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 Table of Contents  
CASE REPORT
Year : 2022  |  Volume : 6  |  Issue : 3  |  Page : 133-141

Management of unilateral ocular myasthenia gravis through Ayurveda therapies: A case report


1 Sreedhareeyam Ayurvedic Eye Hospital and Research Center, Nelliakkattu Mana, Kizhakombu, Koothattukulam, Kerala, India; Sreedhareeyam Ayurvedic Research and Development Institute, Nelliakkattu Mana, Kizhakombu, Koothattukulam, Kerala, India
2 Sreedhareeyam Ayurvedic Research and Development Institute, Nelliakkattu Mana, Kizhakombu, Koothattukulam, Kerala, India

Date of Submission23-Feb-2022
Date of Acceptance02-May-2022
Date of Web Publication01-Nov-2022

Correspondence Address:
Dr. Aravind Kumar
Sreedhareeyam Ayurvedic Research and Development Institute, Nelliakkattu Mana, Kizhakombu, Koothattukulam, Kerala 686662
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jras.jras_33_22

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  Abstract 

Myasthenia gravis (MG) is a serious but treatable autoimmune condition characterized by muscle fatigue and weakness. Ocular MG is characterized by muscle weakness isolated to the eyelids and extraocular muscles. Unilateral ocular MG refers to a condition in which only one eye shows the cardinal features of ptosis and the restriction of extraocular movement. The management of ocular MG is mainly symptomatic and is aimed at curing muscle weakness. The closest approximation of ocular MG in Ayurveda is Vatahata Vartma, an incurable eyelid disease. A case of a 40-year-old man who was diagnosed with unilateral ocular MG and treated with Ayurveda interventions is presented here. In this case, the evaluation of the severity of ptosis revealed a 4 mm of ptosis in the right eye and 2 mm in the left eye; margin reflex distance of 1 mm in the right eye and 4 mm in the left eye; and a levator palpebrae superioris function of 2 mm in the right eye and 12 mm in the left eye. The absence of adduction, intorsion, and extorsion was noted in the right eye, whereas movements were normal in the left eye. Cogan’s sign and eyelid fatigue were present in the right eye and absent in the left eye. The patient underwent two courses of Ayurveda inpatient treatments with regular follow-ups in between. The treatment course included oral interventions (herbal decoctions, oils, and tablets), bio-purification therapies (nasal medication, the retention of medicine in the mouth), sudation (Nadi Sveda, Pinda Sveda), and external therapies for the eyes and head (ocular irrigation, massage, eye drops, irrigation over the head, the application of medicated paste over the head), along with lifestyle modifications. The Ayurveda treatment protocol was found effective in reducing the ptosis and improving the ocular movements. The relapse of the ptosis was observed after the discontinuation of the treatment. A long-term regular treatment strategy with regular inpatient therapies can improve the disease outcomes, despite not being able to produce a complete relief owing to the autoimmune nature of the disease.

Keywords: Ayurveda, case report, Cogan’s sign, Kriyakalpa, Vatahata Vartma


How to cite this article:
Namboothiri N, Parameswaran SN, Kumar A, Sukumaran K. Management of unilateral ocular myasthenia gravis through Ayurveda therapies: A case report. J Res Ayurvedic Sci 2022;6:133-41

How to cite this URL:
Namboothiri N, Parameswaran SN, Kumar A, Sukumaran K. Management of unilateral ocular myasthenia gravis through Ayurveda therapies: A case report. J Res Ayurvedic Sci [serial online] 2022 [cited 2022 Dec 7];6:133-41. Available from: http://www.jrasccras.com/text.asp?2022/6/3/133/360160




  Introduction Top


Ocular myasthenia gravis (MG) limits itself to the extraocular muscles, levator palpebrae superioris (LPS), and orbicularis oculi and progresses to systemic MG within 2 years in 90% of patients.[1],[2] Diplopia is due to the weakness of the extraocular muscles, and ptosis is due to the involvement of the LPS muscle and may be either unilateral or bilateral.[3] Unilateral ocular involvement with the other eye being unaffected is rare.[4] Patients with ocular MG present objective and measurable findings on the physical examination, which can be confirmed by an injection of edrophonium chloride (Tensilon).[5] Differential diagnoses to be considered in the context of MG are other varieties of ptosis, diplopia without pupillary involvement, thyroid conditions, external ophthalmoplegia that mimics cranial nerve palsies, and strabismus. Treatment is mainly conservative and aims to improve muscle weakness and prevent progression to systemic MG. Ocular management aims to improve the quality of life by maintaining a state of clear vision and either preventing or limiting its progression into generalized MG.[6] Acetyl-cholinesterase inhibitors, corticosteroids, and immunosuppressive therapy are employed in its management in contemporary medicine. Surgical management is for symptomatic MG that involves the thymus gland. Managing ocular MG using Ayurveda therapies is an area worth exploring. This case study reports the clinical observations in a patient of ocular MG treated with Ayurveda therapies.


