|Year : 2022 | Volume
| Issue : 4 | Page : 151-155
Ayurvedic management of Vartma sthambha (ptosis) with Panchakarma (bio purificatory measures) and Netrakriyakalpa (ocular therapies): A case report
Krishna Kumar Venugopal1, Akshatha K Bhat2, GN Sree Deepthi1
1 Ayurveda, National Ayurveda Research Institute for Panchakarma, Palakkad, Kerala; Ayurveda, Central Council for Research in Ayurvedic Sciences, Ministry of AYUSH, Government of India, New Delhi, India
2 Department of Shalakya Tantra, Yenepoya Ayurveda Medical College and Hospital, Mangalore, Karnataka, India
|Date of Submission||26-Feb-2022|
|Date of Acceptance||09-Nov-2022|
|Date of Web Publication||29-Dec-2022|
Dr. Krishna Kumar Venugopal
Department of Ayurveda, National Ayurveda Research Institute for Panchakarma, Cheruthuruthy, Shoranur, Palakkad - 679 531, Kerala
Source of Support: None, Conflict of Interest: None
This is to report a case of ophthalmoplegia developed after transsphenoidal surgery for pituitary adenoma, which was treated effectively with Ayurvedic Panchakarma (~bio purificatory measures) and Netrakriyakalpa (~ocular therapeutic procedures). Ophthalmoplegia refers to paralysis of both extrinsic and intrinsic muscles of the eyes. It is an uncommon complication after transsphenoidal surgery for pituitary adenoma and recovers spontaneously in most of the cases. If not resolved even after 6-12 months, surgery is done to correct the squint and ptosis. In this case, as the patient was apprehensive about surgery, Ayurvedic Panchakarma and Netrakriyakalpa procedures were prescribed. An Indian female aged 69 years reported with drooping of the left upper eyelid, deviation, and restricted eye movements in the left eye, and double vision for one year. It was a diagnosed case of postsurgical ophthalmoplegia due to third (oculomotor) and sixth (abducens) cranial nerve palsy. She was administered Panchakarma and Netrakriyakalpa. Oral medicines, Dhanadanayanadi kashaya and Ekangavira rasa, were prescribed for one month. After treatment, there was a remarkable improvement in ptosis. However, squint, restricted eye movements, and diplopia persisted. Ayurveda treatment, including Panchakarma and Netrakriyakalpa, is safe and effective in managing postsurgical ptosis, especially in patients who are apprehensive about surgery. This treatment plan could be further tried in ptosis of other etiologies as well. In Ayurveda, treating squint, restricted eye movements, and diplopia is challenging, and further research needs to be done.
Keywords: Dhooma, Ekangavira rasa, Kriyakalpa, Netra seka, Ptosis
|How to cite this article:|
Venugopal KK, Bhat AK, Sree Deepthi G N. Ayurvedic management of Vartma sthambha (ptosis) with Panchakarma (bio purificatory measures) and Netrakriyakalpa (ocular therapies): A case report. J Ayurveda Case Rep 2022;5:151-5
|How to cite this URL:|
Venugopal KK, Bhat AK, Sree Deepthi G N. Ayurvedic management of Vartma sthambha (ptosis) with Panchakarma (bio purificatory measures) and Netrakriyakalpa (ocular therapies): A case report. J Ayurveda Case Rep [serial online] 2022 [cited 2023 Jan 28];5:151-5. Available from: http://www.ayucare.org/text.asp?2022/5/4/151/365931
| Introduction|| |
Ophthalmoplegia refers to paralysis of both extrinsic and intrinsic muscles of the eyes. Extrinsic muscles are innervated by the third (oculomotor), fourth (trochlear), and sixth (abducens) cranial nerves. They move or rotate the eyes in different directions and, if paralyzed, cause squint, restricted eye movements, and double vision. Intrinsic muscles are the constrictor pupillae, and ciliary muscles and palsy lead to large unreactive pupils and loss of accommodation. The third cranial nerve also innervates the levator palpebrae superioris muscle, which keeps the eye open, and its paralysis results in ptosis. Ophthalmoplegia is an uncommon complication after transsphenoidal surgery for pituitary adenoma, and it recovers spontaneously in most of the cases. If not resolved even after 6-12 months, surgical correction is preferred to correct the squint and ptosis. Nonsurgical management includes eye muscle exercises, which could improve ocular motility and diplopia. The symptomatic management of binocular diplopia includes unilateral eye occlusion therapy using an eye patch. In this case, as the patient was apprehensive about surgery, Ayurvedic Panchakarma and Netrakriyakalpa procedures were prescribed. Netrakriyakalpa includes therapeutic topical procedures for the eye.
