A comparative clinical study to evaluate the efficacy of ...

A comparative clinical study to evaluate the efficacy of Triphala choorna with Krishnadi anjana and Triphala choorna in the management of Timira w.s.r. to Senile

immature cataract

by

Santosh Kumar Shaw

Dissertation Submitted to the

Rajiv Gandhi University of Health Sciences, Karnataka, Bengaluru

In partial fulfillment

of the requirements for the degree of

Ayurveda Dhanwantari Master of Surgery (Ayu)

in

Shalakya Tantra

Under the guidance of

Dr. Sujathamma K

Department of Post Graduate Studies in Shalakya Tantra

Sri Kalabyraveshwaraswamy Ayurvedic Medical College, Hospital & Research centre,

Vijayanagar, Bengaluru- 560 104

2015 – 2018

Scanned by CamScanner

Page I

ABBREVIATIONS

“A COMPARATIVE CLINICAL STUDY TO EVALUATE THE EFFICACY OF TRIPHALA

CHOORNA WITH KRISHNADI ANJANA AND TRIPHALA CHOORNA IN THE

MANAGEMENT OF TIMIRA W.S.R. TO SENILE IMMATURE CATARACT” Page VI

LIST OF ABBREVIATIONS USED

A. H. Ni. Ashtanga Hridaya Nidanasthana

A. H. Su. Ashtanga Hridaya Sutrasthana

A. H. Ut. Ashtanga Hridaya Uttarasthana

A. S. Sha. Ashtanga Sangraha Sharirasthana

A. S. Su. Ashtanga Sangraha Sutrasthana

A. S. Ut. Ashtanga Sangraha Uttarasthana

B. P. Bhavaprakasha

B. P. Ma. Bhavaprakasha Madhyamakhanda

B. P. N. Bhavaprakasha Nighantu

Bh. Sha. Bhela Sharirasthana

Bh. Su. Bhela Sutrasthana

BID Twice a day

Ch.S.Chi. Charaka Samhita Chikitsasthana

Ch.S.Ni. Charaka Samhita Nidanasthana

Ch.S.Sha. Charaka Samhita Sharirasthana

Ch.S.Su. Charaka Samhita Sutrastana

Ch.S.Si. Charaka Samhita Siddhisthana

C.D. Chakradatta

D Dioptre

Dal. Dalhana tika

G.N. Gada Nigraha

H.S. Harita Samhita

ABBREVIATIONS



MANAGEMENT OF TIMIRA W.S.R. TO SENILE IMMATURE CATARACT” Page VII

HS Highly significant

Ka.S. Kashyapa Samhita

M.N. Madhava Nidana

NS Nonsignificant

Pg Page

Pp Printed pages

Rig. Rigveda

S Significant

Sha.S.Pu. Sharangadhara Samhita Purvakhanda

Sha.S.Ut. Sharangadhara Samhita Uttarakhanda

Su.S.Sha. Sushruta Samhita Sharirasthana

Su.S.Su. Sushruta Samhita Sutrastana

Su.S.Ut. Sushruta Samhita Uttaratantra

Y.R. Yoga Ratnakara Uttarardha

V.S. Vangasen Samhita

< Less than

> Greater than

% Percentage

LIST OF TABLES



MANAGEMENT OF TIMIRA W.S.R. TO SENILE IMMATURE CATARACT” Page VIII

LIST OF TABLES

Sl.No. Tables Pages

01. Description of Timira in Brihatrayis 8

02. Description of Timira in Laghutrayis and other Medieval texts 9-10

03. Classification of Netrarogas based on Adhistana 47

04. Viharaja nidana of Netrarogas by various Acharyas 51

05. Aharaja nidana of Netrarogas by various Acharyas 52

06. Manasika nidana of Netrarogas by various Acharyas 52

07. Samprapti ghataka of Timira 54

08. Samanya Purva Rupas of the Netra rogas 56

09. Patalagata Timira Lakshanas according to various Acharyas 57

10. Timira lakshanas based on location of doshas according to

various Acharyas 58

11. Kriyakalpas mentioned by various Acharyas 81

12. Container used for storing anjana dravyas 84

13. Type of Anjana shalaka 85

14. Classification of Anjana Based on Karma 85

15. Classification of Anjana based on Rasa, Guna and Karma 86

16 Classification of Anjana based on Kalpana 86

17. Anjana matra as per Acharya Sushruta 90

LIST OF TABLES



MANAGEMENT OF TIMIRA W.S.R. TO SENILE IMMATURE CATARACT” Page IX

18. Anjana matra as per Acharya Vagbhata 90

19. Anjana matra as per Sharangadhara samhita 91

20. Anjana kala as per Sharangadhara 91

21. Anjana kala as per Acharya Sushruta 91

22. Details of Haritaki 93

23. Details of Vibhitaki 94

24. Details of Amalaki 95

25. Details of Pippali 96

26. Details of Bhringaraja 97

27. Pharmacodynamic properties of Goghrita 98

28. Composition of Goghtrita 99

29. Details of Madhu 99-100

30. Scoring index 109-111

31. Distribution of patients based on Age 112

32. Distribution of patients based on Gender 113

33. Distribution of patients based on Religion 114

34. Distribution of patients based on Marital status 115

35. Distribution of patients based on Educational status 115

36. Distribution of patients based on Socio-economic status 116

LIST OF TABLES



MANAGEMENT OF TIMIRA W.S.R. TO SENILE IMMATURE CATARACT” Page X

37. Distribution of patients based on Habitat 117

38. Distribution of patients based on Occupation 118

39. Distribution of patients based on Diet 119

40. Distribution of patients based on Sleep 120

41. Distribution of patients based on Addiction 121

42. Distribution of patients based on Family history 122

43. Distribution of patients based on Chronicity 123

44. Distribution of patients based on Bala pramana pariksha 125-126

45. Distribution of patients based on Nidana 131

46. Distribution of patients based on Lakshana 133

47. Distribution of patients based on Visual acuity(DV) 134

48. Distribution of patients based on Visual acuity(NV) 136

49. Effect of treatment on Avyakta Darshana within the groups 138

50. Effect of treatment on Avyakta Darshana between the groups 139

51. Effect of treatment on Gocharavibhrama within the groups 140

52. Effect of treatment on Gocharavibhrama between the groups 140

53. Effect of treatment on Vihwala darshana within the groups 142

54. Effect of treatment on Vihwala darshana between the groups 143

55. Effect of treatment on Dwidha-bahudha drushti within the

groups 144

LIST OF TABLES



MANAGEMENT OF TIMIRA W.S.R. TO SENILE IMMATURE CATARACT” Page XI

56. Effect of treatment on Dwidha-bahudha drushti between the

groups 145

57. Effect of treatment on Glare within the groups 146

58. Effect of treatment on Glare between the groups 147

59. Effect of treatment onVisual acuity (Distant vision) within the

group 148

60. Effect of treatment on Visual acuity (Distant vision) between

the groups 149

61. Effect of treatment on Visual acuity(Near vision) within the

group 150

62. Effect of treatment on Visual acuity (Near Vision) between the

groups 151

LIST OF FIGURES



MANAGEMENT OF TIMIRA W.S.R. TO SENILE IMMATURE CATARACT” Page XII

LIST OF FIGURES

Sl. No. Figures Pages

01. Distribution of patients based on Age 112

02. Distribution of patients based on Gender 113

03. Distribution of patients based on Religion 114

04. Distribution of patients based on Marital status 115

05. Distribution of patients based on Educational status 116

06. Distribution of patients based on Socio-economic status 117

07. Distribution of patients based on Habitat 118

08. Distribution of patients based on Occupation 119

09. Distribution of patients based on Diet 120

10. Distribution of patients based on Sleep 121

11. Distribution of patients based on Addiction 122

12. Distribution of patients based on Family history 123

13. Distribution of patients based on Chronicity 124

14. Distribution of patients based on Bala pramana pariksha 126

15. Distribution of patients based on Nidana 131

16. Distribution of patients based on Lakshana 133

17. Distribution of patients based on Visual acuity(DV) 135

LIST OF FIGURES



MANAGEMENT OF TIMIRA W.S.R. TO SENILE IMMATURE CATARACT” Page XIII

18. Distribution of patients based on Visual acuity(NV) 136

19. Effect of treatment on Avyakta Darshana within the group 139

20. Effect of treatment on Gocharavibhrama within the group 141

21. Effect of treatment on Vihwala darshana within the group 143

22. Effect of treatment on Dwidhabahudha drushti within the group 145

23. Effect of treatment on Glare within the groups 147

24. Effect of treatment on Visual acuity (Distant vision) within the

group 149

25. Effect of treatment on Visual acuity (Near vision) within the

group 151

ABSTRACT



MANAGEMENT OF TIMIRA W.S.R. TO SENILE IMMATURE CATARACT” Page XV

ABSTRACT

Title:

A comparative clinical study to evaluate the efficacy of Triphala choorna with

Krishnadi anjana and Triphala choorna in the management of Timira w.s.r. to Senile

immature cataract.

Background & Objectives:

Timira is one among the drishtigata nerta roga explained by our ancient

Acharyas. If proper care is not taken, Timira leads to kaca which in turn to linganasha.1

Based on the clinical manifestations it can be correlated to cataract. Any opacity in the

lens or its capsule, whether developmental or acquired is called as cataract.2 There are no

non-surgical measures which delay, prevent or reverse the development of cataract in

conventional system of medicine, the only definite management is lens extraction once it

reaches matured stage.

Objectives are to evaluate the efficacy of Triphala choorna with Krishnadi

anjana and Triphala choorna in the management of Timira and to compare the clinical

efficacies of both the groups.

Methods:

A randomized clinical study was taken up. 40 patients of Timira were selected

from OPD/IPD of the Shalakya tantra department of SKAMCH&RC, Bengaluru and

made into two groups. Patients of Group A were treated with Krishnadi varti anjana

along with Triphala choorna internally for 48 days. Patients of Group B were treated

ABSTRACT



MANAGEMENT OF TIMIRA W.S.R. TO SENILE IMMATURE CATARACT” Page XVI

with Triphala choorna internally for 48 days. The effect of treatment was statistically

analyzed using Unpaired and Paired student’s ‘t’–test.

Results:

The group with both Krishnadi varti anjana and Triphala choorna responded

better when compared to the group with only Triphala choorna based on statistical

analysis indicating the added effect of Krishnadi varti anjana in Group A.

Interpretation & Conclusion:

Krishnadi varti anjana and Triphala choorna are the two effective modalities of

treatment which can be adopted in Timira w.s.r. to Senile immature cataract.

Key words: Timira; Cataract; Triphala choorna; Krishnadi varti anjana.

INTRODUCTION



MANAGEMENT OF TIMIRA W.S.R. TO SENILE IMMATURE CATARACT” Page 1

Title:

A comparative clinical study to evaluate the efficacy of Triphala choorna with

Krishnadi anjana and Triphala choorna in the management of Timira w.s.r. to Senile

immature cataract.

