DOI: 10.7860/JCDR/2019/42659.

13328
Case Report

An Ayurvedic Protocol to Manage

Complementary/Alternative
Medicine Section

Proliferative Diabetic Retinopathy

with Tractional Retinal Detachment

Narayanan Namboothiri Narayanan1, Aravind Kumar2, Krishnendu Sukumaran3, Neethu Kulangaraveettil4

ABSTRACT
Proliferative Diabetic Retinopathy (PDR) occurs in 50% of cases of diabetic retinopathy after 25 years of onset of diabetes.
Neovascularization associated with diabetic retinopathy stimulates scar formation, which leads to retinal detachment, the separation
of the neuro-sensory retina proper from the retinal pigment epithelium. Management options, which include pars plana vitrectomy,
anti-Vascular Endothelial Growth Factor (anti-VEGF) injections, and pan-retinal LASER photocoagulation, are not always effective.
Here, the present authors report a case of 41-year-old male who presented with foreign-body sensation for 1 year, photophobia for
8 months, and distorted image perception for 6 months. The patient was diagnosed as having Kacha (diminished vision) according
to Ayurveda. He was managed using oral medications, viz., Samirapancakam Kashaya, Cirivilvadi Kashaya, and Laksha Jala, and
external therapy, which comprised of local therapies for both the eyes and head. Assessment at discharge by fundus photography
demonstrated reduction in retinal haemorrhages, and optical coherence tomography showed reduction in macular oedema and
vitreo-macular traction.

Keywords: Alternative medicines, Kacha, Kriyakalpa

Case Report
A 41-year-old male presented to the OPD with a complaint
of foreign body sensation in both eyes (OU) since one year
associated with photophobia OU since 8 months and distorted
image perception OU for 6 months.
The patient was apparently healthy before one year, after which
he started gradually experiencing foreign body sensation, which
he neglected. Photophobia developed 8 months ago. The
patient consulted an ophthalmologist, who diagnosed him with
Proliferative Diabetic Retinopathy (PDR) and retinal detachment.
He underwent pars plana vitrectomy and silicone oil removal
in his right eye but got no relief. Gradually, his left eye also
became affected. He was diagnosed with PDR in his left eye and
underwent two courses of Laser therapy. He has advised surgery
in his left eye also, but he refused. He came to Hospital to seek
alternative options.
The patient is a known diabetic for 8 years and has been under
medication for 6 months. His father was a known case of diabetes.
[Table/Fig-1]: a) Fundus photograph OS at admission; b) OCT scan OD at ­admission;
His treatment history is remarkable for pars plana vitrectomy in his
c) OCT scan OS at admission.
right eye in November 2018, silicone oil removal in his right eye in
February 2019, and two rounds of Laser therapy in his left eye in A provisional diagnosis of proliferative diabetic retinopathy
January 2019. His personal history is unremarkable and he does with tractional retinal detachment was made based on the
not have any addictions or habits. examination and investigations. Raktaja Kacha (diminished vision
Distant Visual Acuity (DVA) at admission was hand movements due to blood), a Drishtigata Roga (disease of vision) according to
(HM+ve) in his right eye (OD) and 6/36 Snellen (LogMAR 0.77) in Ayurveda, was explored for this patient based on the symptom of
his left eye (OS); anterior segment examination OU was normal; and blurring of vision and vascular abnormalities and haemorrhages
pupillary reactions OU were within normal levels. seen in the fundus. Parimlayi, a type of Kacha according to
Fundus examination OS showed a macular scar and presence Susruta, and involvement of Rakta Dhatu (haemoglobin fraction
of haemorrhages near the optic disc and in the inferior quadrant of blood) was explored based on the changes in the retinal
[Table/Fig-1a]. Optical Coherence Tomography (OCT) scanning vasculature seen in proliferative diabetic retinopathy. Tractional
OD showed elevation of the retina due to vitreous accumulation retinal detachment was explored along the lines of increased
under the structure [Table/Fig-1b]. OCT scanning OS showed Kapha Dosha and Rakta.
vitreo-macular traction and cyst-like lesions at the macula, He was prescribed Samirapancakam Kashaya (60 mL at 6 am and
suggestive of cystoid macular oedema and tractional retinal 6 pm)*, Cirivilvadi Kashaya (60 mL at 10 am and 4 pm), and Laksha
detachment [Table/Fig-1c]. Jala (500 mL at 10 am) orally [Table/Fig-2]. External therapies
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 Narayanan Namboothiri Narayanan et al., An Ayurvedic Protocol to Manage Proliferative Diabetic Retinopathy with Tractional Retinal Detachmen www.jcdr.net

