I asked my mother how she got this book. She explained that she received a direct mail solicitation several months earlier that contained testimonials about the book and touted the authors credentials.
Thats how I became interested in complementary and alternative medicine (CAM), including its application to eye care. Complementary and alternative medicine refers to therapeutic practices that lie outside of conventional medical practices. We use the term complementary to describe a practice used as an adjunct to traditional practice. Alternative means the approach is used instead of conventional treatment.
Chances are you have patients who have become interested in nontraditional forms of vision care. A survey administered in 1990 found that 34% of the U.S. population used some form of CAM, spending $13.7 billion.1 A follow-up survey in 1997 found that 42% of the U.S. population used some form of CAM, totaling 629 million visits to alternative practitioners, with expenditures of $21.2 billion.2 This represented more visits to alternative practitioners than general physicians that year. Studies have found that patients who turn to alternative medicine tend to be well-educated, affluent, white and female.3
And, theyll expect you, as their primary eye care provider, to answer their questions about these approaches. Here, well look at a few alternative approaches to eye care that patients may ask about.
Bates Eye Exercises
Having heard radio commercials and celebrity endorsements for the See Clearly Method, your patients may ask if it can really free them from glasses or contact lenses.
For about $300, the See Clearly Method includes a videocassette or DVD, books, eye exercise charts, a CD-ROM, and live customer support with trained See Clearly Method consultants. Other similar plans include Vision for Life, which is marketed on the Internet (
www.rebuildyourvision.com).
The See Clearly Method and other such programs incorporate eye exercises developed by the late William Horatio Bates, a prominent New York ophthalmologist who in 1920 published the best-selling book, Perfect Sight Without Glasses.
Dr. Bates believed that refractive error and even floaters are the result of nervous tension and mental strain. To normalize vision, Dr. Bates proposed a series of exercises, including:
Palming. The patient cups his hand over a closed eye and imagines total darkness. The idea is to get rid of nervous energy.
Shifting. The patient looks back and forth between two targets using eccentric fixation, being careful not to stare. According to Dr. Bates, staring causes mental strain and myopia.
Sunning. Dr. Bates recommended staring at the sun to normalize vision. His argument was that a patient who had normal vision could stare at the sun indefinitely without causing damage. We now know this practice can lead to solar retinitis and permanent vision loss.
Elwin Marg, O.D., Ph.D., once wrote about the Bates exercises, saying that, Most of his claims and almost all of his theories have been considered false by practically all visual scientists.4 Despite that, the Bates method is still alive and strong today.
Martin Gardner, a former columnist for Scientific American for three decades and well-known skeptic, once wrote of Bates exercises: a fantastic compendium of wildly exaggerated case records, unwarranted inferences and anatomical ignorance.5
Homeopathy
Homeopathy dates back some 200 years to the German physician Samuel Hahnemannsome 50 years before Louis Pasteur and the germ theory became prominent. Medicine at that time included such treatments as bloodletting, high-dose cathartics, and treatment with heavy metals such as mercury.6 Dr. Hahnemann was rightfully disturbed by these medical practices, which often made patients worse than no treatment at all. So he developed his own therapeutic system, known today as homeopathy.
Homeopathy relies on the scientifically-disputed premise that infinitesimally small amounts of poisons will relieve the same symptoms they produce if administered in larger amounts. In other words, Dr. Hahnemann believed that if you administer a small amount of a noxious substance to a patient, you can stimulate the bodys healing response. For example, ingesting a homeopathic remedy with onion extract is claimed to provide relief tearing and a runny nose. This premise is known in homeopathy as the Law of Similars, in which a particular substance is used to treat the same symptoms it would produce in a larger quantity.6
Homeopathic remedies may consist of many different substances, including minerals, botanicals and zoological substances. The remedies come in many forms including pills, elixirs, sprays and drops.
Examples of eye-related homeopathic remedies include:
Similasan. These are perhaps the best known homeopathic eye drops, made by Similasan AG, a Swiss company. There are four formulations: dry eyes and red eyes, allergy eyes, computer eyes, and pink eye relief.
Mark Abelson, M.D., and co-workers, performed a study of Similasan #2 (allergy eyes) on 47 subjects, comparing the efficacy of it against placebo for reducing signs and symptoms of ocular allergy.7 Dr. Abelson found that Similasan #2 is equivalent to saline placebo for treating ocular allergy, with no statistically significant differences between the two.
Also, a non-controlled evaluation of Similasan Dry Eye (formerly #1), sponsored by Similasan AG, found that 57% of all individuals using this drop were completely free of eye irritation symptoms or substantially improved.8
PrimaVu (PrimaVu Herbal Health Care, San Diego), a homeopathic herbal eye drop for, dry, tired eyes.
Optique 1 (Boiron Laboratories, France), a homeopathic drop for eyes that are, red, dry, itchy, burning.
