Diabetic Retinopathy

Diabetic retinopathy is a potentially blinding microvasacular complication of both type 1 and type 2 diabetes that damages the retina of the eye. It occurs when diabetes damages the tiny blood vessels in the retina. In terms of its pathophysiology, it is a complex disease and probably does not stem from a single retinal change. Instead, it is probably triggered by a combination of biochemical, metabolic, and hematologic abnormalities. For instance, a chronic increase in normal blood glucose levels may gradually alter cell metabolism in the retinal blood vessels, while diabetes-related biochemical changes may make circulating blood platelets abnormally sticky. Further, hematologic changes may cause the retinal blood vessels to constrict. These abnormalities may cause certain cells within the retinal blood vessels to die, thus leading to altered blood flow, increased blood vessel permeability, and the growth of certain blood vessel components. As a result, tiny out-croppings called microaneurysms may bulge from the weakened blood vessel walls. If these microaneurysms leak blood onto the central retina or macula, they may cause macular edema ^[1] and probable loss of vision. This condition is generally suspected when loss of visual acuity is not corrected by glasses.

In fact, there are three stages to this disease. The earliest phase is known as background diabetic retinopathy (BDR). In this phase, due to the death of the pericytes which line the vascular endothelium, the arteries in the retina become weakened and leak, forming small, dot-like hemorrhages as described above. In addition, hard exudates due to the leakage of proteins and lipids may form as ring-like structures around the leaking capillaries. Background diabetic retinopathy may be asymptomatic. Eighty percent of people who have had diabetes for over 20 years have some BDR, but only about one out of every 4-5 of those with BDR will eventually suffer measurable vision impairment. The next stage is known as preproliferative diabetic retinopathy. Preproliferative diabetic retinopathy is a more advanced stage of damage to the eye than the early signs found in BDR. In this stage, intraretinal microvascular abnormalities (IRMA) are present. These are irregularly shaped blood vessels that appear in a localized area of the retina as squiggly lines. They signify irregular dilation of the retinal blood vessels in response to poor blood circulation. In addition, there may be cotton wool spots or exudates which are microinfarcts. These are seen as pale white areas in the retina where the blood vessels have become blocked and the nerves in the localized areas have been damaged. Once this stage is present, vision may worsen rapidly. The third stage of this disease is proliferative diabetic retinopathy (PDR). In this stage, circulation problems cause areas of the retina to become oxygen-deprived or ischemic. New, fragile vessels develop as the circulatory system attempts to maintain adequate oxygen levels within the retina. This is called neovascularization. Unfortunately, these delicate vessels hemorrhage easily, and blood may leak into the retina and vitreous, causing spots or floaters along with decreased vision. In the later phase of this disease, continued abnormal vessel growth and scar tissue may cause serious problems, such as retinal detachment and glaucoma. As a result, severe visual loss or blindness will occur. ^{[2] , [3]}

For many people with diabetic retinopathy, there are no early symptoms. There is no pain, no blurred vision, and no ocular inflammation. In fact, many people do not develop any visual impairment until the disease has advanced well into its proliferative stage. At this point the vision has been lost and cannot be restored. However, some people in the early and advanced stags of diabetic retinopathy amy notice a change in their central and/or color vision. The loss of central vision results from macular edema which can often be effectively treated. Many diabetics notice blurred vision when their blod sugar is particularly high or low. This blurred vision is due to changes in the shape of the lens of the eye and usually reverses when the blood sugar returns to normal. It is not a symptom of diabetic retinopathy.

The incidence of diabetic retinopathy is strongly correlated to the duration of disease and age of onset. After 20 years of diabetes, nearly all patients with type 1 diabetes and more than 60% of patients with type 2 diabetes have some degree of retinopathy. Vision-threatening retinopathy virtually never appears in type 1 patients in the first 3-5 years of diabetes or before puberty. However, in the subsequent two decades, nearly all type 1 patients develop retinopathy. For instance, after having diabetes for 15 years, about 80% of type 1 diabetics have some degree of diabetic retinopathy, and 50% have PDR. Up to 21% of patients with type 2 diabetes have been found to have retinopathy at the time of first diagnosis of diabetes, and most develop some retinopathy over subsequent decades. Overall, diabetic retinopathy is estimated to be the most frequent cause of blindness among adults aged 20-74 years. ^{[4] , [5]}

The Western medical diagnosis of diabetic retinopathy primarily consists of ophthalmoloscopy with magnification and illumination of the retina subsequent to pupil dilation looking for leaking blood vessels, macular edema, cotton wool patches, or any other changes in the blood vessels of the retina. If there is macular edema, flourescein angiography is usually performed. Flourescein angiography is a technique which involves injecting a dye (fluorescein) into the veins and taking a series of photographs of the retina while the dye circulates through the retinal vessels. Ultrasound imaging of the eyes may also sometimes be used.

The Western medical prevention of this condition consists of careful control of blood sugar levels through attention to diet, exercise, and medications, monitoring for and control of hypertension, avoidance of smoking, and early detection and treatment of diabetic retinopathy. The Diabetes Control and Complications Trial (DCCT) has shown that better control of blood sugar levels slow the onset and progression of retinopathy and lessen the need for laser surgery for severe retinopathy. The United Kingdom Prospective Diabetes Study (UKPDS) conclusively demonstrated that improved blood glucose control in type 2 diabetics reduces the rate of development of retinopathy. The National Eye Institute’s Early Treatment Diabetic Retinopathy Study (ETDRS) showed that a daily dose of aspirin has no significant effect on preventing retinopathy.

Remedial treatment in any particular case depends upon multiple factors, including the type and degree of retinopathy, associated ocular factors such as cataract or vitreous hemorrhage, and the medical history of the patient. Treatment options include laser photocoagulation, kyrotherapy, and pars plana vitrectomy surgery (i.e., the removal of the vitreous gel along with blood, scar tissue, etc. and its replacement with a clear saline solution). As mentioned above, patients with diabetes are at greater risk for developing retinal tears and detachment. Such tears are often sealed with laser surgery. Retinal detachment requires surgical treatment to reattach the retina to the back of the eye. Current treatment guidelines are so successful that even people with proliferative retinopathy have a 90% chance of maintaining their vision. ^{[6] , [7]} In terms of experimental treatments, an oral inhibitor of protein kinase C, a substance involved in the stimulation of certain growth hormones, is already in Phase II/Phase III clinical trials, and other growth hormone antagonists are also being looked at by researches. The development of such an oral medication would avoid the inherently destructive properties of current laser treatments. The heparin analogue, beta-cyclodextrin tetradecasulfate, may prevent proliferative retinopathy.

Chinese disease mechanisms:

In Chinese medicine, there are two main disease mechanisms of diabetic retinopathy. These are yin vacuity with dryness and heat leading to essence and blood depletion and detriment not nourishing the eyes and static blood obstructing the network vessels of the eyes. In diabetes, there are three main disease causes leading to yin vacuity with dryness and heat. First, overeating fats and sweets and drinking alcohol may result in accumulation of heat brewing internally which transforms dryness and damages fluids. Secondly, due to emotional stress and frustration, liver depression may transform fire which disperses and burns yin fluids. And third, habitual bodily yin vacuity compounded by aging, overtaxation, and unregulated bedroom affairs (i.e., too much sex) may also damage yin fluids. If any of these three factors result in enduring yin fluid depletion and consumption, essence and blood may suffer detriment. According to the Nei Jing (Inner Classic), the eyes can see only if they obtain blood, and the Ling Shu (Spiritual Axis) says, “The essence of the five viscera and six bowels flows upward to the eyes and makes their essence.” Thus the eyes’ function of sight is dependent on receiving sufficient blood and essence to moisten, enrich, and nourish them, and, therefore, conversely, a liver blood-kidney yin vacuity is a major mechanism of vision problems. In addition, if yin vacuity gives rise to fire effulgence, vacuity fire may flame upward, burning and damaging the network vessels in the eyes and forcing the blood in the eyes to move outside its vessels.

