Female, age 58. Initial Visit: August 5 ^th, 2008

Chief Complaint: Dryness of the right eye with a stinging pain and decreased visual acuity for four days prior to treatment.

History: Four days prior to treatment, the right eye was scratched by a childs toy. Dryness, a stinging pain and decreased visual acuity appeared immediately afterwards. The patient purchased chloramphenical eye drops and self-administered them for two days with no obvious improvement. She also developed a burning sensation in the eye, photophobia, headache and a dry throat. At the local hospital, she received a subconjunctival injection of gentamicin. The patient also applied levofloxacin eye drops. After two days the symptoms remained unchanged, accompanied by burning tears, an aggravated headache and a dry burning pain in the throat. The local hospital recommended Chinese medical treatment.

Signs and Symptoms: Eye pain, headache, burning heat, photophobia, warm and constant tearing, and blurred vision. The eyelid was red and swollen. The sclera was a turbid red color. A nebula at the lower outer corner of the cornea had an unclear border. Its surface was dirty, as if it were covered with congealed fat. There was upward rushing of yellow pus and a dry, burning pain in the throat. The tongue was red with a thin yellow coating and the pulse was floating and rapid.

Past History: Chronic dacryocystitis in both eyes for 10 years.

Ophthalmologic Examination: Visual acuity: right eye 0.2, left eye 1.0. Redness and swelling in the right eyelid, mixed conjunctival hyperaemia, ulceration below the outer cornea with an unclear border, some discharge attached to the surface, positive corneal fluorescein staining test, small amount of yellow fluid exuding from the anterior chamber.

This case of purulent keratitis originated from an external injury to the cornea The disease, located in the cornea, was an excessive pattern of wind heat congestion; the progression of this is analyzed as below:

● Pathogenic toxic wind heat invaded via the injury, burning and injuring the cornea and resulting in the corneal nebula. The nebula blocked brightness and light from entering the eye, leading to blurred vision.

● Due to the congestion of wind heat and the resultant internal transportation of congested toxins, the borders of the nebula appeared unclear and the surface seemed dirty and covered by congealed fat.

● Pathogenic, toxic wind heat invasion from the lung into the liver combined with lung and liver heat congestion, causing the dull redness in the sclera, the burning sensation, photophobia and the constant warm tearing.

● An upward attack of pathogenic toxic wind heat disturbed the clear yang qi, causing eye pain, headache and a dry burning pain in the throat.

● Wind heat invaded the yangming channel that has formed channel sinew mesh below the eyes, and then intense heat scorched aqueous humor, leading to the exudation of yellow pus.

● The tongue was red with a thin yellow coating and the pulse was thin and rapid, which are indications of wind heat invading the exterior.

WM diagnosis: Purulent keratitis (right eye)

TCM diagnosis: Congealed-fat nebula (right eye) due to wind heat congestion

The patient in this case had a history of dacryocystitis. It originated from an injury to the cornea along with inward invasion of pathogenic toxic wind heat, which subsequently transformed into heat. However, based on the current symptoms, tongue, and pulse diagnosis, the main etiology was exterior heat. Therefore, the treatment principle should focus on releasing exterior heat along with clearing interior heat. This may be combined with the use of antibiotics and pupil-dilating medication.

Principles: Eliminate wind, clear heat, abate nebula and brighten the eyes

Formula: Modified Xīn Zhì Chái Lián Tāng (Newly-Manufactured Bupleurum and Coptis Decoction)

[新制柴连汤加减]

[Formula Analysis]

Chái hú, màn jīng zĭ and jīng jiè eliminate wind, dissipate pathogens and abate the nebula.

Huáng lián and huáng qín clear and sedate heat in the lungs and liver.

Chì sháo and căo jué míng clear heat, cool the blood, abate redness and stop pain.

Shí gāo reduces yangming heat.

Lián qiào and qiān lĭ guāng clear heat, resolve toxins and expel pathogenic qi.

Boil the following medicinals to steam the eyes, and apply a hot moist compress, once daily: jīng jiè 10g , fáng fēng (Radix Saposhnikoviae) 10g , jīn yín huā (Flos Lonicerae Japonicae) 15g, băn lán gēn (Radix Isatidis) 15g , qiān lĭ guāng 15g.

20 days after the treatment, the symptoms of dryness, pain and burning in the eye, photophobia and continual warm tearing had greatly decreased. The patient’s visual acuity had also improved. However, the dry eyes, throat and mouth remained, coupled with fatigue. The tongue was red with reduced coating, and the pulse was thin and rapid. Ophthalmologic Examination: right eye vision acuity 0.8, dark red hemorrhage in the ciliary body, nebula in the cornea with a clear border; a corneal fluorescein staining test showed a light color in the center.

After the above treatment, the nebula in the cornea became thin and the border was clear. However, there was a light color in the center of the nebula accompanied by symptoms of qi and yin damage. The treatment principle should, therefore, focus on supporting the upright qi and dispelling pathogens.

Principles: Nourish the qi and yin, abate the nebula and brighten the eyes

Formula: Modifed Hăi Zàng Dì Huáng Săn (Ocean Treasure Rehmannia Powder)

[海藏地黄散加减]

[Formula Analysis]

Shú dì huáng, shēng dì huáng, xuán shēn, huáng jīng and shān yào nourish yin and benefit qi to support the upright qi.

Dāng guī and chōng wèi zĭ nourish and invigorate blood because blood is essential for vision.

Gŭ jīng căo, mù zéi căo and chán tuì eliminate pathogens, abate the nebula and brighten the eyes.