Omega-3 fatty acids after trabeculectomy: Anti-inflammatory ally or bleeding risk?

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Omega-3 Fatty Acids after Trabeculectomy: Anti-Inflammatory Ally or Bleeding Risk? Trabeculectomy – a common surgery to lower eye pressure in glaucoma – creates a bleb (a fluid-filled reservoir) under the conjunctiva. After surgery, patients often face ocular surface inflammation and dry eye because of disrupted tear films and inflammation from wound healing. Since omega-3 fatty acids (the anti-inflammatory oils in fish oil) are known to calm inflammation elsewhere in the body, some surgeons and patients wonder: Can fish oil supplements help with eye comfort and bleb health after trabeculectomy, or do they pose a bleeding risk? We review the evidence. Overall, many trials show that the EPA/DHA omega-3 oils can reduce inflammation and improve tear quality after eye surgery, but their direct effects on bleb function are unproven. On the other hand, omega-3s do make platelets less sticky – a theoretical concern for bleeding. Fortunately, large analyses indicate routine omega-3 doses have minimal impact on surgical bleeding. In practice, moderate omega-3 supplements may help with post-op eye comfort, but clinicians should watch for any extra bleeding in high-risk patients. What Are Omega-3 Fatty Acids? Omega-3 fatty acids (especially eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA)) are healthy polyunsaturated fats found in fatty fish (salmon, mackerel, etc.) or supplements. They cannot be made by our bodies and must come from diet or pills. Omega-3s are famously anti-inflammatory: in the body they compete with the usual inflammatory fats (arachidonic acid) and lead to the production of anti-inflammatory molecules (resolvins and protectins) (). In practical terms, omega-3s can reduce swelling and improve tissue healing in many parts of the body. In the eye, inflammation and tear-film imbalance underlie dry eye symptoms. Omega-3s are thought to improve the oily layer of tears (from the eyelid glands) and calm surface inflammation. Indeed, trials in dry-eye patients have shown that omega-3 supplements can lengthen the time between eye blinks before tearing occurs (tear break-up time) and reduce tear osmolarity (less irritating, more stable tears) () (). These changes translate to patients feeling less dryness, burning and scratchiness when it works. (Note: for severe chronic dry eye, a very large trial (the DREAM study) found 3,000 mg/day of omega-3 did not beat placebo on symptom scores, a result that some experts debate due to study design ().) In summary: Omega-3s are generally anti-inflammatory fats that can improve tear-film stability and may soothe irritated eyes after surgery () (). This forms the rationale for trying them after trabeculectomy. Omega-3 Supplements and Post-Op Eye Comfort Several randomized trials have tested omega-3 supplements for post-surgical dry eye and inflammation. Although no study has looked specifically at trabeculectomy patients, we can apply findings from cataract and refractive surgery cases: Cataract surgery: In a 2017 trial, patients with new dry eye symptoms after cataract removal were given standard treatment with or without omega-3 capsules (each tablet: 180 mg EPA + 120 mg DHA, taken 3 times daily). After a few weeks, the omega-3 group had significantly greater improvement in symptom scores and tear stability than controls (). For example, the average eye-comfort score fell more in the fish-oil group, and tear break-up time improved more on omega-3 (P<0.05) (). This suggests that adding fish oil to routine therapy reduced postoperative inflammation and improved ocular surface comfort. Photorefractive keratectomy (PRK): Another small trial looked at patients undergoing PRK (another eye surgery that can cause dry eye). Those who took omega-3 supplements before and after surgery healed quicker and had better vision outcomes and tear stability than those without omega-3 (). (This pilot study supports that omega-3 may speed corneal healing after surgery.) Chronic dry eye (non-surgical): A trial comparing krill oil vs. fish oil vs. placebo in people with dry eye (not after surgery) found both omega-3 groups improved objective tear measures. After 3 months, tear osmolarity and tear break-up time were significantly better with krill or fish oil than placebo (). In that study the krill-oil group (higher EPA ratio) also had a significantly greater drop in symptom scores (patient comfort) than placebo (). Meta-analyses of dry-eye trials generally conclude omega-3s give small but real benefits on tear-film health and symptoms – especially when doses are high and used long-term () (). However, not all reviews are uniformly positive. A 