​The Treatment of Hordeolum in Chinese Medicine

​The Treatment of Hordeolum in Chinese Medicine

Cara Frank, L.OM.

Earlier this month I had a stye for the first time in my life. There is very little English language literature on this disease, so I was grateful that I had written a chapter on the topic. It made it easy for me to diagnose and treat myself. Today I am sharing an excerpt of the chapter.

A hordeolum or stye is an acute infection of the sebaceous glands of the eyelid, usually caused by a localized infection of the eyelash follicle and adjacent meimobian glands. It is sometimes associated with blepharitis. Most hordeola are external, and diagnosis is made visually through clinical examination.

Hordeola are characterized bygrain-shaped boils appearing on the margin of the eyelid that can easily form pus and rupture. Symptoms include redness, swelling, itchiness and pain of the lid margin. Mild hardness and tenderness are followed by localized swelling with increased pain.Vision may be blurred. In some cases the abscess may rupture spontaneously. The condition is seen more frequently in adults than children and most cases are self-limiting, usually resolving within two weeks.

As the hordeolum progresses, there will be a gradual reduction of redness and swelling with the induration softening into pus. Pus formation in an external hordeolum occurs on the surface of the eyelid. The pus in the internal hordeolum forms at the inner part of the eyelid, often with a rupturing of the lesion. Lesions located close to the inner canthus will be more painful. The sclera on the diseased side will turn red with the swelling embedded in the palpebral fissure. There may also be palpable nodules anterior to the ears.

Western medical treatment consists of hot compresses applied to the eye, along with improvements in eye hygiene. Surgical incision and drainage may be used if the hordeolum is large. If hordeola present with local cellulitis,antibiotics will be prescribed.

In TCM, hordeola usually result fromwind-heat evil attacking the eyelid, an improper diet, or heat accumulation in the spleen and stomach rising upward to attack the eyelid. Recurrence is usually due to lingering pathogens not being completely resolved, or retention of wind-heat due to deficiency of spleen qi and wei-defense qi.Causative factors include poor eye hygiene, malnutrition, fatigue, or wasting and thirsting patterns.

COMMON CLINICAL PATTERNS

·Wind-heat evil attacking the eyelid

·Toxic heat

·Spleen deficiency combined with excess signs and symptoms

CASE STUDY

Male, age 9. Initial Visit: September 15, 2008.

Chief Complaint: Redness, swelling and tenderness of the upper right eyelid for 5 days.

History: Approximately 1 year prior to treatment, the patient frequently experienced redness, swelling and pain in his right eye. The same symptoms appeared again 5 days prior to the first visit. Several hospitals diagnosed him with an external hordeolum of the right eye. During the previous year, the patient received three drainage surgeries afterwhich the localized redness and swelling would gradually be reduced. The patient had frequent recurrences.

Signs and Symptoms: Localized redness and swelling close to the margin of the upper right eyelid with palpable induration and tenderness with no pus formation. The patient was a picky eater with a poor appetite, dry mouth, pale complexion, hard stools and frequent colds. The tongue body was tender with a thin sticky yellowish coating; his pulse was thin and rapid.

Past History: Frequent upper respiratory infections.

Diagnostic Analysis

The patient’spoor eating habits are associated withspleen-stomach deficiency, as well as weakenedwei-defense. The poor appetite, hard stools, dry mouth, thinsticky yellowish tongue coating and thinrapid pulses areall signs of food stagnation in the spleen-stomach transforming into heat. The pale face and frequent colds areboth signs of spleen-stomach deficiency and weakenedwei-defense.

Lingering pathogens and unresolved heat ascended to attack the eyelid leading to frequent recurrence of the hordeolum. Due to an inability of the wei defensive qi to ward off external pathogens, the condition remained persistent, although the redness and swelling were not severe.

The location of the disease is the eyelid. According to traditional Chinese eye anatomy the eyelid belongs to the “muscle wheel”, which is associated with thespleen, thus confirming the diagnosis.

This is a case of spleen deficiency with excessivesigns and symptoms. The root symptoms are deficient with branch excess at the surface.

