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A randomized, double-masked Study to evaluate the effect of
supplementation of Omega-3 fatty acids in Meibomian Gland
Dysfunction
1 Department of Ophthalmology. Jiménez Díaz Foundation, Madrid, Spain 2 Department of Ophthalmology. Jiménez Díaz Foundation, Madrid, Spain 3 Deparmartment of Statistics. Jiménez Díaz Foundation, Madrid, Spain; Correspondence: Andrea R. Oleñik Memmel C/ Fray Luís de León 5A, 3A. 28012. Madrid, Spain Background: Meibomian glands dysfunction (MGD) is one of the most common causes of
ophthalmological symptoms. The inflammation is part of the pathogenesis, so we accept the sufficient evidence of antioxidant-inflammatory properties of omega 3 fatty acids Objective: Our scope is aimed to the effectiveness assessment of Omega 3 fatty acids versus placebo
on the improvement of patient symptoms and signs of meibomian glands dysfunction. Methods: The method is a 3-month prospective, randomized, double-masked, parallel-group controlled
trial. We enrolled 60 patients with symptomatic MGD and unstable tear film [tear breakup time (TBUT) < 10 seconds]. Participants were randomly assigned to homogeneous two subgroups, with different treatments during 3 months. Group A had to clean the lid margins with baby shampoo neutral + artificial tears without preservatives + placebo. On the other side, the patients Group B must clean the lid margins with baby shampoo neutral + artificial tears without preservatives + oral supplementation with omega 3 fatty acids during 3 months. Additionally we performed the following test: (1) Ocular Surface Disease Index (OSDI), (2) lid margin inflammation, (3) meibomian gland expression, (4) corneal and inter- palpebral dye staining, (5) tear breakup time (TBUT), and (6) Schirmer I Results: After 3-month of evaluation, mean OSDI, TBUT, lid margin inflammation and meibomian gland
expressibility showed improvement from baseline in group B (P < 0.001, P< 0.001, P<0.01, P<0.01, respectively).Schimer test was also statistically significant result with P < 0.01. Conclusion: 1.5 grams of oral Omega 3 fatty acids per day may be beneficial in the treatment of MGD,
Keywords: meibomian glands dysfunction, Omega 3 fatty acids, blepharitis, dry eye.
Introduction
Meibomian gland dysfunction (MGD) is one of the most common disorders encountered in ophthalmic practice and is the main cause of evaporative dry eye1. According to the report of the international workshop on MGD2, the core mechanisms for development of obstructive MGD are hyperkeratinization of the ductal epithelium and increased meibum viscosity, which in turn are influenced by aging, hormonal changes, and use of contact lenses and topical medications. Other causes include acinar atrophy and inflammation. Consequently, MGD is the major cause of lipid tear deficiency, which results in a lack of or an abnormal lipid tear layer and causes instability of the tear film and shortening of the tear breakup time (TBUT)3,4 Conventional treatments for MGD include lid hygiene, warm compression, artificial tear supplements, topical erythromycin, topical corticosteroids, and oral tetracycline/doxycycline.3–5 These treatments can be challenging and are frequently ineffective. Currently, there is no medication that acts on the core mechanism of this condition. Also, degenerative changes of the meibomian gland, which might be irreversible, play a role in the pathogenesis of MGD. Tear cytokines also play an important role in the chronic inflammation of MGD. Interleukin (IL)-1β, IL-7, IL-12, IL-17, and macrophage inflammatory protein-1β levels in MGD patients were higher than those in a normal group when comparing the inflammatory cytokine levels in tears of MGD patients and those in a normal group.6,7 IL-6, IL-8, IL-12, interferon-γ (IFN- γ), and tumor necrosis factor-α (TNF- α) levels were higher in dysfunctional tear syndrome with MGD than in the control group8. Essential fatty acid supplementation has shown to have an anti-inflammatory effect on dry eye symptoms9. Fish oil is a source of long-chain omega-3 polyunsaturated fatty acids: eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA). The omega-3 fatty acid EPA and the omega-6 fatty acid arachidonic acid (AA) act competitively as substrate for both enzymes cyclooxygenase and 5- lipoxygenase. The anti-inflammatory action is believed to result from the synthesis of prostaglandin E3 (PGE3) and of leukotriene B5 (LTB5) from EPA that inhibits the conversion of AA to potentially harmful inflammatory mediators prostaglandin E2 (PGE2) and leukotriene B4.10. There have been 2 anecdotal reports of dietary supplementation with flaxseed oil thinning meibomian gland secretions and improving In the present study, we evaluated the relationship between oral supplementation of a combined formulation of antioxidants and omega-3 (ω-3) on the improvement of the signs and symptoms of patients diagnosed with MGD, as compared to MGD patients not taking these supplements (placebo). Material and methods
This prospective randomized, double-masked, parallel-group controlled trial was performed under the approval of the Ethical Committee (CEIC-FJD) and the Institutional Review Boards of the University Hospital Fundación Jiménez Díaz (Madrid, Spain), and all tenets of the Declaration of Helsinki for the protection of human subjects in medical research were strictly observed. Study design
A total of 61 subjects of both sexes, aged 23–85 years, were enrolled during ophthalmologic appointments at the study center in Madrid, Spain between March 2012 and December 2012 according to the main inclusion/exclusion criteria listed in Table 1. Prior to the baseline visit, subjects were required to discontinue use of nutritional supplements, related treatments such as: antibiotics, non-steroidal and anti-inflammatory drugs, corticosteroids, as well as tears with vitamins, for at least 15 days. Participants were asked to strictly follow the recommendations of the ophthalmologists throughout the duration of the study. Ocular lubricants without nutritional agents were not restricted. Patients with obvious infection were excluded from the present study. Patients To classify our study participants, a systematized ophthalmologic examination and a questionnaire, with scores including objective/subjective criteria, were performed. Other signs and symptoms of MGD At the month 0 (baseline) visit, patients were checked for the protocol’s inclusion and exclusion criteria, and the following baseline parameters were assessed: (1) Ocular Surface Disease Index (OSDI), (2) tear breakup time (TBUT), (3) lid margin inflammation, (4) meibomian gland secretion and expressibility, (5) corneal dye staining with fluorescein, (6) Oxford Test, and (7) tear volume measured by Schirmer I test. Additionally, daily tear supplement without preservatives usage was assessed. Fifteen minutes of warm compression combined with daily lid scrub with dilute baby shampoo and lid massage was encouraged in all patients. All participants were randomized in block: 2 groups, A and B. Patients in group A received placebo: 500mg capsules incorporating sunflower oil, with no other components or excipients, a part of the same gelatin (bovine) for cover and titanium oxide colorants (E 171), iron oxide and hydroxides (E172). Whereas those in group B received supplement formulation as reflected in Table 2 ( Brudysec 1.5 gr.; Brudy Laboratories, Barcelona, Spain) was based on Omega-3 , vitamins, glutathione, amino acids, and oligoelements, in a combined nutraceutical formulation with (per capsule): docosahexaenoic acid (350 mg), eicosapentaenoic acid (42.5 mg), docosapentaenoic acid (30 mg), vitamin A (133.3 µg), vitamin C (26.7 mg), vitamin E (4 mg), tyrosine (10.8 mg), cysteine (5.83 mg), glutathione (2 mg), zinc (1.6 mg), copper (0.16 mg), manganese (0.33 mg), and selenium (9.17 µg). The objective parameters were reassessed at follow-up visits at 1, 2, and 3 months after the assigned treatments were begun. The objective parameters were assessed by 1 investigator (Andrea Oleñik (A.O.)) to reduce inter-observer variability. Given that compliance with long-term self-administered medication therapy is approximately 50% for those who remain in care, at each visit handed the empty blisters of medication received the researcher in order to improve compliance with the same and increase the benefit they may receive from these supplements, as well as to ensure the validity of the final data of the study. Therefore, subjects were followed each month after the initial visit during the 3 months of Patient management
