|Year : 2022 | Volume
| Issue : 1 | Page : 10-16
Ayurvedic management of retinopathy combined with central serous macular edema: A case report
K Nethradas Pathiyil, Sumitha Prakash Cheruvillil
Ramavarma District Ayurveda Hospital, Trissur, Kerala, India
|Date of Submission||16-Jun-2021|
|Date of Acceptance||04-Mar-2022|
|Date of Web Publication||20-Apr-2022|
Dr. K Nethradas Pathiyil
Ramavarma District Ayurveda Hospital, Trissur, Kerala
Source of Support: None, Conflict of Interest: None
Dealing with intemperate diabetes and hypertension, one of the main challenge to deal with is retinopathy. Early management and preventive treatments through Ayurveda can make a great impact as it helps in preventing vision loss. The major cause of vision loss in diabetic retinopathy is macular edema, which is the thickening of macula due to fluid accumulation. This will result in significant deterioration of vision and if untreated will result in permanent loss of vision. The pathophysiology of hypertension and diabetes can cause altered immune functions and vascular endothelial dysfunction. In Ayurveda, retinopathy can be considered as Timira (~errors of refraction/partial blindness). A 61-year-old male patient complaining of defective distant and near vision for one year sought Ayurvedic treatment. Clinical findings include Central Serous Macular Edema (CSME), Non-proliferative Diabetic Retinopathy (NPDR) with maculopathy, and Grade 2 hypertensive retinopathy in both eyes. The selected treatment protocol includes Rakta sangrahi (~medicine that helps in blood coagulation), Stambhana (~procedure or action of drug causing arrest of secretion or control of bleeding), and Ama pachana (~the action of a drug or medicine which helps in digesting toxins in body), Sirovirechana (~medication through nose for cleansing or errhine), Talapotichil (~patching the scalp with herbal paste), Sirodhara (~pouring medicated oil over the scalp), Takradhara (~therapeutic butter milk-streaming over body), and Akshi tarpanam (~filling the eyes with medicated Ghee). Significant improvement in Visual Acuity (VA) and changes in CSME were observed at the end of the treatment. During follow-up period of three months, VA was further improved. The observations reveal that Ayurvedic management of the mixed retinopathy is significantly effective in reducing the subjective and objective symptoms and improve VA.
Keywords: Diabetic macular edema, diabetic retinopathy, hypertensive retinopathy, Timira, Takradhara, Talapotichil
|How to cite this article:|
Pathiyil K N, Cheruvillil SP. Ayurvedic management of retinopathy combined with central serous macular edema: A case report. J Ayurveda Case Rep 2022;5:10-6
|How to cite this URL:|
Pathiyil K N, Cheruvillil SP. Ayurvedic management of retinopathy combined with central serous macular edema: A case report. J Ayurveda Case Rep [serial online] 2022 [cited 2023 May 30];5:10-6. Available from: http://www.ayucare.org/text.asp?2022/5/1/10/343505
| Introduction|| |
According to the International Diabetes Foundation, approximately 14% people worldwide living with diabetes have Diabetic Macular Edema (DME). Out of this, about 30% people have a vision-threatening form. Diabetic retinopathy is of two types – proliferative and non-proliferative. The early non-proliferative diabetic retinopathy is characterized by increased vascular permeability and is usually symptomless. It is detectable only with fundal imaging. During this stage, although the patients may be asymptomatic, microaneurysms, hemorrhages, and hard exudates can be detected by indirect ophthalmoscopy or fundal picture. In proliferative diabetic retinopathy, severe vision impairment will be noticed due to the formation of new blood vessels, which is called neovascularisation and consequent hemorrhage. The condition in diabetic retinopathy will be more severe in case of macular edema, which is the thickening of macula due to fluid accumulation. This will result in the significant deterioration of vision and if untreated will result in permanent loss of vision. Prevention and conservation are possible through Ayurvedic approaches of Netra chikitsa (~eye treatment). With Ayurvedic Netra chikitsa, quality medical care becomes affordable even to patients who are indicated for expensive modern interventions.
