How does Optimel improve Dry Eye?
Optometry Practice
If you’re interested to learn more about Optimel and how it can improve Dry Eye, have a listen to this interview with Dr Katrina Schmid.
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Full Transcript
If you prefer to read, here’s the full transcript of our interview below:
Leigh: Thanks guys, for joining us today for the show! I’m very excited to have Dr. Katrina Schmid. She’s an Associate Professor within the School of Optometry and Vision Science at QUT in Brisbane, Australia, and she’s course coordinator of the Bachelor of Vision Science. She’s a research and teaching optometrist with her PhD in Optometry. She teaches ocular anatomy and physiology, ocular pharmacology, refractive error development and management. She’s a senior fellow of the higher education academy. The success of her application was based on her mentoring others in their pursuit of teaching excellence. She has more than 90 published research articles, with over two thousand citations. Her research interests include myopia, binocular vision, lens design, ocular surface disease, dry eye, and learning theory. It’s a pleasure to welcome Dr. Katrina Schmid.
Katrina: Thanks so much for inviting me to chat today, Leigh.
Leigh: It’s great to have you!
Leigh: Katrina, your background was in myopia and development. What interested you about dry eye and getting into treating dry eye?
Katrina: Well, I’d always been interested in the dry field, but obviously, it needs an opportunity or something to come along so that you can actually further that interest in terms of research. Of course, it’s a really common problem. It’s probably our most common eye condition, and also as you get older yourself, you start to really realise the impact that it has on you and other people and all your patients. As you would know, Julie Albietz has been working on the honey type products for many years since early in 2000. I’ve known her for a long period of time, and she came to me wanting to have some assistance in terms of research collaborations. It’s no fun to do research on your own. It’s much, much nicer to work with a team towards solving problems and working together, and you can work out the design and do things just much more creatively, quickly, and just a better way in terms of two heads are better than one, so to speak. She came to me asking for my help and assistance to collaborate on the honey research that she’d been doing, and wanted to reinvigorate and start again recently. Then I started working with her on the honey products in about 2013 and 2014, I guess.
Leigh: That’s fantastic. That was just before the study period came out in 2014-15.
Katrina: The first main collaborative research publication that I had with her, that’s the big study in Clinical and Experimental Optometry that we did, that was published in 2017, but it was based on the research data that we collected from about 2014 through to 2015. No research, project, data collection is done overnight. It takes a long time, particularly in a study like this where there was a 114 participants that we recruited, and then we randomised them to different treatment groups. Then they obviously had a treatment period, so then they have to do the treatment, and you get the measures before and after. By the time you actually collect all the data, analyse all the data, then submit it for publication and then it gets published, you’re looking at that three year time frame to do that. So, yes, that’s the reality of research.
Leigh: It’s been wonderful, I know for myself, to have that original research to be able to prove to my patients that it does work. It’s been worth the wait for me.
Katrina: In terms of doing the research and the project, I guess, ocular surface disease in the dry eye field, has its challenges in that imagine that you have patients coming in who are using lubricant eye drops four or five times a day. That’s controlling their dry eye. They’re not suddenly going to go, oh, I’m just going to go into the control group, and I won’t use my lubricant eye drops for two or three months so that you can compare your new product and your new agent and see if the honey eye drops work better than nothing. It’s just impossible to do that. If you look at the research, the publication, you’ll see that what we’ve done is actually had the patients in both groups still continue with their lubricant eye drops, and then the Manuka honey is added as an extra. That’s the reality, really, of doing this type of work, as you can imagine as well.
Leigh: It’s important to maintain some of the status quo so that patients can then feel comfortable to try the new treatment.
Katrina: Yeah, exactly. We couldn’t possibly recruit participants where we see it, and we’ve tried, of course we’ve tried. Actually, everyone has tried. We say, I need you to do a wash out and not use any medications or anything for your dry eye for two months so that we can then start and look at the effect of the treatment. The best option is what we’ve done in our study where you keep patients on their existing lubricant treatment, then you add the new treatment as an adjunct, and they can pretty quickly tell you whether it’s making an improvement or it’s not based on what they’re already using if then, over time, they can drop down their lubricant, the lubricants that they’re using.
