INTERNATIONAL

AYURVEDIC
MEDICAL JOURNAL
Case Report ISSN: 2320 5091 Impact Factor: 5.344

MANAGEMENT OF PROLIFERATIVE DIABETIC RETINOPATHY AND MACULAR

EDEMA BY AN AYURVEDIC PROTOCOL - A CASE REPORT
Sreekala Nelliakkattu Parameswaran1, Aravind Kumar2, Krishnendu Sukumaran3

1
Deputy Chief Physician and Vice-President, 2Research Coordinator, 3Research Coordinator;
Sreedhareeyam Ayurvedic Research and Development Institute, Nelliakkattu Mana, Koothattukulam, Ernakulam-
686662, Kerala, India

Email: [email protected]

Published online: November 2019

© International Ayurvedic Medical Journal, India 2019

ABSTRACT
Proliferative Diabetic Retinopathy (PDR) is defined as the presence of newly formed blood vessels or fibrous tissue
arising from the retina or optic disc and extending along their inner surfaces or into the vitreous cavity. Macular
edema, which is defined as an area of retinal thickening at the region of the macula, is more prevalent in proliferative
diabetic retinopathy than in non-proliferative diabetic retinopathy (NPDR). As modalities such as LASER photo-
coagulation and injecting intravitreal anti-vascular endothelial growth factors (anti-VEGFs) may not always prove
effective; an Ayurvedic approach may be explored. This condition may be compared to Timira according to Ayur-
veda. The case of a 47-year-old male who presented with diminished vision in both eyes is presented here. His
treatment plan consisted of oral medications such as Kashaya (decoction) and Vati (tablet), and external treatments
for the eye and head. Results showed slight improvement in vision and significant improvement in fundus exami-
nation and optical coherence tomography (OCT) scanning.

Keywords: Anjanam, Exudates, Case report, Kriyakalpa, Pramehajanya Netra Roga, Timira

INTRODUCTION
Diabetes Mellitus (DM) is a group of metabolic disor- Complications of DM may be acute or chronic. Chronic
ders that share the common phenotype of persistent hy- complications result from micro-angiopathy, macro-
perglycemia over a prolonged period. It is classified vascular disease, and immune dysfunction. Microvas-
into type 1 DM (insulin-dependent DM or IDDM), type cular complications affect all organs, especially the eye
2 DM, (non-insulin-dependent DM or NIDDM), and (retinopathy), kidneys (nephropathy), and nerves (neu-
gestational DM (GDM). An estimated 425 million peo- ropathy).
ple worldwide suffer from DM, with 90% of the cases Diabetic Retinopathy (DR) is more common in type 1
made up of type 2 DM. diabetics than in type 2, with 10% of the population
suffering from vision-threatening disease.[1] Risk fac-
Sreekala Nelliakkattu Parameswaran, et al: Management of Proliferative Diabetic Retinopathy and Macular Edema by an Ayurvedic Proto-
col - A Case Report

