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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.
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