11) Seleritis: This is a collagen disease of the eye caused by auto-immunity, and is related to tuberculosis, leprosy, syphilis and endocrinal disturbance. The typical physical sign is localized purplish blood congestion on the lesion of the sclera, and iridocyclitis is a complication of this disease.
12) Glaucoma: This is a common dangerous eye disease, resulting in blindness due to increase of ocular pressure and progressive atrophy of the optic nerve. Patients of open-angle glaucoma may have blurred vision, slight ciliary congestion, slightly dilated pupils, sluggish light reflex and an apparent red and green halo around the light source. Patients of angle-closure glaucoma may have increase of ocular pressure, defect or reduction of the visual field and depression of the optic disc. Glaucoma can be divided into the congenital and secondary types.
13) Cataracts: This is an eye disease with opaque lens. Congenital cataracts in infants is caused by viral infection from German measles, mumps or chicken-pox in pregnant mothers; acquired cataracts in aged people is caused by turbidity in the equatorial cortex of the lens arranged in a radiating pattern. Turbidity of the lens can be clearly observed after the pupil is dilated.
14) Strabismus (squint): This is an eye disease with impairment of contraction of the extra-ocular muscles due to intracranial, intra-orbital or general diseases of the human body, and the patients may show deviation of the eyeball and impairment of movement of the eyeball, and suffer from poor orientation, dizziness and nausea due to double vision.
2. Inspection of the eyes and diagnosis of diseases of the whole body:
(1) Five wheels of the eyes and diagnosis of diseases:
According to the theory of the five wheels of the eyes (the blood, wind, qi, water and muscle wheels) in traditional Chinese medicine, the different wheels are correspondingly related to the five internal organs (Fig.3-1).
As mentioned in the ancient medical book, An Exhaustive and Comprehensive Survey of the Silver Sea: "For inspection of the eyes, the pupils should be observed first, and then the wind wheel, sclera, eyelids and canthi in sequence. The patient should stand straight, with the eyelids slowly opened with the fingers. The pupils are observed first; they may promptly dilate and contract in clear eyes. Then the wind wheel is observed, and the mental activity is normal if the iris can freely dilate and contract. Then the qi wheel is observed, and there is no sickness if the sclera is shiny and smooth. And finally, the muscle wheel is observed, and the eyelids can be forcibly opened and closed in normal subjects, and the canthi are not a dirty red color."
1) Water wheel: The water wheel is the pupil, 2-4 mm in diameter under ordinary light. The brightness of the pupil should be observed fh'st, and then its size and shape. A normal pupil can freely contract and dilate following the change of light it is smaller in a strong light and larger in a dim light. The pupils should be clean and transparent to clearly observe any subject. Both pupils should be round in shape and the same size. Excessive dilation or contraction, and change of color and transparency are all abnormal changes in a pupil.
Excessive dilation of a pupil is due to emotional disturbance, loss of essence and qi in the body or upward invasion of phlegm and fire pathogens; dilated pupils may appear in cases of acute diseases, such as apoplexy and in critical patients about to die; the sluggish response or loss of light reflex of pupils may appear in patients with coma; unequal pupils or irregular change of pupil size may be due to diseases of the central nervous system or disturbance of nervous control in the iris; unequal pupils, sluggish or abolished light reflex of pupils and mental confusion may be caused by dysfunction of the midbrain; and the bilateral dilation of pupils and loss of light reflex are physical signs of dying patients.
Constricted pupils may appear in patients with intoxication of chloropromazine, barbitals, morphine, organic phosphorous compounds and chloral hydrate, and the constriction is in proportion to the severity of intoxication; this condition may also occur in patients with epidemic encephalitis B and paralysis of the sympathetic nerves. The pupils of aged people are smaller than those of young people, because of deficiency of kidney qi. The reduction of the pupils in size is usually caused by injury to the liver and kidneys, or deficiency of vital energy.
