PER OTTE: The correct diagnosis was Rod Cone Dystrophy. I apologize for the incorrect diagnosis of macular dystrophy. As you can see in my reply the boy has no vision whatsoever, including peripheral vision. I am happy that you are able to help your patients utilizing the peripheral vision and prepare them for the "future."

DR. JEN: Clinically, I am a low vision rehab optometrist. I can work with a patient with macular degeneration who sees, perhaps 20/400 and simply by teaching eccentric viewing skills, get them seeing 20/100 or even better. All it takes is a bit of instruction (and costs far less than microacupuncture).

What visual field testing are you doing? Humfrey? Confrontation fields? How great a field are you testing, in degrees?

PER OTTE: Your approach might be less expensive than microacupuncture BUT without a chance to improve the condition of the eye. The visual fields scan machine that we have in our office is an Octopus Perimeter 1-2-3. We are running thirty degrees full threshold which is an excellent program because of the central light and they don't allow too much eye movement by the patient. We are doing a color printout which makes it much easier for patients with low vision to see changes on the test. [see below]

DR. WENDY: In reference to the Octopus Visual Field machine you use, the macula is responsible for colors, and patients with macular problems have diminished color vision. Also, many patients have cataracts which further decrease color vision. Black on white gives better contrast and is more easily seen by low vision patients. Also, most patients with macular degeneration cannot look directly at anything at near because they disappear into their blind spot, as does the central fixation light while testing. However, I can see how colors can be beneficial for family members and friends to see changes.

DR. JEN: It is crucial to understand that patients with macular problems will have normal peripheral vision. How much they attend to that vision may vary from person to person, and sometimes relaxation, support, and instruction are all that is needed to get them attending to this immense amount of usable vision. How do you know that it is the microacupuncture that is doing the trick with these people, and not the setting that they are in? I do believe that the kinds of results that you are talking about can be attributed easily to placebo effect, given that the potential for this kind of visual acuity is already there.

PER OTTE: You must see different patients than we are seeing with macular degeneration. Nine out of ten patients that we see in our office have lost a large part of their peripheral vision too, especially when you are talking about Dry Macular Degeneration. I think in most cases it would be more correct to talk about Retinal

Degeneration. Most of our patients have tried the low vision aids such as Prism glasses and feel that their money has been wasted without any real improvement. Patients complain of headaches wearing the glasses and eventually throw them away, which means the patients have tried the instruction and techniques including relaxation that you mentioned without satisfactory results for them prior to visiting our clinic. Most of the patients HAVE TRIED EVERYTHING because it was less expensive if it worked and find that they wasted a lot of money in the process. We receive feedback from many patients after they have returned to their homes and find their vision is continuing to improve once they are home and in their usual "setting". If you want to call this a placebo effect - it is the first time I have heard of a "placebo" effect of 99% and I will take that any day of the week!

DR WENDY: Patients with any type of macular degeneration lose their central vision, but retain their peripheral vision. I agree with Dr. Jen that, "it is crucial to understand that patients with macular problems will have normal peripheral vision." Understanding ocular anatomy and the disease process of macular degeneration can only lead to this conclusion.

DR. JEN: In your program, do you only do microacupuncture, or are you also incorporating low vision rehabilitation services, support groups, or other forms of more team-oriented specialists?

PER OTTE: A success rate of 99% with microacupuncture speaks for itself. We are getting referrals from a low vision center located in Florida suggesting the patients try microacupuncture first before purchasing glasses and other low vision aids. THIS IS WHAT I CALL TEAMWORK!!!!

SHARON C: Does it make a difference as to how long one has had severe vision loss?

PER OTTE: Yes, it matters how long you have had severe vision loss. The longer you have had it, the more severe it will be, and of course it will take longer to treat it. Whether you have had an eye disease for six months or sixty years, the microacupuncture has to take effect within two days.

SHARON C: Do you recommend life style and/or diet, changes? Do you use herbs or vitamins as part of your treatments?

