Male, age 60. Initial Visit: January 5 ^th, 2009

Chief Complaint: Sudden ptosis presenting on the right side one day prior to treatment.

History: The patient noticed his right upper eyelid drooping and blocking his vision immediately afer waking one day prior to treatment with no obvious decrease of visual acuity.

Signs and Symptoms: The patient presented with ptosis on the right side, with the upper palpebral edge covering the upper edge of the iris by 5 mm, with normal movement of the eyeball and normal pupil refex towards the light in both eyes. Other symptoms include dizziness and fatigue. His body type was overweight. Urination was normal and bowel movements were regular. The tongue body was red with a white, greasy coating. The pulse was wiry.

Past History: Patient was diagnosed with diabetes two years prior to treatment.

The main characteristics of this patient are: sudden onset right-sided ptosis presenting one day prior to treatment, normal movement of the eyeballs, overweight with a history of diabetes. Other symptoms include dizziness, fatigue, normal urination and regular bowel movements. The tongue body was red with a white, greasy coating. The pulse was wiry. All these signs indicate a patern of wind phlegm. The fatigue is a sign of qi defciency.

The origin of this condition was in the eyelid, which belongs to the muscle wheel. The main organ associated with this condition is, therefore, the spleen.

WM diagnosis: Ptosis (right side)

TCM diagnosis: Drooping of the upper eyelid (right side) due to wind phlegm blocking the collaterals coupled with qi defciency

This case showed an underlying deficiency pattern with clinical manifestations of an excessive nature. The root etiology was due to wind phlegm attacking the collaterals, blood stasis and retardation of the sinews. Based on the principle of treating the branch symptoms first in acute cases, treatment should focus on wind phlegm attacking the collaterals and blood stasis. After the initial symptoms have been alleviated, then the treatment should shif to the root defciency.

Principles: Dispel wind, resolve phlegm, invigorate the blood and unblock the collaterals

Formula: Modifed Zhèng Róng Tāng (Face-Righting Decoction)

[正容汤加减]

[Method]

Precook the dry-fried bái fù zĭ for 30 min.

[Formula Analysis]

Fáng fēng, qiāng huó and qín jiāo are acrid and warm in nature as well as rising and dispersing to treat wind in the upper body.

Bái fù zĭ, zhì bàn xià and jiāng cán eliminate wind, transform phlegm and stop spasms.

Mù guā and huáng sōng jié soothe the sinews and invigorate the collaterals.

In order to invigorate the blood, wind should be eliminated first. Once the blood moves, wind will resolve independently, hence the use of chì sháo and hóng huā to move blood and dissolve stasis.

Chén pí moves qi and transforms phlegm.

Gān căo harmonizes the other medicinals.

Main points: GB 20 ( fēng chí), ST 40 ( fēng lóng), LV 3 ( tài chōng), BL 62 ( shēn mài)

Supplementary points: BL 2 ( cuán zhú), SP 10 ( xuè hăi), LI 4 ( hé gŭ), SJ 23 ( sī zhúkōng)

Method: Select two main points every day along with 2-3 supplementary points, alternating the points every other day. Retain the needles for 20 min afer obtaining needle sensation. 10 visits constitute one course of treatment.

Techniques: Mainly sedating technique.

Afer seven days of treatment, the ptosis showed some improvement. The upper eyelid was able to lif a litle, leaving the upper edge covering the iris by 3 mm. The other presenting symptoms remained the same.

Principles: Eliminate wind, transform phlegm, beneft qi, nourish and invigorate blood and open the collaterals

Formula: Modifed Zhèng Róng Tāng (Face-Righting Decoction) was repeated.

[Formula analysis]

Based on the patient’s medical history of being overweight, fatigued and diabetic, huáng qí (Radix Astragali) 30g and dān shēn (Radix et Rhizoma Salviae Miltiorrhizae) 15g were added to beneft qi, nourish blood and move stasis; thereby supporting the body’s immunity.