Diagnosis

WM Diagnosis: Hordeolum

TCM Diagnosis: Hordeolum due to Spleen deficiency with qi stagnation and wei-defense weakness

Clinical Treatment: The clinical manifestations of this case showed a root deficiency with excessive symptoms manifesting at the surface, along with unresolved pathogenic heat ascending to attack the eyelid. According to the treatment principle offirst treating the branch in acute-stage cases, treatment should start by addressing the unresolved pathogenic heat.After the heat is resolved, treatment should then focus on correcting the root deficiency.

Treatment Principles: Strengthen the spleen tosupplement qi and promote the discharge of pus.

Formula: Modified Tuō Lǐ Xiāo Dú Săn(Interior-Drawing and Toxin-Removing Powder)

[托里消毒散]

黄芪

huáng qí

15g

Radix Astragali

茯苓

fú líng

10g

Poria

白术

bái zhú

10g

Rhizoma Atractylodis Macrocephalae

陈皮

chén pí

6g

Pericarpium Citri Reticulatae

赤芍

chì sháo

10g

Radix Paeoniae Rubra

薏苡仁

yì yĭ rén

20g

Semen Coicis

桔梗

jié gĕng

10g

Radix Platycodonis

皂角刺

zào jiăo cì

6g

Spina Gleditsiae

连翘

lián qiào

15g

Fructus Forsythiae

金银花

jīn yín huā

15g

Flos Lonicerae Japonicae

蒲公英

pú gōng yīng

15g

Herba Taraxaci

莱菔子

lái fú zĭ

15g

Semen Raphani

    [Formula Analysis]</p><p>
<em>Huáng qí</em> tonifies the yang qi of the spleen and stomach to ascend and disperse pathogenic factors. It is combined withbái zhú, fú líng, yì yĭ rénand gan cao to supplement qi and strengthen the spleen.</p><p>
<em>Chén pí</em> regulates qi, clears obstruction and relieves qi stagnation.</p><p>
<em>Lái fú z</em><em>ĭ</em> regulates qi to resolve food stagnation.</p><p>
<em>Jié gĕng</em> circulates the lung qi, opening and regulating the waterways. While nourishingEarth and generating Metal, it guides the effects of the other medicinals upward.</p><p>
<em>Chì sháo</em> cools the blood and dissipates redness.</p><p>
<em>Lián qiào</em><em>, </em><em>jīn yín huā</em>and<em>pú gōng yīng</em> clear heat and toxic fire to treat the superficial excessive manifestations, while also draining accumulated heat.</p><p>
    External Therapy</p><p>
    Eye Drops: 0.5% bear bile eye drops or antibiotic eye drops, 4-6 times per day.</p><p>
    Warm Compresses: to invigorate the blood and help dissipate inflammation.</p><p>
    Acupuncture</p><p>
    Main Points:EX-HN 3 (<em>yìn tang</em>), BL 1 (<em>jīng míng</em>), BL 2 (<em>cuán zhú</em>), SP 10 (<em>xuè h</em><em>ă</em><em>i</em>) and LV 3 (<em>tài chōng</em>).</p><p>
    Supplementary Points: GB 20 (<em>fēng chí</em>), LI 4 (<em>hé gŭ</em>) and SJ 23 (<em>sī zhú kō</em>).</p><p>
    Method: Select 2 main points and 2-3 supplementary points for daily treatment, using alternate points every other day. After obtaining the needling sensation, retain all needles for 20 minutes. 10 sessions constitute one course of treatment.</p><p>
    Techniques: During recurrenceswithaggravated redness and swelling, needle with drainage; supplementation and even methods should be applied between onsets.</p><p>
<u>Second Visit</u></p><p>
    After 5 days of treatment, the redness and swelling at the lid margins were almost resolved, and the area was less tender although the induration remained. The patient’s appetite and dry mouth improved. The constipation was completely resolved. The tongue body appeared with a thin white coating. The pulse was thin and rapid.</p><p>
    The reduced redness and swelling showed that the excess branch manifestations had improved. The root pattern of spleen-stomach deficiency pattern and wei-defense weakness remained.</p><p>
    Treatment Principles: Strengthen the spleen,supplement qi, support the upright qiand eliminatepathogens.</p><p>
    Formula: Modified <em>Shēn Líng Bái Zhú Săn</em>(Ginseng, Poria and Atractylodes Macrocephalae Powder)</p><p>
    [参苓白术散]</p>