PER OTTE: Regarding eye diseases, I'm recommending two things. Two multivitamins called Mega-Once-A-Day and Viso-Plex. To me it is one of the best combinations for the eyes.I tell my patients not to eat the same meal twice in two weeks. Be sure to always change something on your plate. The reason, the more variety in the food we eat, the wider the nutritional supply. A big problem in our modern society is that we are now able to grow vegetables without soil; and when they grow vegetables that way, the farmer doesn't think nutrition. He only uses what is absolutely necessary for the plants to grow (fiberglass insulation, water, and some fertilizer). What about trace minerals? This, and the way food is processed, makes it very difficult to get the proper nutrition without adding vitamins and minerals to the diet.

GIDEON: You stated at the outset of the discussion, "It is able to change your visual acuity dramatically. We often see 20/300 go to less than 20/100 in a week of treatments." As far as I have known, the photoreceptor cells are gradually and "irreversibly" destroyed by AMD. A cell gone cannot be renewed/replaced (up to now)!. All the currently known treatments (hot laser, PDT, TTT, FVT, etc.) do not pretend to cure. They all aim barely at halting, stopping that one leakage. How then technically/biology is it possible to have dramatic improvement achieved by micropuncture? Does it make the remaining cells see now (for some time) by a third as good as before the treatment?

PER OTTE: The way I look at dry macular degeneration from a traditional Chinese medicine standpoint is that the blood supply to the pigment layer supporting the retina with nutrition is shut off, due to clogged blood vessels which result in the photoreceptors ceasing to work. One thing we know about the microacupuncture treatments is that five to seven treatments shows an average 15% decrease in cholesterol levels, which probably occurs due to a change in enzymes. Whatever changes the cholesterol level is probably responsible for the restoring of the blood vessels, which results in the pigment layer being able to nourish the photoreceptors once again.

When dry macular degeneration becomes wet macular degeneration it is actually blood vessels leaking out into the tissue like a bruise on the body, most areas of the body absorb bruises fairly quickly due to good blood circulation, in the eye suffering from dry macular degeneration the blood flow is so low that it is unable to reabsorb the blood from the leakage. That is why after the ophthalmologist has stopped the leakage, if possible, microacupuncture will be able to improve the vision by increasing the blood flow in the surrounding tissue for reabsorption.

When we talk about macular degeneration, I don't think it means a totally dead area in the central part of the eye. (If an area is totally dead, the body will normally discharge it.) If the area is only dormant, it will still be accepted as being alive, and when nourishment is restored, I would guess the production of rhodospin and new discs can be restored to make the rods function again and new visual pigment to repair the cones. In this way, I am not talking about bring dead cells back to life, but simply helping the eyes to repair themselves, which is a rapidly ongoing process in healthy eyes. So, as I answered earlier, good blood flow restores vision.

DR. WENDY: The Optometric Clinical Practice Guideline for Care of the Patient with Age-Related Macular Degeneration (AMD) describes appropriate examination and the standard of care. [Editor's note: Guidelines were quoted here, but were too lengthy for this transcript.] When eyecare professionals are held to the standard of care when examining and treating macular degeneration and other patients with other retinal degenerations and can be sued for malpractice if they do not, how can you treat these same patients by only testing what they see on an eye chart and with visual fields?

PER OTTE: We do have the patient's best interest in mind, and I am happy to see that our treatments live up to your standards! There is no way needles in your hands and feet can damage your eyes. When it comes to measuring the effectiveness of the treatments, I use the visual acuity test, with out any correction to eliminate the possibility that the patient is using glasses with the wrong prescription. (I don't know why, but quite a few of our patients read better without their glasses than with them.) When patients we treat continue to improve their acuity, as they receive microacupuncture treatments, it is proved to me and the patients that the treatments are proven right for them. The treatments are very patient friendly, and they do not receive any anesthetic drugs, dilation of the eyes, "flashlights," and other things we hear them complain about every day. Most of our patients have been, and are, following their regular schedule for their ophthalmologist. Others have quit going to their ophthalmologist after years of being seen every three to six months. They knew they had macular degeneration, so for them it was just a pain always going through the same testing, getting the same answer-- "you still have macular degeneration, and there is nothing I can do." When I see those people, I tell them "It's time to go back to your ophthalmologist." And the patients say, "Why? You are the one who helped me!" I tell them so many things can go wrong in the eyes, and they need to keep in contact with their ophthalmologist; and they say, "OK, Dr. Otte." These are alternative treatments. I follow the standards for acupuncture treatments and not optometrist care standards.

