Case Collection of Acupuncture Treatment for the Refractory Eye Diseases by Professor Zhang Ren

Zhang Shu-jing, Zhang Yan-min, Zhang Ren

1 Shanghai Research Institute of Acupuncture and Meridian, Shanghai 200030, China

2 Yi County Hospital of Traditional Chinese Medicine, Hebei 074200, China

3 Shanghai Literature Institute of Traditional Chinese Medicine, Shanghai 200020, China

Case Collection of Acupuncture Treatment for the Refractory Eye Diseases by Professor Zhang Ren

Zhang Shu-jing1, Zhang Yan-min2, Zhang Ren3

1 Shanghai Research Institute of Acupuncture and Meridian, Shanghai 200030, China

2 Yi County Hospital of Traditional Chinese Medicine, Hebei 074200, China

3 Shanghai Literature Institute of Traditional Chinese Medicine, Shanghai 200020, China

Famous Doctor’s Experience; Acupuncture-moxibustion Therapy; Eye Diseases; Points, Extraordinary, Head & Neck; Point-toward-point Method

Zhang Ren, a master of medicine, professor, chief physician, and State Council expert for Special Allowances. He is the current vice president of Chinese Acupuncture Society, the honorary chairman of Shanghai Acupuncture Society, a member of Shanghai Intangible Cultural Heritage Assessment Committee. He used to be the director of Shanghai Municipal Literature Museum of Traditional Chinese Medicine and the director of the Shanghai Information Institute of Traditional Chinese Medicine.

He has been engaged in acupuncture clinical and literature research for more than 40 years. He has been to Europe to give lectures and treat patients in clinic for 3 times, and received a favorable evaluation. And he has independently written and edited more than 60 books on acupuncture and traditional Chinese medicine as a chief editor (including English and Japanese versions), which were published in Beijing, Shanghai, Chongqing, Taipei and Tokyo. He has published nearly 100 papers in both English and Chinese. He has also chaired Shanghai Municipal Public Health Bureau research projects, and participated in a number of projects such as Shanghai Municipal Science and Technology Commission project, the National 973 project. He has accumulated a wealth of clinical experience on acupuncture treatment for multiple modern intractable diseases, especially has unique experience on the acupuncture treatment for stubborn eye diseases.

Professor Zhang Ren has been involved in a medical career for more than 40 years, gaining medical knowledge by self-study, apprentice and school education. In clinic, he has formed his own characteristics of diagnosis and treatment that he mainly focuses on acupuncture treatment for refractory eye diseases, but also involving a variety of difficult diseases by absorbing comprehensive use of different treatment methods. I had the privilege of attending the teacher’s clinic, and now Prof. Zhang’s acupuncture treatment experience for refractory eye diseases is described as follows.

1 Optic Nerve Contusion

A 20-year- old male patient firstly visited the clinic on February 6, 2012.

Chief complaint: Blurred vision of the left eye for more than a month.

History of present illness: The patient had a history of myopia, he was hit by a plastic dart at the corner of the eye under the left brow one month before coming here, and he immediately felt painful in the left eye and difficult to open it, and he also felt eye protrudent and could not stop the tears. He was sent to the Ear, Nose and Throat (ENT) Emergency, and the examination showed that there was congestion and decreased vision of the left eye, and the pupil was dilated, so the diagnosis was the left optic nerve contusion. His symptoms did not relieve at all after treated with Western medicines, such as rat nerve growth factor injection. So, he turned to ask for acupuncture treatment.

Examination: Left pupil moderately dilated and was unresponsive to light. The papilledema color was acceptable and the reflection of the macula center was dispersive. The corrected visual acuity by wearing glasses of the left eye was 0.15; that of the right eye was 0.4.

Western medicine diagnosis: Left optic nerve contusion.

