Glaucoma

=Glaucoma (Qing Feng Nei Zhang)= Means “Blue-green Wind internal obstruction” A group of diseases characterized by damage to the optic nerve, usually associated with an increase in intraocular pressure, that result in loss of vision (beginning at the periphery) and, if untreated, blindness.

Angle closure glaucoma--Bi Jiao Qing Guang Yan Open angle glaucoma--Kai Jiao Qing Guang Yan

Eye Symptoms That Should Always Be Taken Seriously
-Blurred vision: This is quite a common symptom, but it is potentially serious and may need urgent attention, especially when it gets steadily worse or occurs in one eye only. Blurred vision accompanied by pain is another warning of serious pathology. If blurred vision suddenly recovers and the patient is healthy, then it is reasonable to wait while treating according to TCM principles.

[[image:eye_-_flow_of_aqueous_humor.png width="295" height="223" align="right" caption="flow of aqeuous humor"]]
-Pain: Visual disturbance accompanied by pain is always serious and urgent referral is necessary. -Double vision (Diplopia): There are several causes of double vision including injury and inter-cerebral disease. It is important to check if the disorder is in fact double vision (where two separate objects are distinctly seen) or just blurring. -Redness: Visual disturbance with redness of the eye(s) needs urgent assessment by an ophthalmologist unless it resolves spontaneously over a few days. The severity of the redness is no guide to the severity of the underlying disorder. Serious diseases like glaucoma (see below) and iritis (inflammation of the iris) may present with redness, as may herpes zoster affecting the eye area, and corneal lesions. In the case of iritis and corneal lesions there will be more redness around the cornea. -Floaters, spots etc.: Floaters are not considered to be of much significance in Western medicine. They must be differentiated from the occurrence of a solitary area or areas of blurring that do not float but move with the eye. These may be progressive and may indicate retinal disease or a neurological condition. A sudden change in visual acuity or visual field may indicate a detached retina, especially if the spots are associated with seeing sparks or stars. This is a potentially serious threat to sight.

Types of Glaucoma
-Angle-closure -Open-angle -Low tension -May be caused by a variety of medical conditions, medications, physical injuries, and eye abnormalities or deformities. Infrequently eye surgery can be associated with secondary glaucoma. Occurring in babies and young children, it is usually diagnosed within the first year of life. This is a rare condition that may be inherited, caused by incorrect development of the eye’s drainage system before birth. This leads to increased intraocular pressure, which in turn damages the optic nerve.
 * Primary, secondary, congenital**
 * Secondary Glaucoma**
 * Congenital Glaucoma**

[[image:angle_closure_glaucoma.png width="203" height="216" align="right" caption="angle closure glaucoma"]]Angle-closure Glaucoma
Can be chronic or acute. Occurs when the drainage angle formed by the cornea and the iris narrows or becomes blocked. As this angle narrows, the iris gets closer to the trabecular meshwork. If it gets too close, the aqueous humor can't exit through the trabecular meshwork, resulting in a buildup of fluid and an increase in eye pressure. Develops suddenly when the iris is forced up against the trabecular meshwork and completely blocks the drainage of the aqueous humor, causing a rapid rise in introcular pressure Permanent vision loss can occur within a day of the attack, so it requires immediate medical attention Attacks often happen in the evening or in a darkened room when the light is dim and your pupils have become relatively dilated -Unilateral blurred vision -Halos around lights -Red and/or swollen eye -Severe eye pain and/or headache -Nausea and vomiting and/or GI pain -IOP >40 mm Hg
 * Acute Angle-closure Glaucoma**
 * Signs and Symptoms**

Biomedical Tx for Angle-closure Glaucoma
-Miotics (e.g., Pilocarpine) -β-adrenergic blockers (e.g., Timoptic, Betoptic, Betinol, Carteolol) -α-adrenergic agonists (e.g., Iopidine, Propine, Alphagan) -Carbonic anhydrase inhibitor (e.g., Trusopt, Azopt, Diamox) -Hyperosmotic agents (e.g., Mannitol) -Prostaglandin analogs (e.g., Xalatan) -Laser or surgical iridectomy -Asians are more prone to develop angle-closure glaucoma. -Inuit peoples have a twenty to forty times higher risk than Caucasians of developing primary angle closure glaucoma. -Women are three times more likely than men to develop acute angle-closure glaucoma due to their shallower anterior chambers. -There is a tendency for this disease to be inherited, and often several members of a family will be afflicted.
 * Risk Factors**

