Background to this website

I am an Ophthalmologist (eye surgeon and eye physician). For me this has meant 6 years training as a medical doctor, 3 years working in different specialty areas as a junior doctor, 4 years training as an eye specialist, 1 year subspecialising in ocular inflammation, anterior segment surgery and oculoplastics, and some extra time after qualifying devoted to immunology, glaucoma, and other areas which especially interest me.

Having studied Western Medicine, I am trained to think critically, rely as far as possible on peer reviewed and evidence-based information, and apply a healthy dose of scepticism before adopting a belief or practice. I recognise that Big Pharma, the rampant and unregulated Natural Health Industry and the food industry, all have vested interests in winning the support of myself and my patients.

Almost every disease has a manifestation in the eye so general health is really important to eye health. Before resorting to the use of western medicine or surgery, I prefer to know that my patients are doing as much as they are able, to manage their eye problems with a healthy lifestyle. I would rather they tweak their diet and lifestyle in as inexpensive a manner as possible, than resort to expensive supplements and remedies. As a time-poor professional, mother and wife, I also understand how busy people are, and try not to recommend any diet or intervention that I am not already doing / able to do in my own life.

If a condition is sight threatening or there is no alternative, I will advise medical treatment that is as efficacious, cost-effective and has as few side effects as possible. I have kept this website concise enough that you can read it from top to bottom. You can also click on these headings to go to a specific topic.

Other links which may be helpful:

Inflammation and the eye

A short explanation of immunity and inflammation: Why me and why NOW?

The immune system is constantly evolving throughout life.

At birth we are protected by the innate immune system which responds quickly to danger. We also initially rely on maternal antibodies passed over the placenta and through the breast milk.

During childhood the adaptive immune system recognises specific threats by developing a specific antibody repertoire. In people with overactive or poorly regulated innate immunity, certain triggers can result in allergy or later acne or rosacea.

In adulthood the thymus gland loses its ability to develop adequate new antibody responses and many people start to experience compensatory overactive innate responses to minor dangers. Allergies and rosacea may become easier to trigger. Newly acquired infections like chickenpox or glandular fever are much more severe if acquired in adulthood because of the body’s limited adaptive immunity (inability to generate a quick effective antibody response) and also to regulate its overactive innate response.

In late adulthood adaptive immunity is very limited. Antibody related responses decline and reactivation of dormant viruses occurs. The chicken pox virus leads to shingles. This is partially preventable with high strength vaccine boosters. Debris (known in geriatric immunology as garbage) accumulated as a result of aging, builds up. The body has to rely on its innate immune system to clean up and this results in activation of the inflammosome. This highly inflammatory response is known as inflammaging. It leads to damage of vital body structures like the eye and brain. Drusen in the retina are an example of garbage and the inflammaging in response to such debris leads to age related macular degeneration.

Some people are genetically predisposed to develop certain types of inflammation. If one inflammatory pathway is blocked by drugs, another will sometimes take over. For these people, lifestyle modification is particularly important. Even with the best diet and lifestyle, factors such as stress, environment and infection can trigger episodes of inflammation. If this is severe enough, initiation of medical treatment or a change in treatment may be needed.

What can be done about inflammation without using drugs?

Regulating immunity and inflammation

The reality for more than 10% of people is that they may not have perfect regulation of innate immunity and even worse, some may develop autoimmunity where their adaptive immune system mistakenly attacks their own body. These people may need medical treatment to dampen the inflammation or to suppress the immune system. For a whole variety of reasons including worries about dependence, suspicion of the motives of “Big Pharma”, being in denial about the seriousness of their condition and concern about side effects, people prefer not to take “drugs” or “Western Medicine”. It is important to remember that much Western Medicine is based on refinement of natural remedies to give acceptably safe and effective doses and evidence-based outcomes with minimal / known side effects, at prices, to some extent regulated by government oversight. Alternative / natural therapies are also drugs (just ones derived from nature). They can be very expensive, deserve equal “Big Pharma / Big Business” scrutiny, are poorly regulated and have variable active doses with limited evidence base, as well as side effects which may be just as bad as those of conventional therapies. Whatever your level of cynicism towards either route of therapy, the good news is that there are many evidence-based lifestyle measures that can help reduce the body’s overactive innate immune response:

Weight control

Note that this is NUMBER 1 on my list

Abdominal visceral fat is a potent trigger for inflammation. Type II diabetes, especially when linked to excess weight, is strongly associated with inflammation in most of the body’s systems including the eye, brain, cardiovascular and musculoskeletal system. In psoriasis and psoriatic arthritis, being overweight is linked to worse disease which is more difficult to control. The metabolic syndrome associated with being overweight, has been closely linked to blepharitis (inflammation of the eyelid margin). Losing weight can make a great difference in all of these settings. The massive health benefits of losing weight have been very obvious to me in some of my patients who have lost weight and subsequently needed fewer immunosuppressive drugs to control their serious conditions like psoriatic arthritis and uveitis. Dry eye related inflammation on the eye surface which has been severe enough to require antibiotics, steroids, hourly lubricant drops and punctual plugs has also dramatically improved following weight loss: Positive benefits have included no more need for antibiotics, steroids or punctual plugs as well as reduced requirement for lubricants.

Insulin resistance

Insulin and Insulin like growth factor (IGF) are elevated in metabolic syndrome, type II diabetes and simply by being overweight. Intermittent fasting can improve insulin sensitivity and reduce IGF levels, helping to control inflammation. If you wish to read about fasting, Dr Michael Mosely, who trained as a medical doctor and is now a health advocate and writer, is constantly updating our understanding of this subject as the evidence becomes available. Consuming one’s entire daily intake within a 10-hour period (i.e. 14 hour overnight fast) is a way of benefiting from fasting without feeling starved. Intermittent fasting has been shown to reduce inflammatory markers and symptoms in psoriatic arthritis and other related inflammatory problems. Almost anybody can safely try intermittent fasting but if you are a diabetic on insulin it is important to seek advice from your doctor on managing your blood sugar levels during fasting.

Avoid or stop smoking

Smoking is one of the most powerful triggers for inflammation and scarring. Everybody knows about the risk of cancer, the wrinkly aged looking skin, and the raspy smokers’ cough. The eye is just as severely affected: Inflammation on the eye surface that can be triggered by dry eye is significantly worsened by smoking. Thyroid associated ophthalmopathy or thyroid eye disease is more severe and rapidly progressive, even sight threatening, in smokers. In families with genetic risk factors for macular degeneration it is the smokers who lose their vision first. Smoking leaves the body unable to control the inflammation triggered by the products of aging which accumulate in the macula. People with dry eye, Graves disease or risk of macular degeneration should avoid even second-hand smoke.

Exercise

Exercise can help with weight loss to a limited extent although the mainstay of losing weight is reduced caloric intake. More important aspects of exercise are its role in improving insulin sensitivity, reducing inflammation and generating muscle. Well exercised muscles produce nerve growth factors which are protective against degenerative diseases such as glaucoma and dementia. At least an hour of activity every day is healthy and the aim should be to build up to moderate and, if possible, high intensity exercise in order to develop and maintain muscle. People with cardiovascular risk should do this under supervision.