Treatment: Xinming I [Extra, locates at 0.5 cun anterior and superior to Yifeng (TE 17), and at the mid-point of the folds behind ear lobule], Xinming II (Extra, locates at 1 cun upper and 0.5 cun exterior to the end of eyebrow), Taiyang (EX-HN 5), Qiuhou (EX-HN 7), Fengchi (GB 20) and Yiming (EX-HN 14) were selected, and the needles were retained after arrival of qi. For Taiyang (EX-HN 5) and Qiuhou (EX-HN 7), acupuncture and acupoint injection were alternately manipulated, which meant that Taiyang (EX-HN 5) was injected when Qiuhou (EX-HN 7) was acupunctured, while Qiuhou (EX-HN 7) was injected when Taiyang (EX-HN 5) was acupunctured. And the operation stopped until there was an obvious distention sense in local acupoint. The needles in Xinming I (Extra) and Xinming II (Extra) were connected with electroacupuncture instrument with 2 Hz continuous wave during retention, and the intensity depended on the patient’s tolerance. The needles were removed after 30 min. However, the needle in Taiyang (EX-HN 5) needed to be shank to enlarge pinhole until letting a few drops of blood. As to acupoint injection, Mecobalamin injection (0.5 mg/mL) was injected into Qiuhou (EX-HN 7), 0.5-1 mL per point, and Dan Shen (Radix Salviae Miltiorrhizae) injection was injected into Taiyang (EX-HN 5), 1 mL per point, 2-3 times a week.

After a 2-month treatment, the corrected visual acuity increased to 0.4, but there was no obvious improvement in pupil dilation. Therefore, tapping the skin around the eye with cutaneous needles was added, 3-4 min each time, and acupuncture was given twice a week.

After another 1.5 months of treatment, the corrected visual acuity of the left eye increased to 0.7, the left pupil size also significantly reduced, but was still slightly larger than the right side. The treatment was given once a week to consolidate the effect.

Note: The optic nerve contusion is indirect optic nerve injury, usually caused by a violent head trauma. The main clinical manifestation is rapid vision loss, and it is equivalent to traumatic injury of eyes in traditional Chinese medicine, and there is rare report of modern acupuncture treatment for the disease in clinic. Based on the principle of "symptomatic treatment in acute condition", Prof. Zhang mainly selected local acupoints, and selected the neck acupoints as supplement, aiming at clearing meridian qi, activating blood circulation and dispersing blood stasis in order to improve eyesight. It’s intended to increase the power of activating blood circulation to dissipate blood stasis by adding the bleeding of Taiyang (EX-HN 5). It is effective in improving vision and reducing the pupil size by combining with electrical stimulation and acupoint injection. However, the efficacy of acupuncture to treat the disease is closely related to disease duration and degree of injury, thus the patient should be clearly diagnosed and timely treated.

2 Eyelids Twitching

A 42-year-old female staff of the bank firstly visited the clinic on May 6, 2012.

Chief complaint: Bilateral upper eyelid had twitched more than six months.

History of present illness: Six months before coming here, she suddenly suffered from involuntary twitching of bilateral upper eyelids without any obvious inducement, and the right one was worse. The symptom gradually became worse. It frequently occurred, got worse in case of labor or fatigue, inducing inability of reading. It was better when she got up in themorning, but was worse in the afternoon. She was diagnosed with eyelids twitching in another hospital, but she didn’t get significantly better after symptomatic treatment. Recently, she felt the bilateral upper eyelid twitching more frequently, even felt difficult to open eyes, which seriously affected her daily life, and she was unable to work. Besides, she also had the complicated symptoms including dizziness and headache. Her appetite and sleep were normal as well as urination and bowel movements. Then she visited Prof. Zhang’s clinic for acupuncture treatment.

Western medicine diagnosis: Eyelids twitching.

