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

1. Male, 58 years old. The patient complained of redness, dryness and a slightly itchy sensation in the left eye, accompanied by photophobia and tearing. Examination showed an early stage pterygium in the canthus that gradually moved towards the pupil. The tongue body was red with a thin yellow coating and the pulse was floating and rapid.

Select the most appropriate formula:

A. Dăo Chì Săn (Red-Guiding Powder)

B. Sān Huáng Xiè Xīn Tāng (Three Yellow Heart-Draining Decoction)

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

D. Xiè Pí Chú Rè Yĭn (Spleen-Draining and Heat-Eliminating Beverage)

E. Zhī Băi Dì Huáng Wán (Anemarrhena, Phellodendron and Rehmannia Pill)

2. Female, 62 years old. The patient had intermittent dryness and itchy sensation in the right eye. The pterygium was pink and thin. Symptoms would wax and wane accompanied by a dry mouth and tongue as well as vexing heat in the five centers. The tongue body was red with scanty coating and the pulse was thin and rapid.

Select the most appropriate formula:

A . Yín Qiào Săn (Lonicera and Forsythia Powder)

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

C . Xiè Pí Chú Rè Yĭn (Spleen-Draining and Heat-Eliminating Beverage)

D . Zhī Băi Dì Huáng Wán (Anemarrhena, Phellodendron and Rehmannia Pill)

E . Sān Huáng Xiè Xīn Tāng (Three Yellow Heart-Draining Decoction)

3. Male, 45 years old. The patient presented with redness and dryness in the right eye, and a red and swollen protrusion at the top of pterygium that had formed rapidly. He had a dry mouth with the desire to drink, dark urine and constipation The tongue body was red with a yellow coating and the pulse was rapid.

Select the most appropriate formula:

A . Yín Qiào Săn (Lonicera and Forsythia Powder)

B . Xiè Pí Chú Rè Yĭn (Spleen-Draining and Heat-Eliminating Beverage)

C . Zhī Băi Dì Huáng Wán (Anemarrhena, Phellodendron and Rehmannia Pill)

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

E . Xiè Fèi Tāng (Lung-Draining Decoction)

1. C

2. D

3. B

The first study case treats the pterygium with a parade of medicinals that clear heat from the eyes. Notable is the inclusion of shé tuì (Periostracum Serpentis), which is specific for removing superficial visual obstructions, making it a leading medicinal for the treatment of pterygium irrespective of the patern presentation. A diagnosis is not ofered for this case, but we gather from the details provided that it arises from deficiency heat. The formula is Zhī Zĭ Shèng Qí Săn (Gardenia Miracle-Gaining Powder) from the Ming Dynasty ophthalmological text Explanation on theSubtleties of the Original Mechanism ( Yuán Jī Qĭ Wēi, 原机启微) by Ni Wei-de. The actions of the formula are to remove superfcial visual obstruction by clearing heat, expelling pathogenic wind and clearing the network vessels to eliminate blood stasis. Based on the structure of the formula, it would be useful for the treatment of many ophthalmological diseases caused by wind-heat including ocular migraines, red eyes, cataracts and possibly glaucoma.

Formula: Zhī Zĭ Shèng Qí Săn (Gardenia Miracle-Gaining Powder)

[栀子胜奇散]

In the second case, the predominant patern is yin defciency with excess fre. The eyes are dry and irritated with intermitent itchiness. The overall presentation is less severe than the previous two cases. As a result, rather then use a formula to drain efulgent heat, Zhī Băi Dì Huáng Wán (Anemarrhena, Phellodendron and Rehmannia Pill) is administered as its actions bridge clearing vigorous fire and nourishing the yin.

The fnal study case may be the most important of this chapter. A 45-year-old man presents with symptoms of spleen heat. His eye is red and dry and the pterygium has formed rapidly. His accompanying symptoms are dry mouth with a desire to drink, dark urine and constipation. The formula for this case is Xiè Pí Chú Rè Yĭn (Spleen-Draining and Heat-Eliminating Beverage). In contrast to the primary case, this formula clearly has a combined strategy of supplementation and draining. Although it was frst recorded in the Essentials from the Silver Sea ( Yín Hăi Jīng Wēi, 银海精微), its structure is reminiscent of formulas by Li Dong-yuan.

Formula: Xiè Pí Chú Rè Yĭn (Spleen-Draining and Heat-Eliminating Beverage)

[泻脾除热饮]

Li’s formulas were notable for combining sweet warm medicinals to strengthen the spleen and stomach with the following: acrid cool medicinals to raise the clear yang; biter cold medicinals to clear heat and descend fre; and lastly, medicinals to address any other paterns or symptoms. Xiè Pí Chú Rè Yĭn follows a similar structural rubric. Within the formula, huáng qí and jié gĕng raise the spleen qi, while dà huáng and máng xiāo drain downwards. Dà huáng, huáng qín and huáng lián create the formula Sān Huáng Xiè Xīn Tāng, which was used in the formula for the primary case. Chē qiánzĭ and chōng wèi zĭ clear heat from the eyes. To understand the role of fáng fēng, we can consider its inclusion in Li Dong-yuan’s formula, Xiè Huáng Săn (Yellow-Draining Powder). The formula’s ingredients are shí gāo (Gypsum Fibrosum) 15g, zhī zĭ (Fructus Gardeniae) 3g, fáng fēng 120g, huò xiāng (Herba Agastachis) 21g, and gān căo 90g. The actions of the formula are to clear lurking fre from the spleen and stomach. While the large dosage of fáng fēng is in dispute as a translational error, its role in the formula is clear: the medicinal clears fire through dispersal. It also supports the ascending movement of the huáng qí and jié gĕng, which corrects the normal transportive mechanisms of the spleen. If this were merely a simple case of stomach fre, then the use of heat-clearing and downward-draining medicinals would suffice to resolve the condition. The structure of Xiè Pí Chú Rè Yĭn illustrates the subtle diferences in treatment of stomach and spleen yin defciency.