|
 
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| CASE REPORT |
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| Year : 2021 | Volume
: 4
| Issue : 4 | Page : 138-145 |
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Ayurvedic management of idiopathic retinal vasculitis: A case report
Narayanan Namboothiri Narayanan, Sreekala Nelliakkattu Parameswaran, Aravind Kumar, Krishnendu Sukumaran, Kavya Rama Varma
Department of Clinical Research, Sreedhareeyam Ayurvedic Research and Development Institute, Ernakulam, Kerala, India
| Date of Submission | 07-Jun-2021 |
| Date of Acceptance | 21-Dec-2021 |
| Date of Web Publication | 02-Feb-2022 |
Correspondence Address:
Dr. Aravind Kumar
Sreedhareeyam Ayurvedic Research and Development Institute, Nelliakkattu Mana, Kizhakombu, Koothattukulam, Ernakulam - 686 662, Kerala
India
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/jacr.jacr_45_21
Retinal vasculitis may be either idiopathic or associated with systemic illnesses and is characterized by inflammation of the retinal blood vessels. Management of the underlying condition and controlling inflammation are the sine qua non for achieving remission; however, these medicines may produce side effects. Management of idiopathic retinal vasculitis in Ayurveda has not been reported. A 47-year-old female presented with bilateral blurring of vision, more in her right eye than left, since eight years. Her consulting physician diagnosed the condition as idiopathic retinal vasculitis. Ayurvedic assessment of the condition revealed impaired Agni (~digestive and metabolic capacity) and the presence of Ama (~metabolic toxins). She underwent two inpatient Ayurvedic treatment courses, which consisted of oral medicines, Panchakarma (~five internal bio-cleansing therapies), Netra kriyakalpa (~local ophthalmic therapies), and external therapies for the head along with customized oral medicines, eye drops, and nasal medication. The protocol was found to be effective in arresting further pathogenesis and improving both visual acuity and posterior segment findings.
Keywords: Case report, Kriyakalpa, Panchakarma, Timira
How to cite this article:
Narayanan NN, Parameswaran SN, Kumar A, Sukumaran K, Varma KR. Ayurvedic management of idiopathic retinal vasculitis: A case report. J Ayurveda Case Rep 2021;4:138-45 |
How to cite this URL:
Narayanan NN, Parameswaran SN, Kumar A, Sukumaran K, Varma KR. Ayurvedic management of idiopathic retinal vasculitis: A case report. J Ayurveda Case Rep [serial online] 2021 [cited 2022 Aug 11];4:138-45. Available from: http://www.ayucare.org/text.asp?2021/4/4/138/337115 |
| Introduction | |  |
Isolated retinal vasculitis occurs rarely and may be idiopathic by nature. It is usually bilateral and vision threatening, and an estimated one-third of patients suffer from severe visual loss (< LogMAR 0).[1] Inflammation of the optic nerve head may also be associated with retinal vasculitis and should be differentiated from optic disc neovascularization. The main cause of vision loss is associated macular edema. Uncontrolled vasculitis may often result in deleterious consequences including vision loss. Management depends on the underlying etiology, and control of inflammation is sine qua non for achieving remission.[2] However, these may not produce satisfactory effects, and hence approaches in Complementary and Alternative Medicine may be sought. The Ayurvedic management of idiopathic retinal vasculitis is presented in this report.
| Patient Information | | |
A 47-year-old non-diabetic and non-hypertensive female homemaker presented with diminished vision since eight years. She initially experienced difficulty in viewing small letters, for which an ophthalmologist a prescription to use spectacles. In April 2020, she experienced profound decrease in vision in both eyes [Oculus Uterque (OU)]. She was diagnosed with retinal vasculitis and was prescribed medication, which did not provide relief. In June 2020, she consulted Sreedhareeyam Eye Hospital, where she was advised inpatient management. At admission, her diminished distant vision was more in her right eye [oculus dexter (OD)] than her left eye [– oculus sinister (OS)]. She denies any history of significant illnesses, and her immediate family members do not present with similar complaints. Bowels, appetite, and micturition are normal, sleep was disturbed, and menstruation was regular. Examination of her cardiovascular, gastrointestinal, urinary, musculoskeletal, and nervous system was within normal limits. Her blood pressure, pulse, heart rate, and respiratory rate were also normal. She is 156 cm tall and weighs 63 kg.