Katrina: Of course, you only have to look at the website and different comments of patients and people who used the Manuka honey eyedrops just to see how it works for them and how popular it is and how the improvements that people actually report that they get.
Leigh: Absolutely. It’s been a great product. Can you remember yourself when you tried one of the Optimel products for the first time?
Katrina: Yeah, so I have tried both of the Optimel products. The first one, of course, that was produced was the gel that’s in the tube. I don’t remember being quite shocked at … This was five years ago or more, about how much it stung. I just went oh my gosh. But then afterwards you go, oh, but my eye feels just … It’s lovely, and you get a little bit of an issue wetness, but that disappears and then your eye is beautiful white and your eyes feel better, and you see that improvement, so you’re willing to put up with that sting and initial discomfort because of improvements that you experience yourself within that 10 to 15 minute timeframe. Then that lasts for the rest of the day nearly.
Katrina: I’ve since switched to the, because I don’t have major, major dry eye, of course, to the eye drop formulation, which is a lower percentage of honey. It’s easier to get out of the bottle because it’s a solution. It doesn’t sting as much, and for my very mild condition that I have, it’s the better treatment. There’s obviously the two different forms of Manuka products that Optimel has. They’ve got the stronger gel ones for really severe blepharitis, and really, I think you’re supposed to more put it onto the lid margin where the problem is, meibomian gland problem and where the blepharitis is. Then for patients who might have less severe types of lid problems and dry eye problems, then it’s the drop that they’ve made, and to make it a little bit more user friendly for patients as well. People can use either. Some of our patients have a strong preference for one or the other. I think most of that’s about the type of problems that they have.
Katrina: I should mention that there is also a nasal spray as well, so there is an Optimel honey nasal spray that we’ve done. There’s one really small trial on in terms of whether that helps patients rhinosinusitis and then also their dry eye. Our experience with that is that the patients who have that sort of problems who use the nasal spray really find lots of benefit from it, and really we like that product as well. So there’s a range of products, and that’s been my personal experience with using them as well over the past few years.
Leigh: That’s fantastic. It’s great to hear about Optimel’s being used in many different areas of dry eye.
Leigh: Going back to your study, you had a really good uptake with using Optimel. How did you best explain to patients about the sting?
Katrina: I don’t think there’s any other way of telling them except that it’s going to sting for a really short period of time, and then it disappears. Obviously the most common reporting in the study was that patients say it stings, but that doesn’t stop them from using it. The drop version stings much, much less than the ointment version does. I guess, if you’ve got a … yeah, I guess if you’ve got a patient who’s particularly sensitive with that sting, then you need to maybe consider the drop form instead, which doesn’t sting very much at all. But you have to remember that the gel form is being recommended to our patients who have got severe dry eye. Often they have tried every other product on the market for many years and got nowhere. They’re pretty willing to really just have a go and to try anything. This is a product that can be used long terms without any side effects, really, without any long term problems, and it works differently to anything else in terms of its antibacterial and its anti-inflammatory effects.
Katrina: The only really contra-indication is people who are allergic to honey or bee products. That’s written on all of the packaging information, but I don’t think we come across very many people who have that as an allergy. But it must exist because it’s on the packaging, and it’s obviously a known effect. Because it is honey that you’re putting on to your eye surface.
Leigh: Sure. Most of the people I ask about, I ask them have you ever had an allergy to bee stings, and they’re no, so they seem like a good candidate to try Optimel.
Katrina: Yeah. We ask that as the one precautionary really major question, just in case. We haven’t seen any other adverse reactions or any other problems with patients using this product at all. Nothing else come up that we know of.
Leigh: That’s really good.
Leigh: With the mechanism of action, so could you tell me a bit more about how Optimel works in an anti-bacterial sense?
Katrina: Don’t know how honey actually has its anti-bacterial properties are really well known. It’s obviously a really complicated type of product in that there’s many active ingredients or components within it. It might be something to do with the PH of it. It’s got something to do with the actual ingredients in it. When you, obviously, take swabs of patients eyes, and you swab them onto plates, and you see what grows, there’s a lot less bacteria and other organisms that grow in patients who’ve used the Optimel. It’s known to decrease the bacterial load on the surface of the eye.
