Press Needle: A Traditional Chinese Medicine Therapy for Myopia Patients with Dry Eye

Summary

Here, we present a protocol to standardize the operation of acupuncture in the treatment of myopia with dry eye.

Abstract

Most patients with myopia have dry eye, which has been shown to adversely affect ocular symptoms, myopia progression, and quality of life in patients with myopia. Needle prickling has been shown to be effective in providing symptom relief in patients with myopia and dry eye. Press needle is a long-lasting, easy-to-operate, and inexpensive traditional Chinese medicine treatment. The standard practice of needle insertion is very important for the treatment of myopia and dry eye. The specific steps include selecting the appropriate acupoints, piercing them with appropriate needles, and fixing them in the skin or subcutaneously at the acupoints, burying them for 2 days, resting for 1 day; the course of treatment lasts for 2 weeks. Specifically, the following indicators were assessed: uncorrected visual acuity and the ocular surface disease index. This article will explain how to standardize the operation of a press needle in the treatment of myopia and dry eye.

Introduction

Myopia is a refractive error; when the eye is in a relaxed state of adjustment, parallel light rays are focused in front of the retina after passing through the refractive retina, resulting in a clear image on the retina, which is called myopia. The main manifestations of this disease are clear vision of near objects and blurred vision of distant objects¹. When the normal eye adjusts to a relaxed state, the parallel light rays from 5 m away pass through the refractive system of the eye, and the focus falls on the retina, forming a clear image. However, when a myopic patient sees a distant object 5 m away, the parallel light rays are focused in front of the retina after passing through the refractive system of the eyeball, so the vision will be blurred. If you look at a near object within 5 m, the parallel light rays will be focused on the retina after passing through the refractive system of the eyeball, and it will be clearer. Due to the rapid changes in the socio-economic environment in recent years, the widespread use of electronic screens, and the increase of refined eye use methods, the incidence of myopia has increased rapidly, and it is showing a trend of younger age, which has a serious impact on social health.

According to statistics, the number of myopic people in the world will reach nearly 5 billion in 2050. With the spread of computers and smartphones, coupled with the impact of the previous novel coronavirus outbreak, more and more myopic patients are beginning to have comorbid dry eye symptoms². Nearly 400 million people in China suffer from dry eye, and the prevalence of dry eye in myopia is significantly higher than that in emmetropia and hyperopia, and the incidence of dry eye in myopic adolescents is about 20%. Tear deficiency and tear film instability are key factors that lead to dry eye, and changes in the cornea and increased eyelid space during eye elongation in myopia patients can cause uneven tear film distribution, resulting in decreased tear film stability, which increases the risk of dry eye.

Dry eye syndrome is characterized by an imbalance of tear film and eye discomfort. It is a chronic inflammatory reaction of corneal conjunctival dryness, which is mainly manifested by sensitivity to the external environment, insufficient tear fluid, and foreign eye sensation. It can lead to corneal conjunctival lesions and visual impairment, and then affect the quality of life and vision of patients³. The etiology of dry eye is complex; the main cause is the abnormal quality, quantity, and dynamics of tears, resulting in tear film instability or imbalance of ocular surface microenvironment. The specific onset of the disease is related to the patient's ocular surface tear film osmotic pressure changes, immune inflammatory response, tear film hyperoxidation, neuroparesthesia, and apoptosis, and the pathological process involves MAPK, NF-κB, Wnt, TLR, PI3K/AKT, and other signaling pathways^4,5.

Traditional Chinese medicine believes that the main pathogenesis of dry eye in myopia patients is liver and kidney insufficiency. In the Yellow Emperor's Neijing-Su Wen, it is recorded that "the five internal organs and six internal organs are infiltrated into the eyes", which shows that the dysfunction of the internal organs, the insufficient production of the fluid to moisturize the eyes, or the poor infusion are important pathogeneses. Yinhai Subtlety clearly states: "Tears are less responsible for the deficiency of liver and kidney"-the main blood of the liver is the outer part of the eye, the liver blood is enough, and the liver qi is regulated, and the subtle substances are injected on the surface of the eye for tears. The main water of the kidney is the source of the fluid, and the kidney is sufficient, the kidney qi is full, and the source of the whole body is sufficient. The liver and kidney essence and blood are homologous and interconnected, so liver and kidney insufficiency is an important pathogenesis⁶. At present, the clinical treatment of dry eye is mainly based on artificial tears, vitamins, nerve growth factor, and thermal pulse therapy, which has good short-term effects, but the long-term effects are still limited. Traditional Chinese medicine treatment is mainly based on the internal administration of traditional Chinese medicine, acupuncture, hot compress fumigation, auricular pressure pills, etc. The durability of the curative effect is good, but the operation is more complicated, and the patient's compliance is not strong.

