Comment on “The short-term effect of acupuncture on different ocular blood flow parameters in patients with primary open-angle glaucoma: a randomized, clinical study”

Dear editor

We read with great interest the recent study by Leszczynska et al, who investigated the efficacy of acupuncture on patients with glaucoma.¹ However, we noticed some inaccuracies in the details of the acupuncture treatment in their study.

First, the abbreviations for all the acupuncture points mentioned were incorrect. They should be described according to international standard acupuncture nomenclature. In addition, a uniform alphanumeric code should be used to facilitate international communication on acupuncture. The international standard nomenclature of acupuncture points that were inaccurately mentioned in the paper are listed in the following Table 1.^2,3

Table 1 International standard nomenclature of acupuncture points that were inaccurately mentioned in the original text

Second, the locations of some acupuncture points in the paper were inaccurate. For instance, Figure 2 in the original text shows that PC6 is located on the anterior aspect rather than on the posterior aspect of the forearm. The authors also imprecisely stated that ST36 and GB37 are located on tuberositas tibiae and on the leading edge of the fibula above the lateral malleolus. According to international standards, ST36 is located on the anterior aspect of the leg, on the line connecting Dubi (ST35) with Jiexi (ST41), 3 B-cun inferior to ST35, in the tibialis anterior muscle, while GB37 is on the fibular aspect of the leg, anterior to the fibula, 5 B-cun proximal to the prominence of the lateral malleolus.⁴ On the basis of traditional Chinese medicine theory, the accuracy of acupuncture-point location influences the curative effect of acupuncture. Therefore, the clinical results of this study are untrustworthy.

Third, the needling sensation deqi, one of the key factors influencing acupuncture effectiveness, was not described in the course of acupuncture treatment. In accordance with Chinese medicine theory, the deqi sensation induced by needle insertion into the acupuncture point stimulates the transmission of qi through the acupuncture channels.⁵ Therefore, deqi should be mentioned when performing acupuncture operations.

Considering these inconsistencies, we find it hard to accept the authors’ conclusion that acupuncture may affect ocular blood flow in patients with glaucoma.

Acknowledgments

This communication was supported by the National Natural Science Foundation of China (81373784) and the State Administration of Traditional Chinese Medicine of China (JDZX2015023).

Disclosure

The authors report no conflicts of interest in this communication.

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References

1.		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;12:1285–1291.
2.		World Health Organization. WHO international standard terminologies on traditional medicine in the western Pacific region. Manila: WHO Regional Office for the Western Pacific; 2007.
3.		General administration of quality supervision, inspection and quarantine of the People’s Republic of China, Standardization Administration of the People’s Republic of China. National standards of the People’s Republic of China: nomenclature and location of acupuncture points. Beijing: Standards Press of China; 2006.
4.		World Health Organization. WHO standard acupuncture point locations in the western Pacific region. Manila: WHO Regional Office for the Western Pacific; 2008.
5.		Tian DS, Xiong J, Pan Q, et al. De qi, a threshold of the stimulus intensity, elicits the specific response of acupoints and intrinsic change of human brain to acupuncture. Evid Based Complement Alternat Med. 2014;2014:914878.

Authors’ reply

Anna Leszczynska, Lisa Ramm, Eberhard Spoerl, Lutz Pillunat, Naim Terai

Department of Ophthalmology, University Hospital Dresden, Dresden, Germany

Correspondence: Naim Terai, Department of Ophthalmology, University Hospital Dresden, 74 Fetscherstrasse, Dresden 01307, Germany, Tel +49 351 458 5091, Fax +49 351 458 4335, 3Email [email protected]

Dear editor

We thank the authors for their comment on our manuscript “The short-term effect of acupuncture on different ocular blood flow parameters in patients with primary open-angle glaucoma: a randomized, clinical study”.

First of all, we agree that the nomenclature in our manuscript may not adhere to the international standard. However, at this point we think this issue may be considered a minor factor, since the location of the points does not change and is independent of the nomenclature used. In future studies, we may consider using the international nomenclature to avoid misunderstandings. At this point, we thank the authors for their constructive comment.

Second, we agree that acupuncture point PC6 is illustrated wrongly in the figure, but it was correctly applied during acupuncture treatment on the anterior aspect of the forearm, so we can exclude a methodological mistake concerning the treatment itself. All acupuncture treatments in our study were performed by a certified and experienced acupuncturist. All acupuncture points in the present study were well checked prior to the inclusion of patients. As stated in the manuscript, acupuncture points were selected based on studies by Professor Gerhard Litscher of Graz (Austria), a renowned expert of acupuncture in traditional Chinese medicine, who has done extensive research on this field and who observed marked increases of blood flow in the ophthalmic artery after stimulation of certain acupuncture points in the facial region. As such, our acupuncture points (including GB37 and ST36 [Ma 36 in our nomenclature]) were chosen exactly according to his publications and his personal and oral recommendations. Therefore, our points are consistent with the needling points shown in Figure 2 and described in the methods section of Litscher et al.¹ Also, ST36 was applied according to Litscher et al’s description of one finger breadth away from the anterior crest of the tibia and of course not directly on the bone of the tuberositas.

At this point, we also refer to Litscher et al² and Litscher.³ Based on your comment, we rechecked the acupuncture points and also the figures and cannot find further inaccuracies.

The present study was conducted as a randomized, “placebo”-controlled study with adequate sample size investigating the effect of acupuncture on ocular blood flow in glaucoma patients. We were able to show that the acupuncture regimen used had some effect on choroidal blood flow, which is in fact consistent with previous findings of Takayama et al.⁴ Our preliminary results may serve as a basis for further research, as data on this topic are still very limited. Also, it has to be clarified which acupuncture points appear to be the most suitable for the optimal effect on ocular blood flow. At present, this issue is still unclear.

In consideration of the aforementioned arguments and in awareness of our results, we believe that ocular blood flow is affected by a specific acupuncture regimen and do not agree with the authors’ comments.

Disclosure

The authors report no conflicts of interest in this communication.

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References

1.		Litscher G, Wang L, Yang NH, Schwarz G. Computer-controlled acupuncture. Quantification and separation of specific effects. Neurol Res. 1999;21(6):530–534.
2.		Litscher G, Yang NH, Schwarz G, Wang L. [Computer-controlled acupuncture. A new construction for simultaneous measurement of blood flow velocity of the supratrochlear and middle cerebral arteries]. Biomed Tech (Berl). 1999;44(3):58–63. German.
3.		Litscher G. Computerkontrollierte akupunktur® – messung spezifischer stimulationskorrelierter effekte im gehirn. [Computer-controlled acupuncture® – measurement of specific stimulation-correlated effects in the brain]. De Gruyter. 2009;45(S1):214. German.
4.		Takayama S, Watanabe M, Kusuyama H, et al. Evaluation of the effects of acupuncture on blood flow in humans with ultrasound color Doppler imaging. Evid Based Complement Alternat Med. 2012;513638.
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