DR. WENDY: I am open to alternative treatments as long as they are low risk, proven effective, patient friendly, do not put the patient's ocular health in jeopardy, and are performed within the standard of care. Anything less is not in the patient's best interest.

I can't understand how you can ethically treat someone with an eye health problem without ever looking in the eyes. As and optometrist, I am told all the time that I am not a "real doctor". We are thoroughly trained in ocular anatomy, disease, and management and treatment of ocular disease. You admittedly are trained in none of these, but you are treating eye diseases "blindly".

PER OTTE: Ethically, I don't have a choice in treating those patients, as long as this is the only way of improvement. Ethically, now you know about the microacupuncture treatments. Wouldn't it be your responsibility to come and learn about it, so you can advise your patients about an option other than that "there is nothing else we can do for you?"

What can you do to increase the sensitivity of the vision? (Not including magnifying things.)

You are stating patients with macular degeneration only lose their central vision. I agree with that one. What do you call it when the nutrition nourishment outside the macular goes down effecting the peripheral vision?

I have never heard about any optometrist doing all those examinations on every patient visit. And I wonder what the cost is of an examination like that? Regarding Judy's comment about the cost of microacupuncture, we see patients several times a year. How many times a year would Medicare pay for an examination such as yours?

DR. WENDY: I have never said, "there is nothing else we can do for you," to any of my patients. This is the response that 99% of ophthalmologists say to their macular degeneration patients. I suppose they think surgically, their is nothing they can do. Unfortunately, they usually don't even mention that low vision services are available. Unfortunately, I have found their way of thinking is if they don't do it, it doesn't work. I give my patients every available option. Often times several options in combination do the best.

You asked, "What do you call it when the nutrition nourishment outside the macular goes down effecting the peripheral vision?" I'm not quite sure what you mean. I haven't seen any MD patients with decreased peripheral vision. They always have good side vision. This is typical in other conditions, like retinitis pigmentosa, rod cone dystrophy, and glaucoma. Cataracts can depress a visual field, too.

In response to your questions about examinations and cost, if optometrists are not doing all these tests on each patient, they are not providing the standard of care. I can say with certainty that I do all these tests and more, as does Dr. Jen and any other low vision specialist.

Ophthalmologists do the fluorescein angiographies typically. The price for a low vision evaluation varies with the time spent. An initial exam can cost around $200 and subsequent visits $85 to $115. The prices charged vary from doctor to doctor. I explain everything in detail to each and every patient and give them every option available. If the first thing doesn't work, we try something else. I don't stop until the our expectations are met, mine and the patient's. Medicare will pay for as many office visits as needed as long as there is a medical diagnosis pertaining to the patient's symptoms and findings.

You also said, "We are running thirty degrees full threshold." A full threshold 30 degree visual field is the central 30 degrees. Most optometrists and ophthalmologists I know use a Humphrey automated visual field machine. The equivalent field is a central 30-2, also a threshold field. Central 30 means it is testing the central 30 degrees. It has a circular appearance. Also, you can see how much a cataract is contributing to the visual field loss. You can see where each eye's most useful vision is.

A macular visual field tests the central 4 degrees and is a square in appearance. The macula represents a vaguely delineated area, 5 to 6mm in diameter, located temporal to the optic disc. In its center is an avascular region, the fovea, which is approximately 1.5 mm in diameter. The thin, sloping fovea lies 4mm temporal and 1mm inferior to the temporal margin of the optic nerve. So when you want to test the sensitivity of the macula, a macular visual field is best. The Humphrey version gives the sensitivity for each point tested in decibels, like hearing tests, in each of the 4 quadrants of the square, and the central reference sensitivity and there are comparisons to the normal age-expected levels.

You explained: After central vision loss there is gradually less damage to the peripheral vision as the vision field is increased. I will explain it this way: There is 100% vision loss in the 0 - 3 degree range; a 30% vision loss from 15 - 30 degrees and very little or no vision loss at 50 - 75 degrees.

You're last statement above says exactly what Judy, Dr. Jen, and I have been trying to say. There is very little or no loss in the periphery, what you are calling 50-75 degrees. The periphery would be 31 degrees to 75 degrees. You say there is 100% vision loss in the 0-3 degree range. I disagree with this. Many times, the patient's central blindspot is not completely round, but is oblong or irregular in shape. It may be 1 degree up, 4 degrees down, 2 degrees left, and 1 1/2 degrees right, for example. From my experience, they vary too much between eyes and between patients that it is difficult to make generalizations like you have made.

