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 the 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. 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, cataracts are referred 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 a 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’s 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 regular heartbeat 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 were opaque refractive media in both eyes. The color and vessels of the optic nerve head were normal with a 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 was 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 |
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, healthy bowel movements were restored. The examination showed that the 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, leads to reduced appetite. Therefore, three medicinals were added to the original formula to promote 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 as 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 the 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 physicians and patients. So much so that prayer is included as part of the treatment protocol. The Essentials from the Silver Sea is a 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 that 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.
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 37 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. 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.