Healthy Omega-3 to Omega-6 ratio

The majority of oils consumed in a typical diet can be broadly classified into Omega-3 and Omega-6 fatty acids. The metabolites of Omega-6 fatty acids tend to drive inflammation whereas those of Omega-3 fatty acids are predominantly anti-inflammatory. Epidemiologic observations suggest that diets high in omega-3 fatty acids may have health benefits: The Norwegians who consume salmon as a staple, live significantly longer than the Danes whose diet is far richer in dairy products and meat. The traditional Japanese who also have an abundance of seafood in their diet are noted for their longevity. Findings such as these have led to decades of research into the role of omega-3 fatty acids in the health of many organ systems. There are so many factors which could be involved but it is relatively easy to test consumption of omega-3 fatty acids by supplementing fish oil in clinical studies. Unfortunately, studies looking at fish oil supplementation have failed to show significant benefit in cardiovascular disease, macular degeneration or dry eye. The reality is that it is unlikely to be only oil from the fish which has offered the benefit seen in population studies. Other nutrients in fish may play a role. Equally important may be the fact that intake of unhealthy omega-6 oils is reduced. Some studies suggest that it is helpful to consume both animal and non-animal sources of omega-3 oils when managing dry eye. Omega-3 fatty acids are found in oily fish (such as tuna, salmon, mackerel, sardines, hiramasa, herring, tailor) and seeds such as chia, linseed/flaxseed, hemp seeds, walnuts and pepitas. (Omega-6 oils, the ones to limit, are found in meat and dairy fats)

Omega-3 and Macular Degeneration

Macular degeneration: Several studies have shown that fish consumption is associated with reduced risk of visual loss from Age Related Macular Degeneration. One found that consuming fish 4 times a week and, in particular canned tuna at least once a week, significantly reduced the risk of visual loss from macular degeneration. Another found that consuming oily fish at least once a week halved the chance of developing wet macular degeneration. omega-3 fatty acid supplementation was trailed in an arm of the AREDS study, no protective effect was found. This suggests either that there is something else about the fish that has a protective effect,or that it is the unhealthy foods replaced by the fish that are predisposing to visual loss from macular degeneration.

Omega-3 and Dry Eye

There are two broad groups of dry eye, both of which trigger inflammation on the surface of the eye: evaporative (the commonest, caused by break-up of the oil layer covering the tears), and tear deficient (in which there is reduced tear production). Several studies suggest that omega-3 supplementation improves the measured quality of the tear film but this does not always correlate with improved symptoms. Unfortunately, scant information exists on the role of dietary intake of omega-3 fatty acids in managing dry eye. Given that dry eye is strongly linked to ocular surface inflammation, it makes sense to attempt to consume more anti-inflammatory omega-3 fatty acids and fewer inflammatory omega-6 fatty acids.

Fibre, colour and good bugs:

During childhood a substantial proportion of the gut microbiome consists of bacteria from the Bacteroidetes group. These thrive on soluble fibre (indigestible gel like carbohydrates from vegetables and seeds). They are associated with a reduced inflammatory drive. During aging, particularly if soluble fibre intake is inadequate the gut microbial population is dominated by Firmicutes group bacteria which are thought to drive inflammation. Dietary pre and probiotics as well as diverse food intake may help to maintain the beneficial microbial diversity characteristic of the younger gut.

Despite much hype and promotion by health websites and natural medicine practitioners, we do not yet have adequate understanding of individual microbiomes to be able to recommend specific bacterial supplements or probiotics. Certain lactobacillus varieties appear to reduce inflammation. This effect is still possible even when lactobacilli are dead. Most do not manage to colonise the gut and have to be consumed regularly in order to exert their beneficial effects. Some varieties such as lactobacillus rhamnosus (found in filmjölk) are able to survive the acidity of the stomach, adhere to the gut mucous layer and have the potential for more lasting benefit. At this stage, a reasonable approach is to try and include these lactobacilli in the diet through consumption of fermented products such as yogurt, kefir, filmjölk, sauerkraut and kimchi. Spending large amounts of money on commercial probiotic supplements is hard to justify unless an individual finds a very clear benefit.

Berries and foods with naturally bright or dark colours are rich in flavonoids. Along with the bacteria that live on soluble fibre, flavonoids can increase the activity of T regulatory cells. These cells can help control the more damaging players in the immune system which are responsible for inflammation.

