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The Role of Nutrition and Nutritional Supplements in Ocular Surface Diseases

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The Role of Nutrition and Nutritional Supplements in Ocular Surface Diseases nutrients Review The Role of Nutrition and Nutritional Supplements in Ocular Surface Diseases Marco Pellegrini 1,* , Carlotta Senni 1, Federico Bernabei 1, Arrigo F. G. Cicero 2 , Aldo Vagge 3 , Antonio Maestri 4, Vincenzo Scorcia 5 and Giuseppe Giannaccare 5 1 Ophthalmology Unit, S.Orsola-Malpighi University Hospital, University of Bologna, 40138 Bologna, Italy; [email protected] (C.S.); [email protected] (F.B.) 2 Medical and Surgical Sciences Department, University of Bologna, 40138 Bologna, Italy; [email protected] 3 Eye Clinic of Genoa, Policlinico San Martino, Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DiNOGMI), University of Genoa, 16132 Genoa, Italy; [email protected] 4 Medical Oncology Department, Santa Maria della Scaletta Hospital, 40026 Imola, Italy; [email protected] 5 Department of Ophthalmology, University Magna Græcia of Catanzaro, 88100 Catanzaro, Italy; [email protected] (V.S.); [email protected] (G.G.) * Correspondence: [email protected]; Tel.: +39-3343-308141 Received: 11 March 2020; Accepted: 27 March 2020; Published: 30 March 2020 Abstract: Dry eye disease (DED) is a multifactorial disease of the ocular surface system whose chore mechanisms are tear film instability, inflammation, tear hyperosmolarity and epithelial damage. In recent years, novel therapies specifically targeting inflammation and oxidative stress are being investigated and used in this field. Therefore, an increasing body of evidence supporting the possible role of different micronutrients and nutraceutical products for the treatment of ocular surface diseases is now available. In the present review, we analyzed in detail the effects on ocular surface of omega-3 fatty acids, vitamins A, B12, C, D, selenium, curcumin and flavonoids. Among these, the efficacy of omega-3 fatty acid supplementation in ameliorating DED signs and symptoms is supported by robust scientific evidence. Further long-term clinical trials are warranted to confirm the safety and efficacy of the supplementation of the other micronutrients and nutraceuticals. Keywords: ocular surface; dry eye disease; nutritional supplements; nutraceuticals 1. Introduction 1.1. The Ocular Surface System The ocular surface system consists of various components of the eye that are structurally and functionally linked by continuous epithelia and common nervous, endocrine, vascular and immune systems. It includes cornea, conjunctiva, lacrimal and meibomian glands, nasolacrimal duct and eyelids [1]. Being a direct connection between the eye and the external environment, all components act synergistically to maintain a healthy and well-performing refractive status and to protect the key structures of vision against external pathogenic noxa. Both the aforementioned functions of the system are ensured by the production of an efficient tear film. In particular, lacrimal glands secrete the watery component as well as electrolytes and protective proteins; the corneal and conjunctival epithelia release mucins that transform the aqueous tears into a muco-aqueous gel and increase lubrication; meibomian glands secrete lipids (meibum) that form the outermost layer of the tear film, preventing its evaporation. Any factor perturbing the homeostasis of the ocular surface system may disrupt the stability and osmolarity of the tears, leading to tissue damage by means of osmotic, mechanical and inflammatory mechanisms [2]. Nutrients 2020, 12, 952; doi:10.3390/nu12040952 www.mdpi.com/journal/nutrients Nutrients 2020, 12, x FOR PEER REVIEW 2 of 16 Nutrientsdisrupt2020 the, 12stability, 952 and osmolarity of the tears, leading to tissue damage by means of osmotic,2 of 16 mechanical and inflammatory mechanisms [2]. 1.2.1.2. DryDry EyeEye DiseaseDisease DryDry eyeeye diseasedisease (DED)(DED) is a multifactorial disease of of the the ocular ocular surface surface system system that that affects affects 5 5%% to to 30%30% of of individualsindividuals overover thethe ageage of 50 [3] [3].. DED DED has has a a higher higher incidence incidence in in older older people, people, postmenopausal postmenopausal women,women, contactcontact lenslens wearerswearers andand patientspatients with autoimmuneautoimmune conditions. Symptoms Symptoms of of DED, DED, such such as as blurryblurry vision, vision, light light sensitivity, sensitivity, irritation, irritation, burning burning and itching,and itching, may restrictmay restrict daily activitiesdaily activities with negative with impactnegative on impact quality on of quality life [4]. of life [4]. AA combinationcombination ofof subjectivesubjective questionnaires and and diagnostic diagnostic tests tests are are us useded