[[image:open_angled_glaucoma.png width="223" height="235" align="right" caption="Open angled glaucoma"]]Open-angle Glaucoma
The drainage angle formed by the cornea and the iris remains open, but the aqueous humor drains too slowly. This leads to fluid backup and a gradual increase in intraocular pressure, which damages the optic nerve. Damage to the optic nerve is slow and painless. Can progress with few or no symptoms until the condition reaches an advanced stage.

-Loss of peripheral vision happens first -Left untreated, progresses to tunnel vision and eventually blindness -Usually affects both eyes, although at first may have vision loss in just one eye -IOP>21mm Hg
 * Signs and Symptoms**

Tx for Open-angle Glaucoma
-Miotics (e.g., Pilocarpine) -β-adrenergic blockers (e.g., Timoptic, Betoptic, Betinol, Carteolol) -α-adrenergic agonists (e.g., Iopidine, Propine, Alphagan) -Carbonic anhydrase inhibitor (e.g., Trusopt, Azopt) -Systemic Carbonic anhydrase inhibitor (e.g., Diamox) -Prostaglandin analogs (e.g., Xalatan) -Argon laser trabeculoplasty -Glaucoma surgery -Diabetics and those of African descent are three times more likely to develop primary open angle glaucoma -Approximately one percent of all Americans have this form of glaucoma, making it the most common form of glaucoma in our country. -It occurs mainly in those over 50 y.o.
 * Risk Factors**

Low Tension Glaucoma
Intraocular pressure remains within the normal range, but the optic nerve is damaged nevertheless Some experts believe that people with low-tension glaucoma may have an abnormally sensitive optic nerve or a reduced blood supply to the optic nerve caused by atherosclerosis. Under these circumstances even normal pressure on the optic nerve seems to be enough to cause damage.

Glaucoma TCM Etiology and Pathomechanisms
1) Five excessive emotions convert into internal Fire → Liver-Wind stirred up by excessive Heat → Wind-Fire attacking eyes 2) Liver Qi stagnation transforms into Fire → rebellion of stagnated Qi and Fire → scorching of body fluids → transformation into Heat-Phlegm Internal injury due to overstrain or poor diet→dysfunction of the Spleen → hyperactive Liver Qi attacks Spleen → stagnation of Phlegm → transform into Phlegm-Fire
 * Emotional imbalance:**


 * Internal injury due to aging, congenital weakness of Liver and Kidney (Blood and Essence), or enduring illness** → deficiency of Kidney and Liver Yin → hyperactivity of Liver yang→ Liver-Wind → rebellion of Liver Yang and Wind


 * Pathogenic factors (Wind Fire, Phlegm Fire, Stagnated Qi generating LV Fire, Hyperactive LV Yang) block the LV channel** ->stagnation of Qi and Blood in eyes -> stagnation of fluids -> glaucoma

Liver and Gallbladder Heat Causing Upward Flaring of Wind-Fire
Lu Feng Ling Yan Yin: [Ling Yan Jiao, Huang Qin, Xuan Shen, Zhi Mu, Da Huang, Che Qian Zi, Fu Ling, Fang Feng, Jie Geng, Xi Xin] Ling Yang Gou Teng Tang: [Ling Yang Jiao, Gou Teng, Sang Ye, Ju Hua, Sheng Di Huang, Bai Shao Yao, Chuan Bei Mu, Zhu Ru, Fu Ling, Gan Cao] Extinguishes internal Wind
 * Main Symptoms:** unilateral blurred vision, halos around lights, possibly even blindness, red and/or swollen eye, severe eye pain and/or headache, nausea and vomiting and/or GI pain
 * Signs:** acute increase in intraocular pressure, corneal edema, mydriasis, greenish-blue pupil margin
 * Symptoms specific to Liver and Gallbladder Heat:** nausea and vomiting and/or GI pain, constipation, dark yellow urine, red tongue with yellow coating, wiry and rapid pulse
 * Treatment Principles:** Clear Liver and Gallbladder Heat,extinguish internal Wind, and improve vision
 * Herbal Treatment:** Lu Feng Ling Yan Yin + Ling Yang Gou Teng Tang

