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 Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 5  |  Issue : 4  |  Page : 179-184

Central retinal vein occlusion and its management through Ayurveda: A case report


Department of Shalakya Tantra, Institute of Post Graduate Teaching and Research Institute, Jamnagar, Gujarat, India

Date of Submission07-Nov-2021
Date of Decision13-Feb-2022
Date of Acceptance14-Feb-2022
Date of Web Publication29-Apr-2022

Correspondence Address:
Sangita Kamaliya
Department of Shalakya Tantra, Institute of Post Graduate Teaching and Research Institute, Jamnagar, Gujarat
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jras.jras_90_21

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  Abstract 

Central retinal vein occlusion (CRVO) is a condition in which the main vein that drains blood from the retina closes off partially or completely. This condition is associated with sudden, unilateral, and moderate-to-marked or total loss of vision. In the present case report, a 58-year-old male patient suffered from CRVO with chief complaints of sudden painless diminution of distant and near vision of the right eye with a duration of 1 week and was treated with Ayurveda medications and therapeutic procedures. Oral medicines such as decoctions, herbal powder, and tablets were administered along with therapeutic procedures which include Nasya (medication through nasal route) therapy and local therapies such as Bidalaka (application of medicated paste on eye lids) and Shirolepa (application of medicated paste on head). Pre- and post-assessments were done by visual acuity (VA), posterior segment examination, and optical coherence tomography, which showed improvement at the end of 3 months’ treatment. At the end of the treatment, there is improvement noted in distance and near VA in the right eye. Ophthalmoscopic findings revealed a reduction in hemorrhages and edema in the right eye. The effectiveness of Ayurveda interventions observed in the present case indicates that CRVO can be treated with Ayurveda medication and therapeutic procedures such as Nasya, Bidalaka, and Shirolepa.

Keywords: Bidalaka, case report, central retinal vein occlusion, Nasya, Shirolepa


How to cite this article:
Kamaliya S, Gevariya J, Vaghela DS. Central retinal vein occlusion and its management through Ayurveda: A case report. J Res Ayurvedic Sci 2021;5:179-84

How to cite this URL:
Kamaliya S, Gevariya J, Vaghela DS. Central retinal vein occlusion and its management through Ayurveda: A case report. J Res Ayurvedic Sci [serial online] 2021 [cited 2022 May 22];5:179-84. Available from: http://www.jrasccras.com/text.asp?2021/5/4/179/344416




  Introduction Top


Retinal vein occlusion (RVO) is a common cause of vision loss in older individuals, and the second most common retinal vascular disease after diabetic retinopathy.[1] The central retinal vein and artery possess a common sheath at crossing points posterior to the lamina cribrosa, so that atherosclerotic changes of the artery may precipitate central retinal vein occlusion (CRVO). Most cases occur above 50 years of age. Hypertension, diabetes mellitus, glaucoma, hyperviscosity of blood, smoking, etc. are the risk factors of CRVO.

CRVO is divided into two categories: non-ischemic and ischemic. Non-ischemic CRVO is the most common clinical variety (75%). It may present with unilateral mild-to-moderate blurring of vision of sudden onset, retinal hemorrhages and cotton wool spots, and no relative afferent pupillary defect (RAPD).[2] It may resolve completely without any complications or may progress to the ischemic type in about 10% of the cases. In about 50% of the patients, vision may be 20/200 or worse. One-third of the patients may progress to the ischemic type in the first 6–12 months after presentation.[3]

In Ayurvedic literature, eye diseases and their pathology and treatment are narrated in detail. The Ayurveda aspect of treatment of eye diseases can be divided into internal medication and external therapeutic procedures. The choice for internal medicine depends on physiological individual constitutes, diseases pathology, and manifested symptoms of Dosha. The external therapeutic procedures include Nasya (nasal drops), Bidalaka (application of medicated paste on eye lids), and Shirolepa (application of medicated paste on head). In this work, a case report of a 58-year-old male patient who was suffering from CRVO and treated with Ayurveda intervention is presented.


  Patient Information Top


A 58-year-old male patient visited to the outpatient department of Institute of Teaching and Research in Ayurveda, Jamnagar on January 28, 2021with chief complaints of sudden painless diminution of distant and near vision of the right eye since a week. The patient had history of treatment from an ophthalmologist and was diagnosed as a case of non-ischemic CRVO of the right eye. He was advised to be treated with intraocular Avastin injection. However, the patient was not willing for such treatment and thus he decided to take Ayurveda treatment. Ocular coherence tomography (OCT) of the right eye was done on January 23, 2021, i.e., 4 days before when the patient arrived for treatment. Therefore, the previous report was considered and OCT was not repeated. The OCT findings showed CRVO along with cystoid macular edema of the right eye. The left eye was absolutely normal. The patient was a vegetarian, appetite was poor, bowel was regular, and micturition and sleep were normal. He has no habit of smoking and alcohol. There was no medical history of hypertension, cardiovascular disease, and diabetes. He was advised to do all medical tests including complete blood count (CBC), erythrocyte sedimentation rate (ESR), serum homocysteine level, lipid profile, and blood glucose level, which were within normal limits. Ayurvedic treatment was started on January 28, 2021 after taking his consent.

