Supplementary Kelulut Honey Therapy in Juvenile Open-Angle Glaucoma: Effects on IL-6, RNFL and Dry Eye.
Phase: PHASE4
Conditions: Juvenile Open Angle Glaucoma, Dry Eye Disease (DED), Interleukin 6, Retinal Nerve Fiber Layer Thickness, HbA1c Level
Sponsor: Universiti Sains Malaysia

 
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DISSERTATION PROPOSAL 
 
 
SUPPLEMENTARY KELULUT HONEY THERAPY IN JUVENILE OPEN-ANGLE  
 
GLAUCOMA: EFFECTS ON IL-6, RNFL AND DRY EYE 
 
 
NMRR ID: 24-04301-DXV  
JEPeM CODE: USM/JEPeM/KK/24090790 
 
 
 
BY: 
 
DR THAMARAI A/P MUNIRATHINAM 
P-UM 0217/22 
DEPARTMENT OF OPHTHALMOLOGY AND VISUAL SCIENCE 
SCHOOL OF MEDICAL SCIENCES 
UNIVERSITI SAINS MALAYSIA, KUBANG KERIAN KELANTAN 
 
 
MAIN SUPERVISOR: 
 
ASSOC. PROF DR. AZHANY YAAKUB 
DEPARTMENT OF OPHTHALMOLOGY AND VISUAL SCIENCE 
SCHOOL OF MEDICAL SCIENCES 
UNIVERSITI SAINS MALAYSIA, KUBANG KERIAN KELANTAN 
 
 
 
CO-SUPERVISORS: 
 
DR MOHD ZULKIFLI MUSTAFA  
DEPARTMENT OF NEUROSCIENCES, SCOOL OF MEDICAL SCIENCES 
UNIVERISTI SAINS MALAYSIA 
 
DR NURUL KHAIZA BINTI YAHYA 
DEPARTMENT OF IMMUNOLOGY, SCHOOL OF MEDICAL SCIENCES 
UNIVERSITI SAINS MALAYSIA, KUBANG KERIAN KELANTAN 
 
 
 
 
 
 
 
 
 
 

 
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TOPIC OF CONTENTS 
 
 
 
 
 
 
PAGES 
TITLE  
 
 
 
 
 
 
 
 
1 
TABLE OF CONTENTS 
 
 
 
 
 
 
2 
 
1. CHAPTER 1: INTRODUCTION  
1.1 Study introduction 
 
 
 
 
 
 
4 
1.2 Study rationale 
 
 
 
 
 
 
5 
 
2. CHAPTER 2: LITERATURE REVIEW 
                                                    
2.1 Juvenile open angle glaucoma 
 
 
 
 
6 
2.2 Immunomodulation 
 
 
 
 
 
 
8 
2.3 Interleukin-6  
 
 
 
 
 
 
11 
2.4 Retinal nerve fiber layer 
 
 
 
 
 
11 
2.5 Stingless bee honey (Kelulut)  
 
 
 
 
12 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
3. CHAPTER 3: STUDY OBJECTIVES, RESEARCH QUESTIONS, RESEARCH 
HYPOTHESIS                                                        
 
 
3.1 Objective 
 
 
 
 
 
 
 
14 
 
 
3.2 Research questions 
 
 
 
 
 
 
14 
 
3.3 Research hypothesis  
 
 
 
 
 
14 
 
 
 
4. CHAPTER 4: MATERIAL AND METHODS 
4.1 Study design  
 
 
 
 
 
 
14 
                           
4.2 Population, locations and duration   
 
 
 
14 
 
                         
4.3 Sampling method  
 
 
 
 
 
 
14 
4.4 Sample size   
 
 
 
 
 
 
15 
 
 
4.5 Selection criteria  
 
 
 
 
 
 
17 

 
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4.6 Randomization 
 
 
 
 
 
 
18 
 
4.7 Honey supplement 
 
 
 
 
 
 
18 
 
 
4.8 Definition of terms 
 
 
 
 
 
 
19 
 
 
4.9 Study instruments 
 
 
 
 
 
 
21 
 
              
4.10 Methods of data collection  
 
 
 
 
23 
 
4.11 Data entry and statistical analysis   
 
 
 
27 
 
 
 
 
5. CHAPTER 5: RESULTS 
 
 
 
 
 
29 
6. CHAPTER 6: FLOW OF STUDY CHART  
 
 
31 
7. CHAPTER 7: GANTT CHART  
 
 
 
 
32 
8. CHAPTER 8: MILESTONE  
 
 
 
 
32 
 
9. CHAPTER 9: ETHICAL CONSIDERATION 
 
 
33 
10. CHAPTER 10: RESEARCH REGISTRATION 
 
 
37 
11. CHAPTER 11: REFERENCES 
 
 
 
 
38 
12. CHAPTER 12: APPENDICES 
 
 
 
 
43 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
                                                       
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

 
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CHAPTER 1: INTRODUCTION 
 
1.1 
STUDY INTRODUCTION 
 
Glaucomatous optic neuropathy (GON) is a group of eye disease, characterized by progressive 
by loss of retinal ganglion cells (RGC) and axonal degeneration with concomitant optic disc 
cupping, thinning of the retinal nerve fiber layer (RNFL) and clinically detectable early visual 
field defects. 
 
It represents a leading cause of irreversible visual impairment and blindness worldwide, 
estimated to affect 111.8 million people worldwide in 2040 (Tham YC et al, 2014). According 
to National Eye Survey II, glaucoma is the third leading causes of blindness and low vision in 
Malaysia (Chew et al, 2018). 
 
Glaucoma can be further divided into two main categories, which are open or closed angle 
glaucoma. It can be subdivided into primary or secondary. Primary open angle glaucoma 
(POAG) is the most common type of glaucoma and occurs in elderly individuals with an open 
angle without gonioscopic abnormalities. Juvenile open angle glaucoma (JOAG) affects the 
younger population age ranging from 3 to 40 years old.  
 
Pro-inflammatory cytokines such as Interleukin-6 have been linked to play an active role in the 
immunomodulation of the nerve layer, leading to glaucomatous optic neuropathy. Stingless bee 
honey (Kelulut) was found to have antioxidant, anti-inflammatory and free radical scavenging 
properties. The beneficiary effects of honey confer protective effects on neurons against 
oxidative damage as well as reducing the pro-inflammatory cytokine such as Interleukin-6.  We 
believe that this non-invasive study which involves evaluation of honey Kelulut on the mean 

 
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serum level of Interleukin-6 and retinal nerve fiber layer thickness will provide a potential 
supplementary therapy for JOAG.  
 
 
1.2 
STUDY RATIONALE 
Juvenile open-angle glaucoma (JOAG) is a rare form of primary open-angle glaucoma that 
manifests between the ages of 3 and 40. It is often associated with mutations in the myocilin 
(MYOC) gene, leading to improper drainage of aqueous humor and resulting in elevated 
intraocular pressure (IOP). This increased IOP can cause optic nerve damage, leading to 
irreversible vision loss. JOAG typically follows an autosomal dominant inheritance pattern and 
often requires surgical intervention due to its resistance to medical therapies.  
Kelulut honey, produced by stingless bees, has demonstrated significant anti-inflammatory and 
antioxidant properties, attributed to its high polyphenolic content. These properties suggest 
potential neuroprotective effects, which could be beneficial in managing neurodegenerative 
conditions. In view of oxidative stress and inflammation are key factors in the pathogenesis of 
glaucoma, Kelulut honey may serve as a valuable adjunct to conventional antiglaucoma 
therapies. 
Monitoring serum levels of interleukin-6 (IL-6), peripapillary retinal nerve fiber layer (RNFL) 
thickness and its effect on dry eye parameters are established methods for evaluating 
inflammatory status and glaucomatous damage, respectively. The immunomodulatory effects 
of Kelulut honey could potentially modulate these biomarkers, leading to improved clinical 
outcomes for JOAG patients. Findings from research into Kelulut honey's therapeutic potential 
may lead to the development of more effective treatment strategies for JOAG, ultimately 
enhancing patient quality of life. 

 
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JOAG is a progressive condition that can lead to irreversible damage to the optic nerve if not 
treated promptly. Given its early onset (often in individuals under 40), the risk of significant 
vision loss over a long period is high if IOP is not controlled. Since JOAG typically affects 
younger individuals, if left untreated, the cumulative loss of vision can be substantial, potentially 
affecting the patient's ability to work, drive, and perform daily activities. The psychological 
burden of losing vision at a young age can be immense, potentially leading to depression and 
anxiety, especially for those who are still in school or early adulthood. The role of 
immunomodulation via the usage of Kelulut honey can prevent the disease from progressing to 
advanced stages where treatment becomes more complex and reduces the need for invasive 
interventions.  
 
CHAPTER 2: LITERATURE REVIEW 
2.1 
JUVENILE OPEN ANGLE GLAUCOMA 
 
Juvenile open angle glaucoma (JOAG) is a type of primary open angle glaucoma, where the 
onset of disease ranges from 3-40 years of age (Elgin U et al, 2014). Genetic factors have been 
implicated in the pathophysiology of POAG. JOAG is most commonly inherited in an autosomal 
dominant fashion with incomplete penetrance. This inheritance pattern has been documented in 
various studies of familial glaucoma cases (Wiggs & Pasquale, 2017). 
 