It is also possible for any of a number of other disease mechanism associated with diabetes to result in blood stasis. If there is a spleen qi vacuity failing to upbear, the blood may lack the power to move to and through the network vessels in the eyes, instead becoming static there. Since the qi moves the blood, it is also possible for enduring liver depression qi stagnation to result in blood stasis. If overeating thick-flavored, fatty foods leads to gumming up of the qi mechanism, clear and turbid will not be separated, and phlegm, dampness, and turbidity may impede and block the free and easy flow of qi and blood to the eyes. Likewise, if yin blood is scanty and insufficient to nourish the vessels, this may lead to blood stasis since the vessels will not be able to perform their proper function in terms of the circulation of blood. And finally, if yin and/or qi vacuity reaches yang, yang vacuity may lead to cold congealing the blood and, hence, blood stasis. In other words, any or all these disease mechanisms may ultimately result in the formation of static blood within the network vessels, thus depriving the eyes of proper nourishment. Since diabetic retinopathy is a chronic, enduring condition, based on the saying, “Enduring diseases enter the network vessels,” most cases of diabetic retinopathy are complicated by at least an element of blood stasis. For instance, in one group of 46 Chinese patients with diabetic retinopathy, 91.3% met the criteria for the diagnosis of blood stasis. ^[8]     

Treatment based on pattern discrimination:

1. Yin vacuity with dryness & heat pattern

Main symptoms: This pattern is mostly seen in patients with first stage diabetic retinopathy or BDR before there are any symptoms of visual disturbance. The clinical signs and symptoms of this pattern include dry mouth, polydipsia, polyphagia and easy hungering, an emaciated body, frequent, profuse urination, dry, bound stools, a red tongue with thin, yellow fur, and a bowstring, fine or surging, slightly rapid pulse.

Treatment principles: Enrich yin and engender fluids, clear heat and moisten dryness

Rx: Zeng Ye Tang (Increase Fluids Decoction) plus Bai Hu Tang (White Tiger Decoction) with additions and subtractions

Ingredients: Uncooked Radix Rehmanniae (Sheng Di), Radix Scrophulariae Ningpoensis (Xuan Shen), and uncooked Gypsum Fibrosum (Shi Gao), 30g each, Radix Trichosanthis Kirlowii (Tian Hua Fen), 20g, Tuber Ophiopogonis Japonici (Mai Men Dong) and Rhizoma Anemarrhenae Aspheloidis (Zhi Mu), 9g each, Radix Glycyrrhizae (Gan Cao), 6g

Formula analysis: Sheng Di, Xuan Shen, and Mai Men Dong enrich yin and engender fluids. Uncooked Shi Gao, Zhi Mu, and Tian Hua Fen clear and discharge lung-stomach dryness and heat, engender fluids and stop thirst.

Additions & subtractions: If there is retinal bleeding, add nine grams each of Cortex Radicis Moutan (Dan Pi), carbonized Flos Immaturus Sophorae Japonicae (Huai Hua Mi), and uncooked Pollen Typhae (Pu Huang) to cool the blood and stop bleeding. For bowel repletion constipation, add nine grams each of uncooked Radix Et Rhizoma Rhei (Da Huang), Fructus Immaturus Citri Aurantii (Zhi Shi), and Fructus Trichosanthis Kirlowii (Gua Lou) to free the flow of the bowels and discharge heat. If there is lung-stomach dryness and heat with polydipsia and polyphagia, increase the dose of Tian Hua Fen and add nine grams each of Calcitum (Han Shui Shi) and Herba Dendrobii (Shi Hu) to further clear heat and engender fluids. If there is concomitant qi stagnation, add 18 grams of Radix Albus Paeoniae Lactiflorae (Bai Shao) and nine grams each of Radix Bupleuri (Chai Hu), Fructus Citri Aurantii (Zhi Ke), and Fructus Trichosanthis Kirlowii (Gua Lou). If there is simultaneous blood stasis, one can add 30 grams of Radix Salviae Miltiorrhizae (Dan Shen), 15 grams of Radix Ligustici Wallichii (Chuan Xiong), and nine grams each of Flos Carthami Tinctorii (Hong Hua), Radix Rubrus Paeoniae Lactiflorae (Chi Shao), Cortex Radicis Moutan (Dan Pi), and uncooked Pollen Typhae (Pu Huang). 

Acupuncture & moxibustion: Jing Ming (Bl 1), Qiu Hou (M-HN-8), Feng Chi (GB 20), Tai Xi (Ki 3), San Yin Jiao (Sp 6), Guang Ming (GB 37), Ge Shu (Bl 17), Gan Shu (Bl 18)

Formula analysis: Supplementing Tai Xi, San Yin Jiao, Guang Ming, Ge Shu, and Gan Shu nourishes the blood, enriches the kidneys, and brightens the eyes. Guang Ming is the connecting point between the gallbladder channel and a channel divergence of the liver, Therefore, this pathway is how liver qi and blood ascend to the eyes. Even supplementing-even draining Jing Ming and Qiu Hou moves the qi and quickens the blood in the network vessels of the eyes. Draining Feng Chi clears heat from the head and eyes.

Additions & subtractions: If there is oral dryness and polydipsia, add supplementing Zhao Hai (Ki 6) and even supplementing-even draining Lie Que (Lu 7). If there is polyphagia and easy hungering, add draining Nei Tong (St 44) and He Gu (LI 4). If there is liver depression, add even supplementing-even draining Tai Zhong (Liv 3) and draining He Gu (LI 4). For liver depression transforming heat, add even supplementing-even draining Xing Jian through to Tai Zhong.

2. Lung-stomach qi & yin dual vacuity pattern

Main symptoms: This pattern is mostly seen in preproliferative and the early stage of proliferative diabetic retinopathy. The clinical signs and symptoms of this pattern include dry mouth and polydipsia, polyphagia and easy hungering, fatigue, lack of strength, low back and knee soreness and limpness, dizziness, tinnitus, a dark red or dark, fat tongue with white, possibly scanty fur, and a surging and slippery or deep, fine, possibly rapid pulse

Treatment principles: Supplement the lungs and boost the qi, enrich and supplement kidney yin

Rx: Sheng Mai San (Engender the Pulse Powder) plus Qi Ju Di Huang Tang (Lycium & Chrysanthemum Rehmannia Decoction) with additions and subtractions

Ingredients: Radix Scrophulariae Ningpoensis (Xuan Shen), 20g, Radix Codonopsitis Pilosulae (Dang Shen), Radix Dioscoreae Oppositae (Shan Yao), uncooked Radix Rehmanniae (Sheng Di), and cooked Radix Rehmanniae (Shu Di), 15g each, Sclerotium Poriae Cocos (Fu Ling), 12g, Tuber Ophiopogonis Japonici (Mai Men Dong), Rhizoma Alismatis (Ze Xie), Fructus Corni Officinalis (Shan Zhu Yu), Cortex Radicis Moutan (Dan Pi), Flos Chryanthemi Morifolii (Ju Hua), and Fructus Lycii Chinensis (Gou Qi Zi), 9g each    

Formula analysis: Dang Shen, Mai Men Dong, Sheng Di and Xuan Shen boost the qi and nourish yin. Gou Qi Zi and Ju Hua nourish the liver and brighten the eyes, while Shu Di enriches the kidneys and fosters essences. Shan Zhu Yu supplements the liver and kidneys at the same times as it astringes the essence. Shan Yao supplements and boosts the kidney qi, fortifies the spleen and disinhibits dampness. Ze Xie drains kidney fire and protects against Shu Di’s enriching sliminess. Dan Pi clears and discharges liver fire and controls Shan Zhu Yu’s warmth.

Additions & subtractions: If retinal bleeding has endured and cannot be stopped, one can add nine grams each of Radix Salviae Miltiorrhizae (Dan Shen) and uncooked Pollen Typhae (Pu Huang) and three grams of powdered Radix Pseudoginseng (San Qi) swallowed with the decoction to cool the blood and stop bleeding. If there is macular edema, add more Fu Ling and Ze Xie as well as nine grams each of Semen Plantaginis (Che Qian Zi) and Radix Salviae Miltiorrhizae (Dan Shen) to quicken the blood and disinhibit water. for more pronounced macular sclerosis and leakage, add nine grams each of Thallus Algae (Kun Bu), Herba Sargassii (Hai Zao), Concha Ostreae (Mu Li), and Fructus Crataegi (Shan Zha) to soften and scatter binding, quicken the blood and transform stasis. If there is concomitant qi stagnation, add 18 grams of Radix Albus Paeoniae Lactiflorae (Bai Shao) and nine grams each of Radix Bupleuri (Chai Hu), Fructus Citri Aurantii (Zhi Ke), and Fructus Trichosanthis Kirlowii (Gua Lou).

