (P<0.01) but comparably in both treatment (−2.3±0.4 s decrease) and control groups (−3.5±0.7 s decrease) (P=0.105). More eyes in the control group (43.4%) had conjunctival staining with Lissamine green, at 3 months, compared with the treatment group (14%) (P=0.009). The Schirmer test score, at 3 months, was significantly higher (P=0.003) in the treatment group (30.5±0.90 mm) than in the control group (25.7±1.3 mm) with an increase of 5.9±1.3 mm from the baseline in the treatment group and a decrease of 1.5±1.2 mm in the control group.

Giannaccare et al. [18] performed a study on the efficacy of omega-3 FA supplementation in treatment of dry eye disease. A meta-analysis of randomized clinical trials showed significantly improved dry eye symptoms and signs in patients with dry eye disease [standardized difference in mean values (SDM)=0.968; 95% CI 0.554–1.383; P<0.001] and corneal fluorescein staining (SDM=0.517; 95% CI, 0.043–0.991; P=0.032), whereas it increased the TBUT (SDM=0.905; 95% CI, 0.564–1.246; P<0.001) and Schirmer test values (SDM=0.905; 95% CI, 0.564–1.246; P<0.001).

On the contrary, Asbell et al. [19] conducted a study on the effect of omega-3 FA supplementation in the treatment of dry eye disease on 349 patients who were assigned to the active supplement group and 186 assigned to the placebo group. The primary analysis included 329 and 170 patients, respectively. The mean change in the OSDI score was not significantly different between the active supplement group and the placebo group (−13.9 points and −12.5 points, respectively; mean difference in change after imputation of missing data, −1.9 points; 95% CI, −5.0 to 1.1; P=0.21). This result was consistent across the prespecified subgroups. There were no significant differences between the active supplement group and the placebo group in the mean changes from baseline in the conjunctival staining score (mean difference in change, 0.0 points; 95% CI, −0.2 to 0.1), corneal staining score (0.1 points; 95% CI, −0.2 to 0.4), TBUT (0.2 s; 95% CI, −0.1 to 0.5), and result of Schirmer’s test (0.0 mm; 95% CI, −0.8 to 0.9). At 12 months, the rate of adherence to treatment in the active supplement group was 85.2%, which means no evidence of a beneficial effect of n-3 FA supplements as compared with placebo supplements among patients with dry eye disease.


  Conclusion Top


The present study showed the effectiveness of omega-3 supplements in the management of dry eye syndrome after phacoemulsification in terms of both subjective and objective measurements. Therefore, it could be safely added to the postoperative protocols following phacoemulsification to reduce the incidence of postoperative dry eye syndrome.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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Goyal P, Jain AK, Malhotra C. Oral omega-3 fatty acid supplementation for laser in situ keratomileusis-associated dry eye. Cornea 2017; 36:169–175.  Back to cited text no. 17
    
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