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Written by a Medical Acupuncture for Veterinarians Course Graduate. Author’s name available upon request. Signed release obtained from client/author/4924.

Abstract

Abby is a four-year-old Friesian that presented for persistent unilateral ocular pain due to a delayed-healing superficial corneal ulcer. Ocular pain was appreciated as unrelenting blepharospasm, photophobia, epiphora, moderate to severe hyperemia and chemosis, moderate miosis, and patient resistance to treatment following two days of medical management prescribed by the primary care veterinarian. Four consecutive days of once daily acupuncture facilitated patient cooperation for topical ophthalmic treatment due to the pain relieving and healing benefits of acupuncture.

History Presentation

Abby stands at 17 hands and presented to the stable’s primary care veterinarian early one morning after the barn manager/co-owner found her in her stall with her right eyelids held closed. An ophthalmic exam and fluroscein stain revealed a superficial corneal ulcer at the medial canthus of the right eye. The underlying cause of the ulcer was not determined, but due to the close proximity of the ulcer to the overriding nictitating membrane and being stalled overnight, a shaving (or other particle) previously stuck under the third eyelid was suspected.

Abby was prescribed ophthalmic triple antibiotic ointment and ophthalmic lubricant (both to be applied by the barn manager four-six times daily), as well as once daily oral banamine paste at 0.5mg/lb for pain relief.

On the third morning of ulcer treatment, the barn manager/co-owner contacted the majority owner and primary care veterinarian to inform them that Abby was showing no improvement in ocular comfort or in the overall appearance of the ulcer. Treating the ulcer with ophthalmic topicals had proven extremely difficult due to poor patient compliance as a result of inadequate pain control. The owner elected to discontinue Banamine and try implementing additional topical therapy using autologous serum (from Abby’s blood drawn by the primary care veterinarian), as well as trying dry needle acupuncture.

Physical Examination and Clinical Assessments

On presentation, Abby was quiet, standing in the corner of the pasture with her head hung low. After removing her fly mask, she was noted to have moderate blepharospasm and photophobia, moderate epiphora, moderate to severe hyperemia and chemosis, elevated nictitating membrane, and a moderately miotic pupil.  The ulcer was only partially visible on the surface of the corneal towards the medial canthus, as the elevated third eyelid partially covered the ulcer. It was difficult to part the patient’s eyelids for examination without her throwing her head violently in protest. It was obvious that pain control was inadequate and continued topical therapy would be difficult without controlling pain. The remainder of her physical exam was unremarkable.

Medical Decision Making

The acupuncture points chosen were based on suggestions for ocular pain from the Medical Acupuncture for Veterinarians course manual (1), due to the point relationships to local nerve innervation (mainly trigeminal n. and facial n.), and the resulting crosstalk/reflexes that lead to neuromodulation, allowing for these points to decrease nociceptor firing, windup, pain perception, and inflammation.  LI-16 was chosen as a good initial point to test the patient’s response to needles (as well as for benefits towards anxiety).

Acupuncture Treatment

Acupuncture Points (all done bilaterally where applicable): GV-20, HT-7, LI-16, ST-36
Rational: Autonomic neuromodulation via vagus nerve/sympathetic pathways (GV-20 via trigeminal nerve for agitation, LI-16 cervicothoracic spinal nn., and HT-7 and ST-36 for emotional stress and anxiety associated with restraint/manipulation/pain, with ST-36 having parasympathomimetic function via somatic afferent stimulus to the nucleus tractus solitaries/vagal input/neuromodulation)

Acupuncture Points (all done bilaterally where applicable): ST-1
Rational: Trigeminovagal reflexes

Acupuncture Points (all done bilaterally where applicable): BL-2
Rational: Autonomic neuromodulation/sympathetic pathways (decrease sympathetic tone to eye/pain/inflammation with decreased nociception from trigeminal nerve neuromodulation)

Acupuncture Points (all done bilaterally where applicable): BL-10
Rational: Trigeminocervical reflexes, decrease nociception and windup, via vagal neuromodulation

Acupuncture Points (all done bilaterally where applicable): GB-1
Rational: Influence on the trigeminal and facial nerves and their branches affecting post synaptic parasympathetic input to the lateral superior eyelid and conjunctiva, and the lacrimal gland

Acupuncture Points (all done bilaterally where applicable): GB-20
Rational: Trigeminocervical reflexes, decrease facial/ocular pain

Acupuncture Points (all done bilaterally where applicable):
Rational:

Acupuncture Points (all done bilaterally where applicable):
Rational:

Needles used: Seirin J type, various sizes
Acupuncture technique: Dry needling

Patient Position: Standing, on lead

Additional modality: Therapeutic massage prior to needling

Frequency: One acupuncture session once daily for four consecutive days

Outcomes

The aforementioned acupuncture sessions were performed once daily for four consecutive days; the barn manager continued with topical ophthalmic therapies, applying three separate applications of Abby’s serum at 0.3mL’s at each administration, triple antibiotic ointment, and ophthalmic lubricant to the eye over the course of each day following her acupuncture treatments. By the morning after her last acupuncture treatment, her eyelids were parted, the pupil appeared normal in size, no blepharospasm or epiphora, and there was minimal hyperemia/chemosis/elevation of the nictitating membrane.  After starting the massage/acupuncture treatment sessions and serum application, the barn manager and handlers reported that Abby seemed less apprehensive and was less resistant to receiving her eye medications, allowing for more effective dosing and application of the eye medications.

Discussions

As the serum and acupuncture were started simultaneously, it is difficult to assign credit for clinical improvement solely to one therapy over the other.

Watching the barn manager apply the eye medication to see her technique following the first acupuncture treatment revealed a very minimal amount of serum/antibiotic ointment/lubricant getting into the eye and just on the external lid margin.  It is for this reason that I do believe the acupuncture treatment sessions facilitated decreased patient anxiety, inflammation, and ocular pain (2) allowing for more accurate and complete application of the topical therapies to work in conjunction with the acupuncture to facilitate ulcer healing.

No adverse events occurred during treatment sessions, although ST-1 was not tolerated by the patient for safe placement until session/day 3.  This case demonstrated the importance of adequate pain management combined with appropriate medical therapy for successful treatment of any painful medical condition, and that analgesia such as that provided by acupuncture can be a suitable and beneficial alternative to pharmaceutical analgesics.

References

1.  MAV 2016 course material

2. Nepp, J., Jandrasits, K., Schauersberger, J., Schild, G., Wedrich, A., Sabine, G. L., & Spacek, A. (2002). Is Acupuncture An Useful Tool For Pain-Treatment In Ophthalmology? Acupunct Electrother Res Acupuncture & Electro-Therapeutics Research, 27(3), 171-182.