PER OTTE: There is one difference between acupuncture and the treatments you are talking about (as Judy stated in her e-mail on February 12). Acupuncture works by balancing the body's energy to neutral unless you are using gold and silver needles. Acupuncture's effect should stop at neutral so you don't get too much of something. When people get close to 20/20 vision, they stop the treatment.

DR. JEN: You actually test people without their glasses? If they are receiving proper optometric or ophthalmologic care, then their glasses should be up to date. Even if the glasses are out of date, it is still a constant, so testing them with glasses should not make any difference in the end findings. If you take a person who normally wears glasses, test their vision, let them wander around for a while without their glasses, and test their vision a second time, their vision will be better. It is a phenomenon called blur interpretation improvement. This is true of absolutely everyone, eye problem or not.

PER OTTE: Yes, most patients we see do not wear their glasses when they come in the clinic. Mostly their shades. Which are those nice, big frames! The effect you talk about, that eyes change after removing their glasses. This does not effect the result very much because they didn't wear any glasses. Another reason is microacupuncture treatment in most cases, changes the strength of your eyes to where you need a less prescription. Which means, after a few treatments, the glasses may actually have an adverse effect on a result. Then the glasses are too strong. Most patients we see change their prescription three to four weeks after the microacupuncture treatments.

DR. JEN: I was not talking about the eyes changing, I was talking about the person's ability to interpret blur to change...these are two completely different entities. Blur interpretation improvement absolutely would alter your results. A similar phenomenon can explain your "improvement" in visual fields. As Dr. Wendy pointed out, someone with MD can not possibly fixate on a central target, due to the physiology of the disease. Also, take a perfectly normally sighted individual, give them a field test, then test them again some time later, and you will see an improvement. This is why you can't diagnose glaucoma based on one visual field, you need at least two.

PER OTTE: How would you explain the continuos improvement in the vision field done on a patient with glaucoma, diabetes retinopathy, and RP until they started microacupuncture? Every vision field scan that they have done shows gradually decreased vision to where quite a few don't see any lights at all. In this case, it cannot be because they are learning how to do a vision field scan. They should have learned that by either their optometrist or ophthalmologist after doing it for ten to fifteen years. So please find another reason. How would you explain continuous improvement in visual acuity?

DR. JEN: With regard to ethics, you have yet to provide any biomechanism to explain your treatments, no evidence that there is anything but a placebo effect going on. This is nothing against microacupunture or any other "alternative" treatment. I routinely work with nutritionists, occupational therapists, physical therapists, and a host of other specialists that help my patients achieve their highest potential. I believe that no one practitioner has a monopoly on the capacity to help, and keep my options open with regard to referring my patients to other professionals. However, I am also going to critically analyze those very same professionals to ensure that what they are doing has some scientific ground on which to stand (and I do not necessarily mean double blind studies).

PER OTTE: There are widely used drugs on the market which are FDA approved, but which have never been shown scientifically effective. It is approved due to the clinical results, most known of which is probably aspirin.

DR. WENDY: I have some comments . . . about [that]. The following are exerpts of Aspirin: A New Look at an Old Drug by Ken Flieger which appeared in the January-February 1994 FDA Consumer. [Article quoted here, but too long to print.] . . . You stated that aspirin hasn't been shown scientifically effective. The information in the above [article] seems to refute that arguement. Extensive laboratory research and the largest clinical studies ever carried out sounds to me that scientific studies were done establishing effectiveness of aspirin. How could anyone determine that aspirin is effective in inhibiting the production of prostaglandins if scientific research was not done? . . . I'm sorry, but I disagree with the point you were trying to make about aspirin and not being proven to be scientifically effective. . . Aspirin's use is generally considered very safe by the public, but the author of the article and the FDA consider that it is "well-advised to regard aspirin with appropriate caution." Acupuncture is similar in regard to how the public views it and how the FDA and other medical authorities view it.

PER OTTE: Thank you for the information . . . but my question was, "What do you tell your patients who suffer from both dry and wet MD when they ask your opinion of taking aspirin?" Does it have any positive or negative effects for MD sufferers?

DR. JEN: Aspirin has been studied in infinite clinical testing scenarios and published reports. Again, I did not mean to insinuate that a double blind study is necessary in your case, we both agree that the logistics of that would be nearly impossible. However, if you truly want fellow professionals to take your work seriously, you do need to provide some hard, objective data. Again, I do ask why you have not been involved with doing ERG testing before and after your treatment regime? This would give a clear indication in a completely objective manner of whether or not your treatments are truly working, eliminating any variables at all. It would also provide additional information such as what cells is the microacupuncture affecting, and in what way. It seems to me that you are shying away from hard clinical data rather than embracing it as you should to logically enforce your theory.

