The shift toward preventive eye health
There is a growing focus on preventive and lifestyle-based healthcare, fueled by patients' increasing interest in nutrition, supplements, and wellness strategies. This represents a shift from reactive disease management to proactive wellness.
Watch this video for a quick overview of how nutrition is playing a bigger role in supporting ocular health and patient care.
Currently, 88% of Americans view eye health as critical to overall health, and 47% consider vision loss the worst possible health condition they could experience.1 Nutrition is now recognized as an important, modifiable factor in eye health, providing eyecare providers (ECPs) with the opportunity to engage in evidence-based discussions.
Nutrition as a foundational component of eye health
Poor dietary habits are a leading global risk factor for death and disability and have links to chronic inflammation, immune dysfunction, hormonal imbalance, and neurological disorders.2,3
The prevalence of eye conditions is expected to continue to increase, including age-related macular degeneration (AMD) by ~50 million and glaucoma by ~20 million from 2020 to 2030.4 About 50% of the global adult population reports dry eye, which means symptoms and prevalence will continue to rise.5,6
Figure 1: Key factors contributing to this rise include aging, digital device use, and lifestyle, as shown below.7,8 *Lifestyle includes patient diet, environment, and smoking.
There is a strong link between systemic health and the risk of eye disease. For example, cis-β-carotene has been linked to myopia and high myopia,9 and B-vitamin supplements have been associated with a lower risk of AMD and glaucoma.10
Dry dye disease (DED) and nutrition
Nutrition's impact on the ocular surface includes food intolerances, gut microbiome, dietary supplements, macro- and micronutrients, and hydration.11
Eating disorders, food intolerances, and allergies
Poor nutrient absorption can increase the risk of dry eye disease. Conditions that can lead to malabsorption include eating disorders, chronic alcoholism, systemic autoimmune conditions such as Sjögren’s, lupus, and rheumatoid arthritis, and pancreatic and liver disorders.
These usually affect key nutrients, including vitamin A, B1, B2, B3, B6, B12, D, and E, omega-3 fatty acids, copper, and zinc. For example, anorexia nervosa, an eating disorder, can lead to ptosis, enophthalmos, lagophthalmos, and eyelid petechiae.3
Food intolerances are proinflammatory, non-immune responses to certain foods. Patients often react to ingested substances like lactose, gluten, and preservatives. Symptoms typically appear 12 to 24 hours after consumption and include distension, gas, and diarrhea. In about 5% of cases, food intolerance has been associated with non-allergic rhinitis. Moreover, lactose intolerance may be associated with an increased risk of dry eye disease.3
Food allergy is an immune response mediated by IgE antibodies to food proteins like eggs, milk, peanuts, and shellfish. Reactions vary from mild to severe, and in severe cases, they can cause anaphylaxis and be fatal. Additionally, food allergies can affect the eyes, with 14% of cases leading to allergic conjunctivitis.3
Macronutrients
Essential fatty acids naturally modulate inflammatory activity through their conversion to eicosanoids, which are hormone-like lipids that play a role in controlling immune and inflammatory responses. These eicosanoids originate from three fatty acid precursors: dihomo-γ-linolenic acid, arachidonic acid (ARA), and eicosapentaenoic acid (EPA).
A higher omega-6-to-omega-3 fatty acid ratio has been linked to a significantly higher risk of dry eye syndrome. The optimal ratio is less than 1:4 (omega-3 to omega-6).12
Micronutrients
Nutraceuticals are a combination of nutrition and pharmaceuticals derived from food sources. They are intended to provide health benefits in addition to their normal nutritional value.13
Micronutrients are products taken orally to supplement patients' diets. They may contain vitamins, minerals, fibers, amino acids, fatty acids, and herbs. These supplements are typically available as tablets, powders, or liquids.3
Evidence suggests vitamins A, B12, C, and D are beneficial. For patients with vitamin A deficiency, systemic vitamin A effectively treats OSD, alleviating both the signs and symptoms of DED. Furthermore, systemic vitamin D deficiency can worsen DED symptoms and reduce tear production.14
Selenium is an essential trace element in animals and is a component of the amino acid selenocysteine. Selenium has been shown, with limited evidence, to be associated with Graves' ophthalmopathy, and supplementation has been shown to decrease signs of DED.15,16
Oxidative stress and inflammation contribute to the development of dry eye. Carotenoids, natural lipid-soluble antioxidants present in fruits and vegetables, include approximately 20 types detectable in human blood.
