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, age 42. The patient complained of pain, photophobia, and tearing of the left eye with prompt decline in vision for one day. At present, there was bearingdown quality to his pain, blurred vision, photophobia and excessive tearing at the left eye, accompanied by headache, fever and a dry mouth. His visual acuity was tested 1.0 in the right eye and 0.1 in the left, which was not improved after wearing lens. Examination showed ciliary hyperemia, keratic precipitates on the posterior surface of the cornea, turbid aqueous humor and unclear texture of the iris at the left eye, with no abnormity of the right eye. The tongue was red with a thin yellow coating, and the pulse was floating rapid.

Select the most appropriate formula:

A. Xīn Zhì Chái Lián Tāng (New Bupleurum and Coptis Decoction)

B. Lǜ Fēng Líng Yáng Yĭn (Green Wind Antelope Horn Decoction)

C. Yì Yáng Jiŭ Lián Săn (Yang-Restraining Wine-Washed Coptis Powder)

D. Qiāng Huó Shèng Fēng Tāng (Notopterygium Wind-Eliminating Decoction)

2. Male, age 49. The patient complained of bearing-down pain of the right eye with declined vision for 7 days. At present, there was bearing-down pain and blurred vision at the right eye, with distention at the temple area. Other symptoms included a heavy sensation in the head, chest oppression, aching pain of the extremities. His visual acuity was tested 0.5 in the right eye and 1.0 in the left, which was not improved after wearing lens. Examination showed ciliary hyperemia, keratic precipitates on the posterior surface of the cornea, turbid aqueous humor and unclear texture of the iris at the right eye, with no abnormity of the left eye. The tongue was light red with a yellow greasy coating, and the pulse was soggy and rapid.

Select the most appropriate formula:

A. Xīn Zhì Chái Lián Tāng (New Bupleurum and Coptis Decoction)

B. Wēn Dăn Tāng (Gallbladder-Warming Decoction)

C. Yì Yáng Jiŭ Lián Săn (Yang-Restraining Wine-Washed Coptis Powder)

D. Qiāng Huó Shèn Fēng Tāng (Notopterygium Wind-Eliminating Decoction)

3. Female, age 46. The patient complained of recurrent pain and blurred vision at the left eye for 2 months. At present, the patient’s left eye presented with dryness, blurred vision, redness and pain, accompanied by occasional dizziness and insomnia, vexing heat in the five centers (chest, palms and soles), dry mouth and throat. Her visual acuity was tested 1.0 in the right eye and 0.5 in the left, which was not improved after wearing lens. Examination showed mild ciliary hyperemia, keratic precipitates on the posterior surface of the cornea, unclear texture of the iris, synechia at the 2 o’ clock position of the pupil, and dilated pupil in a diameter of 7 mm at the left eye; no abnormity of the right eye. The tongue was red with scanty coating, and the pulse was thready rapid.

Select the most appropriate formula:

A. Yòu Guī Wán (Right-Restoring Pill)

B. Bŭ Zhōng Yì Qì Wán (Center-Supplementing and Qi-Boosting Pill)

C. Sì Wù Tāng (Four Substances Decoction)

D. Qĭ Jú Dì Huáng Tāng (Lycium Berry, Chrysanthemum and Rehmannia Decoction)

4. Female, age 36. The patient complained of pain in left eye with rapid decline in visual acuity for 4 days. At present, her left eye presented with sharp pain, photophobia, tearing, and blurred vision, accompanied by fever, aversion to cold, splitting headache, nausea and desire to retch. Visual acuity was 1.0 in the right eye and 0.08 in the left, which was not improved after wearing lens. Examination showed ciliary hyperemia, turbid aqueous humor, keratic precipitates (++), pupil contraction, and hypopyon at the left eye; no abnormity of the right eye. The tongue was red with a yellow coating, and the pulse was rapid.