  Patient Information Top


A 40-year-old man presented to the outpatient department with restricted eyeball movement and double vision in his right eye (OD—oculus dexter) since 2016 and drooping of the right eyelid since May 2020. When the patient first experienced double vision, he consulted an ophthalmologist and was prescribed medication, but he did not felt satisfactory relief. Magnetic resonance imaging scans of his brain showed no abnormality. Another ophthalmologist injected Tensilon and assessed for acetylcholine receptor (AChR) antibodies, which enabled him to clinch the diagnosis of ocular MG. The tablet containing pyridostigmine was prescribed to the patient, which was stopped after 6 months as relief was not observed in the symptoms. In October 2019, the patient developed a sudden drooping of his right eyelid. He restarted the pyridostigmine tablets, which subsided the symptoms. He stopped the medication after the symptoms subsided. In May 2020, he developed drooping of his right eyelid again, for which the patient was again prescribed to take pyridostigmine tablets but no relief was noted.

Upon the admission for Ayurveda treatments, the patient presented with drooping of his right upper eyelid, restricted eyeball movement, and diplopia when moving his eyes in the direction of restriction. The patient neither had significant illness in the past nor any family history of a similar illness. His bowel habit, appetite, micturition, and sleep were normal. He does not have any addictions or habits. The pyridostigmine tablets were stopped 2 days before admitting the patient for Ayurveda treatment. The general examination of the patient muscle showed normal tone, strength, bulk, coordination, and the absence of abnormal movements. The examination of cardiovascular, gastrointestinal, and central nervous systems showed normal findings. All vital signs were normal.


  Clinical Findings Top


Unaided distant visual acuity (DVA) of the patient was LogMAR 0.477 OD and LogMAR 0.176 in his left eye (OS—oculus sinister); aided DVA was LogMAR 0 in both eyes (OU—oculus uterque); and near visual acuity was N6 OU. The patient’s head position was normal, and his eyeballs showed no deviation. The examination of the eyelids showed a complete ptosis based on the degree of disease, the margin reflex distances I and II, and the function of the LPS OD, and normal position, palpebral aperture, lid margin, and movements OS [Figure 1]. Extraocular movements showed restrictions in adduction, intorsion, and extorsion OD; and normal extraocular movements OS. Diplopia was noted when the patient attempted movement in restricted directions. Other areas of the anterior segment were within normal limits OU, pupillary examination showed normal responses to direct, consensual, and near reflexes OU, and the posterior segment examination was within normal limits OU. Cogan’s sign and lid fatigue were present OD and absent OS.
Figure 1: Examination of ptosis OD at admission before the first inpatient course

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  Time Line Top


The patient underwent two inpatient courses of Ayurveda treatment from June 27 to July 11, 2020, and from December 17, 2020, to January 1, 2021. He reported for three follow-up consultations on August 13 and October 27, 2020, and February 16, 2021 [Table 1].
Table 1: Time line of events

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  Diagnostic Focus and Assessment Top


A detailed history-taking, clinical examination of signs and symptoms, and diagnostic parameters were done prior to deciding the diagnosis. The patient’s already-established diagnosis was taken and the diagnosis of ocular MG was established. Ayurveda diagnosis was established as Vatahata Vartma based on the presenting symptoms. Vatahata Vartma is an incurable condition caused due to Vata Kapaha vitiation in the eyelid, as per Ayurveda classical texts.[7]

The results of routine hematological and biochemical laboratory investigations of the patient were within normal range, including thyroid function test. Computerized tomography scan of the chest prior to the admission demonstrated no lung masses, opacities, thymomas, or mediastinal masses. Other specific tests such as neurography, electromyography, and repetitive nerve stimulation (RNS) showed normal findings. The same assessments, repeated on August 6, 2019, and January 2021, showed the same findings. Both healthy and immunosuppressed patients with ocular MG show a lower rate of conversion into generalized MG; however, a subset of patients develop generalized MG in 2 years from the onset of ocular MG, which warrant close monitoring.[8]