Among the major genes associated with JOAG includes Myocillin (MYOC), Cytochrome P450 
1B1 (CYP1B1), Forkhead Box C1 (FOXC1), Optineurin (OPTN). Myocilin, MYOC gene 
mutations are associated with 2% to 4% of POAG, and this mutation are reported to be higher 
in JOAG (Fingert JH et al, 2002). The MYOC gene is located on chromosome 1q24.3 (Stone et 
al., 1997). It encodes myocilin, a protein thought to be involved in the regulation of intraocular 

 
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pressure (IOP) by modulating aqueous humor outflow through the trabecular meshwork. MYOC 
mutations account for 10–30% of JOAG cases (Sarfarazi & Stoilov, 2000). Mutation of myocilin 
results inprotein misfolding and accumulation in the trabecular meshwork cells, causing 
impaired aqueous outflow and increased IOP. MYOC mutations often result in early-onset, 
aggressive disease and genetic screening for MYOC mutations is recommended in families with 
a history of JOAG (Wiggs & Pasquale, 2017). 
CYP1B1 is located on chromosome 2p22.2 (Kaur, Mandal, & Chakrabarti, 2008). It plays a role 
in ocular development and metabolism of endogenous compounds. Homozygous or compound 
heterozygous mutations in CYP1B1 can lead to structural abnormalities in the trabecular 
meshwork. Higher prevalence are seen in Middle Eastern, Indian, and other consanguineous 
populations.  
Forkhead Box C1 is located on chromosome 6p25 (Wiggs & Pasquale, 2017). It is involved in 
the regulation of ocular embryogenesis. Mutations are associated with anterior segment 
dysgenesis and increased risk of JOAG. 
Optineurin (OPTN) is located on chromosome 10p13 (Fingert, 2011), a gene responsible in 
neuroprotection and the regulation of apoptosis in retinal ganglion cells. Some mutations have 
been linked to both normal-tension glaucoma and JOAG. 
While specific genes like MYOC and CYP1B1 have been implicated, JOAG is likely influenced 
by multiple genetic loci, each contributing a small effect. Genome-Wide Association Studies 
(GWAS) have identified additional loci associated with glaucoma risk, including regions near 
TMCO1, CDKN2B-AS1, and SIX6 (Tham et al., 2014). These loci highlight pathways related 
to trabecular meshwork function, retinal ganglion cell survival, and anterior chamber 
development. 

 
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While comprehensive epidemiological data specific to Malaysia is limited, studies from 
neighboring countries and regional research provide valuable insights into its prevalence and 
characteristics. A recent population-based study in South Korea reported that the incidence of 
JOAG was 5.02 per 100,000 residents and average prevalence of JOAG was 14.17 per 100,000 
residents (Baek Su et al, 2024). In a study conducted in Singapore, JOAG accounted for 3.3% 
of all newly diagnosed glaucomas, with a mean age at diagnosis of 26 ± 9.8 year (Selvan H et 
al, 2022).  
 
JOAG is distinct from congenital glaucoma which presents with buphthalmos, megalocornea, 
Haab's striae, and ocular or other systemic developmental anomalies. JOAG is distinguished by 
its elevation in intraocular pressure with large fluctuations, faster progression and severity of 
visual field loss compared to adult POAG. Managing JOAG patients is challenging as medical 
treatment is often inadequate where most patient eventually requires surgical intervention for 
effective management (Ciociola EC et al 2022). The resulting visual impairment and blindness 
can significantly impair the patient's quality of life and limit daily living activities. 
 
2.2 
IMMUNOMODULATION 
 
Recent studies suggest that immune system and neuroinflammation plays a major contributing 
factor in the pathogenesis of optic neuropathy in glaucoma (Adornetto A et al, 2019). Adaptive 
and protective responses of resident or systemic immune cells can support neurons and promote 
tissue repair mechanisms after injurious insults, however prolonged inflammatory processes can 
also produce neurotoxic mediators (Tezel G, 2013). In glaucoma, chronic glial activation along 
with a failure in the regulation of immune response pathways may compromise the immune 
homeostasis resulting in neurodegeneration and promote secondary injury to neurons. Both 

 
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astroglia and microglia resident in the retina and optic nerve (head) profoundly respond in 
glaucomatous human donor eyes and animal models with glaucoma.  
Astroglia (retina and optic nerve astrocytes, and retinal Müller cells) normally preserve tissue 
homeostasis, maintain synapses, recycle neurotransmitters, deliver neurotrophic factors and 
metabolites, control blood flow and vascular barriers, and participate neurogenesis. These 
neurosupportive cells quickly recognize and respond to stress and injury signals as a neuronal 
defense and recovery mechanism. In glaucomatous optic nerve head, astroglia responses leads 
to tissue remodeling and glial scarring, creating biomechanical stress on optic nerve axons. 
Microglia cells normally provide neurotrophic support, and their scavenger and phagocytosing 
functions promote tissue cleaning and healing. Similar to astroglia cells, its chronic activation 
leads to injury to optic nerve axons (Barış M, 2019) 
Other cells such as myelin-producing oligodendrocytes and blood-borne monocytes are also 
linked to inflammatory component in glaucoma. Thus, chronic tissue stress, neuron injury, glial 
and systemic immune responses, and sustained release of neurotoxic mediators may create a 
vicious cycle that may promote progressing neuron injury. Treatments targeting these 
neurodestructive outcomes is critical for the survival of neuronal tissue while avoiding 
neurodegenerative inflammation.         

 
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Figure 1: Immune regulation in glaucoma. Various pathways, such as pro-inflammatory 
cytokine signaling (including TNF-α/TNFR signaling), TLR signaling, NF-κB activation, NLRs 
and inflammasome assembly, and complement activation are co-players of inflammatory 
responses in glaucomatous tissues. A failure in the regulation of immune response pathways 
may shift the physiological equilibrium toward an inflammatory neurodegenerative process. 
 

 
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2.3 
INTERLEUKIN-6 
 
IL-6 is a proinflammatory cytokines that plays an important role in mediating inflammation in 
glaucomatous eye. Retinal ganglion cells (RGC) do not normally regenerate axons after injury, 
instead undergo apoptotic cell death (Leibinger M et al, 2016). IL-6 is synthesized by injured 
retinal ganglion cells following elevation of intraocular pressure and transported in an 
orthograde fashion along the nerve, accumulating at axonal disruption in the optic nerve head 
(Chidlow G et al, 2012). This results in inflammation and apoptosis of RGC. 
 
While direct studies on serum IL-6 levels in JOAG are lacking, existing research on POAG and 
NTG suggests a potential association between IL-6 and glaucoma. Studies also suggests that 
higher serum levels of IL-6 are associated with primary open angle glaucoma and its severity 
(Huang P et al, 2010, Ulhaq ZS et al, 2021). Another study found that serum IL-6 levels were 
borderline higher in NTG patients compared to controls, suggesting a potential association 
between serum IL-6 alterations and glaucoma. (Lin KH et al, 2014). 
 
 
2.4 
RETINAL NERVE FIBER LAYER 
 
The retinal nerve fiber layer (RNFL) contains the non-myelinated axons of the RGCs that form 
the optic nerve. RNFL thinning reflects the axonal loss within the optic nerve. In normal discs, 
the RNFL is thicker in the inferior and superior quadrants of the disc, and thinner in the nasal 
and temporal quadrants of the disc. The mean RNFL thickness for the normal population is 97.3 
± 9.6 µm (Alasil T et al, 2013) whereas the rate of normal age-related retinal thinning is -0.54 ± 
0.23 µm/year (Wu Z et al, 2017).  
 

 
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Structural damage almost always precedes functional damage. Damage to the RNFL precedes 
observable changes in the optic nerve head and significant RNFL loss can occur before 
reproducible functional loss can be demonstrated (Choplin NT et al, 2015). Using light from a 
low coherence source, optical coherence tomography (OCT) precisely measures the RNFL 
surrounding the optic nerve head (peripapillary RNFL). A normative database of the RNFL 
thickness has been obtained to identify and monitor the changes during follow up.  
 
RNFL thinning often precedes visual field loss, which is why monitoring RNFL changes is so 
important. In the early stages, patients with JOAG may not notice significant changes in their 
vision, but OCT can detect the thinning of the RNFL long before visual field defects appear. 
The rate at which the RNFL thins over time is a critical factor in determining the progression of 
JOAG. A rapid rate of RNFL loss may indicate that the glaucoma is progressing more quickly, 
and treatment may need to be adjusted to prevent further damage. 
 
2.5 
STINGLESS BEE HONEY (KELULUT)    
 
With the advent of recent scientific approaches, honey is being widely recognized as treatment 
adjuvant for many diseases owing to its anti-oxidant, anti-inflammatory, anti-microbial, anti-
cancer and wound healing properties (Al-Hatamleh MA et al, 2020). Honey possesses a wide 
variety of bioactive components, approximately 200 different compounds. It beneficiary effects 
is attributed particularly by flavonoids and polyphenols, which protects neurons against 
oxidative damage and neurotoxicity, improve neuronal function and enhance regeneration 
(Iftikhar A et al, 2022).  
 
Stingless bee honey (Kelulut) is a tropical rainforest honey produced by tropical Meliponini bee 
species. It is postulated that Kelulut has better antioxidant, anti-inflammatory and free radical 

 
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scavenging properties than other local honey, owing to the higher contents of phenolic acid and 
flavonoid substance (Kek SP et al, 2017).   
Recent evidence indicates stingless bee honey decreased the IL-6 secretion by macrophages 
after lipopolysaccharide (LPS) stimulation, reaching a reduction of 43.9% (Biluca FC et al, 
2020). In support of these findings, stingless bee honey decreased the circulating levels IL-6 in 
different tissues of lipopolysaccharide-induced rats (Ranneh Y et al, 2021). Trigona honey 
(Madu Kelulut) significantly reduced the mean IL-6 level among ventilated pneumonia patient 
in intensive care unit compared to control group (p value < 0.001). The reduction was observed 
between Day 0 and Day 6 of treatment (Omar SC et al, 2020). In Malaysia, the domestic 
cultivation of Kelulut honey on a large scale is made possible in a controlled farm environment, 
hence adding to the cost effectiveness (Mustafa MZ et al, 2018). The majority of honey's health-
promoting qualities can only be obtained by applying large dosages of the substance, between 
50 and 80 g per intake (Bogdanov S et al, 2018). 
Another study evaluated the effect of honey on macular thickness, retinal nerve fiber layer 
thickness and optic nerve head parameters in post-menopausal women with honey cocktail of 
20g/day for 3 months showed significant increase in the mean change of global RNFL 
thickness in honey cocktail group at three months post honey cocktail supplement, with p 
value of < 0.001 (Sivagurunathan et al, 2019).  
The article titled "Therapeutic Potential of Honey and Propolis on Ocular Disease" by 
Norhashima et al published in Pharmaceuticals in November 2022, provides a comprehensive 
review of the pharmacological properties of honey and propolis in the context of ocular health. 
A clinical study Jung Won Park et al. highlights the neuroprotective effects of Brazilian Green 
Propolis (BGP) on retinal ganglion cells (RGCs) in an ischemic mouse retina model. Results 
suggest that BGP has a neuroprotective effect on RGCs through the upregulation of histone 
acetylation, downregulation of apoptotic stimuli, and suppression of NF-κB mediated 

 
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inflammatory pathway in ischemic retina. Kelulut honey which also known for its potent anti-
inflammatory and antioxidant properties, might have similar effects on the retina. This study is 
proposed to evaluate whether Kelulut honey reduces IL-6 levels and protects against 
neurodegeneration in JOAG patients, paralleling the effects seen with propolis in the mouse 
model. 
 
