Dry eye disease is a common and frequent disease in ophthalmology. Any cause of abnormalities in the tear film and ocular surface can cause dry eye disease. In the early stage of the disease, there is only discomfort such as dryness of the eye, foreign body sensation, photophobia, blurred or fluctuating vision, etc. After the disease progresses, filiform keratitis may appear, and the symptoms evolve into unbearable. In the late stage, corneal ulcers, corneal thinning, perforation, and occasionally secondary bacterial infections appear. After corneal scar formation, vision is seriously affected. In this paper, we review and analyze the literature on the treatment of dry eye disease by Chinese and Western medicine to clarify the advantages of combining Chinese and Western medicine in the treatment of dry eye disease.
1.Western medicine treatment.
1.1 Physical therapy.
It is applicable to lipid deficient dry eyes caused by low lipid secretion or abnormal lipid leading to rapid tear evaporation. The most common is lid gland dysfunction, which focuses on cleaning the eyelids and insisting on massage, hot compresses and scrubbing of the eyelids, thus promoting lipid discharge from the lid glands. Room humidity can also be increased to reduce tear evaporation.
1.2 Topical tear replacement agents.
Local tear replacement agents are divided into two types: artificial tears and their own serum.
Artificial tears are ordered for the main treatment of dry eye disease. In addition to moistening the eye surface, artificial tears also promote the recovery of corneal epithelium, treat lacrimal gland lesions, and nourish the optic nerve. The development of new artificial tears has led to significant improvements in maintaining viscosity and extending the residence time of tears on the ocular surface. However, they also have the problem of causing eye irritation, blurred vision, and a feeling of stickiness in the eyelids. And the most significant disadvantage of these artificial tears is the presence of preservatives, stabilizers and some other additives. It is worth noting: it should not be assumed that the more drops of artificial tears the better. In fact, it is better not to exceed 6 times a day, because too frequent drops can completely wash away the normal tear film and, on the contrary, accelerate the evaporation of tears.
Topical application of autologous serum for the treatment of dry eye has also been reported. However, its application is less frequent due to its complicated preparation and restricted source. It is usually applied only when severe dry eye will cause corneal complications.
1.3 Preservation of tears.
Silicone eye shields and wet room lenses provide an airtight environment to reduce air flow over the ocular surface and tear evaporation for the purpose of tear preservation, but are often not tolerated by patients with easily allergic skin. Therapeutic corneal contact lenses are mostly used for patients with mild dry eye, and are less frequently used for patients with moderate to severe dry eye who wear lenses that tend to dry out and fall off.
1.4 Anti-inflammatory and immunosuppressive therapy.
Corticosteroid drops cause a series of anti-inflammatory responses by inhibiting the production of inflammatory factors and reducing the synthesis of matrix-degrading enzymes, thereby improving the signs and symptoms of dry eye. However, such drugs are prone to complications such as hormonal glaucoma and posterior subcapsular clouding of the lens. Therefore, they are only used in the worsening phase of dry eye.
The mechanism of action of immunosuppressive eye drops is to inhibit apoptosis of lacrimal gland cells and conjunctival cupped cells, promote apoptosis of lymphocytes, and reduce the inflammatory response on the ocular surface. Lin Bijuan and Liu Zuguo [6] reported that the treatment of moderate to severe dry eye with CsA2g/L was significantly more effective than sodium carboxymethylcellulose. Clinical controlled trials by the US Food and Drug Administration also showed that 0.1% CsA was the most effective in improving objective signs of dry eye, while 0.05% CsA was the most effective in relieving symptoms.
1.5 Increasing tear secretion.
Bromhexine hydrochloride and its derivatives: Early scholars reported oral or topical application of Bystolic for SS at an oral dose of 16 mg each time, 3 times a day, for 2-3 months, but the efficacy evaluation was mixed.
Cholinergic drugs: Tear secretion is governed by autonomic nerves, and cholinergic drugs, which can promote glandular secretion. In recent years, the United States, Europe and Japan have reported oral pilocarpine hydrochloride 9 mg per day, 3 times a day for at least 1 month, as a treatment for SS, and received good results.
Phosphodiesterase inhibitor (IBMX): It can stimulate the paracrine glands and promote tear secretion by increasing intracellular cyclic adenosine monophosphate (XAMP) or cyclic guanosine monophosphate (CGMP) levels.
1.6 Sex hormone therapy.
Studies have found that the average incidence of postmenopausal women is significantly higher. Li Lianxiang et al. concluded that menopausal or postmenopausal women have an increased incidence of dry eye due to diminished secretory activity of the lid and Zeis glands caused by diminished ovarian secretion, reduced lipid component of the tear film, and more water evaporation.
1.7 Anti-inflammatory therapy.
Tetracycline can achieve anti-inflammatory effects by reducing the production of certain inflammatory factors and inhibiting the synthesis and activity of matrix-degrading enzymes. Clinical trials have shown that doxycycline (a semi-synthetic tetracycline) improves symptoms of eye irritation and increases tear film stability.
1.8 Surgical treatment.
Tear preservation surgery includes.
(1) Lacrimal duct system obstruction: Obstruction of the tear dots and ducts is the most common surgical treatment for dry eye by delaying the drainage of artificial and natural tears. The disadvantage is that the blockage reduces tear production, slows renewal, and diminishes ocular surface sensation. The nasolacrimal duct should be patent before surgery to prevent acute dacryocystitis.
(2) Lid suturing: avoids corneal exposure, reduces evaporation, and is indicated for persistent epithelial lesions in severe dry eye. A further lid fissure can be performed when needed.
Alternative lacrimal gland procedures include.
(1) parotid duct transplantation: this method is effective in relieving tear deficiency symptoms, but this method is now rarely used due to excessive secretion, more secretion when the parasympathetic nerve is stimulated, and the fact that the parotid gland secretes only plasma saliva, which does not contain the mucus layer structure required for tear film formation.
(2) Sublingual gland transplantation: The disadvantage is that the sublingual gland secretes mucus, and some patients have poor function after transplantation, and it was reported that the Schirmer experiment only increased by 2 mm.
(3) Submandibular gland transplantation: Individual patients after this procedure are unable to produce a normal lacrimal gland reflex due to the denervated gland transplantation and can only maintain the inherent basal secretion. Some individual patients will have opportunistic tear overflow after the operation, such as tearing during physical activity, emotional stress, chewing, massage and high fever.
2.TCM treatment.
2.1 Discriminatory treatment.
From the dryness theory to treat white astringency, Hua Pingdong used nourishing yin and clearing dryness soup with yellow essence, smallpox powder and ghost acupuncture grass, and added and subtracted with consultation, treating 40 cases of lung yin deficiency type, with an efficiency of 70%; using Siwuwu Wu Zi Wan as the main treatment with Huang Qi, Maimendong and ghost acupuncture grass, and added and subtracted with consultation, treating 64 cases of liver and kidney yin deficiency type, with an efficiency of 67.19%.
Wang Limin treats white astringency from liver and kidney, with Qiju Dihuang Wan plus or minus: Wolfberry, Chrysanthemum, Radix Rehmanniae, Yam, Poria, Dampi, Zelig, Cornus, Medlar, Mulberry leaf, Temperate bamboo leaf. If the kidney yang is insufficient, add codonopsis and raspberry. If the liver is not harmonized, add stone cassia, tribulus terrestris and raw oyster. This method has been used to treat this disease with good results.
In the treatment of dry eyes with Xuan Tong Xuan Fu method, Zhu Huaying randomly divided 30 patients with dry eyes into a treatment group and a control group, 15 patients each. In the treatment group, Chinese herbal soup with Xuan Tong Xuan Fu effect was administered orally, and topical drops of Tearan were applied at the same time; in the control group, Tearan drops were administered in the same way as in the treatment group, and vitamin A was taken orally at the same time.
According to the pathogenic factors of dry eye disease, Li Sheli classified the disease into Yin and Blood deficiency, Spleen and Stomach weakness, Damp-Heat congestion, and Qi stagnation and Blood stasis, and treated the disease by nourishing Yin and Blood, strengthening the Spleen and Qi, clearing Damp-Heat, and activating Blood stasis. In the control group, eye drops of R&S were administered and vitamin AD pills were taken orally. After treatment, the total effective rate of the treatment group was 80%, and there was a significant difference in the efficacy of the two groups. In the treatment of this disease by Prof. Hao Xiaobo, the type of lung-yin deficiency was treated with Baihe Gujin Tang, with the addition of anti-feng, cicada moth, peppermint, and rehmannia root for external dryness. The liver and kidney yin deficiency type should be treated with Liu Wei Di Huang Wan or Qi Ju Di Huang Wan and Er Zhi Wan with addition and reduction.
2.2 Single prescriptions.
The efficiency of Tian Yue’e’s formula was 73.65%. The addition of Sha Shen Mai Dong Tang can promote the secretion of tears and can promote the repair of diseased cornea.
Yan Hanyin treated 30 patients with dry eye syndrome with self-prepared Yiyin Yunming Tang. The control group was given Tear Ran eye drops, and the treatment group was superior to the control group, and there was a significant difference in the efficacy of the two groups.
Qin Xingrui et al. treated dry eyes with homemade eye-clearing granules (Sheng Di Huang, Su Hao Hao Shell, White Chrysanthemum, Fructus Lycii, Whole Angelicae, Northern Chai Hu, White Peony, Dendrobium, etc.). The control group was treated with Tearan eye drops with an efficiency of 91.7%, compared with 66.1% in the control group, with a significant difference in efficacy.
He Huiqin et al. found that in addition to clinical manifestations of deficiency of yin and blood, or deficiency of yin and fire, and deficiency of fluid, a significant number of patients showed signs of blood stasis and lack of spleen movement. Dry eyes were treated by invigorating blood and strengthening the spleen; the control group was given Tearan eye drops five times a day. The experimental results showed that there were significant differences in SIT and BUT between the two groups after treatment, and the efficacy of the Chinese medicine group was better than that of the artificial tear drops group.
2.3 Acupuncture therapy.
Wang Zhonglin et al. randomly divided 45 patients with dry eyes into an overall evidence-based acupuncture group, a local acupuncture group and a control group. The overall identification acupuncture group was divided into the heat-inciting and yin-injuring group (Quchi, Hegu, Sanyinjiao, Taixi, Yingxiang, and Sibai, with the addition of Zhaohai and Daling for insomnia) and the phlegm-stasis-interacting group (Blood Sea, Yinlingquan, Foot Sanli, Fenglong, Sanyinjiao, and Sibai, with the addition of Nei Ting, Xingma, and Foot Linobu for dry mouth, halitosis, eyelid redness, and yellow, greasy coating, and other heat symptoms); the local acupuncture group was divided into Zanzhu, Yangbai, and In the control group, eye drops were given with “Tearful”. The total effective rate was 86.7%, 66.7% and 33.3%, respectively. The experimental results showed that the use of holistic evidence-based acupuncture can promote the secretion of tears, effectively improve the stability of the tear film, and improve the patients’ self-conscious symptoms, and its efficacy is significantly better than local acupuncture and artificial tear replacement therapy.
Blood nourishing and eye moistening method: Zhang Yanchao et al. randomly divided 61 patients with dry eyes into acupuncture and control groups.
Acupuncture points in the acupuncture group: Baihui, Miming, Zanzhu, Sun, Sibai, Fengchi, Hegu, Feosanli, Sanyinjiao, Taixi, and Taichong. Add and subtract: Qihai for Qi-Yin deficiency, Waiguan and Fenglong for damp-heat congestion, and Blood Sea and Quchi for internal blockage of blood. At the same time, moxibustion for both eyes with eyes closed, moxibustion for both ears in rotation, acupuncture first once a day, then herbal moxibustion. The control group was treated with tears.
The results of the study suggest that the efficacy of the acupuncture group in treating dry eyes was significantly better than that of the artificial tear group. The acupuncture group can promote tear secretion, can effectively improve the stability of the tear film, and improve the patient’s self-conscious symptoms.
