Is Your Gut Destroying Your Vision? Expert Interview

What if I told you that your vision problems like dry eyes, macular degeneration, glaucoma, and others did not in fact start in the eye, but instead started in your gut. Sounds a bit crazy, right? Well, new research is showing of something called the gut eye axis, meaning that bacteria and microorganisms in your gut could be silently destroying your vision. Today on the Dr. her eye health podcast. I interview Mila Jussi Fova, who's not only an optometrist and dryey specialist, but also holds a degree in nutrition and she helps break down how the gut microbiome is connected to eye diseases and what type of foods you can eat to help. Today's episode is made possible through InMode and the Envision Workstation. If you've never heard of Nvision before, this technology offers groundbreaking non-surgical and highly efficacious dermatological procedures, including bipolar radio frequency and intense pulseed light. Two procedures that myself and many other dryey specialists frequently recommend to help improve our patients quality of life. In fact, the Envision workstation is the exact same model and technology that we offer to our patients here at our clinic. To learn more, you can check out envisiontreatment. com. We'll put links in the show notes for you. And stay tuned because we'll be sharing more details about this fascinating and impactful treatment later in the episode. And hey, if you find value in this information coming directly from real doctors and researchers, then be sure to hit the subscribe and follow buttons because that will not only help us reach more people like yourself, but also if you turn on that notification setting, you'll be reminded anytime we post something. And so that's not just something that helps us but also helps you. Otherwise, thanks for being here and let's get into it. So, Dr. Uisa Fova or UC FOVA, I'm making sure I say that right. Thank you so much for being here. This is always an honor and um just uh to be able to spend some time talking about not only eye care, but talking about the topic of nutrition, diet, and now kind of gut health and the gut microbiome. This is a topic that I think is getting a lot more light and interest uh especially in the last seven or eight years as more information about the gut microbiome has been surfacing in kind of just the medical world. So you yourself are not only a doctor of optometry but you are a dryey specialist and you've been uh like running a dryey specialty clinic for close to 10 15 years now, right? — Yes. And then you also not only have all of that accomplishment, but then you also have a more of a formal degree in nutrition and you're a board member of the Ocular Wellness Nutrition Society or Owns. So, uh I'm again I'm really honored and uh really happy to have you on here uh to kind of talk to us about diet nutrition from your perspective. So, uh with all of that, uh can we just kind of kick it off? tell us a little bit kind of how you even got into nutrition and that being such a kind of a focus and interest of yours. — Yes. Well, first of all, thank you for having me. The honor is all mine. I know how much you talk about gut health and nutrition when you are talking about dry eye and other conditions. So um this is a topic that's very exciting and I as you know I lecture on this and I um talk about the correlation between gut eye access and the reason why I got started and got interested in it is I so I've been practicing for 18 19 years something like that and my uh primary focus really from day one of practicing within few years I started to really pay attention to dry eye conditions and patients that are struggling with dry eye and when I opened my practice 13 years ago it was a coldstar practice the from day one I started to invest in all these advanced treatments so in office procedures there's thermal treatments there's IPL treatments uh light procedures you know all the advanced at this point now fast forward we do a lot of inoff procedures we even do blood draws and makeus serum metallicus PRP in our office so we are treating dry high at a high level, but there was still something missing. These patients that I was doing, everything that I had in my power, they were still not getting better. So, I was I just kept looking for answers. What's missing? And obviously, I knew that nutrition and that plays a role in a lot of diseases, a lot of conditions. And dry eye is we it's an immune mediated disease. We've known that. we know that disregulated inflammation is involved in dry eye. So I started to um you know dig a little deeper. What I found was my own

knowledge of just nutrition and nutrition science was limited because as you know in optometry school in medical schools we're really not we don't learn too much about nutrition. So then I started to do you know take classes and really look into you know a self-education. Um I've been a part of Ocular Wellness and Nutrition Society from my residency and that was a while ago and um and I learned that with you know being part of the society I was exposed to a lot more education and then that led me through them to actually get my certification which is through um American nutrition association. So it's a accredited um certification. It took me a long time to get um took me almost four years with 1,000 clinical hours working with a nutritional supervisor, you know, uh which was great because I was using these cases to uh present my cases, my own patients, patients that had dryey disease, that had autoimmune conditions, that had uh other you know [clears throat] metabolic dysfunctions. So I was able to help them get past the inoff treatments or the pharmaceuticals and I really on personal and nutrition level really able to get them feeling better with their eyes and also you know other symptoms as well. So this is how I you know the the drive or the need for incorporate nutrition was from my dryey patients and that's how I started to really get into it and the more I you know I was learning the more I was like oh there's so much I don't I still don't know. I know it's typically a lot of times like again I think most people who go in to see an eye doctor uh or even sometimes their medical doctor for anything people don't necessarily I think even expect to hear uh guidance on diet and nutrition and so do you ever have patients who come in and see you maybe for a consult about their dry eye or even just like routine care uh are do they ever get kind of confused or do they respond in a weird way when you bring up nutrition or ask them about their diet. Yeah, I think it's always, you know, the patients will give me a funny look if I ask them about or when their bowel movements like why are you asking about my if I have regular bowel movements but that's how I sess those are you know I do have questions on your you know your sleep your exercise levels your stress levels and you know and what you're eating and if you have regular bellums that gives me just a quick you know already a synapse of or the picture of what is happening with your you know GI system if you have a nice healthy microbiome healthy uh GI function. So, um I get funny looks for sure, but I also get patients that are really relieved or they they feel so um excited that oh, I know I mean they people know about the importance