Gluten Free Works: TREATMENT GUIDE Get well and stay healthy living gluten free
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Dry Eye Due to Riboflavin Deficiency. GFW
What Is Chronic Dry Eye Syndrome?
Chronic dry eye syndrome is an inflammatory condition of the conjunctiva with inadequate tear production or distribution over the eye surface. It is characterized by surface damage to the conjunctiva, giving the appearance of redness.
This complex condition involves the lacrimal glands, eyelids, and tear film, as well as a variety of eye surface tissues, including epithelial, inflammatory, immune, and goblet cells.1
Q: What is the conjunctiva?
A: The conjunctiva is the mucous membrane that lines the inside of the eyelids and covers the eyeball surface, also called the white of eye. The conjunctiva has a rich blood supply that can quickly bring microbe fighting cells to prevent invasion and overcome infection.
While infection and inflammation go hand-in-hand, they are not the cause of, but may result from, chronic dry eyes.
Dry eye syndrome develops from poor health of the conjunctiva that is associated with inadequate nutrition and poor quality of the tears that steadily lubricate the eye surface. These tears are called the tear film and are not the same as tears produced when crying or that result from irritating substances such as onions. Blinking spreads the tears that protect the surface from drying and flushes away unwanted matter.
The tear film is made up of three layers: mucous layer produced by goblet cells in the conjunctiva, aqueous (water) layer produced by the lacrimal glands, and lipid (fat) layer produced by the meibomian glands in the eyelids. Dysfunction of any of these layers impairs the the tear film. Without an adequate tear film the conjunctiva becomes dry and inflamed.
When the meibomian glands fail to produce sufficient lipid that is clear and fluid but rather cloudy and thick, the condition is called meibomian gland dysfunction (MGD). The main cause of MGD is hyperkeratinization (thickening of the glands) and its related pathogenesis (for example, ductal dilatation and acinar atrophy). Other disorders such as atopy, pemphigoid acne, rosacea, and seborrhea are related to MGD and may result in a chronic inflammation of the eye surface.2
MGD is “the most underrecognized, underappreciated and undertreated disease in ophthalmic care. It is so common as to be taken as ‘normal’ in many clinical practices,” according to Joseph Tauber, MD, an anterior segment subspecialist and refractive surgeon in Kansas City, Mo.3
Untreated dry eye progresses to xerophthalmia, a condition of extreme drying and thickening of the conjunctiva characterized by hazy, dry cornea. Other causes of dry eye, beside celiac disease, include certain systemic conditions such as Sjogren’s syndrome, an autoimmune disease.
What Is Chronic Dry Eye Syndrome In Celiac Disease and/or Gluten Sensitivity?
- Relationship between dry eye and celiac disease. Chronic dry eye is a feature of nutritional deficiencies, in particular vitamin A deficiency, associated with malabsorption in celiac disease.
- Relationship between dry eye and treatment failure in celiac disease.The conjunctiva is not inflamed by infection, injury or allergy, and so, dry eyes do not respond to treatments for these conditions.
- Relationship between dry eye and vitamin A. Vitamin A plays an essential role in the maintenance of epithelial (cell) surfaces on the cornea and conjunctiva. Inadequate vitamin A results in thickening of the eye surface (hyperkeratinization). This blurs vision.
- Relationship between dry eye and meibomian gland health. Vitamin A is also required for the function of the meibomian glands in the eyelids to adequately produce the tear film. Deficiency of vitamin A results in hyperkeratinization of the meibomian glands, and the structural changes that result damages the ability of the glands to produce the tear film. It is well established that malnutrition, protein and vitamin-A deficiencies are extremely deleterious to tear film health and supplementation with oral vitamin A in this setting is of clear benefit. The relative impact of diet on tear film within what would be considered normal ranges of consumption is less clear.4
- Relationship between dry eye and tears. The tear film requires riboflavin and omega-3 fatty acids for their production and stability. In deficiency, failure to produce normal tear film is called meibomian gland dysfunction. In these people, omega-3 fatty acids may improve tear film stability, decrease the inflammation of lid margins, and recover the homeostasis (balance) of the eye surface.2
- Relationship between dry eye and omega-3 fatty acid therapy. A meta-analysis of available research showed that omega-3 fatty acid supplementation was associated with better tear break-up time and Schirmer’s tear test. “Consequently, our findings suggest that omega-3 fatty acid offers is an effective therapy for dry eye syndrome.”5 Note: Omega-3 fatty acids oppose omega-6 fatty acids in the body.
