LONG GONE FOR MANY OF your patients are the days when they could stay up all night, eat whatever junk food presented itself, and still function well. Instead, as older individuals, they need to eat a balanced diet, get enough sleep, and care much better for themselves than in their younger days. Over 40, we just don’t quite have the functional reserves we once had.

In this article, I’ll explore what I call the “five pillars of wellness” and how to stave off age-related decreases in visual physiologic reserve. These five pillars are hydration, nutrition, sleep hygiene, exercise, and mindfulness. Good science supports the wisdom of each of these pillars. As a physician, you can help your patients, including presbyopic patients, by understanding the science around these five pillars for optimizing visual performance.

Hydration

Maintaining adequate hydration remains a key not only to overall well-being but also to eye health. For instance, in 2012, researchers investigated whether whole-body hydration played a role in dry eye disease (DED). Using a hospital-based design, they found that individuals classified as having DED had higher plasma osmolality, indicating suboptimal hydration, compared with non-DED individuals. “The present findings,” the authors write, “showing suboptimal whole-body hydration in DED versus non-DED individuals raise the exciting prospect that improving whole-body hydration with fluid intervention might confer important therapeutic effects for patients with DED.”¹

Nutrition

In considering the pillar of nutrition, your patient’s eye health may benefit from an anti-inflammatory diet and one high in antioxidants. For instance, one study found that oral antioxidant supplementation may increase tear production and improve tear film stability by reducing reactive oxygen species formed by oxidative stresses on the ocular surface. The antioxidant supplement, said the researchers, could be used as an adjuvant therapy to conventional artificial tear therapy for patients with DED.²

In my practice, we advise antioxidant-rich foods to our patients and adherence to the Whole30 nutrition plan, which is a powerful way for patients to identify the foods that may be contributing to their gut, brain, and ocular inflammation. The typical offenders are gluten and dairy. We also stress supplementation with omega fatty acids and quality multivitamins.

Also of interest was a literature review gauging the effectiveness of antioxidant therapies in reducing the incidence of cataract formation.³ The results of the analysis, write the authors, tend to confirm the belief that nutrients, provided as a part of food, were superior to mononutrient-type supplements to prevent and delay cataract disease. “In general, the literature suggests diets high in fruit and vegetables, Vitamin C, zeaxanthin, lutein and multivitamin-mineral supplements are associated with lower disease rates, while supplemental forms of selenium and Vitamin E had little effect,” the authors write. Antioxidants help neutralize the reactive oxygen species that may contribute to the formation of disulfide bonds in cataracts, according to one study.⁴

A review article in the International Journal of Ophthalmology notes that the main changes in the lens that occur with aging are reduced diffusion of water; crystalline changes due to the accumulation of high molecular weight aggregates and insoluble proteins; and production of advanced glycation end products, lipid accumulation, reduction of reduced glutathione content, and destruction of ascorbic acid. The authors note that, even if effective strategies in preventing cataract onset are not already known, good results have been reached in some cases with oral administration of antioxidant substances.⁵ Topical lipoic acid therapy that addresses the disulfide bonds are in phase 2 clinical development.⁴

In another study, the authors discuss the potential benefit of flavonoids for cataract prevention. They note that it’s important to identify novel compounds with antioxidant effects that could modulate molecular targets and prevent cataract formation.⁶

Additionally, they say, compounds that can inhibit the expression of matrix metalloproteinases (MMPs) may help to maintain the integrity of the extracellular matrix and avoid further damage that could lead to cataracts. In this regard, they say, plant-derived polyphenols, particularly flavonoids, have received attention.⁶

“This review,” the authors write, “provides evidence and strongly supports the use of flavonoid supplements that may increase Nrf2 [factor-erythroid-2-related factor 2] activity and attenuate MMP-9 expression, which may be new targets to prevent or slow the lens’s cataract progression.”⁶

Sleep Hygiene

When it comes to sleep hygiene, we suspect that, for DED patients, it’s a two-way street: DED patients have poor-quality sleep, and poor-quality sleep is associated with DED.

Two studies provide significant evidence for the association between poor sleep and DED. In 2011, a survey was conducted among all the employees, mainly young and middle-aged Japanese office workers, who used visual display technology at a company in Osaka, Japan. Some 45% of the DED participants reported having poor sleep quality, while 34% of the no DED disease participants did so.⁷

In a more recent study, researchers in the Netherlands assessed more than 71,000 participants for DED and sleep quality. Overall, 8.9% of the participants had DED. Of these, 36.4% had poor sleep quality compared to 24.8% of controls. The researchers concluded that all components of sleep quality were significantly reduced in participants with DED, even after correcting for comorbidities.⁸

You’ll want to screen patients for sleep apnea on review of systems. If you see temporal upper eyelid lash ptosis, excess laxity, or papillary conjunctivitis in the upper conjunctiva, think floppy eyelid syndrome, which is highly correlated with obstructive sleep apnea. Some guidelines I offer my patients for good sleep hygiene include eliminating screen time before bed (to reduce the negative impacts of excess light before sleep via the pineal gland and circadian rhythms) and making sure the room is dark or wearing a dark silicone sleeping mask. Another sleep optimizing tip: making sure the feet are warm before bedtime can help to speed the onset of sleep.

