Diabetic retinopathy (DR) is a blinding eye disease characterized by occlusive circulatory disorders of the retinal vessels as the main pathological changes. There are a series of pathological changes such as retinal tissue edema, macular cystoid edema, and retinal hemorrhage.
Ophthalmic examination reveals ocular signs such as retinal microangiomas, hemorrhagic spots, hard exudates, soft exudates (cotton wool spots), edema, proliferative mechanized degeneration; retinal vascular sclerosis, small artery occlusion and neovascularization; limited or diffuse macular edema, ischemic macular lesions; vitreous hemorrhage, proliferation, etc. According to the complex characteristics of diabetic retinopathy, it is simple and proliferative type II; the degree of diabetic retinopathy is divided into six stages.
It is often complicated by retinal neovascularization, recurrent hemorrhage of retinal vitreous, proliferative retinopathy, tractional retinal detachment, and neovascular glaucoma, resulting in severe visual dysfunction and even blindness.
Modern medicine believes that: early pathology is selective capillary microangioma formation. Hyperglycemia leads to increased blood viscosity, increased energy consumption for blood flow, reduced red blood cell energy supply, microthrombus formation in microvasculature, repeated bleeding, bleeding, fibrosis and even tractional retinal detachment, resulting in blindness. In case of ocular retinopathy, treatment of the primary disease diabetes, control of hyperglycemia, blood pressure and blood lipids should be accompanied by the timely application of ophthalmic vasoprotective agents and blood barrier stabilizers, such as Guoxin, calcium hydroxybenzene sulfonate tablets and aspirin. Supplemented with retinal laser treatment if necessary, the purpose of laser treatment is to destroy the hypoxic retina, reduce oxygen consumption, and avoid the creation of neovascularization. Vitreoretinal retinoplasty is also required for severe proliferative lesions.
Early diagnosis and treatment is of positive significance. Fundus fluorescence angiography (FFA) provides quantitative estimation of the extent and size of capillary occlusion, i.e., nonperfused areas; diagnosis of the nature, extent, and degree of macular lesions (edema, cystic degeneration, ischemia, etc.); precise estimation of the location and activity of neovascularization; and biological information for treatment, efficacy assessment, and prognosis of diabetic retinopathy. Fundus fluorescence angiography (FFA) reveals microangioma-like hyperfluorescence, capillary dilatation, window-like defects, and retinal areas of portless perfusion with pigment epithelial dysfunction that help in the early diagnosis of glycoplasia to guide treatment and judge the course of treatment.
Diabetic retinopathy is one of the serious complications of diabetes mellitus. The Treatise on the Three Disorders says: “Those who are thirsty, many change deafness and blindness, sores, acne and so on, are dry and hot fries in the intestines and stomach, and water cannot infiltrate the surrounding body.”
According to the Chinese medicine, diabetic retinopathy belongs to the category of thirsty eye disease, cloud shift, storm blindness, and dim vision. Patients with this disease are characterized by excessive drinking, polyphagia, polyuria, urine sugar and elevated blood glucose, and the eyes may be asymptomatic at the beginning, or may only have clinical manifestations such as flashing sensation, flying mosquitoes, diminished visual acuity, frontal shadow, sudden drop in visual acuity, etc., with non-specific self-conscious symptoms. The “Review of Yaohuan? Firefly star full of eyes” records: “This disease is said to have countless fine red stars outside the eyes, such as fireflies flying chaos, and even as lights sweeping stars carry on ……” “secret evidence of the treatment of the key? Three elimination” said: “three elimination for a long time, the essence of blood both deficit, or eye no see, or hand and foot bias such as wind disease, non-wind”.
The author observes: the etiology of diabetic retinopathy is mostly a deficiency of the root cause and symptoms, and the evidence of mixed deficiency and reality. Most of the disease is caused by deficiency and deficiency leads to stasis; the disease affects the upper, middle and lower jiao, burnt and qi, blood, yin and yang, and the internal organs and meridians are out of order. It is a multi-factorial, diversified and complex pathological changes of multiple internal organs and meridians in the reaction of the eye. Most of the diseases are caused by the deficiencies of the body, poor diet, excessive strain, and internal injuries of the seven emotions, resulting in dryness and heat in the internal organs, deficiency of essence and fluid, poor blood flow, deficiency of yin and yang over time, deficiency of qi and yin, stagnation of qi and blood, inability to support the eye ligaments, and loss of nourishment of the eye essence. Internal obstruction, stagnation of blood vessels and veins, all lead to damage to the eye ligaments, blood does not follow the meridians, the eyes lose their nourishment, and dizziness, blurred vision, and even blindness.
The Three Treatises on Dissipation: “The thirsty are deaf, blind, sore, acne and so on, all of which are dry and hot in the stomach and intestines, so that the water is not able to infiltrate the body.” “Therefore, we know that the eyes, ears, nose, tongue, body, mind, and consciousness can be used, all have the access to lift and lower, and some closed, it can not be used.” “If the eyes do not see, the ears do not hear …… have heat and fries, and the xuanfu is closed, and the fluids and blood, and the clear air of the glory and health, can not rise and fall.” Review of the Yaohuan? The “storm blindness”: “This disease is said to be the eye plainly no other disease, outside does not hurt the contours. Inside does not damage the pupil God, suddenly blind and not seen also …… is the disease of occlusion Guange. The disease is caused by Yang injury, because of anger and violence, wanton wine and spices. Good dry and greasy. And long suffering from fever phlegm fire people get it. Then irritable secret thirst.”
As the sugar network is a deficiency, the three jiao deficiency is mixed with the real, and the qi, blood, yin and yang atmosphere is disordered. Stasis and heat are intertwined, phlegm and dampness are not transported, dryness and heat are accumulated within the body → yin deficiency and fire → qi and yin are deficient → yin and yang are deficient → qi and blood are out of order, and blood stasis is throughout the disease. Therefore, in the diagnosis and treatment, the four diagnoses must be combined, local and systemic identification must be combined, identification treatment and staging treatment must be complementary, Chinese medicine treatment must be applied, and multi-wavelength laser treatment must be applied at the right time to effectively control the course of the disease.
I. Identification treatment
1.Dry heat in the lung and stomach
Main evidence: easy to eat and hunger, emaciation, irritability and insomnia, dry stool, light red tongue, yellow coating, slippery pulse, retinal hemorrhagic spots and exudation on fundus examination, mainly hemorrhage.
Treatment: Clearing heat and fire, cooling the blood and stopping bleeding prescription: Baihu Tang plus or minus gypsum, Zhi Mu, pedicel rice, raw grass, Huang Lian, Sheng Di Huang, Mai Men Dong, Gardenia, Niubizi, Mudan Pi, Panax notoginseng, wolfberry, wild chrysanthemum.
Addition and subtraction: constipation with rhubarb and xuan ginseng; bleeding with small thistle and white foxglove.
2.Dampness due to spleen deficiency and phlegm obstruction
Main symptoms: heavy head and dizziness, dizziness of the eyes, vision like clouds covering the clear, chest tightness and fullness, heavy limbs and dullness, loose stools, light red tongue, white greasy coating, moist and smooth pulse. Fundus examination is based on retinal edema and exudation, with little bleeding.
Treatment: Strengthening the spleen and drying dampness, resolving phlegm and clearing the channels.
Addition and subtraction: phlegm plus gall bladder, tiredness and weakness plus Radix et Rhizoma Ginseng, Radix Astragali, Atractylodes Macrocephala.
3.Yin deficiency internal heat
Fundus examination shows bright red microangioma, punctate hemorrhage, or a small amount of hard exudation.
Treatment: Nourish Yin and lower fire, moisten dryness and resolve stasis.
Add and subtract: thirsty with asparagus, genistein, kudzu, dendrobium; frequent urination with yam, wolfberry, mulberry cuttlebone; retinal bleeding bright red with white foxglove, acacia, artichoke, small thistle to cool the blood and stop bleeding
4, the main evidence of Qi and Yin deficiency: the face is less florid, fatigue, less breath and lazy speech, dry throat, spontaneous sweating, five heartburn, light fat tongue, weak pulse or fine count. Microangioma, speckled hemorrhage, retinal edema and hard exudation are seen in the fundus of the eye.
Treatment: Benefit qi and nourish yin, resolve blood stasis, prescriptions: Shengwen San and Qi Ju Dihuang Tang plus or minus Dang Shen, Mai Men Dong, Wu Wei Zi, Cornus officinalis, Astragalus, Peony Peel, Yam, Ze Di Di, Shu Di Huang, Poria, Wolfberry, Chrysanthemum. Take 1 dose daily with water decoction.
Add or subtract: spontaneous sweating, night sweating, add raw oyster, floating wheat; retinal edema, more significant exudation can be added poria, psyllium, motherwort.
5.Spleen and kidney deficiency
Main symptoms: emaciation or fatness, dizziness and tinnitus, pale yellow face or floating fat, impotence, frequent nocturia or long clear urine, cold form and cold limbs, pale white tongue, sunken weak pulse. Hard exudation, cotton wool-like white spots, hemorrhage, retinal edema or macular cystoid edema in the fundus of the eye.
Treatment: Nourish the kidneys, warm the yang, strengthen the spleen and remove stasis.
Add and subtract: retinal edema plus psyllium, Chen gourd; increased cotton wool white spots plus Fuxin, Zhe Bei Mu, Atractylodes, Danshen.
6.Blood stasis and internal obstruction
Main symptoms: Chest tightness, dizziness, numbness of limbs, dark tongue with petechiae, stringent or thin pulse. Retinal veins are filled with uneven thickness, small blood vessels in the retina are twisted into tufts or new blood vessels are seen, patchy hemorrhage occurs repeatedly or blood accumulates in the vitreous, and mechanized film is formed.
Treatment: To remove blood stasis and stop bleeding at the early stage of bleeding.
Radix et Rhizoma Ginseng, Radix Astragali, Radix et Rhizoma Yam, Radix et Rhizoma Dioscorea, Radix et Rhizoma Senna, Radix et Rhizoma Drynaria, Radix et Rhizoma Bupleurum, Radix et Rhizoma Thistle, Radix et Rhizoma Charcoal.
In the late stage of hemorrhage, it is advisable to invigorate blood circulation and remove blood stasis, softening and dispersing the knots.
Radix Angelicae Sinensis, Radix Paeoniae Alba, Radix et Rhizoma Glycyrrhiza Glabra, Rhizoma Zelkova, Rhizoma Charcoal, Oyster, Radix Achyranthes Bidentatae, Radix Salviae Miltiorrhizae, Radix Quinquefolium, Rhizoma Alba.
Add and subtract: if there is new bleeding again, add hemostatic and stasis-removing medicine, Pu Huang, Xi Cao Root, Xian He Cao; if there is edema in macular area, add Ze Lan, Yi Mu Cao, Che Qian Zi.
Second, staged treatment.
1.Simple stage.
Yin deficiency and internal heat type has irritation and thirst, frequent urination or thin and hungry, weakness of waist and knees, dark red tongue or red side tips, and fine pulse. Small bright red hemangiomas and small bleeding spots are seen in the fundus of the eyes, with little hard exudation. This type is more common, and the treatment is to nourish Yin, clear heat and eliminate blood stasis. Basic formula: smallpox powder, genistein, raw groundnut, yam, yucca, kudzu, salvia, henbane, fried rhubarb, gypsum, Zhi Mu, raw fried pueraria, large and small thistle, rhubarb charcoal, buckwheat leaves.
Spleen deficiency and weakness: generalized fatigue and fatigue, shortness of breath and lazy speech, or poor appetite and loose stool, easy to see fatigue, dark and fat tongue with teeth marks, weak pulse, small hemangioma, hard exudate, omental edema. Treatment is to strengthen the spleen and benefit the qi. Basic formula: Radix Astragali, Radix Astragali, Rhizoma Atractylodis Macrocephalae, Rhizoma Atractylodis, Rhizoma Zeleniae, Poria, Radix et Rhizoma Gastrodiae, Radix et Rhizoma Dioscoreae, Fried Hawthorn, Cornus Officinalis, White Lotus Seed, Rhizoma Polygonati.