How Prevalent Is Chronic Dry Eye Syndrome In Celiac Disease and/or Gluten Sensitivity?
Chronic dry eyes has increased frequency in untreated patients with celiac disease.
A recent Dutch study of 80 patients newly diagnosed with celiac disease found 7.5% had vitamin A deficiency which is a cause of dry eye syndrome:6
What Are The Symptoms Of Chronic Dry Eye Syndrome?
Chronic dry eyes are marked by these symptoms:
- Eye discomfort.
- Blurred vision.
- The feeling that something is in the eye, the need to squint, and close the eyes.
- There is annoying difficulty in reading, computer work, and performing fine tasks that require concentrated viewing.
How Does Chronic Dry Eye Syndrome Develop In Celiac Disease and/or Gluten Sensitivity?
- Chronic dry eyes result primarily from vitamin A deficiency due to malabsorption in celiac disease, and protein deficiency contributes because it is required for vitamin A absorption and use in the body.
- Deficiencies that impair the ability to make tears are riboflavin and omega-3 fatty acids.
Does Dry Eye Syndrome Respond To Gluten-Free Diet?
Yes. Chronic dry eye improves on gluten free diet containing adequate vitamin A and protein for tissue integrity and riboflavin and omega-3 fatty acid for tear production.
Omega-3 fatty acid offers an effective therapy for dry eye syndrome.5
6 Steps To Improve Dry Eye Syndrome In Celiac Disease and/or Gluten Sensitivity:
- 1Remove the Trigger (Gluten). Maintain a Strict, Nutritious Gluten Free Diet:
- Gut health is the foundation to restore ALL health. Restored health will enable you to maintain a strict gluten free diet, just as other life tasks will be easier.
- A strict gluten free diet means removing 100% of wheat, barley, rye and oats from the diet.
- Cutting out bread and other obvious sources of gluten is not good enough for recovery. Even 1/8th teaspoon of flour or bread crumb is enough to sustain the inflammation that is damaging your small intestine, causing increased permeability (leaky gut) and allowing undigested gluten to enter your body where it can damage structures and function, and instigate immune inflammatory responses.
Correct Your Individual Nutritional Needs.
- Eat foods that can replenish missing nutrients. Find them under NUTRIENT DEFICIENCIES.
- Take nutritional supplements as needed. Find them under NUTRIENT DEFICIENCIES.
Recovery. You should begin to feel better within a week and notice more energy as inflammation subsides and the absorbing cells that make up the surface lining of your small intestine are better able to function.
- Intestinal lining cells are replaced every 5 days. The healing process is like sunburn where the damaged surface layer of skin sloughs off and is replaced with new normal cells.
- Leaky gut normally resolves in two month after starting a gluten free diet and brings about a big improvement in health. Improvement in intestinal permeability precedes morphometric recovery (cell appearance and structure) of the small intestine in celiac disease.7
- The intestinal lining may take up to a year to heal.
Limit time staring at screen devices, such as computers and phones, exacerbates dry eye because it reduces blinking which reduces flushing with tears, leaving the delicate eye surface vulnerable to damage and discomfort.
Use the 20/20/20 rule as long as you view a screen device that is recommended by world-renowned dry eye expert, Dr. Donald Korb: Every 20 minutes, close your eyelids shut & then squeeze lightly for a count of 2. Open and then look 20 feet across the room for 20 seconds. This blinking action activates your distance vision & rests your eyes! Take time to look out a window or simply close your eyes.8
Yawn and squeeze the eyes which should produce a quick wash of tears.
Use hot packs once or twice a day which is the best treatment to improve tear movement of the meibomian glands in the eyelids: Run nearly hot water on a clean washcloth, wring out and lay over closed eyes. Water must not be so hot as to burn the skin over the eyelids. Cover the packs with a clean handtowel to help hold in the heat. Keep packs on eyelids for 10 minutes. Reheat as needed to keep the packs hot.
Use preservative free eye drops. Preservatives definitely aggravate dryness.
