#this website has other virtual tours but i thought i’d show you guys this one bc it’s making me a little bit insane

[johntorrington]

just found this virtual tour some guy did of the cape evans hut. ough.

[azraeldean]

the devinee episode 1

 (Nash’s house - Edge’s room.)

(Edge (a blond human of about 12) is sitting with his communication device with his best friend Malik ( a brunette human of about 12))

Edge: Can you believe it Malik?

Malik: That you hacked your communication device?

Edge: No, that I am talking to a female.

Malik: Ok, it is hard to believe your talking to Faelerah female. Considering we live in a society devoid of women.

Edge: I know I am so lucky! ( They both giggle.) Let’s look at her picture again. ( He pushes a button on his communication device and we see a cute blue skinned female in several pictures.) I am more intrigued every time I see her figure.

Malik: I bet you are.

Edge: Hey Malik, Do you have the Chance collectible doll. I want him to sign it. ( We see a box with a blond doll in it, who must be Chance)

(The Nash’s house downstairs)

We see a picture, of what must be Edge and his Human father when Edge was little. The camera moves up and we see his human father put it back on a shelf)

Static: ( Human father Nash’s first name) Edge! Ready to go?

Edge: Hold on a second.

Static: I can’t hold on a second. Jace is waiting for us.

(Edge pushes a button to make the pictures disappear from his communication device and tries to put thedevice back to a neutral screen. Both humans get nervous. Edge’s father enters the room.)

(Edges room)

Static: Baby, what are you two doing? I thought you guys were excited for today.

Edge: we are.

Static: and what are you doing on your communication device?

Edge: Me and Malik were just looking up information on our new school.

( Edge brings up the school website. Static starts scrolling threw the popped up virtual website. Scrolling threw a virtual tour of the school.) 

Static: ( looks over and picks up the doll) I always knew he would become something big. Me back when I was in school I had a blonde Mohawk. Obviously I was the coolest person there. I mean how could anyone beat a hair do like that.

Edge: Probably easily.

Static: Well, meeting up with everyone again is going to be great. You are going to love all the memories your going to make. Now let’s go meet up with our friends. ( as he leaves he takes the hat off Malik’s head.)

Malik: (to Static) Hey! I liked wearing that.

Static: Well I have to return it. Come on Edge! (Edge gets up to leave and looking on his communication device sees he has a new message.) Edge! (Edge leaves)

The Devinee 

(Devinee park)

Static: Go and play with the others.

Malik: Thanks for bringing us Mr. Nash I am excited to see some of the new people we will be at the school with.

Jace :(a Devinee) Don’t you think we will be seeing enough of them over the year to come?

Static: Stay where I can see you guys.

Jace : You don’t have to worry about us.

Edge: Yeah, we are practically adults.

Static: Yes, twelve is so old. And baby...

Edge: Yes, I know you’ll be right over there. He rushed me out of the house so fast I didn’t get to read my new message from Jasmine the Faelerah. In her last message she told me that ...( walks away talking to Malik)

Jace: Guys! Over here!

(Over by the playground) 

Malik: That sucks about the message.

Edge: I know but Jasmine messaged me last night too.

Malik: Oh? What did she say.

Edge (closes his eyes) “ I keep looking at your picture the Faelerah don’t have much interaction with humans and your so interesting to look at and talk too.”Babe every time we talk it just makes me want to get to know you even better. Your amazing.”

Malik: Wow

Edge: it seems like she’s just as fascinated by me as I am by her.

Malik: Too bad she doesn’t live on planet.

Jace: Hey! (Edge and Malik run to catch up with him)

They all gather together and survey the park together looking at a group of older Devinee holding instruments.)

Edge: oh no, I bet they are going to play music from the 8,000s.

(Jaiden’s cafe)

Jai (Devinee): I made a new coffee blend I highly recommend it. It has tapioca and coco in it. It’s very sweet and has a kick of texture with it. It also goes great with the muffins I make that you love so much Lucien.

Lucien: Jai, ideally I’d like something that wasn’t a days worth of calories. You know I am watching my weight.

Jai: The drink is healthier than it sounds. Why don’t you try some. Then we can take a walk together, so you can burn some of the calories. We can go to the park we’re some of our friends and their kids are gathered and you can brag about the new drink.

Lucien: Alright, alright. Oh my gosh is that Armand? (A small human of about 5 walks up to them)

Jai: Yeah.

Lucien: Hey sweetie, look at how grown up you are.

Jai: Can you say, “Hi Lucien”?

Armand: Hi. (He waves)

Lucien: Hi. (He waves back)

Jai: He starts kindergarten next week, can you believe it? It’s going to be great for him. I am excited for him to meet Devinee and other humans his age.

KLucien: speaking of being around people your own age. I checked and you haven’t confirme your going to the “reunion gathering” thats happening tomorrow night. 

Jai: I know. I know.

Lucien : Jai, we’re all really sorry your mate died, but it’s been a year. I think Julian would want you to get out and spend time with your friends. He wouldn’t want you to cut yourself off.

Jai: Can we.... uh... why don’t I go grab the keys so I can lock up and we will go for that walk, ok. We are going to go to the park. Sound good baby? ( Goes in back with Armand)

(The park)

Edge: Oh, hi. Your Mr. Sternshine right?

Axle (Devinee) : I am. And you must be Edge. Wow. Wow. Wow. Static’s son, I can’t believe your going to be one of my students. Time just flies by.

Malik: Static?

Edge: My papas first name. Weird, right? (They both smile and glance over to Static in the distance.)

Axle: (Takes the hat from Jace)  Thanks for bringing that I will take it to its proper owner. (Puts the hat on his head) Great, it was great meeting you guys. Uh, listen, go and enjoy your time at the park go meet some other people.

Jace: Static? (Edge hits him) Ow! (They start to run)

Axle: Hey guys, be careful! Be careful! Be careful! Okay just keep going. Don’t listen to me. Alright.

(Further in the park)

(As they run, they laugh loudly together. They stop running as they get to the pond.)

Edge: Look...

Malik: Yeah, that’s a really big tree.

( Malik and Jace start to walk away, but Edge stays.)

Jace: Edge? Let’s go. Oh, I see. Gonna hide behind that tree and message Jasmine?

Edge: Shut up!

Jace: ( mimicking Edge) Oh. She’s just so different, yet she understands me so completely. (Edge punches him) Ow.

Mr. Rasnic (Devinee): And here is the pond you will see a lot of children both Devinee and Human gather around here. Most of the kids here feel too grown up for the playground even the humans.

Jensen ( Devinee): Oh, you see Tobias? This won’t be like our old town.

Jace: Tobias?

Tobias (Devinee): Jace?

( Jace goes up to Tobias.)

Jace and Tobias: Omg! It’s so good to see you! Me? You! Lol Jinx you owe me a coke.

Jace: Dude what are you doing here?

Malik: I guess they’re friends. 

Tobias: My Apha father moved in with his new mate. Who happens to live in this town. So Alpha brought me here so I could meet some of the kids I would be spending the year with.

Mr. R.: I think we’ll let you two get reaquantied and your alpha and I will finish talking about the benefits of this community and your future school together.

Jensen: Tobias come find me when your done, ok?

Tobias: Yes Alpha, I won’t go far ok?

Jensen: Good.

Jace: Oh, sorry. Malik, Edge, this is Tobias. We were on a Devinee softball team over the summer together.

Edge: We could tell you guys are friends.

Tobias: Nice to meet you

Edge: Yeah. Ok, the coast is finally clear. Malik your coming with me,

Malik: No, no.

Edge: You two stand guard.

(Edge and Malik go behind the large tree so Edge can check the message on his communication device.)

Tobias: So is your friend always like that?

Jace: Yes.

Tobias: Really?

(Malik runs up behind them and scares them by screaming boo!)

Tobias: Humans.

(Another part of the park) 

(Axle is looking at his communication device)

(In a black ufo a blond man (Chance Roberts) is talking on his communication device)

Chance: Kyson I am really truly okay but if you want to come to this gathering with me you can. (As he talks they show his collectible doll, and then him actually talking.) I just don’t want you to get bored it’s all very small town. Alright, it is sweet of you to want to meet my friends and I do want to show them my future mate. I love you too.

(He hangs up his device. As he does you see the flash of his engagement ring.)

(The park)

( Chance gets out of the ufo and enters the park)

Chance: Thanks. (To the driver who opened the ufos door for him)

Driver: Your welcome.

(In the park)

Chance: Slash!

Axle: Chance. Oh wow...(closes his communication device and gives him a hug) Well. Hey. Oh my, it’s great to see you.

Chance: You too. So your a teacher at our old school now. Ok, here (gives him a present)

Axle: Ok now, this is an upgrade for the schools technology system, right?

Chance: Yes, it’s just something to show my gratitude to the school that gave me my start.

Axle: Speaking of our old school days... How about this Jai’s old hat.

Chance: Ok ( puts the hat on)

Axle: Nice, it works on you.

Chance: Yeah, it goes well with this shirt really well doesn’t it.

Axle: Well, we all know you’ve always had better fashion sense than Jai.

(Outside the park)

Lucien: (Sees the ufo) Oh wow, look at that someone is certainly traveling in style aren’t they Jai.

(Jai scans the park and sees Chance and Chance sees him. He waves at Jai when he sees him.( You get the sense that maybe they were once together))

(Behind the big tree)

Edge: Malik, Can you please chill, if we are caught I’ll just say you didn’t know what I was going to do.

Malik: Oh, yeah great... So what does the message say?

Edge: Malik, Jasmine is going to be on planet and she wants to meet me tomorrow.

(Park entrance)

Chance: What’s your stuffy’s name?

Armand: Art

Chance: Art?

Jai: So you have a future mate? Congratulations.

Lucien: Yeah, when’s the ceremony?

Chance: Oh soon, but we haven’t pegged the exact date yet, but, well, your all invited.

Axle: Cool, So when do we all get to meet Kyson?

Chance: He’s going to fly down this afternoon. He’s so sweet he really wants to meet all my old friends.

Axle: He’s an Aztle isn’t he?

Chance: Yes he is.

Jai: I always knew you’d meet the perfect mate.

Chance: Well, so, I guess I should probably go now and check in to the hotel on planet. But Joey your really not going to the reunion gathering tomorrow?

Jai: No, I am not.

Chance: Well then why don’t you at least come hang out with us later it will be a smaller group.

Jai: Well, um...

Lucien: Of course he would. We will both come. We can’t wait to catch up.

Chance: Great. So I’ll see you guys later then.

( Mr. Sternshine takes the hat off her as she leaves)

Lucien: By Chance.

(Playground)

(Edge and Malik are Swinging)

Edge: I want to meet her, but I am worried I won’t meet up to her expectations of humans.

Malik: I am sure you will. Jasmine is coming here. You can sate some of your curiosity. It’s a golden opportunity.

Tobias: Who’s Jasmine?

Jace: A female Falererian Edge me on some inter-spacial chat room. I bet she’s actually one of those spikey alien things, that will poke him anytime he gets close.

Edge: And your a young immature Alien with wings but I am still friends with you.

Jace: Oh, very funny.

Tobias: Ok. If your meeting some strange alien you met in a chat room. It could be really dangerous.

Edge: We just met I have been talking to him for months and your telling me about strangers.

Malik: Guys don’t worry Jasmine is totally cool she’s coming here on some Falerian mission.

Jace: What kind of mission would a Falerian go on?

Edge: She’s a voluntary missionary. She travels with other aliens that help planets that are at war even ones like ours were the war our soldiers are fighting is on a different planet. She’s going to have some spare time. Stop worrying about me.

( They start chasing each other around the park)

(The Nash house - Edges room)

(Static and Chance are looking at Edges collectible figurines)

Chance: You have such a wonderful child and to have raised him all by yourself too. So cute too, even better than the cutie you were haha.

Static:(looking at chances engagement ring) I can’t wait to meet Kyson. He got you such a pretty ring he must think highly of you.

Chance: Thank you he wanted to get me a collar too which is traditional for his race. He says it’s to protect me from other aliens showing his claim but it seems so possessive to me.

Static: I am sure he just doesn’t want anyone to get any ideas.

(Edge enters the room drinking water)

Edge: Why are you in my room?

Static: It’s my house I am allowed to go where I want.

Edge: Your showing off my figurine collection again? I know you like to show me off but next time can you ask before you trespass?

Static: Next time can we be more polite to our guest. Baby...

Edge: Your Chance Royal, I am such a big fan. You make a great superhero on your show, I love it when they give big parts to humans.

Static: and your gushing.

Edge: I can’t believe your actually here and friends with my papa.

Chance: Shocking right? It’s great to see you my friends kid all grown up.

Static: He wishes. So sneaking off to send secret messages?

Edge: Did you... have you been spying on me? I deserve some privacy.

Static: Relax, I wouldn’t do that to you. But I can tell your getting that attitude us humans get in our teen years.

Edge: Papa I am not doing anything wrong.

Static: Do yourself a favor and don’t have kids.

Chance: No promises. (They leave) Bye.

(Edge closes the door)

(Edges’s room - later)

Edge: Ok. We’ve gone through all the messages. No spikes and no mention of any other weirdness.

Malik: Jace is just worried about you.

Edge: Jace is just an idiot.

Malik: That Tobias seems kinda cool.

Edge: He’s fine I guess but he’s just your typical overprotective Devinee. That’s why I like Jasmine she’s so unique and exciting. I have never met a potential mate like her.

Malik: Babe, you’ve never had a potential mate before.

Edge: I know.

Malik: Maybe...

Edge: What?

Malik: What Tobias said, about meeting strange aliens from a chat room. He’s right it could be dangerous.

Edge:  Not you too Malik, with all the overprotectiveness, I am twelve I can handle it. Don’t worry so much.

Malik: Maybe you should talk to your papa. He could take you to meet her then we would all know you were safe.

Edge: Are you kidding me he would freak out. Are you saying you don’t think I should meet Jasmine.

Malik: I don’t know.

(A lounge)

Kyson: Wow I’ve never met Devinee before but Chance has told me so much about you guys I am thinking of writing an Aztle guide to the Devinee. (His phone communication device beeps) Hold on guys I got to take this. Yo Francine, yes, yes I am with my human on Nevarah. Yes it is a beautiful planet.

Lucien: Chance, I watch your show every Saturday morning. Seeing you as a star it’s so great for kids to have a role model like you.

Chance: Me as a role model what about you.

Lucien: What about me?

Jai.: Come on don’t be so modest. The things you do for this community. You must have raised money for every local charity and spending time with the soldiers.

Static: Plus, your furthering your education.

Chance: All humans should look up to you and take after your amazing example.

Lucien: It’s not that amazing, I have just done everything I’ve been told to do been the perfect human Devinee expect.

Axle: Its better than being like Will he was given so much and just threw everything away.

Jai: (On a translucent screen) Hey, come on down to Jaidens cafe. I have all the goodies and sweets you could want! I even have things for the health nuts out there. There’s always new creations too so come on ever you won’t find better drinks or sweets on planet and that’s a promise. (Gives two thumbs up)

Lucien: Jai! That’s awful!

Jai: What I had to advertise some how didn’t I. 

Kyson: Your absolutely right that’s how you keep a business going. Francine, Francine, this just isn’t the time I need to be spending time with my future mate and his friends you know how important this kind of thing is to humans. I gotta go bye. (Hangs up) Hey next time you want to do something like that let me know I can totally hook you up. I can get you professionals give it a real polished vibe you know attract even off planet customers.

Jai: Yeah, your right Kyson.

Kyson: Glad I could help, plus if you want I’ll even write the script free of charge.

Axle: I don’t know I kind of liked it. It had a happy friendly family friendly vibe to it.

Everyone: Yeah, it was totally Jai.

Chance: Kyson, we were talking about human role models. Well Jai has to be one for the Devinee and hey you are writing that book. Jai would be the perfect person for you to interview.

Jai: No, I don’t think that’s a good idea I am not the same Devinee yo used to know.

Kyson: Um...

(Jai gets up and gets a drink at the juice bar.)

(Axle comes up to him)

Axle: (To bartender) Can I get a pineapple juice? Thanks. Jai talk to me what’s going on here?

Jai: I can’t do this I am having this drink and going home.

Axle: You can’t do what hang out with old friends.

