The Location and Function of the Macula
When discussing macular degeneration, it is crucial first to understand the location and function of the macula. Situated in the central part of the retina at the back of the eye, the macula is responsible for central vision used in activities such as reading, driving, and recognizing faces.
Classification and Incidence Rate of Age-Related Macular Degeneration
Age-related macular degeneration (AMD) can be classified into exudative (wet) and nonexudative (dry) types.The cause of exudative (wet) macular degeneration is attributed to local stagnation of qi (vital energy) and blood in the macula—that is, impaired circulation of blood and energy. In an effort to acquire blood and nutrients from blood vessels, new blood vessels may emerge (referred to as choroidal neovascularization). These newly formed choroidal blood vessels have extremely fragile walls, making them susceptible to leakage and bleeding. This, in turn, damages the eyes and leads to visual impairment.
According to statistics, the exudative type accounts for approximately 10 percent to 20 percent of patients with AMD. Although this represents less than one-fifth of cases, the exudative type is the primary cause of vision loss in AMD patients.
Symptoms of Age-Related Macular Degeneration
In the early stages of AMD, patients may experience hazy vision, with the central field appearing blurry and indistinct. As the condition progresses and new blood vessels form, leading to macular edema, patients may perceive distorted images. If bleeding or leakage occurs from these new blood vessels, the central vision may turn black, leaving only peripheral vision. Eventually, individuals with this condition may experience a gradual loss of reading ability and, in severe cases, complete blindness.
Diagnosis of Age-Related Macular Degeneration
The diagnostic criteria for macular degeneration can be broadly divided into the following three parts:- No abnormalities in the external eye: Objects viewed by the affected eye appear distorted or accompanied by blurred vision, resulting in a decline in visual acuity.
- Central vision examination: When using the Amsler grid, there may be distortions in the central area, including bent lines, uneven thickness, curtain-like shadows, intermittent lines, and other irregularities.
- Retinal examination: Manifestations may include macular edema, exudation, and bleeding, as well as pathologies such as subretinal membrane, detachment of neuroepithelium or pigment epithelium, and atrophy.
Principles and Methods of TCM Treatment
In addressing macular degeneration in TCM, the focus extends beyond the microscopic examination of localized eye changes (which must be complemented by Western ophthalmological examinations). Attention is also given to observing the lesions’ morphology, color, and nature through visual diagnosis. More importantly, TCM employs a holistic approach that considers factors such as constitution, environment, emotions, and other macro aspects, thereby identifying the cause and formulating an effective treatment plan. The following discussion explores the etiology and treatment principles of macular degeneration from the perspective of TCM.According to TCM theory, the energy of internal organs circulates throughout the entire body. A deficiency of energy in the body can lead to diseases in corresponding parts of the body.
In terms of the constitution, macular degeneration is primarily associated with spleen qi deficiency and liver-kidney yin deficiency. Interestingly, these two constitutional states can correspond to issues in the superficial or deep layers of the macula.
Superficial lesions in macular degeneration are characterized by distorted straight lines and a curtain-like shadow (a relative central dark spot). The primary pathology occurs in the retina, with retinal edema or serous detachment being the main manifestations. From the perspective of TCM, this is primarily associated with spleen qi deficiency.
In TCM, the concept of the spleen extends beyond the anatomical organ; it represents a central energy system. Alongside its immune functions, the spleen collaborates with the pancreas and the gastrointestinal tract, forming an integrated system responsible for the digestive system and fluid metabolism. When the spleen and stomach are weakened, exposure to external factors (such as wind-heat or wind-toxicity) or experiences like physical and mental exhaustion, emotional distress, etc., may disrupt the flow of qi, leading to the stagnation of dampness and the formation of edema. In TCM, such factors contributing to illness are called “external pathogenic factors,” including excessive wind, heat, and other influences.
Deep-layer lesions in macular degeneration are typically chronic conditions, evolving from long-term cumulative effects. Such conditions are prone to recurrent episodes, accompanied by distorted straight lines, a central dark spot, decreased visual acuity, and a complex lesion involving the retinal pigment epithelium, Bruch’s membrane, and choroidal capillaries. This leads to retinal choroidal exudation, bleeding, new blood vessel formation, and scarring. The primary cause of such lesions is liver-kidney yin deficiency, leading to excessive internal heat that scalds the meridians, causing blood to overflow and stagnate, resulting in blood stasis.
The energy of internal organs is classified into yin and yang, and maintaining a balance between these two is crucial. Individuals with liver-kidney yin deficiency often exhibit a shortage of body fluids, leading to symptoms such as heat in the hands, feet, and chest, as well as dry mouth and tongue. This condition is collectively referred to as “excessive internal heat.” The kidneys store the essence of the body, known as kidney essence, while the liver stores liver blood. Insufficient kidney essence and liver blood can result in liver-kidney yin deficiency, depriving the eyes of adequate energy and nutrients.
