​The Treatment of Chronic Open-Angle Glaucoma with TCM

​The Treatment of Chronic Open-Angle Glaucoma with TCM

Cara O. Frank, L.OM.

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

Chronic Open-Angle Glaucoma is the most common type of glaucoma and the third most common cause of blindness worldwide. In most cases, its cause is unknown[i]. It is the second leading cause of blindness in the United States, and the leading cause of blindness for African and Hispanic Americans. In contrast to acute angle-closure glaucoma, which is characterized by acute onset, open-angle glaucoma has a slow, often asymptomatic onset. Glaucoma occurs when there is a constriction of the flow of aqueous humor from the back of the eye to the anterior chamber, through the angleformed by the junction of the iris and cornea at the periphery of the anterior chamber. This causes an increase in intraocular pressure, which causes optic nerve damage resulting in blindness.

Chronic Open-Angle Glaucoma is an eye condition characterized either by no obvious discomfort or only mild eye distention, blurred vision, a narrowed visual field and eventual blindness. The onset is slow with no obvious symptoms during the early stages. It is, therefore, often neglected by the patient and frequently diagnosed clinically in the late stages. By this time, severe vision damage and blindness may be inevitable. This disease often occurs in both eyes either concurrently or consecutively.

In TCM, the condition is often due to excessive anxiety or anger, indicative of liver depression and qi stagnation. Qi stagnation transforms into fire, which attacks the upper orifice. Alternatively, dampness in the spleen generates phlegm that transforms into fire, resulting in an upsurge of phlegm fire attacking the eyes. Other contributing factors include overuse of the eyes causing yin damage, liver and kidney deficiency causing qi and blood disharmony, collateral damage and fluid stagnation.

COMMON CLINICAL PATTERNS

  • Liver depression and qi stagnation
  • Damp-phlegm flooding the eyes
  • Liver kidney deficiency

CASE STUDY

Female, age 42. Initial visit: November 11, 2006.

Chief Complaint: Distention and pain in both eyes after long periods of reading during the previous 2 years, becoming particularly aggravated 1 day prior to treatment.

History: For the previous 2 years, the patient often felt fatigued in both eyes with distention, pain and blurred vision after long periods of reading. The patient complained of seeing a rainbow of halo lights. The symptoms were triggered by a fight with a family member 1 day prior to treatment and were relieved by rest.

Signs and Symptoms: The above symptoms were accompanied by depression, chest tightness and frequent sighing. There was slight dryness with a bitter taste in the mouth. The sides of the tongue were red with a thin yellow coating and the pulse was wiry.

Physical Examination: The patient’s body temperature, respiration, pulse rate and blood pressure were normal. She had a medium body type. There was normal auscultation in both lungs with no rales, a normal heart size and rhythm. There was no swelling in the lower extremities and the liver and spleen were non-palpable under the ribs.

Eye Examination: Visual acuity was right 0.8, left 0.8, with no obvious vision improvement after lens insertion. The outsides of the eyes were normal, clear refractive, “0” D revealed a depression and enlargement of the optical papilla in both eyes, C/D >0.7. Intraocular pressure: 30mmHg (bilaterally). Vision field: shrinking medially by about 10 degrees (bilaterally).

Diagnostic Analysis

The main characteristics of this patient were a slow onset of symptoms induced by emotional stress. The glaucoma cup appeared at the fundus, leading to a slight decrease of visual acuity and a narrowed visual field.

The key function of the liver is to promote the smooth flow of energy, and it governs dissipation. Fighting caused liver stagnation. This transformed into fire and led to the counterflow ascent of qi and fire with fluid retention. This resulted in an increase of intraocular pressure, causing eye distention and headache. The liver channel traverses the hypochondriac region. The inhibited qi dynamic and blocked collaterals within the channel cause chest tightness and frequent sighing. The slight dryness and bitter taste in the mouth, redness in the tip and sides of the tongue with a thin yellow coating and the wiry pulse were all signs of liver depression transforming into fire.

The location of the disease was in the liver and is an excessive condition that can be categorized according to the signs of qi stagnation transforming into fire.

