Many patients present with the ocular symptoms of burning, dryness, and irritation. Traditionally, they have been considered to have dry eye disease. However, if Schirmer’s testing is performed, fewer than 5% of these patients will have wetting of the tear strip of less than 5 mm. With greater than 5 mm of wetting, these patients have enough tears to be comfortable, however, any stress to the tear film causes problems.

The reason they have these symptoms is because of meibomianitis. The normal secretion, which stabilizes the tear film, has changed from soothing oil to inflammatory oil. This results in earlier break up of the tear film in mild cases with a resultant dry feeling. In more severe cases, the eye is red and has superficial punctate keratitis. Bacteria will take advantage of the eye’s inflamed oil glands and add more inflammation to the process.

The traditional treatment for posterior blepharitis, as this condition is also called, has consisted of artificial tears, topical steroids, oral tetracycline and its derivatives, and more recently, topical azithromycin. In the past 30 years, none of these agents has brought long-lasting relief to patients. Topical azithromycin has been useful, however, because it can penetrate the lid’s oil glands and con- trol or even eliminate the bacteria there. When the agent is used by itself, the blepharitis returns in 2 to 4 weeks. Topical steroids have too much difficulty penetrating the oil glands to have much effect.

In order to control or resolve blepharitis, the nature of the oil within the meibomian glands must be normalized. Elimination of the bacteria or anti-inflammatory effect of antibiotics such as azithromycin, erythromycin, and tetra- cyclines simply result in a temporary change, which returns more often than we would like.

Fortunately, there is a terrific treatment for inflammation of the meibomianitis. The best treatment I have found in more than 30 years of practicing ophthalmology is omega- 3 fatty acids in the triglyceride form. I have an approximately 80% success rate after using this product in about 700 patients. It is crucial to use the triglyceride form of omega- 3.1 Studies have shown that the absorption of this type of omega-3 is nearly 100%. The absorption of an omega-3 in ethyl ester form ranges from 20% to 50%. This means that the patient must take up to 20 pills a day to achieve the proper blood levels necessary to treat the eyelids.2

Physician Recommended Nutraceuticals (Plymouth Meeting, PA) makes the form of omega-3 that achieves this near 100% absorption.3

How does it work? What I tell patients is the following.
The oil in the glands in your lids is inflamed. It is no longer soothing oil, and when it spills onto the surface of your eyes it is like grease on a frying pan. No matter how much water you use, when the water stops the oil is still there. To the cornea, this feels like a foreign body on the surface. In order to relieve the symptoms we need to normalize the oil in the oil gland. You will take a triglyceride omega-3, which is an anti-inflammatory oil. The body will absorb the oil, and since it is oil it will concentrate in the oil glands first. This is exactly what we want. We now have perfectly targeted therapy, anti-inflammatory oil inside the inflamed oil gland.

In summary, the vast majority of dry eye is blepharitis. Always evaluate the meibomian glands in these patients for inspissation and telangiectasias. Treat with topical azithromycin if secondary infection of the glands is present but the primary long-term treatment should be in the form of omega-3s in the triglyceride form.