Liu Zhimin used electro-acupuncture therapy to treat dry eye from liver, kidney and spleen, taking Zhanzhu, Miming, Sibai, Sun, Baihui, Hegu, Feet Sanli, Sanyinjiao and Taichong; Fengchi, Cataract, Sun, Baihui, Hegu, Liver Yu and Kidney Yu. The two groups of acupoints were used alternately to treat 20 cases of dry eyes. The total effective rate was 85.0%.
2.4 Other therapies.
Li Jie et al. used fishy grass injection nebulization to treat dry eye disease compared with Chai Hu injection nebulization and RUNSHU eye drops. the treatment group was sprayed once every other day for 10 minutes each time. 2 weeks was a course of treatment, and the control group was given topical points of RUNSHU eye drops 4-6 times a day. The efficiency of fishy herb group was 81.8%; the efficiency of Chaihu group was 76.67%; the efficiency of control group was 55.56%. After statistical analysis, there were significant differences between the ichthyological herb group and the control group, some differences between the Chaihu group and the control group, and no significant differences between the ichthyological herb group and the Chaihu group.
Song Li et al. randomly divided 40 patients with dry eye into treatment and control groups, and the treatment group was treated with thunder fire moxibustion by giving moxibustion to both eyes with eyes closed, moxibustion to both eyes with eyes open, moxibustion to both ears with eyes closed, and moxibustion to both ears in rotation, as well as topical application of Ally eye drops; the control group was given Ally eye drops alone. After 1 month of treatment, the results confirmed that moxibustion treatment has a certain effect on improving the symptoms of dry eye, especially on relieving visual fatigue.
HOU Shuhong used acupressure combined with western medicine drops to treat 200 cases of dry eye with visual fatigue, taking Zhanzhu, Miming, Shangming, Pupil s, Chengwe, Sibai, and Sun acupoints, together with eye movement, for 30 minutes a day for 10 days, for 30 days. At the same time, 0.3% ofloxacin eye drops and artificial tears were given to the eyes. The total efficiency reached 100%. Modern medical research believes that local eye massage has the effect of improving central excitability and immune two-way regulation, so it can synergistically treat visual fatigue dry eye disease.
2.5 Combination of Chinese and Western medicine treatment.
Tang Guofen et al. treated 180 cases of dry eye syndrome patients, randomly divided into a control group and a treatment group. The control group was treated with artificial tear drops alone, and the treatment group was treated with Chinese herbal soup (astragalus, maitake, pollen, angelica, wolfberry, rehmannia, yam, mulberry, peppermint) in water decoction on top of the control group. After 1 month of treatment, the total effective rate of the treatment group was 85.56%, and the total effective rate of the control group was 76.67%.
Li Yuanfu randomly divided 79 patients into observation group and control group, both groups were treated with artificial tears, oral B vitamins and physical therapy, in the observation group, traditional Chinese medicine was also applied with the treatment, and SIt was used as the index for quantitative determination of efficacy, the symptoms and signs of dry eyes in the observation group were significantly improved, and the effective rate was 79.5%.
Zhu Ying treated dry eyes with Qiju Dihuang Tang and Sheng Yi Jing to nourish the liver and kidney. The patients in the observation group took Qiju Dihuang Tang and Sheng Yi Jing orally; the control group took external drops of Tearan Eye Drops. There was a significant difference in the efficacy of the two groups. The efficacy of Qiju Dihuang Tang combined with Sheng Yi Yin Drink in the treatment of dry eye has the effect of promoting tear secretion and prolonging the tear film rupture time.
3.Outlook.
With the development of society, the treatment of dry eye gradually becomes important in ophthalmology outpatient clinics. At present, the exact cause of dry eye is not very clear, and can be caused by a variety of factors leading to impaired tear secretion or destruction of the physiological function of the lacrimal gland. Most of the Western medical treatments use symptomatic treatment, i.e., local medication and surgical interception, but they can only improve the local symptoms of dry eye and cannot be stopped and cured; Chinese medicine treats the symptoms with evidence, and the effect is slow. This makes the advantages of combining Chinese and Western medicine increasingly prominent, and the combination of Chinese and Western medicine will certainly become the future development trend in the treatment of dry eye disease.