THE JOURNAL OF ALTERNATIVE AND COMPLEMENTARY MEDICINE

Volume 16, Number 12, 2010, pp. 12911294

Mary Ann Liebert, Inc.
DOI: 10.1089/acm.2009.0537

Acupuncture Reduces Symptoms of Dry Eye Syndrome:

A Preliminary Observational Study
Ju-Hyun Jeon, OMD, PhD,1 Mi-Suk Shin, RN,2 Myeong Soo Lee, PhD,2 So-Young Jeong, BS,2
Kyung Won Kang, MS,2 Young-Il Kim, OMD, PhD,1 and Sun-Mi Choi, OMD, PhD2

Abstract

Objective: The aim of this study was to evaluate the effect of acupuncture treatment on dry eye syndrome.
Design: This was a prospective observational study.
Setting: The study was conducted at a clinical evaluation center for acupuncture and moxibustion of the Korean
Institute of Oriental Medicine, Republic of Korea.
Subjects: The subjects were patients with dry eye disease (N 36), defined by Schirmer test scores of <10 mm/
5 min and tear film break-up times (BUTs) of <10 seconds.
Treatments: Participants were treated with acupuncture three times per week for 4 weeks.
Measure of effectiveness: Schirmer test scores, BUTs, symptom scores, ocular surface disease index (OSDI) scores
and dry eye symptom questionnaires were compared before and after treatment to evaluate the efficacy of
acupuncture treatment.
Results: After treatment, symptom scores, OSDI scores and the number of dry eye symptoms were all significantly lower ( p < 0.0001). Although tear wettings were significantly higher (left: p < 0.0001, right: p 0.0012),
there were no significant differences in BUTs.
Conclusions: This study suggests that acupuncture treatment can effectively relieve the symptoms of dry eye
and increase watery secretion.
Introduction

ry eye syndrome is a tear film disorder that occurs due

to a deficiency of tears or excessive evaporation.1 Dry
eye syndrome causes damage to the interpalpebral ocular
surface and is associated with symptoms of ocular discomfort.1 The most common cause of this syndrome is damage to
the lacrimal gland, which is involved in aqueous secretion.2
Early interventions for dry eye syndrome were palliative, attempting to replace water lost from the tear film.3 Current
therapies are directed at underlying inflammation, an important component of dry eye syndrome, and at the resulting
changes to the ocular surface.3
Patients with eye diseases often turn toward complementary and alternative medicine (CAM).4,5 There is a wide range
of CAM used for treating dry eye, including dietary supplements, herbal medicine, and acupuncture. Acupuncture is
considered to be effective for various conditions.6 It is also
thought to be effective at modulating the autonomic nervous
system and immune system.79 Based on this information, it is
reasonable to assume that acupuncture might be able to regulate lacrimal gland function and thereby relieve dry eye

symptoms. As there are few reports on this hypothesis,10,11

this observational study investigated whether acupuncture is
effective at treating symptoms of dry eye syndrome.
Patients and Methods
Participants
Fifty (50) subjects were recruited from an Internet homepage, a newspaper insert, and a poster billing. Subjects were
included if they were 1970 years of age and had dry eye
symptoms, Schirmer test scores of <10 mm/5 min, and tear
film break-up times (BUTs) of <10 seconds. All subjects were
required to provide written informed consent before any
study-specific procedures were performed.
We excluded subjects with previous anterior segment inflammation or trauma (surgical or other trauma), active blepharitis, previous facial palsy, allergy, punctal occlusion, or
punctal plug insertion. Contact lens users were also excluded.
Patients were excluded if they used systemic medications such
as sleeping tablets, tranquilizers, antidepressants, monoamine oxidase inhibitors, dopaminergics, neuroleptics, benzodiazepines, antiserotoninergics, b-blockers, or antiemetic

Acupuncture, Moxibustion, and Meridian Research Center, Korea Institute of Oriental Medicine, Daejeon, South Korea.
Division of Standard Research, Korea Institute of Oriental Medicine, Daejeon, South Korea.

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JEON ET AL.

3.7
(1.5)
<0.0001
3.7
(1.7)
<0.0001
4.2
(1.3)
<0.0001
4.0
(1.9)
<0.0001
4.3
(1.7)
<0.0001
4.2
(1.7)
<0.0001
4.3
(2.4)
<0.0001
6.9
(1.8)
p-value
Number of dry
eye symptoms
p-value

48.6
(16.6)

2.22
(0.71)

Symptom
score
p-value
OSDI

Values are represented as mean (standard deviation). Wilcoxon signed-rank test was used to test significance between baseline and each visit.
OSDI, ocular surface disease index.