Introduction:

Ayurveda is the most ancient science of life and Shalakya tantra is one of the

branches of Ashtanga Ayurveda which deals with the prevention and treatment of

Urdhwajatrugata rogas including netra.

Eyes are the most precious gift of the God to the living beings. Good vision is

crucial for social and intellectual development of a person. According to Ayurveda,

“sarvendriyanaam nayanam pradhanam” i.e., among all the sense organs, eyes are the

most important. “Everyone should be dedicated enough to protect their vision, throughout

the period of life because for an individual who is blind, day and night are the same and

the beautiful world is useless to him even if he possess lot of wealth.3

Acharya Sushruta explains seventy six netrarogas.4 Among them Timira is an

important disease, explained under Drushtigata rogas. Clinical features of dwiteeya

patalagatha timira and some features of triteeya patalagata timira such as avyakta

darshana, gochara vibhrama and dwidhabahudha drushti is simulated to that of signs

and symptoms of immature cataract. The early symptoms of cataract include blurrness of

vision, glare, polyopia and colour halos.5

According to WHO “In spite of the progress made in surgical techniques in many

countries during the last ten years, cataract (47.9%) remains the leading cause of visual

INTRODUCTION




impairment in all areas of the world, except for developed countries.”6 As per National

Programme for Control of Blindness of Govt. of India about 62.60% blindness is due to

cataract.7

If proper care is not taken at time, Timira leads to kaca which in turn to

linganasha.8

There are no non-surgical measures which delay, prevent or reverse the

development of senile cataract in conventional system of medicine, the only definite

management is lens extraction once it reaches matured stage or complete opacification.

The success rate of cataract surgery is more than 90%9, but complications such as

sensitivity to anaesthesia, injury to the cornea and iris, vitreous loss, expulsive choroidal

haemorrhage, uveitis, retinal detachment, secondary cataract etc may occur which cause

loss of vision.10

The treasure of ancient wisdom depicted in our classical texts has to be

considered at this critical juncture which provides potentiality in probing of disease

and its management through vast scientific advancements.

Ocular therapeutic like Anjana karma11

and internal administration of Triphala

choorna12

are mentioned in Ayurvedic classics for the management of Timira roga. Thus

the present study is being undertaken to scientifically study and validate the effect of

Triphala choorna and Krishnadi varti anjana in the management of Timira.

OBJECTIVES




Objectives

To evaluate the efficacy of Triphala choorna with Krishnadi Anjana in the

management of Timira w.s.r. to Senile Immature Cataract.

To evaluate the efficacy of Triphala choorna in the management of Timira

w.s.r. to Senile Immature Cataract.

To compare and evaluate the clinical efficacies of both the groups.

REVIEW OF LITERATURE




Review of literature

Historical review

Ayurvedic review:

Development of Ayurveda- “the science of life” has taken place from the

beginning of the creation as it was the necessity of human beings to preserve their health.

Vedas - the oldest records of mankind has vast scattered references about medical

knowledge. History is a root of knowledge in scientific researches. In the initial stage of

planning in any scientific work, it is very important to know the evolution of the present

knowledge, origin of the present knowledge and the basic idea given by ancient

scientists. Hence, at the outset an attempt is made to throw light over the history of the

eye disease, Timira w.s.r. to immature cataract.

Shalakya tantra is one of the renowned branch of Ashtanga Ayurveda is a unique

contribution to the present modern world. A Greek physician Megasthanes (BC 300) who

visited northern part of India in 300BC wrote in his book „Indica‟ that Indians had their

own remedies for curing Urdhwa jatrugata rogas.14

The king of Videha, Rajarshi Nimi was the original expounder of the Shalakya

Tantra; hence it is also called as „Nimi Tantra‟. Nimi got knowledge from Sun God

(Brahma kanda 16). Today Sushruta Samhita is the main source of Shalakya Tantra.

Acharya Sushruta has accepted that the description regarding Shalakya given in

Uttartantra has been taken from Videha Tantra. Gargya Tantra, Galava Tantra, Satyaki

Tantra, Karala Tantra and Shounaka Tantra are other legends of Shalakya Tantra.15





The references pertaining to netra rogas in general and Timira in specific have been

compiled from the following periods:

Vedic period: (5000BC to 1500BC)

In Vedic periods we find many references in the „Rigveda‟, curing the disease by

medicine as well as surgery by Ashwini kumaras. The word Timira means Andhakara or

sequel of it i.e. Linganasha (loss of vision) is taken into consideration, there are many

references in the Vedic literature to support the same. Here are few examples found in

these literatures which are related to Shalakya Tantra, probably it is the first evidence of

flourished medical knowledge and the treatment of eye diseases have been recorded in

the history.

In „Rigveda‟, we have reference of replacement of injured eye with artificial eye

(1.116.16). There are references available in texts where Ashwini kumaras have

cured the blindness and the persons Kanwa, Rijaswa, Paravrija, Kaksivit, Kavi puru

regained their eyesight. (Rigveda 1.112, 116, 117)

In Yajurveda, various anjanas were mentioned to cure the eye diseases like sisa

anjana and also for Timira roga chikitsa with medicated ghee prepared from

sahadeva, satavari, rasna, guduchi, saireyaka and triphala are described. (Yajurveda

21/36)

Atharva Veda is a vital source of origin of Ayurveda. In Atharva veda there is

description of several indications of Anjana for improvement of vision (7.30.36) and

other local medicaments (19.45.4) has mentioned. (Akshiroga bheshaja 6/16)





Upanishad period (4000 BC to 1000 BC)

During Upanishad period, various authors wrote several books on the subject of

Shalakya like Nimi Tantra, Videha Tantra, Karala Tantra, Gargya Tantra, Kankayana

Tantra, Galava Tantra, Krishnatreya Tantra, Satyaki Tantra,Chakshushya Tantra,

Shaunaka Tantra but unfortunately none of those books are available today; but

commentators of various Samhitas and other books quote names of these books and some

shlokas.

Brhadaranyaka Upanishad (11.2.3) has narrated that two eyes are Vishwamitra and

Jamadagni; they are located in two of the seven cavities of the skull.

Brhadaranyaka Upanishad (11.2.3) has also mentioned that Urdhwa vartma, Adhara

vartma and three distinct layers of the eye ball as Suklam, Lohinum and Krishnam.

Chandogya Upanishad (1.6.5 and 1.6.6) has described internal features of eye with

its reflections as Shukla-bha, Neela-bha and Krishna-bha. It has identified golden

glow inside the eyes.

Chakshushopanishat is a short summary of prayers to sun, chanting of which

promote eye sight and better health.

Samhita period (2000 BC to 800 AD)

In Samhita period “Netra Rogas” have been elaborately illustrated by all the authors

of the Ayurvedic literatures.

Acharya Charaka (200BC) mentioned the eye diseases as four in Sutra sthana16

and

ninty-six in chikitsa sthana explained some of the names of eye diseases like

Vartmastambha, Vartamasankocha, Timira, Pilla Roga etc., in chikitsa stana.17





Acharya Charaka has included Timira under the Vata Nanatmaja Vyadhi.18

Statement of Charaka indicates that Shalakya was well established in that period.

Acharya Sushruta (200 AD), the first and the foremost scientist of the

Dhanvantarian School, has given vivid description of Urdhvajatrugata Rogas in

Uttaratantra where he described ailments of netra, karna, nasa and shiro-rogas.

Acharya Sushruta was a pioneer of the Indian Surgery, and hardly left any

specialized branch. His contribution to the surgical field is a most valuable and

priceless gift. He had described ophthalmology in a systematic way. Acharya

Sushruta has devoted first twenty six chapters in Uttara Tantra, last chapter of

Nidana Sthana, 16th chapter of Sutra sthana and 22nd chapter of Chikitsa Sthana for

Shalakya Tantra. He has described Timira roga in detail19

along with its treatment20

in uttaratantra.

In Ashtanga Sangraha21

(600 AD), and Ashtanga Hridaya22

(800 AD), there is

description of ninety-four eye diseases. They have described Timira under 27 types

of Drishtigata rogas. Vagbhata considers Timira, kacha and linganasha as separate

clinical entities and each of them are of six types.





Table No. 01 Description of Timira in Brihatrayis:

Text Sthana Chapter No.& Name Reference

Charaka

Samhita

Sutrasthana 19- Ashtodareeyam 4types of netrarogas

Chikitsa

sthana

20- Maharoga adhyayam

26-Trimarmeeya chikitsitam

-Timira as nanatmaja

vyadhi of vata

-96 Netrarogas

-Netraroga lakshana &

Chikitsa

Sushruta

Samhita

Uttaratantra 7- Drushtigataroga

Vijnaneeyam

-Timira types and lakshana

Uttaratantra 17-Drushtigataroga

pratishedham

-Timira chikitsa

Uttaratantra 18- Kriyakalpa vijnaneeyam -Detail explanation of

anjana vidhi

Ashtanga

hrudaya

Uttarasthana 12-Drushtiroga vijnaneeyam

13-Drushtiroga

pratishedham


-Timira chikitsa

Sutrasthana 23-Aschyotananjana viddhi -Anjana bhedadravya,

pratyanjana, bheda-matra,

Shalaka, kala, arha,

anarha, vidhi.

Ashtanga

Sangraha

Uttarasthana 15-Drushtiroga vijnaneeyam

16-Timira Pratishedham


-Timira chikitsa

Sutrasthana 32-Aschyotananjana vidhi -Anjana bhedadravya,

pratyanjana, bheda-matra,

Shalaka, kala, arha,

anarha, vidhi.





Medieval period: (700 AD to 1600 AD)

Chakrapani commenting on Acharya Charaka‟s Timira under the Vata

Nanatmaja Vyadhi says that other doshas are present only in lesser proportion

with Vata being predominant.

Gangadhara calls it a special Netra roga when it is explained as a „rupa of vataja

arsha‟ and as alpa drishti while „rupa of vataja grahani‟ is described.

Madhava Nidana23

(700AD), Chakradatta24

(1100 AD), Sodhala

(Gadanigraha)25

, Sharangadhara Samhita26

, Bhavaprakasha27

, Yogaratnakara28

,

Bhaishajyaratnavali, Hareeta samhita, Rasendrasara sangraha etc., have dealt

the subject in detail along with its management aspects. But regarding disease

aspect most of them have followed Sushruta‟s opinion only.

Many Rasa Shastra texts like Rasaraja Mahodadhi, Rasa Ratnakara, Rasa

Kamdhenu, Rasa Ratna Samucchaya (1300 AD) etc., have advised a number of

compound preparations for disease Timira, kacha and linganasha for both

external and internal routes.

