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| REVIEW ARTICLES |
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| Year : 2022 | Volume
: 10
| Issue : 2 | Page : 136-140 |
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A review study on Ayurveda treatment protocol for diabetic retinopathy
Sangita O Kamaliya, Dharmendra S Vaghela
Shalakya Tantra Department, IPGT & RA, Jamnagar, Gujarat, India
| Date of Submission | 12-Feb-2021 |
| Date of Acceptance | 28-Mar-2022 |
| Date of Web Publication | 28-Jun-2022 |
Correspondence Address:
Sangita O Kamaliya
Department of Shalakya Tantra, Institute of Post Graduate Teaching and Research Institute, Jamnagar, Gujarat
India
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/jism.jism_10_21
Background: Diabetic retinopathy (DR) is a serious hurdle seen in diabetic patients and major problem of visual impairment in developed nations. DR is essentially a microangiopathy affecting arterioles, venules, and capillaries of the retina. Recently, available treatments for DR have some obstacles; taking this into consideration best treatments from other streams are being searched. Materials and Methods: The present study is aimed to review research works carried out in Shalakya Department, Jamnagar. This study is planned to establish the effect of different Ayurvedic treatment protocols, viz., Panchakarma therapy like Nasya (use of medicated drugs through nostrils) and Virechana/Koshta Shodhana (therapeutic purgation) and ocular procedures (Netra Kriya Kalpa) like Takra Shirodhara (pouring of medicine-mixed buttermilk to the head) and Takra Shirolepa (application of buttermilk-mixed paste to the head) in DR. The numbers of patients in trials 1, 2, and 3 are 33, 46, and 100, respectively. Duration of treatment in trials 1 and 2 was 2 months and in trial 3 it was 3 months. Follow-up in all the trials was 1 month. Results: These treatment protocols were found to be significantly effective and safe. During the treatment and follow-up period, no any adverse drug reactions were reported. Conclusion: It can be said that selected intervention was found to be safe, having appreciative, effective, and helpful results for DR as a conventional treatment protocol and other choice of treatment for patients’ better quality of life. Keywords: Diabetic retinopathy, Madhumehajanya Timira, Nasya, Virechana
How to cite this article:
Kamaliya SO, Vaghela DS. A review study on Ayurveda treatment protocol for diabetic retinopathy. J Indian Sys Medicine 2022;10:136-40 |
| Introduction | |  |
Diabetic retinopathy (DR) is a serious hurdle seen in diabetic patients[1] and the major problem of visual impairment in developed nations.[1] Uncontrolled blood sugar is a most important risk factor.[2] The pathophysiology of DR includes microaneurysms, superficial and deep hemorrhages, soft and hard exudates, retinal neovascularization; all of these can cause vision disturbances at first and turn in to blindness finally. The recent treatment for DR is intravitreal anti-vascular endothelial growth factor drugs, laser therapy, intravitreal steroids, and pars plana vitrectomy. All these treatments only stop the blood and fluid leakage in the retina and does not crack the root pathophysiology of the disease. These are very costly and have many side effects. Thus, it is very important to describe the topic of diabetes, prevention, complications, and management of all the problems with reasonable medical care.
In our classics, there is no direct reference available for ophthalmic complications of diabetes. Only Netra Prakashika has highlighted Timira (errors of refraction/partial blindness) as a complication of diabetes. There are some similarities between Timira and Prameha (diabetes), so diabetic retinopathy features can also be correlated accordingly. There is no direct reference in our classics that can told that Timira may be a complication of Prameha. Poojyapada Mahamuni, one of the leaders of Ayurveda in his work―Netra Prakashika, clearly mentioned that diabetes can cause eye diseases.
Prameha is mentioned in Ashtavidha Mahagada (eight major diseases) due to its multiple Dhatu (major structural components of the body) involvement, no cure nature, deep rootedness, chronicity, and difficulty in treatment.[3] It is the prodromal symptoms that persist even after the manifestation of clinical symptoms and in its complication stage. This may form an important link between Prameha and Timira and also with DR. It has Subahupadravas, which means complications affecting vital structures of the body like Marmas (vital part). Siras (vessels) are one of the most important vital parts and when it affects, it must have its effects in eyes also, which are located in the former.
