acupuncture reduces symptoms of dry eye syndrome
TRANSCRIPT
Acupuncture Reduces Symptoms of Dry Eye Syndrome:A Preliminary Observational Study
Ju-Hyun Jeon, OMD, PhD,1 Mi-Suk Shin, RN,2 Myeong Soo Lee, PhD,2 So-Young Jeong, BS,2
Kyung Won Kang, MS,2 Young-Il Kim, OMD, PhD,1 and Sun-Mi Choi, OMD, PhD1
Abstract
Objective: The aim of this study was to evaluate the effect of acupuncture treatment on dry eye syndrome.Design: This was a prospective observational study.Setting: The study was conducted at a clinical evaluation center for acupuncture and moxibustion of the KoreanInstitute of Oriental Medicine, Republic of Korea.Subjects: The subjects were patients with dry eye disease (N¼ 36), defined by Schirmer test scores of <10 mm/5 min and tear film break-up times (BUTs) of <10 seconds.Treatments: Participants were treated with acupuncture three times per week for 4 weeks.Measure of effectiveness: Schirmer test scores, BUTs, symptom scores, ocular surface disease index (OSDI) scoresand dry eye symptom questionnaires were compared before and after treatment to evaluate the efficacy ofacupuncture treatment.Results: After treatment, symptom scores, OSDI scores and the number of dry eye symptoms were all signifi-cantly lower ( p< 0.0001). Although tear wettings were significantly higher (left: p< 0.0001, right: p¼ 0.0012),there were no significant differences in BUTs.Conclusions: This study suggests that acupuncture treatment can effectively relieve the symptoms of dry eyeand increase watery secretion.
Introduction
Dry eye syndrome is a tear film disorder that occurs dueto a deficiency of tears or excessive evaporation.1 Dry
eye syndrome causes damage to the interpalpebral ocularsurface and is associated with symptoms of ocular discom-fort.1 The most common cause of this syndrome is damage tothe lacrimal gland, which is involved in aqueous secretion.2
Early interventions for dry eye syndrome were palliative, at-tempting to replace water lost from the tear film.3 Currenttherapies are directed at underlying inflammation, an im-portant component of dry eye syndrome, and at the resultingchanges to the ocular surface.3
Patients with eye diseases often turn toward complemen-tary and alternative medicine (CAM).4,5 There is a wide rangeof CAM used for treating dry eye, including dietary supple-ments, herbal medicine, and acupuncture. Acupuncture isconsidered to be effective for various conditions.6 It is alsothought to be effective at modulating the autonomic nervoussystem and immune system.7–9 Based on this information, it isreasonable to assume that acupuncture might be able to reg-ulate lacrimal gland function and thereby relieve dry eye
symptoms. As there are few reports on this hypothesis,10,11
this observational study investigated whether acupuncture iseffective at treating symptoms of dry eye syndrome.
Patients and Methods
Participants
Fifty (50) subjects were recruited from an Internet home-page, a newspaper insert, and a poster billing. Subjects wereincluded if they were 19–70 years of age and had dry eyesymptoms, Schirmer test scores of <10 mm/5 min, and tearfilm break-up times (BUTs) of <10 seconds. All subjects wererequired to provide written informed consent before anystudy-specific procedures were performed.
We excluded subjects with previous anterior segment in-flammation or trauma (surgical or other trauma), active ble-pharitis, previous facial palsy, allergy, punctal occlusion, orpunctal plug insertion. Contact lens users were also excluded.Patients were excluded if they used systemic medications suchas sleeping tablets, tranquilizers, antidepressants, mono-amine oxidase inhibitors, dopaminergics, neuroleptics, ben-zodiazepines, antiserotoninergics, b-blockers, or antiemetic
1Acupuncture, Moxibustion, and Meridian Research Center, Korea Institute of Oriental Medicine, Daejeon, South Korea.2Division of Standard Research, Korea Institute of Oriental Medicine, Daejeon, South Korea.
THE JOURNAL OF ALTERNATIVE AND COMPLEMENTARY MEDICINEVolume 16, Number 12, 2010, pp. 1291–1294ª Mary Ann Liebert, Inc.DOI: 10.1089/acm.2009.0537
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agents. We also excluded women who were receiving hor-mone replacement therapy, were pregnant or lactating, andthose for whom pregnancy was possible.
