Management of Macular Dystrophy Through Ayurveda - A Case Study

Introduction

Macular dystrophies are a group of inherited disorders with bilateral progressive macular atrophy. They are characterised by bilateral symmetrical macular abnormalities associated with progressive visual loss.¹ The global prevalence rate is one in 1490.² The severity of visual impairment is also dependent on the age of disease onset. Onset is most common in childhood. It is present with reduced central visual function with highly variable visual acuity (VA), depending on the degree of foveal involvement, photophobia and slow dark adaptation.¹

Evaluation of macular dystrophy is done through history, visual acuity, Ishihara colour vision chart, Amsler grid chart, Fundoscopy, Optical Coherence Tomography (OCT), Electroretinograms (ERGs).³ According to contemporary science, there is no precise course of treatment for macular dystrophy. Presently, treatments like gene therapy, cellular therapy, and pharmacological management are being adopted.¹ However, these therapies do not provide long-term promising results for retinal disorders and are not cost-effective. Any visual disorders are considered as Timira according to Ayurveda. In classics, progressive vision loss from the infrequent blurring of vision to complete blindness is explained under Patalagata Timira (Prathamapatala to Chathurtha), Kacha, and Linganasha succeedingly.⁴ The signs and symptoms of macular dystrophy can be analysed under second and third Patalagata Timira. Dwiteeya Patalagata lakshanas include Yatnat asannam Dhoore Sukshmam Cha Nekshate; if Doshas are lodging in the upper part of Drishti, then distant vision is affected and near vision is affected when the Doshas are in the lower part. In macular dystrophy, these Lakshanas can be analysed as progressive hypermetropia, central vision loss.^5,6 The Lakshanas of Triteeya patalagata⁷ includes Roopa that looks like Chadhitaniva Vasasa, Karna Nasa Akshiyuktani, the Drishti Raga will be impacted based on the Bala of Dosha. These Lakshanas can be analysed under macular dystrophy as scotoma, colour vision difficulties, Amsler grid chart findings. This disease is considered as Kruchrasadhya Vyadhi. Samanya Timira Chikitsa are explained as Snehana, Rakthamokshana, Nasya, Murdhabasthi, Basthi Karma, Tarpana, Lepa and Seka. ⁸ In this case, the first line of treatment is the management of rapid progression of disease. Hence, the adoption of Samanya Timira Chikitsa approach.

Case Presentation

A 16-year-old female patient was apparently healthy till 2016. She noted difficulty in reading blackboard sitting in the third bench (approximately three and half meters), consulted an ophthalmologist and was advised to use spectacles with a cylindrical power of -1.50 at 180° right eye and left eye, -2.00 at 175° with Best Corrected Visual Acuity (BCVA) 6/24. She was referred to a retina specialist and on examination was diagnosed with macular degeneration. She was informed that no specific treatment exists for the condition and was advised to continue using the spectacles. However, the patient refused to wear the spectacles as no improvement was appreciated after wearing them. Gradually, she noticed an increase in diminution of vision and photophobia without any colour vision and night vision difficulties were evident within a year. Later, the patient sought advice from another retina specialist and the condition was diagnosed as Macular dystrophy. With this information, she visited our OPD for further management.

There was no significant past illness or medical history. Father gave a history of myopic astigmatism since childhood. The patient was a vegetarian with reduced appetite. She had regular micturition (3-4 times a day) and bowel movements. Her menstrual cycle was regular and her sleep was sound. On clinical examinations, vitals were within normal limits. The patient was well-built with no significant systemic abnormality. Head posture was orthophoria. Her face was symmetrical and on fundal examination, optic discs were normal. Bilateral retinal pigment epithelium (RPE) thinning at fovea & macula was normal by Maddox rod test and Ishihara test (21/21).

Investigations

• 29/sept/2016 - OCT- central foveal thinning with degeneration of PR+RPE layer 
• 30/sept/2016: ERG - bilateral normal responses in both scotopic and photopic state suggestive of normal photoreceptor function
• Photopic ERG - On pattern ERG P50 response was reduced function of macular receptors

Table 1 and 2 presents the Visual acuity and autorefraction and BCV in three visits.

Treatment history

Table 3 and 4 demonstrate the treatments given on three consecutive visits and discharge medications on three visits.

