E-ISSN:2456-3110

Review Article

Corneal Ectasia

Journal of Ayurveda and Integrated Medical Sciences

2022 Volume 7 Number 4 May
Publisherwww.maharshicharaka.in

Ayurvedic management of Corneal Ectasia - A Conceptual Study

Magi S.1*, Hiremath V.2, Shashikala D.3, Gururaj N.4, Raju S.5
DOI:

1* Sujata Magi, Post Graduate Scholar, Department of Shalakya Tantra, Shree Jagadguru Gavisiddeshwara Ayurvedic Medical College, Koppal, Karnataka, India.

2 Veerayya R Hiremath, HOD & Professor, Department of Shalakya Tantra, Shree Jagadguru Gavisiddeshwara Ayurvedic Medical College, Koppal, Karnataka, India.

3 DK Shashikala, Associate Professor, Department of Shalakya Tantra, Shree Jagadguru Gavisiddeshwara Ayurvedic Medical College, Koppal, Karnataka, India.

4 N Gururaj, Assistant Professor, Department of Shalakya Tantra, Shree Jagadguru Gavisiddeshwara Ayurvedic Medical College, Koppal, Karnataka, India.

5 SN Raju, Assistant Professor, Department of Shalakya Tantra, Shree Jagadguru Gavisiddeshwara Ayurvedic Medical College, Koppal, Karnataka, India.

Corneal ectasia is a disorder that results in thinning of the central, paracentral, or peripheral cornea that leads to progressive myopia and irregular astigmatism. Keratoconus, Pellucid marginal corneal degeneration (PMCD), Terrien's marginal degeneration (TMD), Keratoglobus, Posterior keratoconus are the conditions/types of corneal ectatia. In Ayurveda there is no direct reference of corneal ectasia, based on signs and symptoms it can be correlated with Vataja Timira. Timira is the Drustigata Roga which further leads to Linganasha if not treated initially. Based on symptoms and Dosha-Dushya involvement Brhumhana and Vatahara line of treatment should be followed in the form of Virechana, Nasya, Tarpana, Putapaka and Pindi. These treatment modalities are more beneficial in corneal ectasia.

Keywords: Corneal ectasia, Vataja timira, Vatahara, Bruhmana

Corresponding Author How to Cite this Article To Browse
Sujata Magi, Post Graduate Scholar, Department of Shalakya Tantra, Shree Jagadguru Gavisiddeshwara Ayurvedic Medical College, Koppal, Karnataka, India.
Email: 		Sujata Magi, Veerayya R Hiremath, DK Shashikala, N Gururaj, SN Raju, Ayurvedic management of Corneal Ectasia - A Conceptual Study. J Ayu Int Med Sci. 2022;7(4):102-106.
Available From
https://jaims.in/jaims/article/view/1847

Manuscript Received Review Round 1 Review Round 2 Review Round 3 Accepted
2022-03-28 2022-03-30 2022-04-06 2022-04-13 2022-04-20
Conflict of Interest Funding Ethical Approval Plagiarism X-checker Note
Nil Nil Yes 17%

© 2022by Sujata Magi, Veerayya R Hiremath, DK Shashikala, N Gururaj, SN Rajuand Published by Maharshi Charaka Ayurveda Organization. This is an Open Access article licensed under a Creative Commons Attribution 4.0 International License https://creativecommons.org/licenses/by/4.0/ unported [CC BY 4.0].

Journal of Ayurveda and Integrated Medical Sciences 2022;7(4)102
Magi S et al: Ayurvedic management of Corneal Ectasia

Introduction

Corneal ectasia are group of uncommon, Non-inflammatory disorder characterized by bilateral progressive thinning of the central, paracentral or peripheral cornea and apical protrusion. The prevalence rate is 54.5 per 1 lakh and both men and women are affected equally. Corneal ectasia includes keratoconus, Pellucid marginal corneal degeneration (PMCD), Terrins marginal degeneration (TMD), Keratoglobus, Posterior keratoconus. Corneal ectasia are the complication of corrective surgeries like PRK (Photorefractive keratectomy) and LASIK (Laser-Assisted in situ keratomileusis).[1] Among the corneal ectasia keratoconus is common.

