The Treatment of Cataracts with TCM

The Treatment of Cataracts with TCM

Cara O. Frank, R.OM., Dipl. OM

The following is an excerpt from my book TCM Case Studies: Eye, Ear, Nose and Throat Disorders, published by People’s Medical Publishing House

Licensed practitioners can order these formulas from China Herb Company

This chapter focuses on the treatment of cataracts using traditional Chinese medicine. As the author of the cases suggests, treatment with traditional Chinese medicine is a practical first step to improve vision and slow or prevent the progression of the cataract. In modern clinical practice, there can be several practical reasons to delay surgery. Often, a surgeon will want to wait until vision is so compromised that it interferes with normal activities. Until that time other measures, such as brighter light and better eyeglasses, can mitigate such interference. It is at this stage of cataract development that Chinese medicine is especially helpful.

A cataract is a clouding that develops in the lens of the eye that affects vision. The majority of cataracts are related to aging, but they can also occur in younger people. They present with a cloudy pupil and deteriorated vision, which eventually leads to blindness. Cataracts develop slowly, in one or both eyes, and vary in degree from slight opacity to completely obscuring the light. Most cataracts will not interfere with vision until people are in their 60s, at which point the cataract may have grown large enough to obscure the lens. They do not spread from one eye to the other. Symptoms include cloudy or blurry vision, sensitivity to glare and dulled color perception. Early treatments include adjusting prescriptions for corrective lenses and brighter lighting. Later, they require surgical removal.

Cataracts can also be secondary to certain diseases, such as diabetes or glaucoma. Trauma, radiation exposure and nutritional deficiencies may also be factors in their development.1

In TCM, cataractsarereferred to as yuán yì nèi zhàng (圆翳内障, round nebula internal obstruction). The etiologies of this disease are numerous. A key factor is general deficiency due to aging, often seen as deficiencies of the liver, kidney, essence and blood. Spleen deficiency can play a role as it fails in its function of transportation, while a deficiency of qi, blood and essence leads to malnourishment of the eyes. Depressive heat in the liver or liver yin deficiency can combine with damp heat to attack an upward.

COMMON CLINICAL PATTERNS AND FORMULAS

Liver and kidney deficiency: Qĭ Jú Dì Huáng Wán (Lycium Berry, Chrysanthemum and Rehmannia Pill)

Spleen qi deficiency: Bŭ Zhōng Yì Qì Tāng (Center-Supplementing and Qi-Boosting Decoction)

Liver heat rising upward: Shí Jué Míng Săn (Abalone Shell Powder)

Yin deficiency with damp-heat: Gān Lù Yĭn (Sweet Dew Beverage)

CASE STUDY

Female, age 62. Initial Visit: March 4th, 2004

Chief Complaint: The patient had gradually deteriorating vision in both eyes with dark shadows appearing in the field of vision. These symptoms had affected her for two years in the right eye and one year in the left eye.

History:Other than decreased visual acuity, which was worse in the left eye, there was no other significant discomfort. A hospital diagnosed senile cataract but failed to deliver appropriate treatment.

Signs and Symptoms: Blurred vision in both eyes covered with dark shadows. Other symptoms included insomnia, tinnitus and dry stools. The tongue body was pink with a reduced coating. The pulse was deep and thready.

Past History:Unremarkable.

Physical Examination: The patient body type was thin. Her temperature, breathing, pulse rate and blood pressure were normal. Both lungs produced clear breathing sounds without rales. She had a normal heart beat and normal-sized heart border, liver and spleen, with no edema in either of the lower extremities.

Ophthalmologic Examination: Visual acuity in both eyes was 0.5. There were cloudy, wedge-shaped spokes in the cortex of the lens. There was opaque refractive media in both eyes. The color and vessels of the optic nerve head were normal witha normal macula.

Laboratory Examination: Normal.

Pattern Differentiation

This patient was elderly and weak, with a thin body type. Due to deficiency, the liver and kidneys failed to nourish the eyes, hence the cloudy lenses and blurred vision. Malnourishment of the clear orifices led to insomnia and tinnitus. Deficiency of yin essence resulted in a lack of moisture in the intestines, hence the dry stools. The pink tongue body with a reduced coating and deep, thin pulse were indicative of liver and kidney deficiency.

The origins of this condition were deficiency of the liver and kidneys, which led to malnourishment of the lens. The root cause of this condition was deficiency with the branch symptoms manifesting as excessive.

