UNUSUAL OCULAR INJURY BY AN ACUPUNCTURE NEEDLE Timothy T. You, MD, Daniel W. Youn, BSc, John Maggiano, MD, Sanford Chen, MD, Bogdan Alexandrescu, MD, Marinel Casiano, CRA

Purpose: To educate ophthalmologists on the potential dangers of periocular acupuncture and to describe an unusual mechanism of retinal injury. Methods: A 42-year-old woman who presented with blurred central vision and loss of peripheral vision. Her medical history was significant for hemifacial spasms related to a facial nerve injury, for which she had sought treatment. Clinical examination showed vertically oriented subretinal track measuring 12 mm in length, contiguous to the macula, with normal optic nerve appearance and foveal reflexes. Spectral domain optical coherence tomography showed a full-thickness perforation of the neurosensory retina at the inferior retinal arcade. Visual field testing 3 weeks after her injury showed 90% loss of her nasal hemifield. Electroretinography performed 8 weeks postinjury showed a 50% decrease in the right B-wave. Multifocal electroretinography showed a mild decrease in the recording of the right eye versus that of the left eye. Conclusion: Based on the history and clinical findings, the acupuncture needle penetrated the inferior globe and created a subretinal track. The particular location of the needle entry into the eye and the extreme malleability of the acupuncture needle created a long subretinal track. Ophthalmologists should be familiar with the ocular injuries caused by periocular acupuncture therapies. RETINAL CASES & BRIEF REPORTS 8:116–119, 2014

uncorrected visual acuity was 20/30 bilaterally. Intraocular pressures by Tonopen measured 15 mmHg in the right eye and 18 mmHg in the left eye. The patient did not show any external

From the Orange County Retina Medical Group, Santa Ana, California.

Case Report A 42-year-old woman presented with blurred central vision and loss of peripheral vision in the right eye. The family history was negative for eye problems. Her ocular history was significant for bilateral laserassisted in situ keratomileusis (LASIK) surgery several years ago. The patient developed constant, right-sided hemifacial spasms related to a facial nerve injury without ocular injury 5 years ago. She was treated by an unlicensed acupuncturist at home to “increase blood flow to the face.” The patient reported that the acupuncturist placed a needle on her lower eyelid, presumably at a standard acupuncture location ST-1 (Figure 1). During 30 minutes, the needle was kept in the patient’s eyelid, she complained of blurred vision in the right eye, which persisted even after the needle was removed. After the acupuncture treatment, the patient sought the care of her comprehensive ophthalmologist, who referred her promptly to our retinal office. At the time of her initial examination, her None of the authors have any financial/conflicting interests to disclose. Reprints requests: Timothy T. You, MD, Orange County Retina Medical Group, Santa Ana, CA; e-mail: [email protected]

Fig. 1. Displays the ST-1 acupuncture known as Cheng Qi in traditional Chinese medicine (stomach meridian). Note its close proximity to the eye.

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Fig. 4. Initial spectral domain optical coherence tomography demonstrates a disruption of the retinal layers with a subretinal track.

injury. Both globes appeared normal externally with no signs of hemorrhages or trauma. Dilated fundus examination revealed a slight vitreous hemorrhage. The optic nerve appeared normal. Examination of the Fig. 2. Color fundus photograph shows a vertical subretinal track in the temporal macula.

Fig. 3. Fluorescein angiogram shows retinal vascular filling. The central region demonstrates leakage along the track in the late frames.

Fig. 5. Humphrey visual field shows nasal hemifield defect with the preservation of the central region.

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Fig. 7. Spectral domain optical coherence tomography 8 weeks after injury shows a disruption of the retinal pigment epithelium and neurosensory retina.

Fig. 6. Multifocal electroretinography demonstrated a mild decrease in the recording of right eye versus that of the left eye.

posterior pole revealed a vertically oriented retinal track 12 mm in length, extending inferiorly at the 6:30 position from the midequatorial location through the temporal macula in a contiguous fashion to just outside the superior vascular arcade. Limited retinal hemorrhages were noted along a subretinal track (Figures 2 and 3). Subretinal fluid was noted at both ends of the subretinal track, more prominent at the inferior portion of the track. These peripheral regions were treated with retinal laserpexy. Dilated examinations and testing of the left eye were normal. A spectral domain optical coherence tomography showed a fullthickness disruption of the retina and retinal pigment epithelium, where small preretinal hemorrhages were located (Figure 4). Visual field testing performed 3 weeks postinjury showed dense nasal hemifield scotoma (Figure 5). Subsequent visual fields did not show any change. A standard electroretinogram performed 8 weeks postinjury showed a significant 50% decrease in the right B-wave (right = 130 uV vs. left = 268 uV) supportive of diffuse retinal injury

likely related to a disruption of the nerve fiber layer. Multifocal electroretinography showed a mild decrease of the central amplitude in the right eye versus the left eye (Figure 6). The patient’s central vision decreased over 3 weeks to a bestcorrected visual acuity (VA) of the right eye because of an epiretinal membrane, causing macular traction. A follow-up spectral domain optical coherence tomography 8 weeks after injury showed contraction of the macula with a small intraretinal cyst. The fovea depression was present, with irregularity of the retina and retinal pigment epithelium. The option of surgical treatment consisting of vitrectomy with a membrane peel was reviewed with the patient (Figure 7). No additional documentation was available because the patient did not return for follow-up care.

Discussion A standard acupuncture needle for facial treatment has a stainless steel filiform tip, measuring 0.1 mm diameter and 20 mm in length. An acupuncture needle is designed as a tapered point to slide between muscle fibers rather than slicing through tissue. Unlike stiff hypodermic needles used for other medical applications, an acupuncture needle has extreme flexibility (Figure 8). The malleability of the acupuncture needle resulted in a novel injury in this patient because the

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a pinpoint retinal injury, which is typical of globe perforations caused by intraocular needle injuries.2,3 The subretinal track is not mentioned in previous reports. Based on the history and clinical findings, the acupuncture needle penetrated the inferior globe and slid into the subretinal space. The unique location of the needle entry into the eye and the extreme malleability of the acupuncture needle created a long subretinal track, which has not been reported in penetrating needle injuries. Ophthalmologists should be familiar with this novel mechanism of injury related to periocular acupuncture treatments. Key words: ocular penetration, acupuncture, acupuncture injury, retinal track, intraocular. Acknowledgments The authors thank Marinel Casiano, CRA, and Sarah Sakamoto for assistance with the photographs. References Fig. 8. Acupuncture needle is shown in both normal and flexed positions.

needle penetration into the potential subretinal space caused a long subretinal track. Despite the popularity of acupuncture, there is only one published report of ocular complications arising from facial or periorbital treatment described by Fielden et al.1 This previous case reported

1. Fielden M, Hall R, Kherani F, et al. Ocular perforation by an acupuncture needle. Can J Ophthalmol 2011;46: 94–95. 2. Havens S, Kosoko-Lasaki O, Palmer M. Penetrating eye injury: a case study. Am J Clin Med 2009;6:42–49. 3. Bullock JD, Warwar RE, Green RW. Ocular explosions from periocular anesthetic injections: a clinical, histopathologic, experimental and biophysical study. Ophthalmology 1999;106:2341–2353.

Unusual ocular injury by an acupuncture needle.

To educate ophthalmologists on the potential dangers of periocular acupuncture and to describe an unusual mechanism of retinal injury...
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