Timeline

• 29/9/2016 - Patient accidently felt painless diminution of vision and consulted an ophthalmologist.
• 3/10/2016 - Visited retina specialist
• 14/05/2019 - Taken second opinion from another retina specialist and was diagnosed with macular dystrophy
• 8/4/2021 - First visit to our hospital 
• 28/5/2022 - Reported for first follow up
• 24/4/2023 - Reported for second follow up

Follow up and outcome

Although the fundus did not improve throughout the course of the follow-ups objectively, there was a significant improvement in the visual acuity, going from 3/60 to 5/60. When compared to the initial visit, the visual acuity and auto-refraction were steady throughout the duration of treatment. The patient had noticed improvements in her photophobia and vision clarity

Discussion

This case has been analysed in three consecutive visits. As the disease was progressive in nature, the first aim was to limit the progression. The patient noticed subjective improvement in vision in the last two follow ups.

Acharyas had mentioned that Dosha predominance during the Shukra-Shonita Samyoga has a role to play. Here, Vata is the Pradhana Dosha, which helps in maintaining the normal function of Indriyas. ⁹

Timira is a Vyadhi characterised by painless progressive diminution of vision. Acharya Vagbhata and Sushruta explained Timira elaborately as Patalagata Timira. Macular dystrophy has similar signs and symptoms of Vataja Dwitiya and Tritheeya Patalagata Timira.

Acharyas mentioned Snehana, Rakthamokshana, Nasya, Murdhabasthi, Basthi Karma, Tarpana, Lepa and Seka as treatment protocol for Timira. The administration of Pachana and Shodhana Karmas help in Srothoshodhanartha. Both internal and exterior therapies have been used to treat the disease. Although macular dystrophy is a degenerative disorder that affects eyesight, Ayurveda can help to manage it by taking the patient's age into account and having a clear understanding of how each Dosha is involved.

Snehapana

Snehapana is the primary treatment for both the Vataja Vikara and Timira Roga. ¹⁰ Mahatriphala Ghrita was chosen here as Acchasnehapana and Vicharana Sneha. It possesses Tridoshahara, Sadhyobalavarna, and Agni Vardhana qualities. It is specifically mentioned as being beneficial in Timira, Sarvanetraroga, and Ghridhra Drishti Karam. ¹¹ The Ghrita is administered in the Madhyabhakta Kala and it will act by correcting Samanavata and Pachaka pitta.¹² Once Pachaka pitta is corrected, all the other pittas will also function normally. Akshi is the seat of Alochaka pitta which is one among the Pancha pittas.

Virechana

It helps for Pittaharana. The Roopagrahana in the eye is caused by Alochaka pitta, one of the Sarvadehika Pitta Doshas. On correcting the Alochaka Pitta, by Pachaka Pitta correction, Chakshur Vaishaeshikata was maintained in this case.

Matrabasthi

Basthi has Chakshur Prinana, Shariropachaya Varna Bala Arogya and Vatahara properties.¹³ The drugs have Balya and Brimhana properties and the Basthi will act at the level of Dhatus. Ashwagandha bala lakshadi taila and Guggulu thikthaka ghrita are administered as Matrabasthi Dravya. Here, Vata is the Pradhana Dosha and Majjanughata Dhatus are involved. These drugs will act as Dhatu Prasadana, Chakshushya. The mechanism of Basthi will act at the level of rectum where the medicines get absorbed. It stimulates the ENS (enteric nervous system), has synergistic working mechanism with CNS. So Basthi will stimulate the brain and act accordingly.¹⁴

The Shodhana procedures will help to maintain the stability of Dhatu and improves the Agni, which in turn strengthens the Indriyas.

Seka

Seka is the procedure where a thin stream of medicated liquid is poured over the eye. Ksheera has Madhura rasa, Madhura Vipaka, and Sheethaveerya and possesses both hydrophilic and lipophilic vitamins.¹⁵ In the Seka procedure, the active principle of Dravyas will be delivered through the skin of eyelids, conjunctiva, and cornea layers. The corneal epithelium is lipophilic and the stroma is hydrophilic when poured in a thin stream of Seka, providing more drug delivery to the cornea. The medications will enter the anterior chamber through the corneal layer. In this case, Ashwagandha¹⁶ Ksheerapaka has been selected because it possesses the properties of Ushna veerya, Balya, Brimhana, Rasayana, Vishagna which help to enhance the microcirculation and removes the Srothosangha, nourishes the tissues, strengthens the nerves and slows the progression of macular dystrophy.

