Did you know that the Department of Ophthalmology at the University of Pittsburgh has a Center for Integrative Eye Care? Established in 2007, it was the first in the country.
The person behind this is Deepinder K. Dhaliwal, MD, LAc, Professor of Ophthalmology at the University of Pittsburgh School of Medicine, Director of Refractive Surgery, Co-director of the Cornea Service at the UPMC Eye Center, Director of the UPMC Laser Vision Center, Associate Medical Director of the Campbell Ophthalmic Microbiology Laboratory, and Clinical Co-Director of the Corneal Stem Cell Task Force.
At the Eye & Ear Foundation’s September 9th webinar, she discussed “Integrative Ophthalmology: A Holistic Approach to Eye Care,” with fellow presenter Marie Hélène Errera, MD, PhD, Associate Professor of Ophthalmology at the University of Pittsburgh School of Medicine who specializes in uveitis and the retina.
The goal of the Center is to approach each patient with eye disease in a holistic manner. Practitioners have studied acupuncture and plan to incorporate nutrition, behavior modification, mindfulness, and psychology. The team is excited to move to the new Vision and Rehabilitation Institute at the UPMC Mercy Pavilion next year to have space for its programs.
Dr. Dhaliwal’s acupuncture journey began in 2005. She started studying acupuncture at UCLA and became a licensed acupuncturist in 2006. Acupuncture is a blend of East and West to optimize patient care and becomes especially important when the limits of Western medicine are reached.
What is Acupuncture?
Acupuncture can be traced back to China, 2000 years ago. The concept is that all living beings have a circulating life force or “Qi” that protects, nourishes, and animates. Qi circulates through a network of invisible acupuncture channels (meridians) that cover the body.
“Dis” ease occurs when there is a disruption in the flow of energy, or Qi. Stimulation of specific acupuncture points can remedy this disorderly flow, remove blockages, and restore the natural energy – thus treating disease.
Dr. Dhaliwal used a flowing stream analogy to describe the flow of Qi: A blockage of a stream causes stagnant water to build up and result in a deficiency of water downstream.
Acceptance of acupuncture has become more mainstream. Just look at the establishment of the National Center for Complementary and Integrative Health in 1991, one of 27 institutes and centers that make up the National Institutes of Health. The mission statement reads: “The mission of NCCIH is to determine, through rigorous scientific investigation, the fundamental science, usefulness, and safety of complementary and integrative health approaches and their roles in improving health and health care.” The budget for the 2022 fiscal year is $159.4 million.
Efficacy of Acupuncture
Studies have shown that acupuncture can alter immune function, the secretion of neurotransmitters and neurohormones, and the regulation of blood flow.
The University of Pittsburgh completed an IRB approved randomized, double-blind, placebo-controlled, prospective trial to assess the efficacy of acupuncture as a treatment for dry eye. The protocol was developed by Dr. Richard Niemtzow. Forty-nine patients were enrolled in the study. Patients were randomized into two groups: real acupuncture treatment and sham (needles placed in arm where there are no known acupuncture points). They were evaluated at one, three, and six months. Tests and questionnaires were incorporated, like tear break up time and ocular surface staining.
Acupuncture for dry eye does not involve needles on the face or in the eyes. Needles are placed in the ears and index fingers only for a total of 12 needles. These needles are FDA-approved, sterile, single use, very thin, flexible, do not have a lumen, and “slide between cells” instead of impaling them. Each treatment lasts 45 minutes. Two treatments are done one day apart. The results last 9-12 months.
An April 2019 article in Clinical Ophthalmology entitled, “Acupuncture and dry eye: current perspectives, A double-blinded randomized controlled trial and review of the literature,” published the results. True acupuncture treatment significantly improved patients’ subjective assessment of dry eye symptoms as compared to the sham treatment. The true acupuncture treatment group required less artificial tear drop usage six months after treatment compared to the sham. They also had significant improvement in “tiredness” and “redness” at six months. There was no significant difference in objective measures.
Possible mechanisms of effect include the following:
- Reduction of inflammation
- Modulation of autonomic nervous system and immune system (influence lacrimal gland function)
- Reduction in pain intensity or increase of pain threshold
Acupuncture is not the only holistic practice used in eye care. Meditation has been shown to help glaucoma. The Journal of Glaucoma published an article in its September 25, 2018 issue, titled, “Mindfulness Meditation Reduces Intraocular Pressure, Lowers Stress Biomarkers and Modulates Gene Expression in Glaucoma: A Randomized Controlled Trial.” It concluded that a short course of mindfulness-based stress reduction by meditation in primary open angle glaucoma reduces intraocular eye pressure, improves quality of life, normalizes stress biomarkers, and positively modifies gene expression. “Mindfulness meditation can be recommended as adjunctive therapy for POAG,” the study authors wrote.
In 2019, the Journal of Current Glaucoma Practice published an editorial, “Mindfulness Meditation Can Benefit Glaucoma Patients.”
Integrative ophthalmology is a holistic way of treating patients with eye disease. The Center for Integrative Eye Care was established to validate complementary approaches with well-designed scientific studies. Acupuncture, nutrition, meditation, behavior modification are some modalities that will be studied.
“It’s important to do this because we see so many of these treatments where there’s an ad for this or a webinar about that,” Dr. Dhaliwal said. “But if they don’t have science or validation, then we just don’t know, does it work or not? Sometimes we’ll spend a lot of resources on treatments that may not have scientific merit. It’s important to really scientifically study these treatment approaches.”
Integrative Eye Care
Dr. Errera started her presentation by describing integrative eye care as a complementary approach to both eye care and eye health maintenance. It is also a holistic approach to eye care integrating health and wellness.
“For example, when evaluating a chronic inflammatory eye condition, we look at the entire health and lifestyle, which means that we look at how all areas of life are connected,” Dr. Errera said. She will soon be starting a clinical trial to understand the links of lifestyle habits on inflammatory eye diseases. “Hopefully, the results will allow us to get a more holistic approach,” she added.
Dr. Errera specializes in uveitis, which is an eye inflammation caused by a heterogeneous collection of disorders, either noninfectious (autoimmune) or infectious (Bacterial, virus, parasitic). The poor visual prognosis associated with uveitis acute, chronic, or recurrent is mostly due to its complications: macular edema, cataract, glaucoma, posterior synechia, retinal necrosis, retinal ischemia, and optic atrophy. There are a total of 20 major subgroups depending on its cause.
Dr. Errera works at several locations: Children’s Hospital of Pittsburgh, Mercy Hospital, Shadyside Hospital, and Eye & Ear Institute. She is part of a network of well-trained caring practitioners of various disciplines for referrals (cornea, glaucoma, cataract, retina surgery, oculoplastics, and optometrists).
The team includes:
- Combined rheumatology/uveitis clinic once a month (Dr. Andreea Coca, MD)
- Rheumatology team for adults and at CHP (Dr. Kietz, Dr. Rosenkranz)
- Infectious diseases (Dr. K Byers)
- Clinical immunologist (Dr. A. Petrov)
- Pulmonologists (Dr. K. Gibson)
Clinical Trial: Microbiome and Uveitis
Dr. Errera recently received approval for an IRB clinical trial that will start in the next couple of months on uveitis. This Eye & Ear Foundation article covers the study and patient eligibility.
“Together, we’ll work to find out how to better manage your eye conditions,” Dr. Errera said. “Does BMI have an impact on the disease? Food? Diet? Mental and physical energy? The goal is to get a deep understanding of the food and lifestyle choices that work best for you and that will improve inflammatory ocular diseases.”