E-ISSN:2456-3110

Case Report

Diabetic Retinopathy

Journal of Ayurveda and Integrated Medical Sciences

2024 Volume 9 Number 1 January
Publisherwww.maharshicharaka.in

An Ayurvedic Management of Diabetic Retinopathy - A Case Report

Panwar A1*, Kumar A2, Pahwa P3
DOI:10.21760/jaims.9.1.51

1* Arti Panwar, Post Graduate Scholar, Department of Shalakya Tantra, Rishikul Campus Haridwar Uttarakhand Ayurved University, Dehradun, Uttarakhand, India.

2 Arun Kumar, Assistant Professor, Dept of Shalakya Tantra, Rishikul Campus Haridwar Uttarakhand Ayurved University, Dehradun, Uttarakhand, India.

3 Preeti Pahwa, Associate Professor, Dept of Shalakya Tantra, Patanjali Bhartiya Ayurvigyan Evum Anusandhan Sansthan, Haridwar, Uttarakhand, India.

Diabetic retinopathy (DR) is the most frequent micro vascular complication of Diabetes mellitus. It is an eye condition that can cause vision loss and blindness. Globally the prevalence of Diabetic retinopathy among diabetic patients is estimated to be 27.0% which leads to 0.4 million blindness in the world.[1] It affects blood vessels in the retina (the light-sensitive layer of tissue in the back of the eye). It commonly affects both eyes and can lead to vision loss if it left untreated. Currently available conventional treatments (Focal laser therapy, Anti-vascular growth factor drug) for DR have certain limitations, considering which options from alternative resources are being searched. Despite advances in science the treatment of DR is challenging. So, in this case Ayurveda treatment was done.

Keywords: Diabetes mellitus, Diabetic retinopathy

Corresponding Author How to Cite this Article To Browse
Arti Panwar, Post Graduate Scholar, Department of Shalakya Tantra, Rishikul Campus Haridwar Uttarakhand Ayurved University, Dehradun, Uttarakhand, India.
Email: 		Panwar A, Kumar A, Pahwa P, An Ayurvedic Management of Diabetic Retinopathy - A Case Report. J Ayu Int Med Sci. 2024;9(1):318-323.
Available From
https://jaims.in/jaims/article/view/3045

Manuscript Received Review Round 1 Review Round 2 Review Round 3 Accepted
2023-11-02 2023-11-13 2023-11-23 2023-12-04 2023-12-14
Conflict of Interest Funding Ethical Approval Plagiarism X-checker Note
None declared Nil Yes 20.96

© 2024by Panwar A, Kumar A, Pahwa Pand 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].

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Introduction

Diabetes mellitus is a serious metabolic disorder, with a major impact on the lives and well-being of individuals, families and societies worldwide. Diabetes mellitus is becoming a global epidemic and now one of the major causes of vision loss globally. Uncontrolled blood sugar is a risk factor to develop Diabetic retinopathy by damage to the blood vessels in the tissue at the back of the eye (retina). The degree of retinopathy is highly correlated with duration of Diabetes, Blood glucose level. Diabetic retinopathy is a leading cause of blindness.[2] Globally the prevalence of Diabetic retinopathy among diabetic patients is estimated to be 27.0%, which leads to 0.4 million blindness in the world. Blurring of the central vision may be the first symptoms the patient notice. Diabetic macular edema (DME) is a potential complication of Diabetic retinopathy.[3] There is no direct reference of a visual disturbance caused by Madhumeha in the Ayurveda classical text. But Netra Prakasika has mentioned Granthi and Meha Roga as the causes of eye diseases. A description of Timira (a diseases characterized by blurred vision) as a cause or complication of Prameha. Thus, DR would be taken as Madhumehajanya Timira.[4] The major constituents of Madhumeha are Bahudrava Sleshma Dosha Vishesa along with Abaddha Meda, Mamsa, Sarira Kleda, Sukra, Sonita, Vasa, Lasika, Majja, Rasa and Oja. Similarly in Diabetic retinopathy, visual loss depends upon the site of pathology in the retina. If more damage is created to the central macula, the central vision is reduced and if it is in peripheries, peripheral vision diminishes. The dominance of Bahudrava Sleshma greatly disturbs Alochaka Pitta by increasing its Dravatwa. The three Doshas are affected with Rakta (as both Dosha and Dushya), mainly Vata, Pitta, Rakta and Kapha Anubandha. All the Dhatus are affected with Rakta, Meda and Mamsa predominant, Sira Srotas, Raktavaha Srotas and Ojavaha Dhamani get affected in successive stages. This Samprapti results in Kaphaja Raktapitta or Urdhwaga Raktapitta.[5] It can be understood by massive haemorrhages in some cases of Diabetic retinopathy. As the management is aimed at both preventing further damage and relieving the complaints. The Chakshushya drugs and regimen are of great value. So following Ayurveda line of treatment, Kleda Harana, Rakta Vaha Sroto Dusti Harana