included Siroveshtana (application of paste on a Cora cloth over OCT scanning OS showed reduction in vitreo-macular traction and
the head), Anjana (collyrium), Ascyotana (eye drops), Purampada absorption of macular oedema [Table/Fig-4c].
(application of paste over the eyelid), Sirolepa (application of paste
over the head), and Talapoticchil (application of paste in a plantain
leaf over the head) [Table/Fig-3].

Medicine Preparation Dosage Time Duration

1 part of the
Samirapancakam
ingredients are
Kashaya (decoction 6 am and 07/05/2019-
boiled in 4 parts of 60 mL
of Cyperus rotundus 6 pm 22/05/2019
water and reduced
Linn., etc.)*
to 1/4.
1 part of the 10 am 10/05/2019-
Cirivilvadi Kashaya
ingredients are and 4 pm 14/05/2019
(decoction of
boiled in 4 parts of 60 mL
Holoptelea integrifolia 15/05/2019-
water and reduced 10 am
Planch., etc.) 23/05/2019
to 1/4.
1 part of the
Laksha Jala (water
powder is taken 10/05/2019-
processed with 500 mL 10 am
and mixed with 23/05/2019
Laccifer lacca Kerr.)
500 mL of water
[Table/Fig-2]: Oral medicines.

Treatment Medicine Method of administration Duration

Vasa Lakshadi [Table/Fig-4]: a) Fundus photograph OS at discharge; b) OCT scan OD at discharge;
Churna (powder 45g of powder was made c) OCT scan OS at discharge.
prepared from into a paste by mixing
Adathoda vasica with water. The decoction
Nees., etc.) was added to one Gutika
The patient was prescribed medicines at discharge [Table/Fig-5]
(tablet). A Cora cloth was and advised regular follow-ups. One of the medicines, Chimium-
Vasa Triphala
immersed in 350 mL of the 07/05/2019- Co, was manufactured by J&J Dechane Laboratories Pvt. Ltd.; the
Siroveshtana Kvatha (decoction
decoction and the paste 12/05/2019
of Terminalia others were manufactured by Sreedhareeyam Ayurvedic Medicines,
is smeared over the cloth.
chebula Retz., etc.)
The cloth was applied over Pvt. Ltd. A timeline of events is also given [Table/Fig-6].
Karutta Gutika the forehead from one ear
(tablet prepared to the other and tied over
Medicine Dosage Time
from Boswellia the head.
serrata Planch., etc.) 15 mL with 45 mL
Samirapancakam Kashaya (decoction Twice a day before
boiled and cooled
Netramrtam (sterile 1 drop of the medicine of Cyperus rotundus Linn., etc.)* food
water
Anjana drops prepared was instilled from a height 07/05/2019
from NaCl, etc.)* of 2 Angula (2 fingers) in Amalaki Churna (powder of Emblica Make into a paste by
5 gm
both eyes. The patient was officinalis Gaertn.) mixing with decoction
Drops prepared asked to gently rotate the 07/05/2019- Laksha Churna (powder of Laccifer and apply over the
Ascyotana from Veronia eyes while keeping them 5 gm
19/05/2019 lacca Kerr.) forehead for one hour
cinerea Less. closed.
Desmodium A paste prepared from the Chinium-Co (capsule prepared from Twice a day after
1 capsule
triflorum Linn. and medicine was applied over 16/05/2019- Rheum emodi Wall.)^ food
Purampada
Cynodon dactylon the eyelid, obviating the 24/05/2019 Vasa Sree (tablet prepared from Twice a day after
C. Fisher lashes. 1 tablet
Adathoda vasica Nees., etc.)* food
Desmodium Vara Curna (powder prepared from 1/2 hour after food
triflorum Linn. 60g of the powdered 3 gm
Terminalia chebula Retz., etc.) at night
and semisolid ingredients and semisolid 16/05/2019-
Sirolepa Cardocure (tablet prepared from
constituency of were made into a paste and 24/05/2019 Twice a day after
Adathoda vasica applied to the forehead. Rauwolfia serpentina Royle ex. 1 tablet
food
Nees. Benth., etc.)*

