The following cases present variations of this condition. After familiarizing yourself with the possible common pattern presentations and appropriate formulas for treatment, use the following exercises to test your overall understanding of the condition.

1. Male, 49 years old. After contracting a cold the previous week, the patient’s left eye started to feel dry and painful with photophobia and tearing. He self-administered chloramphenicol eye drops for three days with no obvious improvement. He then tried using hydrobenzole eye drops, which showed some efficacy, however, the eye pain remained. The patient’s visual acuity also decreased and was accompanied by headaches and nasal congestion. An eye examination revealed mixed conjunctival hyperaemia in the left eye and grayish-white cloudiness in the deep layer of the cornea with many newly generated blood vessels at the edge. The tongue was red with a thin yellow coating and the pulse was floating and rapid.

Select the most appropriate formula:

A. Shū Fēng Qīng Gān Tāng (Wind-Expelling and Liver-Clearing Decoction)

B . Yín Huā Jiĕ Dú Tāng (Lonicera Toxin-Relieving Decoction)

C . Gān Lù Xiāo Dú Tāng (Sweet Dew Toxin-Removing Decoction)

D . Xī Jiăo Dì Huáng Tāng (Rhinoceros Horn and Rehmannia Decoction)

E . Qiāng Huó Shèng Fēng Tāng (Notopterygium Wind-Eliminating Decoction)

2. Female, 43 years old. The right eye presented with dryness, distension, pain, photophobia, tearing and blurred vision. The patient went to a local clinic and was prescribed acyclovir eye drops with no improvement after one week of use. Left eye pain and visual acuity became worse within the next two days, accompanied by heaviness in the head, chest tightness, a poor appetite and loose stools. An eye examination revealed ciliary hyperaemia in the right eye; grayish-white cloudiness in the deeper layer of cornea with many newly generated blood vessels at the edge. The tongue was red with sticky, yellow coating and the pulse was soft and rapid.

Select the most appropriate treatment principle:

A. Expel wind and clear heat

B. Clear heat and relieve toxins

C. Clear heat and transform dampness

D. Clear the liver and sedate fire

E. Nourish the yin and calm fire

3. Female, 52 years old. The patient presented with stinging pain in the right eye with photophobia, tearing and decreased vision for three weeks. Symptoms were slightly relieved with local application of cortisone acetate eye drops. Two days prior to treatment, the patient became irritable and all her symptoms worsened, accompanied by distension in the hypochondria region, a bitter taste in her mouth, constipation and yellow urine. An eye examination revealed mixed conjunctival hyperaemia in the right eye; a grayish-white cloudiness in the deeper layer of cornea with many newly generated blood vessels at the edge. The tongue was red with a yellow coating and the pulse was wiry and rapid.

Select the most appropriate differential diagnosis:

A. Liver channel wind heat

B. Liver and gallbladder toxic heat

C. Damp heat congestion

D. Phlegm fire congestion

E. Yin deficiency fire rising

4. Male, 42 years old. Two months prior to treatment, the patient’s left eye started to feel painful with photophobia, tearing and blurred vision. Symptoms fluctuated after both Western and traditional Chinese medicinal interventions. The eye pain became aggravated with distension after alcohol consumption three days prior to treatments, and was accompanied by dizziness, heaviness in the head, chest tightness, loose stools and yellow urine. An eye examination revealed mixed redness in the sclera and a circular grayish-white cloudiness in the deep layer of the cornea. The cross-section between the cornea and sclera was congested with blood vessels where some had entered the deep layer of the cornea. The body of the tongue was red with a yellow, greasy coating and the pulse was soft and rapid.