2) Wind wheel (iris): The wind wheel is related to the liver, because the wind in the body is controlled by the liver. The upward protrusion of the upper border of the iris to form a dome is due to stagnation of excessive liver qi in meridians, poor dispersion of liver qi and upward accumulation of excessive qi.
A purplish red halo in a deep layer around the iris and arranged in a radiating pattern is due to blood stasis caused by excessive fire pathogens in the liver and gallbladder.
The vision may be interfered with by a layer of greyish white turbid membrane in the deep layer over the iris, produced by toxic heat pathogens in the liver and gallbladder, which can attack the eyes, consume body fluid and cause stasis and coagulation of blood.
In children with indigestive malnutrition, complication of the eyes is a serious disease with turbid fluid in the anterior chamber, and ulcerated and softened cornea of the eyes.
3) Qi wheel (sclera): The qi wheel is related to the lungs, because qi in the body is controlled by the lungs.
The yellow color on the sclera of jaundice is an early physical sign of liver disease: Red sclera indicates diseases of the heart; white sclera indicates diseases of the lungs; blue sclera indicates diseases of the liver and black sclera indicates diseases of the kidneys. In patients with red eye disease (acute conjunctivitis), the sclera is flesh red in color, with a hot sensation, shedding tears and difficulty in opening the eyes, and it is an infectious eye disease caused by toxic wind-heat pathogens and transmitted by the dirty secretion of the eyes. The bluish grey or purplish blue spots on the sclera are produced by attack of toxic heat and fire pathogens. Red nodules like immovable red beans protruding from the sclera without definite location are caused by toxic fire pathogens accumulated in the lungs, stagnation of wind, dampness and heat pathogens in the eye collaterals, and may also be caused by some general diseases of the body. The pterygium on the sclera may cover the cornea or protrude from the palpebral fissure, and it is caused by stagnation of toxic heat pathogens in the spleen and stomach produced after eating too much spicy and greasy food.
4) Blood wheel (canthi of eye): The blood wheel is related to the heart, because the blood is controlled by the heart.
In normal canthi of the eye, the fine blood vessels are red and vivid in appearance, without sticky and turbid discharge, and no blood vessels spread onto the cornea. The lacrimal gland and duct are patent.
The fine branches of the blood vessels spread from the canthus through the sclera onto the cornea are caused by accumulated heat pathogens in Sanjiao (tr.iple energizer), flaming up of heart fire, wasting of essence and blood, and upward attack of deficient fire due to anxiety or sexual intemperance. Lacrimation from the canthi of the eyes induced by attack of wind is caused by deficiency of liver blood, deficiency of qi and blood, invasion of wind pathogens and loss of control of lacrimation. The continuous shedding of tears is due to extreme sadness or deficiency of liver and kidney Yin, disturbance of the metabolism of the body fluids, upward flaming of deficient fire and loss of control of lacrimation. Red inner canthus is produced by upward flaming of heart fire; and red outer can-thus is caused by accumulation of fire in the gallbladder. Red canthi, shedding tears, red cheeks as shown in a drunken person, with cold fingers, are the prodromal symptoms of measles, and the canthi of the eyes are red in patients of typhoid fever.
5) Muscle wheel (eyelid): The muscle wheel is related to the spleen. The normal upper and lower eyelids can freely open and close to protect the eyeballs. The normal eyelid is soft, shiny and yellow in color, the eyelash is regularly arranged along the border of the eyelids and the palpebral conjunctiva is smooth and pink in color.