JUDY: This first week's barrage of questions takes patience and understanding on your part. We all thank you for helping us learn more about microacupuncture. You said, "Nine out of ten patients that we see in our office have lost a large part of their peripheral vision too, especially when you are talking about dry maculardegeneration." It is extremely important to understand that peripheral vision always remains with all types of macular degeneration. How can you possibly equate loss of peripheral vision with dry MD?

PER OTTE: When we talk about peripheral vision, let's narrow it down. I am talking about 15 to 30 degrees when I am discussing peripheral vision, whereas you may be thinking of 60 to 75 degrees.

We both agree that macular degeneration (which involves the central three degrees of your vision) doesn't affect the extreme peripheral vision. As you go into the peripheral vision, the retina becomes less sensitive. A small change in nourishment is crucial to the macular area but will probably not have any measurable effect on the extreme peripheral vision.

After central vision loss, there is gradually less damage to the peripheral vision as the vision field is increased. I will explain it this way: There is 100% vision loss in the 0 - 3 degree range, a 30% vision loss from 15 - 30 degrees, and very little or no vision loss at 50 - 75 degrees.

JUDY: Thank you for your explanation of peripheral vision and how it works after central vision loss. I understand much better now where you are coming from with some of your answers.

I think a lot of people would agree with you about the prism glasses being ineffectual, but that's pretty well the only thing. There are some very effective low vision aids available which are currently being used by many individuals on this list. They certainly do not feel that "their money is wasted" as you say. Once they learn how to use their peripheral vision more effectively, these aids are of great help for their daily living. Vision loss is not just about "having a driver's license back", as you say.

PER OTTE: Please read my comment to Dr. Wendy again. Your comments lead people to believe that I don't approve of any type of low vision aids, and nothing could be further from the truth. I only mentioned prism glasses causing difficulty for my patients. Projection type aids, such as Video Eyes are certainly a tremendous help, and I recommend them to patients who will benefit from using them. Vision loss is certainly more that having a driver's license back BUT the ability to drive again gives patients back their independence and the freedom that comes without having to depend on others every day for rides to the grocery stores, banks, church, etc. Think of your family and what it would mean to them personally.

JUDY: When you wrote "have tried everything," I assumed you meant all low vision aids. I apologize for just speaking about prism glasses, and not your whole statement. I better understand now how this might have been misleading, but I am trying to be as brief as I can with my questions.

If you can prove, without placebo thought or talk of temporary visual acuity improvement, that you have found a mechanism by which you are able to regenerate degenerated dead cells in the macula, I guarantee you that people will be lined up for miles, far into the horizon, to visit your [clinic].

PER OTTE: I know of very few things in life that are permanent. Life is temporary, relative to the age of Earth. The only permanent treatment for the body that I am aware of is "cut it off or out" and that is a permanent fix, with one exception: you might get phantom pain!

JUDY: It is very difficult to accept that any of our body parts are suddenly missing, and we dearly want them back. I suppose you could say that this phantom thinking is also a placebo effect.

You sound like a compassionate man, and it's obvious why many of your patients think so highly of you.

BILL: In defense of Dr Otte, the scientific proof or evidence for the positive effect of acupunture is not established, and may not become established, for quite a long time. The mechanisms by which acupunture provides relief and healing have not been discovered. What is known is that the techniques work in quite a lot of instances. While this form of alternative medicine has no known causality in modern science, the anecdotal support is great. In essence, acupuncture and microacupunture are a "try it, you'll like it" experience. There is no guarantee, and the cost is not subsidized; but there is no other treatment that offers real hope of remission or cure. There are no guarantees with scientifically established treatments, either. Moreover, since there is no known mechanism for the development of MD, there is little likelihood for a scientifically established cure in the near future. It would seem that our options as MD sufferers are to attempt to control the symptoms with the current array of tools provided by western medicine. What Dr. Otte offers is a potential way to obtain some relief/remission and perhaps a semblance of control of the condition. Badgering him about scientific proof of effectiveness is not productive. Helping him to develop a body of evidence that can establish the efficacy of the treatment would be positive. But berating him for not having such evidence is not constructive. It is a mammoth task for one man or small group of men to amass the sort of evidence that alternative medical treatments require to gain any recognition of efficacy in the western health care world. And remember that since Dr Otte's treatments are not intended to replace current treatment, any benefit is in addition to what is provided by western medicine.