太子参

tài zĭ shēn

15g

Radix Pseudostellariae

茯苓

fú líng

10g

Poria

白术

bái zhú

10g

Rhizoma Atractylodis Macrocephalae

山药

shān yào

20g

Rhizoma Dioscoreae

陈皮

chén pí

6g

Pericarpium Citri Reticulatae

扁豆

biăn dòu

15g

Semen Lablab Album

桔梗

jié gĕng

10g

Radix Platycodonis

炙甘草

zhì gān căo

5g

Radix et Rhizoma Glycyrrhizae Praeparata cum Melle

薏苡仁

yì yĭ rén

20g

Semen Coicis

防风

fáng fēng

10g

Radix Saposhnikoviae

赤芍

chì sháo

10g

Radix Paeoniae Rubra

连翘

lián qiào

15g

Fructus Forsythiae

    Formula Analysis</p><p>
<em>Tài z</em><em>ĭ</em><em> shēn</em><em>, </em><em>fú líng</em> and dry-fried <em>bái zhú</em> supplement qi and strengthen the spleen. Combined with fáng fēng, tài zĭ shēn and bái zhú, they supplement qi and consolidate the surface.</p><p>
<em>Yì y</em><em>ĭ</em><em> rén</em><em>, </em><em>biăn dòu</em> and <em>chén pí</em> support bái zhú and fú líng to strengthen the spleen, harmonize the stomach and regulate qi to resolve dampness.</p><p>
<em>Jié gĕng</em> circulates lung qi and benefits qi, opens and regulates water passages, directs the other medicinals upwards and nourishes Earth to generate Metal.</p><p>
<em>Chì sháo</em> and <em>lián qiào</em> invigorate blood, clear heat and resolve stagnation to eliminate lingering pathogens.</p><p>
<em>Zhì gān căo</em> supplements the spleen and stomach and harmonizes the other medicinals.</p><p>
    COMMENTARY AND DISCUSSION</p><p>
    In TCM, hordeolum is discussed under the category of eyelid diseases. According to the English Chinese Encyclopedia of Practical Traditional Chinese Medicine<a href="#_edn1">[i]</a>, eyelid diseases are called <em>Y</em><em>ǎ</em><em>n Bì </em>Eyelid block. The specific term for hordeolum is <em>Mài Lì Zh</em><em>ǒ</em><em>ng</em> Wheat Grain Swelling.</p><p>
    Hordeola and all eyelid diseases have a close exterior/interior relationship. The eyelids correspond to the spleen and stomach. They are especially vulnerable to external pathogenic factors. The condition is usually caused by qi and blood stagnation in the eyelids that combines with external wind-heat. Alternately, toxic fire affects the yangming channels of the eyes leading to hordeola. This is usually a consequence of over consumption of spicy or greasy foods, alcohol and overeating in general. Underlying spleen qi deficiency is also a significant causative factor in the disease progression of the case history presented here.</p><p>
    A stye or hordeolum is commonly thought of as a localized fire-toxin. In this case history, the stye was slow to suppurate and resolve, and was recurrent in nature. These factors, combined with the patient’s poor appetite, frequent colds and overall physical presentation lead to the diagnosis of qi deficiency. Spleen and stomach qi deficiency leads to wei qi deficiency. This, in turn, leads to the retention of latent pathogens as the body is not robust enough to expel pathogenic factors.</p><p>
    The physician’s treatment strategy was stratified to expel first the pathogenic factor, and subsequently treat the root deficiency. In fact, the selected formula acts to treat both the root and branch simultaneously.</p><p>
  It is important to comment on the use of the topical bear bile solution. Readers should understand that this case history is from China, where there is an historical precedent for its use for medicinal purposes. Today, worldwide, the use of bear bile is strictly forbidden. Currently, there are no commercial topical herbal eye drop preparations that are manufactured. Thus, if the hordeolum was not resolved with a combination of acupuncture, herbal formulas and warm compresses, then treatment with antibiotic drops would be indicated.</p><p>
    Additional Formula Commentary</p><p>
