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 Table of Contents  
CASE REPORT
Year : 2018  |  Volume : 1  |  Issue : 2  |  Page : 3-9

Ayurvedic Management of Diabetic Retinopathy


1 Regional Ayurveda Research Institute for Eye Diseases, Central Council for Research in Ayurvedic Sciences, Lucknow, India
2 Dept. of Shalakya Tantra, All India Institute of Ayurveda, New Delhi, India
3 Institute for Post Graduate Teaching and Research in Ayurveda, Gujarat Ayurved University, Jamnagar, India

Date of Web Publication13-Jul-2022

Correspondence Address:
V Krishna Kumar
Regional Ayurveda Research Institute for Eye Diseases, Central Council for Research in Ayurvedic Sciences, Lucknow
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2667-0593.350868

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  Abstract 


Diabetic Retinopathy (DR) is an important complication of Diabetes Mellitus (DM). Currently available conventional treatments for DR have certain limitations; considering which options from alternative resources are being searched. In Ayurveda, DR can be compared with Madhumehajanya timira, for which treatment modalities have been mentioned elaborately. In this current case of Madhumehajanya timira, Ayurvedic treatment was done along with conventional treatment. A male patient of 61 years visited the OPD complaining of defective distant and near vision since six months. Based upon the history and clinical features, he was diagnosed to be suffering from Non Proliferative Diabetic Retinopathy (NPDR) with maculopathy in both eyes. He underwent one sitting of Intra Vitreal Triamcinolone Acetonide injection in both eyes before starting Ayurvedic treatment. Deepana (~stomachic) and Pachana (~digestant), Mridu virechana (~mild therapeutic purgation), Shiro virechana (~eliminative nasal medication) and three sittings of Pratimarsha nasya (~nasal medication of mild dose) with Durvadi ghrita and Takradhara (~pouring medicated buttermilk over the scalp) were the treatment procedures adopted in this case. He was prescribed with Rasayana yoga and Pratimarsha nasya with Durvadi ghrita for three months. At the end of the treatment; there was improvement in near vision and visual acuity in both eyes. Ophthalmoscopy revealed reduction in exudates and hemorrhages. HbA1C was reduced to 7.4 from 10.3 after treatment. The observations reveal that Ayurvedic approaches are helpful in managing Diabetic Retinopathy successfully.

Keywords: Diabetic Retinopathy, Madhumehajanya timira, Nasya, Takradhara.


How to cite this article:
Kumar V K, Manjusha R, Vaghela D B, Pawar DK. Ayurvedic Management of Diabetic Retinopathy. J Ayurveda Case Rep 2018;1:3-9

How to cite this URL:
Kumar V K, Manjusha R, Vaghela D B, Pawar DK. Ayurvedic Management of Diabetic Retinopathy. J Ayurveda Case Rep [serial online] 2018 [cited 2022 Dec 9];1:3-9. Available from: http://www.ayucare.org/text.asp?2018/1/2/3/350868



Introduction: Diabetic Retinopathy (DR), the leading cause of visual disability in diabetics, is an important complication of diabetes mellitus (DM).[1],[2],[3],[4],[5] Conventional treatment for DR is LASER Photocoagulation, which stops the leakage of blood and fluids into the retina, but doesn’t break the root pathogenesis of DR.[6] The use of intra-vitreal pharmacotherapies in the last decade has revolutionized the management of Diabetic Macular Edema (DME) as well as Proliferative Diabetic Retinopathy (PDR).[7] These costly procedures improves the vision, but are to be applied at regular intervals and are not affordable by a common man. Hence, it is high time to address the management aspects of DR to develop affordable medical care.

DR and other diabetic ophthalmopathies, which lead to poor vision, can be taken under the concept of Madhumeha leading to Timira.[8] Ayurvedic treatment targets upon countering pathogenesis from the root level. In case of Madhumehajanya timira, it aims at nourishing capillaries enabling the self-maintenance of the system.[9] In this case of DR, Ayurvedic treatment was done along with conventional medicines.


