Comparison of different acupuncture therapies for dry eye disease: A systematic review and network meta-analysis

Introduction: Dry eye disease (DED) has become increasingly prevalent in ophthalmology, significantly impacting patients' quality of life. Despite the widespread use of acupuncture therapies in treating DED, the most effective acupuncture treatment strategy remains uncertain. This study aimed to provide guidance in clinical practice for selecting the most effective acupuncture treatment strategy using the network meta-analysis (NMA) method. Methods: Seven English and Chinese databases were searched from their inception to October 15, 2023, to collect randomized controlled trials (RCTs) related to acupuncture therapies for treating DED. The risk of bias was assessed using the revised Cochrane risk of bias tool (ROB 2.0). Network meta-analysis was conducted using R 4.1.2 and Stata 17.0. The Confidence in Network Meta-Analysis (CINeMA) tool was used to evaluate the certainty of evidence. Results: A total of 41 studies with 2931 participants were included. The network meta-analysis results showed that conventional acupuncture combined with thumbtack needle had the best efficacy in improving tear break-up time (TBUT) (MD = 2.95, 95% CI [1.49, 4.39]) and Schirmer's test (MD = 3.34, 95% CI [0.90, 5.79]). In terms of improving the corneal fluorescein staining score, conventional acupuncture combined with electroacupuncture demonstrated the best efficacy (SMD =-0.80, 95 % CI [-1.40,-0.18]). The confidence ratings of different treatment comparisons were judged as very low to low. Eight studies reported adverse effects, none of which were serious. Conclusion: The NMA results support the use of acupuncture for treating DED. Among the therapies, conventional acupuncture combined with thumbtack needle and conventional acupuncture combined with electroacupuncture have higher priority. However, before widespread adoption, more multicenter, randomized, double-blind, and placebo-controlled clinical trials are needed to confirm these findings.