Vasa Lakshadi [Table/Fig-5]: Discharge Medicines.

Churna (powder
prepared from
Adathoda vasica A paste prepared by mixing
Discussion
Nees., etc.) 60g of the powder and 300 Diabetic retinopathy (DR) is a micro-angiopathy that primarily affects
mL of the decoction mixed pre-capillary arterioles, capillaries, and post-capillary venules of the
Vasa Triphala
with the tablet was applied 16/05/2019-
Talapoticchil Kvatha (decoction retina [1]. The Early Treatment Diabetic Retinopathy Study (ETDRS)
on a plantain leaf, which 24/05/2019
of Terminalia
was kept face down over classifies DR into background or Non-Proliferative DR (NPDR),
chebula Retz., etc)
the head, obviating a small
Karutta Gutika circular hole in the centre. diabetic maculopathy, pre-proliferative DR, proliferative DR (PDR),
(tablet prepared and advanced diabetic eye disease. PDR affects 5-10% of the
from Boswellia
diabetic population, especially Type 1 diabetic, with an incidence of
serrata Planch.)
60% after 30 years [2]. In general, the pathogenesis of DR involves
[Table/Fig-3]: External Therapies.
cellular damage.
Ingredients for the medicines were procured at Sreedhareeyam’s Neovascularization, the hallmark finding of PDR, can be either
own herbal gardens and the medicines were manufactured by at the optic disc (neovascularization disc or NVD) or elsewhere
Sreedhareeyam Ayurvedic Medicines Pvt. Ltd., the hospital’s GMP- (neovascularization elsewhere or NVE). It is caused by capillary
certified manufacturing unit. non-perfusion, which leads to retinal hypoxia. New vessel growth
Assessment was done by DVA, fundus examination, and OCT. DVA is thought to be caused by an imbalance between angiogenic and
was maintained at discharge. Fundus examination OS showed anti-angiogenic factors, in an attempt to re-vascularize the already
reduction in haemorrhages [Table/Fig-4a]. OCT scanning OD hypoxic retinal tissue. Neovascularization may encourage scarring
showed absorption of vitreous humour from the retina [Table/Fig-4b]. at the macula, which results in retinal detachment.
2 Journal of Clinical and Diagnostic Research. 2019 Dec, Vol-13(12): KD01-KD04
www.jcdr.net Narayanan Namboothiri Narayanan et al., An Ayurvedic Protocol to Manage Proliferative Diabetic Retinopathy with Tractional Retinal Detachmen