2023 Cochrane review concluded that omega-3s probably have little to no effect on patient-reported dry eye symptoms compared to placebo, though they may improve some tear-test signs (). Importantly, the Cochrane authors noted that combining omega-3 with standard treatments (like artificial tears) seemed more helpful than omega-3 alone. In practice, this suggests fish oil is an add-on therapy: it may work best alongside drops, lid hygiene and other post-op care. What does this mean for trabeculectomy? Trab patients often stop many glaucoma drops (which can irritate the surface) but still experience dry eye and inflammation from surgery trauma. The cataract and PRK trials above imply that omega-3 supplements can make a difference in post-op ocular comfort. While we lack a trial in trab patients, it is reasonable to extrapolate: an omega-3 supplement regimen (e.g. several hundred to a few thousand mg of combined EPA/DHA per day) might reduce irritation, dryness and redness after trabeculectomy, improving patient comfort. Potential Effects on Bleb Health A key question is whether reduced inflammation from omega-3 translates into better bleb healing. The ideal bleb is thin, functioning and leak-free; too much early inflammation can cause scarring and bleb failure. In theory, omega-3’s anti-inflammatory action could help keep fibrosis in check. To date, there are no direct trials of omega-3 on bleb outcomes. However, some clues come from studies of tear biochemistry after trabeculectomy. One 3-year cohort study measured inflammatory lipid mediators in tears before and after trab. It found that pro-inflammatory tear lipids (like certain prostaglandins) dropped markedly after surgery in most patients (). Interestingly, patients who later needed needling of their bleb (a sign of failing bleb with scarring) had higher levels of some inflammatory lipids in their tears than those with healthy blebs (). This suggests chronic inflammation may underlie some bleb problems. By extension, if an intervention like omega-3 could suppress that inflammation, bleb health might benefit. However, this is speculative: no data show that fish oil actually prevents bleb scarring or reduces needling rates. It is also possible that reducing inflammation too much could impair the normal wound closure of the conjunctiva. On balance, most experts would say omega-3’s potential benefits on wound healing via inflammation control are theoretical in the bleb context. We note it as a possible plus, but emphasize the lack of direct evidence. Platelet Function and Bleeding Risk Omega-3s and Platelets: One known effect of EPA/DHA is that they make platelets somewhat less likely to clump. In very high-fish diet populations (like Greenland Inuit), scientists observed prolonged bleeding times and altered platelet fatty acids compared to typical Western diets (). This anti-platelet effect has raised caution among surgeons that omega-3 supplements could increase surgical bleeding. In fact, many guidelines currently advise stopping fish oil before surgery and delaying non-urgent ops for a few days if patients are on fish-oil supplements (). The idea is largely precautionary: fish oil does change cell membranes to be less pro-thrombotic (). However, whether this translates into real harm is the question. Clinical evidence on bleeding risk: Recent analyses have been reassuring. A 2024 meta-analysis of 11 randomized trials (over 120,000 patients) compared bleeding rates in those taking omega-3 supplements vs. controls. It found no significant difference in overall bleeding events (including strokes or gastrointestinal bleeds) between the groups (). Only very high-dose purified EPA (like icosapent ethyl used for heart disease) showed a slight relative increase in bleeding (50% higher risk) – but this change was tiny in absolute terms (0.6% more events) (). Likewise, a large perioperative trial (OPERA, n≈1500) tested giving 8–10 g of fish oil before open-heart surgery and 2 g/day after. The fish-oil group did not have more bleeding – in fact, they had slightly fewer blood transfusions than placebo () (). The odds of major bleeding were not higher (OR≈0.8) in the fish-oil group (). These findings suggest that at least in major surgery, fish oil at high dose didn’t worsen bleeding outcomes. Bottom line on bleeding: In practical terms, normal omega-3 use (roughly 1–3 grams/day of fish oil) appears to have negligible effect on surgical bleeding risk () (). The small impairment in platelet function is mostly offs

Transcript

