Glaucoma: effectiveness of acupuncture

Glaucome : évaluation de l'acupuncture

1. Systematic Reviews and Meta-analysis

1.1. Law 2020

Law SK, Wang L, Li T. Acupuncture for glaucoma. Cochrane Database Syst Rev. 2020. [205260]. doi

BackgroundGlaucoma is a multi-factorial optic neuropathy characterized by an acquired loss of retinal ganglion cells at levels beyond normal age-related loss and corresponding atrophy of the optic nerve. Although many treatments are available to manage glaucoma, patients may seek complementary or alternative medicine approaches such as acupuncture to supplement their regular treatment. The underlying plausibility of acupuncture is that disorders related to the flow of Chi (traditional Chinese concept of vital force or energy) can be managed by stimulating relevant points on the body surface.
ObjectivesTo assess the effectiveness and safety of acupuncture compared with other treatments, no treatment, or placebo in patients with glaucoma.
MethodsSEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL), which contains the Cochrane Eyes and Vision Trials Register (2018, Issue 11); Ovid MEDLINE; Embase.com; the Cumulative Index to Nursing and Allied Health Literature (CINAHL); the Allied and Complementary Medicine Database (AMED); PubMed; Latin American and Caribbean Literature on Health Sciences (LILACS); ZETOC; the metaRegister of Controlled Trials (mRCT); ClinicalTrials.gov; the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP); and the National Center for Complementary and Alternative Medicine (NCCAM) website. We did not use any language or date restrictions in the search for trials. We last searched electronic databases on November 16, 2018, with the exception of NCCAM, which we last searched on July 14, 2010, and the metaRegister of Controlled Trials (mRCT), which we last searched on January 8, 2013. We handsearched Chinese medical journals at Peking Union Medical College Library in April 2007. We searched the Chinese Acupuncture Trials Register, the Traditional Chinese Medical Literature Analysis and Retrieval System (TCMLARS), the Chinese Biological Database (CBM), and the China National Knowledge Infrastructure (CNKI). We last searched Chinese electronic databases on November 19, 2018. SELECTION CRITERIA: We included randomized controlled trials (RCTs) in which one arm involved acupuncture treatment. DATA COLLECTION AND ANALYSIS: Two review authors independently screened results, then extracted the data and assessed risk of bias for eligible trials.
Main results We included three completed trials and one ongoing trial in the 2019 update of this review. The three completed trials, conducted in Taiwan and the United States, included participants with glaucoma or intraocular hypertension. The interventions investigated varied across trials. One trial compared auricular acupressure-a non-standard acupuncture technique-with the sham procedure in 33 patients. Another trial compared transcutaneous electrical nerve stimulation (TENS) with a sham procedure in 82 patients. The third trial compared 12 sessions of acupuncture on eye-points versus on non-eye-points in 22 patients. All three trials were rated at high risk of bias for at least one domain. The certainty of evidence across all outcomes was very low due to high risk of bias in at least one contributing study; substantial clinical heterogeneity and methodological heterogeneity; and imprecision of results. One trial reported change in the visual field from baseline without any between-group comparison. Because of the quantity of missing data (50%), we did not calculate a between-group comparison, as the quantitative results are difficult to interpret. All three trials reported data for estimation of reduction of intraocular pressure (IOP). However, time points of IOP measurement varied. For the trial comparing acupressure to a sham procedure, the difference in IOP reduction (measured in mm Hg) is estimated to be -3.70 (95% confidence interval [CI] -7.11 to -0.29) for the right eye and -4.90 (95% CI -8.08 to -1.72) for the left eye at four weeks, and -1.30 mm Hg (95% CI -4.78 to 2.18) for the right eye and -2.30 mm Hg (95% CI -5.73 to 1.13) for the left eye at eight weeks. For the trial comparing TENS to sham treatment, the difference reduction is estimated to be -2.81 (95% CI -3.8 to -1.84) for the right eye and -2.58 (95% CI -3.36 to -1.80) for the left eye immediately after treatment, -2.93 (95% CI -3.72 to -2.13) for the right eye and -3.56 (95% CI -4.35 to 2.78) for the left eye 30 minutes after treatment, and finally -3.61 (95% CI -4.47 to -2.75) for the right eye and -3.61 (95% -4.47 to -2.74) for the left eye. For the trial that compared acupuncture on eye-points versus non-eye-points, 11 out of 22 (50%) participants did not complete the treatment. One trial reported data for estimation of visual acuity. When acupressure is compared to sham treatment, the difference in uncorrected visual acuity (UCVA, measured in logMAR) is estimated to be -0.01 (95% CI -0.24 to 0.22) for the right eye and -0.04 (95% CI -0.27 to 0.19) for the left eye at four months, and -0.03 logMAR (95% CI -0.27 to 0.21) for the right eye and -0.16 logMAR (95% CI -0.43 to 0.11) for the left eye at eight months. The difference in best corrected visual acuity (BCVA) is estimated to be 0.10 (95% CI -0.06 to 0.26) for the right eye and 0 (95% CI -0.14 to 0.14) for the left eye at four months, and -0.04 logMAR (95% CI -0.09 to 0.17) for the right eye and -0.04 logMAR (95% CI -0.18 to 0.10) for the left eye at eight months. One trial reported progression of optic disc damage or nerve fiber layer loss without any between-group comparison. Because of the quantity of missing data (50%), we did not calculate a between-group comparison, as the quantitative results are difficult to interpret. One trial reported adverse events in two patients (out of 22) who experienced needle sensitivity. However, the study did not report between-group comparisons. Because of the quantity of missing data (50%), we did not calculate a between-group comparison, as the quantitative results are difficult to interpret.
Authors' conclusionsAt this time, it is impossible to draw reliable conclusions from available data to support the use of acupuncture for treatment of patients with glaucoma. Because of ethical considerations, RCTs comparing acupuncture alone with standard glaucoma treatment or placebo are unlikely to be justified in countries where the standard of care has already been established.

