Female, 68 years old. Initial Visit: March 16 ^th, 2008

Chief Complaint: Frequent recurrence of reddening of the white of both eyes for one year. Redness in the right eye presented one day prior to seeking treatment.

History: The patient has had frequent recurrence of reddening of the white of both eyes for about a year. When the symptoms are less severe, they disappear spontaneously within a few days. When exacerbated despite the use of medicine, symptoms can persist for two weeks before resolving. The morning prior to treatment, the bulbar conjunctiva in the right eye became red with some pain and discomfort. The vision remained normal.

Signs and Symptoms: The symptoms included a large patch of bloody macules under the surface of the conjunctiva, at the inner canthus of the right eye, with pain and discomfort. This was accompanied by lower back and knee soreness and weakness, vexing heat in the five hearts and insomnia. Bowel movements and urination were normal. The tongue was red with litle coating. The pulse was thin and rapid.

Past History: Diabetes for three years. Thin body type, denied smoking and drinking.

Physical Examination: Physical examination showed blood pressure of 126/84 mmHg, a thin body type, clear breathing sounds in lungs, no rales and a heart rate of 86 beats/min with a normal rhythm. The abdomen was sof and fat. The liver and spleen were impalpable.

Ophthalmologic Examination: Examination showed visual acuity at 1.0 in both eyes, with a large patch of bleeding under the conjunctiva of the inner canthus of the right eye; the color was bright red, with a clear and bright cornea, anterior chamber (-), pupil (-). Lef eye (-). The fundus of the eye: the color of both optic discs was normal; the retina artery was relatively small, A∶V=1∶3, and the central fovea refection of macula lutea appeared blurred but with no bleeding or discharge at the back of retina

Laboratory Examination: Blood and urine routine tests were normal. Liver and kidney function and EKG were also normal. The fasting blood glucose level was 7.8 mmol/L, and the 2-hour postprandial blood glucose level was 11.6 mmol/L.

Pattern Differentiation

The chief characteristics of this patient were a thin body type, a history of diabetes for three years and frequent recurrence of reddening of the white of both eyes for one year. The patient had redness in the right eye for one day prior to treatment, with a large bright red patch of bloody macules under the surface of the conjunctiva that is near the inner canthus, accompanied by slight pain and discomfort. Other symptoms included lower back and knee soreness and weakness, vexing heat in the fve hearts and insomnia. The tongue was red with a reduced coating. The pulse was thin and rapid.

The patient’s thin body type is associated with yin deficiency. Here the yin deficiency resulted in fire abundance, which damaged the eye collaterals. This led to the large area of bleeding under the superficial layer of the sclera, causing eye discomfort. The lower back houses the kidneys. Here, kidney yin defciency caused the lower back and knees to be sore and weak. Yin defciency and the resultant fre abundance caused malnourishment of the heart and spirit; hence, the vexing heat in fve hearts, insomnia, red tongue with reduced coating and the thin rapid pulse which indicate defcient fre ascending.

The location of the pathology in this case originated in the kidneys, but its efect reached the heart and lungs. It can be categorized as subconjunctival hemorrhage with the diferentiation of yin defciency and fre abundance. This case had root defciency with branch excess.

WM diagnosis: Subconjunctival hemorrhage (right eye)

TCM diagnosis: Blood spillage in the white of the eye due to yin defciency and fre abundance

The clinical manifestations in this case showed a root defciency and branch excess. The treatment principle, therefore, should focus on nourishing the yin, descending fre to the root, stopping bleeding and dissipating stasis for the branch excess. To control the bleeding under the surface of the bulbar conjunctiva and prevent recurrence, treatment should address the root and the branch at the same time.

Principles: Nourish the yin, descend fre, stop bleeding and dissipate stasis

Formula: Supplemented Zhī Băi Dì Huáng Wán (Anemarrhena, Phellodendron and Rehmannia Pill)

[知柏地黄丸加味]

[Formula Analysis]

Shēng dì huáng, huái shān yào, shān zhū yú, dān pí, fú líng and zé xiè (Six-Ingredient Rehmannia Pill) nourish yin and tonify the kidney.

Zhī mŭ and huáng băi clear and descend deficient fire.

Bái máo gēn, cè băi yè and hàn lián căo cool the blood and stop bleeding.

Tián sān qī stops bleeding and dissipates stasis.

Compress therapy: A cold compress should be applied at the early stage to stop bleeding. If bleeding ceases afer 48 hours, change to a warm compress to improve the absorption of static blood under the superfcial layer of the sclera.

After seven days of treatment, the color of the bloody macules under the superficial layer of the bulbar conjunctiva in the right eye shrank, turning to a dark red color. The insomnia improved, but the lower back and knee soreness and weakness remained. The tongue was still red with little coating, and the pulse was thin and slightly rapid.

The above treatment brought the conjunctival hemorrhage under control and the symptoms improved. The kidney yin defciency remained along with blood stasis.

Principles: Nourish and tonify kidney yin, dissipate stasis and open the collaterals

Formula: Supplemented Liù Wèi Dì Huáng Wán (Six-Ingredient Rehmannia Pill)

[六味地黄丸加味]

[Formula Analysis]

Liù Wèi Dì Huáng Wán nourishes and tonifies the kidney yin.

Chōng wèi zĭ, dān shēn, zhĭ qiào and tián sān qī move qi, invigorate blood, dissipate stasis and open the collaterals.

Hàn lián căo and nü˘ zhēn zĭ nourish the yin and tonify the blood while preventing a recurrence of the bleeding.