Male, age 12. Initial Visit: April 15 ^th, 2006

Chief Complaint: Recurrent redness of the eyes with intense itching over a course of fve years.

History: Five years ago the patient started experiencing redness in the eyes with unbearable itching and sticky secretions. His symptoms were worse during spring and summer, but relieved during autumn and winter. He was treated by various doctors and had tried Rifampicin (antibiotic), cortisone acetate and sodium cromoglicate (antihistamine) eye drops, but these had no lasting efects and the disease continued to come on go on a seasonal basis.

Signs and Symptoms: The conjunctiva was a dirty red color, with intense itching and sticky, stringy secretions. He had a sallow complexion, thin body, slightly loose stools, a light red tongue with a thin, white, slightly greasy coating, and a wiry, weak pulse.

Past History: A weak constitution and susceptibility to catching colds. The patient did not smoke or drink.

Physical Examination: Blood pressure: 116/72 mmHg, symmetrical thorax, clear breath sounds in both lungs, heart rate 80 beats/min, fat and sof abdomen, liver and spleen not palpable.

Ophthalmologic Examination: Bilateral vision 1.2. Bilateral turbid hyperemia of palpebral conjunctiva, with papillae of diferent sizes packed together forming a rough surface. Dark red bulbar conjunctiva with a jelly-like prominence at the corneal limbus, clear central cornea, normal anterior chamber and pupils. No abnormalities of the fundus.

Laboratory Examination: Routine blood and urine tests, ECG and liver function test all showed normal results. A smear of the conjunctival exudate showed eosinophils were present.

The patient historically had a weak constitution and susceptibility to catching colds. He presented with redness and intense itching of the eyes, with very sticky stringy secretions. The disease was chronic and recurrent for the last fve years. His other symptoms included: sallow complexion, thin body, light red tongue with thin, white and slightly greasy coating, and a wiry, weak pulse.

The patient’s spleen deficiency and insufficiency of qi and blood contributed to his sallow complexion and thin body. Spleen deficiency failing to effectively transport fluids resulted in pathogenic dampness brewing internally, which accumulated and atacked upward afecting the eyes, leading to the red conjunctiva, intense itching and secretions. Spleen deficiency with dampness brought about slightly loose stools, light red tongue with thin white and slightly greasy fur, thready and weak pulse.

This disease is primarily an issue of the spleen, but also involves the liver and lungs. It belongs to a patern of spleen defciency and weakness of the qi, with damp accumulation. This is a mixed case of root defciency and branch excess.

WM diagnosis: Vernal conjunctivitis

TCM diagnosis: Seasonal eye itching due to spleen deficiency and qi weakness with damp accumulation

The clinical manifestations in this case showed a root deficiency and branch excess. The treatment principle, therefore, should focus on treating the root and branch simultaneously by fortifying the spleen and boosting qi, dispelling dampness and relieving itching. In addition, anti-histamine eye drops can be used to stop itching and prevent this disease from recurring.

Principles: Fortify the spleen and boost qi, dispel dampness and relieve itching

Formula: Modifed Bŭ Zhōng Yì Qì Tāng (Center-Supplementing and Qi-Boosting Decoction)

[补中益气汤]

[Formula Analysis]

Dăng shēn, bái zhú and huáng qí fortify the spleen and boost qi.

Dāng guī regulates the liver and nourishes the blood.

Chái hú and shēng má raise the clear yang.

Chén pí and gān căo rectify qi and harmonize the center.

Kŭ shēn, shé chuáng zĭ, bái xiān pí and dì fū zĭ dispel dampness and relieve itching.

Local points: ST 1 ( chéng qì), BL 2 ( cuán zhú), SJ 23 (sī zhú kōng), EX-HN5 ( tài yáng), GB 20 ( fēng chí),

Supplementary points: LI 4 ( hé gŭ), SJ 5 ( wài guān), ST 36 ( zú sān lĭ), SP 6 ( sān yīnjiāo)

Manipulation: Choose 3 local points and 2 supplementary points each time. Needle all points with even technique. Retain the needles for 30 min, once daily. Ten days constitute one course of treatment.

After 20 days of treatment, the patient’s itching was significantly relieved with decreased secretions in his eyes. The redness in the eyes subsided. But he still had a sallow complexion, thin body, light red tongue with thin white and slightly greasy fur, and a wiry, weak pulse.

After treatment, his symptoms were alleviated, meaning that branch excess symptoms were relieved, but, while the spleen deficiency was improved, the defciency of qi and blood and pathogenic dampness still remained.

Principles: Supplement and nourish qi and blood, dispel dampness.

Formula: Bā Zhēn Tāng (Eight Gem Decoction)

[八珍汤]

[Formula Analysis]

Dăng shēn, bái zhú, fú líng and gān căo supplement and fortify the spleen and boost qi.

Dāng guī, bái sháo and chuān xiōng regulate the liver and nourish the blood.

Chén pí rectifes qi and harmonizes the center.

Kŭ shēn and shé chuáng zĭ dispel dampness and stop itching.