| Clinical Findings | | |
Unaided Distant Visual Acuity (DVA) was LogMAR 1 OD and LogMAR 0.301 OS, aided DVA was LogMAR 0.778 OD and LogMAR 0 OS, and Near Visual Acuity (NVA) was N18 OU. Confrontational visual fields were normal OU. The anterior segment examination was within normal limits OU. Pupillary examination demonstrated normal responses to direct, consensual, and near reflexes OU. Posterior segment examination and fundus photography demonstrated optic disc swelling and some sheathing in the blood vessels surrounding the optic disc OU and exudates near the optic disc OD. Foveal reflexes were blurred OU, suggesting accumulation of subretinal fluid [Figure 1] and [Figure 2]. Routine hematology, serology, and biochemistry assessments, including erythrocyte sedimentation rates, C-reactive protein, serum urea, RA factor, and antistreptolysin-O titer, were within normal limits. | Figure 1: Fundus photograph oculus dexter at admission before inpatient course 1
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 | Figure 2: Fundus photograph oculus sinisterat admission before inpatient course 1
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Nadi (~pulse) was Vata-Pitta; Mutra (~urine), Mala (~waste products), Jihva (~tongue), Shabda (~sound), and Akriti (~form) were Prakrta (~normal); Sparsa (~touch) was Anushnasita (~lukewarm); and Drik (~vision) was Vaikrta (~pathological). Prakriti (~constitution) was Pitta and Vata; Samhanana (~compactness), Pramana (~anthropometry), Sattva (~psyche), Satmya (~habituation), Ahara shakti (~power of intake and digestion of food), and Vyayama shakti (~power of performing exercise) were Avara (~inferior); and Vaya (~age) was Madhyama (~middle-age).
| Timeline | | |
The patient underwent one course of inpatient treatment from April 6 to April 26, 2020. She reported for two follow-up consultations on August 6, 2020 and September 9, 2020. Her second course of inpatient therapy was from October 19 to November 20, 2020. She reported for two more follow-up consultations on June 17, 2021 and August 28, 2021 [Table 1].
| Diagnostic Focus And Assessment | | |
A diagnosis of idiopathic retinal vasculitis was made based on her history, examination, and findings. The condition was compared to Timira (~blurring of vision), a Drshtigata roga (~disease of vision) as per Ayurveda. As there was inflammation, the possibility of involvement of Ama (~metabolic toxins) due to increased Doshas (~humors) was explored.
| Therapeutic Intervention | | |
The patient's first course of treatment was from June 4 to 25, 2020 and her second course from October 19 to November 03, 2020. She underwent an Ayurvedic treatment protocol comprising of oral medicines, Panchakarma (~five internal bio-cleansing therapies), Netra kriyakalpa (~local ophthalmic therapies), and treatments for the head [Table 1]. Pathya-apathya (~do's and don'ts) regarding diet and regimen included consuming boiled vegetables, green gram, Peya (~liquid gruel), and light and easily digestible foods; maintenance of mental composure and avoidance of stress; and abstinence from excess sunlight, dust, and smoke; deep-fried, fermented, and spicy foods, and edibles made from refined flour.
| Follow-Up And Outcome | | |
Assessment was done based on Visual Acuity (VA) and fundus photography. Unaided DVA was maintained OU, aided DVA improved to LogMAR 0.602 OD, and NVA improved to N12 at discharge. Posterior segment examination showed marginal reduction of the optic disc swelling, vascular sheathing, and exudates OU. Unaided DVA improved to LogMAR 0.176 OS at the first follow-up, while the other readings were maintained. These readings were maintained at the second follow-up and at both admission and discharge at her second course of inpatient treatment. Optic disc inflammation, exudates, and sheathing of vessels reduced at discharge after the first course of treatment [Figure 3] and [Figure 4]. Posterior segment findings gradually improved throughout the follow-ups, and fundus photography at both admission and discharge at the second course of treatment showed the optic disc coming into its normal state and reduction of both sheathing and exudates [Figure 5], [Figure 6], [Figure 7], [Figure 8]. DVA and fundus findings were maintained and NVA improved to N6 OU at two further follow-up consultations. Improvement in Agni was noted at the end of the first course of treatment with gradual improvement of retinal signs and vision and increased digestion. The patient was comfortable during treatments and overall clarity of vision improved after the treatments. | Figure 3: Fundus photograph oculus dexterat discharge after inpatient course 1
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 | Figure 4: Fundus photograph oculus sinisterat discharge after inpatient course 1
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 | Figure 5: Fundus photograph oculus dexterat admission before inpatient course 2
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 | Figure 6: Fundus photograph oculus sinisterat admission before inpatient course 2
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 | Figure 7: Fundus photograph oculus dexterat discharge after inpatient course 2
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 | Figure 8: Fundus photograph oculus sinisterat discharge after inpatient course 2
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| Discussion | | |
The probable Nidana sevana (~etiological factors) for this patient were consumption of Vidahi (~burning) and Abhishyandi (~channel-blocking) Ahara such as curd, pickles, fish, and spicy foods; and Vihara such as emotional outbursts and excess exposure to sunlight. These factors increased Kapha and Pitta, and by their combined qualities of Snigdha (~unctuous), Ushna (~hot), Guru (~heavy), and Manda (~slow), they invaded the Amasaya (~stomach) and diminished Samana vata (~type of Vata responsible for digestion) and Pachaka pitta (~type of Pitta responsible for digestion) to result in Ama. Features of Ama observed in this patient were Mandagni (~depressed/weak state of Agni) in the Koshtha (~alimentary tract). The Doshas invaded the first two Abhyantara patalas (~inner layers) of the Netra to cause Timira.[3] Ischemia was caused by Kha-vaigunya (~pathological activity) of Vyana vata (~type of Vata responsible for circulation and movement), in which pathologically-increased Kapha lodged in the retina and prevented Vata from movement, thus depriving the tissue of necessary nutrition. The inflammatory changes in the retinal blood vessels and optic disc were caused by pathological Pitta and Rakta (~blood) due to the two having Asraya-asrayi bhava (~homologous relationship) with each other and thus having the proclivity to complement each other's pathological activities.