Table No. 02 Description of Timira in Laghutrayis and other Medieval texts

Text Sthana Chapter No. Reference

Madhavanidana Uttarardha Chapter 59 Timira lakshana

Chakradatta Chapter 59 Netrarogadhikara Timira chikitsa

Gadanigraha _ 3-Netrarogadhikara -Timira lakshana

-Timira chikitsa





Sharngadhara

samhita

Prathamakhanda

Uttarakhanda

Chapter 7

Chapter 13

-Netraroga sankhya

-Kriyakalpa

Bhavaprakasha Madhyama

khanda

63-Netraroga

adhikara

-Timira lakshana, -Chikitsa,

Kriyakalpas

Yogaratnakara Uttarardham Netrarogadhikara Timira chikitsa

Bhaishajyaratnavali Netrarogadhikara Timira chikitsa

Hareeta samhitha Triteeya sthana 45-Netraroga

chikitsa

-Netrapushpa

-Patalagatadosha lakshanam

-Patalagatadosha chikitsa

Rasendrasara

sangraha

Chapter 2 Netraroga chikitsa Different formulations for

Timira and other netrarogas

Other textual references 29

Jain Agama classics like Sthananga sutra has mentioned treatments of eye

diseases like shiro basti, tarpana and putapaka.

Acaranga sutra has provided the list of diseases which also includes blindness

(kaniya).

„Pujyapada Muni‟ explains Timira as the „Upadrava of Meha roga‟ in his book

“Netra Prakashika”.

Mahayana baudha offers the details of akshi sula and also explains eradication of

blindness from the society.

Parahita Samhita is a compilation by Srinatha pandita of 15th

century, in which

description of akshiroga, shiroroga, karnaroga, mukharoga, nasaroga and

diseases of neck are mentioned.





Modern Review: 30

History of cataract

The oldest documented case of cataract throughout history was reported in a

famous and small statue from the 5th dynasty (about 2457-2467 B.C.) contained

in the Egyptian Museum in Cairo, Egypt.

This fact confirms that old Egyptians knew the disease. By analysis of ancient

surgical instruments it is possible to define the history of medical specialties, and

acquaint the evolution of specific surgical techniques and operations through the

centuries (Aruta et al., 2009). Scientists have often discussed whether cataract was

firstly operated in Ancient Egypt (Bernscherer, 2001). This hypothesis seems

plausible (Ascaso et al., 2009). Thus, a wall painting in the tomb of the master

builder Ipwy at Thebes (about 1200 B.C.) reveals an oculist treating the eye of a

craftsman. Because of the length of the instrument, the scene might also be

interpreted as a cataract surgery by couching of the lens into the vitreous cavity.

Cataract surgery by “couching” (lens depression) was, without a doubt, one of the

oldest surgical procedures. This technique involved using a sharp instrument to

push the cloudy lens to the bottom of the eye. Perhaps this procedure is that which

is mentioned in the articles of the Code of Hammurabi (Cotallo & Esteban, 2008;

Ascaso et al., 2011).

However, there are some doubts about the real meaning of the term “na-kap-tu”,

which someone translated as “cloud”and other directly as “waterfall”. It is even

possible that these articles of the Code of Hammurabi made some reference to





treatment of corneal pathology instead of cataract (Gorin, 1982). So, couching for

cataract is one of the most ancient surgical procedures.

This method may have been brought to the West by Greek travelers from India

and the Middle East (Wales, 2010). The removal of cataract by surgery was also

introduced into China from India (Lade & Svovboda, 2000).

New revolution: Cataract extraction surgery

Later, “couching” technique would be replaced by cataract extraction surgery.

The lens could be removed by suction through a hollow instrument. Bronze oral

suction instruments that have been unearthed seem to have been used for this

method of cataract extraction during the 2nd century A.C. Such a procedure was

described by the 10th-century Persian physician Muhammad ibn Zakariya al-Razi,

who attributed it to Antyllus, a 2nd-century Greek physician.

The procedure “required a large incision in the eye, a hollow needle, and an

assistant with an extraordinary lung capacity” (Savage-Smith, 2000).

The French ophthalmologist Jacques Daviel (1696–1762) was the first modern

European physician to successfully extract cataracts from the eye. He performed

the first extracapsular cataract extraction on April 8, 1747. It was the first

significant advance in cataract surgery since couching was invented.

John Taylor (1703-1772) was a coucher, or cataract surgeon, who performed

removal of cataracts by breaking them up into pieces.





The era of Intraocular Lenses (IOLs)

Sir Nicholas Harold Lloyd Ridley (1906, Kibworth Harcourt, Leicestershire –

2001, Salisbury, Wiltshire) was an English ophthalmologist who pioneered

artificial intraocular lens transplant surgery for cataract patients.

29 November 1949, Harold Ridley successfully implanted the first IOL at St.

Thomas‟ Hospital in London. The implant was made of an inflexible material

called PMMA. It was not until 1950 that he left an artificial lens permanently in

place in an eye.

The first lens was manufactured by the Rayner Company of Brighton & Hove,

East Sussex (Spalton, 2009).

The modern phacoemulsification technique

In 1967, Charles D. Kelman (1930, Brooklyn, New York–2004, Boca Raton,

Florida), an ophthalmologist pioneer in cataract surgery, introduced

phacoemulsification after being inspired by his dentist's ultrasonic probe. This

technique uses ultrasonic waves to emulsify the nucleus of the crystalline lens in

order to remove the cataracts without a large incision.





Rachana shareera of Netra

In Ayurvedic literature, the references regarding the anatomical description of

netra is scattered in different contexts and it is mentioned as an important sense organ

among the panchagnanendriyas.

Nirukti :

चष्टे रुऩं रुऩवन्तं च प्रकशमतत इतत चऺष् । (Ch.S.Su.8/8)

According to Acharya Charaka „chakshu‟ is one among pancha jnanendriyas

which is responsible for roopa grahana.

तत्र ऩूववाणि ऩंच फषध्दीन्द्न्िमवणि । (Su.S. Sha. 1/4)

Acharya Sushruta mentioned buddhindriya originating from „Roopatanmatra‟

which performed visual perception with the dominance of tejomahabhoota.

Synonyms and its meaning:

Chakshu, Akshi,Drishti, Lochanam, Netram, Nayanam

Chakshu :

1. Cakşa – Darşane + “Sinca Karaņe” Pratyaya31

(Vachaspatyam).

Which is responsible for sight.

2. Cakşa + “us” Pratyaya32

(Shabdakalpadruma)

Which means Darshanendriya.

3. According to Sir Monier Williams - It means eye, vision, faculty to see, Lord

Shiva, name of Maruta, Sage, Sun, responsible for sight.33





Akshi :

Ashu– to reach + “Ktin Karane” Pratyaya (Shabdakalpadruma)

अश्नषते अनेन 34

(Shabdakalpadruma)

This means source of reaching or seeing.

Drishti :

Driś – to see + “Ktin Karaņe” Pratyaya35

(Shabdakalpadrum)

Means source or tool with which one sees. The word „Drishti‟ has different

meanings in Ayurvedic texts including Netra, „Drishti‟ Mandala, Netrakriya

(vision), Darshana etc.

Lochanam :

Loch– to see + “ Karane lyut ” Pratyaya (Shabdakalpadrum)

Means the tool with which one sees.

रोचते अनेन इतत। 36 (Shabdakalpadruma)

Which has the capacity to see.

Netram :

Ni – to drive + “Ktin Karaņe” Pratyaya37

(Shabdakalpadruma)

Means which leads or drives one towards knowledge.

Nayanam :

Ni – to drive, to lead + “Karaņe Lyut” Pratyaya 38

(Shabdakalpadruma).

Means the source, which drives towards the subject.

Thus it is clear from the above discussion of the synonyms related to the organ of sight

that Akshi, Netra, Nayana and Lochana are the words used in anatomical sense and

Chakshu in functional.





Netra utpatti :

1. As per Acharya Sushruta Ekadasha indriyas are produced from vaikarika

ahankara with the aid of tejasa ahankara. Out of this first five are called

buddhindriyas, Next five are karmendriyas and manas is ubhayatmaka, having

both functions. 39

2. As per Acharya Charaka indriyas are made up of pancamahabhoota; in which

tejomahabhoota in chakshu, akasha in shrotra, prithvi in ghrana, jala in rasana

and vayu in twak are the specially dominated ones. 40

Embryological development of Netra :

The evolution of all sense organs occurs in the 3rd

month of intrauterine life (Ch.S.

Sha. 4/11) and completes at about 7th

month (A.S. Sha. 2/13). There were differences in

opinions among ancient Acharyas regarding the evolution of Netra.

1. According to Kashyapa and Bhela, eye is the first organ to develop in the foetus.

(Ka. S. and Bh.Sha. 4/30).

2. Videha Janaka (Ch.S. Sha. 6/21) opines that all Indriyas are the foremost organ to

develop in the foetus as they are the Adhisthana of Buddhi.

3. According to the opinion of Shaunaka, Shirah is the first organ to develop, as it is

the seat of Indriyas. (Su.S. Sha. 3/32).

4. Atreya and Dhanvantari conclude that all organs in the human body develop

simultaneously (Ch.S. Sha. 6/21 & Su.S. Sha. 3/32).





Panchabhoutikatwam of Netra :

ऩरं बूवो अन्द्ननतो यक्तं ववतवत ्क्रष ष्िं ससतं जरवत ् आकवशवदश्रषभवगवांश्च च जवमन्ते

नेत्र फषद्फषदे। (Su.S. Ut. 1/11)

Netra is composed of all the five Mahabhutas i.e,

The muscular portion of eye is derived from prithvi, rakta from agni,

krishnabhaga from vayu, shwetabhaga from jala and ashrumarga from

akashamahabhutas.

Tridosha in Netra rachana :

All 3 doshas have active part in normal functioning of eye.

Vata - Pranavayu, Udanavayu, Vyanavayu, Apanavayu

Pitta - Aalochakapitta, Saadhakapitta.

Kapha - Tarpaka kapha, Avalambaka kapha.

तथव कपयक्तववहहनवं स्रोतसवं भहवबूतवनवं च प्रसवदवहदन्द्न्िमवणि तेष्वपऩ च नेत्र ेश्रेष्भि्

प्रसवदवत ्शषक्रभण्डरं च तत ्पऩत्रषजभ ्भध्मे द्र्षन्द्ष्टभण्डरं च तत ्उबमवत्भकभ ्।

(A.S. Sha. 5/48-49)

Mamsa Prithvi

Rakta Agni

Krishna mandala Vayu

Shweta mandala Jala

Ashrumarga Akasha





Tridoshas play important role in determining the colour of the eye. like Teja in

association with Rakta dhatu results in Raktaksha (reddish eye) the same Teja in

association with Pitta forms Pingaksha (dark brown eyes) and with Kapha causes

Shuklaksha (pale eye), If Tejo Mahabhoota does not reach to Drishti part then child is

born congenitally blind and Vata in association with Tejo mahabhoota causes vikrutakshi.

Dhatus in Netra rachana:

All dhatus have active part in formation and normal functioning of netra.

Rasa, Rakta, Mamsa, Meda, Asthi, Majja, Shukra ( Sarvadehavyaapi)

Pramana and akruti of Netra:

Akshikoota:

It is the orbital cavity which is two in number. It is placed just below the bhru.

The eyeball is placed in akshikoota.

Netrakriti:

सषवतृ ंगोस्तनवकवयं सवाबूतगषिॊद्धवभ ्। (Su.S.Ut.1/10)

Eye ball is round and resembles the tout of a cow in appearance and originates

from all the five elements with their attributes.

