An Ayurvedic insight to Keratoconus - A Case Report

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[Find the meaning and references behind the names: Munawar, Syed, Sudhakar, Anu, Pasha]

CASE REPORT July-Aug 2020 Journal of Ayurveda and Integrated Medical Sciences | July - Aug 2020 | Vol. 5 | Issue 4 412 An Ayurvedic insight to Keratoconus - A Case Report Dr. Sudhakar T. Biradar 1 , Dr. Ankitha C. S. 2 , Dr. Syed Munawar Pasha 3 1,2 Post Graduate Scholar, 3 Associate Professor and HOD, Department of Shalakya Tantra, Govt. Ayurveda Medical College, Bangalore, Karnataka, INDIA. I NTRODUCTION Keratoconus is a non inflammatory bilateral ectatic condition of cornea in its axial part. Usually starts at puberty and progresses slowly [1] Etiopathogenesis of which is still not clear (developmental, degenerative, hereditary dystrophy) mostly due to environmental and genetic causes and presents with defective vision due to progressive myopia and irregular astigmatism. Prevalence of keratoconus being 2300 per 100,000 in central India [2] It is diagnosed by clinical examination Address for correspondence: Dr. Sudhakar T. Biradar Post Graduate Scholar, Department of Shalakya Tantra, Govt. Ayurveda Medical College, Bangalore, Karnataka, INDIA. E-mail: drsudhakarayush@gmail.com Submission Date: 07/07/2020 Accepted Date: 23/08/2020 Access this article online Quick Response Code Website: www.jaims.in Published by Maharshi Charaka Ayurveda Organization, Vijayapur, Karnataka (Regd) under the license CCby-NC-SA and corneal topographic techniques. In contemporary medicine, it is treated with collagen cross linking which may slow down the disease progress, effectiveness of treatment is still questionable. Overall efficacy of this treatment is less consistent and reliable in their abilities to halt Keratoconus [3] Here comes the need of Ayurveda to explore with better treatments. Based on symptoms, it can be correlated to Prathama Patalagata Timira , being Vatika predominance and treated accordingly. C ASE R EPORT Chief complaints A 20 year old female patient approached Shalakya Tantra OPD of GAMC Bangalore, with chief complaint of diminution of vision for distant objects since 1 year associated with headache occasionally since 6 months History of present illness Patient was apparently normal one year back, gradually she started developing diminution of vision for distant objects for which she consulted an A B S T R A C T Achievement of scientific integrity and credibility of the concepts can only be with well designed and conducted research studies. Keratoconus is a non inflammatory bilateral ectatic condition of cornea in its axial part presenting with defective vision due to progressive myopia and irregular astigmatism. It is diagnosed by clinical examination and corneal topographic techniques. In contemporary medicine, it is treated with collagen cross linking which may slow down the disease progress, effectiveness of treatment is still questionable. Here comes the need of Ayurveda to explore with better treatments. Based on symptoms in Ayurveda it can be correlated to Prathama Patalagata Timira , being Vatika predominance. This study describes a 20 Year old female patient diagnosed as Keratoconus and underwent Ayurvedic treatment protocol according to the line of management of Prathama Patalagata Timira which is Vatahara in nature such as Mahatriphala Ghrita internally, Nasya with Anu Taila,Tarpana with Mahatriphala Ghrita , Putapaka, Shigru Navaneeta Pindi for 3 sittings. Results were observed and noted during treatment and follow up period. Key words: Keratoconus, Vataja Timira, Prathama Patalagata Timira, Timira, Tarpana.

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[Find the meaning and references behind the names: Deep, Mala, Rasa, Asta, Min, Iris]