Katrina: In honey in bee hives, where they’re obviously making all the honey, there obviously needs to be that anti-bacterial type properties to the honey to keep the whole hive functioning well and prevent disease in the bees and so on. It’s inherent within the product, this type of anti-bacterial effect it has. Then it’s known that honey of different kinds, so this one’s from [delicto 00:11:48] [spermin 00:11:50], which is basically Manuka, it’s particularly rich in whatever those factors are in terms of the anti-bacterial factors. I think that’s about probably all that I can tell from what it is about in the honey that actually gives it that affect. I think they’re still working on trying to work out what that active ingredient is that does it, but I don’t think they know yet which component of it is, really.
Leigh: In the Optimel gel, I believe that there’s no preservatives in that. Is that because it’s super saturated?
Katrina: Yeah. That’s right. I mean, you would know that if there’s no water component within a product, so then it doesn’t need to have … and it has its own anti-bacteria properties anyway, then it doesn’t need to have a preservative in it. The other ointments, like Lacri-lube and different things that are 100% ointments, where they have no water component, therefor don’t need to be preserved.
Leigh: Right, okay. That’s interesting. The anti-inflammatory properties, we’re still learning more about what they are and how they work?
Katrina: One of the unanswered questions in this field is really how the honey does that in terms of both its anti-bacterial effect and it’s anti-inflammatory effects. It would be really interesting to do studies on the mechanisms and how it works. The difficulty is that once you have products actually working and on the market, it’s hard to get research money to actually prove how and why they work because you’ve got a product on the market and it’s working, and so what, in a clinical sense, are you going to change in terms of understanding that. That’s the difficulty. It would be really nice to work out how those anti-inflammatory and anti-bacterial actions work. They know that they do in terms of research studies where you can see the cell counts or the bacterial go down. You can see on the patient’s eyes that all the inflammatory mediators decrease, but what it is within the honey itself that causes that effect’s really difficult to know.
Katrina: The microbial activity, it’s definitely something about that high acidic PH, and that’s why the produce stings when it goes on. There’s something else about methyl glycol and cationic antimicrobial peptides that are involved in the honey itself, but as I said, exactly isolating the actual parts of the honey that do those things is not well described at all.
Leigh: It would be interesting from an eye point of view, but also for medical uses, too, as it becomes clearer what the properties are.
Katrina: Yes. That’s right. Like it’s known that MMP-9 cytokine goes down patients who’ve used the honey products, and that’s one of the main inflammatory markers on the ocular surface, but actually working out which of the active components are responsible isn’t really known. That’s also stated in our paper when we’ve researched and gone through the literature. As you know, honey is used in wound healing and repair as ointments for non-healing ulcers, skin ulcers, and has many different applications.
Katrina: I guess you’re meaning that there’s a limited supply of honey, and as this product becomes more and more popular, how can the demand … You many totally outpace supply in terms of the ability to get honey. And if there were some commercial product that was based on one or two of the components, of course that might give you better supply chain in terms of the product, but on the other hand, it may impact the whole effect that you get, like often it’s like vitamins compared to eating the whole apple thing, it’s an analogy. Once you take away just bits and just put bits together, you may not get the effect of the whole, and so I think that would be the concern in terms of just doing a chemical hone in of the honey product itself.
Leigh: For sure. Yeah, if you were dreaming up the ultimate dry eye drop or medication, you might discover all the components, but the synergy between them, it just might not be there compared to the Manuka.
Katrina: Yeah. That’s right. It may be 10 or 20 different components of the Manuka honey that produce the anti-bacterial and anti-inflammatory effects, not just one of the bits of if. I think that would be what the outcome would probably be because I’m just doing a non-scientific prediction there.
Leigh: Yeah, it’s interesting to play around with ideas. We know that Demodex produces or is associated with some bacteria, and in the paper you suggested that perhaps there might be some influence of the Manuka on those bacteria, that might be one of the outcomes.
