IJCRR - 12(14), July, 2020
Pages: 10-16
Date of Publication: 22-Jul-2020
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An Ayurvedic Protocol to Manage Rhegmatogenous Retinal Detachment and the Resultant Macular Hole - A Case Report
Author: Narayanan Namboothiri Narayanan, Aravind Kumar, Krishnendu Sukumaran
Category: Healthcare
Abstract:Introduction: Retinal detachment (RD) is when the neurosensory retina (NSR) separates from the retinal pigment epithelium (RPE). Sometimes it may be associated with a macular hole. The symptom of diminished vision seen in both conditions may be compared with Kacha in Ayurveda.
Case: The case of an 8-year-old boy who presented to the OPD of Sreedhareeyam Ayurvedic Eye Hospital with the blurring of vision and who was diagnosed with retinal detachment and the macular hole is presented here.
Intervention: The patient underwent two courses of inpatient management, which included Ayurvedic oral medicines, and external therapies for the eyes (Kriyakalpa) and head.
Results: Signs of improvement in visual acuity, fundus photography, and optical coherence tomography (OCT) were observed at the end of both treatments.
Conclusion: The main aim of management was to preserve and give a better quality of vision for the patient. The results indicate the potential of Ayurvedic treatments to manage and maintain vision in RD and macular hole.
Keywords: Alternative medicine, Case report, Kacha, Kriyakalpa
Full Text:
Introduction
RD is classified based on the mechanism of fluid accumulation into rhegmatogenous, tractional, and exudative. From a clinical standpoint, this classification may be modified to group the tractional and exudative varieties under secondary RD and the rhegmatogenous variety under primary RD.1 Rhegmatogenous RD occurs secondary to a full-thickness defect in the sensory retina; tractional RD occurs when the NSR is pulled away from the RPE by contracting vitreo-retinal membranes in the absence of a break; and exudative RD is due to subretinal fluid derived from the vessels of either the NSR, the choroid, or both.2
A macular hole is a full-thickness defect or loss of the neuro-retinal tissue in the macula involving the fovea. Causes include idiopathic (83% of cases, usually in women aged 60-80 years), traumatic (5%), and others (cystoid macular edema, vitreo-macular traction, rhegmatogenous RD, post-surgical myopia, post-LASER treatment).3
Both RD and the macular hole may be considered as Kacha (diminished vision), a Drishtigata Roga (disease of vision) according to Ayurveda, due to their common symptom of profound vision loss. In Kacha, the patient sees objects above but not below, objects are perceived as though covered by a thin cloth, and vision gradually diminishes. Management is repeated administration of Sneha (drinking of fats), Asra-visravana (bloodletting), Reka (purgation), Nasya (nasal medication), Anjana (collyrium), Murdha-Basti (retention of oil over the head), Basti Kriya (enema), Tarpana (retention of fat over the eye), Lepa (application of paste), and Seka (pouring of liquids over the eye).
Methodology
The efficacy of an Ayurvedic treatment protocol to manage rhegmatogenous RD and the resultant macular hole was assessed in this report. It was prepared according to the Case Report (CARE) guidelines.4 to ensure transparency and effectiveness in reporting. Institutional ethical clearance was not required for this study. As the patient is underage, written informed consent was obtained from his mother prior to detailing his case.
Case Presentation
An 8-year-old boy presented with a 3-week complaint of blurring of vision and presence of a stationary black spot in his right eye (OD), as revealed by his mother. The patient sustained a sports-related injury 8 months ago when a football collided with his forehead. The trauma was accompanied by bleeding, redness of the eye, and swelling above his right eyelid. 3 weeks ago, he started experiencing a black spot in his visual field and blurring of vision OD. He was diagnosed with retinal detachment with macular hole OD and was advised surgery, which he declined. He came to Sreedhareeyam for alternative options.
The child was born into a non-consanguineous family. His height is 139cm and his current weight is 38kg. His personal history readings (bowel, appetite, micturition, and sleep) were also normal. Review of systems and vital signs were normal.
Unaided distant visual acuity (DVA) was counting fingers (CF +ve) OD and LogMAR 0 in his left eye (OS); and his near vision was N36 OD and N6 OS. Anterior segment examination revealed normal findings in both eyes (OU). Pupillary examination revealed an afferent pupillary defect OD and normal reflexes OS. Fundus examination OD revealed a macular hole, elongated optic disc, and a subtotal rhegmatogenous retinal detachment (Figure 1a). Optical coherence tomography (OCT) scanning OD showed a dome-shaped elevation under the retina, suggestive of retinal detachment (Figure 1b).
Therapeutic Intervention
The patient underwent 2 courses of treatment. One was from May 5th, 2019 to May 24th, 2019, and the other was from December 28th, 2019 to January 8th, 2020. He was administered oral medicines such as Kvatha (herbal decoction), Gutika (herbal tablets), and Ghrta (medicated ghee or clarified butter) (Table 1), and external therapies for both the eyes (Netra Kriya Kalpa) and the head (Table 2). As he was under 10, Panchakarma (bio-purification) was not attempted due to his age.