Diagnosis:

WM: Chronic open-angle glaucoma

TCM: Chronic open-angle glaucoma due to qi stagnation transforming into fire

Clinical Treatment

This case showed signs of excessive patterns in both the root cause and branch manifestation. The root cause can be seen as liver depression transforming into fire, while fluid retention is the branch manifestation. The treatment should focus on the root and branch simultaneously.

Treatment Principles: Soothe the liver, relieve depression, clear heat and sedate fire.

Formula: Modified Xiāo Yáo Săn (Free Wanderer Powder)

[丹栀逍遥散加减]

柴胡 chái hú 10g Radix Bupleuri
牡丹皮 mú dān pí 10g Cortex Moutan
栀子 zhī zĭ 10g Fructus Gardeniae
生白芍 shēng bái sháo 15g Radix Paeoniae Alba
当归 dāng guī 15g Radix Angelicae Sinensis
白术 bāi zhú 15g Rhizoma Atractylodis Macrocephalae
茯苓 fú líng 10g Poria
车前子 chē qián zĭ 15g Semen Plantaginis
炙甘草 zhì gān căo 6g Radix et Rhizoma Glycyrrhizae Praeparata cum Melle
Formula Analysis
  • Chái hú is the chief medicinal to soothe the liver and resolve depression.
  • Dān pí and zhī zĭ clear the liver and sedate fire.
  • Dāng guī and bái sháo nourish blood and calm the spirit.
  • Bái zhú, fú líng and chē qián zĭ benefit the spleen and promote urination.
  • Gān căo harmonizes the formula.

External Therapy

1% Pilocarpine eye drops for both eyes, 2-4 times per day.

Prepared Medicine: Xiāo Yáo Wán (Free Wanderer Pill), twice per day.

Acupuncture

Main Points: LV 3 (tài chōng), LV 6 (zhōng dū), GB 20 (fēng chí), EX-HN5 (tài yáng), PC 6 (nèi guān), ST 36 (zú sān lĭ).

Treatment plan: Needles should be retained for 20-30 minutes after obtaining needle sensation, once per day. 10 visits constitute 1 course of treatment.

Needling technique: Sedating technique for the distal points.

Follow Up

After 21 days of treatment, the bitter taste in the mouth and insomnia were reduced, and the intraocular pressure in both eyes decreased to 22.38mmHg. Bái zhú, fú ling and chē qián zĭ were omitted from the original formula and nŭ zhēn zĭ (Fructus Ligustri Lucidi) 15g and gŏu qí zĭ (Fructus Lycii) 15g were added. After 14 days of taking the new formula, the intraocular pressure decreased to 20.55mmHg, visual acuity in both eyes was 1.0 and there was no discomfort in the body. The tongue body was pink with a thin white coating and the pulse was wiry and thin.

Through the above treatment, eye and body symptoms improved completely and vision and intraocular pressure normalized, indicating that residual depressive heat in the liver channel had been resolved. The current main clinical pattern appeared to be liver kidney yin deficiency.

Treatment principle: Nourish and tonify the liver and kidney.

Formula: Modified Qí Jú Dì Huáng Tāng (Lycium Berry, Chrysanthemum and Rehmannia Decoction)

[杞菊地黄加减]

枸杞子 gŏu qí zĭ 15g Fructus Lycii
菊花 jú huā 10g Flos Chrysanthemi
熟地 shú dì 20g Radix Rehmanniae Praeparata
山萸肉 shān zhū yú 10g Fructus Corni
山药 shān yào 10g Rhizoma Dioscoreae
丹皮 dān pí 10g Cortex Moutan
茯苓 fú líng 15g Poria
泽泻 zé xiè 10g Rhizoma Alismatis
赤芍 chì sháo 15g Radix Paeoniae Rubra
当归 dāng guī 10g Radix Angelicae Sinensis
[Formula analysis]
  • Shú dì, shān yú ròu and shān yào nourish and tonify liver, spleen and kidney.
  • Zé xiè, fú líng and dān pí percolate dampness, clear heat and discharge turbidity, sedating through tonifying so as not to injure the correct qi.
  • Both groups blend sedating and tonifying methods
  • Gŏu qí zĭ and jú huā brighten the eyes and eliminate the nebula.
  • Dāng guī and chì sháo nourish and benefit yin, and invigorate blood.

