Management of Superior Branch Retinal Vein Occlusion - A Case Study

CASE REPORT Mar-Apr 2021 Journal of Ayurveda and Integrated Medical Sciences | Mar - Apr 2021 | Vol. 6 | Issue 2 245 Management of Superior Branch Retinal Vein Occlusion - A Case Study Dr. Premcy CR 1 , Dr. S. M. Pasha 2 1 Post Graduate Scholar, 2 H.O.D & Associate Professor, Dept. of PG Studies in Shalakya Tantra, Govt. Ayurvedic Medical College, Bengaluru, Karnataka, INDIA. I NTRODUCTION Retinal vein occlusion is the second most common cause of vision loss due to retinal vascular disease after diabetic retinopathy. Population based studies report the prevalence of RVO ranges from 0.7-2% [1] Retinal vein occlusions occur when there is a blockage of veins carrying blood with needed oxygen and nutrients away from the nerve cells in the retina [2] Retinal vein occlusions can be classified into 3 based on the site of the obstruction. CRVO (central retinal Address for correspondence: Dr. Premcy CR Post Graduate Scholar, Dept. of PG Studies in Shalakya Tantra, Govt. Ayurvedic Medical College, Bengaluru, Karnataka, INDIA. E-mail: premcy 85@gmail.com Submission Date: 15/03/2021 Accepted Date: 08/04/2021 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 vein occlusion) HRVO (hemi retinal vein occlusion) and BRVO (branch retinal vein occlusion). In CRVO the site of obstruction will be within optic head, in HRVO site of obstruction will be at major bifurcation and in BRVO obstruction will be in tributary Causes of retinal vein occlusions are pressure on the vein by an atherosclerotic retinal artery, hypertension, diabetes mellitus, hyperviscosity of blood, periphlebitis retinae, raised intra ocular pressure and local causes like orbital cellulitis, orbital tumors and cavernous sinus thrombosis. It can also occur secondary to inflammation or vasospasm. But the common cause of BRVO is venous compression by atherosclerotic artery. The most common symptom of branch retinal vein occlusion is vision loss or blurry vision in a part or all of an eye [3] It can occur as sudden or become worse over several hours or days. Sometimes there will be sudden complete loss of vision or blurred and distorted central vision due to macular edema. There will be presence of floaters in front of the eye due to A B S T R A C T Introduction: Branch retinal vein occlusion (BRVO) is a type of retinal vein occlusion which is the second most common vascular disorder found in retina. BRVO is a blockage of one or more branches of the central retinal vein. Its symptoms include floaters, peripheral loss of vision, retinal hemorrhages and blurred or distorted central vision due to macular edema Materials and Methods: A female of 28 years old approached to Shalakya Tantra OPD of GAMC with symptoms of visual field defects and blurred center vision since 1 week. After thorough examination, the case was diagnosed as superior BRVO and was treated with the help of Aurvedic medicines. The treatment prescribed was Nasya, Puarnavadi Kashaya, Puarnavadi Guggulu, Mahavasakadi Kashaya, Kaishora Guggulu, Kushmada Avaleha, Seka And Vidalaka Result: Significant improvement was observed both subjectively and objectively Discussion: BRVO can be compared to Kaphanubandha Urdhwaga Rakthapitha. So in this case study, Pitha Kaphahara followed by Rakthapithahara line of treatment is adopted Key words: Superior Branch Retinal Vein Occlusion, BRVO, Nasya, Punaravdi Kashaya, Kaishora Guggulu, Case Study.

