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 Table of Contents  
CASE REPORT
Year : 2022  |  Volume : 5  |  Issue : 1  |  Page : 22-27

Approach towards management of anterior uveitis through Ayurveda: A case report


1 Baba Khetanath Government Ayurvedic College and Hospital, Patikara, Narnaul, Haryana, India
2 Department of Shalakya Tantra, FIMS, SGT University, Gurugram, Haryana, India
3 All India Institute of Ayurveda, New Delhi, India

Date of Submission16-Aug-2020
Date of Acceptance15-Feb-2022
Date of Web Publication20-Apr-2022

Correspondence Address:
Dr. Akanksha Thakur
Department of Shalakya Tantra, FIMS, SGT University, Gurugram, Haryana - 122 505
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jacr.jacr_61_20

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  Abstract 


Uveitis is a broad term used to describe the inflammatory pathology of vascular layer of the eyeball. It is composed of a diverse group of disease entities, which, in total, has been estimated to cause approximately 10% of blindness. It can lead to serious complications such as cataract, glaucoma, and cystoid macular edema if not diagnosed and treated promptly. A 31-year-old male patient residing in urban area presented to the outpatient department with complaints of redness, pain, and watering from both eyes for the last 10 years. He also complained of photophobia, floaters, and discoloration of skin under the eyes for the last one year. The clinical features of anterior uveitis simulated to Pitta-Raktadhimantha and the treatment modalities adopted were based on Doshas and Samprapti (~pathogenesis). On examination, both the eyes were severely congested. The patient was treated with oral Ayurvedic drugs and topical medication. Satisfactory improvement was noticed by the end of management inferring the potential of Ayurveda approaches in management of such conditions.

Keywords: Pitta-Raktadhimantha, Raktashodhana, Shirovirechana, uveitis


How to cite this article:
Yadav P, Thakur A, Rajagopala M, Bavalatti N. Approach towards management of anterior uveitis through Ayurveda: A case report. J Ayurveda Case Rep 2022;5:22-7

How to cite this URL:
Yadav P, Thakur A, Rajagopala M, Bavalatti N. Approach towards management of anterior uveitis through Ayurveda: A case report. J Ayurveda Case Rep [serial online] 2022 [cited 2022 May 28];5:22-7. Available from: http://www.ayucare.org/text.asp?2022/5/1/22/343506




  Introduction Top


Uveitis is inflammation of the uvea, the vascular coat of the eyeball, i.e., the iris, ciliary body, and choroid. Clinically, it can be classified as acute, recurrent, and chronic uveitis. Anterior uveitis is one of the most common intraocular inflammatory diseases, which occurs due to various causes. It is a sight-threatening disease entity, which mainly affects working-age individuals and may lead to irreversible visual loss if not treated timely. It is responsible for 10% of legal blindness in the United States and up to 25% in the developing world.[1]

Uveitis includes a varied group of intraocular inflammatory conditions that may occur at any age but affect mostly people of working age. The total population prevalence of uveitis varies globally with an estimated prevalence of 730 cases per 100,000 in India.[2] Uveitis is the fifth most common cause of severe visual loss in the developed world, and up to 20% of legal blindness is due to complications of uveitis.[3] In addition, major vision loss (defined as best-corrected visual acuity <20/50) has been reported in 20% to 70% of patients treated in uveitis referral centers or academic ophthalmology clinics.[4]

The pathophysiology of uveitis depends on the specific etiology, but in all types, there is a breach in the blood–ocular barrier. The blood–ocular barrier, similar to the blood–brain barrier, normally prevents the cells and large protein entering the eye. Inflammation causes this barrier to break down, and WBCs enter the eye. Neutrophils predominate in acute cases, and mononuclear cells predominate in chronic cases.[5]