Dark eyelids indicate deficiency of the kidneys; blue eyelids indicate pain; light red and slightly swollen eyelids and a tired complexion indicate overfatigue; bright eyelids indicate disease caused by accumulation of phlegm and body fluid; dark eyelids indicate diseases caused by cold phlegm; edematous eyelids swollen like balls indicate deficiency of lung and spleen qi or deficiency of spleen and kidney Yang and upward invasion of warm pathogens; ptosis of both upper eyelids, interfering with the vision is due to deficiency of qi and blood, failure of spleen qi to support various organs of body in their normal position, invasion of wind pathogens or congenital deficiency of essence; patients with retracted lower eyelids incapable of covering the eyeballs are susceptible to diseases of the heart and respiratory system; symmetrical edema of both eyelids indicates general diseases of the whole body, such as severe anemia, malnutrition, insomnia, deficiency of the spleen and stomach, menopausal syndrome, chronic liver diseases and angioneurotic edema; unilateral edema of the eyelid is usually caused by local diseases. In normal people, the eyes may twinkle 5-6 times per minute; the eyes may seldom twinkle in patients with insensible cornea, facial palsy or exophthalmic hyperthyroidism; and repeated twinkling of the eyes may appear in patients with irritable conjunctiva, psychological disturbance and hysteria; the failure of closure of the eyes is a symptom of facial palsy; sudden downward staring is a sign of exhaustion of qi and spirit, and indicates a short life span; and automatic twinkling of the eyes may appear in children with dominance of the liver over the spleen caused by an improper
(2) Inspection of eye color and diagnosis of diseases:
As mentioned in the Miraculous Pivot: "Red color indicates disease of the heart; white indicates disease of the lungs; yellow indicates disease of the spleen; blue indicates disease of the liver; and black indicates disease of the kidneys."
Redness and swelling of the whole eye indicates wind and heat pathogens in the liver; red pupils are due to intra-ocular bleeding; red sclera is due to fire pathogens in the lungs; red eyelids with erosion is due to fire pathogens in the spleen; swelling and redness of the upper eyelids is due to wind-heat pathogens in the spleen; and swelling and redness of the lower eyelids is due to fire and heat pathogens in the stomach; redness in the canthi of the eye is due to fire pathogens in the heart; redness and erosion of the inner canthus is due to invasion of wind-heat pathogens to Shangjiao (upper energizer); redness and erosion of the outer canthus is due to accumulation of heat pathogens in the gallbladder; pale red color in the sclera is due to deficient heat pathogens; and red eyes, red face, tremor of the head, locked jaw, opisthotonus and stiffness of the neck and back are the physical signs of tetanus.
Black eyes in patients with moaning and difficulty in walking is due to invasion of cold and dampness pathogens into the bones; greyish black color below the eyes is due to accumulation of cold rheum in the body; dim color in the eyelids is due to deficiency of the kidneys; bright color in the eyelids is due to retention of rheum; black eyelids, ashen face and flaccid limbs are due to retention of wind phlegm in the body; a blue or dark grey halo around the eyes is due to listlessness, tiredness or insomnia; blue color in the canthi is due to liver disease; blue sclera is due to invasion of liver wind to the lungs; black eyes and pale face are due to emptying of blood vessels and loss of flushed color; black sclera indicates tuberculosis; bluish purple sclera and hollow and uneven pulse indicates tuberculosis in deficient patients with coagulated blood retained in the body; drunken eyes with tears, hot and flushed cheeks and slightly cold fingers are the prodromal physical signs of poxes and measles; and the reduction of black color in pupils and sluggish light reflex indicate the worsening of eye diseases.
Yellow sclera is due to diseases of the gallbladder; yellow pupil indicates a serious disease; dark yellow color in the sclera indicates indigestive malnutrition; yellow pupils, pale lips and blue spots on a red face are the prodromal physical signs of stroke; a faint color between red and yellow in the eyes of patients with diseases caused by external pathogens indicates the transmission of pathogens from the body's surface to internal organs of the body; yellow eyes and irritation indicate the deterioration of a disease; light yellow eyes indicate diarrhea due to deficiency of the spleen; and yellow sclera indicates retardation of urination. Yellow is a normal eye color in aged people.
