|Year : 2021 | Volume
| Issue : 2 | Page : 54-57
Ayurvedic management of recurrent anterior uveitis (Raktaja adhimantha) with bloodletting therapy: A case report
Akshatha K Bhat1, V Krishnakumar2
1 Department of Shalakya Tantra, Yenepoya Ayurveda Medical College and Hospital, Yenepoya (Deemed to be) University, Mangaluru, Karnataka, India
2 Clinical Research, National Ayurveda Research Institute for Panchakarma, Cheruthuruthy, Thrissur, Kerala, India
|Date of Submission||23-Jan-2021|
|Date of Acceptance||22-May-2021|
|Date of Web Publication||16-Aug-2021|
Dr. Akshatha K Bhat
Associate Professor, Department of Shalakya Tantra, Yenepoya Ayurveda Medical College and Hospital, Naringana, Mangalore, Karnataka - 575018
Source of Support: None, Conflict of Interest: None
A 34-year-old female patient reported to the outpatient department with recurrent anterior uveitis who presented with blurred vision, severe pain, redness, watering, and unable to bear bright light since one day in the left eye. On examination, inflammatory changes were seen in the anterior chamber. These symptoms appeared alternatively in both the eyes; three to four times a year for consecutively two years. She was under pred forte 1% eye drops, homide eye drops, and prednisolone tablets during relapses as advised by an ophthalmologist. Further, she developed hyperglycemia and started medications for that. During this period, steroids were withdrawn. Considering the limited benefits, she opted for Ayurveda treatment. The condition was diagnosed with Raktaja adhimantha and treated with Jalaukavacharna (~leech therapy), Shirovirechana nasya (~intranasal drug delivery with cleansing action) with Shadbindu taila. Kaishora guggulu and Rasnaerandadi Kashaya were administered orally. The symptoms subsided within a week, while after a month, the signs of the anterior chamber were normalized. The oral medicines were continued for a month. She was asymptomatic for three years. A similar mild symptom appeared in the right eye that was managed in similar lines. Thereafter, no exacerbation was noticed till January 2021. Ayurveda bloodletting therapy along with Shirovirechana nasya and oral medicines is effective and safe as a stand-alone therapy in recurrent anterior uveitis and prolong the interval between recurrent attacks in uveitis.
Keywords: Jalaukavacharana, Kaishora guggulu, Raktaja Adhimantha, Rasnerandadi kashaya, recurrent anterior uveitis
|How to cite this article:|
Bhat AK, Krishnakumar V. Ayurvedic management of recurrent anterior uveitis (Raktaja adhimantha) with bloodletting therapy: A case report. J Ayurveda Case Rep 2021;4:54-7
|How to cite this URL:|
Bhat AK, Krishnakumar V. Ayurvedic management of recurrent anterior uveitis (Raktaja adhimantha) with bloodletting therapy: A case report. J Ayurveda Case Rep [serial online] 2021 [cited 2021 Oct 25];4:54-7. Available from: http://www.ayucare.org/text.asp?2021/4/2/54/323910
| Introduction|| |
Anterior uveitis is the inflammation of the anterior uveal tract and it is recurrent when there are relapses separated by more than three months without treatment. Conservative management includes steroid eye drops, cycloplegic eye drops and oral steroids. Steroid eye drops may lead to complications such as glaucoma and cataract, while oral use may cause diabetes. Ayurveda treatment approaches can be useful in the management of this condition. Ayurveda considers it as Raktaja adhimantha and a Pilla roga (~eye disease of recurrent nature). A 34-year-old female reported to the outpatient department who was suffering with recurrent anterior uveitis and developed hyperglycemia during the course of conventional management. The condition was managed effectively with Jalaukavacharna (~leech therapy), Shirovirechana nasya (~intranasal drug delivery with cleansing action), and oral medications.
| Patient Information|| |
A 34-year-old female patient reported severe pain in the left eye associated with blurred vision, redness, watering and was unable to bear bright light since one day. On slit-lamp examination, there were inflammatory changes in the anterior chamber. These symptoms appeared in both the eyes, one eye involved at a time during the relapse; three to four times a year consecutively for two years since October 2014. She was under pred forte (1%) eye drops, homide eye drops, and prednisolone tablets during relapses as advised by an ophthalmologist. Due to the prolonged course of steroids, she developed hyperglycemia, and as a result, she had to quit steroids and start medications for hyperglycemia. When again her symptoms appeared in September 2016, she opted Ayurveda for further treatment. Jaloukavacharna was performed on lateral canthus of the left eye. Shirovirechana nasya with Shadbindu taila; Kaishora guggulu and Rasnaerandadi kashaya were administered orally. The symptoms were subsided within a week. The oral medicines were continued for one month. The signs of anterior chamber were subsided by the end of the month. The patient was asymptomatic for a period of three years and again similar symptoms appeared in the right eye in November 2019, which was milder than the previous attack. She was managed with the same medicines, with which symptomatic relief was noticed within a week. The patient was followed further and was symptom-free until January 2021.
| Clinical Findings|| |
The patient was afebrile. Pulse was 82 beats/min. Blood pressure was 130/80 mmHg. No abnormality was noticed in the functioning of the respiratory, circulatory and digestive systems.