- 2 Reduce Inflammation. Foods to Eat and Foods Not to Eat:
Because gluten is inflammatory, eliminate OTHER inflammatory foods from your diet to reduce an additive effect to gluten. At the same time, try to eat foods that reduce inflammation (anti-inflammatory).
- Damaging Foods. In susceptible persons, includes corn, dairy (cow), and soy. Lactose, the sugar in any animal milk disrupts intestinal permeability causing leaky gut.9
- Allergenic Foods. Includes foods that trigger the immune sytem to produce IgE antibodies. Allergy testing is the usual way to discover these offending foods.
- Shelf Stable Processed Foods. Includes any that contain additives and preservatives. Look for them on the nutrition label of the box or package. Additives and preservatives also disrupt intestinal permeability causing leaky gut.9
- Fats. Limit deep fried foods, trans-fats, saturated fats (animal fat/butter), and EXCESSIVE omega-6 fatty acid oils like corn oil. Rancid fats, sodium caprate (a medium chain fat), and sucrose monester fatty acid (a food grade surfactant) induce significant disruption of the intestinal barrier that causes leaky gut.9.
- Excessive Refined White Flours (bran layer removed). Includes products made from them such as cookies, bread, cakes, pies. Bran contains the vitamins and minerals that metabolize grains and slows the otherwise rapid entry of sugar from their digestion into the bloodstream. Also disrupt intestinal permeability causing leaky gut.9
- Refined Sugars. Includes white sugar, corn fructose and high fructose corn syrup.
- Certain Spices. Includes paprika and cayenne pepper which disrupt intestinal permeability causing leaky gut.9
- Alcohol and Caffeine. Disrupt intestinal permeability causing leaky gut.9
- Fruits. Contain ample amounts of vitamins, minerals and phytochemicals which are naturally occuring components in plants that detoxify toxins, carcinogens (reducing the risk by 50%) and mutagens.
- Non-Starchy Vegetables. Support intestinal integrity and provide ample amounts of vitamins, minerals and phytochemicals. Includes lettuce, kale, onion, broccoli, garlic, and others.
- High Quality Complex Carbohydrates. Provide vitamins, minerals, and fiber while boosting serotonin levels to help you relax and feel calm. Includes whole grains, legumes, and root vegetables such as carrots, parsnips, sweet potatoes, turnips, red beets, and others.
- Antioxidants. Protect the body from inflammatory oxidant molecules that continually occur and help us handle stress and reduce irritability. Includes vitamin C-containing foods such as lemon, grapefruit, apricot, Brussels sprouts and strawberries, and others. Also, includes vitamin E-containing foods such as nuts, seeds, avocado, olive oil, and others. Cocoa is good, too.
- Omega-3 Fatty Acids. Balance opposing omega-6 fatty acids and bad fats. Fish sources includes tuna, salmon, cod, and others. Plants sources include flax, chia seeds, canola oil, and others.
- Probiotics. Supply normal microbes needed for colon health and health of the body such as these fermented foods: yogurt, kefir, and unpasteurized apple cider vinegar.
- Prebiotics/ High Fiber Foods. Food with fiber keeps our population of colonic microbes healthy.
- Protective Herbs and Spices. See below #6 below for examples.
- 3 Information Sheet You Can Take to Your Doctor or Other Health Professional:
- 4 Manage Your Medications Safely:
Certain prescription drugs can cause nutritional deficiencies of vitamin A along with protein and vitamin B2 (riboflavin) that increase risk for dry eye syndrome. Ask your doctor or pharmacist about this possible adverse effect if you are taking any of the drugs listed below. Do not stop prescribed medications without supervision.
This is not a complete listing.
FEMALE HORMONES disrupt intestinal permeability.
- Oral Contraceptives (Norinyl®, Ortho-Novum®, Triphasil®, and others) deplete Vitamin B2.
- Oral Estrogen/Hormone Replacement (Evista®, Prempro®, Premarin®, Estratab® and others) deplete Vitamin B2.
CHOLESTEROL DRUGS
- Colestid® and Questran® deplete Vitamin A.
