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Successful Treatment of Ocular Myasthenia Gravis

Journal of Chinese Medicine Number 84 June 2007

Successful Treatment of Ocular Myasthenia Gravis Using Acupuncture in Conjunction with Pharmaceutical Treatment: A Case Report
By: Nozomi Donoyama and Norio Ohkoshi Keywords: Myasthenia gravis (MG), acupuncture, ptosis, diplopia, immunological processes.

Abstract
In an ocular myasthenia gravis patient without antiacetylcholine receptor antibody, symptoms of ptosis (droopiness of one or both upper eyelids) and diplopia (double vision) improved with the use of acupuncture in combination with conventional medicine.

Introduction
yasthenia gravis (MG) is an autoimmune disorder affecting neuro-muscular transmission. Its primary cause is an acquired immunological abnormality, characterised by the development of antiacetylcholine receptor antibodies, mainly to the 1 subunit of the muscle postsynaptic nicotinic acetylcholine receptor.1 The blocking antibody, which deposits on the receptor muscle membrane prevents the entry of acetylcholine molecules. The resulting attenuation of neuromuscular transmission leads to muscular fatigue and, in some cases, frank paralysis. The subject of this article, ocular MG, is a mild form of MG whose only symptoms are ptosis and diplopia. In conventional medicine, pharmaceutical medication is most frequently used in the treatment of MG, typically: Anti-cholinesterase, which inhibits the action of cholinesterase, causing accumulation of acetylcholine in the neuromuscular junction. Steroids (adrenocorticoids), which are used to suppress the immune system of the patient. At present it is rare that patients with MG visit an acupuncture clinic for the treatment of ptosis and diplopia. However, in this article, we report an ocular MG patient without antiacetycholine receptor antibody on whom we practised acupuncture therapy successfully from the early stages of the disease.

were shown in the magnetic resonance imaging scans or computed tomography of the brain. Without receiving any diagnosis, his symptoms improved after a week of taking vitamin B agents. His symptoms reappeared a few years later; he experienced diplopia in the right eye on the 17th of June 2004. Again, no abnormalities were revealed by the magnetic resonance imaging scans of the brain during his initial visit to the hospital the next day. Then on the 19th, he developed ptosis of the right eyelid. On the following day he visited a nearby ophthalmologist, who diagnosed him with oculomotor nerve paralysis and prescribed vitamin B agents. However, despite taking the prescribed medication for a week, his symptoms did not improve. Hopeful of the effectiveness of acupuncture treatment, he nally visited us on the 28th of June 2004. Chinese medical examination and treatment according to pattern identication In traditional Chinese medicine, patterns comprising specic muscle weakness, muscle fatigue or muscular motor disturbances are believed to be due to either: fever injuring the Lung and Stomach yin deciency of the Liver and Kidneys frailty of the Spleen and Stomach damp-heat fever Moreover, according to the classics, vision is maintained by Liver blood.2 When Liver blood is decient, it fails to nourish the muscles and sinews (the Liver rules the muscles and sinews and opens into the eye.)3 In addition, disorders of the seven emotions affect the function of the Liver.2 In the current case, palpation of the abdomen and the back revealed tenderness at the points Qimen LIV-14, Ganshu BL-18 and Tianshu ST-25. Considering his age, the ocular muscle disturbances, and the great mental stress in his life, the cause of disease was presumed to be yin deciency of the Liver and Kidneys.

Case report
A 59-year-old male was referred to acupuncture therapy at the Centre for Integrative Medicine, Tsukuba University of Technology on June 28 2004. Since starting a business in 2000, he had felt physical and psychological stress at work and at home. In October 2001, he experienced symptoms of ptosis and diplopia in the right eye. However, no abnormalities

