Thursday, May 8, 2008

My Omega-3 journal: Omega Swirls

I've been plodding along happily with my lemonade and cinnamon Barleans flaxseed oil in yoghurt, supremely unmotivated to take the next step - trying it straight off the spoon. My fingernails are getting nice and strong, by the way.

But when I called Barleans the other day to place an order, Patti told me all about two new products they have called Omega Swirls. They're kind of a smoothie-type consistency, she said, with natural flavors, and they're having a terrific response to them. I said fine, we'll try them out. Promptly forgot all about it.

So the shipment comes in today and sure enough, there's a bottle of strawberry-banana and a bottle of lemon.

I let Chaidie (my 5-year-old) try the strawberry-banana because I'm not keen on that combination in any context. At first sip, she said Hey this tastes like a milkshake! Then a moment later... she politely suggested we save the rest of her sample for Dad to try.

So we moved on to Lemon Zest. All it took was one sip and she was hooked!

MOM! This is the same stuff my lemon Starbursts are made of. No, I'm serious! It's GOT to be made from the same thing. Tastes just like them!

So I tried it. Yup, that's a fairly strong kind of candy-reminiscent lemon flavor - but then, to take it straight like that, you want it kind of strong.

Now comes the kicker.

I'm looking at the label and it says 730 mg of EPA/DHA per serving and I'm thinking - oh no! it can't be! I thought these were both flaxseed oils!

You mean I just got conned into DRINKING COD LIVER OIL? What is this, a scene from Mary Poppins?

I can't believe it. I think they have a winner.

So I'm looking at the label again. Sweetened with Xylitol. Which I didn't know anything about and had to go look up on Wikipedia. I don't do artificial sweeteners, and this seems OK but if anybody thinks otherwise let me know.

Last but by no means least: Before posting about this, I waited for a - ahem, forgive me - burp, just in case. Pure lemon, no fish. OK.

Well, leave it to Barleans to come up with something like this. I knew there was a reason I like that company.

Wednesday, May 7, 2008

Abstract: Surgical approaches to dry eye

The abstract of course doesn't include what we really want to see (the flowchart) but amongst what it does tell us is the important message that surgical approaches should not be attempted unless there are clinical signs present.

Flow chart on surgical approaches to dry eye.
Geerling G, Brewitt H.
Dev Ophthalmol. 2008;41:313-6.

Introduction: Based on the type and severity of dry eye, we propose a structured approach to the surgical management of the disease.

Material and Methods: The guidelines for assessing the form and grade of dry eye as recently suggested by the 'Dry Eye Workshop (DEWS)'. Flow chart on the surgical and medical management are presented.

Results and Conclusion: Surgery should only be considered if any significant inflammation and concomitant adnexal disease has been controlled and medical management remains insufficient to control signs and symptoms of dry eye. The presence of signs of surface disease is considered mandatory. Although infrequent pre-existing occlusion of the lacrimal drainage system should be excluded, since this can also induce surface disease. The suggested sequence of treatment options makes use of less invasive procedures first while at the same time maximising efficacy and practicality. Often several measures have to be applied simultaneously to prevent loss of vision. Visual rehabilitation should only be attempted (e.g. by means of stem cell transplantation, keratoplasty). Once all concomittant factors have been addressed and measures to substitute the tear have been applied. In persisting aqueous deficiency osteoodontokeratoprosthesis remains the final option to improve visual function.

Abstract: One view on why dry eye clinical trials fail and where we go from here

With the recent demise of what were once promising dry eye therapies in advanced clinical trials, this is a timely (if perhaps incomplete) summary of why we don't seem to get anywhere with dry eye drug clinical trials, by well known leader in the field Michael Lemp MD.

Clinical trials in dry eye in surgery for dry eye?
Dev Ophthalmol. 2008;41:283-97.
Lemp MA.

Purpose: To provide an overview of considerations in the design and performance of prospective clinical trials in the evaluation of new pharmaceutical and surgical treatments in dry eye disease (DED). Design: A compilation and interpretation of experiences in the challenges and pitfalls of clinical trial design based on experiences documented in the peerreviewed literature over the last 40 years.

Methods: A review of the literature in the design and performance of clinical trials in DED with an interpretative and prognostic outlook.