Diagnosis

WM diagnosis: Age-related cataract (both eyes)

TCM diagnosis: Round nebula internal obstruction (both eyes) due to liver and kidney deficiency

Clinical Treatment

This case showed a root deficiency pattern with an excessive branch manifestation, where liver and kidney deficiency were the root and lens cloudiness constituted the branch. At this time, the patient’s visual acuity was still 0.5, so the condition had not affected her daily routine. Treatment therefore, should focus on the root, leaving surgery for later consideration, if necessary.

Principles: Nourish and tonify the liver and kidneys, eliminate the nebula and brighten the eyes

Formula: Qĭ Jú Dì Huáng Wán (Lycium Berry, Chrysanthemum and Rehmannia Pill)

[杞菊地黄丸]

枸杞子 gŏu qĭ zĭ 15g Fructus Lycii
菊花 jú huā 6g Flos Chrysanthemi
熟地黄 shú dì huáng 20g Radix Rehmanniae Praeparata
山萸肉 shān yú ròu 10g Fructus Corni
山药 shān yào 10g Rhizoma Dioscoreae
丹皮 dān pí 10g Cortex Moutan
茯苓 fú líng 10g Poria
泽泻 zé xiè 10g Rhizoma Alismatis

[Formula Analysis]

This formula is a modification of Liù Wèi Dì Huáng Wán (Six-Ingredient Rehmannia Pill) with gŏu qĭ zĭ and jú huā added. It is one of the main formulas used to nourish and tonify liver and kidney yin. Within the formula, three ingredients tonify while the other three sedate.

Shú dì huáng, shān yú ròu and shān yào, the main tonifying medicinals, nourish liver, spleen and kidney.

Zé xiè, fú líng and dān pí resolve dampness, clear heat and discharge turbidity.

Combining both groups of medicinals simultaneously sedates, tonifies and protects the correct qi.

Gŏu qĭ zĭ and jú huā brighten the eyes and eliminate the nebula.

Acupuncture

Points: BL 1 (jīng míng), qiú hòu (EX-HN7), BL 2 (cuán zhú), yú yāo (EX-HN4), LI 14 (bì nào), LI 4 (hé gŭ), ST 36 (zú sān lĭ), SP 6 (sān yīn jiāo).

Method: Select 1-2 local points each treatment, supplemented with two distal points. Needles should be retained for 20-30 min after obtaining needle sensation, one treatment a day. 10 visits constitute a course of treatment.

Techniques: Apply mainly tonifying technique.

Further Consultation

After one month of treatment, the blurred vision had improved, the dark shadows became lighter and, despite a poor appetite, normal bowel movements were regained. Examination showed that vision in both eyes was 0.6. The cloudiness of the lens was unchanged and the fundus was normal. The pulse was thin and the tongue had a sticky coating.

After treatment, the eye symptoms had improved so the same formula and treatment principle were maintained. However, tonifying formulas tend to induce stickiness, which in this case, lead to poor appetite. Therefore, three medicinals were added to the original formula to promote the digestion and relieve the stagnation.

Principle: Nourish and tonify the liver and kidney, eliminate the nebula and brighten the eyes

Formula: Supplemented Qĭ Jú Dì Huáng Wán (Lycium Berry, Chrysanthemum and Rehmannia Pill)

[杞菊地黄丸加味]

枸杞子 gŏu qĭ zĭ 15g Fructus Lycii
菊花 jú huā 6g Flos Chrysanthemi
熟地黄 shú dì huáng 20g Radix Rehmanniae Praeparata
山萸肉 shān yú ròu 10g Fructus Corni
山药 shān yào 10g Rhizoma Dioscoreae
丹皮 dān pí 10g Cortex Moutan
茯苓 fú líng 10g Poria
泽泻 zé xiè 10g Rhizoma Alismatis
山楂 shān zhā 10g Fructus Crataegi
神曲 shén qū 10g Massa Medicata Fermentata
麦芽 mài yá 10g Fructus Hordei Germinatus

[Formula Analysis]

Shú dì huáng, shān yú ròu and shān yào nourish liver, spleen and kidney.

Zé xiè, fú líng and dān pí percolate dampness, clear heat and discharge turbidity.

Combining both groups of medicinals simultaneously sedates, tonifies and protects the correct qi.

Gŏu qĭ zĭ and jú huā brighten the eyes and eliminate the nebula.

Shān zhā, mài yá and shén qū promote digestion and eliminate stagnation.