  Case Report Top


A 61 years old, male reported to the OPD on 16-03-2016 complaining of gradual painless diminution of distant as well as near vision since six months. He was a known diabetic and hypertensive and was on oral hypoglycemic and anti-hypertensive medicines since eight years. On his visit to the OPD, glycemic control was poor. He was on Metformin (500mg) twice daily before food and Amlodipine (5mg) twice daily after food. He had history of Left Ventricular Failure that was treated elsewhere by allopathic physicians. He was a chronic smoker, had a habit of smoking for the past 40-years (about 10 cigarettes per day), which he stopped only about a month before the visit to the OPD. There was no family history of DM or DR. Patient had defective vision for distant and near objects and was diagnosed as a case of Non Proliferative Diabetic Retinopathy (NPDR) with maculopathy in both eyes during September 2015. He underwent one sitting of Intravitreal Triamcinolone Acetonide (ITA) injection on 22.02.2016 and on 03.04.2016 for right and left eyes respectively. He visited to the OPD enquiring Ayurvedic solutions for his condition. Ayurvedic treatment was started on 28.05.2016 after taking his consent.

Clinical findings: Patient was afebrile. Pulse was 78/ minute. Respiratory Rate was 18/minute and Blood Pressure was 150/90 mmHg. No abnormality was noticed in the functioning of respiratory, circulatory or digestive systems.

Visual examination: In both eyes distant visual acuity by Snellen chart was 6/60. After ITA, distant visual acuity remained 6/60 in both eyes. Best corrected visual acuity in both eyes was 6/24. Correction for right eye was -1.00 spherical/-2.50 cylindrical at 90 degree. Correction for Left eye was -1.00 spherical/-2.00 cylindrical at 90 degree. Pin hole correction without spectacles in both eyes was 6/24. Near vision with and without spectacles was N36 in both eyes.

Ocular examination: Eyelids, conjunctiva, sclera, cornea and anterior chamber were normal in both eyes. Pupils were of normal size and of normal reaction. Both lens had immature senile cataract (Grade- Cortical -1 by LOCS [Lens Opacities Classification System] III). Intra Ocular Pressure [IOP] by Schiotz Tonometry was 14.6 mmHg in both the eyes. Direct Ophthalmoscopy revealed Non Proliferative Diabetic Retinopathy (NPDR) with maculopathy in both eyes. RAPD (Relative Afferent Pupillary Defect) and Iris neovascularization was absent in both eyes.

Dashavidha pareeksha (~Tenfold Examination): Prakriti of the patient was Vatapitta. Pitta pradhana tridosha vikriti such as Urdhwaga raktapitta (intra-retinal haemorrhages) was observed during the analysis. Satwa (~psyche), Sara (~excellence of tissues), Samhanana (~compactness of organs), Ahara shakti (~power of food intake and digestive functions), Vyayama shakti (~power of performing exercises), Satmya (~suitability) and Pramana (~measurements of body organs) of the patient were of Madhyama (~moderate) level.

Ashtavidha pareeksha (~Eightfold Examination):

Nadi (~pulse), Mutra (~urine) and Shabda (~voice) were Sadharana (~normal). Bowels were regular, Jihwa (~tongue) was Anupalepa (~non-coated), Sparsha (~touch) was Anushna sheeta (~normal temperature), Akriti (body built) was Madhyama (~moderate) and Drik (vision) was Heena (~diminished vision).

Sroto pareeksha (~Examination of body channels):

Raktavaha srotas (~blood circulating channels) is involved in this manifestation and the pathology is Vimarga gamana (~flowing abnormal or in opposite directions) that possibly manifested as haemorrhages in retina.

Diagnostic assessment: Fasting blood sugar was 126mg/dl, PPBS was 210 mg/dl and HbA1C was 10.3. Urine sugar was nil. Serum triglycerides were 75mg/ dl. Other hematological findings were within normal limits. Fundus examination was done that confirmed the diagnosis of NPDR in both eyes [Figure 1],[Figure 2]. Optical Coherence Tomography [OCT] reported severe Diabetic macular oedema with sub-foveal fluid in both eyes [Figure 3].
Figure 1: Fundus photo Right eye before treatment. Red arrow-Hemorrhage, Yellow arrow-exudates

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Figure 2: Fundus photo Left eye before treatment. Red arrow-Hemorrhage, Yellow arrow-exudates

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Figure 3: OCT Right and Left eye before treatment. Severe DME with sub-foveal fluid was noticed

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Therapeutic intervention: The interventions adopted in the present case are placed at [Table 1].
Table 1: Therapeutic interventions adopted

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At the end of this treatment procedure; Nasya for further seven days and Takra dhara for fifteen days was repeated in the next two months. Two follow-ups were done with an interval of 15 days.