2, Pre-proliferative.
Stasis and bleeding type of retinal vein filling and anger, vascular condensation, bleeding. Treatment is to nourish Yin and resolve blood stasis. Basic formula: Astragalus membranaceus, Radix et Rhizoma Dioscorea, Radix et Rhizoma Drynariae, Radix et Rhizoma chastea, Radix et Rhizoma Bupleurum, Radix et Rhizoma Alba, Radix et Rhizoma Senna, Radix et Rhizoma Rheum, Radix et Rhizoma Lotus, Radix et Rhizoma Thistle.
Stasis obstructing exudation type is dominated by oedema of the ocular retina. The treatment is to benefit the qi and strengthen the spleen, resolve stasis and eliminate dampness and eliminate stasis. Basic formula: Radix Astragali, Rhizoma Atractylodis Macrocephalae, Atractylodes Macrocephalae, Poria, Salviae Miltiorrhizae, Zelenia, Radix Angelicae Sinensis, Fructus Sempervis, Rhizoma Polygonati, Zeleniae Sinensis, Plantago ovatae (separately wrapped decoction), Pericarpium Citri Reticulatae.
3. Proliferative phase treatment.
Laser with total retinal photocoagulation; vitrectomy; Chinese medicine treatment as an adjunctive treatment.
Blood stasis retention type: multiple bleeding, vitreous hemorrhage, treatment to activate blood circulation, remove blood stasis, move Qi and eliminate stagnation method.
Basic formula: Astragalus, Yam, Salvia, Atractylodes, Radix et Rhizoma, Ginseng, Radix et Rhizoma, Radix et Rhizoma, Radix et Rhizoma, Radix et Rhizoma, Radix et Rhizoma, Radix et Rhizoma, Radix et Rhizoma, Radix et Rhizoma, Radix et Rhizoma.
Proliferative mechanized type: fibroproliferative membrane, mechanized striae. Treatment is to benefit the qi and support the righteousness, soften the hardness and disperse the knots method basic formula: Astragalus, Atractylodes, Yam, Chuanxiong, mother of pearl, turtle nail, Zhebei mother, raw oyster, sea clam powder, kombu, seaweed, safflower.
The organic combination of Chinese medicine treatment and retinal laser complement each other’s advantages
The combination of traditional Chinese medicine and retinal laser can reduce the damage of laser on macular tissue on the one hand, and bring the advantages of overall regulation of traditional Chinese medicine on the other. For example, macular edema of diabetic retinopathy is the main cause of visual impairment, which is the comprehensive result of damage to the internal and external barrier of macular area, prone to recurrent attacks, resulting in irreversible central vision. Low-energy laser photocoagulation, local photocoagulation with lattice-like photocoagulation or C-shaped photocoagulation is often used to promote the absorption of macular edema and exudate. For proliferative diabetic retinopathy, the combination of Chinese and Western medicine is often used to benefit Qi and nourish Yin, dispel phlegm and promote water retention or warm Yang and promote water retention, with oral Chinese medicine taking the formula of nourishing the kidney, strengthening the spleen and resolving stasis as the basic formula (Cornu Cervi Pantotrichum, Astragalus, Shijiazhuang, Pueraria Mirifica, Baishijian, Radix et Rhizoma, Cortex Eryngium, Panax Ginseng, Rhizoma Rheum); for Qi and Yin deficiency, benefit Qi and dispel stasis and promote water retention, with the basic formula combining Pig Ling Tang and addition and reduction; for Yin and Yang deficiency, warm Yang and promote water retention and resolve stasis The basic formula is combined with Zhen Tang with addition and subtraction; for edema with cold and heat preference, add Yi Mu Cao, Che Qian Zi, Gui Zhi and Chen Hulu. The organic combination of Chinese medicine treatment and retinal laser can reduce the limitation of laser and accelerate the recovery of visual function after laser.