3.8
(1.5)
<0.0001

1.46
(0.63)
<0.0001
1.52
(0.72)
<0.0001

1.66
(0.7)
0.0004
34.8
(18.1)
<.0001
4.2
(1.4)
<0.0001
1.50
(0.63)
<0.0001
1.60
(0.68)
<0.0001

1.69
(0.78)
0.0004
35.0
(17.2)
<.0001
4.3
(1.3)
<0.0001
1.63
(0.72)
0.001
1.91
(0.78)
0.031

1.97
(0.82)
0.088
38.7
(20.2)
0.004
5.0
(1.9)
<0.0001
1.81
(0.74)
0.007

Visit 9
Visit 8
Visit 1
Variable

FIG. 1. Treated acupuncture points. (A) LU3; (B) Extra

acupuncture point (Duomingxue); (C) Auricular acupuncture
point Eye 2; (D) Korean hand acupuncture point E2.

2.03
(0.93)
0.311

Visit 7

Visit 6

Visit 2

Visit 5

Acupuncture treatments were performed by 3 Korean

doctors who had received postgraduate training in acupuncture and had more than 3 years of clinical experience.
Disposable stainless steel needles (0.2030 mm, Haeng Lim

Visit 4

Acupuncture treatment

Visit 3

Participants were scheduled for acupuncture treatment 3

times a week for 4 weeks (12 times total). Dry eye symptoms
and questionnaires were evaluated pretreatment and after
each of the 12 acupuncture treatments (total 13 times). Ocular
surface disease index (OSDI) was measured baseline and
after the 3rd, 6th, 9th, and 12th sessions (total 5 times). BUT
and Schirmer tests were also performed pretreatment and
after 12 acupuncture treatments (total 2 times).

Table 1. Mean (Standard Deviation) of Variables at Each Measurement Point

Procedures

Visit 10

Visit 11

Visit 12

Visit 13

agents. We also excluded women who were receiving hormone replacement therapy, were pregnant or lactating, and
those for whom pregnancy was possible.
This clinical study received formal approval from the
Ethics Committee and was conducted in conformance with
the provisions of the Declaration of Helsinki (1995). The recording of adverse events was a means of assessing the
safety of acupuncture treatment.

1.44
(0.56)
<0.0001
31.1
(19.5)
<.0001
4.0
(1.7)
<0.0001

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1293

Seo Won Co., Korea) were inserted into acupuncture points

(auricular acupuncture point eye 2 and Korean hand acupuncture point E2 to a depth of 0.1 cun and LU3 and extra
acupuncture point to a depth of 0.5 cun). The sparrow
pecking technique (alternate pushing and pulling of the
needle) was not applied. The needles were left in place for 30
minutes.
Acupuncture points
We select the LU3 (Fig. 1A) according to Traditional
Chinese Medicine. The other treatment point selections were
based on microacupuncture rules and the chief virtue
of each acupuncture point. The extra acupuncture point,
Duomingxue, is located in the middle point of Acromion and
LU5 (Fig. 1B).12 Auricular acupuncture point Eye 2 is located
below the intertragic notch (posterior of the notch) (Fig. 1C).
Points were selected according to the method of the school of
Noiger.13 Korean hand acupuncture point E2 is located on
the palm of the middle finger, in the distal phalanx, at the
intersection of the Radial and Ulnar vertical line. The point
was selected according to the Yoo Tae Woos Koryo hand
therapy method (Fig. 1D).14
Outcome measures
Primary outcomes. Symptom scores and OSDI were the
primary outcomes used to evaluate the efficacy of the acupuncture treatment.15 Symptom scores were evaluated using
a scoring system of 04, where 0 indicates an absence of
symptoms and 4 indicates very severe symptoms. Participants scored 10 symptoms associated with dry eye syndrome,
including burning sensation, stinging sensation, itching sensation, foreign body sensation, dryness, soreness, lid heaviness, photophobia, injection, and tearing. Total scores,
obtained by adding the scores of each symptom, were used for
the evaluation of ocular discomfort.
OSDIs were used to quantify the specific impact of acupuncture on dry eye syndrome. This disease-specific questionnaire included three subscales: ocular discomfort,
function, and environmental triggers. Questionnaires were
filled out and collected once a week throughout the study.
Possible responses referred to the frequency of the disturbance: none of the time, some of the time, half of the time,
most of the time, or all of the time. Subscale scores were