Dr. Sudhakar T. Biradar et al. An Ayurvedic insight to Keratoconus - A Case Report ISSN: 2456-3110 CASE REPORT July-Aug 2020 Journal of Ayurveda and Integrated Medical Sciences | July - Aug 2020 | Vol. 5 | Issue 4 413 ophthalmologist and prescribed with spectacles, but she could not find any improvement in vision and underwent correction for 4 times, then after 6 months she started developing headache occasionally for which she consulted the ophthalmologist again and underwent various investigations and diagnosed as having bilateral keratoconus and advised to undergo C 3 R, she denied and consulted Shalakya OPD of GAMC, Bangalore History of past illness Not a known case of diabetes mellitus or hypertension or any other systemic illness Personal history Aharaja: Diet predominantly of Katu and Kashaya Rasa, Rooksha Ahara. Viharaja: Straining and rubbing eyes. Family history: Cousin brother of the patient is a diagnosed case of Bilateral Keratoconus since 2 years. Ocular history: Using spectacles since 1 year . Treatment history: Nothing specific G ENERAL EXAMINATION Asta Sthana Pareeksha ▪ Nadi : Prakruta, 78/min ▪ Mutra : Prakruta, 4 to 5 times/day, once at night ▪ Mala : Prakruta, regular, once a day ▪ Jihwa : Alipta ▪ Shabda : Prakruta ▪ Sparsha : Prakruta ▪ Druk : Vaikruta ▪ Akruti : Pittavatala Systemic examination Respiratory system, Cardiovascular system, Gastro intestinal system. Central nervous system and Musculoskeletal system has shown no abnormality Ocular examination Table 1: Visual Acuity Distant Vision Near Vision Without spectacles With spectacles Without spectacles With spectacles OD 6/18 6/12 N-6 N-6 OS 6/18 p 6/18 N-6 N-6 Table 2: Examination of Eye structures Structure Right Left Eye brows Normal Normal Eye lids Normal Normal Conjunctiva Normal Normal Sclera Normal Normal Cornea - Size Normal Normal Shape Bulge Bulge Sheen Normal Normal Sensation Normal Normal Surface Clear Clear Transparency Normal Normal Munson’s sign Positive Positive Rezuttis sign Positive Positive Anterior chamber Deep Deep Iris Normal Normal Pupil ERLA ERLA Lens Normal Normal IOP 16 mm of hg 17 mm of hg Distant direct Ophthalmoscophy Oil droplet sign is positive in both the eyes.

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[Find the meaning and references behind the names: Krishna]

Dr. Sudhakar T. Biradar et al. An Ayurvedic insight to Keratoconus - A Case Report ISSN: 2456-3110 CASE REPORT July-Aug 2020 Journal of Ayurveda and Integrated Medical Sciences | July - Aug 2020 | Vol. 5 | Issue 4 414 Table 3: Direct Ophthamoscophy Features Right Left Media Clear Clear Fundal glow Normal Normal Vessels Normal Normal Macula Foveal reflex + Foveal reflex + Optic disc Normal Normal Table 4: Slit lamp examination Findings Right Left Shape of the cornea Conical protrusion Conical protrusion Fleischer’s ring Not found Not found Vogt’s striae Not found Not found Investigations Corneal topography (Pentacam) - depicted in figure No. 01, 02, 03, 04 Treatment adopted 1 Mahatriphala Ghrita 1 tsp BD with warm milk for 25 days. 2 Nasya with Anutaila for 7 days 3 Tarpana with Mahatriphala Ghrita for 5 days 4 Snehana Putapaka for 2 days 5 Shigru Navaneetha Pindi for 15 days Same treatment course is repeated for 3 sittings with a gap of 1 month. Table 5: Observation during treatment course. Before Treatment After 1 st course of treatment After 2 nd course of treatment After 3 rd course of treatment During first follow up During second follow up V/A Without glass With glass Without glass With glass Without glass With glass Without glass With glass Without glass With glass Without glass With glass OD 6/18 6/12 6/18 6/12 6/18 6/12 6/12 p 6/12 6/12 p 6/12 6/12 p 6/12 OS 6/18 p 6/18 6/18 6/12 6/18 6/12 p 6/12 p 6/12 6/12 p 6/12 6/12 p 6/12 R ESULTS 1 Marked improvement in visual acuity as depicted in Table No. 05 recorded at various levels of treatment and during follow up period. 2 Head ache was reduced 3 Pentacam reports before and after treatment are shown in Figure No. 01, 02, 03, 04. Keratometric values are maintained after the treatment. DISCUSSION Many studies says that keratoconus is caused due to genetic and environmental factors, approximately 10% of cases have a family background in which mutations are responsible for the disease to be happened, it is inherited as an autosomal dominant trait, mutations are raised specially on gene KTCN 1. Allergies such as eczema, asthma, food allergies and hay fever is responsible for keratoconus, as these allergies are known to cause itching and irritation that leads to eye rubbing, results in weakness of bonding between collagen fibers which is also due to lack of anti oxidants. According to Sushruta, Krishna Mandala is originated from Vayu Mahabhuta [4] Vayu in Garbhavastha is vitiated due to Dauhruda Avamana leads to Vikrutakshi [5]

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[Find the meaning and references behind the names: Netra, Mark, Nikhil, Sneha, Rupa]

