The Treatment of Subconjunctival Hemorrhage with TCM

The Treatment of Subconjunctival Hemorrhage with TCM

Cara O. Frank, L.OM.

The following is a chapter from my forthcoming book, TCM Case Histories: Eye, Ear, Nose and Throat Disoders by Peoples Medical Publishing House. I hope that ou find this information helpful.

Subconjunctival hemorrhage, also known as red eye,is an ophthalmologic disease characterized by patchy light red bloody macules under the surface of the sclera. In some cases, it may cover the entire sclera. It occurs when small vessels in the eye rupture. Causes include violent sneezing or coughing increases in blood pressure as well as in those taking blood-thinning medications.

In TCM, subconjunctival hemorrhage is referred to as bái jīng yì xuè (白睛溢血, blood spillage in the white of the eye). It usually results from heat invading the lung channel, which causes a failure of lung qi to descend, which forces, the blood to move frenetically and spill into the sclera. Alternately, it can be caused by yin deficiency and essence loss due to aging, causing deficient heat to rise and resulting in blood spillage and damage to the collaterals. Other causes include external injury damaging the eye collaterals causing blood spillage into the sclera, strong coughing, excessive consumption of alcohol and vicarious menstruation. The etiology of this condition relates to an imbalance between the lung, kidney, liver and other specific organs, and will manifest with patterns of both excess and deficiency.

COMMON CLINICAL PATTERNS AND FORMULAS

Heat invading the lung channel: Modified Tuì Chì Săn (Redness-Abating Powder)

Yin deficiency and fire excess: Modified Zhī Băi Dì Huáng Wán (Anemarrhena, Phellodendron and Rehmannia Pill)

External injury damaging the eye collaterals: Modified Táo Hóng Sì Wù Tāng (Peach Kernel and Carthamus Four Substances Decoction)

CASE STUDY

Female, 68 years old. Initial Visit: March 16th, 2008

Chief Complaint:Frequent recurrence of redness in the sclera of both eyes for one year. Redness in the right eye presented one day prior to seeking treatment.

History:The patient has had frequent recurrence of redness in the sclera of both eyes for about a year. When the symptoms are less severe, they disappear spontaneously within a few days. When exacerbated despite the use of medicine, symptoms can persist for two weeks before resolving. The morning prior to treatment, the sclera in the right eye became red with some pain and discomfort. The vision remained normal.

Signs and Symptoms:The symptoms included a large patch of bloody macules under the surface of the inner canthus in the sclera of the right eye, with pain and discomfort. This was accompanied by lower back and knee soreness and weakness, vexing heat in the five hearts and insomnia. Bowel movements and urination were normal. The tongue was red with little coating. The pulse was thin and rapid.

Past History:Diabetes for three years. Thin body type, denied smoking and drinking.

Physical Examination: Physical examination showed blood pressure of 126/84 mmHg, a thin body type, clear breathing sounds in lungs, no rales and a heart rate of 86 beats/min with a normal rhythm. The abdomen was soft and flat. The liver and spleen were impalpable.

Ophthalmologic Examination: Examination showed visual acuity at 1.0 in both eyes, with a large patch of bleeding under the conjunctiva of the inner canthus of the right eye; the color was bright red, with a clear and bright cornea, anterior chamber (-), pupil (-). Left eye (-). The fundus of the eye: the color of both optic discs was normal; the retina artery was relatively small, A: V=1: 3, and the central fovea reflection of macula lutea appeared blurred but with no bleeding or discharge at the back of retina.

Laboratory Examination: Blood and urine routine tests were normal. Liver and kidney function and EKG were also normal. The fasting blood glucose level was 7.8 mmol/L, and the 2-hour postprandial blood glucose level was 11.6 mmol/L.

Pattern Differentiation

The chief characteristics of this patient were a thin body type, a history of diabetes for three years and frequent recurrence of redness in the sclera of both eyes for one year. The patient had redness in the right eye for one day prior to treatment, with a large bright red patch of bloody macules under the superficial layer in the inner canthus of the sclera accompanied by slight pain and discomfort. Other symptoms included lower back and knee soreness and weakness, vexing heat in the five hearts and insomnia. The tongue was red with a reduced coating. The pulse was thin and rapid.

The patient’s thin body type is associated with yin deficiency. Here the yin deficiency resulted in fire abundance, which damaged the eye collaterals. This led to the large area of bleeding under the superficial layer of the sclera, causing eye discomfort. The lower back houses the kidneys. Here, kidney yin deficiency caused the lower back and knees to be sore and weak. Yin deficiency and the resultant fire abundance caused malnourishment of the heart and spirit; hence, the vexing heat in five hearts, insomnia, red tongue with reduced coating and the thin rapid pulse, which indicate deficient fire ascending.