Acupuncture & moxibustion: Jing Ming (Bl 1), Qiu Hou (M-HN-8), Zu San Li (St 36), San Yin Jiao (Sp 6), Fei Shu (Bl 13), Ge Shu (Bl 17), Gan Shu (Bl 18), Shen Shu (Bl 23), Tai Xi (Ki 3), Guang Ming (GB 37), Feng Chi (GB 20)

Formula analysis: Supplementing Zu San Li, San Yin Jiao, Fei Shu, Ge Shu, Gan Shu, Shen Shu, Tai Xi, and Guang Ming supplements the lungs, spleen, liver, and kidneys, nourishes the blood, enriches yin, and brightens the eyes. Even supplementing-even draining Jing Ming and Qiu Hou moves the qi and quickens the blood in the network vessels of the eyes. Draining Feng Chi clears heat from the head and eyes.

Additions & subtractions: If there is marked liver depression, add even supplementing-even draining Tai Chong (Liv 3) and draining He Gu (LI 4). If there is marked blood stasis, add even supplementing-even draining Xue Hai (Sp 10) and draining He Gu (LI 4). For heat in the stomach with dry mouth and oral thirst, add draining Nei Ting (St 44) and change supplementing Zu San Li to even supplementing-even draining Zu San Li.

3. Yin & yang dual vacuity pattern

Main symptoms: This pattern is mostly seen in proliferative diabetic retinopathy. The clinical signs and symptoms of this pattern include fear of cold, chilled limbs, shortness of breath, lack of strength, superficial edema, a bright white facial complexion, a dark fat tongue, and a deep, fine, weak pulse

Note: Although the name of this pattern does not say so, there is also a pronounced qi vacuity.

Treatment principles: Foster yin and warm yang, quicken the blood and scatter binding or nodulation

Rx: Jin Gui Shen Qi Wan Jia Jian (Golden Cabinet Kidney Qi Pills with Additions & Subtractions)

Ingredients: Radix Astragali Membranacei (Huang Qi) and Radix Salviae Miltiorrhizae (Dan Shen), 30g each, cooked Radix Rehmanniae (Shu Di) and Radix Disocoreae Oppositae (Shan Yao), 15g, Sclerotium Poriae Cocos (Fu Ling), 12g, Fructus Corni Officinalis (Shan Zhu Yu), Rhizoma Alismatis (Ze Xie), Cortex Radicis Moutan (Dan Pi), Thallus Algae (Kun Bu), and Semen Plantaginis (Che Qian Zi), 9g each, Ramulus Cinnamomi Cassiae (Gui Zhi), 6g

Formula analysis: Shu Di and Shan Zhu Yu supplement the liver and kidneys, while Huang Qi and Shan Yao supplement the spleen and kidneys. Fu Ling, Ze Xie, and Che Qian Zi seep dampness and lead ministerial fire downward along the yin tract. Gui Zhi warms and supplements kidney yang. Dan Shen, Dan Pi, and Kun Bu quicken the blood and scatter nodulation.

Additions & subtractions: If there is marked sclerosis and cotton wool patches, add nine grams each of Herba Saragassii (Hai Zao), Bulbus Fritillariae Thunbergii (Zhe Bei Mu), uncooked Fructus Crataegi (Shan Zha), and uncooked Pollen Typhae (Pu Huang) to increase the effect of quickening the blood, transforming stasis, and scattering nodulation. If there is marked phlegm dampness, add nine grams each of Fructus Trichosanthis Kirlowii (Gua Lou) and Rhizoma Pinelliae Ternatae (Ban Xia). If there is concomitant qi stagnation, add 18 grams of Radix Albus Paeoniae Lactiflorae (Bai Shao) and nine grams each of Radix Bupleuri (Chai Hu), Fructus Citri Aurantii (Zhi Ke), and Fructus Trichosanthis Kirlowii (Gua Lou).

If there is marked kidney yin depletion and vacuity with vacuity fire flaming upward, one can use Er Zhi Wan (Two Ultimates Pills) plus Zhi Bai Di Huang Wan (Anemarrhena & Phellodendron Rehmannia Pills) with added flavors: Herba Ecliptae Prostratae (Han Lian Cao) and Fructus Ligustri Lucidi (Nu Zhen Zi), 15g, cooked Radix Rehmanniae (Shu Di) and Sclerotium Poriae Cocos (Fu Ling), 12g each, Fructus Corni Officinalis (Shan Zhu Yu), Radix Dioscoreae Oppositae (Shan Yao), Cortex Radicis Moutan (Dan Pi), Rhizoma Alismatis (Ze Xie), Rhizoma Anemarrhenae Aspheloidis (Zhi Mu), and Cortex Phellodendri (Huang Bai), 9g each, and Cortex Cinnamomi Cassiae (Rou Gui), 3-6g.

Acupuncture & moxibustion: Jing Ming (Bl 1), Qiu Hou (M-HN-8), Feng Chi (GB 20), Zu San Li (St 36), San Yin Jiao (Sp 6), Tai Xi (Ki 3), Pi Shu (Bl 20), Shen Shu (Bl 23), Ming Men (GV 4), Qi Hai (CV 6), Guan Yuan (CV 4)

Formula analysis: Supplementing Zu San Li, San Yin Jiao, and Pi Shu supplements the spleen and upbears the clear, while supplementing Tai Xi and San Yin Jiao supplements the kidneys and enrich yin. Moxaing Shen Shu, Ming Men, Qi Hai, and Guan Yuan warms and invigorates yang. Even supplementing-even draining Jing Ming and Qiu Hou moves the qi and quickens the blood in the network vessels of the eyes, while draining Feng Chi clears heat in the head and eyes.

Additions & subtractions: For simultaneous liver depression, add even supplementing-even draining Tai Chong (Liv 3) and draining He Gu (LI 4). For simultaneous blood stasis, add draining Xue Hai (Sp 10) and He Gu (LI 4). 

Abstracts of representative Chinese research:

Zhang Hong-ming, "The Treatment of 50 Cases of Diabetic Retinopathy with Jiang Tang Yin (Lower Sugar Drink)," Si Chuan Zhong Yi (Sichuan Chinese Medicine), #3, 1999, p. 45: Of the 50 patients described in this study, 38 were male and 12 were female. They ranged in age from 42-71 years, with a median age of 52.5 years of age. The course of their disease had lasted from 5-21 years. All were diagnosed with type 2 (i.e., NIDDM) diabetic retinopathy according to the criteria promulgated at the 1985 National Eye Disease Symposium. Symptoms included decreased visual acuity, abnormal changes in the visual field, and abnormal changes in the eye ground. Twenty-eight cases had non-proliferative retinopathy, while 22 cases had the proliferative type.

Jiang Tang Yin consisted of: uncooked Radix Rehmanniae (Sheng Di), Radix Trichosanthis Kirlowii (Tian Hua Fen), and Semen Leonuri Heterophylli (Chong Wei Zi), 30g each, Rhizoma Anemarrhenae Aspheloidis (Zhi Mu), Tuber Ophiopogonis Japonici (Mai Dong), Fructus Pruni Mume (Wu Mei), Cortex Radicis Lycii Chinensis (Di Gu Pi), Cortex Radicis Moutan (Dan Pi), and Radix Rubrus Paeoniae Lactiflorae (Chi Shao), 15g each, uncooked Radix Dioscoreae Oppositae (Shan Yao), 60g, uncooked Gypsum Fibrosum (Shi Gao), 90g, Radix Scrophulariae Ningpoensis (Xuan Shen), 20-30g, Radix Salviae Miltiorrhizae (Dan Shen), 15-20g, Semen Cassiae Torae (Cao Jue Ming), 25g, and Flos Chrysanthemi Morifolii (Ju Hua), 10g. If there was qi vacuity, Radix Astragali Membranacei (Huang Qi) and Radix Pseudostellariae (Tai Zi Shen) were added. If there was skin itching, Cortex Radicis Dictamnia Dasycarpi (Bai Xian Pi) and Periostracum Cicadae (Chan Yi) were added. If there were skin infections, Flos Lonicerae Japonicae (Yin Hua), Fructus Forsythiae Suspensae (Lian Qiao), and Herba Taraxaci Mongolici Cum Radice (Gong Ying) were added. If there was relatively pronounced seepage, Rhizoma Atractylodis (Cang Zhu), Rhizoma Atractylodis Macrocephalae (Bai Zhu), and Semen Coicis Lachryma-jobi (Yi Mi) were added. The above were decocted in water and administered internally two times per day. Thirty days equaled one course of treatment.

