Introduction: Retinal pigment epithelial detachments (PEDs) are characterized by separation between the RPE and the inner most aspect of Bruch's membrane. The space created by this separation is occupied by blood, serous exudate, drusenoid material, fibro vascular tissue or a combination. The symptoms of RPE detachment can be considered under Drustigata Rogas mentioned by Sushrutha. This is a case study of a 73year old male patient who was diagnosed with PED with Subretinal fluid in Right eye since 8 months. Materials and methods: The subject who approached Shalakya Tantra OPD of Government Ayurveda Medical College Bengaluru with symptoms of diminished vision for both near and far objects in right eye associated with flashes in front of eye since 8 months, patient underwent two courses of inpatient management, which included Ayurvedic oral medicines, and external therapies for the eyes (Kriyakalpa) and head. Results: Signs of improvement in visual acuity and optical coherence tomography (OCT) were observed at the end of both treatments. Conclusion: The main aim of management was to preserve and give a better quality of vision for the patient. The results indicate the potential of Ayurvedic treatments to manage and maintain vision in REP detachment

Dr. Rathi S

Dr. Soundarya N.

Dr. Vivek Gowda S

English

Journal of Ayurveda and Integrated Medical Sciences (JAIMS)

                                                     CASE REPORT Mar-Apr 2021  Journal of Ayurveda and Integrated Medical Sciences | Mar - Apr 2021 | Vol. 6 | Issue 2 265  An Ayurvedic management of Retinal Pigment Epithelial Detachment - A Case Study Dr. Soundarya N1, Dr. Vivek Gowda S2,  Dr. Rathi S3 1,2Post Graduate Scholar, 3Associate Professor, Department of PG Studies in Shalakya Tantra, Government Ayurveda Medical College, Bengaluru, Karnataka, INDIA.                        INTRODUCTION Retinal pigment epithelial detachments (PEDs) are characterized by separation between the RPE and the inner most aspect of Bruch's membrane. The space created by this separation is occupied by blood, serous exudate, drusenoid material, fibrovascular tissue or a combination.[1] The   classification   of   PEDs  in  AMD  can  be  divided  Address for correspondence:  Dr. Soundarya N. Post Graduate Scholar, Department of PG Studies in Shalakya Tantra, Government Ayurveda Medical College, Bengaluru, Karnataka, INDIA. E-mail: soundaryareddy13@gmail.com  Submission Date: 08/03/2021 Accepted Date: 11/04/2021 Access this article online Quick Response Code Website: www.jaims.in  Published by Maharshi Charaka Ayurveda Organization, Vijayapur, Karnataka (Regd) under the license CC-by-NC-SA based on their contents. Categories include drusenoid, serous, vascularized, or mixed components. Drusenoid PEDs are seen mostly in non-neovascular or dry AMD. Serous PEDs are typically associated with the neovascular or wet form of AMD, but their natural history is relatively more favorable. Vascularized PEDs associated with Type 1 (sub-RPE) neovascularization and wet AMD, in contrast, have a greater risk of vision loss. In eyes with AMD, it is not uncommon to see more than one type of PED.[2]  Proper anatomical apposition between the retina, the RPE, and Bruch’s membrane is crucial for nutritional support of the photoreceptors, retinol metabolism, phagocytosis of the photoreceptors outer segments, and formation of the outer blood-retinal barrier. The forces maintaining normal adhesion between the RPE and Bruch’s membrane are not well understood. Under normal conditions, there exists a net bulk flow of fluid towards the choroid from the vitreous, with its generation dependent upon hydrostatic and osmotic A B S T R A C T  Introduction: Retinal pigment epithelial detachments (PEDs) are characterized by separation between the RPE and the inner most aspect of Bruch's membrane. The space created by this separation is occupied by blood, serous exudate, drusenoid material, fibro vascular tissue or a combination. The symptoms of RPE detachment can be considered under