Journal of Chinese Medicine Number 84 June 2007

Successful Treatment of Ocular Myasthenia Gravis

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With the aim of holistic coordination, mainly tonifying the Liver and Kidneys, the following points were chosen; Ganshu BL-18, Shenshu BL-23, Ququan LIV-8, Yingu KID-10, Taichong LIV-3, Chongyang ST-42, Qimen LIV-14, Tianshu ST-25, Zhongwan REN-12 and Qihai REN-6. Furthermore, in order to relieve fatigue of the levator palpebrae superioris muscle and to improve the ocular blood ow, needles were added locally on the right margins of supra- and infra-orbitals; Jingming BL-1, Zanzhu BL-2, Sizhukong SJ-23, Tongziliao GB-1, Taiyang M-HN-9, Chengqi ST-1 and Yangbai GB-14. Needles with a diameter of 0.16mm and length of 40mm, sterilised with ethylene oxide gas (Seirin) were inserted by means of a disposable tube 0.5-0.7 cm deep depending on the part of the body, and retained for 30 minutes. Clinical course When the patient came into the treatment room for the rst time, his right eyelid was closed, completely covering his oculus. As soon as the rst acupuncture treatment was nished, he was able to open his right eyelid completely. However, after returning home and taking a nap for a few hours, his eyelid closed again. Since medical doctors had not diagnosed him with MG, we referred him to the neurology department of the Centre on the 29th of June 2004, the day following his rst treatment. Ambenonium chloride, an anticholinesterase, was prescribed by a neurologist. The patient came for a second acupuncture treatment with his right eyelid 80% closed, and again as soon as the acupuncture treatment was nished he was able to open his right eyelid completely for several hours. On the morning of the 6th of July, he was able to elevate his right eyelid, but not open it completely. This cycle of alleviation and deterioration continued until the third session on 13th July, at which time the symptom of ptosis disappeared and his eyelid remained open. Diplopia disappeared by the 10th acupuncture treatment session on 6th September 2004. On the 28th of September, he was diagnosed with ocular MG without antiacetycholine receptor antibody or thymoma, and prescribed prednisolone. He complained of languor and spasms of the right eyelid, thought to be after-troubles of ptosis, for several months. All symptoms of the right eyelid disappeared completely after the 33rd acupuncture treatment session on the 23rd of May 2005. For two months after completion of pharmacotherapy, the symptoms did not reappear, at which point acupuncture treatment was also completed. We conrmed that he had no reoccurrence of MG through a one-yearand-half follow-up survey in December 2006.

Discussion In the current case of mild ocular MG, symptoms of ptosis and diplopia improved with the use of acupuncture in combination with conventional medicine. The fact that the ptosis improved immediately after acupuncture treatment (both before and after medication had commenced) suggests that acupuncture has a positive effect on this condition. It has been implied in previous studies that acupuncture therapy has signicant effects on immunological processes,4,5 so it is possible that acupuncture positively affects the transmission of acetylcholine at the neuromuscular junctions (though this would need further research). Generally, in cases of ocular MG without antiacetylcholine receptor antibody, spontaneous remissions are possible. However, it is possible that acupuncture may induce spontaneous remission through some immunological process, although its mechanism of action is still unknown.
Nozomi Donoyama is an assistant professor at Tsukuba University of Technology, with an acupuncturist national license (Japan) and master's degree in physical education. Norio Ohkoshi, Ph.D. is a medical doctor, neurologist and professor in Tsukuba University of Technology. Both work in the Centre for Integrative Medicine, Tsukuba University of Technology, and teach students Oriental and Western medicine in the university. Contact: donoyama@k. tsukuba.ac.jp

References
1. L i n d s t ro m J M ( 2 0 0 0 ) . "Acetylcholine receptors and myasthenia", Muscle Nerve, 23, 453-77. 2. Nei jing su wen (Inner Classic Basic Questions) In: Su Wen and Ling shu, Japan Traditional Acupuncture and Moxibustion Society, 1993, Tokyo. (in Japanese) 3. Nei jing ling shu (Inner Classic Divine Pivot) In: Su Wen and Ling shu, Japan Traditional Acupuncture and Moxibustion Society, 1993, Tokyo. (in Japanese) 4. Joos S, Schott C, Zou H, Daniel V & Martin E (2000). "Immunologic effects of acupuncture in the treatment of allergic asthma", J Altern Complement Med, 6, 519-25.

5. Tanaka K, Yamaguchi S, Omata H, Arai C, Abe Y, Asaka T, Hirose K, Kikuchi T., Ohno S & Doi Y. (2006). "The results of blood and biochemical examination for patients who received acupuncture therapy in our clinic: comparing one-month later with the rst treatment", Journal of the Japan Society of Acupuncture and Moxibustion, 56, 502. (in Japanese)