A 27-year-old Chinese man was admitted to our hospital on 3rd Jan 2022 because of blurry vision and an inferior visual field defect in his right eye for more than half a month. He had a history of moderate myopia and a history of trauma to his right eye sustained 3 years ago. His family history was unremarkable. On presentation, the best-corrected visual acuity (BCVA) in the right eye was 20/40. The rest of the anterior segment examinations were within the normal range. Dilated fundus examination (DFE) demonstrated RD and retinal fold proliferation from 10 to 2 o'clock, involving the macula, with an oval retinal hole at 12 o'clock in the periphery (Fig. 1A). Optical coherence tomography (OCT) (Cirrus 5000, Carl Zeiss Meditec Inc., Singapore) of the macula showed RD and foveal involvement (Fig. 2A). Visual field examination (Octopus 900, Haag-Streit Inc, Switzerland) revealed extensive inferior visual field defect (Fig. 4A).
The patient received retinal laser photocoagulation on 4th Jan 2022. Retinal laser photocoagulation (VISULAS 532s, Carl Zeiss Meditec Inc., Germany) was performed with 3–4 circles around the retinal tear using established parameters (300 µm spot diameter, 150 ms duration, 200–240 milliwatt power, III thick white spots, and a total of 305 spots). A CHM prescription, mainly consisting of a modified Buzhong Yiqi Decoction and Wuling Powder, which contains Radix astragali, Ginseng, Cimicifuga foetida, Radix Bupleuri, Pericarpium Citri Reticulatae, Angelica sinensis, Atractylodes macrocephala koidz, Polyporus umbellatus, Alisma Orientalis, Poria cocos, Ramulus Cinnamomi, Glycyrrhiza uralensis was also prescribed. The herbal materials were decocted with water (soaked in 1,500–2,000 mL of water for 30 minutes, allowed to simmer for 40 minutes, followed by extraction of 300 mL of preparation). The patient was administered 150 mL decoction twice a day starting from the day of hospitalization until hospital discharge. Improvement in SRF and clinical symptoms was noticed from 5th Jan 2022. The OCT showed longitudinal change in central foveal and superior temporal retinal detachment area thickness (Fig. 2B, C, Fig. 3A, B, C, D). The BCVA improved from 20/40 to 20/25, with significant improvement in blurriness and visual field defect on 10th Jan 2022 (Fig. 4B). As the SRF around the hole was absorbed, the patient underwent repeat retinal laser photocoagulation, which was performed with 7–8 circles around the retinal hole, avoiding the proliferative area, applying the laser in the degeneration area, using established parameters (300 µm spot diameter, 150 ms duration, 170 milliwatt power, III white spots, and a total of 689 spots). At discharge, the patient's raised retina was largely flattened (Fig. 1B) with complete absorption of SRF of macula fovea (Fig. 2C). Two months after the initial presentation, the patient's condition was stable (Fig. 2D). Ethical issues were completely observed by the author (the First Affiliated Hospital of Zhejiang Chinese Medical University (Zhejiang Provincial Hospital of Chinese Medicine) 2021-KL-047-01).