Katrina: Yeah, so Demodex are a little mite that lives on the skin and near the lashes that everybody has in different amounts. In a majority of people, it doesn’t cause a problem, but in some people, it adds to blepharitis and to lid disease, so it is possible, in particularly the gel ointment, when you put it along the lid line, it has an effect on Demodex, but we haven’t definitively show or done studies on that. But it’s a potential mechanism in terms of improvement with the product.
Katrina: Tea tree oil lid scrubs are the favoured way at present of dealing with the Demodex mite in blepharitis, but unless you’ve got really special high microscopes, we only are assuming that that’s part of the cause of a patient’s blepharitis. A diagnosis in terms of that it is actually related to Demodex and not something else is difficult. Definitely something that could work, and I would think the honey product in all kind of blepharitis, no matter what the underlying cause might be.
Leigh: For sure. With the tea tree cleansers, is there a role for using tea tree and Optimel for treating two components of the disease?
Katrina: Yeah, maybe. Obviously, the issue with patients who have got severe dry eye, if they’ve tried everything, and they’ve tried lid scrubs, and they’ve tried everything, none of those things are helping, then obviously having a new product like, well [inaudible 00:17:54] now, or the Optimel honey or something extra for them to try is a real bonus. Then you would hopefully, gradually be able to decrease their need for other things. One of the standard treatments for disease induced dry eye are lid scrubs, and how you do those and with what products probably you’ll still need to do at least the lid scrubs and things how you usually would and then add in the Optimel as an adjunct extra treatment.
Katrina: Again, in the paper, we didn’t stop patients from doing their lid scrubs. I don’t think we particularly said whether they had to have a tea tree oil component to them, but that it’s still obviously important to clean the lash line, get rid of all the crud and things along that lash line at the same time. That makes the Optimel probably work better as well, but we haven’t obviously done studies on that.
Leigh: For sure. That makes sense to clear the lashes and keep everything fresh.
Leigh: With Optimel, for me, this study, your study, was interesting because it was done on patients with specifically MGD. Where should Optimel ideally sit in our dry eye treatment plan?
Katrina: We particularly recruited patients who had meibomian gland dysfunction because the gel is particularly designed to go onto the lids to help with the bacteria and help with the inflammation. Whereas if you have severe aqueous deficiency type dry eye from Sjogren’s disease or something else, it’s probably unlikely in that situation that the Optimel will give you the effects that you’re after because your problem is you’re just not making enough tears. It’s not that the oil component is wrong and it’s the lack of oil or problems with those meibomian glands that’s giving you are problem. Eighty to 90%, though, of dry eye is from meibomian gland disease and not those other kinds of problems, but it is particular to helping the lids, helping the dry that’s caused by problems with the meibomian glands and problems with bacteria and problems with the inflammation. That kind of tear problem rather than a tear problem that’s simply due to an aqueous deficiency. You can see, we’re not replacing aqueous component with this product. We’re helping the meibomian glands to produce more oil and the right kind of oil.
Leigh: For sure, yeah. And that’s preventing some of the stasis from the bacteria and [inaudible 00:20:19] and things like that.
Katrina: Yes, presumably.
Leigh: So, with Optimel, when someone starts using it, I know in the study you checked them at week eight, how quickly did you find that the Optimel, that patients started to notice a difference? Were there any interim checks before the eight weeks?
Katrina: In this study that we did, we didn’t do visits at shorter timing at all, so one of the limitations that we mentioned is that we don’t know in this study design whether the patients started to get their effects really quickly and then they plateaued, or whether they were still seeing improvements and it was a gradual increase and that they would continue to get improvements. Then we, of course, haven’t had a look at if you stop treatment, do you continue to have that beneficial effect for a certain period of time, or does it wear off quickly? We haven’t looked at any of those time dynamics in a controlled manner. I think the anecdotal type reports, though, from our patients is that straight away they’d see a benefit, and within a week a two most definitely a benefit that they would think of that was quite substantial, but that unfortunately probably if you stop taking the medication your problems come back because whatever’s caused the problems with the meibomian glands and the bacteria counts and all those things in the first place is still there and still existing, really.
