However, for those who already experience symptoms of computer vision syndrome or digital eye strain from focusing on a computer display for prolonged periods, the true, long-term impact of constant computing remains unclear.
Traditionally, eye health has been viewed as an issue isolated to seniors. As a leading cause of vision loss in older adults that generally affects people age 50 and older, age-related macular degeneration (AMD) gradually destroys the macula—the part of the eye that provides sharp, central vision required to see objects clearly, according to the National Eye Institute (NEI), part of the National Institutes of Health and the U.S. government’s lead agency for vision research.
Moreover, by age 80, more than half of all Americans either have a cataract, a clouding of the lens in the eye that affects vision, or have had cataract surgery. “Cataracts develop for a variety of reasons,” according to Dr. Rudi Moerck, president and CEO, Valensa International, Eustis, FL, “including long-term ultraviolet exposure, exposure to radiation, secondary effects of diseases such as diabetes or simply due to advanced age. They are usually a result of denaturation of retinal lens proteins, which then clump together and cause cloudiness, resulting in blurred vision and potentially blindness.”
In his book, Herbal Prescriptions for Health and Healing: Your Everyday Guide to Using Herbs Safely and Effectively, Donald Brown, ND, managing director, Natural Product Research Consultants, and advisor to Linnea, Inc., Easton, PA, noted that free radical damage to the lens of the eye is a major factor in cataracts and macular degeneration. Thus, prevention centers on using antioxidant supplements to block free radical buildup.
“The leading cause of blindness among diabetics is retinopathy,” he added. “This condition causes the capillaries in the eye to become fragile and begin leaking, which in turn leads to swelling in the retina and eventual loss of normal vision. Advanced complications include scarring and retinal detachment.”
‘New School’ Thinking
There is a new world of thought emerging from the scientific community supporting the notion that “the key to eye health is maintenance through a lifetime,” said Abhijit Bhattacharya, COO, OmniActive Health Technologies, Morristown, NJ, which has partnered with researchers, scientists and doctors on a new consumer education campaign called “Lutein for Every Age.”
“This campaign is to promote eye health through healthy living, diet and supplementation and to correct some of the misguided information that is out there,” noted Mr. Bhattacharya. “For instance, there is a misconception that lutein is just for the senior population. This is not the full truth.”
While seniors do benefit from this potent carotenoid, compelling science indicates even more effective benefits to consumption throughout the lifespan, beginning in childhood, he added. “Lutein can even be found in breast milk, supplying babies with a healthy jumpstart on eye health. “
The importance of disease prevention continues to resonate among savvy consumers of all ages, who are “being more proactive with their own health,” noted Mr. Bhattacharya. “Formulators have been taking notice of this new need in the market and are including eye health ingredients, such as lutein and zeaxanthin, in supplements as well as functional food and beverages aimed at all age demographics. They have even been included in products for children and babies such as gummies and formula as well.”
Christian Artaria, marketing director and head of functional food development for Italy-based Indena S.p.A., noted that awareness for eye health nutrients is increasing as people understand that proper nutrition and the right supplements can contribute to healthier eyes. “Eye health is a relatively new area that has only been explored extensively over the last 10-15 years. Eye doctors have also become more involved about educating their patients on the benefits of nutrition and supplements for eye health.”
While older consumers have been the most susceptible to eye diseases, Mr. Artaria said that “as our culture has evolved into heavy computer and mobile phone users, it will be interesting to monitor the impact of these behaviors on eye health. This trend may result in eye health products being consumed to help eye fatigue or stress.”
A.T. Jacob, managing director and CEO of India-based nutraceutical supplier Katra Phytochem, also noted that continuous exposure to light from various sources such as computer devices, LCD screens and sunlight may lead to eye problems in young people. “Teenagers and young adults are increasingly aware of the need for supplements to replenish essential eye nutrients to protect against risk of AMD, cataract and glaucoma later in life. New forms of such supplements catering to specific age groups are now available in the market such as gummy vitamins, chews and soft gel capsules.”