Select the most appropriate formula:

A. Píng Gān Qīng Huŏ Tāng (Liver-Calming and Fire-Clearing Decoction)

B . Gān Lù Xiāo Dú Dān (Sweet Dew Toxin-Removing Elixir)

C . Nèi Shū Huáng Lián Tāng (Interior-Expelling Coptis Decoction)

D . Huán Yīn Jiù Kŭ Tāng (Yin-Returning Bitterness-Relieving Decoction)

E . Chú Fēng Yì Sŭn Tāng (Wind-Eliminating and Damage-Benefiting Decoction)

5. Female, 57 years old. The right eye appeared to be dry approximately one year prior to treatment. The patient self-administered antibiotic eye drops, but the symptoms were not relieved. Gradually, the patient experienced eye pain, photophobia, tearing and decreased vision. She visited the hospital and was diagnosed with stromal keratitis, with positive results for a tuberculin test. Immediately, she was given anti-tuberculin treatment and local glucocorticoid eye drops. Symptoms improved after the above treatments; however, she often experienced dryness and dull pain in the right eye. Two days prior to treatment, the symptoms worsened along with a dry throat and mouth. An eye examination revealed mild ciliary hyperaemia in the right eye, with light grayish cloudiness in the deep layer of the cornea. The tongue body was red with reduced coating and the pulse was thin and rapid.

Select the most appropriate differential diagnosis:

A. Liver and spleen deficiency patterns

B. Spleen deficiency and liver heat patterns

C. Lung and kidney yin deficiency patterns

D. Combined qi and yin deficiency patterns

E. Yin deficiency and fire rising patterns

1. E

2. C

3. B

4. B

5. E

The case scenarios should be considered for their ability to round out the clinical patterns one might encounter when treating this population. The presentation for the first case suggests a pattern of wind warmth.

Formula: Qiāng Huó Shèng Fēng Tāng (Notopterygium Wind-Eliminating Decoction)

[羌活胜风汤]

[Method]

Decoct in two cups of water until one cup remains. Take as one single dose. Discard the dregs and take hot.

The original source of the formula is the Guide to the Subtleties of the OriginalMechanism ( Yuán Jī Qĭ Wēi, 原机启微) writen in 1370 by Ni Wei-de. It is indicated for fulminant wind with invading fever and wind-prevalent eye pain.

The formula’s actions are to expel wind-heat, dispel wind damp, harmonize the shaoyang and regulate the qi. It is indicated for the treatment of wind heat that ascends, disturbing the upper body and causing hot, rough and dry eyes. Symptoms include visible red vessels in the eyeball, headache, blocked nose and a heavy head. The upper margin of the brow bone is sore and achy. It is as if a veil has misted the eyes, shading the vision.

The discussion of the formula states that all diseases involving inhibition of the orifices are a reflection of spleen-stomach insufficiency. Therefore, the sovereign medicinals are bái zhú and zhĭ qiào because they regulate the qi and treat the stomach. Qiāng huó, chuān xiōng, bái zhĭ, dú huó, fáng fēng, and qián hú are the ministers. They dispel wind and govern uplifing. Jié gĕng treats chills and fever. Bò he and jīng jiè clear and disinhibit the upper jiao. Gān căo harmonizes all the medicinals and serves as an assistant. Chái hú resolves heat and clears the shaoyang and jueyin channels. Huáng qín serves as the envoy. It clears heat in the upper body and is indicated for redness and swelling in the eyes. The formula should be taken hot because heat by nature fames upwards. In this way, the heat will be dissipated in the upper body without fowing downwards.

Classical modifications: If a nebula (covering the eyes) is engendered, add medicinals according to the channel or collateral of which the nebula is seen. If the nebula begins at the inner canthus, add màn jīng zĭ and cāng zhú (Rhizoma Atractylodis). If it grows inward, obliquely from the outer canthus towards GB 3, add lóng dăn căo and găo bĕn (Rhizoma Ligustici), with a small amount of rén shēn (Radix et Rhizoma Ginseng). If it goes downward from the eye connector, double the dosage of chái hú and add huáng lián. If it goes upwards, then add mù tōng (Caulis Akebiae) and wŭ wèi zĭ (Fructus Schisandrae Chinensis).

The actions of the medicinals are focused on treating the upper body, yet its realm is larger, as it addresses a constitutional presentation as well. The formula’s sovereign medicinals are a complete surprise: bái zhú and zhĭ qiào create the mini-formula Zhĭ Zhú Wán (Immature Bitter Orange and Atractylodes Macrocephala Pill), which strengthens the spleen and reduces focal distention. The heart of the formula centers on treating the root paterns of defciency and stagnation.