1.2. Law 2013 Ø

Law Sk, Li T. Acupuncture for glaucoma. Cochrane Database Syst Rev. 2013. [160277].

Objectifs The objective of this review was to assess the effectiveness and safety of acupuncture in people with glaucoma.
Méthodes SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (which contains the Cochrane Eyes and Vision Group Trials Register) (The Cochrane Library 2012, Issue 12), Ovid MEDLINE, Ovid MEDLINE In-Process and Other Non-Indexed Citations, Ovid MEDLINE Daily, Ovid OLDMEDLINE (January 1946 to January 2013), EMBASE (January 1980 to January 2013), Latin American and Caribbean Literature on Health Sciences (LILACS) (January 1982 to January 2013), Cumulative Index to Nursing and Allied Health Literature (CINAHL) (January 1937 to January 2013), ZETOC (January 1993 to January 2013), Allied and Complementary Medicine Database (AMED) (January 1985 to January 2013), the metaRegister of Controlled Trials (mRCT) (www.controlled-trials.com), ClinicalTrials.gov (www.clinicaltrials.gov), the WHO International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en) and the National Center for Complementary and Alternative Medicine web site (NCCAM) (http://nccam.nih.gov). We did not use any language or date restrictions in the search for trials. We last searched the electronic databases on 8 January 2013 with the exception of NCCAM which was last searched on 14 July 2010. We also handsearched Chinese medical journals at Peking Union Medical College Library in April 2007.We searched the Chinese Acupuncture Trials Register, the Traditional Chinese Medical Literature Analysis and Retrieval System (TCMLARS), and the Chinese Biological Database (CBM) for the original review; we did not search these databases for the 2013 review update. SELECTION CRITERIA: We included randomized controlled trials (RCTs) in which one arm of the study involved acupuncture treatment. DATA COLLECTION AND ANALYSIS: Two authors independently evaluated the search results and then full text articles against the eligibility criteria. We resolved discrepancies by discussion.
Résultats We included one completed and one ongoing trial, and recorded seven trials awaiting assessment for eligibility. These seven trials were written in Chinese and were identified from a systematic review on the same topic published in a Chinese journal. The completed trial compared auricular acupressure-a nonstandard acupuncture technique-with the sham procedure for glaucoma. This trial is rated at high risk of bias for masking of outcome assessors, unclear risk of bias for selective outcome reporting, and low risk of bias for other domains. The difference in intraocular pressure (measured in mm Hg) in the acupressure group was significantly less than that in the sham group at four weeks (-3.70, 95% confidence interval [CI] -7.11 to -0.29 for the right eye; -4.90, 95% CI -8.08 to -1.72 for the left eye), but was not statistically different at any other follow-up time points, including the longest follow-up time at eight weeks. No statistically significant difference in visual acuity was noted at any follow-up time points. The ongoing trial was registered with the International Clinical Trials Registry Platform (ICTRP) of the World Health Organization. To date this trial has not recruited any participants.
Conclusions At this time, it is impossible to draw reliable conclusions from available data to support the use of acupuncture for the treatment of glaucoma. Because of ethical considerations, RCTs comparing acupuncture alone with standard glaucoma treatment or placebo are unlikely to be justified in countries where the standard of care has already been established. Because most glaucoma patients currently cared for by ophthalmologists do not use nontraditional therapy, clinical practice decisions will have to be based on physician judgments and patient preferences, given this lack of data in the literature. Inclusion of the seven Chinese trials in future updates of this review may change our conclusions.