Globally, the main cause of blindness is cataract (51%) while uncorrected refractive errors are the major cause of visual impairment (43%), according to the World Health Organization. Data from 2010 indicated that overall, 80% of all blindness and visual impairment is avoidable. The poor and least educated communities remain most affected by visual impairment and blindness.
In an effort to increase global awareness, WHO has developed an initiative “Universal Access to Eye Health: A Global Action Plan, 2014-2019,” which aims to improve eye health at community and national levels. The goal of the action plan is to provide a global framework that contributes to elimination of avoidable blindness and visual impairment through comprehensive eye care services integrated in the health system with an approach that ensures quality and equity.
“Balanced nutrition is an integral part of good eye care,” noted Mr. Jacob. “Most eye diseases are a result of oxidative damage and/or inflammation, which in turn produce free radicals—singlet oxygen, reactive oxygen species (ROS)—which lead to the onset of various eye diseases. Strong scientific evidence with respect to their function, mechanism of action, safety and commercial viability makes ingredients such as lutein, zeaxanthin, omega 3 fatty acids (EPA/DHA), vitamins, minerals and other herbal extracts a sensible and convenient choice for manufacturers, physicians and consumers to assertively address major eye health concerns.”
Building On AREDS
Predominantly, Baby Boomers are driving growth in eye health products, according to Nithya Hariharan, market research analyst at DSM Nutritional Products, Parsippany, NJ, who cited a 2012 report from Nutrition Business Journal (NBJ), Boulder, CO. “Currently, about 1.75 million Americans have advanced AMD with vision loss, and that number is expected to hit 3 million by 2020. According to the National Eye Institute, an estimated 30.1 million U.S. residents will have a cataract and 9.5 million will lose or have complete occlusion of a lens by 2020.”
Sales of eye health supplements reached $419 million in 2012, up 6% according to NBJ. Clinical research has certainly benefited sales of eye health products. For example, the landmark Age-Related Eye Disease Study (AREDS 1), a major clinical trial sponsored by the NEI and published in 2001, showed that high levels of antioxidants and zinc significantly reduced the risk of progression to advanced AMD by 25%, and the risk of moderate vision loss by 19%.
Specifically, the AREDS formula contained 500 mg of vitamin C; 400 IU of vitamin E; 15 mg of beta-carotene; 80 mg of zinc as zinc oxide; and 2 mg of copper as cupric oxide—copper was added to prevent copper deficiency, which may be associated with high levels of zinc supplementation.
Building on these results, NEI initiated AREDS 2 in 2006, which will refine the findings of the original study by adding lutein, zeaxanthin and omega 3 fatty acids EPA and DHA. Results are expected to be released this year.
Dr. Jodi Luchs, an ophthalmologist from Long Island, NY, and inventor of OJO, a functional beverage that contains therapeutic amounts of the AREDS vitamins, said age and family history are among the primary risk factors for eye disease, and the role of nutrition has gained renewed importance. “This is particularly true for diseases such as cataracts, glaucoma and macular degeneration. However, we are learning that factors such as cumulative ultraviolet light exposure, which produces damaging free radicals, also play a role in the development of macular degeneration and cataracts. Proper nutrition, including antioxidants, is now acknowledged as an important factor to help reduce the risk of eye diseases.”
Dr. Luchs noted that many of his patients have trouble swallowing large pills. “Accordingly, I developed OJO fortified eye care nectar as a great-tasting beverage alternative to these pills. OJO contains the AREDS 1 (vitamin C, vitamin E and zinc) and AREDS 2 supplements (lutein, zeaxanthin, and omega 3 fatty acids)."
Eating a nutrient-dense diet including fruits and vegetables, particularly dark leafy greens such as spinach, kale or collard greens is important to keeping eyes healthy, noted Deshanie Rai, PhD, FACN, senior scientific leader at DSM Nutritional Products. Supplementation with vitamins, minerals and carotenoids is also beneficial for consumers both young and old.
