E-ISSN:2456-3110

Review Article

Blepharitis

Journal of Ayurveda and Integrated Medical Sciences

2024 Volume 9 Number 4 April
Publisherwww.maharshicharaka.in

Understanding of Krimigranthi w.s.r. to Blepharitis

Basavaling1, Rohan Gajanan B2, Prakruthi G3*
DOI:10.21760/jaims.9.4.31

1 Basavaling, UG Scholar, Sri Paripoorna Sanathana Ayurveda Medical College Hospital and Research Centre Arjunabettahalli, Nelamangala Bangalore Rural, Karnataka, India.

2 Bhagwat Rohan Gajanan, UG Scholar, Sri Paripoorna Sanathana Ayurveda Medical College Hospital and Research Centre Arjunabettahalli, Nelamangala Bangalore Rural, Karnataka, India.

3* Prakruthi G, Associate Professor Hod, Department of Shalakya Tantra, Sri Paripoorna Sanathana Ayurveda Medical College Hospital and Research Centre, Arjunabettahalli Nelamangala Bangalore Rural, Karnataka, India.

Ayurveda deals with Ashtangas (8 branches of ayurveda) and Shalakya tantra is one among them. Acharya Sushruta has explained seventy-six eye diseases with their medical and surgical management in detail. Krimigranthi is one among the nine Sandhigata Roga which can be correlated to blepharitis based on the signs and symptomatology. The signs and symptoms include a swelling in the lid margin, lodging of organism in the junction of the eyelids and eyelashes to produce severe itching in the lids. These organisms can move along the eyelid junction which can penetrate and affect the Shuklamandala. Blepharitis is said to be the most common chronic inflammatory disease of the lid margin which can occur at any age. The disease is usually bilateral and become chronic with recurrence and relapse associated with seborrhea of scalp, trichiasis and ectropion. Krimigranthi is said to be a Kaphaja Vyadhi and the management constitutes Swedana, Bhedana, Pratisarana, Rasakriya Anjana and also Nidanaparivarjana, following Pathya-Apathya. The selection of the appropriate treatment depends on the Yukti of the physician and following the appropriate treatment methodology can be helpful to remove the disease from the root and also it is helpful to reduce the recurrence rate.

Keywords: Sandhigataroga, Krimigranthi, Blepharitis

Corresponding Author How to Cite this Article To Browse
Prakruthi G, Associate Professor Hod, Department of Shalakya Tantra, Sri Paripoorna Sanathana Ayurveda Medical College Hospital and Research Centre, Arjunabettahalli Nelamangala Bangalore Rural, Karnataka, India.
Email: 		Basavaling, Rohan Gajanan B, Prakruthi G, Understanding of Krimigranthi w.s.r. to Blepharitis. J Ayu Int Med Sci. 2024;9(4):196-203.
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Manuscript Received Review Round 1 Review Round 2 Review Round 3 Accepted
2024-02-13 2024-02-23 2024-03-04 2024-03-14 2024-03-18
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© 2024by Basavaling, Rohan Gajanan B, Prakruthi Gand 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

In Ayurveda, the significance of the eyes, referred to as Netra, is emphasized with the saying "Sarvendriyanam Nayanam Pradhanam,"[1] highlighting their importance among all sense organs. Sushruta classified Netra Rogas into 76 types,[2] while Vagbhata enumerated 94 types.[3] Within these classifications, Sandhigata Netra Roga encompasses nine diseases, with Krimigranthi being one of them. Krimigranthi manifests specifically

in the Pakshma-Vartma Sandhi, demonstrating the intricate categorization and understanding of eye ailments in Ayurveda. The disease is said to be a Kaphaja Bhedana Sadhya Vyadhi which arises at the junction of the eyelids and eyelashes. The Lakshanas of Krimigranthi are Kandu, Vartma Shopha and formation of various form of Krimi in Pakshma-Vartmagata Sandhi which can move towards the Shukla Mandala. The Krimis will be of various shapes and size which invade the inner structure of eye. The treatment principle includes Swedana, Pratisarana, Rasakriyanjana with the drugs having Krimihara, Kanduhara, Shothahara Gunas. Blepharitis is a common inflammation of the lid margin which can be exhibited in acute or subacute or chronic forms. The prevalence of blepharitis in the general Indian population is estimated to be around 40% by the surveyed eye care practitioners. The treatment includes mechanical removal of the nits with forceps followed by rubbing of antibiotic ointment on lid margins, anti-inflammatory drugs and also the patient should be advised to refrain from touching or rubbing lids or eyes.