A personal interview was performed with all participants regarding their personal and familial backgrounds and characteristics of their disease, mainly symptoms of MGD. The Ocular Surface Disease Index (OSDI) questionnaire assessed the subject’s frequency of dry eye symptoms and problems with their ocular surface13. The OSDI questionnaire was assessed on: normal, mild, moderate and severe. A systematized ophthalmologic examination was carried out on all participants as follows: best corrected visual acuity (BCVA) in each eye. Objective signs included slit-lamp examination of the lid and meibomian glands, conjunctival and corneal dye staining (Oxford Test), TBUT, and tear volume (Schirmer I test). Lid inflammation were graded as follows: 0: no injection, 1 mild injection, 2 moderate injection, and Meibomian glands dysfunction was defined as abnormal discharge and / or abnormal expression using a finger on both covers and watching the secretion of the same: clear fluid, cloudy fluid, cloudy particulate fluid, Inspissated toothpaste (Table 3) 1. The primary outcomes of the ophthalmologic measures for effectiveness of the oral nutraceutical formulation were the fluorescein tear breakup time (TBUT); the secondary measure was Schirmer test I and dry eye symptoms13. TBUT was measured by using 2 mL of 2% fluorescein dye. The first disappearance of the dye was recorded, and the average value of 3 measurements was calculated. The corneal fluorescein scores were assessed using the Oxford grading. Tear volume (Schirmer I test) was measured over a 5-minute period without anesthesia. Safety outcomes were assessed via ophthalmic examinations and the occurrence of adverse events throughout the study. Statistical analysis
The study was analyzed using results from the patient’s right eyes. The primary efficacy parameter was the TBUT. Descriptive statistics were represented as mean values and standard errors of the mean, using t-Student of dependent data for comparison intragroup and group’s data. Both comparisons used an intention-to –treat analysis. Statistical significance was considered as a P, 0.05 (2 sided) and was performed using the Statistical Package for the Social Sciences software, version 11.0 (SPSS, Inc., Patients’ Demographic Data
Sixty-five patients were enrolled in the study, 32 patients in group A and 33 patients in group B. Five patients were withdrawn from the study, 1 (3.03%) from group B due to drug intolerance; and 1 (3.12%) from group A + 1 from group B (3.03%) due to loss to follow-up. Sixty one patients completed the study: 31 (50.82%) in group A and 30 (49.18 % ) in group B. The mean age of group B patients (xx ± xx years) was significantly greater than that of group A patients (xx ± xx years; P = xxx). Most patients in both the groups were women, and the difference in gender distribution between the groups was not statistically significant. There were no significant differences in baseline signs and symptoms between the 2 groups. Demographic data and baseline signs and symptoms are shown in Table 3. During the trial, both the investigators and the patients were blinded to the treatment assigned. Treatment Responses
At baseline, mean values for TBUT were 6.45 ± 2.57 seconds and 6.94 ± 2.75 seconds in groups A and B, respectively (Table 3). At each follow-up visit, mean TBUT values in group B were significantly increased compared with baseline and compared with group A. The final test results of TBUT were 8.03 ± 2.86 seconds and 12.63 ± 1.75 second in groups A and B, respectively, (P ; < 0.0.1, Fig. 1). In the control group (group A), TBUT were not significantly different from baseline. On the other hand, lid inflammation was decreased significantly from baseline at each follow-up visit in group B (P <, xxxx), whereas group B showed significant improvements at 1 month and 2 months (P = xxxx and P = xxxxx, respectively). There were statistically significant differences in degrees of lid inflammation between the 2 treatment groups at each of the 3 visits (P = , P = , and P = , respectively; Fig. 2). Meibomian gland expressibility was significantly increased