Dr. Premcy CR. et al. Management of Superior Branch Retinal Vein Occlusion ISSN: 2456-3110 CASE REPORT Mar-Apr 2021 Journal of Ayurveda and Integrated Medical Sciences | Mar - Apr 2021 | Vol. 6 | Issue 2 246 leakage of tiny clumps of blood into the vitreous from retinal vessels. Branch retinal vein occlusion can be correlated with Kaphanubandha Urdhwaga Rakthapitha and here treatment is given based on the Doshas involvement. C ASE R EPORT Basic information of the patient Age: 28 years Sex: Female Religion: Hindu Occupation: House maker Chief complaints Loss of vision in lower side of the left eye and blurriness in the center of vision since 1 week associated with pain in the left lower lid in the lateral aspect. History of present illness The patient was apparently normal before 1 week and she suddenly developed loss of vision in inferior temporal visual field in left eye. She observed this while moving her eye ball into left lateral side in the inferior aspect. She also complaints of blurriness in the center of vision and slight pain in the lower lid in the temporal aspect. Thus, she approached Shalakya OPD of GAMC Bangalore. During the examination by direct ophthalmoscope, she was diagnosed with superior branch retinal vein occlusion associated with macular edema. History of past illness: no history of hypertension, diabetes, Asthma Family history: nothing significant Personal history Appetite: good Sleep: good Bowel: regular Micturition: 4-6 times/ day E XAMINATION Ashtashtan Pareeksha ▪ Nadi: 74/min ▪ Mutra: 4-6 times/day ▪ Mala: regular ▪ Jihwa: Aliptha ▪ Shabda: Parkrutha ▪ Sparsha: Anushna Seetha ▪ Druk: Vikrutha ▪ Akruthi: Madhyama Vitals ▪ Pulse rate: 74/min ▪ Respiratory rate: 24/min ▪ BP: 110/70 mmof Hg Systemic examination All the systemic examinations revealed no abnormalities. Ocular examination Given in table number 1 Table 1: Ocular examination Head posture Normal posture Visual acuity Distant vision PH Near Vision RE 6/6 6/6 N 6 LE 6/9 6/12 N 8(P) Visual field examination RE :- Normal visual sensation LE:- Reduced visual sensation in lower field of left eye

Dr. Premcy CR. et al. Management of Superior Branch Retinal Vein Occlusion ISSN: 2456-3110 CASE REPORT Mar-Apr 2021 Journal of Ayurveda and Integrated Medical Sciences | Mar - Apr 2021 | Vol. 6 | Issue 2 247 Slit lamp examination Eye brow Normal, bilaterally symmetrical Eyelash Normal, bilaterally symmetrical Eyelids Edema in left eyelid, RE normal Conjunctiva Normal BE Sclera Normal BE Cornea and iris Normal BE Pupil Round, regular, reactive (BE) Distant Direct Ophthalmoscopic examination RE RE was within normal limits LE BRVO with macular edema Fundus ▪ Pale ▪ Haemmorrhages in superior temporal region near optic disc Optic disc No demarcation in the disc margin in superio temporal region Optic cup Obliteration in superior temporal region Macula Macular edema Fovea No foveal reflex Investigations: investigations given in table number 2. Table 2: Investigations Hb 12.1 gm/dl FBS 100 mg/dl Lipid profile LDL 70 mg/dl HDL 60 mg/dl Triglycerides 110 mg/dl Total cholesterol 156 mg/dl OCT imaging was done. Given in figure number 1. Figure 1: OCT imaging Diagnosis Superior branch retinal vein occlusion with macular edema ( Kaphanubandha Urdhwaga Rakthapitha ). Diagnosis was done by distant direct ophthalmoscopy, confrontation test and OCT imaging. Treatment given Treatment was given for a period of 7 weeks. Patient was administered Nasya with Anuthaila 8 drops in each nostril for 7 days at early morning in empty

