Introduction: Sushkakshipaka is one among the Sarvagata, Sadhya Netrarogas described in in classical Ayurveda texts. A feature of Shushkakshipaka includes hard and dry eye lids, found drooping; blurred vision and difficulty to open the eyes with irritation and foreign body sensation. The Lakshanas of Shushkakshipaka can be equated with the signs and symptoms of Dry Eye Syndrome. Dry eye is a multifactorial ocular surface disease characterized by symptoms of discomfort, irritation, and visual disturbance. Here the patient presenting with signs and symptoms of dry eye disease was treated according to the treatment principles of Shushkakshipaka as explained in Ayurvedic classics. Erandamoola Kheera Seka and Shatavari Ghrita was selected for the treatment and the same has been presented in the article. Materials and Methods: The subject who approached Shalakya Tantra OPD of Sri Jayachamarajendra Institute of Indian Medicine Hospital, Bengaluru, with signs and symptoms of dry eye disease was thoroughly examined and systematically reviewed. Treatment was planned based on the Chikitsasutra of Shushkakshipaka. Result: The patient showed considerable improvement subjectively and objectively. Improvement in Schirmer’s reading, visual acuity improvement was observed in both eyes. Conclusion: The maintenance of stability of tear film is the main challenge in this pandemic time due to the increased screen time. This can be achieved up to an extend by proper administration of treatment techniques described in classical Ayurveda texts along with Pathyasevana

Nirmal Krishnan R

S M Pasha

Swarna Ranjita Bhat

English

Journal of Ayurveda and Integrated Medical Sciences (JAIMS)

