|Year : 2018 | Volume
| Issue : 2 | Page : 36-42
Ayurvedic management of Chronic Scleritis (Sirajala)
Pundareekaksha Rao Punna1, Prem Sankar2
1 Dept. of Shalakya Tantra, Ayurveda College, Coimbatore, Tamilnadu 641 402, India
2 Ayurvedic Physician, AVP (Netra), Coimbatore, Tamilnadu 641 402, India
|Date of Web Publication||13-Jul-2022|
Pundareekaksha Rao Punna
Dept. of Shalakya Tantra, Ayurveda College, Coimbatore, Tamilnadu 641 402
Source of Support: None, Conflict of Interest: None
Scleritis is a systemic manifestation of sclera. Topical eye drops frequently are ineffective in this condition and systemic therapies can have serious adverse effects. No satisfactory treatment modalities are available in modern medicine for this condition. A case of 24 years old male, having severe red eye, conjunctival congestion extending from nasally and temporally towards cornea was attended successfully in this case. The patient was diagnosed to be suffering from Sirajala (~scleritis) and was treated with a combination of Lekhana anjana (~a type of collyrium) with oral Ayurvedic medicines for a month. Mridu virechana was done to eliminate Doshas of systemic level before starting the main treatment. After 15 days of treatment; redness and discomfort were disappeared. Pain, headache, discomfort were decreased, with slight redness around the nodule in the right eye, while left eye was normal after a month of treatment.
Keywords: Lekana anjana, Scleritis, Sirajala
|How to cite this article:|
Punna PR, Sankar P. Ayurvedic management of Chronic Scleritis (Sirajala). J Ayurveda Case Rep 2018;1:36-42
Introduction: Scleritis is a chronic inflammatory condition that primarily involves the episclera and sclera. Fifty percent of patients with Scleritis are diagnosed with an associated systemic disease including auto-immune conditions and infections. The inflammatory process may extend to adjacent structures, causing several complications that may lead to loss of vision. Topical eye drops are ineffective in this condition. Systemic administration of Non-Steroidal Anti- Inflammatory Drugs (NSAIDs), corticosteroids, non- steroidal immuno-suppressive agents or a combination of these drugs, is the mainstay of treatment given for Non-infectious Scleritis., Though these therapies re beneficial, can lead to serious adverse effects. Systemic corticosteroids are often accompanied by a poor safety profile characterized by multiple adverse effects, such as fluid retention, hypertension, hyperglycemia, greater susceptibility to infections, mood changes, osteoporosis, psychosis etc., The systemic immuno-suppressive therapy for eye diseases has shown data regarding treatment with Biological Response Modifiers (BRM) for inflammatory diseases., No satisfactory treatment modalities are available in modern medicine for this condition, further uncontrolled conditions may settle in complications. Considering which, satisfactory treatment modalities in other systems of medicines is being explored. This current case was successfully treated on the line of Ayurvedic management of Sirajala, one among the curable Shuklagata rogas (~diseases involving Sclera).
A 24 years old, non-smoking, non-alcoholic male reported to the OPD with progressive binocular redness, lacrimation, pain and photophobia along with mild discomfort and headache since one month. None of the family members had a history of Scleritis. He was suffering with similar symptoms since past three years, where remissions and exacerbations of the symptoms were experienced at the intervals of two months, each episode continuing for a fortnight. The condition was diagnosed as Scleritis by the Opthalmologist for which, he was advised Prednisolone (1%) eye drops four times a day, atropine (1%) eye drops two times a day and Ofloxacin eye drops (0.3%) four times a day. Topical Moxifloxacin eye drops three times daily, oral Doxycycline 100 mg/day were also used by the patient under the supervision of an ophthalmologist. However, no significant relief was noticed in his condition; considering which, he stopped using allopathic medicines.
On examination, the patient was found to be anxious, had disturbed sleep, moderate appetite, unstable digestive functions, hard stools and normal micturition.
Patient was of Vatakapha prakriti with medium stature. Respiratory, Cardio vascular functioning was normal. Pulse rate was 76/min, Blood pressure was 130/90 mmHg and Respiration rate was 18/min. No features of systemic autoimmune diseases, joint pain, oro-genital or skin ulcerations, rashes or photosensitivity to sunlight were observed. General grading of clinical features of Scleritis are presented at [Table 1].
On slit lamp examination; eye lids and adnexa of both eyes were normal. Conjunctival congestion extending from nasally and temporally towards cornea was noticed. Pupils were round and reactive. A small nodule of around 3-4 mm diameter was noted in the right eye, at 4o clock position, little away from the limbus that was freely movable with the conjunctiva and episcleral tissue. Episcleral vessels on the same side were congested. No abnormality was noticed in cornea, iris or in anterior and posterior chambers. Extra- ocular movements were normal. There were no relative afferent pupillary defects. Intra-ocular pressure was normal in both the eyes. Fundus examination of both eyes did not reveal any pathology. The best corrected visual acuity was 6/9 in right eye and 6/6 in left eye. Hematological investigations were done in April 2017 [Table 2]. C-Reactive Protein was negative, Human Leukocyte Antigen (HLA-B27) was positive and Urine routine examination revealed presence of Albumin, 1-2 pus cells/HPF and traces of Urine bile pigment. RA factor, uric acid and Anti Neutrophic Cytoplasmic Antibody (ANCA) were within the normal limits. Written informed consent was obtained from the patient before starting the treatment.