Past history

No past history of major illness was noted in the patient and his family.

Physical examination

The patient was afebrile. Pulse rate was 75/min and respiratory rate was 19/min; blood pressure was 112/80 mmHg. No abnormality was noted in examinations of respiratory and circulatory systems.


  Clinical Findings Top


Eye examination

Eye examination by torch light and slit lamp in both eyes is depicted in [Table 1]. The examination revealed normal appearance of the eyelid, conjunctiva, cornea, sclera, anterior chamber, and iris. Pupils were normal in size and normal in reaction, and both the lens were clear. Intraocular pressure (IOP) by Schiotz tonometry was 17.3 mmHg in the right eye and 14.3 mmHg in the left eye.
Table 1: Ocular examination (torch light and slit lamp) (both eyes)

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Visual acuity

Distant and near visual acuity (VA) of both the eyes is described in [Table 2]. Distant VA by Snellen chart in the right eye was 6/60 and left eye was 6/6. The best corrected VA in the right eye was 6/36 and left eye was 6/6. Pin hole correction in the right eye was 6/36 and left eye was 6/6. Near vision without spectacles was N60 in the right eye and N18 in the left eye.
Table 2: Improvement in vision

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Fundus examination

In direct ophthalmoscopy, the right eye showed attenuated and tortuous blood vessels, superficial flame-shaped hemorrhages, and macular edema. Left eye was within normal limits [Figure 1][Figure 2][Figure 3]. Direct ophthalmoscopy revealed CRVO in the right eye. RAPD and iris neovascularization were absent.
Figure 1: Fundus photo right eye before treatment. Superficial flame-shaped hemorrhage with macular edema

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Figure 2: Fundus photo left eye before treatment. Normal picture without any changes

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Figure 3: OCT report of the right eye before treatment. Retinal hemorrhage with macular edema was noticed

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  Diagnostic Assessment Top


Fundus examination was done which confirms the diagnosis of CRVO and macular edema, which was earlier confirmed by OCT. Hematological findings such as CBC, ESR, serum homocysteine level, lipid profile, and blood glucose level were within normal limits.


  Therapeutic Intervention Top


The interventions adopted in the present case are described in [Table 3]. Deepana-Pachana (appetizer and digestive action) was done with 3 g of Trikatu Choorna, which was administered twice daily before food with lukewarm water. Koshta Shodhana (cleansing of the gastrointestinal tract) was done with 5 g of Avipatikara Choorna at bed time with lukewarm water which was administered for the next first 5 days. Nasya was done with Anu Taila at the dose of 8 drops of oil instilled in each nostril in the morning for 7 days. After 7-day interval of Nasya, 8 drops of Durvadi Ghirta instillation in each nostril was done for 7 days. Three such sittings were done with an interval of 7 days. Bidalaka (application of herbal paste over the eye lids) was done with Mukkadi Yoga mixed with Ksheera in the morning for 7 days. The Bidalaka procedure was performed for three sittings with a 7-day interval. Shirolepa (application of herbal paste on head) was done with a mixture of Amalaki (Phyllanthus emblica) 3 g, Musta (Cyperus rotundus) 3 g, and Nagkeshara (Mesua ferrea) 3 g mixed with Takra (buttermilk) for 2 months in the morning. Kaishor Guggulu was given at the dose of 1 g with lukewarm water after food twice daily. Punarnavadi Kashaya, 10 mL, was administered internally in the morning and evening on empty stomach. Punarnavadi Kashaya was started after Koshta Sodhana and was continued for 2 months.
Table 3: Therapeutic intervention adopted

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Follow-up and outcome

Follow-up was done with an interval of 15 days during the course of treatment. After the treatment, considerable improvement was seen in distant and near VA in the right eye. Fundus examination revealed reduction in superficial flame-shaped hemorrhages with reduced exudates [Figure 4]. VA was maintained during the follow-up period. No adverse and unanticipated events of any intervention were noticed during the course of treatment and follow-up period too.
Figure 4: Fundus photo right eye after treatment. Flamed-shaped hemorrhages resolved and macular edema reduced

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  Discussion Top


Timira is a condition narrated in Ayurveda literature, which is related to a range of symptoms from indistinct vision to blindness. As per literature, the condition occurs when the vitiated Doshas (humors) create specific pathological changes in the interior layers of the eye.[4]Timira is a complicated condition which, if left untreated, then may progress to diminished vision and later to complete blindness.[5] Thus it can be interpreted that the Ayurveda treatment measures narrated for the management of Timira can be applied to disease condition which involves diminished vision or blindness.

