Cara Frank, L.OM.
I first published this excerpt from my book TCM Case Studies: Eye, Ear, Nose, and Throat Disorders in 2013. Recently, one of my office managers got a huge stye that was red and angry. The doctor told her he’d seen a lot of these cases this year. It’s been such an intense season with pollen, resulting in eye irritation. I was so happy to be able to reference my material to help resolve it.
Even though a stye is only one disease in Western Medicine, in Chinese Medicine, there are several causes. Even a condition this common and straightforward is carefully differentiated to treat the whole person and not just the symptom. This essay is a long and geeky read- more directed at practitioners and students of Chinese Medicine. Nevertheless, I hope that you find it helpful.
-Cara
Earlier this month, I had a stye for the first time in my life. There is very little English language literature on this disease, so I was grateful that I had written a chapter on the topic. It made it easy for me to diagnose and treat myself. Today I am sharing an excerpt of the chapter.
A hordeolum or stye is an acute infection of the sebaceous glands of the eyelid, usually caused by a localized infection of the eyelash follicle and adjacent meibomian glands. It is sometimes associated with blepharitis. Most hordeola are external, and diagnosis is made visually through clinical examination.
Hordeola are characterized by grain-shaped boils appearing on the margin of the eyelid that can quickly form pus and rupture. Symptoms include redness, swelling, itchiness, and pain of the lid margin. There can be mild hardness and tenderness, followed by localized swelling with increased pain and blurred vision. In some cases, the abscess may rupture spontaneously. The condition is seen more frequently in adults than children, and most cases are self-limiting, usually resolving within two weeks.
As the hordeolum progresses, there will be a gradual reduction of redness and swelling with the induration softening into pus. Pus formation in an external hordeolum occurs on the surface of the eyelid. The pus in the internal hordeolum forms at the inner eyelid, often with rupturing of the lesion. Lesions located close to the inner canthus will be more painful. The sclera on the diseased side will turn red with the swelling embedded in the palpebral fissure. There may also be palpable nodules anterior to the ears.
Western medical treatment consists of hot compresses applied to the eye, along with improvements in eye hygiene. Surgical incision and drainage are used if the hordeolum is large. If hordeola present with local cellulitis, antibiotics will be prescribed.
In TCM, hordeola usually result from wind-heat evil attacking the eyelid, an improper diet, or heat accumulation in the spleen and stomach rising upward to attack the eyelid. Recurrence is usually due to lingering pathogens not being entirely resolved, or retention of wind-heat due to deficiency of spleen qi and wei-defense qi. Causative factors include poor eye hygiene, malnutrition, fatigue, or wasting and thirsting patterns.
COMMON CLINICAL PATTERNS
Wind-heat evil attacking the eyelid
Toxic heat
Spleen deficiency combined with excess signs and symptoms
CASE STUDY
Male, age 9. Initial Visit: September 15, 2008.
Chief Complaint: Redness, swelling, and tenderness of the upper right eyelid for 5 days.
History: Approximately 1 year before treatment, the patient frequently experienced redness, swelling, and pain in his right eye. The same symptoms appeared again 5 days before the first visit. Several hospitals diagnosed him with an external hordeolum of the right eye. During the previous year, the patient received three drainage surgeries after which the localized redness and swelling would gradually be reduced. The patient had frequent recurrences.
Signs and Symptoms: Localized redness and swelling close to the margin of the upper right eyelid with palpable induration and tenderness with no pus formation. The patient was a picky eater with a poor appetite, dry mouth, pale complexion, hard stools, and frequent colds. The tongue body was tender with a thin, sticky yellowish coating; his pulse was thin and rapid.
Past History: Frequent upper respiratory infections.
Diagnostic Analysis
The patient’s poor eating habits are associated with spleen-stomach deficiency, as well as weakened-defense. The reduced appetite, hard stools, dry mouth, thin, sticky yellowish tongue coating, and thin rapid pulses are signs of food stagnation in the spleen-stomach transforming into heat. The pale face and frequent colds are both signs of spleen-stomach deficiency and weakened-defense.
Lingering pathogens and unresolved heat ascended to attack the eyelid leading to frequent recurrence of the hordeolum. Due to an inability of the wei defensive qi to ward off external pathogens, the condition remained persistent, although the redness and swelling were not severe.
The location of the disease is the eyelid. According to traditional Chinese eye anatomy, the eyelid belongs to the “muscle wheel,” which is associated with the spleen, thus confirming the diagnosis.
This is a case of spleen deficiency with excessive signs and symptoms. The root symptoms are deficient with branch excess at the surface.
Diagnosis
WM Diagnosis: Hordeolum
TCM Diagnosis: Hordeolum due to Spleen deficiency with qi stagnation and wei-defense weakness
Clinical Treatment: The clinical manifestations of this case showed a root deficiency with excessive symptoms manifesting at the surface, along with unresolved pathogenic heat ascending to attack the eyelid. According to the treatment principle of first treating the branch in acute-stage cases, treatment should start by addressing the unresolved pathogenic heat. After the heat is resolved, treatment should then focus on correcting the root deficiency.