DR. JEN: With regard to your comments about Medicare... Medicare does pay for all of the testing and evaluations, including low vision rehabilitation visits. Aids are another story, but we work closely with state blindness associations and Lions clubs. Every patient, even those without a dime in their pockets, receive the care that they need.

PER OTTE: It is nice to know that Medicare pays for all of your rehab, and I'm also proud to know that my patients keep coming back, even though they have to pay for it themselves. Which gives me an indication that there are benefits from the microacupuncture treatments. If it would be free, paid for by insurance, you would never know.

DR. JEN: Have you considered that the change in diet during their stay with you causes the drop in cholesterol levels? Or the decreased stress of getting away from life for a while and going on a microacupuncture vacation?

PER OTTE: The testing we did on cholesterol was preformed in Denmark, and the patient was staying home driving back and forth for treatments. So I don't think that has decreased the stress.

GEOFF: I have been following this discussion with interest but remain unconvinced that acupuncture has a lasting beneficial effect.

If this treatment is responsible for such dramatic improvements in vision for MD patients, should not these changes in the retina be obvious when looking at before and after photographs? Are any such photographs available?

How the brain processes visual information is complex and not well understood. Recent research indicates that up to 50% of what we "see" is not supplied directly from the eye, but comes from our memory of previous experiences. In other words, we are seeing our own private version of the world.

When we have vivid dreams we may see images in great detail that look like "the real thing," but clearly, 100% of these images have come from our memory and not directly from our eyes.

It is well known that there may be significant damage to the retina before it becomes apparent to the patient in the form of visual problems. I can confirm this in my case. Presumably the brain is very good at "filling in the blanks."

All this would indicate to me that vision is not supplied to our conscious mind in the same way that a camera would faithully record light and colour on a film. I would be grateful for any comments from the doctors on this point.

I have good and bad vision days, many on this list will have the same phenomenon. Does this mean that there are physiological changes to the retina on a day by day basis, large enough to cause changes in vision? Surely it is more likely to be a psychological effect, our vision being affected by our state of mind.

I suggest that the placebo effect on vision disorders may be very significant, given the complex way the brain processes information from the retina. Vision tests are subjective and rely on the perceptions of the patient. I would have thought that vision tests and descriptions of vision state by a patient should be treated with great caution by the doctor, particularly if they show a sudden significant "improvement." It is clear that many patients perceive an improvement after acupuncture, so it must be doing something. The question is, what is the "something?" Is it a psychological effect, which does nothing to affect the progress of the disease, or is it physiological and is actually repairing damaged or dying cells? I suggest the former explanation is far more likely.

I fail to see how you can claim that dying cells are being saved simply on the basis of patients perceptions, without studying the actual cells and documenting any changes.

PER OTTE: Regarding your question concerning photographs, it probably will. I have never looked into that option but I am sure it will be done by some ophthalmologist in the near future. Some patients receive alternative treatment and tend to hide it from their physicians, in part due to the fear that they won't receive the proper care or will be chastised for seeking out other treatment options.

How does the brain process vision, I cannot give you the answer. I would suggest you forward that question to a neurologist. In response to your last three paragraphs, finding the answer to those questions will require unlimited resources and would definitely be over my head. I would hope that people like yourself and others in this forum that are interested in the effect of microacupuncture would sit down together and hold a brainstorming session: "There is something about microacupuncture, now let's prove it".

DR. JEN: Dr. Otte, could you explain why the people on this forum should have to "prove" anything? As the professionals in the field, it is up to us to research our methodologies, show scientific support, and clinical studies to prove that it works. This is why we are scientists, doctors, etc. It is our responsibility to our patients, and not up to the patients to do this kind of work!

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: The basic difference between optometrist, ophthalmologist, and acupuncturist is: optometrists and ophthalmologists are eye care specialists and give themselves out as such, (that's why you can be sued), as an acupuncturist, you are just an alternative, and people know and don't expect you to be their eye care expert. When any person feels a change in the vision they contact either one, with the belief that they will be provided with the best possible eye care. When I see patients, (as an acupuncturist, you are just an alternative, and people know and don't expect you to be their eye care expert), with eye problems, they have already been seen several times by an eye care professional (probably both optometrist and ophthalmologist), and feel they have gotten as much improvement as they could get for the time being from that source.