Cure was defined as a return to normal of visual acuity and visual field. Any microanuerysms, bleeding, or seepage in the eye ground basically disappeared. Marked effect meant that visual acuity improved by three competencies or more and the visual field enlarged by 10-15E. Bleeding and seepage were either completely eliminated or greatly improved. Fair effect meant that visual acuity increased by two competencies, the visual filed enlarged by 5-10E, and any areas of bleeding and seepage shrunk. No effect meant that there was no marked change from before to after treatment. Based on the above criteria, six cases were deemed cured, 18 got a marked effect, 21 got a fair effect, and five got no effect. Thus the total amelioration rate was 90%.

Liu Li, “A Survey of the Treatment Efficacy of Qing Ying Tang (Clear the Constructive Decoction) as the Main Treatment for Bleeding of the Fundus of the Eye,” Zhong Yi Za Zhi (Journal of Chinese Medicine), #2, 2001, p. 101-102: This study describes the treatment of 68 out-patients with bleeding in the fundus of their eyes. Among these, there were 36 men and 32 women, 16 of whom had diabetic eye fundus bleeding. Qing Ying Tang was administered to all 68 patients based on the principles of clearing the constructive and out-thrusting heat, cooling the blood and dispelling stasis, and blandly seeping and eliminating dampness. The formula consisted of: Sclerotium Poriae Cocos (Fu Ling), 20g, uncooked Radix Rehmanniae (Sheng Di), Radix Salviae Miltiorrhizae (Dan Shen), Herba Lycopi Lucidi (Ze Lan), Lumbricus (Di Long), and Radix Scrophulariae Ningpoensis (Xuan Shen), 15g each, Fructus Forsythiae Suspensae (Lian Qiao), Herba Lophatheri Gracilis (Dan Zhu Ye), and Flos Lonicerae Japonicae (Jin Yin Hua), 12g each, and Rhizoma Coptidis Chinensis (Huang Lian), 3g. During the early stage of this condition, only this formula was administered. During the middle stage, based on the treatment principles of clearing the constructive and out-thrusting heat, quickening the blood and transforming stasis, and blandly seeping and eliminating dampness, Sheng Di was removed, 20 grams of Radix Astragali Membranacei (Huang Qi), 15 grams each of Flos Carthami Tinctorii (Hong Hua) and Radix Ligustici Wallichii (Chuan Xiong), and 1.5 grams of Radix Psuedoginseng (San Qi) were added. The San Qi was administered in 0.5 gram capsules, one capsule three times per day. During the latter stage, base don the principles of clearing the constructive and out-thrusting heat, enriching yin and dispelling stasis, softening the hard and scattering nodulation, Huang Lian and Sheng Di were removed and 30 grams each of Herba Sargassii (Hai Zao) and Thallus Algae (Kun Bu), 20 grams of Concha Ostreae (Mu Li), 15 grams each of Tuber Ophiopogonis Japonici (Mai Men Dong) and Radix Glehniae Littoralis (Sha Shen), and 10 grams of mix-fried Radix Glycyrrhizae (Gan Cao) were added. In addition modifications were also made on the basis of each patient’s pattern discrimination in terms of liver-kidney insufficiency, ascendant liver yang hyperactivity, yin vacuity fire effulgence, qi vacuity, and internal exuberance of phlegm turbidity.

Cure was defined as marked improvement in the symptoms, complete resolution of retinal bleeding, disappearance of edema, and increase in visual acuity by three of more degrees. Marked effect was defined as improvement of subjective symptoms, resolution of the greater part of retinal hemorrhage, disappearance of edema, and increase in visual acuity. Good effect meant that the subjective symptoms markedly improved and retinal bleeding was somewhat resolved. No effect meant that there was no improvement in subjective symptoms or possible worsening, decreased visual acuity, and worsening of ophthalmoscopic findings. Based on these criteria, 56 patients were judged cured, eight got a marked effect, and four got a good or fair effect. In terms of the outcomes amongst the 16 diabetic patients, 15 of these were judged cured and the other got a marked effect.

Cao Su-lan et al., "The Treatment of Diabetic Retinopathy with Zeng Shi Jiao Nang (Improve the Vision Gelatin Capsules)," Shan Dong Zhong Yi Za Zhi (Shandong Journal of Chinese Medicine), #5, 2000, p. 281-282:  From 1993-1999, the authors treated 52 cases of diabetic retinopathy using self-composed Zeng Shi Jiao Nang. The oldest patient was 78 years old and the youngest 35 years old. Thirty patients were male and 22 were female. The longest duration of diabetes was 30 years, the shortest duration was five years, and the average duration was 12.5 years. Of these 52 cases, 43 cases were affected in both eyes, while nine cases were affected in only one eye. In all of these cases, the pattern was primarily qi and yin dual vacuity with phlegm and stasis mutually binding. Six to eight capsules of Zeng Shi Jiao Nang were administered each time, three times per day. One month was considered one course of treatment, and, generally, three courses were administered. The treatment principles were to boost the qi and nourish yin, engender fluids and stop thirst, quicken the blood and transform stasis, and disinhibit water and transform phlegm. The formula consisted of: uncooked Radix Astragali Membranacei (Huang Qi), Fructus Lycii Chinensis (Gou Qi Zi), Radix Dioscoreae Oppositae (Shan Yao), Radix Puerariae (Ge Gen), and Radix Salviae Miltiorrhizae (Dan Shen), 30g each, uncooked Radix Rehmanniae (Sheng Di Huang), Fructus Leonuri (Chong Wei Zi), Thallus Algae (Kun Bu), and Herba Sargassii (Hai Zao), 20g each, Rhizoma Alismatis (Ze Xie) 15g, Fructus Citri Aurantii (Zhi Ke) 12g, and powdered Radix Pseudoginseng (San Qi), 5g.

Of these 52 cases, 82.6% experienced a marked effect. When those patients with moderate improvement were also included, the total amelioration rate rose to 100%. In additions, before treatment, the fasting blood sugar level was lower than 8.33mmol/L for only 31.73% of the 52 cases, but, after treatment, 68.27% of the 52 cases had a blood sugar level lower than 8.33mmol/L.

Liu Ling & Guo Xia, "The Treatment of Diabetic Retinopathy with Tang Mu Qing (Diabetic Eye-clearing Decoction)," Shan Dong Zhong Yi Za Zhi (Shandong Journal of Chinese Medicine), #3, 2000, p. 145-146: In this study, there were a total of 58 patients with diabetic retinopathy divided into two groups: a treatment group of 30 cases receiving Tang Mu Qing and a control group of 28 cases receiving Qi Ju Di Huang Wan (Lycium & Chrysanthemum Rehmannia Pills). In the treatment group, the ages ranged from 50-70 years old, with an average age of 58.6 years. There were nine men and 21 women in this group, and the duration of their diabetes was from 0.5-23 years, with an average duration of 10.38 years. The duration of the retinopathy was from 0.5-24 months, with an average duration of 5.7 months. In the control group, the ages ranged from 42-70 years old, with an average age of 59.6 years. There were eight men and 20 women in this group. The duration of the diabetes was from 1-18 years, with an average duration of 9.39 years. The duration of the retinopathy was from 2-23 months, with an average duration of 7.5 months.

Tang Mu Qing consisted of: Radix Astragali Membranacei (Huang Qi), uncooked Radix Rehmanniae (Sheng Di), Herba Epimedii (Xian Ling Pi), Radix Angelicae Sinensis (Dang Gui), Tuber Ophiopogonis Japonici (Mai Men Dong), Fructus Lycii Chinensis (Gou Qi Zi), Herba Gynostemmae (Jiao Gu Lan), Cortex Radicis Lycii Chinensis (Di Gu Pi), Rhizoma Alismatis (Ze Xie), Radix Puerariae (Ge Gen), and Radix Et Rhizoma Polygoni Cuspidati (Hu Zhang). These medicinals were boiled in water, and one ji was administered in two divided doses, morning and evening, every day. Thirty days was considered one course of treatment. After the symptoms were alleviated, the same presciption was administered in capsule form, 15 grams each time,  two times per day for another 30 days. If the bleeding in the fundus was heavy and the blood fresh, then Ge Gen and Xian Ling Pi were omitted from the basic formula, and Herba Cephalanoploris Segeti (Xiao Ji), Radix Rubiae Cordifoliae (Qian Cao Gen), and powdered Radix Pseudoginseng (San Qi) were added. If the fundus showed a large amount of seepage, then  Herba Lycopi Lucidi (Ze Lan), Thallus Algae (Kun Bu), Herba Sargassii (Hai Zao), and Radix Salviae Miltiorrhizae (Dan Shen) were added. If there were yellow spots or severe edema, then Sclerotium Poriae Cocos (Fu Ling), Rhizoma Atractylodis (Cang Zhu), and Semen Coicis Lachryma-jobi (Yi Yi Ren) were added. If the bleeding was not severe, the blood vessels were thin, and the retina was pale in color, then Radix Morindae Officinalis (Ba Ji Tian), cooked Radix Rehmanniae (Shu Di), Radix Pseudostellariae Heterophyllae (Tai Zi Shen), and Radix Albus Paeoniae Lactiflorae (Bai Shao) were added. The control group received Qi Ju Di Huang Wan,  nine grams each time, three times per day. One month was considered one course of treatment, and both groups were treated for six months. The treatment group had an amelioration rate of 93.1%, while the rate for the comparison group was only 82%.