of the gut health and nutrition, lifestyle, all of those things in everything. But when their eye doctor makes a connection and brings it up and says that, hey, let's work on other things as well while we're working on your gland function, your ocular surface homeostasis, you know, all those things that we're going to be working on, but we're going to go broader. We're going to go, you know, bigger. We're going to do more like comprehensive approach. And so patients kind of get that sense of relief that I'm hearing something new. I'm not hearing the same thing I've heard from the last five doctors I've seen who just told me use more lubricating drops, use ointments, do warm compresses, you know, just like same thing over and over. Now they're getting more options. And what I love about when we talk about nutrition and lifestyle is that you're giving patient the power to do something themselves, right? To make those changes. and and without a doubt when they make these, you know, even small modifications, they feel better not just on the ocular surface that we were trying to address, but really systemically they feel better energy. They feel they have they tell me they their skin is clear. They tell their hair is feeling better. It's not falling out anymore. They sleep better, you know. So that's what's rewarding and that's really why I love incorporating this functional medicine into my treatments into my patient education because then I'm you know impacting or empowering patients to do a lot for themselves but also I'm really positively helping patients in all aspects of their life — right and I can just kind of echo that same thing even uh from a personal experience in my life and I, you

know, I went through my training and I've shared my story in some previous episodes of, you know, with residency and everything, you're trained really hard to just, you know, diagnose, prescribe medication, uh, instruction on followup when you're what your plan is. Uh, and it's kind of rinse and repeat and it's very focused on just the medical side of training. Um but then I started listening in and recognizing hey when I educate my patients for like diabetes for example I would say hey um just eat a heart healthy diet make sure you follow up with your family doctor take your medications and we'll see you in you know 6 months 12 months and then I finally was like wait when I'm telling people to eat a heart healthy diet what does that even mean? like I didn't really it's I didn't I never got training on what that meant and so I had to start digging into it and as I started reading things and I started changing some little things in my diet and I started experiencing these changes in my own life and so uh I just wanted to echo that and share kind of a little bit of my story. I think uh you're right, people are starting to become more interested and aware of how these diet and lifestyle factors affect so much of our health and there's quite a bit of discussion on the gut microbiome and how our gut affects many different parts of our body including the brain and as you kind of mentioned earlier what is called the gut eye axis right there I've heard gut retinal axis and then just gut eye axis uh do you mind kind of just starting off that conversation, can you kind of set the playing field of what the gut microbiome is and really why this is such an exciting discussion in the field of not just medicine but in eye care specifically, — right? So the microbiome in we have microbiomes in different parts of our bodies, right? We have it on our skin, we have in our mouth, we have in um on our ocular surface, intraocular microbiome biome as well. The biggest ecosystem of this microbiome of the microbes is in our gut. And the you know if you hear the word microbiota, microbiota are the microbes and microbiome is the ecosystem that makes up those mic those that microbi biota and microbiota can is like trillions of microbes. And this is you know these are bacteria, viruses, protozoa, u fungi. So there are different bugs. I mean we're full of bugs on our skin in our body you know um and different trackcts have essentially different u micro biota and so different levels. So mouth you know and then going down the intestinal tube and the highest concentration is in the large intestine colon mostly. So these microbes they have this um symbiotic relationship with the host. So they are there to really benefit our body. They are communicating with you know they have essentially especially the beneficial the commensal bacteria have this bene beneficial effects on the body. So uh we have you know if you kind of categorize it into the pathogenic bacteria the microbes that are harmful for the body they release more of the pro-inflammatory metabolites and then we have the beneficial the good guys. These are the commensal bacteria. These are the bugs that really help to kind of uh regulate our immune system to make sure that our immune system is not going haywire. And then, you know, that's when like autoimmunity and things like that um happens. And um there we have a nice balance. We don't have all good bugs and all, you know, we don't want to have all bad bugs. we have more of the good commensal bacteria that kind of you know regulate the microbiome and less of the pathogenic so that the pathogenic don't have that the you know opportunity to overpop populate. If there is an opportunity to overpop populate they take that opportunity that's why they call opportunistic bacteria pathogens and then they start to overpop populate and this is what's called dispiosis. So when there's that imbalance where there's more of the pathogenic microbes in the gut, this is the term that's um used dispiosis. This is when we start seeing things go disregula. Disregulation happens there. The immune system becomes disregulated. More of the pro-inflammatory mediators are you know upregulated in the body. Um and then that can trigger autoimmunity. And as you know with autoimmunity which is such a complex um you know complex con like you know group of conditions that really um they go in pairs. So if one autoimmunity is triggered then a patient is more likely to have another one that can come up in 10 years or so that disregulated immunity really drives that disease process. Um so for patients