Select the most appropriate formula:

A. Xīn Zhì Chái Lián Tāng (New Bupleurum and Coptis Decoction)

B. Yín Qiào Săn (Lonicera and Forsythia Powder)

C. Yì Yáng Jiŭ Lián Săn (Yang-Restraining Wine-Washed Coptis Powder)

D. Huáng Lián Jiĕ Dú Tāng (Coptis Toxin-Resolving Decoction)

1. A

2. C

3. D

4. D

The diagnosis for the patient presented in case 1 is wind-heat in the liver channel: in contrast to the primary case, the key symptoms to clinch the diagnosis is excessive tearing, the headache, the fever and the floating rapid pulse. Of course, we think of wind heat as an exogenous patterns and liver wind as an endogenous one. Here, we have a hybrid presentation. The signs of liver heat include the pain, the photophobia, and the red with a thin yellow coating.

He is treated with a formula from the Qing Dynasty text Compilation ofOphthalmology ( Yăn Kē Zuăn Yào, 眼科纂要) by Huang Yan:

Formula: Xīn Zhì Chái Lián Tāng (New Bupleurum and Coptis Decoction)

[新制柴连汤]

The actions of the formula are to drain fire and resolve toxin, scatter wind and dissipate heat. It is indicated for purulent keratitis caused by wind-heat congestion or iridocyclitis caused by excess heat in the liver and gallbladder.

The formula clearly merges the medicinals and principles of Lóng Dăn Xiè GānTāng and then folds in wind-dispelling medicinals.

If, as in case 2, there is a presentation of wind-heat with dampness, the best formula is modified Yì Yáng Jiŭ Lián Săn (Yang-Restraining Wine-Washed Coptis Powder) from the Ni Wei-di’s Enlightenment of Ophthalmology ( Yuán Jī Qĭ Wēi, 原机启微)

Formula: Yì Yáng Jiŭ Lián Săn (Yang-Restraining Wine-Washed Coptis Powder)

[抑阳酒连散]

The actions are to dispel wind, eliminate dampness, and clear heat. It is indicated for iridocyclitis caused by complex wind-heat-damp pathogen. The formula features hán shuĭ shí, which is rarely used in formulas. It is acrid, salty and cold. It enters the heart, stomach and kidney channels. Key amongst its characteristics is that is clears yangming heat and clears fire, thus, is helps to reduce inflammation.

Because the formula contains numerous warm and acrid herbs, if there are signs of wind-heat causing pain and congestion around the cornea then omit the qiānghuó, dú huó and bái zhĭ to prevent the formula from being overly drying and thus, exacerbating the wind heat.

If there are signs of liver heat, then add chōng wèi zĭ (Fructus Leonuri) 15g, qīngxiāng zĭ (Semen Celosiae) 10g and chì sháo (Radix Paeoniae Rubra) 12g to clear the liver, cool the blood and relieve pain.

Turbidity of the aqueous humor, with mild red and pain of the eye, suggests a pattern of wind dampness. In that case, omit the zhī mŭ, hán shuĭ shí, shēng dì which can engender dampness and then add bái kòu rén (Fructus Amomi Rotundus) 8g, fú líng (Poria) 15g and hòu pò (Cortex Magnoliae Officinalis) 10g to dispel dampness.

Case 3 veers off into a slightly new direction. Rather than a presentation of full fire, this patient has a presentation of hyperactivity of fire due to yin deficiency. Therefore, according to our rubric, she should be treated with modified Zhī Băi DìHuáng Tāng. The formula is simple enough to understand and only requires the addition of medicinals that clear heat from the eyes. Consider merging this with Qĭ JúDì Huáng Wán (Lycium Berry, Chrysanthemum and Rehmannia Pill) by adding jú huā and gŏu qĭ zĭ. Furthermore, chōng wèi zĭ is always helpful for treating eye disease with yin deficiency or deficiency fire.

Case 4 drives home one single, strong message: if there is one single unifying principle in the chapter, it is that iridocyclitis is caused by fire. And, If there were one single medicinal to treat this disease, it would have to be huáng lián, which has been included in the majority of these case presentations. The wide realm of its actions is unparalleled to clear heat, drain fire, dry dampness and resolve toxicity. All these characteristics and it also enters the yangming channels, which targets its actions to the qi wheel of the eye.