Krimigranthi according to different Acharyas:[4-7]

According to Acharya Sushruta: There will be cyst like swelling produced by Krimis in Vartmana Pakshmana Sandhi - in eye lids and eye lashes, which produces Kandu - itching, developing Krimis in Netrasandhi. It may extend to the junctional place of Vartmamandala and Shukla Mandala. The Krimis will be of various shapes and sizes which can invade the inner structures of eye.

According to Acharya Vagbhata: Krimigranthi refers to the painful cystic swelling caused by pathogenic organisms, accompanied by symptoms such as Puyasrava - pus discharge, Kandu - itching, Arti - burning sensation, and Pakshma Potavan

- skin cracks. These symptoms can even manifest in areas beyond the eyelids, such as the Apanga and Kaninika Sandhi.

According to Acharya Videha: Acharya Videha has described Krimigranthi as a Sannipataja disease which continuously irritates the eye. The pathology includes a Granthi (cystic swelling) is produced due to Pitta and Kapha in Vartma Shukla Sandhi. The heat digests the Granthi to produce various Janthu (Krimi). These Krimis, having very minute legs, move into Vartma and Pakshma and settles there.

According to Acharya Yogaratnakara: Yogaratnakara has followed Sushruta’s version but replaced the word Krimigranthi with Janthugranthi.

Chikitsa of Krimigranthi according to different Acharyas:[8-12]

According to Acharya Sushruta: Krimigranthi is one among the five Bhedhya Vyadhi, following treatment protocol should be advocated.

  • Swedana: Fomentation to the lid margins. A type of Mridu Swedana is effective and it is termed as Lochanochita Sweda (fomentation suitable to the eye - Dalhana).
  • Bhedana: Puncturing of Granthi.
  • Pratisarana: Manashila, Ela, Tagara and Saindhava Lavana mixed with Madhu. Triphala, Tutha, Kasisa, Saindhava. According to Dalhana, Pratisarana Dravyas advised in Anjananamika are useful in Krimigranthi Triphaladi Rasakriya should be used after that.

According to Acharya Vagbhata: Swedana has to be done with Gomaya Churna. Pratisarana should be done with Triphala, Kshoudra, Kasisa, Saindhava.

According to Acharya Indu: Swedana should be done to the effected eye lids by a Pottali prepared with Gomaya.

According to Acharya Arunadatta: Bhedana should be done by Vrihi Mukha.

According to Acharya Yogaratnakara: Triphala, Amruta, Kasisa, Saindhava, Rasanjana, Rasakriya, Pratisarana and Bhedana Chikitsa has to be followed.

Blepharitis:[13] Blepharitis is an eyelid inflammation usually surrounding the lid margin.


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It includes both infectious and non-infectious forms which is an extremely common disease in ophthalmic practice. It may present as acute or subacute or chronic condition and among all chronic is of more incidence and prevalence.

Chronic blepharitis, a frequent source of eye discomfort and irritation, can affect both eyes simultaneously. It's typically categorized into anterior and posterior types, although symptoms often blend between the two.

Chronic anterior blepharitis: It impacts the area surrounding the eyelash bases and can be either staphylococcal or seborrheic in nature. Seborrheic blepharitis often coincides with generalized seborrhea, potentially affecting the scalp, nasolabial folds, behind the ears, and the sternum.

