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.
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 when the lacrimal passage is washed; however, no mucus excretion from the lacrimal punctum will occur. This condition is more common in winter and spring, occurs in one or both eyes. It is usually encountered in those people with weak constitutions.
Epiphora is divided into chronic and acute types. The leading cause is irritation and inflammation that obstructs 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 an 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: Modified Zuŏ 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 before 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 the 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 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 the 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: Modified Zuŏ 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 and shí 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 and jú huā are used to expel wind and stop lacrimation.
Fú líng tonifies the spleen and drains dampness, while also tonifying the 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 primary and supplementary points every other day. Ten days constitute 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 older 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 on 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 Yĭn is 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 Yĭn is 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 lí and 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 distinct 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 Xiāng Chuān Wū Wán (Frankincense Aconite Main Tuber Pill). 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 |
| – 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, remove xià kū căo (Spica Prunellae) 30g.
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 30 years Cara’s 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.