Restoration of digestion, restoration of normal physiology in the retina, and improvement of vision were the aims of the Chikitsa krama (~treatment protocol) for this patient. Ama pachana (~digestion of Ama), Seka (~ocular irrigation), Bidalaka (~paste over the eyelids), and Avaguntana (~bolus sudation to the eyes) were the hallmarks of Amahara chikitsa (~treatment of Ama) in this patient. Seka, Bidalaka, and Avaguntana induced Mrdu swedana (~mild sudation), while Ama pachana acted as the Langhana krama (~lightening therapy). Both Mridu sweda and Langhana are advocated in Netra ama chikitsa.[4] Shodhana was done along the lines of Vatarakta chikitsa (~treatment of gouty arthritis) based on the following observations: Snehapana is the first line of management of Vatarakta, and Virechana with a Ruksha (~dryness) and Mridu (~mild) medicine is indicated, especially in the patient who has excess Snigdhata (~unctuousness).[5] The head treatments were done with medicines that are Shothahara (~anti-edematous) by nature.
Amrtottaram kwatha[6] and Varanadi kwatha[7] reduce uncomfortable symptoms of indigestion[8] and possess anti-inflammatory activity.[9] Amrtottaram kwatha has Deepana-Pachana,[10] Anulomana (~mild purgative),[10] Grahi (~absorptive),[10] and Rakta Shodhaka (~blood-purifying) properties.[11] Varanadi kwatha has Agni deepana, Chedana (~excision),[10] and Lekhana (~therapeutic scrapping) properties.[10],[12] The two medicines were administered together to achieve Deepana (~enhancing gastric fire), Pachana (~enhancing metabolic fire), and reducing Kapha, Rakta, and Vata.
Shamana snehapana (~intake of fats in a fixed dose) was done with Patoladi ghrita,[13] which is Kapha-pitta hara (~mitigates Kapha and Pitta) and Chakshushya (~ophthalmic),[14] and has anti-inflammatory and antioxidant properties. Virechana (~therapeutic purgation) was done with Avipatti kara churna,[15] which is a Rechaka (~laxative),[10] indicated for all Pitta rogas (~diseases of Pitta),[15] and has gastroprotective,[16] antioxidant, antisecretive, and anti-inflammatory properties.[17] Virechana karma is instrumental in the modulation of gut micro-biota in the intestine, which play a key role in inflammatory disease.[18] Virechana was prescribed once a week with Avipatti kara churna at the first and second follow-ups to prevent the progression of pathology. Pratimarsa nasya was done during the second course of treatment as it was determined that the body was considerably purified. It enters through the cribriform plate and instigate excitatory neural activity by acting on neurotransmitters in the brain.[19] Anu taila was used for Nasya due to its properties of Tridosha shamana (~pacifying all three Doshas) and Indriya balaprada (~strengthening the sense organs).[20]
The medicines given for Pachana were continued as Shamana aushadha (~palliative medicine) to prevent inflammation. These were augmented by medicines such as Triphala guggulu,[21] Patola katurohinyadi kwatha,[22] Shadanga pana,[23] and Vidanga tanduliya churna,[24] which helps in normalizing the retinal circulation and reduce inflammation due to their antibacterial, antioxidant, hepatoprotective, and anti-inflammatory properties.[25],[26],[27] Vara churna and Saptamrita lauha[28] helps in optimizing eyesight by their Rasayana (rejuvenating) property[29] and are antioxidant by nature.[30] Triphala guggulu alleviates Shopha and is Kapha-vata hara.[21] Patola katurohinyadi kwatha is Kapha-pitta hara, and by its action against fevers, performs Ama pachana and Agni deepana.[22] Shadanga pana performs Pachana karma and reduces Pitta.[23] Vidanga tanduliya churna is Kapha-vata hara and purifies the Koshtha by its action as a Vairecanika dravya (~purgative).[24] Vara (Triphala), the Agryaushadha (~ideal medicine) for Netra roga,[31] pacifies Kapha and Rakta and rids the body of excess moisture.[32] The indication of Saptamrita lauha in conditions such as Chardi (~vomiting), Amlapitta (~hyperacidity), and Jvara, target the Koshtha and restore its homeostasis; its indication in Timira restores eyesight; and its indication in Shotha targets edema, in this case, of the optic disc. Most of the medicines contain Guduchi [Tinospora cordifolia (willd) Miers.], the Agryaushadha (~ideal medicine) for Vatarakta.[31] It has anti-inflammatory, antioxidant, and immunomodulatory properties.[33]