Results: Published results of clinical trials in DED reveal problems in the design of clinical trials which are unique to this disease. These include a discordance between the signs and symptoms of DED, variability in disease course and short-term environmental effects on ocular surface staining.

Conclusions: The development of better efficacy endpoints will be necessary to improve the outcomes of clinical trials to evaluate new pharmaceutical and surgical approaches to the management of dry eye. The most promising field is that of biomarkers which serve as surrogates for disease severity. As these markers undergo validation with clinical changes, it is likely that they will assume greater significance in future clinical trial designs.

Abstract: Implanted pumps applying tears

They're claiming a high success and low risk profile for this interesting approach to "constant" eye lubrication. I found this whole concept interesting but puzzling: I'm glad to hear it works, but it only makes sense if you assume that no lubricant is capable of providing more than a few minutes' worth of lubrication, which I don't believe is correct. Hm.

Mechanical pump dacryoreservoirs.
Dev Ophthalmol. 2008;41:269-82
Murube J, Geerling G

Background: The two most important characteristics of the natural tear are its chemophysical properties and the continuity of its delivery. The chemical characteristics of tears are very difficult to reproduce since they contain more than 200 different components. In severe dry eyes - due to their relative short residence - manual application of artificial tears from small bottles to the eye has to be performed every 5-10 min, while at night no lubrication at all is provided. Previously, for continuous lubrication of the ocular surface, dacryoreservoirs attached to spectacles or placed in pockets of the patient's clothes were used, but were often complicated by infection. A new option is the implantable pump dacryoreservoir.

Material and Methods: In 21 patients with a Schirmer test without anaesthesia of <2mm in 5 min, a Medtronic 60-ml reservoir was implanted into a pocket under the subcutaneous tissues of the anterior abdominal wall and connected to a silicone catheter that ascended subcutaneously along the chest, neck and temple to the upper conjunctival fornix. The results of this procedure and complications associated with the implantation of reservoirs in general - as evaluated on the basis of a Medline search - are presented.

Results: Postoperatively all patients reported a dramatic improvement of dry eye symptoms. Slit-lamp microscopy revealed a substantially prolonged break-up time and a reduction of signs of ocular surface disease such as superficial punctuate keratopathy and conjunctival hyperaemia. A penetrating keratoplasty was successfully performed in 2 eyes with an implanted dacryoreservoir and remained clear throughout the follow-up of up to 3.5 years. No infections of the catheter reservoir were observed. Prominent parts of the catheter induced skin ulceration, but no infection, in 2 patients which was managed successfully by removal of the catheter, systemic antibiotics and subsequent re-implantation of a new catheter. A literature review showed that infection is not a frequent problem with implantable and external reservoirs.

Conclusion: At present, this is the only safe and effective method able to maintain a continuous lubrication of the ocular surface with artificial tears, and the only one that allows corneal, conjunctival or limbal transplantations in severe dry eyes.

Abstract: Salivary gland transplants

Continuing on the theme of surgical dry eye treatments.... Like most "dry eye" surgeries this is not to be attempted on your garden variety DryEyeZone I'm-in-severe-pain-I'll-try-anything dry eye. We're talking hardcore I'm-also-about-to-go-blind-so-I-have-nothing-to-lose dry eye.

The results described below are medicalspeak for abysmal, by the way.

Transplantation of the major salivary glands.
Geerling G, Sieg P.
Dev Ophthalmol. 2008;41:255-68.

Background: In absolute aqueous-deficient dry eye, severe signs and symptoms may persist despite punctal occlusion and frequent application of artificial tear substitutes. In this group of patients the three major salivary glands, the parotid, the submandibular and the sublingual gland, have been used to lubricate the ocular surface.

Material and Methods: A PubMed search was performed using the keywords 'dry eye, major salivary glands, parotid gland, parotid duct, sublingual gland, submandibular gland (SMG), transposition, transplantation' to identify the current literature on major salivary gland transplantation. The surgical procedures are described, their principle advantages and disadvantages and the published results are analyzed.