tors include duration of diabetes, poor glycemic con- The notion of metabolic disorders such as Meha (dia-
trol, pregnancy, hypertension, hyperlipidemia, smok- betes) being a cause of eye disease was put forth by the
ing, obesity, and anemia. The Early Treatment Diabetic Netra Prakashika, an ancient text of ophthalmic care
Retinopathy Study (ETDRS) classifies DR into: [2] according to Ayurveda. [4] PDR per se does not have a
⚫ Non-proliferative DR (NPDR), which is charac- direct correlation in Ayurveda. But, its symptom of di-
terized by micro-aneurysms, dot-and-blot hemor- minished vision may be considered along the lines of
rhages, hard exudates, cotton-wool spots, venous Timira (blurring of vision), which is a Drishtigata Roga
changes, and intra-retinal microvascular anoma- (disease of vision). The involvement of Rakta (blood)
lies (IRMA), may also be explored, keeping in mind the neovascular
⚫ Diabetic maculopathy or diabetic macular edema status of PDR.
(DME), which affects the macula and is restricted According to Susruta, Timira is characterized by
to vision-threatening edema and ischemia, Drishti Vibhrama (improper vision), Mithya Padartha
⚫ Proliferative DR (PDR), which is characterized by Darsana (visualization of nonexistent objects), and In-
neovascularization, either at the optic disc (NVD) driyartha Vibhrama (improper visualization of existing
or elsewhere (NVE), and objects).
⚫ Advanced diabetic eye disease, which is charac- Management of Timira involves repeated administra-
terized by tractional retinal detachment and neo- tion of Sneha (intake of fats), Asra-visravana (blood-
vascular glaucoma. letting), Reka (therapeutic purgation), Nasya (nasal
PDR is classified into mild-to-moderate and high-risk. medication), Anjana (collyrium), Murdha-basti (reten-
Mild-to-moderate PDR is characterized by NVD and tion of oil over the head), Basti Kriya (enema), Tarpana
NVE that is insufficient to meet the high-risk criteria. (retention of ghee in the eye), Lepa (application of
High-risk PDR is characterized by NVD and NVE pastes), and Seka (irrigation of the eye). [5]
greater than the ETDRS standard and associated with
pre-retinal or vitreous hemorrhage. Case Report
Diabetic macular edema (DME), the most common A 54-year-old diabetic and hypertensive male pre-
cause of visual impairment in diabetics, is divided into sented to the OPD of Sreedhareeyam Ayurvedic Eye
diffuse and focal edema. [3] Diffuse macular edema is Hospital and Research Center, Koothattukulam, Ker-
characterized by extensive capillary leakage, and local- ala, with a complaint of bilateral blurring of vision that
ized edema by focal leakage from microaneurysms. was more in his right eye since 2014 associated with
Cystoid macular edema results from further retinal floaters and occasional flashes of light since 1 year.
thickening. Focal macular edema is characterized by a The patient was apparently well before 2014. He devel-
well-circumscribed area of thickening surrounded by oped blurring of vision with vertical distortion of the
rings of exudates. Clinically significant macular edema image in 2014, which prompted him to seek ophthalmic
(CSME) is diagnosed based on 3 grades: consultation. He was diagnosed with proliferative dia-
⚫ Grade 1 is characterized by retinal thickening at or betic retinopathy and was advised intra-vitreal injec-
within 500m of the fovea. tions. He underwent 4 rounds of injection of Avastin
⚫ Grade 2 is characterized by retinal thickening and (Accentrix and Ozurdex) in both eyes but got minimal
exudates at or within 500m of the fovea. relief. He consulted Sreedhareeyam Hospital in De-
⚫ Grade 3 is characterized by retinal thickening one- cember 2017 for alternative options.
disc diameter or larger. The patient has diabetes and hypertension for 18 years
Diagnosis of PDR is made by fundus examination and and renal problems for 1 year, for which he is currently
OCT scanning. Management options involve LASER under medication. The patient underwent cataract sur-
photocoagulation to treat maculopathy and anti-VEGF gery in 2009 and 2013. He also underwent one round
injections. of LASER therapy.

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Sreekala Nelliakkattu Parameswaran, et al: Management of Proliferative Diabetic Retinopathy and Macular Edema by an Ayurvedic Proto-
col - A Case Report

The patient’s bowel, appetite, and micturition are nor- alcohol nor tobacco. His vital signs and general sys-
mal, and his sleep is sound. He is neither addicted to temic examination are normal.

Table 1: Visual and External Ocular Examination at Admission

Parameters Right Eye (OD) Left Eye (OS)
Unaided Distant Visual Acuity 1/60 Snellen (LogMAR 1.778) 6/60 Snellen (LogMAR 1)
Aided Distant Visual Acuity 1/60 Snellen (LogMAR 1.778) 6/60 Snellen (LogMAR 1)
Near Visual Acuity N36 N18
Cornea Clear Clear
Sclera Normal Normal
Iris No rubeosis iridis No rubeosis iridis
Pupil Within normal limits Within normal limits
Pseudophakia (posterior segment intra- Pseudophakia (posterior
Lens
ocular lens) segment intra-ocular lens)
Media Clear Clear
Optic Disc Within normal limits Within normal limits
Fundus
Pale areas, edema, neovascularization
Background Hard exudates (Figure 1b)
(Figure 1a)

Figure 1a: Fundus examination OD Figure 1b: Fundus examination OS

at Admission at Admission
Ancillary Diagnostics
OCT scanning showed a dome-shaped elevation at the macula with a hyporeflective area within the dome OD
(Figure 1c) and multiple, small cyst-like lesions within the macular region OS (Figure 1d).

