Dr.Sreeja Sukesan, MD (Ay),
Professor & HOD, Department of Shalakyatantra,
Govt.Ayurveda College, Tripunithura
Shalakyatantra is one among the 8 branches of Ayurveda. Even though it is a speciality branch and deals with the treatment of diseases pertaining to eye, ear, nose, throat and head, the understanding of these diseases and treatment is based on the basic concepts of our shastra. A solid foundation is necessary to have a strong superstructure.
A lot of students lack the confidence to practice even after post- graduation. Pathology in modern science is easy to understand but many of the students find it tough to make an Ayurvedic diagnosis and plan a management. Even though generally spoken so, the effectiveness of Ayurveda in management in shalakya related roga is challenging.
The importance of the foundation of basic principles in a specialization can be seen to be well reflected in Shalakya managements. To quote an example, in the context of vatika timira chikitsa, acharya has mentioned the use of niruha and anuvasana vasthi mentioned in vatika prathisyaya chikitsa, which in turn is taken from ardita chikitsa. Thus even a general physician who excels in analysing dosha can treat any disease but need to develop a skill to understand samprapthi of shalakyarogas .Without an insight into the sidhantas, a mere localized purview of the disorders is achieved and this cannot be said to be a fully-fledged management. Application of such concepts of dosha- dooshya assessment, samana and shodhana approaches can be well explained with the aid of case discussions and hence it is planned to do so.
Concept 1. Samana, its limitations and importance of shodhana
A case which was presented with complaints of persistent redness, severe pain, blurring of vision in left eye, left sided headache associated with photophobia since 2yrs. As per her treatment history for past 15 yrs, she has been using topical eye drops which subsided her symptoms, but symptoms reappeared with in a gap of 2-3 months. In due course she also developed cataract. On examination, with lens opacity circum corneal congestion, she had grade 2 posterior sub capsular cataract as well as slightly raised intra ocular pressure.
In this case as the integrity of the structure is lost the involvement of asthidhatu was considered, dharana being the main karma of this dhatu. The irreparable damage which has happened to lens and iris highlights the involvement of asthidhatu along with tridoshaja dushti with vata, pitta and raktha predominance.
In this case, Samana line of treatment was started targeting the predominant doshas ie; Vata,Pitta and Raktha. Treatments such as netradhara, bidalaka, internal medications were done. After one month she had complete relief. In order to check the chance of recurrence anupashaya prayoga was tested by giving ushnaveerya oushadha which ended up in earlier state. In this case, samana chikitsa was effective only in the shakha level due to which it responded to localised therapies. After a course of shodhana therapy, her disease was completely cured with no recurrence till date. She was also advised with proper pathya .Through this case, the importance of assessment of dosha gati and Impact of ahita ahara vihara in the recurrence of disease is highlighted.
Concept no 2: Assessment of dosha based on different colours:
By analysing gross appearance we can analyse dosha in some cases with the help of colour codes given. For example,
• In Intercalary staphyloma (localised bulge in limbal area), black colour indicates the presence of vata.
• In SCH(sub conjunctival haemorrhage), from redness, we can assess presence of pitta dosha samana chikitsa.
• In cataract, the white discolouration of lens (opacity), indicate the presence of kapha dosha.
Here the dosha assessment will help us to get closer to the right diagnosis and it also help us to determine the prognosis. The below case will help to highlight this point.
A Diagnosed case of cataractous nigra (black discolouration of lens) was posted for surgery. But due to the presence of myopic retinal degeneration his vision was not regained even though the opaque lens was removed. The condition was diagnosed as vatika linganasha as here in addition to the symptoms of linganasha, the black colour denotes the vata predominant state. As per the classics however, only kaphaja linganasha is sadya, where in the lens should have white discolouration. Here, we see the importance of understanding the prognosis of the condition we are dealing with. This according to our classics is clearly an asadhya avastha where the shastra karma done would be futile, as has been seen with this case. We should be capable to identify the condition as well as when to suggest surgery such as retinal repair surgeries including invasive techniques (PRP, IVI).
Concept no 3: how to correctly use Anjana concept clinically.
Application of Souveeranjana daily and rasanjana once in a week has been mentioned in samhitha, as a part of dinacharya. This is to protect the pitta pradhana netra from kaphakopa which otherwise may lead to abhishyanda netraroga. Its importance can be seen in clinical perspective also, where we need to protect the eyes from kaphakopa from use of medicines which have an inclination to increase kapha dosha.
This is a case which was diagnosed with diabetic retinopathy with poor vision in left eye (visual acuity been close to fingers) due to vitreous haemorrhage. The right eye had good vision even though the fundus showed haemorrhage and laser points of previously done PRP. Targeting the pitta raktha dushti which was more predominant in the left eye, treatment was done in both eyes. And the haemorrhage of right eye improved up to 80% with remarkable reduction in haemorrhage in left eye. But the presence of oedema was noticed in the right eye. While assessing the vikalpa samprapthi, with the help of OCT images, the increased oedema was identified and this can be correlated to kapha kopa in right eye, which may have resulted from sheeta kriyas which was adopted. This highlights the importance of maintaining the balance of kapha in pitta pradhana netra. The netra in shiras is always prone to abhishyanda. Thus stressing the importance of anjana application which would have maintained the balance of kapha and pitta.
