Traditional Chinese Medicine in Dry Eye Syndrome (TCM Treatment Dry Eyes)
In recent years, the prevalence of dry eye has been on the rise due to the aging global population, and increased usage of medication and environmental irritants.
The development of dry eye treatments has been hampered by a limited understanding of the underlying pathophysiological processes. Current available Western treatments for dry eye include artificial eye drops, artificial tear ointment, vitamin A ointment, special eyewear, anti-autoimmune drugs, and lacrimal punctal occlusion. However, these treatments have limited effects.
Based on clinical research trial data from recent years, strong evidence suggests that Traditional Chinese Medicine (TCM) would provide an alternative treatment modality for the patients with dry eye syndrome . In addition, TCM has its advantages over the standard western clinical measurements when comparing the treatments.
Clinical trial data strongly suggest that TCM provides an alternative mode of treatment that is safer, more economical, and provides longer lasting effects.
In this chapter, we aim to explore common TCM treatment for dry eyes, comprising herbal medicine, acupuncture or a combination of both methods.
Dry eye syndrome is a lacrimal film abnormality caused by decreased lacrimal secretions, or hyperactive lacrimal evaporation. The condition is presented with symptoms of discomfort in the eye which may accompany ocular surface diseases. Patients with isolated symptoms of dry eyes may recover with rest or short-term use of artificial tears. If there are no ocular surface damage and/or any other local or systemic causes present, it is termed ‘simple dry eye’. Patients with both symptoms and clinical signs of dry eyes are termed patient’s with ‘dry eye syndrome’.
The increased usage of the computer and other IT gadgets in modern lifestyle, has also gradually increased the occurrence of dry eyes. Dry eye disease affects millions of people around the world with prevalence rates estimated to be as high as 35% in the general population.
Traditional Chinese Medicine
There are various modalities of treatment in TCM, which include acupuncture, herbal remedies, massage (tui na 推拿), cupping, moxibustion, ear acupuncture and scraping (guasha 刮痧). The most commonly employed methods today are acupuncture, herbal remedies and massage. Acupuncture is the insertion of needles into the skin or even the tongues and mucosal layer, based on the system of meridians and its connectivity to the various organs deep in the human body. Herbal remedies are usually prescribed in the form of decoctions. However, other forms such as pills, pastes and baths are also available. The principle of all modalities of treatment would be to eliminate pathogenic forces, while restoring the body’s balance and strengthening it.
In Chinese medicine, the disease pertains to bai se zheng (白涩症，white dry eyes), or shen shui jiang ku (神水将枯，impending desiccation of spirit water), belonging to the category of zao zheng (燥症，dryness pattern).5 The causes are mostly attributed to lung yin insufficiency or liver and kidney yin deficiency, which lead to nutritional deficiency of the eyes.
2. Clinical Manifestation of Dry Eye Syndrome
Clinical signs of dry eye include vasodilatation, oedema, folding of bulbar conjunctiva, shortened tear meniscus height, occasional mucopurulent discharge in the lower fornix, and punctuate staining in the corneal epithelium. Some patients may also complain about blurring of vision. When dry eye syndrome is suspected, relevant objective tests will be considered. Such as Schirmer’s test and tear break up time (TBUT) test. If left untreated, dry eye syndrome may lead to eye inflammation, corneal ulcers and possible infections..
3. Types of pattern for dry eyes according to TCM
In most patients presenting with dry eyes, their disease condition could be attributed to one or a combination of five main categories of ‘pattern deviation’. These disease patterns are identified as pathologies stemming from the ‘organs’, or the root of the disease, and usually present overlapping symptoms apart from dry eye. These patterns include insufficiency of lung yin, insufficiency of liver and kidney yin, and dry eye initiated by heat in various organs. These will be described in the sections below:
1. Insufficiency of Lung Yin
Patients in this category often present with the following characteristics: Dry eyes that result in inability to see clearly over a long period, mild conjunctival hyperemia, point lesions of the superficial corneal layer, relapses with poor recovery, dry cough with little phlegm, dry pharynx, constipation, reddish tongue with dry mouth and a thready rapid pulse.