This clinical study received formal approval from theEthics Committee and was conducted in conformance withthe provisions of the Declaration of Helsinki (1995). The re-cording of adverse events was a means of assessing thesafety of acupuncture treatment.
Procedures
Participants were scheduled for acupuncture treatment 3times a week for 4 weeks (12 times total). Dry eye symptomsand questionnaires were evaluated pretreatment and aftereach of the 12 acupuncture treatments (total 13 times). Ocularsurface disease index (OSDI) was measured baseline andafter the 3rd, 6th, 9th, and 12th sessions (total 5 times). BUTand Schirmer tests were also performed pretreatment andafter 12 acupuncture treatments (total 2 times).
Acupuncture treatment
Acupuncture treatments were performed by 3 Koreandoctors who had received postgraduate training in acu-puncture and had more than 3 years of clinical experience.Disposable stainless steel needles (0.20�30 mm, Haeng Lim
A B
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FIG. 1. Treated acupuncture points. (A) LU3; (B) Extraacupuncture point (Duomingxue); (C) Auricular acupuncturepoint Eye 2; (D) Korean hand acupuncture point E2.
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1292 JEON ET AL.
Seo Won Co., Korea) were inserted into acupuncture points(auricular acupuncture point eye 2 and Korean hand acu-puncture point E2 to a depth of 0.1 cun and LU3 and extraacupuncture point to a depth of 0.5 cun). The ‘‘sparrowpecking’’ technique (alternate pushing and pulling of theneedle) was not applied. The needles were left in place for 30minutes.
Acupuncture points
We select the LU3 (Fig. 1A) according to TraditionalChinese Medicine. The other treatment point selections werebased on ‘‘microacupuncture’’ rules and the chief virtueof each acupuncture point. The extra acupuncture point,Duomingxue, is located in the middle point of Acromion andLU5 (Fig. 1B).12 Auricular acupuncture point Eye 2 is locatedbelow the intertragic notch (posterior of the notch) (Fig. 1C).Points were selected according to the method of the school ofNoiger.13 Korean hand acupuncture point E2 is located onthe palm of the middle finger, in the distal phalanx, at theintersection of the Radial and Ulnar vertical line. The pointwas selected according to the Yoo Tae Woo’s Koryo handtherapy method (Fig. 1D).14
Outcome measures
Primary outcomes. Symptom scores and OSDI were theprimary outcomes used to evaluate the efficacy of the acu-puncture treatment.15 Symptom scores were evaluated usinga scoring system of 0–4, where 0 indicates an absence ofsymptoms and 4 indicates very severe symptoms. Partici-pants scored 10 symptoms associated with dry eye syndrome,including burning sensation, stinging sensation, itching sen-sation, foreign body sensation, dryness, soreness, lid heavi-ness, photophobia, injection, and tearing. Total scores,obtained by adding the scores of each symptom, were used forthe evaluation of ocular discomfort.
OSDIs were used to quantify the specific impact of acu-puncture on dry eye syndrome. This disease-specific ques-tionnaire included three subscales: ocular discomfort,function, and environmental triggers. Questionnaires werefilled out and collected once a week throughout the study.Possible responses referred to the frequency of the distur-bance: none of the time, some of the time, half of the time,most of the time, or all of the time. Subscale scores were
computed for OSDI-symptoms, OSDI-function and OSDI-triggers, as well as an overall averaged score. OSDI subscalescores ranged from 0 to 100, with higher scores indicatingmore problems or symptoms.
Secondary outcomes. The secondary outcome measureswere the number of dry eye symptoms, Schirmer test score,and BUT score. The number of dry eye symptoms wasevaluated by counting 10 dry eye symptoms (burning sen-sation, stinging sensation, itching sensation, foreign bodysensation, dryness, soreness, lid heaviness, photophobia, in-jection, and tearing). The total number of symptoms wasused to evaluate the level of ocular discomfort.
Schirmer tests were performed by placing a Schirmer tearstrip (Eagle Vision�, USA) over the lower lid margin at thejunction of the middle and lateral third of the tear film for5 minutes. Patients were given anesthesia (0.5% propar-acaine (Alcaine�)) prior to testing. Schirmer test scores wereobtained by measuring the lengths (millimeters) of the wetportions of the strips and recorded.
BUTs were calculated as the number of seconds betweenthe last complete blink and the first disturbance of the pre-corneal tear film after touching the inferior temporal bulbarconjunctiva with a fluorescein sodium strip that was damp-ened with a preservative-free saline solution. The mean valueof a total of three measurements was recorded.