Jai: You know what, everyone wanted me to get out, but I don’t feel like I belong anymore.

Axle: Oh Jai, that’s not true.

Jai: Slash, you don’t understand so don’t act like you do.

Axle: Cutting off people, isn’t going to help. It isn’t going to change anything. Being around people may even help with the pain of your loss.

Jai: Stop, you and everyone else thinks they know what’s best for me how I should grieve how I should get past this. I don’t need your opinions, I know what’s best for me not you or anyone else.

Axle: We are friends. We are just trying to help.

Jai: No, your meddling and feeling sorry for me all of you are and I am sick and tired of it so please leave me alone.

Axle: Oh, and none of this has to do with Chance?

Jai: No, of course not. I mean I don’t like him but I don’t think the rest of you do.

Axle: Maybe not but it’s his choice.

Jai: Yes, I know that, but he feels sorry for me too, just like the rest of you. I am tired of all this and I am leaving.

Axle: I think you’re the one feeling sorry for yourself, so stop blaming everyone else.

(Axle finishes his drink and goes back to join the others. Leaving Jai alone. Jai looks at them then looks away)

(The Nash house)

(Edge is asleep when the humans come in being loud and rambunctious.)

The humans: Wild thing you make my heart sing, you make everything groovy. Wild thing I think I love you. But I want to know for sure! (Singing)

Lucien: Can you believe a song from so long ago is still known today?

Static: Come on let’s have a real drink.

Lucien: Ooh, yes.

Chance: We should do each other’s hair just like old times. We can fix Statics hair like she had it back in the day. Bring back old fashion. I think the planets ready for it.( Edge wakes up and makes his way downstairs.)

Static: Oh, Edge I am sorry we woke you up.

Chance: Yeah babe, I am sorry too.

Static: We promise we will quite down. Humans ready for that drink.

Chance: Yes, but just one Aztles are almost as panicky about humans drinking as Devinee. Edge it’s good to see you again how are you?

Edge: Chance, can I ask you something.

Chance: Sure, Is this about a potential mate?

Edge: Yes, but it’s a girl and my friends are freaked out.

Chance: Well, how do you feel about it?

Edge: I think she’s great, I am not freaked out by her gender I am intrigued by it.

Chance: Well, then maybe you should go for it. Trust how you feel. Sometimes you just have to do things despite what your friends think.

Edge: Like you do on your tv show, always going for what you want, being the hero.

Chance: Yes, if my parents had their way. I wouldn’t have my tv show. I would just be your good typical human sitting at home with a good Devinee mate. How awful would that be? So come on tell me about her what race is she I want to know more.

(The kitchen)

Lucien: Hey Static, what do you think of Kyson?

Static: Chance could do a lot better.( Lucien teases his hair) ooh, nice.

(The stairs (static is listening to Chance and Edge talk))

Edge: Your so smart, how do you know all these things?

Chance: This ( meaning your brain) learns a lot of things when you get older. It’s cliche but true.

(Static comes up to them.)

Static: Am I interrupting something?

Chance: Oh no, we were just discussing some of the moments on my show.

Edge: Yeah, he has some really great stories.

Static: Honey do you want to join us for a little while.

Edge: No, I am going to go back to bed.

Chance: Good night.

Static: Night baby, So what exactly were you telling him.

Chance: wouldn’t you like to know? He’s so young.

Lucien: Oh yes because your ancient.

Chance: I basically am.

Lucien: I refuse to think like that. I am young in my mind. I don’t even feel my age.

Static: I mean I wouldn’t mind going on a date or something.

Chance: Yes, that’s what’s great about Kyson he take me on dates all the time. He’s so sweet.

Lucien: I am sure all kinds of aliens would fall all over themselves to be with you.

( Edge’s room he’s on his communication device typing a message to Jasmine saying he wants to meet.( it says “ I would love to meet you in person.”))

Edge: Sometimes you just...( sends the message) go for it.

END

[paleorecipecookbook]

RHR: The Ocular Microbiome, with Dr. Harvey Fishman

In this episode we discuss:

What is the ocular microbiome?

How the microbiome affects eye diseases

T cell activation in the eye

HLA-B27 and genes that play an important role in immune function

A nutrient-dense and anti-inflammatory diet for eye health

Antibiotics prior to surgery

Show notes:

Dr. Harvey Fishman's website: fishmanvision.com

[smart_track_player url="https://ift.tt/2L2k8B9" title="RHR: The Ocular Microbiome, with Dr. Harvey Fishman" artist="Chris Kresser" ]

Chris Kresser: Dr. Fishman, welcome to Revolution Health Radio. I'm so happy you could join us. I've really been looking forward to this.

Dr Harvey Fishman: Thank you so much for having me, Chris. This is wonderful.

What is the ocular microbiome?

Chris Kresser: So, my audience has been well aware of the gut microbiome for many years. We've also talked about the skin microbiome. We talked about the vaginal microbiome, the lung microbiome, more recently the nasal microbiology, and so it's not surprising to learn that there is also an ocular microbiome. I'm really looking forward to talking to you more about this and how it contributes to eye disease. Because in the conventional world, the options for preventing eye disease in the first place and then addressing them, I think, have come a long way but maybe still leaves something to be desired. I'd first love to start out with just hearing a little bit more about your background, how you became interested in the ocular microbiome in your work as an ophthalmologist, and what led you down this path.

Dr. Fishman: That's great. So, I have a pretty interesting background, where I started off in the world as a physical chemist, studied neuroscience. I was in an analytical chemistry microfluidic laser lab at Stanford and really got interested in how to measure molecules almost at the single molecule level. We were looking at vesicular and synaptic release, neurotransmitters, and what the chemical basis of learning and memory was.

 You’ve heard of the gut microbiome—and maybe even the skin, nasal, and vaginal microbiome. But did you know that the eyes also have a microbiome and that it plays a key role in ocular health? 

That was sort of my background, and then I sort of did some interesting work in neurobiology, looking at retinal cells and how they grow and their regeneration, so I've had a lot of sort of technical background and analytical chemistry background. And then the last couple of years, I started getting very interested in the microbiome of the intestine and the gut, which led me into this whole world of what is actually happening in the eyes. Is there an ocular microbiome and is there a biome that controls disease in the eye that similar to that in the gut?

What's interesting is that I didn't necessarily sort of think about it in those ways. I actually got into my research that I'm working on right now is we're actually looking at how to measure cancer on the eye. We're using some of the analytical techniques that I developed or had been working on for my whole sort of academic career, which is how do you measure very small amounts of materials in microenvironments, and so I naturally led to this concept of how do you measure cancers on the eye. We started using similar techniques and sort of the illumina high throughput sequencing technology using 16S rDNA and rRNA to look at different things on the cancer. Chris has led me right into how they are looking at the microbiome and that’s sort of what got my interest sparked. The other thing that's sort of interesting is I've been working with a company called Microbiome to do some studies where I'm actually looking at intestinal microbiomes and how that compares to disease in the eye. That's sort of a whirlwind tour of how I got interested.

Chris Kresser: Right. It's a fascinating background, and as is often the case, it seems like in some way you could have never designed this career path or predicted it would happen, but when you look at it in retrospect, it seems like each step kind of perfectly informed the next step.

Dr. Fishman: That’s right. It’s actually really interesting; I never in my wildest dreams would have thought that I'd be doing genomics, and in fact one of my previous advisers always laughs because I'm doing genomics and I was a physical chemist and a microanalytical guy.

Chris Kresser: Right, right.

Dr. Fishman: Whippersnapper.

Chris Kresser: Right. So let’s talk a little bit about the ocular microbiome and what we know about it so far and what we don't know about it. Do we have any sense of the number of species, microorganisms, what the functions of the ocular microbiome are? I imagine it's significantly less developed as a field of study than the gut microbiome, but what do we know so far?

Dr. Fishman: It's really the beginning of this field. What's interesting about the microbiome of the eye is that we've been interested in, as ophthalmologists, not me personally, but at the ophthalmology community, we've been very interested in the bacteria that lived on the eye. The reason is that most of our intraocular surgeries like cataract surgery, vitreoretinal surgery, corneal surgery, when you make incisions into the eye, most of the serious infections that occur, occur because the exogeneous either bacteria that live on the lashes, the eyelid margin, or in the cornea. And so we've been very interested in this for years, and they've done a lot of interesting work, but the concept of the ocular microbiome, whether there's like some low-level core bacteria and microbiological species that lives on, in, and around the eye, that's really kind of a new concept.

One of the papers that has come out just recently was actually by Mark Wilcox. I don’t know if you're familiar with it; it was a major paper in 2017, and they looked at basically the temporal stability and composition of the ocular surface microbiome. It was probably one of the best papers, if not the sentinel paper in the field. What they found is … well, there's a couple of things they found, that first of all the ocular biome is very different, if at all, than the microbiome of the intestine. One of the things that they found is that in addition to other work that's been done, is that it's actually a pretty low number of species. I mean, there’s a diverse number of species, but it’s a low number. It’s just a regular number. And then there was some work that was done by Russell Van Gelder who's also shown similar work, but basically they started to talk about a bacteria microbiome that’s just very small in number.

Chris Kresser:  It's interesting; there is some parallel too with the gut. For most of the 20th century, we were very well aware of the existence of pathogenic bacteria, parasites and other organisms that could cause dysfunction in the gut, and most of the focus there was on identifying those pathogens and then treating the disease, eradicating them if possible with antibiotics or treating the diseases that were caused by them, whereas now at least, the awareness has shifted, and to some extent toward how do we support and nourish the protective microbiome and look at it more in the context of an ecosystem where we understand that if the health of the ecosystem is the primary focus, then that may actually be the most effective way of protecting against pathogenic activity.

Do you think that something similar is going to happen with the ocular microbiome or that it's just too— because it's not as significant in terms of the volume of the number of organisms and we may not have as much ability to influence it with things like diet and lifestyle, we’re not going to go down a similar path there?

How the microbiome affects eye diseases

Dr. Fishman: It’s a great question, and that's really what a lot of … myself and many other people are working on—whether you can influence it. I have some anecdotal discussions on that, papers as well, that actually would suggest that you may be able to do the exact same thing for the ocular health as you do for the gut health. Let me give you a couple examples. There are some really significant diseases of the eye, like, for example, dry eye disease, which is actually an area that I'm super interested in and really focusing a lot of my academic and clinical research. Dry eye disease is … they think there's a very big component of how the ocular microbiome interacts with the cornea and the lid and so forth, but there are also a bunch of other diseases like episcleritis, chronic follicular conjunctivitis, pterygium, or surfer’s eye, scleritis, even things that are as interesting as macular degeneration and glaucoma, a lot of people are starting to have … some of these diseases are actually idiopathic, not macular degeneration necessarily, but like episcleritis and dry eye disease. There are these so-called idiopathic diseases. What we think is that it's really controlled by dysbiosis of microbiome.

Chris Kresser: Wow, that's interesting. For listeners, idiopathic means “we don't really know.” It's a fancy way of saying, “We don’t know where this comes from or how it starts.” It's fascinating and by now not surprising, given what we talked about at the beginning of the show, we know now about the microbiome is not just in the gut. There's microbiology and virtually in any surface that interacts with the exterior world, whether it's the gut, the inside of the gut, technically is outside the body. We've talked about that on the show, which is always kind of fascinating, especially if you haven't thought about that, and then the lungs, which of course interface with the exterior environment, and the skin, the vagina, there's a penis microbiome, and clearly these organisms are playing some important role and clearly there's something about the modern lifestyle that is antithetical to the health of microbiomes. I imagine with the ocular microbiome, is it influenced by the same factors? Does systemic antibiotic use contribute to a degradation of the quality of the ocular microbiome? Are any kind of eye products that people use like drops, can they interfere? What do we know about that?

Dr. Fishman: Right. Those are great. Certainly areas that people are looking at. In the eye, there are so many aspects of the eye in terms of the ocular microbiome of the eye that makes it complex because the thing about the microbiome of the eye is that it’s not only that we think a core microbiome exist in a very low level, there's a lot of other bacteria and other species of organisms that sort of “contaminate” those measurements and also the surface.

One of the interesting things, there's a lot of sort of noise, in the sense that there's the noise from contaminants at any one time on the eye can overwhelm the signal of the actual microbiome. But what does seem to occur is that it's very possible that when people have sort of acute issues is because they do get some sort of dysregulation of their normal biome by this sort of contaminant. The sort of things that can really change the ocular surface biome is exactly the source that you're mentioning. If you use makeup, if you use products—Latisse, for instance, the Latisse, which people use to make their eyelashes grow longer contain a lot of— basically cause of the eyelashes that have more inflammation, more debris on them and that those are basically culture plates for bacteria on the eyelashes. That really does change it.

A lot of what you're mentioning really is sort of the dry eye disease realm, which is that all these different products that people use, including unnecessary eye drops or things like viral bacterial conjunctivitis, which you wouldn't use an antibiotic but that changes the microbiome. The other thing that is very fascinating is parasites. It turns out Demodex, I'm sure you—maybe we had many shows on Demodex, but Demodex is a big, big deal, and there is an interesting sort of life cycle of Demodex in the lashes and how that relates not only to the skin microbiome, but actually of people who have dysbiosis of their intestine. It’s just incredibly fascinating and it plays into the whole ocular rosacea story as well.

Chris Kresser: Not too long ago we had a periodontist, Al Danenberg, who's been through my clinician training program and is a really knowledgeable guy. He has looked at the connection between the gut microbiome and the oral microbiome and has found from his perspective and from what the research is showing that when there's a disruption in the oral microbiome, it's usually or often driven by dysfunction of the gut microbiome rather than the other way around, although certainly we know that infections in the mouth can influence the gut and other parts of the body, but because stomach acid protects against, hopefully if it's sufficient, a lot of what we would swallow and the saliva from the mouth that the relationship is probably more strongly influenced in the other direction. Has there been much work done on the influence of the gut microbiome on the ocular microbiome?

Dr. Fishman: That's a huge area that people … there's a lot of really interesting work, but just to kind of go back to what you said, there was a really interesting paper that came out that talked about the oral microbiome linked to neurodegeneration and glaucoma.

Chris Kresser:  Ah …

Dr. Fishman: We actually know that there are people with worse oral disease and dental disease. Actually, you have higher rates of primary glaucoma than other people, and that was a very well done study that was recently published. Essentially one of the things that we've known forever, and as a medical student, we learned very early in the game, the connection between ulcerative colitis, Crohn's disease, and uveitis. You may have touched upon before, but that is one of the most clear-cut associations that we have enough knowledge. In fact, ophthalmologists often sometimes will look … brilliant clinicians … when the person comes in and we see uveitis and then we do a little bit of the history and it turns out that they have Crohn’s and then we send them to the GI specialist and the GI guy thinks we're brilliant. We've discovered Crohn’s disease by looking in their eye and yet there are a few associations.

What's interesting is that there are multisystem disorders, autoimmune diseases that are associated with uveitis that are absolutely related to the gut and in other areas. That's an area that NIH is doing a very—there is a big push to look at the association. In particular, some of the work they're doing with T cell activation, both protective T cells and non-protective T cells, and how it influences uveitis, and they've been looking at some really interesting experimental autoimmune uveitis models, the EUA, so to speak, and they looked at how the regulatory T cells in the gut and other tissues really affect the uveitis and so forth.

Chris Kresser: I think there are probably a fair number of listeners who are not that familiar with disease. Uveitis being an inflammation of the middle layer of the eye, right?

Dr. Fishman: That's right.

Chris Kresser: With the connection between the gut and depression for example, the speculation is that in terms of the mechanism is that inflammatory cytokines are produced in the gut and they enter the bloodstream, perhaps because the barrier is permeable and they travel through the blood and they cross the blood–brain barrier and they suppress the activity of the frontal cortex, and that's one way gut pathology can lead to anxiety and depression.

In the case of the connection between the gut and eye disease, let's take ulcerative colitis and Crohn's, which are both autoimmune GI pathologies. Is the speculation that the systemic inflammation caused by the autoimmune disease is what's causing the inflammation in the eye, or is it that something related to a disruption of the microbiome leading to maybe the production of certain chemicals or inflammatory cytokines or something that's more specific to the microbial ecology of the gut is the contributing factor, or do we just not really know?