Untreated retinopathy can be a risk factor for ischemic shock. Further, it can drain the quality of life. Continuous lasers and injections with minimal clinical improvement may leave the patient frustrated and depressed. A structured and well-planned Ayurvedic treatment depending upon the patient's condition reduces the risks and complications while catering all patient needs.
| Patient Information|| |
A 61-year-old diabetic male patient visited OPD with complaints of gradual painless diminution of binocular Distant Vision (DV) and Near Vision (NV) on December 24, 2020. He was previously diagnosed as severe non-proliferative diabetic retinopathy with Clinically Significant Macular Edema (CSME). The patient had a history of five years of diabetes mellitus, hyper-cholestremia, and hypertension. He was taking conventional medicines and these conditions were under control. However, after two years, he discontinued anti-diabetic drugs. Later, on a routine checkup, when the patient was advised for a spectacle change in his nearby eye clinic, he was diagnosed with CSME through Optical Coherence Tomography (OCT) examination [Figure 1] and [Figure 2]. HbA1c was 13.8 at that time. During October 2020, he started 10 units of insulin in the morning. The patient was suggested for a laser treatment after one month by the allopathic eye clinic, but he was reluctant for the procedure and opted for Ayurvedic treatment. At the time of visit, he was taking Gepride M (0.5) one tablet morning time, Encelin 50 one tablet evening time, Lipigo 10 one tablet at night time, and Telminorm-40 one tablet morning. Ayurvedic treatment was started after taking informed consent from the patient. His bowels and micturition were normal, whereas appetite was more and sleep was reduced. No allergies have been known till date.
| Clinical Findings|| |
The patient was afebrile, pulse rate was 80/min, respiratory rate was 18/min. Blood pressure was 130/80 mmHg under medication. Details of the fundal examination and Visual Acuity (VA) are depicted in [Table 1]. No other systemic abnormalities were found except poor glycemic control.
| Timeline|| |
The detailed timeline is given in [Table 2].
| Diagnostic Assessment|| |
Fasting blood sugar was 168 mg/dl and postprandial blood sugar was 249 mg/dl on November 14, 2020. No other systemic abnormalities were found. Bilaterally anterior segment was within normal limits. The unaided VA was 4/60 in right eye and 6/60 in left eye. Media was clear in both eyes with cup-to-disc ratio (CDR)-0.5, dot, blot hemorrhages were seen in both eyes. Right eye showed Clear media. CDR-0.5 is normal, dot, blot, and flame-shaped hemorrhages in upper quadrants. Hard exudates present, copper wiring, optic disc ischemia with blurred margin, venous tortusity, pale optic disc and neovascularization of optic disc were seen. Focal macular edema, retinal thickening within 500 μ of center of the macula was present. Central Foveal Thickness (CFT) in right eye was 386. Absence of foveal reflex in indirect ophthalmoscopy. Left eye fundus picture showed clear media CDR-0.5 which is normal, dot, blot hemorrhages in lower quadrants, flame-shaped hemorrhages, congested retinal veins, arteriovenous nicking, hard exudates present, venous tortusity, pale optic disc, neovascularization of optic disc, retinal thickening within 500 μ of center of the macula. CFT in left eye was 265. OCT of right eye reported severe DME [Table 1], [Table 2] and [Graph 1].
| Therapeutic Interventions|| |
The interventions adopted in the present case are placed in [Table 3]. The patient was continuing his allopathic medications. At the end of the treatment, Ayurvedic internal medicines were continued for further 15 days and follow-up was done in an interval of 15 days for the next three months.
| Follow-up and Outcome|| |
Improvement noticed after 28 days of in-patient treatment. Follow-up was done in an interval of 15 days. At the end of four months of Ayurvedic treatment, his VA in both eyes was improved from 4/60 to 6/36 in right eye and from 6/60 to 6/18 in left eye. Vision chart, fundal pictures, and OCT reports supported the results [Figure 3] and [Figure 4]. There was improvement in DV and NV in both eyes [Table 1]. Fundus examination revealed reduction in exudates and hemorrhages in both eyes [Figure 5], [Figure 6], [Figure 7], [Figure 8]. VA was further improved during the follow-up. The distant VA (DV) improved by 10% in right eye and 25% in left eye. Best corrected VA (BCVA) improved by 15% in right eye and 15% in left eye. Pin Hole (PH) improvement was noticed by 15% in right eye and 15% in left eye [Table 4] and [Table 5].
