After presenting a recent lecture on dry eye disease (DED) to fourth-year optometry students and residents, an attendee asked me about acupuncture as a potential therapeutic option for ocular surface disease (OSD). I confessed my ignorance on the subject and began to research the literature; I owe her a debt of gratitude. I discovered an abundance of information about Traditional Chinese Medicine (TCM), including studies on acupuncture therapy for OSD.
Acupuncture is a form of non-pharmacologic therapy that has been practiced in TCM for more than 2,000 years. It has been used to treat a broad variety of disorders, including infertility, postoperative pain, arthritis, and, more recently, OSD (Belgrade and Huntoon, 2009). Acupuncture needles are typically made of stainless steel and are inserted into very specific “acupuncture points.”
What the Research Says
Liu et al (2017) evaluated acupuncture plus artificial tears versus artificial tears alone for menopausal dry eye disease. Study endpoints included pre- and post-assessment of Ocular Surface Disease Index (OSDI) scores, symptom scores, sign scores, and tear breakup time (TBUT). In addition, they used two-dimensional nano-liquid chromatography coupled with mass spectrometry to assess more than 2,400 protein levels prior to and after therapy.
The results of this study are fascinating. After treatment, both groups showed improvement in OSDI scores, symptom assessment scores, sign assessment scores, and TBUT. However, the degree of improvement in the acupuncture and artificial tears group was significantly greater compared to the the artificial tears alone group. In the acupuncture group, beneficial proteins were upregulated after treatment, while those involved in apoptosis were downregulated.
Yang et al (2015) conducted a literature search/meta-analysis of seven studies that compared the efficacy of acupuncture to artificial tears. They focused on specific test results, i.e., Schirmer 1 test (SIT), TBUT, corneal fluorescein staining (CFS), and visual analog scale (VAS) outcomes to evaluate the value in treating confirmed dry eye patients. Their findings indicate that acupuncture is effective in treating DED and has “superior efficacy” in TBUT, SIT, CFS, and VAS outcomes compared to artificial tears.
The mechanism(s) through which acupuncture exerts its effects has been a subject of discussion and multiple studies. Until recently, the answers have been elusive. TCM recognizes 361 acupoints, specific locations in which needles are inserted to exert a desired effect or therapeutic benefit. In some cases, those benefits may occur at a location far away from the treatment site. Conventional and electron microscopic studies of acupoint microstructure consistently demonstrate abundant mast cells, vascular vessels, and cholinesterase-positive nerve fibers (Mingfu et al, 2013). After acupuncture, there is an increase in mast cell and histamine release (Yin et al, 2017).
Multiple studies show that acupuncture exerts its therapeutic effects through the modulation of neuronal activity at the level of the dorsal root ganglion, spinal cord, trigeminal nucleus, thalamus, and brain. Acupuncture may also inhibit the neuronal discharges induced by somatic and visceral pain (Kim et al, 2017).
An Alternative to Consider
How does this impact our dry eye practices? It may not, but the potential patient benefits of acupuncture suggests that, at the very least, we should consider contacting an acupuncturist and explore working together as a possibility.
CPT codes for this procedure exist, but Medicare does not cover acupuncture for any condition. The National Institutes of Health and other agencies are reviewing reimbursement for acupuncture, and some supplemental healthcare plans already provide compensation for this procedure. CLS
For references, please visit www.clspectrum.com/references and click on document #266.