T cell activation in the eye

Dr. Fishman: One of the thoughts, and there was a paper that … and these are all interesting, really recent papers like 2015 to 2016, but there’s that commensal microbiota and bacteria in the gut that activate T cells. These T cells then circulate and then actually pass into and through the retina, in other parts of the eye, to then activate directly. It’s definitely via the immune system, but there are very specific immune cells that actually can penetrate into the eye. There's always been that thought that the eye is immunologically pristine, and that really is obviously not the case, but there are very selective T cells that can in fact get into the eye or pass into the eye, and so that's what we think that is going on, is that there's a dysregulation in the microbiome of the gut.

As you pointed out, you get T cell activation, and then it actually activates the local immune system in the eye. Actually, a really interesting situation that we see with respect to that, we actually can see diseases like sympathetic ophthalmia, which is a disease where if you injure one eye, activation of the T cells from one eye actually can go to the other eye, and you can actually lose the other eye, so you could actually have a question where are you …

Chris Kresser: Oh, wow.

Dr. Fishman: Yes, it's awful. That's why people have to get their eyes enucleated or taken out when they have a trauma. They have to do that within about 10 to 15 days or sooner because they can get this autoimmune activation that can actually blind them in the other eye. It’s just fascinating how that works, but that is sort of the same idea in the gut that you get with activation, and it causes inflammation. One of the things that we know, Chris, and this is my own personal experience in my practice, and I've seen this over and over and over again, is that my uveitis patients, they always come in with an active disease, almost always some kind of a gut-related situation that sets off their uveitis or inflammation. They'll come in and I’ll say, “What did you do last week?” “I was in Las Vegas and then we ate a lot of carbohydrates,” and these are patients who are very strict about being on a gluten-free diet, and they just say they cheated, so to speak, they had a bad weekend, fun weekend, but now they're paying the price and then they come back and they get uveitis. I can't tell you the number of times I've seen that. It's just clear cut. That's actually withm in particular, HLA-B27 uveitis. I don’t know if you have covered that, but that’s a big area.

HLA-B27 and genes that play an important role in immune function

Chris Kresser: I love to hear a little bit. I’m familiar with HLA-B27 and AS, ankylosing spondylitis, and the connection there. In fact, in our clinic, we will often test patients for HLA-B27 if they have joint pain, and if they test positive for Klebsiella bacteria on the stool test, I forget the name of a physician in London who discovered that connection, but then we’ll often put them on a low-starch diet and will treat the Klebsiella, and their joint pain will go away, or at least that will significantly improve. Tell me more about HLA-B27 and the eye.

Dr. Fishman: That’s our biggest immune screening. We screen for that in every single uveitis patient and screen for HLA-B27. In fact, 50 percent of every non-necrotising anterior uveitis, which is just a fancy word for basically idiopathic, meaning we don't know what the cause is, it's almost always related to an HLA-B27-positive uveitis, and so we see that all the time. Those patients are particularly sensitive to changes in their diet, and a lot of those patients, I will really push for strong control, at least in my practice. We always start off with a gluten-type restriction because that seems to be one of the big areas that sets off uveitis. HLA-B27 is such a prominent factor in most of our inflammation. You can also get sclerites with HLA-B27, you can get uveitis, you can get episcleritis, any of the autoimmune diseases around the eye seemed to be linked to that marker.

Chris Kresser: Just for the listeners, if your eyes are glazing over here, we're geeking out a little bit, but I want to back up. HLA-B27 is a gene, and it's one that plays a really important role in immune function. Its prevalence varies around the world in different ethnic groups and populations. I think it's about 8 percent in Caucasians, maybe this 2 to 9 percent in Chinese, 4 percent North Africans. As I was mentioning before, the association that I was most familiar with, I'm really fascinated to learn about the connection with uveitis is with ankylosing spondylitis. Back in the ’80s, there was a physician in London, whose name I'm unfortunately forgetting at the moment, and he was treating patients with AS, and by accident some of them he put on a low-carb diet for weight loss, and their AS improved dramatically. He did some more research and he found that there is a greater abundance of Klebsiella in stool samples of patients with AS, and then he found that Klebsiella bacteria that have preference for starch, and the patients that he put on a low-carb diet were of course eating a lot less starch. The low starch intake starved the Klebsiella and reduced the Klebsiella, which then reduced the autoimmune attack against the HLA-B27-expressed enzymes that were in the joints, and that's reduced the symptoms of AS, or ankylosing spondylitis, but there was later research that showed that sometimes can be connected to Crohn's disease. You just told me that Crohn's is connected to uveitis. Things like this, there’s a very interesting connection going on here, and that it may possibly a low-carb, low-starch diet, if it works for AS and HLA-B27, might be effective for uveitis.

Dr. Fishman: Absolutely. I basically, in a very non-scientific way, have my patients try these diets and often they don't want to go on to these heavy-duty immunosuppressants like methotrexate or Imuran. They want a natural … not natural, but they want a way to control the inflammation not to do these other sources. They will grab it, and a lot of the way I practice is I've learned so much from the multitude of patients who tell me, maybe the patients who have seen you as well, I learn from them what works, and I can then pass it on to other people. But in terms of the gut association with HLA-B27, it’s fascinating when you were mentioning Klebsiella, it turns out that Klebsiella as well as other bacteria … and in particular, there's a big connection with blepharitis and dry eye disease. In fact they did a study where they looked at patients—Bacillus was the other one—they looked at a setting where they looked at patients who had dry eye disease, and it turned out that Bacillus and Klebsiella were the huge association with blepharitis and dry eye disease. Just as an aside, another very interesting thing, because I'm very interested in dry eye disease and a lot of people with ocular rosacea, there is that story that the microbiome of your gut are being eaten, so bacteria that actually get eaten by the parasites, which hurt the Demodex on your eyelashes and your hair follicles, they eat the bacteria, then the parasites puke up the bacteria, and then the products and the exogenous components from the bacteria then irritates the eyelashes and the meibomian glands, which are glands in your eyelid, cause severe dry eyes. That's this interesting lifecycle between bacteria, Demodex.  The other thing that I've looked at, and I know that you guys have talked about SIBO, and there seems to be this association with SIBO, bacteria, blepharitis, Demodex and ocular rosacea and dry eye disease.

Nutrient-dense and anti-inflammatory diet for eye health

Chris Kresser: Fascinating. I mean, there's so many directions, but it all really comes back to, I mean, I think one of the things I like to emphasize, these discussions are fascinating and they're important, and these lines of research are really crucial to figuring out what's going on, and at the same time it comes back to the same basic steps that we need to take. Eat a nutrient-dense, anti-inflammatory diet, make sure you're taking care of your gut microbiome, avoid unnecessary antibiotics.Make sure to eat plenty of fermented foods and fermentable fibers. It can be easy to get overwhelmed by the complexity of all of these connections, but the good news is that usually it's just the same simple steps that we need to take in order to protect our health.

Dr. Fishman: Absolutely. One of the things that we found, and you'll just be amazed, ophthalmologists, we have been running the largest nutritional study in the history of mankind, and it was for macular degeneration. That statement is not a trivial one. I don't know if you’ve talked about this, and essentially the use of lutein as the advancement in your diet. There are a lot of interesting connections between the intestine and macular degeneration, and there's a big suggestion that the intestinal dysbiosis as seen in AMD patients … and when you're doing these supplementations, you're really supplementing the intestinal microbiome to reduce inflammation in the retina, which is actually the cause of macular degeneration, so it's just incredibly fascinating. Every time I leave my patient, I feel that there are two things I want you guys to leave this office with because I don't have the bandwidth, obviously, that your practice has in terms of … I have this focus on different things, but I tell them spinach pills, which is just spinach and omega-3 fatty acids. Omega-3 fatty acid is a very interesting controller of eyelid health and dry eye disease despite the fact that there was a recent paper that came out that disputed that, and I would really argue that that was not a very well-done … it was a study that was well done, but they had a lot of problems with it. My two big go-to things at least in my practice are spinach and fish.

Chris Kresser: That certainly fits into the context of the nutrient-dense, anti-inflammatory diet. It's really fascinating to me how the change, I think, that's happening in medicine, not just in functional integrative medicine but even in conventional medicine, that we started out allopathic medicine grew out of this Cartesian dualistic framework, where the body is basically just a bunch of disconnected parts that are kind of loosely connected, but not really influencing each other, and now we're really starting to understand that under traditional systems of medicine, they certainly didn't get everything right, but the one thing that they did get right was this idea of holism, that every part of the body is connected to and influences the body as a whole.

Now we're seeing this, I think, really play out. Look, it's Crohn's disease and ulcerative colitis increase your risk of eye inflammation. We now have the inflammatory cytokine model of depression that shows that inflammation in the gut can cause inflammation in the brain and symptoms that mimic depression. We've got connections between dysfunction in the HPA axis and stress and all kinds of skin conditions like eczema and psoriasis. I mean, the list goes on and on, and now we're adding to this the connection between the oral microbiome and the gut microbiome and inflammation in the eye, which even just, I think, 20 or 30 years ago would have been completely dismissed as a woo-woo kind of out-there stuff. It's just encouraging to me that we're really starting to move, no matter what kind of perspective on medicine, we're talking about into a more holistic view of the body.

Dr. Fishman: There was an interesting paper where one researcher looked at treating, it wasn't a corneal ulcer, but they were treating sort of a conjunctivitis using a probiotic eye drop.

Chris Kresser: I was going to ask you about that.

Dr. Fishman: There’s a disease called vernal keratoconjunctivitis, and that’s a pretty tough one to treat. Vernal means spring, and basically it’s allergic conjunctivitis. A lot of kids get it, and the way we typically treat that is with steroids and so forth, which you obviously don't want to do for children. There was a paper back in 2008 where they looked at using a probiotic eye drop, and they found it was equivalent to some of the other drops that they were using, which to me makes complete sense. I had a very interesting case recently of a patient who had actually an open globe. She actually had some sort of a tube that was put in for glaucoma, and it eroded through the conjunctiva. Bottom line, you see an open globe and she had opened up for essentially six months and nothing happened. She didn't get an infection, nothing. For whatever reason, she had a very well-controlled ocular biome.

One of the interesting questions that we're now looking at is how do the intestinal, oral, or skin biomes relate to the ocular microbiome? I think it's a pretty clear situation, and we know and I've had private conversations with some pretty famous microbiologists, anything that comes out of your intestine is going to be in your eyes, so basically just think of it that way. I mean, it doesn't sound great, and I joke with my patients, “You're basically getting poop in your eyes, and it happens all the time, every single day.” That’s what happens, not to be completely crap, but that is the connection.

Chris Kresser: Yes, yes. That's interesting. The probiotic eye drop reminds me of, I talked about this before, the nasal microbiome and the connection between the nasal microbiome and sinusitis. Dr. Susan Lynch at UCSF has done some really interesting work in this area. She did a fascinating study that was both animal and human, and they had an animal model of sinusitis, and they found that the main difference between animals with sinusitis and the controls was not—and this was true in humans too—was not the presence of certain pathogens. It wasn't that the people with sinusitis had much higher levels of fungus or certain species of pathogenic bacteria. The biggest difference between the two groups was microbial diversity.

Dr. Fishman: Right.

Chris Kresser: The people who were the controls, the people who didn't have sinusitis, had a much richer diversity of healthy protective bacteria, whereas the people who had sinusitis had a lower diversity, even when the presence of pathogenic species was basically the same. There was no difference between the two groups. The difference was that the healthy people had much higher levels of protective bacteria, and then she went a step further, and in the animals, they treated them with antibiotics until they were basically depleted of the microbiome in both the healthy controls and the animals with sinusitis. And in one group of animals, they didn't do anything. They just let the bacteria grow back as they would, and then the other group, they inoculated them with a protective species, Lactobacillus sakei, which they had observed in higher numbers in the healthy controls. And those animals that were inoculated with that nasal probiotic didn't develop sinusitis or anything the other animals that were not inoculated with that. That really actually speaks to probiotics in both maintaining and then restoring a healthy microbiome as being a more effective strategy than using antibiotics or antimicrobials to try to get rid of pathogens.

Dr. Fishman: Right. When you mention those two things, there were two interesting things that come to mind. The first one, just to let you know that there was a paper that came out in Nature in 2016 which said exactly the same thing. They were looking at Sjӧgren's disease—for your listeners, it’s one of the most severe forms of dry eye disease and other dry parts of your body. They found the exact same finding, that people with the severity of Sjӧgren's disease was inversely correlated with microbial diversity in your gut.

Chris Kresser: Wow.

Dr. Fishman: And with just as clear as day. It was just super clear that this was the case. We know, and I know from my own clinical experiences, that people who have, do have, a much higher control level, people who do a better job in terms of their diet, people who are more precise about the food that they eat and so forth, do much better with dry eyes. Dry eye disease, for the longest time, we've been treating dry eye disease with omega-3s or any type of fatty acid, but any sort of derived can lead to that. What I always mention is that, is it actually the omega-3 acting directly in your eye, or is it basically an activation, a biological cascade, that then causes the improved function in the eye? I clearly believe that it is a cascade effect because there is no way that just a simple little fish oil capsule could have that much of an improvement in people with dry eye disease.

Chris Kresser: Right, right.

[Crosstalk]

Chris Kresser: Go ahead, please.

Antibiotics prior to surgery

Dr. Fishman: Yes. I just have one other really interesting comment, which was one of the things that is interesting is that you talked about treating infections with basically displacing the bad bacteria with “good bacteria” and so forth, and that whole concept, which makes a lot of sense. One of the things that we've seen is that in eye disease, especially in ocular surgery, we routinely treat our patients basically from medicolegal reasons with antibiotics prior to surgery.

Chris Kresser: Right.

Dr. Fishman: It turns out that the studies are coming out that there's no data whatsoever to support those claims.

Chris Kresser: Yes.

Dr. Fishman: Those are billions of dollars a year in an antibiotics that were sold by pharmaceutical companies to basically do nothing and maybe, who knows, but maybe actually not even improve outcomes, but maybe make outcomes worse by selecting for bacteria that if it does get into eye, it actually would be a much worse situation.

Chris Kresser: Right.

Dr. Fishman: That's really interesting data that we have.

Chris Kresser: That happens, of course, not just in the world of the eye, ocular issues, but of course in the dental surgery, where patients will often come and say, “Oh, I'm about to get this dental surgery. My dentist is just prescribing antibiotics prophylactically.” Of course I've had the thought, “Well, okay, does this become a self-fulfilling prophecy?” Because we know that disruption of the oral microbiome with antibiotics can actually predispose you to an oral infection, and so by prophylactically prescribing an antibiotic is not really prophylaxis, or is that actually more likely to develop an infection? And as you said, not only have you reduced your body's ability to fight the infection, if it does happen, by reducing the number of beneficial protective bacteria, you've also potentially contributed to creating a more resistant strain of pathogenic bacteria by killing the ones that were least … the types of pathogenic bacteria that were least robust and just leaving the ones that were more robust.

Dr. Fishman: Well, there is some evidence that suggests that may actually be the case. I mean, with eye surgery, we use povidone iodine before surgery. That is the gold standard and at least cuts down sort of universally all … it doesn't select, do you know what I mean? You're not selecting for bacteria. You're basically wiping it out. Antibiotics, on the other hand, are probably selecting for it. That’s a good example where that period self-selecting bad bacteria really might be coming true. It’s very interesting where we’re going, especially with the eye, because there are still many “idiopathic” diseases and infections that really relate to the biome, not only of the eye, but also the gut being the cause of it.

Chris Kresser: Who knows? Maybe someday you'll go to the dentist and you'll get a dental probiotic instead of antibiotic for an infection. Maybe you’ll go to your ENT for an ear infection, and instead of putting antibiotic ear drops, they’ll put in probiotic ear drops. You’ll go the ophthalmologist and instead of getting antimicrobial treatment, you'll get probiotic eye drops. Seems that's not far-fetched at this point.

Dr. Fishman: Not at all. In fact, you might argue we’re already doing that through indirectly by using our gut as a way to … [crosstalk]

Chris Kresser: Right. To modulate.

Dr. Fishman: Correct.