ANTACIDS / ULCER MEDICATIONS
- 5Nutritional Supplements To Help Correct Deficiencies:
The type and quantity of nutritional supplements that may be needed depend on which nutrients are deficient. Supplementation with oral vitamin A in this setting is of clear benefit.4
- Multivitamin/mineral combination once a day is useful to improve overall nutrient levels. This is a safe dose, but always check with your doctor to avoid interactions with medications. Always check to be sure that the vitamin A listed as an ingredient is NOT retinyl acetate. You rather want retinyl palmitate.
- Vitamin A as retinyl palmitate, prescribed following a blood test for vitamin A status.
- Riboflavin as prescribed.
- Fish oil supplements to supply EPA and DHA omega-3 fatty acids.
Storage Note: Store container tightly sealed, away from heat, moisture and direct light to avoid loss of potency. That is, in a safe kitchen cabinet – not in the bathroom or on the kitchen table. Fish oil goes in the refrigerator.
- 6Manage Natural Remedies:
- Eight glasses of water are recommended per day unless there is a contraindication such as kidney or heart disease. The Institute of Medicine recommends approximately 2.7 liters (91 ounces) of total water, from all beverages and foods, each day for women and 3.7 liters (125 ounces) daily of total water for men.
- If you are thirsty, drink water. Add fresh, squeezed lemon to water. Lemon is anti-inflammatory, alkalizing and provides vitamin C.
- Hydration Test: Urine should be pale yellow. Fingertips should be plump, without pruning but this may not be reliable when fingers are swollen with edema. Lips should be plump, without puckering. The feeling of thirst can be unreliable.
- What is wrong with soda, coffee, tea, and alcohol? These drinks are dehydrating, increase acid, and deplete nutrients.
Carminative Food Remedies:
- Raspberry.
- Carrot is also a cleansing digestive tonic.
- Grape is also bile stimulating and a cleansing remedy for sluggish digestion and laxative.
- Redbeets also stimulate and improve digestion and are easily digested.
- Cabbage also stimulates and improves digestion and is also a liver decongestant.
- Lettuce also stimulates and improves digestion and is also an alterative, meaning it improves the function of organs involved with the digestion and excretion of waste products to bring about a gradual change.
- Potatoes are antispasmodic (due to atropine like properties) and a liver remedy.
Carminative Herb Remedies:
- Sage is also a digestive, astringent, bile stimulant and energy tonic that heals the mucosa. Drink as tea or use in cooking.
- Chamomile, lemon balm, and fennel, (as a tea) also help relieve nervous tension.
- Parsley also relieves indigestion.
- Rosemary as a tea and in cooking also is a nervous system tonic for stress and fatigue, bile stimulant, and can relieve headaches and indigestion.
- Thyme is also soothing remedy useful for stimulating digestion of rich, fatty foods.
Carminative Spice Remedies:
- Cloves are also antispasmodic.
- Nutmeg is also useful for indigestion.
- Ginger.
Exercise improves circulation and rids the body of toxins.
- Walking is aerobic exercise that reconditions the whole body to improve stamina. Read more about Exercise and Fitness.
- Weight training builds muscle. Read more about Exercise and Fitness.
- Stretching improves flexibilty. Read more about Exercise and Fitness.
Note: Exercise is important, but the amount and type of exercise undertaken depends on your health. Your first priority is to heal.
What Do Medical Research Studies Tell About Chronic Dry Eye Syndrome In Celiac Disease and/or Gluten Sensitivity?
RESEARCH STUDY SUMMARIES
“Omega-3 essential fatty acids therapy for dry eye syndrome: a meta-analysis of randomized controlled studies. “ This study aimed to use meta-analysis to compare omega-3 fatty acid and placebo fatty acid in the management of dry eye syndrome. Based on the data included in this meta-analysis, omega-3 fatty acid was associated with better tear break-up time (TBUT) and Schirmer’s tear test. No significant differences were detected in OSDI test results. “Consequently, our findings suggest that omega-3 fatty acid offers is an effective therapy for dry eye syndrome.”
Comparative studies published until 1 June 2014 were searched through a comprehensive search of the Medline, Embase, Web of Science, and the Cochrane Library electronic databases. A systematic review and cumulative analysis of comparative studies reporting the effect of omega-3 fatty acid on dry eye syndrome was conducted. All analyses were performed using the Review Manager (RevMan) v.5 software (Nordic Cochrane Centre, Copenhagen, Denmark).