Results: To use the parotid gland as a source of substitute lubrication its secretory duct is transposed to the lower conjunctival fornix. The procedure results in a purely serous secretion and severe gustatory reflex epiphora. Parts of the sublingual gland, which produces a mucoserous secretion, have been transplanted into the subconjunctival space. Since the graft is left without a direct vascularisation, it frequently becomes non-functional. The SMG finally produces a more tear-like, seromucinous secretion. It is transferred as a free, denervated graft to the temporal fossa, where a microvascular anastomosis with the temporal artery and vein is established. Graft survival in the long term is 72%. Graft viability is associated with a significant improvement of Schirmer's test, break-up time, rose bengal staining and symptoms. In 38% of eyes with a viable graft, salivary epiphora results, which is independent of gustatory stimuli. Since the salivary tear film is substantially hypoosmolar, microcystic epithelial oedema can result and subsequent corneal transplantation remains unsuccessful.

Conclusion: Of the three major salivary glands, the parotid and the SMG have been used successfully to provide substitute lubrication in severely dry eyes. The surgical technique varies significantly in terms of complexity and reversibility. While the procedures are capable of improving comfort, due to the salivary character of the new tear film subsequent ocular surface reconstruction remains unsuccessful.

Abstract: Moving mucous (shifting snot?)

A nice summary of current technologies to graft mucous onto the eye.

Mucous membrane grafting.
Dev Ophthalmol. 2008;41:230-42
Henderson HW, Collin JR.

Introduction: We review the use of mucous membrane grafting in the clinical management of dry eye-associated ocular surface disease. Material and Methods: Literature review of the scientific evidence, presentation of guidelines and surgical details. Results and Conclusion: The reformation and maintenance of a conjunctival fornix requires the addition of epithelial tissue, or a basement membrane which can be populated by healthy host epithelial cells. A healthy conjunctival or tarsal autograft, when available, is the ideal material. Oral mucosa does not contain goblet cells and therefore does not supplement the tear film: a full-thickness oral mucous membrane graft is the simplest graft to use if conjunctiva or tarsus is not available. Split-thickness mucosal grafts contract more, but are less bulky and pink than full-thickness grafts, and therefore should be used on the globe. Hard palate grafts are the thickest oral mucosal grafts and contract the least. Nasal mucosal grafts contain goblet cells that may contribute mucous to the tear film. This is maximised in turbinate mucosal grafts, which can relieve discomfort in extreme dry eye situations. Nasal septal cartilage contains fewer goblet cells, but adds rigidity. Amniotic membrane is thin and translucent-like conjunctiva, and possesses antiangiogenic, antiscarring and anti-inflammatory properties. It may become re-epithelialised with normal a conjunctival cell population and prevent postoperative cicatrisation, but requires the presence of healthy conjunctival stem cells to repopulate the graft, adequate lacrimal function to keep the graft moist, and a host site that is free from inflammation, otherwise it rapidly contracts. It can be combined with limbal transplantation and with an adjunctive antimetabolite.

Abstract: Surgically shutting the ducts...

I've never been all that familiar with the methods of cauterizing the puncta and this "Punctum switch" method sounds kind of interesting.

Surgical occlusion of the lacrimal drainage system.
Geerling G, Tost FH.
Dev Ophthalmol. 2008;41:213-29

Background: If a lacrimal plug that successfully improves dry eye symptoms is spontaneously lost or causes unwanted effects other than epiphora, surgical occlusion of the lacrimal drainage system should be considered. Here we review current irreversible and reversible techniques to occlude the lacrimal drainage and describe a new surgical technique, termed 'punctum switch', which has the advantage of being permanent and yet potentially is reversible. Material and

Methods: A PubMed search was performed to identify the current literature on surgical occlusion of the puncta and canaliculi for dry eyes. The characteristics of the procedures are described, classifying them as temporary or permanent and their localization being either on the level of the lacrimal puncta or canaliculi. A 'punctum switch' graft involves a superficial excision of a piece of lid margin including the punctum. This graft is then rotated and fixated so that the excised punctum comes to rest lateral to the remaining lacrimal ampulla, which in turn is covered by full-thickness lid margin tissue.

Results: Established methods include cauterizing or ligating the puncta or canaliculi as well as everting the medial portion of the lid. Both thermal and surgical techniques show a high rate of reopening. If permanent occlusion is achieved, this however often is irreversible and can only be treated by means of lacrimal bypass surgery. The 'punctum switch' procedure can achieve long-term occlusion of the canalicular system while offering potential reversibility.