| Discussion|| |
New studies have inferred that, diabetes is the most important single cause of moderate-to-severe visual impairment and blindness, with 12% attributed to diabetic retinopathy, especially in working age group of 16–64 years. In the present case, there is an association of hypertensive retinopathy as well, which was classified as Grade 4, according to KeithWeigner's classifications. The selection of the anti-hypertensive drugs in the management of diabetic retinopathy helped in the management of the condition without leading to surgical intervention. This case of combined diabetic and hypertensive retinopathy can be taken as Sarakta sannipatika affecting different layers of eye. The use of Achakshyushya aahara like curd and pickles with rice and Vihara (~life style) like day sleeping resulted in the Shiro abhishyanda (~inflammatory reactions in channels of head resulting in the exudative discharge) which in turn leads to Nethra abhishyanda. The influence of the Achakshushya factors by the patient vitiates the Pittavaha srotas. Eye being the Pitta sthana, vitiation of Rakta, and the Kapha paithika avastha of the disease results in the progression of the disease started as a Kapha pitta predominant Aavarana janya vyadhi, which is characterized by microaneurysms and exudates. The predominance of Kleda in the Pitta sthana vitiates the Kapha pitta avastha and this can be explained as multiple forms of cell death like apoptosis, necrosis, autophagic cell death, and pyroptosis that has been established during the progressive course of diabetic retinopathy.
The changes which took place in the blood-retinal barrier function of the endothelial cells account for the severity in the progression of the disease. The necrosis is featured by excitotoxicity, DNA damage, which can be regulated depending upon the microenvironment. Apoptosis is mainly mediated by the mitochondrial damage of endothelial cells.
Raktavaha srotas (~channels carrying blood tissue) is involved in this manifestation through the pathology of Vimarga gamana (~diversion to the flow of the contents to the improper channels). Pranavaha srotas (~channels of respiration) and Vyana vaha srotas are involved because in case of sense organs perception of their objects takes place with the help of Pranavayu and the conduction of the perceived images works with the help of Vyana vayu. If both are altered, there can be Aavarana resulting in Vyanavruta prana. The end result is the defective conduction and perceprtion of images.
The primary Kapha pitta predominant stage was managed by the administration of the internal medicines with Rakta sangrahana (~ability to control bleeding) property. Deepana, pachana (~digestant), and Rookshana (~dryness inducing) followed by Snehana (~oleation) methodology adopted in the case helped in preventing further pathology. As Punarnavadi Kashaya is Sarvanga sopha hara, it may help in reducing retinal ischemia and retinal edema. Devadaru (Cedrus deodara [Roxb. ex D. Don] G. Don) in the Kashaya possesses anti-inflammatory, immune enhancing, diuretic, anti-diabetic, and antioxidant effects., Kashaya itself is Aama pachana (~digestive stimulant) owing to the presence of Sunthi (Zingiber officinale Roscoe). Flavonoids are excellent antioxidants and phytonutrients, which help in improving the permeability of capillary membranes. The immune stimulant and hypoglycemic activity of saponins aid in the recovery. The antioxidant property of most of the drugs aid in releasing prostacyclin from the endothelium which releases the blockages and inhibits platelet aggregation.
Primary focus was on Kleda samshamana (~de-exudation therapy) followed by Pitta prasadana. This was done with the help of Seta rooksha therapy procedures such as Talapotichil and Takradhara. As the eye is the Pitta sthana, there is a Kapha involvement in the disease process, the Anjanam treatment done during the whole course of treatment is to pacify the associated Kapha.
The visual manifestations of retinopathy in this case can be attributed to the Aavarana in the initial stage and Dhatu kshaya (~excessive depletion of Dhatu) in the later stage due to long standing and uncontrolled hyperglycemia. The etiological factors of Prameha (~diabetes mellitus) can also be attributed to the factors leading to the Samprapti (~pathogenesis) of Timira (~errors of refraction/partial blindness). In that case of Kapha pitta avaranajanya vikaras, the first line of treatment is Stambhanam and Sroto shodhanam (~cleaning the channels). The Aama pachana treatment methodologies adopted in this stage of the disease helps in pacifying the Ulkleshana of Doshas. It helps in the reduction of the Kapha and the Kleda factors, which are the reasons behind Abhishyandi srotas. Guduchi (Tinospora Cordifolia [Willd.] Miers) in the Takradhara and Talapothichil helped in that process. The Takradahara has Sroto shodhana effect in the management of diabetic retinopathy and possibly helps in arresting hemorrhages.
