Male, age 57. Initial Visit: May 17 ^th, 2007

Chief Complaint: A dry, stinging pain in the left eye, photophobia and tearing with decreased visual acuity for two weeks prior to treatment.

History: A month ago, the patient contracted herpes zoster in his left eye that resulted in a palpebral scab after having been treated for two weeks with both Western and traditional Chinese medicine. At the onset, the patient experienced dryness and a painful sensation in the lef eye with obvious photophobia, tearing and decreased visual acuity. He went to the local hospital where he was diagnosed with lef eye stromal keratitis. He was given acyclovir eye drops and ganciclovir eye gel for one week, with no improvement in the symptoms. He was then given cortisone acetate eye drops for one week, which also did not signifcantly relieve the symptoms. The local hospital suggested using traditional Chinese medicine to treat this case.

Signs and Symptoms: Additional symptoms included blurred vision, a slight swelling of the lid, bloody vessels in the sclera, grayish white cloudiness in the deep layer of the cornea with invasion of bloody vessels. The patient had a biter taste in his mouth, a dry throat, constipation and yellow urine. The tongue was red with a yellow coating and the pulse was wiry and rapid.

Past History: A history of hypertension for 12 years; cholecystectomy fve years prior to treatment.

Ophthalmologic Examination: Visual acuity: right 1.0, lef 0.2. Closer examination of the eye showed slight swelling of the left eyelid, mixed hyperaemia in the conjunctiva, and a round, grayish-white color in the deep layer of the cornea with small degree of newly generated blood vessels entering through the corneal edge. A corneal fuorescein staining test showed negative results. The slit lamp examination showed that the pupillary light refex was present.

The location of this case was in the cornea, which is associated with the wind wheel in the five-wheel theory and belongs to liver. The unresolved external toxic wind heat invaded the zang-fu organs, causing congestion of excessive toxic heat in the liver and gallbladder, which attacked upward along the liver channel and resulting in the development of a nebula in the deep layer in the cornea. The nebula causes corneal opacity, obstructing the perception of light, hence the blurred vision.

Congestion of toxic heat in the liver and gallbladder, wood fre tormenting metal, and heat stagnation causing blood stasis in the eye collaterals were the contributing factors leading to bloody vessels in the sclera and invasion of the cornea with a dry, stinging sensation. Toxic heat is associated with yang, and therefore manifests with yang symptoms, including photophobia and tearing. Toxic heat in the liver and gallbladder tends to atack upward, and in this case led to the biter taste in the mouth and dry throat. Excessive heat was also seen in the zang-fu organs, evidenced by the constipation and yellow urine. The red tongue with a yellow coating and the wiry rapid pulse further indicate the paterns of toxic heat in the liver and gallbladder.

The location of this case was in the cornea and was an excessive patern belonging to the patern of toxic heat in the liver and gallbladder.

WM diagnosis: Interstitial keratitis (lef eye)

TCM diagnosis: Murky eye nebula (left eye) due to toxic heat in the liver and gallbladder

This case was due to toxic heat in the liver and gallbladder attacking upwards, burning the fluids and causing qi and blood stagnation. The treatment principle should focus on clearing the liver, sedating fire, and clearing toxic heat. Local treatment can be supplemented with corticosteroid eye drops or subconjunctival injection.

Principles: Drain the liver, relieve toxins, eliminate the nebula and brighten the eye

Formula: Modifed Yín Huā Jiĕ Dú Tāng (Lonicera Toxin-Relieving Decoction)

[银花解毒汤加减]

[Formula Analysis]

Lóng dăn căo and xià kū căo clear liver and gallbladder heat.

Huáng qín and sāng bái pí clear heat and sedate lung.

Jīn yín huā and pú gōng yīng clear heat and relieve toxins.

Dà huáng and dàn zhú yè opens and regulates urination and bowel movements to clear heat by inducing draining precipitation.

Chì sháo and yù jīn move and cool the blood and clear the bloody vessels.

Màn jīng zĭ disperses wind, clears heat and eliminates nebula.

Warm moist compress: Combine 30g each of jīn yín huā, jú huā (Flos Chrysanthemi), pú gōng yīng and qiān lĭ guāng (Herba Senecionis Scandentis), and bring to a boil for use as a warm, moist compress twice daily.

28 days after the above treatment, the stinging pain, photophobia and tearing in the left eye had decreased significantly and vision acuity had improved. The dryness in the eye, dull pain and dry throat and mouth remained. The tongue was red with a reduced coating and the pulse was thin and rapid. Close examination of the eye showed visual acuity in the right eye to be 0.8, with mild mixed hyperaemia in the conjunctiva, thin cloudiness with a smooth surface in the deep layer of the cornea, and a negative corneal fluorescein staining test. The newly generated corneal vessels from the corneal edge had shrunk.

Through the above treatment, even though the toxic heat in the liver and gallbladder had been reduced, yin-deficient patterns were apparent due to yin damage from the heat, thereby changing the excessive pattern into a pattern deficient fire.

Principle: Nourish yin, subdue fre, eliminate the nebula and brighten the eye

Formula: Modified Zī Yīn Jiàng Huŏ Tāng (Yin-Enriching Fire-Downbearing Decoction)

[滋阴降火汤加减]

[Formula Analysis]

Shēng dì huáng, shú dì huáng, mài dōng, bái sháo and shā shēn enrich water, moisten wood, nourish yin and brighten the eyes.

Zhī mŭ and huáng băi sedate and calm ministerial fire.

Tŭ fú líng clears heat and relieves toxins.

Chán tuì and mì méng huā eliminate the nebula and obstruction.