“Vitamin A is an essential fat-soluble vitamin and is best-known for its role in preventing blindness through the formation of rhodopsin,” she noted. “This photopigment is responsible for vision under low light. Vitamins C and E play an important role in protecting the eye through their actions as antioxidants. Beta-carotene, which has vitamin A activity, has also been shown to play an important antioxidant role in the eye. Zinc is an essential nutrient that acts as a cofactor for more than 100 enzymes. Zinc is also found in high concentrations in the retina and plays a role in the metabolic function of several enzymes.”
Required for many vital cell functions, zinc is probably the most publicized mineral for healthy vision. Zinc concentrations are high in the eye, especially in the retina. “Zinc has been shown to help support healthy night vision and is also essential to the activity of dozens of enzymes important for vision health,” said Paul Dijkstra CEO, InterHealth Nutraceuticals, Benecia, CA.
InterHealth’s L-OptiZinc for eye health, a zinc mono-L-methionine sulfate offers great absorption, retention and antioxidant properties, according to the company. “The benefits of zinc are highly dependent on the amount of zinc that actually gets absorbed and utilized by the body, making L-OptiZinc a great choice for eye health formulations,” Mr. Dijkstra added.
With continued research, more eye care professionals are prescribing dietary supplements to patients, which further expands consumer awareness and understanding of important nutrients, he added. “Many companies have created educational brochures, advertisements, and have worked closely with the media to communicate the science behind their ingredients. Reaching potential consumers and educating them on the latest developments remains the key to success in this growing marketplace.”
Keri Marshall, MS, ND, chief medical officer with Nordic Naturals, Watsonville, CA, said a growing body of scientific research indicates that EPA and DHA omega 3 fatty acids from fish oil “play key roles in maintaining the healthy structure and function of eye tissue. DHA in particular is abundant in the retina, and its protective action is associated with decreased likelihood of having age-related damage and degeneration of eye tissue.”
Nordic Naturals’ Omega Vision is a concentrated DHA fish oil with 20 mg FloraGLO brand lutein and 4 mg zeaxanthin in each serving. “It supports healthy tissue moisture and tear production, supports the body’s key anti-inflammatory pathways and provides natural pigment to ocular cells,” according to Dr. Marshall.
Steve Dillingham, general manager for Norway-based GC Rieber Oils, said awareness for eye health nutrients is on the rise, and formulators have shown increased interest in high DHA products using smaller capsules, or formulating with multiple ingredients while still delivering clinically-relevant amounts of DHA in a single serving. “Our newest product is a 90% total omega 3 concentrate called VivoMega 70 DHA Ultra, which provides a minimum of 650 mg/gram DHA, 50 mg/gram EPA, and a total omega 3 of 820 mg/gram as triglyceride.”
Carotenoids Are King
Supporting the function of omega 3s are the carotenoids lutein and zeaxanthin, whose presence throughout the eye suggests a protective role against damaging blue light, according to Nordic Naturals’ Dr. Marshall. “As these natural pigments slowly decrease with age, it becomes necessary to acquire them through diet or supplementation. Recent clinical studies demonstrate a safe and efficacious role for both fish oil and these natural carotenoids in protecting and promoting healthy eyes. Within the eye, the retina and the macula are particularly susceptible to degenerative changes associated with age. As a result, it’s not surprising that as Baby Boomers age, they are becoming increasingly aware of essential fatty acids and carotenoids for the promotion of eye health.”
Consumer interest in carotenoids has been growing rapidly, according to Dr. Wenzhong Wu, president of China-based InnoBio Limited. “In the 1980s, the carotenoid market was all about beta-carotene, and lutein and lycopene came on strong in the 1990s. With all the new research being done on carotenoids, the public is becoming more aware of just how beneficial these products are.”