CHAPTER 3: STUDY OBJECTIVES, RESEARCH QUESTIONS, RESEARCH 
HYPOTHESIS 
3.1. STUDY OBJECTIVES 
3.1.1. GENERAL OBJECTIVES 
To evaluate the effects of supplementary therapy of stingless bee honey (Kelulut) 
on the mean serum level of Interleukin-6, retinal nerve fiber layer thickness and 
dry eye disease parameters in patients with JOAG.  
 
3.1.2. SPECIFIC OBJECTIVES 
1. To compare the mean serum level of Interleukin-6 in patients with JOAG with and 
without honey Kelulut consumption for 3 months.  
2. To compare the mean retinal nerve fiber layer thickness in patients with JOAG with 
and without honey Kelulut consumption for 3 months.  
3. To compare the tear break-up time (TBUT) and Schirmer test in patients with 
JOAG with and without honey Kelulut consumption for 3 months.  
4. To compare the level of glycated hemoglobin (HbA1c) level in patients with 
JOAG with and without honey Kelulut consumption for 3 months. 
 
 
3.2. RESEARCH QUESTIONS 
3.2.1. Does the mean serum level of interleukin-6 differs with and without 

 
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consumption of honey Kelulut for 3 months among JOAG patients? 
3.2.2. Does the mean thickness of retinal nerve fiber layer increases with consumption 
of honey Kelulut for 3 months among patients with JOAG?  
3.2.3. Does the tear break-up time (TBUT) and Schirmer test increases with 
consumption of honey Kelulut for 3 months among patients with JOAG? 
3.2.4. Does the level of glycated hemoglobin (HbA1c) increases with consumption 
of honey Kelulut for 3 months among patients with JOAG? 
 
 
3.2. RESEARCH HYPOTHESIS 
3.2.1. The mean serum level of Interleukin-6 reduces after consumption of honey  
Kelulut for 3 months among patients with JOAG.  
3.2.2. The mean thickness of retinal nerve fiber layer increases after consumption of 
Honey Kelulut for 3 months among patients with JOAG. 
3.2.3 The tear break-up time (TBUT) and Schirmer test increases after 
consumption of honey Kelulut for 3 months among patients with JOAG. 
3.2.4  The level of glycated hemoglobin (HbA1c) does not increase with the 
consumption of honey Kelulut for 3 months among patients with JOAG.  
 
3.3. NULL HYPOTHESIS  
3.3.1. For Interleukin-6 (IL-6) levels: 
Null Hypothesis: 
There is no significant difference in the mean serum level of Interleukin-6 (IL-6) 
before and after 3 months of Kelulut honey consumption among patients with juvenile-
onset open-angle glaucoma (JOAG). 
 
3.3.2. For retinal nerve fiber layer (RNFL) thickness: 
Null Hypothesis: 
There is no significant difference in the mean retinal nerve fiber layer (RNFL) 

 
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thickness before and after 3 months of Kelulut honey consumption among patients with 
juvenile-onset open-angle glaucoma (JOAG). 
 
3.3.3 For dry eye disease parameters  
Null Hypothesis: 
There is no siginificance difference in tear break-up time (TBUT) and Schirmer 
test increases after consumption of honey Kelulut for 3 months among patients 
with juvenile-onset open-angle glaucoma (JOAG). 
 
 
3.3.4  For level of glycated hemoglobin 
Null Hypothesis: 
There is no siginificance difference in the level of glycated hemoglobin level after 
consumption of honey Kelulut for 3 months among patients with juvenile-onset 
open-angle glaucoma (JOAG). 
 
 
 
CHAPTER 4: METHODOLOGY 
4.1. STUDY DESIGN 
Randomised controlled trial 
 
4.2. STUDY POPULATION, LOCATIONS AND DURATION 
Study population: 
Patients diagnosed with Juvenile Open Angle Glaucoma (JOAG) 
 
Study site: 
Department of Ophthalmology Hospital Universiti Sains Malaysia (HUSM) 
Department of Ophthalmology Hospital Raja Perempuan Zainab II (HRPZ II) 
Department of Ophthalmology Hospital Sultanah Nur Zahirah (HSNZ) 
Department of Ophthalmology Hospital Sultan Ismail Petra (HSIP) 
 
Co-researchers:  
Dr Azhany Binti Yaakub MPM 34859 (HUSM) 

 
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Dr Munira Binti Yusoff MPM 39594 (HRPZ II) 
Dr Nor Anita binti Che Omar MPM 33552 (HSNZ) 
Dr Norihan Binti Ibrahim MPM 49484 (HSIP) 
 
Study site involves patients from the Department of Ophthalmology attending Glaucoma  
follow up clinic, under the supervision of Glaucoma Specialist. These centers have the 
appropriate expertise, facilities and patient populations.  
All recruited patients are managed by trained Glaucoma specialists following a 
standardized protocol for the administration of Kelulut honey, clinical assessments, and 
data collection to minimize inter-site variability. Further measures include standardize 
procedures for IL-6 sample collection, RNFL imaging, and standardized clinical 
evaluations across all sites. 
 
Study duration:  
Feburary 2026– June 2026 
End point: Completion of honey supplement for 3 months, followed by comprehensive 
ophthalmic examination, blood sampling collection and OCT RNFL measurement.  
 
4.3. SAMPLING METHOD 
Sampling method 
1. All JOAG patients that fulfilled selection criteria 
2. Patients who are treated at Ophthalmologyy Clinic HUSM, HPRZ II, HSNZ and HSIP 
from February 2026 – November 2026. 
 
 

 
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4.4. SAMPLE SIZE 
Sample size calculation   
GPower 3.1.9.7 software was used to calculate the sample size. 
The power of the study will be set at 80% with a significance level of 5%.  
For the sample size calculation was statistical data used was repeated measures ANOVA 
within and within between.  
The largest sample size was 24.  
To account for the attrition rate, 20% was added, which gives a total estimated minimum 
sample size of 30 per group.  
Total sample size: 60 (30 per group) 
 
Objective 1:  
To compare the mean serum level of Interleukin-6 before and after consumption of 
honey Kelulut for 3 months among patients with JOAG. 
Calculated sample size: 24 
By the addition of 20% drop outs, the sample size that needs to be collected for each 
group is 30 subjects 
Total sample size: 60  
 
Objective 2:  
To compare the mean RNFL thickness before and after consumption of honey Kelulut 
for 3 months among patients with JOAG. 
Calculated sample size: 24 
 

 
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By the addition of 20% drop outs, the sample size that needs to be collected for each 
group is 27 subjects.  
Total sample size: 60  
 
4.5. SELECTION CRITERIA  
Inclusion criteria 
All JOAG patients age 15 years old and above – 40 years old at the time of diagnosis  
Compliant to conventional treatment and achieved target intraocular pressure 
 
Exclusion criteria 
Patients with allergy to honey or honey-based products 
OCT signal less than 6/10 
Concurrent retinal diseases and other optic neuropathies 
Systemic neurodegenerative disease 
Systemic comorbidities such as diabetes mellitus and autoimmune diseases 
Patients on other honey-based products for the last 3 months  
Patient who consumes honey-based products during the study duration of 3 months 
(monitoring via honey-diary, return of the used sachet during the follow up visits) 
Patients on anti-oxidants, traditional medications or herbal products for the last 3 months 
Topical usage of steroids, systemic steroids and non-steroidal anti-inflammatory drugs. 
Sepsis 
Compliance less than 75%.  
The duration of treatment with honey will be 3 months (90 days), patient who missed 
more than 22 sachets of honey will be excluded.  

 
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Compliancy will be assessed through regular monitoring via monitoring of honey-diary 
and patients are required to return the used honey sachets during clinic visits. 
 
 
Withdrawal criteria 
All patients who do not receive standard treatment for JOAG 
All candidates who develops sudden unexpected severe allergic reaction (SUSAR) to 
the investigated product. 
Participants who withdraw or drop out of the study will not be replaced. Follow-up 
assessments will continue for all participants, including those who withdraw from the 
honey supplementation, to allow for comprehensive data collection and minimize loss 
to follow-up. Throughout the study period, participants will continue their conventional 
glaucoma medications without interruption to ensure standard clinical care is 
maintained. 
 
4.6. RANDOMISATION 
The design for this study includes four centers, with two centers randomly assigned to 
the treatment “honey” group and the remaining two to the control “no-honey” group.   
Individual randomization poses practical limitations due to the rarity of juvenile-onset 
open-angle glaucoma (JOAG), In this context, such randomization is more feasible and 
logistically advantageous, particularly in terms of coordinating the supply Kelulut honey 
to patients and simplifies distribution of Kelulut honey.  The Kelulut honey is supplied 
to participants on a monthly basis. During each monthly visit, compliance with the honey 

 
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consumption regimen is reviewed, and any potential side effects are systematically 
monitored and documented. This regular follow-up ensures adherence to the 
intervention and allows for timely identification of adverse events, thereby enhancing 
the safety and reliability of the study.  
Blood samples for the measurement of serum Interleukin-6 (IL-6) levels will be 
collected and these samples will then be transported under controlled conditions to the 
HUSM (Hospital Universiti Sains Malaysia) laboratory for analysis. This ensures a 
coordinated transportation of blood samples to HUSM laboratory.  
4.7. HONEY SUPPLEMENT  
The honey used in this study is Brainey Madu Kelulut, harvested from Heterotrigona 
Itama. It will be supplied for a total of three months after the recruitment and completion 
of initial examination and blood sampling. The participants in the ‘no honey’ group did 
not receive any placebo. Patient in the ‘no-honey’ group is prohibited from consuming 
products that is based on honey Kelulut or other honey-based products throughout the 
study period. The control group will consist of matched JOAG patients receiving 
standard treatment without honey.  
Both the patients and the Principal Investigator will not be blinded by the modality of 
treatment.  
Participants were instructed regarding the consumption of the honey by the Principal 
Investigator. The honey will be supplied in the form of sachet, dosage of 30g per sachet 
per day for 3 months. The participants are advised to consume the honey at least 30 
minutes prior to meals or other medications to avoid any interactions. Participants are 
also advised not to mix or dilute the honey using other solutions or food products. 
Participants are also prohibited from consuming other honey-based products throughout 

 
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the duration of the study. Those who develop any allergic reaction such as rashes, 
shortness of breath, wheezing, dysphagia or anaphylactic reactions are advised to 
immediately discontinue the product and seek immediate treatment from the nearest 
Emergency Department and contact the Principal Investigator regarding the side effects.  
 