Patients usually present with a painful red eye, floaters, and blurred vision. There may be pupillary constriction or sluggish reaction, photophobia, and tearing. On slit-lamp examination, there are cells and “flare” (protein) in the anterior chamber. The inner surface of the cornea may be speckled with keratic precipitates that are either fine (“granular”) or globular (“granulomatous” or “mutton fat” keratic precipitates).[6],[7]

In conventional medicine, systemic corticosteroids, antibiotics, and Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) are the commonly preferred treatment regimen. The use of corticosteroids, immunosuppressants, and local therapy with steroid implants has become more popular in recent years.[8] All these treatments have many side effects such as glaucoma, cataract, activation of infection (if given in herpetic, fungal, and bacterial keratitis), dry eye, and ptosis.[9]

According to Ayurveda, this disease shows similarities with Adhimantha (~glaucoma). Almost all the affections of the eye originate from Abhishyanda (~mucopurulent conjunctivitis) as the root cause. Therefore, a wise clinician should treat a case of developing Abhishyanda promptly for the benefit of the patient.[10] There are four types of Abhishyanda and when these get aggravated, they lead to corresponding Adhimanthas with severe pain in the eyes.[11] In Adhimantha, there is an intense feeling as if the eye is being churned up along with (the corresponding) half of the head, in association with specific features of particular Doshas involved.[12] In Pittadhimantha and Raktadhimantha, the eye is severely congested, has discharge associated with pricking pain, and feels as if burning with fire.[13] Symptoms mentioned in context to Pittadhimantha and Raktadhimantha show similarities with anterior uveitis.


  Patient Information Top


A 31-year-old male patient of moderate built, and Pitta-kaphaja prakriti, reported to the Shalakya outpatient department (OPD) of the institute with chief complaints of watering, redness, and pain in both the eyes for the last 10 years. He also complained of photophobia, floaters, and blackish discoloration below the eyes for the last one year. The patient was apparently well 10 years back and gradually developed the aforementioned symptoms. The condition was diagnosed as anterior uveitis from a multispecialty modern hospital and was on medication from there. However, the response was not significant and recurrence of the symptoms was noticed frequently over the past 10 years.


  Clinical Findings Top


When the patient reported to Shalakya OPD of the institute, he was on loteprednol etabonate 0.5% eye drop (E/D), fluorometholone 0.1% E/D, tobramycin 0.3% E/D, alcaftadine 0.25% E/D, and a lubricant drop carboxymethyl cellulose E/D. Even after using these drops, the patient had persistent watering and redness in the eyes along with discoloration below the eyes which prompted the patient to shift to Ayurvedic treatment.


  Diagnostic Focus and Assessment Top


The patient had a history of glandular tuberculosis 10 years back, for which he completed a full treatment course of two years. There was no history of other systemic diseases. The patient had normal appetite, disturbed sleep pattern, and had irregular bowel habits [Table 1]. Based on the symptomatology, the condition was diagnosed as Pitta-Raktadhimantha.
Table 1: Baseline examination

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  Timeline Top


The detailed timeline of treatment is given in [Table 2].
Table 2: Timeline of treatment

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  Therapeutic Focus and Assessment Top


The treatment plan was decided on the basis of Doshas and Samprapti (~pathogenesis) involved. Drugs with Amapachana (~digestive), Sroto shodhana (~cleanses channels), Pittarakta dosha shamaka, Rakta prasadana, Shothaghna (~anti-inflammatory), Vedana sthapaka (~analgesic), Chakshushya, and Rasayana (~rejuvenators) properties were used in the management. The details of treatment are given in [Table 2].


