Case of Conjunctivitis

Patient Information
Mr. Xian, Male/62 years old. Insurance employee.

Medical History
Denies medication and food allergies. History of hypertension and high cholesterol, currently medicated; history of nasal allergies. Bilateral cataract surgery performed in April 2021.

Present Illness
Itchy red eyes for four years.

Complains of discomfort in the eyes since returning from Malaysia in 2018, with itching, redness, and irritation. Diagnosed with eye infection by Western medicine and prescribed steroid eye drops, which provided relief. However, prolonged use of steroid eye drops led to bilateral cataracts, with surgery performed in April 2021. Despite the surgery, persistent itching and redness remained, and the patient preferred not to use steroid eye drops again. Following his wife's advice, he sought traditional Chinese medicine treatment.

August 23, 2021 - Initial Consultation
Complains of itchy eyes, non-painful, tearing, slightly dry with yellow discharge, sensitive to wind, excessive tearing, worse in the morning. Examination shows redness in the eyes. Mentally alert, speech slightly rapid and loud. Moderate build, dark complexion. Normal sleep, good appetite, no gastrointestinal symptoms, no chest discomfort, occasional headache and dizziness, easily irritable and anxious. Bowel movements once a day, loose. Normal urination. Sweats easily, heat intolerance, occasional lower back and leg soreness. Tongue dark red with ecchymosis, white greasy coating; pulse deep and string-like, slightly rapid.

Diagnosis: Conjunctivitis. Liver depression with lung heat and wind-heat syndrome. Treatment with methods to soothe the liver, clear the lungs, and dispel wind.

Treatment: Prescribe concentrated herbal powder as follows:
Yin Chaihu, Fang Feng, Bai Shao, Wumei, Wuweizi, Foshou, Sangbaipi, and Chaihu Shugan San. 5 days, one dose after breakfast and dinner.

Rationale: Cold and heat balance, dispersing and soothing allergy decoction as the main treatment principle to regulate lung qi, supplemented by Sangbaipi to clear lung heat, combined with Chaihu Shugan San and Foshou to regulate liver qi, aiming to soothe liver stagnation, dispel wind, and clear heat.

September 6, 2021 - Second Consultation (Treatment interrupted due to vaccination, resumed after completing the dose)
Symptoms improved after taking medicine, decreased redness in the eyes, but occasional itching persists. Patient deliberately reduced the use of steroid eye drops and switched to artificial tears. Also reports recent sleep disturbances and worries about business and his son's DSE exam. Other symptoms unchanged. Tongue dark red with ecchymosis, yellowish (stained) coating; pulse deep and string-like, slightly rapid. Considering two different conditions, two separate treatments are proposed:
Regimen One:
Yin Chaihu, Fang Feng, Bai Shao, Wumei, Wuweizi, Foshou, Sangbaipi, Chaihu Shugan San, and Longdan Xiegan Tang. 6 days, one dose after breakfast.

Rationale: Similar to previous treatment with an addition of Longdan Xiegan Tang to further clear liver fire. The dosage is increased from 12g to 15g per dose due to improved efficacy.

Regimen Two:
Guizhi, Shengjiang, Muli, Huangqin, Dangshen, Dazao, Chaihu, Dahuang, Longgu, Duan Cishi, Fushen, Suanzaoren (fried), and Hehuanpi. 6 days, one dose after dinner.

Rationale: Considering the patient's restless sleep, Chaihu plus Longgu and Muli Decoction with Suanzaoren and Hehuanpi are prescribed to harmonize and calm the spirit.

September 15, 2021 - Third Consultation
After medication, eye symptoms significantly improved, itching greatly reduced, redness disappeared. No longer needs steroid eye drops and can use artificial tears instead. Sleep has also improved after medication, with no relapse after discontinuing medication. However, bowel movements are not as smooth as before, requiring two separate sessions for complete evacuation. Also complains of abdominal rumbling, belching, and flatulence, seeking relief. Tongue dark red, thin white coating; pulse moist, slightly string-like. Due to the new symptoms, two separate treatments are proposed:
Regimen One:
Same as before. 6 days, one dose after breakfast.

Rationale: Same as before, to consolidate the treatment effect.

Regimen Two:
Houpo, Zhishi (fried), Foshou, Wuzhualong, and Shenlingbaizhusan. 6 days, one dose after dinner.

Rationale: Symptoms of abdominal discomfort are indicative of spleen deficiency and qi stagnation. Shenlingbaizhusan combined with the mildly warming Wuzhualong and Foshou is prescribed to strengthen the spleen and invigorate qi, supplemented with Houpo and Zhishi to resolve qi stagnation.

Pathological Summary
Conjunctivitis, commonly known as "red eye" or "pink eye," refers to redness in the white part of one or both eyes. The patient's complaints align with this condition. Conjunctivitis can manifest in various patterns, including external wind-heat, liver-gallbladder fire, hidden heat in the lungs, and internal accumulation of heat from alcohol. Additionally, there is the infectious epidemic form known as epidemic conjunctivitis. Diagnosis involves differentiating between excess and deficiency, with excess patterns manifesting acutely and deficiency patterns developing slowly. Excess patterns may further be differentiated into external wind-heat and internal injury.

Based on the theory of the Five Wheels and organ patterns: Since the white part of the eyes is associated with the lungs and the eyes are the "window of the liver," and there are no clear signs of other organ or meridian involvement, treatment should focus on the liver and lungs. Initially, the patient's condition likely stemmed from external wind-heat after returning from a tropical climate (Malaysia), but unfortunately, it was not promptly treated, resulting in a four-year course of illness. Considering the patient's history of nasal allergies, an allergic constitution is suspected. Therefore, based on the onset time and the history of nasal allergies, the prescription of Zhu She Yu's allergy decoction combined with Sangbaipi to regulate lung qi and treat wind-heat was chosen. For liver depression syndrome, Chaihu Shugan San combined with Foshou to regulate liver qi was prescribed. Originally, Longdan Xiegan Tang was considered, but due to the initial consultation, the patient's constitution was not fully understood, so Chaihu Shugan San was used as an exploratory treatment. After understanding the condition in the second consultation, Longdan Xiegan Tang was added to further clear liver fire. Now, it appears that Chaihu Shugan San can be discontinued at the second and third consultations to enhance the efficacy of the treatment.

Additionally, the insomnia and changes in bowel habits during the second and third consultations may be influenced by environmental and emotional factors, possibly as a result of medication. However, it is essential to maintain focus on the primary condition in treatment and not be led solely.