, Vata Anulomana, Pitta Harana was advised. In contemporary medical science few treatment modalities are available like Intravitreal anti-vascular endothelial growth factor injections (anti VEGF injections), Intravitreal steroids. For high risk or complicated proliferative retinopathy, Pan retinal laser photocoagulation (reduce the risk of severe vision) and sometimes Pars-Plana Vitrectomy (PPV) surgery (to preserve and often restore lost vision) etc are done.[6] But these management do not provide significant relief. Hence it is the need to find out safe, effective and economic therapy in alternate systems of medicine which can decelerate the progression of disease and the risk of visual loss.

Materials and Methods

A male patient, aged 37 years, came to OPD of Shalakya Tantra, Rishikul Campus, Haridwar on 2-10-2022 with chief complaints of progressive painless blurring of vision from both eyes for both distant and near vision along with mild watering from both eyes, floaters and black spots in front of both eyes since 6 months. He was chosen to have a signs of Retinal haemorrhages.

Past History

There was H/O Type 1 Diabetes mellitus since 2009.

Family History

Mother - Type 1 Diabetes mellitus since 15-16 years, HTN since 13 Years.

History of Present Illness

According to the patient he was asymptomatic 13 years back, then he gradually developed painless blurring of vision from both eyes [rt>lt) for both distant and near objects. There were occasional floaters and black spots in front of eyes. After passing of time the patient also started having complaints of heaviness and mild pain in both eyes, around the eyes and forehead for 5 years. Patient gradually developed a blurring of vision. For this he approached an Ophthalmologist and found out that his blood sugar level was high and after his thorough examination, OCT was done, where he was diagnosed having Diabetic retinopathy in both eyes. He was advised to take Intravitreal bevacizumab (0.5mg). Patient was not willing to undergo the above advised treatment


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and wanted to take Ayurveda treatment. Thus, he approached our OPD.

History of Past Illness

He was a known case of Diabetes mellitus past 13 years.

Personal History

  • Sleep: Disturbed
  • Appetite: Good
  • Bowel: Once a day
  • Micturition: 5-6 times /day
  • Alcohol: Occasionally
  • Tobacco chewing: No
  • Smoking: 1-2 /Day

General Examination

The vitals were within normal limits.

Systemic Examination

All the Systemic Examinations were within normal limits.

Ashta Sthana Pareeksha

  • Nadi: 72/min
  • Mala: Prakrta
  • Mutra: 7-8 times/day
  • Jihwa: Prakrta
  • Shabda: Prakrta
  • Sparsha: Prakrta
  • Drika: Vikrta
  • Akriti: Madhyama

Dashavidha Pareeksha

  • Prakriti - a) Sharira: Vata-Pittaja
     b) Manasa: Rajasika
  • Vikriti - Madhyama
  • Satva - Madhyama
  • Sara - Madhyama
  • Sahanana - Pramana
  • Satmya - Madhyama
  • Aharshakti - Madhyama
  • Vyayamashakti - Avara
  • Vaya - Madhyama

Ocular Examination

Table 1: Slit lamp examination

Ocular structureRight EyeLeft Eye
AdnexaNo abnormalitiesNo abnormalities
Conjunctiva – Palpebral
Bulbar		Normal
Congested		Normal
Congested
CorneaClear transparentClear transparent
Ant ChamberNormal depthNormal depth
IrisNormalNormal
PupilRound, regular, reactive to lightRound, regular, reactive to light
LensGrayish blackGrayish black

Table 2: Visual Acuity Test

Right EyeLeft Eye
DVA6/246/12
NVAN10N8
PH6/126/12 (NI)

Test for Colour Vision: Ishihara Colour Plates - The patient identified the colour patterns as well numbers in the plates.

Amsler Grid Test:

Right Eye - Normal

Left Eye - Normal.

IOP: RE - 18mm/Hg, LE - 16mm/Hg.