  Therapeutic Intervention Top


The Ayurveda treatment comprised the administration of oral medicines such as decoctions, tablets, and herbal oils [Table 1] and [Table 2]; bio-purification therapies such as nasal medication, the retention of herbal oil in the mouth, and sudation [Table 1] and [Table 3]; and local external therapies, specific for the eyes and head such as ocular irrigation, eye massage, eye drops, irrigation over the head with medicated oils, medicinal paste application over the bregma, massage, and the application of medicated paste with rice over the eyelids [Table 1] and [Table 4]. The patient was advised to follow specific dietary and lifestyle regulations during the treatment, discharge, and follow-up consultations. The dietary advice comprised consuming more clarified butter, green gram, leafy vegetables, and carrots in his daily diet; maintenance of mental tranquility; avoiding the direct exposure to sunlight, dust, smoke, anger, fear, and other emotional outbursts; and abstaining from consuming fermented items and items made of refined flour and processed sugar. In addition to these, simple eye exercises were prescribed at the third follow-up consultation, such as slow movements of the eyes in all cardinal positions of gaze and tossing of a ball.
Table 2: Oral medicines

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Table 3: Bio-purification therapies

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Table 4: External therapies

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  Follow-up and Outcome Top


The evaluation of ptosis, extraocular movements, and the presence of ocular MG were assessed. At discharge, the amount of ptosis reduced, and both margin reflex distance and LPS function improved OD [Figure 2], maintaining the other parameters. The improvement in the abduction and adduction OD was observed at the first follow-up on August 13, 2020, and further improvement of ptosis OD was observed at the second follow-up on October 27, 2020. Marginal ptosis and restriction in intorsion OD were observed at admission before the second inpatient course [Figure 3]. The improvement in these parameters, along with extorsion, was observed at discharge [Figure 4]. A third follow-up on February 16, 2021 showed a complete ptosis, the maintenance of eyeball movements, and positive Cogan’s sign and lid fatigue OD [Figure 5].
Figure 2: Examination of ptosis OD at discharge after the first inpatient course

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Figure 3: Examination of ptosis OD at admission before the second inpatient course

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Figure 4: Examination of ptosis OD at discharge after the second inpatient course

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Figure 5: Examination of ptosis OD at the third follow-up consultation

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The patient was able to tolerate the treatments and adhere to the instructions given to him, and he diligently took the discharge medicines and adhered to the dietary and lifestyle regulations. No unanticipated events were reported during therapy. The adherence, tolerability, and unanticipated events were recorded by directly interviewing the patient.


  Discussion Top


The prognosis of systemic and ocular MG depends on its timely diagnosis and judicious management, vigorous control of symptoms, and regular monitoring to prevent disease progression involving vital muscle groups. Computerized tomography scanning of the chest, electromyography, neurography and RNS were advised for this patient to monitor disease progress. The Ayurveda assessment for this patient indicates that the pathological activity of Vata Dosha, especially Vyana Vata (sub-type of Vata Dosha responsible for movement and circulation) was the main causative factor of the disease.[9] In Ayurveda perspectives, the obstruction of Vata Dosha with Kapha Dosha (somatic humor responsible for stability and strength) hindered the Chala Guna (mobile quality) of Vata. The involvement of the third Patala of eye by Doshas leads to the manifestation of symptoms such as diplopia.[10] Restricted ocular motility was compared to the invasion of the sense organs (in this case, the eye) by Vata Dosha, which caused impairment of their physiological activities.[11]

In the treatment of this case, a systematic protocol of bio-purification was not attempted because of the patient’s inability to tolerate the treatment. Therapeutic purgation was facilitated by the combination of Gandharvahastadi Kvatha and Gandharvahastadi Eranda. The nasal spetum is permeable to lipid soluble molecules, and therefore, the medicines used through nasal route can stimulate neuronal activity. The ingredients possess antioxidant effects, which have been shown to ward off neurodegeneration and neurotoxicity by their free radical scavenging activities.[12],[13],[14] Sudation may cause vasodilation and increases metabolic rate, allowing the body to eliminate more waste materials and the cleansed intestines to absorb more nutrients and other important elements. During the sudation procedure, bandaging of the eyes was done before sudation to reduce the exposure of eyes to heat. Gargling may cause the parasympathetic nervous system to produce more saliva and irritate the oral mucosa, increasing vascular permeability.[15] The increased vascular permeability can help in increasing absorption of the therapeutic components from the medicine used for gargling.