The trials involved a total of 790 participants in 7 independent studies. All the studies are published between 2007 and 2013. Meta-analysis of the 5 studies that reported data in mean SD values revealed that the tear break-up time (TBUT) was significantly greater by 1.58 s (WMD=1.58, 95% CI=0.60 to 2.55; P=0.007). Combination of all the Schirmer’s test data showed that omega-3 fatty acid supplementation could significantly improve the Schirmer’s test (WMD=0.74, 95% CI=0.29 to 1.19; P=0.001). However, the combination of all the OSDI (Ocular Surface Disease Index ) test data showed that omega-3 fatty acid supplementation did not significantly improve the OSDI test results (WMD=-4.54, 95% CI=-9.85 to 0.78; P=0.09).5
“Vitamin and mineral deficiencies are highly prevalent in newly diagnosed celiac disease patients.” This study investigating the nutritional and vitamin/mineral status of current “early diagnosed” untreated adult celiac disease patients in the Netherlands found that vitamin/mineral deficiencies are still common in newly “early diagnosed” celiac disease patients.
Eighty newly diagnosed adult celiac disease patients were included and a comparable sample of 24 healthy Dutch subjects was added to compare vitamin concentrations. Nutritional status and serum concentrations of folic acid, vitamin A, B6, B12, and (25-hydroxy) D, zinc, haemoglobin (Hb) and ferritin were determined (before prescribing gluten free diet). Almost all CD-patients (87%) had at least one value below the lower limit of reference. Specifically, for vitamin A, 7.5% of patients showed deficient levels. Vitamin/mineral deficiencies were counter-intuitively not associated with a (higher) grade of histological intestinal damage or (impaired) nutritional status. Extensive nutritional assessments seem warranted to guide nutritional advices and follow-up in treatment of celiac disease.10
“Oleñik A, Jiménez-Alfaro I, Alejandre-Alba N, Mahillo-Fernández I. A randomized, double-masked study to evaluate the effect of omega-3 fatty acids supplementation in meibomian gland dysfunction.” This study investigating the effectiveness of omega-3 fatty acids versus placebo (sunflower oil capsules), in improving the symptoms and signs of meibomian gland dysfunction (MGD) found that oral omega-3 fatty acids, 1.5 grams per day, may be beneficial in the treatment of MGD, mainly by improving tear stability.
This randomized and double-mask trial of 3 months duration enrolled 61 patients of both sexes who presented with symptomatic MGD and no tear instability (defined as tear breakup time [TBUT] less than 10 seconds). Participants were randomly assigned to group A or Group B. For patients in group A, the study treatment included cleaning the lid margins with neutral baby shampoo and use of artificial tears without preservatives, plus a placebo capsule.
For patients in group B, the study treatment included cleaning the lid margins with neutral baby shampoo and use of artificial tears without preservatives, plus oral supplementation with omega-3 fatty acids. The supplement was based on omega-3, vitamins, glutathione, amino acids, and oligoelements in a combined nutraceutical formulation and contained (per capsule) docosahexaenoic acid (350 mg), eicosapentaenoic acid (42.5 mg), docosapentaenoic acid (30 mg), vitamin A (133.3 μg), vitamin C (26.7 mg), vitamin E (4 mg), tyrosine (10.8 mg), cysteine (5.83 mg), glutathione (2 mg), zinc (1.6 mg), copper (0.16 mg), manganese (0.33 mg), and selenium (9.17 μg).
After 3 months of evaluation, TBUT, lid margin inflammation, and MG expression (quality of meibomian oil) presented improvement from the baseline values, in group B. Lid inflammation was decreased significantly compared with baseline, at each follow-up. In the control group (group A), the TBUT did not change significantly from baseline.
The Schirmer test results were also improved and statistically significant.11
“The role of omega-3 dietary supplementation in blepharitis and meibomian gland dysfunction.” This study investigating the effect on ocular symptoms, ocular findings, and serum and meibomian gland contents in patients with blepharitis and meibomian gland dysfunction (MGD) found that diet improves these conditions. This is the first demonstration of an induced change in the fatty acid saturation content in meibum produced by meibomian glands as a result of dietary supplementation with omega-3 fatty acids.