Conclusion: A large variety of surgical techniques to occlude the nasolacrimal drainage system exists. These vary significantly in terms of complexity and reversibility. Surgical occlusion should be used more often in patients with moderate or severe dry eye, which previously responded well to temporary occlusion with plugs.

Study: Restasis better than Endura?

I think I hear an echo. Seems like there was a published study not long ago demonstrating that Restasis is better than some other artificial tear. I find this type of study very amusing.... I guess not everyone is marching to the same drumbeat if five years after FDA approval the $100-a-month Rx treatment still has to be defended against OTC drops.

My question now: Are we destined to see a study comparing Restasis to every single tear on the market?

And my follow-up: As long as you include DWELLE, bring it on. I dare anyone out there (yoo hoo, are you listening industry?) to study comparative results of twice-daily dosing of Restasis and Dwelle.

Topical cyclosporine halts progression of dry eye better than tears, study shows
OSN Supersite, May 5 2008

FORT LAUDERDALE, Fla. — The use of topical cyclosporine is more effective than artificial tears at increasing goblet cell density and halting the progression of dry eye disease, according to the results of a study presented here.

The single-center clinical trial enrolled 74 patients between February 2006 and January 2007, and 58 of the patients completed the 12-month study, according to Sanjay N. Rao, MD, who presented the results at the Association for Research in Vision and Ophthalmology meeting.

Patients were randomized to twice-daily treatment with either cyclosporine 0.05% (Restasis, Allergan) or artificial tears (Refresh Endura, Allergan), according to the study abstract. Outcomes were measured with Schirmer's test, the Ocular Symptom Disease Index, tear break-up time, staining, and goblet cell density at baseline and months 4, 8 and 12, the abstract said.

Patients who received cyclosporine treatment were less likely to have progression of dry eye: 5.5% of 36 cyclosporine patients compared with 31.8% of 22 artificial tears patients (P = .007). The cyclosporine patients also were more likely to have the disease halted or improved: 94% with cyclosporine vs. 68.2% with tears (P = .007).

Patients using artificial tears were more likely to discontinue their treatment regimen, the study showed.

Abstract: A plug for plugs

Does not appear to add much of anything to the existing knowledge base about plugs, but note the mention of using ultrasound to figure out what's in there and where it is.

Plugs for occlusion of the lacrimal drainage system.
Dev Ophthalmol. 2008;41:193-212
Tost FH, Geerling G.

Background: Next to medical therapy, blockage of the lacrimal drainage system is the commonest form of treating dry eye. Rather than applying an artificial tear, the latter helps to preserve any remaining natural tear fluid, which by far has the best wetting and nutrient capacity for the ocular surface. A temporary block is usually induced by implants to tamponade on the level of the lacrimal puncta or canaliculi.

Materials and Methods: A Medline search was performed with the keywords 'lacrimal drainage system, punctum, canaliculus, temporary occlusion, plug, dry eye, keratoconjunctivitis sicca' for the years 1986-2006. Plugs are a suitable treatment in patients with moderate or more severe disease. The characteristics of the devices used and procedures as well as the complications described were analyzed.

Results: Criteria such as a lack of Schirmer strip wetting, ocular surface staining and the frequency of artificial tears instillation should be assessed prior to making the decision to occlude the lacrimal drainage. Lacrimal plugs made of silicone or a thermodynamic acrylic polymer, such as hydrogel, appear to be safe and effective, although each patient should be followed on a long-term basis to exclude alterations of the lacrimal system such as chronic inflammatory reactions, extrusion or migration, which may all lead to discomfort. High-frequency ultrasound as a non-invasive, simple diagnostic technique can be used to identify the type or position of plug or inflammatory reaction present.

Conclusion: Tamponade of the lacrimal drainage system is a simple procedure that is underused. Preserving natural tears by blocking the lacrimal drainage system can successfully maintain the integrity of the ocular surface and corneal transparency and visual acuity. In patients with moderate or severe dry eye, it is capable of improving quality of life and preventing loss of vision.

Newsblurb: Dry eye after IOL implants

This the first time I remember seeing dry eye mentioned as a common complaint after IOLs! But as we know, there is simply no free lunch with refractive surgery, period.