The principal investigator will also advise the patients regarding the compliance to 
treatment. The compliance will be monitored via a printed diary that will be given upon 
enrolment. Patients are required to tick on the diary upon completion of the honey 
sachets daily.  
 
 
 
4.8. DEFINITION OF TERMS 
Juvenile open angle glaucoma 
Juvenile-onset open-angle glaucoma (JOAG) is a subset of primary open-angle 
glaucoma that is diagnosed before 40 years of age. Myocilin gene mutations are the most 
commonly associated. JOAG is characterized by high intraocular pressures (IOP 
elevation in intraocular pressure with large fluctuations, faster progression and severity 
of visual field loss compared to adult POAG.  
 
Interleukin-6 
IL-6 belongs to the class of four-helical cytokines. The cytokine can be synthesized and 
secreted by many cells. It acts via a cell surface-expressed interleukin-6 receptor, which 
is not signaling competent. This receptor, when complexed with interleukin-6, associates 
with the signaling receptor glycoprotein 130 kDa (gp130), which becomes dimerized 
and initiates intracellular signaling via the Janus kinase/signal transducer and activator 

 
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of transcription and rat sarcoma proto oncogene/mitogen-activated protein 
kinase/phosphoinositide-3 kinase pathways. 
 
Retinal nerve fiber layer  
The retinal nerve fiber layer (RNFL) or nerve fiber layer, stratum opticum, is formed by 
the expansion of the fibers of the optic nerve; it is thickest near the optic disc, gradually 
diminishing toward the ora serrata. As the nerve fibers pass through the lamina cribrosa 
sclerae they lose their medullary sheaths and are continued onward through 
the choroid and retina as simple axis-cylinders. Upon reaching the internal surface of the 
retina they radiate from their point of entrance over this surface grouped in bundles, and 
in many places arranged in plexuses. 
 
 
Honey Kelulut  
Stingless bee honey (Kelulut) is a tropical rainforest honey produced by tropical 
Meliponini bee species, bees are from genus Trigona. stingless bees (Meliponini sp.) 
or lebah Kelulut which do not have stingers, build nests in already existing cavities or 
hollowed out areas of trees, buildings and hives.  The major composition of stingless bee 
honey includes sugars (fructose and glucose) with nearly zero hydroxymethylfurfural 
(HMF). It also contains small amounts of other compounds, such as organic acids, 
phenolic compounds (eg., phenolic acids and flavonoids), proteins, amino acids (eg., 
phenylalanine, alanine, tyrosine, valine, acetate and trigonelline), enzymes, vitamins and 
minerals. 
 
4.9. STUDY INSTRUMENTS 

 
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4.9.1. SLITLAMP BIOMICROSCOPY  
Slit lamp biomicroscope (Topcon Corp, Japan) was used for ocular examination. It is 
used for assessment of the patients’ eye through binocular, stereoscopic magnified 
views of the anterior segment and posterior segment. Posterior segment examination 
was conducted with the aid of + 78 or +90 Diopter lens.  
 
4.9.2. GOLDMAN APPLANATION TONOMETER (HAAG STREIT, GERMANY) 
Goldman applanation tonometer (Haag Streit, Germany) has been regard as a gold 
standard to measure intraocular pressure (IOP), based on Imbert-Fick principle.  
 
4.9.3. GOLDMAN GONIOSCOPE 
The status of angle structure in the anterior segment of the eye was determined by using 
single mirror Goldman gonioscopy lens.  
 
4.9.4. HUMPHREY VISUAL FIELD ANALYSER II MODEL 750 
It is an automated, static, computerized perimetry machine used as the gold standard 
perimetry to assess patients’ visual field. Swedish Interactive Threshold Algorithm 
Standard (SITA-STANDARD) with test pattern 10-2 or 24-2 full threshold was used as 
strategy in assessment of visual field. 
 
4.9.5. ELISA KIT  
The BioLegend LEGEND MAX™ Human IL-6 ELISA Kit is a Sandwich Enzyme 
Linked Immunosorbent Assay (ELISA) with a 96-well strip plate that is precoated with 
a rat monoclonal anti-human IL-6 antibody. The detection antibody is a biotinylated rat 
monoclonal anti-human IL-6 antibody. This kit is specifically designed for the accurate 

 
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quantitation of human IL-6 from cell culture supernatant, serum, plasma, and other 
biological fluids. This kit is analytically validated with ready-to-use reagents.  
 
4.9.6. OPTICAL COHERENCE TOMOGRAPHY Cirrus HD-OCT 500  
(Carl Zeiss Meditec, Germany) 
OCT is a noninvasive in vivo cross-sectional imaging technology using low-coherence 
interferometry. OCT is the optical analogue of ultrasound imaging; it generates high-
resolution cross-sectional 2D images of internal tissue microstructures. Specifically 
pertaining to  glaucoma, OCT enables the objective quantitative evaluation of critical 
neural structures, including the RNFL, the optic nerve head (ONH), and the macula. By 
comparing these measurements with established normative databases, clinicians can 
determine whether structures are borderline or outside normal limits, improving 
detection of disease and its progression.  
 
The eyes are dilated with Gutt Tropicamide 1% and Gutt Phenylephrine 5% before 
recording the images. Internal fixation was chosen (subject fixation with the eye being 
studied because of better reproducibility). The average thickness for each composite 
scan was calculated by taking the arithmetic mean of the 100 data points. In addition, 
the peripapillary RNFL thickness was divided into four quadrants defined as superior 
(46 to 135 degrees), nasal (136 to 225 degrees), inferior (226 to 315 degrees), and 
temporal (316 to 45 degrees). 
 
 
 
 
 

 
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4.10. 
DATA COLLECTION AND ANALYSIS 
4.10.1. PATIENT RECRUITMENT  
The study will be conducted after obtaining approval from the Universiti Sains Malaysia 
Ethical Committee. Patient from the Department of Ophthalmology Hospital Universiti 
Sains Malaysia (HUSM), Department of Ophthalmology Hospital Raja Perempuan 
Zainab II (HRPZ II), Department of Ophthalmology Hospital Sultanah Nur Zahirah 
(HSNZ) and Department of Ophthalmology Hospital Sultan Ismail Petra (HSIP) will be 
selected according to our inclusion and exclusion criteria. Participants who fulfilled the 
selection criteria are identified and provided with the information sheet regarding the 
study. Written informed consent is obtained from all participants or legal guardian.  
 
The eye with the better visual acuity will be selected to standardize the examination. A 
comprehensive ophthalmic assessment is done which includes visual acuity, Schirmer 
test, Tear break-up time (TBUT), intraocular pressure measurement by Goldmann 
applanation tonometry, slitlamp and fundus examination and gonioscopy using 
Goldmann three mirror contact lens. OCT macula and RNFL thickness measurement 
using optical coherence tomography is done after pupillary dilatation by some identified 
single-blinded trained personnel.  
 
Blood sampling will be taken from all participants, serum separated, stored and 
transported to HUSM Laboratory and assayed. Quantification of cytokine IL-6 
performed using IL-6 enzyme-linked immunosorbent assay (ELISA) kit. The 
participants were randomized into either ‘honey’ or ‘non-honey’ groups. The honey used 
in this study is Brainey Madu Kelulut, harvested from Heterotrigona Itama supplied for 
a total of three months after the recruitment and completion of initial examination and 

 
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blood sampling. The participants in the ‘no honey’ group did not receive any placebo. 
After 3 months of honey supplement therapy, participants in both groups were reassessed 
during follow-up. The mean serum IL-6 and RNFL thickness were re-measured, using 
the same OCT machine and IL-6 ELISA test kit. Participants who were not compliant to 
the honey supplement were excluded from the study.  
 
 
4.10.2. COLLECTION OF BLOOD SAMPLE 
Approximately 3-4 milliliters of venous blood will be taken from all participants and 
collected by identified trained blinded medical personnel into a plain tube, sample will 
be labelled. Similar amount is collected into EDTA tube for HbA1c analysis. The sample 
is allowed to be at room temperature about 20-30 minutes to allow for clot formation. 
Centrifugation is then done for 10 minutes; the resultant supernatant is the serum. The 
serum formed will be transferred into a clean polypropylene tube using Pasteur pipette, 
the serum is later stored and transported at temperature -70°C or lower.  
The sample will be transported to the Immunology Laboratory at Hospital Universiti 
Sains Malaysia for quantification and analysis of IL-6, processed by a identified trained 
blinded laboratory personnel. 
 
4.10.3.  QUANTIFICATION OF IL-6 
The serum level of Interleukin-6 is measured using the Human IL-6 ELISA kit with pre-
coated serum (LEGEND MAXTM, BioLegend, Inc). The sampling, storage, assay 
procedures were done according to the kit protocol. The analysis will be conducted in 
the Biomedical Laboratory and Central Research Laboratory, USM.  
 