COMMENTARY AND DISCUSSION

In traditional Chinese medicine, Open-Angle Glaucoma is referred to as Qīng Fēng Nèi Zhàng, Green-Blue Internal Obstruction. Although the onset is insidious, the root cause is similar to acute closed-angle glaucoma. Both variations of the disease are thought to be caused by emotional disharmony that creates a terrain of liver stagnation that, over time, generates fire. Unlike closed-angle glaucoma, this type is responsive to treatment with Chinese medicine if diagnosed early.

The primary case is simple and easy to understand. The patient is described as a healthy, relatively young woman. She shows signs of depression and had ignored early, subtle signs and symptoms of glaucoma such as visual fatigue and halos. The tipping point for this case was an argument that she had the day before seeking treatment

The TCM treatment is remarkable in its simplicity. The doctor chooses modified Xiāo Yáo Săn with only one addition: chē qián zĭ. That the formula is so effective is a testimony to its accurate and precise application. It is surprising that other medicinals that clear liver fire and benefit the eyes are not in the formula. Not included are medicinals such as xià kū căo (Spica Prunellae), shí jué míng (Concha Haliotidis) or jué míng zĭ (Semen Cassiae). Even bò he (Herba Menthae), a standard component of Xiāo Yáo Săn is omitted. It is impressive that the formula lowers the patient’s optic pressure 8 points in three weeks.

Even more striking is the case management during the second visit. The doctor omits bái zhú, fú ling and chē qián zĭ. While details of the follow-up visit are thin, the doctor’s intention is clear: he omits medicinals that drain fluids. It appears counterintuitive to remove this group of medicinals; after all, if the eyes have too much pressure, then wouldn’t there also be excessive fluid build-up? The reasoning is subtler; the pupil is associated with the kidney and the iris is associated with the liver. Both are yin organs, and are said to have the same source. By shifting the formula away from damp-percolating medicinals to ones that nourish the liver and kidney yin, the actions of the formula are re-directed: the purpose is not to make the eyes wetter, but to make them softer. This allows pressure caused by the “angle” to relax and resume its normal function of allowing aqueous humor to flow freely between the front and back of the eye. In addition to moistening and softening the eyes, the liver is soothed and comforted and thus, the emotions are smoother. The root cause and the branch symptoms of glaucoma are controlled.

The second phase of the patient’s treatment is also simple and straightforward: Modified Qí Jú Dì Huáng Tāng (Lycium Berry, Chrysanthemum and Rehmannia Decoction) is prescribed with the addition of chì sháo (Radix Paeoniae Rubra) and dāng guī (Radix Angelicae Sinensis). Chì sháo pairs with dān pí to clear heat from the liver. Dāng guī pairs with gŏu qí zĭ and shú dì to nourish the liver blood and yin.

STUDY QUESTIONS

  • 1.What is the key treatment principle for Chronic Open-Angle Glaucoma?
  • 2.What is the prognosis for Chronic Open-Angle Glaucoma?
  • 3.During the second stage of treatment, what was the theoretical reason for omitting the water-elimination medicinals and adding the liver kidney tonifying medicinals?
  • 4.What areas should be focused on with regard to patient care in this case?

Answers:

  • 1.There are two main treatment principles in treating this condition. No surgery is required if the intraocular pressure can be controlled at a safe level using medication, when injury to both the visual field and visual disc can be circumvented. Surgery is required if the medication is ineffective or patient cannot tolerate the medication. TCM differentiation, diagnosis and treatment can protect the patient’s vision and relieve the clinical symptoms.
  • 2.The onset of chronic open-angle glaucoma is very slow; it is often ignored due to its hidden nature. Patients usually come to the clinic in the later stages, which often results in ineffective treatment. It commonly has a poor prognosis and results in blindness.
  • 3.Chronic Open-Angle Glaucoma belongs to the pupil disease category of the Five Wheel theory; the pupil belongs to the water wheel, which is associated with the kidneys. The liver and kidney have the same origin. The liver also opens into the eyes. Therefore, water-promoting medicinals are omitted, and liver and kidney tonifying medicinals are added during the later stages of treatment, after the disease has been stabilized.
  • 4.The etiology of this condition is somewhat complicated. Under the current circumstances, it is impossible to prevent the condition from recurring with only a root treatment. Attention should be paid to early diagnosis and treatment in order to limit injury to the vision. The main treatment principles are:
  • a.Adults over 30 years old, if experiencing acute halo vision, blurred vision with headaches, or with a family history of glaucoma, should have periodic eye examinations. If the patient has an increase in intraocular pressure or changes to the visual field, or if an increase in the number of the visual discs C/D are detected, then further tests are required.
  • b.If a diagnosis of open-angle glaucoma has been confirmed, all efforts must be made to treat it effectively to avoid blindness.
  • c.The patient must rest well and avoid staying up late.

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. Female, 28 years old. Intermittent distention and pain in both eyes with gradually deteriorating vision over 2 years. Current symptoms include mild eye distension with nausea that worsens with blurred vision accompanied by irritability, insomnia, chest tightness and profuse phlegm. A visual examination showed right eye 0.6, left eye 0.4 and C/D=0.7. There was a normal anterior section in both eyes and a normal concave shape that became enlarged and deeper in the optical papilla of the fundus. Broken blood vessels deviating medially were also observed. The periphery of the visual field shrank by approximately 20 degrees. Intraocular pressure reached 30mmHg in the right eye and 34mmHg in the left. The tongue body was red with a sticky yellow coating and the pulse was slippery and fast.

Select the most appropriate formula:

  • A.Huáng Lián Wēn Dăn Tāng (Coptis Gallbladder-Warming Decoction)
  • B.Dĭ Tán Tāng (Phlegm-Flushing Decoction)
  • C.Chú Shī Tāng (Damp-Eliminating Decoction)
  • D.Gān Lù Xiāo Dú Dān (Sweet Dew Toxin-Removing Elixir)
  • E.Guī Pí Tāng (Spleen-Restoring Decoction)
  • 2. Female, 36. Distention and pain in both eyes for 4 years. Presenting symptoms at the treatment included slight distention and discomfort in both eyes, blurred vision, the appearance of rainbow- colored halo lights and symptoms that were aggravated by fatigue. Accompanying symptoms included dizziness, insomnia, tinnitus, vexing heat in the five hearts, a dry mouth and throat. A visual examination showed right eye 0.4, left eye 0.5 and C/D=0.8. There was a normal anterior section in both eyes, and a normal concave shape that became enlarged and deeper in the optical papilla of the fundus. Broken blood vessels deviating medially were also observed. The peripheral visual field shrank by approximately 35 degrees. The intraocular pressure reached 26mmHg in the right and 22mmHg in the left. The tongue body was deep red with a reduced coating and the pulse was thin and rapid.

Select the most appropriate formula:

  • A.Bŭ Zhōng Yì Qì Tāng (Middle-Supplementing and Qi-Benefiting Decoction)
  • B.Guī Pí Tāng (Spleen-Restoring Decoction)
  • C.Ē Jiāo Jī Zĭ Huáng Tāng (Donkey-Hide Gelatin and Egg Yolk Decoction)
  • D.Jīn Guì Shèn Qì Wán (Golden Cabinet’s Kidney Qi Pill)
  • E.Shí Quán Dà Bŭ Tāng (Perfect Major Supplementation Decoction)
  • 3. Male, 24. The vision in both eyes had slowly deteriorated over 5 years. The patient presented with blurred vision, a shrinking visual field and eye distention — especially when fatigued — accompanied by dizziness, irritability, insomnia, a bitter taste in the mouth and a dry throat. A visual examination of his eyes showed right 0.6, left 0.6 and C/D=0.6. There was a normal anterior section in both eyes, and a normal concave shape, which became enlarged and deeper in the optical papilla of the fundus. Broken blood vessels deviating medially could also be seen. The visual field had shrunk from the periphery by approximately 30 degrees. Intraocular pressure reached 22mmHg in the right eye and 28mmHg in the left. The tongue body was red with a thin, yellow coating and the pulse was wiry.