for example if they and as you know you know with autoimmune conditions dry eye is it you can't avoid it you're going to have dry eyes. So if I suspect patient has um autoimmunity, I do I'm even more aggressive at looking at the gut um gut health and more aggressive with really helping especially if they're you know younger patients because that's usually when we start seeing some signs of that dysregulation and then you know that for the next 20 30 years they may have more problems with their immune system. So that was a long answer to kind of tell to your question of what has gut microbiome, but it's such an important role. I mean, it's literally the control center of our immune system. That's kind of how I think about it. It's it's not just the immune cells, but our hormones and our essentially like the our nervous system, you know. So it really has it's without the you know proper gut health the whole body the whole system I think can be very um disrupted and disregulated — right and uh I've read even that uh and you kind of mentioned there that there's some influence over like our nervous system right there are certain metabolites that somehow make I believe make serotonin right like a large percentage of that is made first our gut — like up to 90% of our serotonin is actually made in our gut and um you know 70 over 70% of our immune cells are in our gut too. So it just makes sense that what's happening in the gut really is important. What happens in the gut doesn't stay in the gut. It really does affect all systems. And we have a lot of evidence on the gut brain axis, right? We've heard we keep talking about these different axes but um gut skin axis but gut brain one is really huge. There's strong evidence um on how gut health really affects conditions like um depression, anxiety. So patients with dispiosis are more likely to have those um those conditions and those conditions could be more severe the more severe dispiosis we have. I know uh I want to get into specific kind of like what causes gut dispiosis or what's good for the gut, what's bad for the gut. I definitely want to get into that, but first I think there is this bit of a mystery because we're talking about the eyes, right? And certainly we have this connection between the brain and we know uh like we have cranial nerves that go all the way down to our gut, but it's like how would inflammation or changes to the gut somehow get to the eye? Right? There's a couple of different theories I've read in a couple of publications. Uh but can you speak to that? Can you kind of break down how the eye can somehow respond to these changes? — Yeah. So I mentioned how we have really strong evidence on the gut brain access. As far as gut eye access, the evidence is growing. So even as we speak more uh articles are coming out more evidence you know so a lot of in animal studies but we are seeing in human studies as well and the and then the theory that's been accepted is that what's happening in the gut lining and this is again not just when it when we're talking about the eyes but in general um well I'll get to the eyes as well but what's happening in the gut um ecosystem in the gut microbiome is that when you have a nice healthy microbiota, microbiome is, you know, there's no dispiosis. So, we have more of the good bugs doing all their, you know, anti-inflammatory. They they're releasing short- chain fatty acids and they're keeping the gut nice and um healthy, which means there's a nice strong lining of the gut. There's a mucosal lining that's protecting the uh the gut integrity essentially. Um, and that means that as we eating food, ingesting food, and that, you know, we're digesting it and absorbing all the nutrients, and then we have enough fiber to kind of move the um, you know, the what's not needed out and excrete it. And when we now have a dispiosis, and we'll talk about what causes dispiosis. So, now we're in a scenario where there's a imbalance of those, you know, microbes. So these pathogenic bacteria now they're releasing more of the pro, you know, bad things and one of them, you know, um these metabolize these things that basically microbes um release. One of them is lipopolyaccharides. So they release these pathogenic bacteria. What they do in that environment is that they're eating up the lining of the gut. So they're actually digesting the mucosal lining

and then they actually cause separation of the interases. Those are the cells of the lining of the gut. So now we you probably heard the term leaky gut. So we have this permeability of the gut lining and things that are not supposed to get into our bloodstream like endotoxin toxins from bacteria like LPS lipopolysaccharides and other like protein fragments and things that are again should be excreted because they're not digestible they're not helpful for the body they now get absorbed into the bloodstream. Now these are foreign bodies in the bloodstream and the body recognizes that as hey this isn't this shouldn't be here and they release these pro-inflammatory mediators interlucans and cytoines into the bloodstream. Now we have this hypen immune system and this increase of the inflammatory mediators in the bloodstream and then what's one of the most vascularized organs in our body. I mean the eyeball is very there's a lot of blood vessels right so now the all these inflammatory mediators you know get to different parts of the uh body not necessarily just the eyes but eyes are also one of the end organs so that that's how kind of we see this um so what's the inflammatory processes inflammatory mediators that really started in the gut because of that lining uh the breakdown of the lining and now it's in the bloodstream circulating through um to the brain, to the joints, and to the eyes. And what's interesting is and I talk about this in one of my lectures when I talk about gut health is that we we've isolated um there was a study that looked at the microbiome of so these were patients that were getting cataract surgeries and they looked they took this was a um metagenomic sequence of the acquous humor. So they took samples of aquous humor on patients that were getting cataract surgery and those then there was a group of patients that had no other eye conditions. So they just had cataract surgery but no glaucoma or macular degeneration. And then there was a group of those u patients that were getting cataract surgery who had macular degeneration and there was a group that had glaucoma. And they did all these metagenomic sequences on all of those groups and they were and they identified specific pathogens that were specific for that disease. So it's really fascinating to kind of see that you know um some microbes maybe biomarkers for a disease that we can identify maybe years before they the patient you know develops a disease. — Wow. I'm glad you mentioned this. I don't think I've read this study. So I'll probably have to uh see if I can get uh the citation for that one and I'll try to include it in the show notes too. But that that's fascinating. I think the only ones only studies I've really found were again more in like dry eyes specifically and then they've been able to find hey for patients who do have more autoimmune conditions uh like Shoggrren's for example they have a distinctly different gut microbiome than people who are either normal without dry eye but even compared to people who do have dry eye but not necessarily autoimmune defined those dryey people kind of their gut microbiome is not normal but it's also like somewhere in between. It's like is it heading toward that autoimmune level of gut dispiosis? I've read a few publications on that. — Yes. Do you recall I'm sure you read I think you might have mentioned — and there's some you know uh studies now again not a ton right we don't have like a really strong uh hopefully that'll change in the next five years 10 years um but one of the studies showed that changing the modulating the gut microbiome actually did change the inflammatory markers released by the lacrial gland. So these patients that had dry eye, they were put on specific probiotics and they um actually was probiotic with prebiotic. We'll talk about that um combination. So these patients after you know four months they had improved signs and symptoms but also the inflammatory markers were decreased in in the ocular surface. So it's really fascinating. Again, it's not surprising because what we talked about, you know, with the what happens in the gut microbiome is really affects all areas of our of our body. But the inflammation