PER OTTE: Bill, I thank you for the support. It sounds like you have been there yourself. As you see from the discussion, whatever you are, acupuncturist, optometrist, or ophthalmologist, (see Dr. Wendy's earlier remarks), there is no help from one group to another. Wouldn't it be nice if someone would open their EYES with BIG LETTERS, and put together the best of three worlds! But I guess it will never happen as long as the green $$$$$$ is in charge.

DR. JEN: Money has nothing to do with the reason that I do not refer patients for microacupuncture. It is because there is no logical reason, no physiological reason, and no evidence that it works.

I did not get into low vision because I want to get rich. This is good, because I will never be rich doing what I do. In fact, many of the people who are referred to me are veterans. As we have a local VA hospital with a very good blind center, I refuse to see these patients, even those willing to pay me, and refer them to the VA, where they can receive all services and aids at no charge. This is what is best for the patient, and certainly not best for my income. I treat every patient that walks through my exam room door like they are a member of my family. I do for them like I would hope that any doc would do for someone in my family.

If you could present reasonable data regarding microacupuncture, real reasons as to why it works instead of conjectures and maybes, then I would certainly re-evaluate my position on not referring people for it, but until that time, it is my job to ensure that my patient's needs are met, and this includes protecting them from throwing their money into bottomless pits of non-treatments.

DEBRA: I agree with Bill.

OPAL: I was composing a letter in my mind to send in defense of Dr. Otte when I read your post, which said exactly what I intended to say. I've had the establishment's treatments which have been helpful in slowing this disease, but I want something more, and I am willing to try alternative medicine.

IRVING: Bravo. I feel that Dr. Otte is in the same boat as any person attempting to advance and alternative treatment approach. The current mind-set of the western medical community is such that it closes off any and all consideration of anything different from what they are advocating.

I had a very long and lonely search to find an alternative treatment approach to my prostate cancer. I finally found it, no thanks to the western medical community. When I went home from my first round of treatments with specific recommendations for follow-up treatment through my home based medical team, I was told to go back to Reno if I wanted that treatment.

I have been told that the patient who retains an active part in his/her own treatment does much better. My experience would substantiate that, but I would add that the medical team is very threatened by such a patient and will do everything in their power to force that patient back into line.

Much of alternative treatment is both very old and, at the same time, on the cutting edge. Someday, the AMA is going to recognize this. I would like to think that it will be in my lifetime, but in actuality, I suspect that we are talking at least 25 or more years down the road (or down the pike as we say in Tennessee.)

GIDEON: By what mechanism does microacupuncture empower the remaining living cells to see twice, or three times, as good as before the treatment, thus to be able to replace the destroyed cells, or otherwise?

PER OTTE: My first answer to you should have explained how we get nourishment back to the pigment layer, if the photoreceptors are dead or just dormant. It is known that a detached retina (which means no nourishment whatsoever is getting through) can resist degeneration for a number of days and can become functional again if reattached. This means they can survive a short term without nourishment at all. When we talk about macular degeneration, I don't think it means a totally dead area in the central part of the eye. (If an area is totally dead the body will normally discharge it.) If the area is only dormant, it will still be accepted as being alive, and when nourishment is restored, I would guess the production of rhodospin and new discs can be restored to make the rods function again and new visual pigment to repair the cones. In this way, I am not talking about bring dead cells back to life but simply helping the eyes to repair themselves, which is a rapidly ongoing process in healthy eyes. So, as I answered earlier, good blood flow restores vision.

DR. JEN: You said to Dr. Wendy that "there is no way needles in your hands and feet can damage your eyes" If this is true, then how on earth can needles in your hands and feet help your eyes? Every medical treatment, alternative or otherwise, has the potential for adverse side effects. This includes homeopathic remedies like herbal medicine (i.e. echinacea can worsen autoimmune disorders), as well as surgery (i.e. the damage that can be caused by laser for the retina can be just as harmful as the benefits it brings). Even vision therapy can induce double vision as a potential side effect. For something to work on the body, the potential for adverse effect on the body is ever present (too much of something, not enough of something, biovariation in a population).