The Treatment of Epiphora- Excessive Tearing with Chinese Medicine

 The Treatment of Epiphora- Excessive Tearing with Chinese Medicine

Cara Frank, L.OM.

Epiphora refers to an eye condition in which tears overflow from the margin of the eyelid by not following the normal lacrimal passage. Aside from tearing, there is no redness, swelling or pain in the affected eye. The symptoms are often worse during windy weather, winter and early spring. Eye examination reveals the constant overflow of tears. The skin under the inner canthus becomes very moist and there may be an eversion of the lacrimal punctum and no excretion of mucus when applying pressure to the acupuncture point BL 1 (jīng míng). An obstruction may or may not be identified upon washing the lacrimal passage, but no mucus excretion from the lacrimal punctum will occur. This condition is more common in winter and spring, occurs in one or both eyes and is often seen in those with a weak constitution.

Epiphora can be divided into chronic and acute types. The main cause is irritation and inflammation that causes obstruction of the normal drainage of tears. Other causes are malformation of the eyelid, sinus infection or trauma to the area. It is diagnosed by observing the eyelid as well as the clinical history of the symptoms. During the differential diagnosis, inquire if there has been any loss or change in vision, headaches, sinus congestion or nasal allergies, as well as joint aches and pains. The tears may be cultured for bacteria to check for infection.

Western medical treatment usually includes antibiotics, artificial tears or topical antihistamines. Surgery may be required to repair the eyelid if there is ectropion or entropion.

In TCM, this disease is referred to as liú lèi zhèng (流泪症, lacrimation syndrome). It is usually caused by liver blood deficiency, a loose lacrimal orifice or external wind pathogen. It can also be caused by qi and blood deficiency or liver and kidney deficiency. Lacrimation is the result of these deficiencies and the subsequent inability to control fluids.

COMMON CLINICAL PATTERNS AND FORMULAS

Liver blood deficiency with external contraction of wind pathogen: Modified Sì Wù Tāng(Four Substances Decoction)

Qi and blood deficiency failing to control the fluid overflow: Modified Bā Zhēn Tāng (Eight-Gem Decoction)

Liver and kidney deficiency failing to contain fluids: ModifiedZuŏ Guī Yĭn(Left-Restoring Beverage)

CASE STUDY

Female, age 75. Initial Visit: January 5th, 2009

Chief Complaint:Persistent lacrimation in both eyes for more than two years.

History:The patient had suffered from excess tearing for more than two years,which was initiated by an invasion of external wind in both eyes. She began to tear persistently starting six months prior to treatment. The lacrimation was watery and the symptoms worsened when facing the wind. The vision became blurred when her eyes were tired. The patient visited numerous hospitals and was diagnosed with bilateral epiphora. Washing the lacrimal passage revealed no obstruction and, therefore, no treatment was offered.

Signs and Symptoms: Persistent bilateral lacrimation with watery discharge, exacerbated when facing into the wind, blurred vision upon overuse of the eyes, lower back and knee soreness, moist skin below the inner canthus. The tongue body was pale with a thin white coating. The pulse was thready.

Past History:Hypertension for eight years.

Pattern Differentiation

Tears are the fluid associated with liver, while the kidney governs the entire five fluid systems. The liver and kidney deficiency resulted in a failure to restrain fluids, which subsequently caused the persistent lacrimation with watery discharge. The blurred vision upon overuse of the eyes, lower back and knee soreness were symptoms of liver and kidney deficiency. Moist skin below the inner canthus was the result of the chronic lacrimation. The pale tongue body and thready pulse were both signs of deficiency.

The location of this condition was in the liver and kidney, which failed to restrain fluids. Therefore, this case can be categorized as a deficient pattern.

Diagnosis

WM diagnosis: Epiphora

TCM diagnosis: Lacrimation syndrome due to failure of the liver and kidney to restrain fluids

Clinical Treatment

This was a deficiency case. The underlying cause of this case was failure of the liver and kidney to restrain fluids. The treatment principle, therefore, should focus on tonifying the liver and kidney.

Principles: Tonify the liver and kidney, astringe and stop lacrimation

Formula:ModifiedZuŏ Guī Yĭn(Left-Restoring Beverage)

[左归饮加减]

熟地黄 shú dì huáng 20g Radix Rehmanniae Praeparata
怀山药 huái shān yào 20g Rhizoma Dioscoreae
枸杞子 gŏu qĭ zĭ 15g Fructus Lycii
茯苓 fú líng 20g Poria
山茱萸 shān zhū yú 10g Fructus Corni
五味子 wŭ wèi zĭ 15g Fructus Schisandrae Chinensis
防风 fáng fēng 10g Radix Saposhnikoviae
巴戟天 bā jĭ tiān 10g Radix Morindae Officinalis
白蒺藜 bái jí lí 15g Fructus Tribuli
菊花 jú huā 10g Flos Chrysanthemi
石榴皮 shí liú pí 20g Pericarpium Granati
甘草 gān căo 5g Radix et Rhizoma Glycyrrhizae
[Formula Analysis]

Shú dì huáng, huái shān yào and gŏu qĭ zĭ tonify and benefit the liver and kidney and nourish the kidney essence.

