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Home > Newsletters > April 2004 >

Classical Chinese Ophthalmology

By Cofe Fiakpui

The Yin hai jing wei or “Essential subtleties on the silver sea” is a classical Chinese text on ophthalmology that has traditionally been ascribed to Sun si Miao (581-682). However, recent evidence shows that this text was probably compiled in the 14th or 15th century and thus could not have been written by Dr. Sun but rather comes from the Ni family lineage. The eye being the window into the Shen is also the main window through which one’s Shen perceives the outer world and comes to describe and categorize his or her environment. Although the eye is most closely connected in TCM theory with the liver, heart and kidney, all of the organs are connected with the eye and thus various pathologies of the internal organs are manifested in the eyes. This has been confirmed by the Western naturopathic science of iridology, which images the entire body on top of the iris as an accurate system of diagnosis. The “Essential subtleties on the silver sea” presents flowing, poetic descriptions of several eye pathologies, many of which are still commonly seen in clinical practice such as conjunctivitis, cataracts, stroke, glaucoma, trachoma, keratitis, xerophthalmia, trichiasis, corneal abrasions, mydriasis, strabismus and iridocyclitis. There are various philosophical principles underlying this text, which provide a profound understanding of the eyes as a reflection of nature. It states:

Human beings have two eyes, just as heaven and earth have the two luminaries (the sun and moon). They view all things and observe even the minutest. They reach everywhere. Just as sun and moon are at times obscure by the arrival of wind, clouds, thunder and rain, the eyes may lose their vision when they are harmed by four (climatic) influences or by the seven emotions. Generally speaking the eyes are an essential reflection of the five viscera and constitute an important junction for the entire body.

Each anatomical section of the eye is associated with a particular element and zang organ that corresponds to a particular sphere. The wood phase represented by the zang organ of the liver is called the wind sphere and corresponds to the iris. The heart and fire element is called the blood sphere and corresponds to the inner and outer canthi. The spleen and earth phase is called the flesh sphere and corresponds to the upper and lower eyelids. The lung being metal is called the qi sphere and corresponds to the conjunctiva. The kidney being water is called the water sphere and corresponds to the pupil. In a Chinese person with green eyes all of these correspondences would follow the typical five element color associations when there is no pathology present. The pupil is black and corresponds to water. The conjunctiva is white and corresponds to metal. The eyelids would be yellow and correspond to earth. The canthi are red and correspond to fire. The iris would be green and correspond to wood.

The etiology of ophthalmological diseases presented in the “Essential subtleties on the sliver sea is” no different than that of any disease in TCM. They are basically divided into exogenous and endogenous pathogenic influences. The text states, “If wind or heat accumulate in the body, or if the qi of any one of the seven emotions is repressed and constrained and fails to dissipate, these influences move upward and attack the eye. There they become manifest at that part of the eye that is associated with one of the five viscera from where these influences originate. As a result, there may be swellings and pain, photophobia, roughness and plenty of tears, or an obstruction may grow that makes vision dim or causes a complete loss of one’s eyesight.” This classic then goes on to describe 72 eye diseases in great detail listing the symptoms and the etiology of the diseases along with their treatments. These treatments consist of over 200 herbal formulas designed specifically for ophthalmology in various forms for both topical and internal usage as well as several minor surgical procedures acquired by the ancient Chinese physicians from Ayurvedic surgeons from the Indian Buddhist tradition. Since surgery is quite far out of our scope of practice today and because acupuncture was not included in this text, (although acupuncture points are mentioned for using moxa) I will focus this paper on the herbal treatment for the common ophthalmological disorders that occur today in the clinical setting.

Pterygium

The Yin hai jing wei begins with descriptions of degenerative and hyperplastic changes of the conjunctiva that describe the condition known in Western medicine as pterygium. The author describes red vessels spreading from the outer or inner canthus to the eyeball with an invasion of the cornea and an impairment of vision. It states, “These tendons obtain blood, and they gradually spread into the black part of the eye and slowly extend to the pupil. In severe cases, vision is impaired just as if one were looking at things through a partition of silk.” These “tendons” are really conjunctival vessels that fill up with blood and restrict vision. This occurs due to repletion evil in the heart and liver accompanied by the minister of fire of the triple burner flaring upward. The etiology could be from excessive reading at night, heavy consumption of wine or indulging in spicy, fried or hot food, all of which seem to be the principle etiologies behind many of the eye diseases involving heat pathologies. The treatment for red vessels spreading from the inner canthus utilizes herbs to release the fire and clear heat from the heart, liver and san jiao. First the patient should take the “pills with three yellow ingredients” (huang lian, huang qin and da huang) and then the “powder to cleanse the heart” (dang gui, chi shao, da huanng, ma huang, jing jie, huang lian, zhi zi) to expel the illness. The “powder to lead off redness” (mo tong, gan cao, zhi zi, huang bai, sheng di, zhi mu) can also be used for the inflamed red vessels and ba zheng san can be used to open the conduit of the small intestine to make the heart fire descend. For vessels spreading from the outer canthus, the “powder to drain the liver” (jie geng, huang qin, da huang, mang xiao, zhi zi, che qian zi) or the “powder with nine celestial ingredients” (huang qin, jing jie, gan cao, chi shao, ju hua, chuan xiong, dang gui, mu tong, bai zhi) can be used.