Upward Flaring of Phlegm-Fire
[Huang Lian, Huang Qin, Huang Bai, Da Huang, Ling Yang Jiao, Jiang Can, Bai Shao Yao, Yu Jin, Bai Fu Zi, Zhu Ru, Bai Mao Gen]
 * Main Symptoms:** unilateral blurred vision, halos around lights, possibly even blindness, red and/or swollen eye, severe eye pain and/or headache, nausea and vomiting and/or GI pain
 * Signs:** acute increase in intraocular pressure, corneal edema, mydriasis, greenish-blue pupil margin
 * Symptoms Specific to Phlegm-Fire:** fever or heat effusion, red face, vertigo, nausea, vomiting, constipation, dark yellow urine, red tongue with yellow, greasy coating, wiry, slippery and rapid pulse
 * Treatment Principles:** Clear Heat and transform Phlegm, extinguish internal Wind and improve vision
 * Herbal Treatment:** Mao Gen Zhu Li Tang

Liver Depression, Qi stagnation generating Liver Fire
[Chai Hu, Dang Gui, Bai Shao Yao, Bai Zhu, Fu Ling, Gan Cao, Sheng Jiang, Bo He] + Mu Dan Pi, Zhi Zi, Zuo Jin Wan, Huang Lian, Wu Zhu Yu
 * Main Symptoms:** unilateral blurred vision, halos around lights, possibly even blindness, red and/or swollen eye, severe eye pain and/or headache, nausea and vomiting and/or GI pain
 * Signs:** acute increase in intraocular pressure, corneal edema, mydriasis, greenish-blue pupil margin (similar to previous two patterns only less severe)
 * Symptoms specific to Liver Depression, Qi stagnation generating Liver Fire:** anger, irritability, depression, chest tightness or rib side pain or distention, belching, poor appetite, nausea, vomiting, bitter taste in the mouth, red tongue with yellow coating, wiry, rapid, and slippery pulse
 * Treatment Principles:**Course the Liver, rectify the Qi, clear Heat and resolve depression, downbear counter flow Qi and harmonize the Stomach
 * Herbal Treatment:** Dan Zhi Xiao Yao San

Liver/Kidney Yin vacuity with Hyperactivity of Liver Yang
Note: this pattern is commonly associated with chronic glaucoma (either angle closure or open angle) Zhi ai Di Huang Wan: [Shu Di Huang, Shan Zhu Yu, Shan Yao, Ze Xie, Mu Dan Pi, Fu Ling, Zhi Mu, Huang Bai] E Jiao Ji Zi Huang Tang: [E Jiao, Ji Zi Huang, Sheng di Huang, Bai Shao Yao, Gan Cao, Gou Teng, Shi Jue Ming, Mu Li, Fu Shen, Luo Shi Teng] OR Qi Ju Di Huang Wan: [Shu Di Huang, Shan Zhu Yu, Shan Yao, Ze Xie, Mu Dan Pi, Fu Ling, Gou Qi Zi, Ju Hua]
 * Main Symptoms:** unilateral or bilateral blurred vision, halos around lights, possibly even blindness, red eyes, possible eye pain and/or headache
 * Symptoms Specific to Hyperactivity of Liver Yang (Hyperactive Liver Yang with Liver/Kidney Yin vacuity):** irritability and insomnia, dry mouth and throat, 5 center heat, malar flush, night sweats, dizziness, tinnitus, red tongue with scanty coating, wiry, thin and rapid pulse, or thin and rapid pulse
 * Treatment Principles:** Calm the Liver and extinguish Wind, supplement Yin and clear Heat
 * Herbal Treatment:** Zhi Bai Di Huang Wan +E Jiao Ji Zi Huang Tang OR Qi Ju Di Huang Wan

