Management of Ptosis (Vartma Sankocha) - A Case study

INTRODUCTION

Vartmasankocaa is one of the 80 vatajananatmajavikarascharacterised by unable to open eyelid. Akshisankochab ASS-29/7(difficulty in opening lid) is mentioned under indications forbrumhananasya.

Ptosis is drooping of the upper lid to a level that covers more than 2 mm of the superior cornea, It is usually due to paralysis or defective development, hypoplasia of lavator palpebral superioris or associated with anomalies of the genes PTOS1, PTOS2, and ZFH-4. Ptosis is generally unilateral, in over 70% of individuals. Elevation of the upper lid is largely a function of thelevator palpebrae superioris, assisted by the frontalis and Müller muscle.³

Ptosis may be classified as follows:

1. Congenital–Simple and complicated (associated with ocular motor anomalies, blepharophimosis syndrome and Marcus Gunn ptosis).

2. Acquired- Neurogenic, Myogenic, Aponeurotic, Mechanical type ptosis.3

This case was diagnosed as Neurological type of acquired ptosis.

Acquired Ptosis-Acquired ptosis is usually unilateral and its cause needs to be identified so that appropriate therapy can be instituted.

Neurogenic ptosis: It may be part of the symptomcomplexinvolving the entire third nerve at any point in itspath, or rarely it may be due to affection of the branch supplyingthe levator. Isolated ptosis without other signs of oculomotor paralysis may result from disease of the supranuclear pathways. In cases ofparalysis, treatment must be directed at first to the cause. In all neurogenic ptosis, the patient should be reviewed periodically on conservative management to allow for any spontaneous recovery and for the deficit to stabilize. Incomplete paralysis of the third nerve, surgery is usually contraindicated till strabismus has been corrected, since if the lid is raised in these cases diplopia becomes manifest. Crutch spectacles may be used in the presence of levatorparalysis. Surgery for neurogenic ptosis seldom gives perfect results. Two techniques may be applied: (i) if the levator is not completely paralysed this muscle may be resected (ii) if the levator is paralysed, the action of the frontalis muscle may be utilized in raising the lid.3

Treatment of vartmasankochac (CS 20/) includes oral administration of drugs havingmadhura, amla, lavana rasa andsnigda, ushnaguna. Procedures like snehana, swedana, asthapana, anuvasana, nasya etc. should be administered with vatashamakadravya. Vatashamakaahara and viharashould be advised as pathya.4

As Ayurvedic treatment Surgery can be avoided, so ayurvedic treatment is best compared to line of treatment of Neurological type of Ptosis.

MATERIALS AND METHOD:

Case History: A 60year male patient came with complaint of drooping of right upper eyelid associated with intolerance to light since 18 months. He was diagnosed as a case of Ptosis.

He got hit by insect over right upper eyelid before 18 months, resulting in swelling and drooping of right upper eyelid,associated with burning sensation. For which he consulted local physician and was been treated symptomatically. As the days progressed complete reduction of swelling and slight reduction of burning sensation but drooping of eyelid progressed . He then visited Ophthalmologist at Hubliand Hydrabadwhere he was treated with antibiotic drops and neostigmine tablet for which only burning sensation of eye was reduced,hence he visited our hospital for further treatment.

Clinical Findings: The Patient was Conscious and oriented, with normal vital values. Systemic examination were in normal limits.

Ocular Examination: Head position – Chin is elevated to uncover the pupillary area in a bid see clearly. Forehead- Increased wrinkling in right side. Eyebrows-Elevation of right eyebrow due to over action of frontalis. eEyelid-Right upper lid covers >than 2mm of cornea. Palpebral aperture was reduced in right eye .Rest all parts were normal.

Visual examination: Distant vision-Right eye-6/24 and Left eye6/9, near vision-bilateral N6.

Dasavidha Pariksha: Prakriti: Kapha pitta; vikruti-udhanavatadushti, dushyaMamsa; sara, samhanana, satwa, aharashakti, vyayamashakti, pramana and satmya, were madyama; vaya-vruddhavasta.

Astavidha Pariksha: Nadi, mutra, shabha, mala, jihwa were in prakrutavasta, sparsha was ushna.

Sroto Pariksha: Pranavaha Srotodusti.

Diagnostic Criteria: Three Diagnostic criteria are mentioned; 1.Palpebral fissure height 2.Levator function 3.MRD(Margin Reflex Distance).We considered palpebral fissure height in this patient. Palpebral fissure heightis the distance between the upper and lower lid margins, measured in the pupillary plane. The upper lid margin normally rests about 2 mm below the upper limbus and the lower 1 mm above the lower limbus. This measurement is shorter in males (7–10 mm) than in females (8–12 mm). Unilateral ptosis can be quantified by comparison with the contralateral side. Ptosis may be graded as mild (up to 2 mm), moderate (3 mm) andsevere (4 mm or more).⁶

This case has 2mm of palpebral fissure height i.e,he had severe ptosis.

Therapeutic Intervention:Hewas treated with Mukhabyanga with kshirabalatailaand Marsha nasya with karpasastyaditaila (6 drops/nostril) followed by lukewarm water gargling and dhumapana. Tablet palsineuron (bid) was given orally for 7 days.He was advised to avoid sheetaahara and vihara.

RESULT

His wordings after treatment were “I can ride the bike now where before I couldn’t. As the treatment progressed patient was able to tolerate the sunlight and dropping went on reducing and he was feeling the clarity of vision. Palpebral fissure height after treatment was 9mm.

DISCUSSION:

Usually Ptosis is compared to VatahataVartma, but Acharya Sushrutahas explained it as loosening of sandhi where patient is unable to close the lids which may or may not be associated with pain.g And vagbhata explains it as dysfunctionof eyelid due to loosening of sandhi leading to less closure of eye(lagophatalmus).⁸ Unable to open the eyelid is considered under Vartmasankoca (one of 80 vatajananatmajavyadhi).¹

Mukhabyanga and Marsha Nasya(brumhana type) was chosen for treatment because abhyanaga is said to do drustiprasadana,i and brumhananasya is told in akshisankocha.² Nasya is followed by luke warm water gargling and shodhana type of dhumapana for removal of snigdhata caused by sneha.¹⁰

Mukhabyanga was performed with kshirabalataila containingkshira, bala and tilataila which does balya and vatahara karma. Marsha nasya was performed with karpasastyaditailak, its chief components are karpasa, bala, kulatta, masa, rasna, punarnava,shigruthat doesbalya and vatahara and other drugs are satavha, pippali, chavya, nagarawhich are deepana, paachana, srotoshodhanakarma. Tablet Palsineuron containing mahavatavidhvamsa rasa,ekangaveer rasa, sameerapannaga chiefly does vatashamana, rasayana karma. So, in this patient treatment is was planned for sarvangavatashaman, sthanikavatashamana and rasayana. This proves that ayurvedic line of management is superior to Modern management of Neurological type of Ptosis.

CONCLUSION:

Ptosis should be taken as VartmaSankoca. VartmaSankoca can be treated with Mukhabyanga and Brumhana type of Marsha Nasya.This case proves that ayurvedic treatment is superior to modern line of management of neurological ptosis. As it’s a case study,this needs to be performed in large sample to establish the same.