Mridu virechana with 3gm of Avipattikara churna and 10 ml of Eranda taila (Castor oil) followed by lukewarm water was done at 5 AM during the first three days that helped him to pass bowels smoothly followed by Vata anulomana (~downward movement of Vata) without any complications. After Mridu virechana, the patient was applied with one drop of Chandanadi anjana in both eyes in the morning and evening along with a tablet (250 mg) of Saptamruta loha followed by 15 ml of Pathyakshadhatryadi kashaya thrice a day before food and Triphala guggulu (250 mg) and Gandhaka rasayana (325 mg) along with milk thrice a day after food. These medicines were administered for thirty days. During the treatment period; the patient was advised to foment his eyes with a clean cotton fabric soaked in lukewarm water. In addition; patient was advised not to consume mustard oil, other oily foods, diet predominant in Amlarasa (~sour in taste), exposure to dust and awakening till late nights.
Results: After one month of treatment; more than 80% reduction was noted in pain, headache and discomfort in both eyes except mild redness around the nodule in right eye. Changes observed in the symptoms before and after treatment are placed at [Table 3].
Follow up: After 30 days of treatment; patient was followed-up on 3rd, 7th and 15th day and examined by Slit lamp and ophthalmoscope. Hematological examination revealed non-significant changes in all parameters except ESR that is reduced to 20 mm/hr from 60 mm/ hr. On 3rd day, discomfort in left eye and headache were reduced but pain and redness were continuing. On 7th day, change was observed in the redness and there were no complaints of pain or headache. Reduced congestion up to 80% percent and no discomfort were noticed by the end of 15th day. At this stage, a few episcleral vessels were observed around the nodule in Right eye.
Scleritis is a chronic, painful, and potentially blinding inflammatory disease that is characterized by oedema and cellular infiltration of the scleral and episcleral tissues. Maha jalabha kathina sira (~red and extensive network of hardened veins) spreading over the Shukla mandala (sclera) is seen in Sirajala as observed in the current case. In right eye a Sirapidaka (~a white nodular growth near the limbus covered over the veins) was also noticed. Sirotpata [characterized by Shukla mandala full of Akshiraja (~corneal congestion) associated with Daha (~burning sensation), Vedana (~pain)] and Siraharsha [characterized by Ati akshiraja (~intense corneal congestion), Asra sravana (~blood stained discharge), Na shaknotyabhivikshitam (~unable to see objects)] were the conditions differentiated from the current case. According to Susruta; Sirajala and Sirapidaka are Shuklagata rogas (diseases of sclera), while Sirotpata and Siraharsha are Sarvagata roga (diseases involving entire eye). Vagbhata mentioned all these diseases under Shuklagata roga. Chedana, Lekhana anjana and oral medicines are the main line of treatment in Sirajala.
Avipattikara churna (3gm) mixed with 10ml of Eranda taila (Castor oil) was given for initial three days. It causes Mridu virechana (~mild purgation) and Dosha anulomana thus employed before treatment for elimination of exacerbated Doshas.
Ingredients of Chandanadi anjana possesses Tikta, Kashaya, Madhura rasa, Laghu, Ruksha guna, Ushna virya, Tridosha hara mainly Kapha vatahara. Ingredients of Pathyakshadhatryadi kashaya possesses Tikta, Kashaya rasa and Rasayana, Vrana ropana properties. Tikta rasa is Pitta hara and Kashaya rasa is Vrana ropaka., Besides pacifying the aggravated Doshas, contents of Triphala guggulu will be helpful as Anti-oxidant and anti- inflammatory agents that also play a crucial role in the management of Scleritis.
Gandhaka rasayana is useful in pathologies manifested due to aggravated Vata and Kapha and in cough, dyspnea, dyspepsia etc. This is equally effective in pathologies of skin and mucous membrane, eye diseases and is useful as a potent Rasayana. Ingredients of Saptamruta loha pacifies all the three Doshas predominantly of Pitta. The ingredients are useful as Rasayana, Sroto shodhaka, Rakta shodhaka, Vrana ropaka and possesses Anti-oxidant and Anti-inflammatory activities. Various glycol proteins, lipids, essential amino acids, glycerol, gallic acid, chebulic acid, tannin, vitamin C (of Amalaki), B Complex (of Honey), A (of Cow ghee), E (of Honey and cow ghee) also may play a crucial role in breaking the pathology at different levels. Currently, the patient is under follow- up and taking Gandhaka rasayana, and Triphala guggulu. No relapses have been noticed after the treatment.
