Eye Swelling and Pain: A Chinese Herbal Case Study by Brian B. Carter

30 year old female presents with upper and lower eyelid swelling on the right side. This is an occasional symptom in the last 6 months. Normally, only her upper eyelid swells. The swelling is worse in the morning, better after standing for a while, and there is a sharp shooting pain when she moves her eye (looks around).

Her eye was checked by an MD, who said it was ok, but there was some nystagmus. Cognitive abilities are ok and there is no dizziness or vertigo. She also has dry mouth, and stool that breaks up. She just finished her period, which was scant and dark, and during which she feel a dull, distending, downbearing pain. She also had a new facial rash which was red and not swollen.

Pulse and Tongue

The pulse was slightly rapid. Both proximal positions were deficiency and the left was floating and thready. The right middle position was soft. The pulse may have been choppy, but I cannot yet confidently identify that quality. The tongue was swollen, tremulous, and dusky with a thin white coating.

Past History

The patient has lupus. My wife and I have treated her off and on through the PCOM clinic for 11 months. Normally she feels best at the beginning of her cycle; this time she felt she had gotten no relief from her period. Her baseline diagnosis has been Spleen deficiency damp and Liver qi stagnation heat, both of which combine at times into damp-heat skin rashes.

Discussion and Diagnosis

• The swelling could be due to dampness, heat, and/or stagnated blood.
• Symptoms worse in the AM can be due to yang deficiency. On the other hand, fluids may collect in the head at night and move elsewhere after standing due to the effects of gravity. Regardless, there is fluid and/or blood outside of its normal pathways.
• Sharp, shooting pain indicates blood stagnation.
• Pain that is worse with movement is usually due to deficiency.
• Nystagmus is a jerky movement typical of CNS problems. There is no corroborating evidence of CNS dysfunction. Perhaps minor nystagmus can be an expression of qi stagnation. It is possible that since the eye muscles have been deprived of nourishment (blood), the qi stagnated, leading to a movement dysfunction.
• Dry mouth indicates heat, and stool that breaks up is either Spleen deficiency or dryness (heat).
• The period appears to have been incomplete. The dark scanty blood indicates blood stagnation.
• The dull, distending, downbearing pain is qi stagnation and/or Spleen qi sinking. However, if Spleen qi were sinking, you would expect more - not less - bleeding during the period. Perhaps the downbearing was the normal movement of the qi, but the blood stagnation obstructed the blood flow. But then you would expect sharp pain- not dull. Since the Liver blood stagnation has manifested in the upper jiao (eyes), perhaps the stagnant blood did not reach the lower jiao in sufficient quantity to cause all the typical blood stagnation symptoms.

In the past I have treated her successfully for painless upper eyelid swelling with a diagnosis of Spleen deficiency damp. This time, however, there was clear evidence of Liver blood stagnation.

The diagnosis was Liver blood stagnation heat, and the case corresponded to the Chinese Medical diagnoses swollen eyelids (mu bao zhong zhang) and distention in the eyes (mu zhang) [I couldn't find an 'eye pain' disease]. The breaking up stool was qi deficiency and blood stagnation heat drying the fluids. Associated constitutional diagnosis included Spleen deficiency and Liver qi stagnation.

Treatment

The treatment was herbs only. Since I could not find a reference text that included Liver blood stagnation within the scope of my disease diagnoses, I had to get creative. Besides relieving the blood stagnation in the eyes, I wanted to use herbs that addressed menstruation, since that was part of the etiology. I also included herbs that treated the skin rash.

The prescription was Tao Ren 9g, Hong Hua 9g, Chi Shao 6g, Ze Lan 6g, Dang Gui 9g, Bai Zhu 12g, Cang Zhu 3g, Dang Shen 15g, Gan Cao 3g, Huang Qin 9g, Zhi Zi 6g, Qing Pi 3g, Yan Hu Suo 6g, Xiang Fu 6g

Discussion of Formula

• Blood moving herbs: Tao Ren moistens the intestines. Hong Hua relieves rashes. Chi Shao clears heat and cools the blood, and clears Liver fire from the eyes (although this was not the pattern responsible for the eye problem, it does demonstrate that the herb has an affinity for the eyes, so I expected it to be something of a medicine horse. Plus, there was some heat from the blood stagnation which it would clear.) Ze Lan unblocks the menses (the etiology of eye problem was blood stagnation from incomplete menstruation). Dang Gui can tonify and move the blood (she has a history of blood deficiency too), and moistens the intestines. Yan Hu Suo relieves pain and is specific for menstrual problems.
• Blood tonifying herbs: Ye Jiao Teng was used to nourish the blood, calm the shen, and it also relieves rashes. (see Dang Gui above)
• Spleen tonifying herbs: Bai Zhu, Dang Shen, and Cang Zhu tonify the Spleen and dry dampness (I wanted to protect the Spleen, plus Cang Zhu treats night-blindness and so was also used as a medicine horse).
• Heat clearing herbs: Huang Qin clears heat from the upper jiao and Liver and descends Liver yang (can clear the excess yang from the Liver, including the eyes) [In retrospect, Mu Dan Pi might have been better than Huang Qin]. Zhi Zi clears heat from all 3 jiaos, cools the blood, and treats hot and blood stagnation rashes.
• Qi moving herbs: Xiang Fu moves the Liver qi, regulates menstruation, and relieves pain.

Result

The patient reported significant improvement after the first dose, and the swelling and pain were gone by the next day.

The patient has since used the formula on an as-needed basis. However, for that use she probably needs a formula that focuses a bit more on the Spleen, dampness, and fluid metabolism. This formula was heavy on the blood movers, and meant to be used for this acute blood stagnation problem. She could continue to use it if the eye swelling and pain manifests after her period, but would need another formula for use mid and late cycle.