Table 3: Refraction

RELE
SPHCYLAXISVisionSPHCYLAXISVision
Distance-0.75-0.75906/12-1.00-0.751006/9p
Near+0.75--N/8+0.75--N/6

Table 4: Confrontation Test (Visual field finding)

RELE
Superotemporal quadrant -veSuperotemporal quadrant -ve
Inferotemporal quadrant +veInferotemporal quadrant +ve
Superonasal quadrant +veSuperonasal quadrant +ve
Inferonasal quadrant +veInferonasal quadrant +ve

Table 5: Fundus Examination

CharactersRELE
MediaClearClear
Disc
§ Size
§ Shape
§ Color
§ Margin		Normal
Oval shape
Pinkish - yellow
Clear		Normal
Oval shape
Pinkish - yellow
Clear
C:D ratio0.30.3
Macula - Foveal reflexDullDull
General backgroundMicroaneurysms (+)
Blot haemorrhages in superotemporal, inferotemporal, and inferonasal quadrant. (+)		Microaneurysms (+)
Multiple dot-blot haemorrhages in superotemporal and inferonasal quadrant. (+)

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Table 6: Laboratory Investigations 

FBS180 mg/dl
PPBS260 mg/dl
HBA1C9

After examination of the patient, his consent was taken for the treatment and the prognosis was explained in detail to him and his family members. He was treated on an OPD basis. The total duration of the treatment was 90 days.

Table 7: Treatment planned

SNDate of visitTherapeutic Intervention
MedicationDurationDose
1.On the First visit 03-10-2022Deepan PachanaFirst 5 daysChitrakadi Vati 2 tab 500mg tds
2.Start this medication from 08-10-20221 - Tarpana with Doorvadi Ghrita7 daysRepeated after 15 days interval (2 Sittings)
2 - Sirotalam with,
§ Jatamansi Churna - 5gm
§ Amalki Churna - 5gm
§ Brahmi Taila - 100ml		7 daysRepeated after 15 days interval (2 Sittings)
3 - Punarnava Kwath30 days20ml with 5 ml Gomutra Arka BD before meal
4 - Chandraprabha Vati30 days2 tab BD with water after meal
5 - Nisha-Amalki Churna30 days5gm BD with water after meal
6 - Cap. Netramrit30 days1cap BD with milk after meal
7 - Madhumeha Kusumakar Ras30 days2 tab BD with water after meal
3.On the Second visit 9-11-2022There was some improvement in vision so the same treatments advised to continue for 30 days more.
4.On the Third visit 11-12 -2022There was marked improvement in visual acuity, some reduction also found in the value of FBS, PPBS and HbA1C level. Tarpana and Sirotalam stopped. All other treatments were advised to take continuously for 30 days more.

Pathya-Apathya

Patient was advised to avoid Achakshushya and Rakta-Pitta Vardhaka diet and regimen.

Follow-up

During the subsequent follow-up there was marked improvement in visual acuity and blood sugar was controlled.

Result

The results were evaluated after 90 days. Blood sugar level was controlled along with marked improvement in visual acuity from 6/24 to 6/9(p) in the right eye, and from 6/12 to 6/6(p) in left eye.

Table 8: Visual acuity changes

RELE
DVA6/9(P)6/6(P)
NVAN8N8
PH6/96/6(P)

Table 9: Fundus examination

Macula: Foveal reflexDullDull
General backgroundMicroaneurysms (+)
Blot hemorrhage (-)		Microaneurysms (-)
Dot -blot hemorrhage changes (-)

Table 10: Changes in laboratory investigations

FBS130 mg/dl
PPBS180 mg/dl
HBA1C7.8

Discussion

Diabetic retinopathy is a silent until the patient will not experience blurred vision. Diabetic retinopathy basically a Dristipatalagata Roga, is mainly attributed to Sira Srotasabhisyandam and Raktavaha Sroto Dusti due to a variety of Achakshyushya Ahara and Vihara Karanas especially in Prameha patients. In order to understand the Samprapti of diabetic retinopathy in Ayurveda, general Samprapti of eye disease must be considered. Nidana of endogenic eye diseases are mainly Achakshyushya factors which vitiate Pitta. The vitiated Pitta in turn vitiates the Pitta Vaha Srotas. Due to interconnection of Pitta and Rakta, which shares Ashrya Ashrayee Bhava, the Raktavaha Srotasa also gets vitiated due to Pitta vitiation. As the Nidana factors are Achakshyushya, the vitiated Pitta and Rakta have an affinity towards penetrating the eyes. Hence the vitiated dosha moves towards the eyes through Jatroordhwa Srota and finally gets confined to the eyes, there is a stage when the Sirasrotasa are deeply involved which is known as Sira Abhisyanda.[7] The whole pathology of diabetic retinopathy which starts with Sroto Dusti of Raktavaha Srotasa manifested as microangiopathy in the form of Attipravriti, Sanga and Granthi as haemorrhages, exudates and venous beading in diabetic retinopathy respectively. Diabetic retinopathy can be compared with Timira involving all the four Patalas. Patalas are described on the basis of functional composition of Dhatus of Dristi. The symptoms of vision are manifested when the vitiated Dosha afflicts the concerned Dhatu in Dristi Patalas. All the three Dosha in single or in combination can affect one or more Patalas. Treatment is all about correcting and preventing


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the etiopathological mechanism (Samprapti Vighatana). So as per etiopathological mechanisms described above, the first and foremost care should be given to prevent Madhumeha. The treatment of diabetic retinopathy revolves around treating the causes of Madhumeha, management of Urdwaga Raktapitta, treatment of Avarana, prevention of Dhatu Kshaya including Oja Kshaya, and prevention of Agnimandya in general.