Netra pramana:

पवध्मवत ्व्दमंगषरं फवहष ल्मं स्ववंगषष्टॊदय संसभतभ ्।

व्दमंगषर ंसवात: सवधां सबषक् नमन फषद्फषदं ॥ (Su.S.Ut.1/10)





Taking central part of the patient‟s own thumb as one finger unit, the eyeball

should be known by the clinicians to measure two finger units from before backwards

and a half from side to side. The distance between two eyes is two angulas.

नेत्रवमवभ त्रत्रबवगं तष कृष्िभण्डरभषच्मते ।

कृष्िवत ्सप्तसभच्छन्द्न्त दृन्द्ष्ट दृन्द्ष्टपवशवयदव् ॥ (Su.S.Ut.1/13)

The black circle of the eye is said to be 1/3rd

of the transverse extent of the eye

ball and the eye specialists consider drishti to measure 1/7th

of this black portion.

Parts of Netra :

भण्डरवतन च सन्धधंश्च ऩटरवतन च रोचने मथवक्रभं पवजवनधमवत ्ऩंच षट् च षडवे च।

(Su.S. Ut 1/14)

Parts of eye were described by Acharya Sushruta as five mandalas, six sandhis

and six patalas.

Acharya Vagbhatta, Bhavamishra and Madhavakara have also mentioned same

as Acharya Sushruta.

1) Netra mandala :

ऩंचनेत्र ेचक्रवदवन्तयत् भण्डरवतन । (A.S. Sha. 5/50 Indu teeka)

The consecutive circular layers of the eyes are termed as mandalas.

ऩक्ष्भ वत्भा श्वेत क्रष ष्ििषष्टीनवं भण्डरवतन तष

अनषऩूवां तष ते भध्मवश्च्त्ववयो अन्त्मव मथोत्तयभ।् (Su.S. Ut. 1/15)





The mandalas are 5 in number. They are pakshma, vartma, shweta, krishna and

drishti. Beginning from the first, the outer four lie successively towards the periphery if

considered from the last (drishti).

a) Pakshma Mandala-

This is the first and outermost mandala of the eye formed by the pakshma.

b) Vartma Mandala-

Upper and lower eyelids jointly form a circle in front of the eyeball, which is

termed as vartma mandala.

c) Shukla Mandala-

This portion appears as whitish and therefore known as shukla mandala.

d) Krishna Mandala-

This portion appears as blackish and therefore known as Krishna mandala.

e) Drishti Mandala:

It is the innermost circular structure of the netra.

भसूयदरभवत्रवं तष ऩंचबूतप्रसवदजवं। खद्मोत पवस्पष सरन्गवबवसभद्धवं तेजोसबयव्मम ्॥

आव्रषतवं ऩटरेनवक्ष्िौ फवह्मेन पववयवक्रष ततभ। शधतसवत्ममवं न्रषिवं िषन्द्ष्टभवहषनामन

चचन्तकव्। (Su.S. Ut.7/3)

The Acharya Sushruta describe size of drishti is like masura dala and it is

originated from the essence of panchabhutas, resembling glow worm and spark,

shining with constant light covered with the outer most layers of eyes, appearing

like a hole and suited for cold.





2) Netra sandhi:

ऩक्ष्भ वत्भागत् सन्द्न्धवात्भाशषक्रगतॊ अऩय् ।

शषक्रकृष्िगतस्त्वन्म: कृष्िदृन्द्ष्टगतॊ अऩय् ।।

तत् कनधतनकगत् षष्ट्श्चवऩवन्ग् स्भृत्। । (Su.S.Ut.1/16)

Netra Sandhis are junctional areas between two mandalas. There are 6 sandhis in netra:

a) Pakshma vartma gata sandhi-

The union line of Pakshma Mandala and Vartma Mandala is called as the

Pakshma Vartmagata Sandhi and it is considered as the lid margin.15

b) Vartma shukla gata sandhi-

The union line of Vartma and Shukla Mandala is called as Vartma Shuklagata

Sandhi. Fornix of the eyeball where the palpebral conjunctiva is reflected on to

the bulbar conjunctiva seems to be Vartma Shuklagata Sandhi.

c) Shukla krishna gata sandhi-

The circular line joining between Shukla Mandala and Krishna Mandala is called

as Shukla Krishnagata Sandhi. This junctional area can be considered as the

sclero - corneal junction i.e., Limbus.

d) Krishna drishti gata sandhi-

The union line of Krishna and Drishti Mandala is called as Krishna – Drishtigata

Sandhi. By considering iris part in Krishna Mandala, this Sandhi can be explained

and the central free margin of the iris, which rests on the anterior capsule of the





lens, can be considered as the Krishna Drishtigata Sandhi. Otherwise there is no

apparent union line between the cornea and pupil.

e) Kaneenika sandhi-

Acharya Dalhana describes kaneenika sandhi and it can be considered as the

inner or nasal canthus of the eye.

f) Apanga sandhi-

Acharya Dalhana describes apanga sandhi and it can be considered as the outer

canthus of the eye.

3. Netra patalas:

ऩटर दृष्टेयववयकभ ्। चऺषषव ऩयदव इतत बवषव ॥

Patalas means an enclosing membrane of the eye. V.S. Apte, in his Sanskrit –

English dictionary describes the meaning of Patala as a film or coating over the eyes.

According to Monier Williams, it can be considered as a layer of the eyeball.

The term patala denotes a thin membrane with a thickness of 1/5th

of width of drishti.

व्दे वत्भाऩटरे पवध्मवत ्चत्ववरय अन्मवतन चवक्षऺणि ।

जवमते ततसभयं मेषष व्मवचध् ऩयभ दवरुि् ॥ (Su.S.Ut.1/17)

Two patalas should be known to be the eye lids and other in the eye proper itself,

in which Timira, a most formidable disease occurs. The first two patalas are vartma

patala namely urdhwa vartma i.e., the upper eye lid and the adho vartma patala or lower

eyelid.





तेजॊजरवचश्रतं फवह्मं तेषष अन्मत ्पऩसशतवचश्रतभ ्।

भेदस्ततृधम ंऩटरवचश्रतं त्वन्द्स्थ चवऩयभ ्॥

ऩन्चभवंशसभं दृष्टेस्तेषवं फवहष ल्मसभष्मत े॥ (Su.S.Ut.1/18)

Out of them the outer most subsists in the tejas and jala, the next one is the mamsa,

the third patala in the meda and the last one is asthi. Their thickness is said to be 1/5th

of

the drishti. Acharya Dalhana has described the first or outermost patala as

“tejojalashrita” and the word Teja means alochaka pitta and so siragata rakta can be

taken as Teja. Jala, according to him implies rasa dhatu. So it can be considered that the

first patala is supported by rasa and rakta dhatus.

a) Tejojalashrita patala-

It is the outer most among four patalas.

अत्र तेजॊ शब्देनवरॊचक तेज् सभवश्रमं ससयवगत ंयक्त ंफॊध्दव्म ं। जर ंत्वक् गतॊ यस धवतष:

॥ (Dal. Su. S.Ut.1/18)

Acharya Dalhana interprets the word teja as alochaka teja present in the blood of

blood vessels and jala as rasa dhatu in twak. Bahya patala is supported by agni

and ambasi. This patala is nourished by rasa and rakta dhatus.

b) Pishitashrita/ mamsashrita patala-

It is supported by mamsa dhatu.

c) Medoshrita patala-

It is supported by medo dhatu.

d) Asthyashrita patala-

It is supported by asthi and particularly by kalakasthi.





Kriya shareera of Netra

Chakshu is the visual sensual faculty i.e., one of the panchendriyas.

आत्भेन्ि भनो अथवानवं सन्द्न्नकषवात प्रवतात े।

व्मक्तव तदत्वे मव फषन्द्ध्द् प्रत्मऺं स तनरुच्मत े॥ (Ch. S. Su.11/20)

A mental faculty is instantaneously manifested in a particular form as a result of

proximity of the soul, sense faculties, mind and the objects are known as pratyaksha

(percepition or direct observation).

भन् ऩषयस्सयवणि इन्द्न्िमवणि अथाग्रहि सभथवातन बवन्द्न्त । (Ch. S. Su.8/7)

The sense faculties are capable of perceiving their respective objective, only when

they are motivated by mind.

There are five kinds of perception viz., visual, tactile, auditory, gustatory and

olfactory. These are again the products of combination of sense faculties, their objects,

the mind and the soul; they are momentary and determinative.

These perceptions are momentary in the sense that they fade away soon. Even

though they fade away soon, they are determinative in relation to the size, shape etc., of

the objects just as a momentary light of a lamp illuminates its surroundings.

There are things which though existent, cannot directly be perceived due to over

proximity, over distance, weakness of senses, diversion of mind, confusion with other

similar objects, over shadowing and over minuteness.





इन्द्न्िमेि इन्द्न्िमवथां तष स्वं गॄह्िवतत भवनव् ।

न्द्स्थतं तषल्ममोतनत्ववत ्न अन्मेन अन्मसभतत न्द्स्थतत् ॥ (Su.S.Sh.1/15)

Human beings have the perception of the objects of indriyas by that indriyaartha

only because the origin of both is similar. One indriya cannot perceive the object of

another indriya.

Eye which receives the light and light which illuminates the object both are

derivatives of tejo mahabhuta. Hence eye perceives only rupa of the object and not other

characters like sound etc. Rupa is the adhibhuta, surya is the adidaiva of chakshu which

is adhyatma (pertains to soul)

Among 6 indriyas including manas, 3 perform functions with remoteness and 3

with proximation. Amongst these manas, eyes and ears function with remoteness while

nose, tongue and skin with proximation.

Role of alochaka pitta in visual perception:

अन्द्ननयेव शरयये पऩतवन्तगात् …… दशानभदशानभ ्…… । (Ch. S. Su.12/11)

It is agni alone represented by pitta which is responsible for vision or loss of

vision depending on its normal or abnormal state.

दशानवदशाने नेत्रगतस्मवरोचकस्म । (Chak. Ch. S. Su.12/11)

Alochaka pitta present in netra is responsible for vision or loss of vision.

Its function is to form the image of an external object presented to the eye.

रुऩवरॊचनत् स्भृतं दृकस्थभवरोचकं । (A.H.Su.12/14)

Alochaka pitta is situated in the eye and its function is rupa grahana or forming

images presented to it.





स न्द्व्दपवध् चऺषवैशपेषको फषन्द्ध्दवैशपेषकश्चतेत । (Bh. Sha.4/15)

Bhela has envisaged two aspects of alochaka pitta viz, chakshur vaisheshika and

buddhir vaisheshika.

The chakshurvaisheshika alochaka pitta begins its function after the sannikarsha

(union) of atma and manas, when the object has made contact with it, leading to the

production in chitta, the knowledge of the characteristics, form, colour etc., of such

things as flowers, fruits, leaves.

Buddhirvaisheshika is that which is located in shringataka, between the two eye

brows. It seizes subtle objects, retains and recalls them. This is the factor which enables

concentration, responses and cognition.