from baseline at 1 month and 3 months in group B (P = and P = , respectively) and significantly improved compared with group A at 1 month (P = ); Fig. 3). In group A, there was no change in expressibility at any visit. In both the groups, cornea fluorescein staining scores were not significantly different from baseline. Although the scores were lower in group B at each follow-up visit, there were no significant differences between the 2 treatment groups. Tear volumes, as measured by Schirmer I test without anesthesia, at baseline in both the groups (mean 16.61 ± 7.57 and 18.94 ± 7.47 mm in groups A and B, respectively). These values were not significantly changed from baseline at the 3-month visit in both the groups, but there was significant difference between the 2 treatment groups (P< 0.01) Symptoms of tear dysfunction were assessed using the OSDI. Comparisons of OSDI scores before and after treatment showed a significant decrease in symptoms in both the treatment groups: in group B at 2 and 3 months (P = xxxx and P , xxxx, respectively) and in group A at every time point (P = xxxxx, P, xxxxx, and P , xxxxxx, respectively). Discussion
Pathogenesis of obstructive MGD is based mainly on hyperkeratinization and its consequences, such as ductal dilatation and acinar atrophy. Other conditions leading to chronic inflammation of the ocular surface, such as atopy, pemphigoid, acne rosacea, and seborrhea, are associated with secondary MGD as shown in the schematic of MGD classification14. Altogether, these conditions may lead to clinically apparent inflammation, eye irritation, tear film alteration, and dry eye seen in MGD patients. Inflammatory cytokines, such as epidermal growth factor, interleukin (IL)-1, IL-6, IL-8, IL-12, and tumor necrosis factor- alpha, have been reported to be increased in MGD15,16, which may explain the irritative symptoms and lid inflammation observed in patients with this disorder. Based on these effects, inflammatory properties Inflammatory power of essential polyunsaturated fatty acids in the ocular surface compared with corticosteroids for acting in the same mediator of inflammation cascade: are mediated through NF-κB signal transduction17. This study suggests that Omega 3 fatty.acids may improve tear film stability in Recent study shows the effectiveness of omega-3, omega-6 added to vitamin PLP10 as adjuvant therapy multiple sclerosis to prevent the progression of the same, showing their anti-inflammatory put18. In contrast to the study by Wojtowicz et al 19, where they found no statistically significant differences in the treatment of dry eye with Omega-3, we did find differences in the MGD, both TBUT like symptoms (OSDI), so this study is a starting point for further research to extend the benefit of Omega 3 fatty acids in inflammatory disease of the ocular surface. This study had the advantage of being a doublemasked, randomized prospective assessment, which may have minimized any possible bias. The main efficacy outcome was tear film stability measured. Greater differences may be been seen in a larger patient population. A multicenter and larger controlled study may be required to ascertain whether this improvement in TBUT is applicable to clinical In conclusion, this study demonstrated that Omega 3 fatty-acids 1,5 gr in the treatment of MGD can increase TBUT. When conventional treatment with artificial tears has proved unsatisfactory, Omega - 3 fatty acids 1,5 gr may be an effective adjunctive treatment for patients with MGD. Adverse Events
No serious adverse events occurred during the study. One of 33 patients (3.03%) in the intention-to-treat analysis group reported digestive upset of omega 3 treatment. These symptoms of discomfort occurred within the first month of treatment and recovered immediately after stopping the medication Disclosures
The author reports no conflicts of interest in this work. Acknowledgments/
Medications used in this tri were provide by Brudy Laboratories (Barcelona, Spain) Nicolas Alejandre (Department of Ophthalmology, Fundación Jiménez Díaz, Madrid, Spain) was involved in the promotion of this clinical trial. References
