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Osteopathic Techniques for Open-Angle Glaucoma

Rahul Pandey and Indian colleagues recently conducted a small pilot study to explore the effect of muscle energy technique and myofacial release on primary open-angle glaucoma (POAG). POAG, the most prevalent form of glaucoma, is a major cause of blindness worldwide. A build-up of intraocular pressure (IOP), due to poor aqueous humor outflow, is the primary risk factor for POAG. In patients with POAG, intraocular pressure slowly increases to 20-30 mm Hg, from a normal of 10.5 to 18 mm Hg, damaging the optic nerve and producing peripheral and, eventually, central vision loss. Conventional treatment includes lifelong medication use to control the pressure and surgery.

Pandey et al say that autonomic dysfunction, constriction of the superior and inferior orbital fissure that provides space for blood vessels and nerves, and muscular dysfunction are among the contributors to increased IOP. Contraction of muscles around the eye orbit that govern the eyelid (orbicularis-oculi muscle) is known to raise IOP. A normal blink increases IOP by about 10 mm Hg, and powerful contraction of the muscle can push IOP to 50 mm Hg or higher. Moreover, the authors say, "An imbalance in the ocular muscles tone can cause a movement dysfunction at the sphenoid bone, at the maxilla and at the ocular muscle nerves." In addition to muscle contraction, flexibility between the bones in the eye orbit and skull - particularly the phenopetrosal suture, the occipitomastoid suture, and the lacrimal bone--are key for functional drainage in the head and preventing IOP.

Pandey et al decided to test the effect of two osteopathic techniques to balance extra-ocular muscle tone and improve drainage of aqueous humor--muscle energy technique (MET) and myofascial release (MFR). Nine patients, ages 15 to 30 years old, completed three weeks of MET/MFR treatment, consisting of a 30-minute session, six days per week. Intraocular pressure, measured at baseline and at treatment's end, showed a mean reduction of 3.1[+ or -]1.9 mm Hg (p=0.002). The authors note, "The reduction in each 1 mm Hg of IOP lowers the progression of the risk of disease by approximately 10%." In addition to reducing intraocular pressure, the treatment relieved eye irritation and headache reported by patients.

In addition to small sample size, lack of a control group, and lack of randomization, the authors viewed their failure to document physical activity level and other symptoms as study limitations. More research, of course, is needed to confirm the effects of this treatment and to identify responsive populations.

I found the osteopathic view of muscle tone and bone structure in relation to glaucoma fascinating. It made me wonder if there are exercises that can help prevent the constrictions that contribute to increased intraocular pressure. Do people who habitually contract the orbital eye muscles (when squinting or frowning) increase their risk of open-angle glaucoma? Do the same physiological processes contribute to other forms of glaucoma? Would breathing techniques that balance autonomic function affect IOP? It amazes me how simply looking at a problem from another viewpoint can generate all kinds of possibilities.

Pandey R, et al. Non-pharmacological therapies for primary open angle glaucoma: A quasi-experimental pilot study. Saudi Journal of Ophthalmology. 2017;31:95-98.

Nanoparticles and Allergy Response

Over the past decade, manufacturers have increased their use of nano-sized chemical compounds (diameter, 1-100 nm) in commercial products. The Project on Emerging Nanotechnologies ( lists over 110 nanoparticle-containing foods and cooking supplies. Nano-sized materials are also used as anti-setting agents in cosmetic foundations, for ultraviolet radiation protection in sunscreens, and as antimicrobial agents in clothing, bandages, detergents, and other products that contact the skin. Some researchers, like Kazuma Higashisaka and colleagues at Osaka University (Japan), are concerned that these particles may have unrecognized toxic effects.

Present regulations evaluate safety by the chemical structure: "... If the bulk or submicron-sized material is deemed safe, the nano-sized material is also assumed to be safe." However, nano-sized particles don't act the same as larger materials. Nanoparticles can display unique electrical properties, greater tensile strength, increased liquidity, and greater chemical reactivity. Nano-materials have greater surface area per unit weight than larger amounts of the same material and readily interact with proteins and other biological molecules. In fact, proteins in plasma will surround nanomaterials within 30 seconds of exposure, forming a "protein corona." "The protein corona is thought to confer nanoparticles with a biological identity that determines where they will localize and what biological effects they will have," say Higashisaka et al.