Keratocous is a progressive non inflammatory bilateral ectatic condition of cornea in which cornea assumes a conical shape secondary to stromal thinning and protrusion.[2]

Pathophysiology: It is not clear. Various theories proposes that corneal thinning and ectasia of cornea is the result of an interlamellar and interfibrillar slippage of collagen within the stroma due to a loss of cohesion between collagen fibrils and the non-collagenous matrix.[3]

Symptoms[4]

It usually starts in their late teens or early twenties.

  • Progressive myopia and irregular astigmatism.
  • Blurred vision, distortion, glare
  • Frequent changes in refraction
  • Other includes[5]
  • Increased light sensitivity
  • Difficulty driving at night
  • A halo around light and ghosting (especially at night)
  • Eye strain
  • Headache and general eye pain
  • Eye irritation
  • Excessive eye rubbing

Signs[6]

  • Distorted window reflex
  • Placido’s disc examination shows irregular circles
  • Direct ophthalmoscopy: oil droplet reflex
  • Retinoscopy: irregular scissoring reflex
  • Slit – Lamp biomicroscopy : Vogt striae, Fleicher ring
  • Progressive corneal thinning
  • Munson sign
  • Corneal topography shows irregular astigmatism
  • Acute hydrops

Gradings (Keratometry)[6]

  • Mild : <48D
  • Moderate : 48-54 D
  • Severe : >54 D

Morphological classification[6]

1. Nipple cone : Small size (<5mm) and steep curvature

2. Oval cone : Larger (5-6mm) and Ellipsoid in nature

3. Globus cone : Very large (>6mm) and globe like

PMCD is a variant of keratoconus.[7] It is a bilateral rare progressive peripheral corneal thinning disorder, typically involving the inferior cornea. Symptoms includes blurring of vision due to increasing astigmatism. Signs include crescentic 1-2mm band of inferior corneal thinning extending from 4-8 o’ clock, 1mm away from the limbus, Butterfly pattern seen in corneal topography.[8]

TMD is an uncommon idiopathic thinning of the peripheral cornea (circumferential cornea). It usually starts with deposition of refractile yellowish- white dots in peripheral anterior stroma followed by the appearance of narrow gutter parallel to the limbus with progressive thinning.[9]

Keratoglobus an extremely rare congenial Hereditary condition in which entire cornea is abnormally thin. Characterized by thinning and hemispherical protrusion of entire cornea. Symptoms include, it may be associated with congenital amaurosis and blue sclera. Signs includes cornea develops globular, thinning is generalized, acute hydrops occurs less commonly, cornea id prone to rupture on relative mild trauma. Topography shows generalized steepening.[10]

Keratoconus posterior is a rare, congenital, unilateral condition.


Journal of Ayurveda and Integrated Medical Sciences 2022;7(4)103
Magi S et al: Ayurvedic management of Corneal Ectasia

There is slight cone like bulging of posterior surface of the cornea. Non progressive thinning of the inner surface of the cornea, while curvature of anterior surface remains normal.[11]

Treatment of corneal ectasia includes spectacles or contact lenses, rigid contact lenses, Intracorneal ring segment (intacs) implantation are useful in early cases, corneal cross linking with riboflavin (CXL or C3R) may slow down the progression of disease, Keratoplasty may be required in later stages.[12]

