1.The Role of Diet in Ocular Surface Disease Peter J Polack MD FACS Ocala Eye Ocala FL

2. Ocala Eye est. 1971 13 Providers 140 Employees 4 Locations + ASC 100,000+ Patient Encounters 3. Dry Eye in the US 14 to 33% Of The Population Has Dry Eye Dry Eye Disease: The Clinicians Guide to Diagnosis and Treatment. P Asbell 4. Why Are We Seeing So Much Dry Eye? Dry Eye Disease: The Clinicians Guide to Diagnosis and Treatment. P Asbell Dietary changes Hormonal effects Aging population Awareness Electronic devices Better diagnostics Treatments are now available 5. Ocular Surface Disease Dry Eye Disease Aqueous Deficient Dry Eye Evaporative Dry Eye Other Non-Dry Eye Disease Lid-related Disease MGD Anterior Blepharitis Other Other OSD Allergic conjunctivitis, Chronic infective and non-infective Keratoconjunctivitis, Post-refractive Prodromal States Symptomatic 6. Dry Eye in the US Aqueous Deficiency: 34% Of Problem But 95% Of Products On The Market 2012 Annual Report on Dry Eye Diseases, Contact Lens Spectrum 7. Dry Eye in the US Lipid Deficiency: 65-86% Of Problem But Only 5% Of Products On The Market Lemp MA, et al. Distribution of aqueous deficient and evaporative dry eye in a clinic-based patient population. Cornea, 2012; 31(5):472-478 8. Symptomatic Dry Eye 52.7% Contact Lens Wearers 14-33% General Population Scaffidi RC, Korb DR: Eye Contact Lens. Jan 2007 9. Why do we care about Dry Eye ? 10. Rheumatoid Corneal Melt 11. Tear Osmolarity Performance of tear osmolarity compared to previous diagnostic tests for dry eye diseases. Versura et al. Curr Eye Res 2010 Jul;35(7):553-64 12. Acne Rosacea 13. Blepharitis 14. Lacrimal Gland System 15. Tear Film Layers 16. Blink Blink Cycle Repeats TFBUT Tear Protected Ocular Surface Unprotected Ocular Surface Time (Seconds) Ocular Discomfort Staining 0 1 2 3 4 5 6 7 COURTESY OF OPHTHALMIC RESEARCH ASSOCIATES, NORTH ANDOVER, MASS. 17. Meibomian Gland Evaluator(MGE) Grade Secretion Characteristics 3 Clear liquid oil 2 Colored / cloudy liquid 1 Inspissated (toothpaste consistency) 0 No secretion (includes capped orifices) 18. Meibomian Glands Yielding Liquid Secretion (MGYLS) DRY NOT DRY 0 - 4 5 6 7 8 10+ 1. Korb DR, Blackie CA. Meibomian gland diagnostic expressibility: correlation with dry eye symptoms and gland location. Cornea. 2008;27(10):1142-1147. 2. Blackie CA, Korb DR. Recovery time of an optimally secreting meibomian gland. Cornea. 2009;28(3):293-297. With Symptoms1 (n=133) Asymptomatic healthy eyes2 (n = 24)Severe Symptoms Moderate Symptoms Minimal Symptoms Symptom Score, SPEED questionnaire (0-28) 10 (14.39 0.69) 69 (7.26 0.17) 5 (2.30 0.23) 0 Number of MGYLS for entire lower eyelid 4.14 0.56 5.14 0.41 6.25 0.35 10.6 2.6 19. Lipid layer thickness correlates to MGD and can be measured with Interferometry Donald Korb OD 20. LipiView Report 21. Intense Pulsed Light (IPL) Therapy Treatment Area: 22. Meibomian Gland Expression (Post-IPL) 23. LipiFlow Mechanism of Action Activator Applies intermittent pressure to the outer eyelid Inflatable air bladder Shields eye from heat and vaults above the cornea to prevent corneal contact Heats comfortably to liquefy the Meibomian gland contents Lid warmer Applies directional heat to inner eyelid 24. Restasis (Cyclosporine 0.05%) Improves ocular surface health Increases goblet cells Improves LASIK & Premium IOL outcomes Good safety profile Decreases artificial tear use 25. Adapted from Holland EJ. Ophthalmol Times. 