Treatment: Yangbai (GB 14), Yuwei (Extra, locates at the outer end of eyebrow), Cuanzhu (BL 2), Fengchi (GB 20) and Toulinqi (GB 15) were selected. Yangbai (GB 14) was punctured with a needle of 0.30 mm in diameter and 25 mm in length, with the tip obliquely towards Yuyao (EX-HN 4), and it was rotated to induce the heat and distention sensation in the local area. A needle of 0.30 mm in diameter and 25 mm in length was punctured from Yuwei (Extra) to Cuanzhu (BL 2);“cross acupuncture method” was manipulated in Cuanzhu (BL 2), that two needles of 25 mm in length were respectively punctured into Shangjingming [Extra, locates 0.2 cun above Jingming (BL 1)] and Yuyao (EX-HN 4), and were remained after arrival of qi by rotating manipulation. And a needle was punctured into Fengchi (GB 20) towards outer canthus of the same side. After arrival of qi, the needling sensation was promoted to radiate to the forehead and eye areas by slow lifting-thrusting manipulations, which was called inducing qi method. A needle of 25 mm in length was subcutaneously punctured into Toulinqi (GB 15) towards Muchuang (GB 16). The needles in the pair acupoints of Yuwei (Extra) and Yangbai (GB 14) or Cuanzhu (BL 2) were connected with the electroacupuncture instrument with sparse-dense wave. And the strength degree depended on obvious eye muscle contraction and the patient’s tolerance. The patient’s eyelid spasm temporarily disappeared at the end of the first acupuncture treatment, but soon relapsed, and there was a slight reduction in the number of attacks. She continued to be treated in accordance to the method. After 10 times, her eyelid spasm was basically controlled. She could go to work, but still did not dare to use the computer. After 20 times of treatment, the symptoms disappeared completely. She could already work properly. Therefore, the treatment reduced to once a week to consolidate the curative effect. So far, the disease has not recurred.

Note: Eyelids twitching is an unexplained nonautonomous spasm of facial muscles. The clinical symptoms include the paroxysmal and frequent spasms of orbicularis muscles, and severe and obvious spasms can impact vision because of the difficulty opening eyes.

It’s believed in traditional Chinese medicine that the disease is related to liver-blood deficiency causing malnutrition of the eyes. Blood deficiency can produce wind, whose characteristic is moving and shaking, that is why it can attack eyelid and induce its spasm. For the disease, Prof. Zhang focuses on choosing local acupoints, such as Cuanzhu (BL 2) and Yuwei (Extra) to tonify qi-blood to nourish eyelip; secondly, he select Yangbai (GB 14), Fengchi (GB 20) and Toulinqi (GB 15) to inhibit endogenous wind. As to operation, he prefers point-toward-point needling method and electroacupuncture. The former one can promote qi movement to dredge meridian, as well as balance yin and yang to soothe qi; while the latter one with sparse-dense wave can improve curative effect.

Acupuncture works rapidly in treating this disease, with significant effect, but it requires good compliance to treatment. Because most patients reflect that the symptoms disappear immediately after acupuncture, but only for 1-2 d. Therefore, the patients should be treated every other day at the beginning of treatment. When they are in stable conditions, they can be treated twice a week till the symptoms disappear, then insist on once 1 or 2 weeks to prevent recurrence.

3 Keratopathy

A 25-year-old female patient firstly visited on January 5, 2012.

Chief complaint: She had suffered from redness, pain and other discomfort in the eyes for 2 years, and the symptoms became more severe and accompanied with hypopsia for nearly a month.

History of present illness: Since the beginning of last year, the patient presented with redness, swelling, pain and discomfort of the right eye due to wearing contact lenses for a long time and other reasons, and eye drops could relieve symptoms. However the symptoms occurred frequently this year and there were new symptoms including dryness and foreign body sensation companied with photophobia, tearing, redness and blurred vision of the eyes, and eye drops made the symptoms worse and induced prickling-like pain instead of effect. And she was diagnosed with conjunctivitis complicated with keratitis.

Examination: There was mild hyperemia of conjunctiva, mild ciliary congestion of the bulbar conjunctiva, and punctate infiltrates in the corneal. The corrected visual acuity of the left eye by wearing glasses was 0.3, and that of the right eye was 0.9, but there was no fundus abnormality.

Western medicine diagnosis: Keratitis.