                                                     CASE REPORT          September 2022  Journal of Ayurveda and Integrated Medical Sciences | September 2022 | Vol. 7 | Issue 8 181  An Ayurvedic approach to the management of Shushkakshipaka w.s.r. to Dry Eye Syndrome - A Case Report Nirmal Krishnan R1, Swarna Ranjita Bhat2, S M Pasha3 1,2Post Graduate Scholar, Department of Shalakya Tantra, Government Ayurveda Medical College, Bengaluru, Karnataka, India. 3Associate Professor and HOD, P.G. Department of Shalakya Tantra, Government Ayurveda Medical College, Bengaluru, Karnataka, India.                       INTRODUCTION Sushkakshipaka is one among the Sarvagata, Sadhya Netrarogas described in in classical Ayurveda texts. Shushkakshipaka is Vataja according to Sushruta[1] and Vata-Pittaja according to Vagbhata.[2] Features of Shushkakshipaka includes hard and dry eye lids, found drooping; blurred vision and difficulty to open the eyes with    irritation    and   foreign   body   sensation.   The Address for correspondence:  Dr. Nirmal Krishnan R Post Graduate Scholar, Department of Shalakya Tantra, Government Ayurveda Medical College, Bengaluru, Karnataka, India. E-mail: drnirmalkr94@gmail.com  Submission Date: 15/07/2022 Accepted Date: 21/08/2022 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 Lakshanas of Shushkakshipaka can be equated with the signs and symptoms of Dry Eye Syndrome. Dry eye is a multifactorial ocular surface disease characterized by symptoms of discomfort, irritation, and visual disturbance. The climate of tropical India and globalization along with the sprout of millions of IT professionals are making Dry Eye Syndrome, a fast-growing disease, as all these leads to increased tear evaporation (due to dry wind, air conditioning, decreased blink reflex etc.) along with other causes like aqueous tear deficiency, mucin deficiency, lipid deficiency, impaired lid function, irregular corneal surface etc.  During this pandemic period, the digital screen time has increased drastically due to the online classes, work from home etc. that affect the tear film stability and augments the occurrence of dry eye syndrome in young adults and children. The prevalence of DES in India is higher than the global prevalence and ranges from 18.4% to 54.3%. To explore effective solution in A B S T R A C T  Introduction: Sushkakshipaka is one among the Sarvagata, Sadhya Netrarogas described in in classical Ayurveda texts. A feature of Shushkakshipaka includes hard and dry eye lids, found drooping; blurred vision and difficulty to open the eyes with irritation and foreign body sensation. The Lakshanas of Shushkakshipaka can be equated with the signs and symptoms of Dry Eye Syndrome. Dry eye is a multifactorial ocular surface disease characterized by symptoms of discomfort, irritation, and visual disturbance. Here the patient presenting with signs and symptoms of dry eye disease was treated according to the treatment principles of Shushkakshipaka as explained in Ayurvedic classics. Erandamoola Kheera Seka and Shatavari Ghrita was selected for the treatment and the same has been presented in the article. Materials and Methods: The subject who approached Shalakya Tantra OPD of Sri Jayachamarajendra Institute of Indian Medicine Hospital, Bengaluru, with signs and symptoms of dry eye disease was thoroughly examined and systematically reviewed. Treatment was planned based on the Chikitsasutra of Shushkakshipaka. Result: The patient showed considerable improvement subjectively and objectively. Improvement in Schirmer’s reading, visual acuity improvement was observed in both eyes. Conclusion: The maintenance of stability of tear film is the main challenge in this pandemic time due to the increased screen time. This can be achieved up to an extend by proper administration of treatment techniques described in classical Ayurveda texts along with Pathyasevana. Key words: Shushkakshipaka, Erandamoola kheera, Seka, Anutaila, Case Report   Nirmal Krishnan R. et al. Management of Shushkakshipaka w.s.r. to Dry Eye Syndrome ISSN: 2456-3110                                                               CASE REPORT September 2022  Journal of Ayurveda and Integrated Medical Sciences | September 2022 | Vol. 7 | Issue 8 182  Ayurveda is the need of the hour as there is no complete cure for Dry eyes in contemporary medicines at present. Some of the treatment modalities which have been tried with variable results include supplementation with tear substitutes, topical cyclosporine, mucolytic, topical retinoid, preservation of existing tears etc. along with correction of lid abnormalities, which are not long lasting and thus long-term usage is recommended. Ayurveda has described safe and cost-effective treatment for Shushkakshipaka with oral medications and topical therapies (Kriyakalpa). A case of Shushkakshipaka treated with Ayurvedic management is recorded here. CASE REPORT Basic information of the patient Age: 35 years Sex: Male Religion: Hindu Occupation: IT Professional Chief complaints  Patient consulted Shalakya Tantra OPD of Sri Jayachamarajendra Institute of Indian Medicine Hospital, Bangalore on 27/01/2022 with the complaints of irritation, foreign body sensation and dryness in both eyes with burning sensation which was leading to slight visual disturbance.  