Current Thoughts on Nutrition With Emphasis on Treating the Cause of Degenerative Eye Disease, Safety Issues, B Vitamins and Essential Fatty Acids and Dry Eyes Ellen Troyer, MT MA

1. Current Thoughts on Nutrition
With Emphasis on Treating the Cause of
Degenerative Eye Disease, Safety Issues, B
Vitamins and Essential Fatty Acids and Dry Eyes
Presented by:
Ellen Troyer, MT MA

2. Course Learning Objectives:
• To Review Current Science
• To Separate Fact From Marketing Fiction
• To Identify Safety Issues and Possible
Complications

3. Financial Disclosure & Other Info
• Biosyntrx CEO / Chief Research Officer
• Founding Board Member, Ocular Nutrition
Society
• Board Member, Ophthalmic Women Leaders
• Scientific Advisory Board – MDSupport.org
• ARVO Member
• Board Member – Falls & Fractures Alliance
• Voting Member – Council for Responsible
Nutrition

4. U.S. Visual Impairment and Disease
•
•
•
•
•
Dry Eyes: 20+ million
Macular Degeneration: 10.6 million
Cataracts: 20.5 million
Diabetic Retinopathy: 5.3 million
Glaucoma: 2.2 million (2 million undiagnosed)
• These numbers are projected to double in
20 years!

5. The Cost of Visual Impairment
• Total financial burden of major adult
visual disorders is $35.4 billion
• $6.8 billion for cataracts
• $5.5 billion for refractive error
• $2.9 billion for glaucoma
• $575 million for AMD
• $493 million for diabetic retinopathy

6. Lifestyle Matters Most Where Eye,
Body and Mental Health is Concerned
•
•
•
•
•
•
•
•
•
Nutrient-dense Quality Food Intake
Protection From Sun
Weight Control
Adequate Exercise
Nutritional Supplementation to Prevent
Deficiencies
Supportive Relationships
Passion for Life and Causes
Sense of Belonging
Concern for Society

7. Nutrient Deficiencies
• Most people are micronutrient deficient.
• Bruce Ames, PhD. (one of the most published
nutrition scientists in the world) triage theory
posits that the slightest deficiency of any of
the essential vitamins and minerals, over time,
increases the risk of degenerative disease,
including eye disease.

8. Why Eye Care Professional Care
• HHS data collected from phone interviews
found that most people over-estimate fruit
and vegetable consumption during phone
interviews.
• The CDC released data in 2007 suggesting that
fewer than 15% of the population consume 5
servings of fruits and vegetables a day.
• The current HHS recommendation is 9-13
servings a day.

9. Multiple Vitamin / Mineral Safety
• According to the latest research published in
the Feb. 2013 American Journal of Clinical
Nutrition, multi-vitamin /mineral / antioxidant
supplements at levels that do not exceed the
Academy of Medicine Safe Upper Level (UL)
does not increase mortality risk, in spite of the
poorly-designed studies or meta-analysis that
suggest it does.

10. US National Poison Data System
• Data collected by NPDS and published by the
American Association of Poison
Control Centers in Clinical Toxicology reported
NO deaths from multiple vitamins; zero deaths
from any of the B vitamins; zero deaths from
vitamins A, C D, or E.

11. Nutritional Genomics Views
• The Reductionist Approach-tries to
identify THE ONE gene that causes a particular
disease, or THE ONE dietary chemical or supplement
that will prevent it.
• The Systems Approach-uses methods
from genetics, molecular biology, physiology and
nutrition to study how diets affect an individual
person: instead of analyzing only genes, it analyzes
blood chemistries, enzymes, and metabolites, etc.;
instead of looking at one gene, it considers many.

12. Genetic Role in Aging

13. Why our cells respond to our
nutritional status
 Our body’s cellular response to RNA
decoded messages is dependent on
our environmental status, including
nutritional status.
 Nutritional deficiencies cause cells to
respond to degenerative or toxic
genetic messages that may be ignored
when the body is properly nourished.

14. B- Vitamins
• B vitamins are water soluble and our needs change on a daily
basis based on environmental conditions. Our bodies remove
any extra without risk of overdose.
• B1 is a big player in type-2 diabetes
• B-2 in crosslinking
• B3 in cholesterol control
• Vitamins B6, B12, and folic acid are suggested to protect
women against age-related macular degeneration, as well as
required to prevent the body from producing excessive
amounts of homocysteine, a marker for disease including eye
disease.

15. Folate, B6, B12 and Methionine Metabolism

16. Water Soluble B Vitamin FACTS
Adequate B Vitamin intake is critical for those who are at risk of
gene-related degenerative diseases like AMD and Alzheimer’s.