Role of other doshas in visual perception:

Vayu is the stimulator of all sensory organs and makes them to perceive their

respective objects. Pranavayu attends the function of chakshuradi sense organs.

Vyanavayu is responsible for closing and opening of eyes. The compactness of eye, its

Bandhana are all brought about by kapha.

सशय् संस्थॊ अऺतऩािवत ्तऩाक् । (A.H.Su.12/17)

Akshi Tarpana is the function of tarpaka kapha which is present in Shiras.





Anatomy and Physiology 41, 42

Anatomy of the eye:

The eye is situated in a quadrilateral pyramid-shaped bony cavity called orbit. Eye

ball is a cystic structure, not a sphere but an ablate spheroid. Each eye is protected

anteriorly by two shutters called the eyelids. The anterior part of the sclera and posterior

surface of lids are lined by a thin membrane called conjunctiva. For smooth functioning,

the cornea and conjunctiva are to be kept moist by tears which are produced by lacrimal

gland and drained by the lacrimal passages. These structures (eyelids, eyebrows,

conjunctiva and lacrimal apparatus) are collectively called „the appendages of the eye‟.

Dimensions of an adult eyeball

Anteroposterior diameter - 24 mm

Horizontal diameter - 23.5 mm

Vertical diameter - 23 mm

Circumference - 75 mm

Volume - 6.5 ml

Weight - 7 gm

Coats of the eyeball

The eyeball comprises three coats:

1) Outer - fibrous coat

2) Middle - vascular coat

3) Inner - nervous coat





1) Fibrous coat:

It is a dense strong wall which protects the intraocular contents.

Anterior 1/6th of this fibrous coat is transparent and is called cornea.

Posterior 5/6th opaque part are called sclera.

Junction of the cornea and sclera is called limbus.

Conjunctiva is firmly attached at the limbus.

2) Vascular coat:

Vascular coat includes three parts from anterior to posterior. These are

iris, ciliary body and choroid.

3) Nervous coat: It includes retina.

Segments and chambers of the eyeball:

1) Anterior segments

2) Posterior segments

1) Anterior segment:

Anterior segment includes:

Crystalline lens (which is suspended from the ciliary body by zonules)

Iris

Cornea

Aanterior and posterior chamber.

Anterior chamber: It is bounded anteriorly by the back of cornea, and posteriorly by the

iris and part of ciliary body. It contains about 0.25 ml of the aqueous humour.





Posterior chamber: It is a triangular space containing 0.06 ml of aqueous humour. It is

bounded anteriorly by the posterior surface of iris and part of ciliary body, posteriorly by

the crystalline lens and its zonules, and laterally by the ciliary body.

3) Posterior segment.

Posterior segment includes- Vitreous humour, Retina, Choroid and Optic disc.

Lens:

Lens is a transparent, biconvex, crystalline structure placed between iris and the

vitreous in a saucer shaped depression, the patellar fossa. The posterior surface of the lens

is in intimate contact with the vitreous in this fossa and is attached to it in a circular area

with ligamentum hyaloideo capsulare (Wiegert‟s ligament). With in this area, is a small

potential space called as retrolental or Berger‟s space. The lens is encircled by the ciliary

process, to which it is attached by the zonular fibres, collectively forming the zonule

holding the lens in place and transmitting the forces stretching the lens except in visual

accommodation. The zonular fibres are inserted into the lens capsule, a basement

membrane completely enclosing the eye.

Dimensions of the lens:

Equatorial diameter: 6.5 mm at birth, increases to 9-10 mm in second decade

then remains constant.

Thickness (Axial/Anteroposterior diameter): 3.5 mm (at birth) to 5 mm (at

extreme of age)

Weight: (0-9 years) - 135 mg, (40-80 years) - 255 mg





Surfaces: Anterior surface – Less convex (radius of 8 to 14mm.)

Post surface - More curved (radius of 4.5 to 7.5 mm.)

Both surfaces meet at the equator

Poles (and post):

Anterior pole - Centre of the anterior surface

Posterior pole- Centre of the posterior surface

Refractive Index: 1.39

Nucleus - 1.42, Cortex- 1.38

Refractive Power: 16 – 20 D

14-16 D at Birth, 7-8 D at 25 years and 1-2 D at 50 years of age.

Colour: Changes with age

Infants – Transparent, Young Adults - Colourless

By 30 years - Definite yellow finge, Old Eye - Amber colour

Structure of the Lens:

1. Lens capsule:

Capsule is the outer covering of lens. It is thin, transparent, hyaline collagenous

membrane surrounding the lens completely. Though the capsule has no elastic

tissue, it is highly elastic. The elastic nature of lens is of much importance in the

mechanism of accommodation. The lens capsule is secreted by the basal cell area

of the lens epithelium anteriorly and by the basal area of the elongating fibres

posteriorly. The lens capsule is thickest at pre equator regions (14micron) and

thinnest at the posterior pole (3 μ). Light microscopy shows capsule to be as a





transparent structure. Ultra microscopy reveals the lamellar appearance of the lens

capsule. Each lamella contains fine filaments. During exfoliation of capsule, it is

these superficial lamellae getting separated (splitting off) from deeper layers.

Principally it is composed of type IV collagen and 10% glycosamino glycans and

also contains enzymes, ATP and glycolytic intermediates.

2. Anterior lens epithelium:

Anterior lens epithelium is a single layer of cuboidal nucleated epithelial cells

which lies deep to the anterior capsule. These cells contain all the organelles

found in typical epithelial cells. The entire lens metabolic activities, synthetic and

transport processes of the lens occurs in this layer. It is the cells of this layer,

which are actively involved in dividing and elongating to form new lens fibres

throughout life, but limited to equatorial region. There is no posterior lens

epithelium, as these cells are used up in filling the central cavity of lens vericle

during development of the lens. Anterior lens epithelium has highest metabolic

rate. Have prominent, well characterized cytoskeletal network consisting of actin,

vimentin, spectrin, microtubules, alpha actinin and myosin. Anterior epithelium

can be divided into 3 zones- Central Zone, Intermediate Zone and Germinative

zone.

Central Zone- This zone is of some importance as the age progresses. The

cuboidal epithelium of this region reduces with age and under normal

circumstances do not undergo mitosis. If tissue insult occurs, repair occurs by





elongating the epithelial cells resembling fibroblasts and as much as up to 10

layers thick cell piling up occurs leading to anterior subcapsular cataract.

Intermediate Zone- Consists of much smaller and more cylindrical cells located

peripheral to central zone.

Germinative zone- Situated most peripheral and cells are actively dividing to

form new cells which migrate posteriorly to become lens fibres. Dysplasia of

these cells results in posterior subcapsular cataract.

3. Lens fibres:

The epithelial cells elongate to form lens fibres which have a complicated

structural form. Mature lens fibres are cells which have lost their nuclei. As the

lens fibres are formed throughout the life, these are arranged compactly as

nucleus and cortex of the lens.

Nucleus-

Nucleus is the central part containing the oldest fibres. It consists of different

zones, which are laid down successively as the development proceeds. In the

beam of slit-lamp these are seen as zones of discontinuity. Depending upon the

period of development, the different zones of the lens nucleus include:

Embryonic nucleus is the innermost part of nucleus which corresponds to the

lens up to the first 3 months of gestation. It consists of the primary lens fibres

which are formed by elongation of the cells of posterior wall of lens vesicle.





Fetal nucleus lies around the embryonic nucleus and corresponds to the lens

from 3 months of gestation till birth. Its fibres meet around sutures which are

anteriorly Y-shaped and posteriorly inverted Y-shaped.

Infantile nucleus corresponds to the lens from birth to puberty, and

Adult nucleus corresponds to the lens fibres formed after puberty to rest of the

life.

Cortex-

It is the peripheral part which comprises the youngest lens fibres.

4. Suspensory ligaments of lens (ciliary zonules):

It consists of a series of fibres which run from the ciliary body and fuse into the

outer layer of the lens capsule around the equatorial zone. Thus, they hold the lens

in position and enable the ciliary muscle to act on it. Structurally, the ciliary

zonules are transparent, stiff and not elastic. Each zonules are composed of

microfibrils and fibres are made up of glycol protein and muco polysaccharides.

They are susceptible for hydrolysis by α-chymotrypsin has been used to

advantage in intracapsular cataract surgery. These zonular fibres are divided into

4 zones- Pars orbicularis, Zonularplexus, Zonular Fork and Zonular limbs.

Apart from these main zonular fibres, there are other supporting fibres/ auxillary

fibres that help lens to maintain its position they are hyaloid zonule, hyalocapsular

zonule and circumferential zonular girdle.





Biochemical composition of lens

Main constituents of the lens are water and proteins. Water constitutes about 65 %

of the lens wet weight of the solids; the highest is protein which constitutes about 34 % of

the total weight of an adult lens. The other constituents present in the lens are lipids,

inorganic ions, carbohydrates particularly glucose and its derivatives, ascorbic acid,

glutathione and amino acids.

Lens water:

Lens is a relatively dehydrated organ, cortex being more hydrated than nucleus.

Lens dehydration is maintained by an active sodium pump that resides with in the

membrane of the cell, in the lens epithelium and in each lens fibre. 80% of water is in

free form while remaining is bound water low amount of water is necessary to

differentiate it from the surrounding acqueous structures in refractive indices.

Proteins:

Lens has richest content of proteins than any other structures/organs of the body.

The structure of these proteins is very important in maintenance of transparency of lens.

The proteins of crystalline lens can be divided into an insoluble fraction at physiological

PH called Albuminoids and the soluble fraction called crystallins.

Various protein fractions in the lens as follows:

Insoluble albuminoid - 12.5%

Alpha- crystalline - 31.7%

Beta- crystalline - 53.4%

Gamma-crystalline or albumin - 1.5%

Mucoproteins - 0.8%

Nucleoproteins - 0.07%





Beside these few minor proteins like glycoproteins, phosphoprotein, lipoprotein

and fluorescent proteins are reported in the lens.

Crystallins:

As much as 40 % of net weight of lens fibre cells can be accounted for crystalline.

It can be classified as classical and taxon specific. Classical crystallins include members

of the alpha crystallins family and the beta/gamma crystallins super family. All vertebrate

lenses accumulate large amounts of classical crystalline in their lens. There are many

transcription factors which are responsible for high lens specific crystalline gene

expression. Protein structure of alpha crystallins showed that they are members of the

family of small heat shock proteins.

An important function of small heat shock proteins is to stabilize proteins that are

partially unfolded and prevent them from aggravating (chaperone activity). Thus

increases in alpha crystallins prevent protein aggregation. Excessive protein aggregation

could lead to light scattering and cataract formation.

Insoluble proteins:

The chief insoluble protein of lens is albuminoid. It is a mixture since it is only

partly digested by the urea. Amino acid composition of albuminoid is similar to alpha

crystallin. The urea soluble and insoluble albuminoid varies with species.

Amino acids:

Two groups of amino acids are present in the lens: Proteogenic and Non-

proteogenic.





