Integrative Therapeutics For The Tear Film

Benjamin Clarence Lane, OD

Tear-replacement drops can be useful, and some are more effective than others, but full return to normal tear-film production is unlikely as long as tear-augmentation drops are relied on.

Reduction of the following risk factors characteristically results in improved tear-film function.

Risk Factors for Common Tear Film issues

A. "Jelly-Bump" Lipid Deposits Spoiling Hydrogel Contacts
1. Excessive (XS) medication with anticholinergics, sympathomimetics, diuretics that do not spare potassium, some anti-depressants [––list includes Aldomet, Benadryl, Desyrel, Lasix, Librax, Minipress, Tavist, Tolinase, Ventolin, but also diabetics on hypoglycemics––], resulting in depressed tear potassium
2. XS (protein intake > 167% RDA)/(physical activity calories expended); Odds Ratio (OR)=24, p=0.0056, after excluding those on specific medications or alcohol ≥10 g/day
3. Depressed tear potassium, a highly significant risk factor if we include those on specific medications, OR=7.65, p=0.008
4. XS (cholesterol intake ≥ 680 mg/day)/(cholesterol otherwise synthesized by the body and in ratio to pyridoxine, ascorbic acid, Cr intake, & physical activity)
5. XS (alcohol ≥ 9 g/day)/(fresh fruit rich in potassium, magnesium, and food folate), especially at meals high in fats and animal protein

SEE: Hart, Lane, Josephson et al, Ophthalmol 1987;94(10):1315-21. Also: Lane & Hart, Invest Ophthalmol Vision Sci 1986; 27(3, Supplement):138.

B. Depressed Tear-film Break-Up Time (TBUT) <10 sec

1. XS (sucrose intake)/(food-folic-acid intake) ≥6x10-2 tsp/µg, OR=40, p=0.0126

2. food-potassium intake ≤2500 mg/day, OR=15, p=0.0357
C. Dry Eyes & CL-Deposit / Coating Syndromes
Identified by superlow export of sodium (Na) &/or potassium (K) to hair, such that nape-hair Na<12 ppm &/or K<8 ppm, OR=625, p=3.7x10-7 !! [Lane, Fed Proc 1984; 43(March):1052] and tears are superlow in Na [Poster, 1983 NYAO lect] and K [RA Gorn, 1981 lect]. In 1978 Ned Paige reported that many patients with dry-eye syndrome could be helped with megadoses of pyridoxine (vitamin B6), although some did not respond. In December 1983 Graeme Wilson and associates reported that calcium, magnesium, potassium, and sodium are essential and sufficient minerals in tears for the maintenance of corneal epithelium integrity. Lane (1984) found mean hair K was 8.9±9.7 ppm for cases vs 65.3±43.0 for controls and that the single most significant nutrient intake associated with both of these syndromes is deficiency of food folate <310 µg/day. Second most significant is intake of sucrose exceeding 11 teaspoons/day. Intake of ascorbic acid (vitamin C) no more than 175 mg and food-vitamin B6 no more than 2 mg/day are third and fourth most significant.{Note: Rebello, Hodges & Smith [Am J Clin Nutr 1983; 38(Jul):84-94] have shown that the short-term effect of ingestion of sucrose, glucose, fructose, or lactose independent of the foods in which they are found in nature––foods normally well-endowed with K, magnesium, or calcium––results in conservation of Na and K in the form of antinatriuresis and antikaliuresis.}

Dietary Intervention
A. If K intake < 4000 mg daily, encourage consumption of additional fresh fruit. 1000 mg K may be obtained from 2-1/2 med bananas or 3-1/2 med oranges or 1/2 med cantaloupe or 3 med tomatoes.

B. If food folate < 500 µg daily, encourage consumption of additional raw, fresh fruits and vegetables, especially green, leafy or sprouting, and raw fruits. 100 µg food folate may be obtained from 6 raw Brussels sprouts or 2 cups of raw red cabbage or 7 raw asparagus spears or 1 cup of raw stringbeans or 5/8 cantaloupe (raw) or 2/3 cup of raw broccoli or 1/4 cup of raw chick peas or 1/2 cup of raw spinach or 1-1/3 med raw yams or 1 cup of raw romaine lettuce or 1-1/2 med oranges or 1-1/2 cups of raw hazelnuts (filberts).