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Omega-3 fatty acids after trabeculectomy, anti-inflammatory ally or bleeding risk. Trabeculectomy, a common surgery to lower eye pressure and glaucoma, creates a bleb, a fluid-filled reservoir under the conjunctiva. After surgery, patients often face ocular surface inflammation and dry eye because of disrupted tear films and inflammation from wound healing. Since omega-3 fatty acids, the anti-inflammatory oils in fish oil, are known to calm inflammation elsewhere in the body, some surgeons and patients wonder: can fish oil supplements help with eye comfort and bleb health after trabeculectomy, or do they pose a bleeding risk? We review the evidence. Overall, many trials show that the EPA DHA omega-3 oils can reduce inflammation and improve tear quality after eye surgery, but their direct effects on bleb function are unproven. On the other hand, omega-3s do make platelets less sticky. A theoretical concern for bleeding. Fortunately, large analyses indicate routine omega-3 doses have minimal impact on surgical bleeding. In practice, moderate omega-3 supplements may help with post-op eye comfort, but clinicians should watch for any extra bleeding in high-risk patients. What are omega-3 fatty acids? Omega-3 fatty acids, especially icosapentenoic acid, EPA, and docosahexanoic acid, DHA, are healthy polyunsaturated fats found in fatty fish, salmon, mackerel, etc., or supplements. They cannot be made by our bodies and must come from diet or pills. Omega-3s are famously anti-inflammatory. In the body, they compete with the usual inflammatory fats, arachidonic acid, and lead to the production of anti-inflammatory molecules, resolvins and protectins. In practical terms, omega-3s can reduce swelling and improve tissue healing in many parts of the body. In the eye, inflammation and tear film imbalance underlie dry eye symptoms. Omega-3s are thought to improve the oily layer of tears from the eyelid glands and calm surface inflammation. Indeed, trials in dry eye patients have shown that omega-3 supplements can lengthen the time between eye blinks before tearing occurs, tear breakup time, and reduce tear osmolarity, less irritating, more stable tears. These changes translate to patients feeling less dryness, burning, and scratchiness when it works. Note, for severe chronic dry eye, a very large trial, the DREAM study, found 3,000 mg per day of omega-3 did not beat placebo on symptom scores, a result that some experts debate due to study design. In summary, omega-3s are generally anti-inflammatory fats that can improve tear film stability and may soothe irritated eyes after surgery. This forms the rationale for trying them after trabeculectomy. Omega-3 supplements and post-op eye comfort. Several randomized trials have tested omega-3 supplements for post-surgical dry eye and inflammation. Although no study has looked specifically at trabeculectomy patients, we can apply findings from cataract and refractive surgery cases. Cataract surgery. In a 2017 trial, patients with new dry eye symptoms after cataract removal were given standard treatment with or without omega-3 capsules, each tablet 180 mg EPA plus 120 mg DHA, taken three times daily. After a few weeks, the omega-3 group had significantly greater improvement in symptom scores and tear stability than controls. For example, the average eye comfort score fell more in the fish oil group, and tear breakup time improved more on omega-3, P0.05. This suggests that adding fish oil to routine therapy reduced postoperative inflammation and improved ocular surface comfort. Photorefractive kectomy, pyrotectomy, PRK, another small trial looked at patients undergoing PRK, another eye surgery that can cause dry eye. Those who took omega-3 supplements before and after surgery healed quicker and had better vision outcomes and tear stability than those without omega-3. This pilot study supports that omega-3 may speed corneal healing after surgery. Chronic dry eye non-surgical. A trial comparing krill oil versus fish oil vs. placebo in people with dry eye, not after surgery, found both omega-3 groups improved objective tear measures. After three months, tear osmolarity and tear breakup time were significantly better with krill or fish oil than placebo. In that study, the krill oil group, higher EPA ratio, also had a significantly greater drop in symptom scores patient comfort than placebo. Meta-analyses of dry eye trials generally conclude omega-3s give small but real benefits on tear film health and symptoms, especially when doses are high and used long term. However, not all reviews are uniformly positive. A 2023 Cochrane review concluded that omega-3s probably have little to no effect on patient-reported dry eye symptoms compared to placebo, though they may improve some tear test signs. Importantly, the Cochrane authors noted that combining omega-3 with standard treatments, like artificial tears, seemed more helpful than omega-3 alone. In