Wang Da-qian, "The Treatment of 161 Cases of Diabetic Retinal Bleeding with Dan Qi Di Huang Tang (Salvia, Pseudoginseng & Rehmannia Decoction)," Bei Jing Zhong Yi (Beijing Chinese Medicine), #5, 1999, p. 25-26: The author of this study treated 161 patients in two groups of 106 and 55. In the treatment group of 106 cases, 65 were men and 41 were women. Their ages ranged from 48-70 years old, with an average age of 56.76. The duration of disease was 5-24 years, with an average duration of 14.67 years. The treatment group received Dan Qi Di Huang Tang which consisted of: Radix Salviae Miltiorrhizae (Dan Shen), 30g, uncooked Radix Rehmanniae (Sheng Di), 20g, stir-fried Pollen Typhae (Pu Huang) and Herba Dendrobii (Shi Hu), 15g each, Radix Rubrus Paeoniae Lactiflorae (Chi Shao), 12g, Cortex Radicis Moutan (Dan Pi), 10g, Rhizoma Cimicifugae (Sheng Ma), 6g, and  powdered Radix Pseudoginseng (San Qi), 3g, taken with the decocted medicinals. These medicinals were administered orally, one ji per day, 200ml each time in the morning and evening. The control group received Yun Nan Bai Yao Jiao Nang (Yunnan White Medicine Gelatin Capsules) together with Tong Sai Mai Pian (Free the Flow of Blocked Vessels Tablets) at a dosage of two tablets each time, two times per day for one month. For both groups, one month was considered one course of treatment. 

In the treatment group, 39.62% had marked improvement, 42.45% had moderate improvement, and 17.86% had no improvement. Thus the total amelioration rate in that group was 82.14%. In the control group, 32.26% had marked improvement, and 41.91% had moderate improvement. Therefore, the total amelioration rate in that group was only 74.19%.

Ling Bi-da, "The Treatment of Diabetic Retinal Bleeding with Integrated Chinese-Western Medicine," Bei Jing Zhong Yi (Beijing Chinese Medicine), #3 1999, p. 17-18. The author of this study treated 27 type 2 diabetics with retinopathy in a total of 36 individual eyes. Twenty-two of these had extensive areas of bleeding in the retina, 10 had bleeding due to proliferated vessels, and four had bleeding in the vitreous body. There were nine men in the study and 18 women. Their ages ranged from 55-76 years old, with an average age of 62.5 years. The duration of disease ranged from 3-16 years, with an average duration of 9.7 years. The patients were divided into two patterns: 1) liver-kidney yin vacuity with frenetic movement of hot blood (20 patients with 25 individual eyes) and 2) qi and yin dual vacuity with blood spilling outside the vessels (seven patients with 11 individual eyes). The Chinese medicinal formulas were administered orally, one ji per day, with 30 days as one course of treatment. Both patient groups continued with the Chinese medicinals for three months. 

The patients in the liver-kidney yin vacuity with frenetic movement of blood pattern presented with dizziness, tinnitus, tidal reddening of the face, a dry mouth with a sour taste, heart vexation, insomnia, low back and knee soreness and limpness, and diminished vision or sudden flashes of red in front of the eye. Their tongues were dark red with thin, white or thin, yellow fur, and their pulses were bowstring and fine.  The treatment principles for this group were to enrich and nourish the liver and kidneys, quicken the blood and transform stasis. The medicinals used were: uncooked Radix Rehmanniae (Sheng Di), 20g, Fructus Lycii Chinensis (Gou Qi Zi), Radix Scrophulariae Ningpoensis (Yuan Shen), Ramulus Loranthi Seu Visci (Sang Ji Sheng), Radix Achyranthis Bidentatae (Niu Xi), Radix Salviae Miltiorrhizae (Dan Shen), and Semen Cassiae Torae (Cao Jue Ming) 15g each, Flos Chrysanthemi Morifolii (Ju Hua) and Radix Puerariae (Ge Gen),12g each, Radix Angelicae Sinensis (Dang Gui), Radix Rubrus Paeoniae Lactiflorae (Chi Shao), and Herba Dendrobii (Shi Hu), 10g each, and powdered Radix Pseudoginseng (San Qi fen), 3g, taken with the decocted medicinals. 

The patients in the qi and yin dual vacuity with blood spilling outside the vessels presented with lack of strength, lassitude of spirit, dizziness, spontaneous perspiration, a sallow yellow facial complexion, a weak voice and/or disinclination to speak, and declining vision with sudden flashes of redness in front of the eyes or complete loss of vision. Their tongues were pale red and enlarged with thin, white fur, and their pulses were deep and fine. The treatment principles in this group were to boost the qi and nourish yin, quicken the blood and transform stasis. The medicinals prescribed were: Radix Pseudostellariae Heterophyllae (Tai Zi Shen) 30g, uncooked Radix Astralagi Membranacei (Huang Qi), 20g, uncooked Radix Rehmanniae (Sheng Di), Radix Scrophulariae Ningpoensis (Yuan Shen), Fructus Lycii Chinensis (Gou Qi Zi), Semen Cassiae Torae (Cao Jue Ming), and Radix Salviae Miltiorrhizae (Dan Shen), 15g each,  Flos Chrysanthemi Morifolii (Ju Hua) 12g, Radix Anemarrhenae Aspheloidis (Zhi Mu), Herba Dendrobii (Shi Hu), and Radix Angelicae Sinensis (Dang Gui), 10g each, and powdered Radix Pseudoginseng (San Qi fen), 3g, taken with the decocted medicinals. The patients in both groups also took oral doses of blood sugar controlling drugs to maintain their blood sugar levels in the range of 6-8mmol/L, together with vitamins C and E. The total amelioration rate for the 27 patients in this study after three months of treatment was 75%.      

Yang Hai-yan & Yang Jian-hua, “Clinical & TCD Observations on Frequency Spectrum of Ophthalmic Arterial Blood Flow in 61 Eyes with Diabetic Retinopathy Treated with Yi Shen Huo Xue Fang (Boost the Kidneys & Quicken the Blood Formula),” Zhe Jiang Zhong Yi Za Zhi (Zhejiang Journal of Chinese Medicine), #1, 2001, p. 30-31: There were 60 patients in this study who were divided into two group, a treatment group and a comparison group. Among these 60 patients, 29 were male and 31 were female. They ranged in age from 51-75 years, with an average age of 61.2 years. Thyeir course of disease had lasted from 4-20 years, with an average duration of 8.5 years. After division, there was no significant differences in terms of sex, age, or disease course between the two groups. All these patients had type 2 diabetes and retinopathy. Patients with type 1 dianetes, other endocrine disorders, or serious organic heart, liver, lung, or kidney diseases were excluded. The comparison group was treated with typical oral hypoglycemic drugs, such as glyburide. The treatment group also received these typical Western hypoglycemic medications as well as the following Chinese medicinal formula: Concha Haliotidis (Shi Jue Ming), 24g, Radix Scrophulariae Ningpoensis (Xuan Shen), 20g, uncooked Radix Rehmanniae (Sheng Di), cooked Radix Rehmanniae (Shu Di), Rhizoma Polygonati (Huang Jing), and Fructus Lycii Chinensis (Gou Qi Zi), 15g each, and Herba Dendrobii (Shi Hu), Radix Angelicae Sinensis (Dang Gui), Flos Carthami Tinctorii (Hong Hua), Radix Puerariae (Ge Gen), Caulis Milletiae Seu Spatholobi (Ji Xue Teng), Radix Achyranthis Bidentatae (Niu Xi), Cortex Eucommiae Ulmoidis (Du Zhong), and Fructus Citri Aurantii (Zhi Ke), 10g each. One ji of these medicinals was decocted in water and administered per day for one month

In terms of outcomes, marked effect was defined as visual acuity increasing by more than three steps, complete disappearance of eye ground blood vessel tumors, bleeding, and seepage or disappearance of at least the major portion of these, and improvement of peripheral vision by 10-15E or more. Improvement mean that visual acuity increased 1-3 steps or grades, eye ground blood vessel tumors, bleeding, and seepage partially disappeared, and peripheral vision increased 5-10E. No effect meant that the preceding criteria were not met or that the condition worsened. Based on these criteria, out of a total of 61 eyes in the treatment group, 27 eyes (44.26%) got a marked effect, 25 eyes (40.98%) improved, and nine eyes (14.75%) got no effect. In the comparison group, 13 eyes (25.00%) got a marked effect, 19 eyes (36.54%) improved, and 20 eyes (38.46%) got no effect. Hence there was a marked statistical difference in treatment outcomes between these two groups suggesting that Chinese medicinals combined with Western oral hypoglycemic agents is more effective for diabetic retinopathy than Western oral hypoglycemics alone. 

