Influence of Ocular Therapies on Spherical and Cylindrical Power of the Eye: A Case Report

Introduction

Astigmatism is a type of refractive error wherein the refraction varies in different meridian of the eye preventing the rays of light entering eye to converge to a point focus but to form focal lines. Broadly, there are two types of astigmatism - regular and irregular. Depending upon the position of the two focal lines in relation to retina, the regular astigmatism is further classified into three types: simple, compound and mixed astigmatism. When the rays of light in both the meridians (Horizontal and Vertical) are focused either in front or behind the retina, the condition is labelled as compound myopic or compound hypermetropic astigmatism, respectively. In all types of astigmatism, the common symptoms are asthenopia (characterized by difficulty in focusing, transient blurred vision, dull ache in eyes, frontal headache and sometimes nausea and drowsiness), blurred and defective vision when astigmatism is more than or equal to 1D, reading close to the eyes to achieve large retinal image. Spectacles with full correction of cylindrical power and appropriate axis for distance and near vision or contact lenses have been the mainstream treatment for regular astigmatism in conventional medicine. In Ayurveda, the refractive errors are studied and treated as Timira with respect to each Patala and Dosha and various Kriyakalpa (~Ayurvedic ocular therapies) are administered depending upon the eye disorders.¹ 

Case Presentation A 28-year-old female patient reported with complaints of diminution of vision for distant objects in both the eyes since twelve years with occasional symptoms of eye strain and headache while working on the computers since five years. She is a software professional and her work requires her to be in front of the computers for an average of eight hours per day. The patient has been using spectacles since the age of 16 and periodically visits her ophthalmologist once in every six months for vision checkup and change of glasses, if required. In June 2021, as per the advice of her friend, she decided to undergo Ayurvedic treatment for her complaints.

The patient is a known asthmatic since childhood.

Clinical Findings

The patient was afebrile. Pulse was 72 beats/min, with blood pressure 120/80 mm Hg. Respiratory, cardiovascular and central nervous system examinations revealed no significant abnormalities.

Visual Examination

Visual acuity

Distant visual acuity by Snellen’s chart was 6/12 in both the eyes. Pinhole correction in both eyes was 6/6. The distant vision with spectacles in the right and left eye was 6/6. Near vision was N6 in both the eyes. The autorefraction report before Virechana is also denoted

Intraocular pressure

Right eye- 15, LE- 17 at 11 AM on 07/07/2021.

Slit lamp examination

The findings of slit lamp examination are shown in Table 1.

Fundal examination

The findings are shown in Table 2.

Dashavidha Pareeksha (~Ten-fold examination)

Prakriti of the patient was Vata- Kapha Prakriti. Vikriti (~morbidity) was Vataja. Satwa (~psyche), Sara (~excellence of tissues), Samhanana (~compactness of organs), Ahara shakti (~digestive power), Vyayama shakti (~capacity of exercise), Satmya (~suitability) and Pramana (~body proportion) of the patient were of Madhyama (~mediocre) level.

Ashtavidha Pareeksha (~Eight-fold examination)

No abnormalities were found in eight-fold examination except Drik (visual apparatus), which was poor.

Timeline

The timeline is depicted in Table 3.

Diagnostic Assessment

This was diagnosed as a case of Compound Myopic Astigmatism as confirmed by subjective refraction and autorefraction. It is correlated to Prathama Patalagatha Timira based on the description of Samprapthi.

Therapeutic Intervention

The treatment adopted is depicted in Table 4.

Follow-up and Outcomes

The symptoms like eye strain and headache were reduced after Virechana. The blurring of vision was greatly improved after Marsha Nasya and Tarpana. The reports of autorefraction before and after Virechana, after Tarpana, after eye exercises, Pindi and Ghrita pana and during follow up after two months are denoted in Figure 1, Figure 2, Figure 3, Figure 4 and Figure 5, respectively. The before and after treatment comparison of powers of the eye is shown in Table 5 and Table 6. The visual acuity measured using Snellen’s chart before and after the treatment is shown in Table 7.