The location of the pathology in this case originated in the kidneys, but its effect reached the heart and lungs. It can be categorized as subconjunctival hemorrhage with the differentiation of yin deficiency and fire abundance. This case had root deficiency with branch excess.

Diagnosis

WM diagnosis: Subconjunctival hemorrhage (right eye)

TCM diagnosis: Blood spillage in the white of the eye due to yin deficiency and fire abundance

Clinical Treatment

The clinical manifestations in this case showed a root deficiency and branch excess. The treatment principle, therefore, should focus on nourishing the yin, descending fire to the root, stopping bleeding and dissipating stasis for the branch excess. To control the bleeding under the superficial layer of the sclera and prevent recurrence, treatment should address the root and the branch at the same time.

Principles: Nourish the yin, descend fire, stop bleeding and dissipate stasis

Formula: Supplemented Zhī Băi Dì Huáng Wán (Anemarrhena, Phellodendron and Rehmannia Pill)

[知柏地黄丸加味]

知母 zhī mŭ 10g Rhizoma Anemarrhenae
黄柏 huáng băi 10g Cortex Phellodendri Chinensis
生地黄 shēng dì huáng 15g Radix Rehmanniae
怀山药 huái shān yào 15g Rhizoma Dioscoreae
山茱萸 shān zhū yú 10g Fructus Corni
丹皮 dān pí 10g Cortex Moutan
茯苓 fú líng 10g Poria
泽泻 zé xiè 10g Rhizoma Alismatis
白茅根 bái máo gēn 15g Rhizoma Imperatae
侧柏叶 cè băi yè 15g Cacumen Platycladi
旱莲草 hàn lián căo 15g Herba Ecliptae
田三七 tián sān qī 3g Radix et Rhizoma Notoginseng (Take drenched)
[Formula Analysis]Shēng dì huáng, huái shān yào, shān zhū yú, dān pí, fú líng and zé xiè (Six-Ingredient Rehmannia Pill)nourish yin and tonify the kidney.

Zhī mŭ and huáng băi clear and descend deficient fire.

Bái máo gēn, cè băi yè and hàn lián căo cool the blood and stop bleeding.

Tián sān qī stops bleeding and dissipates stasis.

External Therapy

Compress therapy: A cold compress should be applied at the early stage to stop bleeding. If bleeding ceases after 48 hr, change to a warm compress to improve the absorption of static blood under the superficial layer of the sclera.

Further Consultation

After seven days of treatment, the color of the bloody macules under the superficial layer of the sclera in the right eye shrank, turning to a dark red color. The insomnia improved, but the lower back and knee soreness and weakness remained. The tongue was still red with little coating, and the pulse was thin and slightly rapid.

The above treatment brought the conjunctival hemorrhage under control and the symptoms improved. The kidney yin deficiency remained along with blood stasis.

Principles:Nourish and tonify kidney yin, dissipate stasis and open the collaterals

Formula: Supplemented Liù Wèi Dì Huáng Wán (Six-Ingredient Rehmannia Pill)

[六味地黄丸加味]

生地黄 shēng dì huáng 15g Radix Rehmanniae
怀山药 huái shān yào 15g Rhizoma Dioscoreae
山茱萸 shān zhū yú 10g Fructus Corni
丹皮 dān pí 10g Cortex Moutan
茯苓 fú líng 10g Poria
泽泻 zé xiè 10g Rhizoma Alismatis
旱莲草 hàn lián căo 15g Herba Ecliptae
女贞子 nǚzhēn zĭ 15g Fructus Ligustri Lucidi
茺蔚子 chōng wèi zĭ 10g Fructus Leonuri
丹参 dān shēn 15g Radix et Rhizoma Salviae Miltiorrhizae
枳壳 zhĭ qiào 6g Fructus Aurantii
田三七 tián sān qī 3g Radix et Rhizoma Notoginseng (take drenched)

[Formula Analysis]

Liù Wèi Dì Huáng Wán nourishes and tonifies the kidney yin.

Chōng wèi zĭ, dān shēn, zhĭ qiào and tián sān qī move qi, invigorate blood, dissipate stasis and open the collaterals.

Hàn lián căo and nǚ zhēn zĭ nourish the yin and tonify the blood while preventing a recurrence of the bleeding.