Wu De-yin, “The Treatment of 32 Cases of Diabetic Retinopathy Mainly by Quickening the Blood & Transforming Stasis,” Zhe Jiang Zhong Yi Za Zhi (Zhejiang Journal of Chinese Medicine), #4, 2000, p. 158: There were 32 patients in this study, 21 men and 11 women aged 38-62, with an average age of 52.6 years and a disease course of 3-18 years, with an average disease duration of 9.3 years. There were 19 cases of background DR, five cases of yellow macule pathological changes, six cases of preproliferative DR, and two cases of proliferative DR. Twenty-one cases presented the Chinese medical pattern of blood stasis and yin vacuity, and 11 presented blood stasis and qi vacuity. In addition to typical Western oral hypoglycemic agents, patients received the following Chinese medicinals: Radix Salviae Miltiorrhizae (Dan Shen), 30g, Pollen Typhae (Pu Huang), Herba Ecliptae Prostratae (Han Lian Cao), and Radix Rubiae Cordifoliae (Qian Cao Gen), 15g each, Radix Ligustici Wallichii (Chuan Xiong), Radix Rubrus Paeoniae Lactiflorae (Chi shao), Semen Pruni Persicae (Tao Ren), Radix Bletillae Striatae (Bai Ji), and uncooked Radix Rehmanniae (Sheng Di), 12g each, and Flos Carthami Tinctorii (Hong Hua), 10g. If there was accompanying yin vacuity, 15 grams of Radix Trichosanthis Kirlowii (Tian Hua Fen) and 12 grams each of Tuber Ophiopogonis Japonici (Mai Men Dong), Radix Scrophulariae Ningpoensis (Xuan Shen), Cortex Phellodendri (Huang Bai), and Radix Achyranthis Bidentatae (Niu Xi) were added. If there was simultaneous qi vacuity, 18 grams of Radix Astragali Membranacei (Huang Qi), 15 grams of Radix Codonopsitis Pilosulae (Dang Shen), and 12 grams each of Radix Pseudostellariae Heterophyllae (Tai Zi Shen), Rhizoma Atractylodis Macrocephalae (Bai Zhu), and Radix Dioscoreae Oppositae (Shan Yao) were added. If there was seepage into the eye ground, 30 grams of Fructus Crataegi (Shan Zha), 12 grams each of Endothelium Corneum Gigeriae Galli (Ji Nei Jin) and Massa Medica Fermentata (Shen Qu), and 10 grams of Fructus Amomi (Sha Ren) were added. If there was eye ground edema, 30 grams of Semen Coicis Lachyrma-jobi (Yi Yi Ren), 15 grams of Sclerotium Poriae Cocos (Fu Ling), and 12 grams of Semen Plantaginis (Che Qian Zi) were added. Patients were treated with this protocol from two weeks to three months, with an average length of treatment of 36 days.

Cure was defined as increase in visual acuity equal or more than 0.6 and complete control of eye ground bleeding and/or edema. Improvement was defined as recovery visual acuity two steps or stages or more, basic control of eye ground bleeding and/or edema, and a reduction in seepage. No effect meant that recovery of visual acuity was less than two steps or that there was no improvement in eye ground bleeding, edema, and/or seepage. Based on these criteria, 23 cases with background DR were cured and five improved. Three cases with yellow macule pathological changes were cured, four improved, and one got no effect. Five cases with preproliferative DR were cured and four improved. One case with proliferative DR improved and one got no effect. Hence, a total of 31 cases were cured and 14 improved using this protocol. 

Zhao Hong, “The Treatment of Diabetic Retinopathy Based on Pattern Discrimination,” He Nan Zhong Yi (Henan Chinese Medicine), #3, 2001, p. 54: There were 70 patients in this study with diabetic retinopathy, 44 men and 26 women aged 45-66 years old. All had suffered from diabetes for 8-20 years, and all had disease changes in both eyes. In addition to hypoglycemic and antidiabetic medications, these patients were administered Zhi Bai Di Huang Tang Jia Jian (Anemarrhena & Phellodendron Rehmannia Decoction with Additions & Subtractions): Radix Salviae Miltiorrhizae (Dan Shen), Radix Puerariae (Ge Gen), Rhizoma Alismatis (Ze Xie), Sclerotium Poriae Cocos (Fu Ling), and Radix Scrophulariae Ningpoensis (Xuan Shen), 30g each, Rhizoma Anemarrhenae Aspheloidis (Zhi Mu), Cortex Radicis Moutan (Dan Pi), uncooked Radix Rehmanniae (Sheng Di), Radix Dioscoreae Oppositae (Shan Yao), Fructus Corni Officinalis (Shan Zhu Yu), Radix Trichosanthis Kirlowii (Tian Hua Fen), and Semen Leonuri Heterophylli (Chong Wei Zi), 20g each, and Cortex Phellodendri (Huang Bai) and Lumbricus (Di Long), 15g each.

Prior to treatment, 17 cases had visual acuity less than 0.1 degree, 16 had 0.1-0.3 degrees, 13 had 0.4-0.6 degrees, and 24 had 0.6 to less than 1.0 degrees. After treatment, nine had visual acuity less than 0.1 degree, seven had 0.1-0.3 degrees, 11 had 0.4-0.6 degrees, and 43 had visual acuity of more than0.6 degrees. Altogether, 88% of the patients in this study experienced an increase in their visual acuity. Among these, 10 cases vision increased 1-3 steps, 16 improved 4-5 steps, and 15 improved more than five steps or grades.Only nine cases failed to experience a marked improvement in visual acuity from before to after this treatment.

Representative case histories:

Case 1 ^[9]

The patient was a 50 year old female who had had diabetes for eight years and had experienced blurred vision for three years. Previously, the patient had been taking three tablets of glibenclamide ^[10] orally per day. That and controlling her diet had managed to keep her blood sugar 11.2-16.5mmol/L, her urine glucose (++-+), and her urine ketone (-). The patient’s symptoms at the time of her initial examination were polydipsia, polyphagia, and polyuria, dizziness, blurred vision, dry stool, a red tongue with scanty fur, and a fine, rapid pulse. In the last few days, the woman’s vision was more blurry than usual. Ophthalmic examination confirmed diabetic retinopathy in both eyes complicated by cataracts.

Based on the above signs and symptoms, the woman’s Chinese pattern discrimination was categorized as yin fluid depletion and vacuity with dryness and heat. Therefore she was prescribed Qi Ju Di Huang Wan Jia Jian (Lycium & Chrysanthemum Rehmannia Pills with Additions & Subtractions): Herba Ecliptae Prostratae (Han Lian Cao) and Rhizoma Imperatae Cyclindricae (Bai Mao Gen), 30g each, Rhizoma Atractylodis (Cang Zhu), 20g, uncooked Radix Rehmanniae (Sheng Di), Radix Dioscoreae Oppositae (Shan Yao), and Rhizoma Alismatis (Ze Xie), 15g each, Fructus Lycii Chinensis (Gou Qi Zi), Radix Scrophulariae Ningpoensis (Xuan Shen), and Fructus Corni Officinalis (Shan Zhu Yu), 12g each, Flos Chrysanthemi Morifolii (Ju Hua), Scapus Et Inflorescentia Eriocaulonis Buergeriani (Gu Jing Cao), Cortex Radicis Moutan (Dan Pi), and carbonized Herba Seu Flos Schizonepetae Tenuifoliae (Jing Jie Sui), 9g each. One ji was decocted in water and administered orally per day. In addition, the woman was also prescribed 80mg of glibenclamide three times per day.