Ayurveda management attacks to break the pathophysiology from starting; and its aim for DR is nourishment of Rasayanis (capillaries) to activate the natural feeding of body systems.[4] Considering huge range of management protocols available for DR in Ayurveda, different researches were done at different Ayurvedic organizations all over India. This work is a review of research works done in Shalakya Department, IPGT & RA, Jamnagar, Gujarat, India to highlight the effectiveness of Ayurvedic treatment protocol on DR.
Aim and Objective
To review previously done clinical research work on DR in Jamnagar.
To highlight effectiveness of selected protocol for the treatment of DR.
| Materials and Methods | | |
In the present review, researches done in the Department of Shalakya Tantra, Jamnagar on DR from 2013 to 2018 were compiled to assess the effect of Ayurvedic treatment protocol on DR.
Drugs
All the selected trial preparations were made in the pharmacy of our institute. Pharmacognostical and pharmaceutical evaluations were done in respected laboratories of our institute.
Investigation
Blood examination (haemoglobin [Hb], total leucocyte count [TLC], differential leucocyte count [DLC], erythrocyte sedimentation rate [ESR], and random blood sugar [RBS]), urine routine and microscopic examination, biochemical-fasting blood sugar (FBS), post-prandial blood sugar (PPBS), lipid profile, HbA1C (in 20 patients), liver function test (LFT), renal function test (RFT) (if needed only) were done before and after trial for evaluation.
Examination
Eye examination including visual acuity, slit lamp examination, intraocular pressure, and fundus examination were done before and after treatment. Fundus was examined by direct ophthalmoscopy, indirect ophthalmoscopy, and fundus photography for record of DR after complete pupil dilatation with short-acting mydriatic tropicacyl plus eye drops (combination of phenylephrine and tropicamide). Due care was taken in hypertension patients in whom in simple tropicamide eye drops were instilled to avoid complications.
Assessment Criteria
To study the pathogenesis and result of provided medicine and complications of drugs, a special proforma was prepared. The efficacy of therapy was analyzed on the basis of subjective and objective criteria. Recovery in visual acuity and fundoscopic clinical finding are required in DR assessment.
Assessment of Overall Effect of Therapy
For the assessment of improvement rate, assessment scale was made. The result was presented in view of percentages at the end of treatment.
Statistical Analysis
Obtained data were assessed statistically by paired and unpaired t-test.
| Observations and Results | | |
Till date the following works were done on DR in Shalakya Tantra Department, IPGT & RA, Jamnagar, Gujarat, India.
Trial 1
Priyanka Rani et al. (2013): “A clinical study to evaluate the role of holistic Ayurvedic treatment in Pramehaja Timira w.s.r. background diabetic retinopathy.” In this work, 33 patients from the OPD of Shalakya Tantra, suffered from DR and accomplishing inclusion criteria for this work, were enrolled and randomly divided into two groups.
Group A (treatment group)
- Virechana: After proper Snehapana (internal use of medicated ghee-oleation) and Swedana (sudation), classical method of Virechana (purgation) was adopted for Koshtha Shuddhi (purgation without prior oleation) under the supervision of Panchkarma (five procedures of Ayurveda) experts. Trikatu was used for Deepana (digestive fire), Pachana (anabolism), Triphala Ghrita was used for Snehana. A compound of Triphala, Trivrita, and Katuki (Picrorhiza kurroa) powder in 2:1:1 ratio was used for Virechana;
- Takra Shirodhara with medicated butter milk (Buttermilk + Amalaki - Embilica officinalis);
- Pratimarsha Nasya (nasal medication in mild dose) with―Anutaila
- Oral medication, Anubhuta Rasayan Yoga (5 mg bd with honey and ghee empty stomach or 2 h before meal) containing four contents in equal parts—Haridra (Curcuma longa), Amalaki (E. officinalis), Musta (Cyprus rotundus), and Guduchi (Tinospora cordifolia).
Effect of therapy
On comparisons of overall effect of treatment between Groups A (treatment group) and B (control group), statistically highly significant (P < 0.001) result was found on subjective parameters such as floaters and on dark adaptation. Statistically significant (P < 0.05) result was found on objective parameters such as hemorrhages. Statistically significant (P < 0.05) result was found on laboratory parameters such as FBS and HbA1c. Insignificant result found on rest of the parameters. Better results were found in the trial group than the control group.