Drustigata Rogas mentioned by Sushrutha. This is a case study of a 73year old male patient who was diagnosed with PED with Subretinal fluid in Right eye since 8 months. Materials and methods: The subject who approached Shalakya Tantra OPD of Government Ayurveda Medical College Bengaluru with symptoms of diminished vision for both near and far objects in right eye associated with flashes in front of eye since 8 months, patient underwent two courses of inpatient management, which included Ayurvedic oral medicines, and external therapies for the eyes (Kriyakalpa) and head. Results: Signs of improvement in visual acuity and optical coherence tomography (OCT) were observed at the end of both treatments. Conclusion: The main aim of management was to preserve and give a better quality of vision for the patient. The results indicate the potential of Ayurvedic treatments to manage and maintain vision in REP detachment. Key words: RPE detachment, Kriyakalpa, Drishtigata Roga, Case Study. Dr. Soundarya N. et al. An Ayurvedic management of Retinal Pigment Epithelial Detachment ISSN: 2456-3110                                                            CASE REPORT Mar-Apr 2021  Journal of Ayurveda and Integrated Medical Sciences | Mar - Apr 2021 | Vol. 6 | Issue 2 266  forces within the two bodies. Both the RPE and the retina produce resistance to this fluid flow. The RPE has greater resistance due to its limited hydraulic conductivity, subsequently; a vector force is generated pushing it against Bruch’s membrane.[3] The attachment of the RPE basement membrane to Bruch’s membrane is possibly supplemented by regions of hemidesmosomes containing fine filaments of laminin, proteoglycans and collagen types IV and V.[4] Age-related deposition of lipids, such as cholesterol esters, triglycerides, and fatty acids in Bruch's membrane may change its permeability altering retinochoroidal flow. Fluid may accumulate in the sub- RPE space, unable to pass through Bruch membrane, resulting in RPE elevation. Currently no treatment for serous PED is proven effective, nor are recommendations for treatment guidelines established. Several strategies, however, have being used to treat vascularized PEDs, including laser photocoagulation, photodynamic therapy (PDT), intravitreal steroids and anti-VEGF therapy. The results from the VIP trial indicated that PDT could significantly reduce the risk of moderate and severe vision loss among patients with subfoveal occult CNV.[5]  Another treatment modality, described recently by Costa et al as a pilot trial, is photothrombosis at the neovascular ingrowth site using ICG visualization followed by laser application to feeder vessels. Occlusion of the feeder vessel with cessation of leakage, restoration of macular architecture and visual improvement were induced in two patients with CNV associated with PEDs.[6]  PED may be considered as Kacha (diminished vision), a Drishtigata Roga (disease of vision) according to Ayurveda, due to their common symptom of profound vision loss. In Kacha, the patient sees objects above but not below, objects are perceived as though covered by a thin cloth, and vision gradually diminishes. Management is repeated administration of Sneha (drinking of fats), Asra-visravana (bloodletting), Reka (purgation), Nasya (nasal medication), Anjana (collyrium), Murdha-Basti (retention of oil over the head), Basti Kriya (enema), Tarpana (retention of fat over the eye), Lepa (application of paste), and Seka (pouring of liquids over the eye).[7] OBJECTIVES  1. To understand the pathophysiology of Retinal pigmental layer detachment. 