Time Event In this patient, the neovascularization caused a macular scar, which
in turn led to a tractional retinal detachment. The Atipravrtti of
05/2018 •  Experiences foreign body sensation OU, which he neglects
Doshas ended up at the macula and the already-increased Kapha
09/2018 •  Experiences photophobia OU
solidified Rakta into a scar. The Gurutva (heaviness) and Mahatva
•  Experiences distorted vision OD (prominence) of Kapha caused the mzàcula to undergo tractional
•  Diagnosed with proliferative diabetic retinopathy and retinal
11/2018
detachment movement and thus detach the retina from its normal place.
•  Pars plana vitrectomy OD and injection of silicone oil Based on the above descriptions, a treatment protocol according
•  Experiences distorted vision OS to Ayurvedic principles may be explored. Two case studies of
01/2019 •  2 rounds of LASER therapy OS
•  Advised surgery, which he declines
diabetic retinopathy managed with Ayurvedic treatments such
as Panchakarma (detoxification) and Kriyakalpa (local ocular
02/2019 •  Silicone oil removal OD
therapeutics) showed improvement in maintenance of serum
•  Consultation at Sreedhareeyam and admission for inpatient
glucose, identification of primary colours, and clarity of vision both
management
•  DVA: HM +ve OD and 6/36 OS at discharge and at follow-ups [8].
•  Fundus exam OS: macular scar and haemorrhages near the optic
06/05/2019 disc and in the inferior quadrant
Ciribilvadi Kashaya acts as a digestive agent and helps move
•  OCT scanning OD: elevation of the retinal layers due to vitreous adherent Doshas including Vata downwards. Laksha (Laccifer
accumulation lacca Kerr.), by its properties of Pitta-Kapha Nasaka (diminishing
•  OCT scanning OS: vitreo-macular traction and cyst-like lesions at
the macula Pitta and Kapha), Sandhaniya (binding), Balya (strengthening), and
Ropana (healing), helps the retina restore itself to the rest of the eye,
•  Samirapancakam Kashaya* is started
•  Siroveshtana with Vasa Lakshadi Churna, Vasa Triphaladi and at the same time, treats Rakta by acting on Pitta and Kapha.
07/05/2019 Kashaya, and Karutta Gutika is started Mixing Laksha with water helps to flush out the impurities caused by
•  Anjana with Netramrtam* is done
•  Ascyotana with drops prepared from Veronia cinerea Less. is started
aggravated Pitta and Kapha.
•  Cirivilvadi Kashaya is started (at 10 am and 4 pm) Siroveshtanam, Sirolepa, and Talapoticchil reach the target tissue
10/05/2019
•  Laksha Jala is started by absorption through the skin and hair follicles. This allows them to
12/05/2019 •  Siroveshtana is stopped bypass the blood-brain barrier and the blood-ocular barriers.
15/05/2019 •  Cirivilvadi Kashaya is continued by giving only at 10 am The ingredients used for Siroveshtana, Sirolepa, and Talapoticcihil
•  Purampada with paste prepared from Desmodium triflorum Linn. all act on Rakta Dhatu, Netra (eye), and help to rejoin the retina to
and Cynodon dactylon C. Fisher. is started the rest of the eye. Vasa (Adathoda vasica Nees.) is known to treat
•  Sirolepa prepared from Desmodium triflorum Linn. and semisolid Raktapitta (bleeding disorders) by its wound-healing properties. Vasa
16/05/2019
constituency of Adathoda vasica Nees. is started
•  Talapoticchil with Vasa Lakshadi Churna, Vasa Triphaladi improved breaking strength, absorption, and extensibility in wound
Kashaya, and Karutta Gutika is started tissue, and hence has been proven to be an excellent wound healing
19/05/2019 •  Ascyotana is stopped drug [9]. Triphala (Terminalia chebula Retz., Terminalia bellerica
22/05/2019 •  Samirapancakam Kashaya is stopped Linn., and Emblica officinalis Gaertn.) are indicated in both Prameha
23/05/2019 •  Laksha Jala is stopped
(diabetes) and Netra Roga (ophthalmic diseases). Terminalia chebula
Retz. and Terminalia bellerica Linn. have antioxidant properties,
•  Purampada, Sirolepa, and Talapoticchil are stopped
•  Fundus exam OS: Reduction in haemorrhages which eliminate free radicals in the retinal tissue. The ingredients
24/05/2019 •  OCT scan OS: Reduction in vitreo-macular traction and of Karutta Gutika possess binding and healing properties, and thus
absorption of macular oedema
enable the retina to firmly adhere to the rest of the eye.
•  OCT scan OD: Absorption of vitreous
[Table/Fig-6]: Timeline. Purampada (application of paste over the closed eyelids) reduces
*Patented medicines of Sreedhareeyam Ayurvedic Eye Hospital and Research Centre pressure by applying counterpressure from the lids. It allows for
^Patented medicine of J & J Dechane Laboratories
faster mobilisation of toxins, stimulation of peripheral nerves, and
reducing subretinal fluid in the eye. Ascyotana (eye drops) and
Kacha is a Drishtigata Roga (disease of vision) described by
Anjana (collyrium) allows deeper penetration by factors such as
Acharya Vagbhata in the Ashtanga Hrdaya Uttara Sthana. When
height and temperature of the medicine.
the pathological Doshas (humours) invade the 3rd Patala (layer) of
the eye, objects are perceived above but not below, objects are Samirapancakam Kashaya, prepared from Cyperus rotundus  Linn.,
covered by a thin cloth, vision gradually reduces, and the area of Hordeum vulgare Linn., Picorrhiza kurroa Royle. ex. Benth.,
vision (Drshti) gets colorized based on the Dosha [3]. Raktaja Kacha Santalum album Linn., and Tinospora cordifolia Miers., is indicated
is characterised by redness of the organ of vision and seeing of in Pramehajanya Netraroga (DR) and Raktapitta (bleeding disorders).
objects as either red or black [4]. Netramrtam is prepared from NaCl, KAl (SO4)2, and distilled water, and
is a promoter of vision. Vasa Sree is prepared from Adathoda vasica
The concept of Meha (metabolic disorders including diabetes)
Nees., Mesua ferrea Linn., Emblica officinalis Gaertn., and Hemidesmus
as a cause for Netraroga was mentioned by Netra Prakashika,
indicus Linn., and is indicated in Raktaja Netra Rogas (ophthalmic
an ancient text dealing with eye care [5]. The Samprapti
diseases caused by blood) and diabetic retinopathy. Cardocure is
(pathogenesis) of diabetic retinopathy according to Ayurveda
prepared from Rauwolfia serpentina Royle ex. Benth, Terminalia
revolves around Srotobhishyanda (pathological oozing of fluid
chebula Retz., Terminalia bellerica Linn., Emblica officinalis Gaertn, and
from Srotas or channels) and Raktavaha Sroto Dushti (pathological
Clitoria ternatea Linn., and is indicated in hypertensive conditions.
activity of the channels carrying blood) [6]. Acakshushya Ahara
and Vihara (diet and lifestyle choices detrimental to eye health) Challenges in managing of DR include vigorous maintenance of
aggravate Pitta Dosha. Pitta in turn aggravates Rakta as the serum glucose and preservation of existing vision. Promising effects
two share Asraya Asrayi Bhava (homologous connection) with of the Ayurvedic intervention were noted in the fundus examination
each other. These two traverse the Urdhvavaha Sira (vessels of and OCT scanning. Vision was maintained throughout, with no
the upper extremity) and lodge in Netra. The pathogenic factors further deterioration. Hence, this modality may be explored.
of DR are due to the Kleda (moisture) and Kapha in Prameha,
causing Srotorodha (obstruction of the channels) in the retinal Conclusion
vasculature. This Srotorodha results in Atipravrtti (increased This Ayurvedic protocol for managing Proliferative Diabetic
flow) of already-increased Doshas, which may be compared to Retinopathy (PDR) and TRD not only targeted the ocular conditions,
neovascularization [7]. but enabled normal physiology to be adequately restored in terms of
Journal of Clinical and Diagnostic Research. 2019 Dec, Vol-13(12): KD01-KD04 3
 Narayanan Namboothiri Narayanan et al., An Ayurvedic Protocol to Manage Proliferative Diabetic Retinopathy with Tractional Retinal Detachmen www.jcdr.net