| Patient Information|| |
An Indian female aged 69 years reported drooping of the left upper eyelid, deviation, and restricted eye movements in the left eye, and double vision for one year. The patient developed a headache on January 18, 2019 and was diagnosed with pituitary adenoma and underwent transsphenoidal surgery. Postsurgically, she was unable to open her left eye and was diagnosed with postsurgical ophthalmoplegia due to third and sixth cranial nerve palsy. After three months, she could open her eyes slightly but noticed deviation and restricted eye movements in the left eye, along with double vision. There was no further improvement in squint and ptosis. She has advised another surgical correction for the same after one year. Due to her unwillingness to surgery, she approached for Ayurvedic treatment. She is undergoing medication for hypertension and hypothyroidism. She was prescribed Cilaheart (Cilnidipine – 10 mg) twice daily, Clopitab A (Aspirin – 75 mg + Clopidogrel – 75 mg) once daily, and Euthyrox (Thyroxine – 50 mcg) once daily. She also complained of vertigo for the past 7 years for which tablet Vertin (Betahistine-8 mg) twice daily was prescribed. Later on, she discontinued these medicines and started homeopathic medications, the details of which are unavailable.
| Clinical Findings|| |
Her height was 156 cm, her weight was 70 kg, and body mass index was 29.16 kg/m2. Blood pressure was 140/80 mm Hg; pulse rate was 74/min. Pallor, icterus, cyanosis, clubbing, and edema were absent. The examination of the cardiovascular, digestive, and respiratory systems was within the normal limits. The central nervous system was normal except for the third and sixth cranial nerve involvement. In the left eye, there was esotropia and a deficit in abduction, levoelevation, and levodepression. The levator function was also poor (4 mm) in the left eye. The left pupil was semi-dilated and sluggish in reacting. The degree of ptosis in the left eye was severe (5 mm) before treatment [Figure 1]a.
| Timeline|| |
The timeline of the case is depicted in [Table 1].
| Diagnostic Assessment|| |
The hematological and biochemical investigations carried out were within the physiological limits. Based on Ayurvedic clinical assessment, she was identified as Vatakapha prakriti (~physical constitution) with Samaagni (~normal state of Agni) and Krurakoshta (~irregular nature of bowel). Involved Dosha (~regulatory functional factors of the body) is Vata and Dhatus (~major structural components of the body) are Sira (~tubular vessel of the body) and Snayu (~sinew). Since it was a diagnosed case, it did not consider other probable diagnoses.
| Therapeutic Intervention|| |
The treatment adopted is mentioned in [Table 2]. During the course of treatment, she was continuing eye exercises and patching of the left eye as advised by the ophthalmologist. No changes were made in the course of Ayurvedic therapeutic intervention.
| Follow-Up and Outcomes|| |
Normally, the upper lid margin covers 2 mm of the cornea and the lower lid margin covers 1 mm. The distance between the two is measured in the pupillary plane; normal values are 7-10 mm in males and 8-12 mm in females. The difference between it and the contralateral side is used to classify unilateral ptosis as mild (1-2 mm), moderate (3-4 mm), or severe (4 mm or more). After treatment, there was a remarkable improvement in ptosis, improving from a severe degree (5 mm) to a mild degree (2 mm). This improvement persisted in the follow-up period of the next six months [Figure 1]b and [Figure 1]c. However, squint, restricted eye movements, and diplopia persisted. The left eye pupil remained mid-dilated and sluggish in reacting even after the treatment. There were no intervention adherence and tolerability issues or adverse and unanticipated events during the treatment and follow-up period.
| Discussion|| |
This case highlights the holistic approach of Ayurveda incorporating oral medicines, Panchakarma, and Netrakriyakalpa as a substitute for surgical management in postsurgical ptosis. There is little literature available regarding the management of ptosis with Ayurveda. Based on clinical presentation, ptosis can be correlated to Vartma sthambha, a disease with the worst prognosis, where motor functions of eyelids are affected due to aggravated Vatadosha. The treatment of Vatabhishyanda (~a disease where all structures of eyeball is involved) is recommended for eye diseases with a poor prognosis caused by Vatadosha. Hence, treatment modalities of Vatabhishyanda were followed in this case to pacify aggravated Vatadosha. The line of management of Vatabhishyanda includes Snehapana (~internal oleation), Swedana (~sudation), Siramoksha (~blood-letting therapy), Vasti (~medicated enema), Snehavirechana (~purgation with medicated oils), Tarpana (~therapeutic retention of medicated liquids over eyes), Putapaka (~instillation of medicated juices which is extracted after heating a bolus of herbs), Dhooma (~therapeutic smoking), Aschyotana (~eye drops), Nasya (~nasal therapy), Netraseka (~pouring medicated liquid over closed eyelids), and Shirovasti (~therapeutic retention of oil over the head region). In this case, based on suitability, Snehapana, Swedana, Snehavirechana, Dhooma, Nasya, Netraseka, Netrapichu, and Shirodhara (~pouring of medicated oil over the scalp) were adopted.