<em>Huáng qí</em>, dry-fried <em>bái zhú</em>, <em>chén pí</em> and <em>gān căo</em> are used together in <em>Bŭ Zhōng Yì Qì Tāng</em> (Center-Supplementing and Qi-Boosting Decoction). It is apparent that the physician has focused on strengthening the spleen and raising yang. A noteworthy action of huáng qí in relation to this case is that it also expels pus making it an excellent choice for this and all cases of infection with underlying qi deficiency.</p><p>
<em>Bái zhú, fú ling, yì y</em><em>ĭ</em><em> rén</em> and <em>jié gĕng</em> are components of the formula <em>Shēn Líng Bái Zhú Săn</em> (Ginseng, Poria and Atractylodes Macrocephalae Powder), which treats spleen and lung qi deficiency. We usually select this formula when there are loose stools from spleen qi deficiency. In this case, <em>yì y</em><em>ĭ</em><em> rén</em> has a dual role for both its spleen strengthening function, as well as its ability to resolve abscesses. <em>Lián qiào</em> and <em>jīn yín huā</em> also serve two functions. They are key ingredients for clearing heat in the wei level and resolve fire-toxins making them an ideal combination for treating hordeolum.</p><p>
<em>Jīn yín huā</em> and <em>pú gōng yīng</em> are used together in <em>Wŭ Wèi Xiāo Dú Y</em><em>ĭ</em><em>n</em> (Five-Ingredient Decoction for Resolving Toxin). Both medicinals clear toxic fire and reduce nodulation.</p><p>
<em>Lái fú z</em><em>ĭ</em> pairs with <em>chén pí</em> to regulate the qi and resolve food stagnation. <em>Chì sháo</em><em>, </em><em>zào jiăo cì</em><em>, </em><em>chén pí</em> are used together in the formula <em>Xiān Fāng Huó Mìng Y</em><em>ĭ</em><em>n </em>(Sublime Formula for Sustaining Life). This formula clears toxic fire, reduces fever, cools and moves the blood, and reduces early-stage sores and carbuncles, illustrating why this group can be used to treat hordeola. Thus, we see how a physician can employ key medicinal relationships from various formulas to craft a harmonious treatment strategy.</p><p>
    At the follow-up visit, the acute symptoms had resolved, but the patient still had deficient spleen qi and wei-defense qi. The physician is primarily concerned with supplementation. <em>Shēn Líng Bái Zhú Săn</em> (Ginseng, Poria and Atractylodes Macrocephalae Powder) was modified in the following ways: The patient’s tongue is still tender red and the pulse is still thready and rapid, thus tài zĭ shēn is used, which is cooler and more moistening than <em>dăng shēn</em> or <em>rén shēn</em>; by adding <em>fáng fēng</em> in concert with <em>bái zhú</em>, a modification of the formula <a><em>Yù Píng Fēng Săn</em></a> (Jade Wind-Barrier Powder), is created, stabilizing the exterior, stopping sweating and supplementing the qi. <em>Lián qiào</em> and <em>chì sháo</em> remain from the first formula to clear heat, reduce nodulation and move blood.</p><p>
Cara Frank, L.OM. was raised by in a health food store in Brooklyn NY. When she was 8 she cartwheeled 5 miles from Greenwich Village through Soho and Chinatown and across the Brooklyn Bridge.</p><p>
For over 30 years she has had the same crazy passion for Chinese medicine.</p><p>
At 17 she had her first acupuncture treatment. At 20 she enrolled in acupuncture school. 1n 1998 she went to China to study where she fell deeply in love with herbs and has never recovered.</p><p>
Cara is the founder of Six Fishes Healing Arts in Philadelphia. She is the president of China Herb Company and she is the Academic Director of the Department of Chinese Herbology at the Won Institute of Graduate Studies. You can read her <a href="http://sixfishes.com.php54-1.ord1-1.websitetestlink.com/about/staff/cara-frank">bio</a> or schedule an <a href="http://sixfishes.com.php54-1.ord1-1.websitetestlink.com/contact">appointment.</a></p><hr>

[i] Page 61, Higher Education Press, Beijing, China. Volume 17, Ophthalmology, 1994

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