Press needle is a kind of intradermal acupuncture, which is widely used in clinical practice, mainly used for the treatment of facial paralysis, insomnia, dysmenorrhea, and other diseases, and has gradually expanded to ophthalmic diseases in recent years, with the characteristics of long-lasting effect, easy operation, low cost, and good patient compliance⁷. Specifically, a special small needle (0.2-0.3 cm long) is inserted and fixed in the acupoint area or subcutaneously for a long period of burial. There is no need to immediately produce a sense of air when burying the needle, and the air can be adjusted only after the needle is buried. This therapy combines the theory of acupoints and the skin theory of traditional Chinese medicine, adopts the ancient idea of "staying still for a long time", combines the advantages of traditional acupuncture and thread embedding, and has a long period of continuous stimulation of the skin, to achieve the purpose of preventing and treating diseases.

Press needles can improve unaided distance vision, improve the state of visual fatigue, reduce refraction, and delay the axial growth of myopia patients, which has been confirmed by clinical studies^8,9,10. Press needle can improve dry eye and is better than sodium hyaluronate eye drops alone in improving the stability of the tear film, tear secretion, and the degree of corneal epithelial damage in patients with dry eye^11,12,13. The effect of press needle combined with auricular pressure beans, traditional Chinese medicine atomization fumigation, and massage in the treatment of dry eye is more significant, which may be related to the regulation of multiple signaling pathways such as MAPK, NF-kB, Wnt, TLR, and PI3K/AKT.

Based on the theory of acupoints and dermatozoa in traditional Chinese medicine, this study was treated with a press needle (Figure 1), aiming to improve the symptoms of dry eye, improve visual function, and quality of life. A press needle is a long-lasting, easy-to-operate, and inexpensive traditional Chinese medicine treatment. To sum up, it is necessary to propose a standard scheme on how to correctly operate acupuncture for the treatment of myopia with dry eye. This article explains how to properly use a press needle to treat dry eye in patients with myopia.

Protocol

This protocol has been approved for clinical trial ethics in the Department of Ophthalmology, Affiliated Hospital of Chengdu University of Traditional Chinese Medicine (ethics record number: KY2023001). Ensure that the environment is clean and pollution-free, with plenty of light and quiet surroundings. Informed consent was obtained from the patients to use and publish data shown in this paper.

1. Doctor preparation

1. Check the basic information of the patient. Make sure the patient meets the diagnostic criteria for myopia in the Myopia Prevention and Control Guidelines and has dry eye: (1) Make sure that the patient has blurred vision at a distance, good near vision, often fluctuating distance vision in the early stage, and squinting when looking at distant objects; (2) Determine myopia by refraction and determine the degree.
2. Exclude patients with the following conditions: (1) Patients with motion sickness; (2) Skin ulcers; (3) Patients with poor blood sugar control, poor blood pressure control, and dizziness; (4) Patients with coagulation dysfunction and severe cardiac insufficiency; (5) Rheumatic heart disease, congenital heart disease, kidney failure, liver failure, etc.; (6) Patients who do not cooperate with treatment.
3. Wear a medical mask and medical hat
4. Wash hands with soapy water and the seven-step handwashing method, keep them dry, and use hand sanitizer before taking the needle.
   NOTE: Avoid touching other items after hand sanitization. Hand washing must be carried out before and after the procedure, and hands must be kept clean.