Figure 1c: OCT scanning OD Figure 1d: OCT scanning OS

at Admission at Admission

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Sreekala Nelliakkattu Parameswaran, et al: Management of Proliferative Diabetic Retinopathy and Macular Edema by an Ayurvedic Proto-
col - A Case Report

Diagnosis Samprapti Ghataka (factors for pathogenesis) was de-

The patient was diagnosed with proliferative diabetic termined as follows:
retinopathy with macular edema. The condition Timira Dosha: Pitta, Kapha; Dushya: Rasa, Rakta; Agni:
was explored based on the patient’s symptoms, along Mandagni; Rogamarga: Madhyama; Srotas:
with Dushita Rakta Dhatu (pathological blood). The Rasavaha, Raktavaha; Srotodushti: Atipravrtti, Sanga

Therapeutic intervention
Table 2: Oral Medicines
Medicine Dose Anupana Time Duration
Samirapancakam Kashaya* 60mL
Lukewarm water 6 am and 6 pm
Candraprabha Vati 1 tablet
Vara Churna
10g Lukewarm water Bedtime
Pathya Punarnavadi Churna* 16/12/2017 -
Amrtadi Kashaya 31/12/2017
60mL Lukewarm water 6 am and 6 pm
Drakshadi Kashaya
Vasti Rasayana* 1 tablet Lukewarm water Twice a day after food

Table 3: External Therapies

Treatment Medicine Procedure Duration
Patient lay supine and the medicine was poured in a thin
Netradhara Mrdvikadi Kashaya* stream over the eyes. The patient was asked to blink dur- 16/12/2017 -
ing the procedure. 31/12/2017
Anjana Eye Plus Drops* One drop of the medicine was poured into the inner can-
Drops prepared from Sa- thus. The patient was asked to slowly move the eyeballs 26/12/2017 -
Ascyotana
hadevi with closed lids. 31/12/2017
30g of Churna was mixed with 60mL of Kashaya to pre-
Vasalakshadi Churna and 16/12/2017 -
Siroveshtana pare a paste. This was placed on a Cora cloth and tied
Vasaguducyadi Kashaya 31/12/2017
around the patient’s head.
Mukkadi Purampada and A paste prepared from the ingredients was applied over 18/12/2017 -
Purampada
Karutta Gutika the eyelids, obviating the lashes. 31/12/2017

Outcome Measures and Results He was discharged on 31st December 2017 with medi-
The patient was assessed for visual acuity, fundus ex- cines (Table 4) and was advised to report for regular
amination, and OCT findings. Both unaided and aided follow-ups.
DVA was 1/60 OD and 6/60 OS at discharge. Fundus He reported for 2 subsequent follow-ups. VA was
examination showed reduction in hemorrhages and ne- maintained at the first follow-up and showed improve-
ovascularization OD and reduction in exudates OS. ment at the 2nd follow-up (Table 5). Fundus examina-
OCT scanning showed absorption of edema OD and re- tion and OCT scanning were done at the 2nd follow-up,
duction in cyst-like lesions OS. and those results are shown in Table 6.

Table 4: Discharge Medicines

Medicine Dosage Anupana Time
Laksha Churna, Yashti Churna, 5g each is mixed with castor oil into a paste and
- 1 hr daily
and Haritaki Churna applied over the forehead and temporal region
Guggulu Tiktakam Kashaya 15mL Lukewarm water Twice a day
Triphala Guggulu 1 powdered tab with Kashaya (45mL) before food

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Sreekala Nelliakkattu Parameswaran, et al: Management of Proliferative Diabetic Retinopathy and Macular Edema by an Ayurvedic Proto-
col - A Case Report

Twice a day
Vasti Rasayana Tablet* 1 tab
after food
Lukewarm water
Twice a day
Pathya Shadangam Tablet 1 tab
after food
Netramrtam* 1 drop in both eyes - Twice a day
Aloe syrup 30 ml - Morning
*Patented medicines of Sreedhareeyam Ayurvedic Eye Hospital and Research Center

Ingredients of all medicines were procured at Sreedhareeyam’s own herbal gardens. The medicines were manufac-
tured at Sreedhareeyam Ayurvedic Medicines, Pvt. Ltd., the hospital’s GMP-certified drug manufacturing unit.