Chris Kresser: Well, this has been really fascinating, Dr. Fishman. I've enjoyed talking with you, and I think the listeners are really going to get a lot out of this, and it's hopeful. I feel hopeful to know that there are folks like you who are exploring these new frontiers and really kind of pushing the boundaries and questioning some of the most basic assumptions that we've made and finding a new path forward that could lead to better, safer treatments. Where can folks learn more about your work or if people are in the Bay Area? It sounds like you definitely are still seeing some patients. Tell us where people can learn more.

Dr. Fishman: Sure. Well, they can always find me on my website, which is www.fishmanvision.com, and they can get involved in my practice in multiple ways. I definitely see patients. Half the time I'm seeing patients, half the time I'm doing research.

[Crosstalk]

Chris Kresser: It looks like they can do some video consultation as well. Is that right?

Dr. Fishman: Yes. For people in California, I can do video consultations if they can't make it to the office. Especially for dry eye disease, it’s very helpful.

Chris Kresser: Right, right. Great. Well, keep us posted on your research. We’d love to hear it, stay in touch, and have you back on the show at some point and just keep track of your work. These are really exciting developments.

Dr. Fishman: I really appreciate the opportunity, and I wanted to thank you because we've shared some patients, and their lives have actually changed because of the work that you're doing with them, so thank you.

Chris Kresser: Fantastic. It’s my pleasure. Take care.

Dr. Fishman: Okay, thank you.

The post RHR: The Ocular Microbiome, with Dr. Harvey Fishman appeared first on Chris Kresser.

Source: http://chriskresser.com July 10, 2018 at 02:10AM

[bffhreprise]

Best Friend For Hire Reprise, Entry 370

 “Who are you?” asked Jamie.  She had gotten up to answer the door.  She wasn’t too happy.  Jamie didn’t like mornings.

 “Good morning, Jamie.  I am Mila, Noelle’s ride to work.” replied Mila.

 Mila…?  I knew Mila!  “Mila!  How are you!?” I exclaimed, running to the door.

 “Noelle, you actually know this person?  Why’s she in cosplay?” asked Jamie suspiciously.

 “This is Mila!  We met some time ago and are great friends.  I remember talking with her for ages!  And…” I started, hesitating as I clung on to what the other question was.  “That’s just how she looks?” I asked.

 “I am the maid of James Michael Somerset III, who hired Noelle yesterday to work at Best Friend For Hire, one of his companies.” explained Mila.

 “Riiight…  I don’t know what you did with my sister yesterday, but we’re not buying it.  Please, leave.” stated Jamie, starting to shut the door.

 I grabbed the door, holding on and saying, “Mila, please come in and explain.  I remember James!  He’s nice!”

 “If you don’t mind, Jamie, I would gladly show you our website and explain what your sister will be doing for us.” stated Mila, not bothered at all by Jamie’s reaction.  Mila was nice too.

 Jamie turned to me and stared, doing that thing where she wasn’t exactly looking at me.  Then she sighed and said, “Okay, I’ll listen.”

 Mila brought up a website, and showed us a picture of James!  I recognized him.  She continued explaining things about how the company worked and the different types of jobs I might do, even explaining about some school program that I’d be using to learn.  She seemed convinced that I’d remember the lessons more easily through it.

 Throughout the speech, my eyes were mainly on Jamie, watching how she reacted.  I wanted her to be happy.  She was getting married soon, and she shouldn’t be worrying about me.  I was an adult and had to find a way to take care of myself.

 “This is real?” asked Jamie with obvious disbelief.

 “Yes, Jamie.  Furthermore, Noelle should probably move to Somerset Estate, so she can eventually learn the names of her coworkers, study more easily, and have adequate reminders about her jobs from the moment she wakes.” explained Mila.

 Jamie laughed, but she was crying too.  Mila brought up a picture of a beautiful mansion and then the picture turned into a movie, giving us some sort of virtual tour.  As the video continued, we were told about all sorts of benefits provided by the company.

 Reaching over to hug me with one arm, Jamie asked “Is this what you want, Noelle?”

 “Yes!” I told her, doing my best to keep in mind how Jamie looked.  She seemed so excited, despite the tears.

 “I’ll want to see the place before you move in, and I’ll make time with Tom to help you move.” she told us.

 “I should mention that one of the company perks is a free moving service for employees.  Please, don’t rent a truck.  We have company vehicles and people to handle all of the hauling.” insisted Mila.

 “Really?” asked Jamie in surprise.  She turned to face Mila.

 “Yes.  The moving service extends to family, so please don’t hesitate to inform us when you’d like to move in with Tom.  We’ll gladly help.” insisted Mila.

 Jamie had a few more questions, but I was sent off to get ready for work.  I was working today!  I couldn’t focus on that though, not if I wanted to remember Jamie’s face as she accepted that I had a job.  The smiles and tears weren’t something I wanted to forget.

 After several hugs and some well-wishing, Jamie let me get to work.  The ride didn’t seem terribly long, though I might have forgotten most of it, but Mila made a picture of James appear on the limo’s window, telling me not to forget what he looked like.  James was the boss.

 “James!  I came back!” I exclaimed when I saw him approaching.  I was inside the mansion, standing in a giant, beautiful hallway.  “Mila’s been introducing me to everyone!”

 “Reintroducing, really.” came a voice from next to me, drawing my attention to her.  We were hugging!  She had beautiful dyed hair.  “We met yesterday.”

 “Sorry.” I told her, my grip loosening around her.  I was hugging her.  I was hugging her!  “I remembered that Emma likes hugs!” I explained excitedly.

 “Yep.  I should have told her I like hugs.” came a manly voice.  The owner of the voice had red hair and was being elbowed by a tall girl with a blonde streak in her brown hair.

 “Do you?” I asked, hoping I’d remember.

 “Don’t worry.  I give him plenty.” insisted the tall girl, elbowing the guy again.

 “Did Mila explain our morning exercises to you?” questioned James.  James was easy to remember.

 “Umm… Probably?” I replied uncertainly.  Mila seemed very good at explaining things, so I couldn’t doubt her.  I just couldn’t remember, but that was normal.

 “Master, Noelle was detained by her sister.  Jamie didn’t really believe that Noelle had found a job so quickly and thought I was in cosplay rather than being an actual maid.” explained Mila.  “I eventually did get her to believe me after showing her our website and giving in-depth detail of the types of jobs Noelle will be doing.”

 “Thank you, Mila.  Hopefully, things will be easier from here on out.” stated James with a wry smile.

 “Jamie was so excited!  She cried!  Not a sad cry, I think.  This seemed like a happy cry.  I bet she’ll tell her fiancé today.  Maybe she already has.” I considered, uncertain whether or not Jamie and Tom were doing anything today.

 “Jaaaaaaaaaaames!” exclaimed the voice of a young girl.

 When a girl with black hair, brown eyes, and a wild grin came literally flying into the room, I ducked behind the girl I had been hugging.

 “Kayla,” stated James sternly, “you were running and yelling through the halls again.”

 “Sorry, James.” mumbled the young girl.

 “So why were you looking for me?” he questioned as she met his eyes, still floating.

 “Well… Mila’s supposed to give me a ride later to see my friend, Katie, and I was wanting to go in a limo, but Mila said that we can’t take one without your permission, so I wanted to come ask you.” she rapidly explained.

 “I see.  Why do you feel you need a limo for two people?” he asked.

 “Uh… They’re cooler?” she suggested with a grin.

 “Not really.  If you were to translate the price of vehicles into equivalent coolness as you’ve been doing of late, master’s DB5 is actually the most valuable car on the lot due to the modifications done to it which exceed the modifications of the limo.  I must also point out that the original DB5 was actually more valuable as well before modifications.” argued Mila.

 James frowned as he said, “Kayla, you’re surrounded by valuable things, but how much you enjoy them for what they are matters far more.  My daughter’s paintings mean far more to me than any from most other artists around the building.  I only say ‘most’ because I have a painting from an old friend as well as one from my mother.”

 “But Dani’s like the best painter ever!” insisted Kayla, making me want to see the paintings.

 “Yet her paintings wouldn’t sell for nearly as much as some of the others around the house.” insisted James.

 “But why not!?  They’re really good!” she exclaimed.

 James smiled kindly now and said, “Dani’s artwork isn’t well enough known to sell for as much as my mother’s, much less compare with the great artists of history.  Figure out what you like best and go with it.  You know Dani always does.”

 “Is he the sweetest person ever?” I asked, wanting to hug them both.

 “Pretty much.” replied the girl in front of me.

 The smile slipped away as James asked “Did you finish your homework?”

 The girl’s feet hit the floor as she said, “Uh…  Catch you later!”  Then she quickly turned around and speed-walked out of the room.

 “She is in a way.” stated Mila.  “I’ve been increasing her load considerably to keep her busy, so she’s actually far past what her friends are studying.”

 James nodded and said, “We’ll get her tinkering with Jarod in no time.”

 “You’ll need to be the one to tell Jemal.” replied Mila with a smile.

 “Who’s Jarod?” I whispered to the girl in front of me.

 “Not sure you met him yet.  He’s usually in his lab or with his wives.” she replied.

 I nodded, and then realized what all she had said.  “Wives!?  Is he a… uh…”

 “He’s a Jarod.  You’ll see.” she told me.

 “Let’s get Noelle around for more introductions.  Mila, mind leading the way?” questioned James.

 “Would you follow me anywhere?” flirted Mila with a mischievous grin.

 “Behave.” he told her, though he smiled.

 “Mila looks similar to his wife and flirts twice as much.” whispered the girl as she pulled me up to walk beside her.  She was really pretty.

 Mila glanced back at the girl and asked “Just twice as much?  Am I failing to do your teaching justice?”

 The girl giggled and said, “Fine, ten times as much!”

 “Much better.” replied Mila as she looked forward again.

 I smelled such wonderful food that I was starting to feel hungry, but we passed from one hallway into a very large garage.  I was a bit confused when we came to a stop, but the floor started lowering under us like in some spy movie!  The drop wasn’t far before I was looking into a giant room with all sorts of machinery spread throughout it.  A group of people were around a large screen that showed a car.  Seconds ticked on by as we lowered, but we eventually reached the ground.

 “Aurora wants her own transportation.  The prototype flying car won’t be approved for city use within the year.” stated Mila.  “She also seems determined to pay for it herself.  Don’t worry.  I’m giving her our company discount on materials.”

 James nodded but didn’t comment.

 “Car?  Company discount?” I asked curiously.

 “Yes!” exclaimed the pretty girl with dyed hair.  “Mila, Jarod, and Aurora take care of everyone’s cars for us, even upgrading them as they develop better parts.” she told me, pointing out who was who as she said their names.  Pointing to a girl with curly, light brunette hair, she said, “That one may or may not help.  She is really bright, just a bit mischievous.

 “That’s so cool!  Think I could eventually pay them to work on Jamie’s?” I asked hopefully, picturing how excited Jamie would be.  “She always takes me places.”

 “I’ll be taking you places now, but we can most certainly work on your sister’s car whenever she needs something done.” insisted Mila.  “We’re best friends for hire, after all, excluding Maxine.”

 “That’s awesome!  I should get a car eventually.” I told her as I thought about it.  “If I call you, will you remind me where I park it?”

 Mila nodded and said, “I’ll also call to remind you that you parked it when your jobs are over.”

 “Really!?  That’s awesome!  I once borrowed Jamie’s and… um… we kinda spent a week looking for it.”

 “Don’t worry.  I intend to install an incredible tracking system on your keys and vehicle when the time comes.” replied Mila, smiling at me.

 “Sure you don’t want one on me too?” I teased, appreciating the idea of a key and car locator.

 “Your phone suffices when you remember it, but I’m adept at finding people even if you forget.  When you get your company enhancement suit, I’ll be able to track it.  Raine, the skittish girl you met yesterday, will find you if I cannot.” replied Mila with perfect confidence.

 “Wow.  How?” I asked, thinking Jamie would love knowing that trick.

 “Scent, probably.  She has many gifts.” stated Mila with no trace of joking.

 As I gave myself a quick sniff, trying to determine what she meant, a blonde boy with a big grin waved at us.  “Hey, guys.  Nice to meet you, Noelle.  Come check this thing out!”  The diagrams moved to even larger screens on the wall as the boy started explaining them to us.

 The explanation was really detailed, and I didn’t have a clue what he was talking about too quickly.  The best I could do is picture how the shapes would fit together, but I didn’t get what they actually did.

 “Aurora came up with this sweet composite to be used in the suspension system here.”  He pointed, and the screen zoomed in on part of the diagram.  “I’m going to have to modify everyone’s cars again if all this works as well as we think.  I’d also like you to do a bit of spellwork on it if you don’t mind.  Since this is for her use only, we left out the batteries entirely and created plans based on what we know you can do.”

 “Sure thing.” agreed James, as if spells weren’t an issue.  “Out of curiosity, what would you do if I actually declined?”

 “Well, I’ve had this idea of creating a biomechanical battery and thought a bit of Iris’ DNA might give it a little extra spark.” replied the crazed blonde boy with an even wider grin.

 “Personally, I still prefer that idea.” stated the curly-haired brunette.

 James just nodded, seeming to take the idea as nothing strange.  My eyes were probably bulging, and I was worried that I would be expected to learn… that, whatever that was.  I always did fine with math in school after I spent time going over the process, but I was terrible at remembering the terms even when I knew how to use formulas.  The whole conversation had been too much for me, and I found myself doubting whether or not I’d be able to do whatever I was supposed to do here.

[mrdanielblack]

Applying VR and AR to property

Jeff Turner is the CEO of iMovie Viewer, a leading virtual 360° and 3D tour technology company. In his segment, he helps you understand how you can apply virtual and artificial reality to your real estate practice. He also explores the obstacles that can hinder this groundbreaking technology from going mainstream.

Topic – Inman Connect highlights

Mentor – Jeff Turner

Transcript:

Kevin:   Jeff Turner is the CEO for Immoviewer, and joins me. I haven’t seen Jeff for so long, and that’s why it’s great to see you again, my friend. How are you?

Jeff:   It’s very, very good to see you again.

Kevin:   Tremendous to be in your country. I think last time we spoke was from a little, tiny studio-

Jeff:   In the back of your house.

Kevin:   In the back of my house, which is still working, by the way, too. We do-

Jeff:   We were there with Peter Brewer, and it was … We would’ve talked about this before, but you’ve played an interesting role in my life. Because the first time that we spoke was at AREC in 2011 in Sydney.

Kevin:   I was going to remember, yeah.

Jeff:   And a little company based out of Manly Beach was just starting. It was their first launch, and they advertised behind my head on your show.

Kevin:   They did, they did.

Jeff:   I met them, and ended up working with them and bring RealSatisfied to the US and selling that into existence.

Kevin:   And RealSatisfied has just been a massive success, and to think it came out of Australia. And I think at the time, you guys were just looking for links, and I think that interview was actually the link that you picked up with them on, so-

Jeff:   Yeah.

Kevin:   But you’ve been a part of that.

Jeff:   You know, what’s interesting is, we went from zero, like I didn’t know who they were or what they were on that day, to six months later launching a product in the United States.

Jeff:   Quite amazing. It’s an incredible how things, how small this world is, and we come here to do this, then I meet you again. Tell me about what you’re doing.

Jeff:   Well, so, it’s interesting. We experienced with David and Peter in Australia, has sort of turned into a form of … I call it a new expertise for me, helping start-ups understand all of the intricacies and nuances of the American market. And I’ve been a mentor for NAR Reach since its inception, and I met Ralf von Grafenstein and Steve Bintz, who was the national sales director for Immoviewer, as part of the Reach mentorship programme almost two years ago. And I really liked their product, but I really thought that if they were going to continue on the strategy they were going, it was never going to get them to where they want to go.

And so, I do it with one or two companies each mentoring session. If there’s one I like, we just continue talking. And there was no commercial arrangement between us or any of that. It was just me spending time, giving friendly advice. And long story short, they asked me to be the CEO of North America, and I took them up on the offer, and we’ve since moved the company in another direction. Just this past week, we launched a new product in the restoration and home inspection market called DocuSketch.

Kevin:   How does that work?