 
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4.10.4. REAGENT AND SAMPLE PREPARATION 
The 20X Wash Buffer was diluted to with 1X deionized water. Any crystals formed 
within the 20X Wash buffer will be dissolved by bringing to room temperature and 
vortex until dissolved.  Reconstitute the lyophilized Human IL-6 Standard by adding the 
volume of Assay Buffer A to make the standard stock solution. Allow the reconstituted 
standard to sit at room temperature for 15-20 minutes, then briefly vortex to mix 
completely. Initial testing of biological samples should be performed to determine an 
optimal concentration that is within the linear range of the standard curve. Dilute 
samples using Assay Buffer A. 
 
4.10.5. ASSAY PROCEDURES 
Dilute 12.5 µL of the standard stock solution in 487.5 µL of Assay Buffer to create 500 
µL of the 500 pg/mL top standard. Next, Assay Buffer A is used as the diluent and six 
two-fold serial dilutions are made using the 500 pg/mL top standard in different tubes. 
Assay Buffer A acts as the zero standard (0 pg/mL), and the human IL-6 standard 
concentrations in the tubes are 500 pg/mL, 250 pg/mL, 125 pg/mL, 62.5 pg/mL, 31.3 
pg/mL, 15.6 pg/mL, and 7.8 pg/mL, respectively. Next, at least 300 μL of 1X Wash 
Buffer is used to wash the microplates four times.  
 
 
50 μL of Assay Buffer A and 50 μL of standard dilutions or samples are added to the 
corresponding wells in each well. After that, the plates are sealed with a plate sealer and 

 
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incubated for two hours at room temperature with 200 rpm shaking. After discarding the 
contents, the plate is cleaned four times using 1X Wash Buffer. After adding 100 μL of 
Human IL-6 Detection Antibody solution to each well, the plate is sealed and left to 
incubate for an hour at room temperature while being shaken. After discarding the 
contents, the plate is cleaned four times using 1X Wash Buffer. Following that, 100 μL 
of Avidin-HRP After adding a solution, the plate is sealed and allowed to sit at room 
temperature for half an hour while being shaken. After discarding the contents, the plate 
is cleaned five times using 1X Wash Buffer. After adding 100 µL of Substrate Solution 
F to each well, each one is left in the dark for 15 minutes. Human IL-6-containing wells 
ought to become blue in a way that is proportionate to the amount of the substance 
present. Each well should contain 100 µL of Stop Solution to stop the reaction, and the 
resultant solution should turn yellow instead of blue. After 30 minutes, the absorbance 
at 450 nm wavelength is measured, and the findings are recorded. Sample will be 
discarded after the completion of data collection and analysis.  

 
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4.10.6. DATA COLLECTION AND ANALYSIS 
Data recorded in data collection sheet transferred into electronic data and analyzed using 
Statistical Package for Social Sciences (SPSS), the latest version. The mean serum IL-6 
and mean RNFL thickness of both groups will be analyzed using ANOVA repeated 
measures; within factors and within-between factors. All the p-value of less than 0.05 
was considered statistically significant.  
 
4.10.7. FOLLOW UP 

 
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Patients are assessed after a period of 3 months. RNFL thickness and serum IL-6 level 
will be measured. All these parameters will be measured using the same machine using 
same techniques.  Compliance to the honey supplement will also be tested, by evaluating 
the diary filled by the patients and the consumed honey packages. Participants who were 
found to be less than 75 % compliant with the study were excluded from the study. 
 
 

 
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CHAPTER 5: RESULTS 
 
5.1 
DEMOGRAPHIC DATA 
Variables 
Honey group  
(n = 43) 
Control group 
 (n = 43) 
p value 
 
Age (years) 
 
 
 
Sex 
Male, n (%) 
Female, n (%) 
 
 
 
Race 
Malay, n (%) 
Chinese, n (%) 
Indian, n (%) 
Others, n (%) 
 
 
 
BCVA (Log MAR) 
 
 
 
Duration of JOAG (years) 
 
 
 
Number of topical antiglaucoma 
medications 
 
 
 
Received surgical intervention 
for IOP control  
 
 
 
 
 
 
 
 

 
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5.2 
COMPARISON OF MEAN SERUM LEVEL OF IL-6 PRE AND POST 3 MONTHS OF 
HONEY (KELULUT) TREATMENT AMONG PATIENTS WITH JOAG 
Comparison of mean serum level of IL-6 pre and post 3 months of honey (Kelulut) treatment 
among patients with JOAG 
__________________________________________________________________________________ 
 
 
Mean serum IL-6 level  
 
Group  
Mean diff (95% CI)  
 
p 
value 
__________________________________________________________________________________ 
 
Time 
 
 
 
Baseline 
 
 
Honey 
 
 
 
 
 
No honey  
 
 
3 months’ post treatment 
Honey 
 
 
 
 
 
No honey  
__________________________________________________________________________________ 
        
 
5.3 
COMPARISON OF MEAN RETINAL NERVE FIBER LAYER THICKNESS PRE AND 
POST 3 MONTHS OF HONEY (KELULUT) TREATMENT AMONG PATIENTS WITH 
JOAG 
 
__________________________________________________________________________________ 
 
RNFL thickness  
 
 
Group  
Mean diff (95% CI)  
 
p value 
__________________________________________________________________________________ 
Time 
 
 
Baseline  
 
 
 
Honey 
 
 
 
 
 
No honey  
 
3 months’ post treatment 
 
Honey 
 
 
 
 
 
No honey  
__________________________________________________________________________________ 
 
 
 
 
 
 

 
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5.4 
COMPARISON OF DRY EYE DISEASE PARAMETERS PRE AND POST 3 MONTHS 
OF HONEY (KELULUT) TREATMENT AMONG PATIENTS WITH JOAG 
__________________________________________________________________________________ 
 
Comparison of TBUT  
 
Group  
Mean diff (95% CI)  
 
p value 
__________________________________________________________________________________ 
Time 
 
 
Baseline  
 
 
 
Honey 
 
 
 
 
 
No honey  
 
3 months’ post treatment 
 
Honey 
 
 
 
 
 
No honey  
__________________________________________________________________________________ 
 
__________________________________________________________________________________ 
 
Comparison of Schirmer test   
Group  
Mean diff (95% CI)  
 
p value 
__________________________________________________________________________________ 
Time 
 
 
Baseline  
 
 
 
Honey 
 
 
 
 
 
No honey  
 
3 months’ post treatment 
 
Honey 
 
 
 
 
 
No honey  
__________________________________________________________________________________ 
 
 
5.5 
COMPARISON OF LEVEL OF GLYCATED HEMOGLOBIN PRE AND POST 3 
MONTHS OF HONEY (KELULUT) TREATMENT AMONG PATIENTS WITH JOAG 
 
__________________________________________________________________________________ 
 
HbA1c ` 
 
 
 
Group  
Mean diff (95% CI)  
 
p value 
__________________________________________________________________________________ 
Time 
 
 
Baseline  
 
 
 
Honey 
 
 
 
 
 
No honey  
 
3 months’ post treatment 
 
Honey 
 
 
 
 
 
No honey  
__________________________________________________________________________________ 
 

 
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CHAPTER 6: FLOW CHART  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Allocation  
Follow up 
Analysis  
Excluded (n=  ) 
▪ 
Not meeting 
inclusion criteria 
(n=  ) 
▪ 
Refused to 
participate (n=  ) 
▪ 
Other reason (n=  ) 
Allocation to intervention (n= ) 
▪ 
Received allocated 
intervention (n= ) 
 
▪ 
Did not received 
allocated intervention 
(n= ) Reason: 
Allocation to intervention (n= ) 
▪ 
Received allocated 
intervention (n= ) 
 
▪ 
Did not received 
allocated intervention 
(n= ) 
Reason: 
Lost to follow up (n= ) 
Reasons 
 
Discontinued intervention 
(n= ) 
Reason: 
 
Lost to follow up (n= ) 
Reasons 
 
Discontinued intervention 
(n= ) 
Reason: 
 
Analyzed (n= ) 
 
Excluded from analysis 
(n= )  
Reason: 
Analyzed (n= ) 
 
Excluded from analysis 
(n= )  
Reason: 
Randomisation (n= ) 
Assessed for eligibility (n= ) 

 
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CHAPTER 7: GANTT CHART   
 
Year 
2024 
2024-2025 
2025-2026 
2026 
Months 
Jan-May 
Jun-Nov 
Dec-May 
Jun-Nov 
Dec-May 
Jun 
Proposal 
preparation and 
ethical approval  
 
 
 
 
 
 
Data collection  
 
 
 
 
 
 
Data analysis/ 
interpretation 
 
 
 
 
 
 
Report writing  
 
 
 
 
 
 
Submission of 
research book  
 
 
 
 
 
 
 
 
 
CHAPTER 8: MILESTONE  
 
 
Data 
Expected achievement 
Jan 2024 – November 2024 
Proposal presentation (Department of Ophthalmology 
USM) 
Jawatankuasa Etika Penyelidikan Manusia (JEPeM) 
USM presentation  
NMRR application  
December 2024-February 2025  
JEPeM and NMRR approval  
March 2025 – May 2025 
30% of data collection 
June 2025 – November 2025  
80% of data collection 
30% of report writing  
December 2025 – May 2026 
100% data collection  
100% of data analysis 
100% of report writing 
June 2026  
Submission of research book 
 

 
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CHAPTER 9: ETHICAL CONSIDERATION 
 
 
9.1. ETHICS 
This study will be conducted after the approval from the Ethical Committee USM, in 
accordance to the Declaration of Helsinki and International Conference of 
Harmonisation (ICH). All researchers of this study were GCP-certified.  
 
9.2. VULNERABILITY 
The subjects for this study involve subjects with JOAG attending the Ophthalmology 
Clinic HUSM, HRPZ II, HSNZ and HSIP that fulfills the study requirement and capable 
of giving their own consent. Legal age in Malaysia is 18 years old.  
For participant aged 15 to-under 18 years old: Co-sign informed consent with parents 
are obtained.  
They will be provided full information about the study’s purpose, duration, procedure, 
benefit, risk and institutional approval. They will be given full authority to decide and 
full freedom to participate in the study without affecting his/her condition management 
and care. The investigator could withdraw the subject, or the subject could withdraw 
from participation in the study any time without penalty or any loss of benefits. The 
reason for withdrawal will be recorded. In cases of developing allergic reaction or severe 
adverse effects, appropriate treatment will be provided accordingly and patients will be 
followed up in ophthalmology clinic for further management and treatment. 
 