Statistical analysis
The statistical analysis was performed using SAS 9.1. Tocompare therapeutic effects between preacupuncture andpostacupuncture, a paired t-test and Wilcoxon’s signedrank test were used. The same analysis was used to com-pare between baseline (pretreatment) and each visit. Theresults are presented as mean values and standard devia-tion. Probability ( p) values< 0.05 were considered signifi-cant in all statistical testing. Effect size was calculated withCohen’s d.
Results
A total of 50 patients volunteered for the study, and 12 didnot fit the inclusion criteria. Only 2 of the remaining 38 pa-tients were excluded because they took medicine on the firsttreatment day. Two (2) participants withdrew their consent
Table 2. Outcome Measures After 12 Sessions of Acupuncture for Dry Eye Syndrome
Outcome measures Pretreatment Post-treatment Effect size (95% CI) p
Symptom score 2.22 (0.71) 1.44 (0.56) 1.21 (0.67, 1.74) <0.0001OSDI 48.6 (16.6) 31.1 (19.5) 1.64 (1.07, 2.21) <0.00001Number of dry
eye symptoms6.9 (1.8) 4.0 (1.7) 0.95 (0.43, 1.46) 0.0003
Schirmer testLeft 5.3 (1.9) 7.4 (3.2) 0.80 (0.29, 1.31) 0.002Right 5.3 (1.9) 7.4 (3.4) 1.13 (0.60, 1.66) <0.0001
BUTLeft 5.4 (1.7) 5.3 (2.2) 0.05 (�0.44, 0.54) 0.82Right 4.9 (1.7) 4.8 (2.3) 0.05 (�0.44, 0.54) 0.84
Values are represented as mean (standard deviation). The Wilcoxon signed-rank test was used to test significance between pretreatmentand post-treatment.
CI, confidence interval; OSDI, ocular surface disease index; BUT, tear film break-up time.
ACUPUNCTURE FOR DRY EYE SYNDROME 1293
for the trial, and 2 were excluded because they took steroidsor other medications during the treatment period. The re-maining 32 patients completed the study.
The mean age and duration of disease were 47.4 (range22–62) years and 5.6 years (range 2 months–20 years), re-spectively. The changes in the symptom scores, OSDI, andnumber of symptoms are shown in Table 1. All of the out-come measures were improved by the acupuncture sessions.Table 2 lists outcome measures before and after treatment.These measures indicate that there were significant im-provements in dry eye symptoms, OSDIs, the number of dryeye symptoms, and Schirmer test scores. However, therewere no significant changes in BUTs. The most affectedvariable was OSDI (effect size¼ 1.64).
None of the participants reported any adverse events.
Discussion
Our pilot study suggests that 12 sessions of acupuncturetreatment significantly improved subjective outcome mea-sures of dry eye syndrome, including total symptom score,number of symptoms and OSDI, as well as the objectiveoutcome measure of the Schirmer test. This finding is con-sistent with results of previous studies. Tseng et al.11 reportedthat 16 sessions of acupuncture treatment improved symp-toms of dry eye syndrome. Another study also reportedbeneficial effects of 10 sessions of acupuncture treatment ondry sensations in the eye.10
Assuming that acupuncture is a potentially useful treat-ment option for dry eye syndrome, its mechanism of actionmay be of interest. The results presented here suggest thatacupuncture can influence lacrimal glandular function in thesynthesis and secretion of aqueous secretions.16 Others havepostulated that acupuncture may reduce tension and allevi-ate pain intensity or increase pain threshold.17 However,none of these theories have been addressed.
The results from this uncontrolled pilot study providea foundation for the exploration of acupuncture as a non-pharmacological therapy for improving symptoms of dry eyesyndrome. However, we cannot completely discount thepossibility that a placebo effect during the intervention causedimprovements in symptoms related to dry eye syndrome.Other limitations of this pilot study include the small samplesize and the absence of a control treatment and appropriatefollow-up of possible recurrences. Further studies that includea randomized design, larger sample sizes, and more detaileddata on the subjects are needed to convincingly show the ef-fects of acupuncture in patients with dry eye syndrome.
Disclosure Statement
No competing financial interests exist.
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Address correspondence to:Sun-Mi Choi, OMD, PhD
Acupuncture, Moxibustion & Meridian Research CenterKorea Institute of Oriental Medicine
Daejon, 305–811South Korea
E-mail: [email protected]
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