COMMENTARY AND DISCUSSION

In traditional Chinese medicine, cataracts are referred to yuán yì nèi zhàng(round nebula cataract). In references as early as Essentials from the Silver Sea (Yín Hăi Jīng Wēi, 银海精微), surgery was known to be the most effective method to eliminate cataracts. There is a vivid description of the method called Jīn Zhēn Bō Nèi Zhàng (a golden needle to remove internal obstruction of the eye [i.e., cataracts]). The passage details that the weather should be warm and not windy. The physician is instructed to wait until noon and light incense, chant an invocation to Guān Yīn, and then sit quietly to calm the breath. The physician is instructed to insert a golden needle to a specific depth of 3 fēn, move it around and up and down, and finally, when the cataract adheres to the needle, lift the needle from the eye. Post-operative care regarding bandaging and recovery time is clearly outlined to assist the patient’s recovery. One can only imagine how harrowing eye surgery might have been, for both physician and patient. So much so that prayer in included as part of the treatment protocol. The Essentials from the Silver Sea is modern book in the sense that the etiologies of the disease are rooted in the natural world, so a directive to pray to the Bodhisattva of compassion underscores the intricacy of the procedure.

One of the greatest attributes of Chinese medicine is how many practical tools there are to slow and improve the aging process. The primary case illustrates this point. The patient’s constitution is liver and kidney yin deficient. The formula selection, therefore, is logical and easily understood: Qĭ Jú Dì Huáng Wán is a well-known modification of Liù Wèi Dì Huáng Wán. By adding gŏu qĭ zĭ and jú huā, the formula treats dry eyes, tearing when exposed to wind, photophobia and diminished visual acuity. The patient can—and should—take the formula for a long time, even years, but tonic formulas frequently contain heavy and cloying medicinals. A frequent side effect of many tonic formulas, especially ones that contain shú dì huáng or shēng dì huáng (Radix Rehmanniae), is gastrointestinal distress. The follow up visit solves this in a nifty way by adding a well-known trinity of medicinals that resolve food stagnation. The modification balances the formula, so it can be tolerated for an extended period. If one were to use prepared medicines, you could combine QĭJú Dì Huáng Wán with Băo Hé Wán (Harmony-Preserving Pill) to achieve comparable results.

CASE SCENARIOS

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, 72 years old. Deterioration of the vision in both eyes, for more than 10 years in the right eye and six years in the left. Presently, the symptoms included blurred vision along with fatigue, weakness of the extremities, poor appetite and loose stools. An examination revealed visual acuity of 0.02 in the right eye and 0.1 in the left, no abnormality of the outside of the eyes and grayish, cloudy lenses with non-visible fundus. The tongue body was pale with a thin, white coating and scallops on both sides. The pulse was thin and weak.

The first case scenario outlines another constitutionally supportive strategy. This patient has signs and symptoms of spleen qi sinking, so he is prescribed Bŭ Zhōng Yì Qì Tāng (Center-Supplementing and Qi-Boosting Decoction). Li Dong-yuan’s iconic formula supplements the center, boosts qi, raises yang and lifts the sunken. A modern application of the formula is the treatment of cataracts. In this case, the causative factor of the blurred or clouded vision is that the clear yang has failed to ascend to the eyes. A classical modification of the formula when there is diminished visual acuity is to add gŏu qĭ zĭ (Fructus Lycii) and chuān xiōng (Rhizoma Chuanxiong).

2. Female, 58 years old. Gradual deterioration of the vision for two years. Symptoms included blurred vision, headache, dry eyes, irritability, insomnia, a bitter taste in the mouth and a dry throat. Examination showed visual acuity of 0.6 in the right eye and 0.3 in the left, no abnormality of the outside of the eyes and wedge-shaped spokes in the cortex of the lens that was cloudy after pupil dilation. There was no obvious abnormity in the fundus. The tongue body was red with a thin, yellow coating and the pulse was wiry.

For the second study case, the patient shows a pattern of liver heat.

Formula: Shí Jué Míng Săn (Abalone Shell Powder)

[石决明散]

石决明shí jué míng20gConcha Haliotidis
草决明căo jué míng10gSemen Cassiae
羌活qiāng huó10gRhizoma et Radix Notopterygii
栀子zhī zĭ10gFructus Gardeniae
大黄dà huáng6gRadix et Rhizoma Rhei
荆芥jīng jiè10gHerba Schizonepetae
木贼mù zéi10gHerba Equiseti Hiemalis
青葙子qīng xiāng zĭ10gSemen Celosiae
芍药sháo yào10gRadix Paeoniae Alba
麦冬mài dōng10gRadix Ophiopogonis

[Formula Analysis]

Shí jué míng is the monarch. Salty, heavy and cold, it cools the liver, extinguishes liver wind, nourishes liver yin and brightens the eyes.