After one half month of this regime, the woman’s symptoms of diabetes were decreased with less frequent and less profuse urination and clearer vision. Her blood glucose was 11.2mmol/L and her urine glucose was (++). Ophthalmic examination showed that fresh retinal bleeding had stopped and the exudate was reduced. Twelve grams of Fructus Ligustri Lucidi (Nu Zhen Zi) was added to the original formula and this was administered continuously for another four months. At the end of that time, the woman’s blood glucose was 8.4mmol/L and her urine glucose was (+). Eye examination showed no fresh bleeding and reabsorption of part of the extravasated blood.

Case 2 ^[11]

The patient was a 50 year old female who had had diabetes for eight years and had experienced blurred vision for three years. Previously, the patient had been taking three tablets of glibenclamide ^[12] orally per day.That and controlling her diet had managed to keep her blood sugar at 11.2-16.5mmol/L. In addition, her urine glucose was (++-+) and her urine ketone was (-). The patient’s symptoms at the time of her initial examination were polydipsia, polyphagia, and polyuria, dizziness, blurred vision, dry stools, a red tongue with scanty fur, and a fine, rapid pulse. In the previous few days, the woman’s vision was more blurred than usual. Ophthalmic examination confirmed diabetic retinopathy in both eyes complicated by cataracts.

Based on the above signs and symptoms, the woman’s Chinese pattern discrimination was categorized as yin fluid depletion and vacuity with dryness and heat. Therefore, she was prescribed Qi Ju Di Huang Wan Jia Jian (Lycium & Chrysanthemum Rehmannia Pills with Additions & Subtractions): Herba Ecliptae Prostratae (Han Lian Cao) and Rhizoma Imperatae Cyclindricae (Bai Mao Gen), 30g each, Rhizoma Atractylodis (Cang Zhu), 20g, uncooked Radix Rehmanniae (Sheng Di), Radix Dioscoreae Oppositae (Shan Yao), and Rhizoma Alismatis (Ze Xie), 15g each, Fructus Lycii Chinensis (Gou Qi Zi), Radix Scrophulariae Ningpoensis (Xuan Shen), and Fructus Corni Officinalis (Shan Zhu Yu), 12g each, and Flos Chrysanthemi Morifolii (Ju Hua), Scapus Et Inflorescentia Eriocaulonis Buergeriani (Gu Jing Cao), Cortex Radicis Moutan (Dan Pi), and carbonized Herba Seu Flos Schizonepetae Tenuifoliae (Jing Jie Sui), 9g each. One ji was decocted in water and administered orally per day. In addition, the woman was also prescribed 80mg of glibenclamide each time, three times per day.

After one half month of this regime, the woman’s symptoms of diabetes were decreased with less frequent and less profuse urination and clearer vision. Her blood glucose was 11.2mmol/L and her urine glucose was (++). Ophthalmic examination showed that fresh retinal bleeding had stopped and the exudate was reduced. Therefore, 12 grams of Fructus Ligustri Lucidi (Nu Zhen Zi) were added to the original formula and this was administered continuously for another four months. At the end of that time, the woman’s blood glucose was 8.4mmol/L and her urine glucose was (+). Eye examination showed no fresh bleeding and reabsorption of part of the extravasated blood.    

Case 3 ^[13]

The patient was a 41 year old male who had been diabetic for eight years. Vision in both his eyes had declined over the last two years even though he had taken oral medications regularly for diabetes. During the previous week, he would suddenly lose his sight in both eyes and could only see his hands in front of his eyes. Examination revealed that the corpus vitreum contained accumulated blood and that the patient had little or no vision. He was also emaciated. This patient was given Dan Qi Di Huang Tang (Salvia, Pseudoginseng & Rehmannia Decoction) which consisted of: Radix Salviae Miltiorrhizae (Dan Shen) 30g, uncooked Radix Rehmanniae (Sheng Di), 20g, stir-fried Pollen Typhae (Pu Huang) and Herba Dendrobii (Shi Hu) 15g each, Radix Rubrus Paeoniae Lactiflorae (Chi Shao), 12g, Cortex Radicis Moutan (Dan Pi) 10g, Rhizoma Cimicifugae (Sheng Ma) 6g, and powdered Radix Pseudoginseng (San Qi) 3g, taken with the decocted liquid. The prescription was administered orally, one ji per day in two divided doses, 200ml each time in the morning and evening.

After seven days of these medicinals, the man’s vision in his right eye was 0.1 and in his left eye,  0.2.  Both eyes showed that the accumulated blood had been absorbed and blood vessels could be seen in the area of the fundus. After an additional week of this prescription, the vision in the patient’s right eye tested at 0.4 and in the left, at 0.5. One year later, both eyes tested at 0.3, but the retinal bleeding had not recurred.

Case 4 ^[14]

The patient was a 63 year old woman who had been diabetic for 12 years.  During the previous two months, dark shadowy shapes would appear from the side of this woman’s left eye. Examination revealed that the vision in the right eye was 1.0, but in the left eye was 0.04. Both eyes contained crystals and turbidity. She was given Dan Qi Di Huang Tang (Salvia, Pseudoginseng & Rehmannia Decoction) which consisted of:  Radix Salviae Miltiorrhizae (Dan Shen) 30g, uncooked Radix Rehmanniae (Sheng Di), 20g,  stir-fried Pollen Typhae (Pu Huang) and Herba Dendrobii (Shi Hu), 15g each, Radix Rubrus Paeoniae Lactiflorae (Chi Shao) 12g, Cortex Radicis Moutan (Dan Pi) 10g, Rhizoma Cimicifugae (Sheng Ma) 6g, and powdered Radix Pseudoginseng (San Qi), 3g, taken with the decocted liquid. The prescription was administered orally, one ji per day in two divided doses, 200ml each time in the morning and evening.  After 14 days on this prescription, the bleeding in the entire region of the fundus was absorbed, the woman’s vision improved to 0.6, and her vision did not decline even six months after stopping taking these medicinals.

Case 5 ^[15]

The patient was a 60 year old woman who had been diabetic for three years. While she was taking oral medications, her blood sugar levels remained close to 7mmol/L. Thinking that she no longer needed to observe good eating habits, the woman went off her diabetic diet, thinking that taking the orally administered  blood sugar lowering medications was enough. However, after two months, her blood sugar levels rose to 18.1mmol/L. Again, the oral dosages were adjusted to lower the blood sugar to 10mmol/L.  Six months later, she experienced sudden flashes of redness in front of her eyes, her vision declined, and she was diagnosed with retinal bleeding. The Chinese medical pattern discrimination was liver-kidney yin vacuity with frenetic movement of blood, and the treatment principles were to enrich and nourish the liver and kidneys, quicken the blood and transform stasis.

The medicinals used were: uncooked Radix Rehmanniae (Sheng Di) 20g,  Fructus Lycii Chinensis (Gou Qi Zi) 15g, Radix Scrophulariae Ningpoensis (Yuan Shen), Ramulus Loranthi Seu Visci (Sang Ji Sheng), Radix Achyranthis Bidentatae (Niu Xi), Radix Salviae Miltiorrhizae (Dan Shen), and Semen Cassiae Torae (Cao Jue Ming), 15g each, Flos Chrysanthemi Morifolii (Ju Hua) and Radix Puerariae (Ge Gen), 12g each, Radix Angelicae Sinensis (Dang Gui), Radix Rubrus Paeoniae Lactiflorae (Chi Shao), and Herba Dendrobii (Shi Hu), 10g each, and powdered Radix Pseudoginseng (San Qi), 3g, taken with the decocted medicinals. 

After taking this prescription for one month, much of the retinal bleeding had stopped, and, after an additional month on these medicinals, the bleeding had stopped completely and the vision was returned to its initial condition. In addition, the woman’s blood sugar levels remained normal. Then, for the next six months, this patient used this prescription without powdered San Qi with no recurrence of the problem.