practice, this suggests fish oil is an add-on therapy. It may work best alongside drops, lid hygiene, and other post-op care. What does this mean for trabeculectomy? Trab patients often stop many glaucoma drops, which can irritate the surface, but still experience dry eye and inflammation from surgery trauma. The cataract and PRK trials above imply that omega-3 supplements can make a difference in post-op ocular comfort. While we lack a trial in TRAB patients, it is reasonable to extrapolate. An omega-3 supplement regimen, e.g., several hundred to a few thousand milligrams of combined EPA DHA per day, might reduce irritation, dryness, and redness after trabeculectomy, improving patient comfort. Potential effects on bleb health. A key question is whether reduced inflammation from omega-3 translates into better bleb healing. The ideal bleb is thin, functioning, and leak-free. Too much early inflammation can cause scarring and bleb failure. In theory, omega-3's anti-inflammatory action could help keep fibrosis in check. To date, there are no direct trials of omega-3 on bleb outcomes. However, some clues come from studies of tear biochemistry after trabeculectomy. One three-year cohort study measured inflammatory lipid mediators in tears before and after TRAB. It found that pro-inflammatory tear lipids, like certain prostaglandins, dropped markedly after surgery in most patients. Interestingly, patients who later needed needling of their bleb, a sign of failing bleb with scarring, had higher levels of some inflammatory lipids in their tears than those with healthy blebs. This suggests chronic inflammation may underlie some bleb problems. By extension, if an intervention like omega-3 could suppress that inflammation, bleb health might benefit. However, this is speculative. No data show that fish oil actually prevents bleb scarring or reduces needling rates. It is also possible that reducing inflammation too much could impair the normal wound closure of the conjunctiva. On balance, most experts would say omega-3's potential benefits on wound healing via inflammation control are theoretical in the bleb context. We note it as a possible plus, but emphasize the lack of direct evidence. Platelet function and bleeding risk. Omega-3s and platelets. One known effect of EPA DHA is that they make platelets somewhat less likely to clump. In very high fish diet populations, like Greenland Inuit, scientists observed prolonged bleeding times and altered platelet fatty acids compared to typical Western diets. This antiplatelet effect has raised caution among surgeons that omega-3 supplements could increase surgical bleeding. In fact, many guidelines currently advise stopping fish oil before surgery and delaying non-urgent ops for a few days if patients are on fish oil supplements. The idea is largely precautionary. Fish oil does change cell membranes to be less pro-thrombotic. However, whether this translates into real harm is the question. Clinical evidence on bleeding risk. Recent analyses have been reassuring. A 2024 meta-analysis of 11 randomized trials, over 120,000 patients, compared bleeding rates in those taking omega-3 supplements versus controls. It found no significant difference in overall bleeding events, including including strokes or gastrointestinal bleeds, between the groups. Only very high-dose purified EPA, like icosepent ethyl used for heart disease, showed a slight relative increase in bleeding, 50% higher risk, but this change was tiny in absolute terms, 0.6% more events. Likewise, a large perioperative trial, opera, n to one of 1500, tested giving 8 to 10 grams of fish oil before open heart surgery and 2 grams day after. The fish oil group did not have more bleeding. In fact, they had slightly fewer blood transfusions than placebo. The odds of major bleeding were not higher, OR or 0.8 in the fish oil group. These findings suggest that at least in major surgery, fish oil at high dose didn't worsen bleeding outcomes. Bottom line on bleeding. In practical terms, normal omega-3 use, roughly 1 to 3 grams day of fish oil, appears to have negligible effect on surgical bleeding risk. The small impairment in platelet function is mostly offset by other compensations in clotting. However, caution remains recommended if patients are on multiple blood thinners. Managing real-world risk at two weeks post-op. By about two weeks after trabeculectomy, the main surgical wound has usually begun healing, but the bleb is still vulnerable. Here are practical considerations. Anticoagulant patients. If a patient must continue systemic anticoagulants or strong antiplatelets, e.g., warfarin, doax, clopidogrel, through surgery, fish oil adds another mild blood-thinning factor. Ophthalmologists typically assess systemic bleeding