  Follow-up and Outcome Top


During the course of treatment, there was a reduction in congestion of eyes, pain, watering, and number of floaters observed by the patient. The patient used Lotepred E/D daily in the dose of one drop twice a day which was initially reduced to one drop on an alternate day and then further tapered off to once or twice a week and later discontinued. There was a reduction in intraocular pressure and improvement in Schirmer's I score. By the end of six month treatment, pain, redness in eyes, watering from eyes, and photophobia were completely subsided. Considerable reduction in floaters was also reported by the patient [Table 3] and [Table 4]. The patient started feeling improvement in bowel movements and sleep as well as reported reduction in redness in eyes within two weeks of initiation of treatment. After the Tarpana (~Ayurvedic eyes rejuvenation) therapy, there was an improvement in watering from eyes, photophobia, and also the pupillary reaction became normal. The patient stopped all allopathic eye drops after first sitting of Nasya (~errhine therapy) and Tarpana (~satiating). The patient complained of recurrence of mild pain and redness in eyes in the middle of treatment, which was managed by Netraseka with Yashtimadhu ksheera without starting loteprednol etabonate 0.5% eyedrop (E/D) or fluorometholone 0.1% E/D. All the symptoms were managed by the end of six months and were maintained with the internal medications and Kriya kalpa procedure for one year.
Table 3: Subjective criteria for assessment of results

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Table 4: Objective criteria for assessment of results

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  Discussion Top


Anterior uveitis is a process of intraocular inflammation involving the iris, ciliary body, and choroid. It can result from many causes including systemic immune-mediated disease, infectious agents, and masquerade syndromes (including cancer).[14] Considering the signs and symptoms of anterior uveitis, namely redness of eyes, severe pain, burning sensation in both eyes, and extensive congestion, the manifestation is compared with Pittadhimantha and Raktadhimantha.

Adhimantha has drawn attention of ancient physicians, which is evident from the fact that its description, classification, symptomology, complication, and management are available in literature. If the treatment is given well in time, Adhimantha has been considered as a curable disease; otherwise, the disease results in further deterioration which can lead to Hatadhimantha, and ultimately, blindness ensues.[15] The primary objective of management of acute anterior uveitis is to provide relief in eye pain and photophobia as well as elimination of inflammation and prevention of structural complications such as synechiae, secondary cataract, and glaucoma with preservation and restoration of good visual function.

The management of acute anterior uveitis includes the use of steroids, mydriatic, cycloplegic, NSAIDS, and immunosuppressive agent. Anterior uveitis is sight-threating condition, which may end up with inevitable blindness, so it should be diagnosed and treated at the earliest.

The treatment principles mentioned by Acharyas for Pittaja-raktaja adhimantha are Snehana (~unctuousness), Virechana (~purgation therapy), Parisheka (~therapeutic streaming), Nasya, Anjana (~collyrium), and Rakta mokshana (~bloodletting).[16] All the 76 diseases of the eyes can be produced by untreated Abhishyanda, as it settles in Kapha (Shleshma asraya) of the eye.[17] This Kaphasraya produces Ama lakshanas such as pain, swelling, redness, and foreign-body sensation in eye.[17] Jeerakarishta by the virtue of its ingredients such as Jeeraka (Cuminum cyminum Linn.),[11] Musta (Cyperus rotundus Linn.),[12] Shunthi (Zingiber officinale Roxb),[13] and Dhataki (Woodfordia fruticosa Linn.)[18] helps in Amapachana. Drugs of Dashmoolarishta such as Agnimantha (Clerodendrum phlomidis Linn.), Shyonaka (Oroxylum indicum Vent.), Gambhari (Gmelina arborea Linn.), and Bilwa (Aegle marmelos Corr.) are proven to be best for their anti-inflammatory activities.[19],[20] Arogyawardhini vati is a well-known remedy for fatty liver.[21] It also does the Pachana (~digestion) of Drava (~liquid) and Kleda (~clammy) and does the Rakta shodhana (~purifies blood). Panchasakara churna and Trivrit churna were used for the elimination of aggravated Doshas. They help in removing the toxins from the body on a regular basis. Chandraprabha vati is mentioned in Ayurveda as Sarvaroga pranashini[22] (i.e., useful in all disorders). Pathyaksha dhatryadi kashaya[23] contains turmeric which is a potent anti inflammatory[24] drug and Triphala,[25] Nimba (Azadirachta indica A. Juss.),[26] Bhunimba (Andrographis paniculata Burm. f.)[27] and Guduchi (Tinospora Cordifolia [Willd.] Miers) acts as an antioxidant, antiviral, antibacterial and antimicrobial, due to which the inflammatory pathology of uveitis subsides thereby relieving the patient from pain and inflammation.[28] Khadirarishta,[29] Dashmoolarishta, and Punarnavasava[30] have anti-inflammatory and antioxidant properties. They possibly help by reducing the inflammation.

