FLOATERS AND THEIR TREATMENT WITH CHINESE HERBS

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FLOATERS AND THEIR TREATMENT WITH CHINESE HERBS

by Subhuti Dharmananda, Ph.D., Director, Institute for Traditional Medicine,

Portland, Oregon

The nature of floaters can be understood in terms of the fluid in which they

occur, namely the vitreous. This is a gel matrix filling the vitreous cavity,

making up about 2/3 the volume of the eye. In front of it is the lens

structure, behind it is the retinal structure. The vitreous is a transparent

gel, about 98% water, but it is 2-4 times more viscous than water, mainly due

to the content of sodium hyaluronate (the salt of hyaluronic acid, a

component of many fluid structures in the body). The hyaluronic acid

molecules are large coils that hold water; in the vitreous they are entrapped

in a matrix of collagen fibers (type II, the main fiber making up cartilage).

Most of the collagen is at the surface region of the vitreous, where it comes

in contact with the rest of the eye, giving it a somewhat more solid surface.

There is less collagen in the central region, which is a more liquid portion,

comprised of about 99% water. Collagen fibrils attach the vitreous gel to

points around its margin, particularly to the retinal and lens structures.

The vitreous mainly functions as a transparent fill for the eyeball. The

fluid maintains the shape of the eye, acts as a shock absorber, allows

transmission of light to the retina, and helps maintain the contact between

the retina and the back wall of the eye by applying a mild pressure. It

contains no blood vessels and is essentially cell free. A few cells may be

present near the retina, including hyalocytes that appear to be responsible

for producing hyaluronic acid; these are similar to immune cells called

macrophages. Aside from hyalocytes, there are other sources of the vitreous

components among the various types of cells of the eye structure, though it

is not yet established which ones play a key role.

The original three-dimensional net-like structure of collagen fibers begins

to deteriorate once body growth has halted at adolescence. This deterioration

is slow and involves having some strands of collagen clump up, and some of

the original compartments of gel merge into larger compartments. At this

point, " floaters " may begin to appear. Many people believe that these

floaters are materials released into the eye, when, in fact, they are shadows

on the retina from light encountering the irregularities in the gel matrix.

Such irregularities are mainly caused by coalesced collagen filaments,

forming fibrils. The floaters are especially visible while looking at a

plain, well-lit background.

 

It is not until middle age, around age 40, that there are significant changes

in the vitreous that generate floaters. The vitreous begins to slowly dry

out, and the collagen becomes more clumped, leaving the vitreous almost

entirely a free flowing fluid with some intervening gel lumps. These produce

the floaters that are most frequently reported. They tend to " float " more

easily because of the breakdown of the gel matrix. Nothing needs to enter the

vitreous to make these floaters and nothing is present to break down the

floaters, so they remain for many months. They may eventually degrade or

settle out, or they may persist.

With further aging, the vitreous will dry, thicken, and shrink to an extent

that it starts to pull away from the retina (the condition is called

posterior vitreous detachment). This process may be the result of a sudden

drying of the fluid, rather than the gradual drying that is normally

expected. When a sudden vitreous shrinkage occurs, there can be a substantial

appearance of floaters over a short period.

While vitreous detachment through a gradual process is common by age 70, it

occurs more often and sometimes earlier in people who are nearsighted, have

undergone cataract surgery or laser eye surgery, or who have an inflammatory

disease of the inner portion of the eye, such as retinitis. When the vitreous

gel pulls away from the retina, nothing may happen (vision remains basically

the same), but this pulling can cause some retinal tears. Tearing of the

retina may allow some blood cells to flow into the vitreous cavity, which

accounts for some of the new floaters; other floaters may appear as a result

of contraction of the fibers that had been attaching the vitreous to the

retina.

When a retinal tear occurs, some of the vitreous fluid can penetrate into the

torn areas and lift away the rest of the retina, which is extremely thin,

leading to partial or full detachment. During retinal tearing or detachment,

flashes of light (like flurries of fireflies) are detected by the patient,

and the vision may be blurred, particularly in certain portions of the visual

field. The torn retina should be examined carefully, as it may require

treatment, such as laser photocoagulation, cryopexy (freezing), or surgery,

to avoid complete retinal detachment or to treat a detached retina.

The condition of the vitreous fluid and the nature of floaters are observed

by dilating the eye (applying eye drops to do so), and then examining the

region through the pupil. There are no medical treatments for floaters. Some

floaters, particularly those that occur as a young adult, will eventually

disappear as the gel matrix changes. Other floaters, particularly those that

occur in later years, may disappear as they settle out of the fluid. In

persons suffering from severe disorders of the vitreous, which occurs in some

cases of diabetes or where injuries have allowed blood into the vitreous, a

vitrectomy may be performed; the vitreous is removed and placed with an

artificial substitute liquid called hyaluronate.