The most controversial premise in homeopathy is the Law of Infinitesimals which posits that the smaller the dose, the more powerful the effect. The potency ratings on homeopathic remediestypically 6x to 30xrefer to the exponential number of serial dilutions a toxin undergoes. For example, a 1x remedy would involve one part of a noxious substance added to 10 parts of a diluted substance, a 2x would be one part of a noxious substance added to 100 parts of a diluting agent, etc. In theory, a potency rating of 24x or greater means that the remedy may not contain a single molecule of the noxious substance. At these dilutions, these remedies should have no physiological effect.
There is some evidence supporting the validity of homeopathy. Wayne Jonas, M.D., and colleagues performed a meta-analysis of four independent systematic reviews of homeopathy and published their results last year. Interestingly, three of these reviews indicated that homeopathy worked slightly better than placebo, but the fourth did not find any statistically significant difference.6
The authors concluded that while homeopathy deserves an open-minded opportunity to demonstrate its value on evidence-based principals, we should not allow patients to substitute it for proven therapies.
Homeopathic remedies gained legal status in the United States in 1939. The U.S. Food and Drug Administration currently requires no proof of efficacy for homeopathic remedies. This has opened up marketing loopholes.
Iridology
Iridology is a diagnostic system based on the premise that each part of the body is represented by a corresponding part of the iris. Iridologists look at the color, texture and the location of iris pigmentation to reveal health status.
Iridology is credited to a Hungarian homeopathic practitioner, Ignatz von Peczely. He was believed to have developed this system while imprisoned during the Hungarian revolution in 1848. Legend has it that when he was a child, he noticed that an owl with a broken leg showed a black linear iris lesion. As the owls leg healed, the lesion slowly disappeared. This apparently sparked von Peczelys hypothesis behind iridology. About one century later, a chiropractor by the name of Bernard Jensen, pioneered the practice of iridology in the U.S.
Today, iridology is a common diagnostic tool used among the more than 1,000 licensed naturopathic doctors. Iridology even has its own professional organization.9
Some examples of what one iridologist believes: A rust-colored ring around the pupil confirms bowel toxicity and constipation, while a white ring outlining the iris indicates a compromised circulatory system with memory loss.10
Based on iris diagnosis, the iridologist identifies imbalances and may recommend certain vitamins, minerals and herbs in order to correct them.
The dangers in iridology are several: inefficient use of time and money, delayed diagnosis, and perhaps most serious, the possibility of false negative diagnosis on a patient with serious illness.9 In one study, for example, three iridologists evaluated 143 patients, 48 of whom had renal disease. There was no statistically significant ability to detect kidney diseaseone iridologist found that 88% of normal individuals had kidney disease, leading the authors to conclude that the likelihood of correct detection was statistically no better than chance.11
In another study, the author took stereo color slides from the right eye of 39 patients with known gallbladder disease and 39 patients without, then showed them in random order to five iridologists.12 None of the iridologists reached a high validity of correct diagnosis, leading the researchers to conclude that iridology is not a useful diagnostic aid.
This should be no surprise, as there is no known mechanism by which a diseased organ can transmit its health status to the iris.
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Complementary and Alternative: Five Categories
Source: National Center for Complementary and Alternative Medicine. What is complementary and alternative medicine (CAM)? http://nccam.nih.gov/health/whatiscam/. |
Nutraceuticals
The Dietary Supplement Health and Education Act (DSHEA), passed by Congress in 1994, freed the nutritional supplement industry from FDA oversight. The result: an explosion in the amount of available nutraceuticals. As with homeopathic remedies, manufacturers of nutraceuticals do not have to disclose or prove efficacy.
More recently, however, there has been renewed concern about the safety of some of these products, especially performance enhancers such as ephedra, which have been associated with heart problems and over 160 deaths.
Examples of nutraceuticals include:
Eyebright (Euphrasia officinalis), a flowering plant that herbalists claim treats conjunctivitis. In one study, researchers diagnosed 65 people with conjunctivitisalthough they didnt state the type of conjunctivitis, presumably non-gonococcal acute bacterial conjunctivitisand had these patients administer Eyebright for two weeks. After two weeks, they found that 53 of 65 patients had a complete recovery.
Some things to keep in mind, however: First, this was an uncontrolled study. Second, a review found that in non-gonococcal acute bacterial conjunctivitis, saline placebo resulted in clinical recovery in 64% of patients within two to five days.13 Since bacterial conjunctivitis is frequently self-limiting, we need further research to assess the effectiveness of Eyebright and other herbal remedies.14
Bilberry. This is one of the top 10 most popular herbs in the United States.15 Herbalists claim that it can help improve night vision and cataracts.
Legend has it that British Royal Air Force pilots during World War II were rationed bilberry jam or bilberry tea.15 Afterwards, their night vision allegedly improved so much that they bombed their targets with incredible accuracy.