Case 6 ^[16]

The patient was a 72 year old woman who had been diabetic for 12 years. Her dosage of oral hypoglycemic medication was 2.5mg each time, two times per day. Her blood sugar levels averaged between 6-7mmol/L, but, even so, she suddenly experienced a decline in her vision and red flashes in front of her eyes. Opthalmologic examination revealed bleeding anterior to the retina. The woman’s Chinese medical pattern discrimination was qi and yin dual vacuity with blood spilling outside the vessels, and the treatment principles were to boost the qi and nourish yin, quicken the blood and transform stasis. The medicinals prescribed were: Radix Pseudostellariae (Tai Zi Shen) 30g, uncooked Radix Astralagi Membranacei (Huang Qi) 20g, uncooked Radix Rehmanniae (Sheng Di) and Radix Scrophulariae Ningpoensis (Yuan Shen), Fructus Lycii Chinensis (Gou Qi Zi), Semen Cassiae Torae (Cao Jue Ming), and Radix Salviae Miltiorrhizae (Dan Shen), 15g each, Flos Chrysanthemi Morifolii (Ju Hua) 12g, Radix Anemarrhenae Aspheloidis (Zhi Mu), Herba Dendrobii (Shi Hu), and Radix Angelicae Sinensis (Dang Gui), 10g each, and powdered Radix Pseudoginseng (San Qi), 3g, taken with the decocted medicinals. After two months on this prescription, the bleeding finally stopped and the woman’s vision was restored to 0.1.

Case 7 ^[17]

The patient was a 56 year old woman who had been diabetic for 26 years. After pulmonary surgery five years previously, the woman’s blood sugar had become uncontrolled even after years of taking biguanide phenformin and Chinese medicinals. She had had three laser treatments for retinopathy, but the effects of each of the procedures had only lasted a few months. The patient presented with an emaciated body, a red facial complexion, a thin, red tongue with slimy, yellow fur, and a slippery, fine, rapid pulse. Medicinals to boost the qi and enrich yin were prescribed but were ineffective. Then, Wen Dan Tang Jia Wei (Warm the Gallbladder Decoction with Added Flavors) was prescribed as follows: Flos Chrysanthemi Morifolii (Ju Hua) and Sclerotium Poriae Cocos (Fu Ling), 15g each, Caulis Bambusae In Taeniis (Zhu Ru), Cortex Radicis Moutan (Mu Dan Pi), and bile-processed Rhizoma Arisaematis (Dan Nan Xing), 10g each, and Rhizoma Pinelliae Ternatae (Ban Xia), Pericarpium Citri Reticulatae (Chen Pi), and Fructus Citri Aurantii (Zhi Ke), 6g. After 17 ji, the patient’s facial complexion returned to normal, but her tongue was slightly red with thin, white fur.

Therefore, the prescribing physician thought that it was appropriate to nourish yin and supplement the kidneys. Hence, Zhi Bai Di Huang Tang Jia Jian (Anemarrhena & Phellodendron Rehmannia Decoction with Additions & Subtractions) was prescribed: Herba Ecliptae Prostratae (Han Lian Cao) 30g, Radix Pseudostellariae Heterophyllae (Tai Zi Shen) and Flos Chrysanthemi Morifolii (Ju Hua), 20g each, Sclerotium Poriae Cocos (Fu Ling) 15g, uncooked Radix Rehmanniae (Sheng Di), Radix Dioscoreae Oppositae (Shan Yao), Cortex Radicis Moutan (Dan Pi), and Radix Anemarrhenae Aspheloidis (Zhi Mu) 10g each, Cortex Phellodendri (Huang Bai) and Pericarpium Citri Reticulatae (Chen Pi), 6g each, and mix-fried Radix Glycyrrhizae (Gan Cao), 3g. The patient took this prescription continuously for three more months, at which time her blood sugar levels remained normal and her eyesight was stable.

Remarks:

1. Effective treatment of diabetic retinopathy with Chinese medicine depends on simultaneous effective control of glucose levels.

2. Like many contemporary Chinese authors, Li Zhen-zhong et al. ^[18] identify the disease mechanisms of diabetic retinopathy as qi and yin dual vacuity with insufficiency of the liver and kidneys and enduring blood stasis obstructing the network vessels of the eyes. However, they give an interesting series of modifcations for various ophathalmoscopic indications.  For instance, 30 grams of calcined  Concha Ostreae (Mu Li) and 15 grams of Thallus Algae (Kun Bu) can be added to various formulas to treat retinal bleeding. When the corpus vitreum is unclear or contains accumulated blood, one can add 30 grams of calcined  Concha Ostreae (Mu Li), 15 grams each of Thallus Algae (Kun Bu) and Spica Prunellae Vulgaris (Xia Ku Cao), and nine grams each of Squama Manitis Pentadactylis (Chuan Shan Jia), Radix Achyranthis Bidentatae (Niu Xi), Bombyx Batryticatus (Jiang Can), Herba Sargasii (Hai Zao), and Bulbus Fritillariae (Bei Mu). If there is fresh bleeding in the corpus vitreum or anterior to the retina, add 15 grams each of Herba Cirsii Japonici (Da Ji) and Herba Cephalanoploris Segeti (Xiao Ji) and nine grams each of Radix Rubiae Cordifoliae (Qian Cao Gen), Flos Immaturus Sophorae Japonicae (Huai Hua Mi), and Radix Rubrus Paeoniae Lactiflorae (Chi Shao). If the bleeding is in a deep layer of the retina and is accompanied by seepage of blood, add nine grams each of Herba Lycopi Lucidi (Ze Lan) and Tuber Curcumae (Yu Jin), six grams of Flos Carthami Tinctorii (Hong Hua), and three grams of powdered Radix Pseudoginseng (San Qi) taken with the decocted liquid. If the seepage of blood is considerable or the exudate is white or yellow in color, add nine grams each of Fructus Crataegi (Shan Zha) and Endothelium Coreum Gigeriae Galli (Ji Nei Jin). If there accompanying retinal edmea, add 12 grams of Sclerotium Poriae Cocos (Fu Ling) and 20 grams of Semen Coicis Lachryma-jobi (Yi Yi Ren). If retinal proliferation is extensive, add nine grams each of Radix Rubiae Cordifoliae (Qian Cao Gen), Flos Immaturus Sophorae Japonicae (Huai Hua Mi), Radix Rubrus Paeoniae Lactiflorae (Chi Shao), and Tuber Curcumae (Yu Jin).  When this condition is accompanied by peripheral neuropathy, add nine grams each of Cortex Erythriniae (Hai Tong Pi), Herba Siegesbeckiae (Xi Xian Cao), Caulis Millettiae Seu Spatholobi (Ji Xue Teng), and Radix Clematidis Chinensis (Wei Ling Xian). For albuminuria, add 30 grams of Radix Astragali Membranacei (Huang Qi), 18 grams of Herba Oldenlandiae Diffusae Cum Radice (Bai Hua She She Cao), and nine grams each of Rhizoma Imperatae Cylindricae (Bai Mao Gen) and Radix Dioscoreae Oppositae (Shan Yao). For swelling in the lower limbs, add nine grams each of Radix Achyranthis Bidentatae (Niu Xi) and Semen Plantaginis (Che Qian Zi). For concomitant constipation, add 3-9 grams of uncooked Radix Et Rhizoma Rhei (Da Huang) and nine grams of Semen Pruni (Yu Li Ren).

3. Vision degeneration problems are often difficult to treat satisfactorily with either fine needle acupuncture or internally administered Chinese medicinals. One explanation for this is that there is blood stasis in the grandchild network vessels which nourish the eyes, and fine needles are not so good for freeing the flow of the network vessels, especially in this region. Therefore, daily local self-massage, including tapotement around the orbits of the eyes, is recommended as local adjunctive therapy. Likewise, cupping, gua sha, and bleeding therapy may also be helpful adjunctively as these are more successful for freeing the flow of the network vessels and dispelling stasis.

4. If there is diabetic retinopathy and generalized signs and symptoms are not marked, this is mainly due to blood stasis. In that case, one should quicken the blood and transform stasis using formulas such as Tao Hong Si Wu Tang (Persica & Carthamus Four Materials Decoction) or Tong Qiao Huo Xue Tang Jia Jian (Free the Flow of the Orifices & Quicken the Blood Decoction) with additions and subtractions. According to Liu Li, whose study on fundal bleeding is presented above, this condition is intimately associated with blood stasis no matter what the other presenting patterns. The blood-quickening medicinals that Liu favors for the treatment of this condition are Radix Salviae Miltiorrhizae (Dan Shen), Herba Lycopi Lucidi (Ze Lan), Lumbricus (Di Long), Radix Pseudoginseng (San Qi), Flos Carthami Tinctorii (Hong Hua), and Radix Ligustici Wallichii (Chuan Xiong).

5. Daily supplementation of 1,000IU of vitamin E has been shown to help prevent retinal hemorrhage in patients with diabetic retinopathy. However, ingestion of 3,000IU of vitamin E per day may actually cause or promote retinal hemorrhage.

Endnotes: