Liu Xin-quan, Zhu Hua-ying, Ruan Wen-jie

Longhua Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, Shanghai 200032, China

Clinical Study on Combined Acupuncture and Chinese Medicinal Fumigation for Dry Eye Syndrome

Liu Xin-quan, Zhu Hua-ying, Ruan Wen-jie

Longhua Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, Shanghai 200032, China

Objective: To observe the clinical effect of combined acupuncture and Chinese medicinal fumigation for dry eye syndrome (DES).

Methods: A total of 90 DES cases (180 eyes) were randomized into a treatment group of 44 cases and a control group of 46 cases. Combined acupuncture and Chinese medicinal atomizer fumigation was used in the treatment group, whereas Sodium Hyaluronate eye drops was used in the control group. The subjective symptoms, Schirmer I Test (SIT) and Break-up Time (BUT) of tear film were observed before and after treatment.

Results: The total effective rate in the treatment group was 78.4%, versus 12.0% in the control group, showing a statistical difference (P＜0.01). After treatment, there were between-group statistical differences in SIT and subjective symptom grades (P＜0.05, P＜0.01). However, there was no between-group statistical difference in BUT grade (P＜0.05).

Conclusion: Combined acupuncture and Chinese medicinal atomizer fumigation can help alleviate DES symptoms.

Acupuncture Therapy; Acupuncture Medication Combined; Dry Eye Syndromes

Dry eye syndrome (DES) is an umbrella term for ocular surface damage that results from instability of the tear film and decreased or abnormal tear production[1]. Symptoms include discomfort, dry, burning or itchy feeling in the eyes, photophobia, redness of the eyes and eyestrain. Severe conditions of DES can affect patients’ life and work. Although no cure exists for DES, many treatments are available. These include supplementing tears, decreasing tear evaporation, surgery and etiologic management, such as artificial tears, punctal occlusion, hydrophilic soft corneal contact lens and submaxillary duct transplantation. We’ve treated 44 DES cases with combined acupuncture and Chinese medicinal fumigation and compared with 46 cases treated with eye drops. The results are now summarized as follows.

1 Clinical Data

1.1 Diagnostic criteria

1.1.1 Diagnostic criteria in Western medicine

This is based on clinical symptoms and eye examinations[2]. Clinical symptoms include burning, itching or a sensation of having a foreign body in the eyes, eyestrain and unexplained discomfort of the eyes. Tear volume of Schirmer I Test (SIT) ＜10 mm/5 min and Break-up Time (BUT) of tear film＜10 s.

1.1.2 Diagnostic criteria in traditional Chinese medicine (TCM)

This is based on “dry eyes due to yin deficiency of the liver and kidney” in Ophthalmology of TCM[3]. Major symptoms include dry eyes and light sensitivity. Minor symptoms include redness of the white part of the eyeball, soreness/weakness of the low back and knee, dry mouth and throat, a dry red tongue with a thin coating, and a thready pulse. Patients with the above major symptoms and two of the minor symptoms can be diagnosed.

1.2 General materials

According to the above diagnostic criteria in both Western and Chinese medicines, a total of 90 cases treated between August 2010 and September 2011 were randomly allocated into a treatment group of 44 cases (88 eyes) and a control group of 46 cases (92 eyes) by their visiting sequence. Of the 44 cases in the treatment group, there were 11 females and 33 males; age ranged from 36 to 74 years old (mean age was 58). Of the 46 cases in the control group, there were 19 females and 27 males; age ranged from 29 to 70 years old (mean age was 56). There were no statistical differences between the two groups in terms of gender, age and duration (P＞0.05), indicating that the two groups are comparable.

The clinical process was shown in Fig.1.

Fig.1 Flow chart of clinical management in the two groups

2 Treatment Methods

2.1 Treatment group

2.1.1 Acupuncture treatment

Major acupoints: Bilateral Chengqi (ST 1), Cuanzhu (BL 2), Jingming (BL 1) and Tongziliao (GB 1).

Adjunct acupoints: Bilateral Fengchi (GB 20), Ganshu (BL 18), Shenshu (BL 23) and Taixi (KI 3).