POSSIBLE CAUSATIVE FACTORS

Little is known about what causes the changes in the vitreous with age, and

what can speed up or slow down the process. It is relatively easy to

speculate on some potential causes. It is known that excessive exposure to

sunlight can cause damage to the eyes and skin, and is a contributor to

cataract formation and drying, wrinkling skin. There is no reason to think

that these types of effects could not occur in the vitreous to some extent,

perhaps contributing to the clumping of the collagen fibers and the drying of

the fluid. Hence, a rational protective effort would be to utilize good

quality sunglasses and, in cases where there is considerable exposure to sun,

to utilize shading (such as a visor or hat). Similarly, one should be careful

about exposure to bright lights from copy machines, lasers, and other indoor

sources. The drying of fluid within the eyes may be accelerated by poor

circulation in the retina (capillary bed circulation) and by general lack of

hydration. Blood circulation can be worsened by high blood sugar, high blood

fat, and high oxidative levels in the blood, while it can be improved by

maintaining healthy blood conditions and having a diet rich in flavonoids and

antioxidants; hydration is improved by drinking plenty of water, juice, tea,

or other healthy beverages. Thus, protecting the eyes and maintaining good

circulation and hydration are potential preventive measures for floaters,

retinal tearing, and retinal detachment.

CHINESE MEDICAL VIEWS

In the Yinhai Jingwei (Essential Subtleties on the Silver Sea), a text on

ophthalmology from the time of the Ming Dynasty (1), there is a discussion of

floaters, described as " black blurred specks in the eyes resembling fly

wings. " The pathology is said to be related to the " water of the kidney "

refers to the kidney yin, as distinguished from the " fire of the kidney, "

which corresponds to the kidney yang or mingmen fire:

[Floaters] are a sign of weakness of the water of the kidney. The kidney is

the mother of the liver. If the water of the kidney can not nourish the wood

of the liver, the liver will display deficiency heat. The gallbladder lies

beside the liver. If the wood of the liver is withered and parched, the qi of

the gallbladder will be insufficient. As a result, whenever one starts or

halts a movement of the head, black specks resembling fly wings float in the

spirit water of the eyes. To regulate this condition, one must first employ

Zhuling San (Polyporus Powder) to return the evil fire in one's liver and in

the kidney to normalcy. Next, one employs Heishen Tang (Scrophularia

Decoction) to cool the liver. Then the conduit of the gallbladder will no

longer be invaded by evil heat. Afterward, one employs Bushen Wan (Supplement

the Kidney Pills). Then the black specks will disappear by themselves.

The formulas mentioned for this condition are as follows:

Zhuling San(Polyporus Powder)

Polyporus 30 g

Akebia 30 g

Rhubarb 30 g

Gardenia 30 g

Cibotium 30 g

Talc 30 g

Polygonum 30 g

Plantago seed 15 g

Red atractylodes 15 g

Instructions: grind the ingredients to powder; one dose is 9 grams, to be

consumed with salty water. Actions: This formula clears damp-heat of the

liver/gallbladder and the kidney/bladder; it is comprised mainly of bitter

herbs of cold nature. Most of the herbs are classified as diuretic in modern

terms; rhubarb and gardenia purge the gallbladder.

Heishen Tang(Scrophularia Decoction)

Scrophularia Scute

Raw rehmannia Chrysanthemum

Red peony Celosia

Tribulus

Instructions: to grind the ingredients in equal parts to powder. Each

dose is 12 grams, with the powder boiled in water for a brief time and the

resulting decoction consumed. Actions: These herbs clear heat from the blood

and dispel wind-heat from the eyes.

Bushen Wan(Supplement Kidney Pills)

Ginseng Acorus

Hoelen Lycium

Peony Cuscuta

Alisma Cistanche

Instructions: grind equal amounts of these herbs to powder, mix with

honey to form pills. The quantity of the herbs to be used for each dose is

unclear. Actions: This formula nourishes the kidney and moistens the essence.

 

The same text includes a description of retinal detachment, as " the eyes turn

dull and develop specks: "

Retinal detachment is caused by depletion in the kidney. Even though the eyes

belong to the orifices [that is, the eyes are the orifices associated with

the liver], they are tied to the kidneys as their ruler. When the kidney is

depleted, the eyesight will become dim. Greed, licentiousness, overindulgence

in pleasures, and an unrestrained passion for wine and women weaken and

exhaust the kidney. Or, when a person's original qi and essence are

incomplete, or when essential spirits have become insufficient, all this

causes the pupil and the spirit water to lose their clarity and the eyes to

be without strength. As a result, the eyes develop specks and the patient is

unable to watch anything for an extended time. To regulate this condition,

one must employ Bushen Guijing Wan (pills to nourish the kidney and return

the essence). They cause the yin water to be sufficient again, and to return

everywhere.