Netrabhyanga

Abhyanga is a Drushtiprasadhaka and aids in lowering vitiated Vata. ¹⁷ The Twak contains Bhrajaka Pitta, which helps in Dosha Pachana and absorption of the Taila Dravya. The drug's Snehana, Brimhana, and Balya characteristics could help in muscular relaxation and stimulate nerve endings. Balashwagandhadi taila, which contains Vatarogahara and Pushtikara properties, was utilized in this case.¹⁸

Pindi

This is a local therapeutic treatment where the Aushadha Kalka is made into a Pinda form. This procedure is indicated to remove the Amatva of Dosha-Dhatus. The Dravyas have the properties of Ushna Veerya, Vishagna, Rakthashodhaka and Chakshushya which will act on the ocular tissues and remove the toxins from the tissues.^19-21

Shashtika Shali Pindi Sweda

It is applied in the Pottali form. Sthanika Snigdha Sweda²² will help in improving the microcirculation. Shashtika has Madhura rasa, Sheeta Veerya, Sthairyakara, Tridoshgna properties.²³ It penetrates into the tissues, nourishes and helps to maintain the strength of the tissues.

Tarpana

Tarpana has a longer (15 min) tissue contact time compared to other kriyakalpas. Ghrita is chosen as the medicament in the present case. Probably, the biomolecules in Ghrita, which have a lipophilic character, diffuse across the layers of the cornea before entering the anterior chamber. Part of the molecules from the anterior chamber were absorbed in the highly vascular choroid layers, while the remaining molecules were absorbed in the vitreous humour. Additionally, portion of the molecular absorption takes place in the sclerocorneal junction.²⁴ Pitta Kapha Samana, Raktha prasadana, Chakshushya, and Vishaghna qualities are present in Sapthamrita Ghrita. Jeevantyadhi ghrita is Chakshushya and Tridoshahara. ²⁵ As a result, this medicine would have helped in Srothoshodhana and removed the Dhatugata Malas. This in turn does the Poshana to the Dhatus.

Eye exercises

These were advised to manage the further deterioration of vision. We included eye exercises to control the refractive errors.

• Sunning - It loosens the muscles responsible for malfunctions, stimulates the retina and improves the blood circulation.
• Shifting and Swinging - The bar exercise stimulates the macula and improves the depth perception. Fine movements of the eyeball during this exercise are also stimulated which helps in gaining clarity of vision and correction of accommodative defects. Swinging breaks the staring habits and puts the body and mind in rhythm. It does the exercise of intra ocular muscles and removes the ciliary spasm caused due to excessive accommodation.
• Eye Wash - It helps in cleansing of the eyes. The lukewarm Kashaya facilitates dilatation of the vessels which improves the circulation and relaxes the muscles. The Triphala has anti-microbial, antiinflammatory and anti-oxidant properties which help in maintaining the health of the eyes.
• Candle Exercise - Trataka- Concentrating on the flame of candle helps in relaxing the mind. It also enhances the metabolism of rods and cones through the mechanism of dark and light adaptation. It helps in increase of perception of sight.
• Fine Print Reading - Reading under proper lighting with periodic blinking relaxes the eyes and helps in improving the vision.
• Ball Exercise - Ball exercises help in correction of imbalances in the action of extra ocular muscles and brings the co-ordinated movements of the eyes.
• Vaporization - Causes vasodilation, thus improves the circulation, thereby relaxing the muscles. 
• Cold Pad - It helps in vasoconstriction and pooling of fresh blood in the periocular area.²⁶

The patient was prescribed Cap. Netraraksha and Tab. AOIM-Z during the first visit, to be taken for 45 days. During the second visit, Tab. AOIM-Z, Maha Triphala Ghrita, and Sapthamrita Loha were prescribed. During the third follow-up, Netraraksha Kashaya was recommended to be taken for three months. These medications possess antioxidant and Rasayana properties, which can aid in slowing the progression of dystrophy. The Shamana Chikitsa is intended to control the vitiated Agni, Dosha and Poshana to the dhatus. As per the Acharyas, administering Rasayana after the Shodhana procedure is important for maintaining tissue integrity.

Macular dystrophy is a hereditary disease characterised by progressive vision loss. Since it is a relatively uncommon disease, proper evaluation of the disease is required. No specific treatment guidelines are available for this disease in the contemporary science. Ayurveda has thrown light on this condition by managing the further progression of visual loss. Vagbhatta mentioned that once vision is lost, the versatility of Jagath becomes merged to one, Tamomayam. Ayurvedic treatment internal medications like Rasayanas and external therapy like Kriyakalpas, eye exercises would help to manage the disease.

Declaration of patient consent

Authors certify that they have obtained patient consent form, where the patient/caregiver has given his/her consent for reporting the case along with the images and other clinical information in the journal. The patient/ caregiver understands that his/her name and initials will not be published, and due efforts will be made to conceal his/her identity, but anonymity cannot be guaranteed.

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