Among these, lutein and zeaxanthin are found in the retina and lens, where they help protect the eye from oxidative stress, apoptosis, mitochondrial dysfunction, and inflammation.17 Dietary intake of carotenoids has been shown in randomized clinical trials to reduce the signs and symptoms of dry eye.18,19
Hydration
Hydration is essential for ocular health, as it influences plasma and tear osmolarity.20 It promotes overall tissue well-being and can alleviate symptoms in some individuals.21
However, despite some patients' beliefs, in our opinion, hydration does not repair aqueous tear deficiency caused by gland damage, nor does it resolve chronic inflammation, meibomian gland dysfunction (MGD), or neuropathic ocular pain.
The gut–eye axis
A gut-eye axis exists in dry eye disease. The holobiont refers to the microbiota—the community of organisms residing in the human body—shaped by environment, diet, genes, and disease. Signaling molecules from gut microbiota affect gut motility, energy extraction, epithelial integrity, and mucosal immunity.
These microbiota also have distant effects on organs such as the brain, skin, and the ocular surface. An imbalance may contribute to conditions such as uveitis, AMD, glaucoma, and dry eye disease.3
Modulating the microbiome can support the ocular surface using the following:3
- Antibiotics for targeting selected bacteria
- Prebiotics to provide nutrients for healthy bacteria
- Probiotics are beneficial for live bacterial strains
- Postbiotics to help with bacterial metabolic byproducts
Moreover, studies have shown that pre- and probiotic supplementation helps increase TBUT and Schirmer tear secretion and reduces OSDI scores.22-24
Early intervention and preventive counseling
There is a need to shift the patient's mindset toward wellness. Having an early conversation with the patient is important. If a patient has a family history of an ocular condition, such as AMD, discussing the condition before disease onset can drastically improve quality of life.
Screen your patients who are at higher risk, such as those with a family history of ocular disease, older patients, high digital device use, systemic conditions such as diabetes, and those with nutritional risk factors.
Ocular support, depending on the condition, can include lipid-based tears, anti-inflammatory therapy, meibomian gland treatment, and high-bioavailability supplements. Also include multidisciplinary support through primary care physicians, specialty physicians, and nutritionists.
Integrating nutrition into clinical practice
Integrating nutrition discussions into routine eye exams can seem overwhelming, especially in busy settings. However, leveraging these exams as an opportunity for preventive talks benefits both patients and practitioners over the long term. Time limitations can be mitigated by providing patient handouts and resources through patient portals.
Emphasize adherence to treatment plans and communicate clearly and simply. It can be as simple as encouraging patients to increase their intake of vegetables and fatty fish.
Additionally, educational tools and accessible resources not only help patients but also ensure clear communication channels, making it easy for patients to contact the practice with follow-up questions. Further, reinforcing educational messages during follow-up appointments is essential.
Recommending accessible nutritional strategies
Early intervention and treatment are crucial for addressing patient needs before any structural changes occur. This includes promoting annual eye exams and taking the time to educate patients about their conditions and available treatment options.
ECPs should provide patients with personalized, multifaceted treatment plans. Here are some insights on the importance of recommending accessible nutritional strategies.
Promoting practical dietary advice involves encouraging realistic and sustainable changes. For example, the average American intake of lutein/zeaxanthin is 1.5mg/day, compared with a recommended 6mg/day.
The line between over-the-counter (OTC) and prescription medications is gradually shifting. It's important to understand when and how to recommend supplements to help patients make informed, evidence-based choices.
OTC options can be a vital part of patient care because they are easily accessible. Instead of seeing them as secondary, they should be considered a strategic supplement that enhances prescription treatments. Additionally, ECPs should know how to evaluate quality, formulation, and credibility.
Encouraging patient engagement in preventive care
Driving behavior change means encouraging patients to adopt lifestyle changes and motivating them to continue treatment plans even when they are asymptomatic.
An example of how lifestyle affects eye health can be seen in patients with AMD. Key factors for maintaining eye health include quitting smoking, exercising regularly, managing weight, controlling blood pressure, having annual eye exams, protecting against UV rays, and following a healthy diet. Unfortunately, awareness of the nutrients crucial for supporting eye health is surprisingly low among individuals at high risk of eye diseases.25,26
Setting expectations is key, and it’s important to emphasize the gradual and long-term benefits of nutrition. When discussing with patients, connect their health to overall health goals.
Key takeaways for clinical practice
Eyecare providers play a vital role in promoting not only ocular health but also overall systemic well-being. By emphasizing proper nutrition and early intervention, they can significantly reduce long-term health risks. Moreover, offering clear and practical advice enhances patient adherence to recommended health practices.