In simpler terms, superficial lesions are generally characterized by edema and exudation, mainly caused by spleen qi deficiency and the accumulation of dampness. On the other hand, deep-layer lesions commonly involve the development of new blood vessels, bleeding, and eventually scarring, affecting vision. Treatment approaches often prioritize the liver and kidneys in these cases. For those with spleen qi deficiency, the focus lies on invigorating the spleen and resolving dampness with prescriptions such as Wuling San. Additionally, increased doses of Astragalus and ginseng are recommended to tonify qi.
Individuals with liver-kidney essence and blood deficiency, especially those exhibiting pigment deposits or clusters in the fundus, may benefit from a kidney-nourishing and vision-improving formula. This formula may include ingredients like Herba Cistanche, Cullen corylifolium, Chinese Ecliptae herba, Ligustri Lucidi Fructus, raw Radix Astragali, Angelica sinensis, Rhizoma Atractylodis, Salvia miltiorrhiza, and San Qi powder. It is recommended for regular consumption over an extended period.
TCM Treatment for Retinal Hemorrhage
Notably, TCM demonstrates distinct advantages in treating retinal hemorrhage, yielding excellent therapeutic outcomes.Excess Heat
For individuals manifesting symptoms of excess heat, the treatment involves cooling the blood, clearing heat, draining fire, and detoxifying. The prescription may include the following:- Gypsum fibrosum.
- Anemarrhena asphodeloides.
- Glycyrrhizae radix.
- Rhizoma Coptidis.
- Radix Scutellariae.
- Gardeniae Fructus.
- Scrophulariae radix.
- Radix Paeoniae Rubra.
- Radix Rehmanniae.
- Moutan Cortex.
Yin Deficiency
For those exhibiting hyperactivity of fire due to yin deficiency, the prescription may comprise the following:- Pollen Typhae.
- Chinese Ecliptae herba.
- Ligustri Lucidi Fructus.
- Charred Schizonepeta.
- Salvia miltiorrhiza.
- Radix Curcumae.
- Moutan Cortex.
- Radix Rehmanniae.
- Rhizoma Chuanxiong.
- Anemarrhena asphodeloides.
- Phellodendri Cortex.
One to two weeks after stopping bleeding, it is advisable to use a prescription for promoting blood circulation and removing blood stasis to facilitate the dispersion of stasis. One of the common prescriptions is the Taohong Siwu Decoction. It is important to note that blood-activating herbs should not be used too early, as they may exacerbate bleeding. In cases of acute bleeding, the focus should be on stopping bleeding without leaving stasis, using herbs such as Radix Rubiae Cordifoliae, Pollen Typhae, Rhizoma Bletillae, and Panax notoginseng. When there is blood stasis, the approach should be to “move the blood stasis” instead of “breaking up the blood stasis,” using herbs such as Angelica sinensis, Rhizoma Chuanxiong, and safflower.
While effective in stopping bleeding, some medications may inadvertently lead to blood stasis. However, herbs like Pollen Typhae and Panax notoginseng do not have this tendency. “Moving the blood stasis” involves facilitating blood movement, while “breaking up the blood stasis” is primarily reserved for cases with prolonged and severe blood stasis, such as tumors and hardened masses. For milder cases of blood stasis, it is unnecessary to use blood-breaking herbs to avoid compromising the body’s qi.
Over time, if blood stasis persists for more than three months, it may lead to the formation of hardened masses. In such cases, the treatment approach should focus on softening and dispersing these hardened masses. This involves using herbs such as Fritillaria thunbergii Miq., Prunella, Concha Ostreae, seaweed, kelp, Rhizoma Sparganii, and Curcumae Rhizoma.
Remarkable Efficacy of Bloodletting From the Ear in Treating Acute Retinal Hemorrhage
In my clinical practice, bloodletting from the ears stands out as the primary treatment for acute retinal hemorrhage. Usually, following the initial bloodletting session, there is an immediate reduction in the size and thickness of blood clots in the retina. Bloodletting is performed every two days, spanning three to five consecutive sessions. When complemented with acupuncture therapy, this approach can reduce the size of blood clots by at least 80 percent.Why does bloodletting from the ears have a remarkable effect on acute retinal hemorrhage? This is primarily because bloodletting from the ears promotes qi and blood circulation throughout the entire head, face, eyes, ears, and neck. This, in turn, leads to a rapid improvement of macular edema, bleeding, and blood stasis in the retina’s macular region.
The specific method of bloodletting involves first rubbing and congesting the ears (generally, bloodletting is performed on both ears). Then, using 23-gauge needles, five bleeding points are punctured at the ear apex and helix 4. Afterward, wipe with a damp alcohol swab, allowing about 50 drops of blood to be released from both the ear apex and helix 4. The amount of blood for each drop is minimal, with a total release of about 5 to 10 cubic centimeters of blood from one ear. While the overall blood loss is not much, it is advisable to avoid this procedure for patients with conditions such as qi deficiency, anemia, or coagulation disorders.
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