A 2017 review, by Yasuo Yoshioka et al, examined the possibility of allergic responses caused by skin exposure to nanomaterials in commercial products. The authors point out that about 4,000 chemicals are known to sensitize the skin and induce allergic contact dermatitis, but little is known about the effects of nanoparticles on the skin or its microbiota. "Because sensitization to chemicals is sometimes induced at relatively low levels of exposure to that substance via skin exposure," the authors write, "the sensitization potential of nanomaterials might be an important potential nanotoxicity." At this point, researchers are debating whether nanoparticles can penetrate the epidermis and the protective barriers of healthy, intact skin. Nonetheless, some studies indicate that nanoparticles have immunomodulating effects--"even if they do not penetrate the skin." Nanoparticles may affect antigen-presenting cells in the epidermis (eg, Langerhans cells). They may also reach the dermis and other protective immune cells via hair follicles.

Of course, if the skin is damaged and the barrier is broken, nanoparticles are free to travel into the body. A 2015 study conducted by S. Smulders et al found that titanium levels increased in lymph node cells after topical application of titanium dioxide nanoparticles, along with a skin-sensitizing chemical, to a cut in a mouse ear. Also, mice exposed to the titanium compound--unlike those exposed to silver or silicon dioxide nanoparticles--displayed increased skin sensitization.

In addition to chemical compounds, nanoparticles may increase the body's response to pollen or other antigens on the skin. Because of their greater surface area, nanomaterials can bind more antigen per mass unit. Yoshioka et al write: "... we must not forget that exposure to nanomaterials via skin often occurs simultaneously with exposure to other chemical compounds and allergens, such as foods and pollen and that this interaction might modulate the antigenicity of these compounds. Many recent reports have shown that skin is an important site for the onset of allergy."

The Japanese researchers do not discount the useful and unique properties that nanomaterials bring to commercial products, but they seek ways to use nanomaterials with an eye on safety. "Given that the health effects of exposure to nanoparticles may become evident only after long-term exposure, there is an urgent need to begin collecting information on the health effects of real-world exposure to nanoparticles in humans" say Higashisaka and colleagues. The Osaka researchers are working on the use of biomarkers to predict nanotoxicity during early stages of a product's development--long before a company releases a new product to the market.

Higashisaka K, et al. Nano-Safety Research: Examining the Associations among the Biological Effects of Nanoparticles and Their Physicochemical Properties and Kinetics. Biol. Pharm. Bull. 2017;40(3):243-248.

Smulders S, et al. Nano-Ti02 modulates the dermal sensitization potential of dinitrochiorobenzene after topical exposure (abstract). Br J Dermatol. 2015;172(2):392-9.

Yoshioka Y et al. Allergic Responses Induced by the Immunomodulatory Effects of Nanomaterials upon Skin Exposure. Frontiers in Innumology. February 16, 2017.

Omega-3 Fatty Acids and Dry Eye

"Because omega-3 fatty acids decrease inflammation and promote health, they can provide significant benefits for patients with dry eye--a disease inflammatory in nature," says Julie Poteet, an optometrist and certified nutrition specialist, in a 2017 article. The higher the ratio of omega-6 to omega-3 tear lipids in people with dry eye, the lower the tear volume. While this association does not prove causation,

studies have found that omega-3 supplementation decreases dry eye symptoms.

Because the Western diet is high in omega-6 fatty acids, Poteet recommends supplementation with omega-3s. Omega-3 fats, such as EPA and DHA, compete with omega-6 fats for incorporation into cell membranes. Cells use both types of polyunsaturated fats to make signaling molecules. Leukocytes use omega-6 fats, such as arachidonic acid, to make pro-inflammatory cellular mediators, including thromboxanes, prostaglandins, and leukotrienes. Omega-3 fats, however, are used to make resolvins and other molecules that serve as a brake to inflammation. The presence of more omega-3s in the cell membrane limits the amount of pro-inflammatory mediators that cells can make and provides other benefits. In studies of moderate to severe dry eye conditions, omega-3 fats have inhibited several markers of inflammation, including tear inflammatory cytokines and T-cell infiltration. Also, omega-3-derived resolvins have reversed corneal epithelial damage due to dry eye and increased tear flow in animal studies.