Lutein and zeaxanthin are the only carotenoids present in the eye’s lens and retina, he said. They screen blue light, which is the highest energy form of visible light and known to induce photo-oxidative damage by generating reactive oxygen species (ROS). They also function as antioxidants to protect the photoreceptor cells from the damage of ROS. Lutein and zeaxanthin are highly concentrated in the macula. Consumption and serum levels of lutein have been shown to be inversely related to the risk for ocular diseases, including AMD and cataracts.
“In practical applications, in order to improve the stability, solubility and bioavailability of lutein, and broaden its field of application, lutein is made into various preparation forms by novel compounding techniques and microencapsulated techniques, and thus to obtain stable, water-dispersible, highly bioavailable lutein products. Common lutein products in the market include oil solutions, oil suspensions, emulsions and water-dispersible dry powders.” InnoBio offers its XanGuard Lutein product line to meet needs in different application fields.
OmniActive’s Mr. Bhattacharya said the three yellow carotenoids found in the eye, lutein, RR-zeaxanthin and
meso-zeaxanthin, are known collectively as xanthophylls, and act like a pair of internal sunglasses to protect sensitive photoreceptor cells essential to vision.
“These carotenoids perform several protective functions. First, they are potent antioxidants that protect against oxidative stress in nervous tissue, especially in the eyes and brain. They are intimately associated with omega 3 fatty acids, which are also abundant in nerve cells, and protect these easily damaged fats from peroxidation. Zeaxanthin is thought to be more effective than all antioxidants, including vitamin E, at inhibiting lipofuscin, which accumulates in the retina with age and is associated with vision loss. Lutein and the zeaxanthin isomers also span the entire membrane bilayer, which helps stabilize cell membranes. Their polar cyclic end groups extend into the aqueous environment both inside and outside of the cell, enabling the antioxidant to be recharged by vitamin C and other water-soluble antioxidants.”
Lutein and the zeaxanthin isomers not only neutralize most free radicals, including singlet oxygen, superoxide, hydroxyl and peroxynitrite radicals, but also activate antioxidant enzymes. “The different xanthophylls differ in their antioxidant spectrum, and complement each other, especially in the macula (central retina). The thickness of the macular pigment formed by xanthophylls is associated with clear vision and resistance to AMD and cataracts. Compelling science has shown that long-term supplementation in humans with xanthophylls may assist in retaining healthy eyesight, visual performance and acuity, as well as aid glare sensitivity and contrast sensitively, and support vision in dim light and chromatic blur.”
DSM’s Ms. Rai noted that since lutein and zeaxanthin accumulate in the macula of the eyes, they increase macular pigment optical density (MPOD). “In general, higher MPOD is associated with better visual performance and AMD. There is accumulating evidence through both epidemiological and intervention studies that suggest the consumption of lutein and zeaxanthin along with DHA and EPA may be relevant and effective nutrition approaches to protect against AMD. “
Another potent carotenoid, astaxanthin protects lipids contained in membranes and in blood plasma against oxidative damage, and has been shown to provide beneficial support for a broad range of health conditions associated with oxidative stress, according to Valensa’s Dr. Moerck.
“Due to this incredible antioxidant power, regular supplementation with astaxanthin supports eye, skin and neurological health and overall graceful aging,” he said. “It has been shown to cross the blood-brain and blood-retina barriers, meaning it can positively impact brain, central nervous system, retinal and optic nerve systems for improved protection from light induced oxidative degradation and thus improved eye health. About 30% of the brain’s and the eye’s dry mass consists of DHA, and it is unequivocal that astaxanthin protects this membrane component for damage caused by oxidation. It has also been shown that astaxanthin prevents damage to DNA at just 2 mg per day.”
Dr. Moerck said Valensa’s Eye Pro MD eye health formula recognizes the science that supports both lutein and zeaxanthin and adds the antioxidant potency of astaxanthin into the mix. “At Valensa, we are not marketers of single ingredient products and recognize the excellent potential for astaxanthin, lutein and zeaxanthin for supporting eye health in combination. The use of astaxanthin in a supplement form is all the more important when you consider how difficult it is for the human body to acquire it via diet. While lutein and zeaxanthin are available from a healthy diet featuring leafy greens and vegetables, natural astaxanthin is only available in diets high in wild salmon, certain shellfish and supplements.”