Tx of Glaucoma with Acupuncture and Moxibustion
Modification Based on Pattern:
 * Primary Points:** BL 1, GB 20, Tai Yang, Yin Tang, GV 14, ST 8, LV 2, GB 37, LV 3
 * Wind-Fire** – BL 18, BL 19, LV 2, GB 34, GB 43, GB 1, GB 14, GB 16, BL 2, LU 7, GV 20, GB 39, Er Jian
 * Wind-Phlegm-Fire** – BL 20, Si Shen Cong, ST 40, PC 6, CV 12, ST 36, SP 6
 * Qi Stagnation Generating Fire** – BL 17, BL18, BL 19, 4 Gates, CV 17, BL 10, LV 14, ST 2, CV 12
 * LV/KI Yin vacuity with hyperactive Liver Yang** – BL 18, BL 23, KI 3, KI 6, SP 6, LV 2, GB 34
 * To Move Blood:** BL 15, BL 17, SP 10, LV 8, SP 6

ACT lists the following as points for treating glaucoma: Note: there are no intraorbital points listed
 * Primary Points:**GB 20, BL 2, GB1, LI 4, LV 3, KI 3, SP 6, BL 18
 * Secondary Points:** BL 62, BL 63, LV 2, ST 36

Primary Points: Liver, Eye, Lower Blood Pressure Groove (prick and bleed) Secondary Points: Vision #1, Vision #2
 * Auricular Points:**

Supplements for Glaucoma
Forskolin (from Coleus Forskohlii): in eydrop form; not currently available in the U.S. Gingko biloba extract (24% ginkgo flavonglycosides): 40-80 mg tid Alpha Lipoic Acid: 150 mg qd Magnesium: 200-600 mg qd Melatonin: <1 mg qd Omega-3 Fatty Acids: 1,000 mg qd Vitamin C: minimum of 2,000 mg qd Bilberry extract (25% anthocyandidin content): 80 mg tid Sorry, dude: it would take the equivalent of smoking 8-10 large joints a day to have an appreciable effect on IOP. While it can reduce intraocular pressure, marijuana also can constrict blood supply to the optic nerve, exacerbating vision problems. Couple that with the increased risk of asthma, emphysema, lung cancer and it’s clear marijuana is not a viable tx for glaucoma.
 * Marijuana: Tx for Glaucoma?**

Herbs For Eye Disorders
Bai Ji Li Bo He Chan Tui Chi Shao Che Qian Cao/Zi Chi Shao Chong Wei Zi Ci Shi Da Huang Gou Qi Zi Gu Jing Cao Hei Zhi Ma Jiang Can Ju Hua Jue Ming Zi Ling Yang Jiao Man Jing Zi Mu Zei Nu Zhen Zi Sang Shen Zi Sang Ye Shi Jue Ming Zhen Zhu Mu Xia Ku Cao

Andy Rosenfarb, L.Ac. specializes in the treatment of eye disorders using a new procedure called Micro AcupunctureTM that involves the use of 48 newly discovered acupuncture points located only on the hands and feet, and not associated with any other acupuncture system. His website is: http://www.acupuncturehealth.net/index.html

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Phytotherapeutic Recommendations
-Vinca Minor (Periwinkle) -Ginkgo Biloba

Orthomolecular Treatment
-Alpha-lipoic Acid

Ayurvedic Recommendations
Coleus Forskohlii

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IBIS

Definition:
A problem of gradually increasing intraocular pressure causing at first a slow loss of peripheral vision, but leading to late loss of central vision and complete blindness if uncontrolled.

Etiology:
This is the most common type of glaucoma, usually seen in patients over 30, though it may develop in childhood. It is usually familial and affects both eyes.

The reason glaucoma develops is unknown, although the physiology is recognized. There is in imbalance between the production and drainage of the aqueous humor, usually due to an obstruction of outflow, although in chronic open angle there is usually no clear reason for this to occur, as the anterior chamber appears anatomically normal.