Select the most appropriate formula:

A.Chái Hú Shū Gān Săn (Bupleurum Liver-Soothing Powder)

B.Lóng Dăn Xiè Gān Tāng (Gentian Liver-Draining Decoction)

C.Líng Yáng Jiaŏ Tāng (Antelope Horn Decoction)

D.Qí Jú Dì Huáng Wán (Lycium Berry, Chrysanthemum and Rehmannia Pill)

E.Lù Fēng Líng Yáng Yĭng (Green Wind Antelope Horn Beverage)

4) Female, 40. Vision in both eyes had deteriorated slowly for 20 years with a gradually narrowing visual field. At the time of treatment, the patient presented with blurred vision, a narrowed visual field, a pale face, cold extremities and fatigue. Visual examination showed right eye 0.08, left 0.1 and C/D=0.8. There was a normal anterior section in both eyes and a normal concave shape, which became enlarged and deeper in the optical papilla of the fundus. Broken blood vessels deviating medially could also be seen. The visual field was a barrel shape at approximately 30 degrees. Intraocular pressure was 28mmHg in the right eye and 32mmHg in the left. The tongue body was pale with a thin, white coating and the pulse was deep, thin and weak.

Select the most appropriate formula:

  • A.Bŭ Zhōng Yì Qì Tāng (Middle-Supplementing and Qi-Benefiting Decoction)
  • B.Jīn Guì Shèn Qì Wán (Golden Cabinet’s Kidney Qi Pill)
  • C.Sì Wù Tāng (Four Substances Decoction)
  • D.Qí Jú Dì Huáng Wán (Lycium Berry, Chrysanthemum and Rehmannia Pill)
  • E.Xiāo Yáo Săn (Free Wanderer Powder)

ANSWERS:

  • 1.A
  • 2.C
  • 3.C
  • 4.B

Additional Commentary

In the first case scenario, the doctor describes a case with a phlegm-heat presentation. A notable detail is that when the patient’s vision is more blurred, her nausea is exacerbated. For the purpose of diagnosis, it is not necessary to over think whether phlegm-heat caused the blurred vision, which causes nausea and distention, or vice versa. It is only important to know that the bìng, the disease, is phlegm-heat. The treatment must center on principles of resolving phlegm and clearing heat. Therefore, the correct formula must be Huáng Lián Wēn Dăn Tāng (Coptis Gallbladder-Warming Decoction)

The second scenario presents a case of open-angle glaucoma with an etiology of internal wind caused by blood and yin deficiency. The formula Ē Jiāo Jī Zĭ Huáng Tāng (Donkey-Hide Gelatin and Egg Yolk Decoction) is relatively modern, having first appeared in the Qing dynasty text, the Revised Popular Guide to ‘Treatise on Cold Damage’.

Formula: Ē Jiāo Jī Zĭ Huáng Tāng (Donkey-Hide Gelatin and Egg Yolk Decoction)

[阿膠雞子] [阿胶子黄]

阿胶 ē jiāo 6g Colla Corii Asini
雞子黃 jī zĭ huáng 2 yolks Egg Yolk
生地 shēng dì 12g Radix Rehmanniae
白芍 bái sháo 9g Radix Paeoniae Alba
炙甘草 zhì gān căo 1.8g Radix et Rhizoma Glycyrrhizae Praeparata cum Melle
钩藤 gōu téng 6g Ramulus Uncariae Cum Uncis
石决明 shí jué míng 15g Concha Haliotidis
牡蛎 mŭ lì 12g Concha Ostreae
茯神 fú shén 12g. Sclerotium Poriae Pararadicis
络石藤 luò shí téng 15g Caulis Trachelospermi
The formula’s key actions are to enrich the yin, nourish the blood, soften the liver and extinguish wind.[ii] The formula relaxes spasms and opens the channels by including luò shí téng. This is the only classical formula that includes this medicinal.