Diagnosing blepharitis relies on both observable signs and reported symptoms. Symptoms alone don't reliably indicate the type of blepharitis and typically arise from disruptions in normal ocular surface function and decreased tear stability. Common symptoms include burning, grittiness, and mild sensitivity to light, often with periods of improvement and worsening. Morning symptoms are typical, though in cases of concurrent dry eye, symptoms may intensify throughout the day.

The signs include - Staphylococcal blepharitis presents with firm scales and crusting primarily concentrated around the eyelash bases. Mild papillary conjunctivitis and persistent conjunctival redness are common. In severe, longstanding cases, scarring, lid margin thickening (tylosis), eyelash misalignment (trichiasis), and whitening (poliosis) may occur. Styes, marginal keratitis, sometimes, phlyctenulosis can arise as secondary complications. Tear film instability and dry eye often accompany this condition. Seborrheic blepharitis is characterized by inflamed and oily eyelid margins with lashes sticking together. Soft scales can be found anywhere along the eyelid margin and lashes.

Treatment:

1. Lid hygiene:

  • Apply a warm compress for several minutes to soften crusts around the eyelash bases.
  • Clean the eyelid margins once or twice daily by gently scrubbing with a cotton bud dipped in
  • a diluted solution of baby shampoo or sodium bicarbonate.
  • Commercially available soap or alcohol impregnated pads for lid scrubs can also be used cautiously to avoid mechanical irritation.

2. Antibiotics:

  • Topical antibiotics like sodium fusidic acid, bacitracin, or chloramphenicol can be used to treat acute folliculitis but are of limited efficacy in chronic cases. After lid hygiene, apply the ointment to the anterior lid margin using a cotton bud or clean finger.
  • Oral azithromycin may be beneficial for controlling ulcerative lid margin disease.

3. Weak topical steroids such as fluorometholone 0.1% can be helpful for severe papillary conjunctivitis, marginal keratitis, and phlyctenular lesions, although repeated courses may be necessary.

4. Tear substitutes are necessary to address associated tear instability and dry eye symptoms.

Chronic posterior blepharitis: It stems from dysfunction of the meibomian glands and alterations in their secretions. Bacterial lipases can lead to the production of free fatty acids, raising the melting point of meibum and hindering its release from the glands. This contributes to eye irritation and potentially fosters the growth of Staphylococcus aureus. Additionally, the loss of tear film phospholipids, which act as surfactants, leads to increased tear evaporation, elevated osmolarity, and an unstable tear film. Symptoms mirror those of anterior blepharitis, while signs include indications of meibomian gland dysfunction, such as abnormal secretion and gland orifice abnormalities.

Treatment:

1. Lid hygiene: Warm compresses and cleaning similar to anterior blepharitis management, with an emphasis on massaging the lid to express accumulated meibum.

2. Systemic tetracyclines serve as the primary treatment, as they can inhibit staphylococcal lipase production at concentrations below the minimum inhibitory level. Few examples are Oxytetracycline, doxycycline, minocycline, and erythromycin.


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Conditions associated with chronic blepharitis include tear film instability, dry eye, chalazion formation, epithelial basement membrane disease, cutaneous conditions (like acne rosacea, seborrheic dermatitis, acne vulgaris), bacterial keratitis, atopic keratoconjunctivitis, and contact lens intolerance.

Discussion

Among the nine diseases of Sandhigata Netra Roga, Krimigranthi occurs specifically in the Pakshma-Vartma Sandhi. This condition is considered as a Kaphaja Bhedana Sadhya Vyadhi, manifesting at the junction of the eyelids and eyelashes. Its symptoms include itching, swelling of the eyelids, and the formation of various types of parasites in the Pakshma-Vartma region, which can migrate towards the Shukla Mandala. These parasites vary in shape and size and can infiltrate the inner structures of the eye. Treatment typically involves Swedana, Pratisarana, Rasakriya Anjanas with Krimihara, Kanduhara and Shothahara Dravyas. Blepharitis, on the other hand, is a common inflammation of the lid margin that can manifest in acute, subacute, or chronic forms. General measures include improvement of health and balanced diet.