As pathogenesis of CRVO involves the blood vessels of the retina, hence according to the Ayurveda point of view, the pathology of CRVO can be correlated to involvement of Rakta Dhatu (blood). Impaired digestion which can create Ama (undigested/undesirable harmful components) and diet which can vitiate Pitta and Kapha Dosha, such as curd, Teramnus labialis seeds, black gram [Vigna mungo (L.)], and excessive intake of spicy diet rich in sweet-sour taste may be susceptible factors for CRVO. The vitiated Pitta and Kapha Dosha may affect normal formation and functioning of Rakta Dhatu and may also accumulate Ama in blood, blood plasma, or in vitreous humor. This may further result in blockage of blood supply or reaching harmful components to various parts of eye including retina. Such pathology may manifest as retinal hemorrhage or blindness.

As per aforementioned approach, it can be interpreted that impaired digestion of the patient in the present case resulted in compromised nutrition to the eyes as well as formation of Ama and obstruction of blood channels. The pathological effect on blood vessels present in the eye may have been manifested as edema and tortuous blood vessels. Compromised nutrition may also result in lower oxygen tension in the ocular region, triggering a hypoxic reaction that might lead to pathological neovascularization of the fragile neuronal retina, resulting in the formation of cotton-wool spots or vision loss.

In the studied case, due to diminished digestive capacity, congestion may have occurred in the blood-carrying vessels of the eyeball, or supply of critical nutrients to the eyes may have been hampered. Therefore, it was decided to treat diminished digestion by using an appetizer and digestive powder such as Trikatu choorna. Trikatu choorna is a combination of Zingiber officinale, Piper nigrum, and P. longum. This formulation increases production of digestive juices, thereby stimulating digestion.[6] This formulation can help in clearing the obstruction from the blood channels and thereby increases nutrition to the eyeball and retina. The active principle of Trikatu is piperine (1-piperoyl piperidine), an amide alkaloid, which is also responsible for enhancing the bioavailability of concurrently administered drugs.[7]

Virechana (therapeutic purgation) can make subtle changes in the body at the cellular level by modulating physiological, biochemical, and immunological activities at the molecular level.[8] In the present case, such action of Virechana may have resulted in enabling absorption of the subretinal fluid and correcting the vascular pathology. Koshtha Sodhana by using Virechana can also enhance anti-hemorrhagic physiological mechanisms.[9] The features of CRVO are similar to intra-retinal hemorrhages and thus Koshtha Sodhana may help to alleviate related pathology.

While considering Punarnavadi Kashaya, researchers have proven that Punarnava has anti-inflammatory, diuretic, hepato-protective, anti-stress, and immunomodulatory activity.[10] With the anti-inflammatory and diuretic activity, it can balance the Vata and Kapha Dosha and removes the blockage and can reduce the inflammation from the retina. Main ingredients of Kaishor Guggulu are Guduchi, Triphala, and Trikatu which bind by using Guggulu (extract of Commiphora wightii). Kaishor Guggulu may act as a blood purifier and also may have created a detoxifying and rejuvenating action along with pacifying vitiated Kapha and Pitta from the eye tissues.[11]

Anu Taila was used for Nasya as it has properties to permeate into minute channels, so it can remove accumulated toxins from the head region and strengthen the sense organs.[12]Nasya was followed by Durvadi Ghrita, which is hemostatic and anti-inflammatory and can arrest bleeding, overcome hemorrhage, vitalize cells, repair the cellular damage, and help to nourish the Dhatus seen in CRVO.[13]

Mukkadi Bidalaka is indicated in inflammatory ocular conditions like Ruja (pain), Ragata (redness), Shopha (swellings), Srava (discharges), etc.[14] The majority of the contents have hemostatic activity and properties to pacifying vitiated Pitta and Rakta. Hence, based on its pharmacological properties, it has been selected for transdermal absorption in CRVO to overcome hemorrhages and macular edema from the retina. Shirolepa (application of paste to the head) can facilitate vasodilation, which may further allow faster absorption of hemorrhages, toxins, and thereby reduction in edema. Constitutes of the ingredients used in Bidalaka (application of paste over the eye lids) and Shirolepa may get absorbed through the skin into the bloodstream. These constitutes may also have some role in correcting the vascular pathology in the retina and reducing the excess subretinal fluid from the macula. However, this pharmacodynamic action is a hypothesis which may need to be assessed and validated by further advanced analytical researches.

The combined effect of all the Ayurveda interventions may have resulted in the observed curative effect in the studied case of CRVO. However, as the effect of therapy is retrospectively correlated with drug action narrated in classical Ayurveda literature and selected researches, it can be mentioned that the correlation claims to have their own limitations. Further studies on pharmacokinetic, pharmacodynamic, and network pharmacology along with clinical trials on large sample size may be needed to validate the findings of the present case study.

