Ayurvedic management of papilledema.

The term Shotha ordinarily means a swelling which may be because of inflammatory process in any part of the body or may be general, due to causes other than inflammatory. A diagnosed case of papilledema (Kapha-Pittaja Drishti Nadi Shotha) was treated on the lines of Shotha Chikitsa. The patient was given Dashamoola and Punarnavashtaka Kwatha internally and locally Nasya and Takradhara for 3 months. At the end of 3 months, papilledema completely regressed. Follow-up of the patient for more than 3 years, no recurrence has been reported.

Introduction

The term Shotha ordinarily means a swelling which may be because of inflammatory process in any part of the body or may be general, due to causes other than inflammatory.[1] Shotha occurring any part of the body may occur as either Swatantra Vyadhi (primary) or Paratantra (secondary) condition. It may also occur as a symptom of other diseases. Keeping this concept of Shotha in view, papilledema can be considered Drishti Nadi Shotha which may be primary or secondary.

The term papilledema and disc edema look alike, and per se means swelling of the optic disc[2] However, arbitrarily, the term papilledema has been reserved for the passive disc swelling associated with increased intracranial pressure, which is almost always bilateral although it may be asymmetrical. If not treated in time, this condition can lead to optic atrophy and loss of vision that is Sannimitaja Linganasha,[3] due to Shiroabhitapa or raised intracranial pressure. In this case study, a female patient of papilledema presented with Kapha-Pitta predominant symptomsthat is, blurring of vision, heaviness in both eyes (BEs), mild pain in left eye, and signs of papilledema. Patient was diagnosed as bilateral papilledema, more in the right eye than the left eye. In ayurvedic parlance, this case had been diagnosed as Kapha-Pittaja Drishti Nadi Shotha.

Case Report

A female patient aged about 53 years visited outdoor patient Department of Shalakya Tantra, IPGT and RA Hospital, Jamnagar, presenting with complaints of blurring of vision, heaviness in the head and BEs throughout the day with associated complaints of mild pain in the left eye. For these complaints, patient had undergone treatment by an eye surgeon and was provisionally diagnosed as benign raised intracranial pressure with a normal report of magnetic resonance imaging - brain, presenting with bilateral papilledema (comparatively more in the right than left eye). Patient was on tablet Diamox 250 mg (acetazolamide twice a day), but patient complained generalized weakness after taking this tablet. Even after taking tablet Diamox, patient had persistent heaviness in head and mild pain in the left eye. Hence, patient wanted to discontinue it and thus, came for ayurvedic treatment. In the past history, it is a known case of hypertension since 8 years on antihypertensive (tablet Amlovas 50 mg once a day), and blood pressure was under control. Further suffering from diabetes mellitus since 6 years and on oral antihyperglycemic agent (tablet Glyciphage 500 mg), blood sugar level was - fasting 125 mg% and postprandial 151 mg%.

There was no history of severe headache or nausea or vomiting or neurological deficit.

On examination

Visual status

Distance vision acuity (DVA) - 6/6 BEs, Near Vision (NV) - N/6 BE

Intraocular pressure (IOP) -15.9 mmHg BE

Third, fourth, and sixth cranial nerve in BEs were normal

Slit lamp examination - no keratitis, no iritis

Pupil - no afferent pupillary defect.

Fundii disc

Right eye - moderate papilledema

Left eye - mild papilledema.

No papillitis/neuritis, retinal hemorrhage, retinal exudates, hypertensive retinopathy changes.

Looking into the above clinical picture, patient had been diagnosed as benign raised intracranial pressure leading to papilledema, which is painless swelling of the optic disc with hyperemia of the disc with engorged retinal vessels. From ayurvedic point of view, it was diagnosed as Kapha-Pittaja Shotha and treated on the line of Shotha Chikitsa.

The following treatment was administered:

Dipana Pachana - Ama Pachana Vati – 2 tablet (each 500 mg) twice daily after meals for 7 days

Koshta Shuddhi - Eranda Bhrishta Haritaki 6 g with lukewarm water at bedtime for 7 days

Dosha Pratyanika Chikitsa:

Dashamoola Kwatha[4] and Punarnavashtaka Kwatha[5] each 20 ml twice daily orally on empty stomach for 3 months

Nisha Amalaki Churna[6] 6 g twice a day orally for 3 months

Takradhara[7] - along with internal medication three sittings of Takradhara were given with 7 days gap between each sitting

In between two sittings of Takradhara, one course of Nasya for 7 days with Ksheerabala Taila (101 Avartana)[8] was done.

Total duration of treatment was 3 months. The patient started feeling better in blurring of vision after 1 week of start of the treatment in right eye. Slight heaviness in the left eye persisted for 15 days; after this period, patient reported gradual improvement in the heaviness of the left eye. After 1 month of treatment, a decrease in papilledema was observed. Blood sugar level was normal (within biological limit). On follow-up of more than 3 years, patient was asymptomatic; on examination, papilledema of BEs completely regressed.

Discussion

As mentioned by Acharya Charaka in Vimana Sthana in the context of Anukta Vyadhi[9] that, for the management of diseases which are not named in the text, the physician should use his knowledge, intelligence and try to comprehend the vitiated Dosha and treat it accordingly.

Though there is no definite treatment protocol in the management of benign raised intracranial pressure presenting with papilledema, with the clinical experiences, an attempt was made to treat this clinical entity on lines of Shotha Chikitsa. Thus, the treatment aimed at reducing the Shotha by administering Shothahara preparations such as Dashamoola and Punarnavashtaka Kwatha. Along with internal medication, the local procedure Takradhara (Ruksha, Sheeta quality) to pacify Kapha and Pitta Dosha and to pacify Vata, Nasya with Ksheerabala Taila were planned. At the same time by giving due consideration to control diabetes, Nisha Amalaki Churna was administered. The patient responded well both subjectively and objectively to the treatment.

Drugs of Dashmoola Kwatha such as Agnimantha (Clerodendrum phlomidis Linn.),[10] Shyonaka (Oroxylum indicum Vent.),[11] Gambhari (Gmelina arborea Linn.),[12] and Bilwa (Aegle marmelos Corr.)[13] are proven to be best for their anti-inflammatory activity, and drugs of Punarnavashtaka Kwatha such as Punarnava (Boerhavia diffusa Linn.),[14] Haritaki (Terminalia chebula Retz.),[15] and Gomutra (cow urine)[16] are having antioxidant, diuretic, anti-inflammatory as well as antimicrobial properties. Nisha Amalaki Yoga is very commonly used drug for controlling blood sugar, and Harida (Curcuma longa Linn.),[17] as well as Amalaki (Emblica officinalis Gaertn.),[18] both are known for their free radical scavenging and antioxidant activity.

Conclusion

New ocular disorders, for example, papilledema which is not described in ancient texts can be understood by following the guidelines given in the context of Anukta Vyadhi and can be successfully managed by analyzing the vitiated Doshas based on the signs and symptoms. The entity papilledema can be considered Kapha-Pitta predominant Drishti Nadi Shotha and managed by following the treatment prescribed for Shotha.

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Conflicts of interest

There are no conflicts of interest.