2. Patient examination

1. Get basic patient information: ask for the patient's name, sex, age, doctor number, height, weight, past medical history, chief complaint, and other basic information.
2. Test the patient's naked eye visual acuity.
   1. Ask the patient to be 5 m away from the eye chart; cover one side of the eye.
   2. Identify the "E" on the eye chart and check it until it is no longer recognizable. Keep the direction of the label from top to bottom.
   3. Read the decimal notation on the left side of the eye chart and judge the patient's visual acuity based on the reading of the eye chart.
   4. The other eye is then evaluated using the same method. A score of less than 1.0 is considered myopia compared to the Universal Visual Acuity Chart (UCVA).
3. Test the patient's dry eye syndrome score.
   1. Make sure the patient has one of the subjective symptoms such as dry eyes, foreign body sensation, burning sensation, fatigue, discomfort, eye redness, and vision fluctuations.
   2. Check the corresponding conditions against the ocular surface disease index scale (OSDI): Have you experienced photophobia, foreign body sensation, eye pain, eye irritation, blurred vision, or vision loss in the last week? Always appearing is 4 points, often appearing is 3 points, half of the time appearing is 2 points, sometimes appearing is 1 point, no appearance is 0 points.
   3. Calculate the score using equation: 0-12 is normal; 13-22 is classified as mild dry eye; 23-32 for moderate dry eye; 33-100 is severe dry eye.
      Final score =   
   4. If the patient's UCVA score is <1.0 and the OSDI is ≥13 points, perform the next step of needle therapy; otherwise, suspend the needle administration. Make sure the skin is not damaged and ulcerated.
4. Measure the patient's blood pressure.
   1. Let the patient relax and rest quietly for 5-10 min before the measurement.
   2. Prepare a mercury sphygmomanometer; have the patient sit with their feet flat and their elbows and forearms comfortably positioned approximately parallel to the heart.
   3. Turn on the blood pressure monitor and bring the mercury column down to zero.
   4. Tie the sphygmomanometer cuff above the elbow joint of the patient's upper arm; ensure that one finger can still be inserted between the cuff and the skin.
   5. Put the stethoscope in the elbow joint where there is an arterial pulse, and then slowly raise the pressure in the blood pressure monitor until the pulse of the blood vessels cannot be heard through the stethoscope. Now slowly deflate: systolic blood pressure is when the first sound of the pulse of the blood vessels is heard while diastolic blood pressure is when no sound can be heard.
   6. If the blood pressure is normal (systolic blood pressure is lower than 90-140 mmHg, diastolic blood pressure is higher than 60-90 mmHg), perform the next step of needle therapy; otherwise, suspend the needle application.
5. Detect the patient's pulse rate and oxygen saturation.
   1. Prepare a clip-on oximeter, put the index finger of the left or right hand into the clip-on of the clip-on oximeter, and check that the infrared light in the clip-on is turned on.
   2. Keep the finger in full contact with the clip-on oximeter, showing the progress of the test on the display. After entering the detection state, keep fingers in a stable state.
   3. Once the test result is displayed on the display, take the finger out. The %SpO2 at the top of the display screen is the blood oxygen index, and the Min on the screen is the pulse rate.
   4. If the pulse rate is normal (60-100 bpm (times/min)), carry out the next step of needle treatment; otherwise, suspend the needle application.
6. Measure the patient's respiratory rate.
   1. Ask the patient to be quiet, sitting or lying flat for calm breathing.
   2. Observe the person's breathing pattern (chest breathing or abdominal breathing) and place their hands on the chest or abdomen.
   3. Count with a watch or clock and judge the respiratory rate per minute by observing the rise and fall of the chest or abdominal cavity.
   4. If the respiratory rate is normal (12-20 breaths/min), perform the next step of needle therapy; otherwise, suspend the needle application.

3. Identification and disinfection of acupuncture points

1. Lay the patient flat on the treatment bed in a supine position. Remove glasses, if any, to expose the face. Let the doctor stand on the right side of the patient.
2. Follow acupuncture point positioning: according to the standardized acupoint positioning, Cuanzhu (BL2), Yuyao (Ex-HN04), Sibai (ST2) (see Figure 2).
   1. BL2: locate on the face, take the depression on the inner edge of the eyebrows (the middle of the eyebrows, the supraorbital notch).
   2. Ex-HN04: locate on the forehead, looking straight up, the pupil is straight up; take the middle of the eyebrows.
   3. ST2: locate on the face, the eyes are square, the pupil is straight down; take the depression of the infraorbital foramen.
      CAUTION: Ask the patient if they have an alcohol allergy before disinfection. It should not be used by those allergic to alcohol and stainless steel.
3. Take 75% medical disinfection alcohol, spray 2-3x at the acupuncture point, and wipe with a disposable medical disinfection swab from inside to outside, from top to bottom; the diameter of the disinfection part is about 2-3 cm. Wait for the alcohol to evaporate and ensure that the operating part is dry.