Method: Stabilize the eyeball using the left thumb, and then puncture Chengqi (ST 1) 1 cun slowly using a filiform needle of 0.30 mm in diameter and 40 mm in length. Then puncture Cuanzhu (BL 2) 0.5 cun perpendicularly. Push outward and stabilize the eyeball by the left hand, and puncture Jingming (BL 1) and slowly insert the needle 0.5-1 cun perpendicularly along the orbital border. Puncture Tongziliao (GB 1) 0.3-0.5 cun obliquely and puncture Fengchi (GB 20) 1.5 cun perpendicularly towards the tip of the nose. Puncture Ganshu (BL 18) 0.5-0.8 cun obliquely towards the spine. Puncture Shenshu (BL 23) and Taixi (KI 3) 0.5-1.0 cun perpendicularly. A sensation of soreness or distension is required for each point. Apply even reinforcing-reducing manipulation to all acupoints except Jingming (BL 1). Retain the needles for 30 min.

2.1.2 Chinese medicinal atomizer fumigation

Ingredients: Gou Qi Zi (Fructus Lycii) 12 g, Ju Hua (Flos Chrysanthemi) 9 g, Qin Pi (Cortex Fraxini) 9 g, Gui Zhen Cao (Herba Bidentis Pilosae) 12 g and Bing Pian (Borneolum Syntheticum) 0.3 g.

Method: Decoct above ingredients with water and bag after condensation. Prior to each treatment, pour 30 mL liquid into a medicine cup of atomizer (manufactured by Shanghai Yuyue Medical Equipment Co., Ltd.) to produce cool mist. Then ask the patient to open the eyes, allowing for the contact between mist and conjunctiva. Each treatment lasted 15 min.

Acupuncture and Chinese medicinal fumigation were both conducted once every other day, 30 d for a course of treatment and 3 courses in total.

2.2 Control group

Cases in the control group were treated with Sodium Hyaluronate eye drops (manufactured by Zhuhai Federal Pharmaceutical Co., Ltd., Zhongshan Branch) 3 times a day, 1-2 drops for each dose, 30 d for one course of treatment and 3 courses in total.

3 Therapeutic Efficacy Observation

3.1 Observation indexes

These include the patient’s subjective symptoms, SIT value measured with tear detection filter paper strip (manufactured by Tianjin Jingming New Technology Development Co., Ltd., Registration No. 2400004) before and after treatment and the mean BUT value calculated by 3 times of measurement for each eye.

3.2 Grading standard

3.2.1 Patient’s subjective symptoms

According to the DES diagnostic and grading standard in relevant literature[2], the major symptoms include dry eyes, a sensation of having a foreign body in the eyes, light sensitivity and eyestrain.

0 point: Absence of above symptoms.

1 point: Occasional presence of mild symptoms that have little effect on daily activities.

2 points: Frequent presence of moderate symptoms that can affect daily activities.

3 points: Continuous presence of severe symptoms that greatly affect daily and working activities.

3.2.2 SIT value

0 point: Negative, SIT ≥10 mm/5 min.

1 point: Mild, SIT ≥5 mm/5 min but ＜10 mm/5 min.

2 points: Moderate, SIT ≥2 mm/5 min but ＜4 mm/5 min.

3 points: Severe, SIT ＜2 mm/5 min

3.2.3 BUT value

0 point: Negative, BUT ≥10 s.

1 point: Mild, BUT ≥5 s but ＜10 s.

2 points: Moderate, BUT ≥2 s but ＜5 s.

3 points: Severe, BUT ＜2 s.

3.3 Therapeutic efficacy criteria

The efficacy index was calculated according to the clinical symptoms, SIT and BUT values.

The efficacy index = (Total scores of pre-treatment symptoms — Total scores of post-treatment symptoms)/ Total scores of pre-treatment symptoms × 100%.

Marked effect: The efficacy index ≥70%, significant alleviation of major symptoms, 3 times of SIT values＞10 mm/5 min and BUT ＞10 s.

Improvement: The efficacy index ≥30%, somewhat alleviation of major symptoms, 3 times of SIT values are all increased and BUT value is increased after treatment.

Failure: The efficacy index ＜30%, major symptoms, 3 times of SIT values and BUT value all remain unchanged.

