E-ISSN:2456-3110

Case Report

Branch Retinal Vein Occlusion

Journal of Ayurveda and Integrated Medical Sciences

2023 Volume 8 Number 7 July
Publisherwww.maharshicharaka.in

Management of Branch Retinal Vein Occlusion (BRVO) in Ayurveda - A Case Study

Supriya T.1*, Sujathamma K.2
DOI: http://dx.doi.org/10.21760/jaims.8.7.31

1* TS Supriya, Post Graduate Scholar, Department of Shalakya Tantra, Sri Kalabyraveshwara Swamy Ayurvedic Medical College, Hospital and Research Centre, Bangalore, Karnataka, India.

2 K Sujathamma, HOD & Professor, Department of Shalakya Tantra, Sri Kalabyraveshwara Swamy Ayurvedic Medical College, Hospital and Research Centre, Bangalore, Karnataka, India.

Retina is the innermost tunic of the Eyeball; it is thin, delicate and transparent membrane. It is the most highly developed tissue of the Eye. Retinal arteriole and Vein share an adventitial sheath and because of Arteriolosclerosis thickening of arteriole is associated with compression of the Vein and this intern causes secondary changes including Venous endothelial cell loss, Thrombus formation and Occlusion.[1] These changes appear in both arteriole and vein that contribute to Retinal Vein Occlusions. Branch Retinal Vein Occlusion caused when a single branch of the central vein is blocked due to an embolism and spasm. Retinal Vein Occlusion is the second most common retinal disease after Diabetic Retinopathy. BRVO has a good prognosis of 50 to 60% of eyes are reported to have an improved Visual Acuity or better.

Keywords: Branch Retinal Vein Occlusion, Arteriolosclerosis, Embolism, Spasm

Corresponding Author How to Cite this Article To Browse
TS Supriya, Post Graduate Scholar, Department of Shalakya Tantra, Sri Kalabyraveshwara Swamy Ayurvedic Medical College, Hospital and Research Centre, Bangalore, Karnataka, India.
Email: 		TS Supriya, K Sujathamma, Management of Branch Retinal Vein Occlusion (BRVO) in Ayurveda - A Case Study. J Ayu Int Med Sci. 2023;8(7):163-168.
Available From
https://jaims.in/jaims/article/view/2491

Manuscript Received Review Round 1 Review Round 2 Review Round 3 Accepted
2023-05-29 2023-05-31 2023-06-07 2023-06-14 2023-06-21
Conflict of Interest Funding Ethical Approval Plagiarism X-checker Note
Nil Nil Yes 17%

© 2023by TS Supriya, K Sujathammaand 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 2023;8(7)163
Supriya T et al: Management of Branch Retinal Vein Occlusion (BRVO) in Ayurveda

Introduction

Branch Retinal Vein Occlusion (BRVO) is an abnormal arteriovenous crossing with Vein compression. It is more common than the central retinal vein occlusion. It occurs due to Hemispheric Occlusion, Quadrantic Occlusion and Small branch Occlusion.[2]

Features of Branch Retinal Vein Occlusion are: Vision is affected when the macular area is involved; Retinal Oedema and Retinal Haemorrhages are limited to the area drained by the affected vein, Secondary Glaucoma changes rarely occur in some cases. Chronic Macular Oedema and Neovascularization may occur as complications of BRVO in about one third cases.

Case Report

A 65 years old female patient presented to us at outpatient department with the complaint of sudden blurriness of vision for distant objects in left eye from 2 months, which was not associated with pain. But the patient had associated complaints like headache on left side of the head from 2 months; she noticed the hazy vision in left eye as if all the objects are filled with the water from 1 month. From 20 days she experienced distorted vision, dark spots in front of left eye with watering of eyes. There was no history of ocular trauma and allergies. She was operated for cataract 5 years back in both eyes and all-family members are said to be healthy. Patient is not a known case of Diabetes Mellitus, Hypertension or any other systemic illness and does not present any complaints related to retinal neovascularization and glaucomatous changes of eyes.

External ocular examination and slit lamp examination was normal. Intra ocular pressure (IOP) was normal in both the eyes and glaucomatous changes are not seen in both eyes.

Fundus angiography reveals tortuous superotemporal[3,4] branch retinal veins with dot and flame shaped haemorrhages with yellowish retinal hard exudates. A cotton wool exudate was seen along the inferotemporal arcade. Macula showed loss of normal foveal reflex with thickening due to macular oedema. Optical coherence tomography reveals cystoid macular oedema in left eye. Angiographic findings and optical coherence tomography of right eye was normal.

Systemic examination of the patient was normal. Her blood pressure was 120/80 mmHg and pulse rate was 68 beats/ minute.