She was suffering with myopia. Distant visual acuity by Snellen's chart was 6/36 in both the eyes. The distant vision with spectacles in the right eye was 6/6 and left eye was 6/12. The correction for the right eye was - 1.00 spherical/2.50 cylindrical at 90° and for the left eye was -1.00 spherical/2.00 cylindrical at 90°. Pinhole correction without spectacles in both eyes was 6/24. Near vision was N6 in both eyes.
The left eye was semi-closed due to photophobia. There was circumciliary congestion in left eye. [Figure 1] The left cornea was hazy. The anterior segment of the right eye was within normal limits. Pupils were equal and normally reacting to light (PEARL). Intra ocular pressure by Schiotz Tonometry was 16.0 mmHg in the left eye and 14.0 mm Hg in the right eye. Direct Ophthalmoscopy was normal except for hazy media in the left eye. The findings of slit lamp examination are shown in [Table 1].
Dashavidha pareeksha (~ten-fold examination)
Prakriti of the patient was Kaphapitta. Vikriti (~morbidity) was Tridosha along with Rakta. Satwa (~psyche), Sara (~excellence of tissues), Samhanana (~compactness of organs), Ahara shakti (~digestive power), Vyayama shakti (~capacity of exercise), Satmya (~suitability) and Pramana (~body proportion) of the patient were of Pravara (~excellent) level. No abnormalities were found in eight-fold examination except Drik (visual apparatus) that was poor.
Sroto pareeksha (~examination of body channels)
Rasavaha (~nutrition channels in eyes) and Raktavaha srotas (~blood circulating channels) were involved in the current manifestation.
| Timeline|| |
The timeline is depicted in [Table 2].
| Diagnostic Assessment|| |
It was a diagnosed case of idiopathic non-granulomatous recurrent anterior uveitis. Relevant laboratory investigations were done to rule out systemic causes of uveitis like sarcoidosis, tuberculosis etc., The diagnosis was confirmed by ocular and slit examination. It was compared with Raktaja adhimantha considering the symptoms like Nistoda (~severe pricking pain), Rakta paryantham (~circumciliary congestion) Pashyati agninibha disha (~unable to bear bright light). The interventions adopted in the present case are placed in [Table 3].
| Follow up and Outcome|| |
The patient got improvement in the symptoms of blurred vision, pain, photophobia, watering and redness within a week of initiating Ayurveda treatment. The changes observed in pain and in symptoms of anterior chamber during the first visit are depicted in [Table 4]. After a month, the anterior chamber cells and aqueous flare was completely resolved and distant vision with spectacles became 6/6. She remained symptom-free for a period of next three years. Since the time she discontinued prednisolone, the sugar levels were maintained in normal limits. Changes in the signs and symptoms are denoted in [Figure 2].
| Discussion|| |
The pathophysiology of uveitis involves breakdown of the blood aqueous barrier due to many causes like trauma, autoimmune diseases, neoplasm, infections, while in 50% of cases, it is idiopathic. It is striking to see that the cause of Raktaja adhimantha is Abhishyanda which is Srota syandana (~oozing of channels in the eyes) which could be contextually taken as a break in the barrier. The general line of management in Raktaja adhimantha includes Snehana (~unction), Rakta mokshana (~blood-letting), Virechana (~therapeutic purgation), Shirovirechana, Aschyotana (~eye drops), Anjana (~ocular ointment), Tarpana (~retention of ghee over eyes), Pradeha (~medicated paste), Parisheka (~ocular irrigation), Dhoomapana (~medicinal smoke inhalation) and Snigdha putapaka (~retention of specially prepared medicine over eyes) of which Rakta mokshana in the form of Jalaukavacharana and Shirovirechana nasya were selected in this case. Management principles of Pilla roga also include Rakta moksha. The specific treatment for acute pain in Raktaja adhimantha also includes Jalaukavacharana, other being Acha snehapana (~oral intake of medicinal ghee in large dose) and Swedana (~sudation).