White pupil is due to cataracts or turbidity of the cornea; white eyes and red face are due to anxiety; pale white canthus is due to deficiency of blood; white eyes and black face are due to wasting of kidney qi; pale white or light yellow pupils indicate deficiency of the kidneys; pale conjunctiva indicates anemia; pale and slightly puffy eyelids, shortness of breath, palpitations of the heart, low speaking voice, spontaneous sweating and general weakness are due to deficient cold pathogens in the spleen and stomach, and deficiency of qi and blood; black eyelids may appear in patients with allergic rhinitis and sinusitis; and greyish black eyelids may appear in women with leukorrhagia, amenorrhea and dysmenorrhea.
(3) Inspection of the movement of the eyeballs and diagnosis of diseases:
The normal eyeball is like a ball or pearl, and it can freely turn around. A protruded, depressed or deviated eyeball is an abnormal physical sign.
Protruded eyeball usually appears in patients with hyperthyroidism or intraorbital tumor; depressed eyeball may appear in patients with local inflammation; deviation of the eyeball to different degrees and in various directions is due to deficiency of qi and blood in intemal organs or relaxation of muscles and dilation of blood vessels caused by invasion of wind pathogens into a deficient body.
The sudden deviation and limitation of eyeball movement with double vision is due to deficiency of the spleen and block-age of collaterals hy phlegm and wind pathogens; sudden protrusion of a red eyeball from the palpebral fissure is due to accumulation of wind and heat pathogens in the five internal solid organs, prompt increase of Yang pathogens and upward attack of toxic heat pathogens, blocking orifices; downward inclination of the eyeball, like the sinking sun at sunset and limitation of movement of the eyeball is due to attack of wind and cold pathogens to the extra-ocular muscles and optic nerve; upward deviation of a single eyeball is due to deficiency of vital energy, weakness of subcutaneous interstices (defensive structures) and invasion of external pathogens, or is caused by external injury; and upward deviation of both eyeballs is due to disturbance of mental activity by upward attack of excessive fire and heat pathogens.
(4) Inspection of @dash and tears, and diagnosis of diseases:
In a healthy person black and sleek eyelashes are regularly arranged. The loss of eyelash reflex is a bad sign of a critical ailment; crying without tears is normal in babies below two months; the absence of tears in older children and adults is due to disturbance of secretion of the lacrimal gland; the absence of tears is due to deficiency of liver and kidney Yin, deficiency of Yin and blood, and exhaustion of body fluid in febrile diseases; itching and dryness in the eyes without tears is due to insufficiency of blood and attack of wind pathogens; shedding of tears with itching and swollen eyelids is due to insufficiency of qi and blood; constant shedding of cool tears with poor vision is due to deficiency of liver and kidney Yin; shedding of hot tears may appear in patients with heat syndrome; and shedding of tears due to cough and asthma may appear in patients with severe cough caused by wind-cold pathogens or whooping cough.
The constant shedding of tears may appear in patients with eyelids incapable of normal opening and closing, or blockage and constriction of the lacrimal duct due to rhinitis, external trauma, nasal polyps, deviation of the nasal septum or tumor in the nose; poor contraction of the orbicular muscle or scar formation on the lacrimal sac may also cause poor drainage of tears; and inflammation of the lacrimal duct, as in patients with styes, may also cause constant shedding of tears.
(5) Inspection of the brightness of eyes and diagnosis of diseases:
Normal eyes with good vision should show a clear and bright appearance, with a clear-cut margin between the black iris and white sclera.
A face like a dull mask with spiritless stating eyes is a facial appearance of psychiatric patients; eyes with dirty sclera, dark cornea, blurred vision, but without tears or gum are considered to be spiritless eyes; vertigo and blurred vision is due to deficiency of liver and kidney qi; and lusterless eyes with blurred vision is due to deficiency of blood and body fluid.
(6) Inspection of the eyebrows and diagnosis of diseases:
In general, the eyebrows of children are narrow, sparse and pale; they are thick and dense in youths; and the tips of the eyebrows are much longer in aged people. The eyebrows of male youths are broad, dense, dark and long, while they are narrow, long, curved and pale in women. This is a normal variation of eyebrows in human beings.