17. Hydro Carbon Beta Carotene – Not So
Much
• Not an appropriate source of Vitamin A where eye health is
concerned.
• Does not as readily covert to pre-formed Vitamin A (retinol) in
the older population as it does in younger people
• Does not quench the singlet oxygen associated with AMD if
other singlet oxygen quencher antioxidants like Bilberry are
available through diet or other supplementation
• Inhibits the absorption of the two xanthophyll carotenoids,
lutein and zeaxanthin, which are vital for optimal macula
pigment density and UV lens protection
• Synthetic beta carotene associated with
increased cancer risk

18. Vitamin E
• A 2005 study in the JAMA suggested that excessive (400 IU) synthetic
Vitamin E can be dangerous.
• A closer look shows that the isolated finding applied only to an older
group of patients (over the age of 70) with a long history of heart disease,
stroke or diabetes, who were also taking a combination of medications,
including ACE inhibitors, calcium channel blockers, anti-platelet agents and
lipid-lowering agents during the course of the study.
• A significant percentage of study participants were also cigarette smokers,
further clouding the issue.
• Always look for nutrition products that include only natural vitamin E
tocopherols and tocotrienols – the d-form is natural, the dl-form is
synthetic.
• Vitamin C regenerates Vitamin E so 200-300 mg of daily natural vitamin E
including all 8 forms of the Vitamin E molecule is adequate.

19. Vitamin D – The Sunshine Vitamin
• Lowers the risk of many cancers
• Improves bone calcium absorption
• Reduces blood pressure in hypertensive
patients
• Helps prevent chronic renal failure
• Reduces risk of multiple sclerosis
• Lowers risk of skin infections

20. Zinc, Copper, & Manganese Magic
• Zinc can biochemically shut down the nuclear
factor kappa-B (NFk-B) pathway, which shuts
off production of inflammation and paincausing compounds (cytokines). It becomes
even more efficient when presented with a
balanced amount of copper and manganese,
which creates mn(SOD) enzymes that create
antioxidant defense in cells exposed to
oxygen.

21. Why we must include
nutritional antioxidants in
our diets?

Specific plant-based antioxidants
scavenge free radical damaged
molecules from inside cells, thereby
protecting DNA.

Vitamins C and E help to prevent intraand extra-cellular oxidative damage to
oxidized lipid molecules.

22. Macula Pigment Nutrients
Lutein, Zeaxanthin, Meso-zeaxanthin
Lutein and Zeaxanthin also possess antioxidant
properties

23. Bilberry: Fact or Fiction?
• Anecdotal evidence of improved night vision of
pilots in WWII.
• Since the structure of anthocyanins is consistent
with an ability to donate hydrogen atoms, it has
been concluded that these compounds have
powerful antioxidant capability.
• Accordingly, anthocyanins have been shown to
scavenge chemically-generated superoxide and
nitric oxide radicals, as well as quench
destructive singlet oxygen.

24. N-Acetyl Cysteine
 Precursor to glutathione- an amino acid
complex
 Glutathione is the “master” antioxidant
 Glutathione is destroyed by digestive
process, therefore must be created
internally.
 Glutathione is depleted in cataractous
lenses

25. NFk-B, Antioxidants &
Inflammation
 The generation of reactive oxygen species (ROS) by
phagocytic leukocytes is one of the most important
hallmarks of the inflammatory process.
 In addition to promoting general cytotoxicity, ROS may
also act to up-regulate pro-inflammatory gene
expression by activating nuclear factor kappa b (NFkB).
 A variety of antioxidant molecules, such as
N-acetylcysteine (NAC) glutathione and vitamin E
can inhibit NFk-B activation associated with eye disease.

26. ↑ Mitochondrial Function
Mitochondria are
dependent on water based
amino acids, particularly
• acetyl-l-carnitine
• lipoic acid,
•COQ-10
• small amounts of
Omega-3 DHA
…for ATP energy and
mitochondrial
housekeeping. Small
amounts of DHA is vital for
membrane permeability
that allows nutrients in
and waste material out.

27. A powerful antioxidant that has been
proven in new clinical studies to improve
brain function, alter mood, and increase
cellular energy when taken with a balanced
amount of Lipoic Acid.
This is particularly important to the AMD
patient because most suffer from low to
medium grade depression.

28. Lipoic Acid
• Lipoic Acid is the nutrient that
intracellularly regenerates most
all other nutrients.
• Along with acetyl-L-carnitine, it
increases ATP cellular energy.
• Both fat and water soluble
antioxidant.