Turmeric

This spice comes in several varieties, all of which contain curcuminoids, the anti-inflammatory group of yellow compounds which give it its beautiful colour. Turmeric has been used as a traditional medicine to treat many types inflammation including arthritis and colitis. Curcuminoids found in Turmeric are undergoing randomised trials and are showing promise in the prevention and management of Alzheimer’s type dementia.

Turmeric is safe and has almost no known side effects. Caution is advised for people who have previously suffered from biliary colic. Its active components are oil soluble and are best absorbed as part of the turmeric spice (which contains turmeric oil) or in food containing some oil. Black pepper reduces the elimination of turmeric and can increase its efficacy.

Turmeric and Eye inflammation

A prospective non-randomised European trial which recruited 106 patients with recurrent anterior uveitis of various causes has found that Curcumin, one of the active components of Turmeric, reduced the recurrence rate and severity of attacks of uveitis. (The preparation used was twice daily Meriva, a curcumin-phospholipid complex marketed in Europe and the USA as Norflo). A prospective randomised placebo-controlled trial has been approved to run at the Bascom Palmer Institute (USA). This trial will specifically look at the preparation’s efficacy in preventing recurrence of HLA B27 acute anterior uveitis.

Given turmeric’s safety and the positive benefits of curcumin and the other curcuminoids contained in this spice, it seems worth including it in a healthy anti-inflammatory diet. I sometimes use turmeric powder but when they’re available, I buy whole fresh roots from my local supermarket, food process them and freeze them. I always double the amount suggested in recipes. I make sure I add plenty of black pepper if it’s a spicy recipe or some full fat yogurt in a non-spicy recipe.

Vitamin D:

In addition to its known role in bone health, vitamin D has important effects on the immune system. Vitamin D metabolism is extremely complex and we still do not understand it fully. Evidence suggests that most people benefit from maintaining levels above those required for bone health. When blood vitamin D levels are high (e.g. above 75ng/ml), the immune system is better able to fight off infections such as tuberculosis. High levels also reduce allergy related inflammation such as asthma. Low levels (e.g. below 50ng/ml) are associated with asthma that is more difficult to control, increased risk of multiple sclerosis and some cancers. People often present with iritis at the end of winter when their vitamin D levels are low. In general it is a good idea to maintain vitamin D levels near the upper limit of normal. An important exception is rosacea as high levels of vitamin D activate an antimicrobial peptide called cathelicidin. This molecule can trigger skin and eye inflammation in rosacea.

An Ophthalmologists understanding and views on diets relevant to people managing inflammation

It has been proven experimentally that proteins help you feel full longer than carbs (carbohydrates) or water. Ketosis from high fat diets with very low carbs can suppress appetite. Diets such as Atkins, Paleo and Keto make use of these principles. Studies show that it is possible to lose weight when following a high protein, high fat or high carb diet. In fact, it is possible to lose weight on any diet, as long as caloric intake is low enough. Unfortunately, animal fats (other than fish) and proteins as well as unknown factors associated with red meat are linked to increased inflammatory drive, increased risk of cancers and shorter life expectancy. People who lived during the paleolithic period had very short life spans and their lifestyle would not be one on which to model ours. Any diet that excludes food groups or types can lead to an imbalance in major or micronutrients Restrictive diets are best avoided except as part of a planned exclusion diet to determine true sensitivities or because of a proven medical condition. They are best undertaken with nutritional, dietetic or medical supervision. I commonly encounter people who have put themselves on socially restrictive and often expensive exclusion diets e.g:

With these ideas in mind, choosing a moderately high protein diet is still a good idea but the protein should come from legumes, nuts, fish and lean flesh with limited red meat intake. Fat intake should be predominantly omega-3, rather than omega-6 unsaturated oils with as little trans-fat content as possible. Carbohydrates should come from low glycaemic index (GI) sources such as non-starchy vegetables and legumes. Vegetable based diets are higher in fibre which sustains an anti-inflammatory gut flora and allows lower caloric intake per volume consumed. These concepts more closely fit with Mediterranean and Okinawan type diets, both of which are associated with longevity. Diets high in non-starchy vegetables and colourful vegetables and berries promote bacteria in the gut associated with lower weight and lower inflammatory drive.