to to diagnose diagnose DED DED and and scorescore itsits severity.severity. TheThe stabilitystability ofof the tear filmfilm is estimated by by measuring measuring the the time time interval interval between between a a completecomplete blink blink and and the the appearance appearance of of the the first first break break in in the the tear tear film film (break-up (break-up time). time). The The tear tear volume volume is evaluatedis evaluated by measuringby measuring the length the length of wetting of wetting of paper of strips paper kept strips into kept the temporal into thelower temporal conjunctival lower sacconjunctival for 5 minutes sac for (Schirmer 5 minutes test), (Schirmer or more test), recently or more by recently assessing by assessing the height the of height the inferior of the tearinferior film meniscustear film meniscus by means by of means anterior of segmentanterior segment optical coherenceoptical coherence tomography. tomography. The measurement The measurement of tear osmolarityof tear osmolarity is considered is considered one of theone best of the metric best tometric grade to the grade DED the severity DED severity [5]. Finally, [5]. Finally, dyes such dyes as fluorescein,such as fluorescein, rose bengal, rose bengal, and lissamine and lissamine green green are used are used to stain to stain the ocularthe ocular surface surface and and evaluate evaluate the epithelialthe epithelial integrity integrity (Figure (Figure1a) [ 61a].) [6]. TheThe classificationclassification of of DED DED includes include twos maintwo main sub-types sub- thattypes are that characterized are characterized by lower productionby lower ofproduction tear (aqueous of tear deficient (aqueous DED) deficient or increased DED) or evaporationincreased evaporation (evaporative (evaporative DED), which DED) often, which coexist often in thecoexist same in clinical the same picture. clinical The picture. latter form The islatter typically form associatedis typically withassociated meibomian with glandmeibomian dysfunction, gland adysfunction, quali/quantitative a quali/quantitative alteration of thealteration lipids of produced the lipids by produced these glands, by these which glands, are essentialwhich are to essential prevent excessiveto prevent evaporation excessive evaporation of the tear film of the (Figure tear1 filmb) [ 7(Figure]. Both low1b) [7] production. Both low and production high evaporation and high of tearsevaporation lead to hyperosmolarityof tears lead to hyperosmolarity and subsequent and inflammation, subsequent which inflammation, cause epithelial which damagecause epithelial and loss ofdamage goblet cells.and loss The of resulting goblet cells. tear filmThe instabilityresulting tear amplifies film instability tear hyperosmolarity, amplifies tear thus hyperosmolarity self-maintaining, thus self-maintaining the vicious circle of DED [8,9]. the vicious circle of DED [8,9]. (a) (b) FigureFigure 1.1. Representative Representative imageimage fromfrom aa patientpatient with dry eye disease owing owing to to Meibomian Meibomian gland gland dysfunction.dysfunction. ((aa)) SlitSlit lamp photograph of the cornea cornea after after instillation instillation of of 20 20 µLµL unpreserved unpreserved 2% 2% sodium sodium fluoresceinfluorescein (corneal (corneal fluorescein fluorescein staining). staining). The The epithelial epithelial damage damage is visible is visible as multiple as multiple punctate punctate epithelial erosionsepithelial staining erosions with staining fluorescein with scatteredfluorescein over scatte thered corneal over surface.the corneal (b) Slitsurface. lamp ( photographb) Slit lamp of thephotograph lid margin of showingthe lid margin typical showing signs of typical meibomian signs glandof meibomian dysfunction, gland including dysfunction, hyperemia including and irregularityhyperemia ofand the irregularity lid margin, of telangectasia, the lid margin, plugged telangectasia, gland orifices plugged and gland anterior orifices displacement and anterior of the mucocutaneousdisplacement of junction. the mucocutaneous Hyposecretion junction of meibomian. Hyposecretion lipids leads of meibomian to tear film lipids instability leads and to tear increased film evaporationinstability and rate. increased evaporation rate. 1.3.1.3. TheThe RoleRole ofof OxidativeOxidative Stress and InflammationInflammation TheThe ocularocular surfacesurface isis almostalmost constantlyconstantly exposed to sunlight, which which consists consists of of wavelengths wavelengths includingincluding ultravioletultraviolet light,light, aa well-recognizedwell-recognized causative factor of oxidative stress. Under Under normal normal conditions, antioxidant enzymes, such as superoxide dismutase, catalase and glutathione peroxidase, eliminate the reactive oxygen species generated by oxidative
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