Jeff:   Well, so DocuSketch is a take on the 3D virtual reality space. One of the thing that Immoviewer does that’s kind of unique is that they’re able to build floor plans and 3D models from just flat 360 images. And it’s a really interesting piece of math that’s required to do that. And so, that expertise plays actually better in that market because of the need to document, the need to get a sketch, a floor plan out, the value of 3D models inside of the restoration/home inspection space, than it does in a market like real estate, where agents still haven’t really caught on to virtual tours, not really.

Kevin:   I was … talking about that, and we’ll get right back, I was talking to the owner of a major franchise, one of the biggest franchises in the world. And he was telling me, the challenge he’s having just in getting his brokers and agents to embrace video, let alone virtual tours, virtual reality, artificial intelligence.

Jeff:   Yeah.

Kevin:   Tell me, Jeff, are you staggered at the pace that this is all going at? I mean, I’m not young. I’m older than you are. But it never ceases to amaze me, when I look back even five years ago, the advances in this industry.

Jeff:   Yeah, I mean, obviously I’ve been around a long time. You’ve been around a long time. I think it does give us a better perspective on how big the change is. I think I’m staggered more by the pace, even from last year. That’s the thing that’s … you don’t need to have a tonne of perspective to really appreciate how fast this is going. And that’s true on the 360 3D VR side of the equation. It’s true on artificial intelligence and machine learning and deep learning, and even [inaudible]. All of these things are, because of how quickly those chip sets that were really required to jumpstart the movement have been developed, the pace has just continued to pick up. And it really is staggering.

Kevin:   When we talk about real estate, the Inman Conference, I think, has been the benchmark for the world for many, many years. But if we probably go back a decade, tech didn’t play a real big part in it. But if you look at this now, there’s a whole floor of new tech. There’s another floor underneath this that devoted to new technology that’s coming through. The pace is just enormous.

Jeff:   Yeah, but until recently, there weren’t … there’s really not been a major change in the real estate industry itself.

Kevin:   Interesting.

Jeff:   You know, when you talk about his struggles to get agents to do video, we did some study in an MOS in upstate New York. More homes were sold last year with zero photos or a single photos that homes that had a virtual tour. So, agents will change when the consumer demands the change. And until that time, they’re not going to change their model. They’re no going to change the way they market homes. They’re not going to change a lot of those things, and I obviously think that’s a mistake.

Kevin:   Yeah, I do, too.

Jeff:   I think real estate in general, and this is a gross generalisation, I’ll apologise in advance, but I think the leaders of real estate are expecting to look for some technology meteor to come and make them dinosaurs, and I just don’t think that’s the way it’s going to work. I think it’s going to be other areas, other verticals, adapting and adopting to new technologies, and consumers just learning to expect more from that, to where it’s going to force change in the industry. Or, something bad will happen.

Speaker 1:                           Yeah, well, and I don’t think we should wait for that. And I agree, I think it’s a mistake that, as an industry, we are waiting for this change to happen. It shouldn’t be driven by the consumer. It should be driven, I think, by the agents who are using this to educate the consumers.

Jeff:   Yes.

Kevin:   It’s a big mistake.

Jeff:   Yeah, I think so, too. You know, you want to … I get it. I mean, I understand the mentality. A house is going to sell, whether I do X or not.

Kevin:   Yeah, but that’s lazy.

Jeff:   Well, I’m going to say that you said that, because-

Kevin:   It’s lazy.

Jeff:   It is lazy. But there are also … if you take a step back and look at it from an agent perspective, especially on the North America side of the equation, might be a little bit different in Australia, because agents go out, and the vendor pays for a lot of these services. The agent eats all of that cost here, up front, before a house even sells. And they’re constantly bombarded from all sides with new technologies and shiny objects and things that they could do. And they really do have to weigh everything against what’s really required for me to do that.

Kevin:   Ah, well, Jeff, this is your territory. I’ve been here five minutes, but I can already sense an element of requiring a change in how brokerage is done. I interviewed an agent just today who was talking about, “No BS in my company.” He is embracing technology. He’s trying to change the model, working for buyers and sellers. We see the [I’d buy a] model. All of these challenges are forcing change on this industry.

Jeff:   I think there’s been more of that hint that something’s coming in the last year than there has been in any year previous. That’s a fact. I mean, I feel that, as well. And I think the industry’s feeling it, too.

Kevin:   I think they are, too.

Jeff:   The talk is becoming a higher volume.

Kevin:   Yeah,. I think the smart operators are anticipating that, trying to get ahead of that, and that’s what I was sort of saying, without … I think we need to be driving this change rather than sitting back and waiting for it to happen.

Jeff:   Yeah, I agree.

Kevin:   Right, talking to my friend, it’s always, you’re always welcome.

Jeff:   It’s always good to see you.

Kevin:   Yeah, thank you, Jeff.

Jeff:   It’s been too long.

Kevin:   Yeah, it’s been too long. We’ll catch up again soon.

Jeff:   Thank you very much.

Kevin:   Good on you.

Kevin:   That was just one of the 60 interviews we did when we were at Inman Connect in New York. Now you can see those. We recorded them in video, and you can see them all right now at propertyTV.io. Check it out for yourself. We compiled them into shows, and we’ll also be featuring them individually. That website again is propertyTV.io.

from Real Estate Uncut http://bit.ly/2ScOobS

[healthandfitnessrecipes-blog]

RHR: The Ocular Microbiome, with Dr. Harvey Fishman

https://healthandfitnessrecipes.com/?p=7327

In this episode we discuss:

What is the ocular microbiome?

How the microbiome affects eye diseases

T cell activation in the eye

HLA-B27 and genes that play an important role in immune function

A nutrient-dense and anti-inflammatory diet for eye health

Antibiotics prior to surgery

Show notes:

Dr. Harvey Fishman's website: fishmanvision.com

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Chris Kresser: Dr. Fishman, welcome to Revolution Health Radio. I'm so happy you could join us. I've really been looking forward to this.

Dr Harvey Fishman: Thank you so much for having me, Chris. This is wonderful.

What is the ocular microbiome?

Chris Kresser: So, my audience has been well aware of the gut microbiome for many years. We've also talked about the skin microbiome. We talked about the vaginal microbiome, the lung microbiome, more recently the nasal microbiology, and so it's not surprising to learn that there is also an ocular microbiome. I'm really looking forward to talking to you more about this and how it contributes to eye disease. Because in the conventional world, the options for preventing eye disease in the first place and then addressing them, I think, have come a long way but maybe still leaves something to be desired. I'd first love to start out with just hearing a little bit more about your background, how you became interested in the ocular microbiome in your work as an ophthalmologist, and what led you down this path.

Dr. Fishman: That's great. So, I have a pretty interesting background, where I started off in the world as a physical chemist, studied neuroscience. I was in an analytical chemistry microfluidic laser lab at Stanford and really got interested in how to measure molecules almost at the single molecule level. We were looking at vesicular and synaptic release, neurotransmitters, and what the chemical basis of learning and memory was.

 You’ve heard of the gut microbiome—and maybe even the skin, nasal, and vaginal microbiome. But did you know that the eyes also have a microbiome and that it plays a key role in ocular health? 

That was sort of my background, and then I sort of did some interesting work in neurobiology, looking at retinal cells and how they grow and their regeneration, so I've had a lot of sort of technical background and analytical chemistry background. And then the last couple of years, I started getting very interested in the microbiome of the intestine and the gut, which led me into this whole world of what is actually happening in the eyes. Is there an ocular microbiome and is there a biome that controls disease in the eye that similar to that in the gut?

What's interesting is that I didn't necessarily sort of think about it in those ways. I actually got into my research that I'm working on right now is we're actually looking at how to measure cancer on the eye. We're using some of the analytical techniques that I developed or had been working on for my whole sort of academic career, which is how do you measure very small amounts of materials in microenvironments, and so I naturally led to this concept of how do you measure cancers on the eye. We started using similar techniques and sort of the illumina high throughput sequencing technology using 16S rDNA and rRNA to look at different things on the cancer. Chris has led me right into how they are looking at the microbiome and that’s sort of what got my interest sparked. The other thing that's sort of interesting is I've been working with a company called Microbiome to do some studies where I'm actually looking at intestinal microbiomes and how that compares to disease in the eye. That's sort of a whirlwind tour of how I got interested.

Chris Kresser: Right. It's a fascinating background, and as is often the case, it seems like in some way you could have never designed this career path or predicted it would happen, but when you look at it in retrospect, it seems like each step kind of perfectly informed the next step.

Dr. Fishman: That’s right. It’s actually really interesting; I never in my wildest dreams would have thought that I'd be doing genomics, and in fact one of my previous advisers always laughs because I'm doing genomics and I was a physical chemist and a microanalytical guy.

Chris Kresser: Right, right.

Dr. Fishman: Whippersnapper.

Chris Kresser: Right. So let’s talk a little bit about the ocular microbiome and what we know about it so far and what we don't know about it. Do we have any sense of the number of species, microorganisms, what the functions of the ocular microbiome are? I imagine it's significantly less developed as a field of study than the gut microbiome, but what do we know so far?

Dr. Fishman: It's really the beginning of this field. What's interesting about the microbiome of the eye is that we've been interested in, as ophthalmologists, not me personally, but at the ophthalmology community, we've been very interested in the bacteria that lived on the eye. The reason is that most of our intraocular surgeries like cataract surgery, vitreoretinal surgery, corneal surgery, when you make incisions into the eye, most of the serious infections that occur, occur because the exogeneous either bacteria that live on the lashes, the eyelid margin, or in the cornea. And so we've been very interested in this for years, and they've done a lot of interesting work, but the concept of the ocular microbiome, whether there's like some low-level core bacteria and microbiological species that lives on, in, and around the eye, that's really kind of a new concept.

One of the papers that has come out just recently was actually by Mark Wilcox. I don’t know if you're familiar with it; it was a major paper in 2017, and they looked at basically the temporal stability and composition of the ocular surface microbiome. It was probably one of the best papers, if not the sentinel paper in the field. What they found is … well, there's a couple of things they found, that first of all the ocular biome is very different, if at all, than the microbiome of the intestine. One of the things that they found is that in addition to other work that's been done, is that it's actually a pretty low number of species. I mean, there’s a diverse number of species, but it’s a low number. It’s just a regular number. And then there was some work that was done by Russell Van Gelder who's also shown similar work, but basically they started to talk about a bacteria microbiome that’s just very small in number.

Chris Kresser:  It's interesting; there is some parallel too with the gut. For most of the 20th century, we were very well aware of the existence of pathogenic bacteria, parasites and other organisms that could cause dysfunction in the gut, and most of the focus there was on identifying those pathogens and then treating the disease, eradicating them if possible with antibiotics or treating the diseases that were caused by them, whereas now at least, the awareness has shifted, and to some extent toward how do we support and nourish the protective microbiome and look at it more in the context of an ecosystem where we understand that if the health of the ecosystem is the primary focus, then that may actually be the most effective way of protecting against pathogenic activity.

Do you think that something similar is going to happen with the ocular microbiome or that it's just too— because it's not as significant in terms of the volume of the number of organisms and we may not have as much ability to influence it with things like diet and lifestyle, we’re not going to go down a similar path there?

How the microbiome affects eye diseases

Dr. Fishman: It’s a great question, and that's really what a lot of … myself and many other people are working on—whether you can influence it. I have some anecdotal discussions on that, papers as well, that actually would suggest that you may be able to do the exact same thing for the ocular health as you do for the gut health. Let me give you a couple examples. There are some really significant diseases of the eye, like, for example, dry eye disease, which is actually an area that I'm super interested in and really focusing a lot of my academic and clinical research. Dry eye disease is … they think there's a very big component of how the ocular microbiome interacts with the cornea and the lid and so forth, but there are also a bunch of other diseases like episcleritis, chronic follicular conjunctivitis, pterygium, or surfer’s eye, scleritis, even things that are as interesting as macular degeneration and glaucoma, a lot of people are starting to have … some of these diseases are actually idiopathic, not macular degeneration necessarily, but like episcleritis and dry eye disease. There are these so-called idiopathic diseases. What we think is that it's really controlled by dysbiosis of microbiome.

Chris Kresser: Wow, that's interesting. For listeners, idiopathic means “we don't really know.” It's a fancy way of saying, “We don’t know where this comes from or how it starts.” It's fascinating and by now not surprising, given what we talked about at the beginning of the show, we know now about the microbiome is not just in the gut. There's microbiology and virtually in any surface that interacts with the exterior world, whether it's the gut, the inside of the gut, technically is outside the body. We've talked about that on the show, which is always kind of fascinating, especially if you haven't thought about that, and then the lungs, which of course interface with the exterior environment, and the skin, the vagina, there's a penis microbiome, and clearly these organisms are playing some important role and clearly there's something about the modern lifestyle that is antithetical to the health of microbiomes. I imagine with the ocular microbiome, is it influenced by the same factors? Does systemic antibiotic use contribute to a degradation of the quality of the ocular microbiome? Are any kind of eye products that people use like drops, can they interfere? What do we know about that?

Dr. Fishman: Right. Those are great. Certainly areas that people are looking at. In the eye, there are so many aspects of the eye in terms of the ocular microbiome of the eye that makes it complex because the thing about the microbiome of the eye is that it’s not only that we think a core microbiome exist in a very low level, there's a lot of other bacteria and other species of organisms that sort of “contaminate” those measurements and also the surface.

One of the interesting things, there's a lot of sort of noise, in the sense that there's the noise from contaminants at any one time on the eye can overwhelm the signal of the actual microbiome. But what does seem to occur is that it's very possible that when people have sort of acute issues is because they do get some sort of dysregulation of their normal biome by this sort of contaminant. The sort of things that can really change the ocular surface biome is exactly the source that you're mentioning. If you use makeup, if you use products—Latisse, for instance, the Latisse, which people use to make their eyelashes grow longer contain a lot of— basically cause of the eyelashes that have more inflammation, more debris on them and that those are basically culture plates for bacteria on the eyelashes. That really does change it.

A lot of what you're mentioning really is sort of the dry eye disease realm, which is that all these different products that people use, including unnecessary eye drops or things like viral bacterial conjunctivitis, which you wouldn't use an antibiotic but that changes the microbiome. The other thing that is very fascinating is parasites. It turns out Demodex, I'm sure you—maybe we had many shows on Demodex, but Demodex is a big, big deal, and there is an interesting sort of life cycle of Demodex in the lashes and how that relates not only to the skin microbiome, but actually of people who have dysbiosis of their intestine. It’s just incredibly fascinating and it plays into the whole ocular rosacea story as well.

Chris Kresser: Not too long ago we had a periodontist, Al Danenberg, who's been through my clinician training program and is a really knowledgeable guy. He has looked at the connection between the gut microbiome and the oral microbiome and has found from his perspective and from what the research is showing that when there's a disruption in the oral microbiome, it's usually or often driven by dysfunction of the gut microbiome rather than the other way around, although certainly we know that infections in the mouth can influence the gut and other parts of the body, but because stomach acid protects against, hopefully if it's sufficient, a lot of what we would swallow and the saliva from the mouth that the relationship is probably more strongly influenced in the other direction. Has there been much work done on the influence of the gut microbiome on the ocular microbiome?

Dr. Fishman: That's a huge area that people … there's a lot of really interesting work, but just to kind of go back to what you said, there was a really interesting paper that came out that talked about the oral microbiome linked to neurodegeneration and glaucoma.

Chris Kresser:  Ah …

Dr. Fishman: We actually know that there are people with worse oral disease and dental disease. Actually, you have higher rates of primary glaucoma than other people, and that was a very well done study that was recently published. Essentially one of the things that we've known forever, and as a medical student, we learned very early in the game, the connection between ulcerative colitis, Crohn's disease, and uveitis. You may have touched upon before, but that is one of the most clear-cut associations that we have enough knowledge. In fact, ophthalmologists often sometimes will look … brilliant clinicians … when the person comes in and we see uveitis and then we do a little bit of the history and it turns out that they have Crohn’s and then we send them to the GI specialist and the GI guy thinks we're brilliant. We've discovered Crohn’s disease by looking in their eye and yet there are a few associations.

What's interesting is that there are multisystem disorders, autoimmune diseases that are associated with uveitis that are absolutely related to the gut and in other areas. That's an area that NIH is doing a very—there is a big push to look at the association. In particular, some of the work they're doing with T cell activation, both protective T cells and non-protective T cells, and how it influences uveitis, and they've been looking at some really interesting experimental autoimmune uveitis models, the EUA, so to speak, and they looked at how the regulatory T cells in the gut and other tissues really affect the uveitis and so forth.