COMMENTARY AND DISCUSSION

By now, the reader may have observed the treatment algorithm that has been used for every case. First, the diagnosis is based on pattern discrimination combined with five wheel differentiation. Using this information, the doctor forms a treatment strategy, selects a formula that addresses the pattern of disease and, finally, modifies the formula so that it is specific to the disease and its location. Thus, every formula is dictated by the patient’s constitution, the cause of the disease, its nature and the location.

This chapter discusses a species of bleeding. Bleeding has four major causative factors: heat, qi deficiency, blood stasis and trauma. For this case, the formula selection addresses the patient’s underlying constitutional pattern with modifications that stop bleeding and have an affinity for the eyes.

In the primary case, the bleeding is caused by heat. Further discrimination clarifies that the heat is caused by yin deficiency with fire abundance, which incites the blood to move recklessly. One of the guiding formulas to treat this pattern is Zhī Băi Dì Huáng Wán. While it treats the root pattern, it does not treat the branch symptom of bleeding in the eye. The modifications include a group of medicinals that stop bleeding by cooling the blood and one medicinal to eliminate blood stasis.

By the second visit, the bleeding is controlled. The symptoms of empty fire have abated. The symptoms of yin deficiency and blood stasis remain. The doctor makes an astute diagnostic observation: the bleeding was resolved, but the pinprick macules were dark. Thus, the diagnosis moves from heat, to blood stasis. The second formula is a modified Liù Wèi Dì Huáng Wán. The doctor adds hàn lián căo and nǚ zhēn zĭ, which nourish the blood and control bleeding. Chōng wèi zĭ is an especially nice choice in this formula as its actions are to move the blood and clear the vision. Dān shēn and zhĭ qiào round things out, harmonizing the qi and blood.

STUDY QUESTIONS

1.What is the prognosis in this case?

2.During the follow-up visit, what were the manifestations of kidney yin deficiency and blood stasis?

3.What details warrant attention with regard to the care for this case?

Answers

1.This was a chronic case of subconjunctival hemorrhage with frequent recurrence for a year combined with a 3-year history of diabetes. With correct differentiation and treatment, the hemorrhage in the sclera will dissipate and be controlled to avoid recurrence. Without intervention, the disease will progress, not only with the recurrence of hemorrhage, but also with the occurrence of diabetic retinal hemorrhage.

2.By the follow-up visit, the bloody macules below the superficial layer of the right sclera had become dark red, indicating blood stasis. The lower back and knee soreness and weakness, the red tongue with reduced coating, and the thin rapid pulse all indicated kidney yin deficiency.

3.The occurrence of this disease often relates to heat invading the lung channel, yin deficiency with fire abundance, and external injury damaging the eye collaterals. The patient should consume less spicy-hot food in order to avoid heat and fire accumulation inside of the body. She should also avoid staying up too late and overusing the eyes to prevent damaging the kidney yin, and avoid external injury to the eye and heavy lifting that may damage the eye collaterals.

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, 25 years old. Blood spillage into the superficial layer of the sclera of the left eye, bright red in color, accompanied by a cough with yellow phlegm, a dry mouth and throat, yellow urine and dry stools. The tongue was red with a yellow coating and the pulse was rapid.

Select the most appropriate formula:

A.Sāng Jú Yĭn (Mulberry Leaf and Chrysanthemum Beverage)

B.Tuì Chì Săn (Redness-Abating Powder)

C.Yăng Yīn Qīng Fèi Tāng (Yin-Nourishing and Lung-Clearing Decoction)

D.Zhī Băi Dì Huáng Wán (Anemarrhena, Phellodendron and Rehmannia Pill)

E.Sāng Bái Pí Tāng (Mulberry Root Bark Decoction)

2. Male, 18 years old. The right eye was struck by a basketball a week prior to treatment resulting in a purplish color and swelling of the eyelid. There was a large dark red patch of bloody macules on the superficial layer of the sclera. The appetite, bowel movements and urination were normal. The tongue was red with a white coating and the pulse was wiry.

Select the most appropriate formula:

A.Tuì Chì Săn (Redness-Abating Powder)

B.Xiè Fèi Tāng (Lung-Draining Decoction)

C.Xuè Fŭ Zhú Yū Tāng (Blood Mansion Stasis-Expelling Decoction)

D.Dān Zhī Sì Wù Tāng (Moutan and Gardenia Four Substances Decoction)

E.Zhī Băi Dì Huáng Wán (Anemarrhena, Phellodendron and Rehmannia Pill)

Answers

1. B

2. C

Additional Commentary

The case scenarios illustrate other causes of bleeding. In the first scenario, the hemorrhage is caused by heat that injures the collaterals in the eye. The patient has symptoms of dryness, heat and phlegm. The guiding formula is Tuì Chì Săn (Redness-Abating Powder). This formula warrants a brief discussion as it is infrequently seen in English language literature.