essentially we know is a driver is a corp in a lot of uh the systemic and uh even ocular diseases. So modulating the gut microbiome to help with reducing inflammation should be again the goal that we ultimately do for all of our patients with dry eye because we what we do with dry eye treatments is we really focusing on the eyeballs, right? We're just like, "All right, let's put some drops in some imunomodulators. Let's do some treatments that reduce inflammation, but that's just localized inflammation. So we really have to look at it as supporting the eyeballs systemically. — Now I want to take a moment to discuss a significant factor in dry eye which is that of mayomian gland dysfunction where inflammation in the eyelids contributes to swelling and the clogging of the oil glands in those lids that contributes to decreased tier production and tear film instability which is where the Envision workstation from InMode comes in. Again, this is the exact same device that we offer here at our clinic and is a technology that offers non-surgical and highly efficacious dermatological procedures that have been Health Canada certified for improving the symptoms of dry eye disease from myomian gland dysfunction. The inmode forma eye radio frequency treatment uses radio frequency energy to generate heat. This improves blood flow and stimulates collagen formation. This gentle heat also helps open up clogged mayomian glands, helping with tear production and secretion. Whereas the inmode lumcha IPL uses the energy of light to seal off irregular blood vessels that release inflammatory mediators to the eyelids. Research has also shown that IPL can help reduce demodex and bacteria along those eyelids as well as provide some level of photobiomodulation which is the stimulation of the cellular mitochondria in the treated tissues. Again, these are two procedures that myself and many fellow eye doctors frequently do recommend for helping improve the quality of life for our patients who are struggling with myomian gland dysfunction and dry eye. with so many of my patients absolutely loving the results both in their dryey symptoms but also in just how their eyes look. To learn more or to see which doctors or clinics are offering this technology near you, go to envision treatment. com or check out our link in the show notes. Now, of course, dry eye and eye health is complex, so always consult a licensed provider in your area to determine what is right for you. Otherwise, thank you again to InMode and the Envision Workstation and let's get back to the episode. So, just to kind of rewind and sum up, uh, so when we eat food and we're eating food stuffs and probably on a long enough timeline, right, because it's not like, oh, I just ate one bad thing and now the guts thrown off. Um, maybe I don't know if if there's such a thing, but uh, — if your gut is not resilient, then yes, but that's — There we go. But we eat food stuffs and these food stuffs maybe are not the best for our gut and we're having a harsh reaction. The gut lining can get kind of broken down or metabolites from this disbiosis, this buildup of not so friendly bacteria. uh these microbes release these metabolites or endotoxin that can get through the gut lining into the bloodstream that pass throughout our body and our body's own immune system kind of gets shot really high levels, right? It's starting to be hyperactive. These immune cells are going throughout the body and that kind of kicks up inflammation into overdrive into all systems in many ways, right? Is that sounds like a good summary? just on a basic level. — Yes. So, specifically with the eyes, um, now again, I know the research is still kind of coming out and research takes a lot of time and money, but when you see a patient, like what are some of the like conditions or eye issues that you've either read have a connection to the gut or you've personally seen in somebody's eye and been like, "Wow, there might be a connection here. The strongest evidence we have is for uvitis. Uvitis, macular degeneration, glaucoma and dry eye. Basically everything we see every all the ocular diseases we see essentially have now evidence to be linked some somehow to gut dispiosis. And if you think about it with it's

probably not surprising some of your patients that you can recall with the most advanced glaucoma if you look at their systemic health they probably had a lot of systemic conditions also and you know we sort of like always you know link them like okay patients with diabetes and cardiovascular disease they're higher risk of having glaucoma and AMD but we didn't make the connection of high, we just assume, okay, this patient has family history of these ocular diseases and they have systemic conditions, so they're higher risk of they are higher risk of having these um conditions. You know, if there's a suspect, then you may be monitoring them a little closer and but again, but those systemic conditions started with something, right? It started with poor diet, poor lifestyle, um and all of that, you know, again, I'm just kind of summarizing. were like making assumptions of like the gut they had disregulated or they had got dispiosis. But that's what the evidence is now showing is that really dispiosis has been identified to be connected to most uh if not every um uh non-communicable disease. So anything from Alzheimer's, obesity, diabetes to skin conditions, you know, uh eczema, rosacea. We see a lot of patients with rosacea. That's kind of become a big thing in eye care, right? Because of the connection between my gland dysfunction and rosacea. Rosacea patients, they have imbalance of their skin microbes, they have an imbalance of the gut microbes. So very high um likelihood that they have some GI problems these patients. So this is where the connection happens, right? So recognizing that all right you have these things that are you're coming to me for but you also have this other things that most likely related to this. So let's go a little bit broader and not just focus on my boming glands and eyelid hygiene and things like that but talk about rosacea and what's flaring up your rosacea. it's probably you have some gut imbalances and it may be mild and they may be you know in control of it but or they have like flare-ups here and there but a lot of patients don't know that this is all connected. Mhm. — I was going to say that probably the biggest thing when I think of like glaucoma, uh, diabetic any sort of diabetic retinopathy, macular degeneration, like the number one thing that kind of connects them all that I see is obesity. Uh, and that one kind of it it's connected between all of those. Uh but I did want to come back to the rosacea just for a moment because uh we've talked about rosacea a little bit here on various videos and even podcasts that we've produced. Uh and we've talked a little bit more about uh the surface or the skin microbiome or the eyelid microbiome. But uh are you telling me that there's a stronger connection between rosacea and the gut as well? Like the gut being upset can cause these flare-ups in rosacea? Yes, rosacea patients I've seen in my practice and when I mentioned earlier how I had to do