Operation: Shangjingming (Extra), Cuanzhu (BL 2), Yiming (EX-HN 14), Xinming I (Extra) and Qiuhou (EX-HN 7) were selected. A needle of 0.30 mm indiameter and 25-40 mm in length was inserted into Yiming (EX-HN 14), and the sensation radiated to the temporal direction. And a needle was perpendicularly inserted into Shangjingming (Extra) by 1.2 cun till there was sore sensation in the eye. And a needle was subcutaneously inserted into Cuanzhu (BL 2) to make distention sensation in eye area. The needles in Xinming I (Extra) and Cuanzhu (BL 2) were respectively connected with electroacupuncture instrument with continuous wave, and the strength was appropriate to patient’s tolerance. The needles were retained for 30 min.

Magnetic beads were pasted onto selected auricular points including Liver (CO12), Kidney (CO10), Eye (LO5), Eye 1 (TG2), Eye 2 (AT11) and Erzhong (HX1).

After the needles were removed, Erjian (EX-HN 6) was pricked by a thick needle for bloodletting by 5 drops. The patient was treated three times a week, and the symptoms of redness, pain and discomfort relieved after 10 sessions, and the vision became clearer, thus the corrected visual acuity of the left eye was 0.7, and that of the right eye was 1.0, but outside the upper conjunctiva of the left eye was still slightly reddish. Then she was treated twice a week, and her visual acuity was totally recovered, and there was no hyperemia conjunctiva after another 10 sessions. Considering that this disease was easy to recur, so she continued to be treated once a week, and she was cured after 4 sessions.

Note: Keratopathy is currently one of the eye diseases that can induce blindness, including corneal inflammation, corneal degeneration and corneal dystrophy. Generally it affects unilateral eye. And it is mainly caused by some infectious disease-causing factors invading corneal epithelial cell layer, and its main clinical symptoms include pain, photophobia, lacrimation and blepharospasm.

There are rare reports on acupuncture treatment for corneal diseases, and Prof. Zhang has begun to study to treat the disease with acupuncture in recent years. Shangjingming (Extra), Cuanzhu (BL 2), Yiming (EX-HN 14), Xinming I (Extra) and Qiuhou (EX-HN 7) constitute the basic formula of Prof. Zhang for refractory eye diseases, while Taiyang (EX-HN 5) and Erjian (EX-HN 6) are used to clear heat and toxic. As to operation, he calls for a comprehensive variety of methods. And for corneal diseases caused by dystrophy, the treatment usually is combined with point injection to improve efficacy.

4 Paralytic Strabismus

A 48-year-old male patient firstly visited the clinic on June 12, 2012.

Chief complaint: Blepharoptosis of the right eye accompanied by diplopia for two weeks.

History of present illness: The patient was admitted to the hospital on April 16, 2012 due to "sudden headache and dizziness for 6 d, and blepharoptosis of the right eye for 2 d, which had become severe for 5 h". Then physical examination showed that consciousness was clear, the left pupil diameter was 2.5 mm, light reflection was positive, and the right pupil diameter was 4 mm, light reflection (±), and the right eyelid drooped. The limbs’ muscle strength and tension were normal, and Babinski sign was negative. The diagnosis was ruptured intracranial aneurysm. The patient had had immediate interventional treatment under anesthesia. After discharge, his headache and dizziness symptoms disappeared, both of bilateral pupil diameters were 2.5 mm, and the light reflection existed. But there were blepharoptosis of the right eye accompanied by diplopia, which was diagnosed as oculomotor nerve palsy by neurology and ophthalmology departments. There was no improvement after medicine treatment.

Examination: There was right eye ptosis; the eye couldn’t open without finger’s help. There was exotropia of the right eye, which could not rotate inward and downward. The tongue was pale, with greasy coating and teeth-print, and the pulse was soft.

Western medicine diagnosis: Oculomotor nerve palsy.