Trial 2
Haripriya et al. (2015): “Further clinical study on Pramehajanya Timira (background diabetic retinopathy) and its Ayurvedic management.” Forty-six patients having DR were selected from the outpatient department and inpatient department of the Shalakya Tantra, divided into two groups.
Group A (treatment group)
- Koshta Shodhana: After proper Sadhya Snehana (fast oleation) and Swedana, Koshta Sodhana was adopted depending on the Koshta and Prakriti of the patient. Trikatu Churna 3 g bd and Chitrakadi Vati were used for Deepana Pachana. Cow ghee was used for Sadhya Snehana. A compound of Aragwadha (Cassia fistula Linn. fruit pulp), Hareetaki (Terminalia chebula Retz. dried fruits), Draksha (Vitis vinifera Linn.-dried fruits), and Taruni Pushpa (Hibiscus rosa-sinensis Linn.—flower) in equal quantity was given in the form of decoction at morning time preferably 7.30–8.0 am for 1–3 days depending on Shuddhi attained.
- Marsha and Pratimarsha Nasya with Drakshadi Ghrita;
- Takra Shirolepa with Mukkadi Lepa Yoga;
- Oral medication (Anubhuta Rasayana Yoga) (5 g bd with honey and ghee empty stomach 2 h before meal) containing 9 drugs Nisha (C. longa Linn.), Amalaki (E. officinalis Gaertn.), Guduchi (T. cordifolia Thunb. Miers), Musta (Santalum album Linn.), Bala (Abutilon indicum), Yashtimadhu (Glycerrhiza glabra Linn.), Bhringaraja (Eclipta alba Linn.), Vasa (Adhatoda vasica Nees) and Chitraka (Plumbago zeylanica).
Effect of therapy
On comparisons of overall result of treatment between Groups A (treatment group) and B (control group) on floaters with t-value of 5.855, it was observed to be statistically significant (P < 0.05). For the rest of the parameters, no statistically significant result was found. Better results were found in the trial group than the control group.
Trial 3
Krishna Kumar et al. (2018): “Effect of Ayurvedic treatment protocol in the management of Madhumehajanya Timira w.s.r. to diabetic retinopathy—A clinical study.” A total of 100 patients from the outpatient and inpatient departments of Shalakya Tantra, Jamnagar, Gujarat, India having clinical features of DR and accomplishing the criteria of inclusion were registered in the work.
Group A (treatment group)
Preparatory stage
- Deepana Pachana with Shivakshara Pachana Choorna/Chitrakadi Vati/Ama Pachana Vati/Trikatu Choorna—5–10 g/1 tablet with lukewarm water orally twice daily for 5–7 days according to the Koshta of patients.
- Koshta Shodhana with Eranda Brishta Hareetaki/Avipattikara Choorna—5–10 g with lukewarm water orally in the morning for 3–5 days according to the Koshta and Prakriti of patients.
- Shirashodhana with Anu Taila—8–10 drops into each nostril for 7 days.
Treatment phase
- Marsha Nasya with Durvadi Ghrita—8–10 drops into each nostril for 7 days followed by Pratimarsha Nasya with same. Three sittings of Marsha Nasya were done.
- Takradhara by Siddha-Takra as medium 30 min daily for 15 days in the morning. Three sittings of Takradhara were done.
- Oral medication (Anubhuta Rasayana Yoga)—3 g at bed time with 3 g honey and 6 g ghee.
Effect of Therapy
On comparisons of the overall effect of treatment between Groups A and B on FBS, it was observed to be statistically significant (P < 0.05). Result was statistically insignificant on rest of the parameters. Better results were found in the trial group than in the control group.
Group B (Control Group—Same in All Three Studies)
In all the three studies, diagnosed cases of DM having DR changes were included and kept under observation till the whole therapy period. They were continued with their anti-hyperglycemic and anti-DR treatment, if any. No any Ayurvedic intervention was done in this control group.
Overall Effect of Therapy
After assessment at the end of treatment course, percentage-wise better relief was found on most of the subjective and objective parameters of disease on group A than on group B in all three trials. Details are given in [Table 1].
| Discussion | | |
Among these three clinical studies, two studies were carried out on NPDR (non-proliferative diabetic retinopathy) and one study included all types of DR; it may be due to higher prevalence of NPDR when compare with other stages of DR. Different therapeutic protocols were used in all three research works. References of used drugs in three research works are listed in [Table 2].