Căo jué míng, mù zéi and qīng xiāng zĭ support these actions to clear liver heat, nourish liver yin and clear the vision.

Zhī zĭ and dà huáng drain fire through urination and defecation.

Qiāng huó and jīng jiè eliminate wind heat.

Mài dōng and sháo yào nourish the liver blood and yin.

3. Male, 65 years old. Gradual deterioration of the vision over four years. Symptoms included blurred vision, dry eyes, night sweats, insomnia with dreaming, a dry mouth with no desire to drink, irritability, hot and foul breath and constipation. Examination showed visual acuity of 0.4 in both eyes with no abnormality of the outside of the eyes. A grayish-white cloudiness was observed in both lenses with unclear refractive media, visible optical papilla in the fundus and vessels in the retina and no obvious changes in macula. The tongue body was red with a yellow, greasy coating and the pulse was thin and rapid.

The third study case uses Gān Lù Yĭn (Sweet Dew Beverage) to resolve a case of cataracts caused by yin deficiency with internal heat. The key to understanding the selection of this formula over another yin tonic formula, for instance, Zhī Băi Dì Huáng Wán (Anemarrhena, Phellodendron and Rehmannia Pill), is the patient’s symptoms of constipation and mouth sores. Gān Lù Yĭn nourishes the yin, clears heat, disseminates the lung qi and resolves dampness. The root of the pattern for this case is unresolved heat in the yangming that injures fluids. The residual heat combines with dampness, which causes the symptoms of mouth sores, bad breath, constipation and gum inflammation. Zhī Băi Dì Huáng Wán, clears empty fire and nourishes the kidney yin, while Gān Lù Yĭn clears heat from the stomach and lung channels. The stomach channel commences below the eye and the muscle wheel of the eye belongs to the stomach and spleen. This channel relationship also suggests that Gān Lù Yĭn would also be useful when treating blepharitis.

4. Female, 52 years old. Gradual deterioration of the vision over four years in the right eye and two years in the left eye. Symptoms included blurred vision and slight distention and discomfort in both eyes accompanied by depression and distention of the eyebrow. An examination showed visual acuity of 0.6 in the right eye and 0.8 in the left with no improvement with corrective lenses and no abnormality of the outside of the eyes. After dilation of the pupils, it showed grayish-white wheel type turbidity in the areas surrounding both lenses and clear refractive media, with no obvious abnormality of the optical papilla, retina vessels or macula at the fundus. The tongue body was red with a thin, yellow coating and the pulse was wiry and rapid.

The final case scenario is a presentation of qi stagnation with heat. The key to understanding the difference between this case and Shí Jué Míng Săn presentation lies in the patient’s symptoms of depression and eye distention. Like depression, sensations of distention reflect qi stagnation. There are fewer symptoms of heat, the most notable being the wiry rapid pulse and the red tongue body with yellow coating. Thus, the physician uses Dān Zhī Xiāo Yáo Săn (Moutan and Gardenia Free Wanderer Powder) to treat the case.

END NOTE

1. National Eye Institute, National Institute of Health, Facts about Cataracts [Updated in September 2009]. Available from: http://www.nei.nih.gov/health/cataract/cataract_facts.asp

About Cara Frank, L.OM.

Cara Frank, L.OM. was raised 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. For over 35 years she has had the same crazy passion for Chinese medicine. At 17 she had her first acupuncturetreatment. At 20 she enrolled in acupuncture school. In 1998 she went to China to study where she fell deeply in love with Chinese herbs. Since then, she has devoted her life to studying and teaching the topic.

Cara is the founder of Six Fishes Healing Arts and Six Fishes Neighborhood Acupuncture, both in Philadelphia where she maintains a busy acupuncture practice and acts as the head fish of two warm and lively offices. She is also the president of China Herb Company. You can read her full bio or schedule an appointment.

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Cara is simply the best! So knowledgable; her acupuncture and customized herb mixtures have knocked out sinusitis, bronchitis, stomach ailments…she’s worth traveling from the ‘burbs to go see. Philadelphia is lucky to have someone of her knowledge, experience and down-to-earth manner.

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