  Results: Top


There was improvement in near vision and visual acuity in both eyes [Table 2]. Fundus examination revealed reduction in exudates and hemorrhages in both eyes [Figure 4],[Figure 5]. HbA1C was reduced to 7.4 from 10.3 after three months of treatment. Visual acuity was maintained during the follow-up period.
Figure 4: Fundus examination of Right eye after treatment showing reduced hemorrhage and exudates

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Figure 5: Fundus examination of Left eye after treatment showing Reduced hemorrhage and exudates

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Table 2: Improvement in vision

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  Discussion: Top


The line of management in Timira includes Snehana (~oleation), Rakta mokshana (~blood-letting), Virechana (~therapeutic purgation), Nasya, Anjana (~ocular ointment), Shiro basti (~retention of medicated oil over scalp), Basti (~therapeutic enema), Tarpana (~retention of ghee over eyes), Lepa (~medicated paste) and Seka (~ocular irrigation) that are to be followed repeatedly[14] of which Snehana, Virechana (koshta shodhana and shiro virechana), Nasya, Pratimarsha nasya and Takra dhara were followed in this case. It is said that, Snehana is to be preceded by Rookshana (~dehydrating) in conditions of Kaphamedo vridhi.[15] Considering Pitta pradhana vikriti of the patient, Koshta shodhana was done with Avipattikara churna. Koshta shodhana expels out accumulated Kleda (~moisture) from the body, which possibly helps in reduction of macular oedema. Moreover, as the features of Madhumehajanya timira are similar to Urdhwaga raktapitta; Koshta shodhana was used as Pratilomahara chikitsa.[16] Snehana was done by administering Rasayana yoga along with Ghrita. Rasayana yoga [Table 3] is an experience based powdered herbo- mineral combination being practiced at Institute for Post Graduate Teaching and Research in Ayurveda, Jamnagar. Madhu was added to Rasayana yoga as an adjuvant considering its Chakshushya (~congenial to eyes) properties. Different components of Rasayana yoga possesses Pramehaghna property.[17],[18],[19],[20] Possibly, this combination might have caused reduction in blood sugar and changes in HbA1C [Graph 1].
Table 3: Ingredients of Rasayana yoga

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Rasayani daurbalya (~weakness of vascular channels) is the basic pathogenesis in DR and Rasayana yoga might help in strengthening vascular channels and prevent further progression of disease. Shiro virechana was done with Anu taila owing to its properties of Indriya sroto pravesha (~permeating into minute channels).[21] Nasya was done with Durvadi ghrita, that is Raktapitta hara and may help in absorption of intra retinal haemorrhages. [22] Takra dhara with Siddha takra [Table 4] is selected as it has got special indication in Netra rogas (~eye diseases).[23] The reduction in macular oedema and hemorrhages may be attributed to drugs present in Siddha takra like Chandana, Vasa, Utpala and Lodhra that can pacify Shopha (~inflammation) and Raktapitta.[24],[25],[26],[27] The improvement in near vision may be due to reduction in macular oedema. Pratimarsha nasya strengthens visual acuity (drishtibala) by doing Sroto shodhana (maintaining the functioning of ocular structures).[28] This might be the reason why the visual acuity was maintained in the follow-up period also.
Table 4: Ingredients of Siddha takra

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Patient was using conventional anti-diabetic and anti- hypertensive drugs throughout these days of Ayurvedic management. No adverse events or drug- drug interactions were noticed during the course of treatment and follow-up period too. This reveals that the conventional and traditional drugs concomitantly used in this case are not interacting with each other.


  Conclusion: Top


Thus, it can be concluded that Ayurvedic approaches are helpful in managing complications like Diabetic Retinopathy. This study emphasizes on the importance of integrated approach in healthcare. Considering such beneficial activities of Ayurveda approaches; there is a need to undertake collaborative researches to generate evidences at larger scale in the management of Diabetic Retinopathy.

Acknowledgements: Financial and other support from IPGT & RA,Jamnagar, Gujarat is acknowledged.

Source of support: Nil

Conflicts of Interest: None declared



 
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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