The ingredients of the oral medicines such as Commiphora mukul Linn., Terminalia chebula Linn., Terminalia bellirica Linn., Emblica officinalis Gaertn., Withania somnifera (Linn.) Dunal., Acorus calamus Linn., Glycyrrhiza glabra Linn., and Tinospora cordifolia Miers. and Commiphora mukul Linn., have antioxidant and neuroprotective properties, and thus they may have enhanced neuronal stimulation and immunity, which is expected in treating ocular MG.[15],[16],[17],[18],[19]

The ocular irrigation eliminates pathological elements in the eye by stimulating peripheral nerves, irrigating obstructive lesions, and preparing the eyes to receive further treatments.[20] Eye massage, general massage, and rice paste over the eyelid positively affect Vata Dosha. Eye drops with both lukewarm lipids and cooling sterilized eye drops maintain the delicate balance of Ushna (hot) and Shita (cold) in the eye.

Irrigation over the head can exert a tranquilizing effect, thus inducing a relaxed awareness and a dynamic psychosomatic state.[21],[22] In this patient, it can be interpreted that the treatment stimulated the nerves supplying both the eyes and the LPS. The application of the paste over the bregma may have contributed in preventing the pathological activity of the metabolic channels. The use of herbal oil as a mixing medium in the paste applied to the head utilized the phospholipids present in the cell membranes in the scalp to induce more effective absorption of the essential elements, thus enabling the essential elements to reach the target tissues.[23]

The goal of omitting fermented foods from the daily diet was to prevent the disease’s pathogenic activity from reoccurring. The recommended foods were rich in antioxidants and vitamins A, C, and E and thus were good for eye health. The regular consumption of clarified butter was advised to enhance both digestion and ocular health.[24] Eye exercises help in maintaining and enhancing ocular motility.[25]

The manifestation of ptosis along with positive Cogan’s sign and eyelid fatigue at the third follow-up may have been due to persistent autoimmunity, and as such, this was a limitation to the effectiveness of therapy. Regular and repeated courses of therapy would be required to keep further manifestations of ocular MG at bay.


  Conclusion Top


Full improvement of signs and symptoms without relapse was a major challenge encountered in this case. The entire pathology of this condition could not be reversed because of the persistence of some symptoms. Ayurveda treatments may have halted the progression of the disease, with some symptoms showing improvement. The autoimmune nature of the disease indicates that ocular MG can only be managed and not completely cured. The results obtained in this study may be validated using large-scale sample trials and studies.

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 report. The authors are also grateful to the authors/editors/publishers of all those articles, journals, and books from where the literature for this report has been reviewed and discussed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understand that his name and initial will not be published and due efforts will be made to conceal his identity, but anonymity cannot be guaranteed.





 
  References Top

1.
Grigg J Extraocular muscles: Relationship of structure and function to disease. Aust N Z J Ophthalmol 1999;27:369-70.  Back to cited text no. 1
    
2.
Oosterhuis HJ Observations of the natural history of myasthenia gravis and the effect of thymectomy. Ann N Y Acad Sci 1981;377:678-90.  Back to cited text no. 2
    
3.
Nair AG, Chhablani PP, Venkatramani DV, Gandhi RA, Ocular myasthenia gravis: A review. Ind J Ophthalmol 2014;62:985-91.  Back to cited text no. 3
    
4.
Chouhan JK, Soni TB, Mishra YC Unilateral ocular myasthenia gravis—A case report. Indian J Ophthalmol 1990;38:35.  Back to cited text no. 4
    
5.
Noel MEC, Guy VJ, Yen MT, Thyparampil P, Marcet M, Burkat CN, et al. Myasthenia Gravis. American Academy of Ophthalmology; 2020. Retrieved from: https://eyewiki.aao.org/Myasthenia_Gravis.  Back to cited text no. 5
    
6.
Benatar M, Kaminski H Medical and surgical treatment for ocular myasthenia. Cochrane Database Syst Rev 2012;12:CD005081.  Back to cited text no. 6
    
7.
Murthy KRS, editor. Uttara Sthana, Vartma Roga Vijnana, Chapter 8, verse 5. In: Ashtanga Hrdaya of Vagbhata: Text, English Translation, Notes, Appendices, and Index. Vol. III. 2nd ed. Varanasi: Krishnadas Academy; 1999. p. 75.  Back to cited text no. 7
    
8.
Nagia L, Lemos J, Abusamra K, Cornblath WT, Eggenberger ER Prognosis of ocular myasthenia gravis: Retrospective multicenter analysis. Ophthalmology 2015;122:1517-21.  Back to cited text no. 8
    