cases, you know, first line nutrition, a lot of a majority of my cases were dryey patients with rosacea and I found and then I looked into literature. Yes. Sure enough, um high number high proportion um of these patients with rosacea have some gut problems whether it's um IBS, IBD, irritable bowel disease or and etc like H. pylori small intestinal bacterial overgrowth is a huge one up to like 60% of patients may have some SIBO and you know a lot of times these patients don't they say if you start asking them like hey do you have any GI things and they'll dismiss it they're like oh I've always had yeah I have had IBS for a long time or always had gut so they may not be diagnosed or they may be diagnosed as sort of like it's not bad enough that it's you know, it's dismissed, but you'll see a if you start asking these questions your rosacea patients and sometimes it's not they don't think that it's a it's a problem once you start asking do you have regular bowel movements? Do you have any, you know, food intolerances? Do you get bloated easily? Do you get uncomfortable after meals? Do you, you know, if you start asking specific questions, you'll they'll be like, "Oh, yeah. I've always had that problem. " So, it's sort of like accepted as like just part of them, but they don't understand that no, that's not normal and it's probably getting worse because you're not doing the right things to kind of mitigate that and fix that. But

also, it is connected to your eyes and as you get older, it is not going to be connected to other things that will pop up later. — So, let's kind of dive into like how do we in a way remedy this? But before we talk about like maybe foods that are ideal for the gut but also maybe for the eyes u what kind of what do we know maybe an instigator what kind of causes or contributes to gut dispiosis in the first place — when we there are many things but if we talk about just the food it's the standard American diet the sad diet which is highly processed high saturated fats that's high sugar, low fiber, low phytonutrients, low color, very, you know, uh, browns and white color. Um, so that's one of the things that when I talk to patients about, you know, if I give them personalized nutrition, talking about color in their food, a lot of variety, you know, our microbiome, the good bugs like fiber. They like a lot of, you know, variety of fiber. That's how we help with the diversity of the microbes. And um so when it comes to food, essentially, you know, a lot of processed foods, things that come in packages, you know, frozen foods and or frozen like pre-made foods. Um I'm not talking about frozen vegetables and things like that. Um I would say also like just eating out a lot, right? So we we're we don't know what we're getting in our food. So people will be like, "Oh, I eat pretty healthy. " you know, but when you ask them, you know, how much they cook at home and how no, they're eating out a lot and um but they think that they're eating healthy. So, so it's essentially standard American diet. And also, if we're talking about outside of food, there's other things. People take a lot of supplements. Some supplements, you know, may actually cause more harm. And if you're taking obviously like antibiotics, if you've taken that early on in life and or frequently if you get sick and that you may be getting sick because you're you have a disregulated dis um gut microbiome and that actually makes you more susceptible to getting you know getting colds and flu and things like that and other things. Stress is a big one which people don't think people know that stress is not good for them but stress can actually change your microbiome. Sleep can is yes it's you know there's no light in our gut. But — you can probably see my facial expression. I was like wait what sleep affects my gut? — The light. Yes. So um just being outside being um you know being exposed to light can actually have an effect on the gut microbiome and sleep can have effect. Being outside essentially helps to regulate our circadian rhythm and help with our sleep. But so many Americans I mean I'm guilty of it too when traveling you know poor sleep and then but I feel it. I feel it the next day. Hey, it takes me a while to recover from poor sleep, but sleep is a big one, too. So, when I talk to patients about gut health, these are the things I talk about. It's not just the foods or the drinks that we It's about, you know, whole, you know, approach, stress management, exercise, that's another thing affects your microbiome. I I think I uh read somewhere even like different types of exercise can change make shifts in your microbiome too, you know, like strength training versus um a cardio or you know things like that. So it's really interesting to I think this whole science of microbiome is changing so much so rapidly. we're getting we understand some things, but we're there's a lot of things that we're still learning of really how to help and support our microbiome, but it really yes starts with food. That's the obvious, but there's other things that really are supportive as well. I know I've spoken to a few other uh eye doctors who we've had um like basically a history of GI issues since they were young, since they were a teenager or early college. And we were just kind of discussing, you know, like was there something that went on in our early lives? Uh and the kind of the common denominator between all of us and pro perhaps everybody in maybe our generation is we had a lot of antibiotics as young kids. — Uh like I had a lot of earaches when I was a boy and um you know oh I was sick so what did my parents do? Bring me to the pediatrician's office and I get a high dose of antibiotics and uh and then you know sometimes you get sick and then you get sick because kids often do that right? they pass whatever one flu

to the next kid and then three weeks later they get the next round of flu from the other kids and that's daycare, right? Uh and so I just know that is kind of something I've talked with a few other professionals about like I wonder if being exposed to different and many rounds of antibiotics as a young kid. Did that upset my GI uh in a way, you know, started me kind of in back a few steps before I could rebuild it to a normal level? It's tough to say, but — I mean it goes even like further up than that, right? We get our microbiome from our mother when we're born through a vaginal canal. So that's our first exposure to So really our microbiome depends on how good our mom's microbiome is. — And we get that. But, you know, with so much sterility around hospital settings and if it's a C-section birth and the baby is not exposed to that healthy microbiome and then depending on who's holding the baby right away, if it's a nurse or doctor, they getting exposed to their essentially, you know, surface, whether it's their glove or, you know, whatever they're set down and things like that. So it really starts from birth and how we're exposed and then it and the first three to five years of our life is where it's really variable. So this is the time to really expose your kids to dirt to animals to you know just have them play in the garden. I mean that's the best thing. Put them you know take them to the garden have them play in the garden and not over sterilize things not over clean things. Um, two, the more, you