Formula:Tuì Chì Săn(Redness-Abating Powder)

[退赤散]

黄芩(酒炒) huáng qín (jiǔ chǎo) Radix Scutellariae (wine fried)
桑白皮 (蜜制) sāng bái pí Cortex Mori (honey fried)
白天花粉 tiān huā fěn Radix Trichosanthis
瓜蒌仁 guā lóu rén Trichosanthis Semen
桔梗 jié gĕng Radix Platycodonis
甘草 gān cǎo Glycyrrhizae Radix
牡丹皮(酒洗) mǔ dān pí (jiǔ xǐ) Cortex Moutan (wine washed)
当归尾 dāng guī wěi Radix Angelicae Sinensis Extremitas
赤芍 chì sháo Radix Paeoniae Rubra

This formula appears in the Ming Dynasty classical text AClose Examination of the Precious Classic [on Ophthalmology] (Shĕn Shì Yáo Hán,审视瑶函). The formula clears the lung heat and dissipates blood stasis. There are several easily recognizable herbal pairs within the formula. Huáng qín and sāng bái pí are used again and again in formulas that clear lung heat. Tiān huā fěn, guā lóu rén and jié gĕng are used together in Bèi Mǔ Guā Lóu Sǎn(Fritillaria and Trichosanthes Powder), which clears lung heat and moistens the lungs. Jié gĕng and gān cǎo benefit the throat. Mǔ dān pí, dāng guī wěi and chì sháo clear heat from the blood level and eliminate blood stasis. Even though the case is summarized very briefly, it is apparent that formula addresses the patient’s entire constellation of signs and symptoms.

Another formula, by the same name appears in the Essentials from the Silver Sea (Yín Hăi Jīng Wēi, 银海精微). However, it uses different medicinals. One could make a strong argument for the use of this formula to treat the case as well.

Tuì Chì Săn(Redness-Abating Powder) from Essentials from the Silver Sea

[退赤散]

黄芩 huáng qín Radix Scutellariae
黄连 huáng lián Rhizoma Coptidis
白芷 bái zhĭ Radix Angelicae Dahuricae
当归 dāng guī Radix Angelicae Sinensis
赤芍 chì sháo Radix Paeoniae Rubra
栀子 zhī zĭ Fructus Gardeniae
桑白皮 sāng bái pí Cortex Mori
木通 mù tōng Caulis Akebiae
桔梗 jié gĕng Radix Platycodonis
连翘 lián qiào Fructus Forsythiae

Huáng qín, huáng lián and zhī zĭ are from the formula Huáng Lián Jiĕ Dú Tāng (Coptis Toxin-Resolving Decoction). Its actions are to stop bleeding from fire and to clear heat in the upper jiao. Dāng guīand chì sháo cool and harmonize the blood to eliminate blood stasis.

Mù tōngand sāng bái pí drain heat through urination. Sāng bái pí alsoclears heat from the eyes when it affects the sclera. This is because sāng bái pí enters the lung channel and the sclera belongs to the qi wheel of the eyes, which is governed by the lungs. This version of Tuì Chì Săn was originally indicated for the treatment of hordeolum. Keeping in mind that hordeolum is a kind phlegm nodule; consider eliminating bái zhĭ and lián qiào from the formula.

The second case scenario is bleeding caused by trauma. The guiding formula is Xuè Fŭ Zhú Yū Tāng (Blood Mansion Stasis-Expelling Decoction). This is Wang Qing-ren’s classic formula from Correction of Errors in Medical Works (Yī Lín Găi Cuò, 医林改错). The formula invigorates the blood, dispels blood stasis, regulates the qi and unblocks the channels, making it an excellent choice for acute trauma. Consider modifying the formula with medicinals specific to the head and eyes. A good starting point would be to look at a related formula, also written by Wang: Tōng Qiào Huó Xuè Tāng (Orifice-Freeing Blood-Quickening Decoction). This formula is indicated for the treatment of head trauma. Single medicinal modifications could include chuān xiōng (Rhizoma Chuanxiong) to move blood, scatters wind and relieve head pain; or tián sān qī, which staunches bleeding and eliminates blood stasis.

t 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 and Six Fishes Neighborhood Acupuncture 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.

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Compassionate Care – Cara Frank is wonderful. I have gone to her for two years and she has successfully treated me for both acute and chronic conditions. Her treatments and knowledge of herbs are amazing. Cara’s experience and wisdom is a rarity. Her new office is comfortable and she always treats me with kindness, respect and compassion. I would highly recommend her.

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