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, 55 years old. The patient presented with left eye dryness and stinging pain two days after an abrasion injury, accompanied by persistent hot tears and decreased visual acuity. After the injury, the patient self-administered chloramphenicol eye drops, but the symptoms were not significantly relieved. Other symptoms included headache, dry throat, and a stuffy and runny nose. The eye examination revealed mild swelling in the left eyelid with bleeding in the ciliary body and an ulcer in the cornea with a thin hemorrhagic appearance on the surface. The tongue was red with a thin yellow coating. The pulse was floating and rapid.

Select the most appropriate differentiation:

A. Wind heat congestion

B. Fire burning in the liver and gallbladder

C. Excess heat in the fu organs

D. Damp heat steaming

E. Yin deficiency with excessive fire

2. Female, 46 years old. Stinging pain in the right eye accompanied by extreme photophobia, non-stop hot tears, headache, a bitter taste in the mouth and fullness in the hypochondriac region for a week. Examination revealed mixed conjunctival hyperaemia in the right eye with ulceration in the cornea where the surface looked like the congealed fat, vitreous opacities and upward rushing of yellow fluid. The tongue was red with a thin yellow coating and the pulse was wiry and rapid.

Select the most appropriate treatment principle:

A. Eliminate wind and clear heat

B. Drain liver and sedate fire

C. Clear heat and resolve toxins

D. Clear heat and drain damp

E. Nourish yin and descend fire

3. Female, 58 years old, presented with a 10-year history of frequent cold tearing in the right eye, accompanied by pain for the previous three weeks. The patient reported slight photophobia, fatigue, a poor appetite and loose stools. Examination revealed dark red hemorrhaging in the left ciliary body, a sunken cornea with congealed fat on the surface. When pressure was applied to BL 1 ( jīng míng), a small amount of sticky fluid leaked from the inner canthus. The tongue was pale with a white coating, and the pulse was weak.

Select the most appropriate treatment principle:

A. Benefit the qi and abate nebula

B. Tonify the blood and abate the nebula

C. Nourish the yin and abate nebula

D. Warm the yang and abate nebula

E. Eliminate wind and abate nebula

4. Male, 57 years old, presented with excruciating pain in the left eye, accompanied by a burning sensation, photophobia, hot watery tearing and decreased visual acuity for 6 days prior to treatment. The patient also complained of headache, sore throat, fever, thirst, dry stools and yellow urine. Examination revealed redness and swelling of the left eyelid, mixed conjunctival hyperaemia in the right eye, a sunken cornea with the appearance of congealed fat on the surface, profuse congested pus in the anterior chamber and a slippery, fast pulse.

Select the most appropriate formula:

A. Modified Xīn Zhì Chái Lián Tāng (Newly-Manufactured Bupleurum and Coptis Decoction)

B . Lóng Dăng Xiè Gān Tāng (Gentian Liver-Draining Decoction)

C . Sì Shùn Qīng Liáng Yĭn Zĭ (Four Smooth Cooling Beverage)

D . Zhī Zĭ Shèng Qí Săn (Gardenia Miracle-Gaining Powder)

E . Jiāng Jūn Dìng Tòng Săn (The General Pain-Relieving Powder)

5. Female, 61 years old, presented with dryness and pain in the left eye appearing more than one month prior to treatment. Accompanying symptoms included slight photophobia and a dry mouth and nose. Examination revealed dark red hemorrhaging in the left ciliary body, a sunken cornea with congealed fat on the surface, a pink tongue with a reduced coating and a thin rapid pulse.