Jalaukavacharana was selected as it is a Raktaja disease with acute pain and also a Pilla roga. Recent studies have also reported that medicinal leeches secrete bioactive substances with analgesic and anti-inflammatory properties. The site of jalaukavacharana was selected in lateral canthus. Shirovirechana was done with Shirovirechana taila owing to its properties of removing morbid Doshas as well as it is indicated in eye diseases.
Rasnerandadi kashaya even though not having a direct indication in Netra roga, but anecdotal evidence suggest it can be used in Shoola (~pain) and Shopha (~oedema) in any parts of the body. Anti-oxidant property of Rasnerandadi kashaya is proven. Researchers have proposed the use of anti-oxidants in uveitis where oxidative stress in the eyes is evident. Hence it is an apt drug of choice in uveitis. Kaishora guggulu was administered due to its anti-inflammatory properties in eye diseases.
| Conclusion|| |
Ayurveda bloodletting therapy along with Shirovirechana nasya and oral medicines is effective and safe as a stand-alone therapy in recurrent anterior uveitis. It would relieve the symptoms satisfactory and prolong the period between recurrent attacks in uveitis.
Declaration of patient consent
Authors certify that they have obtained patient consent form, where the patient/caregiver has given his/her consent for reporting the case along with the images and other clinical information in the journal. The patient/caregiver understands that his/her name and initials will not be published and due efforts will be made to conceal his/her identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Jabs DA, Nussenblatt RB, Rosenbaum JT. Standardization of uveitis nomenclature (SUN) for reporting clinical data – results of the first international workshop. Am J Opthalmol 2005;150:509-16.
Harthan JS, Opitz DL, Fromstein SR, Morettin CE. Diagnosis and treatment of anterior uveitis: Optometric management. Clin Optom (Auckl) 2016;8:23-35.
Dinning WJ. Steroids and the eye – indications and complications. Postgrad Med J 1976;52:634-8.
Conn JW, Fajans SS. Influence of adrenal cortical steroids on carbohydrate metabolism in man. Metabolism 1956;5:114-27.
Acharya YT, editor. Sushruta Samhita of Sushruta, Uttara Tantra. Ch. 6., Ver. 18-19. Varanasi: Chaukhambha Surbharati Prakashan; 2017. p. 604.
Harishastri P, editor. Ashtanga Hridayam of Vagbhata, Uttara Sthana. Ch. 16., Ver. 45. Varanasi: Chowkhambha Surbharati Prakashan; 2017. p. 833.
Salmon JS. Kanski's Clinical Ophthalmology a Sytematic Approach. 9th
ed. China: Elsevier Limited; 2020
Acharya YT, editor. Sushruta Samhita of Sushruta, Uttara Tantra. Ch. 6., Ver. 5. Varanasi: Chaukhambha Surbharati Prakashan; 2017. p. 603.
Acharya YT, editor. Sushruta Samhita of Sushruta, Uttara Tantra. Ch. 12., Ver. 3-6. Varanasi: Chaukhambha Surbharati Prakashan; 2017. p. 616.
Harishastri P, editor. Ashtanga Hridayam of Vagbhata, Uttara Sthana. Ch. 16., Ver. 47. Varanasi: Chowkhambha Surbharati Prakashan; 2017. p. 833.
Acharya YT, editor. Sushruta Samhita of Sushruta, Uttara Tantra. Ch. 12., Ver. 8-9. Varanasi: Chaukhambha Surbharati Prakashan; 2017. p. 616.
Sig AK, Guney M, Uskudar Guclu A, Ozmen E. Medicinal leech therapy-an overall perspective. Integr Med Res 2017;6:337-43.
Acharya YT, editor. Sushruta Samhita of Sushruta, Shareera Sthana. Ch. 8., Ver. 17. Varanasi: Chaukhambha Surbharati Prakashan; 2017. p. 381.
Mishra SN, editor. Bhaishajya Ratnavali, Shiroroga Adhikara. Ch. 65., Ver. 78-80. Varanasi: Chaukhambha Surbharati Prakashan; 2017. p. 1020.
Krishnan V, Pillai G, editors. Sahasrayoga, Kashaya Yoga. 26th
ed. Kerala: Vidyarambham Publishers; 2006. p. 84.
Sruthi CV, Sindhu A. A comparison of the antioxidant property of five Ayurvedic formulations commonly used in the management of vata vyadhis. J Ayurveda Integr Med 2012;3:29-32. [Full text]
Yadav UC, Kalariya NM, Ramana KV. Emerging role of antioxidants in the protection of uveitis complications. Curr Med Chem 2011;18:931-42.
Krishnan V, Pillai G, editors. Sahasrayoga, Vatakadi Yoga. 26th
ed. Kerala: Vidyarambham Publishers; 2006. p. 157.
[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3], [Table 4]