Male, age 46. Initial Visit: May 10 ^th, 2007

Chief Complaint: Red and dry right eye for two years with aggravated symptoms for three months prior to treatment.

History: The patient noticed redness and dryness in his right eye two years ago. It progressed into pterygium in the inner canthus. The symptoms were somewhat resolved afer applying chloramphenicol and ofoxacin eye drops. In the three months prior to treatment, the patient’s right eye was red, dry and painful with photophobia. The membrane of the inner canthus was red, swollen, growing very fast and atacking the pupil.

Signs and Symptoms: There was redness, dryness, pain, tearing and photophobia in the right eye. The triangular membrane was red and swollen in the inner canthus and was atacking the pupil. The patient also had a dry mouth, irritability and yellow urine. The tongue tip was red with a yellow coating. The pulse was rapid.

Past History: Generally healthy with a strong body type, non-smoker with moderate alcohol consumption.

Physical Examination: Blood pressure was 118/76 mmHg. Symmetrical chest size and clear breathing sounds in both lungs without rales. Heart rate was 90 beats/min with a normal rhythm. Flat and soft abdomen with no enlargement of the liver or spleen.

Ophthalmologic Examination: Vision: right eye 0.8, lef 1.0. Examination of the right eye showed thickness of the triangular membrane and hyperaemia in the right inner canthus. The membrane had invaded the cornea by approximately 4 mm. There was conjunctival hyperaemia (++). The cornea was still bright and clear, and the anterior chamber and pupil size were normal. There were no abnormalities detected in the inner eye and the lef eye was normal.

Laboratory Examination: Blood and urine tests, liver and kidney function and EKG were all normal.

The patient’s strong body shape indicated an excessive heat body type. The canthus is associated with the heart. In this case, heart fire became excessive and ascended to cause redness and swelling in the inner canthus and, subsequently, pterygium. Heart fire attacked the eyes and head, causing redness, dryness, pain and photophobia. Furthermore, heat injured the body fluids, causing dry mouth, irritability and yellow urine. The red tip of the tongue with a yellow coating and the patient’s rapid pulse were all signs of heart fre blazing upwards.

The origin of this disease is in the heart channel, which caused the pterygium. It is an excessive case belonging to the category of heart fre blazing upwards.

WM diagnosis: Pterygium (right eye)

TCM diagnosis: Excrescence creeping over the eye due to heart fire blazing upwards

This case was caused by heart fire blazing upwards. The main TCM treatment therefore, should, focus on clearing heat, sedating fire, cooling the blood and dissipating stasis. Local treatment should include glucocorticoid and antibiotic eye drops immediately to control the symptoms, dissipate the infammation and inhibit further progression of the disease.

Principles: Clear the heart and drain fre

Formula: Supplemented Dăo Chì Săn (Red-Guiding Powder) and Sān Huáng XièXīn Tāng (Three Yellow Heart-Draining Decoction)

[导赤散合三黄泻心汤加味]

[Formula Analysis]

Shēng dì huáng, mù tōng, dàn zhú yè and gān căo clear heat and dissipate redness.

Huáng qín, huáng lián, dà huáng, jīn yín huā and lián qiào sedate fre and dissolve toxins.

Dān pí and chì sháo cool blood and dissipate stasis.

Main points: BL 2 ( cuán zhú), tài yáng (EX-HN5), SJ 23 ( sī zhú kōng), ST 2 ( sì bái), GB 1 ( tóng zĭ liáo), GB 20 ( fēng chí)

Supplementary points: LI 4 ( hé gŭ), SJ 5 ( wài guān), LU 11 ( shào shāng)

Method: Select three local points and two distal points daily with one treatment per day. Retain needles for 30 min. 10 visits constitute one course of treatment.

Techniques: Sedation technique.

After 10 days of treatment, the symptoms of redness, dryness and pain in the right eye had noticeably reduced. Swelling and hyperaemia in the membrane of the inner canthus had also dissipated. However, the patient still complained of a slightly dry mouth. The tongue body was red with a thin yellow coating and the pulse was slightly rapid.

After the above treatment, the progression of pterygium in this case had been controlled and the symptoms had been relieved. However, symptoms of heat remained.

Formula: Modifed Dăo Chì Săn (Red-Guiding Powder)

[导赤散加减]

[Formula Analysis]

Shēng dì huáng, mù tōng, dàn zhú yè and gān căo clear heart and dissipate redness.

Mài dōng and xuán shēn nourish yin and generate fuids.

Dān pí and chì sháo cool the blood and dissipate stasis.

Jīn yín huā and lián qiào drain fre poison.