Carbohydrates:

Metabolism of carbohydrates in lens is of highly active and complex. Free

carbohydrate of normal crystalline lens is glucose, fructose and glycogen. Derivates of

sugar found in lens are sorbitol, inositol, ascorbic acid, gluconic acid and glucosamine.

Lenticular glucose has its source in acqueous humor. Fructose is produced from glucose

in the crystalline lens. The concentration of glycogen varies with age and the region of

lens, lenticular glycogen is localized in nucleus where it appears to replace alpha

crystallins normally present there. Sorbitol and inositol is said to have the role in

metabolism of phospholipids.

Lipids:

The main lipids concerned are cholesterol, various phospholipids such as

cephalin, isolecithin, sphingomyelin and glycerides in addition to lipoproteins. Lipids are

present in two forms – free form and bound form (lipoproteins). The lipids are

extensively present in epithelium in young and in cortex in the adults/older. The

membranes of mature fibre cells have an unusual Lipid Composition.

Human lens fibres have the highest proportion of cholesterol of any plasma membrane in

the body and the amount of cholesterol increases as the fibre cells mature. The

cholesterol / phospholipids ratio is nearly 3 fold greater in nuclear than in cortical fiber

cells. Cholesterol content, increases with age especially in nucleus while glycerides

decrease. Similar changes occur in cataract where lecithin is abundant and cholesterol is

frequently evident macroscopically as crystals. The concentration of free lipids increases,

however, lipoprotein decreases.





Electrolytes:

As in any other tissue, Sodium, Potassium, Calcium and Magnesium are present

in lens in relatively large quantities, some being present principally in the extra cellular

fluid of the lens while others predominate within the cell.

Organic phosphates:

Include nucleotides of both adenosine and pyridine. ATP is responsible for

phosphorylation of glucose. Adenosine mono and di-phosphates has also been reported.

Pyridine nucleotides act as co-enzymes to the dehydrogenaces, assisting with the transfer

of hydrogen in oxidation reduction processes. Other co-enzymes assisting in oxidation

reduction during CHO metabolism are co-enzyme 1 (Diphosphopyridine nucleotide) and

co-enzyme 2 (Triphospho pyridine nucleotide). Most of these substances in lens decline

with age and with the development of cataract.

Glutathione:

The level of glutathione in normal individuals varies from 3.5 – 5.5 mm/g net

weight of the lens. The level is altered with age. Its concentration falls with advancing

age. Glutathione is basically an amino acid. It is a tripeptide consisting of 3 amino acids –

glycine, cysteine and glutamic acid. Also known as γ – glutamyl cysteinyl glycine. The

cysteine fraction of glutathione by virtue of the presence of sulph-hydryl group (-SH) is

the most reactive constituent, making glutathione exist in 2 forms – oxidized glutathione

(GSSG) and reduced glutathione (GSH). Lens is constantly exposed to oxidative agents;

indeed there is a high level of hydrogen peroxide in normal aqueous and peroxidase





activity is also present in the lens 1-1 self. Apart from these, several enzyme systems are

available to minimize the oxidative damage. They include – catalase, superoxide

dismutase, glutathione peroxidase and glutathione-S-transferase. Glutathione is produced

from the interaction between glutamate and cysteine in lens cells. Thiol groups in

proteins are also protected by Glutathione especially in cation-transporting membrane

proteins. (Thus prevents excess hydration).

Ascorbic acid:

5-48 mg/100gm net weight concentration of ascorbic acid is present in lens. The

precise role of ascorbic acid is the conversion between ascorbic acid and the oxidized

form -dehydroascorbic acid, might be coupled with other oxidation reduction systems in

lens.

Physiology of vision

Physiology of vision is a complex phenomenon which is still poorly understood. The

main mechanisms involved in physiology of vision are:

Initiation of vision (Phototransduction), a function of photoreceptors (rods and

cones).

Processing and transmission of visual sensation, a function of image processing

cells of retina an individual pathway, and

Visual perception, a function of visual cortex and related areas of cerebral cortex.





Phototransduction

The rods and cones serve as sensory nerve endings for visual sensation. Light

falling upon the retina causes photochemical changes which in turn trigger a cascade of

biochemical reactions that result in generation of electrical changes. Photochemical

changes occurring in the rods and cones are essentially similar but the changes in rod

pigment (rhodopsin) have been studied in more detail. This whole phenomenon of

conversion of light energy into nerve impulse is known as phototransduction.

Photochemical Changes:

The photochemical changes include:

Rhodopsin bleaching: Rhodopsin refers to the visual pigment present in the rods – the

receptors for night (scotopic) vision. Its maximum absorption spectrum is around 500 nm.

Rhodopsin consists of a colourless protein called opsin coupled with a carotenoid called

retinine (Vitamin A aldehyde or II-cis-retinal). Light falling on the rods converts 11-cis-

retinal component of rhodopsin into all-trans-retinal through various stages. The all trans-

retinal so formed is soon separated from the opsin. This process of separation is called

photodecomposition and the rhodopsin is said to be bleached by the action of light.

Rhodopsin regeneration: The 11-cis-retinal is regenerated from the all-trans-retinal

separated from the opsin (as described above) and vitamin-A (retinal) supplied from the

blood. The 11-cis-retinal then reunites with opsin in the rod outer segment to form the

rhodopsin. This whole process is called rhodopsin regeneration. Thus, the bleaching of

the rhodopsin occurs under the influence of light, whereas the regeneration process is

independent of light, proceeding equally well in light and darkness.





Visual cycle: In the retina of living animals, under constant light stimulation, a steady

state must exist under which the rate at which the photochemicals are bleached is equal to

the rate at which they are regenerated. This equilibrium between the photodecomposition

and regeneration of visual pigments is referred to as visual cycle.

Electrical change: The activated rhodopsin, following exposure to light, triggers a

cascade of complex biochemical reactions which ultimately result in the generation of

receptor potential in the photoreceptors. In this way, the light energy is converted into

electrical energy which is further processed and transmitted via visual pathway.

Processing and transmission of visual impulse

The receptor potential generated in the photoreceptors is transmitted by

electrotonic conduction (i.e., direct flow of electric current, and not as action potential) to

other cells of the retina viz. horizontal cells, amacrine cells, and ganglion cells. However,

the ganglion cells transmit the visual signals by means of action potential to the neurons

of lateral geniculate body and the later to the primary visual cortex. The phenomenon of

processing of visual impulse is very complicated. It is now clear that visual image is

deciphered and analyzed in both serial and parallel fashion.

Serial processing: The successive cells in the visual pathway starting from the

photoreceptors to the cells of lateral geniculate body are involved in increasingly

complex analysis of image. This is called sequential or serial processing of visual

information.





Parallel processing: Two kinds of cells can be distinguished in the visual pathway

starting from the ganglion cells of retina including neurons of the lateral geniculate body,

striate cortex, and extrastriate cortex. These are large cells (magno or M cells) and small

cells (parvo or P cells). There are striking differences between the sensitivity of M and P

cells to stimulus features.

The visual pathway is now being considered to be made of two lanes: one made

of the large cells is called magnocellular pathway and the other of small cells is called

parvocellular pathway. These can be compared to two-lanes of a road. The M pathway

and P pathway are involved in the parallel processing of the image i.e., analysis of

different features of the image.

Visual perception

It is a complex integration of light sense, form sense, sense of contrast and colour

sense. The receptive field organization of the retina and cortex are used to encode this

information about a visual image.

1. The light sense:

It is awareness of the light. The minimum brightness required to evoke a sensation of

light is called the light minimum. It should be measured when the eye is dark adapted for

at least 20-30 minutes. The human eye in its ordinary use throughout the day is capable

of functioning normally over an exceedingly wide range of illumination by a highly

complex phenomenon termed as the visual adaptation. The process of visual adaptation

primarily involves:

Dark adaptation (adjustment in dim illumination),

Light adaptation (adjustment to bright illumination).





Dark adaptation: It is the ability of the eye to adapt itself to decreasing illumination.

When one goes from bright sunshine into a dimly-lit room, one cannot perceive the

objects in the room until some time has elapsed. During this period, eye is adapting to

low illumination. The time taken to see in dim illumination is called „dark adaptation

time‟. The rods are much more sensitive to low illumination than the cones. Therefore,

rods are used more in dim light (scotopic vision) and cones in bright light (photopic

vision).

When fully dark adapted: The retina is about one lakh times more sensitive to light than

when bleached.

Delayed dark adaptation: Occurs in diseases of rods e.g., retinitis pigmentosa and

vitamin A deficiency.

Light adaptation: When one passes suddenly from a dim to a bright lighted

environment, the light seems intensely and even uncomfortably bright until the eyes

adapt to the increased illumination and the visual threshold rises. The process by means

of which retina adapts itself to bright light is called light adaptation. Unlike dark

adaptation, the process of light adaptation is very quick and occurs over a period of 5

minutes. Strictly speaking, light adaptation is merely the disappearance of dark

adaptation.

2. The form sense:

It is the ability to discriminate between the shapes of the objects. Cones play a

major role in this faculty. Therefore, form sense is most acute at the fovea, where there





are maximum number of cones and decreases very rapidly towards the peripheral Visual

acuity recorded by Snellen's test chart is a measure of the form sense.

3. Sense of contrast:

It is the ability of the eye to perceive slight changes in the luminance between

regions which are not separated by definite borders. Loss of contrast sensitivity results in

mild fogginess of the vision. Contrast sensitivity is affected by various factors like age,

refractive errors, glaucoma, amblyopia, diabetes, optic nerve diseases and lenticular

changes. Further, contrast sensitivity may be impaired even in the presence of normal

visual acuity.

4. Colour sense:

It is the ability of the eye to discriminate between different colours excited by

light of different wavelengths. Colour vision is a function of the cones and thus better

appreciated in photopic vision. In dim light (scotopic vision), all colours are seen grey

and this phenomenon is called Purkinje shift.

Lens transparency

Factors that play significant role in maintaining outstanding clarity and

transparency of lens are:

Avascularity,

Tightly-packed nature of lens cells,

The arrangement of lens proteins,

Semipermeable character of lens capsule,





Pump mechanism of lens fibre membranes that regulate the electrolyte and

water balance in the lens, maintaining relative dehydration

Auto-oxidation and high concentration of reduced glutathione in the lens

maintains the lens proteins in a reduced state and ensures the integrity of the

cell membrane pump.

Changes in aging lens

There are three stages of age related changes in the crystalline lens development,

growth and ageing. Changes in ageing lens can be grouped as follows:

Physical changes:

Lens weight and thickness increases steadily with age. This results due to

continued growth of the crystalline lens throughout life building up layers of new

cells from the equator.

Light transmission by the lens especially at lower wavelengths decreases with the

increasing age indicating that light absorbance increases with the age.

Light Scattering is increased with the age. It has been reported to be caused by

aggregation and formation of a gel- like state. Some workers have pursued the

idea that the increased light scattering with age could be attributed to synergism, a

process in which conformational changes to the protein release bound water,

enhancing the difference in refractive index between the drier„ protein region and

its surroundings.