know, you got to be responsible. You can't just be responsible with that. But, you know, as a mother, I remember, you know, just being obsessed with cleaning things all the time, too, because that's just like what you think. You want to you want to keep everything sterile around babies. But really, babies, you know, develop their immune system and their microbiome by being around good bugs, you know. Um but then yes and then so if the b if the kid is not exposed if they don't have a good diverse microbiome they're more susceptible to getting sick and now we add antibiotics to that problem now that's causing even further dispiosis and really killing off your good bugs because when we take antibiotics they're not super specific right? Yeah, you might have like specific antibiotic you're taking for that condition, but they're also going to wipe out beneficial bacteria. So, they're not just addressing the pathogenic bacteria. So, when we're taking probiotics or excuse me, antibiotics, uh we uh we should actually come back to that, the combination. I just thought of that. But we are we're really not being specific and we're killing off uh a lot of our good microbio microbiota as well. And this is really changed the way I address how when I prescribe like oral antibiotics. I used to years ago. Um, you know, in our state is depending on the state in as far as like OD's prescriptions. In our state, we can do oral antibiotics. And I, you know, anytime we had a patient with uh a sty that was not improving, especially if it was now looking like there is going to be precept, cellulitis or, you know, spread a little bit more or if they have arculate rosacea, it was not well controlled. I would you know so my I was I didn't hesitate to prescribe doxycycline or other antibiotics as needed uh oral antibiotics and my approach has changed completely and if I do have to use oral antibiotics because I mean they're we need to have we need to be able to do that I'm not saying never prescribe it but you know talk to all the options and I talk to patients about options you have we can use this antibiotic to treat this condition we can do um IPL treatment to treat this condition. These are your options. These are the and then have the patient be involved in their decision. Here's the pros and cons of this approach. shares approach, you know, and um but if I if the patient is going to go on uh antibiotic, it is important to also put them on probiotics to really support their gut health and their and make sure that they can kind of repopulate the diversity of their gut microbiome um over time. It could take time and uh I've read that it just a single course of antibiotic can take up to two years for you to recover some of the microbes in your gut. So it could take and some of them will never recover. So we um you know so we just have to be like more mindful of that when we are prescribing antibiotics and

really tell patients about all the options and potential harm in this approach and how to support their gut health if they choose to go that route. — Yeah. And that's kind of my approach when I talk with patients as well. I like to give them all of their options. Of course, there's cases where it's like, "No, we need to kind of be the general in charge and be like, no, this is the you you're in a potentially dangerous situation. We need this medication. " Um, but I try to be open to being like, "Hey, same thing, pros and cons. Here's where we're at, you know. " Um, but, uh, as far as probiotics, you kind of mentioned that. That's a big discussion because now you go to the supermarket and you'll see probiotics listed almost as if it's, you know, two times protein. You know, you'll see that on cereal, but now it'll say with probiotics, right? It used to just be yogurt had probiotics. Now it's like half of everything at the store has them. Can you speak to like what are probiotics versus the label of prebiotics? And probably just to make it simpler, let's talk about just probiotics first. Like what are probiotics when you see it as an additive versus is it a supplement like a pill form? Uh should everybody be taking these? Should we be cautious about them? Uh can you just give us some insights on? Yeah, this is a big topic and this is where I struggle a little bit because people want a simple answer and it's not a simple here take this probiotic and all your gut problems are going to go away or your eye problems going to go away. So it's not simple. So I'll start with that. But essentially what probiotics are they are the microbes that are put in a supplement form. These are the the not always the commensal but um b beneficial. So they're the positive affecting microbes that are put in a supplement form and sometimes they'll be sold in you know powder forms and other you know added to things right to foods and things like that. The problem is that there it kind of got there's so many companies now making probiotics and um I don't know if you you've heard of like consumer review um so I have a subscription so it basically like looks at things and really tells you know how valid or how you know if the label really matches what's inside. And one of the things that's really alarming about probiotics is that a high majority of them don't actually have active cultures. They don't have the active, you know, microbes in their in the capsules. So they're really, you know, maybe they started out as those act those live bacteria, but now that they've been sitting in a capsule in a, you know, on a shelf, they're by the time they you take them, you may be just taking empty capsules. So there's really nothing that's going to be benefiting you. So, another thing is that a lot of probiotics will say they'll say that they're extra strength or, you know, they're women probiotics or this and that. But if you look at the back and I tell patients to always and I'm sure you do this with your patients too, you know, if they're taking fish oil, you say, "Which one are you taking? " Because you want to see make sure that it's a quality fish oil, meaning that it is in, you know, a specific form. like I recommend triglycerid form that it has a high no adequate dose and it's the right form of EPA to DHA you know all these things that I sort of look at before I say okay this is a good one continue to take this or no this is not really doing much let's switch you to something else I do the same thing with probiotics for probiotic to be evidence-based is has to have a strain and what that means is that in probiotics like if you take a you know probiotic bottle and you see the back of it if you don't see actual microbes that are listed you know like lactobacillus you know and then they that it'll have a for example the one that I have here I'm not promoting this one but this is the one that I'm taking currently probiotic max and like this one has um acidophilles la 14 so lactobacillus is the genus and then we have acid which is the um species and LA14 is the strain of the probiotic what makes it efficacious. That means that specific strain that bug has been studied to benefit something and now is put in a probiotic form to