The absence of a clear correlation between symptoms and observable signs, coupled with the uncertain etiology and mechanisms, renders the management of the disease challenging. However, Ayurveda not only provides a cure for the disease but also offers treatments that can substantially reduce its recurrence.

The disease Krimigranthi is having similarities with blepharitis w.r.to signs, symptoms and treatment. Krimigranthi exhibits Kandu - itching, Puyasrava - pus discharge, affects Vartma-Pakshma Sandhi - infection at junctional area of eye lid and eye lashes, Granthi - cystic swelling, presence of Krimi - presence of micro-organisms, invades Shuklamandala - Krinshnamandala - affects conjunctiva and sclera causing tear film instability, dry eye and affects cornea causing bacterial keratitis and atopic keratoconjunctivitis. The treatment principle of blepharitis is having same principles like that of Krimigranthi which includes Swedana - hot fomentation or warm compressors which can reduces the itching, pain, swelling, Pratisarana - eye lid scrubbing which helps to moisten and remove the microorganisms, Bhedana

- incision can express the accumulated meibum and correct the capping of meibomian gland which is caused by excessive and abnormal meibomian gland secretion. Application of Rasakriyanjanas can be considered as local application of antibiotic ointments.

Table 1: Comparison between Krimigranthi and Blepharitis

Clinical features
KrimigranthiBlepharitis
§ Kandu
§ Puya srava
§ Affects Vartma-pakshma sandhi
§ Granthi
§ Presence of Krimi
§ Invades shuklamandala – krishnamandala		§ Itching
§ Pus discharge
§ Infection at junctional area of eye lashes and eye lid.
§ Cystic swelling
§ Micro-organisms
§ Affects the conjunctiva, sclera, cornea
Treatment Aspect
KrimigranthiBlepharitis
§ Swedana
§ Pratisarana
§ Bhedana
§ Rasakriyanjana		§ Warm compression
§ Eye lid scrubbing
§ Incision
§ Topical antibiotics

Table 2: Description of Rasa-Panchakas of commonly used drugs in Krimigranthi:[14-18]

DravyaRasaGunaVeeryaVipakaKarmaDoshaghnataRogaghnataPharmacological action
AmalakiAmla Pradhana Pancha rasa (except lavana)Laghu
Ruksha		SheetaMadhuraTridoshahara
Vayahsthapana
Rasayana
Chakshushya
Vrishya		TridoshaharaPrameha
Raktapitta
Netraroga
Kushta
Arshas
Somaroga		Antidiabetic
Anti-Peptic Ulcer
Hypo-lipidemic
Anti-Microbial
VibhitakiKashayaLaghu
Ruksha		UshnaMadhuraKeshya
Chakshushya
Bhedana
Madakari		Kapha-PittaharaJvara
Kasa
Shvasa
Atisara
Ashmari
Chardi
Trishna		Bronchodialator
Antispasmodic
Antiasthmatic
HaritakiPancha
rasa
(except lavana)
Kashaya mainly		Laghu
Ruksha		UshnaMadhuraAnulomana
Rasayana
Prajasthapana
Chakshushya
Lekhana		TridoshaharaShotha
Prameha
Kushta
Vrana
Chardi
Vatarakta		Antibacterial
Antifungal
Antioxidant
Hypolipidemic