Blepharitis

In this condition, the eyelids become red, tender and sore with sticky exudates and scales on the edges and may develop styes or meibomian cysts. This is described as “the two eyelids stick together” and occurs when the spleen and stomach are affected by wind, cold and depletion. The evil qi gathers at the lids and as a result, the upper and lower lids turn red from the wind and become sore from the dampness. During sleep the eyelids become glued together stagnating the blood that cannot disperse and eventually develops a “shade membrane” or a meiobomian cyst. If this condition has continued on for years then the patient should take the “decoction with the dang gui to enliven the blood” (dang gui, guang qi, mo yao, chuan xiong, cang zhu, jing, jie, bo he, shu di, qiang huo, ju hua, ma huang) and the “powder to clear the spirit” (chuang xiong, bo he, qiang huo, fu mi, gao ben, fang feng, jing jie, chuan wu, zhi ke, shi gao, bei zhi, gan cao, xi xin, ma huang), which is particularly good for shrinking the shade membrane. If the condition is more acute then the patient should take the “powder with chan hua” (gu jing cao, ju hua, chan tui, qiang huo, gan cao, man jing zi, bai ji li, jue ming zi, fang feng, chuan xiong, zhi zi ren, mi meng hua, huang qin jing jie, mu zei) along with the “powder with mi meng hua” (mi meng hua, qiang huo, ju hua, man jing zi, qing xiang zi, mu zei, shi jue ming, bai ji li, gou qi zi).

Conjunctivitis

Some of the various types of conjunctivitis are described in the classic including purulent and epidemic kerato-conjunctivitis. In purulent conjunctivitis, a “sticky and thick slime” (pus) and tears discharge from the eyes unceasingly. This is due to heart fire over controlling the lungs causing lung depletion. One should take the “pills with steamed ai” (ai ye, bo he, dang gui, di gu pi, wa can sha, nuo mi, qin jiao, huang bai, jie geng, huang qi) to eliminate the evil heat from the lung and large intestine conduits and then supplement with the “powder with e-jiao” (e jiao, shu nian zi, gan cao, nuo mi, ma dou ling, kuan dong hua, zi wan). In epidemic kerato-conjunctivitis or “red eye” poisonous qi flows between heaven and earth and infects entire families at a time. The symptoms of swelling, pain, sandy roughness and difficulty opening the eye should all resolve within five days as it caused by the qi of one of five days period according to Chinese meteorological astrology. This is due to the influence of poisonous vapors that move around in certain times of the year and are transmitted to people. The treatment is to release the poison, clear heat and cool the blood with the “powder to cleanse the liver” (da huang, zhi zi, fang feng, bo he, chuan xiong, dang gui, qiang huo, gan cao) and “the powder to cleanse the heart.”

Paralysis

While this is really a neurological disease rather than an ophthalmological condition, the effect of the neurological lesion can show up on the face and effect the eye causing deviation of the eye described as “wind pulls eye and mouth into a slanting position” as in Bell’s Palsy or paralytic ectropion described as “wind pulls the lower lid outward.” In paralytic ectropion, the spleen and stomach receive wind and the lower lid is affected as the “muscle” or motor nerve is blocked. Tears then flow due to the earth being unable to bank the water any longer and thus water accumulates in the lower lid, which appears soggy and rotten. The patient should take the “pills to improve vision” (ren shen, chuan xiong, jing jie, bai zhi, chuan wu, nan xing, shi gao, shi jue ming, cao wu, gao ben, xiong huang, xi xin, dang gui, pu huang, cang zhu, fang feng, bo he, huo xiang, quan xie, he shou wu, qiang huo, gang song) internally and the “ointment to rub the wind away” (mu xiang, dang dui, bai zhi, fang feng, xi xin, gao ben, hei fu zi, mo yao, gu sui bu, chuan wu, chi shao, rou gui, zhu zhi, niu su, e zhi) topically on the affected side. For Bell’s palsy causing deviation of the eye and mouth, bai fu zi, tian nan xing and ban xia are added to the “pills to improve vision” and the “ointment to rub wind away” should be used on the opposite of the slanting. Moxa is also prescribed for use on the points tai yang, jia che, er men, GB 2, LI 2 and GB 20 on the non slanting side.

