This is a supplement to EyeWorld Magazine.
Issue link: https://supplements.eyeworld.org/i/203232
7 However, not all omega-3 supplements are equally effective. Many omega-3 supplements have alcohol added to them to remove the mercury and the contaminants. But when you add alcohol, you degrade the fish oil. It goes from a natural triglyceride, which is a normal, found-innature substance, to an ethyl ester. As an ethyl ester, the fish oils don't absorb well, which is why many who ingest them complain of gas or burping. Obviously, this does not occur with normal fish consumption. Re-esterified triglycerides have three times more absorption, and high levels of absorption result in improved response to therapy. Three re-esterified triglyceride forms that have had the toxins removed are available from Physician Recommended Nutriceuticals (PRN, Plymouth Meeting, Pa.), Carlson Laboratories (Arlington Heights, Ill.), and Nordic Naturals (Watsonville, Calif.). Patients must be educated that all fish oils aren't created equal. I put all of my surgical patients on PRN Dry Eye Omega Benefits as soon as I see them, and they continue taking it for a minimum of three months postoperatively. This has had a tremendous impact on postoperative surgical results by reducing dry eye and improving ocular surface disease. In addition to omega-3s, over-thecounter artificial tears and prescription anti-inflammatories are important treatment options. Punctal plugs are a solid secondary therapy when a patient is not responsive to tears and immunomodulation with cyclosporine. For MGD, I use the LipiFlow Thermal Pulsation System (TearScience, Morrisville, N.C.). The system applies heat to the palpebral surfaces of the upper and LipiFlow liquefies and evacuates obstructed glands. "In this rapidly changing healthcare environment, clinicians need to practice smarter, increase patient flow, and empower staff to perform testing based on physician-based indications." lower eyelids directly over the meibomian glands. Graded pulsatile pressure is delivered to the outer eyelid. LipiFlow is much more effective than hot compresses because hot compresses are applied to the outside of the eye. The meibomian glands are on the inside of the eyelids, and LipiFlow applies heat to the inside of the eyelid directly to the meibomian glands. The system provides a heating level of more than 40 degrees C for 12 minutes that heats up the oil glands safely and effectively and then slowly, pulsatingly, expresses them. LipiFlow studies have shown posttreatment improvement in meibomian continued on page 8 In the near future, the Meibo-Scan will be able to tell us where meibomian gland dropout occurs first in MGD; this technology is opening the door to a deeper understanding of this disease. The Keratograph 5M also offers the R-Scan, which automatically detects bulbar redness. Even cornea fellowship trained experts can disagree on the staging of conjunctival erythema when asked to examine a given patient. Now, ophthalmologists can use a standardized, automated system to document exactly how much erythema is present. The R-Scan technology is based on the detection of the blood vessels in the black and white representation of the conjunctiva. The grading is a ratio between the vessels and the rest of the conjunctiva. Grading based on this ratio can allow ophthalmologists to very carefully track how red the eye is and how it responds to treatment. Grade 0 is found only in children and cadavers. Grade 1 and Grade 2 are more normal for adults. Optical coherence tomography OCT is widely available in most offices, but is not typically used for dry eye diagnosis by most doctors. It is noninvasive, objective, quick, and easy. It measures the tear meniscus height, and it has a diagnostic sensitivity of 92% and a specificity of 90% for dry eye. It also measures the lid parallel conjunctival folds (LIPCOF), which has a positive predictive value for dry eye of 93% and a very strong correlation with symptoms. Dr. McDonald is in practice at Ophthalmic Consultants of Long Island; clinical professor of ophthalmology, NYU Langone Medical Center; and adjunct clinical professor of ophthalmology; Tulane University Health Sciences Center, New Orleans. She can be contacted at Margueritemcdmd@aol.com.