Chuān xiōng, qiāng huó, bái zhĭ, fáng fēng, jīng jiè, bò he and gān căo are nearly creates the iconic headache formula Chuān Xiōng Chá Tiáo Săn (Tea-Mix and Chuanxiong Powder). The only medicinal missing from this group is xì xīn (Radix et Rhizoma Asari).

Qián hú and jié gĕng regulate the lung qi; the former medicinal descends and difuses the lung qi, while the later ascends the lung qi. The combination opens the chest, and when paired with bò he, they scater wind and clear wind-heat. This pair is featured with many of the medicinals in the group in a range of formulas that scater wind and dissipate cold, or scater wind and clear heat. Jīng Fáng Bài Dú Săn (Schizonepeta and Saposhnikovia Toxin-Resolving Powder) and Yín Qiào Bài Dú Săn (Lonicera and Forsythia Toxin-Resolving Powder) exemplify such formulas.

This upward and downward pivot is also expressed with the teaming of chái hú along with zhĭ qiào. The first two medicinals create the key qi rectifying pair in the formula Sì Nì Săn (Frigid Extremities Powder), and if jié gĕng is added to the equation, then Xuè Fŭ Zhú Yū Tāng (Blood Mansion Stasis-Expelling Decoction) is referenced.

The author does not explore at all the final medicinal relationship, possibly the most important, between chái hú and huáng qín. This ubiquitous pair harmonizes the shaoyang, yet none of the traditional indications for the formula suggests the presence of this patern. For the sake of simplicity, it is easier to grasp their actions by evaluating the medicinals independently. Chái hú eliminates wind, clears heat, and lifts the yang, thus supporting the other medicinals that clear heat from the upper body. Huáng qín is said to be the envoy in this formula.

The second case presents a patern of damp heat. The key symptoms that should be focused on are the sensation of eye distention, heaviness in the head, poor appetite, and loose stools. These are symptoms of a patern of dampness, and while they lack symptoms of heat per se, the patient’s red tongue with a sticky yellow coating clinches the diagnosis.

The third case shows a familiar constellation of symptoms that lead us towards a straightforward diagnosis: The biter taste, the tongue and the pulse presentation aim our atention to the correct patern diferentiation of liver and gallbladder toxic heat.

For the fourth study case, it is important that the correct formula be referenced. Gān Lù Xiāo Dú Dān (Sweet Dew Toxin-Removing Elixir) should not be confused with the more familiar and similar-sounding formula, Gān Lù Yĭn (Sweet Dew Beverage). The actions of the former are to resolve dampness and transform turbidity, while the actions of the latter formula are to nourish the yin, diffuse and descend the lung qi and rectify the stomach qi. That said, both formulas could be used to treat ophthalmological conditions.

Formula: Gān Lù Xiāo Dú Dān (Sweet Dew Toxin-Removing Elixir)

[甘露消毒丹]

The therapeutic actions of the formula are to dispel dampness, remove turbidity, clear heat and eliminate toxins. The patient has a history of alcohol consumption along with dizziness, loose stools and heaviness in the head. This refects a patern of damp turbidity.

There are similarities between the treatment strategies for this and the previous case that uses Qiāng Huó Shèng Fēng Tāng. Yet, upon closer inspection, the mechanisms of the two formulas are very diferent. Both formulas contain medicinals that are fragrant and acrid. Both formulas resolve dampness. Both clear heat, difuse the lungs and rectify the qi. However, Gān Lù Xiāo Dú Dān clears interior dampheat with medicinals that aromatically transform dampness, combined with bitter cold medicinals that clear heat and bland medicinals that seep dampness through urination. Wēn bìng (warm disease) formulas routinely employ variations of this strategy to great efect. In contrast, the actions of Qiāng Huó Shèng Fēng Tāng center on the idea of scatering wind, clearing heat, dispelling wind-dampness and rectifying the qi.