History of present illness  The subject was apparently normal a year back. He gradually started experiencing foreign body sensation in both eyes in the past 1 year, dryness in both eyes in the past 2 months, itching, burning sensation, pricking pain and painful lid occasionally associated with slight visual disturbance. For these complaints he approached an ophthalmologist where he was diagnosed as having dry eye disease. He was prescribed with artificial tear drops. The symptoms get relieved by putting drops but reappears whenever stops. During the lockdown period when he started working from home the symptoms get aggravated. With all these complaints he approached Shalakya Tantra OPD for Ayurvedic management. History of past illness No past history of any systemic diseases like Hypertension, Diabetes, Hyperthyroidism and RA. No surgical history. Family History: Nothing significant. Personal history Appetite: Good Sleep: disturbed  Bowel: once a day. Micturition: 4-5 times a day Habits: None Ashta Sthana Pareeksha Nadi: 74/min Mala: Prakrutha Mutra: 4-5 times a day Jihwa: Aliptha Shabdha: Prakrutha Sparsha: Prakrutha Drik: Shushkatha Akriti: Krisha Vitals Pulse: 74/min Respiratory rate: 16/min Temp: 98.4°F Systemic Examination: All systemic examination was within normal limits. Ophthalmic Examination: findings are explained in Table No. 1. Table 1: Ophthalmic Examination Ocular structures Right eye Left eye Adnexa  No abnormalities No abnormalities Conjunctiva Congested Congested Nirmal Krishnan R. et al. Management of Shushkakshipaka w.s.r. to Dry Eye Syndrome ISSN: 2456-3110                                                               CASE REPORT September 2022  Journal of Ayurveda and Integrated Medical Sciences | September 2022 | Vol. 7 | Issue 8 183  Sclera No abnormalities No abnormalities Cornea Clear Clear Anterior chamber Within normal limit Within Normal limit Pupil 3mm, Round, regular, reactive to light 3mm, Round, regular, reactive to light Lens Phakic Phakic IOP 12mm of Hg 14 mm of Hg Diagnostic Tests / Assessment Criteria Subjective parameters: Self formulated scale was considered. Assessed parameters before the treatment, after the treatment and during follow up are explained in Table No. 3. Objective parameters 1. Schirmers I Test. 2. Tear film breakup time. 3. Visual acuity (Distant Vision and Near Vision) All these parameters assessed before treatment and after treatment and also during follow up are explained in Table No. 4 Treatment Given Treatment was planned accordingly and given Sadyovirechana and Sthanika Shodhana followed by Erandamoola Ksheeraseka in 2 sittings with a gap of 14 days in between along with Internal administration of Shatavari Ghrita. Treatment given is described in Table No. 2.  Table 2: Treatment given Treatment given Medicine Dosage Duration Time Snehavirechana Gandharvahasta Eranda Taila 30 ml 1 day Early morning Nasya Anu Taila 8 drops (In each nostril) 7 days Morning in empty stomach Ksheeraseka Erandamoola Ksheera Quantity sufficient 2 sittings of 7 days with a gap of 14 days Morning Shamana Snehapana Shatavari Ghrita 10 g b.d 28 days Morning and evening after food Patient was assessed after first sitting of Ksheeraseka. After the completion of 2nd sitting, follow-up was on 15th day. Readings were taken after assessing the patient on follow up. RESULT The study showed marked improvement in signs and symptoms of the patient after the treatment as shown in the table no. 3 and 4. The improvement was maintained at the time of follow up. Table 3: Effect of treatment on Subjective Parameters. Subjective Parameters Before treatment (BT) After First sitting of Treatment (AT1) After Second sitting of Treatment (AT2) During Follow Up (FU) Foreign body sensation Severe(+++) Moderate(++) Mild(+) Absent(-) Pricking pain Mild(+) Mild(+) Absent(-) Absent(-) Dryness in lid and eye Moderate(++) Mild (+) Absent(-) Absent(-) Painful lid and eye Mild(+) Absent(-) Absent(-) Absent(-) Burning sensation Severe(+++) Moderate(++) Mild(+) Absent(-) Photophobia Moderate(++) Mild(+) Absent(-) Absent(-) Nirmal Krishnan R. et al. Management of Shushkakshipaka w.s.r. to Dry Eye Syndrome ISSN: 2456-3110                                                               CASE REPORT September 2022  Journal of Ayurveda and Integrated Medical Sciences | September 2022 | Vol. 7 | Issue 8 184  Congestion Mild(+) Absent(-) Absent(-) Absent(-) BT - Before treatment, AT1 - After First sitting of Treatment, AT2 - After Second sitting of Treatment, FU - During Follow Up Table 4: Effect of treatment on Objective Parameters. Objective Parameters Before treatment (BT) After First sitting of Treatment (AT1) After Second sitting of Treatment (AT2) During Follow Up (FU) Schirmer’s Test RE 4mm 8mm 13mm 12mm LE 3mm 7mm 12mm 11mm TBUT RE 5sec 10sec 12sec 12sec LE 2sec 8sec 10sec 10sec Visual Acuity DV RE 6/18 6/18 6/9 6/9 LE 6/9 6/9 6/6P 6/6 BE 6/9 6/9 6/6 6/6 NV RE N8 N6 N6 N6 LE N6 N6 N6 N6 BE N6 N6 N6 N6 DISCUSSION Vata and Pitta along with Raktha are the factors which get vitiated in Shushkakshipaka. The Vata, Pitta, Vridhis indirectly leads to Kapha Kshaya. Decrease of Snigdha Guna and increase of Ruksha Guna initiates the pathology. Ruksha, Laghu, Khara, Sukshma Gunas of Vata and Ushna, Laghu, Tikshna Gunas of Pitta increases and Kapha Kshaya sets in which leads to decreased Netraposhana. The symptoms of Shushkakshipaka are foreign body sensation, pricking pain, burning sensation, dryness, and photophobia. Ksheeraseka described as one of the treatment techniques for Shushkakshipaka. In Gadanigraha Erandamoola Siddha Ksheerapaka Seka is mentioned which is indicated in Vataja Netrarogas.