computed for OSDI-symptoms, OSDI-function and OSDItriggers, as well as an overall averaged score. OSDI subscale
scores ranged from 0 to 100, with higher scores indicating
more problems or symptoms.
Secondary outcomes. The secondary outcome measures
were the number of dry eye symptoms, Schirmer test score,
and BUT score. The number of dry eye symptoms was
evaluated by counting 10 dry eye symptoms (burning sensation, stinging sensation, itching sensation, foreign body
sensation, dryness, soreness, lid heaviness, photophobia, injection, and tearing). The total number of symptoms was
used to evaluate the level of ocular discomfort.
Schirmer tests were performed by placing a Schirmer tear
strip (Eagle Vision, USA) over the lower lid margin at the
junction of the middle and lateral third of the tear film for
5 minutes. Patients were given anesthesia (0.5% proparacaine (Alcaine)) prior to testing. Schirmer test scores were
obtained by measuring the lengths (millimeters) of the wet
portions of the strips and recorded.
BUTs were calculated as the number of seconds between
the last complete blink and the first disturbance of the precorneal tear film after touching the inferior temporal bulbar
conjunctiva with a fluorescein sodium strip that was dampened with a preservative-free saline solution. The mean value
of a total of three measurements was recorded.
Statistical analysis
The statistical analysis was performed using SAS 9.1. To
compare therapeutic effects between preacupuncture and
postacupuncture, a paired t-test and Wilcoxons signed
rank test were used. The same analysis was used to compare between baseline (pretreatment) and each visit. The
results are presented as mean values and standard deviation. Probability ( p) values < 0.05 were considered significant in all statistical testing. Effect size was calculated with
Cohens d.
Results
A total of 50 patients volunteered for the study, and 12 did
not fit the inclusion criteria. Only 2 of the remaining 38 patients were excluded because they took medicine on the first
treatment day. Two (2) participants withdrew their consent

Table 2. Outcome Measures After 12 Sessions of Acupuncture for Dry Eye Syndrome
Outcome measures

Pretreatment

Post-treatment

Effect size (95% CI)

Symptom score
OSDI
Number of dry
eye symptoms
Schirmer test
Left
Right
BUT
Left
Right

2.22 (0.71)
48.6 (16.6)
6.9 (1.8)

1.44 (0.56)
31.1 (19.5)
4.0 (1.7)

1.21 (0.67, 1.74)

1.64 (1.07, 2.21)
0.95 (0.43, 1.46)

<0.0001
<0.00001
0.0003

5.3 (1.9)
5.3 (1.9)

7.4 (3.2)
7.4 (3.4)

0.80 (0.29, 1.31)

1.13 (0.60, 1.66)

0.002
<0.0001

5.4 (1.7)
4.9 (1.7)

5.3 (2.2)
4.8 (2.3)

0.05 (0.44, 0.54)

0.05 (0.44, 0.54)

0.82
0.84

Values are represented as mean (standard deviation). The Wilcoxon signed-rank test was used to test significance between pretreatment
and post-treatment.
CI, confidence interval; OSDI, ocular surface disease index; BUT, tear film break-up time.

1294
for the trial, and 2 were excluded because they took steroids
or other medications during the treatment period. The remaining 32 patients completed the study.
The mean age and duration of disease were 47.4 (range
2262) years and 5.6 years (range 2 months20 years), respectively. The changes in the symptom scores, OSDI, and
number of symptoms are shown in Table 1. All of the outcome measures were improved by the acupuncture sessions.
Table 2 lists outcome measures before and after treatment.
These measures indicate that there were significant improvements in dry eye symptoms, OSDIs, the number of dry
eye symptoms, and Schirmer test scores. However, there
were no significant changes in BUTs. The most affected
variable was OSDI (effect size 1.64).
None of the participants reported any adverse events.
Discussion
Our pilot study suggests that 12 sessions of acupuncture
treatment significantly improved subjective outcome measures of dry eye syndrome, including total symptom score,
number of symptoms and OSDI, as well as the objective
outcome measure of the Schirmer test. This finding is consistent with results of previous studies. Tseng et al.11 reported
that 16 sessions of acupuncture treatment improved symptoms of dry eye syndrome. Another study also reported
beneficial effects of 10 sessions of acupuncture treatment on
dry sensations in the eye.10
Assuming that acupuncture is a potentially useful treatment option for dry eye syndrome, its mechanism of action
may be of interest. The results presented here suggest that
acupuncture can influence lacrimal glandular function in the
synthesis and secretion of aqueous secretions.16 Others have
postulated that acupuncture may reduce tension and alleviate pain intensity or increase pain threshold.17 However,
none of these theories have been addressed.
The results from this uncontrolled pilot study provide
a foundation for the exploration of acupuncture as a nonpharmacological therapy for improving symptoms of dry eye
syndrome. However, we cannot completely discount the
possibility that a placebo effect during the intervention caused
improvements in symptoms related to dry eye syndrome.
Other limitations of this pilot study include the small sample
size and the absence of a control treatment and appropriate
follow-up of possible recurrences. Further studies that include
a randomized design, larger sample sizes, and more detailed
data on the subjects are needed to convincingly show the effects of acupuncture in patients with dry eye syndrome.
Disclosure Statement
No competing financial interests exist.
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Address correspondence to:

Sun-Mi Choi, OMD, PhD
Acupuncture, Moxibustion & Meridian Research Center
Korea Institute of Oriental Medicine
Daejon, 305811
South Korea
E-mail: smchoi@kiom.re.kr

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