Fluorescence property of lens has been confirmed to increase with the age.





Refractive index in the nucleus of bovine lens is reported to increases with age.

However no such change was found in human lens.

Metabolic changes:

Most of the metabolic activities of the lens decreases with age. A few important ones are

as follows:

The proliferative capacity of human lens epithelial cells declines during adult life.

Many enzyme activities decline in the whole lens with age.

There occurs an increase in the urea- soluble protein at the expense of soluble

proteins, on going from cortex to nucleus.

Three enzymes of glutathione metabolism viz. Glutathione peroxidase,

Glutathione reductase and Glutathione transferase do not significantly decline

with age. However both glutathione and ascorbate level decrease in lens by age.

Both superoxide dismutase and glucose-6-phosphate dehydrogenase activity is

lost with age. But the denatured enzyme protein remains.

Changes in crystallins:

There occurs an age- related loss of gamma- crystallines

The gamma- crystallines fraction in particular shows an increase in disulphide

bondage.

There occurs a limited unfolding of bovine gamma- crystallines with age.





Changes of plasma membrane and cytoskeleton:

There occur age-related losses of membrane proteins and lipids and of

cytoskeletal proteins.

A loss of membrane potential and an increase in lens sodium and calcium occurs

with age.

All the large membrane polypeptides are reported to decrease in parallel with age.

Main functional polypeptide is converted into smaller variants with age.

Changes in membrane rigidity- also occur with aging.





Disease Review

Netra roga sankhya and classification:

In Auryvedic classics netravikaras are classified into various types based on their

adhishtana, chikitsa, sadhyasadhyata. Acharya Sushrutha has mentioned 76 eye diseases.

Acharya Charaka has explained only 4 types of netrarogas based on doshas. According

to Acharya Vagbhata and Sharngadhara there are 94 types of netrarogas.

Bhavaprakasha and Yogaratnakara have described 78 and 76 types of netravikaras

respectively.

Table No. 03 Classification of Netrarogas based on Adhistana 43,44,45, 46,47,48

Adhishtana Su.S. A.H. A.S. M.N. Y.R. Sha.S.

Sandhi 09 09 09 09 09 09

Vartma 21 24 24 21 21 24

Shukla 11 13 13 11 11 13

Krishna 04 05 05 04 04 05

Sarvakshi 17 16 16 17 17 08

Drishti 12 27 27 12 12 08

Abhighataja 02 - - 02 02 27

Total 76 94 94 76 76 94

Nirukti and paribhasha of Timira:

ततममतत न्द्क्रध्मतत चऺषयनेन।

ततभ + इपषहदभषहदतत। उण्िवं इतत ककयच ्॥

ततभ ्क्रेदने । आहिबवव ्इतत मववत ्॥ 49

(शब्दकल्ऩिषभ)्





(1) √„Tim‟ + Unadi suffix „Kirach‟ which means:

- The increase of watery substance in the eye,

- Loss of light perception

(2) In Amarakosha, the meaning of Timira is given as darkness.

(3) In Halayudham, Timira means darkness whose enemy is sun.

From this etymological derivation it is clear that Timira means loss of light

perception of darkness or blindness, but this stage is last in Timira Roga. Thus the

nomenclature of this disease was made on the basis of its grave sequeal, which follows

improper treatment of the diseases. So, Timira is a pathological condition in which vision

gets reduced and ultimately leads to blindness- linganasha.

Synonymns of Timira: 50

Andhakara - Darkness

Tamishra - The dark half of the month

Dhwanta - Darkness

Tama - Darkness

Timira - Darkness

Nidana of Timira:

The specific nidana of Timira is not mentioned in the classics. Samanya nidana of

netrarogas is described in classics. In few Ayurvedic classics Timira has been mentioned

as a symptom or sequel of some rogas. Thus Timira roga varies from a symptom to a

full-established disease. Even other urdhvajatrugata rogas can also be the cause of this

roga as many nidanas for other diseases are same as of netra rogas.





The different references regarding etiology of Timira are as follows:

योगव सवे अपऩ भन्दे अननौ, सषतयवभषदयवणि च। (M.N. Udararanidana/1)

Mandagni is the root cause of all diseases. Same way even netra rogas are due to the

hampered agnibala of an individual.

असवत्ममेन्द्न्िमवथा संमोग् प्रज्नवऩयवध् ऩरयिवभश्चतेत त्रमन्द्स्त्रपवधपवकल्ऩव् कवयिं

पवकवयविवभ ्। (Ch.S. Su. 11/43)

As per Acharya Charaka‟s version asatmyendriyartha samyoga, prajna paratha and

parinama are causative factors of diseases.

कवरवथाकभािवं मोगो हीनसभथ्मवहदभवत्रक : सममनमोगश्च पवज्नेमो योगवयोनम क

कवयिभ ्। (A.H. Su. 1/19 )

Acharya Vagbhata has mentioned the samyak yoga of kala, artha and karma is the base

of arogya; If those are not in balance, there will be origin of disease.

योगव् सवेपऩ जवमन्ते वेगोदीयिधवयि ्

तनहदाष्टं सवधनं तत्र बूतमष्ठं मे तष तवन ्प्रतत ।

ततश्चवनेकधव प्रवम् ऩवनो मत्प्रकष प्मतत

अन्नऩवनौषध ंतस्म मषन्जधतवतो अनषरोभनभ ्।। (A.H. Su. 4/22-23)

All diseases are due to the forceful evacuation or withholding of adharaneeyavegas.

In this context, vata is the main prakupita dosha. So anulomana with suitable food,

drinks and medicine plays an important role.





उष्िवसबतप्तस्म जरप्रवेशवत ्दयेूक्ष्िवत ्स्व्प्नपवऩमामवच्च ।।

प्रसक्तसंयोदन कोऩशोक क्रेशवसबघवतवदततभ थषनवच्च ।।

शषक्तवयनवरवमरकष रत्थभवषतनषेविवत ्वेगपवतनग्रहवच्च ।।

स्वेदविजोधूभतनषेविवच्च छदेपवाघवतवत ्वभनवततमोगवत ् ।।

फवष्ऩग्रहवत ्सूक्ष्भतनयीऺिवच्च नेत्र ेपवकवयवन ्जनमन्द्न्त दोषव: ।। (Su. S. Ut. 1/26-27)

Sudden plunging into water after exposure to heat, looking at very distant objects,

improper sleeping habits, prolonged weeping, excess of anger, grief, trauma of head,

excessive intercourse, intake of highly sour foods, horse-gram, black-gram, withholding

natural urges, atiyoga of vamana karma, withholding tears, looking at very minute

objects, atiyoga of sweda karma and exposure to dust and smoke are the causative factors

leading to netraroga.

Acharya Sushruta also highlighted that Abhishyanda is the root cause of all eye

diseases. 51

Atiyoga, heenayoga and mithyayoga of vak-mana-shareera pravrutti are the other

causes mentioned by Acharya Charaka. These have bad effect on all senses including

chakshuindriya. 52

Acharya Harita mentioned intake of ushna, atikshara and katu ahara, injury and

looking at fine object do have harmful effect on netras. 53





Samanya Netraroga nidana by various Acharyas:54,55,56,57,58,59,60

Table No. 04 Viharaja nidana of Netrarogas by various Acharyas:

Viharaja nidana Su.S. Ch.S. A.H. A.S. M.N. B.P. Y.R. H.S.

Ushnabhitaptasya

jalapravesha

+ - - - + + + -

Doorekshana + - - - + + + -

Swapnaviparyaya + + + + + + + -

Prasakta samrodana + - - - + + + -

Abhighata + - + + + + + +

Atimaithuna + - - - + + + -

Vegavinigraha + + + + + + + -

Atisweda + - - - + + + -

Dhoomanishevana + - - - + + + -

Chardi vighata + - + + + + + -

Vamana atiyoga + - - + + + + -

Bashpagraha + + + + + + + -

Sookshma

nireekshana

+ - - - - + - +

Atisheeghrayaana - - - - - + + -

Rutuviparyaya - - - - + - - -

Sooryoparaga anala-

vidyutadi vilokana

- - + + - - - -





Table No. 05 Aharaja nidana of Netra rogas by various Acharyas:

Aharaja nidana Su.S. Ch.S. A.H. A.S. M.N. B.P. Y.R. H.S.

Shukta-aranala- amla + + + + - + - -

Kulatha + - - + - + - -

Masha + - - - - + - -

Madya - - - + + - + -

Nishi dravanna seva - - - - + - - -

Dravannapana

atinishevana

- - - - - - + -

Ushna-atikshara-katu

ahara

- - - - - - - +

Table No. 06 Manasika nidana of Netrarogas by various Acharyas:

Manasika nidana Su.S. Ch.S. A.H. A.S. M.N. B.P. Y.R. H.S.

Kopa + - - + + - - -

Shoka + - + + + + + -

Chinta - - + + - - - -

Bhaya - - + + - - - -





Secondary causes of Timira:

Grahani Roga: Acharya Charaka specifies that if grahani is not treated well results in

Timira.61

Navana Nasya Karma: Acharya Charaka described that a person suffering from fever,

grief or has consumed alcohol, if we give navana nasya karma then he will suffer from

Timira roga. 62

Arsha: According to Acharya Charaka, Timira is a common lakshana of sahaja arsha

and Acharya Vagbhata also describes it as a common symptom of arhsa. 63

Pinasa: Andhatva (blindness) and severe eye ailments are mentioned as complications of

pratishyaya by Acharya Sushruta. 64

Raktasrava: Excessive raktasrava leads to Timira. 65

Bhaspa nigraha leads to Timira as mentioned by Acharya Bhela. 66

Samprapti:

The entire process which represents a sequence from vitiation of doshas to vivid

manifestation of the disease is known as samprapti.67

ससयवनषसवरयसबदोष ् पवगषि रूध्वाभवगत ्

जवमन्ते नेत्रबवगेषष योगव: ऩयभदवरुिव्। (Su.S. Ut 1/20)

Acharya Sushruta has described common samprapti for all the netra rogas. He

explained that vitiated doshas through siras reaches the supra clavicular region and

settles in eyes and cause different eye diseases.





सवायोगतनदवनोक्त यहहत ् कष पऩतव भरव् अचऺषष्म पवाशषेेि प्रवम् पऩत्तवनषसवरयि्

ससयवसबरूध्वां प्रस्रषतव नेत्रववमवभवचश्रतव् वत्भासन्द्न्ध ंससतं क्रष ष्िं िषन्द्ष्टं वव सवाभक्षऺ वव। (A.H. Ut 8/1)

Acharya Vagbhata has mentioned malas (doshas) increased due to the indulgence

in unsuitable ahaara and vihaara described in the sarvaroganidana especially by those

which are not good to the eyes, in which pitta being the dominant dosha, spread upwards

through the veins and get localised in different structures of eye. This localised doshas

lead to different diseases of eye.

Acharya Charaka stated that when the malas are lodged in the indriyas, leads to

Upaghata (Vinaasha:) and thereby Upatapa (Kinchit vaikalyam) in Chakshurendriya.68

Table No. 07 Samprapti ghataka of Timira:

Samprapti Ghataka

Dosha Tridosha

Dushya Rasa, Rakta, Māmsa, Meda, Asthi, Majja

Agnidushti Mandāgni.

