Marginal Therapies


When it comes to reimbursement issues for vision therapy, or practitioners who don’t engage in vision therapy weighing whether or not they’ll refer patients for therapy services, we’ve long had the aspersion cast that vision therapy isn’t “scientifically proven”.  Then the landmark CITT came along and after a 16 year process of phased studies proved indisputably that office based vision therapy is superior to home alone therapy.  Although that has bolstered our arguments with third party carriers, it hasn’t stopped them from trying to ignore the results of the CITT.  And has it influenced the way vision therapy is practiced in the field to the significant degree that it should?  And if not, why?

I’d like to suggest that the answer resides in the trend of eyecare professionals to be seduced by the perception of straightforward cause and effect.  For many years during presentations to ODs I’ve asked the question:  Before the widespread adoption of punctal plugs for dry eyes, was there a scientifically valid study conducted?  It would have been the easiest thing to do:

  1. Examiner 1 determines that patients have dry eyes by objective testing and validated symptom survey.
  2. Subjects are divided into two treatment groups with collagen plugs inserted in one group and nothing in the other group.
  3. Examiner 2 is able to keep the subjects masked by conducting a sham procedure on the no treatment group,  tapping on the puntucm with a forceps and fiddling with the margin, but not inserting the plug.
  4. Three days later, when the plug has dissolved, the patient returns for Examiner 1 to re-assess.

I was reminded of the fact that in most ares of clinical practice what is “accepted” as efficacious isn’t informed purely by scientific study when reading our state’s list serve last night. Rather it is still heavily influenced by respect for what one’s peers have experienced with patients.  The subject at hand was blepharitis.


Here’s how the conversation started:

“I finally tried scrubbing my perfectly happy and clean lids with OcuSoft Original and it burned like the devil. I’ve been recommending them to patients for years without feedback. Today, two or three patients complained of the same. I tried using a Blephadex wipe from my samples and it was very soothing. Thoughts?”


To which a response came:

“Funny you mentioned that. Although sorry about your burn. I just did a thorough lid scrubbing to myself because I have Bleph. I used the same thing you did, and I have in the past. This time I have red “burn” marks below my lashes and its very tender.

I am looking for another option now too 😊I havn’t tried Blephadex, yet.

I don’t recommend baby shampoo to patients…not for the eyes.”

Followed by this simple suggestion:

“Have you tried Avenova? Patients love it.”


To which the original poster replied:

“I did try Avenova for about a month and it felt great, but didn’t really cut down my Bleph. So I didn’t purchase it for the office.

Do you see it helping Bleph a lot? I used the cotton square and all.”

Which elicited this response from another listee:

“I’ve had good luck with optifree pro lid wipes. They are the same as systane lid wipes just different packaging I believe. They work great for removing makeup.

Blink lid wipes are also pretty gentle. I don’t know how well they work for bleph though.

I’ve been using avenona for myself and most of my bleph & ocular rosacea patients and have seen amazing results. I just started trying acuicyn for myself since they have the better coupon now.”



Which was followed by this observation:

“The patients who have been compliant seem to do very well. Many make multiple purchases, considering it’s a chronic condition, and report increased comfort.  I have them use “make-up pad removers” to spray the Avenova on and clean their lids. There is a competing product which sometimes gets substituted for Avenova called Acuicyn, I tried that too and it doesn’t burn either.

I also wanted to see how Tea Tree Oil shampoo would feel so I tried a generic of Paul Mitchell Tea Tree Shampoo and washed my face and eye lid margins…felt pretty good, didn’t burn…Don’t know if it really works because I don’t have any significant bleph, but will recommended it to patients if I suspect Demodex.

ps… I made the mistake of buying a compound microscope, pulling a suspected lash and looking for Demodex…

I found it…and then couldn’t stop itching all day.”


Are you seeing a pattern?  There is still alot of “I tried it and liked it, so I recommended it to my patients” in eyecare.  And when this advice comes from respected colleagues it is often more widely adopted than so-called scientific evidence.  Contrast this with when the list serve in your state, or list serves on open optometric forums raise a question that is VT-related in nature.  Are respected colleagues chiming in?  If so, what is the usual response or set of responses?  Let me reiterate that I’m not making a value judgment here; merely sharing some observations.

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