Dr. Sudhakar T. Biradar et al. An Ayurvedic insight to Keratoconus - A Case Report ISSN: 2456-3110 CASE REPORT July-Aug 2020 Journal of Ayurveda and Integrated Medical Sciences | July - Aug 2020 | Vol. 5 | Issue 4 415 Vayu is said to be Sarvadhatu Vyuhakara, Kartha Garbhakrutinam, responsible for regular functioning of Dhatus in the body, formation of normal body parts, considering all these points in keratoconus Krishnamandala of Netra which originates from Vayu is either malformed or gets degenerated due to abnormal Dhatu functioning, by all these factors and considering the symptoms like Avila Rupa Darshana and Avyakta Rupa Darshana [6] it is taken as Prathamapatalagata Vataja Timira and treated accordingly Action of Nasya Nasa being the gateway for Urdhwajatru, Nasya being the best treatment for Urdhwanga, Anutaila being Tridoshahara, Shodana, can circulate in minute Srothas and expels Doshas is opted for Shodananga Nasya. Action of Ghrita Paana Mahatriphala Ghrita being Vata, Pittahara, Brumhana, Chakshushya having more antioxidants will act as Vatashamana, Brumhana, Rasayana. Action of Tarpana Tarpana exert direct pressure on the cornea there may be changes in refractive index of cornea and lipophilic action of Ghrita facilitates transformation of drug to the target organ finally reaches the cell through cell membrane which is made of lipid. Corneal epithelium is permeable to lipid soluble substances, moreover Ghrita is having rich source of anti oxidants which can reduce the damage of thinned cornea by allowing more tissue contact time and bioavailability of the drug from the corneal surface. Action of Pindi In Pindi medicine is absorbed through the skin of lids, it helps to flatten the corneal curvature by its mechanical pressure and strengthens the cornea by medicinal effect, Shigru is one of the Chakshushya Dravya and proved to be Abhishyandahara in nature, Navaneeta is a Chakshushya Dravya in Sneha form. Hence this Chakshushya Sneha combination is helpful in bringing down the corneal protrusion by Dosha Shamana and mechanical pressure. CONCLUSION Considering Dosha Pradhanyata and symptoms of the disease, keratoconus is correlated to Prathamapatala Gata Timira with Vata predominance. Vataja Timira Chikitsa which is Snehana , Brumhana and Rasayana is adopted in this patient. Both subjective and objective improvements are seen after treatment, and during follow up period. Since it is a single study it needs to be evaluated further and research should be conducted with more sample size, so further study is needed in this regard. As keratoconus is treated in contemporary medicine with correction and prescription of glasses, Intacs, C 3 R, results of which are still under question mark, hence Ayurveda has a wide scope of research in this regard to come up with new researches with better results. REFERENCES 1 A K Khurana. Comprehencive ophthalmology. Disorders of Eyelids, 6 th edition. New Delhi: Jaypee Brothers Medical Publishers (P) Ltd; 2015.chapter 6. Page-131. 2 Nikhil S Gokhale. Epidemiology of Keratoconus. Indian Journal of Ophthalmology. Volume 61, Issue 8 (2013), Page 382-383. Available from http://www.ijo.in/article.asp?issn=0301- 4738;year=2013;volume=61;issue=8;spage=382;epage =383;aulast=Gokhale accessed on 10/01/2020 at 8 pm. 3 Management of keratoconus. Available from https://eyewiki.aao.org/Keratoconus accessed on 10/01/2020 at 8 pm. 4 Acharya Sushruta. Sushruta samhita edited with English translation & explanatory notes by G.D Singhal. Varanasi: Chauhamba Sanskrit Pratishthan; 2018. Volume 3, Uttara tantra, chapter 1, shloka 11, page-4. 5 Acharya Sushruta. Sushruta samhita edited with English translation & explanatory notes by G.D Singhal. Varanasi: Chauhamba Sanskrit Pratishthan; 2018. Volume 2, Shareera sthana, chapter 3, shloka 15-18, page-26. 6 Acharya Sushruta. Sushruta samhita edited with English translation & explanatory notes by G.D Singhal.

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[Find the meaning and references behind the names: Nil, Med]

Dr. Sudhakar T. Biradar et al. An Ayurvedic insight to Keratoconus - A Case Report ISSN: 2456-3110 CASE REPORT July-Aug 2020 Journal of Ayurveda and Integrated Medical Sciences | July - Aug 2020 | Vol. 5 | Issue 4 416 Varanasi: Chauhamba Sanskrit Pratishthan; 2018. Volume 3, Uttara tantra, chapter 7, shloka 18, page-35 I LLUSTRATIONS Figure 1: Pentacam of Right cornea - Before treatment Figure 2: Pentacam of Left cornea - Before treatment Figure 3: Pentacam of Right cornea - After treatment Figure 4: Pentacam of Left cornea - After treatment ******************************* How to cite this article: Dr. Sudhakar T. Biradar, Dr. Ankitha C. S., Dr. Syed Munawar Pasha. An Ayurvedic insight to Keratoconus - A Case Report. J Ayurveda Integr Med Sci 2020;4:412-416. Source of Support: Nil, Conflict of Interest: None declared. Copyright © 2020 The Author(s); Published by Maharshi Charaka Ayurveda Organization, Vijayapur (Regd). This is an open-access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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