Probable mode of action of treatment given

Deepana and Pachana - Chitrakadi Vati mainly of Katu Rasa, Laghu Tikshana Guna, Usna Virya, Katu Vipaka which improve the Jatharagni and removing the Ama Avastha. Premehahara Chikitsa - Mainly to treat the root cause of the disease, we had given internal medication to control the raised blood sugar level. Chandraprabha Vati: It contains Shilajatu which has Kaphhara property. It does Rasayana action also which helps in regenerating the damaged retinal vessels. Some contents of Chandraprabha Vati have a blood glucose lowering effect. It also helps to enhance the action of insulin and also helpful in lowering elevated lipid, associated diabetes. Nisha Amalaki Churna: Main ingredients are Haridra and Amalaki which have antioxidant properties and are mentioned in Prameha Chikitsa. Amalki had vit c which acts as antioxidant, effectively safeguarding retinal cells against oxidative stress. Madhumeha Kusumakar Ras: It contains Shodhit Shilajatu, Yashada Bhasma, Haridra, Amalki, Guduchi, Bilwa Patra Swarasa, Asana, Swarna Bhasma, Rajat Bhasma. It reduces blood and urine sugar effectively due to their Kapha and Meda pachaka action. Punarnavadi Kwath with Gomutra Arka and Triphala Guggulu - Oral administration of Punarnavadi Kwath and Triphala Guggulu contains of both drugs having Shothahara, Pramehanashaka, Rasayana, Mootrala, Chakshushya properties. Cow's urine (Gomutra) also has Katu, Lavana, Tikta, Kasaya, Madhura Rasa, Ushna Virya, Tikshna, Laghu, Ruksha Guna & Kapha Shamaka, Vatanulomaka, Pittanisaraka attributes. Cow urine have Anti-diabetic effect (glucose lowering effect) is might be due to stimulation of beta cells of pancreatic islets or stimulation of glycogenesis. Netramrita - It contain Saptamrit Lauha, Abhrak bhasma, Shatavar, Ashwagandha, Akik Bhasma, Triphala, all contain Tridoshagna Chakshusya and Rasyana properties and help in

DR by disintegrate the pathology of Timira. Shirotalam - It is a type of Sirolepa contain Jatamansi, Amalki, Brahmi. It will reduce the Sanga and Siragranthi (microaneurysm). Sanga and Siragranthi in retinal blood vessels cannot be easily reversed, so Sirotalam which are Srotorodha Harana was an option at this stage. Tarpana - Tarpana with Doorvadi Ghrita has Pittasamana, Raktstambhana and Raktprasadana properties. It used to overcome Retinal haemorrhage under the Urdhvaraktapitta spectrum. It not only arrests bleeding but also strengthens the retinal capillaries, helping reverse and prevent pathogenesis.

Conclusion

Diabetes is the main underlying reason behind Diabetic retinopathy. Restoration of structural and functional integrity in disease of Drushti Patala caused due to Prameha, was the objective of treatment in this case. By adopting Ayurvedic protocols and making changes in Dinacharya and Ahara Vihara, will bring changes not only in the disease condition but also it will upgrade the lifestyle of the person. Here we had adopted Pitta-Kapha Hara Chikitsa, resulting in removing the Sangathva of Rakta Vaha Srotas as it prevents further damage to retinal vessels. Ayurveda treatment principles can help to arrest the progression of the disease. In this patient the subsequent follow-ups while treatment, improvements were noticed though he presented with an advanced stage. Weekly follow-up also taken after treatment up to 2 months. The treatment modalities employed efficacious in controlling Rakta Srava (intraretinal haemorrhages). Promoting resorption, improving visual perception. Madhumehahara properties of the drugs helped to lower the blood glucose level. As a prophylactic treatment a proper screening of patients by Chakshu Visharada's at regular interval with proper intervention of Kriyakalpa, Lifestyle modification, Pathyapathya along with oral medicines at appropriate time will definitely retard the progression of the disease and maintains the retinal function.

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2. Khurana AK, Khurana A, Khurana B. Comprehensive Ophthalmology. 6th ed. New Delhi: Jaypee Brothers Medical Publishers Pvt Ltd; 2015. Chapter 12, Diseases of the Retina. p. 276.

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