If consuming fruit, it is important to select less sweet fruit (such as berries) and limit intake to 2 servings a day, as high fruit sugar (fructose) intake promotes the development of fatty liver (hepatosteatosis). Fruit juice intake should be limited as fruit juices are high in fructose and low in fibre.

When sweetness is needed, artificial sweeteners are best avoided as they stimulate the same receptors as natural sugar and can increase sugar craving and may also activate the same inflammatory pathways as real sugar. Cane sugar sweetness is made up of sweetness from glucose and that of fructose and hence has half the amount of fructose as fruit derived sweetness. If you are somebody who likes their tea or coffee a bit sweet, you could give lactose free milk a try. It tastes much sweeter than ordinary milk as the lactose sugar has been enzymatically broken down into a much smaller sugar, galactose which has a sweeter taste. Adding fruit, honey, maple syrup or other syrups to recipes for sweetness instead of cane sugar makes them more interesting or tasty but the sweetness itself is still unhealthy. Diversity is very important as a varied diet promotes survival of a diverse gut microbiome. It has been shown that people with Sjogren’s type severe dry eye with ocular surface inflammation have reduced gut biodiversity. This may be partly immunologically mediated but can also happen because of antibiotic intake or because of restrictive diet and this last risk factor is the one over which an individual has most control.

In summary, good dietary practices for reducing inflammation are:

  1. A 14-hour gap between the last meal / snack of the day and the first meal the next day
  2. Low calorie intake
  3. Limited sweet fruit and other sources of sweetness
  4. Low to moderate fat consumption, sticking to more omega-3 and less omega-6 and trans (unsaturated) fats
  5. Moderate intake of low glycaemic index (GI) whole food carbohydrates such as pulses, seeds and some grains
  6. Moderate protein intake, particularly from legumes, nuts and fish with some eggs (and, if you like meat, lean antibiotic free meat)
  7. High vegetable intake (especially non-starchy vegetables)
  8. High diversity vegetable intake - plenty of colour (especially dark green and yellow for macular health, but also all the other colours which are associated with antioxidant benefits , promotion of good Bacteroidetes bacteria in the gut and increased activity of T regulatory cells.)

Taking medicine to manage eye inflammation:

Many types of inflammation of the eye and ocular surface can be managed with sustained lifestyle changes. Inflammatory conditions tend to wax and wane with life events such as stress, infection and environment. Flares may require stronger treatment such as steroid drops.

Unfortunately some eye conditions can be sight threatening and immunomodulatory treatment is needed. It can be very daunting to be advised to take medication which is also used in transplantation or chemotherapy, particularly after reading the long list of possible side effects. While it may be tempting to try as many “natural” options as possible, it is important not to delay treatment until irreversible damage has occurred. Many medical options such as cyclosporine and mycophenolate come from natural sources but have undergone enough testing that we have an excellent understanding of safe dosing and which conditions respond best to them. Thanks to advances in diagnostic technology and rapidly dissemination of information it is now possible to diagnose even rare diseases. International collaboration means we are able to pool our experience to provide better advice. If you have a sight threatening condition, it is still a good idea to do all you can in your lifestyle to reduce your body’s inflammatory drive. This may reduce your need for strong medicines and improve your chances of a remission.