Chris Kresser: I think there are probably a fair number of listeners who are not that familiar with disease. Uveitis being an inflammation of the middle layer of the eye, right?

Dr. Fishman: That's right.

Chris Kresser: With the connection between the gut and depression for example, the speculation is that in terms of the mechanism is that inflammatory cytokines are produced in the gut and they enter the bloodstream, perhaps because the barrier is permeable and they travel through the blood and they cross the blood–brain barrier and they suppress the activity of the frontal cortex, and that's one way gut pathology can lead to anxiety and depression.

In the case of the connection between the gut and eye disease, let's take ulcerative colitis and Crohn's, which are both autoimmune GI pathologies. Is the speculation that the systemic inflammation caused by the autoimmune disease is what's causing the inflammation in the eye, or is it that something related to a disruption of the microbiome leading to maybe the production of certain chemicals or inflammatory cytokines or something that's more specific to the microbial ecology of the gut is the contributing factor, or do we just not really know?

T cell activation in the eye

Dr. Fishman: One of the thoughts, and there was a paper that … and these are all interesting, really recent papers like 2015 to 2016, but there’s that commensal microbiota and bacteria in the gut that activate T cells. These T cells then circulate and then actually pass into and through the retina, in other parts of the eye, to then activate directly. It’s definitely via the immune system, but there are very specific immune cells that actually can penetrate into the eye. There's always been that thought that the eye is immunologically pristine, and that really is obviously not the case, but there are very selective T cells that can in fact get into the eye or pass into the eye, and so that's what we think that is going on, is that there's a dysregulation in the microbiome of the gut.

As you pointed out, you get T cell activation, and then it actually activates the local immune system in the eye. Actually, a really interesting situation that we see with respect to that, we actually can see diseases like sympathetic ophthalmia, which is a disease where if you injure one eye, activation of the T cells from one eye actually can go to the other eye, and you can actually lose the other eye, so you could actually have a question where are you …

Chris Kresser: Oh, wow.

Dr. Fishman: Yes, it's awful. That's why people have to get their eyes enucleated or taken out when they have a trauma. They have to do that within about 10 to 15 days or sooner because they can get this autoimmune activation that can actually blind them in the other eye. It’s just fascinating how that works, but that is sort of the same idea in the gut that you get with activation, and it causes inflammation. One of the things that we know, Chris, and this is my own personal experience in my practice, and I've seen this over and over and over again, is that my uveitis patients, they always come in with an active disease, almost always some kind of a gut-related situation that sets off their uveitis or inflammation. They'll come in and I’ll say, “What did you do last week?” “I was in Las Vegas and then we ate a lot of carbohydrates,” and these are patients who are very strict about being on a gluten-free diet, and they just say they cheated, so to speak, they had a bad weekend, fun weekend, but now they're paying the price and then they come back and they get uveitis. I can't tell you the number of times I've seen that. It's just clear cut. That's actually withm in particular, HLA-B27 uveitis. I don’t know if you have covered that, but that’s a big area.

HLA-B27 and genes that play an important role in immune function

Chris Kresser: I love to hear a little bit. I’m familiar with HLA-B27 and AS, ankylosing spondylitis, and the connection there. In fact, in our clinic, we will often test patients for HLA-B27 if they have joint pain, and if they test positive for Klebsiella bacteria on the stool test, I forget the name of a physician in London who discovered that connection, but then we’ll often put them on a low-starch diet and will treat the Klebsiella, and their joint pain will go away, or at least that will significantly improve. Tell me more about HLA-B27 and the eye.

Dr. Fishman: That’s our biggest immune screening. We screen for that in every single uveitis patient and screen for HLA-B27. In fact, 50 percent of every non-necrotising anterior uveitis, which is just a fancy word for basically idiopathic, meaning we don't know what the cause is, it's almost always related to an HLA-B27-positive uveitis, and so we see that all the time. Those patients are particularly sensitive to changes in their diet, and a lot of those patients, I will really push for strong control, at least in my practice. We always start off with a gluten-type restriction because that seems to be one of the big areas that sets off uveitis. HLA-B27 is such a prominent factor in most of our inflammation. You can also get sclerites with HLA-B27, you can get uveitis, you can get episcleritis, any of the autoimmune diseases around the eye seemed to be linked to that marker.

Chris Kresser: Just for the listeners, if your eyes are glazing over here, we're geeking out a little bit, but I want to back up. HLA-B27 is a gene, and it's one that plays a really important role in immune function. Its prevalence varies around the world in different ethnic groups and populations. I think it's about 8 percent in Caucasians, maybe this 2 to 9 percent in Chinese, 4 percent North Africans. As I was mentioning before, the association that I was most familiar with, I'm really fascinated to learn about the connection with uveitis is with ankylosing spondylitis. Back in the ’80s, there was a physician in London, whose name I'm unfortunately forgetting at the moment, and he was treating patients with AS, and by accident some of them he put on a low-carb diet for weight loss, and their AS improved dramatically. He did some more research and he found that there is a greater abundance of Klebsiella in stool samples of patients with AS, and then he found that Klebsiella bacteria that have preference for starch, and the patients that he put on a low-carb diet were of course eating a lot less starch. The low starch intake starved the Klebsiella and reduced the Klebsiella, which then reduced the autoimmune attack against the HLA-B27-expressed enzymes that were in the joints, and that's reduced the symptoms of AS, or ankylosing spondylitis, but there was later research that showed that sometimes can be connected to Crohn's disease. You just told me that Crohn's is connected to uveitis. Things like this, there’s a very interesting connection going on here, and that it may possibly a low-carb, low-starch diet, if it works for AS and HLA-B27, might be effective for uveitis.

Dr. Fishman: Absolutely. I basically, in a very non-scientific way, have my patients try these diets and often they don't want to go on to these heavy-duty immunosuppressants like methotrexate or Imuran. They want a natural … not natural, but they want a way to control the inflammation not to do these other sources. They will grab it, and a lot of the way I practice is I've learned so much from the multitude of patients who tell me, maybe the patients who have seen you as well, I learn from them what works, and I can then pass it on to other people. But in terms of the gut association with HLA-B27, it’s fascinating when you were mentioning Klebsiella, it turns out that Klebsiella as well as other bacteria … and in particular, there's a big connection with blepharitis and dry eye disease. In fact they did a study where they looked at patients—Bacillus was the other one—they looked at a setting where they looked at patients who had dry eye disease, and it turned out that Bacillus and Klebsiella were the huge association with blepharitis and dry eye disease. Just as an aside, another very interesting thing, because I'm very interested in dry eye disease and a lot of people with ocular rosacea, there is that story that the microbiome of your gut are being eaten, so bacteria that actually get eaten by the parasites, which hurt the Demodex on your eyelashes and your hair follicles, they eat the bacteria, then the parasites puke up the bacteria, and then the products and the exogenous components from the bacteria then irritates the eyelashes and the meibomian glands, which are glands in your eyelid, cause severe dry eyes. That's this interesting lifecycle between bacteria, Demodex.  The other thing that I've looked at, and I know that you guys have talked about SIBO, and there seems to be this association with SIBO, bacteria, blepharitis, Demodex and ocular rosacea and dry eye disease.

Nutrient-dense and anti-inflammatory diet for eye health

Chris Kresser: Fascinating. I mean, there's so many directions, but it all really comes back to, I mean, I think one of the things I like to emphasize, these discussions are fascinating and they're important, and these lines of research are really crucial to figuring out what's going on, and at the same time it comes back to the same basic steps that we need to take. Eat a nutrient-dense, anti-inflammatory diet, make sure you're taking care of your gut microbiome, avoid unnecessary antibiotics.Make sure to eat plenty of fermented foods and fermentable fibers. It can be easy to get overwhelmed by the complexity of all of these connections, but the good news is that usually it's just the same simple steps that we need to take in order to protect our health.

Dr. Fishman: Absolutely. One of the things that we found, and you'll just be amazed, ophthalmologists, we have been running the largest nutritional study in the history of mankind, and it was for macular degeneration. That statement is not a trivial one. I don't know if you’ve talked about this, and essentially the use of lutein as the advancement in your diet. There are a lot of interesting connections between the intestine and macular degeneration, and there's a big suggestion that the intestinal dysbiosis as seen in AMD patients … and when you're doing these supplementations, you're really supplementing the intestinal microbiome to reduce inflammation in the retina, which is actually the cause of macular degeneration, so it's just incredibly fascinating. Every time I leave my patient, I feel that there are two things I want you guys to leave this office with because I don't have the bandwidth, obviously, that your practice has in terms of … I have this focus on different things, but I tell them spinach pills, which is just spinach and omega-3 fatty acids. Omega-3 fatty acid is a very interesting controller of eyelid health and dry eye disease despite the fact that there was a recent paper that came out that disputed that, and I would really argue that that was not a very well-done … it was a study that was well done, but they had a lot of problems with it. My two big go-to things at least in my practice are spinach and fish.

Chris Kresser: That certainly fits into the context of the nutrient-dense, anti-inflammatory diet. It's really fascinating to me how the change, I think, that's happening in medicine, not just in functional integrative medicine but even in conventional medicine, that we started out allopathic medicine grew out of this Cartesian dualistic framework, where the body is basically just a bunch of disconnected parts that are kind of loosely connected, but not really influencing each other, and now we're really starting to understand that under traditional systems of medicine, they certainly didn't get everything right, but the one thing that they did get right was this idea of holism, that every part of the body is connected to and influences the body as a whole.

Now we're seeing this, I think, really play out. Look, it's Crohn's disease and ulcerative colitis increase your risk of eye inflammation. We now have the inflammatory cytokine model of depression that shows that inflammation in the gut can cause inflammation in the brain and symptoms that mimic depression. We've got connections between dysfunction in the HPA axis and stress and all kinds of skin conditions like eczema and psoriasis. I mean, the list goes on and on, and now we're adding to this the connection between the oral microbiome and the gut microbiome and inflammation in the eye, which even just, I think, 20 or 30 years ago would have been completely dismissed as a woo-woo kind of out-there stuff. It's just encouraging to me that we're really starting to move, no matter what kind of perspective on medicine, we're talking about into a more holistic view of the body.

Dr. Fishman: There was an interesting paper where one researcher looked at treating, it wasn't a corneal ulcer, but they were treating sort of a conjunctivitis using a probiotic eye drop.

Chris Kresser: I was going to ask you about that.

Dr. Fishman: There’s a disease called vernal keratoconjunctivitis, and that’s a pretty tough one to treat. Vernal means spring, and basically it’s allergic conjunctivitis. A lot of kids get it, and the way we typically treat that is with steroids and so forth, which you obviously don't want to do for children. There was a paper back in 2008 where they looked at using a probiotic eye drop, and they found it was equivalent to some of the other drops that they were using, which to me makes complete sense. I had a very interesting case recently of a patient who had actually an open globe. She actually had some sort of a tube that was put in for glaucoma, and it eroded through the conjunctiva. Bottom line, you see an open globe and she had opened up for essentially six months and nothing happened. She didn't get an infection, nothing. For whatever reason, she had a very well-controlled ocular biome.

One of the interesting questions that we're now looking at is how do the intestinal, oral, or skin biomes relate to the ocular microbiome? I think it's a pretty clear situation, and we know and I've had private conversations with some pretty famous microbiologists, anything that comes out of your intestine is going to be in your eyes, so basically just think of it that way. I mean, it doesn't sound great, and I joke with my patients, “You're basically getting poop in your eyes, and it happens all the time, every single day.” That’s what happens, not to be completely crap, but that is the connection.

Chris Kresser: Yes, yes. That's interesting. The probiotic eye drop reminds me of, I talked about this before, the nasal microbiome and the connection between the nasal microbiome and sinusitis. Dr. Susan Lynch at UCSF has done some really interesting work in this area. She did a fascinating study that was both animal and human, and they had an animal model of sinusitis, and they found that the main difference between animals with sinusitis and the controls was not—and this was true in humans too—was not the presence of certain pathogens. It wasn't that the people with sinusitis had much higher levels of fungus or certain species of pathogenic bacteria. The biggest difference between the two groups was microbial diversity.

Dr. Fishman: Right.

Chris Kresser: The people who were the controls, the people who didn't have sinusitis, had a much richer diversity of healthy protective bacteria, whereas the people who had sinusitis had a lower diversity, even when the presence of pathogenic species was basically the same. There was no difference between the two groups. The difference was that the healthy people had much higher levels of protective bacteria, and then she went a step further, and in the animals, they treated them with antibiotics until they were basically depleted of the microbiome in both the healthy controls and the animals with sinusitis. And in one group of animals, they didn't do anything. They just let the bacteria grow back as they would, and then the other group, they inoculated them with a protective species, Lactobacillus sakei, which they had observed in higher numbers in the healthy controls. And those animals that were inoculated with that nasal probiotic didn't develop sinusitis or anything the other animals that were not inoculated with that. That really actually speaks to probiotics in both maintaining and then restoring a healthy microbiome as being a more effective strategy than using antibiotics or antimicrobials to try to get rid of pathogens.

Dr. Fishman: Right. When you mention those two things, there were two interesting things that come to mind. The first one, just to let you know that there was a paper that came out in Nature in 2016 which said exactly the same thing. They were looking at Sjӧgren's disease—for your listeners, it’s one of the most severe forms of dry eye disease and other dry parts of your body. They found the exact same finding, that people with the severity of Sjӧgren's disease was inversely correlated with microbial diversity in your gut.

Chris Kresser: Wow.

Dr. Fishman: And with just as clear as day. It was just super clear that this was the case. We know, and I know from my own clinical experiences, that people who have, do have, a much higher control level, people who do a better job in terms of their diet, people who are more precise about the food that they eat and so forth, do much better with dry eyes. Dry eye disease, for the longest time, we've been treating dry eye disease with omega-3s or any type of fatty acid, but any sort of derived can lead to that. What I always mention is that, is it actually the omega-3 acting directly in your eye, or is it basically an activation, a biological cascade, that then causes the improved function in the eye? I clearly believe that it is a cascade effect because there is no way that just a simple little fish oil capsule could have that much of an improvement in people with dry eye disease.

Chris Kresser: Right, right.

[Crosstalk]

Chris Kresser: Go ahead, please.

Antibiotics prior to surgery

Dr. Fishman: Yes. I just have one other really interesting comment, which was one of the things that is interesting is that you talked about treating infections with basically displacing the bad bacteria with “good bacteria” and so forth, and that whole concept, which makes a lot of sense. One of the things that we've seen is that in eye disease, especially in ocular surgery, we routinely treat our patients basically from medicolegal reasons with antibiotics prior to surgery.

Chris Kresser: Right.

Dr. Fishman: It turns out that the studies are coming out that there's no data whatsoever to support those claims.

Chris Kresser: Yes.

Dr. Fishman: Those are billions of dollars a year in an antibiotics that were sold by pharmaceutical companies to basically do nothing and maybe, who knows, but maybe actually not even improve outcomes, but maybe make outcomes worse by selecting for bacteria that if it does get into eye, it actually would be a much worse situation.

Chris Kresser: Right.

Dr. Fishman: That's really interesting data that we have.

Chris Kresser: That happens, of course, not just in the world of the eye, ocular issues, but of course in the dental surgery, where patients will often come and say, “Oh, I'm about to get this dental surgery. My dentist is just prescribing antibiotics prophylactically.” Of course I've had the thought, “Well, okay, does this become a self-fulfilling prophecy?” Because we know that disruption of the oral microbiome with antibiotics can actually predispose you to an oral infection, and so by prophylactically prescribing an antibiotic is not really prophylaxis, or is that actually more likely to develop an infection? And as you said, not only have you reduced your body's ability to fight the infection, if it does happen, by reducing the number of beneficial protective bacteria, you've also potentially contributed to creating a more resistant strain of pathogenic bacteria by killing the ones that were least … the types of pathogenic bacteria that were least robust and just leaving the ones that were more robust.