for you to take because it's going to be positively affecting your body in one way or another. Whether it's helping your immune system, whether it's helping with your, you know, helping with the um production of the good bacteria, helping to suppress the bad bacteria, whether whatever it's been studied, but that's how now it's, you know, has the evidence. So, if you go to the, you know, grocery store and really look at all the probiotics, most of them don't have that. They have like um probiotic blend. It'll say pro probiotic blend and that's what does that mean? U we don't know what's in it. So, so choosing probiotics very important. It they they are good probiotics, but you just have to know what to look for. The other thing is that when you're just like with anything, if you're actually eating it in a food form, you're getting a lot more diversity, you're getting all the other benefits from the food. So obviously we have some sources of probiotics like fermented foods, um tempeh, tofu, kimchi, sauerkraut, all those things, kombucha to some extent, but a lot of them are high sugar, you know. So you can incor yogurt you know kafir like all these things. So you can incorporate a lot of it just from foods but taking probiotics may be beneficial but what's more important is the prebiotics. Prebiotics is what your microbes actually eat. So these are soluble fibers that we get from our food and that is so you can take probiotics all you want. You can spend a lot of money on a good probiotic but they're not going to stay alive in your gut if you're not actually feeding them. They are bugs. You got to feed them and the prebiotics which is in our food. So these are um you know things like artichokes, onions, garlic, um chory root, bananas specifically like green bananas, oats and barley and things like that. So, these are the things that flax seed um that you can actually it's important to if you're going to take probiotics, you got to make sure that you have a good diverse diet of prebiotics so that what you're taking is actually going to stick around. They're not going to, you know, die within a couple days of essentially not taking them. — Yeah, I'm glad you kind of segueed into that because that was kind of my next question. Okay. what are the foods um that are good for the gut but maybe can double up and be also good for the eyes. Uh the you already mentioned that some fermented foods may have living cultures of good probiotics in them. Um and then fibrous food. There's lots of different, you know, there's so many different fibrous foods, but can you give us some examples of maybe some of your favorite um like fibrous foods that may be beneficial for the gut and maybe anything that also could be good for the eyes? — If we think about what is the evidence on what's good for our gut and what is good for our eyes, the type of diet and lifestyle is the Mediterranean diet. Mediterranean diet has uh lots of whole [snorts] foods. It is mostly vegetables, fruits, whole grains, and that's like and uh legumes and beans and things like that. So, my favorite, to answer your question, I was telling my husband the other day, if I could just eat one type of food for the rest of my life, it'd be different beans. Not only one type of bean, but different types of beans. I love bean soups. I love to incorporate beans in different things. I throw them in the salad. Like so I would say that is probably the healthiest that with some omega-3s. So healthy fish, your sard sardines, your mackerels, your um salmon, right? So incorporating different um type of seafood that are high in omega-3 polyunsaturated fats into and also um olive oil. So into your diet essentially Mediterranean diet and that has very little processed foods. Uh it's not completely eliminated you know that's the thing we you said earlier is that you know you eat it once then is are you thrown off. No, if you have a healthy diet overall, healthy microbiome is resilient to having, you know, a cake, a piece of cake, not a whole cake, but a piece of cake and not feeling like, you know, oh, now you're you're going to have a flare up. that means resilience, right? A gut resilience to, you know, things that you want to eat occasionally, cupcake or whatever, you know? So just not eating it every single

day. So Mediterranean diet and what I like to also always emphasize is that it's not just the foods that you're ingesting. So it's not just lots of phytonutrients, vegetables and fiber and all those things which mix up majority with legumes and whole grains. And then you have um seafood um you know every day or every other day. And then you have poultry that's less frequent. So, eggs and cheese and dairy and poultry things like that are maybe a couple times a week. And then red meats and more um you know, maybe definitely not processed red meats, but more um good uh sources of red meat and uh maybe you know, a couple times a month. And then what what's really important with the whole system is how you actually eat your food. So, it's really not takeout, not getting those foods and you know, buying them at a restaurant and eating them at home or on the way home. It's actually cooking together with your family. It's smelling the food. It's, you know, it's enjoying the process of making the food. It's sitting down with your family and enjoying that food, talking about the food. It's there's so much happens to our nervous system when we are actually taking the time to eat our food and and chew it and really feel the texture and and the taste of it and have that connection with your family while you're doing that. It's not um it's not you know what I see a lot is people eating in the like drive-throughs and eating in their cars. It's just like the worst thing. you don't digest that food properly and you don't you know it's your when you're driving you're like your nervous system is on on your fight or flight your sympathetic nervous system we can't digest that. So it's this in um this whole sort of like holistic approach to nutrition. It's just incorporating a lot of things not just what you're eating is how you're preparing it and also physical activity and you know stress management and things like that. So when I talk about what's healthy to my, you know, when I discuss this with patients, these are the things, you know, I'll give them resources on sometimes I'll give them a lot of times I'll give them actually recipes and things like that because people don't know. So I'll help them with getting started, but I always talk about, you know, other things that are important, too. So move your body every day. Make sure you have a you have a bedtime. Set a bedtime. Stick to it. You know, go to bed. Make sure you're rested and um do something to help with your stress. So many of our patients with dry eye, they have a very disregulated nervous system. They are on they're more on fight or flight and they have more of the sympathetic overstimulation over overdrive of their sympathetic nervous system and it's the parasympathetic nervous system that helps with our digestion but also our secretion from our glands from our lack glands. So, I tell patients that it's not just the food, it's really working on your nervous system as well as your gut health. — Well, I know you covered a whole bunch of really good points there. Um, I think that basically you've opened up a couple of different questions. I know we just don't have time for today, like the sympathetic nervous system and we could probably dive into that in another topic. Uh, I do want to give a call