Up to date information written by ophthalmologists:

The American Academy of Ophthalmology offers eyewiki which is peer reviewed, evidence based and open to the medical community as well as the general public. The articles are easier to understand if you have a medical or scientific background. If you are prone to anxiety / thinking the worst about your condition you may prefer to discuss it with your ophthalmologist before consulting eyewiki. https://eyewiki.aao.org/Main_Page

Support:

Most types of eye inflammation are rare enough that it is hard to find a good support group but there are a few good ones. These links might be helpful if you have a relevant condition:

Birdshot chorioretinopathy: https://birdshot.org.uk

Sarcoidosis: https://www.sarcoidosisuk.org/information-hub

Rosacea: https://www.rosacea.org/patients/information

You might find it useful to read:

Dr Michael Mosely’s books: including The Fast 800 diet, the Clever Guts Diet and an older book The 5:2 Diet

If you like reading scientific studies, reviews and analyses you might find these interesting:

[Adawi M](https://www.ncbi.nlm.nih.gov/pubmed/?term=Adawi M[Author]&cauthor=true&cauthor_uid=30871045)1, [Damiani G](https://www.ncbi.nlm.nih.gov/pubmed/?term=Damiani G[Author]&cauthor=true&cauthor_uid=30871045)2,3,4, [Bragazzi NL](https://www.ncbi.nlm.nih.gov/pubmed/?term=Bragazzi NL[Author]&cauthor=true&cauthor_uid=30871045)5, et al The Impact of Intermittent Fasting (Ramadan Fasting) on Psoriatic Arthritis Disease Activity, Enthesitis, and Dactylitis: A Multicentre Study. Nutrients. 2019 Mar 12;11(3). pii: E601. doi: 10.3390/nu11030601.

Ahmed, T. and Gilani, A. (2014), Therapeutic Potential of Turmeric in Alzheimer’s Disease: Curcumin or Curcuminoids? Phytother. Res., 28: 517-525. doi:10.1002/ptr.5030

Allegri P, Mastromarino A, Neri P. Management of chronic anterior uveitis relapses: efficacy of oral phospholipidic curcumin treatment. Long-term follow-up. Clinical Ophthalmology (Auckland, NZ). 2010;4:1201-1206. doi:10.2147/OPTH.S13271.

Cristina Augood, Usha Chakravarthy, Ian Young, Jesus Vioque, Paulus TVM de Jong, Graham Bentham, Mati Rahu, Johan Seland, Gisele Soubrane, Laura Tomazzoli, Fotis Topouzis, Johannes R Vingerling, Astrid E Fletcher; Oily fish consumption, dietary docosahexaenoic acid and eicosapentaenoic acid intakes, and associations with neovascular age-related macular degeneration, The American Journal of Clinical Nutrition, Volume 88, Issue 2, 1 August 2008, Pages 398–40

Eunyoung Cho, Shirley Hung, Walter C Willett, Donna Spiegelman, Eric B Rimm, Johanna M Seddon, Graham A Colditz, Susan E Hankinson; Prospective study of dietary fat and the risk of age-related macular degeneration, The American Journal of Clinical Nutrition, Volume 73, Issue 2, 1 February 2001, Pages 209–218,

Lin, P. Importance of the intestinal microbiota in ocular inflammatory diseases: A review. Clin. Experiment. Ophthalmol. 2019; 47: 418– 422. https://doi.org/10.1111/ceo.13493

Liu A, Ji J. Omega-3 Essential Fatty Acids Therapy for Dry Eye Syndrome: A Meta-Analysis of Randomized Controlled Studies. Medical Science Monitor: International Medical Journal of Experimental and Clinical Research. 2014;20:1583-1589. doi:10.12659/MSM.891364.

Rahul Bhargava,1 Prachi Kumar,2 Manjushrii Kumar,3 Namrata Mehra,1 and Anurag Mishra1 A randomized controlled trial of omega-3 fatty acids in dry eye syndrome Int J Ophthalmol. 2013; 6(6): 811–816. Published online 2013 Dec 18. doi: 10.3980/j.issn.2222-3959.2013.06.13

Richards, J. (2019), Manipulating microbiomes: Present and future perspective. Clin. Experiment. Ophthalmol, 47: 315-316. doi:10.1111/ceo.13508