Dr. Fishman: Well, there is some evidence that suggests that may actually be the case. I mean, with eye surgery, we use povidone iodine before surgery. That is the gold standard and at least cuts down sort of universally all … it doesn't select, do you know what I mean? You're not selecting for bacteria. You're basically wiping it out. Antibiotics, on the other hand, are probably selecting for it. That’s a good example where that period self-selecting bad bacteria really might be coming true. It’s very interesting where we’re going, especially with the eye, because there are still many “idiopathic” diseases and infections that really relate to the biome, not only of the eye, but also the gut being the cause of it.

Chris Kresser: Who knows? Maybe someday you'll go to the dentist and you'll get a dental probiotic instead of antibiotic for an infection. Maybe you’ll go to your ENT for an ear infection, and instead of putting antibiotic ear drops, they’ll put in probiotic ear drops. You’ll go the ophthalmologist and instead of getting antimicrobial treatment, you'll get probiotic eye drops. Seems that's not far-fetched at this point.

Dr. Fishman: Not at all. In fact, you might argue we’re already doing that through indirectly by using our gut as a way to … [crosstalk]

Chris Kresser: Right. To modulate.

Dr. Fishman: Correct.

Chris Kresser: Well, this has been really fascinating, Dr. Fishman. I've enjoyed talking with you, and I think the listeners are really going to get a lot out of this, and it's hopeful. I feel hopeful to know that there are folks like you who are exploring these new frontiers and really kind of pushing the boundaries and questioning some of the most basic assumptions that we've made and finding a new path forward that could lead to better, safer treatments. Where can folks learn more about your work or if people are in the Bay Area? It sounds like you definitely are still seeing some patients. Tell us where people can learn more.

Dr. Fishman: Sure. Well, they can always find me on my website, which is www.fishmanvision.com, and they can get involved in my practice in multiple ways. I definitely see patients. Half the time I'm seeing patients, half the time I'm doing research.

[Crosstalk]

Chris Kresser: It looks like they can do some video consultation as well. Is that right?

Dr. Fishman: Yes. For people in California, I can do video consultations if they can't make it to the office. Especially for dry eye disease, it’s very helpful.

Chris Kresser: Right, right. Great. Well, keep us posted on your research. We’d love to hear it, stay in touch, and have you back on the show at some point and just keep track of your work. These are really exciting developments.

Dr. Fishman: I really appreciate the opportunity, and I wanted to thank you because we've shared some patients, and their lives have actually changed because of the work that you're doing with them, so thank you.

Chris Kresser: Fantastic. It’s my pleasure. Take care.

Dr. Fishman: Okay, thank you.

The post RHR: The Ocular Microbiome, with Dr. Harvey Fishman appeared first on Chris Kresser.

http://media.blubrry.com/thehealthyskeptic/traffic.libsyn.com/thehealthyskeptic/RHR_-_The_Ocular_Microbiome_with_Dr._Harvey_Fishman.mp3 Credits: Original Content Source

[shapesnnsizes]

RHR: The Ocular Microbiome, with Dr. Harvey Fishman

In this episode we discuss:

What is the ocular microbiome?

How the microbiome affects eye diseases

T cell activation in the eye

HLA-B27 and genes that play an important role in immune function

A nutrient-dense and anti-inflammatory diet for eye health

Antibiotics prior to surgery

Show notes:

Dr. Harvey Fishman's website: fishmanvision.com

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Chris Kresser: Dr. Fishman, welcome to Revolution Health Radio. I'm so happy you could join us. I've really been looking forward to this.

Dr Harvey Fishman: Thank you so much for having me, Chris. This is wonderful.

What is the ocular microbiome?

Chris Kresser: So, my audience has been well aware of the gut microbiome for many years. We've also talked about the skin microbiome. We talked about the vaginal microbiome, the lung microbiome, more recently the nasal microbiology, and so it's not surprising to learn that there is also an ocular microbiome. I'm really looking forward to talking to you more about this and how it contributes to eye disease. Because in the conventional world, the options for preventing eye disease in the first place and then addressing them, I think, have come a long way but maybe still leaves something to be desired. I'd first love to start out with just hearing a little bit more about your background, how you became interested in the ocular microbiome in your work as an ophthalmologist, and what led you down this path.

Dr. Fishman: That's great. So, I have a pretty interesting background, where I started off in the world as a physical chemist, studied neuroscience. I was in an analytical chemistry microfluidic laser lab at Stanford and really got interested in how to measure molecules almost at the single molecule level. We were looking at vesicular and synaptic release, neurotransmitters, and what the chemical basis of learning and memory was.

 You’ve heard of the gut microbiome—and maybe even the skin, nasal, and vaginal microbiome. But did you know that the eyes also have a microbiome and that it plays a key role in ocular health? 

That was sort of my background, and then I sort of did some interesting work in neurobiology, looking at retinal cells and how they grow and their regeneration, so I've had a lot of sort of technical background and analytical chemistry background. And then the last couple of years, I started getting very interested in the microbiome of the intestine and the gut, which led me into this whole world of what is actually happening in the eyes. Is there an ocular microbiome and is there a biome that controls disease in the eye that similar to that in the gut?

What's interesting is that I didn't necessarily sort of think about it in those ways. I actually got into my research that I'm working on right now is we're actually looking at how to measure cancer on the eye. We're using some of the analytical techniques that I developed or had been working on for my whole sort of academic career, which is how do you measure very small amounts of materials in microenvironments, and so I naturally led to this concept of how do you measure cancers on the eye. We started using similar techniques and sort of the illumina high throughput sequencing technology using 16S rDNA and rRNA to look at different things on the cancer. Chris has led me right into how they are looking at the microbiome and that’s sort of what got my interest sparked. The other thing that's sort of interesting is I've been working with a company called Microbiome to do some studies where I'm actually looking at intestinal microbiomes and how that compares to disease in the eye. That's sort of a whirlwind tour of how I got interested.

Chris Kresser: Right. It's a fascinating background, and as is often the case, it seems like in some way you could have never designed this career path or predicted it would happen, but when you look at it in retrospect, it seems like each step kind of perfectly informed the next step.

Dr. Fishman: That’s right. It’s actually really interesting; I never in my wildest dreams would have thought that I'd be doing genomics, and in fact one of my previous advisers always laughs because I'm doing genomics and I was a physical chemist and a microanalytical guy.

Chris Kresser: Right, right.

Dr. Fishman: Whippersnapper.

Chris Kresser: Right. So let’s talk a little bit about the ocular microbiome and what we know about it so far and what we don't know about it. Do we have any sense of the number of species, microorganisms, what the functions of the ocular microbiome are? I imagine it's significantly less developed as a field of study than the gut microbiome, but what do we know so far?

Dr. Fishman: It's really the beginning of this field. What's interesting about the microbiome of the eye is that we've been interested in, as ophthalmologists, not me personally, but at the ophthalmology community, we've been very interested in the bacteria that lived on the eye. The reason is that most of our intraocular surgeries like cataract surgery, vitreoretinal surgery, corneal surgery, when you make incisions into the eye, most of the serious infections that occur, occur because the exogeneous either bacteria that live on the lashes, the eyelid margin, or in the cornea. And so we've been very interested in this for years, and they've done a lot of interesting work, but the concept of the ocular microbiome, whether there's like some low-level core bacteria and microbiological species that lives on, in, and around the eye, that's really kind of a new concept.

One of the papers that has come out just recently was actually by Mark Wilcox. I don’t know if you're familiar with it; it was a major paper in 2017, and they looked at basically the temporal stability and composition of the ocular surface microbiome. It was probably one of the best papers, if not the sentinel paper in the field. What they found is … well, there's a couple of things they found, that first of all the ocular biome is very different, if at all, than the microbiome of the intestine. One of the things that they found is that in addition to other work that's been done, is that it's actually a pretty low number of species. I mean, there’s a diverse number of species, but it’s a low number. It’s just a regular number. And then there was some work that was done by Russell Van Gelder who's also shown similar work, but basically they started to talk about a bacteria microbiome that’s just very small in number.

Chris Kresser:  It's interesting; there is some parallel too with the gut. For most of the 20th century, we were very well aware of the existence of pathogenic bacteria, parasites and other organisms that could cause dysfunction in the gut, and most of the focus there was on identifying those pathogens and then treating the disease, eradicating them if possible with antibiotics or treating the diseases that were caused by them, whereas now at least, the awareness has shifted, and to some extent toward how do we support and nourish the protective microbiome and look at it more in the context of an ecosystem where we understand that if the health of the ecosystem is the primary focus, then that may actually be the most effective way of protecting against pathogenic activity.

Do you think that something similar is going to happen with the ocular microbiome or that it's just too— because it's not as significant in terms of the volume of the number of organisms and we may not have as much ability to influence it with things like diet and lifestyle, we’re not going to go down a similar path there?

How the microbiome affects eye diseases

Dr. Fishman: It’s a great question, and that's really what a lot of … myself and many other people are working on—whether you can influence it. I have some anecdotal discussions on that, papers as well, that actually would suggest that you may be able to do the exact same thing for the ocular health as you do for the gut health. Let me give you a couple examples. There are some really significant diseases of the eye, like, for example, dry eye disease, which is actually an area that I'm super interested in and really focusing a lot of my academic and clinical research. Dry eye disease is … they think there's a very big component of how the ocular microbiome interacts with the cornea and the lid and so forth, but there are also a bunch of other diseases like episcleritis, chronic follicular conjunctivitis, pterygium, or surfer’s eye, scleritis, even things that are as interesting as macular degeneration and glaucoma, a lot of people are starting to have … some of these diseases are actually idiopathic, not macular degeneration necessarily, but like episcleritis and dry eye disease. There are these so-called idiopathic diseases. What we think is that it's really controlled by dysbiosis of microbiome.

Chris Kresser: Wow, that's interesting. For listeners, idiopathic means “we don't really know.” It's a fancy way of saying, “We don’t know where this comes from or how it starts.” It's fascinating and by now not surprising, given what we talked about at the beginning of the show, we know now about the microbiome is not just in the gut. There's microbiology and virtually in any surface that interacts with the exterior world, whether it's the gut, the inside of the gut, technically is outside the body. We've talked about that on the show, which is always kind of fascinating, especially if you haven't thought about that, and then the lungs, which of course interface with the exterior environment, and the skin, the vagina, there's a penis microbiome, and clearly these organisms are playing some important role and clearly there's something about the modern lifestyle that is antithetical to the health of microbiomes. I imagine with the ocular microbiome, is it influenced by the same factors? Does systemic antibiotic use contribute to a degradation of the quality of the ocular microbiome? Are any kind of eye products that people use like drops, can they interfere? What do we know about that?

Dr. Fishman: Right. Those are great. Certainly areas that people are looking at. In the eye, there are so many aspects of the eye in terms of the ocular microbiome of the eye that makes it complex because the thing about the microbiome of the eye is that it’s not only that we think a core microbiome exist in a very low level, there's a lot of other bacteria and other species of organisms that sort of “contaminate” those measurements and also the surface.

One of the interesting things, there's a lot of sort of noise, in the sense that there's the noise from contaminants at any one time on the eye can overwhelm the signal of the actual microbiome. But what does seem to occur is that it's very possible that when people have sort of acute issues is because they do get some sort of dysregulation of their normal biome by this sort of contaminant. The sort of things that can really change the ocular surface biome is exactly the source that you're mentioning. If you use makeup, if you use products—Latisse, for instance, the Latisse, which people use to make their eyelashes grow longer contain a lot of— basically cause of the eyelashes that have more inflammation, more debris on them and that those are basically culture plates for bacteria on the eyelashes. That really does change it.

A lot of what you're mentioning really is sort of the dry eye disease realm, which is that all these different products that people use, including unnecessary eye drops or things like viral bacterial conjunctivitis, which you wouldn't use an antibiotic but that changes the microbiome. The other thing that is very fascinating is parasites. It turns out Demodex, I'm sure you—maybe we had many shows on Demodex, but Demodex is a big, big deal, and there is an interesting sort of life cycle of Demodex in the lashes and how that relates not only to the skin microbiome, but actually of people who have dysbiosis of their intestine. It’s just incredibly fascinating and it plays into the whole ocular rosacea story as well.

Chris Kresser: Not too long ago we had a periodontist, Al Danenberg, who's been through my clinician training program and is a really knowledgeable guy. He has looked at the connection between the gut microbiome and the oral microbiome and has found from his perspective and from what the research is showing that when there's a disruption in the oral microbiome, it's usually or often driven by dysfunction of the gut microbiome rather than the other way around, although certainly we know that infections in the mouth can influence the gut and other parts of the body, but because stomach acid protects against, hopefully if it's sufficient, a lot of what we would swallow and the saliva from the mouth that the relationship is probably more strongly influenced in the other direction. Has there been much work done on the influence of the gut microbiome on the ocular microbiome?

Dr. Fishman: That's a huge area that people … there's a lot of really interesting work, but just to kind of go back to what you said, there was a really interesting paper that came out that talked about the oral microbiome linked to neurodegeneration and glaucoma.

Chris Kresser:  Ah …

Dr. Fishman: We actually know that there are people with worse oral disease and dental disease. Actually, you have higher rates of primary glaucoma than other people, and that was a very well done study that was recently published. Essentially one of the things that we've known forever, and as a medical student, we learned very early in the game, the connection between ulcerative colitis, Crohn's disease, and uveitis. You may have touched upon before, but that is one of the most clear-cut associations that we have enough knowledge. In fact, ophthalmologists often sometimes will look … brilliant clinicians … when the person comes in and we see uveitis and then we do a little bit of the history and it turns out that they have Crohn’s and then we send them to the GI specialist and the GI guy thinks we're brilliant. We've discovered Crohn’s disease by looking in their eye and yet there are a few associations.

What's interesting is that there are multisystem disorders, autoimmune diseases that are associated with uveitis that are absolutely related to the gut and in other areas. That's an area that NIH is doing a very—there is a big push to look at the association. In particular, some of the work they're doing with T cell activation, both protective T cells and non-protective T cells, and how it influences uveitis, and they've been looking at some really interesting experimental autoimmune uveitis models, the EUA, so to speak, and they looked at how the regulatory T cells in the gut and other tissues really affect the uveitis and so forth.

Chris Kresser: I think there are probably a fair number of listeners who are not that familiar with disease. Uveitis being an inflammation of the middle layer of the eye, right?

Dr. Fishman: That's right.

Chris Kresser: With the connection between the gut and depression for example, the speculation is that in terms of the mechanism is that inflammatory cytokines are produced in the gut and they enter the bloodstream, perhaps because the barrier is permeable and they travel through the blood and they cross the blood–brain barrier and they suppress the activity of the frontal cortex, and that's one way gut pathology can lead to anxiety and depression.

In the case of the connection between the gut and eye disease, let's take ulcerative colitis and Crohn's, which are both autoimmune GI pathologies. Is the speculation that the systemic inflammation caused by the autoimmune disease is what's causing the inflammation in the eye, or is it that something related to a disruption of the microbiome leading to maybe the production of certain chemicals or inflammatory cytokines or something that's more specific to the microbial ecology of the gut is the contributing factor, or do we just not really know?

T cell activation in the eye

Dr. Fishman: One of the thoughts, and there was a paper that … and these are all interesting, really recent papers like 2015 to 2016, but there’s that commensal microbiota and bacteria in the gut that activate T cells. These T cells then circulate and then actually pass into and through the retina, in other parts of the eye, to then activate directly. It’s definitely via the immune system, but there are very specific immune cells that actually can penetrate into the eye. There's always been that thought that the eye is immunologically pristine, and that really is obviously not the case, but there are very selective T cells that can in fact get into the eye or pass into the eye, and so that's what we think that is going on, is that there's a dysregulation in the microbiome of the gut.

As you pointed out, you get T cell activation, and then it actually activates the local immune system in the eye. Actually, a really interesting situation that we see with respect to that, we actually can see diseases like sympathetic ophthalmia, which is a disease where if you injure one eye, activation of the T cells from one eye actually can go to the other eye, and you can actually lose the other eye, so you could actually have a question where are you …

Chris Kresser: Oh, wow.