I sure would like to know Dr. Gayton's specific recommendations about how to "avoid circulating air". Most people undergoing elective refractive surgery would obviously not be thrilled about exchanging bifocals for moisture chamber glasses. Oh, and while we're "aggressively treating" dry eye after IOLs, how about aggressively treating some of those LASIK and PRK patients with dry eye too?

OSN SuperSite
Aggressive approach needed for patients dissatisfied after IOL implantation
April 30, 2008

Johnny L. Gayton, MD.... also addressed the necessity of aggressively treating the most common complaints of patients postoperatively, namely dry eye, decreased vision due to cystoid macular edema and residual refractive error.

Dr. Gayton encouraged surgeons to recommend artificial tears, nutritional supplements and environmental changes — avoiding tobacco smoke or circulating air — to combat dry eye. He also suggested surface ablation as opposed to LASIK as a way to address residual refractive error after IOL implantation.

Newsblurb: Tips for eye allergy season

This article had a couple of tips that were new to me, such as the one about shampooing your hair at night. Hm.

Allergy Alert: For Your Eyes Only!
Fox News, May 6


First, use a tear-free or “baby” shampoo to irrigate gently around your closed eyelids when bathing in the morning. This will wash away unwanted airborne pollens, mold spores and pollutants. Always check with your eye care provider if you have eye diseases such as dry-eye syndrome or other problems in which you are receiving ongoing treatment.

Shampoo your hair at night after pollens have accumulated to reduce the transfer to your pillow and bed sheets and break “the cycle” allowing you to feel better in the morning.


Wear BIG sunglasses to block the entry of allergens into the eyes!


Be aware that localized application of creams, make- up and sunscreen can be irritating.


Make sure you do not have an infection or “dry-eye syndrome” which is handled much differently and would require a visit to your eye care provider. Find out what their recommendation is for specific allergy and/or eye medication.


Take a look at the foods you are eating. Some of them may cross-react with the airborne seasonal pollens, triggering a cross-reaction. You could end up with worse allergy symptoms that affect your eyes, nose and throat.

About one-third of those who suffer from seasonal allergies may experience “oral allergy syndrome” when eating apples, pears, hazelnuts, carrots and almonds (to name a few). The body perceives these foods as an allergy invader, therefore causing histamines and other defender substances to cause itchy, watery eyes, as well as nasal and throat itchiness. This occurs more so during the seasonal peak levels of pollens.

Article: Dry eye issues for glaucoma patients

I really appreciated this summary of special issues for glaucoma patients with dry eye. I encourage you to read the whole article but here are some excerpts about thne risks of over-exposure to BAK and suggestions for alternatives.

PCON Supersite, May 1, 2008
Keep tear film in mind when treating glaucoma patients with dry eye

From Katherine Mastrota OD MS:

...Benzalkonium chloride, in most ophthalmic preparations, is an effective preservative that can potentiate the effect of antimicrobials. However, as a detergent, chronic administration of BAK-containing medications, such as glaucoma medications, can be deleterious to surface epithelial cells and, perhaps, have far-reaching effects altering the stem cell environment and function. This added insult to a dry eye patient can lead to inflamed, uncomfortable eyes in patients who suffer both disease entities and intolerability of the hypotensive agents....

From Kathy Yang-Williams, OD, FAAO

Benzalkonium chloride is a common ocular preservative that can exacerbate ocular surface disease. Timolol and pilocarpine 2% are available in a nonpreserved unit dose format; however, these medications tend to be more expensive and are less widely available than commercial preparations. Newer medications have replaced BAK with other preservatives that are gentler to the ocular surface. For example, Alphagan P (brimonidine tartrate 0.15%, Allergan) is preserved with Purite, Timoptic XE (0.25% timolol maleate, Merck) is preserved with benzododecinum bromide and Travatan Z (travoprost, Alcon) is preserved with SofZia.

Combination agents such as Cosopt (dorzolamide HCL, timolol maleate, Merck) and Combigan (0.2% brimonidine tartrate, 0.5% timolol maleate, Allergan) provide other options for decreasing ocular surface toxicity because fewer drug applications are required compared to the use of individual component drugs.