Treatment Principles: Strengthen the spleen to supplement qi and promote the discharge of pus.
Formula: Modified Tuō Lǐ Xiāo Dú Săn(Interior-Drawing and Toxin-Removing Powder)
[托里消毒散]
黄芪 huáng qí 15g Radix Astragali
茯苓 fú líng 10g Poria
白术 bái zhú 10g Rhizoma Atractylodis Macrocephalae
陈皮 chén pí 6g Pericarpium Citri Reticulatae
赤芍 chì sháo 10g Radix Paeoniae Rubra
苡仁 yì yĭ rén 20g Semen Coicis
桔梗 jié gĕng 10g Radix Platycodonis
皂角刺 zào jiăo cì 6g Spina Gleditsiae
连翘 lián qiào 15g Fructus Forsythiae
金银花 jīn yín huā 15g Flos Lonicerae Japonicae
蒲公英 pú gōng yīng 15g Herba Taraxaci
莱菔子 lái fú zĭ 15g Semen Raphani
[Formula Analysis]
Huáng qí tonifies the yang qi of the spleen and stomach to ascend and disperse pathogenic factors. It is combined with bái zhú, fú líng, yì yĭ rén and gan cao to supplement qi and strengthen the spleen.
Chén pí regulates qi, clears obstruction and relieves qi stagnation.
Lái fú zĭ regulates qi to resolve food stagnation.
Jié gĕng circulates the lung qi, opening and regulating the waterways. While nourishing Earth and generating Metal, it guides the effects of the other medicinals upward.
Chì sháo cools the blood and dissipates redness.
Lián qiào, jīn yín huā and pú gōng yīng clear heat and toxic fire to treat the excessive superficial manifestations, while also draining accumulated heat.
External Therapy
Eye Drops: 0.5% bear bile eye drops or antibiotic eye drops, 4-6 times per day.
Warm Compresses: to invigorate the blood and help dissipate inflammation.
Acupuncture
Main Points: EX-HN 3 (yìn tang), BL 1 (jīng míng), BL 2 (cuán zhú), SP 10 (xuè hăi) and LV 3 (tài chōng).
Supplementary Points: GB 20 (fēng chí), LI 4 (hé gŭ) and SJ 23 (sī zhú kō).
Method: Select 2 main points and 2-3 supplementary points for daily treatment, using alternate points every other day. After obtaining the needling sensation, retain all needles for 20 minutes. 10 sessions constitute one course of treatment.
Techniques: During recurrences with aggravated redness and swelling, needle with drainage; supplementation and even methods should be used between onsets.
Second Visit
After 5 days of treatment, the redness and swelling at the lid margins were almost resolved, and the area was less tender although the induration remained. The patient’s appetite and dry mouth improved. The constipation was resolved entirely. The tongue body appeared with a thin white coating. The pulse was thin and rapid.
The reduced redness and swelling showed that the excess branch manifestations had improved. The root pattern of spleen-stomach deficiency pattern and wei-defense weakness remained.
Treatment Principles: Strengthen the spleen, supplement qi, support the upright qi, and eliminate pathogens.
Formula: Modified Shēn Líng Bái Zhú Săn(Ginseng, Poria and Atractylodes Macrocephalae Powder)
[参苓白术
| 太子参 | tài zĭ shēn | 15g | Radix Pseudostellariae |
| 茯苓 | fú líng | 10g | Poria |
| 白术 | bái zhú | 10g | Rhizoma Atractylodis Macrocephalae |
| 山药 | shān yào | 20g | Rhizoma Dioscoreae |
| 陈皮 | chén pí | 6g | Pericarpium Citri Reticulatae |
| 扁豆 | biăn dòu | 15g | Semen Lablab Album |
| 桔梗 | jié gĕng | 10g | Radix Platycodonis |
| 炙甘草 | zhì gān căo | 5g | Radix et Rhizoma Glycyrrhizae Praeparata cum Melle |
| 苡仁 | yì yĭ rén | 20g | Semen Coicis |
| 防风 | fáng fēng | 10g | Radix Saposhnikoviae |
| 赤芍 | chì sháo | 10g | Radix Paeoniae Rubra |
| 连翘 | lián qiào | 15g | Fructus Forsythiae |
Formula Analysis
Tài zĭ shēn, fú líng, and dry-fried bái zhú supplement qi and strengthen the spleen. Combined with fáng fēng, tài zĭ shēn and bái zhú, they supplement qi and consolidate the surface.
Yì yĭ rén, biăn dòu and chén pí support bái zhú and fú líng to strengthen the spleen, harmonize the stomach and regulate qi to resolve dampness.
Jié gĕng circulates lung qi and benefits qi, opens and regulates water passages, directs the other medicinals upwards and nourishes Earth to generate Metal.