2007;32:3-11. Lotemax QID (loteprednol etabonate Ophthalmic suspension 0.5%) Lotemax BID Lotemax prn Restasis BID (cyclosporine ophthalmic emulsion 0.05%) Thereafter The Asclepius Panel: Recommended Treatment Model for Ocular Surface Inflammation 26. Nutritional Content of Oils. E Bender: Univ of California at San Diego 27. A review of fatty acid profiles and antioxidant content in grass-fed and grain-fed beef, CA Daley et al, Nutr Jour, 2010 9:10 28. Contains unique omega (GLA) clinically backed in 6 controlled dry eye trials Not found in diet/flax/fish. Provides other omegas, nutrient cofactors Stimulates tear production, eases inflammation Effective for almost any Dry Eye (i.e. contact lens, post-refractive, post-menopausal, allergy- related, Sjgren's, other types) Guaranteed relief within 60 days or money back; works for 80-85% of users HydroEye Oral Supplement 29. Essential Fatty Acids Delta-6 desaturase Elongase Delta-5 Desaturase COX 18:2w3 Alpha linolenic (ALA) 18:4w3 SDA 20:4w3 ETA 20:5w3 EPA 20:6w3 DHA Omega-6 18:2w6 Linoleic Acid (LA) 18:3w6 GLA 20:3w6 DGLA 20:4w6 Arachidonic Acid Series 3 (good) Prostaglandins Series 2 (bad) Prostaglandins Series 1 (good) Prostaglandins Omega-3 Flaxseed Oil Black Currant Seed Oil Fish Oil Fish Oil (Parent) (Parent) Black Currant Seed Oil Black Currant Seed Oil Only 15-20% of ALA converts to EPA Rate-Limiting Delta-4Desaturase Anti-inflammatory Fatty Acids 30. Essential Fatty Acids Delta-6 desaturase Elongase Delta-5 Desaturase COX 18:2w3 Alpha linolenic (ALA) 18:4w3 SDA 20:4w3 ETA 20:5w3 EPA 20:6w3 DHA Omega-6 18:2w6 Linoleic Acid (LA) 18:3w6 GLA 20:3w6 DGLA 20:4w6 Arachidonic Acid Series 3 (good) Prostaglandins Series 2 (bad) Prostaglandins Series 1 (good) Prostaglandins Omega-3 Flaxseed Oil Black Currant Seed Oil Fish Oil Fish Oil (Parent) (Parent) Black Currant Seed Oil Black Currant Seed Oil Only 15-20% of ALA converts to EPA Rate-Limiting Delta-4Desaturase Anti-inflammatory Fatty Acids 31. Supplemental GLA: Controlled Trials Significant Improvement Dry Eye patients GLA vs placebo (n=26) Dry Eye Symptom Scores, Lissamine Green, Ocular Surface Inflammation (HLA-DR Expression). PRK patients GLA vs no treatment (n=60) Subjective Symptoms, Schirmer 1 test, Fluorescein Clearance Test Sjgren's patients GLA vs placebo (n=40) Tear Anti-Inflammatory PGE 1 levels, Dry Eye Symptoms, Corneal Fluorescein Staining 1. Barabino S et al. Cornea 22): 97101, 2003. 2. Macri A et al. Graefes Arch Clin Exp Ophthalmolol 241:561-6, 2003. 3. Aragona P, et al. Ophthalmol Vis Sci 46:4474-9, 2005. 32. HydroEye Clinical Trial ARVO 2012: Multi-center, randomized, double-blind, placebo- controlled, prospective trial, 38 postmenopausal women with Dry Eye Syndrome. Investigators: Findings: HydroEye improves symptoms & signs of dry eye and impedes progression of ocular surface inflammation significantly better than placebo. John D. Sheppard MD MMSc Eastern VA Medical School. Stephen C. Pflugfelder MD Baylor College of Medicine 33. Speaking of Inflammation 34. Fasano A Physiol Rev 2011;91:151-175 2011 by American Physiological Society Physiological Reviews Mechanisms Of Gliadin-induced Zonulin Release, Increased Intestinal Permeability, And Onset Of Autoimmunity. 