Focusing first on the key medicinal relationships that initially appear in the Treatise on Cold Damage: ē jiāo, shēng dì bái sháo and zhì gān căo appear together in the formula Zhì Gān Căo Tāng (Honey-Fried Licorice Decoction). Together they nourish the yin and the blood. A sub-group within the formulas is bái sháo and zhì gān căo, which relaxes spasms.

Jī Zĭ Huáng[iii] is used with bái sháo andē jiāo in Huáng Lián: Ē Jiāo Tāng (Coptis Donkey Hide Gelatin Decoction) where, again, the combination enriches the yin and nourishes the blood. The use of these rich, emollient medicinals, combined with ones that clear heat and eliminate wind, treats Xū Fēng deficiency wind. Moving forward in history to the mid 20th century, shí jué míng, gōu téng and fú shen are used together in the formula Tiān Má Gōu Téng Tāng (Gastrodia and Uncaria Decoction), which leads one to surmise that the author of this formula studied the structure and treatment principles of Ē Jiāo Jī Zĭ Huáng Tāng when writing it.

The third case history creates an opportunity to discuss a relatively unknown formula: Líng Yáng Jiaŏ Tāng (Antelope Horn Decoction). There are at least 50 formulas of this name, and the doctor does not specify which one is used. One likely version was recorded in the epic Ming dynasty text Formulas for Universal Relief.

Formula: Líng Yáng Jiaŏ Tāng (Antelope Horn Decoction).

[羚羊角]

羚羊角 líng yáng jiăo Cornu Saigae Tataricae
茯苓 fú líng Poria
车前子 chē qián zĭ Semen Plantaginis
菊花 jú huā Flos Chrysanthemi
决明子 jué míng zĭ Semen Cassiae
羌活 qiāng huó Rhizoma et Radix Notopterygii
防风 fáng fēng Radix Saposhnikoviae
赤芍 chì sháo Radix Paeoniae Rubra
蔓荆子 màn jīng zĭ Fructus Viticis
黄芩 huáng qín Radix Scutellariae
升麻 shēng má Rhizoma Cimicifugae
栀子 zhī zĭ Fructus Gardeniae
麦冬 mài dōng Radix Ophiopogonis
甘草 gān căo Radix et Rhizoma Glycyrrhizae
柴胡 chái hú Radix Bupleuri
枳壳 zhĭ qiào Fructus Aurantii
The formula is large and complex, and, given the number of medicinals that clear heat from the eyes, suggests that this would be the base prescription. Further, the doctor makes a point of mentioning the patient’s irritability, bitter taste and eye distention, which describes a pattern of qi stagnation and depressive heat. The inclusion of chái hú, zhĭ qiào zhī zĭ and huáng qín treats this pattern presentation perfectly.

Another formula by the same name was recorded in the Popular Guide to the ‘Treatise on Cold Damage’ in the early Qing dynasty.

Formula: Líng Yáng Jiaŏ Tāng (Antelope Horn Decoction).

[羚羊角]

羚羊角 líng yáng jiăo Cornu Saigae Tataricae
钩藤 gōu téng Ramulus Uncariae Cum Uncis
生地 shēng dì Radix Rehmanniae
白芍 bái sháo Radix Paeoniae Alba
桑叶 sāng yè Folium Mori
贝母 bèi mŭ Bulbus Fritillaria
菊花 jú huā Flos Chrysanthemi
茯苓 fú líng Poria
甘草 gān căo Radix et Rhizoma Glycyrrhizae
竹茹 zhú rú Caulis Bambusae in Taenia

No dosages are given. Qin Bo Wei describes this version[iv] as being used to treat pathogenic heat that transmits into the jueyin, causing impaired or muddled consciousness. Because the heat is extreme and there is damage to yin, there is stirring wind and phlegm is generated. The spirit will certainly not be calm, and the sinews will be hypertonic. Líng yáng jiăo, gōu téng, sāng yè and jú huā are wind-expelling medicinals that relax the sinews to stop spasmodic pain; however, in the context of our glaucoma discussion, they would be effective for clearing heat from the eyes and eliminating liver wind. Qin also suggests that shí jué míng (Concha Haliotidis) may have been added to enhance the function of calming liver wind as well. Circling back to Ē Jiāo Jī Zĭ Huáng Tāng, both formulas use shēng dì, fú líng and, shí jué míng,underscoring the importance of three key points of treatment: clearing heat and nourishing the yin, constraining and calming the liver yang and draining dampness and transforming phlegm.

