EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.
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July 2013 EW CORNEA 27 Eyeing acupuncture for dry eye and other ophthalmic conditions by Vanessa Caceres EyeWorld Contributing Writer A n alternative medical treatment with ancient roots is garnering more attention within ophthalmology. Acupuncture involves the use of slender needles inserted in the skin. Practitioners believe the needles regulate the flow of energy—called qi— in the body. Acupuncture began to grow in the United States after a reporter covering President Richard Nixon tried it in China. Since then, its growth has continued—a 2007 national survey found that about 3.1 million Americans and 150,000 children had used acupuncture in the previous year. It's currently used most often for back pain, joint pain, neck pain, recurring pain, and migraines. Although a number of clinical trials and scientific studies overseas, especially in China, address the beneficial outcomes of acupuncture in ophthalmology and other specialties, this is a young area for clinical research and practice in the U.S., said Richard C. Niemtzow, MD, Colonel (Ret), USAF, MC, FS, complementary and alternative medicine consultant for the U.S. Air Force Surgeon General, and director, U.S. Air Force Acupuncture Center, Joint Base Andrews, Md. Dr. Neimtzow pioneered the use of acupuncture in the Air Force and was the first known active duty physician to complete formal training in medical acupuncture. "It seems that more and more conventional medicine physicians and researchers are embracing acupuncture as a way to help their patients manage their health conditions," said Andy Rosenfarb, ND, LAc, a doctor of naturopathic medicine in Westfield, N.J. "Acupuncture is safe and effective when done by a well-trained practitioner." There are minimal side effects with acupuncture—there is the risk for infection at the site of needle injection, but that is very rare for trained practitioners, said Dr. Niemtzow. Just as with the use of medications, acupuncture seems to work well for some patients but not others—and it's not always clear why, said Dr. Niemtzow. "This is not a cure treatment, but it appears to be helpful," he said. Although it's not known exactly how acupuncture helps various eye conditions, there's growing evidence to suggest that certain acupuncture points and point combinations seem to activate the nervous system, brain, and other autonomic processes. Although acupuncture is commonly associated with Asian countries, the approach often used within ophthalmology comes from approaches developed in countries like Germany, France, and Canada, said Alston C. Lundgren, MD, Santa Fe, N.M. Eyeing acupuncture for dry eye Within ophthalmology, dry eye is an area where there's been slightly more focus on acupuncture. For example, Dr. Niemtzow conducted two clinical trials on acupuncture treatment for dry eye in the early 2000s; the trials had contradictory results. He went on to incorporate acupuncture into his military practice. Acupuncture is currently used to treat various ailments in the Air Force around the United States and in Germany. The approach that Dr. Niemtzow uses is based on European ear acupuncture. The patients who use acupuncture for dry eye have often not had success with other treatments—some of the patients have Sjogren's syndrome or other medical conditions where more severe dry eye emerges. However, Dr. Niemtzow noted that these patients first exhaust more traditional standard-of-care options. "It's used as adjunctive therapy," he said. Another military physician, Maj. Chantal Cousineau-Krieger, MD, 779th Surgical Specialties Flight, Warfighter Eye Center, Malcolm Grow Medical Clinic and Surgery Center, Joint Base Andrews, Md., has a few patients who receive acupuncture for dry eye, with solid results. She tells the story of a severe dry eye patient with lacrimal and salivary glands that were destroyed. The patient needed cataract surgery, but Dr. Cousineau-Krieger worried about poor healing. Having acupuncture helped the patient, and her cataract surgery was successful. Dr. Lundgren has found success with acupuncture to treat xerophthalmia and xerostomia using Dr. Niemtzow's protocol. "His protocol is simple, fast, and works most of the time, even in persons with radiation-damaged lacrimal and salivary glands," he said. Acupuncture in the United States needs more evidence-based outcomes from clinical trials to prove its effectiveness for dry eye and other eye problems, Dr. Niemtzow said. "There are hundreds of clinical trials in China, and they are scientifically of high merit, but I think we feel here [in the United States] that we have to prove to ourselves that it works to our standards," he said. One study in the works is from Deepinder K. Dhaliwal, MD, University of Pittsburgh. At the 2013 ASCRS•ASOA Symposium & Congress, Dr. Dhaliwal said her study focuses on the efficacy of acupuncture as a dry eye treatment. One treatment group has received real acupuncture treatment, while another group has received a sham treatment. Treatment lasts 9 to 12 months. Researchers are looking for improvement of symptoms and the use of fewer artificial tears. "We feel acupuncture can be an adjunctive treatment for dry eye and pain syndromes," she said. Eyeing acupuncture for other conditions Ophthalmologists and acupuncturists in Western countries are examining the use of acupuncture for other ophthalmic conditions as well. For example, an analysis published in the May issue of Cochrane Database of Systematic Reviews reviewed the effectiveness and safety of acupuncture in people with glaucoma by reviewing randomized clinical trials from around the world.1 Investigators reported that it's too early to make reliable conclusions based on the evidence available. However, they added that seven trials under way in China may change their conclusions in the future. Dr. Rosenfarb sees glaucoma patients who use their prescribed eye drops to control their IOP but also try acupuncture and supplements. He said he frequently works with optometrists, ophthalmologists, and subspecialists to provide tailored care for patients interested in acupuncture treatments. Acupuncture also has a role to help treat age-related macular de- generation (AMD). Dr. Lundgren has done research in this area and presents frequently on the topic, during which he details his use of German ear and Canadian neuroanatomic acupuncture. He has treated more than 1,500 patients with diagnosed AMD, two thirds of them with the dry form of the disease. "Eighty-five percent improve objectively on the ETDRS eye charts and other objective and subjective methods," he said. He insists that AMD and glaucoma patients take their prescribed medications and supplements they may already use, such as AREDS vitamins and lutein. The patients that he treats have non-hemorrhaging AMD—an important point because acupuncture can increase blood flow, Dr. Lundgren added. Retinitis pigmentosa is another area with some research to support the use of acupuncture, said Dr. Rosenfarb. Preliminary results from a case series at Johns Hopkins University in Baltimore reported this year found encouraging results and significant night vision improvements in a subset of treated patients, he said.2 Physicians and acupuncturists realize there are some barriers when encouraging the use of acupuncture among traditional Western medicine clinicians. Some acupuncturists can even give the practice a bad name because it sounds "out there," and they do not have objective results, Dr. Lundgren said. That's where quality clinical trials will give more credence to the approach, Dr. Niemtzow said. EW References 1. Law Sk, Li T. Acupuncture for glaucoma. Cochrane Database Syst Rev. 2013 May 31:5:CD006030. 2. Bittner AK, Gould J, Rosenfarb A, Rozanski C, et al. Visual function improvements following electroacupuncture for retinitis pigmentosa. Invest Ophthalmol Vis Sci. 2013;ARVO E Abstract 4017. Editors' note: The physicians interviewed have no financial interests related to this article. Contact information Cousineau-Krieger: melanie.moore@afncr.af.mil Lundgren: alston@lundgrenmd.com Niemtzow: N5ev@aol.com Rosenfarb: acupunkk@aol.com