C. Avoid added sugar. Added sugar depletes K. Sucrose intake ≥ 11 tsp significantly increases the risk for CL intolerance and dry eyes. A can of Pepsi or Classic Coke contains 9 tsp sugar.

D. If food-ascorbic acid ≤ 400 mg, encourage additional intake of raw, fresh fruits and vegetables. One med cantaloupe delivers 130 mg vit C. Two fresh med oranges deliver 150 mg, 3 med tomatoes deliver 105 mg. [Cf EC Cheraskin on CL intolerance and vit C, 1980.]

E. If food pyridoxine (vit B6) ≤ 4 mg, encourage switching to those high-in-protein foods that may be eaten safely either raw or rare-cooked after washing. For example, 1 mg of food B6 is afforded by 1.1 cups of raw walnuts or 2 cups of raw filberts (hazelnuts) or 1-1/2 cups raw spinach or 6 oz of quite-rare fillet of beef. Medium or well-done flesh proteins are deficit inducing for vit B6. [Cf N Paige, 1978.] Statistically, dry-eye victims are notorious for eating their meats well-done, thereby depleting most of the otherwise available pyridoxine.

Pyridoxine assists the uptake of magnesium, which in turn is essential to maintain adequate intracellular concentrations of K. Horrobin and Campbell (1980) noted that B6 and magnesium are required to convert cis-linoleic acid to GLA & subsequently to convert GLA to DGLA. Ascorbic acid is then needed to convert DGLA to prostaglandin E-1.

F. Conventionally prescribed diuretic drugs deplete K and along with aspirin [Cotlier, 1983] contribute to dry-eye syndrome [keratoconjunctivitis sicca (KCS)] and contact-lens intolerance. Conservative supplementation with B6 and C can create diuresis while yet ameliorating dry-eye syndrome.

G. Consider supplementation for one to 12 weeks with gamma linoleNic acid (GLA) (as from evening primrose oil or human breast milk) supposedly to promote prostaglandin PGE1 formation [DF Horrobin & AC Campbell, 1980]. Two capsules, TID, may be tried. However, it is unnecessary in most cases if one resorts to raw, fresh foods for the K, folate, ascorbic acid, and pyridoxine. Less supplementation of g-linolenic (GLA) is better tolerated than 2 capsules TID. The need for and sufficiency of GLA can be assessed in the blood assay of the "Fatty-Acid Profile." Testing may reveal that “Omega-3” oils (flaxseed oil, walnuts) may be more beneficial. Often patients catch up as to their needs within 2 months.

H. The normal tear film should contain vitamin A.
1. Most adult Americans are not deficient in vitamin A and are not victims of the common form of dry eyes seen largely in hypovitaminosis A in third-world country children.

2. Especially if arthritis, add chondroitin and glucosamine sulfate (100-500 mg QD).

I. The single most effective therapeutic measure for these syndromes may be accomplished by increasing the intake of fresh, ripe, raw fruits of all kinds (and also vegetable salads), while decreasing intake of refined or highly processed foods that may be rich in calories, but poor and unbalanced in vitamins and minerals. The nutrient tables for fresh fruits are misleading, because such a large part of their weight is water. Nonetheless, the fresh fruits are excellently balanced sources for humans for potassium, calcium, magnesium, food-ascorbic acid, food-folate, food pyridoxine, food thiamine (vitamin B1), and glucose-tolerance-factor chromium––all the nutrients essential for the metabolism of sugars found in fruits, but missing from supplemental sugar. Supplemental sugar induces urination of chromium, although it does not replace chromium, and hence is deficit-inducing for chromium, as well as for calcium, magnesium, and potassium.

As fruits and veggies become a larger part of the diet, it becomes more important to consume organically produced fruits and veggies or at least to thoroughly wash and peel fresh fruits if they are not organically grown. Type 2 (non-insulin-dependent) diabetics can benefit from gradual increase in fresh fruit consumption and especially from increased intake of fresh, raw vegetable salads without dressings, but, depending on the severity of their condition and the inadequacy of their individual red-blood-cell chromium/vanadium concentrations, they may not be able initially to handle markedly increased intake of fruit.

The Key Message

Simple dietary therapy is resulting in a high recovery rate.