4. Acupuncture procedures

1. Check the press needle to ensure that it is within the shelf life, open the package, and check whether the press needle is complete, without damage or deformation.
2. Acupuncture the BL2 acupoint: fix the skin with the thumb and index finger of the left hand, pick up the needle tape with tweezers with the right hand, keep the needle sterile, aim the needle tip at the acupuncture point, enter the skin at 45°, press the needle tip completely into the skin, and press the fixed tape with the left hand (see Figure 3).
   1. If touching the blood vessel, reduce the angle between the needle and the skin to avoid further insertion of the needle into the blood vessel.
3. Acupuncture the Ex-HN04 acupoint: follow the procedure outlined in step 4.2 (see Figure 4).
4. Acupuncture the ST2 acupoint: follow the procedure outlined in step 4.2 (see Figure 5).
5. Ask the patient how they feel: gently press the finger 3x to apply the needle, and ask the patient whether there is any sourness, numbness, swelling, pain, and other irritation. If there is any sensation, leave the needle; if there is no sensation, adjust the direction of the acupuncture until there is sensation, and then leave the needle.
6. Remove the needle after 2 days, rest for 1 day, and apply the above acupuncture points again. A course of treatment lasts 2 weeks; administer a total of 2 courses of treatment. Perform compressions approximately every 3 h during the retention period, 3x a day, for ~1 min at a time.
7. Take the needle: fix the skin with the thumb and index finger of the left hand, pick up the needle tape with tweezers in the right hand, take out the needle perpendicular to the skin, press the needle hole with a sterile cotton swab after removal, and disinfect it locally with an alcohol swab.
8. After the needle is removed, keep the patient in the treatment room for 30 min before leaving.
9. Efficacy evaluation: after 1 course (2 weeks), measure the patient's naked eye vision against the International Universal Visual Acuity Chart (UCVA), and assess the improvement of the patient's dry eye score before the next course of treatment.

Results

In this study, a total of 8 patients who met the criteria participated and completed the trial, and none of them were discharged or excluded during the process. The OSDI and UCVA scores were used as the primary evaluation indicators for this trial, with data derived from the scores on the scales completed by patients before and after treatment. Self-control before and after treatment was compared using a paired t-test.

The OSDI scores of patients before and after treatment were compar...

Discussion

As an ancient traditional treatment method in China, the efficacy of acupuncture has been verified in the long history of development, and various research results in recent years have further proved the effectiveness of acupuncture in improving the vision and dry eye symptoms of myopia patients. The effectiveness of this therapy depends mainly on the acupuncture points chosen. The studies of Gao Hui¹⁴ and others have confirmed that acupuncture therapy can significantly improve the symptoms of dry...

Materials

Name	Company	Catalog Number	Comments
75% Alcohol disinfectant	Kangpai (Jiangsu) Medical Technology Co., Ltd.	20230926
Disposable surgical masks	Hunan Kefu Medical Equipment Co., Ltd	20220401
Disposable treatment towels	Chengdu Mingsen medical equipment Co.,Ltd	20230824
Fingertip pulse oximeter	Jiangsu Yuyue Medical Equipment Co., Ltd	20172201070
Medical disposable hat	Qingdao Hairun Medical Technology Co., Ltd	20190576
Medical tweezers	Hunan Kefu Medical Equipment Co., Ltd	P0402311003
Mercury sphygmomanometer	Jiangsu Yuyue Medical Equipment Co., Ltd	20152070947
Sterile medical disposable sterilized cotton swabs	Hunan Kefu Medical Equipment Co., Ltd	20210014
Sterile press needles for single-use	Suzhou Medical Supplies Factory Co., Ltd	233126
SPSS		Data analysis software