On comparisons of the overall effect of treatment between Groups A and B, statistically highly significant result was found on floaters and dark adaptation in trial number 1. It may be due to rejuvenation effect of the drug that will improve general health of the patients. Statistically significant result was found on FBS and HbA1c. It means that the trial group certainly broke down the pathogenesis of diabetes mellitus by acting against the root cause than the control group. On comparisons of the overall effect of treatment between Groups A and B, statistically highly significant result was found on reducing superficial hemorrhages. It can be inferred that results of the trial group indicate improvement of retinal vessels. No statistically significant change was observed in SGPT, SGOT, urea, and serum creatinine in the trial group. This can be said like after taking Anubhuta Rasayana Yoga there was not much change in LFT and RFT in patients of the trial group. In all the three studies, the trial group shows percentage-wise better results on almost all parameters, but statistically the result was not that much encouraging.
From the Panchakarma, Nasya (use of medicated drug through nostrils) and Virechana are the two purification procedures used in these studies.
Nasya
Nose is the gate way of head, so the diseases related to head are best treated by this Nasya procedure.[5] This is an important procedure which affects directly the sense organs including sense of vision[6] by using different therapeutic forms such as ghee, oil, liquid, or powder. The drug administered through the nostrils goes to Shringataka Marma by nasal root and spreads in the whole brain by routes of eyes, ears, and throat and brings out morbid Doshas from the upper clavicular region. So various formulations were tried as Nasya in all these studies. Most of the drugs stop the bleeding (Raktastambhana) and pacify Pitta Dosha and Rakta Prasadana (blood-nourishing quality), which can be used in DR particularly in absorption of retinal hemorrhage under Urdhvanga Raktapitta (bleeding from upper orifices of body) spectrum. Anu Taila Nasya having Srotoshodhana (clear the channels) and Kapha Dosha-pacifying properties eliminate vitiated Kapha Dosha and clearing of channels in head and eyes. Pratimarsha Nasya was used in many of works may be due to Srotoshodhana[7] and Indriya Dridhata (imparting strength to eyes)[8] properties.
Virechana/Koshta Shodhana (therapeutic purgation)
Due to improper state of digestive fire, collection of waste product occurs in the minute channels. For this, therapeutic purgation should be recommended. It is indicated in Urdhwaga Raktapitta, Prameha, and Timira.[9] According to the clinical signs of Pramehajanya Timira are same to Urdhwaga Raktapitta, so Virechana was selected as Pratilomahara treatment in Madhumehajanya Timira.[10] This procedure can eliminate the waste products from the body in extracellular, intracellular, or plasma and can be brought into gastrointestinal tract and removed out of the body by the action of the intestine. This process is prompt by purgation drugs.
Moordha Karma
Takra Shirodhara is a medicated powder mixed with buttermilk to be poured on the head, and Takra Shirolepa is a medicated paste made with powder of drug and buttermilk to apply on the head. Both procedures were tried in different studies. These procedures are producing mental relaxation according to the drug used and help to reduce mental stress in patients.
Deepana-Pachana
Low state of digestive fire can be corrected by proper Deepana Pachana drugs such as Trikatu Choorna. It is increasing the secretions in the digestive system. Thus, it increases the bioavailability of food and medicines. This will lead to the fact that increased metabolism removes metabolic waste accumulated in the body, thus reducing Ama which is the cause of obstruction. By these the Srotasas (microcirculation channels) become clear.
Rasayana Yoga (Anubhuta)
All the drugs selected for Anubhuta Rasayana Yoga were proven to be anabolic, antioxidant, and in majority, antidiabetic also. It is an Ayurvedic polyherbal formulation having hemostatic, vison-enhancing (Chakshusya), and Pramehahara (hypoglycemic) properties. It acts at the level of weakness of structural and functional integrity of nutritive channels, which is seen in the pathophysiology of DR. Poor sugar control is a risk factor of DR. This drug also controls blood glucose level that can prevent or delay the development or progression of DR.