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DravyaRasaGunaVeeryaVipakaKarmaDoshaghnataRogaghnataPharmacological action
TuttaKashaya
Madhura
Katu		Laghu
Guru
Ushna		UshnaKatuLekhana
Bhedana
Rasayana
Krimighna
Chakshushya
Balya
Vamaka
Twak-doshahara
Rechana
Garaghna		Kapha pittaharaNetraroga
Krimiroga
Twak dosha
Vrana
Vishadosha		Antimicrobial
KasisaTikta
Amla
Kashaya		Snigdha
Ushna
Guru
Nirmala		UshnaKatu
Amla		Deepaniya
Pachaniya
Rechaniya
Ama samshoshana
Svitraghna
Jantughna
Netrya		Vata
kaphashamaka		Arsha yakrut roga,
Chakshushya
Krimihara
Vatakaphaja roga
Shula roga
Arshas
Agnimandhya
Palita roga
Ashmari
Kandu,
Krimi		Antibacterial
Antifungal
SaindhavaMadhuraLaghu
Naatiushana		AushanaChakshushya
Deepana
Vrishya
Hridya		TridoshaharaShothahara
Vibandhahara
Vrana
Pathya
Avidahi		Antioxidant
AmrutaKashaya
Tikta		Guru
Snigdha		UshnaMadhuraMedhya
Deepaniya
Grahi
Medohara
Rasayana
Raktashodhana
Balya		TridoshaharaJwaraghna
Chakshushya
Krimihara
Prameha
Shvasa
Pandu
Kamala
Kasa		Anti-rheumatic
Anti-inflammatory
Antioxidant
Antiallergic.
GomutraMadhuraUshna
Tikshna
Aruksha		UshnaKatuDeepaniya
Pachaniya
Lekhaniya
Anulomana		TridoshaharaKushta
Krimi
Kandu
Udara		Antioxidant
Antimicrobial
Immunomodulating
Wound healing
Antihelmenthic
DaruharidraTikta
Kashaya		Laghu
Ruksha		UshnaKatuDeepana
Pachana
Grahi
Yakrututtejaka		PittakaphaharaNetra rogahara
Karna rogahara
Kushtaghna
Pramehahara
Varnya		Antiseptic
Antipyretic
Antineoplastic
Laxative
Bitter tonic

Discussion on the commonly used drugs in Krimigranthi:

The table provided outlines the drugs described by various acharyas for the treatment of the disease Krimigranthi. These medications possess beneficial properties such as Krimihara, Lekhana, Kandughna, Chakshushya, and Shothahara, along with Tridoshashamaka effects. They exhibit pharmacological actions including antimicrobial, antioxidant, and anti-inflammatory properties, making them effective in combating the disease. To authenticate the efficacy of these drugs, we administered the treatment protocol recommended by our acharyas to a patient who visited our OPD, and the details are provided below.

A Case Report

A 40-year-old female patient visited the OPD of SPSAMC, H&RC, complaining of itching on both eyelid margins for the past 15 days, accompanied by sensitivity to bright light, redness, and watering of the eyes for the last 10 days. These symptoms significantly hindered her daily activities. There were no significant findings in her past or family medical history. Upon ocular examination, her visual acuity was normal, but swelling was observed on the eyelid margins, accompanied by scales and conjunctival congestion. The patient was prescribed a course of Kriyakalpa treatment and oral medications. This treatment led to a significant reduction in all symptoms, and a follow-up after one month revealed the absence of any eye-related symptoms. The Kriyakalpa treatment included Darvi Seka and Triphala Rasakriyanjana, supplemented by oral medications such as Chitrakadi Vati and Tab. Septillin.

Scope for further research: Further research is warranted to validate the efficacy of this simple and cost-effective treatment methodology. Conducting research on a larger sample size would enable drawing more conclusive findings regarding its effectiveness.

Conclusion

Exploring the relationship between Krimigranthi and blepharitis provides valuable insights into both conditions, facilitating a deeper understanding of their similarities and differences. This exploration can inform more effective diagnosis


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and treatment strategies by identifying commonalities and distinctions between the two ailments. Managing blepharitis presents significant challenges due to its recurrent nature, necessitating the identification and addressing of specific root causes for optimal outcomes. Ayurvedic treatment offers a holistic approach to managing such conditions, with physicians analyzing both the Dosha Avastha (constitution) and Rogi Avastha (patient's condition) to tailor treatment plans accordingly. By considering the individual characteristics of each patient and their unique imbalances, Ayurveda aims to achieve comprehensive healing and long-term relief from symptoms, thereby enhancing the overall quality of life.

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