The treatment in this case is to enrich yin and moisten the lung meridian. A representative formula is the Yang Yin Qing Fei Tang (Yin-Nourishing Lung-Clearing Decoction, 养阴清肺汤).7 Refer to Table 1 for the prescription. Please note that this prescription is often modified in 3 scenarios:
For cases with pronounced dry throat and mouth, add bei sha shen (北沙参，Radix Glehniae) , Shi Hu (石斛，Caulis Dendrobii) to boost the qi and nourish the yin.
For cases with constipation, add jue ming zi (决明子，Semen Cassiae) to moisten the intestines and allow the stool to move down the rectum
For cases with point lesions of the cornea, add chan tui (蝉蜕，Periostracum Cicadue) 6g, ju hua (菊花， Flos Chrysanthemi)12g, mi meng hua (密蒙花，Flos Buddlejae)10g to clear the heat, and brighten the eyes
2. Liver and Kidney Yin Deficiency
In this syndrome, dry eye is accompanied with symptoms of discomfort, photophobia, symptoms increased after prolonged use, dry mouth with scant saliva, lumbago, weak and/or painful knees, dizziness, tinnitus, insomnia with profuse dreams, red tongue with thin coating and a thready pulse.
For cases with dry mouth, with scanty saliva, add mai dong (麦冬，Radix Ophiopogonis) 10g, xuan shen (玄参，Radix Seroophulariae) 10g to nourish the yin and engender the fluid.
For cases with obvious conjunctival hyperaemia, add sang bai pi (桑白皮，Cortex Mori) 9g, di gu pi (地骨皮，Cortex Lycii) 10g to clear the heat and reduce
3. Dry eye initiated by wind and heat
This type of dry eye is caused by wind and heat, including xerosis conjunctiva, fulminant red eye and conjunctival oedema. The principle of treatment is to ‘scatter’ the wind and clear the heat. The representative formula is Sang Ju Yin桑菊饮, or Mulberry Leaf and Chrysanthemum Beverage.
4.Dry eye initiated by heart–heat
This is dry eye initiated by overwork from prolonged use of computers, insufficient sleep or stress-induced insomnia, and usually presents with photophobia, eye strain, eye sore or pain, with red tongue tip and rapid pulse. In this scenario, the treatment principle is to clear the heart-heat from the heart meridian by promoting urination. A representative formulation to address this is Dao Chi San 导赤散
5.Dry eye initiated by liver – heat
Heat can also be initiated by the liver. In this syndrome, dry eye is initiated by prolonged visual tasks, and the patients in this category are stressed and easily agitated or frustrated with dry eye and headache. He also suffers from pain in the side abdomens at times, has red tongue with white coat and a rapid thready pulse.
Here, the physician aims to clear the liver heat and dampness from the lower part of the body meridians. A formulation such as Long Dan 龙胆草
4. Acupuncture Treatment (TCM dry eyes)
The history of using acupuncture treatment for dry eye dates back to Ancient Time Northern and Southern Dynasties (581A.D). The Yellow Emperor’s Inner Classic (Huang Di Nei Jing, 黄帝内经) had records of the anatomy and physiology of the eyes, as well as the etiology, pathology, clinical manifestation, and acupuncture strategies for eye disorders. More than 30 eye diseases were recorded in this book. In each typical treatment session, 4-6 acupoints were selected, needles were retained for 20-30 minutes, and treatment was performed once a day. Ten acupuncture sessions constitute one course of treatment. Most studies conducted previously did not have proper control groups.
5. Chinese Patent Medicines
In western or clinical medicine, patients with dry eye may be given lubricants such as 1% sodium hyaluronate or carboxymethylcellulose eye drops for daily use. Patients with more severe or uncontrolled symptoms, may seek advice or treatment from an Ophthalmologist, who may initiate immunosuppressive, anti-inflammatory treatment, or punctal occlusion methods.