digestion and metabolism. Hence, the protocol may be considered [3] Murthy K R S. Ashtangahrdaya of Vagbhata: Text, English Translation, Notes,
Appendices, and Index, Vol. III: Uttara Sthana, Krishnadas Academy, Varanasi,
as a treatment option. The case may be used as a stepping stone
2nd Ed., 1997, pg. 107.
for further management and the results obtained may be verified [4] Murthy, K. R. S., Ashtangahrdaya of Vagbhata: Text, English Translation, Notes,
using large-scale sample trials. Appendices, and Index, Vol. III: Uttara Sthana, Krishnadas Academy, Varanasi,
1999 pg. 109.
[5] Shankar, U., Netra Prakashika of Ayurveda Shatpannasara, Chaukhambha
Acknowledgements Vishwabharati, Varanasi, 1st Ed., 2013, pg. 31.
The authors thank Sreedhareeyam Ayurvedic Eye Hospital and [6] Sahoo, P. K., Fiaz, S., Conceptual analysis of diabetic retinopathy in Ayurveda,
Research Centre and Sreedhareeyam Ayurvedic Medicines Pvt. Journal of Ayurveda and Integrative Medicine, (8), 2017, pgs. 122-131.
[7] Dastapure, M., Shekar, V., Mamatha, K. V., and Sujathamma, K., Diabetic
Ltd. for their help in preparing this report.
retinopathy and its management in Ayurveda-A Special Case Report, International
Ayurvedic Medical Journal, Vol. 3, Issue 8, August-2015.
References [8] Sandhya Rani, D., P. Seetha Devi, Kulkarni, P. S., Ayurvedic Management of Diabetic
[1] Kanski JJ. Clinical Ophthalmology: A Systematic Approach, 5th Edition, Retinopathy- Case Study, International Journal of Innovative Pharmaceutical
Butterworth Heinemann, an imprint of Elsevier Science Limited. 2003, pg. 439. Sciences and Research, Vol. 3, Issue 8, August 2015, pgs. 1185-1191.
[2] Kanski JJ. Clinical Ophthalmology: A Systematic Approach, 5th Edition, [9] Gangwar, A. K., Ghosh, A. K., Medicinal uses and Pharmacological activity of
Butterworth Heinemann, an imprint of Elsevier Science Limited, 2003, pg. 447. Adathoda vasica, International Journal of Herbal Medicine, 2014; 2 (1), pgs. 88-91