Concept no 4: Improper administration of kriyakalpa- reflection of importance of considering the samyak yoga lakshanas
A diagnosed case of neovascular glaucoma as a complication of treatment for NPDR approached the hospital. On taking the history, it was found that he had undergone Avastin injection as well as laser treatment. As per the treatment history he had further undergone Ayurvedic treatment for 6 years which was of no benefit. `He also underwent a course of IP treatment after which he developed macular oedema in both eyes. He further underwent 2 courses of IP treatments with 90 days tarpanam which apparently resulted in development of neovascular glaucoma in the right eye. On consulting modern doctors, he was suggested to do cyclocryotherapy. However he was unwilling.
In this case, the patient is a pramehi and in such a condition, nitya langhanam is advised. In such a case it would have been better to do anjana karma. Here, in the abhishyandi avastha, the patient was treated with bruhmana therapy (tarpana ), that too for a long course and it may be due to atibruhmana effect of tarpana that the patient developed athimantha.
Concept no 5: Vikalpa samprapthi and potential treatment Plan
A case with complaints of swelling in upper lid which was diagnosed as chalazion after examination. As per the treatment history, patient had no relief even after using topical antibiotics. Such a condition is generally correlated to lagana in Ayurveda, which is kapha dosha pradhana avastha. However here initially considering the paaka avastha bidalaka and pitta shaman prayogas, used in pitakas were done. This swelling being hard in nature, the presence of kapha should also have been raised. Considering the presence of kapha, even though paaka avastha, peedana dravya lepana were done over the pitaka. Similarly swedanam, vimlapanam, peedanam, daranam and ropanam can be done as it is kapha dosha predominant. A complete cure was reported within 7 days. Thus highlighting the importance of vikalpa samprapthi and treatment plan.
Concept no 6: Relevance of exploring the nidanas in all dimensions
A case was presented with facial asymmetry and headache developed as a complication of thermo coagulation which was done to relive the pain of trigeminal neuralgia. Considering the unilateral right sided facial pain (maxillary and ophthalmic area), it was taken to be vata predominant condition initially. But after the diet assessment, wherein the patient’s daily diet included abhishyandi aharas such as fish, pickles and increased intake of chicken and stale food (previous day rice mixed with curd), it was diagnosed as kapha avruta vatika condition. One course of IP treatment including sadyasnehana, vamana followed by teekshna nasya was done. Patient had 90% relief, and she continued prathimarsha nasya which is still continuing. This highlights the importance of proper assessment of nidanas in dosha assessment for the correct understanding of aetiopathogenesis of disease.
Concept no 7: Importance of proper history taking – targeting the assessment of nidana
A 14 year old boy presented with complaints of head ache, nasal blockage and breathing difficulties since 10 years. He had underwent adenoidectomy and bilateral myringotomy at his 3 yrs. of age. But the symptoms recurred. Here in this case when his diet history was analyzed, it was found that he frequently have egg, idly and dosha which are kaphakara, which is an anupashaya in his case and the major reason for this recurrence He was diagnosed with bilateral maxillary, ethmoidal, sphenoid sinusitis and treatments such as sadyovamana, prathimarsha nasya and internal medications targeting the kapha dosha was done. A complete cure was reported. This shows the importance of addressing the involved dosha assessing through proper history taking.
Conclusion
• Nidana the key factor in deciding treatment plan even in the absence of other objective evidences. Nidana is not only the causative agent. It’s a great factor in deciding the treatment plan. Even in the absence of other supporting signs and symptoms, it will help you in deciding an effective treatment plan. This is the real beauty of Ayurveda.
• Usually upasaya permits to proceed but anupasaya give the chance to rethink and withdraw. The saying “Koodiyitt kurayum” this is not an ethical reasoning and never let anupasaya to proceed.
• We have to in cooperate modern techniques to get more clarity in the concepts, so that we will get a clear-cut vikalpa samprapthi and we can make a very good treatment plan.
• However whenever a patient comes to our OPD with complaints like deafness, it is our responsibility to examine properly- such as, in this case, to assess if the tympanic membrane is intact or not, with the help of a torch.
This is the way that Ayurveda needs to be learnt, practiced, convince ourselves as well as the students. The approach to a disease needs to be solely based on our basic principles. It does not matter even if we fail to do things right initially, the efforts that each of us take to improve ourselves is the important aspect of learning. By reaching into the depths of this science, we can analyze the effectiveness. To be able to grasp this scientific knowledge, we need to always have a positive attitude towards our science. Faith in Ayurveda is essential for all. Surely Ayurveda is scientific. There are lot of concepts in Ayurvedic texts however they are scattered here and there. One needs to explore and find the right path to set an example to the students from their first year of studying itself. It is only when one takes maximum effort to understand the disease properly and to ensure the proper treatment plan as well as by taking regular follow ups and by comparing the results which could have been achieved through available modern treatments, can one to prove the immense scope of Ayurveda. When we approach Ayurveda through a confident look, we in turn as impregnating the future generation of Ayurveda to turn toward Ayurveda without self-doubting. Wishing you all gooduck.
Article Prepared by
Vd. Sreedevi.V
Assistant prof, Dept of shalakyatantra, AACV
Vd. Aswin T Das
Assistant prof, Dept of shalakyatantra, AACV