1.3. Gao 2011 ★

Gao R, Shi CH, Tian JH, Kang Z. [Systematic review of randomized controlled trials of acupuncture for glaucoma]. Chinese Acupuncture and Moxibustion. 2011. 31(12):1142-5. [161620].

Objectifs To assess the efficacy of acupuncture for glaucoma.
Méthodes The search was conducted through database to identify randomized controlled trials of acupuncture for glaucoma until September 2010. The quality assessment, data extraction and Meta-analysis were performed by Cochrane Handbook for Systematic Reviews of Interventions.
Résultats Eight articles were included. Meta-analysis showed that acupuncture did not decrease intraocular pressure compared with eye drops [SMD = -0.1 66, 95% CI (-1.45, 0.13)]. However, acupuncture increased the effectiveness rate of treatment for glaucoma [OR = 4.45, 95% CI (1.96,10.09)]. Compared with placebo, acupuncture did not decrease intraocular pressure 20 min after acupuncture (P = 0.13) and 24 hours after acupuncture (P = 0.21). Nonetheless, acupuncture increased the effectiveness rate of treatment for glaucoma [OR = 45.00, 95% CI (9.73, 208.08)]. Compared with acupuncture, quantitative acupuncture manipulation increased the effectiveness rates of treatment for glaucoma [OR = 2.23, 95% CI (1.14, 4.36)].
Conclusions Acupuncture therapy has potential to increase effectiveness rates of treatment for glaucoma. It lacks reliable evidence to prove that acupuncture decreases intraocular pressure. More trials with high quality are needed to estimate adverse effects and cost effectiveness of acupuncture therapy.

1.4. Law 2007 Ø

Law S, Li T. Acupuncture for glaucoma. Cochrane Database Syst Rev. 2007. 4:CD006030. [146969].

Objectifs The objective of this review was to assess the effectiveness and safety of acupuncture in people with glaucoma.
Méthodes SEARCH STRATEGY: We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, LILACS, ZETOC, CINAHL, AMED (Allied and Complementary Medicine Database), TCMLARS (Traditional Chinese Medical Literature Analysis and Retrieval System), CBM (Chinese Biological Database), the Chinese Acupuncture Trials Register and the National Center for Complementary and Alternative Medicine web site (http://nccam.nih.gov/) in February 2006. We ran update searches of CENTRAL, MEDLINE, EMBASE, LILACS and ZETOC in July 2007. We also handsearched Chinese medical journals at Peking Union Medical College Library in April 2007. SELECTION CRITERIA: We planned to include randomized and quasi-randomized clinical trials in which one arm of the study involved acupuncture treatment. DATA COLLECTION AND ANALYSIS: Two authors independently evaluated the search results against the inclusion and exclusion criteria. Discrepancies were resolved by discussion.
Résultats We found no randomized clinical trials and subsequently no meta-analysis was conducted. Evidence was limited to a few case series of small sample size.
Conclusions At this time, it is impossible to draw reliable conclusions from the available data to support the use of acupuncture for the treatment of glaucoma. Since most glaucoma patients currently cared for by ophthalmologists do not use non-traditional therapy, the clinical practice decisions will have to be based on physician judgement and patients' value given this lack of data in the literature.

2. Randomized Clinical Trials

2.1. Sources

  1. Acudoc2: GERA Database. RCT not cited in other sources.
  2. Law 2020: Law SK, Wang L, Li T. Acupuncture for glaucoma. Cochrane Database Syst Rev. 2020. [205260]. doi
  3. Law 2013: Law Sk, Li T. Acupuncture for glaucoma. Cochrane Database Syst Rev. 2013. [160277].
  4. Gao 2011: Gao R, Shi CH, Tian JH, Kang Z. [Systematic review of randomized controlled trials of acupuncture for glaucoma]. Chinese Acupuncture and Moxibustion. 2011. 31(12):1142-5. [161620].