Select the most appropriate formula:

A. Yì Qì Cōng Míng Tāng (Qi-Boosting Intelligence Decoction)

B . Xiōng Guī Bŭ Xuè Tāng (Chuanxiong and Chinese Angelica Blood-Supplementing Decoction)

C . Zī Yīn Tuì Yì Tāng (Yin-Nourishing Nebula-Removing Decoction)

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

E . Bō Yún Tuì Yì Wán (Clouds-Dispelling Nebula-Abating Pill)

1. A

2. B

3. A

4. C

5. C

The first three case scenarios that discuss pattern identification and treatment principles illustrate the entire arc of purulent keratitis presentations. This helps round out the discussion in the second study question, which provides guidance on the efective staging of treatment for purulent keratitis. The frst case is very early stage. The pulse is floating and rapid; therefore, the pattern is wind heat congestion. The second case is a full-blown pattern of excess liver fire. Last is a chronic case with a patern of qi defciency.

The last two cases provide an opportunity to learn new formulas. Beginning with case 4: in addition to the corneal ulcer, the patient exhibits clear symptoms of exterior wind heat and yangming bowel excessive heat (headache, sore throat, fever, thirst, dry stools and yellow urine and a slippery, fast pulse). The formula below was frst recorded in the A Close Examination of the Precious Classic [on Ophthalmology] ( Shĕn ShìYáo Hán, 审视瑶函), Vol. III.

Formula: Sì Shùn Qīng Liáng Yĭn Zĭ (Four Smooth Cooling Beverage)

[四顺清凉饮子]

The formula treats purulent keratitis and is described in the following way: “Engendered on the wind-wheel, it resembles a star initially. It is white in color and with a depression in the middle as if pierced and damaged by a needle. Later it gradually grows larger and turns yellow.

Based on the formula construction, a few key pairs of medicinals grab our atention. Because the sclera belongs to the qi wheel of the eyes, which is associated with the lungs, huáng qín and sāng bái pí are the core medicinals in the formula. This pair is used over and over in many of the formulas in this book. Simply by knowing which channels the medicinals enter and which channels are associated with diferent parts of the eyes, we can determine that the location of the disease is in the sclera.

After that, the predominant patterns that the formula treats are wind, heat, fire, qi stagnation and blood heat. The realm of the formula is wide: it is constructed to treat interior and exterior excess pathogenic factors.

The medicinals that dispel wind and clear heat are fáng fēng, chuān xiōng, qiāng huó and chái hú.

Chái hú finds itself in three groupings: first, with lóng dăn and huáng qín to clear liver fire. Second, it can be placed with the medicinals that dispel wind, and finally, with zhĭ qiào to rectify the qi. If this last pair is teased apart further, it could be regrouped with dāng guī, chì sháo and shēng dì huáng. Then the formula references XuèFŭ Zhú Yū Tāng (Blood Mansion Stasis-Expelling Decoction) because it regulates the qi and blood.

Another way to re-frame the formula is to view it as a variation of Lóng Dăn XièGān Tāng (Gentian Liver-Draining Decoction) with zhī zĭ (Fructus Gardeniae), mù tōng (Caulis Akebiae), zé xiè (Rhizoma Alismatis), gān căo (Radix et Rhizoma Glycyrrhizae) omitted and sāng bái pí, chì sháo, zhĭ qiào, dà huáng, fáng fēng, chuān xiōng, huáng lián, mù zéi and qiāng huó added. Consider adding gān căo back into the formula. Not only does it harmonize the medicinals, but also it is effective for alleviating fire poison and healing ulcers.

Case 5 presents a sub-acute case of corneal ulcer. There is no exudate, but there are signs and symptoms of bleeding, blood stasis and yin defciency. The physician prescribes Zī Yīn Tuì Yì Tāng (Yin-Nourishing Nebula-Removing Decoction). This formula was recorded in the Notes on Clinical Practice in Ophthalmology ( Yăn Kē LínZhèng Bĭ Jì, 眼科临证笔记).

Formula: Zī Yīn Tuì Yì Tāng (Yin-Nourishing Nebula-Removing Decoction)

[滋阴退翳汤]

In this formula, zhī mŭ, shēng dì, xuán shēn and mài dōng nourish yin and enrich fluids; jí lí, jú huā, chán tuì, mù zéi and qīng xiāng zĭ remove nebula and eliminate obstruction; tù sī zĭ supplements liver and kidney, and gān căo harmonizes all the other formula medicinals.