Corneal ectasia is not described in Ayurveda as a separate entity. Based on signs and symptoms it can be correlated with Vataja Timira (Prathama Patalagata or Dvitiya Patalagata). The Laxanas of Vataja Timira are Roopani Bhramanti (objects look unstable), Avila and Aruna (visualize dirty and slightly reddish objects), Vyavidda (distorted vision),[13] Prasannam (sometimes vision is clear), Jaala, Kesha, Mashaka, Rashmi (visualize webs, hairs, mosquitoes and rays of light).[14] Samanya Chikitsa of Timira is Snehapaana, Visravana, Virechana, Nasya, Anjana, Murdhabasti, Basti, Tarpana, Lepa, Seka.[15] Chikitsa for Vataja Timira is Virechana with Eranda Taila mixed with Ksheera, Nasya with Sthiradigana Sidda Taila, Madhuradigana Sidda Taila and Anutaila, Sahadi Taila, Jaloadhbavadi Grita, Jeevantyadi Taila. Tarpana, Putapaka, Anjana.[16] If Timira is not treated in time it leads to Linganasha, it is better to intervene at the earliest to arrest the further progression of disease. Here considering the concept of Vata Vruddhi in Timira the treatment should be Vatahara and Bruhmana.[17] Shodhana in the form of Virechana and Nasya followed by Tarpana, Putapaka and Pindi are helpful in this condition.

Discussion

In Ayurveda, Vata is responsible for formation of normal body parts. The concept of vitiation of Vata can be understood in different views. Cornea (Krishna Mandala) can be considered as Vayu Mahabhoota predominant. There are so many reasons for taking cornea as Vayu predominant like cornea is transparent, it gets its nourishment directly from Vayu and it is in constant contact with air. As the cornea is Vayu Mahabhoota predominant, the Sthanika Dosha will be Vata. Moreover, it is stated by Sushruta as Vatat Krishnam, which means the Krishna Mandala

is derived from Vayu Mahabhoota.[18] The function of Vata in cornea includes transmission of light rays and their convergence. Vata is said to responsible for Pravartan (stimulation, activation) of Indriyas. So, any defect in Vayu leads to Krishngata Roga. In Garbhavasta, Vayu is vitiated due to Douhrudavimaanana leads to Vikrutaksha (deformed eye).[19] While describing the Sadyasadyata of Kshataja Shukra, mentioned as Dvitvagashrita that is Dvipatalashrita. We can consider outer part of cornea as Tvak. So, corneal ectasia can be considered as Tvakgata Vata.[20] In contemporary science also there is no exact cause for corneal ectasia. Here thinning of cornea is mainly due to the vitiation of Vata which leads to progressive myopia and astigmatism. Based on the symptoms of corneal ectasia, this can be correlated to Vataja Timira. Considering the Dosha involvement, the treatment should be Vatahara and Bruhmana. In this disease Shodhana with Virechana and Nasya followed by Sthanika Chikitsa like Tarpana, Putapaka, Pindi works good.

Mode of action

Virechana[21]: Administration of Virechana Dravya through oral route spreads throughout the body at cellular level and enters into micro and macro channels with its specific quality, dragging the Doshas from Shakha to Kosta and eliminates them through anal route by virtue of Dravya property. This Virechana Karma helps in Samprati Vighatana of Vataja Timira.

Nasya: Drugs in the form of Nasya has probable mode of entry in circulation, hence role in the improving vision is as follows. By general blood circulation, after absorption through mucous membrane, Direct pooling into venous sinuses of brain via, inferior ophthalmic veins and Absorption directly into the cerebrospinal fluid. As this medicine is absorbed in ophthalmic vessels it has its nourishing role in extra ocular muscles and eye proper. Along with this antioxidant property have role in maintaining tissue built.[22]

Bruhmana Nasya in the form of Taila or Grita, these Sneha Dravya possesses Sukshma Guna, so that it is easier to absorb through Shleshmika Kala of nose.

These medicines are highly lipid soluble and are capable of accelerating the Vata Dosha by their antagonistic properties. The lipid soluble drugs


Journal of Ayurveda and Integrated Medical Sciences 2022;7(4)104
Magi S et al: Ayurvedic management of Corneal Ectasia

have delayed action and the duration of action is long. So, Bruhmana Nasya Dravyas acts slowly for longer duration. Lipid provides energy to the nervous tissue.