In contrast, TCM treatment for dry eyes advocates the use of simple remedies comprising core herbs such asju hua (菊花，Flos Chrysanthemi), mai dong（麦冬，Radix Ophiopogonis）, gou qi zi (构杞子，Fructus Lycii), mu hu die (木蝴蝶，Semen Oroxyli) which possess yin-nourishing properties. Depending on the condition and constitution of the patients, a selection of herbs are added (10g each) into a prescription and wrapped as a tea drink. Alternatively, they are brewed in a teapot with boiling water, and consumed 6-9 times in small amounts daily.
Chinese physicians may choose one of these more standard therapies:
- (1) Qi Ju Di Huang Wan (Lycium Berry, Chrysanthemum and Rehmannia Pill, 杞菊地黄丸) 6 pills, twice daily; applicable to liver-kidney yin deficiency
- (2) Zhi Bai Di Huang Wan (Lycium Berry, Chrysanthemum and Redmannia Pill 知柏地黄丸) 6 pills, twice daily; applicable to liver-kidney yin defiency or effulgent yin-deficiency
- Yang Yin Qing Fei Kou Fu Ye (Yin-Nourishing Lung-Clearing Oral Liquid 养阴清肺口服液)10ml, twice daily, applicable to insufficiency of lung yin deficiency
6. Clinical Trial TCM dry eyes
Sometimes, TCM dry eye physicians employ a mixture of acupuncture and oral therapies. Recently, randomized controlled studies have been published, with data that suggests TCM is useful in improving the disease condition. In a randomized placebo-controlled study, the group that received Chi-Ju-Di-Huang-Wan medication had a significant improvement in the Rose-Bengal staining and TBUT compared to the placebo group at 2 and 4 weeks respectively. A Korean study showed that TBUT in the acupuncture group had improved (p not statistically significant) after 3 weeks. Finally, in one meta-analysis of 6 randomized controlled trials, the researchers found that acupuncture significantly improved TBUT, Schirmer test and corneal fluorescein staining.
We have recently conducted clinical research involving qi ju gan lu yin and qi ju gan lu yin with acupuncture on the treatment of lung and kidney yin deficiency type of dry eye. In the study, we aimed to evaluate the efficacy of TCM herbal medicine “qi ju gan lu yin” in treating dry eye, compared to the same“qi ju gan lu yin with acupuncture” and a total of 89 age- and gender-matched subjects were recruited. This included 44 in Group 1, the TCM Herbal Medicine Group, and 45 in Group 2, the TCM Combined Methods Group. All participants had dry eyes as their main complaint and were aged 40-70 years old. All subjects had good general health, no ocular disease, non-smoking and were non-contact lens wearers. The inclusion criteria of dry eye subjects were a positive score in the SPEED Questionnaire (Standard Patient Evaluation for Eye Dryness Questionnaire). The study group (Group 1, TCM Herbal Medicine Group) of 44 patients were given qi ju gan lu yin orally and the control group (Group 2, TCM Combined Methods Group) of 45 patients were given qi ju gan lu yin combined with acupuncture twice a week.
The findings demonstrate the effects of TCM on dry eye patients in Singapore. In this study, acupuncture does not demonstrate any additional therapeutic effect over and above herbal medication alone. In fact, for TBUT, Group 1 (TCM Herbal Medicine alone) it has in fact shown a better result compared to combined TCM methods. The resultant findings suggest that TCM herbal medicine may be used as an alternative medicine to treat dry eyes in Singapore.
7. General Conclusions: TCM dry eyes
A previous study in Singapore has evaluated the knowledge, attitude and practice of TCM practitioners in treatment of dry eye. This study shows that registered Chinese physicians were keen to participate in the treatment of dry eye, at least in institutional practices. Use of combined modalities of TCM may not necessarily be advantageous over a single modality, although the specific nature of the modality used may determine the outcome.
In Asian countries, the use of TCM is widespread and prevalent.
TCM looks at not only the symptoms, but also its root cause. In order to resolve the issue, practitioners work with patients to change their lifestyle habits and prescribe medication.
Due to recent studies, Western healthcare workers are recognising the importance of treating dry eye through a holistic approach and are willing to provide coordinated care for patients. We eagerly await the outcome of the major trials being conducted in this area