A third version of the formula is also referenced in Qin’s book[v] .

Formula: Líng Yáng Jiaŏ Tāng (Antelope Horn Decoction).

[羚羊角]

羚羊角 líng yáng jiăo Cornu Saigae Tataricae
龟板 guī băn Plastrum Testudinis
生地 shēng dì Radix Rehmanniae
白芍 bái sháo Radix Paeoniae Alba
牡丹皮 mŭ dān pí Cortex Moutan
菊花 jú huā Flos Chrysanthemi
夏枯草 xià kū căo Spica Prunellae
石决明 shí jué míng Concha Haliotidis
蝉蜕 chán tuì Periostracum Cicadae
薄荷 bò he Herba Menthae
大枣 dà zăo Fructus Jujubae

The source text is not cited, but the indications are highly suggestive of the symptoms of glaucoma. Qin writes: “This is indicated for a stirring of liver heat and ascension of liver yang with a splitting headache, contracture of the sinew vessels and pain that connects to the eyeball.” Of the three líng yáng jiăo formulas, this one relies on the use of several heavily sedating medicinals. In contrast to the primary case, all the líng yáng jiăo formulas are cooler and more sedating.

The final case study is a presentation of glaucoma caused by kidney yang deficiency. As we have discussed, the pupil belongs to the water wheel of the five wheels, which is associated with the kidneys. The previous cases centered on qi constraint and heat. For this case, the chief clinical concern is warming and tonifying the kidney yang to transform fluids. This should be differentiated from simple diuresis. As we have seen in the previous cases, with the exception of an emergent treatment strategy, diuresis is not the important treatment focus. If we were only to drain fluids, then we might risk injuring the yin. Every ophthalmologic case has discussed the importance of nourishing the yin when treating eye diseases. The actions of Jīn Guì Shèn Qì Wán, as the name of the formula suggests,are to strengthen the kidney qi so that the aqueous humor pressure is balanced in the chambers of the eye. Visualize the yin and yang dynamic of the eye: the aqueous humor is yin; the movement of it between the eye chambers is yang. The kidney yin regulates the storage of fluids and the kidney yang regulates the appropriate movement of the fluids. Jīn Guì Shèn Qì Wán is a balanced selection because it includes medicinals that nourish the yin and tonify the yang.

About Cara Frank, L.OM.

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. For over 32 years she has had the same crazy passion for Chinese medicine. 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.

Cara is the founder of Six Fishes Healing Arts in Philadelphia where she maintains a busy acupuncture practice and acts as the head fish of the office. She is also the president of China Herb Company, a specialty Chinese Herb Dispensary where these formulas can be ordered. You can read her full bio or schedule an appointment.


[i] Primary Open-Angle Glaucoma http://www.merckmanuals.com/professional/sec09/ch103/ch103b.html

[ii] Scheid, Bensky, Ellis, Barolet, Chinese Herbal Medicine Formulas and Strategies, 2nd edition. Eastland Press 2009, page 653

[iii] In modern clinical practice, rather than putting egg yolks in the formula, it is more practical to ask the patient to eat softly cooked eggs.

[iv] Chase, Liang, A Qin Bowei Anthology, Paradigm Publications, 1997, Pg 45

[v] Chase, Liang , pg 65, 

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Simply the best – I found Cara four years ago when I was seven months pregnant with twins and looking for a practioner to help me avoid a C-section. No no one would see me—until I called Cara. I see her still, only now I’m recovering from cancer. Now as then, she helps me help myself. She provides truly person-centered care, taking the time to listen and respond. The new office is warm and relaxing and the herbs are awesome. I would follow her anywhere—she is the best.

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