All medicines, except Geriforte, were manufactured at Sreedhareeyam Farmherbs India, Pvt. Ltd., the hospital’s GMP-certified drug manufacturing unit. Geriforte was manufactured at The Himalaya Drug Company, based in Bengaluru, India.
Outcome Measures
The patient was prescribed medicines at discharge after both courses of treatment (Table 3) and advised regular follow-ups.
DVA at discharge after the first course of treatment was LogMAR 1.778 OD and LogMAR 0 OS, and NVA was maintained. Pupillary reactions were maintained OD and OS. Fundus examination OD showed a reduction in the macular hole (Figure 2a). OCT scanning OD showed absorption of the vitreous from the retina and lowering of the structure towards its normal position (Figure 2b).
The same findings in VA and pupillary reactions were observed at admission for the second course of treatment. Fundus examination and OCT were not done. DVA at discharge after the second course of treatment showed LogMAR 1.477 OD and LogMAR 0 OS. Fundus examination OD showed further reduction of the macular hole, (Figure 3a), and OCT scanning showed further lowering of the retina to its normal position (Figure 3b). A timeline of events for this case is provided in Table 5.
Discussion
Rhegmatogenous RD is characterized by the presence of a retinal break held open by vitreo-retinal traction.8 Predisposing factors include lattice degeneration, snail-track degeneration, degenerative retinoschisis, and pathological myopia, in which the risk of RD is higher when the refractive error is more. Afferent pupillary defect (Marcus Gunn pupil) is present in eyes with extensive detachment.
A causal role of RD attributed to a macular hole can only be made if the detachment involves the posterior pole, or if more extensive, is seen to have advanced from a posterior pole RD.9 This is because it is difficult to determine whether a macular hole is of partial or full-thickness and if the hole is responsible for retinal detachment.
This patient’s condition was explored along the lines of Kacha according to Ayurveda. Kacha as an entity unto itself was described by Vagbhata. He considered it as that in which the Doshas afflict the third Patala (layer) of the eye. Gross deterioration of vision is the hallmark symptom of Kacha and, by its nature, is Yapya (controllable). The improvement of the vision of this patient indicated that the Doshas were being expelled from the third Patala.
Pathyakshadhatryadi Kashaya, indicated in the Patalagata Rogas (diseases of the layers of vision), is Kapha-Pitta Samaka (relieves Kapha and Pitta) and Cakshushya (healthy for eyes). Sudarsanam Gutika is indicated in all varieties of fever, and hence, helps in restoring proper digestion. Pathya PunarnavadiChurna normalized Vata Dosha in this case by enhancing the expulsion of the waste and movement of Doshas out of the body and eye. Vidaryadi Kvatha is Brmhana (nourishing) and relieves Vata and Pitta, hence it helped to anchor the retina to the rest of the eye.
Local therapeutics was employed in this case as the patient was too young for Pancakarma treatments. Purampada or Bidalaka created a counter-pressure gradient that significantly pushes the retina to its original position. Ascyotana enabled the absorption of the medicines to reach the target tissues by such parameters as height and temperature of the medicines. Siroveshtana, Sirolepa, and Talapoticchil enabled absorption of the essential elements through the skin and hair follicles, thus bypassing barriers and reaching the target tissues. Laksha, one of the main ingredients in the medicines for head treatments, helped the retina restore itself to the rest of the eye by its properties of Pitta-Kapha Nasaka (diminishing Pitta and Kapha), Sandhaniya (binding), Balya (strengthening), and Ropana (healing).
Vinayakanjana is prepared from Durva, goat’s milk, and goat’s ghee. It is useful as a healing agent and is prescribed in eye diseases. Ananta Ghrta, prepared from Yashtimadhu, Amalaki, Jivanti, and Haritaki, is indicated as a Tarpanain all eye diseases. Sunetra Junior is prepared from Daruharidra, Haridra, and rose water, and is indicated in pediatric eye cases. Vainateya Ghrta is prepared from Draksha, Jivanti, Vasa, and Triphala, is indicated in retinal diseases. Pancatiktaka Guggulu is prepared from Triphala, Pippali, and Guggulu, and is indicated in muscular growths in the eye.
Conclusion
The main challenge, in this case, was restoring vision and reattaching the retina. It was partially successful in both parameters, as vision marginally improved and the retina showed signs of reattachment. Results were a concerted effort brought about by the combined effect of both oral medicines and external therapies. Repeated courses of treatment may aid to further reattach the retina and give back some eyesight to the patient. The results may be validated and analyzed by large-scale studies and trials.
Acknowledgment:
The authors thank Sreedhareeyam Ayurvedic Eye Hospital and Research Center, and Sreedhareeyam Farmherbs India Pvt. Ltd., for their help in preparing this case report. The authors acknowledge the immense help received from the scholars whose articles are cited and included in references of this manuscript. The authors are also grateful to the authors/editors/publishers of all those articles, journals, and books from where the literature for this article has been reviewed and discussed.
Conflicts of Interest: None declared
Sources of Funding: None declared
Abbreviations:
RD: retinal detachment
DVA: distant visual acuity
NVA: near visual acuity
OD: oculus dexter
OS: oculus sinister
OU: oculus uterque
NSR: neurosensory retina
RPE: retinal pigment epithelium
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