Treatment Of Central Serous Chorioretinopathy With Acupuncture, Moxibustion, And Chinese Herbal Medicine: A Case Report

By Sara Almaraz, DAOM, MAcOM, MSACN

Introduction

Central serous chorioretinopathy (CSC) represents a complex ocular condition marked by fluid accumulation beneath the macula, potentially leading to significant vision impairment (Mrejen et al., 2019; Singh et al., 2023). Since its initial description by von Graefe in 1866, the understanding of CSC has evolved considerably, reflected in its various historical nomenclature such as recurrent central retinitis and capillarospastic central retinitis (Zhang et al., 2023). These shifts in terminology mirror advancement in understanding pathophysiology from early theories of vasospasm to current knowledge of choroidal hyperpermeability (Nicholson et al., 2013). Modern diagnostic techniques, particularly fluorescein angiography and optical coherence tomography, have been instrumental in identifying the characteristic fluid leakage from the retinal pigment epithelium (Ebrahimiadib et al., 2023).

Known risk factors for CSC encompass stress, corticosteroid use, and various conditions suggesting a psychophysiological etiology. Current biomedical management strategies range from conservative approaches focusing on stress reduction to more interventional treatments such as laser photocoagulation and photodynamic therapy (Lee et al., 2016; Kianersi et al., 2022; Manayath et al., 2018; Gupta & Tripathy, 2023).

Traditional Chinese medicine (TCM) offers a paradigm that contextualizes blurred vision (shizhan hunmiao) within broader systemic imbalances, particularly those affecting Spleen qi and Kidney qi (Pacific College of Health and Science, 2015; Wang et al., 2022). This perspective guides the application of acupuncture, moxibustion, and herbal medicine to address the underlying causes of vision impairment. The integration of TCM in treating CSC demonstrates the potential value of alternative medical approaches, particularly for patients seeking options beyond conventional Western medicine.

This case report aims to bridge the gap between biomedical and traditional diagnostics, offering a nuanced exploration of CSC treatment through the lens of both conventional and TCM methodologies. By situating the patient's experience within this integrative framework, the study emphasizes the importance of a multifaceted approach to eye health that honors the complexity of human physiology and the diverse traditions of medical practice.

Case Description

The patient is a 65-year-old female business owner who presented with a chief complaint of diminished vision in the left eye. She was initially assessed by a licensed ophthalmologist who diagnosed her with cataracts. A second opinion yielded a diagnosis of CSC with early-onset cataracts. Visually, she reported that things seemed dim and color was hard to distinguish.

Reading had become difficult without bright lights. However, she became sensitive to bright overhead lights and sunlight. She described waking in the morning with a constant black spot that impaired vision in her left eye.

Additionally, she reported itching in her left ear and left-sided nasal congestion. Energy levels were very low. She often had a hard time falling asleep staying asleep, and would wake between 3 and 4 am every morning.

Emotionally, she felt depressed and said that she had a propensity to cry easily, which she had done for many years. Words and phrases such as vulnerability, kindness to oneself, and being cared for by others provoked her emotionally. She also reported that traumatic events where she lived often created turmoil and episodes of sadness and crying. She found it difficult to accept help and felt like she was being a burden.

The patient shared that she started a company over twenty years ago out of her home as a single mother and had continued to be the head of the company, although it had grown from a sole proprietorship to having 25 employees. She acknowledged of her own accord that she often would take on too much work and had difficulty delegating tasks to others to lighten her workload. She was very proud of her accomplishments, although it had been a great sacrifice; she lived alone and had no significant other.

Her temperature tended to be cold, and she often wore sweatshirts, jackets, and other warm clothing. She reported 1-2 bowel movements per day, loosely formed. She had an occasional sense of urgency with urination, and citrus foods made it worse. Her periods had stopped with menopause in 2008. Exercise consisted of a 1.5-mile walk to work. Her diet included dairy, fruits, rice, and beans. She had a history of sporadic eating, for instance, eating on the run or going for 8 to 12 hours without eating.

The patient walked to and from work daily. She was friendly, open, and adamant about pursuing acupuncture and TCM rather than Western medical treatments. Her tongue appeared moist, pale pink, concave in the middle, scalloped and puffy, concave in the mid-center. Her pulse was moderate, thin, and soft, the left side slightly choppy in the cun and guan positions. Her body image appeared to match the Spleen body type, as indicated by her soft, puffy skin, which was tender upon palpation.

Diagnostic Assessment

The disease name in TCM for blurred vision is "shizhan hunmiao" (Fatrai et al., 2015). The TCM diagnostic patterns in this case were Spleen qi deficiency with damp accumulation and Kidney yang deficiency. These patterns were both the cause and result of the failure of water and dampness to transform, causing them to accumulate in the interior and rise upwards toward the eyes, leading to the development of CSC.

The rationale for the diagnostic patterns can be found in the patient's symptoms of low energy, loose and urgent bowel movements, and a tendency to feel cold, indicating a deficiency in Spleen qi. The Spleen in TCM is responsible for warming and transforming food and fluids; if it is weakened, it can lead to damp accumulation. The presence of dampness was evidenced by complaints of itching in the left ear and left-sided nasal congestion.

Lastly, the patient's patient's sensitivity to cold, preference for wearing extra layers of clothing, and moderate, thin, and soft pulse with the left side slightly choppy in the cun and guan positions point to Kidney yang deficiency. Kidney yang provides warmth to the body, and its deficiency can lead to cold intolerance and reduced metabolic activity (Maciocia, 2013).

Emotionally, the patient's propensity to cry easily, feelings of depression, and difficulty accepting help from others indicate emotional vulnerability and a tendency towards Kidney qi and yang deficiency.