In a prospective randomized placebo-controlled masked trial, patients with simple obstructive MGD and blepharitis, who had discontinued all topical medications and tetracyclines, received oral omega-3 dietary supplementation consisting of two 1000-mg capsules 3 times a day. Patients were examined every 3 months for 1 year with the Ocular Surface Disease Index (OSDI) objective clinical measures, including tear production and stability, ocular surface and meibomian gland health, and biochemical plasma, red blood cell (RBC), and meibum evaluation. Primary outcome measures were change in tear breakup time (TBUT), meibum score, and overall OSDI score at 1 year.
At 1 year, the omega-3 group had a 36% and 31% reduction in their omega-6 to omega-3 fatty acid ratios in RBCs and plasma, respectively, whereas the placebo group demonstrated no change. At 12 months, the omega-3 group had an improvement in TBUT, OSDI score, and meibum score. Changes in meibum content were observed in the omega-3 group; the level of meibum saturated fatty acids decreased.
This trial demonstrated a decrease in the RBC and plasma ratios of omega-6 to omega-3 in patients taking omega-3 dietary supplementation, as compared to controls, and improvements in their overall OSDI score, TBUT, and meibum score. This is the first demonstration of an induced change in the fatty acid saturation content in meibum as a result of dietary supplementation with omega-3 fatty acids.12
- Liu A, Ji J. Omega-3 essential fatty acids therapy for dry eye syndrome: a meta-analysis of randomized controlled studies. Med Sci Monit. 2014 Sep 6;20:1583-9. doi: 10.12659/MSM.891364. [↩]
- Oleñik A, Jiménez-Alfaro I, Alejandre-Alba N, Mahillo-Fernández I. A randomized, double-masked study to evaluate the effect of omega-3 fatty acids supplementation in meibomian gland dysfunction. Clin Interv Aging. 2013;8:1133-8. doi: 10.2147/CIA.S48955. Epub 2013 Aug 30. [↩] [↩]
- Rethinking Meibomian Gland Dysfunction: How to Spot It, Stage It and Treat It. Linda Roach, PhD. OPHTHALMIC PEARLS. [↩]
- Jalbert I. Diet, nutraceuticals and the tear film. Exp Eye Res. 2013 Dec;117:138-46. doi: 10.1016/j.exer.2013.08.016. Epub 2013 Sep 3. [↩] [↩]
- Liu A, Ji J. Omega-3 essential fatty acids therapy for dry eye syndrome: a meta-analysis of randomized controlled studies. Med Sci Monit. 2014 Sep 6;20:1583-9. doi: 10.12659/MSM.891364. [↩] [↩] [↩]
- Wierdsma NJ, van Bokhorst-de van der Schueren MA, Berkenpas M, Mulder CJ, van Bodegraven AA. Vitamin and mineral deficiencies are highly prevalent in newly diagnosed celiac disease patients. Nutrients. 2013 Sep 30;5(10):3975-92. doi: 10.3390/nu5103975. [↩]
- Cummins AG, Thompson FM, Butler RN, et al. Improvement in intestinal permeability precedes morphometric recovery of the small intestine in coeliac disease. Clinical Science. Apr 2001;100(4):379-86. [↩]
- http://www.thinkblink.it/think-blink-pamphlet-instructions.htm [↩]
- Farhadi A, Banan A, Fields J, Keshavarzian A. Intestinal barrier: an interface between health and disease. Journal of Gastroenterology and Hepatology. 2003;18:479-91. [↩] [↩] [↩] [↩] [↩] [↩]
- Wierdsma NJ, van Bokhorst-de van der Schueren MA, Berkenpas M, Mulder CJ, van Bodegraven AA. Vitamin and mineral deficiencies are highly prevalent in newly diagnosed celiac disease patients. Nutrients. 2013 Sep 30;5(10):3975-92. doi: 10.3390/nu5103975. [↩]
- Oleñik A, Jiménez-Alfaro I, Alejandre-Alba N, Mahillo-Fernández I. A randomized, double-masked study to evaluate the effect of omega-3 fatty acids supplementation in meibomian gland dysfunction. Clin Interv Aging. 2013;8:1133-8. doi: 10.2147/CIA.S48955. Epub 2013 Aug 30. [↩]
- Macsai MS. The role of omega-3 dietary supplementation in blepharitis and meibomian gland dysfunction (an AOS thesis). Trans Am Ophthalmol Soc. 2008;106:336-56. [↩]