Sarivadyasavai[31] contains Sariva [Hemidesmus indicus (L.) R. Br.] as the main ingredient which includes hepatoprotective, anticancer, antidiabetic, antioxidant, neuroprotective, anti-ulcerogenic, anti-inflammatory, and antimicrobial properties.[32] The patient also complained of sleeplessness in the middle of treatment, which was managed by giving Sumenta tablet in the dose of 500 mg at bedtime. Tiktaka ghrita was started after 4th month in a dose of 10 ml twice a day. It contains ingredients that possess Tikta and Katu rasa such as Patola (Luffa acutangula [L.] Roxb.), Nimba (Azadirachta indica A. Juss.), Kutaki (Picrorhiza kurroa Royle ex Benth.), and Pippali (Piper longum L.). Tikta rasa (~bitter taste) decreases Sama-pitta condition. Due to Vishada (~clean/clear) quality, it liquefies the stickiness of Ama, thereby clearing the Strotorodha (~blockage of channels). In Ayurveda classics, various therapeutic procedures are explained, which are said to improve or enhance the visual acuity as well as improve the health of the eye. Nasya is one of such efficient procedures. The drugs are administered through the nose as Nasya enters into the nasal cavity, a network of Srotamsi (~structural or functional channels) carry it further to the desired sites and cleanse the channels. The Ama is digested at the cellular level and pacifies the vitiated Doshas as well as nourishes the eyes. It was done for a week, which was followed by Tarpana. The Ghrita which is used for doing Tarpana has the quality of reaching into the minute channels of the body. Hence, when applied in the eye, it enters into deeper layers of Dhatus and cleanses minute parts of them as well as provide nourishment to the eye.[33] Patoladi ghrita[34] was used for Tarpana, which contains Nimba, Patola, Kutaki, Amalaki (Phyllanthus Emblica Linn.), Darvi (Berberis aristata DC.), etc., that possess Vata-pitta pacifying properties. Netraseka (~ocular irrigation on closed eyes) is indicated for the management of inflammatory conditions. Duration of contact time of Sekadravyas with Vartma (~thin fold of skin that covers and protects the human eye) increases the circulation in vessels of eyes and removes blockage of channels (~Srotosanga). Hence, Seka was administered using Pitta shamaka dravyas whenever required throughout the treatment and the condition was managed effectively without using Lotepred and Tobrex E/D.


  Conclusion Top


Reducing the inflammation and establishment of the normal physiology of eye in anterior uveitis was the objective of the management in this case. Ayurveda treatment principles helped to arrest the rate of inflammation and to reduce the rate of reoccurrence, which are evident by subsequent follow-ups. The treatment modalities indicated in allopathic science have some side effects and may not be satisfactory in providing promising results in the recurrence associated with compromised immunity. In Ayurveda, with the understanding of Samprapti and Dosha involvement, one can easily decide the treatment protocol for any disease. The Samprapti vighatana chikitsa with optimizing Amapachana, Pitta-Raktanashaka, Shothashamaka, Vedanashamaka, and Raktashodhaka chikitsa was performed in this case. This treatment not only provided relief in the complaints of the patient but also reduced the rate of recurrence to a significant level. This treatment can further be validated and standardized by performing a pilot study with a larger sample size.

Declaration of patient consent

The authors certify that they have obtained the patient consent form, where the patient has given his consent for reporting the case along with the images and other clinical information in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal his identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



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



 

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