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Acupuncture may Improve Vision in Patients with Age-related Macular Degeneration

ABSTRACT
Background and Aims: Age-related macular degeneration (AMD) is a disease associated with aging that gradually destroys sharp, central vision. Treatment options for AMD are limited and often vision loss can not be prevented. The present study was performed to evaluate the effects of acupuncture treatment on vision in AMD patients.

Methods: A total of 328 patients with a clinical diagnosis of AMD were treated over a period of 2 weeks (Monday to Friday) with acupuncture given two times per day with a minimum time of 60 minutes between treatments. Vision was evaluated at baseline, after one and after two weeks of treatment by a distant (3 m) and at near (40 cm) standard reading test.

Results: Median visual acuity improved during the first treatment week at both distances (p < 0.001). Further improvement of visual acuity was observed during the second week (p < 0.001). From baseline examination to the final examination, vision at 3 m distance improved in 145 (44.2%) patients and vision at 40 cm distance improved in 290 (88.4%) patients.

Conclusion: We conclude that acupuncture may be a treatment option in patients with AMD. Double-blinded, randomized sham-controlled studies will be necessary for final proof of action.

Introduction
Age-related macular degeneration (AMD) is a common vision-threatening disease primarily occurring in patients older than 60 years [, ]. The pathophysiology of AMD is complex and, in addition to genetic predispositions, at least four processes contribute to the disease, i.e. lipofuscinogenesis (with its linkage to oxidative stress), drusogenesis, local inflammation and neovascularization (in the case of wet form of AMD) [].

Due to the fact that there are evidently many various pathogenetic factors underlying AMD, the disease is probably the clinical result of mostly undefined causes. For this reason, available therapies are aimed to help to avoid further vision loss rather than to improve vision. None of up-to-now used treatments can “cure” the disease or reverse its course. Especially in the case of dry AMD, there is no established effective treatment available.

Acupuncture is one of the most frequently used complementary therapies in Western countries and is considered safe in the hands of competent practitioners []. There is an ongoing controversy on the efficacy of acupuncture, however, promising results have emerged showing efficacy of acupuncture in adult postoperative and chemotherapy nausea and vomiting and in postoperative dental pain [x].

In the present study we report novel data on the effects of acupuncture treatment in AMD patients.

Methods
The present study comprised consecutive patients with dry AMD diagnosed by their ophthalmologist. All patients were of Caucasian origin living in the same geographical area in the southern part of Austria and were seen at a medical center specialized for acupuncture. Informed consent was obtained prior to enrolment. The study was performed in accordance with the tenets of the Declaration of Helsinki and the guidelines of the Ethics Committee of the Medical University Graz.

Before enrolment, patients performed an eye test. After one acupuncture treatment, the eye test was repeated. Subjects whose vision had not improved were classified as non-responders and were not eligible for enrolment.

The selection of acupuncture points is summarized in table 1. Each patient was acupunctured at the same points. Acupuncture treatment was given for two weeks two times per day (Monday to Friday) with a minimum time of 60 minutes between treatments. Treatment was done using sterile 0.26 x 16 mm steel needles (Tianyi Acupuncture Instruments, China)

Eye test
Visual acuity was determined using standard eye tests. Patients were asked to letters on a cardboard wall chart from distance of 3 m (distant vision) and 40 cm (near vision). The chart for distant vision test (Oculus chart 4634) had 9 lines of letters with decreasing size and the chart for near vision test had 15 lines with letters of decreasing size. A visual acuity score representing the percentage of letters that were correctly read was assigned. The score ranged from 0% (no letter correctly read) to 100% (all letters correctly read). Eye tests were done at baseline (before acupuncture therapy), after one week of treatment, and after two weeks of treatment. All vision tests were done with both eyes

Statistics
SPSS for windows (release 14.0; SPSS, Inc) was used for statistical analyses. Vision scores were compared by Wilcoxon matched pairs tests. The criterion for statistical significance was p < 0.05.

Results
Of the 344 patients willing to enter the study, 16 (4.7%) were classified as non-responders. The remaining 328 patients (227 women and 101 men) formed the study population. Mean age of patients was 77.4 ± 8.6 (range 51 to 96) years.

Median vision improved from the baseline examination to the first follow-up examination significantly, both at vision tests at 3 m distance as well as 40 cm distance (figure 1). A further significant improvement was observed from the first follow-up examination to the second followup examination.

From baseline examination to the final examination, vision at 3 m distance improved in 145 (44.2%) patients, remained stable in 169 (51.5%) patients and became worse in 14 (4.3%) patients. Vision at 40 cm distance improved in 290 (88.4%) patients, remained stable in 29 (8.8%) patients and became worse in 9 (2.7%) patients

Discussion
Currently, almost no conventional treatment for dry AMD is available. The National Eye Institute’s Age-Related Eye Disease Study (AREDS) found that taking a specific high-dose formulation of antioxidants and zinc significantly reduces the risk of advanced AMD or might delay progression of dry AMD. Nevertheless, the AREDS formulation is not a cure for AMD and can not restore or improve vision already lost from the disease.

These circumstances make acupuncture a promising treatment option for dry AMD. In the present study, acupuncture significantly improved visual acuity in a cohort of 328 patients with dry AMD. During the treatment phase, visual acuity became better in about 44% of patients, and worsened in only 4% of patients.

No side-effects or complications were observed. According to the U.S. Food and Drug Administration (FDA), relatively few complications from the use of acupuncture have been reported in light of the millions of people treated each year and the number of acupuncture needles used [

Before enrolment, patients performed an eye test before and after a test acupuncture treatment. Less than 5% of patients willing to enter the study did not respond to the test acupuncture treatment and were classified as non-responders. The reasons for non-response to acupuncture are unclear and may include chronic inflammation, dental interference fields, scars, mental blockades or the intake of morphines or analgesics [,]

Several publications have suggested beneficial effects of acupuncture in AMD patients [, ]. Lundgren reported in 2003 a series of ten AMD patients who had been treated by acupuncture []. In 2005, a larger study including 108 AMD patients was published by the same author []. In that study, vision improved in 69% of patients, which is a substantially higher success rate compared to the present study. This could be explained by the relatively short treatment phase of the present study and/or the selection of

The beneficial effects of acupuncture on visual acuity in patients with dry AMD reported here were short-termed effects. A long-term follow-up of the participants of the present study is ongoing and will provide data on whether acupuncture might be useful for prolonged improvement of visual acuity.

The acupuncture mechanism of action is currently not known. Improved visual acuity by acupuncture could be due to increased blood supply to the retina or stimulated neuro- electrical function. In a randomized, placebo- controlled, cross-over study in 20 healthy volunteers it could be shown that acupuncture treatment lead to an increased blood flow velocity of the ophthalmic artery []. The design of that study design did not allow an evaluation of why and how the different acupuncture methods had an effect on the brain and eye, however it proved that acupuncture can provide measurable biological effects. Similarly, in the present study we were able to observe therapeutic effects of acupuncture in AMD patients, but the precise mechanisms for this effect remain to be elucidated by further studies. Our data are observational and should be regarded as hypothesis-generating, not hypothesis-testing. Proof of efficacy requires placebo-controlled, double-blinded randomized clinical study. We are confident that the observations we report here justify the design and implementation of such studies. Furthermore, additional reports on acupuncture treatment in AMD patients might help to refine and elaborate the acupuncture protocol for this diseas.

Comment: All research was performed by the author. No financial support was received for the study. The author declares no conflict of interest.

Table 1. Selected acupuncture points (first treatment).

Acupuncture point Anatomical location Yintang Midway between the medial end of the two eyebrows Yuyao In the hollow, at the midpoint of the eyebrow, directly above the pupil Cuanzhu, Urinary Bladder 2 (UB 2) On the medial extremity of the eyebrow Auricular point of cervical vertebrae Curved brim of the cavum conchae on the antihelix. Dahlgren point Palm, between the heads of the fourth and fifth metacarpal bones ECIWO eye point Head of the second metacarpal bone

Table 2. Selected acupuncture points (second treatment).

Acupuncture point Anatomical location Zhijib, Urinary bladder 67 (UB 67) On the lateral side of the small toe, about 0.1 cun posterior to the corner of the nail Kunlun, Urinary bladder 60 (UB 60) In the depresion betwee the external malleolus and tendo calcanceus Zusanli, Stomach 36 (ST 36) One finger breadth from the anterior crest of the tibia, in muscle tibialis anterior Taichong, Liver 3 (LIV 3) On the dorsum of the foot, in the depression distal to the junctio nof the first and secon dmetatarsal bones Auricular point liver (SC 8) Posterior to the district of the stomach in the posteo-inferror part of the superior concha.

Figure 1. Vision of AMD patients at baseline, after the first treatment with acupuncture (follow-up) and after the second acupuncture treatment (final examination). The box indicates the quartile range, the line within the box the median and whiskers indicate minimum and maximum values. At both reading tests from 3 m and 40 cm distance, vision improved significantly (Wilcoxon matched pairs test) from baseline to follow-up as well as from follow-up to the final examination.

Dr. Henrike Krenn-Pfob, MD

Corresponding author

Dr. Henrike Krenn-Pfob, MD. Ragnitzstraße 226, 8047 Graz, Austria
Tel.: +43 664 1108946
Fax: +43 316 678249
E-Mail: henrike.krenn@ichwillbessersehen.com

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