Bushen Guijing Wan (Pills to nourish the kidney and return the essence)

GinsengAtractylodesHoelenLicorice Chiang-huoEquisetumChrysanthemumSiler

TribulusBuddleiaCelosiaCistanche PeonyCnidiumAchyranthesCuscuta

The instructions are to grind the herbs to powder, combine with honey, and

form pills, or boil the powder in water to make a decoction. The total amount

of herbs to be consumed for each dose is unclear. This formula includes

several herbs for nourishing the eyes and dispelling wind-heat.

According to this text, the fluid in the vitreous cavity is viewed as an

integral part of the kidney water, or yin essence. When the kidney's yin

essence is depleted, not only does the eye fluid become drier, but the wood

of the liver/gallbladder system dries out. This causes a turbid essence to go

upward from the gallbladder, and a weak fire to arise from the liver and

kidneys, which combines with invading wind and distorts the fluid contents of

the eye. The gallbladder channel starts at the corner of the eye (tongziliao;

GB-1, a point indicated for redness and pain of the eyes, failing of vision,

and excess tearing). The remedy is to lower the fire, clear it, and then

replenish the fluids.

Just as modern medicine recognizes the vitreous fluid as an original fluid of

the developing eye, the Chinese doctrine views it as part of the " original

water " associated with the kidney, but located in the upper body (referred to

as heavenly original water; tian yizhi shui). It degrades by the weakening of

the kidney and the invasion of pathogenic influences, such as internal heat

from the liver/gallbladder and external wind-heat.

A formula devised after the Yinhai Jingwei was written, Qi Ju Dihuang Wan

(Lycium, Chrysanthemum, and Rehmannia Formula), is an example of an eye

nourishing prescription used to treat this basic condition. Similarly, the

eye-brightening formula, Mingmu Dihuang Wan (Eye-brightening Rehmannia

Formula) is aimed at alleviating the dry deficiency of kidney and liver. Yet

another formula, Yiqi Congming Tang, is designed to clear the deficiency heat

and dispel wind-heat, while benefiting the kidney water indirectly, by

nourishing the spleen. It is indicated for deteriorating vision with aging.

In the English-Chinese Encyclopedia of Practical Traditional

(2), there is a short section on diseases of the vitreous. The clinical

manifestations are said to range from mild cases with black shadows floating

up and down like flying flies (but no other change in vision) to severe

cases, where the eyes seem to be covered by a membrane. There are three

categories of causation listed:

· Accumulation and steaming up of damp-heat and attack of turbid qi. This

corresponds to the disorder of the gallbladder described above. A recommended

formula is modified Sanren Tang (Three Seed Decoction), which clears

damp-heat.

· Stagnation of liver qi, resulting in blood stasis and extravasation of

blood. This corresponds to the leakage of blood into the vitreous cavity,

perhaps as a result of retinitis. A recommended formula is modified Jiawei

Xiaoyao San (Bupleurum and Peony Formula).

· Deficiency of kidney and liver, resulting in flaring up of deficiency

fire. This corresponds to the weakness of the kidney water, and associated

heat that causes drying of the vitreous. The recommended formula is a

modified Zhibai Dihuang Tang (Anemarrhena, Phellodendron, and Rehmannia

Formula).

SUMMARY

Floaters are rarely caused by release of materials into the eye, and are not

a sign of blood deficiency, as is often relayed to Western acupuncturists.

Rather, they are a result of natural processes that may be exacerbated or

accelerated by overexposure to sunlight, poor circulation in the retina, and

lack of hydration, along with deficiency of yin essence and associated

flaring of deficiency heat or accumulation of damp-heat. Although there is no

proof that the formulas described in the Chinese texts can eliminate floaters

and prevent retinal detachment, the use of the herbs and formulas described

here is consistent with the basic tenets of the Chinese medical system. In

general, one wishes to clear deficiency heat, gently dry damp-heat, and

nourish the fluids, particularly the kidney yin, to assure the moistness of

the vitreous.

REFERENCES

1. Kovacs J and Unschuld PU, Essential Subtleties on the Silver Sea, 1998

University of California Press, Berkeley, CA.

2. Xu Xiangcai (chief editor), The English-Chinese Encyclopedia of Practical

Traditional , vol. 17: Ophthalmology, 1994 Higher Education

Press, Beijing.

December 2002