29. 







An enzyme that is required for electron
transport in ATP synthesis (facilitates energy
production at the cellular level)
Immune system support
Provides antioxidative-bioenergetic balance
Useful in maintaining energy levels
Oxidative protection for cellular membranes and
plasma lipoproteins
Neuro-protective
Low level linked to decreased cardiovascular
function
DECREASED WITH STATIN USE

30. RESVERATROL for Eye & Body Health
• Resveratrol regulates protective sirtuin protein
(SIRT1) gene expression in a dose dependent
manner.
• SIRT1 is also referred to as the rescue gene,
longevity gene, or skinny gene.
• A combination of SIRT1 and resveratrol are
suggested to be the regulators needed to protect
our eyes against UVB damage and our bodies
against heart attack, stroke, diabetes, arthritis,
osteoporosis and obesity.

31. Systemic Treatments for Dry Eyes
Orals

Essential Fatty Acids
•
•
•
•
•
•
•
HydroEye
BioTears
Hydrate Essential
TheraTears Nutrition
Fish Oil
Dry Eye Formula
EyePromise EZ Tears

32. Possible Effects of Omega
EFA on Dry Eyes
• Provide overall anti-inflammatory effect
• Increase fluidity of meibomian gland
secretions
• Alter polar characteristics of lipid layer
and decrease evaporative loss
• Optimize function of goblet cells
• Improve epithelial cells microvilli
expression and adhesion

33. What’s So Great About Fish?
Protein, Iron, Vitamins / Minerals and
Omega-3 Fatty Acids
Every patient does not require the same amount of
fish or fish oil.
The American Heart Association recommendation is
still two servings of fish per week for disease
prevention, which is about 3,500 mg of Omega-3 fatty
acids EPA / DHA per week.

34. Omega-3
Omega-3
Omega-3
Omega-3
Omega-3
Omega-3
Omega-3

35. Grade School Logic
The most scientifically sound way to properly
balance Omega-6 / Omega 3 fatty acid rations
is to simply consume fewer empty-calorie processed
junk foods and make the following Dietary changes:
Consume three or four daily small servings of
nutrient-dense foods.
Include small servings of cold-water fish two or
three times a week.
Take one concentrated fish oil capsule a day on the
days you don’t eat fish.

36. Anti-Inflammatory Omega-3 Fatty
Acids From Fish Oil
Excessive Amounts Not Recommended to
Compensate for Nutrient-Empty High Omega-6
Junk Food Diets.
Too Many Fish Being Removed From the Seas for
This Reason.
KRILL OIL: Antarctic krill oil may be superior to fish oil because it contains phospholipids,
carotenoid antioxidants and omega-3 bonded together in a way that keeps them safe from
oxidation and easily absorbed in your body.

37. 7 things to know about Omega-3 EFAs from
HHS-2013
1.
2.
3.
4.
5.
6.
7.
Results of studies provide moderate evidence that people who eat
seafood once a week are less likely to die of hear disease
Supplemental EPA / DHA has NOT shown to protect against heart
disease.
A 2012 review of studies suggest EPA / DHA may be modestly helpful in
relieving symptoms of rheumatoid arthritis.
The nutritional value of seafood is important during fetal growth and
development, particularly DHA.
Ongoing research in omega-3 fatty acids and brain and eye disease is not
yet conclusive about effectiveness.
Conflicting evidence about omega-3 link to prostate disease
Bottom line: including seafood in diet is healthful. Omega-3 supplements
benefit is still uncertain.

38. Fish Oil & Coagulation Status
• CASE REPORT
– Omega-3 fatty acids may lower thromboxane A(2) supplies
within the platelet as well as decrease factor VII levels. This case
report illustrates that fish oil can provide additive anticoagulant
effects when given with Warfarin
Ann Pharmacother. 2004 Jan;38(1):50-2.
• STUDY
– Effects of Marine Fish Oils on the Anticoagulation Status of
Patients Receiving Chronic Warfarin Therapy….. “Fish oil
supplementation in doses of 3-6 grams per day does not seem
to create a statistically significant effect on the anticoagulation
status of patients receiving chronic Warfarin therapy”.
J Thromb Thrombolysis. 1998 Jul;5(3):257-261.

39. Fish Oil Safety & Prostate Cancer
•
Blood level omega-3 fatty acids as risk determinant molecular biomarker for prostate cancer.
Sorongon-Leqaspi MK, Chua M, et al. Prostate Cancer. 2013;: 8756 [abstract]
Plasma phospholipid fatty acids and prostate cancer risk in the SELECT trial. Brasky TM, Darke AK, et
al. J Natl Cancer Inst. 2013 Aug 7;105(15): 1132-41 [abstract]
The relevance of serum levels of long chair omega-3 polyunsaturated fatty acids and prostate
cancer risk: A meta-analysis. Chua ME, Sio MC. et al. Can Urol Assoc J. 2013 May-June;7(5-6): E33343 [abstract]
Consumption of fish products across the lifespan and prostate cancer risk. Torfadottri JE,
Valdimarsdotti UA, et al. Plos One 2012 Apr 17;8(4): e59799 [abstract]
Fatty acid patterns and risk of prostate cancer in a case-control study nested within the European
Prospective Investigation into Cancer and Nutrition. Dahm CC, Gorst-Rasmussen A, et al. Am J Clin
Nutr. 2012 Dec; 96(6): 1354-61
Omega-3 fatty acids and cancers: a systemic update review of epidemiological studies. Gerber M. Br
J Nutr 2012 Jun; 107 [abstract]

40. Another Fish Oil Safety Big Concern
• Immunomodulation by dietary long chain omega-3 fatty acids and
the potential for adverse health outcomes. Denton JL, Hord NG,
Ghosh S, Gurzell EA. Prostaglandins Leukot Essential Fatty Acids.
2013 – Nov-Dec: 89(6): 379-90
• This study demonstrated that excessive Omega-3 long chain fatty
acids EPA / DHA dampens immunity and alters cellular membrane
pathogen clearance during acute infection resulting in adverse
health outcomes and reduced survival.
• This calls for biomarker development and validation as rational first
steps towards setting recommended dietary intake levels.

41. Dry Eye Fish Oil Studies May be Too Short for
Long Term Therapy Consideration
Short-term consumption of oral omega-3 and dry eye syndrome. Kangari H. Efekhari MH, et al.
Ophthalmology 2012 Nov (30 days)
Effects of dietary supplementation with fish oil on dry eye syndrome subjects: randomized
controlled trial. Kawakita T, Dawabata F, et al. Biomed Res 2013 (90 days)
Polyunsaturated fatty acids induce modification in the lipid composition and the prostaglandin
production of the conjunctival epithelium cells. Vial S, Leclere L, et al.
Graefes Arch Clin Exp Ophthalmol 2012 Feb. (Omega 6 GLA affected PGE1 and 2, Omega-3
showed no effect).

42. Oil
Omega-3 Omega-6
GammaLinolenic
Acid
85%
15%
(GLA)
NONE
NONE
75%
9%
Borage
75%
NONE
23%
Black
Currant Seed Oil
15%
65%
18%
FLAX
EPO

43. Omega-6 vs. Omega-3
“Omega-6 administration increases the
PGE1 levels in tears of patients with
Sjögren’s Syndrome and improves
ocular surface signs and symptoms of
ocular discomfort.”
Systemic Omega-6 EFA Treatment and PGE1 Tear Content in
Sjögren’s Syndrome Patients.
Aragona, P., Bucolo,C., et al
IOVS 2005; 46:4474-4479

44. Omega-6 vs. Omega-3
“This study provides evidence for a beneficial
effect of particular orally administered
omega-6 fatty acids in alleviating dry eye
symptoms and improving overall lens comfort
in patients suffering from contact lens
associated dry eye.”
Oral omega-6 essential fatty acid treatment in contact lens associated dry eye,
Kokke KH, et al.,
Contact Lens Anterior Eye (2008),
doi:10.1016/j.clae.2007.12.001

45. Metabolic Pathways of Omega-3 and Omega-6 Fatty Acids
Omega-6
Omega -3
Linoleic Acid (LA)
Polyunsaturated oils, including flax, corn and safflower
Delta--6-desaturase
Alpha-Linolenic-Acid (ALA)
Black Currant (15%) Flax (85%)
Delta 6 enzymes impaired by aging, alcohol and nutrient
deficiencies, trans fatty acids and elevated cholesterol.
Gamma-Linolenic Acid (GLA)
Delta--6-desaturase
Steridonic Acid (SDA)
Black Currant, EPO, Borage (18-24% GLA)
Eicosatetiaenoic Acid (ETA)
Dihomo-Gamma-Linolenic Acid (DGLA)
Delta-5-desaturase
Delta-5-desaturase
PGE1
Series One Prostaglandin
Anti-inflammatory
Fish Oil &Cod Liver Oil
Arachidonic Acid (AA)
Lipoxgenase
LBT--4
Pro--inflammatory
Cylooxygenase
Cylooxygenase (COX2)
PGE-2
Pro- inflammatory
EPA/DHA
EPA appropriately blocks Omega 6
delta-5-desaturase
downstream conversion
PGE3
Anti-inflammatory
Lipoxgenase
LBT-5
Anti-inflammatory

