Statistics from Altmetric.com
Abducent palsy, a dysfunction of cranial nerve VI causing diplopia, has an annual population incidence of about 11 per 100 000, of which 3% follow neurosurgery.1 About 60% of patients with isolated abducent palsy from vascular causes recover within 9 months.2 Diplopia can significantly affect the person’s quality of life, making simple everyday tasks difficult to manage and even dangerous.
Acupuncture has been used for treating diplopia and ptosis in China, but there are few reports of its use in cases of neurosurgical injury.
A 45-year-old man first visited the outpatient department of Baoshan Hospital of Integrated Traditional Chinese Medicine and Western Medicine with symptoms of blurred vision, deep headache and hearing loss. He was diagnosed with right side acoustic neuroma by CT scan and MRI, which showed space-occupying lesions at the opening of the right cerebellopontine angle. The acoustic neuroma was removed by surgery about 1 week later. Diplopia and eye ball movement dysfunction as well as slight vocal cord paralysis and facial paralysis occurred after surgery.
Physical examination demonstrated diplopia and the absence of motility on left lateral gaze related to deficit of the lateral rectus muscle. Ophthalmological and neurological examinations were negative for abnormalities of the oculomotor and trigeminal nerves. Visual acuity (20/20) and pupillary light reflex were also normal before and after surgery and after recovery. At the initial treatment the patient presented with a 45 dioptre basal outward (BO) Fresnel prism over his left lens.
The patient was given electroacupuncture by the first author (LZ), who is an institutionally qualified acupuncture practitioner with 14 years of experience in administering therapeutic acupuncture. Eight points around the affected eye were chosen (see figure 1), together with ipsilateral points LI14, GB20, LI4, GB37, SP6, BL60 and LR3. Stainless steel needles (0.3 mm diameter, 25 mm long) were used for points around and inside the orbit and needles 40 mm long were used for the other points. When needling points inside the orbit, the eyeball was pushed away from the point and held there. We note that orbital needling is not advised without advanced specialised training. For needling the orbital points, the needle tip was turned 5° towards the eye socket when needling through the skin, then advanced to 0.3–0.5 cun without lifting and thrusting. Needles in the other points were manipulated to seek de qi.
Points GB14 and Xinming 2 paired with Taiyang (see figure 2) were treated with electrical stimulation (5 V; 80 pulses/s) in each session for 30 min, while needles in other acupuncture points were retained without any further stimulation. The treatment described above lasted 14 weeks, three times a week.
Diplopia was completely resolved by the end of treatment. At the 10th treatment the patient’s prism changed to a 15 dioptre BO Fresnel prism and returned to normal at the last treatment. However, the facial palsy was hardly improved. It was evaluated using the House−Brackmann Scale (I–VI maximum) and Sunnybrook Scale (0–100 maximum), scores of which changed only slightly from level VI and 5 points to level VI and 9 points. Life Satisfaction Scales were used to evaluate the patient’s quality of life satisfaction which improved from 5 points to 10.
The patient was followed up for 1 year. No diplopia recurred and the patient started driving again. Facial paralysis gradually recovered and the patient's life satisfaction improved.
Acupuncture treatment for oculomotor nerve palsy is widely used and has been found to be effective in China for treating simple oculomotor palsy,3 diabetic oculomotor palsy4 and stroke.5 Case reports have also shown success in treating intracranial aneurysm6 or herpes zoster-induced oculomotor palsy.7 The outcome of treating abducent nerve palsy caused by cerebrovascular accident, hypertension or other unknown conditions has been described,8–10 but no cases were found of acupuncture treatment in abducent palsy after neurosurgery.
Although the diplopia and eye ball movement dysfunction completely recovered within 4 months, we cannot confirm the contribution of acupuncture from a single case since spontaneous recovery is possible. Causes of abducent palsy other than injury include Gradenigo syndrome or isolated peripheral nerve paralysis. We recommend case controlled studies to test the effect of acupuncture therapy.
Point selection varies between reports: Sizhukong, Cuanzu and Taiyang are commonly used,8 the external rectus muscle belly was selected by Zhou et al9 as an extra point using electroacupuncture treatment, and Liu et al10 named it Waiming. Do et al11 mainly used points on the four limbs (LI4, LR3, SP6, ST36 and GB20/32). In this case, we used some extraordinary points (Shangming, Xingming, Zhengguang) which are not commonly seen in textbooks but they proved to be effective in practice.
We suggest that electroacupuncture might be helpful for patients with diplopia from abducent palsy following neurosurgical injury, but further studies are needed to confirm that the effects are genuine.
Twitter Follow Liu Zhidan at @liu54643
Contributors LZ was involved in designing and manipulating the therapy, obtaining the participant's consent, carrying out the literature review and writing the manuscript. HJ conducted the case report, identified the case, reviewed the article and is responsible for the content as guarantor.
Competing interests None.
Patient consent Obtained.
Ethics approval The Institutional Ethics Committee, Baoshan Hospital of Integrated traditional Chinese Medicine and Western Medicine, Shanghai approved the study.
Provenance and peer review Not commissioned; externally peer reviewed.