Wŭ wèi zĭ, shān zhū yú, bā jĭ tiān andshí liú pí tonify and benefit the liver and kidney to astringe and stop lacrimation.

Due to the aggravation of symptoms by wind, bái jí lí, fáng fēng andjú huā are usedto expel wind and stop lacrimation.

Fú líng tonifies the spleen and drains dampness, while also tonifying liver and kidney to prevent the stickiness of the tonifying medicinals.

Gān căo harmonizes the medicinals.

External Therapy

Zinc sulfate eye drops can be applied to the eyes.

Chinese Patent Medicine

Qĭ Jú Dì Huáng Wán(Lycium Berry, Chrysanthemum and Rehmannia Pill), 9g, administered orally, three times per day.

Acupuncture

Main points: BL 18 (gān shù), BL 23 (shèn shù), BL 1 (jīng míng), KI1 (yŏng quán)

Supplementary points: LV 3 (tài chōng), RN 8 (shén què), LI4 (hé gŭ), GB20 (fēng chí)

Method:Two main points and 2-3 supplementary points were chosen every day. Alternate the main and supplementary points every other day. 10 days constitutes one course of treatment.

Techniques: Tonifying technique was mainly applied, using both acupuncture and moxa. Moxa to RN 8 (shén què) was added while needling the following points: BL 18 (gān shù), BL 23 (shèn shù), KI 1 (yŏng quán), LV 3 (tài chōng). A warm needle was applied to BL1 (jīng míng) ipsilaterally.

Further Consultation

Second Visit

After one course of treatment, all the symptoms were reduced. The tongue body remained pale with a white but slightly greasy coating, and the pulse remained thready. This indicated the correct formula was selected to target the condition, and a similar herbal prescription should be continued. The tongue coating, however, changed from thin white to slightly white and greasy, indicating that rich and sticky medicinals should be avoided in future formulas.

Principles:Tonify and benefit the liver and kidney, astringe and stop lacrimation

Formula:Modified Zuŏ Guī Yĭn (Left-Restoring Beverage).

[Formula analysis]

Based on the first formula, yì yĭ rén (Semen Coicis) 20g was added to reinforce fú líng’s function of strengthening the spleen, draining dampness and counteracting the stickiness of the tonifying medicinals.

COMMENTARY AND DISCUSSION

Although it is not painful or dangerous in any way, excessive tearing is a constant nuisance that affects everyday quality of life. Epiphora is defined as watering of the eyes due to a blockage of the lacrimal ducts or the excessive secretion of tears

The primary case presents an elderly woman with kidney deficiency. There are several notable points to the diagnosis, formula selection and modification of this case study: The fact that the patient is not diagnosed as being either yin or yang deficient is deliberate. The focus is the overarching deficiency of the kidneys’ function of stabilizing fluids. The physician emphasizes that the lacrimal orifices are loose. This key phrase brings to our attention the importance of using astringing or stabilizing medicinals to modify the formula. An additional distinction is that modified Zuŏ Guī Yĭnis selected instead of the more commonly used Liù Wèi Dì Huáng Wán (Six-Ingredient Rehmannia Pill). Both formulas benefit the kidneys and nourish the yin, however Liù Wèi Dì Huáng Wán contains three ingredients that tonify and three that drain. Zuŏ Guī Yĭn contains only medicinals that tonify and none that are draining. Based on this comparison, where there is leakage of body fluids, modified Zuŏ Guī Yĭnis the superior formula to stabilize the condition.

Within the formula, wŭ wèi zĭ supports shān zhū yú astringent action. Examples of how this sour flavored pair stabilizes the liver and kidneys, is illustrated by referring formulas such as Dū Qì Wán (Qi-Restraining Pill) and Míng Mù Dì Huáng Wán (Eye Brightener Rehmannia Pill). Jú huā has a relationship with gŏu qĭ zĭ in Qĭ Jú Dì Huáng Wán. The pair is also included in Shí Hú Yè Guāng Wán (Dendrobium Night Vision Pill) and Xĭ Gān Míng Mù Tāng(Liver-Washing Eye-Brightening Decoction) along with bái jí líand fáng fēng to eliminate wind, clear heat and clear the vision. Fáng fēng and wŭ wèi zĭ stabilize the exterior to prevent leakage and to eliminate wind.

By far, the most intriguing modification is the addition of shí liú pí: this medicinal is also in the category of medicinals that stabilize and bind, however, it is usually used to treat diarrhea. Based on that, we can surmise that it is astringent to all body fluids, including tears.