Exercise

No doubt your patients have heard repeatedly about the benefits of exercise, but they may not know that exercise can help eye health. For instance, using the same cohort of office workers in Japan as was studied for DED, findings suggested that a lower level of physical activity and sedentary behavior were associated with DED.⁹ Specifically, participants with abnormal tear break-up time (TBUT) were involved in sedentary behavior for significantly longer duration than those with normal TBUT. Non-DED participants (14.5%) tended to have higher levels of physical activity than definite DED participants (2.5%). Participants with definite DED had significantly lower metabolic equivalents scores than those with non-DED.⁹

Mindfulness

In a world growing seemingly more stressful each day, finding ways to calm the mind, regulate the nervous system, and relax the body can promote mental health, physical health, and eye health. For instance, abdominal breathing was found to increase tear meniscus volume in healthy women, according to one report. In a small study of 20 women, one group breathed normally for 3 minutes while the other performed abdominal breathing for 3 minutes. After the abdominal breathing, tear meniscus volume greatly increased 15 minutes after breathing. The authors conclude that abdominal breathing may be considered among strategy recommendations for DED patients.¹⁰

Similarly, in a study on glaucoma, researchers studied a mindfulness meditation group that practiced meditation for 21 days. Between-group comparisons revealed significantly lowered intraocular pressure (IOP) in meditators, which correlated with significantly lowered stress-biomarker levels. “Mindfulness meditation can be recommended as adjunctive therapy for POAG,” the authors write.¹¹

You can help your patients with mindfulness by advising them to perform square breathing, also known as box breathing. This involves breathing in for 4 seconds; holding the breath for 4 seconds; breathing out for 4 seconds; holding for 4 seconds; and repeating. They should perform this breathing technique while pushing the crown of the head straight up with a neutral head position, which corrects all 5 curves of the spine.

Conclusion

Helping your patients understand and act in accordance with the five pillars of wellness can help to ensure optimization of eye health and whole body health for life. ■

References

1. Walsh NP, Fortes MB, Raymond-Barker P, et al. Is whole-body hydration an important consideration in dry eye? Invest Ophthalmol Vis Sci. 2012;53(10):6622-6627.
2. Huang JY, Yeh PT, Hou TC. A randomized, double-blind, placebo-controlled study of oral antioxidant supplement therapy in patients with dry eye syndrome. Clin Ophthalmol. 2016;10:813-820.
3. Braakhui AJ, Donaldson CI, Lim JC, Donaldson PJ. Nutritional strategies to prevent lens cataract: current status and future strategies. Nutrients. 2019;11(5):1186.
4. Korenfeld MS, Robertson SM, Stein JM, et al. Topical lipoic acid choline ester eye drop for improvement of near visual acuity in subjects with presbyopia: a safety and preliminary efficacy trial. Eye. 2021;35(12), 3292-3301.
5. Pescosolido N, Barbato A, Giannotti R, Komaiha C, Lenarduzzi F. Age-related changes in the kinetics of human lenses: prevention of the cataract. Int J Ophthalmol. 2016;9(10):1506-1517.
6. Hilliard A, Mendonca P, Russell TD, Soliman KFA. The protective effects of flavonoids in cataract formation through the activation of Nrf2 and the inhibition of MMP-9. Nutrients. 2020;12(12):3651.
7. Kawashima M, Uchino M, Yokoi N, et al. The association between dry eye disease and physical activity as well as sedentary behavior: results from the Osaka Study. J Ophthalmol, 2014;2014:943786.
8. Magno MS, Utheim TP, Snieder H, Hammond CJ, Vehof J. The relationship between dry eye and sleep quality. Ocular Surf. 2021;20:13-19.
9. Kawashima M, Uchino M, Yokoi N, et al. The association of sleep quality with dry eye disease: the Osaka study. Clin Ophthalmol. 2016;10:1015-1021.
10. Sano K, Kawashima M, Ikeura K, Arita R, Tsubota K. Abdominal breathing increases tear secretion in healthy women. Ocul Surf. 2015;13(1):82-87.
11. Dada T, Mittal D, Mohanty K, et al. Mindfulness meditation reduces intraocular pressure, lowers stress biomarkers and modulates gene expression in glaucoma: a randomized controlled trial. J Glaucoma. 2018;27(12):1061-1067.

Dr. Periman is founder and director of dry eye services and clinical research at Periman Eye Institute in Seattle. She is a cornea and refractive surgery fellowship-trained physician and surgeon with roots as a molecular biologist.

Disclosures
The authors have no relevant disclosures.