Ayurvedic treatment approaches followed in the current case including Lekana anjana and oral drugs after Mridu virechana are beneficial in treating Scleritis. Such approaches may be taken into consideration in large scale population to evaluate the efficacy through well- designed protocols.
Source of support: Nil
Conflict of Interest: None declared
| References|| |
Galor A, Thorne JE. Scleritis and Peripheral Ulcerative Keratitis. Rheumatic diseases clinics of North America
De la Maza MS, Foster CS, Jabbur NS. Scleritis- associated uveitis. Ophtalmology. 1997;104(1): 58-63.
De la Maza MS, Molina N, Gonzalez-Gonzalez LA, Doctor PP, Tauber J, Foster CS. Scleritis therapy. Ophthalmology. 2012;119:51-58.
Nascimento H, Franca M, Garcia LG, Muccioli C, Belfort R. Sub-conjunctival dexamethasone implant for non-necrotizing scleritis. Journal of Ophthalmic Inflammation and Infection. 2013;3:7
Lowder C, Belfort R, Lightman S, Foster CS, Robinson MR, Schiffman RM et al
. Dexamethasone intra-vitreal implant for non- infectious intermediate or posterior uveitis. Arch Ophthalmol. 2011; 129(5): 545-53.
Kempen JH, Daniel E, Dun JP, Foster CS, et al
. Overall and cancer related mortality among patients with ocular inflammation treated with immunosuppressive drugs: retrospective cohort study. British Medical Journal. 2009; vol. 339, no. 7712: 89-92
Bongartz T, Sutton AJ, Sweeting MJ, Buchan I, Matteson EL, Montori V. Anti-TNF antibody therapy in rheumatoid arthritis and the risk of serious infections and malignancies: systematic review and meta-analysis of rare harmful effects in randomized controlled trials. JAMA. 2006; 295: 2275-2285.
Rahman Z, Biswas J. Current approach in diagnosis and management of scleritis. Kerala Journal of Ophthalmology. 2008; 20(4):341-348.
Murthy SK, editor. Sushruta Samhita of Sushruta, Uttara tantra, Shuklagata roga vijnana, chapter 4, verse 8. Chaukhambha Orientalia; Varanasi: 2012, reprint ed, p. 19.
Murthy SK, editor. Sushruta Samhita of Sushruta, Uttara tantra, Sarvagata roga vijnana, chapter 6, verse 29-30. Chaukhambha Orientalia; Varanasi: 2012, reprint ed, p. 26.
Murthy SK, editor. Sushruta Samhita of Sushruta, Uttara tantra, Shuklagata roga vijnana, chapter 4, verse 3. Chaukhambha Orientalia; Varanasi: 2012, reprint ed, p. 18.
Murthy SK, editor. Sushruta Samhita of Sushruta, Uttara tantra, Sarvagata roga vijnana, chapter 6, verse 3-4. Chaukhambha Orientalia; Varanasi: 2012, reprint ed, p. 22.
Shastri HS, editor. Ashtanga Hridaya of Vagbhata, Uttara sthana, Sandhisitasitaroga vijnana, chapter 10, verse 14-16,19. Choukambha Orientalia; Varanasi: 2005, 9th
ed, p. 810.
Kunjalal K, editor. Sushruta Samhita of Sushruta, Uttara tantra, Chedya roga pratishedha, chapter 15, verse 19-20. Chaukhambha Sanskrit Series Office; Varanasi: 1916, 5th
ed, p. 188.
Anonymous. The Ayurveda Pharmacopeia of India, Part - II, Volume - I. The Controller of Publications; Delhi: 2008, 1st
ed, p. 41-42.
Pandey G, editor. Bhaishajya Ratnavali, Netra rogadhikara, verse 81. Choukhambha Sura Bharati Prakashan; Varanasi: 2008, 1sted, p. 786.
Shastri P, editor. Sharangadhara Samhita of Sharangadhara with dipika commentary. Madhyama khanda, chapter 2, verse 143-145. Chaukhambha Orientalia; Varanasi: 2016, reprint ed., p.262.
Acharya YT, editor. Commentary Ayurveda dipika of Chakrapani on Charaka samhita of Agnivesha, Sutrasthana, Atreya Bhadrakapyeeyam, chapter 26, verse 43, Chaukhambha Orientalia; Varanasi: reprint 2011;145.
Shastri P, editor. Sharangadhara Samhita of Sharangadhara with dipika commentary. Madhyama khanda, chapter 7, verse 82-83. Chaukhambha Orientalia; Varanasi: 2016, reprint ed., p. 204.
Tripathi I, Tripathi DS, editors. Yogaratnakara with Vaidyprabha hindhi commentary, Netra roga nidana chikitsa prakarana, verse 28 - 31, Chowkhamba Krishnadas Academy, Varanasi: 2013. 4th
ed., p. 812.
Pandey G, editor. Bhaishajya Ratnavali, Netra rogadhikara, verse 129. Choukhambha Surabharati Prakashan; Varanasi: 2008, 1sted, p. 803.
[Table 1], [Table 2], [Table 3]