Some people choose by themselves (our relatives) an alternative method. So, in fifteen years I have never seen a patient coming to me asking for help with an eye problem without first being seen by their eye care professionals. So I feel very comfortable that the patients who come here, by regular visits to their health care professionals, have gotten the absolute best care in prevention of serious eye disorders. Actually, I am seeing those few patients who want to see the light.....through the eye of the needle.

JUDE: I have been following the discussions with interest, and have watched both sides trying to "prove" they are right. Sometimes things work, and there is no hard and fast proof, and sometimes things thought to work for one reason are found out to work for another. My own doctor was recently kicked out of our HMO for trying methods to help his patients with Lymes disease when the medical community in general was telling them that they no longer had the disease, and it was all in their heads. He was having success with various treatments, but no matter. Primitive tribes have been using "alternative medicine" for centuries, without explanation of how they work, and recently some of the same herbs are found to be beneficial by modern medicine, now that they have "proof." I wish that the medical community could keep an open mind and accept that there may be things we cannot yet explain. Dr. Otte, don't waste too much time on trying to explain Eastern medicine in Western terms. Put your energy into helping the people who come to you. If you help them, word of mouth will bring more. If you don't, so be it. Energy is best spent in solving the common problems, rather than trying to prove who is "right" and who is "wrong." Along with politics and religion, medicine is always a touchy subject!

Thank you to Dan for allowing this fascinating dialogue to take place.

DR. TUKAN: I was notified about this discussion group by a patient whom I have treated with microacupuncture. I signed on to have a look, and I read the entire consolidated transcript. I found the adversarial tone of the discussion very discouraging, and would like to make a few comments in response.

I am a board certified ophthalmologist with specialty training in diseases and surgery of the retina. I am also a licensed acupuncturist. I had the opportunity to train with Dr. Otte in May of 1999, and I have incorporated microacupuncture into my practice since that time. I have been using it for patients with AMD who do not qualify for any of the conventional therapies, for patients with RP, and for visual field loss secondary to stroke. I am excited by the improvement I see in the majority of patients. Most importantly, patients are happy with the improvement they get. As a eye care specialist, I look for any possible safe means of achieving improvement in vision for all patients who are interested. Sometimes that is best accomplished with surgery, sometimes with laser, sometimes with low vision aides, sometimes through nutrition or lifestyle change, and sometimes with acupuncture.

When I first starting using acupuncture for degenerative retinal diseases, many of my colleagues thought that I was nuts. However, after they started to see improvement in their own patients who had come to me on their own, usually after hearing about another patient's positive experience, they started to change their minds. I am now getting referrals from other ophthalmologists, including retinal specialists, and internists in the area.

The fact that Western Medicine has not been able to determine the mechanism by which acupuncture effects change in the body does not invalidate acupuncture. It has been used for thousands of years for many different medical conditions with undeniable success. It is routinely being used in the United States for more than pain control these days. The line between allopathic medicine and alternative forms of therapy is becoming more blurred all the time. While I can understand the skepticism engendered by the use of acupuncture for the treatment of eye disease (I suffered with that stumbling block myself to begin with), I feel it is important to keep an open mind. Without that, we are of much less benefit to our patients. It is important to have an integrated approach to medical care, regardless of the problem. There is not one universal answer for anything or everyone. Each patient has to be approached as an individual. Though this is certainly more time consuming, the benefit to patients is well worth it.

As stated previously in this discussion, it is impossible to do a double blind study for this particular mode of treatment. I am presently sitting on 21 months of accumulated data on the patients I have treated with microacupuncture, and I am interested in getting this information to the medical community at large, but to date I have not found a way to achieve this. I have no vested interest in what is causing the improvement I see in patients treated with acupuncture. If there is some way to prove that the acupuncture is responsible for the improvement, great. If it can be proved that it is placebo effect, or the result of "healing hands," or mind body control, that's okay too. As long as a patient ends up seeing better, I'm all for it. It is important for patients to know that acupuncture is not a miracle cure for their eye disease, and that at present it is considered an alternative or experimental form of treatment for eye disease. I try to determine a patient's expectation of acupuncture before I decide whether or not to treat them. If they are looking for any improvement at all, and understand that I cannot guarantee a positive outcome, I feel their attitude is appropriate for this form of treatment. If someone with 20/400 vision says they want to get their drivers license back thru acupuncture, I won't even start treatment, because they are not being realistic, and they will certainly be disappointed. While most patients get a modest improvement in vision in the case of MD, and a modest increase in vision/ field of vision for RP, I have had some patients achieve a four-line improvement in vision, which has remained for more than a year. It is my opinion that the ultimate solution for all the retinal degenerative diseases will be through genetic engineering. In the nearer future, anti-angiogenesis will probably be helpful for the wet form of MD. Laser, PDT, TTT, macular translocation, nutritional supplements and acupuncture are all ways to try and keep someone visually active until a cure is reality. Doing something positive instead of accepting impending blindness also helps one of the most prevalent side effects of these retinal problems, namely depression. This, in turn, has a beneficial effect on a patient's immune system.