Informed consent

Patient’s informed consent was taken before starting the treatment.


  Conclusion Top


Based on the marked improvement observed in VA with reduction in retinal hemorrhage and macular edema, it can be claimed that the Ayurveda medicinal interventions such as Trikatu choorna, Punarnavadi Kashaya, Kaishor Guggulu Anu Taila, Durvadi Ghrita and procedures such as Mukkadi Bidalaka, Virechana, Shirolepa can provide considerable effect in curing CRVO. As the present study is a single case report, the result of this study needs to be further validated by clinical trials of a large-scale sample.

Acknowledgments

Institute of Teaching and Research in Ayurveda, Gujarat Ayurved University, Jamnagar, Gujarat, India is acknowledged.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

Authors’ contribution

SOK contributed in the whole conception or design of the work, drafting of the work, literature review, approval of the final version of the manuscript, and agreed for all aspects of the work. JVG contributed in the review, revision of the manuscript for important intellectual content, and agreed for all aspects of the work. DBV contributed for revision of the manuscript for important intellectual content, final checking of manuscript, and gave valuable corrections to it and agreed for all aspects of the work.

Patient declaration of consent statement

Patient’s written consent was taken before starting the treatment.



 
  References Top

1.
Cugati S, Wang JJ, Knudtson MD, Rochtchina E, Klein R, Klein BE, et al. Retinal vein occlusion and vascular mortality: Pooled data analysis of 2 population-based cohorts. Ophthalmology 2007;114:520-4.  Back to cited text no. 1
    
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Hayreh SS, Zimmerman MB. Fundus changes in central retinal vein occlusion. J Retina 2015;35:29-42.  Back to cited text no. 2
    
3.
Yau JW, Lee P, Wong TY, Best J, Jenkins A.Retinal vein occlusion: An approach to diagnosis, systemic risk factors and management. Int Med J 2008;38:904-10.  Back to cited text no. 3
    
4.
Vagbhatta. In: Srikantha Murthy KR, editor. Ashtanga Hridaya. English Translation, Vol. 3. Uttara Shtana, 13/1, Varanasi: Krishnadas Academy; 1994. p. 113.  Back to cited text no. 4
    
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Srikantha Murthy KR. Bhavaprakasha (English Translation), Vol. 2. Madhyama Khanda, GuduchyadiVarga 231–233, Varanasi: Chaukhambha, Krishnadas Academy; 2011.  Back to cited text no. 5
    
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Kaushik R, Jain J, Khan AD, Trikatu RP. A combination of three bioavailability enhancer. Int J Green Pharm 2018;12:S437-41.  Back to cited text no. 6
    
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Bhardwaj RK, Glaeser H, Becquemont L, Klotz U, Gupta SK, Fromm MF. Piperine, a major constituent of black pepper, inhibits human P-glycoprotein and CYP3A4. J Pharmacol Exp Ther 2002;302:645-50.  Back to cited text no. 7
    
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Ashutosh C, Prasanna N, Ashvini Kumar M, Ravishankar B, Rao Niranjana, Ravi M. Effect and mechanism of Virechana Karma (therapeutic purgation) over fructose-induced metabolic syndrome: An experimental study. J Evid-Based Complement Alternat Med 2016;21:194-201.  Back to cited text no. 8
    
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Vagbhata. In: Harishastri P, editor. Ashtanga Hridayam, NidanaSthana, 3/14, Varanasi: Chowkhambha SurbharatiPrakashan; 2017. p. 468.  Back to cited text no. 9
    
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Pooja Verma A, Lal VK. Punarnava—A natural remedy by Ayurveda. Int J Pharm Sci 2014;6:1-6.  Back to cited text no. 10
    
11.
Lather A, Gupta V, Bansal P, Sahu M, Sachdeva K, Ghaiye P. An ayurvedic polyherbal formulation KaishoreGuggulu: A review. Int J Pharm Biol Arch 2011;2:1-7.  Back to cited text no. 11
    
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Vagbhata. In: Harishastri P, editor. Ashtanga Hridayam, Sutra Sthana, 20/38 Varanasi: ChowkhambhaSurbharatiPrakashan; 2017. p. 293.  Back to cited text no. 12
    
13.
Krishnan Vaidyan KV, Gopala Pillai S. Sahasrayogam. 33rd ed. Alappuzha, Mullakkal: Vidyarambham Publishers; 2006. p. 337.  Back to cited text no. 13
    
14.
Krishnan Vaidyan KV, Gopala Pillai S. Sahasrayogam. 33rd ed. Alappuzha, Mullakkal: Vidyarambham Publishers; 2015. p. 381.  Back to cited text no. 14
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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