Glaucoma is the second leading cause of blindness in the U.S. Approximately 1 in 50 people over the age of 35 have the disorder, and it is estimated that about 1 million more people have it and do not know it.

Somatic Therapies:
• aerobic exercise program: has been shown to decrease intraocular pressure

Nutrition:
eating principles: » chronic: • elimination/rotation diet, rotation diet, rotation diet expanded

therapeutic foods: • chrysanthemum tea, mint, oyster shell powder, mulberries, black sesame seeds, lycium fruit, grapefruit, lemons, oranges, carrots, beets, beet tops (Ni, p. 129) • foods that soothe the Liver • increase Vitamin C, rutin, Vitamin A, Choline foods (Airola, p 95)

fresh juices: • carrot (Walker, p. 136) • carrot and spinach (Walker, p. 136) • carrot, beet, and cucumber (Walker, p. 136) • carrot, celery, endive, and parsley (Walker, p. 136) • lemon, grapefruit, carrot, red beet, and beet top juices (Airola, p. 96)

specific remedies: • tea from mulberries, oyster shell, and black sesame, three times daily (Ni, p. 129) • tea from chrysanthemum and mint, twice daily (Ni, p. 129)

avoid: • food intolerances • alcohol, stimulating foods, drugs, coffee, salt

Botanicals
• Physostigma venenosum (toxic): see Ellingwood, pp. 187-189 • Pilocarpus jaborandi (toxic): see Ellingwood, pp. 462-467

Chinese Formulae
• Huang Lian Yang Gan Wan (patent): Liver Yang Rising. (Zhu, p. 178) • Gardenia and Vitex C.: Liver Fire Blazing Upward: strong constitution: pain, inflammation (Hsu, 1980, p. 599; Dharmananda, 1986, p. 227) • Lycium, Chrysanthemum and Rehmannia F. (Qi Ju Di Huang Wan); Shi Hu Ye Guang Wan (patent): Liver Yin Xu (Deficiency) with Kidney Yin Xu (Deficiency) (Lycium: Hsu, 1980, p. 598; Yeung, p. 164, Dharmananda, 1986, p. 173; Bensky and Barolet, p. 264; Shi Hu Ye Guang Wan: Zhu, p. 295) • Cataract Vision-Improving Pills (Nei Zhang Ming Yan Wan) (patent); Rehmannia Tea (patent): Liver Yin Xu (Deficiency) with Kidney Yin Xu (Deficiency) with Empty Fire Blazing (Cataract: Fratkin, p. 202; Rehmannia: Fratkin, p. 206) • Rehmannia Eight F. (Jin Gui Shen Qi Wan): Kidney Yang Xu (Deficiency) (Hsu, 1980, p. 250; Yeung, p. 138; Dharmananda, 1986, p. 173; Bensky and Barolet, p. 275)

Acupuncture
after assessing the person and palpating, consider these patterns: non-acute: Kidney Yin Xu (Deficiency) which causes Wind and Fire in the Liver and Gall Bladder to ascend, disrupting the Qi in the channels, due to Wind, Fire or Phlegm; Liver Yin Xu (Deficiency) with Kidney Yin Xu (Deficiency); Kidney Yang Xu (Deficiency); Shi (Excess) of the Yang Qiao Mai (Yang Motility Vessel) and/or Xu (Deficiency) of the Yin Qiao Mai (Yin Motility Vessel)