3.4 Statistical method

All data were enumeration ranked data. The SPSS 13.0 version software was used for Chi-square test analysis. P＜0.05 indicates a statistical significance.

3.5 Treatment results

3.5.1 Comparison of SIT value

Before treatment, there was no statistical difference in SIT value between the two groups (P＞0.05). After treatment, there was statistical difference in SIT value (P＜0.05) between the two groups, indicating that the treatment group is better than the control group in increasing tear secretion volume (table 1).

3.5.2 Comparison of BUT grading

After treatment, there was no statistical difference in BUT grading between the two groups (P＞0.05); however, compared with the control group, the severe grading eyes in the treatment group were markedly decreased and the negative eyes markedly increased (table 2).

3.5.3 Comparison of DES symptom grading

After treatment, there were statistical differences in DES symptom grading between the two groups (P＜0.05), indicating that the symptoms of patients in the treatment group were more significantly alleviated than those in the control group (table 3).

3.5.4 Comparison of the clinical efficacy

The total effective rate in the treatment group was 78.4%, versus 12.0% in the control group, showing a statistical difference (P＜0.01) and indicating a better effect in the treatment group than in the control group (table 4).

Table 1. Between-group comparison of SIT value (eye)

Table 2．Between-group comparison of BUT grading (eye)

Table 3. Between-group comparison of DES symptom grading (eye)

Table 4. Comparison of the clinical efficacy between the two groups (eye)

4 Discussion

In TCM, DES falls under the category of “dry eyes”or “dryness”. TCM holds that the human body is an organic whole centered on the Zang-fu organs, and eyes are closely associated with these organs. So is dry eye syndrome.

DES can affect the patient’s daily life. In severe cases, DES may also cause depression, anxiety or despair. Consequently, the essential principles of treatment for DES are to slow down the disease progression, improve the symptoms and restore the normal physiological structure of the ocular surface. In Western medicine, DES is currently managed by medication and surgery. However, medications for DES can cause adverse reactions. Long-term use of preservative-contained artificial tears may damage or impair the eyes. Surgeries including transplantation of auto-body submandibular gland, lacrimal duct blockage and eyelid fissure suture are risky and have no exact effects. Acupuncture, on the other hand, can protect the patient’s vision, inhibit the inflammatory reaction of the ocular surface and restore its normal structure and functions. In addition, acupuncture can enhance the secretion of tears, improve the stability of the tear film[4-5], and thus alleviate the patient’s symptoms.

Based on the pattern identification and treatment principle in Chinese medicine, for patients with DES due to yin deficiency of the liver and kidney in this study, we’ve treated with combined acupuncture and Chinese medicinal fumigation to nourish yin, clear heat and reinforce the liver and kidney. Chengqi (ST 1), Cuanzhu (BL 2), Jingming (BL 1) and Tongziliao (GB 1) are all located around the eyes and indicated for eye problems. Needling these points can promote the blood circulation around the eyes and thus increase tears. Needling Fengchi (GB 20) can remove wind, clear heat, sharpen the eyes and inhibits inflammation of the ocular surface. Needling Ganshu (BL 18) and Shenshu (BL 23) can nourish yin-blood and benefit the liver and kidney. Taixi (KI 3) is the Yuan-Primary point of the Kidney Meridian, and needling it can nourish kidney-yin[6-10].

Considering the complex etiological factors of DES, we added Chinese medicinal fumigation. By using the ultrasound sonic energy of the atomizer, the atomized fine molecules of medicinal can permeate into the patient’s conjunctiva and cornea in a direct, successive and comprehensive way. Since the atomization produces no irritation or pain, patients can feel comfortable right away. Furthermore, Chinese medicinal does not contain any preservatives and will not cause any toxic effects as eye drops.

The study findings have shown that combined acupuncture and Chinese medicinal fumigation can alleviate the inflammation of the patient’s conjunctiva and meibomian glands, relieve eye dryness and eyestrain and increase the stability of the tear film. Additionally, this therapy can also increase the secretion of tears and help alleviate DES. In summary, this therapy is worthy of clinical application.

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Translator: Han Chou-ping

R246.82

A

Date: January 20, 2013

Author: Liu Xin-quan, chief physician. E-mail: drliuxinquan@hotmail.com