Katrina: It may be a treatment that maybe gradually over time you can decrease the number of drops you use or how often you use the gel, but it’s probably like all sorts of conditions that are chronic, you need to do a treatment ongoing.
Leigh: For sure. It would be great with the progressive nature of MGD, it would be great to see whether Optimel can influence that pathway.
Katrina: Oh, yeah. That’s right. At the moment, we’ve done our studies on patients who already have quite advanced problems. They’ve pretty much tried all the different treatments. They’re in our dry eye clinics for those problems. They’ve gone through and tried everything, and then honey products come along and we suggested they use the honey products and enrol them in our studies. But, of course, it would be a great thing to do to see if you started patients on a preventative type of treatment, like perhaps this, earlier on, if you could actually prevent the changes to the meibomian glands themselves and prevent the cause of the condition.
Leigh: Yes. That would be exciting if they can show evidence of that.
Katrina: Yeah, and there’s obviously new imaging devices with the scanning laser where you can actually image the meibomian glands and image other cells and things and see what the effect might be.
Leigh: That sounds great, so that can image the asinine of the meibomian glands?
Katrina: Yeah, so yeah, there’s not great protocols out there, but we’re workings on that. But you can image along the openings of meibomian glands to a certain depth. You can’t image a long, long way, but we can actually image the asinine units and have a look at those. Then there’s also the standard meibography, the lower magnification methods where you can actually see the meibomian glands themselves in terms of the imaging, get drop out, look at how many you have left, how long they are, how short they are, what the impact’s been, because as much as you’ve probably had an impact on the meibomian glands and they’re either no longer present or they’re totally been destroyed, or they’re short and not functioning. Well, how do you actually fix that afterwards? You’ve had a real anatomical, physiological change to the structures in the lid, so just preventative treatments would be the way to go. As you know, having patients try things before they need things and getting compliance and actually getting people to do things as a preventative measure is not easy.
Leigh: Yes.
Katrina: Let alone … It’s hard enough to get patients to do the treatments that you recommend, let alone a treatment for the future.
Leigh: Absolutely. Yeah, at least if there’s some symptoms, and if they get that improvement, then they’re more likely to stay motivated to keep using it.
Katrina: That’s right because all the treatments have costs and having to put them in and take time, so that motivation feedback in terms of getting a beneficial effect is obviously really important. If you’re trying to do a preventative treatment for the future, and you have no symptoms, how do you get someone to pay for something and keep doing it? All of us should exercise more for our future health and well being and yet so many of us don’t. It’s the same thing.
Leigh: Yes. Yes, it’s always in the moment there’s plenty of other things that get in the way of those good intentions.
Katrina: That’s right.
Leigh: Yeah. Just going back to the honey. The Manuka honey, it’s been used in medicine for the MRSA, that are resistant to traditional antibiotics. Is there any chance that with continued use of the Manuka on the eyes they could develop a bacterial resistance in your view?
Katrina: No, and I’m not an expert in that field, but my reading is that there’s no … because of the way it works, there’s no potential for resistance to occur. I know they’re not really quite understand how its antibacterial effects work, but it’s something to do with the PH, with changing the environment that the organisms would be trying to grow in. It’s something else about what’s in the product and there’s many different components to it. My understanding is that it’s pretty unlikely to zero that you would get a resistance of any kind to this product. As you say, that’s why it’s being used in Methicillin-resistant staph in hospitals and different situations now.
Leigh: Yeah. It’s been a real bonus for people that have had those infections.
Katrina: Yes. Yeah. That’s right, to have another option of something that might actually work and do something.
Leigh: Absolutely.
Katrina: My understanding is that having resistance, bacterial resistance, to this product is extremely unlikely.
Leigh: Sure. Okay, great.
Leigh: Is there any chance of some stray immune cells getting hyper-sensitized to Manuka honey over time?