risk versus eye risk. Glaucoma surgery is considered high risk for hemorrhage, high hyphema, or suprachoroid risk. Many surgeons will hold warfarin P2Y12 inhibitors a few days before surgery if safe, keeping aspirin if needed. And resume after careful discussion. If anticoagulation truly cannot be paused, recent stent, valve, etc., any additional factor like fish oil is generally avoided until healing is robust. In short, stay on fish oil only after consulting both your eye doctor and prescribing physician in these cases. Blebs with leaks. A leaking bleb means a thin, fragile bleb with an opening. Even without fish oil, these blebs risk over drainage and infection. Adding any blood thinner in this setting could theoretically worsen leak closure. If a bleb leak is detected, most surgeons would focus on sealing it with glue, bandage contact lens, etc., and avoid any supplements that impede clotting until the leak is fixed. So we would delay restarting or starting omega-3 in the presence of a bleb leak. Routine patients. For most patients who are off blood thinners and have an intact bleb, omega-3 supplements could start around one to two weeks after surgery, once the risk of immediate post-op bleeding is lower. The idea is to enhance comfort and help control residual inflammation as corticosteroids are tapered. Clinicians might try a moderate dose, for example, 1000 mg EPA plus 500 mg DHA daily, and adjust based on response. Importantly, fish oil is not a substitute for standard post-op care. Patients still need their eye drops, antibiotics, steroids, and proper eye hygiene. Monitoring. Once started on omega-3, doctors should keep an eye on the surgical outcome. They will watch for any unusual bruising in the eye, new conjunctival hemorrhages, or a falling intraocular pressure, which could signal bleeding in the eye or leak. On the plus side, improved tear assessment, longer TBUT, less redness would be expected. If any bleeding complications appear, supplements would be stopped. Dosing, formulation, and quality of fish oil. If patients and doctors decide to try omega-3s after trabeculectomy, a few practical points on dosing and product are helpful. Dosage. Clinical trials on eye health have used a wide range. For example, in the cataract dry eye trial, patients took 31000 mg capsules per day, total 3 gram fish oil, containing 540 mg EPA plus 360 mg DHA daily. The dry eye Krills fish oil trial provided about 1,500 mg per day of EPA plus DHA. In general, supplements providing 1,000-3,000 mg total EPA plus DHA per day are commonly used for ocular inflammation or dry eye. More is not necessarily better. The meta-analysis noted that higher EPA tended to yield more benefit, but excessive doses and four-green without medical indication should be avoided, as these may tip the bleeding balance. Patients should read labels carefully. A 1,000 mg fish oil capsule often only contains 300 to 600 mg of EPA DHA combined with the rest inert oil. Triglyceride versus ethyl ester form. Fish oil comes mostly as natural triglycerides or ethyl ester EE forms. Reesterified triglyceride RTG forms mimic natural fish oil, and some evidence suggests they are better absorbed and cause less fishy burp than ethyl ester. The Large Dream Trial used EE form and has been criticized that Tg form might have been more effective. Therefore, when choosing a supplement, many experts prefer a high-quality reasterified Tg formula or natural fish oil. Some pharmaceutical grade fish oils like G. L. lavaza, vacepa, are EE and highly purified, but OTC triglyceride forms, especially with added antioxidants, are also effective. The cheapest oils are often EE, so if budgets allow, look for products labeled Tg or RTG. Quality and oxidation. Of major concern in supplements is oxidation. Omega-3 fats spoil easily when exposed to air, light, or heat. A 2015 analysis found that half of fish oil supplements on Canadian shelves exceeded safe limits for peroxide or secondary oxidation products, and even in the US, 27% exceeded peroxide recommendations. Oxidized fish oil can smell rancid, bad breath slash fishy burp, and may even be harmful if consumed in large amounts, though human data is limited. In any case, oxidized omega-3 is likely less effective. To ensure freshness, buy reputable brands that report oxidation values, peroxide value, peanicidine, totox. Store bottles tightly closed in a cool place and prefer dark glass or opaque capsules. If the oil smells strongly fishy or musty, throw it out. Some supplements add vitamin E as an antioxidant. This can help slow oxidation. Triglyceride versus ethyl ester absorption. Although raw absorption differences exist, for moderate doses, 1 to 3 grams per dur, most people will get enough omega-3 from either