World renowned dry eye expert Dr Rolando Toyos was recently in Australia to promote his new book. He tells Insight about his mission to dismantle many of the belief systems around dry eye disease, and why the answer often lies much deeper within patients.
When Dr Rolando Toyos tried to convince the world intense pulsed light (IPL) therapy had applications in eyecare, it took many years until a company finally agreed to commercialise the technology. The approach remains a gold standard treatment in dry eye disease (DED) today, and now he is on a new crusade to compel the industry to change its ways.
Through several decades researching DED – long before it became a part of mainstream eyecare – Toyos says diet is one of, if not the biggest, influencer on outcomes. It fits with his approach that DED goes much deeper than the surface of the eye; instead it’s a skin gland condition linked to systemic issues within the patient.
Toyos’ efforts have manifested in his latest book: Toyos Dry Eye Diet – What to eat to heal your dry eyes. He was in Australia at the beginning of May, linking up with Lumenis and Ms Liz Barrett’s Dry Eye Solution, to promote his work aimed at dry eye sufferers and eyecare professionals who see these patients.
For several years, Toyos discussed diet with DED patients, but around 18 months ago he became more radical in his approach telling patients exactly what to eat, and what to eliminate. With demonstrable improvements in their DED signs and symptoms, Toyos wanted to share his work with the broader community in a book that fuses his clinical experience with scientific and lifespan studies, as well as research into Blue Zone populations where centenarians exist in disproportionately high numbers.
“To achieve a paradigm shift in our field, it’s not like the tech world where a new app comes along and supersedes older technology immediately. It takes about 20 years in medicine – this has been researched and can also be seen in the time it took from when I started promoting IPL to the time it gained acceptance,” he says.
Toyos has been researching DED for more than 25 years. When he started there wasn’t many doctors concentrating on it.
“That was bad, and now we have many doctors concentrating on it, but they’re treating wrong; I’m talking about the traditional way we’ve been taught with warm compresses, lid scrubs, artificial tears, and doxycycline. In terms of ‘dry eye specialists’, I would say about 5% of them are really honing in on diet, and that’s the reason why I wrote this book,” he says.
“For the paradigm shift to happen, we need a new crop of doctors trained in a new way and the older doctors to dump what they have learned previously. There needs to be an unlearning phase, followed by a new learning phase and then implementation. We’re still in the unlearning phase; I can see it in people’s eyes when I’m lecturing. I say don’t do A, B, C and D, and many will say they have been giving artificial tears or doxycycline forever, isn’t that good? We need to completely change our approach.”
It begins in the gut
In the ophthalmic world, Toyos is most famous for discovering IPL’s applications in DED.
In 2001, after incorporating aesthetics into his general ophthalmology practice, he used IPL to coagulate the abnormal telangiectasias of the skin in rosacea and to perform facial rejuvenation. Some with meibomian gland dysfunction (MGD) reported IPL had not only improved their skin but also their DED symptoms. After studying further, his team began investigating how to optimise IPL for DED, which led to Toyos working with DermaMed to bring the first DED IPL system to market, before later working with Lumenis.
Toyos has also developed the Toyos Protocol used to treat dry eye by doctors and other researchers around the world, and authored his first book in 2015: Dry Eye Disease Treatment in the Year 2020, detailing proven treatments, discarding ideas that have failed but continue to exist and offering a glimpse into the future.
Since publishing this work, he says the science has exploded about what changes can be made at the cellular level through diet and supplementation. Researching how this relates to DED has led him down rabbit holes and even required some “unlearning” on his part, but the science points to lifestyle, diet and nutrition as a key factor in DED, with benefits beyond the discomfort patients feel in their eyes.
“DED patients are a difficult group because there are so many problems that can affect the tear film. My definition is different than others, I see it as a skin gland condition that can be affected by systemic problems. All these factors come into play and that creates a poor tear and inflamed tear that starts to affect the ocular structures. Then, over time, it becomes a problem of chronic pain, which starts to affect the psychology of patients,” he explains.
“In my view, dry eye disease is a dermatological disease, it’s an eye disease, an immunological disease, and when you start talking about issues affecting the skin and glands, you’re really talking about issues like diet, lifestyle, and other aspects to help the overall systemic problem that enable you to ultimately improve the tear.”
For Toyos, this often begins in the gut. Even five years ago, he says gut bacteria wasn’t part of the DED conversation, but research in this area has accelerated in more recent years. The gut is where the body’s immunology stems from, but an acidic gut with bad bacteria causes the inflammatory mediators in the body to heighten, while a healthy gut will decrease inflammatory cytokines, having a positive downstream effect on DED.
“I’ve always talked to patients about diet, but I was never very specific. The conversation was more like: ‘don’t eat these inflammatory foods, let me put you on an anti-inflammatory diet’,” he says.
“But a year and a half ago, I started giving patients a specific list of what foods I wanted them to eat, while eliminating everything else. This is to build up their good gut bacteria and it’s something I looked at with stool samples, working with dieticians. It was working. Then patients move on to a different, overall diet after two months and it’s performing great. I’ve also found the uptake is so much better now that I explain each food and why.”