Although specific dosing guidelines for dry eye are not yet available, Poteet says that between 1,000 and 2,250 mg of EPA and DHA from fish oil, using a reliable brand, is a "reasonable starting dose." She says that omega-3 alpha-linolenic acid, found in flax oil, does not "reliably or efficiently" convert to EPA and DHA in humans. In addition, Poteet recommends supplementing with 500 mg of gamma-linolenic acid (GLA), an omega-6 fatty acid that can produce anti-inflammatory prostaglandin El and has benefits for people with dry eye. GLA is found in evening primrose oil, borage oil, hemp oil, and black currant seed oil.

Supplementation may have some adverse effects. Fish oil can produce unwanted gastrointestinal effects, including "fishy burps" and loose stool or diarrhea. Also, high doses of EPA and DHA increase bleeding risk, so Poteet urges practitioners to ask patients if they are taking drugs or other supplements (eg, garlic, ginkgo, saw palmetto) that have anticoagulant effects. Poteet also mentions the possibility that omega-3 supplementation may have immunosuppressive effects, according to a 2013 study (Fenton Jl et al. Immunomodulation by dietary long chain omega 3 fatty acids and the potential for adverse health outcomes. Prostaglandins, Leukotrienes, and Essential Fatty Acids. 2013;89(6):279-90). She says, "While it's unclear if these findings translate to impaired immune function in vivo, exercise caution... in individuals with compromised immune systems."

Poteet J. From Alpha to Omega: How Fatty Acids Fight Dry Eye. Review of Optometry. May 15, 2017; 78-83.

Bifidobacterium Mixture for Seasonal Allergic Rhinitis

A 2017 Italian study, led by Michele Miraglia Del Giudice, found that a combination of Bifodobactrium longum BB536, B. infantis M-63, and B. breve M-16V significantly improved allergic rhinitis symptoms and quality of life in children with pollen-induced rhinitis and intermittent asthma. The unidentified mixture, which is marketed as a medical device I class, has been tested for in vitro compatibility, stability over time, and optimal dosages. In previous research, B. breve improved symptoms of atopic dermatitis and restored enteric microbiota after antibiotic use; and B longum BB536 significantly reduced nasal symptoms and Th2-polarized immune response in patients with seasonal allergic rhinitis. B infantis M-64 is commonly used in probiotic formulas, according to the authors.

The prospective, double-blind, placebo-controlled, randomized study enrolled 40 children (18 males; mean age 9 [+ or -] 2.2 years) with a documented allergy to Parietaria pollen. One group received sachets that contained the Bifidobacterium mixture, and the control received sachets containing an inert excipient placebo. The participants were to dilute the contents of one packet in a little tepid water or milk and drink it in the morning. The treatment continued for eight weeks. The children were evaluated at baseline and at treatment's end. Lung function in the two groups was similar at baseline. At the end of eight weeks, allergic symptoms and quality of life measures significantly improved in children taking the probiotics, while symptoms and quality of life significantly declined in the placebo group.

"The rationale for using probiotics in allergic disorders is robust and is based on the concept that the balance between immunologic tolerance and inflammation is regulated by crosstalk between intestinal microbiota and innate and adaptive immune response," say the authors. Not ail bifidobacteria produce the same results; effectiveness and anti-inflammatory actions vary among bacterial strains.

The small number of patients in this study is the main limitation. The authors would like to see this preliminary trial followed by a larger, multicenter study.

Del Giudice MM, et al. Bifidobacterium mixture (B longum BB536, B infantis M-63, B breve M-16V) treatment in children with seasonal allergic rhinitis and intermittent asthma. Italian Journal of Pediatrics. 2017:43:25.

briefed by Jule Klotter
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Title Annotation:muscle energy technique and myofascial release for glaucoma, nanoparticles and contact dermatitis, omega-3 fatty acids for dry eye
Author:Klotter, Jule
Publication:Townsend Letter
Date:Apr 1, 2018
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