9.
Murthy KRS, editor. Sutra Sthana, Doshabhediya Adhyaya, Chapter 12, verse 20. In: Ashtanga Hrdaya of Vagbhata: Text, English Translation, Notes, Appendices, and Index. Vol. I. 2nd ed. Varanasi: Krishnadas Academy; 1999. p. 180.  Back to cited text no. 9
    
10.
Sharma PV, editor. Uttara Tantra, Drishtigata Roga, Chapter 7, verse 14. In: Sushruta Samhita: With English Translation of Text and Dalhana’s Commentary along with Critical Notes. Vol. III. 10th ed. Varanasi: Chaukhambha Sanskrit Series Office; 2010. p. 140.  Back to cited text no. 10
    
11.
Sharma RK, Dash B, editors. Cikitsa Sthana, Vatavyadhi Chikitsa, Chapter 28, verse 29. In: Charaka Samhita: Text with English Translation and Critical Exposition based on Chakrapani Datta’s Ayurveda Dipika. Vol. V. 10th ed. Varanasi: Chaukhambha Sanskrit Series Office; 2010. p. 28.  Back to cited text no. 11
    
12.
Auddy B, Ferreira M, Blasina F, Lafon L, Arredondo F, Dajas F, et al. Screening of antioxidant activity of three Indian medicinal plants, traditionally used for the management of neurodegenerative diseases. J Ethnopharmacol 2003;84:131-8.  Back to cited text no. 12
    
13.
Korpela R, Ahotupa M, Korhonen H Antioxidant properties of cow’s milk. Proceedings of the NJF/NMR Seminar No. 252. The 2014 UKM FST Postgraduate Colloquium, Turku, Finland; 1995. p. 157-9.  Back to cited text no. 13
    
14.
Hosamani B A review on Gandusha: An Ayurveda therapeutic procedure for oral disorders. Int Ayurveda Med J 2017;1:746-54.  Back to cited text no. 14
    
15.
Sugano M, Akimoto KA Multifunctional gift from nature. J ClinNutr Soc 1993;18:1-11.  Back to cited text no. 15
    
16.
Sarup P, Bala S, Kamboj S Pharmacology and phytochemistry of oleo-gum resin of Commiphora wightii (Guggulu). Scientifica (Cairo) 2015;2015:138039.  Back to cited text no. 16
    
17.
Shukla SD, Bhatnagar M, Khurana S Critical evaluation of Ayurvedic plants for stimulating intrinsic antioxidant response. Front Neurosci 2012;6:112.  Back to cited text no. 17
    
18.
Chirag PJ, Tyagi S, Halligudi N, Yadav J, Yadav J, Pathak S, Singh S, et al. Antioxidant activity of herbal plants: A recent review. J Drug Discov Ther 2013;1:1-8.  Back to cited text no. 18
    
19.
Ilaiyaraja N, Khanum F Antioxidant potential of Tinospora cordifolia extracts and their protective effect on oxidation of biomolecules. Pharmacogn J 2011;3:56-62.  Back to cited text no. 19
    
20.
Dhiman KS Salakya Tantra Kriyakalpa Vijnana. Varanasi: Chaukhambha Sanskrit Series Office; 2010. p. 143.  Back to cited text no. 20
    
21.
Kumar GP, Khanum F Neuroprotective potential of phytochemicals. Pharmacogn Rev 2012;6:81-90.  Back to cited text no. 21
    
22.
Dhuri KD, Bodhe PV, Vaidya AB Shirodhara: A psycho-physiological profile in healthy volunteers. J Ayurveda Integr Med 2013;4:40-4.  Back to cited text no. 22
    
23.
Anirudhan R, Nalinakshan A Effect of Brahmisohaladi Sirolepa in children with autism spectrum disorders. Int J Ayurveda Pharm Res 2017;5 :39-45.  Back to cited text no. 23
    
24.
Ahy M Why is ghee beneficial for eye health?. Kimmu’s Kitchen. Available from: https://www.kimmuskitchen.com/why-is-ghee-beneficial-for-eye-health/. [Last accessed on 10 Mar 2022].  Back to cited text no. 24
    
25.
Di Noto P, Uta S, DeSouza JF Eye exercises enhance accuracy and letter recognition, but not reaction time, in a modified rapid serial visual presentation task. Plos One 2013;8:e59244.  Back to cited text no. 25
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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