1. Foulks GN, Bron AJ. Meibomian gland dysfunction: a clinical scheme for description, diagnosis, classification, and grading. Ocul Surf. 2003;1:107–126. 2. Knop E, Knop N, Millar T, et al. The international workshop on meibomian gland dysfunction: report of the subcommittee on anatomy, physiology, and pathophysiology of the meibomian gland. Invest Ophthalmol Vis Sci. 2011; 52:1938–1978. 3. MathersWD. Meibomian gland disease. In: Pflugfelder SC, Beuerman RW, Stern ME, eds. Dry Eye and Ocular Surface Disorders. New York, NY: Marcel Dekker, Inc. 2004: 247–267. 4. Driver PJ, Lemp MA. Meibomian gland dysfunction. Surv Ophthalmol. 1996; 40: 343–367. 5. Bron AJ, Benjamin L, Snibson GR. Meibomian gland disease. Classification and grading of lid changes. Eye (Lond). 1991; 5 (pt 4):395–411. 6. Kim JT, Lee SH, Chun YS, Kim JC. Tear cytokines and chemokines in patients with Demadex blepharitis. Cytokine. 2011; 53(1): 94 –99. 7. Solomon A, Dursun D, Liu Z, Xie Y, Macri A, Pflugfelder SC. Pro- and anti-inflammatory forms of interleukin-1 in the tear fluid and conjunctiva of patients with dry-eye disease. Invest Ophthalmol Vis Sci. 2001; 42 (10):2283–2292. 8. Lam H, Bleiden L, de Paiva CS, Farley W, Stern ME, Pflugfelder SC. Tear cytokine profiles in dysfunctional tear syndrome. Am J Ophthalmol. 2009; 147(2):198 –205. 9. Brignole-Baudouin F, Badouin C, Aragona P, Rolando M, Labetoulle M, Pisella P, Barabino S, Siou-Mermet R, Creuzot-Garcher C.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 Ophtalmologica. 2011 Nov;89(7):e591- 10. James MJ, Gibson RA & Cleland LG. Dietary polyunsaturated fatty acids and inflammatory mediator production. Am J Clin Nutr. 2000 71: 343S–348S. 11. Boerner CF. Dry eye successfully treated with oral flaxseed oil. Ocular Surgery News 2000 12. Chan CCK, Boxer BS. Evaluation os flaxseed oil and doxycycline on dry eye outcomes in patients undergoing LASIK. ASCRS Annual Meeting. March 2006, San Francisco, CA 13. Schiffman RM, Christianson MD, Jacobsen G, Hirsch JD, Reis BL. Reliability and validity of the Ocular Surface Disease Index. Arch Ophthalmol. 2000;118(5):615–621. 14. Nichols KK, Foulks GN, Bron AJ, et al. The international workshop on meibomian gland dysfunction: executive summary. Invest Ophthalmol Vis Sci. 2011;52:1922–1929. 15. Lam H, Bleiden L, de Paiva CS, et al. Tear cytokine profiles in dysfunctional tear syndrome. Am J 16. Enriquez-de-Salamanca A, Castellanos E, Stern ME, et al. Tear cytokine and chemokine analysis and clinical correlations in evaporative-type dry eye disease. Mol Vis. 2010;16:862–873. linolenic acid on human corneal epithelial cells2012 Jul 3;53(8):4396- 18.A novel oral nutraceutical formula of omega-3 and omega-6 fatty acids with vitamins (PLP10) in relapsing remitting multiple sclerosis: a randomised, double-blind, placebo-controlled proof-of-concept clinical trial2013 19. Wojtowicz Jadwiga, Butovich I, Uchiyama E, Aronowicz J, Agee S, McCulley J Pilot, Prospective, Randomized, Double-masked, Placebo-Controlled Clinical Trial of an Omega 3 Supplement for Dry Eye. Cornea. 2011 March 30(3) 308-314. Table 1 Inclusion and exclusion criteria
Inclusion criteria
Exclusion criteria
Ophthalmic Laser treatment (less than 3 months) Systemic diseases and general treatments Systemic disease association have dry eye clinic Patients with blepharitis who have not been Ocular disorders and eye drops other than Abbreviations: MGD, meibomian gland dysfunction
Table 2 Composition of Brudysec 1.5® (Brudy Laboratories, Barcelona, Spain) formula per capsule
Nutrient
Abbreviations: DHA, docosahexaenoic acid; DPA, docosapentaenoic acid; EPA, eicosapentaenoic acid
Table 3 Baseline Patient Characteristic
Schirmer I test, mm (mean ± SD) 16.61 (7.57) Abbreviations: TBUT, tear break-up time; OSDI, Ocular Surface Disease Index.
Figure 1 Changes in TBUT sec (mean values) from baseline to month 3 in the 2 treatment
groups. Statistically significant differences were noted versus baseline, P , 0.001
Baseline
Figure 2 Changes in lid margin inflammation from baseline to month 3. Statistically significant
improvements from baseline were noted in the Group B at 1, 2, and 3 months
Figure 3 Changes in Meibomian gland expressibility from baseline to month 3

Source: http://brudylab.com/Brudylab/Aplicaciones_files/DGM%20A%20OLENIK.pdf

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