Table 5: Visual Acuity at 2 Subsequent Follow-Ups

Parameters 23/03/2018 26/05/2018
OD OS OD OS
Snellen 1/60 6/60 2/60 6/60
Unaided Distant Visual Acuity
LogMAR 1.778 1 1.477 1
Snellen 1/60 6/60 2/60 6/60
Aided Distant Visual Acuity
LogMAR 1.778 1 1.477 1
Near Visual Acuity N18 N18 N18 N18

Table 6: Fundus Examination and OCT Scanning at the 2nd Follow-Up

26/05/2018
Parameter
OD OS
Media Clear Clear
Optic Disc Within Normal Limits Within Normal Limits
Complete resolution of pale areas, hemorrhages, and
Background Complete reduction of exudates (Figure 2b)
neovascularization (Figure 2a)
OCT Scanning Resolution of edema (Figure 2c) Resolution of cyst-like lesions (Figure 2d)

Figure 2a: Fundus examination OD Figure 2b: Fundus examination OS

at the 2nd follow-up at the 2nd follow-up

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Sreekala Nelliakkattu Parameswaran, et al: Management of Proliferative Diabetic Retinopathy and Macular Edema by an Ayurvedic Proto-
col - A Case Report

Figure 2c: OCT scanning OD at the Figure 2d: OCT scanning OS at the
Second Follow-up Second Follow-up

DISCUSSION Ahara and Vihara (diets and activities that are non-con-
Neovascularization, the hallmark feature of PDR, is ducive to eye health) aggravate the Doshas, with Pitta
caused by capillary non-perfusion to an estimated 1/4 Dosha being dominant. Pitta aggravates Rakta as the
of the retina leading to hypoxia. The predilection of two share Asraya-Asrayi Bhava (homologous connec-
NVD is thought to be caused by the absence of the in- tion) with each other. These two traverses the
ternal limiting membrane at the optic nerve head. New Urdhvavaha Sira (vessels of the upper extremity) and
blood vessels originate as endothelial proliferations lodge in Netra. [8]
from the retinal veins. These pass through ILM defects The pathogenic factors of DR are due to the Kleda
to lie in the potential plane between the posterior vitre- (moisture) and Kapha in Prameha, which cause Sroto-
ous cortex and the retina. [5] rodha (obstruction of the channels) in the retinal vas-
Timira occurs when the Doshas invade the 3rd Patala culature. This Srotorodha results in Atipravrtti (in-
(layer) of the eye according to Susruta, and the 2nd creased flow) of already-increased Doshas, which may
Patala according to Vagbhata. Symptoms observed in- be compared to neovascularization. Macular edema is
clude false perception of flies, mosquitoes, gnats, flags, due to Sanga (obstruction) of the Srotas in that serum
rings, and hairs; seeing small objects as large and vice is leaked into the retina as a result of vascular pathol-
versa; seeing distant objects as near and vice versa; and ogy.
blurring of the visual field based on the position of the The oral medicines treat Prameha and help to correct
Doshas in the Drishti.[6] Timira if not treated on time, the pathological changes internally. Candraprabha
progresses to Kacha (diminished vision) and Lin- Vati is indicated in all types of Prameha, and because
ganasa (loss of vision). [7] of its cooling nature, checks Pitta and is good for the
Meha is included among the eight grave conditions ac- eyes. Vara Churna corrects both Prameha and the ret-
cording to Ayurveda (Ashta Mahagada), viz., inopathy by directly acting on the Tridoshas.
Vatavyadhi (neurological diseases), Asmari (renal cal- Drakshadi Kashaya is indicated in Urdhvaga Rak-
culus), Kushta (skin disorders), Meha (metabolic disor- tapitta, and its direct action on Vata and Pitta makes it
ders including diabetes), Udara (enlargement of the ab- useful in the management of neovascularization and
domen), Bhagandara (fistula-in-ano), Arsas (hemor- hemorrhages.
rhoids), and Grahani (irritable bowel disease). Netra Dhara and Purampada make direct contact with
An appraisal of the Samprapti (pathogenesis) of DR re- the lids and help to correct the ocular pathology by
veals that Srotobhishyanda (pathological oozing of stimulating the peripheral nerve endings and enabling
fluid from Srotas) and Raktavaha Sroto Dushti (patho- faster mobilization and expulsion of obstructive toxins.
logical activity of the Raktavaha Srotas) are prime fac- The medicines used for both conditions relieve Vata
tors in the pathogenesis of the disease. Acakshushya and Pitta, relieve Sotha, and purify Rakta Dhatu. Ascy-
otana and Anjana enable absorption of the medicine by