Discussion

The present case can be analyzed under the heading of Prathama Patalagatha Timira. This Prathama Patala is the Tejo-Jalashrita Patala, the external layer (Bahya) of eyeball (Akshigolaka).² This in particular is cornea of the eyeball. The error of refraction, Astigmatism also occurs due to irregular curvature of the cornea or lens. Dalhana, explains Prathama Patala as Kalakasthi in the pathogenesis of Timira,³ Astigmatism does not occur due to pathology in the retina. Kalakasthi is the bony orbit of the eye and it is understood as retina in the pathogenesis of Timira by the modern-day Ayurveda ophthalmologists because of the proximity of both the structures. The commentator Dalhana has explained Prathama Patala as Kalakasthi in the context of pathogenesis of cataract only. Otherwise, Prathama Patalagatha Timira can be considered as the umbrella term for all types of refractive errors based on similar explanation of symptoms. Dadimadi Ghrita was selected for Snehapana since the patient was asthmatic and Daadimadi Ghrita is useful in Shwasa.⁴ Virechana with Trivrit Leha and Marsha Nasya with Anutaila was done as Shodhana of body and head is the prerequisite before commencing Tarpana.⁵ Trivrit Leha is mainly for conditions with Pitta-Kapha predominance and it was selected in this case because Prathama Patala is composed of Tejas (The Rakta dwelling in the Alochaka Pitta) and Jala (which is Twakgatha Rasa Dhatu). Anutaila was selected for Nasya as its Phalashruti says it as Indriya Balaprada (~nourisher of sense organs).⁶ Mahatriphala Ghrita is selected for Tarpana and Pana since it is best in Drishti Vikara.⁷ Pindi is selected as a pressure acting treatment that is vital in the refractive errors. Both Shigru and butter are Chakshushya (~nourishers of eye) in action. Eye washing with Triphala Kashaya, palming, tossing the ball, bar exercises are the set of eye exercises that are practiced after a course of Tarpana for refractive errors on the understanding that it acts on extra oblique muscles. But the modern-day ophthalmologists reject the claim as pseudoscientific. However, there are references in the classics about eye wash with Triphala Kashaya that it will uproot the eye diseases that have manifested. Similar use is told for palming also.⁸

The pressure exerted from the ocular therapy like Pindi causes some changes in the antero-posterior diameter of the eyeball, thereby decreasing the spherical power of the eyes. This change in the antero-posterior diameter in turn results in the microscopic changes in the curvature of the cornea leading to the increase in astigmatism of the eye. This could be the probable hypothetical understanding for the increase in the cylindrical power and decrease in spherical power of the eyes seen in this case of compound myopic astigmatism. But this did not happen with Tarpana though it exerts pressure on the eyeball. Cylindrical power improved after Tarpana. Undoubtedly, Tarpana is a go to treatment in all types of eye disorders related to vision, but the actual mode of action with respect to astigmatism is difficult to establish and is a point for further research. The scope of further research also includes administration of Anjana that is told for Timira in the management of astigmatism. Overall, the spherical power greatly improved following the ocular therapies planned for this case.

Patient Perspective

Spectacles have become a part of me, like many IT professionals, that there is not even a day as I remember, in last 12 years without spectacles. I have them since when I was an adolescent and wear them regularly. I regularly visit an eye clinic near my home once in six months every year to check if the change of glasses is necessary or not. I was ok like this but owing to my work load after my promotion in my office since last five years, I developed eyestrain and headache after continuous work. That’s when I thought of visiting a doctor who is an Ayurvedic eye specialist who also happens to be a friend of my friend. He suggested me to go through a course of detox with purgation therapy for which he referred me to a Panchakarma specialist. Then the doctor gave me a course of Nasya, Tarpana, Eye exercises, Pindi and a Ghee for daily intake. The eyestrain and headache are almost gone now and my vision is also miraculously improved. I never knew that there is something which can improve the vision! And it is even more heartening to see that this cure originated from the very land we are born in, in the form of Ayurveda. Hopefully, I get to write this in a blog someday so that it will benefit many like me.

Conflict of interest

None