» illustrative combinations: • GB-20, UB-2, GB-1, LI-4, Lv-3, Kd-3, Sp-6 and UB-18 for glaucoma; also consider: UB-63, UB-62, Lv-2 and St-36 (Shanghai, p. 681; Lee and Cheung, p. 344) • GB-20, GB-6, UB-10, GB-14, TW-16, GB-16 and St-2 for "green cataract" (Lee and Cheung, p. 345) • GB-20, LI-1 and SI-1; Kd-1, UB-62 and St-43; GB-3 and GV-24 for glaucoma (Mann, p. 141) • UB-2, tai yang, GB-20, CV-12, PC-6, St-36, Lv-2 and Kd-3 for blurred vision and painful distention due to Liver Fire invading the Stomach and stagnant Phlegm-Dampness (Jirui and Wang, p. 208) • UB-1, UB-2 and tai yang (-): clear Fire from head, relieve distension; open and brighten eyes • UB-62 and SI-3: open the Yang Qiao Mai (Yang Motility Vessel) which transports Yang, moistens the eyes, and controls the opening and closing of the eyes, and for which eye conditions are a Shi (Excess) symptom • Kd-6 and Lu-7: open the Yin Qiao Mai (Yin Motility Vessel) which transports Yin, moistens the eyes, and controls the opening and closing of the eyes, and for which eye conditions are a Xu (Deficiency) symptom

Homeopathy
• Aconitum napellus: pains extend down the face (tic douloureux) especially after exposure to intense cold or cold winds or in rheumatic patients • Belladonna: relieves the pain especially if accompanied by throbbing headache, flushed face etc.; the eyes are injected, pupils dilated, fundus hyperemic and pain in and around the eye, mostly deep seated and of a pressing nature as if eyes being torn out or pressing into head; eyes feel hot, dry and stiff as if might protrude • Cannabis sativa: opacity of cornea in alcoholics, smokers or after nervous trouble • Gelsemium: choroidal and venous congestions with or without serous effusion; amaurotic symptoms, with dilatation of pupils, disturbed accommodation, pain in eyes, with or without lacrimation • Phosphorus: fundus hyperemic, hazy halo around the light; various lights and colors flashing before the eyes • Prunus spinosa: pains severe, crushing in the eye as if pressed asunder or sharp shooting through the eye and corresponding side of the head; aqueous and vitreous humor hazy; fundus hyperemic • Spigelia: pains sharp and stabbing through the eye and head, worse on motion and at night

Subtle Support
• notes: A#, B, C, D#, E, G, G#

• chords: diminished 8th, C Major, D# Major, G# Major (Gimbel, p. 116)

Mind/Body
• Stony unforgiveness; pressure from longstanding hurts; overwhelmed by it all. (Hay, 1984, p. 164) • Eyes represent not liking what you see in your own life. (Hay, 1984, p. 163) • With glaucoma, raised pressure within the eye leads to restricting the field of vision until actual tunnel vision occurs. The wider view is lost; in effect, one is blind to all except that one aspect of reality that one wants to see. The raised pressure within the eye represents the psychological pressure of unwept tears. (Dethlefsen, p. 151)

• Liver ~ Gan is the residence of the Hun (Ethereal Soul); it relates to decisiveness, control, and the principle of emergence; maintains smooth flow of Qi and Xue (Blood); controls the muscles, especially their contractility; reflects emotional harmony and movement; and opens into the eyes. » Healthy expressions are kindness, spontaneity, and ease of movement. » Liver Xu (Deficiency) signs include impotence; frigidity; pain in thighs, pelvic region, and throat; ready tendency to "the blahs" (Seem, p. 28); timidity; depression; irritability; vertigo; pruritus; dry eyes, skin, and/or tendons; asthma; aching at the waist; hernia; and difficulty raising head up and down. Liver Yin Xu (Deficiency) predisposes to the Shi (Excess) conditions of Liver Wind, Liver Yang Rising, and Liver Fire Blazing. » Liver Shi (Excess) signs include discontent; anger; pain in lumbar region and genitals (Seem, p. 28); muscular tension; excessive sex drive; insomnia; moodiness; excitability; genital diseases; red, tearing eyes; compulsive energy; and bitter taste in the mouth. Chronically suppressed anger can implode and give rise to Fire in the Liver and Gall Bladder with symptoms of irritability, bitter taste, headaches, etc. » Liver Wind derives from Liver Yin Xu (Deficiency) and/or Liver Xue Xu (Blood Deficiency) and their subsequent inability to embrace the Yang, and can manifest as joint stiffness, dizziness, tremor, paralysis, convulsions, rashes, itching, and neurological problems.
 * Chinese psychophysiology:**