2.2. Listing

2019 Shang Xia, Li Ruo-Xi. [Observations on the Efficacy of Acupuncture plus Medication for Primary Open-angle Glaucoma of Liver- kidney Yin Deficiency Type]. Shanghai Journal of Acupuncture and Moxibustion. 2019;38(3):307. [197049]. Acudoc2 .
2018 Leszczynska A, Ramm L, Spoerl E, Pillunat LE, Terai N. The short-term effect of acupuncture on different ocular blood flow parameters in patients with primary open-angle glaucoma: a randomized, clinical study. Clin Ophthalmol. 2018;:1285-1291. [168901]. Acudoc2, excluded from Law 2020: No response from study authors to our inquiries about whether the study was a randomized controlled trial .
Luo Haiyan, Wen Guoying, Yang Fan,. [Application of acupoint massage combined with relaxation training for primary glaucoma patients]. Chinese Nursing Research. 2018;32(2):278-80. [100780]. Acudoc2, excluded from Law 2020: Acupuncture as defined in this review was not used .
Wu Hu-Qiang, Zhang An-Ting, Wang Nan-Nan, et al. [Effect of Acupuncture plus Conventional Ocular Hypotensive Agents on Intraocular Pressure in Primary Open-angle Glaucoma]. Shanghai Journal of Acupuncture and Moxibustion. 2018;37(7):785. [186511]. Acudoc2, excluded from Law 2020: No response from study authors to our inquiries about whether the study was a randomized controlled trial .
Yang Ying, Guo Chengwei. [Influence of acupuncture combined with Mingmu Decoction on short-term curative effect and quality of life in patients with primary open angle glaucoma]. Modern Journal of Integrated Traditional Chinese and Western Medicine. 2018;27(21):2311-4. [202131]. Acudoc2, excluded from Law 2020: Acupuncture as defined in this review was not used .
Zhao Liping Li Mei. [Clinical effect of Mingmu Tongqiao decoction combined with acupuncture in the treatment of primary angle-closure glaucoma and its influence on optic nerve function]. Clinical Research and Practice. 2018;3(22):134-5. [203905]. Acudoc2, excluded from Law 2020: Acupuncture as defined in this review was not used .
2017 Li Chunhui, Feng Aicheng. [Effect of Mingmu Decoction combined with acupuncture on the short-term efficacy and quality of life of primary open-angle glaucoma]. Journal of Sichuan TCM. 2017;35(12):159-62. [204085]. Acudoc2, excluded from Law 2020: Acupuncture as defined in this review was not used .
Wang Rui. [Effects of acupuncture on intraocular pressure control and patient's eye function]. International Eye Science. 2017;17(5):958-60. [203922]. Acudoc2, excluded from Law 2020: No response from study authors to our inquiries about whether the study was a randomized controlled trial .
2016 Rao Ning. [To explore the clinical effect of acupuncture on glaucomatous optic neuropathy]. Contemporary Medicine. 2016;22:158-9. [204209]. Acudoc2, excluded from Law 2020: No response from study authors to our inquiries about whether the study was a randomized controlled trial .
Yeh TY, Lin JC, Liu CF. Effect of transcutaneous electrical nerve stimulation through acupoints of Pucan ( BL 61 ) and Shenmai ( BL 62 ) on intraocular pressure in patients with glaucoma: a randomized controlled trial. Journal of TCM. 2016;36(1):51. [198694]. Law 2020, .
Wang Yan, Chen Chun-Yan, Sun He, Gao Wei-Bin, Zhang Xi-Wu. [Therapeutic Observation of Acupuncture at Qiaoming Point for Optic Atrophy Following Angle-closure Glaucoma]. Shanghai Journal of Acupuncture and Moxibustion. 2016;35(5): 558-560. [191565]. Acudoc2, excluded from Law 2020: No response from study authors to our inquiries about whether the study was a randomized controlled trial .
2015 Law SK, Lowe S, Law SM, Giaconi JA Coleman AL, Caprioli J. Prospective evaluation of acupuncture as treatment for glaucoma. Am J Ophthalmol. 2015;160(2):256-65. [183388]. Law 2020, .
Tang Xiaodong, Ye Ying, Yang Guang. [Study of acupuncture on glaucoma with stable intraocular pressure]. China Journal of Chinese Ophthalmology. 2015;6:428-30. [203927]. Acudoc2, excluded from Law 2020: No response from study authors to our inquiries about whether the study was a randomized controlled trial .
