Case Studies

Case Study 1 - Conjunctivitis / Eye Infection

Please note that the following data was based on Oriental medical theories and reflect TCM (Traditional Chinese Medicine) diagnosis and treatment.  Thus terminology used in this report may not have the same meaning as in conventional allopathic medicine.

Date:  October, 1998
Patient:  Miss N.
Attending Doctor:  Dr. Kwong

Chief Complaint:  Red, itchy, and watery right eye for 2 days.

History of Present Illness:  Miss N. is a normal 12-year-old girl who came into our clinic for a complete TCM (Traditional Chinese Medicine) evaluation.  The last two months had been a stressful time for her.  She started junior high last September and she had also been fitted for braces by her orthodontist a week prior to this incident.  Around this time she was also presented with an outbreak of pimples on her forehead.  She was not conscious about her diet and was consuming too many French fries and greasy foods.

Past Medical History:  Several episodes of wheezing each year for the past two years during the winter months.  She has an Albuterol MDI, but never had to use it.  Recently, the patient seems to have a greater sensitivity to chemical irritants and allergens.  Minor skin rashes would develop and go away by themselves.

Subjective Data:  One hot morning while playing in the school playground Miss N. felt very hot, particularly her face, and was sweating profusely.  Later on that afternoon in the classroom her right eye felt "gritty", burning and itchy.  In addition, she had trouble seeing the overhead screen clearly.  Eventually she experienced some soreness in the right eye as the day went on.

Objective Data:

Observation:  The sclera of the right eye was red and inflamed.  Right lower eyelid was swollen with clear watery discharge.  The underside of her right eyelid revealed enlarged papillae.  A small sty was noticeable on right lower eyelid.  Eyes were sensitive to bright lights.  Tongue quality showed a red body with red tip and thin coat.

Palpation and Physical Exam:  Pain and tenderness around her eyes, especially on the right side upon palpation as well as in the jaw area.  Patient also revealed soreness and pain of the gums and teeth due to her braces.  Pulses on left and right sides were wiry, tight and slightly rapid in all cun, guan, and chi positions.

Inquiry:  All TCM reviews of systems were normal except for:

• Energy level - fatigue
• Bowels - constipation
• Emotions - pre-teen emotional swings

Assessment:

Western Allopathic diagnosis:  conjunctivitis

TCM Holistic diagnosis:

1. Wind heat invasion
2. Liver/Gan yang rising
3. Liv. Qi stagnation with damp heat accumulation
4. Underlying Wei Qi deficiency

Plan of Treatment:

1.  Acupuncture prescription with acupoints:  fengchi (GB20), hegu (LI4), weiguan (SJ5), taiyang, taichong (LV3), yinlingquan (sp9), quchi (LI 11) with reducing method.

2.  Herbal prescription is the modification of formula Yin Qiao San: jinyinhua, lian.

Qiao, huangqin, huanglian, niubangzi, jingjie, jiegeng, gancao,juemingzi, shanzhizi, manjingzi, yejuhua, xiakucao, and bohe.  Herbs were dispensed for patient to take home.  Mother cooked and made tea to be taken three times daily.  In addition, an herbal compress over eye twice daily.

3.  Food therapy/nutritional prescription:  Increase in consumption of cooling like foods such as cucumbers, tomatoes, bean sprouts, barley, small red beans, dates, bitter melon, etc.  Refrain from eating spicy, sugary and greasy foods.

4.  Other guidelines for patient:

• Decrease eye strain as in computer work, watching TV, reading story books, etc.
• Frequent hand-washing to prevent spreading of germs and preventing complications.
• Patient is to go to bed earlier to get adequate rest.

Follow Up:

After two treatments of acupuncture and six doses of herbal medicine, the patient's signs of swelling, itchiness, pain, redness and watery eyes were gone.  The patient indicated that these treatments also helped her constipation.  Meanwhile the mother noticed that her daughter's moods had also improved.  Although it was hard for Miss N. to follow the nutritional guidelines, we recommended that she continue it for another week.  The patient was discharged with herbal pills for her constipation.  A followup office visit one year later revealed no relapse of conjunctivitis, but was treated for acne instead.