Table 1: External ocular examination

Parts Examination Right eye Left eye
Eyelids Position Normal Normal
Movements Normal Normal
Lid Margin Normal Normal
Lacrimal Apparatus Lacrimal Sac Normal Normal
Lacrimal Puncta Normal Normal
Eyeball Position Symmetrically Placed Symmetrically Placed
Visual Axis Normal Normal
Size Normal Normal
Movements Normal Normal

Table 2: Slit lamp examination

Part Examination Right Eye Left Eye
Conjunctiva Congestion Absent Absent
Follicle Absent Absent
Pappillae Absent Absent
Cornea Size Normal Normal
Shape Circular Circular
Sheen Present Present
Surface Smooth Smooth
Anterior Chamber Depth Normal Normal
Pupil Size Normal Normal
Shape Circular Circular
Reactions Present Present
Iris Colour Dark Brown Dark Brown
Pattern Normal Normal
Lens Transparency IOL + IOL +

Table 3: Visual Acuity

Without Specs Distant Vision Near Vision
Both Eyes 6/24 P N8
Right Eye 6/9 N8
Left Eye 6/24 P N12 P

Table 4: Fundus examination

Part Right Eye Left Eye
Media Clear Clear
Optic Disc Normal Normal
Macula Foveal Reflex + No Foveal Reflex Flame Shaped Haemorrhagges + Above Macular Area
Retinal Blood Vessels Normal Tortuous Veins
General Background Normal Normal

Table 5: Investigations

Oct findings: ON 10/12/2022 re      veals Cystoid Macular Oedema.

IOP in Right eye - 12mmhg and Left eye - 18mmhg


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Supriya T et al: Management of Branch Retinal Vein Occlusion (BRVO) in Ayurveda

jaims_2491_01.JPG

jaims_2491_02.JPG

Picture 1: OCT

jaims_2491_03.JPGjaims_2491_04.JPG

Picture 2: OCT

A complete haematological investigation reveals normal results.



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Treatment

Date Treatment Given Observations
22-12-2022 to 26-12-2022 1. Bidalaka with Triphala + Yasti Choorna for 5 days. Dv: B.E - 6/24 P
R.E - 6/9
2. Tab. Triphala Guggulu (1-1-1) for 5 days. L.E - 6/24 P
Nv: BE: N8
3. Tab. Oxitard (1-0-1) for 5 days. RE: N8
LE: N12 P
31-12-2022 to 10-01-2023 Shodana given - Virechana Visual Acuity of both eyes improved
Dv: B.E - 6/18 P
Snehapana with Mahatriphala Ghritha for 3 Days R.E – 6/9
L.E – 6/24
Followed by Vishrama Kala for 3 days then Nv: BE: N8
RE: N8
Virechana with Trivrit Lehya given LE: N12
11-01-2023 to 19-01-2023 Vasa Guduchyadi Kashaya (3tsp – 0 – 3tsp) -
19-01-2023 to 01-02-2023 Vasa Guduchyadi Kashaya (3tsp – 0 – 3tsp) Receded haemorrhages seen
Floaters not seen
Dv: BE – 6/18
Darvyadi Anjana once daily RE- 6/9
LE - 6/18 p
02-02-2023 to 07-02-2023 Tarpana with Mahatriphaladi Ghritha for 5 days No Distorted vision, distant vision
Remain same as on 01-02-23.
Nv -
BE – N8
RE – N8
LE – N10
07 - 02 - 2023 Vasa Guduchyadi Kashaya (3tsp - 0 - 3tsp) continue. Dv - BE - 6/12 P
RE - 6/9
LE - 6/12 P
Darvyadi Anjana application once daily also continue Nv -
BE - N8
Syrup. Cardorium Plus (1tsp – 0 – 1tsp) RE - N8
LE - N10

At the time of discharge, her BCVA was 6/12p, distorted vision was not present and patient was advised to take medications for 1 month.

Nidana Panchaka

Nidana

  • Ushnabi Taptasya Jala Praveshat[5] - patient had habit of drinking cold water immediately after field work in hot sun.
  • Chinta (stress)[5]
  • Eating spicy and sour items[5]
  • Vardhakya.

