Richard C. Niemtzow, MD
Kevin J. Kempf, MD
Peter A. S. Johnstone, MD
Background Acupuncture is a useful modality in the treatment
of xerostomia in head and neck cancer patients. It is also useful in
xerophthalmia secondary to Sjogrens syndrome and other pathological
Objectives To describe patients receiving acupuncture for xerophthalmia,
and to establish a technique that is reproducible for practitioners.
Design Acupuncture techniques and case reports.
Main Outcome Measure Increase in tear film, subjectively recognized
by the patient and clinically confirmed.
Results The tear film increased in all patients. Follow-up indicated
that the positive response to acupuncture was maintained.
Conclusion Xerophthalmia may be significantly relieved by acupuncture.
The mechanism is unknown but may be parasympathetically mediated.
Acupuncture, Auriculotherapy, Keratoconjunctivitis Sicca, Sjogrens
Syndrome, Xerophthalmia, Xerostomia
In previous articles, an acupuncture technique was described1,2 and
updated3 for the treatment of pilocarpine-resistant xerostomia following
radiotherapy for head and neck malignancies. This article discusses
how the same acupuncture technique with minor modifications may also
be useful in xerophthalmia (dry eyes).
sicca or xerophthalmia is a common disorder, with increasing prevalence
starting in the 5th decade of life and rising with age. There are many
conditions that predispose one to dry eyes. Some of the more common
entities include Sjogren's syndrome, an autoimmune disorder of exocrine
glands seen primarily in women; medications, which include many antihypertensives,
antidepressants, and anticholinergic agents; and aging.6 In addition,
other conditions that can manifest as dry eyes include infiltrative
processes such as sarcoidosis, HIV, hepatitis B and C, complications
of refractive surgery, and secondary sicca complex from other connective
tissue diseases such as rheumatoid arthritis or systemic lupus.4 Hypofunction
of the lacrimal glands, secondary to lymphocytic infiltration, is a
hallmark of Sjogren's syndrome. This condition is manifested by marked
discomfort and dryness of the eyes, described as a scratchy and burning
sensation with marked decrease in tear film. Sjogren's syndrome also
involves hyposalivation of the mouth, resulting in difficulty talking
or swallowing dry foods. Sjogren's syndrome patients often develop profound
caries at an early age and gastroesophageal reflux due to the loss of
buffering by the saliva.4 Treatment of these conditions is primarily
symptomatic with artificial tears, lubricant solutions, and muscarinic
agonists such as pilocarpine, which often cause significant side effects
or are tedious to use many times a day.5 These complaints, which greatly
affect a patient's quality of life, appear to respond to the acupuncture
treatment developed for radiation-induced xerostomia.1 We also observed
that this acupuncture technique is useful in overcoming the complaints
of both dry eyes and dry mouth from various prescription drugs used
in the treatment of hypertension and other conditions.
A sterile needle (Seiren Laser L Type, gauge 3, length 30 mm, distributed
by OMS Medical Supplies, Inc., Braintree, MA), is inserted bilaterally
in both index fingers in an area on the Large Intestine (LI) meridian
slightly proximal to LI 1. This area is designated LI 29. In addition,
auriculotherapy points Point Zero, Shen Men, and an area designated
Salivary Gland 29 are needled bilaterally (Figure 1).
After 20 minutes,
if there is no increase in the tear film, it is recommended that the
needles in position LI 29 be removed bilaterally and replaced by 2 new
sterile needles placed about 3-4 mm proximal to the original inserted
needles. If the tear film fails to increase after this modification,
the 2 needles located at the Salivary Gland 29 area are replaced by
2 new sterile needles about 3-4 mm proximal to the original insertions.
(The authors have rarely needed to alter this sequential modification
more than 2 times. This is different from the xerostomia technique where
there is usually no need to change the position of the needles to acquire
a saliva secretion.)
Acupuncture treatment requires signed informed consent in our center.
Four patients diagnosed as having dry eyes secondary to other causes
Case Report 1
A 46-year-old man with a diagnosis of chronic myelocytic leukemia underwent
a bone marrow transplantation and developed graft- vs-host effect with
bilateral acute dry eyes that did not respond well to lubricants. The
patient was treated for dry eyes for 11/2 years. His eyes remained adequately
moist for up to 2-3 weeks before he needed to repeat acupuncture.
Case Report 2
A 72-year-old woman with bilateral dry eyes with Sjogren's syndrome
reported that acupuncture increased the tear flow to both eyes. Prior
to treatment, she needed to apply eye drops every 10 minutes; with acupuncture,
only 1-2 times daily. Follow-up visits every 3 weeks appeared adequate.
Case Report 3
A 42-year-old woman, status post surgery for a neuroma with resulting
mild paralysis of the right side of her face, was referred for nocturnal
dryness of her right eye. Acupuncture increased the moisture in the
right eye to a satisfactory level of comfort.