out to all of our viewers and listeners that if you have questions, if you're like really interested in this and you want to be able to ask us questions about what's going on with the gut or dive a little bit more deep into a certain subject, uh, let us know in the comments, review over on the podcast platforms, uh, because we'll hopefully be able to bring Dr. Uisa Fova back on uh, for another episode. to be able to dive into those questions. Uh to kind of like just kind of bring things back to where we began talking about dry eye and you manage and specialize in in treating patients with se significant dry eye disease, right? Probably everything from very mild beginning symptoms to people who have been dealing with for 15 plus years. uh what kind of things do you see in terms of what's going on with dry eye treatment that um you think we're missing as a profession? Because I love asking other eye doctors, especially people in the realm of dry eye, like we see a lot of the same things repeated again and again. But what is there anything that you think we're missing? — I think we've come such a long way from where we used to be 15 years ago when it when we're treating dry eyes. So, it's great. It's a great place to be. We have a lot more tools to offer to our patients. We have a lot more knowledge and it just there's just more innovations coming out, more treatment options coming out for our patients. So, it's great to have all that, but we have

to still remember that this is a immune mediated disease. This is we have to think about it as not just that disregulated immune localized immunity on the ocular surface because we do know that there's loss of homeostasis there's increased oxidative stress on the ocular surface there's increased inflammation but we what we're missing is that there's a lot most likely there's a systemic correlation in these patients and I think a lot of now the focus is getting so much on you know devices you know we're buying all these equipment to treat ocular rosacea and treat the inflammation on the localized patients may feel good for a short period but then the problem comes back right so we really have to start think broader and start thinking you know how to do we support what the dysregulation that's happening on a bigger scale you know their immune system and their nervous system and their mitochondria you know so really all these things that have to be in my opinion which is why I went back to school to study and to really because I felt like no some patients no matter what you do just don't get better and when that happens this is when it's good for our colleagues to stop and think okay instead of doing the same thing over and over can I do something more and if I'm not the right doctor maybe I'll send it to co-manage it with a functional medicine doctor maybe I'll reach out to a nutritionist and say that hey let's um get you connected with this patient so you can talk to them about you know other things. So it's really making the connection I think is where we need to think as dryey specialists as we're treating patients with dry eye is that if you start asking the right questions about just gut health make that connection that all right their problem in the eye is not just in the eye it's starting in the gut. So, just our final thing, just to make actionable steps because I love it when I listen to other podcasts and they give me like some actionable steps that I could take to better my life or kind of open a level of curiosity. Do you think you could give like what would be your top three things for someone to whether it be in their diet or in their lifestyle to focus on uh that may make some positive benefits for their gut microbiome? Can you give us maybe your top three — when it comes to diet is number one removing as much of the processed foods as possible. It may not be right away. Maybe you're, you know, taking out one thing um a week and then slowly working up to having mostly whole foods, incorporating more fiber. Again, maybe you've never liked beans. maybe starting with one type of bean and see how you can like to cook it and and incorporate it and then making sure that you're getting a good amount of omega-3s whether it's if you don't like fish make sure that you take quality supplements. So those are the three things when it comes to diet. And then other things uh other two things I think is really important to talk about sleep. Most people don't sleep well. They don't even know. They're just like, oh, you know, they have variable. So that's what I mentioned is having a bedtime. You remember when we were kids, we had bedtime. We need to set bedtime — for ourselves and tell patients that you have to have a bedtime. This is when your your nervous system has to reset. And that when that resets that helps your immune system, that helps everything. So sleep is the other thing too. Sleep hygiene, making sure that you know turning off electronics two hours before bed and things like that. And then lastly is uh movement. Movement is important. It's important for our mitochondrial health and um it's health it's helpful for our um our metabolism, our you know nervous system and everything. So again, you don't have to do crazy exercises, just walking, right? So walking after meals or making sure that you have um enough movement throughout the day. So those are the three things I would say I know that I talk to patients all the time and I think it's very they're not crazy ideas. People, you know, people have heard that. So, it's not like anything new that they're going to hear, but a coming from your eye doctor who is treating your dry eye is going to now maybe click even more like, oh, I've heard this from my primary care doctor, but haven't really stuck with or I've heard about importance of doing these things. But now, when the do your eye doctor also says who's treating your dry eye says that no, these things are important. They're going to help with your immune system. um metabolic system and they're going to it's going to help with your nervous system. that's I think is actionable and for patients something to take with

them and you could give resources you can write in your um treatment plan so along with all the other treatments you're doing list these things you know whole foods movement sleep — well with all of that thank you so much for just sharing your time with us dropping all this knowledge onto us um as far as a way for people to get a hold of you if they happen to be in your area can you mind sharing uh your clinic name and location. — Yes. So, I'm in Portland, Oregon. South Waterfront Eye Care is the name of the clinic. Um I can also be found on social media. I Dr. Mila is my handle. And um yeah, I'm always h happy to connect with colleagues, with patients. Um I love helping people with their dry eye and obviously incorporating everything that we talked about today. Well, again, thank you so much for being here and hopefully I look forward to maybe having a part two in the future. — Thank you. Thanks for having me. — You've been listening to the Dr. Eyehealth podcast with Dr. Joseph Allen. For more resources, trusted information, and helpful tools, visit drayalth. com. Thanks for joining the community that's focused on healthier eyes and a healthier life. Until next time, stay informed and keep your vision sharp.