After managing the Kaptha pitta predominant Avastha by the Takradhara and Talapotichil, the Doshas are expected to settle down with Vata pitta predominance. That is why Sirodhara and Siropichu with Baladhatrayadi tailam was opted for treatment. The Sarvanga abhyanga enhances the blood circulation and stimulates the neurological pathway. The stimulatory effect, regulatory effect, and the thermal effect play a part. The skin absorption of the pharmacological substances takes place through follicles through trigeminal nerve which in turn reduces the sympathetic nerve stimulation which reduce the metabolic activities and further changes. The external treatment is aimed at repairing the mechanical vascular and cellular factors which aid in the degenerative progression of the disease. The Moordha tailam controls the vitiated Vata and Pitta in the head. Once the Kapha pitta avastha is managed by the treatments and when the disease reaches a Vata pitta stage, Netra is nourished with Tarpana treatment using Patoladi ghrita. The vast surface area of absorption of the topically applied Tarpana medicine aids in the absorption and drug availability of the medicine by the intraocular tissues. The higher drug availability with Pitta samana properties aids in faster structural and functional healing.
Due to the treatment modalities adopted in this case, the DV improved by 10% in right eye and 25% in left eye. BCVA improved by 60% in right eye and 15% in left eye. PH improvement was noticed by 60% in right eye and 15% in left eye. Bilaterally fundal picture showed arteriolar constriction, vascular wall changes, flame-shaped hemorrhages, cotton-wool spots, yellow hard exudates, and optic disk edema more severe in right eye.
| Conclusion|| |
Ayurvedic management of the combined diabetic and hypertensive retinopathy is significantly effective in reducing the subjective symptoms and improving visual acuity. The distant visual acuity improved by 10% in right eye and 25% in left eye. Best corrected visual acuity improved by 15% in both eyes. Pin hole improvement was also noticed by 15% in both eyes. This shows that progression of the disease can be arrested and well managed with Ayurvedic therapy.
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 his/her identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Lee R, Wong TY, Sabanayagam C. Epidemiology of diabetic retinopathy, diabetic macular edema and related vision loss. Eye Vis (Lond) 2015;2:17.
Nentwich MM, Ulbig MW. Diabetic retinopathy – Ocular complications of diabetes mellitus. World J Diabetes 2015;6:489-99.
Wong TY, Sabanayagam C. Strategies to tackle the global burden of diabetic retinopathy: From epidemiology to artificial intelligence. Ophthalmologica 2020;243:9-20.
Santhakumari PK. A Text Book of Ophthalmology in Ayurveda. 2nd
ed. Trivandrum: Minerva Offest Private Limited India.; 2009. p. 219-21.
Sharma S, editor. Chakradatta of Chakrapani; Shotha Chikitsa. Ch. 43. New Delhi: Meherchand Lachmidas Publications; 2000. p. 254.
The Central Council of Research in Ayurveda and Siddha. Database on Medicinal Plants Used in Ayurveda. Vol. 7. New Delhi: The Central Council of Research in Ayurveda and Siddha; 2005. p. 72.
Gupta S, Walia A, Malan R. Phytochemistry and pharmacology of Cedrus deodera
: An overview. Int J Pharm Sci Res 2011;2:2010-20.
Haniadka R, Saldanha E, Sunita V, Palatty PL, Fayad R, Baliga MS. A review of the gastroprotective effects of ginger (Zingiber officinale
Roscoe). Food Funct 2013;4:845-55.
Ullah A, Munir S, Badshah SL, Khan N, Ghani L, Poulson BG, et al.
Important flavonoids and their role as a therapeutic agent. Molecules 2020;25:E5243.
Manohar PR. Critical review and validation of the concept of Āma. Anc Sci Life 2012;32:67-8.
Sharma R, Amin H, Ruknuddin G, Prajapati PK. Efficacy of Ayurvedic remedies in type 2 diabetes: A review through works done at Gujarat Ayurved University, Jamnagar. J Med Nutr Nutraceut 2015;4:63-9. [Full text]
Singh SS, Pandey SC, Srivastava S, Gupta VS, Patro B, Ghosh AC. Chemistry and medicinal properties of Tinospora cordifolia
(Guduchi). Indian J Pharmacol 2003;35:83-91. [Full text]
Madhukar LS, Nivrutti BA, Bhatngar V, Bhatnagar S. Physio-anatomical explanation of abhyanga: An ayurvedic massage technique for healthy life. J Tradit Med Clin Nat 2018;7:252.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]