Poorva Roopa

Netra Avilatha, Shirashoola, Ashrusrava[6]

Roopa

Avyaktha Darshana, Vyavidhani, Bhramantiva Sa Pashyati[7]

Samprapthi

Due to Nidanas

↓

Vata Pradhana Tridosha Prakopa leading to Jatharagni vitiation

↓

Moves upwards through Rupavaha Siras

↓

Takes Sthanasamshraya in Dristimandala of Netra

↓

Tritiya Patalagatha Timira

Samprapthi Ghatakas

Dosha Tridosha
Dooshya Rasa, Raktha
Agni Jataragni Dushti
Ama Jataragni Janya Aama
Srotas Rasavaha-Raktavaha
Srotodushti Prakara Sangha
Udbhava Sthana Amashaya
Sanchara Sthana Urdhwagami Siras
Rogamarga Madhyama
Adhisthana Netra
Vyaktasthana Netra Patala
Sadyasadhyata Krichrasadhya

Discussion

BRVO caused due to venous insufficiency which develops in a portion of retina when a single branch of central vein is blocked, where the vein shares a common sheath with the artery so that two are affected by the same sclerotic process, the compression of the vein is thought to cause turbulent blood flow that leads to thrombus formation, oedema and flame shaped haemorrhages are limited to the area supplied by the vein. In this case superotemporal quadrant is mainly affected.


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Supriya T et al: Management of Branch Retinal Vein Occlusion (BRVO) in Ayurveda

In this case, at first Virechana - Shodana treatment was advised which helps in removing obstruction and retention of fluid in retina, there by reduces oedema. Internally Vasa Guduchyadi Kashaya given, the chemical constituents which are present in the Kashaya inhibits proliferation of endothelial cells and neovascularization, acts as anti - VEGF and anti - oxidant which reverse the cellular damage by inhibiting the excessive oxidative stress to the cells due to excess of free radicles and helps in prevention of haemorrhages. The Madhura and Rasayana properties of Guduchi and Amalaki rich in vitamin C tightens the endothelial barrier and maintains its integrity of the capillary fragility thus has definite role in treating the haemorrhages. The Darvyadi Anjana, which is advised helps to check obstruction and maintains good vision. The Tarpana - Kriyakalpa treatment which helps in improving visual acuity.

Conclusion

A case of BRVO which is referred to our hospital presents same features of Tritiya Patalagatha Timira, Vataja predominant having Vyavidhani Cha Manava i.e., distorted vision and Aavilatha i.e., the objects look like as if filled with water. It is treated with Virechana Karma, Tarpana - a Kriyakalpa procedure and with internal medications. With this treatment the distorted vision got corrected, visual acuity of the patient got improved from 6/24p to 6/12p and floaters disappeared, headache got relieved and on fundus examination haemorrhages are receded. Vasaguduchyadi Kashaya having anti -VEGF property helped in reducing macular oedema. On the basis of this case study, it can be concluded that Ayurvedic treatment modalities along with internal medication is significantly effective in the management of BRVO.

References

1. Kanski’s Clinical Opthalmology - A systemic Approach by John.F.Salmon, 9th Edition, Chapter 13, Retinal Vascular Disease, page no. 520, pp941.

2. Comprehensive Ophthalmology by A. K. Khurana, 6th Edition, chapter 12th, Diseases of Retina, page no. 270, pp623.

3. Parson’s Diseases of the Eye by Ramanjit Sihota and Radhika Tandon, 21st Edition, Section iv, Diseases of the Retina, page no. 314, pp596.

4. Gray’s Anatomy by Churchill Living Stone, Edited by Peter L. Williams, Roger Warwick, Mary Dyson, Lawrence H. Bannister, 37th Edition, chapter 7th, Neurology, The Optic Disc and Retinal blood vessels, page no.1204, pp1598.

5. Acharya Sushrutha, Sushrutha Samhitha with the Nibandhasangrahatika of Sri Dalhanacarya and Nyayacandrikatika of Gayadasa, edited by Vaidya Jadavji Trikamji Acharya, Chowkhamba Krishnadas Academy, Varanasi, Edition 2004, Uttarasthana, 1st Chapter, Aupadravikamadhyayam, Verse 26-27, page no. 597, pp824.

6. Acharya Sushrutha, Sushrutha Samhitha with the Nibandhasangrahatika of Sri Dalhanacarya and Nyayacandrikatika of Gayadasa, edited by Vaidya Jadavji Trikamji Acharya, Chowkhamba Krishnadas Academy, Varanasi, Edition 2004, Uttarasthana, 1st Chapter, Aupadravikamadhyayam, Verse 21-22, page no.597, pp824.

7. Acharya Sushrutha, Sushrutha Samhitha with the Nibandhasangrahatika of Sri Dalhanacarya and Nyayacandrikatika of Gayadasa, edited by Vaidya Jadavji Trikamji Acharya, Chowkhamba Krishnadas Academy, Varanasi, Edition 2004, Uttarasthana, 7th Chapter, Drishtigatarogavignaniyam Adhyayam, Verse 18, page no.607, pp824.


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