PARTICULARS OF CONTRIBUTORS:
1. Chief Physician, Department of Ophthalmology, Sreedhareeyam Ayurvedic Research and Development Institute, Koothattukulam, Kerala, India.
2. Research Coordinator, Department of Clinical Research, Sreedhareeyam Ayurvedic Research and Development Institute, Koothattukulam, Kerala, India.
3. Research Coordinator, Department of Clinical Research, Sreedhareeyam Ayurvedic Research and Development Institute, Koothattukulam, Kerala, India.
4. Junior Medical Officer, Department of Clinical Research, Sreedhareeyam Ayurvedic Research and Development Institute, Koothattukulam, Kerala, India.

NAME, ADDRESS, E-MAIL ID OF THE CORRESPONDING AUTHOR: PLAGIARISM CHECKING METHODS: [Jain H et al.] Etymology: Author Origin
Krishnendu Sukumaran, •  Plagiarism X-checker: Aug 20, 2019
Research Coordinator, Sreedhareeyam Ayurvedic Research and Development Institute, •  Manual Googling: Oct 10, 2019
Kizhakombu PO, Koothattukulam-686662, Ernakulam, Kerala, India. •  iThenticate Software: Nov 05, 2019 (12%)
E-mail: [email protected]

Author declaration:
•  Financial or Other Competing Interests:  No Date of Submission: Aug 19, 2019
•  Was Ethics Committee Approval obtained for this study?  Yes Date of Peer Review: Sep 16, 2019
•  Was informed consent obtained from the subjects involved in the study?  Yes Date of Acceptance: Oct 10, 2019
•  For any images presented appropriate consent has been obtained from the subjects.  Yes Date of Publishing: Dec 01, 2019

4 Journal of Clinical and Diagnostic Research. 2019 Dec, Vol-13(12): KD01-KD04