
An increasing number of cataract surgery patients desire a greater quantity of vision (ie, more spectacle independence across a range of distances) in addition to a higher quality of vision. Continuing advances in premium IOL technology are raising both patients’ and surgeons’ expectations. Satisfaction requires ophthalmologists to pay close attention to ocular surface health. Optimizing the tear film has never been more crucial.
Thanks in large part to the work of my colleagues Joaquin De Rojas, MD, and Priya M. Mathews, MD, MPH, our practice, Center for Sight, has developed a protocol for the diagnosis and treatment of ocular surface disease (OSD) that has been implemented across all US Eye–affiliated practices. The protocol addresses various clinical scenarios and suggests products to use in specific settings. Physicians can tailor the algorithm to their own preferences and their patients’ needs. In my experience, the algorithm provides an excellent starting point for managing patients with OSD.
FUNCTIONAL MEDICINE PERSPECTIVE
Rather than dry eye, I use the term ocular surface disease when speaking to patients to explain that the condition exists on a spectrum and has multiple contributing factors. My certification in functional medicine enables me to address the root causes of their health conditions from an ophthalmologist’s perspective. Traditionally, medical care has focused on treating specific conditions—such as removing cataracts or managing diabetes. A more integrative approach, however, considers not just treating the symptoms but exploring and addressing the root causes of the disease.
I explain that the goal is to decrease ocular inflammation by addressing it both internally and externally. For example, supplementation with a nutraceutical such as HydroEye (ScienceBased Health) may help improve the quality of their tear film by reducing systemic inflammation. I gauge each patient’s level of interest and willingness to consider new ideas and then adapt the conversation accordingly. Some patients prefer clear instructions and a quick visit. Others, particularly those interested in functional medicine, may desire a deeper dive into the science. Most patients fall somewhere in between.
OMEGA-6 AND OMEGA-3 SUPPLEMENTS
Many of my patients take omega-3 fatty acid fish oil supplements, often in high doses, but do not experience the relief of their ocular surface inflammation that they seek. This could be due to an imbalance in the ratios of omega fatty acids being consumed. I explain to patients that the typical US diet does not provide a correct balance of these nutrients, which may contribute to the development of many common chronic diseases.1 HydroEye contains an omega-6 fatty acid—gamma-linolenic acid—in a specific proportion to omega-3 and other ingredients. The patented formulation has been clinically shown to decrease specific markers of ocular inflammation.2-9
Subjectively, about 90% of my patients notice an improvement in their OSD symptoms within the first few weeks of starting treatment with HydroEye in combination with topical therapies. Objectively, I have observed improvement on corneal topography using tools such as the iTrace (Tracey Technologies). Seeing compelling images of their ocular surface healing motivates patients to continue treatment.
MANAGING EXPECTATIONS FOR CATARACT SURGERY OUTCOMES
Many patients are excited when they learn they have cataracts because they are thinking, “Finally, I’ll be able to see everything without glasses!” It often disappoints them to hear that their glaucoma or retinal disease may prevent them from achieving their desired results. I recommend performing macular OCT on all patients but particularly those who desire a presbyopia-correcting IOL to ensure the back of their eyes is healthy. It is important to recognize that patients with conditions such as Sjögren syndrome and severe OSD will not benefit from advanced-technology lenses.
In my experience, most patients seeking premium technology are highly motivated to address their OSD. I explain to them that we are undertaking treatment “not because I want you to have a good result but because I want you to have a great result.” Optimizing the ocular surface can improve their qualitative outcome with any advanced-technology IOL and hasten their postoperative recovery. These patients must be willing to commit to the entire process—before, during, and after surgery. Otherwise, they may be dissatisfied with their postoperative visual quality and attribute the issue to the implant or surgeon when the problem lies with their ocular surface.
1. Balić A, Vlašić D, Žužul K, Marinović B, Bukvić Mokos Z. Omega-3 versus omega-6 polyunsaturated fatty acids in the prevention and treatment of inflammatory skin diseases. Int J Mol Sci. 2020;21(3):741.
2. Kapoor R, Huang YS. Gamma linolenic acid: an antiinflammatory omega-6 fatty acid. Curr Pharm Biotechnol. 2006;7(6):531-534.
3. Barabino S, Rolando M, Camicione P, et al. Systemic linoleic and gamma-linolenic acid therapy in dry eye syndrome with an inflammatory component. Cornea. 2003;22(2):97-101.
4. Macrì A, Giuffrida S, Amico V, Iester M, Traverso CE. Effect of linoleic acid and gamma-linolenic acid on tear production, tear clearance and on the ocular surface after photorefractive keratectomy. Graefes Arch Clin Exp Ophthalmol. 2003;241(7):561-566.
5. Aragona P, Bucolo C, Spinella R, Giuffrida S, Ferreri G. Systemic omega-6 essential fatty acid treatment and PGE1 tear content in Sjögren’s syndrome patients. Invest Ophthalmol Vis Sci. 2005;46(12):4474-4479.
6. Kokke KH, Morris JA, Lawrenson JG. Oral omega-6 essential fatty acid treatment in contact lens associated dry eye. Cont Lens Anterior Eye. 2008;31(3):141-170.
7. Pinna A, Piccinini P, Carta F. Effect of oral linoleic and gamma-linolenic acid on meibomian gland dysfunction. Cornea. 2007;26(3):260-264.
8. Brignole-Baudouin F, Baudouin C, Aragona P, et al. A multicentre, double-masked, randomized, controlled trial assessing the effect of oral supplementation of omega-3 and omega-6 fatty acids on a conjunctival inflammatory marker in dry eye patients. Acta Ophthalmol. 2011;89(7):e591-e597.
9. Sheppard JD Jr, Singh R, McClellan AJ, et al. Long-term supplementation with n-6 and n-3 PUFAs improves moderate-to-severe keratoconjunctivitis sicca: a randomized double-blind clinical trial. Cornea. 2013;32(10):1297-1304.