The nutriceutical industry is bombarded with ‘miracle medicines’ claiming to cure all that ails you, however without any regulating body these over-the-counter non-prescription pills are too varied for the consumer to make sense of when faced with 5 feet of choices at your local superstore or pharmacy. Now, the reality is that some molecules actually do have merit and have been shown in repeated studies and world-renowned institutions like John Hopkins Hospital to have medical efficacy in a variety of conditions. In this article, I will reveal my top 3 picks for nutriceutical supplements for the eyes for 2013 and why. These picks are based on my research and my clinical work with these supplements. A little background here: I have worked with A LOT of supplements over my career and I have scrutinized claims made in scientific literature in clinical settings. I chose them after a detailed due diligence on my part and to be clear I have no financial interests or ties to any of the listed products.
Omega 3 (PRN – Physician Recommended Nutriceutical) : Dry Eye Disease, AMD
Now, I’m being very specific here about the PRN formulation for a few reasons which will be explained shortly. Omega 3s have been historically shown to be essential nutrients derived from dietary consumption. Our bodies cannot produce or store this molecule so where we get it is the only variable we can control. Natural sources of O3’s include plants and animals each with their own unique form. Plant sources, flaxseed being most recognized, contain alpha-linoleic acid and marine animals contain the triglyceride form. From a physiological perspective alpha-linoleic acid (ALA) forms are less bioavailable then triglyceride (TG) forms because the enzyme required to convert ALA to O3, delta-6 desaturase, can be pre-occupied with Omega 6 conversion of pro-inflammatory factors. That’s right – flaxseed in the average omega 6 rich North American diet will not convert to EPA/DHA as readily and will likely add to pro-inflammation.
Triglyceride O3 are available as unpurified, ethyl ester (EE), and re-esterified TG (rTG) forms and with each step the cost of production rises – For good reason. Unpurified forms, the least expensive, are just that and have all the toxins and impurities that come with pressed oil directly from fish. EE forms, which cost slightly more, have been pressed and heat purified using ethanol to convert the TG to and EE which is less bioavailable (Dyeberg J, Nutrition 1995). rTG forms go through the same process as EE but are the ethanol is removed (re-esterification) and replace with the triglyceride backbone. This critical extra step does add to the production cost, but the absorption of rTG O3 nears 100%. It is this small difference that minimizes the gastrointestinal distress, heartburn and fish-burps you experience with many over the counter EE forms.
Dry Eye Disease (DED), macular degeneration (AMD) and other ocular diseases with known inflammatory roots benefit from this supplementation. A recent study by Dr. Gregory Smith MD demonstrated that 82% of patients treated with rTG (1,680 mg EPA/560mg DHA/1,000mg vitamin D) had changes in their oil gland secretions at 8 weeks. rTG O3 is the closest to direct pure fish derived O3 and is a key differentiator in quality of the vast array of choices. For my ocular surface patients/dry eye patients, I see PRN formulation of rTG O3 being a standard all other formulations should be measured against at a minimum dosing of 2000 mg/day. Patients should consult there eye physician prior to taking particularly those on blood thinners.
Resveratrol (Longevinex): Wet/Dry AMD, Cardiovascular Tendencies
Once touted as the next fountain of youth due to myriads of publications demonstrating its cardiac and ‘anti-aging’ health benefits received a big blow to its momentum in January 2012 when Dr. Dipak Das was accused of scientific fraud in a dozens of his publications asserting its efficacy. A midst this brewing controversy, Dr. Stuart Richer OD PhD FAAO has been studying the molecular effects of this drug on the aging eye – specifically eyes with age-related macular degeneration.
Resveratrol is a molecule extracted from the skin of grapes in red wine. Only 1mg trans resveratrol in 5 ounces of best red wine and therapeutic doses require 100mg so don’t think you can drink this into your system. RV modulates protective pathways against oxidative stress,
excitotoxicity, inflammation, DNA damage, and apoptosis or cell death (Richer, S). The mechanism of action is multifaceted, however recently facilitation of survival of endogenous stem-cell by this small molecule was achieved by breaching the protective retina barrier. Stem cells can be implanted, however undifferentiated stem cells are available in adult tissue when it becomes damaged. RV may hold a key in enhancing this process. It also has been shown to down regulatethe mRNA controlling vascular e
ndothelial growth factor gene (VEGF) which is a welcomed alternative to intraocular injections of anti-VEGF drugs for wet AMD patients (Richer S, William S, et al University of Illinois (UIC), Retina Service, Eye and Ear Infirmary, Chicago, IL 2011). The image to the right is a before and 18 days after resveratrol administration (no other forms of treatment). Normally this reduction in lesion size can only be achieved through intraocular injection of anti-VEGF. I do however acknowledge although the natural course of wet AMD tends to worsen, there are cases of self resolution without treatment. In Dr. Richer’s study, however, he demonstrated the repeatability of this finding in 18 patients.
As a practitioner, the potential of this molecule in specific vascular diseases like AMD is immense.
Patients undergoing medical management of AMD should be aware of the brand Longevinex because of its micronized/microencapsulated powder form which allows for slow release of the trans RV. This drug specifically has been used in several eye related studies and the inclusion of vitamin D3 is a key component. I would argue that we have yet to see the full ability of this molecule to improve vascular health.
Macular Carotenoids – Lutein(L), Zeaxanthin (Z) and meso-Zeaxanthin (MZ) (MacuHealth): Dry AMD/pre-Dry
The yellow pigment found at the macula is a distribution of carotenoids L, Z and MZ which are 3 of over 700 found in nature. Together these 3 pigments are known as the macular pigment (MP). MP acts as a filter for blue light and as an antioxidant which is believed to protect against AMD (Snoderly, 1984). In fact studies have indicated that the combined ability of the 3 MP’s to quench singlet oxygen/free radicals therefore reducing oxidative stress is greater than the sum of their parts (Binxing Li, et al 2010).
Several studies have examined serum concentration of MP’s in response to supplementation and demonstrated that the combined consumption can very depending on the cocktail in question. The British Journal of Nutrition in September 2012 published a paper demonstrated a specific proportion (10 mg L,2 mg Z and 10 mg MZ) produced the highest serum concentration in a small group of patients using HPLC (high performance liquid chromatography). By optimizing serum levels of MP, this makes it more bioavailable for capture by the retinal tissue.
MP density at the macula has been shown to be diminished in patients with AMD and it is possible that patients with a reduced MP profile may be at increased risk for macular disease. The AREDS II study, yet to be published, has included L and Z as treatment arms and preliminary results confirm the importance of carotenoid supplementation. Unfortunately MZ wasn’t included in AREDS II, however with the growing body of science supporting the use of all 3 carotenoids vs. L and Z alone it stands to reason to supplement all three inclusively. MacuHealth is a unique supplement that combines all MP’s which is key as MZ is hard to come by in supplement form. As the study of MP continues to evolve, MacuHealth seems to remain at the forefront of preventative treatments for macular disease.
And that rounds out my top 3 nutriceuticals to watch and perhaps consume in 2013. My approach to health care is evidence-based and to my patients and colleagues alike, I do put a great deal of work into what I recommend to you. I encourage you to seek alternatives but to weigh them out in addition to determine if it is truly an effective alternative. As always do consult your eye care physician when deciding whether supplementation is warranted and/or safe.
Dr. Richard Maharaj OD, FAAO
Director of Optometry,