form. If using an ethyl ester product, it is best to take it with a fatty meal to aid breakdown. In contrast, natural TG fish oil or algal oil DHA caps are absorbed well with or without food. Guidance. Who, when, and how to use omega-3. Putting it all together, here are general recommendations for patients and doctors considering omega-3 after trabeculectomy. Patient selection. Beneficial for patients who have significant ocular surface inflammation or dryness after surgery and who are not at high risk of bleeding. Typical candidates, patients noticing gritty, red eyes after stopping glaucoma drops, or those whose IOP post-op is under control, but surface irritation is troublesome. Less suited, patients who are stable and comfortable with current therapy, or those facing complex coagulopathies. Timing. Do not start fish oil immediately on surgery day. Allow initial conjunctival healing and disappearance of hyphema. A good rule is to begin around 1 to 2 weeks post-op once the surgeon is happy with wound closure and bleb formation. Initial dosing, a moderate dose, for example, 1000 mg EPA plus 500 mg DHA per day, is a reasonable starting point, often as two fish oil capsules daily. Some cases may benefit from up to 2,000 to 3,000 mg total, divided doses, if well tolerated. Check the supplement label to confirm EPA-DHA content. Form. Choose a high-quality fish oil or algal DHA-EPA supplement. Look for reasterified triglyceride or TG on the label, or trusted brands, often with third-party testing seals. Avoid supplements past expiration or with a rancid odor. Krill oil, phospholipid-based, is another option. It showed good results in one trial, though generally EPA content per memograms is lower, so pills may be smaller or more frequent. Safety checks. If you're on anticoagulants, warfarin, doax, clopidogrel, tacagrilor, etc., discuss omega-3 with your doctors first. You may need to skip or delay fish oil while those meds are being restarted after surgery. If a bleb leak or significant hyphema occurs, hold off on fish oil until the eye is stabilized. Watch for eye bruising, subconjunctival hemorrhage, or unexpected lowering of IOP, which could signal bleeding. If any bleeding issue arises, stop the supplement and alert your surgeon. Monitoring. At each follow-up visit, your ophthalmologist should evaluate both the bleb for leaks, vascularity, and the ocular surface, redness, tear film. They may inquire if comfort has improved. Routine blood tests are not needed for fish oil itself. However, if on anticoagulants, INR or other relevant labs should guide overall management. Duration. Omega-3 therapy is generally safe long term. If you find it helps your eyes after surgery, you and your doctor might continue it for a few months or more. Some people with chronic dry eye stay on low-dose fish oil indefinitely. If no benefit is felt after a few months, it could be stopped or tapered. Conclusion. In summary, omega-3 fatty acid supplements can be a valuable anti-inflammatory ally for postoperative eye comfort. Randomized trials, mainly in cataract and refractive surgeries, show that EPA DHA can improve tear stability and reduce dry eye symptoms. It is biologically plausible that they may also help control conjunctival inflammation after trabeculectomy, though direct evidence on bleb survival is lacking. On the flip side, omega-3 does mildly affect platelet function, raising theoretical bleeding concerns. Reassuringly, modern meta-analyses indicate that typical supplement doses do not significantly increase real-world bleeding risk. Still, caution is wise. In patients on full anticoagulation or any early bleb leak, fish oil should be postponed. Practical advice for patients. If your eye doctor and you decide to use fish oil after trabeculectomy, aim for a moderate dose, around 1 to 3 grams of EPA plus DHA per day, starting a couple of weeks post-op. Choose a high-quality product, triglyceride form, low oxidation, and keep taking your usual eye drops as prescribed. Watch for any increased eye redness or bleeding and inform your doctor. Key takeaways Omega-3s can improve post-op dry eye and inflammation, good for comfort, with minimal bleeding risk in routine cases. As always, supplements should be part of a comprehensive care plan. Talk openly with your surgeon or ophthalmologist. They can help select the right patients, timing, and dose, and monitor your outcome. In the end, omega-3 may prove a helpful tool in the recovery toolkit, but it should be used wisely. All links to sources are available in the text version of this article. You can find the full article at visualfieldtest.com. Thanks for listening. To check your visual field, click the link at the bottom of this article or visit visualfieldtest.com.