FRANCES: Do you do microcurrent stimulation, or can you discuss this?

PER OTTE: I don't do microcurrent stimulation. I'm only using microcurrent stimulation in case of paralyzed limbs (arms, legs). Where the microcurrent is used to provoke involuntarily muscle movements to benefit the circulatory system, so to do microcurrent stimulation for treating eye disorders the goal must be to relax the tissue and to increase blood supply to the area.

When I treat with acupuncture and other therapies I prefer to use a distal approach. It means: the further away you can get from the problem the higher impact the treatment will allow. (Most people who have had alternative therapies know that a headache is treated very effectively from either the hands or feet--as distal as you can get!)

End of Discussion

In the interest of providing equal time and full disclosure, the following report is published in connection with the discussion between Per Otte and the members of MDList. The information contained herein is the sole responsibility of the author, and further comments are welcome by writing to MD Support Director Dan Roberts.

Public record information from the Texas State Board of Acupuncture Examiners states that Per Godsk Otte's application came before the Texas State Board of Acupuncture Examiners on August 28, 1995, and was considered by the Grandfathering, Reciprocity, and Application Committee. Concerns were raised concerning the Applicant's advertising of acupuncture to treat various vision problems and his use in advertising of a professional designation that was misleading. After discussion with the applicant regarding these concerns and allegations, and the applicant's willingness to remedy perceived problems with his advertising and scope of practice, there was an agreed order "to address the concerns raised regarding the applicant, upon the recommendation of the Grandfathering Committee, with the approval of the applicant, the Acupuncture Board hereby ORDERS that applicant's application for an acupuncture license is granted subject to the following terms and condition for a period of 5 years probation from the date this order is signed..."

The Disciplinary/Licensure Restrictions Information Sheet of the Texas State Board of Medical Examiners and the Board Actions Information states, "Per Godsk Otte was licensed under an agreed order with non-disciplinary restrictions on 8/29/1995 (after a 1995 complaint and hearing about the complaint) under the following terms and conditions. He shall maintain adequate treatment records on all patient office visits and acupuncture treatments to include the amount charged for service and adopt or establish a system of patient record keeping and billing. His acupuncture practice shall be monitored by a licensed Texas acupuncturist or physician. He shall not advertise or attempt to implement acupuncture treatments for vision problems or vision complaints of any patient. He shall comply with any adveritising limitations set forth. Any of his proposed advertising must be reviewed by a licensed Texas Attorney. He shall appear 2 times per year before the Acupuncture Board or a committee or panel to report on his compliance, etc." There was a complaint and alleged violations of the Medical Practice Act. The public information says, "This Complaint and requested relief are necessary to protect the health of the citizens of the state of Texas. Count 1 states that he applied for an acupuncture license on or about May 31, 1994. He was to provide verification by February 2,1996 that he had taken and passed the NCCA or the CCAOM Clean Needle Technique course and practical examination. He failed to provide verification by February 2, 1996. On January 8, 1998, a formal complaint was filed, and it was requested that a hearing on the complaint be held and that an order be entered to cancel or revoke his acupuncture license. He was informed of the hearing and complaint and did not appear at the hearing. His license was cancelled or revoked on January 11, 1999."

His current address is listed as Hot Springs, Arkansas. The Arkansas State Board of Acupuncture has been in existence for about 3 years. Certain educational requirements must be met for an applicant to obtain an acupuncture license in the State of Arkansas. The applicant must complete a program in acupuncture and related techniques from a board approved institute that meets the minimum requirements of a board approved national accrediting body. The training must be of at least four academic years and include a minimum of 800 hours of supervised clinical practice. There are certain examination requirements. The applicant must pass examinations in both acupuncture and Chinese Herbology.