Netra dhara, Bidalaka, and Avaguntana stimulates peripheral nerves and dilates ocular vessels through the skin of the eyelids. Netra dhara performed Mridu swedana (~mild sudation) to the eye, which initiates reduction of inflammation.[34] Avaguntana and Bidalaka increases nutrient uptake of the eyes and enable absorption of the drugs.[35] Ascyotana is one of the beneficial procedures in the cardinal signs of inflammation as per Vagbhata.[36] Anjana, initiated after proper Shodhana of both the body and the head, improves vision by its affinity for penetration into the deeper structures.[37]
The treatments for the head augment the effects of Netra kriyakalpa and reduce excess Kapha from the head. Dashamula kwatha (~group of ten therapeutically beneficial roots) was used as a mixing medium for Thalapothichil due to its anti-inflammatory and analgesic properties.[38] Laksha (Laccifer lacca Kerr.) and Manjishtha (Rubia cordifolia Linn.) delicately balance heat and cold in the eye by reducing Pitta.[39] Siroveshtana and Lepa normalizes the retinal vasculature, reduces inflammation, and augments eyesight possibly by penetration through the capillary network first into minor veins, and then into the systemic circulation, thus absorbing the medicament to achieve the desired effect.[40] Tala was done to initialize and enhance the medicines being absorbed through the scalp. Nimbamrtadi eranda, a version of Panchatikta guggulu ghrita,[41] in which the Sneha employed is oil extracted from Ricinus communis Linn., was used due to its efficacy to augment absorption of the essential nutrients through the layers of the scalp and facilitate their assimilation into the target tissues.[40]
The normalization of retinal physiology, as well as the initial maintenance of and later improvement in VA came about in a gradual manner by the treatments prescribed for the patient. Notable observances in the retina were the reduction of edema in the optic disc, disappearances of exudates around the optic disc, restoration of the integrity of the retinal vasculature, and disappearance of vascular sheathing. Reduction of optic disc edema and resolution of exudates was brought about by the Shophahara action of the treatments, which opened the Srotas and relieved the Srotorodha present in the retina, relieved the Avarana (~obstruction) caused by pathological Doshas, and relieved Vata and Kapha doshas. Restoration of vascular integrity was achieved by Rakta sodhaka action of the treatments. This action was aimed at reducing Kapha and Pitta, the chief instigators of Rakta becoming pathological.[42] Improvement of vision was brought about by the Chakshushya and Rakta shodhaka properties. By normalizing the retinal pathology, clarity and acuity of vision could be improved.
| Conclusion | | |
A concerted effort by the oral medicines, Panchakarma therapies, external ocular and head therapies, and Pathya-apathya were the keystone to performing Samprapti vighatana (~arrest of pathogenesis), resulting in improved findings. Treatments employed were aimed mainly at purifying the body and normalizing digestion; further treatments incorporating Tarpana (~retention of lipids) and Putapaka (~retention of expressed juice) would be needed to augment the present results. The main challenge was maintenance of vision. Although no improvement in VA was observed after the first follow-up, the retinal findings gradually improved. This case also illustrates the role of multiple rounds of treatment, both outpatient and inpatient, to achieve results. These may be analyzed and validated by further trials and studies.
Declaration of patient consent
Authors certify that they have obtained patient consent form, where the patient has given her consent for reporting the case along with the images and other clinical information in the journal. The patient understands that her name and initials will not be published and due efforts will be made to conceal her identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]
[Table 1]
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