Fourth, the treatment experience of blood circulation and blood stasis.
Chinese medicine treatment is based on the identification of stasis and blood obstruction, “activate the blood but do not act recklessly”, do not abuse harsh blood-activating and blood-breaking products to prevent new bleeding caused by excessive “activation” and “transformation”. “Stop the bleeding without leaving stasis”, prevent too much “coagulation” and “stagnation”, and cause stagnation of blood stasis. “Activate but not break the blood, stop but not leave stasis”. For example, hemorrhage of neovascularization is the main pathology of diabetic retinopathy into the proliferative phase; repeated hemorrhage causes mechanization, traction retinal detachment, neovascular glaucoma, and even blindness. Most of them are used to eliminate blood stasis and stop bleeding, nourish blood and activate blood, such as Radix et Rhizoma, Radix et Rhizoma, Radix et Rhizoma, Panax notoginseng, Radix et Rhizoma, Radix et Rhizoma, Radix et Rhizoma, Radix et Rhizoma, Radix et Rhizoma. To stop bleeding, cooling and hemostatic drugs are mostly used, but they should not be too cold, generally using artichoke, small thistle, dried lotus grass, sapodilla leaf, acacia flower, white foxglove root, cynomorium, blood remaining charcoal, lotus root, etc. With cold signs, warm hemostatic drugs such as gun ginger charcoal, Chen Ai charcoal, etc. can also be used.
The application of blood-stasis-activating drugs should be early. Before the appearance of lesions in the fundus of the eye, a small amount of blood-nourishing and blood-activating drugs such as Radix et Rhizoma, Salviae Miltiorrhizae and Angelicae Sinensis should be added to reduce blood viscosity and improve microcirculation.
During the period of fundus hemorrhage, appropriate amount of blood activating and hemostatic drugs such as Panax notoginseng, Radix et Rhizoma Pulsatilla, etc. are applied to stop the hemorrhage without the disadvantage of retaining stasis. When fundus hemorrhage basically stops, it is necessary to benefit qi and nourish yin, tonify the kidney and brighten the eyes, with less adjuvant to invigorate blood circulation and eliminate blood stasis, and to soften and disperse nodules, which can not only prevent rebleeding, but also improve vision.
V. Multi-way drug administration and comprehensive treatment of Chinese medicine
In addition to the traditional Chinese medicine decoction, Chinese medicine can be applied to the eye acupuncture points, such as Chinese medicine ion introduction and Chinese medicine periocular acupuncture point injection, which can effectively enhance the effective concentration of Chinese medicine in the eye. Chinese herbal medicine can be used according to different symptoms of ocular hemorrhage, exudation, mechanization and ischemia, such as Panax ginseng, Xianhecao, Pueraria lobata, Salvia miltiorrhiza, Astragalus, ginseng and seaweed, to stop hemorrhage and eliminate blood stasis, benefit qi and activate blood circulation, and brighten the eyes. Acupuncture points can be selected from Hou Hou, Cheng Wei, Sun, Miao Ming and Zan Zhu.
The effective blood concentration of Chinese patent medicine injection intravenous drip is much higher than that of oral Chinese patent medicine, because the eye is rich in blood vessels, it can reach the retinal microcirculation by breaking the blood-eye barrier and blood-retinal barrier directly through the elbow-arm venous circulation, so as to better play the advantages of Chinese medicine in treating retinal diseases. For example, to activate blood circulation and remove blood stasis in the sugar network, we can use San Qi preparations such as blood plugging and thrombosis injections, and to promote microcirculation, we can use Ge Gen needles, Chuanxiong needles and Dan Shen needles, and to benefit qi and brighten eyes, we can use Ginseng and Astragalus needles, etc. Combining with Chinese herbal medicine, we can achieve both overall and local treatment, and achieve the goal of treating both symptoms and root causes.
In conclusion, the efficacy of TCM in treating diabetic retinopathy, preventing further development of the disease, and effectively preventing blindness in the glycoplasmic retina has attracted great attention and recognition from the academic community, and it is necessary to conduct further in-depth research.