letters to the editor

More Comments About Omega-3s

Dr. Townsend's September Dry Eye Dx and Tx column, "Alternate Omega-3 Sources" was very informative, and Dr. Anshel made some valid points in his November 2007 letter "EFAs and Dry Eye." However, I feel clarification is needed regarding omega-3s. It's extremely important to understand that omega-3s are the only valuable omega to the eye as they are converted to EPA and DHA, which are beneficial for relieving dry eye and for retinal health.

There are two problems with flaxseed oil. First, it's converted to EPA and DHA at only 1 percent, as is any GLA or ALA molecule. Second, flaxseed oil has been linked to increasing the risk of prostate cancer. Therefore, we should avoid it at all costs even though studies show that it results in thinner meibomian secretions.

What I feel physicians in the United States need to understand is that there are two forms of omega-3s: the ethyl ester (EE) form and the natural triglyceride (TG) form. When fish oil is manufactured, EE alcohol is added to the pressed out fish oil to remove the impurities. In the United States, this is the form in which it's most commonly sold.

One problem is that the EE form is 300 percent less absorbable than the TG form, which means our patients aren't getting the amounts that we recommend into their system. This data is definitive and was proven by Dr. Dyerberg in 1995 and never challenged. Another problem is that the EE form can cause liver toxicity, which is why Omacor is available by prescription only. If you read the Omacor package insert, you'll find specific mention of the liver toxicity concern and need for patient monitoring by a primary care physician. This is also why the EE form of omega-3 is not available overthe-counter in any country other than the United States.

Only three companies in the United States make a TG form omega-3: LifeGuard Health, Nordic and Standard Process. These companies remove the EE alcohol, leaving behind the natural TG form. Any other omega-3 is in the EE form and should be avoided due to the aforementioned limited absorption and liver concerns. The EE alcohol in most omegas also causes the side effects associated with fish oil supplements such as belching with a fishy taste, GI upset, bloating and fish smell.

The 4g of absorbable omega-3s recommended for anti-inflammatory effects can not be tolerated when in the EE form. Patients would need to take 12 to 16 capsules to reach 4g because of the lack of absorption. Any patient should be able to take 4g of a TG form easily without any side effects.

Our country's diet is too high in the pro-inflammatory omega-6s and is severely lacking in omega-3s. We have made great strides in helping our patients understand the ocular benefits of omega-3s, but now we need to steer them in the right direction so they can achieve the best results.

Thomas P. Kislan, OD, Medical Director
Hazleton Eye Specialists
Stroudsburg Eye Specialists
The Dry Eye Clinic of Northeast PA

Come in When You're Out

I'm writing in response to the November The Business of Contact Lenses column, "A New Way to Think About Dispensing Annual Supplies," by Gary Gerber, OD. Certainly dispensing a year's supply results in better compliance — with patients hopefully keeping to their replacement schedules — and it derails patients from seeking alternate sources for replacement lens purchases.

I've found that dispensing annual supplies also has a third, more subtle benefit — running out of lenses is an automatic reminder for patients that it's time for an annual exam.

I have a corny/catchy line that I use successfully when prescribing annual supplies to my contact lens patients: "When you're out, you're in," meaning that when you run out of lenses, it's time to come in for your annual exam.

Manny H. Greitzer, OD, EdM
Greenwich, CT