9.3. CONFLICT OF INTEREST  
There is no conflict of interest in any parts of this study, including towards the medical 
devices and pharmaceutical companies.  
 

 
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9.4. INFORMED CONSENT  
Patients will be briefed regarding the study design, any adverse reactions related to the 
procedures and the anticipated benefits of the study. A summary of this information will 
be presented in written consent form. Consent is obtained from patients or guardians 
who agrees to participate in the study. A copy of this will be given to the subjects. A list 
of contact number of the investigators will also be included in the patient information 
leaflet. Any further information regarding the study will be informed to patient 
throughout the study period and patients will be informed regarding the result at the end 
of the study.  
All the subjects will be informed regarding the study findings.  This information will be 
shared as part of the informed consent process, ensuring participants are well-informed 
about the scientific basis for the study and any relevant outcomes from similar studies, 
including those that suggest potential benefits for retinal health. This ensures 
transparency and gives participants a comprehensive understanding of the context of the 
study. 
 
9.5. PATIENT WITHDRAWAL  
The investigators could withdraw the subject, or the subject could withdraw their 
participation from the study without any penalty or loss of benefits. The reason for 
withdrawal would be recorded in the Case Report form. Reasons for cessation of study 
subjects by investigators includes non-compliance with protocol and study requirement 
and adverse effect towards the drug.  
 
9.6. RISK AND BENEFITS TO STUDY PARTICIPANTS  

 
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There are no serious adverse effects by the study procedures such as slit lamp 
examination/ RNFL measurement/venipuncture for serum IL 6 measurement. Dosage 
of the honey provided to the patient is within the therapeutic dosage. Patient will be 
periodically for adverse effect during monthly follow up. In case of developing adverse 
effects to the honey, patients are advised to immediately stop the honey, contact the 
study doctor and seek immediate treatment from the emergency service at the nearest 
hospital.   
 
 
9.7. DATA HANDLING AND RECORD KEEPING 
Participants’ medical records will be kept in the study site (Ophthalmology Clinic and 
Visual Sciences, School of Medical Hospital Universiti Sains Malaysia. Data obtained 
from the study will be kept by the principal investigator in a password locked computer 
for up to 3 years after the study has ended after which the study data will be subsequently 
destroyed. No future research will be done using the similar data or biospecimens. 
 
9.8. PRIVATE AND CONFIDENTIALITY 
All participants will be given a subject identification number to maintain privacy and 
confidentiality. Participants will be informed of their clinical findings and will be 
managed accordingly during the study. Medical information will be kept confidential 
unless disclosed by law, the researcher, the ethical board for this study and regulatory 
authorities for the purpose of verifying clinical trial procedures and/or data. Data 
collection forms are anonymous and the data will be entered into SPSS software. Only 
the research team members have access to the data. In the event that this study is 
published, study result will be published in a collective data format with no identification 

 
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of any individual or disclosure of the participants’ personal information. If the study 
being published, relevant permissions will be obtained prior to publication. 
 
9.9. COMMUNITY SENSITIVITIES AND BENEFITS  
There is no element of sensitivity to the community in this research study. The findings 
from this study will greatly improve future management of JOAG both from the local 
and global community.  
 
 
9.10. 
INCENTIVES AND HONORARIUM  
All participants will be given a leaflet/ brochure that contains information regarding 
the juvenile open angle glaucoma and beneficial effects of honey on the 
neuromodulation involved in the progression of glaucoma disease. This study is fully 
funded, therefore there is no cost for the participant. Additionally, participants will 
continue to receive their standard conventional medications for glaucoma or other 
underlying conditions as prescribed by their treating ophthalmologist or healthcare 
provider, and these will be provided at their usual cost or as per their existing healthcare 
arrangements. An honorarium will be provided to participants as a token of appreciation 
for their involvement in the study. The honorarium will be issued once the MSO 
(Medical and Scientific Office) grant is approved. 
 
 
9.11. 
PARENTAL ROLE 
Parents play a pivotal role in monitoring their child's compliance with both the 
conventional treatment and the investigational product; they also must ensure the child 

 
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follows the instructions that must be followed throughout the study period. The 
consumption of the product should be monitored directly by parents and be recorded in 
a honey diary provided to the participants, which will be handed to the investigator at 
the end of the study period.  
 
9.12. 
ROLE OF PRINCIPAL INVESTIGATOR 
Principal investigator will not be the direct service provider of the recruited patients. The 
principal investigator will be in charge if the subjects may have any enquiries or develop 
health issues throughout the study.  
 
 
 
CHAPTER 10: RESEARCH REGISTRATION 
 
10.1 
Registration 
 
Registration number: RSCH ID-24-04301-DXV 
Name of trial registry: National Medical Research Register (NMRR) 
 
10.2 
Protocol 
 
Research Protocol is available for review at NMRR website  
 
10.3 
Funding  
 
This research is funded by a research grant  
 
Grant funding: Fundamental Research Grant Scheme, FRGS 
Grant number:  203.PPSP.6171354 
Ref Number KPT: FRGS/1/2022/STG02/USM/02/7 
 

 
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neurological disorders: the role of polyphenols. Molecules. 2022 May 20;27(10):3297. 
17. Kek SP, Chin NL, Yusof YA, Tan SW, Chua LS. Classification of entomological 
origin of honey based on its physicochemical and antioxidant properties. International 
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18. Biluca FC, da Silva B, Caon T, Mohr ET, Vieira GN, Gonzaga LV, Vitali L, Micke G, 
Fett R, Dalmarco EM, Costa AC. Investigation of phenolic compounds, antioxidant and 
anti-inflammatory activities in stingless bee honey (Meliponinae). Food Research 
International.2020 Mar 1;129:108756. 
19. Ranneh Y, Mahmoud AM, Fadel A, Albujja M, Akim AM, Hamid HA, Khazaai H. 
Acute inflammation and oxidative stress induced by lipopolysaccharide and the 
ameliorative effect of stingless bee honey. Combinatorial chemistry &amp; high 
throughput screening. 2021 Jul 1;24(6):744-57 
20. Omar SC, Zaini RH, Ismail IS, Mohd W, Hassan NW, Seevaunnamtum P, Hussin CM. 
A randomized study of an evaluation of Trigona honey as immunonutrition among 
ventilated pneumonia patients in intensive care unit. Anaesthesia, Pain &amp; Intensive 
Care. 2022 Oct 18;26(5):649-55. 
21. Mustafa MZ, Yaacob NS, Sulaiman SA. Reinventing the honey industry: Opportunities 
of the stingless bee. The Malaysian journal of medical sciences: MJMS. 2018 
Jul;25(4):1. 
22. Premala-Devi S, Noorlaila B, Zunaina E, Raja-Norliza RO, Abdullah N, Kueh YC, Nik-
Hussain NH. Effect of Honey Cocktail on Macular Thickness, Retinal Nerve Fiber Layer 
Thickness and Optic Nerve Head ParameteArs in Post-Menopausal Women. Malaysian 
Journal of Medicine &amp; Health Sciences. 2019 Jun 1;15(2). 
23. Huang P, Qi Y, Xu YS, Liu J, Liao D, Zhang SS, Zhang C. Serum cytokine alteration is 
associated with optic neuropathy in human primary open angle glaucoma. Journal of 
glaucoma. 2010 Jun 1;19(5):324-30. 
24. Bogdanov S, Jurendic T, Sieber R, Gallmann P. Honey for nutrition and health: a 
review. Journal of the American college of Nutrition. 2008 Dec 1;27(6):677-89. 
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Ophthalmology. 1993 Apr 1;100(4):524-9. 
26. Fingert JH, Stone EM, Sheffield VC, Alward WL. Myocilin glaucoma. Survey of 
ophthalmology. 2002 Nov 1;47(6):547-61. 
27. Baek SU, Kim SH, Ha A, Kim JS, Yoon HJ, Kim YK. Trends in Childhood Glaucoma 
Prevalence and Incidence in South Korea, 2002–2019: A Nationwide Population- 
Based Study. Journal of Glaucoma. 2024 May 1;33(5):361-9. 
28. Mimiwati Z, Nurliza K, Marini M, Liza-Sharmini AT. Identification of MYOC gene 
mutation and polymorphism in a large Malay family with juvenile-onset open angle 
glaucoma. Molecular vision. 2014;20:714. 
29. Barış M, Tezel G. Immunomodulation as a neuroprotective strategy for glaucoma 
treatment. Current ophthalmology reports. 2019 Jun 15;7:160-9. 
30. Wiggs, J. L., & Pasquale, L. R. (2017). Genetics of glaucoma. Human Molecular 
Genetics, 26(R1), R21-R27. 
31. Stone, E. M., et al. (1997). Identification of a gene that causes primary open angle 
glaucoma. Science, 275(5300), 668–670. 
32. Sarfarazi, M., & Stoilov, I. (2000). Molecular genetics of primary congenital 
glaucoma. Eye, 14(3), 422–428. 
33. Kaur, K., Mandal, A. K., & Chakrabarti, S. (2008). Primary congenital glaucoma and 
the involvement of CYP1B1. Middle East African Journal of Ophthalmology, 15(2), 
89–93. 
34. Selvan H, Gupta S, Wiggs JL, Gupta V. Juvenile-onset open-angle glaucoma - A clinical 
and genetic update. Surv Ophthalmol. 2022 Jul-Aug;67(4):1099-1117. 