Adverse drug reaction (ADR)
Trial drugs used in all the studies are found to be clinically safe and during the treatment and follow-up period, no ADRs were reported. No interactions were reported in any study, when used along with conventional drugs.
| Conclusion | | |
Diabetes is a major risk factor for developing retinopathy. After the comparative analysis of efficacy of trial groups in all three trials, Group A shows better percentage relief than group B on subjective and objective parameters of DR. Thus, we may say that Ayurvedic protocol was found to be safe, having appreciative, effective, and helpful results for DR as a conventional treatment protocol and other choice of treatment for patients, better quality of life. For better understanding of selected Ayurvedic drugs effect, trials should be done on large sample size and multicenters.
Acknowledgements
SOK would like to sincerely thank co-author Dr D. B. Vaghela for his valuable guidance and constant support. The authors would like to extend their gratitude to Dr. Deepak Pawar, Assistant Professor, Department of Shalakya Tantra, IT & RA Jamnagar, Gujarat, India, for his continuous advice. We would like to extend our gratitude to Prof. Vd. K. S. Dhiman, Director General, CCRAS and Dr. R. Manjusha, Professor and HOD, Department of Shalakya Thantra, All India Institute of Ayurveda, New Delhi. We would like to acknowledge Dr. Krishna Kumar, Research Officer (Ayu), Regional Ayurveda Research Institute for Eye Diseases, Lucknow. Dr. Anup Thakar, Director of ITRA, Jamnagar, Dr. Hitesh Vyas, Dr. Priyanka Rani, Dr. Haripriya, Dr., Archana, and Dr. Neethu are also acknowledged.
Financial Support and Sponsorship
Nil.
Conflicts of Interest
None.
| References | | |
| 1. | World Health Organization. Global Health Risks. Mortality and Burden of Disease Attributable to Selected Major Risks. Geneva: World Health Organization; 2009.  |
| 2. | Vaishali G, Ramandeep S Atlas and Text on Diabetic Retinopathy, Ramandeep Singh. 1st ed. New Delhi: Jaypee Publishers; 2007. p. 2. |
| 3. | Harishastri P, editor. Ashtanga Hridayam of Vagbhata—With Commentaries (Sarvanga Sundara) of Arunadatta and (Ayurveda Rasayana) of Hemadri, Nidana Sthana. Chapter 8, verse 30. 10th ed. Varanasi: Chaukhamba Orientalia; 2011. p. 497. |
| 4. | Acharya YT, editor. Sushruta Samhita of Sushruta, Chikitsa Sthana, Pramehapidaka Chikitsa. Chapter 12, verse 8. Varanasi: Chaukhambha Surbharati Prakashan; 2017. p. 454. |
| 5. | Acharya YT, editor. Sushruta Samhita—With Nibandha Samgraha Commentary of Sri Dalhanacharya and the Nyayachandrika Panjika of Sri Gayadasacharya, Chikitsa Sthana. Chapter 40, verse 21, Varanasi: Chaukambha Orientalia; 2014. p. 554. |
| 6. | Chakrapanidatta CS Carakasamhita—Elaborated by Charaka and Dridhabala with the Ayurveda—Dipika Commentary, Sutra Sthana. Chapter 5, verse 61–62. Varanasi: Chaukhamba Orientalia; 2011. p. 41. |
| 7. | Ragahvan T Astanga Samgraha—Deepika Commentary, Sutra Sthana, Nasya Vidhi. Chapter 29, verse 17. 3rd ed. Chalakudy: Prakashika Publication; 2010. p. 159. |
| 8. | Harishastri P, editor. Ashtanga Hridayam of Vagbhata, Sutra Sthana; Nasya Vidhi. Chapter 20, verse 29. Varanasi: Chowkhambha Surbharati Prakashan; 2017. p. 292. |
| 9. | Ragahvan T Astanga Samgraha—Deepika Commentary, Sutra Sthana, Vaman Virechanavidhi. Chapter 27, verse 9. 3rd ed. Chalakudy: Prakashika Publication; 2010. p. 66. |
| 10. | Harishastri P, editor. Ashtanga Hridayam of Vagbhata, Nidana Sthana; Raktapittakasa Nidana. Chapter 3, verse 14. Varanasi: Chowkhambha Surbharati Prakashan; 2017. p. 468. |
[Table 1], [Table 2]
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