Operation: Acupoints on the affected side were chosen including Sizhukong (TE 23), Tongziliao (GB 1), Fengchi (GB 20), Cuanzhu (BL 2), Yuwei (Extra) and Guangming (GB 37). Sizhukong (TE 23) and Tongziliao (GB 1) were deeply punctured by the needles of 0.30 mm in diameter with strong stimulation. Generally the needles were inserted 0.8-1.0 cun perpendicularly and were lifted, trusted, and rotated until there was soreness and distention sensation in local areas, and the needling sensation radiated to the orbital or outer corner of the eye. The needle in Fengchi (GB 20) was towards the ipsilateral outer canthus in order to make the needling sensation radiate to forehead. The needles in Cuanzhu (BL 2) and Yuyao (EX-HN 4) were punctured towards Yuwei (Extra). As to Guangming (GB 37), either the affected or the unaffected side one could be chosen, the needle was lifted, thrusted, twirled and rotated for 5 min after arrival of qi. Then Fengchi (GB 20) and Sizhukong (TE 23) comprised a pair as well as Yuwei (Extra) and Cuanzhu (BL 2), and the needles in these acupoints were connected with electroacupuncture instrument with 1 Hz continuous wave to make eyelid twitch, and the strength depended on the patient’s tolerance degree. The needles were retained for 30 min, and his symptoms obviously relieved after 5 treatments. Besides, both Chengqi (ST 1) and Shangjingming (Extra) were deeply punctured by the needles of 0.30 mm in diameter and 0.25 mm in length till arrival of qi, and the patient was treated 3 times a week.

After six sessions, ptosis of the right side disappeared, the eye could partially turn to the right, but could not turn down yet, and diplopia relieved markedly. After 12 treatments, the right eye could rotate inward and downward, and diplopia disappeared. Then he was treated 2 times a week in order to consolidate the curative effect. After 2 months of treatment in total, he was cured.

Note: Strabismus belongs to the extraocular muscle diseases. Which means both of the eyes cannot stare at a target at the same time. It includes concomitant strabismus and paralytic strabismus, and the latter one means eye dysfunction caused by part or total paralysis of one or some extraocular muscles, manifested by limited eye movement and diplopia.

The acupuncture formula is the basic one of Prof. Zhang to treat paralytic strabismus, at the same time, Sizhukong (TE 23) and Tongziliao (GB 1) are deeply punctured and strongly stimulated. Those two acupoints are effective, which has been summed up by Zhang Ren from the practice. Both acupoints are located in the lesion, and play a role of promoting blood circulation and dredging meridian. Tongziliao (GB 1), Fengchi (GB 20) and Guangming (GB 37) belong to the Gallbladder Meridian, thus puncturing them can dredge meridian qi. Puncturing Cuanzhu (BL 2) and Yuwei (Extra) towards Yuyao (EX-HN 4) can unblock meridian and promote qi movement. As to operation, the sparse-dense wave should be selected for electroacupuncture, and the intensity depends on patients’ tolerance.

5 Conclusion

Prof. Zhang has rich experience in diagnosing and treating of refractory eye diseases[1-4]. He pays attention to combination of syndrome differentiation and disease differentiation; he usually chooses extraordinary acupoints, and focuses on integrated use of local and remote acupoints. He pays attention to comprehensive manipulations of multiple therapies, such as pointtoward-point method, acupoints injection, electroacupuncture. He focuses on inducing the needle sensation in the local areas to radiate to the disease location. These clinical features are the keys to get the clinical efficacy, which are worthy of our further exploration and research.

[1] Liu J. Brief introduce to Professor Zhang Ren’s experience on extraordinary points for eye diseases. Shanghai Zhenjiu Zazhi, 2004, 23(7): 3-4.

[2] Zong L. Zhang Ren’s needling experience in treating refractory diseases. J Acupunct Tuina Sci, 2007, 5(6): 324-326.

[3] Liu J. Dr. Zhang Ren’s experience in acupuncture treatment of obstinate eye diseases. Zhongyi Zazhi, 2006, 26(1): 42-46.

[4] Xu H, Wang S, Liu J, Zhang R. Director Zhang Ren’s experience on acupuncture treatment for optic nerve contusion. Shanghai Zhenjiu Zazhi, 2011, 30(6): 354-356.

Translator: Deng Ying

R246.82

B

Date: January 28, 2013

Author: Zhang Shu-jing, M.D., research assistant. E-mail: sea_zhang11@126.com