Contusion

This is described as “an injury caused by a blunt object” and is manifested as the eyelid turning purple or blue, pain, roughness of the eye, difficulty opening the eye. A poultice can be prepared from cong bai and ai ye or from sheng di and applied to the eye warm to disperse the blood. The patient should also internally take the “powder with mo yao” (da huang, xue jie, mo yao, pu xiao).

Trachoma

This is a chronic contagious form of conjunctivitis in which inflammation of the conjunctiva is followed by scarring that causes the cornea to become opaque resulting in blindness. This is described in the text beginning as “drooping yellow membrane” with pain, roughness, photophobia and tears. This membrane stretches out as it progresses and gradually grows large enough to cover the pupil and the entire eye may turn yellow. This is due to the liver over-controlling the spleen and should be treated with the “pills with iron dust to pacify the stomach” (cang zhu, hou po, chen pi, gan cao, zhen sha) along with the “golden flower pills with reduced ingredients” (zhi zi, huang qin, huang bai, sang bai pi, di gu pi, jie geng, zhi mu, gan cao).

Trichiasis

In this condition there is an inversion of eyelashes so that they rub against the cornea, causing a continual irritation of the eyeball. This occurs when the spleen and lung channels receive wind and heat and the skin of the lid shrinks causing the eyelashes to curl and swell due to the spleen storing excessive dampness and heat and there is pain, itching, redness, difficulty opening the eyes and photophobia. The patient should take “decoction with xi xin” (xi xin, fang feng, chong wei zi, zhi mu, da huang, jie geng, ling yang jiao, hei shen), the “potion with fang feng” (huang lian, xi xin, man jing zi, ge gen, fang feng, dang gui, gan cao, ren shen) and the “potion to eliminate dampness and suppress heat” (xi xin, cang zhu, fang feng, zhi mu, chonng wei zi, jie geng, da huang, huang qin, zhi zi ren, pu xiao).

Nyctalopia

When one’s vision gradually deteriorates toward sunset there is depletion of the kidney causing dimness of the eyes. The patient should take the “pills to supplement the kidney and have the essence return” (ren shen, bai zhu, fu ling, bai ji li, qiang huo, mu zei, ju hua, fang feng, gan cao, chuan xiong, shan yao, rou cong rong, mi meng hua, qing xiang zi, niu xi, tu si zi) along with the “pills to supplement the kidney and to clear the vision” (chuan xiong, dang gui, shu di huang, ju hua, shan yao, zhi mu, shi chang pu, huang bai, zing yan, yuan zhi, bai ji li, chuan ba ji, wu wei zi, bai shao yao, sang piao xiao, chong wei zi, tu si zi, qing xiang zi, mi meng hua, gou qi zi, rou cong rong, shi jue ming).

Pruritis

This is described as an unbearable itch due to heat in the liver and gall bladder channel with wind evil attacking and filling the eyes. The text states that itching is usually due to depletion while pain is usually due to repletion. One should rub mashed ginger onto the eyes or rinse them with a decoction of sang bai pi, fang feng, jing jie and bo he to make the tears, pain and itch subside. In addition one should apply the one “pill made from three white powders” (qiang fen, ku fan, bai peng sha) to the inner canthus.

Glaucoma

The text describes the acute form of this disease called closed angle glaucoma manifesting as “dim vision with eye pain resulting from liver wind,” which is caused by depletion of the liver and exhaustion of the kidney, insufficiency of liver qi and depletion of blood. There is pain from time to time in irregular outbreaks that feel as if the eyeball would fall out of its socket. In biomedical terms this is caused by increased intraocular pressure due to the inability of the aqueous humor to drain from the eye. The treatment described in the text involves taking the “powder to supplement the liver and to enliven the blood” (gao ben, bai zhi, shi jue ming, tian ma, fang feng, xi xin, qiang huo, huang qi, ju hua, dang gui, sheng di, huang lian), “the pills to supplement the kidney” (ze xie, xi xin, tu si zi, wu wei zi, chong wei zi, shan yao, shu di) and the “powder with bai ji li” (bai ji li, ju hua, man jing zi, jue ming zi, gan cao, lian qiao, qing xiang zi).

It is truly fascinating that so many specific ophthalmological disorders were described in such great detail with their comprehensive treatments over five hundred years ago. While many of these conditions would require emergency intervention by Western medicine, it is nonetheless very likely that a TCM practitioner practicing in the West will see some of the more minor conditions described in this text on a regular basis. Thus, it is essential to have specific formulas to treat the particular presentation.

Cofe Fiakpui is a Licensed Acupuncturist. His website is: www.ancientscienceherbs.com 

This Month's Articles

April 2004
Volume 2, Number 3

Pros and Cons  of the Ephedra Ban

Classical Chinese Ophthalmology

Recent Research

Ask The Doctor

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