35. Known or Suspected Autoimmune Diseases That Also Present With a Leaky Gut Disease Tissue/Organ Citation 1. Allergies Various Liu et al. Acta Paediatrica 2005, 94, 386-93 2. Ankyllosing Spondylitis Skeletal system Vaile JH et al. J. Rheumatol. 1999, 26, 128-35 3. Apthous stomatis Mouth Veloso FT et al. Hepatogastroenterol. 1987, 34, 36-7 4. Asthma Lungs Benard A et al. J. Allergy Clin. Immun. 1996, 97, 1173-8 5. Autism Nerve/Brain White JF. Exp. Bio. Med. 2003, 228, 639-49 6. Autoimmune gastritis GI Tract Greenwood DL et al. Eur. J. Pediatr. 2008, 167, 917-25 7. Autoimmune hepatitis Liver Terjung B Clin. Rev. Allergy Immunol. 2009, 36, 40-51 8. Behcets Syndrome Small blood vessels Fresko I et al. Ann. Rheum. Dis. 2001, 60, 65-6 9. Celiac Disease Gut Schulzke JD et al. Pediatric. Res. 1998,43, 435-41 10. Chronic Fatigue Synd Multiple Maes M et al. Neuroendol. Lett. 2007, 28, 739-44 11. Crohns disease Gut Caradonna L et al. J. Endotoxin. Res. 2000, 6, 205-14 12. Depression Brain Maes M et al. Neuroendocrinol. Lett. 2008, 29, 117-24 13. Dermatitis herpetiformis Skin Kieffer M et al. Br J. Dermatol. 1983, 108, 673-8 14. Diabetes, Type 1 Pancreas Sapone A et al. Diabetes 2006, 55, 1443-49 15. Eczema Skin Hamilton et al. Q. J. Med. 1985, 56, 559-67 16. Gut migraine children Gut Amery WK et al. Cephalalgia 1989, 9, 227-9 17. Hashimotos Thyroiditis Thyroid Sasso FC et al. Gut 2004, 53, 1878-80 Dietary Mechanisms of Autoimmunity, Loren Cordain, PhD, Christiaan Barnard Memorial Hospital, Jan 24, 2013 36. Known or Suspected Autoimmune Diseases That Also Present With a Leaky Gut Disease Tissue/Organ Citation 18. IgG Nephropathy Kidney Rostoker G et al. Nephron. 1993, 63, 286-290. 19. Intrahep cholest pregnancy Liver Reyes H et al. Hepatology 2006, 43, 715-22 20. Juvenile Arthritis Collagen/joints Picco P et al. Clin. Exp. Rheumatol. 2000, 18, 773-8 21. Lupus erythematosis Multiple Apperloo HZ et al. Epidemiol. Infect. 1994, 112, 367-73 22. Multiple sclerosis Nerve/Brain Yacyshyn B et al. Dig. Dis. Sci. 1996, 41, 2493-98 23. Pemphigus Skin Kieffer M et al. Br J. Dermatol. 1983, 108, 673-8 24. Primary Biliary Cirrhosis Liver Di Leo V et al. Eur. J. Gastro. Hepatol. 2003, 15, 967-73 25. Psoriasis Skin Hamilton et al. Q. J. Med. 1985, 56, 559-67 26. Rheumatoid arthritis Joints Smith MD et al. J. Rheumatol. 1985, 12, 299-305 27. Rosacea Skin Kendall SN. Exp. Dermatol. 2004, 29, 297-99 28. Schizophrenia Brain Wood NC et al. Br. J. Psychiatry 1987, 150, 853-6 29. Scleroderma Connective tissue Caserta L et al. Rheumatol. Int. 2003, 23, 226-30 30. Sclerosing Cholangitis Liver Terjung B Clin. Rev. Allergy Immunol. 2009, 36, 40-51 31. Spontaneous abortion Uterus Friebe A Int. J. Biochem. Cell Biol. 2008, 40, 2348-52 32. Ulcerative colitis Gut Caradonna L et al. J. Endotoxin Res. 2000, 6, 205-14 33. Urticaria Skin Buhner S et al. Allergy 2004, 59, 1118-23 34. Uveitis Eye Benitez JM et al. Eye 2000, 14(pt 3A), 340-3 Dietary Mechanisms of Autoimmunity, Loren Cordain, PhD, Christiaan Barnard Memorial Hospital, Jan 24, 2013 37. Heart Smart Diet 38. Are we as physicians merely treating the effects of the consumption of wheat? William Davis MD Author of Wheat Belly 39. Blepharitis Checklist 40. Why is an Eye Doctor telling my patients what to eat?!! 41. Pre- Treatment 42. Post- Treatment