Valensa is currently designing a multi-arm eye healthcare clinical trial that includes a standalone arm for astaxanthin to explore further its unique properties and utility in eye healthcare in conjunction with a second arm exploring the benefits of mixed carotenoids and advanced omega 3 delivery systems.
The company’s Zanthin astaxanthin was used as a part of the CARMIS (Carotenoids and Antioxidants in Age-Related Maculopathy Italian Study), which showed the role of carotenoids including astaxanthin in improving central vision health. The primary objective of this European study was to evaluate the influence of carotenoid and antioxidant supplementation on retinal function in non-advanced AMD over a one-year period.
Clearly, antioxidants are big players in the eye health market. Frank Schonlau, scientific director, Horphag Research, the exclusive worldwide supplier of Pycnogenol French maritime pine park extract, said several studies show Pycnogenol strengthens the fragile capillaries that nourish the rods and cones in the retina. “Pycnogenol is shown in human pharmacologic studies to improve endothelial function, the ability of blood vessels to self-regulate the diameter of the vessel. By high-resolution ultrasound measurements it is shown that Pycnogenol increases the perfusion of tiny capillaries in the retina, thus oxygen and nutrients are more efficiently delivered to light-sensing cells.
In people with very early stage retinopathy, characterized by swellings of the retina as a result of fluid leakage from capillaries, impaired vision is restored after supplementation with Pycnogenol, he added. “For an affected individual the most appreciated outcome is restoration of vision (using the standard letter reading test), which is only achievable at very early stages of retinopathy. It is for this reason that supplementation with Pycnogenol as a preventative measure as well as for a healthier lifestyle, is key for anybody with elevated blood sugar.”
Mirtogenol is a proprietary combination of the standardized bilberry extract Mirtoselect and Pycnogenol. According to Indena’s Mr. Artaria, this combination favors the maintenance of high intraocular pressure (IOP) levels already within normal range, capitalizing on the synergy between polyphenolics belonging to distinct structural classes, namely anthocyanins and procyanidins.
Indena’s Mirtoselect bilberry extract is made from Vaccinium myrtillus L. fresh berries standardized to contain 36% anthocyanins. “Mirtoselect properties for eye health have been clinically validated in different studies, showing for example, promotion of contrast sensitivity in retinal health and attenuation of free radical damage associated with accommodation in school children,” Mr. Artaria said.
In a 2008 study on 88 patients, one year of supplementation with Mirtoselect among patients with non-proliferative diabetic retinopathy promoted vision, contributing to a beneficial effect on contrast sensitivity, while visual acuity and macular edema were maintained at initial conditions.
In another study completed in 2012 that involved 132 patients, a supplement containing a low dose of Mirtoselect (120 mg/day divided in two capsules of 60 mg), resulted in an amelioration of the best-corrected visual acuity and of the Visual Field when compared to initial conditions.
Studies have also shown the company’s Meriva brand curcumin formula may improve specific eye challenges. In particular, in a trial on 106 patients whose eye middle layer was challenged and relapsing since at least 2 years, Meriva promoted the maintenance of a healthy status on a significant number of patients. Finally, in a recent pilot study, the daily use of 1 gram per day of Meriva was shown to ameliorate retinal function in patients with glucose impairment.
Dr. Brown, of Natural Product Research Consultants, said herbal and nutritional supplements that are known to have antioxidant actions, improve blood flow, or support retinal health are essential for vision health. “Among a long list of considerations are standardized herbal extracts such as bilberry and ginkgo biloba.”
He noted the combination of bilberry and ginkgo as an effective treatment for early stage macular degeneration. He also pointed to promising results from grape seed extracts high in oligomeric proanthocyanidins (OPCs). Like bilberry, these flavonoid-rich supplements may also help in the treatment of mild forms of retinopathy, he said.