A 5-year-old, 5.5 kg male cat presented with sudden-onset eye problems characterized by ptosis, miosis, and enophthalmos (fig 1). There was no history of trauma. Standard Western medical diagnostics, including CBC, Chemistry, heart ultrasound, abdominal ultrasound, and neurological examination, showed mild cholestasis and dirty ears with coffee-like discharge, but were otherwise unremarkable. MRI was recommended but declined by the caretaker. Initial treatment with antibiotics and anti-inflammatory eye drops for 5 days showed no improvement.
TCVM Assessment - Initial Evaluation:
Shen: Good, cat alert
Appetite, stool, urination: Normal
Personality: Earth (mild Wood to other cats)
Ocular findings: Both eyes mildly red, visible blood vessels, left eye had ptosis, miosis, and enophthalmos (Horner's syndrome)
Nose, ears, head, and body: Warm
Tongue: Red with mild white coating
Pulse: Very thin and fast bilaterally
Initial TCVM Pattern: Kidney Yin Deficiency + Phlegm at Brain
Initial TCVM Treatment:
Acupuncture:GV-20, An-shen, Nao shu, GB-14, BL-1, ST-1 of left side; LI-4 and GB-37; once daily for 3 days
Herbal Medicine: Zhi Bai Di Huang + Stasis in Mansion of Mind, 0.3g BID
Outcome After 3 Days of Initial Treatment: mild improvement in pupil size (fig 2), but Dr. Louise Yu Cheng was still not sure if the initial TCVM pattern was correct, then she consulted Prof. Hanwen Cheng for helping.
Re-assessment by Prof. Han Wen Cheng on the 4th Day:
Revised TCVM Pattern: Gallbladder Damp Heat due to Liver Qi Stagnation
Supporting Signs: Dirty ears, mild cholestasis, redness in both eyes, excess heat signs and the cat was mild aggressive to other cats and dogs.
TCVM Treatment Principle: Clear the Damp Heat and smooth the Liver Qi.
Revised Treatment: Jue Ming San herbal formula 0.3g BID + Acupuncture at GV-20, GB-20, BL-1, GB-14, ST-1/4; LIV-3, LI-4 and GB-37
Outcome After 3 Days of Revised Treatment:Significant improvement, near-normal eye appearance ( fig 3).