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Sreekala Nelliakkattu Parameswaran, et al: Management of Proliferative Diabetic Retinopathy and Macular Edema by an Ayurvedic Proto-
col - A Case Report

such parameters as height and temperature. The medi- REFERENCES

cines employed for Ascyotana and Anjana are 1. Kanski, J. J., Clinical Ophthalmology: A Systematic
Drishtiprasadana (promoting eyesight) and Kapha- Approach, 5th Edition, Butterworth Heinemann, an Im-
Pitta Samaka (pacify Kapha and Pitta). print of Elsevier Science Limited, 2003, pg. 493
Siroveshtana, a unique treatment practiced in 2. Kanski, J. J., and Bowling, B., Clinical Ophthalmol-
ogy: A Systematic Approach, 7th Edition, Elsevier Saun-
Sreedhareeyam Hospital, is the application of paste
ders, an imprint of Elsevier Limited, 2011, pg. 536
over the head using a Cora cloth. It has the affinity to
3. Kanski, J. J., and Bowling, B., Clinical Ophthalmol-
reach the target tissues by absorption through the hair ogy: A Systematic Approach, 7th Edition, Elsevier Saun-
follicles and its property of bypassing the barriers of the ders, an imprint of Elsevier Limited, 2011, pg. 537
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Triphala, and Yava and is indicated in diabetic reti- 2013, pg. 31
nopathy and other Raktaja disorders of the eye. Pathya 5. Sihota, R. and Tandon, R., Parsons’ Diseases of the
Punarnavadi Kvatha, with its Sothahara (relieves Eye, 22nd Ed., Elsevier, A division of Reed Elsevier In-
edema) and Kapha-Pitta Samaka (relieves Kapha and dia, Pvt. Ltd., 2015, pg. 433
6. Murthy, K. R. S., Ashtangahrdaya of Vagbhata: Text,
Pitta) properties, relieves hemorrhage and absorbs
English Translation, Notes, Appendices, and Index,
edema from the macula. Vasti Rasayana has Gokshura
Vol. III: Uttara Sthana, Krishnadas Academy, Vara-
and Abhraka Bhasma as its main ingredients and is in- nasi, 2001, pg. 107
dicated in all urinary tract disorders, especially those 7. Sharma, P. V., Susruta Samhita: With English Transla-
related to the kidneys. Gokshura is a potent diuretic, tion of Text and Dalhana’s Commentary alongwith
and it helps to relieve Vata and Pitta. Netramrtam is Critical Notes, Vol. III: Kalpasthana and Uttara Tan-
prepared from Sphatika, Saindhava Lavana, and dis- tra, Chaukhambha Vishwabharati, Varanasi, Reprint
tilled water, and is indicated in all eye disorders, espe- 2005, pg. 139
cially Pitta-related eye disorders. It also acts as a good 8. Sahoo, P. K., and Fiaz, S., Conceptual analysis of dia-
Rakta Prasadana (purifying blood) in case of Netra. betic retinopathy in Ayurveda, J-AIM (8), 2017, pgs.
122-131
The ingredients of Eye Plus eye drops are Ropana
(healing) Pitta-Kaphahara (relieving Pitta and Kapha),
Source of Support: Nil
and Sothahara (relieving edema). Conflict Of Interest: None Declared

CONCLUSION How to cite this URL: Sreekala Nelliakkattu Parameswaran, et

Maintenance of vision was the biggest challenge in this al: Management of Proliferative Diabetic Retinopathy and
Macular Edema by an Ayurvedic Protocol - A Case Report.
case. Although the condition improved after 2 follow- International Ayurvedic Medical Journal {online} 2019 {cited
ups to an extent where the macula almost returned to November 2019} Available from:
normal, VA was maintained in the left eye, while it im- http://www.iamj.in/posts/images/upload/2079_2085.pdf
proved in the right eye. The results of this study may be
validated using large-scale sample trials.

Acknowledgement: The authors thank Sreedhareeyam

Ayurvedic Eye Hospital and Research Center and
Sreedhareeyam Ayurvedic Medicines, Pvt. Ltd. for
their help in preparing this report.

IAMJ: Volume 4, Issue 1, October-November 2019 (www.iamj.in) Page 2085