Dr. Fishman: Yes, it's awful. That's why people have to get their eyes enucleated or taken out when they have a trauma. They have to do that within about 10 to 15 days or sooner because they can get this autoimmune activation that can actually blind them in the other eye. It’s just fascinating how that works, but that is sort of the same idea in the gut that you get with activation, and it causes inflammation. One of the things that we know, Chris, and this is my own personal experience in my practice, and I've seen this over and over and over again, is that my uveitis patients, they always come in with an active disease, almost always some kind of a gut-related situation that sets off their uveitis or inflammation. They'll come in and I’ll say, “What did you do last week?” “I was in Las Vegas and then we ate a lot of carbohydrates,” and these are patients who are very strict about being on a gluten-free diet, and they just say they cheated, so to speak, they had a bad weekend, fun weekend, but now they're paying the price and then they come back and they get uveitis. I can't tell you the number of times I've seen that. It's just clear cut. That's actually withm in particular, HLA-B27 uveitis. I don’t know if you have covered that, but that’s a big area.

HLA-B27 and genes that play an important role in immune function

Chris Kresser: I love to hear a little bit. I’m familiar with HLA-B27 and AS, ankylosing spondylitis, and the connection there. In fact, in our clinic, we will often test patients for HLA-B27 if they have joint pain, and if they test positive for Klebsiella bacteria on the stool test, I forget the name of a physician in London who discovered that connection, but then we’ll often put them on a low-starch diet and will treat the Klebsiella, and their joint pain will go away, or at least that will significantly improve. Tell me more about HLA-B27 and the eye.

Dr. Fishman: That’s our biggest immune screening. We screen for that in every single uveitis patient and screen for HLA-B27. In fact, 50 percent of every non-necrotising anterior uveitis, which is just a fancy word for basically idiopathic, meaning we don't know what the cause is, it's almost always related to an HLA-B27-positive uveitis, and so we see that all the time. Those patients are particularly sensitive to changes in their diet, and a lot of those patients, I will really push for strong control, at least in my practice. We always start off with a gluten-type restriction because that seems to be one of the big areas that sets off uveitis. HLA-B27 is such a prominent factor in most of our inflammation. You can also get sclerites with HLA-B27, you can get uveitis, you can get episcleritis, any of the autoimmune diseases around the eye seemed to be linked to that marker.

Chris Kresser: Just for the listeners, if your eyes are glazing over here, we're geeking out a little bit, but I want to back up. HLA-B27 is a gene, and it's one that plays a really important role in immune function. Its prevalence varies around the world in different ethnic groups and populations. I think it's about 8 percent in Caucasians, maybe this 2 to 9 percent in Chinese, 4 percent North Africans. As I was mentioning before, the association that I was most familiar with, I'm really fascinated to learn about the connection with uveitis is with ankylosing spondylitis. Back in the ’80s, there was a physician in London, whose name I'm unfortunately forgetting at the moment, and he was treating patients with AS, and by accident some of them he put on a low-carb diet for weight loss, and their AS improved dramatically. He did some more research and he found that there is a greater abundance of Klebsiella in stool samples of patients with AS, and then he found that Klebsiella bacteria that have preference for starch, and the patients that he put on a low-carb diet were of course eating a lot less starch. The low starch intake starved the Klebsiella and reduced the Klebsiella, which then reduced the autoimmune attack against the HLA-B27-expressed enzymes that were in the joints, and that's reduced the symptoms of AS, or ankylosing spondylitis, but there was later research that showed that sometimes can be connected to Crohn's disease. You just told me that Crohn's is connected to uveitis. Things like this, there’s a very interesting connection going on here, and that it may possibly a low-carb, low-starch diet, if it works for AS and HLA-B27, might be effective for uveitis.

Dr. Fishman: Absolutely. I basically, in a very non-scientific way, have my patients try these diets and often they don't want to go on to these heavy-duty immunosuppressants like methotrexate or Imuran. They want a natural … not natural, but they want a way to control the inflammation not to do these other sources. They will grab it, and a lot of the way I practice is I've learned so much from the multitude of patients who tell me, maybe the patients who have seen you as well, I learn from them what works, and I can then pass it on to other people. But in terms of the gut association with HLA-B27, it’s fascinating when you were mentioning Klebsiella, it turns out that Klebsiella as well as other bacteria … and in particular, there's a big connection with blepharitis and dry eye disease. In fact they did a study where they looked at patients—Bacillus was the other one—they looked at a setting where they looked at patients who had dry eye disease, and it turned out that Bacillus and Klebsiella were the huge association with blepharitis and dry eye disease. Just as an aside, another very interesting thing, because I'm very interested in dry eye disease and a lot of people with ocular rosacea, there is that story that the microbiome of your gut are being eaten, so bacteria that actually get eaten by the parasites, which hurt the Demodex on your eyelashes and your hair follicles, they eat the bacteria, then the parasites puke up the bacteria, and then the products and the exogenous components from the bacteria then irritates the eyelashes and the meibomian glands, which are glands in your eyelid, cause severe dry eyes. That's this interesting lifecycle between bacteria, Demodex.  The other thing that I've looked at, and I know that you guys have talked about SIBO, and there seems to be this association with SIBO, bacteria, blepharitis, Demodex and ocular rosacea and dry eye disease.

Nutrient-dense and anti-inflammatory diet for eye health

Chris Kresser: Fascinating. I mean, there's so many directions, but it all really comes back to, I mean, I think one of the things I like to emphasize, these discussions are fascinating and they're important, and these lines of research are really crucial to figuring out what's going on, and at the same time it comes back to the same basic steps that we need to take. Eat a nutrient-dense, anti-inflammatory diet, make sure you're taking care of your gut microbiome, avoid unnecessary antibiotics.Make sure to eat plenty of fermented foods and fermentable fibers. It can be easy to get overwhelmed by the complexity of all of these connections, but the good news is that usually it's just the same simple steps that we need to take in order to protect our health.

Dr. Fishman: Absolutely. One of the things that we found, and you'll just be amazed, ophthalmologists, we have been running the largest nutritional study in the history of mankind, and it was for macular degeneration. That statement is not a trivial one. I don't know if you’ve talked about this, and essentially the use of lutein as the advancement in your diet. There are a lot of interesting connections between the intestine and macular degeneration, and there's a big suggestion that the intestinal dysbiosis as seen in AMD patients … and when you're doing these supplementations, you're really supplementing the intestinal microbiome to reduce inflammation in the retina, which is actually the cause of macular degeneration, so it's just incredibly fascinating. Every time I leave my patient, I feel that there are two things I want you guys to leave this office with because I don't have the bandwidth, obviously, that your practice has in terms of … I have this focus on different things, but I tell them spinach pills, which is just spinach and omega-3 fatty acids. Omega-3 fatty acid is a very interesting controller of eyelid health and dry eye disease despite the fact that there was a recent paper that came out that disputed that, and I would really argue that that was not a very well-done … it was a study that was well done, but they had a lot of problems with it. My two big go-to things at least in my practice are spinach and fish.

Chris Kresser: That certainly fits into the context of the nutrient-dense, anti-inflammatory diet. It's really fascinating to me how the change, I think, that's happening in medicine, not just in functional integrative medicine but even in conventional medicine, that we started out allopathic medicine grew out of this Cartesian dualistic framework, where the body is basically just a bunch of disconnected parts that are kind of loosely connected, but not really influencing each other, and now we're really starting to understand that under traditional systems of medicine, they certainly didn't get everything right, but the one thing that they did get right was this idea of holism, that every part of the body is connected to and influences the body as a whole.

Now we're seeing this, I think, really play out. Look, it's Crohn's disease and ulcerative colitis increase your risk of eye inflammation. We now have the inflammatory cytokine model of depression that shows that inflammation in the gut can cause inflammation in the brain and symptoms that mimic depression. We've got connections between dysfunction in the HPA axis and stress and all kinds of skin conditions like eczema and psoriasis. I mean, the list goes on and on, and now we're adding to this the connection between the oral microbiome and the gut microbiome and inflammation in the eye, which even just, I think, 20 or 30 years ago would have been completely dismissed as a woo-woo kind of out-there stuff. It's just encouraging to me that we're really starting to move, no matter what kind of perspective on medicine, we're talking about into a more holistic view of the body.

Dr. Fishman: There was an interesting paper where one researcher looked at treating, it wasn't a corneal ulcer, but they were treating sort of a conjunctivitis using a probiotic eye drop.

Chris Kresser: I was going to ask you about that.

Dr. Fishman: There’s a disease called vernal keratoconjunctivitis, and that’s a pretty tough one to treat. Vernal means spring, and basically it’s allergic conjunctivitis. A lot of kids get it, and the way we typically treat that is with steroids and so forth, which you obviously don't want to do for children. There was a paper back in 2008 where they looked at using a probiotic eye drop, and they found it was equivalent to some of the other drops that they were using, which to me makes complete sense. I had a very interesting case recently of a patient who had actually an open globe. She actually had some sort of a tube that was put in for glaucoma, and it eroded through the conjunctiva. Bottom line, you see an open globe and she had opened up for essentially six months and nothing happened. She didn't get an infection, nothing. For whatever reason, she had a very well-controlled ocular biome.

One of the interesting questions that we're now looking at is how do the intestinal, oral, or skin biomes relate to the ocular microbiome? I think it's a pretty clear situation, and we know and I've had private conversations with some pretty famous microbiologists, anything that comes out of your intestine is going to be in your eyes, so basically just think of it that way. I mean, it doesn't sound great, and I joke with my patients, “You're basically getting poop in your eyes, and it happens all the time, every single day.” That’s what happens, not to be completely crap, but that is the connection.

Chris Kresser: Yes, yes. That's interesting. The probiotic eye drop reminds me of, I talked about this before, the nasal microbiome and the connection between the nasal microbiome and sinusitis. Dr. Susan Lynch at UCSF has done some really interesting work in this area. She did a fascinating study that was both animal and human, and they had an animal model of sinusitis, and they found that the main difference between animals with sinusitis and the controls was not—and this was true in humans too—was not the presence of certain pathogens. It wasn't that the people with sinusitis had much higher levels of fungus or certain species of pathogenic bacteria. The biggest difference between the two groups was microbial diversity.

Dr. Fishman: Right.

Chris Kresser: The people who were the controls, the people who didn't have sinusitis, had a much richer diversity of healthy protective bacteria, whereas the people who had sinusitis had a lower diversity, even when the presence of pathogenic species was basically the same. There was no difference between the two groups. The difference was that the healthy people had much higher levels of protective bacteria, and then she went a step further, and in the animals, they treated them with antibiotics until they were basically depleted of the microbiome in both the healthy controls and the animals with sinusitis. And in one group of animals, they didn't do anything. They just let the bacteria grow back as they would, and then the other group, they inoculated them with a protective species, Lactobacillus sakei, which they had observed in higher numbers in the healthy controls. And those animals that were inoculated with that nasal probiotic didn't develop sinusitis or anything the other animals that were not inoculated with that. That really actually speaks to probiotics in both maintaining and then restoring a healthy microbiome as being a more effective strategy than using antibiotics or antimicrobials to try to get rid of pathogens.

Dr. Fishman: Right. When you mention those two things, there were two interesting things that come to mind. The first one, just to let you know that there was a paper that came out in Nature in 2016 which said exactly the same thing. They were looking at Sjӧgren's disease—for your listeners, it’s one of the most severe forms of dry eye disease and other dry parts of your body. They found the exact same finding, that people with the severity of Sjӧgren's disease was inversely correlated with microbial diversity in your gut.

Chris Kresser: Wow.

Dr. Fishman: And with just as clear as day. It was just super clear that this was the case. We know, and I know from my own clinical experiences, that people who have, do have, a much higher control level, people who do a better job in terms of their diet, people who are more precise about the food that they eat and so forth, do much better with dry eyes. Dry eye disease, for the longest time, we've been treating dry eye disease with omega-3s or any type of fatty acid, but any sort of derived can lead to that. What I always mention is that, is it actually the omega-3 acting directly in your eye, or is it basically an activation, a biological cascade, that then causes the improved function in the eye? I clearly believe that it is a cascade effect because there is no way that just a simple little fish oil capsule could have that much of an improvement in people with dry eye disease.

Chris Kresser: Right, right.

[Crosstalk]

Chris Kresser: Go ahead, please.

Antibiotics prior to surgery

Dr. Fishman: Yes. I just have one other really interesting comment, which was one of the things that is interesting is that you talked about treating infections with basically displacing the bad bacteria with “good bacteria” and so forth, and that whole concept, which makes a lot of sense. One of the things that we've seen is that in eye disease, especially in ocular surgery, we routinely treat our patients basically from medicolegal reasons with antibiotics prior to surgery.

Chris Kresser: Right.

Dr. Fishman: It turns out that the studies are coming out that there's no data whatsoever to support those claims.

Chris Kresser: Yes.

Dr. Fishman: Those are billions of dollars a year in an antibiotics that were sold by pharmaceutical companies to basically do nothing and maybe, who knows, but maybe actually not even improve outcomes, but maybe make outcomes worse by selecting for bacteria that if it does get into eye, it actually would be a much worse situation.

Chris Kresser: Right.

Dr. Fishman: That's really interesting data that we have.

Chris Kresser: That happens, of course, not just in the world of the eye, ocular issues, but of course in the dental surgery, where patients will often come and say, “Oh, I'm about to get this dental surgery. My dentist is just prescribing antibiotics prophylactically.” Of course I've had the thought, “Well, okay, does this become a self-fulfilling prophecy?” Because we know that disruption of the oral microbiome with antibiotics can actually predispose you to an oral infection, and so by prophylactically prescribing an antibiotic is not really prophylaxis, or is that actually more likely to develop an infection? And as you said, not only have you reduced your body's ability to fight the infection, if it does happen, by reducing the number of beneficial protective bacteria, you've also potentially contributed to creating a more resistant strain of pathogenic bacteria by killing the ones that were least … the types of pathogenic bacteria that were least robust and just leaving the ones that were more robust.

Dr. Fishman: Well, there is some evidence that suggests that may actually be the case. I mean, with eye surgery, we use povidone iodine before surgery. That is the gold standard and at least cuts down sort of universally all … it doesn't select, do you know what I mean? You're not selecting for bacteria. You're basically wiping it out. Antibiotics, on the other hand, are probably selecting for it. That’s a good example where that period self-selecting bad bacteria really might be coming true. It’s very interesting where we’re going, especially with the eye, because there are still many “idiopathic” diseases and infections that really relate to the biome, not only of the eye, but also the gut being the cause of it.

Chris Kresser: Who knows? Maybe someday you'll go to the dentist and you'll get a dental probiotic instead of antibiotic for an infection. Maybe you’ll go to your ENT for an ear infection, and instead of putting antibiotic ear drops, they’ll put in probiotic ear drops. You’ll go the ophthalmologist and instead of getting antimicrobial treatment, you'll get probiotic eye drops. Seems that's not far-fetched at this point.

Dr. Fishman: Not at all. In fact, you might argue we’re already doing that through indirectly by using our gut as a way to … [crosstalk]

Chris Kresser: Right. To modulate.

Dr. Fishman: Correct.

Chris Kresser: Well, this has been really fascinating, Dr. Fishman. I've enjoyed talking with you, and I think the listeners are really going to get a lot out of this, and it's hopeful. I feel hopeful to know that there are folks like you who are exploring these new frontiers and really kind of pushing the boundaries and questioning some of the most basic assumptions that we've made and finding a new path forward that could lead to better, safer treatments. Where can folks learn more about your work or if people are in the Bay Area? It sounds like you definitely are still seeing some patients. Tell us where people can learn more.

Dr. Fishman: Sure. Well, they can always find me on my website, which is www.fishmanvision.com, and they can get involved in my practice in multiple ways. I definitely see patients. Half the time I'm seeing patients, half the time I'm doing research.

[Crosstalk]

Chris Kresser: It looks like they can do some video consultation as well. Is that right?

Dr. Fishman: Yes. For people in California, I can do video consultations if they can't make it to the office. Especially for dry eye disease, it’s very helpful.

Chris Kresser: Right, right. Great. Well, keep us posted on your research. We’d love to hear it, stay in touch, and have you back on the show at some point and just keep track of your work. These are really exciting developments.

Dr. Fishman: I really appreciate the opportunity, and I wanted to thank you because we've shared some patients, and their lives have actually changed because of the work that you're doing with them, so thank you.

Chris Kresser: Fantastic. It’s my pleasure. Take care.

Dr. Fishman: Okay, thank you.

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