Katrina: Oh, that’s a good question. I’m sorry, I would have to look up and find the answer. Obviously, it dampens down the inflammatory response. Whether you can … I guess you can develop sensitivities over time to anything, so as you get older, your likelihood of becoming anaphylactic to different things and becoming sensitive to different products obviously increases. That’s just a reality of it, so I guess there’s a potential that more people could gradually over time get honey and get allergic to bee stings and allergic to those things which would decrease their ability to use the product. I don’t think from just being, instilling it into your eye that would create that. I think it would have to be some age related or immune change from a systemic condition that might give you that increased sensitivity would be my thoughts on it. With the thing that I’m not an expert on immune responses, I don’t think we’ve seen any patients, and I think Julie’s got people who have used the product for more than 10 years, develop a reaction to it simply because they’ve been using it for a long period of time. If that’s what you mean in terms of the question.
Leigh: Yeah. That’s great. It’s great to know those people have been comfortably using and no problems so far.
Leigh: The Optimel spray, that’s one of the things you mentioned earlier, what are some of the things that you’re still interested about with Manuka honey and further research?
Katrina: Yeah, so except for that one paper where we had lots of patients use it, there was 144 patients, a big study, the other two small studies that we’ve had published last year, one was on the nasal spray, but it was a really small group of participants. So showing that if you had a inflammatory rhinosinusitis and you used that antibacterial nasal spray for that, then you would also, of course, get some improvement in your dry eye as well. It was a very small sample that we used, so doing more work on that honey nasal spray would be really useful.
Katrina: We had one small study, again, with really small participant numbers, where with looked at whether the honey product could be used in contact lens related dry eye, whether it was safe use in patients who wore contact lenses. Again, it was just a really small pilot study that we published in contact lens and interior eye showing that it was safe to use in contact lens wearers. But actually showing more about when and how our contact lens wearers might find it useful would be interesting as well to do. I know that Julie has a huge series underway in terms of she’s been using this product for many other kinds of conditions and problems, so she’d like to get that information out in terms of the other applications for the honey products. Its not just meibomian gland disease and dry eye. There’s other applications for it in terms of the ocular surface area, in terms of problems that people have. I guess they’re the key things that we’re thinking about and working on at the moment.
Leigh: Yeah. Absolutely. It’s exciting to see all the lots of different conditions and how it could benefit from Optimel.
Katrina: Yeah. That’s really, of course, Julie’s expertise in terms of the patients that she has that have really severe ocular issues and how she’s using the product in those ways. We’ll definitely be hopefully working on something very soon on that for people.
Leigh: Yes. That sounds wonderful. Thank you very much for all the time you put into the study about Optimel, all the hours and research and general articles that you’ve read, and thank you for giving, as practitioners, that you for giving us confidence in Optimel. It’s been terrific.
Katrina: Yeah, so I would think that it’s definitely a product that you could use in your clinic to help patients who’ve got dry eye symptoms, and you’re using it and including it in your batter of different treatment options that you suggest for people to use. I think you’d find a lot of positive responses to it. I think the gel is still only available through optometrists and through ophthalmology practises, but the eye drop form is available the counter and pharmacists as well now, so it’s much more widely available than it had been.
Katrina: Obviously the first thing for all optometrists to do would be to get a bottle of the product themselves, probably the eye drop version, and put it in and try for themselves what the effect is and what they get so they’re aware of the little bit of sting, the effect that you get, and that would make them much more likely to use the product as well. As I said, you only ever get positive reports from patients about the product and how it’s really helped.
Leigh: Absolutely. It’s a really good product. I use it myself. I recommend it to my patients, so yeah, it’s been very good.
Katrina: Excellent to hear.
Leigh: Yes. It’s great. Well, thank you so much, Dr. Katrina Schmid, for giving your time to talk to us today. I wish you all the best for your ongoing research and teaching at QUT.
Katrina: Thanks very much, Lee, and thank you everyone for listening in. I’m sure that you can email or send questions to Lee or to myself if you have.
Leigh: What’s the best way, if people had a question that they wanted to shoot through to you, what’s the best way to get in contact with you?
Katrina: My QUT email, so if you just Google my name, my email should, QUT email should come up. So, k.schmid at qut.edu.au.
Leigh: Okay. Wonderful. Well, thanks so much again for giving your time, Katrina.
Katrina: Oh, you’re most welcome.
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