Chì sháo and lián qiào invigorate blood, clear heat, and resolve stagnation to eliminate lingering pathogens.
Zhì gān căo supplements the spleen and stomach and harmonizes the other medicinals.
COMMENTARY AND DISCUSSION
In TCM, hordeolum is discussed under the category of eyelid diseases. According to the English Chinese Encyclopedia of Practical Traditional Chinese Medicine[i], eyelid diseases are called Yǎn Bì Eyelid block. The specific term for hordeolum is Mài Lì Zhǒng Wheat Grain Swelling.
Hordeola and all eyelid diseases have a close exterior/interior relationship. The eyelids correspond to the spleen and stomach. They are especially vulnerable to external pathogenic factors. The condition is usually caused by qi and blood stagnation in the eyelids that combine with external wind-heat. Alternately, toxic fire affects the yangming channels of the eyes, leading to hordeola. This is usually a consequence of the overconsumption of spicy or greasy foods, alcohol, and overeating in general. Underlying spleen qi deficiency is also a significant causative factor in the disease progression of the case history presented here.
A stye or hordeolum is commonly thought of as a localized fire-toxin. In this case history, the stye was slow to suppurate and resolve and was recurrent. These factors, combined with the patient’s poor appetite, frequent colds, and overall physical presentation, lead to the diagnosis of qi deficiency. Spleen and stomach qi deficiency leads to wei qi deficiency. This, in turn, leads to the retention of latent pathogens as the body is not robust enough to expel pathogenic factors.
The physician’s treatment strategy was stratified to expel first the pathogenic factor, and subsequently treat the root deficiency. The selected formula acts to address both the root and branch simultaneously.
It is important to comment on the use of the topical bear bile solution. Readers should understand that this case history is from China, where there is a historical precedent for its use for medicinal purposes. Today, worldwide, the use of bear bile is strictly forbidden. Currently, there are no commercial topical herbal eye drop preparations that are manufactured. Thus, if the hordeolum weren’t resolved with a combination of acupuncture, herbal formulas, and warm compresses, then treatment with antibiotic drops would be indicated.
Additional Formula Commentary
Huáng qí, dry-fried bái zhú, chén pí and gān căo are used together in Bŭ Zhōng Yì Qì Tāng (Center-Supplementing and Qi-Boosting Decoction). The physician has focused on strengthening the spleen and raising yang. A noteworthy action of huáng qí concerning this case is that it also expels pus making it an excellent choice for this and all instances of infection with underlying qi deficiency.
Bái zhú, fú ling, yì yĭ rén and jié gĕng are components of the formula Shēn Líng Bái Zhú Săn (Ginseng, Poria and Atractylodes Macrocephalae Powder), which treats spleen and lung qi deficiency. We usually select this formula when there are loose stools from spleen qi deficiency. In this case, yì yĭ rén has a dual role for both its spleen strengthening function, as well as its ability to resolve abscesses. Lián qiào and jīn yín huā also serve two purposes. They are key ingredients for clearing heat in the wei level and resolve fire-toxins, making them an ideal combination for treating hordeolum.
Jīn yín huā and pú gōng yīng are used together in Wŭ Wèi Xiāo Dú Yĭn (Five-Ingredient Decoction for Resolving Toxin). Both medicinals clear toxic fire and reduce nodulation.
Lái fú zĭ pairs with chén pí to regulate the qi and resolve food stagnation. Chì sháo, zào jiăo cì, chén pí are used together in the formula Xiān Fāng Huó Mìng Yĭn (Sublime Formula for Sustaining Life). This formula clears toxic fire, reduces fever, cools and moves the blood, and reduces early-stage sores and carbuncles, illustrating why this group can be used to treat hordeola. Thus, we see how a physician can employ key medicinal relationships from various formulas to craft a harmonious treatment strategy.
At the follow-up visit, the acute symptoms had resolved, but the patient still had deficient spleen qi and wei-defense qi. The physician is primarily concerned with supplementation. Shēn Líng Bái Zhú Săn(Ginseng, Poria and Atractylodes Macrocephalae Powder) was modified in the following ways: The patient’s tongue is still tender red and the pulse is still thready and rapid, thus tài zĭ shēn is used, which is cooler and more moistening than dăng shēn or rén shēn; by adding fáng fēng in concert with bái zhú, a modification of the formula Yù Píng Fēng Săn (Jade Wind-Barrier Powder), is created, stabilizing the exterior, stopping sweating and supplementing the qi. Lián qiào and chì sháo remain from the first formula to clear heat, reduce nodulation and move blood.
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. She is the president of China Herb Company, and she is an adjunct faculty member of the Department of Chinese Herbology at the Won Institute of Graduate Studies. You can read her bio or schedule an appointment.
[i] Page 61, Higher Education Press, Beijing, China. Volume 17, Ophthalmology, 1994