Dr. Premcy CR. et al. Management of Superior Branch Retinal Vein Occlusion ISSN: 2456-3110 CASE REPORT Mar-Apr 2021 Journal of Ayurveda and Integrated Medical Sciences | Mar - Apr 2021 | Vol. 6 | Issue 2 248 stomach, For next 2 weeks Kriyakalpas like Seka with Thriphala, Punarnava and Vasa Kashaya , and along with that Shamanoushadhis like, Punarnavadi Kashayam 15 ml BD with Punarnavadi Guggulu 1 BD was given. Next 2 weeks Vidalaka with Mukkadi Yoga, [4] Mahavasakadi Kashayam 15 ml BD with Kaishora Guggulu 1 BD was given. In next 2 weeks Kushmanda Avaleha [5] as Rasayana 1 tsp at night after food was prescribed. O BSERVATIONS AND R ESULTS Phase 1: first 7 days ▪ Nasya with Anuthaila 8 drops in each nostril was given in empty stomach at early morning for Murdhwa Shodhana. ▪ Observation: vision was improved to 6/6(P), PH 6/9(P) and N 8 in left eye Phase 2: For next 2 weeks ▪ Seka with Triphala, Punarnava and Vasa Kashaya was given for 7 days for Sthanika Shothanartham and along with this Puarnavadi Kashayam and Punaravadi Guggulu , was given for 2 weeks. ▪ Observation: pain in lower lid was completely relieved and center vision was improved. There was reduced of macular edema and hemorrhages on direct ophthalmoscopy. Foveal Reflex was present. Phase 3: for next 2 weeks ▪ Vidalaka with Mukkadi Yoga was given for 7 days. Along with this Mahavasakadi Kashaya and Kaishora Guggulu was given for 2 weeks. ▪ Observation: 90% of the hemorrhages was reduced. Optic disc demarcation was present. Phase 4: For next 2 weeks ▪ Kooshmanda Avaleha was given ▪ Observation: complete absence of hemorrhages. Optic cup was clear. And visual field examination was normal for both eyes. Visual acuity was 6/6 and N 6 DISCUSSION In this case, superior branch retinal vein occlusion can be correlated with Kaphanubandha Urdhwaga Rakthapitha. The treatment was given based on the Dosha involvement. Here the Samprapthi can be taken as follows - primarily there will be Kapha Prakopa due to Nidana. Further it leads to Pitha Raktha Prakopa and get Ashraya in Netra. The Rakthavaha Srothas is blocked by Kupitha Kapha and finally it causes the Vimargagamana of Raktha and Pitha in turn leads to Kaphanubandha Urdhwaga Rakthapitha. The treatment given includes both Shodhana and Shamana . Murdhwa Shodhana was given first to remove the Sanga caused by Kapha . Nasya is best treatment to cure the Urdhwa Jathrugatha Vyadhis and it is quoted that “ Nasa Hi Shiraso Dwaram.” Then second phase treatment was given to remove the fluid which collected in the macular region and to remove the Sanga by Kapha. Then third phase treatment was to do the Shamana of the Pitha and Raktha thereby reducing the hemorrhages. Fourth phase treatment was given for a Rasayana property. Table 3: Mode of action of drugs Anuthaila Tridoshahara Thriphala Tridoshahara, Chakshushya Punarnava Pithakaphahara, Sothagna Vasa Pithakaphara, Rakthapithahara Internally Punarnavadi Kashyam Sothagna and Pitha Kaphahara Punarnavadi Guggulu Sothgna and Soolagna Mukkadi Yoga Contains Triphala, Chandana, Rakthachadana, Gairika, Usheera, Nisha, Daruharudra,Lodra, Sariva, Vatshrunga , Durva, Nimba . Action : Sothagna, Dahagna, Rujahara, Raktha Pitha Shamaka.

Dr. Premcy CR. et al. Management of Superior Branch Retinal Vein Occlusion ISSN: 2456-3110 CASE REPORT Mar-Apr 2021 Journal of Ayurveda and Integrated Medical Sciences | Mar - Apr 2021 | Vol. 6 | Issue 2 249 Mahavaskadi Kashayam Rakthapithahara Kaishora Guggulu Pithahara. Kooshmanda Avaleha Rasayana action and Rakthapithahara action CONCLUSION BRVO is the second most frequent retinal vascular disorder. The treatment given in this case based on the Doshas involvement. First aim was to remove Sanga and next line of treatment was to reduce the Rakthapitha. Here Kriyakalpa also helped to reduce the symptoms very quickly without any side effects. REFERENCES 1 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC 6513 508/ 2 https://www.willseye.org?branch-retinal-veinocclusion-brvo/ 3 https://www.aao.org/eye-health/disease/branchretinal-vein-occlusions-symptoms 4 K V Krishnan Vaidyar. Sahasra Yogam. Vidyarambham Publishers. Alapuzha. 30 th Edition. 2011;pp 381. 5 Vagbhata. Ashtanga Hridayam. Arunadatta Sarvanga Sundara Commentary. Chikitsa Sthana. Chaukambha Kishadas Academy. Varanasi. (3/114-117).2009;pp 59 ******************************* How to cite this article: Dr. Premcy CR, Dr. S. M. Pasha. Management of Superior Branch Retinal Vein Occlusion - A Case Study. J Ayurveda Integr Med Sci 2021;2:245- 249. Source of Support: Nil, Conflict of Interest: None declared. Copyright © 2021 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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