According to the Essentials from the Silver Sea(Yín Hăi Jīng Wēi, 银海精微), if there is kidney vacuity, then liver wood is not engendered. Due to the resultant liver deficiency, the channel is weakened and thus, the wood (liver) is stirred which results in tearing when facing or being exposed to wind. In contrast, epiphora is not caused or exacerbated by exterior wind.

There are two passages in the Essentials from the Silver Sea that discuss tearing: Passage 45 discusses Lacrimation Due To Intrusion of Wind, while the topic of passage 64 is Lacrimation when Facing the Wind. The chapters are similar, but the chief pattern in the former passage is internal wind generated by the liver, while the chief pattern in the latter passage centers on external pathogenic factors.

The book continues to discuss different species of tears: Hot tears should be treated with Chuān Xiōng Chá Tiáo Săn (Tea-Mix and Chuanxiong Powder) while tears caused by liver wind are treated with Cāng Zhú Săn (Atractylodes Rhizome Powder). Tears from liver deficiency are treated with Zhĭ Lèi Bŭ Gān Săn (Tear-Checking and Liver-Supplementing Powder). Cold tears are treated using Rŭ XiāngChuānWūWán (Frankincense Aconite Main TuberPill). The recipe involves peeling and pounding aconite and then forming pills with míng fán (Alumen)and pig’s bile. These are formed into pills the size of millet and embedded in the inner canthus, which essentially cauterizes the tear duct.

What is not discussed in the Essentials from the Silver Sea is the relationship of excessive tearing with the inner canthus. All lacrimation originates from the canthus, and thus has a close relationship to the heart. The heart is associated with fire and governs the blood and vessels. Heart fire flaming upward will result in qi congestion, which in turn obstructs the flow of tears. Thus, in addition to the patterns of liver and kidney deficiency and external wind, heart fire may also be a factor in lacrimation pattern.

Formula:Chuān Xiōng Chá Tiáo Săn(Tea-Mix and Chuanxiong Powder) (from the Essentials from the Silver Sea)

[川芎茶调散]

川芎 chuān xiōng Rhizoma Chuanxiong
防风 fáng fēng Radix Saposhnikoviae
羌活 qiāng huó Rhizoma et Radix Notopterygii
甘草 gān căo Radix et Rhizoma Glycyrrhizae
石决明 shí jué míng Concha Haliotidis
木贼 mù zéi Herba Equiseti Hiemalis
石膏 shí gāo Gypsum Fibrosum
荆芥 jīng jiè Herba Schizonepetae
菊花 jú huā Flos Chrysanthemi
薄荷 bò he Herba Menthae
[Method]

Take one liăng of each and pulverize. Each dose consists of 2-3 qián. Swallow with tea after meals.

Formula:Cāng Zhú Săn(Atractylodes Rhizome Powder) (from the Essentials from the Silver Sea)

[苍术散]

苍术 cāng zhú Rhizoma Atractylodis
木贼 mù zéi Herba Equiseti Hiemalis
香附 xiāng fù Rhizoma Cyperi
夏枯草 xià kū căo Spica Prunellae
蝉蜕 chán tuì Periostracum Cicadae
甘草 gān căo Radix et Rhizoma Glycyrrhizae
白蒺藜 bái jí lí Fructus Tribuli
白芷 bái zhĭ Radix Angelicae Dahuricae
防风 fáng fēng Radix Saposhnikoviae
蔓荆子 màn jīng zĭ Fructus Viticis
川芎 chuān xiōng Rhizoma Chuanxiong
僵蚕 jiāng cán Bombyx Batryticatus
[Method]

Take equal amounts of each and pulverize. Each dose consists of 2-3 qián. Swallow with green tea or wine.

Formula:Zhĭ Lèi Bŭ Gān Săn(Tear-Checking and Liver-Supplementing Powder) (from the Essentials from the Silver Sea)

[止泪补肝散]

白蒺藜 bái jí lí Fructus Tribuli
当归 dāng guī Radix Angelicae Sinensis
熟地黄 shú dì huáng Radix Rehmanniae Praeparata
川芎 chuān xiōng Rhizoma Chuanxiong
白芍 bái sháo Radix Paeoniae Alba
木贼 mù zéi Herba Equiseti Hiemalis
防风 fáng fēng Radix Saposhnikoviae
夏枯草 xià kū căo Spica Prunellae

[Method]

Take equal amounts of each and pulverize. Each dose consists of 2-3 qián. Swallow with green tea.

[Modifications]

For blood deficiency,removexià kū căo (Spica Prunellae) 30g.

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 30 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. You can read her full bio or schedule an appointment.

Leave Your Comments

blog comments powered by Disqus

Amazingly attentive health care practitioner – Having been a patient of Cara Frank’s for many years now, I cannot express what a caring and kind practitioner she is.I have many health challenges and Cara was the first to make me feel that these were in fact challenges that she and I would address together as a team. She is meticulous, extemely thorough, and a wonderfully attentive listener. I have recommended Cara and Six Fishes to many of my friends and associates and will continue to do so.

Melissa W.