46. Natural Anti-Inflammatories
•
•
•
•
Quercetin- bioflavonoids
Ginger- gingerols (anti-inflammatory)
White Willow Bark- extracted as salicin
Curcumin- Tumeric

47. Vitamin A
• Vital for the health of epithelial cells of
the cornea and conjunctiva, as well as the
function of the immune system.
• It is also necessary for goblet cell and
lacrimal gland production of the large
variety of mucins now associated with the
base layer of the tear film.

48. Vitamin B6
• One of the nutrient co-factors required to
push the metabolic pathway conversion
of GLA to DGLA.
• Required for the neuronal blink response.

49. Vitamin C
• Absorbyl palmitate (fat-soluble) modulates PGE1
synthesis due to the extended half-life of the fatsoluble vitamin C over ascorbic acid.
• This vitamin C combination also enhances the
production of IgE concentrates in tears, the first
line of basophil and mast cell defense against
invading pathogens and allergens that frequently
cause dry eye symptoms.

50. Vitamin D
It should be included in all nutraceutical
formulations that include Vitamin A due to
an increased risk of fractures in older
patients taking large amounts of
supplemental Vitamin A.

51. Vitamin E
• Vitamin E should be included in all fatty acidbased nutraceutical formulations to help
prevent or slow lipid oxidation.
• This particularly includes any formulation that
includes flax seed oil or any type of fish oil.

52. Lactoferrin
• The replication and biofilm formation of fungi,
bacteria and viruses in mucosal tissues are irondependent. Growth of these pathogens becomes
almost impossible if adequate amounts of ironbinding proteins, particularly lactoferrin, are
concentrated in these fluids.
• Adequate levels of tear lactoferrin, naturally
produced by the lacrimal gland and neutrophils, are
particularly important for the eye surgery or contact
lens patient with an increased risk of infection.

53. Additional Tear Support
• Minerals
– Zinc and Magnesium- important in immune functions
• Mucin Enhancers
– Aloe Vera Oil
– Hyaluronic Acid

54. Flax Seed Oil
• Does contain a large amount of Omega-3 EFA
• Highly unstable, must be refrigerated
• Contains NONE of the nutrient co-factors
necessary to ensure conversion to PGE1 antiinflammatory
• Does not enhance production of lactoferrin
• Excess now linked to cortical opacities and
prostate cancer.
• May cause intestinal blockage, thyroid
problems and reduce platelet aggregation.

55. Metabolic Pathways of Omega-3 and Omega-6 Fatty Acids
Omega-6
Omega -3
Linoleic Acid (LA)
Polyunsaturated oils, including flax, corn and safflower
Delta--6-desaturase
Alpha-Linolenic-Acid (ALA)
Black Currant (15%) Flax (85%)
Delta 6 enzymes impaired by aging, alcohol and nutrient
deficiencies, trans fatty acids and elevated cholesterol.
Gamma-Linolenic Acid (GLA)
Delta--6-desaturase
Steridonic Acid (SDA)
Black Currant, EPO, Borage (18-24% GLA)
Eicosatetiaenoic Acid (ETA)
Dihomo-Gamma-Linolenic Acid (DGLA)
Delta-5-desaturase
Delta-5-desaturase
PGE1
Series One Prostaglandin
Anti-inflammatory
Fish Oil &Cod Liver Oil
Arachidonic Acid (AA)
Lipoxgenase
LBT--4
Pro--inflammatory
Cylooxygenase
Cylooxygenase (COX2)
PGE-2
Pro- inflammatory
EPA/DHA
EPA appropriately blocks Omega 6
delta-5-desaturase
downstream conversion
PGE3
Anti-inflammatory
Lipoxgenase
LBT-5
Anti-inflammatory

56. Supplements
$28.7 Billion spent annually just
in dietary supplements, vitamins
and minerals
Common Misconceptions
They are “natural”, so completely safe
They are ineffective
They are all the same
More is better

58. Summary
• Multi-pronged approach recommended
• Minimize adverse environmental conditions,
anticholinergic medications, visual strain
• Nonpreserved artificial tears
• Use topical corticosteroids only for short periods
because of side effects
• Topical cyclosporine- for severe cases
• Treatment should not cause disruption in patient’s
lifestyle
• Many patients prefer the “natural” approach