Acute zonal occult outer retinopathy (AZOOR) is a less common eye disease. At its onset, the major symptom is the affected eye seeing flashes with obvious visual field defect, and yet fundus examination fails to reveal any corresponding retinal abnormality. Initially, it is mostly unilateral but later the other eye may also be affected. The disease is more commonly found in women.
Visual field test and ERG can detect the abnormality. Currently, it is however yet to have a proven cure of the disease (including using steroids or undergoing immunity modulation therapy). Some statistics indicated that with this disease, it takes six months for the patient to have a more stable vision.
The following case study seek to demonstrate the characteristics of Chinese Ophthalmology in treating this disease.
Case Study 1:
Patient (aged 45, female) came for consultation on 2011/8/4. She reported both eyes seeing flashes for two weeks; and two days before the left eye nasal inferior visual field was obstructed, the condition of which the Western Medicine practitioner diagnosed as AZOOR.
The patient had a history of stiff neck, which had received massage therapy for the past year, with the last one took place on 2011/7/31 (five days before the first consultation). Two days later at night, she experienced numbness in and could not move her upper arms, accompanied by tinnitus.
She reported fair appetite, fitful sleep, frequent urination, and difficult defaecation once every 2-3 days. In the most recent two months, she had a menstrual cycle of two weeks with the period lasted for 4-5 days.
Examination:
Obvious tenderness at some left side cervical transverses
Aided VA:
R: +6.00 / -0.50x170 VA: 0.8+2
L: +6.00 / -0.50x20 VA: 0.8-2
Tonometry: R: 11 mmHg L: 11 mmHg
Fundus examination :
C/D ratios: 0.2-0.3 (OU), narrowing of retinal vessels
Visual field examination:
Figure 1 Right eye visual field test results (2011/8/2)
Figure 2 Left eye visual field test results (2011/8/2)
Figure 3 Left eye visual field test results (2011/8/3)
Tongue inspection: red tongue with petechiae and thin white coating
Pulse manifestation: deep, thready and rapid
Diagnosis: left eye AZOOR
TCM diagnosis: left eye hemianopia
Syndrome: yin deficiency and stirring wind, qi stagnation and blood stasis
Therapeutic principles: extinguishing wind and nourishing yin, activating blood and dredging collaterals
Treatments by oral Chinese medicine: Rhizoma Gastrodiae (天麻), Ramulus Uncariae cum Uncis (鈎藤), Fructus Liquidambaris (路路通), Lumbricus (地龍), Salviae Miltiorrhizae (丹參), Radix Astragali seu Hedysari (黃蓍), Puerariae Radix (葛根), Fructus Lycii (枸杞子), Fructus Mori (桑椹子), Radix Polygoni Multiflori (制首烏), etc.
Figure 4 Left eye visual field test results (2011/9/12)
Figure 5 Left eye visual field test results (2011/11/10)
Figure 6 Right eye visual field test results (2012/3/29)
Figure 7 Left eye visual field test results (2012/3/29)
Figure 8 Right eye visual field test results (2012/4/25)
Figure 9 Left eye visual field test results (2012/4/25)
Figure 10 Left eye visual field test results (2012/6/28)
Figure 11 Left eye visual field test results (2012/10/18)
Table 1 AZOOR case study 1
visual field test results summary
Date
|
Strategy
30-2
|
Strategy
24-2
|
L
|
R
|
L
|
2011/8/2
|
|
VFI:99%
MD:-1.52dB
|
VFI:86%
MD:-6.76dB
|
2011/8/3
|
VFI:88%
MD:-5.41dB
|
|
|
2011/9/12
|
VFI:97%,
MD:-1.14dB
|
|
|
2011/11/10
|
VFI:97%
MD:-1.28dB
|
|
|
2011/12/29
|
VFI:99%
MD:-0.88dB
|
|
|
2012/3/29
|
|
VFI:96%
MD:-2.25dB
|
VFI:99%
MD:-0.23dB
|
2012/4/25
|
|
VFI:99%
MD:-0.47dB
|
VFI:100%
MD:+0.44dB
|
2012/6/28
|
|
VFI:100%
MD:-0.46dB
|
VFI:98%
MD:-1.46dB
|
2012/10/18
|
VFI:100%
MD:-1.44dB
|
|
|
Table 2 AZOOR case study 1 vision changes
Date
|
VA(R)
|
VA(L)
|
2011/8/4
|
0.8+2
|
0.8-2
|
2011/12/29
|
0.8+2
|
0.8-1
|
2012/1/27
|
1.2-1
|
1.0-3
|
2012/2/15
|
1.2-1
|
1.0-2
|
2012/3/15
|
1.2
|
1.0-3
|
2012/6/19
|
1.2
|
1.0-3
|
2012/9/11
|
1.2
|
1.0
|
2013/3/28
|
1.2
|
1.0-2
|
2013/7/6
|
1.0
|
1.0-1
|
2013/11/21
|
1.2-1
|
1.0-2
|
Case Study 1 summary:
In this case study, the chief complaint was left eye visual field loss. At the initial consultation, the patient’s bilateral central vision was slightly below normal, while the left eye visual field test also showed significant nasal visual field impairment. When the patient had follow-up consultation on the 14th day of treatment (2011/8/18), she felt the left eye nasal inferior visual field obstruction had reduced, other symptoms had also gradually alleviated. Despite research statistics demonstrated that with this disease the visual field deterioration tended to continue in the first six months with no subsequent significant improvement; in this case study, the patient had noticeable improvement in just a month or so after receiving TCM treatment.
Given the patient had experienced different visual field test scenarios, the results are listed in Table 1. On 2011/8/3 (the day before the first consultation), the left eye visual field (30-2) results were: VFI (Visual Field Index): 88%, MD (Mean Deviation): -5.41dB while those for the 2011/9/12 vision field test (30-2) were: VFI: 97%, MD: -1.14dB.
In this case study, the patient, after receiving treatment, took only 40 days to achieve considerable visual field improvement. Up to 2011/12/29, the left eye visual field function had raised to VFI: 99%, MD: -0.88dB. Thereafter, when the patient took the medication slightly below the recommended dosage, some fluctuation in the visual field function resulted. It nevertheless returned more or less to the normal range when the recommended dosage was later resumed.
Besides, the patient underwent an OCT on 2011/12/29 with no abnormality observed. The patient did no ERG as recommended when she found her vision had significantly improved.