2. To find a better Ayurvedic approach in PED. CASE REPORT Basic information of the patient Age: 73 years  Gender: Male Religion: Hindu Occupation: Retired employee Socioeconomic status: Middle class Chief complaints A 73-year-old male patient complaining of reduced vision in right eye associated with flashes in front of eyes visited Shalakya Tantra OPD, GAMC Bangalore on January 10/2020. He was systemically reviewed and eye examination was done. His reports suggested right eye PED with Sub retinal fluid, left eye being normal. He has undergone intravitreal steroidal therapy for the right eye 3 times, but did not find any improvement in the vision, hence approached GAMC for further management. Unaided distant visual acuity (DVA) was counting fingers (CF +ve) OD and 6/24 in his left eye (OS); and his near vision was N60 OD and N6 OS. Anterior segment examination revealed normal findings in both eyes (OU). Pupillary examination revealed an afferent pupillary defect OD and normal reflexes OS. Fundus examination OD revealed drusens Optical coherence tomography (OCT) scanning OD showed PED with sub retinal fluid (Figure 1a). History of Past Illness: K/C/O Mild pulmonary Artery Hypertension, Hyperlipedimia Dr. Soundarya N. et al. An Ayurvedic management of Retinal Pigment Epithelial Detachment ISSN: 2456-3110                                                            CASE REPORT Mar-Apr 2021  Journal of Ayurveda and Integrated Medical Sciences | Mar - Apr 2021 | Vol. 6 | Issue 2 267  Personal history Aharaja: Diet predominantly of Madhura and Snigdha Ahara. Viharaja: Day sleep for 1 to 2 hours regularly.  Treatment history Intravitreal steroidal therapy - 3 sitting for right eye. Examination ▪ Asta Sthana Pareeksha 1.  Nadi: Prakruta, 78/min 2.  Mutra: Prakruta, 4 to 5 times/day, once at night 3.  Mala: constipated 4.  Jihwa: Lipta 5.  Shabda: Prakruta  6. Sparsha: Prakruta 7.  Druk: Prakruta  8. Akruti: Kaphavatala  ▪ Vitals were normal.  ▪ Respiratory system, Gastro intestinal system, Central nervous system and musculoskeletal system have shown no abnormality. Treatment The patient underwent 2 courses of treatment. One was from January 11th, 2021 to January 17th, 2021, and the other was from February 11th 2021 to February 17th 2021. He was administered oral medicines such as Kvatha (herbal decoction), Gutika (herbal tablets) and Ghrta (medicated ghee) (Table 1), and external therapies for both the eyes (Netra Kriya Kalpa) and the head (Table 2). As he was above 70 years, Panchakarma (bio-purification) was not attempted.  Table 1: Oral medication advised from 10/01/2021 to 25/02/2021 SN Medicine Anupana Dosage 1. Pathya Punarnavadi Kashaya With luke warm water 20ml BD after food 2. Sapthamrutha Loha with honey 2 tab at night  3. Triphala Gritha With warm milk 10 ml At bed time Table 2: External therapy advised from 10/01/2021 to 17/01/2021 SN Therapy Medicine used 1. Aschothana Freshly extracted Tulasi Swarasa mixed with Madhu [2 drop in each eye]  2. Bidalaka Triphala Choorna, Laksha Choorna mixed with luke warm Triphala Kashya 3. Puspabandhan Rose petals  4. Shiroveshtana Laksha Choorna and Vasa Choorna [30g of powder was made into a paste by mixing with the decoction. A Cora cloth was immersed in 100ml of the decoction and the paste was smeared over the cloth. The cloth was applied over the forehead from one ear to the other and tied over the head] 5. Pindi With Vasa Lakshadi Choorna mixed with luke warm Triphala Kashya 6. Takradhara With Laksha, Vasa, Musta and Amalaki  Kashaya mixed with buttermilk. RESULT After 1st course of management Distant VA OD after 1st course of treatment was improved from CF+ to 6/60, left eye remained same 6/24 OS. Near VA OD showed good improvement from N60 to N24.  After 2nd course of management Distant VA OD 6/24, OS 6/12 Near VA OD N12, OS N6 OCT findings showed reduction in sub retinal fluid and reattachment of the RPE layer. [Figure 1, 2, 3 and 4] Dr. Soundarya N. et al. An Ayurvedic management of Retinal Pigment Epithelial Detachment ISSN: 2456-3110                                                            CASE REPORT Mar-Apr 2021  Journal of Ayurveda and Integrated Medical Sciences | Mar - Apr 2021 | Vol. 6 | Issue 2 268  Figure 1: OCT Showing PED with SRF OD - Before Treatment  Figure 2: After first course of treatment   Figure 3: Report suggesting improvement after therapy  Figure 4: OCT - OD Showing complete reduction SRF and reattachment of RPE Layer  Dr. Soundarya N. et al. An Ayurvedic management of Retinal Pigment Epithelial Detachment ISSN: 2456-3110                                                            CASE REPORT Mar-Apr 2021  Journal of Ayurveda and Integrated Medical Sciences | Mar - Apr 2021 | Vol. 6 | Issue 2 269  DISCUSSION Local therapeutics was employed in this case as the patient was old for Pancakarma treatments.  