Tarpana and Putapaka: Tarpana and Putapaka (Snehana) exerting direct pressure over the cornea, there may be changes in the refractive index of the cornea and Grita has the quality of transpassing into the minute channels of the eye, it enters deeper layer of the Dhatus. Medicine used in Tarpana is Grita. So, the lipophilic action of the Grita facilitates the transformation of the drug to the target organ and the corneal epithelium is permeable to lipid soluble substances. Grita has high levels of antioxidants which can reduce corneal ectasia by allowing more tissue contact time and bioavailability of the drug from the corneal surface.[23]

Putapaka is advised after Tarpana to promote strength to eye as it become fatigued due to Tarpana.[24] Putapaka is of three types: Snehana, Lekhana, Ropana. Among these Snehana type of Putapaka is useful as it is composed of Sneha, Mamsa, Vasa, Majja, Meda and Madhura Dravyas.[25] This act as a Bruhmana and improves the vision.

Tarpana and Putapaka is indicated in Timira the commonly used Ghrita Yogas are Jeevantyadi Grita, Triphala Grita, Mahatriphala Grita, Shatavaryadi Grita. Jeevantyadi Grita has high levels of antioxidants, which reduce the oxidative stress cornea ectasia. It helps in bringing down the corneal protrusion by Dosha Shamana and mechanical pressure. In contemporary science C3R and INTACS is advice to strength the stroma tensile and flatten the central cornea, but there is no assurance of cure as their methods are not without complication.

Pindi: In Pindi medicine is absorbed through the skin of lids and due to heat of Pindi local temperature is increased resulting in vasodilatation. By practice the Pindi can advise to overnight, that will help to flatten the corneal curvature by its mechanical pressure and strengthen the cornea by medicine effect. Pindi is indicated in Shota and Kandu the specific drugs like Sunti (Zingiber officinale) and Nimbadala (Azadirachta indica) should be pasted in hot water with little of Saindhava will help in all the inflammatory conditions of eye.

In contemporary science contact lenses are advised to correct the myopia and astigmatism, aspheric lenses with high eccentric value helps to flatten the cornea quicker compare to other lenses the main effect of the contact lenses is to provide a best vision to corneal ectasia patient, the same effect get by Pindi procedure.[26]

Conclusion

Based on signs and symptoms of corneal ecatsia it can be correlated with Vataja Timira. The aim of treatment is to slowdown the progression of the disease, to strengthen the interlamellar and interfibrillar collegen fibers of stroma and to improve the vision. As corneal ectasia is treated in contemporary medicine with correction and prescription of glasses and operative procedures like INTACS, C3R which are not affordable to common people and success rate is unknown and even not free from complications. Hence, Ayurveda has a wide scope of research in this regard to come up with new researches with better results.

Reference

1. Corneal ectatic disorders - Wikipedia [Internet]. En.wikipedia.org. 2022 [cited 26 January 2022]. Available from: https://en.wikipedia.org/wiki/ Corneal_ectatic_disorders.

2. Kanski J, Bowling B. Clinical ophthalmology A systamic approach. 7th ed. pg no:210 2012.

3. Chaudhari Z,Vanathi M. Postgraguate ophthalmology. 1st ed. Panam: Jaypee-Highlights medical publishers, Inc; 2012, pgno:451-452.

4. Chaudhari Z,Vanathi M. Postgraguate ophthalmology. 1st ed. Panam: Jaypee-Highlights medical publishers, Inc; 2012,pg no:452.

5. Ratnawwa Naik: A Review on Ayurvedic Management of Keratoconus ayurpub; II

6. Khurana A, Khurana A, Khurana B. Comprehensive ophthalmology. New Delhi: Jaypee, The Health Sciences Publisher; 2015,Pgno:131-132.