Case Report 4
A 35-year-old woman had laser surgery to her eyes and developed dry
eyes bilaterally 2 months later. Lubricants and plugs did not result
in satisfactory ocular comfort. The patient received acupuncture and
lubricant applications were reduced. Her tear film became normal in
both eyes. She was lost to follow-up after 6 treatments.
There were no adverse effects related to acupuncture. An increase in
the tear film was subjectively present in all patients after acupuncture.
Follow-up evaluations at 1-month intervals found that patients maintained
a satisfactory tear flow, but monthly retreatments appear necessary
to maintain this capacity over time.
The tissue damage resulting from radiation injury to the salivary glands
is different from that produced by the infiltration of immune cells
into the salivary or lacrimal glands as found in Sjogren's syndrome,
or of the damage done by graft-vs-host reaction accompanying bone marrow
transplant for the treatment of many leukemias. Currently, there is
much discussion in the literature on how to best classify and diagnose
patients with Sjogren's syndrome and the significant overlap of other
patients with dry eye complaints. Many diagnostic criteria exist, but
common to all is a measure of a patient's ocular symptoms and signs.
treatment options such as ocular and oral lubricants, and muscarinic
agonists like pilocarpine or cevimeline, are used to manage severe xerostomia.
Cyclosporine, azathioprine, and low-dose corticosteroids can occasionally
improve dry eye symptoms, and interferon a is being studied to increase
salivary flow. However, these medications are tedious at best, and can
be fraught with significant side effects such as severe hypotension,
headaches, excess sweating, nausea, bone marrow suppression, osteoporosis,
and the risks associated with immune suppression. Granted, we do not
understand the acupuncture mechanism of action that appears to increase
the tear film's aqueous component, but we propose the same mechanism
previously published for xerostomia relief by the use of these points
- parasympathetic activation.2,3 We find this report significant and
of value to our colleagues even though it deals with a small number
of patients. Future research must involve a more substantial population.
Acupuncture using the above protocol may contribute to increasing the
tear film in patients with Sjogren's syndrome and other etiologies where
the aqueous component of the tear film is significantly reduced. This
technique did not produce any adverse effects. Longer observations in
a significant number of patients to optimize the technique and further
prospective objective measurements of both the tear film and its components
should be the subjects of further research. A prospective trial addressing
this has been approved by our institutional review board and is currently
RC, May BC, Peng YP, Inouye WS, Johnstone PAS. Acupuncture technique
for pilocarpine-resistant xerostomia following radiotherapy for
head and neck malignancies. Medical Acupuncture. 2000;12:42-43.
PAS, Peng YP, May BC, Inouye WS, Niemtzow RC. Acupuncture for pilocarpine-resistant
xerostomia following radiotherapy for head and neck malignancies.
Int J Radiat Oncol Biol Phys. 2001;50:353-357.
PAS, Riffenburgh RH, Niemtzow RC. Acupuncture for xerostomia: Clinical
Update. Cancer. 2002;94:1151-1156.
M. Dry eyes: an emerging epidemic. Ophthalmol Manage. 1999;10:4.
L, Jr, McPhee SJ, Papadakis MA, eds. Current Medical Diagnosis and
Treatment. Eye. 2002;202.
RE. Lange Medical Books. 41st ed. New York, NY: McGraw-Hill; 2002.
Colonel Richard C. Niemtzow, MD, is a Radiation Oncologist on active
duty in the United States Air Force. He is currently assigned to the
United States Naval Medical Center, San Diego, California, as their
first physician-acupuncturist. Dr Niemtzow practices Medical Acupuncture
full-time with oncology and general patients, and is also involved in
Colonel Richard C. Niemtzow, MD, PhD, MPH*
1835 E. Main St
El Cajon, CA 92021-5255
Phone: 619-447-6806 o Fax: 619-447-6881 o E-mail: firstname.lastname@example.org
A.S. Johnstone, MD, is Director for Ancillary Services at the Naval
Medical Center, San Diego, California, and Clinical Associate Professor
at the University of California, San Diego, California.
CDR Peter A.S. Johnstone, MD, MA
Naval Medical Center San Diego
Radiation Oncology Division
34800 Bob Wilson Dr, Suite 14
San Diego, CA 92134-1014
Phone: 619-532-7274 o Fax: 619-532-8178
Kevin J. Kempf, MD, is Board-certified in Internal Medicine and Rheumatology,
and is Chief of Rheumatology at the Naval Medical Center, San Diego,
LCDR Kevin J. Kempf, MD
Naval Medical Center San Diego
Divison of Rheumatology
34730 Bob Wilson Dr, Suite 203
San Diego, CA 92134-3202
Phone: 619-532-7301, 7350 o Fax: 619-532-5472
*All comments and reprint requests should be directed to Dr Niemtzow
at the address listed above.