Currently, Arkansas does not have a scope of practice law for acupuncturist, but it is in process. Per Otte is not duly licensed in Arkansas and is not eligible for Grandfathering. He was temporarily given a license, as were 13 other acupuncturists in the state. There was not a quorum of State Board members at the meeting when the acupuncturist licenses were initially granted. This being the case, the licenses were declared null and void and the 13 other acupuncturists returned their licenses willingly. Their licenses were regranted. Per Otte did not return his license. The State Board sent him a cease and desist order. He did not heed it, and he continued to practice acupuncture without a valid license. Under a settlement agreement, he was to take the certification test given by the NCCAOM, the National Crediting group of Acupuncture and Oriental Medicine in February 2001. He must pass this test to treat only what is approved under the scope of practice of acupuncture in Arkansas, of which treating vision problems is not included. He did not take this examination as he was required. The State Board has given him an extension until July 2001. If he does not meet the requirements of the Arkansas State Board, he will be required to cease and desist practicing acupuncture in the State of Arkansas. Dr. Per G. Otte, D.Ac., D.Sc., D.O.M. is the manner in which Per Otte currently represents his designations. He reported that he is a graduate of the Scandinavian College for Acupuncture to the MDList Discussion (2001), but on his original application to the Texas State Board of Acupuncture (1994), he reported that he graduated from The International Open University of Sri Lanka in 1992. He gave the MDList information that he developed microacupuncture in 1988 and received a D.Sc. (Doctor of Science) for microacupuncture, but did not identify the school or organization. Information that he gave to the Arkansas State Board of Acupuncture was from the Frederiks Havn Tekniske Skole in Denmark. www.cswnet.com/~otte/Microacupuncture.htm states, "HISTORY OF MICRO ACUPUNCTURE. Micro Acupuncture is a new procedure involving 48 newly discovered acupuncture points located in the hands and feet only, and not associated with any other acupuncture system. They were discovered by Dr. Freddy Dahlgren, D.Ss., D.Ac., M.Ac.F., M.D. in Denmark in 1984 and researched by both Dr. Dahlgren and Dr. Per G. Otte, D.Sc., D.Ac., M.Ac.F., who now resides in the United States." On his website he has a link to News and Press, and it has an article that was published in the Healthy Living Magazine in December 1998. The article states that Otte, who came to the United States in 1992, trained with an ophthalmologist in Dallas before starting his practice in Arkansas in November of 1995.

The following is from the Acupunture Practice Act of CA, upon which other states have modeled their practice act: 1399.456. Use of the Title "Doctor". It is unprofessional conduct for an acupuncturist to use the title "Doctor" or the abbreviation "Dr." in connection with the practice of acupuncture unless he or she possesses a license or certificate which authorizes such use or possesses an earned doctorate degree from an accredited, approved or authorized educational institution as set forth under Article 4 (commencing with section 94760) of Chapter 7 of Part 59 which is in acupuncture, Oriental medicine, a biological science, or is otherwise related to the authorized practice of an acupuncturist as set forth in Section 4927 and 4937 of the Code. The use of the title "Doctor" or the abbreviation "Dr." by an acupuncturist as authorized above without further indicating the type of license, certificate or degree which authorizes such use, constitutes unprofessional conduct. The Council of Acupuncture and Oriental Medicine Associations lists the following associated degrees, licensing, and credentialing designations:

Licensed Acupuncturist (L.Ac.): State Licensing Agency

Certified Acupucnturist (C.A.): State Licensing Agency

Certifed Diplomate (Dipl.Acupuncture): NCCAOM

Doctor of Oriental Medicine (OMD or DOM): Individual Schools

Many practitioners in the 70's and 80's went on after graduating from approved schools in California to obtain a Doctorate in Oriental Medicine, O.M.D. This course usually consisted of one year additional study, which included a short externship in China. These degrees were halted during the national credentialling process in the late 80's. The ACAOM is in the midst of developing a standardized 4,000-hour advanced doctorate program in Oriental Medicine.

The NCCAOM (National Certification Commission for Acupuncture and Oriental Medicine) has been setting entry-level standards for national certification. Licensing requirements vary from state-to-state, some requiring the NCCAOM certification, others requiring NCCAOM plus additional education and/or examination, and some, like California, which is ahead of NCCAOM standards, have entirely independent licensing examinations.

When an acupuncturist achieves NCCAOM Certification in Acupuncture, they may desiginate themselves as "Diplomate in Acupuncture (NCCAOM)" or "Dipl. Ac. (NCCAOM)."

The impression [which Per Otte has given] that acupuncture techniques cannot be studied through controlled and appropriate clinical trials may be mistaken. In 1998 Congress expanded the status, mandate, and authority of the Office of Alternative Medicine at the National Institutes of Health (NIH) by enacting legislation to create the National Center for Complementary and Alternative Medicine (NCCAM). NCCAM is dedicated to exploring complementary and alternative healing practices in the context of rigorous science; training researchers and disseminating authoritative information. They have also funded work to promote innovative research that will advance our understanding of the underlying mechanisms of this unique form of therapy, and permit improved clinical trials that may yield improved clinical applications.

[Per Otte has been invited to respond to Dr. Watt's entry.]