Sparse eyebrows may appear in patients with endocrinal dysfunction due to necrosis, tumor, inflammation or incision of the pituitary gland; sparse eyebrows are a prodromal sign of mucoid edema and leprosy; complete loss of eyebrows may appear in patients with leprosy, presenility, alopecia areata and alopecia totalis; and white eyebrows may appear in patients with vitiligo and viral iridocyclitis.
(7) Inspection of the eyes and diagnosis of general diseases:
The eyes are closely related to the organs in the body, and the early symptoms of some diseases may first appear in the eyes. The common diseases with symptoms appearing in the eyes are as follows:
1) Severe anemia: Retinal bleeding and pale fundus of the eye may appear in patients with severe anemia.
2) Polycythemia: Retinal bleeding, purplish red, engorged and tortional veins on the retina and dark red retina may appear in patients with polycythemia.
3) Leukemia: Pale fundus, retinal bleeding and engorged and tortional veins may appear in patients with leukemia. The local infiltration or nodules may appear on the eyelids or mass in the orbit of one or both eyes, causing protrusion of the eye.
It is called chloroma and more common in children with acute or subacute granulocytic leukemia.
4) Acute nephritis: Edema of the eyelids may appear in patients with acute nephritis.
5) Diabetes mellitus: Thickness of the lens is increased, producing a transient myopia within a short period when the blood sugar is increased; transient hyperopia may occur when the blood sugar is decreased; and the vision is normal when the disease is under control.
6) Chronic nephritis and uremia: Constriction and reduction of the calibor or retinal artery, retinal edema and flocculent exudate may appear in patients with chronic nephritis with uremia; and edema of the optic disc may appear in severe cases.
7) Gout: Superficial scleritis and uveitis may appear in patients with gout.
8) Deficiency of vitamin A: Night blindness and dryness of the cornea and conjunctiva may appear in patients with this disease.
9) Deficiency of vitamin B1: Retrobulbar neuritis may appear in people drinking too much alcohol over a long period of time or in breast-feeding women.
10) Deficiency of vitamin B2: Keratitis and neoformation of corneal blood vessels may appear in patients with this disease.
11) Deficiency of vitamin C: Subcutaneous bleeding of the eyelids, subconjunctival bleeding and retinal bleeding may appear in patients with this disease, and intra-orbital bleeding with protrusion of the eyeballs may appear in children.
12) Rheumatic fever and rhematoid arthritis: Kuperficial keratitis, keratitis and iridocyclitis may appear in patients with these diseases.
13) Influenza: Conjunctivitis and optic neuritis may appear in patients with influenza.
14) Infectious hepatitis: Icteric sclera and tiredness of the eyes may appear in patients with hepatitis, and night blindness may occur in severe cases.
15) Scarlet fever with septicemia: Metastatic internal ophthalmitis, and orbital cellulitis may appear in patients with this disease.
16) Tuberculosis: Vesicular keratoconjunctivitis, scleritis, choroiditis, retinal periphlebitis and optic neuritis may appear in patients with tuberculosis.
17) Ascariasis: Edema and urticaria on the eyelids may occur in patients with ascaris.
18) Malaria: Keratitis caused by herpes simplex virus may, appear in patients with malaria with high fever.
19) Cerebral schitosomiasis: Septic edema and secondary optic nerve atrophy may appear in patients with this disease.
20) Measles: Conjunctivitis may appear in the early stage, and cornea softening in the late stage of this disease.
21) Chickenpox: Vesicles may appear on the eyelids, conjunctiva and cornea in patients with chickenpox.
22) Epidemic parotitis (mumps): Iridocyclitis and keratitis may occur in patients with this disease.
23) Epidemic encephalitis B: Paralysis of the extra-ocular muscles, failure of accommodation and dilation or spastic constriction of the pupils, sluggish or abolished light reflex and optic edema during increase of intracranial pressure may appear in patients with this disease, and optic nerve atrophy may appear in the late stage of this disease.