2014 Huang Qianlan, Zeng Jing, Yang Renda, Zhou Can, Xie Li. [Observation on Therapeutic Effect of 18 Cases of Primary Open Angle Glaucoma Treated with Acupuncture and Medicine]. Hunan Journal of TCM. 2014;4:97-8. [204341]. Acudoc2, excluded from Law 2020: No response from study authors to our inquiries about whether the study was a randomized controlled trial .
2012 Sun Xin-Yuan. [Therapeutic observation on auricular point sticking with magnetic pearl for chronic simple glaucoma]. Shanghai Journal of Acupuncture and Moxibustion. 2012;31(6):408. [175569]. Acudoc2 .
Yin Lixia, Duan Li. [Clinical observation of acupuncture combined with Breviscapine injection on visual function protection after primary open angle glaucoma]. Chinese Journal of Aesthetic Medicine. 2012;21(18):349-50. [203763]. Acudoc2, excluded from Law 2020: Acupuncture as defined in this review was not used .
2011 Liu Fei, Li Bang-Lei, Yang Jing-Feng. [Observations on the efficacy of combined acupuncture and medicine in treating primary open-angle glaucoma]. Shanghai Journal of Acupuncture and Moxibustion. 2011;30(11):763. [177190]. Liu Fei, Li Bang-Lei, Yang Jing-Feng, et al. Clinical observation on combining acupuncture and eye drops for primary open angle glaucoma. Journal of Acupuncture and Tuina Science. 2013;11(2):93. [166191]. Acudoc2, excluded from Law 2020: No response from study authors to our inquiries about whether the study was a randomized controlled trial .
2010 Her JS, Liu PL, Cheng NC, Hung HC, Huang PH, Chen YL, Lin CP, Lee CH, Chiu CC, Yu JS, Wang HS, Lee YJ, Shen JL, Chen WC, Chen YH. Intraocular pressure-lowering effect of auricular acupressure in patients with glaucoma: a prospective, single-blinded, randomized controlled trial. Journal of Alternative and Complementary Medicine. 2010;16(11):1177-84. [160111]. Law 2020, Law 2013 .
Meira-Freitas D, Cariello AJ, Vita RC, Tabosa A, Melo LA JR. SHORT-term effect of acupuncture on intraocular pressure in healthy subjects. Acupuncture in Medicine. 2010;28(1):25-7. [158425]. Gao 2011 .
Wu Yuhe , Li Tie , Duan Xiaoying , Wang Fuchun. [Clinical Observation on Treatment of Primary Open-angle Glaucoma by Needling Ch'iuhou Acupoint in 60 Cases]. Jilin Journal of TCM. 2010;30(5):424-5. [203672]. Gao 2011, exclu Law 2020 (No response from study authors to our inquiries about whether the study was a randomized controlled trial) .
2009 Huo Q, Shen Q, Zhang DM, Zhang RT. [Effect of pricking blood at neiyingxiang (ex-hn 9) on the intraocular pressure of patients with primary open angle glaucoma]. Chinese Acupuncture and Moxibustion. 2009;29(8):629-30. [154665]. Gao 2011, exclu Law 2020 (Acupuncture as defined in this review was not used) .
Zhang Hong-Xia, He Yi-Heng. [Reducing intraocular pressure effect of acupuncture combined with eyedrops on primary open-angle glaucoma]. Journal of Beijing University of Traditional Chinese Medicine(Clinical Medicine). 2009;16(2):24-8. [190434]. Gao 2011, exclu Law 2020 (No contact information to verify whether the study was a randomized controlled trial) .
2007 Bravo López, Margarita de las Nieves; Jacas García, Caridad Celeste; Castillo Vázquez, Carmen; Esteriz Mesidoro, Niurka; Varela Gener, E. [Emergency acupuncture treatment for controlling intraocular pressure in glaucoma]. Medisan. 2007;11(2):. [115863]. Acudoc2 .
Castillo Vázquez, Carmen; García Espinosa, Sarah María; Navarro Scott, Mayelín; Bravo López, Margarita; Fouces Gutiérrez, Yudania. [Acupuncture and ozonotherapy in patients with simple chronic glaucoma]. Medisan. 2007;11(2):. [115864]. Acudoc2 .
Zhou Jun, Qian Aihua. [Clinical observation of Chuan Shao's point injection on the protection of visual function after glaucoma surgery]. Hubei Journal of TCM. 2007;29(7):33-4. [204342]. Gao 2011 .
2003 Zhang Haixiang, Yang Guang, Xu Li, et al. [Effect of quantitative acupuncture manipulation on f value in the patient of acute angle-closure glaucoma]. Chinese Acupuncture and Moxibustion. 2003;23(8):439. [118954]. Gao 2011 .
1995 Zhang Dengmin. [Study on the Effect of Bloodletting at Point of Ear Point on the Intraocular Pressure of Patients with Glaucoma]. Traditional Chinese Medicinal Research. 1995;8(3):44-6. [205231]. Gao 2011