7. Chaudhari Z,Vanathi M. Postgraguate ophthalmology. 1st ed. Panam: Jaypee-Highlights medical publishers, Inc; 2012, pg no:460.

8. Kanski J, Bowling B. Clinical ophthalmology A systamic approach. 7th ed. 2012, pg no:210-212.


Journal of Ayurveda and Integrated Medical Sciences 2022;7(4)105
Magi S et al: Ayurvedic management of Corneal Ectasia

9. Chaudhari Z,Vanathi M. Postgraguate ophthalmology. 1st ed. Panam: Jaypee-Highlights medical publishers, Inc; 2012, pgno:461.

10. Kanski J, Bowling B. Clinical ophthalmology A systamic approach. 7th ed. pg no:212 2012.

11. Corneal ectatic disorders - Wikipedia [Internet]. En.wikipedia.org. 2022 [cited 26 January 2022]. Available from: https://en.wikipedia.org/wiki /Corneal_ectatic_disorders.

12. Chaudhari Z,Vanathi M. Postgraguate ophthalmology. 1st ed. Panam: Jaypee-Highlights medical publishers, Inc; 2012, pgno:456-459.

13. Sushruta samhita- Uttara tantra edited by Dr Keval Krishna takaral, published by Chaukamba orientalia, Varanasi, Vol-3 cha.no/ Sl.no -7/18-19, Pg no-816.

14. Astanga hrudaya – Uttara tantra edited by Bhishagacharya Harishastri Paradakara Vaidya, published by Chaukambha orientalia, Varanasi, cha.no/sl.no- 12/8-11,pgno- 816.

15. Astanga hrudaya – Uttara tantra edited by Bhishagacharya Harishastri Paradakara Vaidya, published by Chaukambha orientalia, Varanasi, cha.no/sl.no- 13/47,pgno- 822.

16. Sushruta samhita- Uttara tantra edited by Dr Keval Krishna takaral, published by Chaukamba orientalia, Varanasi, Vol-3 cha.no/ Sl.no -17/33-36, Pg no-93-94.

17. Ratnawwa Naik: A Review on Ayurvedic Management of Keratoconus ayurpub; II

18. Sushruta Samhita- Uttara tantra edited by Dr Keval Krishna takaral, published by Chaukamba orientalia, Varanasi, Vol-3 cha.no/ Sl.no -1/11, Pg no-4.

19. Sushruta samhita- Sharira Sthana edited by Dr Keval Krishna takaral, published by Chaukamba orientalia, Varanasi, Vol-2 cha.no/ Sl.no -3/18, Pg no-44.

20. Ratnawwa Naik: A Review on Ayurvedic Management of Keratoconus ayurpub; II

21. Agnivesha Charaka samhita- Siddisthana; edited by acharya vidhydhar shukla and prof.Ravi dutt Tripati;Published by Chaukamba Sanskrit pratisthana,Delhi;cha.no/sl.no-1/5 pg.no-806.

22. Solapurkar Vivek Vishwas & S M Pasha: Madhukadi Taila Nasya In The Management Of Prathama Patalagata Timira - A Pilot Study. International Ayurvedic Medical Journal {online} 2018.

23. Ratnawwa Naik: A Review on Ayurvedic Management of Keratoconus ayurpub; II

24. Astanga hrudaya – Sutra Sthana Tantra edited by Bhishagacharya Harishastri Paradakara Vaidya, published by Chaukambha orientalia, Varanasi, cha.no/sl.no- 24/12-13,pgno- 309.

25. Sushruta samhita- Uttara Tantra edited by Dr Keval Krishna takaral, published by Chaukamba orientalia, Varanasi, Vol-2 cha.no/ Sl.no -18/20-23, Pg no-112-113.

26. Ratnawwa Naik: A Review on Ayurvedic Management of Keratoconus ayurpub; II.


Journal of Ayurveda and Integrated Medical Sciences 2022;7(4)106