24) Diphtheria: Diphtheric conjunctivitis, keratitis, paralysis of the extra-ocular muscles and failure of accommodation may appear in patients with diphtheria, but the pupils are normal.
25) Whooping cough: Subcutaneous bleeding of eyelids and subconjunctival bleeding may appear in patients with whooping cough, and retinal bleeding may appear in severe cases.
26) Tuberculous meningitis: Paralysis of the extra-ocular muscles, uneven or dilated pupils, optic neuritis and optic edema may appear in patients with this disease.
27) Hydroencephalus: Optic edema, optic nerve atrophy and downward displacement of the eyeballs with exposure of the upper part of the sclera may occur in patients with hydroencephalus.
28) Electrical injury: Cataracts may appear a few days or a few years after electrical injury, and severe impairment of vision may occur as a result of optic nerve injury.
29) Poisonous snake or insect bite: Kerotoconjunctivitis, dilation of the pupils, impairment of accommodation, ptosis of the eyelids and paralysis of the extra-ocular muscles may appear in patients of poisonous snake or insect bite.
30) Irregular menstruation: Edema of the eyelids, congestion of the conjunctiva, compensatory subconjunctival bleeding, retrobulbar optic neuritis, cyclitis and glaucoma syndrome may appear in women with irregular menstruation.
31) Menopausal syndrome: Headache, tiredness and pain in the eyes right after a short period of reading which can not be relieved by wearing glasses, and dry kerotoconjunctivitis due to reduction of lacrimal excretion may appear in patients with this disease.
32) Migraine: Scintillating dark spots in the central area of the visual field and spreading to its peripheral part with a frequency of more than 10 times per second and lasting for 10-20 minutes may appear before the onset of migraine. Fundoscopic
examination of eyes is normal.
33) Neurasthenia: Tiredness of the eyes, poor vision, double vision, photophobia and shedding tears may appear in patients with neurasthenia, but examination finds the eyes to be normal.
34) Hysteria: Sudden blindness in one or both eyes with-out dilation of the pupils may appear in patients with hysteria. The light reflex is active, the fundoscopic examination is normal and the patients do not dodder as they walk.
35) Rhinitis and sinusitis: Reflective lacrimation may appear in patients with acute rhinitis; congestion, swelling, tendemess and inflammation of the eyelids may appear in patients with acute sinusitis; orbital cellulitis may appear in cases with disseminated inflammation.
36) Tonsilitis: Relaptic iridocyclitis, retinal choroiditis and retrobulbar optic neuritis may appear in patients with tonsilitis.
37) Nasopharyngeal cancer: Paralysis of the extra-ocular muscles and double vision may appear in patients with this tumor, and protrusion of the eyeballs may appear in cases with invasion of tumor into the orbit.
38) Periodontitis and alveolar abscess: Keratitis, sclerotitis, retinitis, optic neuritis and orbital cellulitis may appear in patients with periodontal infection.
39) Herpes simplex: Vesicles may appear on the eyelids, and keratitis caused by herpes simplex virus may occur in patients with this disease.
40) Leprosy: Nodules on the eyelids, loss of eyebrows and eyelashes, small leprotic nodules on the palpebral conjunctiva, sclera, margin of the cornea and surface of the iris, diffuse conjunctivitis, keratitis, scleritis and iridocyclitis may appear in patients with leprosy; incomplete closure of the eyelids in cases with damage to the facial nerve; dryness of the cornea and conjunctiva due to reduction of lacrimal secretion may occur in cases with damage to the lacrimal glands and paralysis of the extra-ocular muscles and disturbance of movement of the eyes may occur in cases with damage to the abducent and oculomotor nerves.
41) Syphilis: Inflammation of the corneal stroma, syphilitic iridocyclitis and diffuse retinal choroiditis may appear in patients with syphilis; optic neuritis, atrophy of the optic nerve and blindness may occur in cases with damage to the optic nerve.