 
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35. Lin KH, Feng SC, Shen YC, Wei LC, Liang CY, Chang CJ, Yang YY, Chiu CH, Wang 
CY. Interleukin-6 (-174) locus polymorphism and serum IL-6 levels in normal tension 
glaucoma. Ophthalmic Genetics. 2014 Dec 1;35(4):255-7. 
36. Abd Rashid N, Mohammed SN, Syed Abd Halim SA, Ghafar NA, Abdul Jalil NA. 
Therapeutic potential of honey and propolis on ocular disease. Pharmaceuticals. 2022 
Nov 17;15(11):1419. 
37. Park, J. W., Sung, M. S., Ha, J. Y., Guo, Y., Piao, H., Heo, H., & Park, S. W. (2019). 
Neuroprotective Effect of Brazilian Green Propolis on Retinal Ganglion Cells in 
Ischemic Mouse Retina. Current Eye Research, 45(8), 955–964.  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

 
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CHAPTER 12: APPENDICES 
  
12.1 
PATIENT INFORMATION AND CONSENT FORM  
12.2 
DATA COLLECTION FORM  
12.3 
HONEY TREATMENT DIARY  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

 
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RESEARCH INFORMATION 
 
 
 
 
       
Research Title:  
Supplementary Kelulut Honey Therapy In Juvenile Open-Angle Glaucoma: Effects On Il-6, RNFL 
And Dry Eye 
 
  
Name of main and co-Researcher: 
Dr Thamarai A/P Munirathinam MPM 67381 (HUSM) 
Dr Azhany Binti Yaakub MPM 34859 (HUSM) 
Dr Munira Binti Yusoff MPM 39594 (HRPZ II) 
Dr Nor Anita binti Che Omar MPM 33552 (HSNZ) 
Dr Norihan Binti Ibrahim MPM 49484 (HSIP) 
 
 
INTRODUCTION 
 
You or the person under your care are invited to take part voluntarily in a interventional research. This research is 
about the evaluation of supplementary therapy of stingless bee honey (Kelulut) on patients with juvenile open 
angle glaucoma.  
 
JOAG is a subset of primary glaucoma that affects the younger patients and the resulting disability from this 
disease is higher. It has an important impact on the quality of life of young adults whom represent the 
socioeconomically productive subgroup of population. It has a faster progression, higher magnitude of IOP and it 
is often refractory to medical treatment. Therefore, Kelulut may represent a possible adjuvant treatment to 
antiglaucoma medications owing to its anti-inflammatory and anti-oxidant properties. Serum level of IL-6 and 
peripapillary measurement of RNFL may possibly be used to monitor the changes. The immunomodulatory 
effects of Kelulut may possibly give beneficial effect to JOAG patients and results from this research can be used 
as a reference for development of better treatment outcomes.  
 
It is important that you read and understand this research information before agreeing to participate in this study. 
You will receive a copy of this form to keep for your records if you agree to participate. 
 
Your participation in this study is expected to be 3 months from the recruitment of participants until completion 
of the honey therapy and ophthalmic examinationsThis study is estimated to include up to 60 participants. 
 
 
PURPOSE OF THE STUDY 
 
The purpose of this study are to determine the effects of supplementary therapy of stingless bee honey 
(Kelulut) on the serum level of Interleukin-6, retinal nerve fiber layer thickness and dry eye paarmeters in patients 
with juvenile open angle glaucoma. 
 
 
PARTICIPANTS CRITERIA 
 
The research team members will discussed your eligibility to participate in this study.  It is important that you are 
completely truthful with the staff including your health history.  
 
This study will include individual who are: 
1. All JOAG patients above 15 years – 40 years old 
2. All Compliant to treatment and achieved target intraocular pressure 
 
 
This study will not incude individual who are: 
1. Patients with allergy to honey or honey-based products 
2. OCT signal less than 6/10 
3. Concurrent retinal diseases and other optic neuropathies 

 
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4. Systemic neurodegenerative disease 
5. Systemic comorbidities such as diabetes mellitus and autoimmune diseases 
6. Patients on anti-oxidants, traditional medications or herbal products for the last 3 months 
7. Topical usage of steroids, systemic steroids and non-steroidal anti-inflammatory drugs. 
8. Sepsis 
 
 
STUDY PROCEDURES 
 
Participants who fulfilled the selection criteria and agreed to participate are identified and provided with the 
information sheet regarding the study. Written informed consent is obtained from all participants at the beginning 
of the study. A comprehensive ophthalmic assessment is done which includes optical coherence tomography of 
RNFL thickness followed by blood sampling for the quantification of IL-6 using ELISA kit and HbA1c. The 
participants were randomized based on simple randomization technique into either ‘honey’ or ‘non-honey’ groups. 
The honey used in this study is Brainey Madu Kelulut, supplied for a total of three months after the recruitment 
and completion of initial examination and blood sampling. The participants in the ‘no honey’ group did not receive 
any placebo. After 3 months of honey supplement therapy, participants in both groups were reassessed during 
follow-up. The mean serum IL-6 and RNFL thickness were re-measured, using the same OCT machine and IL-6 
ELISA test kit. Participants who were not compliant to the honey supplement were excluded from the study. Data 
entry and statistical analysis is done using Statistical Package for Social Sciences (SPSS) Version 26.0. Comparison 
of the total mean RNFL thickness and serum IL-6 level before and after consumption of honey will be analyzed. 
 
 
RISKS 
 
Honey Kelulut has been identified as a safe supplement, 30g per day for 90 days. The dosage of the honey given 
is within the therapeutic level. Honey kelulut is also given as a supplementary therapy in conjunction with the 
conventional anti- glaucoma medications and treatment.  
 
 
REPORTING HEALTH EXPERIENCES. 
 
Please contact, at any time, the following researcher if you experience any health problem either directly or 
indirectly related to this study.     
 
Dr. Thamarai A/P Munirathinam ,MMC Registration No.67381 at H/P No +60177712935.  
 
 
PARTICIPATION IN THE STUDY 
 
Your taking part in this study is entirely voluntary.  You may refuse to take part in the study or you may stop your 
participation in the study at anytime, without any penalty or loss of benefits to which you are otherwise entitled. 
Your participation also may be stopped by the research team without your consent if in any form you have violated 
the study eligibility criteria. The research team member will discussed with you if the matter arises. This study is 
fully funded, therefore there is no cost for the participant.    
Parents play a pivotal role in monitoring their child's compliance with both the conventional treatment and the 
investigational product; they also must ensure the child follows the instructions that must be followed throughout 
the study period. The consumption of the product should be monitored directly by parents and be recorded in a 
honey diary provided to the participants, which will be handed to the investigator at the end of the study period. 
POSSIBLE BENEFITS [Benefit to Individual, Community, University] 
 
You may obtain information regarding your eye’s health condition and laboratory test that may be provided in the 
study. Information obtained from this study will benefit patients and the community in the future. The 
immunomodulatory effects of Kelulut ay possibly give beneficial effect to JOAG patients and the result from this 
research can be used as reference for developing better treatment outcomes.  

 
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50 
 
 
QUESTIONS 
 
If you have any question about this study or your rights, please contact; 
 
 
 
 
Dr Thamarai A/P Munirathinam MMC 67381 
 
 
 
Department of Ophthalmology and Visual Sciences 
 
 
 
Health Campus, Universiti Sains Malaysia 
 
 
 
Kubang Kerian, Kelantan 
 
 
 
Tel: +60177712935 
 
 
 
 
Assoc. Prof. Dr Azhany Yaakub MMC 34859 
 
 
 
Department of Ophthalmology and Visual Sciences 
 
 
 
Health Campus, Universiti Sains Malaysia 
 
 
 
Kubang Kerian, Kelantan 
 
 
 
Tel: +60199101993 
 
 
 
If you have any questions regarding the Ethical Approval or any issue / problem related to this study, please contact; 
 
Mr. Mohd Bazlan Hafidz Mukrim 
Secretary of Human Research Ethics Committee USM 
Division of Research & Innovation (R&I) 
USM Health Campus 
Tel. No. : 09-767 2354 / 09-767 2362 
Email : bazlan@usm.my  
 
OR 
 
Miss Nor Amira Khurshid Ahmed 
Secretariat of Human Research Ethics Committee USM 
Research Creativity & Management Office (RCMO) 
USM Main Campus, Penang 
Tel. No. : 04-6536537 
Email : noramira@usm.my  
 
 
CONFIDENTIALITY 
 
Your information will be kept confidential by the researchers and will not be made publicly available unless 
disclosure is required by law. 
 
Data obtained from this study that does not identify you individually will be published for knowledge purposes. 
 
Your original records may be reviewed by the researcher, the Ethical Review Board for this study, and regulatory 
authorities for the purpose of verifying the study procedures and/or data.  Your information may be held and 
processed on a computer. Only research team members are authorized to access your information. 
 
By signing this consent form, you authorize the record review, information storage and data process described 
above. 
 
SIGNATURES 
 
To be entered into the study, you or a legal representative must sign and data the signature page [ATTACHMENT 
S or ATTACHMENT G (for genetic sample only) or ATTACHMENT P] 

 
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ATTACHMENT S 
 
 
Subject Information and Consent Form 
(Signature Page) 
 
Research Title:  
Supplementary Kelulut Honey Therapy In Juvenile Open-Angle Glaucoma: Effects On Il-6, RNFL 
And Dry Eye 
 
Name of main and co-Researcher: 
Dr Thamarai A/P Munirathinam MPM 67381 (HUSM) 
Dr Azhany Binti Yaakub MPM 34859 (HUSM) 
Dr Munira Binti Yusoff MPM 39594 (HRPZ II) 
Dr Nor Anita binti Che Omar MPM 33552 (HSNZ) 
Dr Norihan Binti Ibrahim MPM 49484 (HSIP) 
 
To become a part this study, you or your legal representative must sign this page. By signing this page, I am 
confirming the following: 
 
▪ 
I have read all of the information in this Patient Information and Consent Form 
including any information regarding the risk in this study and I have had time 
to think about it. 
▪ 
All of my questions have been answered to my satisfaction.  
▪ 
I voluntarily agree to be part of this research study, to follow the study 
procedures, and to provide necessary information to the doctor, nurses, or 
other staff members, as requested. 
▪ 
I may freely choose to stop being a part of this study at anytime.  
▪ 
I have received a copy of this Participant Information and Consent Form to 
keep for myself. 
▪ 
This study is fully funded, therefore there is no cost for the participants  
 
 
 
Participant Name  
 
 
 
 
 
 
 
 
 
Participant I.C No 
 
 
 
 
 
 
 
 
 
Signature of Participant or Legal Representative 
 
 
 
Date (dd/MM/yy) 
 
 
 
Name of Individual  
Conducting Consent Discussion 
 
 
 
Signature of Individual   
 
 
 
 
 
Date (dd/MM/yy) 
Conducting Consent Discussion 
 
 
 
 
 
Name & Signature of Witness 
 
 
           
 
 
Date (dd/MM/yy) 
 
 

 
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52 
 
 
Note:  
i) 
All participants who are involved in this study will not be covered by insurance. 