The mechanism of action of each therapeutic intervention is mainly by pacifying the Vatadosha, which is the culprit in the pathology of ptosis. Deepana pachana (~stomachic and digestant) was done with Trikatu churna for rectifying internal metabolism before Snehapana. Studies have also shown that it enhances the bioavailability of coadministered medicine due to the presence of piperine. Indukanta ghrita was selected for Avapeedaka snehapana (~medicated ghee intake in specific dosage along with food) as it is Vatashamaka (~pacifying Vatadosha) and Balavardhaka (~imparting strength). Kshirabala taila is known to be an effective remedy in neurological disorders owing to its Vatashamana activities and was used for Abhyanga (~oil massage). Gandharvahastadi erandataila was used for Sneha virechana as it possesses Vatashamana properties. The chemical ricinoleic acid exerts the laxative property of castor oil.
Nasya by Varanadi ksheera ghrita was prescribed as indicated in Vataja shiroroga (~disease of the head due to Vata affliction) and due to its Vatashamana properties. Thalam was done with Rasnadichurna as indicated in diseases of the head region and Dhanwantharam taila as it is Vatashamana. Ksheeradhooma (~sudation over the face) with Balamoola kashaya pacifies Vatadosha causing motor afflictions in the face due to cranial nerve palsy.
Netraseka was done with Dashamula processed in milk as it is a proven drug, effective in primary neurological disorders and it helps in improving nerve conduction velocity. Netrapichu was done with Kshirabalataila as it is Vatashamana as well as nourishing sense organs. Dhanwantharam taila was used for Shirodhara. Shirodhara is indicated in severe Vatadosha affliction in the head region. It is hypothesized that in Shirodhara since the oil is poured from a height, it may produce a momentum, which stimulates nerve conduction. Pratimarsha nasya was done with Anu taila as it permeates minute channels in the head, imparts strength, and nourishes sense organs. Shastikashali pinda sweda (~sudation using bolus prepared out of milk and Shashtika [Oriza sativa Linn.]) was done locally around the left eye after protecting it from excessive heat. It provides nourishment to muscles and peripheral nerves.
Oral medicines such as Dhanadanayanadi kashaya and Ekangavirarasa pacify Vatadosha, causing motor afflictions in the face due to cranial nerve palsy. Kshira kashaya prepared out of Ashwagandha [Withania somnifera (L.) Dunal], Bala (Sida cordifolia Linn.), and Sunthi (Zingiber officinale Roscoe.) was prescribed due to Vatashamana properties and is from anecdotal evidence. A compound derived from Ashwagandha showed axonal regeneration in in-vivo models in spinal cord injury.
It could be presumed that the success of this treatment, as evident in the remarkable improvement of ptosis, might be attributed to two major reasons. First, the procedures such as Snehapana, Nasya, Thalam, Shirodhara, and Shiroabhyanga might have stimulated the oculomotor nerve due to various mechanisms, which in turn led to partial neuromuscular recovery. The exact pathophysiology of the regeneration of the ocular motor nerve is still not known. Second, local ocular procedures, such as Netrapichu, Shastika shali pinda sweda, and Kshiradhooma, might have stimulated the levator palpebrae superioris muscle contributing to the improvement of ptosis. In total, a remarkable improvement in ptosis can be expected from the cumulative action of the holistic approach, including Panchakarma, Netrakriyakalpa, and oral medicines. Plausible explanations for not getting results in squint and restricted eye movements could not be made.
| Conclusion|| |
Ayurveda treatment, including Panchakarma and Netrakriyakalpa is safe and effective in managing postsurgical ptosis, especially in patients who are apprehensive about surgery. This treatment plan could be taken up under further scope of research to perceive its action on neuroregeneration. Furthermore, In Ayurveda, treating diplopia and restricted eye movements is challenging, and further research needs to be undertaken in this aspect too. The same line of treatment can be adopted in ptosis of other etiologies as well.
Declaration of patient consent
Authors certify that they have obtained 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.
The authors would like to acknowledge Dr.D.Sudhakar, Director and Dr.V.C.Deep, Assistant Director (Ayurveda), for their support in this work.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2]