[3] Here the above formulation was selected for Seka along with Shatavari Ghrita internally which is described in Bhaishjyaratnavali. Before the Sthanika Chikitsa systemic and local Shodhana administrated. Sneha Virechana with Gandharvahastha Eranda Taila and Nasya with Anutaila carried out which cleanses the macro and micro channels of the body and imparts Snigdhaguna.    Among the treatment modalities told in the classics for Shushkakshipaka, Ksheeraseka and Snehapana are known to increase the stability of tear film and give relief from the symptoms of Shushkakshipaka. It is the Virya, Karma and Prabhava of the drugs which acts, when comes in to contact with the Skin of the eyelids (Netra Vartma), Netra Sandhi and Siras of Netra. By these quality of the drugs Pachana and Shamana of Netra Gata Dosha can be attained, as Seka is mainly indicated in Amavastha of Netra Rogas. By considering it as effective drug delivery format. As this formulation can successfully cross the barriers present in eye for drug absorption by its amphiphilic nature. It nourishes ocular and periocular structures, gives nutrition directly to the target organ. Eranda having the property of Madhura-Katu-Kashaya Rasa, Snigdha- Tikshna- Sukshma Gunas, Ushna Veerya and Shulahara-Shothahara-Vedanasthapana Karma. It alleviates Vatadosha. Due to the Sukshmaguna the drug acts though the minute channels of the skin and conjunctiva. Due to the Snigdhaguna reduces the dryness of the ocular surface. Shoolahara property of Eranda may help to defeat the pain in Shushkakshipaka.[4]  Goksheera (cow’s milk) have properties like Madhura Rasa, Guru Snigdha Guna, Sheeta Veerya, Madhura Vipaka, Chakshushya and Rasayana. By these properties it is able to cure Vata and Pitta and thus reduces the symptoms, yields stability of the tear film.  Nirmal Krishnan R. et al. Management of Shushkakshipaka w.s.r. to Dry Eye Syndrome ISSN: 2456-3110                                                               CASE REPORT September 2022  Journal of Ayurveda and Integrated Medical Sciences | September 2022 | Vol. 7 | Issue 8 185  The ingredients are Shatavari, Ghrita and Ksheera, all of them has Madhura Rasa, Guru Snigdha Gunas, Sheeta Virya, Madhura Vipaka, Vata Pittahara, Chakshushya, Jeevaniya and Rasayana properties. Shatavari has Anti-inflammatory, Antibiotic, Anti haemorrhagic, Anti-oxidant and immune-modulator property. Ghrita contains Vitamin A, Vitamin E and β carotene which are anti- oxidants and are helpful in reducing ketone bodies and prevents the oxidative injury to the body. Mainly Vitamin A keeps the epithelial tissue of the body intact, keeps the outer layer of the eyeball moist.[5]  The nourishing property and Chakshushya Guna of Shatavari, Ghrita and Ksheera helps in relieving the Vata Prakopaka symptoms like dryness, pricking pain etc. CONCLUSION Subjective and objective parameters is found to be improved. Hence the treatment helps in maintaining the integrity of Aqueous and lipid layer of Tear Film. Erandamoola Ksheerapaka Seka is mentioned for Vata-Paittika Netra Roga and found to be beneficial in reducing signs and symptoms of Shushkakshipaka during treatment. Shatavari Ghrita having Vata-Pittahara properties and Chakshushya Rasayana Karma shown significant result in the relieving the symptoms of Shushkakshipaka by enhancing the tear film integrity and rejuvenating the ocular surface tissue. Systemic and local Shodhana procedures before the local therapies augmented the action of drugs by opening the minute channels and increased micro circulation in the ocular area. Well organized Ayurvedic management is effective in the management of dry eye syndrome and provides sustainable results.   REFERENCES 1. Kaviraj Ambikadatta Shastri. Susrutha samhita of Maharshi Susrutha edited with Ayurveda Tattva Sandipika hindi commentary, scientific analysis notes. Reprint-edition 2015.Varanasi: Choukambha Orientalia; part 2 (uttara tantra), p.39.  2. Prof.K.R.Srikantha Murthy, Vagbhata’s Ashtanga Hrdayam, Vol.III, Chaukamba Krishnadas Academy, Varanasi, Reprint-sixth edition,2015.p140 3. Tripathi Shri Indradeva, Gadanigraha, Vol.III edited Pandey Sri Ganga sahaya Chaukhambha Sanskrit Sanshthan, 2011.p98 4. Prof.D.Shanth Kumar Lucas, Dravyaguna Vijnana, Vol.II, Chaukhamba Vishwabharati, Varanasi, Reprint-2012,p387 5. Alok, S., Jain, S. K., Verma, A., Kumar, M., Mahor, A., & Sabharwal, M. (2013). Plant profile, phytochemistry and pharmacology of Asparagus racemosus (Shatavari): A review. Asian Pacific Journal of Tropical Disease, 3(3), 242–251. https://doi.org/10.1016/S2222-1808(13)60049-3    *******************************  How to cite this article: Nirmal Krishnan R, Swarna Ranjita Bhat, S M Pasha. An Ayurvedic approach to the management of Shushkakshipaka w.s.r. to Dry Eye Syndrome - A Case Report. J Ayurveda Integr Med Sci 2022;8:181-185.  Source of Support: Nil, Conflict of Interest: None declared. Copyright © 2022 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 (https://creativecommons.org/licenses/by-nc-sa/4.0), which permits unrestricted use, distribution, and perform the work and make derivative works based on it only for non-commercial purposes, provided the original work is properly cited.   

An Ayurvedic approach to the management of Shushkakshipaka w.s.r. to Dry Eye Syndrome - A Case Report

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An Ayurvedic approach to the management of Shushkakshipaka w.s.r. to Dry Eye Syndrome - A Case Report

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