In reality, the pilots were bombing their targets with incredible accuracy because they acquired radar. Supposedly, bilberry was introduced as a diversion so that no one else would find out about radar.
Ironically, scientists have since discovered that bilberry is rich in antioxidants and therefore could have some eye-related benefits. But definitive information is lacking.
Perhaps the most telling information available comes from a double-blind, controlled, cross-over study commissioned by the military in Pensacola, Fla., where Navy SEALs are trained.16 Fifteen SEALs ingested the maximum recommended dose of bilberry for three weeks, and researchers measured night vision, visual acuity and contrast sensitivity. At the end of the study, there was no statistically significant improvement in vision.
Although there are substantial voids in information about many nutraceuticals, at least there is some good science. For example, the Age-Related Eye Disease Study, or AREDS by the National Eye Institute found that patients at high risk of developing advanced stages of AMD lowered their risk by about 25% when treated with a high-dose combination of vitamin C, vitamin E, beta-carotene, and zinc.17 Unfortunately, as long as nutraceutical companies are not required to prove efficacy of their products, large scale studies like AREDS will likely be far and few between.
Clinical Practice
So, how do you respond when a patient asks you about the Bates exercises or homeopathic eye drops? Theres no right or wrong way. But, as clinicians, we have a responsibility to provide them with objective information.
Theres the temptation to criticize the patient. But before doing so, realize that 72% of patients using nontraditional health care conceal that information from their primary care physician, probably because they dont feel comfortable talking about it.1 So, if your patient asks you about nontraditional health care, chances are he or she feels comfortable asking for your expert opinion. The best service is providing information based in medical science.
Indeed, there are real dangers with non-traditional eye care. Homeopathic remedies and nutraceuticals are available for purchase over-the-counter on a self-diagnosed basis, a practice that can delay efficacious treatment. In a worst-case scenario, some alternative practices could lead to vision loss. There are anecdotal reports of glaucoma patients going blind after abandoning their eye pressure-lowering drops in favor of Bates eye exercises.
Currently, there is a lack of evidence supporting many non-traditional forms of eye care. However, there are efficacious and safe treatments yet undiscovered and outside the realm of our existing clinical practice. The identification and development of these therapies is welcome, but in so doing, we should not depart from our professions core of scientific evaluation. Although there seems to be a disproportionate amount of unproven therapies under the label of complementary and alternative eye care, we should not stereotype these practices as all ineffective.
Dr. Chou is a partner at Carmel Mountain Vision Care, an optometric group and clinical study site in San Diego. He has no financial or proprietary interests in products mentioned in this article.
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3. Ernst E. Prevalence of use of complementary / alternative medicine: a systematic review. Bull World Health Organ, 2000 78(2):252-257.
4. Marg E. Flashes of clear vision and negative accommodation with reference to the Bates method of visual training. Am J Optom Arch Am Acad Optom 1952 Apr;29(4):167-84.
5. Gardner M. Fads and fallacies in the name of science. Dover Publications, 1957.
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7. Garofalo C, Abelson M, George M, Weintraub D. An effective treatment for allergy sufferers. CL Spectrum 1995 Dec:28-32.
8.Similasan Research Report. Clinical study: Similasan Eyedrops #1.
www.healthyrelief.com/pdfs/DryStudy_Swiss.pdf.
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10. Centre for Healthy Living. Iridology, sclerology. www.centreforhealthyliving.com/iridologyandsclerology.html.
11. Simon A, Worthen DM, Mitas JA 2nd. An evaluation of iridology. JAMAA 1979 Sep 28;;242(13):1385-9.
12. Knipschild P. Looking for gall bladder disease in the patients iris. BMJ 1988 Dec 17;297(6663):1578-81.
13. Sheikh A, Hurwitz B. Topical antibiotics for acute bacterial conjunctivitis: a systematic review. Br J Gen Pract. 2001 Jun;51(467):473-7.
14. Bielory L, Heimall J. Review of complementary and alternative medicine in treatment of ocular allergies. Curr Opin Allergy Clin Immunol 2003 Oct;3(5):395-9.
15. Leslie M. Bilberry bombs. my.webmd.com/content/article/11/1668_50777.htm?lastselectedguid={5FE84E90-BC77-4056-A91C-9531713CA348}.
16. Muth E, Laurent J, Jasper P. The effect of bilberry nutritional supplementation on night visual acuity and contrast sensitivity. Altern Med Rev. 2000 Apr;5(2):164-73.
17. Age-Related Eye Disease Study Research Group. A randomized, placebo-controlled, clinical trial of high-dose supplementation with vitamins C and E, beta carotene, and zinc for age-related macular degeneration and vision loss: AREDS report no. 8. Arch Ophthalmol 2001 Oct;119(10):1417-36.
