We recently read an article published in your esteemed journal regarding the safety of periocular acupuncture with great interest but also with concerns [1]. Acupuncture is known to be used in at least 100 countries worldwide [2], and this number seems to continue increasing. The fact is, acupuncture is a safe intervention when performed by well-educated and trained practitioners in a suitable environment, adhering to established standards as in Western medicine. It has already been supported by various large-scale prospective and retrospective studies [3]. The same applies to acupuncture practice in the field of ophthalmology.

As practitioners who have personally performed acupuncture in clinical settings for over a decade, we have been involved in numerous clinical studies aimed at establishing evidence for acupuncture, including clinical trials on acupuncture dry eye syndrome [4]. To briefly summarize one study, patients with dry eye syndrome received treatment at commonly used acupoints including periocular lesion, such as GB14, BL2, TE23, and ST1, three times a week for 4 consecutive weeks. The only acupuncture-related adverse event in this study was local bleeding at the treatment site, occurring in 3 out of 75 patients. Importantly, only a few of these incidents were associated with periocular acupoints [4]. This result highlights that the application of acupuncture in the periocular region is not always directly linked to serious adverse events.

We understand the concerns of the authors as ophthalmologists regarding the potential adverse events of periocular acupuncture [1]. However, it is crucial to note that their conclusions might be somewhat exaggerated for several reasons.

First, the authors’ research methodology for assessing the risk of periocular acupuncture can exaggerate the actual level of risk. In general, case reports serve the purpose of documenting the effectiveness of novel, relatively unknown interventions or the occurrence of uncommon adverse events in the medical field. It is natural for common occurrences in clinical practice to not be well covered in case reports. Although case reports can be useful in recognizing and organizing infrequent but serious adverse events, they also have limitations in establishing a clear causal relationship between intervention and adverse events, and there is a risk of recall and publication bias [5]. In this sense, the methodology of this study is insufficient to draw generalized conclusions regarding safety, so it is worth reconsidering whether concluding that “acupuncture therapy around the eye is a risky procedure” based on a review of case reports is entirely reasonable [1].

Second, safe procedures reduce the risk of adverse events. As the authors commented, the primary issue is acupuncture being performed by individuals without proper qualifications or training, in inappropriate clinical settings, and without appropriate infection-prevention measures. In the authors’ case review, at least half of the cases involved unclear practitioners or unqualified individuals, leading to adverse events.

Finally, considering common acupuncture practices, periocular acupuncture can also be considered very safe. In our previous acupuncture study, all acupuncture points were located according to the WHO Standard Acupuncture Point Locations in the Western Pacific Region [6], and when needling, the direction of the acupuncture was adjusted to avoid direct penetration into the patient’s orbit, and the depth of needle insertion was very shallow, around 3 to 6 mm. Sterilized, disposable stainless steel needles with a size of 0.20 × 30 mm were used, and clean needle techniques were adhered to during the procedure. Of course, it goes without saying that qualified Korean Medicine doctors with appropriate education and clinical experience participated in our study. We did not experience any severe adverse events as we described before [4].

In summary, while recognizing the potential risks of periocular acupuncture is essential, it is also crucial to consider the context in which the procedure is performed, the qualifications of the practitioner, and the limitations of case report-based conclusions. It is reasonable to assume that periocular acupuncture is performed within an acceptable level of safety for common practices. In addition to this, it should be recommended that studies dealing with acupuncture safety are necessary to clearly distinguish between unlicensed acupuncture practitioners and licensed Korean Medicine doctors, at least in South Korea in the future.

We would like to express our gratitude to the authors for their interest in our paper and for their thoughtful comments. In this response, we address the three main points raised, and we hope to clarify our perspective in our paper [1].

First, we fully agree with the statement that “the application of acupuncture in the periocular region is not always directly linked to serious adverse events.” We also firmly believe that periocular acupuncture, given its inherent risks, should only be performed by qualified professionals. Our position remains unchanged: this procedure should never be undertaken by unlicensed practitioners. When conducted by medical professionals with a thorough understanding of modern anatomical knowledge and infection control standards, acupuncture in the periocular region can indeed be safely administered. Regarding the first point, we did not intend to exaggerate the risks of periocular acupuncture. Our goal was simply to collect and present the real complications that have arisen from such procedures. It is important to note that any reasonable reader would not assume, based on our case series, that adverse events from acupuncture are common occurrences in everyday clinical practice. Instead, we believe that the case reports we compiled highlight the potential, albeit rare, consequences when complications do occur.

On the second point, we wholeheartedly agree with the assertion that “safe procedures reduce the risk of adverse events.” As ophthalmologists, we are aware of the potential dangers that surround periocular interventions, such as intravitreal injections or intraocular surgeries. We constantly remind ourselves of these risks and ensure that our residents and fellows are thoroughly educated about them. We emphasize the critical importance of anatomical knowledge and the expertise of experienced specialists during such procedures.

Thirdly, we agree that periocular acupuncture, when performed following established guidelines and with a solid understanding of ocular and orbital anatomy, can be considered a safe procedure. We acknowledge that qualified Korean Medicine doctors, equipped with proper education and clinical training, can administer acupuncture in a safe and effective manner. However, as we highlighted in our paper, there remain instances where acupuncture is performed without adhering to modern guidelines. This does not serve as a critique of any particular profession, including Korean Medicine doctors. Rather, our paper emphasizes the severe adverse events that may arise when individuals without proper qualifications or anatomical knowledge perform these procedures.

In summary, we reiterate that periocular acupuncture, like any intervention around the eyes, should be recognized as a high-risk procedure. Therefore, it is our firm belief that such treatments should be performed only by highly trained professionals, equipped with the necessary knowledge and skills to ensure patient safety. We also wish to underscore that serious adverse events are not exclusive to acupuncture. Even procedures performed by less-experienced ophthalmologists, such as retrobulbar anesthesia or intravitreal injections, can rarely result in serious complications [2]. Thus, it is not acupuncture alone that is a risky procedure around the eyes; rather, any periocular intervention must be approached with the utmost care, proper medical knowledge, and technical proficiency.