 
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53 
 
 
ATTACHMENT G 
 
 
Subject Information and Consent Form 
(Signature Page – Genetic Sample) 
 
 
Research Title:  
Supplementary Kelulut Honey Therapy In Juvenile Open-Angle Glaucoma: Effects On Il-6, RNFL 
And Dry Eye 
  
 
Name of main and co-Researcher: 
Dr Thamarai A/P Munirathinam MPM 67381 (HUSM) 
Dr Azhany Binti Yaakub MPM 34859 (HUSM) 
Dr Munira Binti Yusoff MPM 39594 (HRPZ II) 
Dr Nor Anita binti Che Omar MPM 33552 (HSNZ) 
Dr Norihan Binti Ibrahim MPM 49484 (HSIP) 
 
To become a part this study, you or your legal representative must sign this page. By signing this page, 
I am confirming the following: 
 
▪ I have read all of the information in this Patient Information and Consent 
Form including any information regarding the risk in this study and I 
have had time to think about it. 
▪ All of my questions have been answered to my satisfaction.  
▪ I voluntarily agree to be part of this research study, to follow the study 
procedures, and to provide necessary information to the doctor, nurses, 
or other staff members, as requested. 
▪ I may freely choose to stop being a part of this study at anytime.  
▪ I have received a copy of this Participant Information and Consent Form 
to keep for myself. 
 
 
 
 
Participant Name 
 
 
 
 
 
 
 
 
 
Participant I.C No. 
 
 
 
 
 
 
 
 
 
 
Signature of Participant or Legal Representative  
 
 
Date (dd/MM/yy) 
 
 
 
 
Name of Individual  
conducting Consent Discussion  
 
 
 
Signature of Individual   
 
 
 
 
 
Date (dd/MM/yy) 

 
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Conducting Consent Discussion  
 
 
 
 
 
Name & Signature of Witness  
 
            
 
Date (dd/MM/yy) 
 
 
Note:  
i) 
All participants who are involved in this study will not be covered by insurance. 
ii) 
Excess samples from this research will not be used for other reasons and will be destroyed with the consent from the 
Human Research Ethics Committee, USM. 
 

 
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ATTACHMENT P 
 
 
Participant’s Material Publication Consent Form 
Signature Page 
 
Research Title:  
Supplementary Kelulut Honey Therapy In Juvenile Open-Angle Glaucoma: Effects On Il-6, RNFL 
And Dry Eye 
 
 
  
Name of main and co-Researcher: 
Dr Thamarai A/P Munirathinam MPM 67381 (HUSM) 
Dr Azhany Binti Yaakub MPM 34859 (HUSM) 
Dr Munira Binti Yusoff MPM 39594 (HRPZ II) 
Dr Nor Anita binti Che Omar MPM 33552 (HSNZ) 
Dr Norihan Binti Ibrahim MPM 49484 (HSIP) 
 
To become a part this study, you or your legal representative must sign this page.  
 
By signing this page, I am confirming the following: 
 
▪ 
I understood that my name will not appear on the materials published and there have been 
efforts to make sure that the privacy of my name is kept confidential although the 
confidentiality is not completely guaranteed due to unexpected circumstances. 
▪ 
I have read the materials or general description of what the material contains and reviewed all 
photographs and figures in which I am included that could be published.  
▪ 
I have been offered the opportunity to read the manuscript and to see all materials in which I 
am included but have waived my right to do so.  
▪ 
All the published materials will be shared among the medical practitioners, scientists and 
journalist worldwide. 
▪ 
The materials will also be used in local publications, book publications and accessed by many 
local and international doctor’s worldwide. 
▪ 
I hereby agree and allow the materials to be used in other publications required by other 
publishers with these conditions: 
▪ 
The materials will not be used as advertisement purposes nor as packaging materials. 
▪ 
The materials will not be used out of context – i.e.: Sample pictures will not be used in an 
article which is unrelated subject to the picture. 
 
 
 
 
Participant Name 
 
 
 
 
 
 
 
 
Participant I.C No. 
 
Participant’s Signature 
Date (dd/MM/yy) 
 
 
 
 
Name and Signature of Individual  
 
 
 
Date (dd/MM/yy) 
Conducting Consent Discussion  
 

 
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56 
 
 
 
Note:  
i) 
All participants who are involved in this study will not be covered by 
insurance. 
 
 
 
 
 
 
DATA COLLECTION FORM  
 
Supplementary Kelulut Honey Therapy In Juvenile Open-Angle Glaucoma: Effects On 
Il-6, RNFL And Dry Eye 
 
 
 
 
A. BIODATA OF PATIENT: 
Date of birth 
 
MRN 
 
Age  
 
Gender 
 
Race 
 
 
B. SYSTEMIC DISEASES: 
Diabetes mellitus Type I 
 
Diabetes mellitus Type II 
 
Hypertension 
 
Hypercholesterolemia 
 
Autoimmune disease 
 
Malignancy  
 
Tuberculosis  
 
Systemic lupus 
erythematosis 
 
Allergy 
 
Others 
 
 
 
 
 
Serial number 
 
MRN 
 
Group 
 

 
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C.  DIAGNOSIS: 
 
RIGHT EYE 
LEFT EYE  
Type of glaucoma 
JOAG 
POAG 
JOAG 
POAG 
Date of diagnosis  
 
 
Onset of disease 
 
 
Duration of disease 
 
 
Severity of glaucoma  
Mild  
 
Mild  
 
 
Moderate 
 
Moderate 
 
 
Severe 
 
Severe 
 
D. OCULAR EXAMINATION 
 
PRE-HONEY 
 
 
 
 
Date of examination:  
 
RIGHT EYE  
LEFT EYE  
Visual acuity  
unaided 
 
unaided 
 
pinhole 
 
pinhole 
 
Intraocular pressure  
RE 
 
LE 
 
Goniscopy (Shaffer 
Grading) 
 
Fundus  
 
 
Humprey 
visual field 
test   
Pattern  
 
 
MD 
 
 
VFI 
 
 
Antiglaucoma eyedrops 
 
 
Types of ocular surgery  
 
 
 
 
POST HONEY 
 
 
 
 
Date of examination: 
 
RIGHT EYE  
LEFT EYE  
Visual acuity  
unaided 
 
unaided 
 
pinhole 
 
pinhole 
 
Intraocular pressure  
RE 
 
LE 
 
Goniscopy (Shaffer 
Grading) 
 
Fundus  
 
 
Humprey 
visual field 
test   
Pattern  
 
 
MD 
 
 
VFI 
 
 
Antiglaucoma eyedrops 
 
 
Types of ocular surgery  
 
 

 
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E. Investigated parameters 
 
 
PRE-HONEY 
POST HONEY 
Serum IL-6 level  
(pg/mL) 
 
 
Retinal 
nerve 
fiber layer 
thickness 
(μm) 
Mean  
 
 
Superior 
 
 
Inferior 
 
 
Nasal  
 
 
Temporal 
 
 
Tear break up time 
(seconds) 
 
 
Schirmer test (mm) 
 
 
Glycated haemoglobin 
HbA1c(%)  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

 
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TREATMENT DIARY 
 
Name 
 
IC 
 
RN 
 
 
 
 
HONEY TREATMENT DIARY (to be completed by patient)  
 
DAY 
DATE 
HONEY USAGE (√ FOR YES, X FOR NO) 
NOTES (SIDE EFFECTS) 
1 
 
 
 
2 
 
 
 
3 
 
 
 
4 
 
 
 
5 
 
 
 
6 
 
 
 
7 
 
 
 
8 
 
 
 
9 
 
 
 
10 
 
 
 
11 
 
 
 
12 
 
 
 
13 
 
 
 
14 
 
 
 
15 
 
 
 
16 
 
 
 
17 
 
 
 
18 
 
 
 
19 
 
 
 
20 
 
 
 
21 
 
 
 
22 
 
 
 
23 
 
 
 
24 
 
 
 
25 
 
 
 
26 
 
 
 
27 
 
 
 
28 
 
 
 
29 
 
 
 
30 
 
 
 
31 
 
 
 
32 
 
 
 
33 
 
 
 
34 
 
 
 
35 
 
 
 
36 
 
 
 
37 
 
 
 
38 
 
 
 

 
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39 
 
 
 
40 
 
 
 
41 
 
 
 
42 
 
 
 
43 
 
 
 
44 
 
 
 
45 
 
 
 
46 
 
 
 
47 
 
 
 
48 
 
 
 
49 
 
 
 
50 
 
 
 
51 
 
 
 
52 
 
 
 
53 
 
 
 
54 
 
 
 
55 
 
 
 
56 
 
 
 
57 
 
 
 
58 
 
 
 
59 
 
 
 
60 
 
 
 
61 
 
 
 
62 
 
 
 
63 
 
 
 
64 
 
 
 
65 
 
 
 
66 
 
 
 
67 
 
 
 
68 
 
 
 
69 
 
 
 
70 
 
 
 
71 
 
 
 
72 
 
 
 
73 
 
 
 
74 
 
 
 
75 
 
 
 
76 
 
 
 
77 
 
 
 
78 
 
 
 
79 
 
 
 
80 
 
 
 
81 
 
 
 
82 
 
 
 
83 
 
 
 
84 
 
 
 
85 
 
 
 
86 
 
 
 
87 
 
 
 
88 
 
 
 
89 
 
 
 
90 
 
 
 
 
 
MONTHLY SUMMARY TABLE (to be completed by principal investigator) 
 
MONTH 
NUMBER OF SACHET 
CONSUMED 
SIDE EFFECTS 
COMPLIANCE (%) 

 
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1 
 
 
 
2 
 
 
 
3