Bidalaka created a counter-pressure gradient that significantly pushes the retina to its original position. Ascyotana enabled the absorption of the medicines to reach the target tissues by such parameters as height and temperature of the medicines and reduce sub retinal fluid by Kaphahara action. Siroveshtana enabled absorption of the essential elements through the skin and hair follicles, thus bypassing barriers and reaching the target tissues. Laksha, one of the main ingredients in the medicines for head treatments, helped the retina restore itself to the rest of the eye by its properties of Pitta-Kapha Nasaka (diminishing Pitta and Kapha), Sandhaniya (binding), Balya (strengthening), and Ropana (healing). Pathya Punarnavadi Kashaya normalized Vata Dosha in this case by enhancing the expulsion of the waste and movement of Doshas out of the body and eye.[7] CONCLUSION  The main challenge, in this case, was restoring vision and reattaching the retina. It was partially successful in both parameters, as vision marginally improved and the retina showed signs of reattachment. Results were a concerted effort brought about by the combined effect of both oral medicines and external therapies. Repeated courses of treatment may aid to further reattach the retina and give back some eyesight to the patient. The results may be validated and analyzed by large-scale studies and trials.  REFERENCES 1. American Academy of Ophthalmology. Pigment epithelial detachment. https://www.aao.org/image/pigment-epithelial-detachment-2 Accessed July 05, 2019. 2. Mrejen, S. (2013). Multimodal imaging of pigment epithelial detachment: a guide to evaluation. Retina, 33(9), 1735-1762. 3. Kirchhof, B., & Ryan, S. J. (1993). Differential permeance of retina and retinal pigment epithelium to water implications for retinal adhesion. International ophthalmology, 17(1), 19-22. 4. Marshall, G. E., Konstas, A. G., Reid, G. G., Edwards, J. G., & Lee, W. R. (1994). Collagens in the aged human macula. Graefe's archive for clinical and experimental ophthalmology, 232(3), 133-140. 5. Arnold, J., Barbezetto, I., Birngruber, R., Bressler, N. M., Bressler, S. B., Donati, G., & Kaiser, P. K. (2001). Verteporfin therapy of subfoveal choroidal neovascularization in age-related macular degeneration: two-year results of a randomized clinical trial including lesions with occult with no classic choroidal neovascularization-verteporfin in photodynamic therapy report 2. American journal of ophthalmology, 131(5), 541-560. 6. Costa, R. A., Rocha, K. M., Calucci, D., Cardillo, J. A., & Farah, M. E. (2003). Neovascular in growth site photothrombosis in choroidal neovascularization associated with retinal pigment epithelial detachment. Graefe's archive for clinical and experimental ophthalmology, 241(3), 245-250. 7. Murthy KRS, Ashtanga Hrudaya of Vagbhata: Text, English Translation, Notes, Appendices, and Index, Vol. I, Krishnadas Academy, Varanasi, 1999;p.201.    *******************************  How to cite this article: Dr. Soundarya N, Dr. Vivek Gowda S, Dr. Rathi S. An Ayurvedic management of Retinal Pigment Epithelial Detachment - A Case Study. J Ayurveda Integr Med Sci 2021;2:265-269.  Source of Support: Nil, Conflict of Interest: None declared. Copyright © 2021 The Author(s); Published by Maharshi Charaka Ayurveda Organization, Vijayapur (Regd). This is an open-access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.  

An Ayurvedic management of Retinal Pigment Epithelial Detachment - A Case Study

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An Ayurvedic management of Retinal Pigment Epithelial Detachment - A Case Study

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