Furthermore, her lifestyle and work habits, such as taking on too much work, difficulty delegating tasks, sporadic eating, and long hours without eating, can also contribute to Spleen qi deficiency and damp accumulation. The patient's tongue and pulse observations, such as a pale pink, moist tongue with a concave shape in the middle and a moderate, thin, and soft pulse with the left side slightly choppy in the cun and guan positions, further supporting the diagnosis of Spleen qi deficiency with damp accumulation and Kidney yang deficiency (Fatrai et al., 2015; Maciocia, 2013).

Treatment and Outcomes

The therapeutic approach was designed around three primary treatment principles: warm the yang, transform dampness, and tonify the Spleen and Kidneys to address the presenting symptoms of CSC and the underlying pattern imbalances. The treatment goals were to improve vision and eliminate dampness.

Acupuncture points used were auricular Sympathetic, Shenmen, Endocrine, and Eye. Distal points were KD3 Rangu, KD6 Zhaohai, KD16 Huangshu, KD27 Shufu combined with SP6 Sanyinjiao, SP9 Yinlingquan, SP15 Daheng, ST25 Tianshu, ST36 Zusanli, ST40 Fenglong, ST25 Tianshu, Ren 4 Guanyuan, Ren 12 Zhongwan. Local points were UB2 Cuanzhu, Yuyao, SJ23 Sizhukong, GB1 Tongziliao and Bitong. A tonification technique was used on the distal points. This involved the needles being inserted with inhalation and withdrawn with exhalation. A reducing technique of breathing in when the needle was inserted and breathing out when the needle was withdrawn was used on local points (Fatrai et al., 2015; Deadman et al., 2016).

Okyu-style moxibustion was used directly above the hairline of the left brow eyebrow and at ST36 (Zusanli), ST40 (Fenglong), SP9 (Yinlingquan), and SP6 (Sanyinjiao). These points were indicated by the TCM condition of blurred vision (shizhan hunmiao) with the diagnostic patterns of Spleen qi deficiency and damp accumulation and/or Kidney yang deficiency (Weizenbaum, 2014; Kim et al., 2011; Deng & Shen, 2013).

The region along the eyebrow contains points UB2 (Cuanzhu), Yuyao, SJ23 (Sizhukong), GB1 (Tongziliao), and Taiyang. Stimulating these points with moxibustion can help improve local circulation and qi flow around the eyes. As CSR had affected vision in the left eye of this patient, moxibustion in that area could enhance blood and qi flow, potentially promoting healing and reducing the symptoms. The acupuncture point ST36 (Zusanli) is one of the most well-known and widely used in TCM. It is known for its ability to tonify Spleen qi, strengthen digestion, and promote overall vitality. By applying moxibustion to ST36 (Zusanli), the patient's Spleen qi deficiency would be addressed, a key aspect of the pattern diagnosis (Kim et al., 2011; Deng & Shen, 2013; Thorne et al., 2014).

Blurriness resolved after 35 acupuncture treatments, three times per week.

Simultaneously, a modified granule formula provided a targeted approach while addressing the complexities of the vision problems (Fatrai et al., 2015; Liu et al., 2019; Lou et al., 2020). A dose of 16g of fu shen was added to address the patient’s emotions while increasing the formula's efficacy. It was recommended that the patient take 6 grams two times per day for 14 days. After 14 days, improvement was observed and so the formula was continued.

Table 1. Granule Herbal Formula: Shen Qi Wan, modified (KPC)

A second herbal formula involving herbs that regulate the blood, cooling herbs, and blood invigorating as a steam bath for the eyes was recommended (Rosenfarb, 2007). Instructions were for the herbs to be decocted, simmered for 15-20 minutes, and then transferred to a vessel for the steam bath, allowing the face to be directly over the bowl to allow the steam to rise, daily eye steams for three months.

Table 2. Raw Herbal Formula: Eye Steam (Spring Wind Herbs, Inc.)

Lifestyle recommendations were made and a follow-up with her biomedical specialist advised.

The patient reported back at three and six months that the symptoms were entirely resolved and imaging had confirmed that scar tissue was gone.

Discussion

Central serous chorioretinopathy, characterized by fluid accumulation beneath the macula, often raises treatment challenges. In this case, the TCM diagnostic lens identified patterns of Spleen qi deficiency with damp accumulation and Kidney yang deficiency, the underlying systemic imbalances, in addition to the ocular symptoms.

The selection of acupuncture points and the utilization of Okyu-style moxibustion were designed to facilitate the flow of qi, dispel cold, and nourish vital organs. Improved health meant restoring harmonious balance to multiple aspects of being.

Herbal formulas and an eye steam treatment furthered the TCM approach, which also took into account the patient's emotional well-being, lifestyle habits, and environmental factors. This approach's safety and efficacy helped resolve the patient's CSC symptoms.

However, it is important to acknowledge the limitations of this case report. As a single instance, it does not apply to a broader population, which requires more study with numerous subjects. A notable strength of the case report is the dialogue and collaboration between TCM and biomedical approaches which supported patient care and evidence-based practice.

Conclusion

TCM provides a multifaceted approach to understanding and addressing vision problems, attributing them to distinct patterns and interconnected organ systems. The harmonization of qi and yin-yang balance underpins an individualized approach to treatment. This case is an example of how TCM may diagnose and treat complex health conditions in conjunction with integrative biomedicine.

Informed Consent

The patient provided written informed consent for the publication of this case report, and a copy is on file with the author. There were minimal safety concerns during treatment, and no adverse events were reported.

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