Toyos says many of the foods within his DED diet have been linked with increase life expectancy.
“Some patients have a wake-up call of a heart attack to really change their health and lifestyle. When I’m talking to patients, I’m telling them this is your wake up call, your dry eye is sending a signal to make yourself better.”
Berries, mushrooms, soy and more
When a DED patient enters Toyos’ clinic, the first thing he’s looking at is their skin; around 90% of patients with a skin condition such as acne or rosacea will have a DED problem affecting either the meibomian or lacrimal glands. Next, he’s looking at the medication they take and other medical problems.
“For example, patients with rheumatoid arthritis or diabetes are at more risk of developing DED. Many of the medications they’re taking can have an impact too: oral anti-histamines, psychology medications, and statins for cholesterol, but it goes beyond that now,” he says.
“We’ve got patients that have been taking something like doxycycline for years to control inflammation, but that’s actually killing all of the good gut bacteria. Now we realise that the immunological heart of our health is controlled by our gut, so if you’re killing your good gut bacteria and bad gut bacteria is taking over your gastrointestinal system, that’s going to affect your eye health.
“The way I see it: if you want to be a dry eye specialist, you have to start reading not only eye journals, but what’s going on in dermatology, anti-ageing, immunology, and nutrition.”
Once Toyos has a clear picture of the patient’s dermatology and medication list, before getting to the slit lamp, he’s then discussing diet. In the past 40 years, he says the Western world has moved away from a more planted-based diet to one that consumes more meat, and ultra-processed foods, leading to heightened and/or chronic inflammation.
The patient’s individual profile will impact what sort of diet is ultimately prescribed. For example, one of the toughest cases is a DED patient with allergen (around 60% of all DED cases). He says there is a study showing in these patients mushroom intake can decrease signs and symptoms of allergy.
Elsewhere, there’s specific studies showing supplementation of resveratrol (found in grapes, wine, berries, and more) can decrease DED signs and symptoms. Lutein and zeaxanthin (found in many vegetable) can also do the same.
“Alcohol intake has also been looked at and shows it will affect women more than men in DED signs and symptoms,” Toyos adds.
“Another study looked at the intake of soy – an oestrogen mimicker – to see if that would decrease the hot flushes women experience in menopause, and it actually didn’t decrease hot flushes but instead decreased the signs and symptoms of DED.”
When looking at the positive affect of probiotics in DED, Toyos says there’s evidence to support this, but warns it’s limited. This is because the study in question did not take stool samples, therefore they could ascertain whether the patient’s gut health had actually improved along with their DED.
“But we know if we can improve gut bacteria, this will improve the signs and symptoms of DED, and the only thing that’s really been shown to do that is a switch in diet. It’s about turning the acidic GI tract into a more basic GI, and there’s foods that we eat that are both prebiotic – that will feed the good bacteria in our body – and probiotic, which will populate the gut with bacteria. That’s what is contained in my starter diet.”
Toyos says a lot of research is focused on sirtuins – a family of signalling proteins involved in metabolic regulation – that are thought to prolong life and improve mitochondria function. Some foods such as strawberries and blueberries contain sirtuin-activating compounds (STACs), so these are abundant in Toyos’ DED diet.
“For example, apples have a lot of quercetin, which is a STAC. Not only that, apples also have a role with the tumour suppressor gene maspin, so I have my patients eating a lot of apples because it’s also a prebiotic, probiotic,” he says, adding that walking and exercise are sirtuin-activating activity.
Once patients finish the starter diet, Toyos advises them to adopt the 90:10 rule when it comes to eating health and unhealthy foods, as adopted by Blue Zone populations. If alcohol is to be consumed, it’s red wine.
Dry eye and fad diets
In his clinic, Toyos persuades many patients off fad diets. In fact, so much so, he has devoted a section in his new book arguing why most modern-day diets are counterproductive in DED.
He’s also included a DED glossary where he gives his take on several common treatments. Here, readers can find out why he’s against the use of artificial tears, lid scrubs, warm compresses.
“This isn’t anecdotal or what I think, it’s backed by research. I discuss the research and if there’s positive or negative, I’ve mentioned them both, so a clinician can go through and make their own informed decision,” he says.
“This book took me two years to write, and the reason is that each rabbit hole I went down would lead to three more. It’s a very complex field, and I think it does take a clinician to decipher it all. You could probably find a research paper that will justify any point of view.”
With all proceeds from the book going towards the Toyos Foundation providing free eyecare to the underprivileged, Toyos says eyecare professionals shouldn’t be afraid to shake up their approach, and begin getting to the root of their patients’ DED.
“When looking at ways to make somebody to change their diet, out of friends, family, TV and other influences, the number one approach is a recommendation by a doctor,” he says.
“We hold a lot of power, and it’s time we used it.”
More reading
Dry eye disease and nutrition: are we what we eat?
How Jason Holland uses the Lumenis OptiLight IPL system in his dry eye clinic
Bausch + Lomb acquiring Xiidra dry eye drug from Novartis