Srotas Rasa,rakta,mamsa,meda,asthi,majja

Srotodushti Vimargagamana

Rogamarga Madhyama

Sancharasthana Roopavaha sira

Adhisţhāna Drishti (prathama-dwiteeya-triteeya patala)





Ahita ahaara-vihaara sevana

(Achakshushya ahaara-vihar)

Pitta pradhana tridosha prakopa

Urdhwagamana of doshas through siras

Sthanasamsraya of doshas in netra

patalas

Produces lakshana

Diseases of drushti

(TIMIRA ROGA)





Poorva rupa:

Poorvarupa is a stage of any disease where there will be vaguely manifested and

very few symptoms; this is because of the anadhishtita doshas in the body.69

In the

classics there are no specific poorvarupa mentioned for Timira, so general purvarupa of

netra rogas mentioned by Acharya Sushruta are applicable to Timira also.

Table No. 08 Samanya Purva Rupas of the Netra rogas: 70

Avilata Turbidity of eyes

Samrambha Congestion

Ashru Lacrimation

Kandu Itching sensation

Upadeha Dirt

Guruta Heaviness

Oosha Burning sensation

Toda Pricking pain

Raga Redness

Vartma kosha shoola Pain in fornices of eye ball

Vartma shookapoorna As if filled with bristles within the eye lids aabhata

Vihanyamana kriya Subnormal functions of the eyes

Vihanyamana rupa Reduced vision

Rupa:

When the clinical features i.e., signs and symptoms become ample conspicuous

and vivid then this particular stage of pathogenesis is termed as rupa.71

The actual

diagnosis of the disease mainly depends upon the signs and symptoms. Rupa is helpful

for prognosis of a disease. In case of Timira, the sign and symptoms have been

mentioned in two ways - according to involvement of patalas and vitiation of doshas.





Table No. 09 Patalagata Timira lakshanas according to various Acharyas.

72,73,74,75,76,77,78

Patala Lakshanas Su.S. A.S. A.H. M.N. B.P. Y.R. V.S.

Prathama Avyakta darshana + + + + + + +

Dwitiya

Vihwala darshana + + + + + + +

Visualization of

false images such

as makshika,

mashaka, kesha

etc.

+

-

-

+

+

+

+

Gochara vibhrama + - - + + + -

Soochi paasham na

pashyati

+ + + + + + +

Tritiya

Urdhwam pashyati

na adhasthat

+ + + + + + +

Mahanthyapi cha

roopani chaaditani

iva vaasasa

+ + + + + + +

Karna nasaakshi

yuktani vipareetani

veekshate

+

+

+

+

+

+

+

Yatha dosham cha

rajyeta drishti

+ + + + + + +





Clinical Features of Timira according to location of Doshas in Drishti:

Acharya Sushruta has mentioned the features of Timira according to location of

doshas in drushti under third patalagata Timira, while Acharya Vagbhata explained

same features in second patalagata Timira.

Table No. 10 Timira lakshanas based on location of doshas according to various

Acharyas.79,80,81,82

Dosha location Symptoms Su.S. A.H. M.N. Y.R.

Urdhwasthita Unable to see distant objects + + + +

Adhasthita Unable to see near objects + + + +

Paarshwasthite Unable to see

peripheral(sides) vision

+ + + +

Samanthata sthita Overlapping of the objects + - + +

Drishti madhya Diplopia + + + +

Dwidha sthita Triple images

Anavasthita Several images + + + +

Clinical features of Timira according to dosha involvement: 83

Predominance of particular dosha governs the clinical features of Timira to a

great extent. The signs and symptoms of Timira according to doshas are as follows:

Vataja Timira:

Objects appear as if they were moving, hazy, reddish in colour and tortuous in

shape.





Pittaja Timira:

Visualization of false flashes of the light, glow worm, rainbow and the lightening.

Bluish and blackish shades appear as variegated like the feathers of a peacock.

Kaphaja Timira:

Patient sees all the objects as glossy white like the colours of clouds. The patients

can see objects which are not excessively small and visualize moving clouds in the

cloudless sky. All the objects appear as if inundated in water.

Vagbhata described that objects are seen dim or dark.

Raktaja Timira:

Objects appear to be in various colours such as dark greenish, greyish, or blackish

and smoky all around.

Sannipataja Timira:

Due to vitiation of all doshas together, objects appear to be in various colours,

scattered and as having double or manifold images all around. Images appear to be

luminous and are seen to possess more or less than normal parts. Non existing things are

visualised and existing things are improperly visualised.

Parimlayi Timira:

Pitta when associated with tejas of shonita produces the Timira called parimlayi,

the patient sees all sides as yellow and visualizes as if the sun is rising. All trees appear to

be full of glow worms and flashes of the light. Patient‟s vision may improve due to

depletion of doshas.





Chikitsa

Timira is one among the diseases of drishti mandala, which commonly starts from

simple visual disturbances which may turn into complete vision loss so proper care

should be taken to restore vision.

Acharya Vagbhata has mentioned that, if Timira is ignored by the physician or

patient, it leads to Kacha and then into Linganasha i.e., blindness. Thus to

manage Timira, the most dreadful one among the diseases of eye, urgent

measures to be taken. 84

According to Acharya Yogaratnakara, Timira is the main cause of blindness so it

must be treated with all efforts. 85

As per Gada Nigraha Netrarogadhikara, Timira is a condition which can destroy

the drishti shakti. Thus it has to be treated by the physician without any delay. 86

तत्र समबवभवसवद्म मथवदोषं सबषन्द्नजतभ ्पवद्मवन्नेत्रजवयोगव् फरवन्त् स्मषयन्मथव संऺेऩत् कक्रमवमोगो तनदवनऩरयवजानभ ्ववतवदीनवं प्रतधघवतो प्रोक्तो पवस्तयत् ऩषन्।

(Su.S.Ut. 1/25)

Upon recognizing the possibility of development of disease, a proper treatment should be

given according to the affection of doshas, failing which grave eye diseases may develop.

In brief, the management essentially consists of avoidance of the etiological factors; and

specifically in detail, it implies counteracting the increased vata and other doshas.

सेक आश्च्मोतन ंपऩण्डध त्रफडवरस्तऩािं तथव ऩषटऩवको अन्जनं च सब् कल्क ् नेत्रभषऩवचयेत।् (B.P. Ma. 63/136)

According to Bhavaprakasha, the eye has to be treated with procedures like Seka,

Aschyotana, Pindi, Bidalaka, Tarpana, Putapaka and Anjana.





Chikitsa sutra:

दोषवनषयोधेन च न कशस्तं स्नेहवस्रपवस्रववियेकनस्म ् उऩवचयेदन्जनभूधाफन्द्स्त

फन्द्स्तकक्रमवतऩािरेऩसेक ् सवभवन्मं सवधनसभदभ।् (A. H. Ut. 13/47)

According to Acharya Vagbhata Snehana, Raktamokshana, Virechana, Nasya,

Anjana, Shirobasti, Basti, Tarpana, Lepa and Seka- these therapies administered several

times suitable to the doshas is the mode of treatment of Timira.

Chikitsa of timira can be classified into two:

1. Shodhana chikitsa

2. Shamana chikitsa

1. Shodhana chikitsa:

Virechana:

The following formulations are mentioned by acharyas for virechana karma in

timira:

Vataja Timira

Dashamoola ghrita pana followed by Virechana with Triphala-Panchamoola

kwatha with ksheera and eranda taila. 87

Pittaja Timira

Virechana with Trivrit choorna mixed with Sharkara, Ela and Madhu. 88

Kaphaja Timira

Virechana with Poogadi kwatha. 89

Raktaja and Pittaja Timira

Ghrita processed with Triphala is good for Virechana. 90

Sannipataja Timira

Virechana by taila processed with Trivrit is desirable. 91





Nasya:

Depending upon doshadhikya in Timira, the formulation for nasya is selected.

Formulations such as Jeevantyadi taila,92

Jeevaneeya-Sita-Utpala siddha ghrita,93

Hreeberadi taila,94

Bhringarajadya taila, Marichadi taila, Vibheetakadyataila,

Triphalataila, Gomaya taila, Ajita taila and Neelotpaladya taila are useful in Timira.95

Basti:

In vataja timira, nirooha and anuvasana bastis are useful.

Raktamokshana:

In Kaphaja timira, Pittajatimira and Raktaja Timira, Siravyadha is indicated.

Siravyadha is contra-indicated in Ragaprapta timira.96

2. Shamana chikitsa:

Shamana Chikitsa can be devided into:

a) Sthanika Chikitsa

b) Sarvadaihika Chikitsa

a) Sthanika Chikitsa

Tarpana with Patoladi ghrita, Jeevantyadi ghrita, Drakshadi ghrita, and

Shatahwadi ghrita and Triphala ghrita are beneficial for treating timira. 97

Seka with prapoundareekadi kwatha is helful to treating timira. 98

Anjana with Krishnadi varti,99

Triphaladi varti,100

Kumarika varti, Drushtiprada

varti, Hareetakyadivarti, Sukhavativarti, Muktadimahanjana, Bhaskara varti and

Chandrodayadi varti are mentioned by acharyas.





Bidalaka with Pathyadi lepa101

and Rasanjanadi lepa102

are useful in treating

timira.

Pindi with Haridradi pindika is indicated in timira.

103

b) Saarvadaihika Chikitsa

Ghrita Kalpanas - Phalatrikadi Ghrita, Patoladi ghrita, Triphla Ghrita,

Mahatriphaladya ghrita, Dwitiya Triphaladya Ghrita, Laghu Triphala Ghrita,

Rasnadi ghrita, Dashamoola ghritam, Drakshadi ghrita, , Jeevantyadi ghritam,

Shatahwadi ghrita.104, 105

Triphala prayoga- In Pittaja timira regular intake of triphala mixed with ghrita,

in vataja timira triphala mixed with taila and in kaphaja triphala mixed with

madhu is indicated. 106

Pathyapathya for Timira:

Pathya Ahaara

Shigru, bhringaraja, yava, raktashaali, mudga, purana ghrita, kulatha, surana,

patola, varthaka, karkataka, karavellaka, navina mocha, nava moolaka, punarnava,

kakamachi, kumarika, draksha, kustumburu, saindhava lavana, lodra, triphala, madhu,

stanya, candana, karpura, matsyakshi, All tikta and laghu ahara.

Pathya Vihaara

Prasanna manasa, guru pooja, pada raksha dharana, umbrella and shirovestana

to protect uttamanga, shirah snana with cold water, regular practice of shiro abhyanga.





Apathya Ahara

Masha, aranala, sura, dadhi, kalinga, pinyaka, adhika jala paana, matsya, patra

shakha, jangala mamsam, tambulam, veshavara, phanita, kanji, amla- lavana-vidahi-

tikshna-katu-ushna-guru anna and paana.

Apathya Vihara

Diva swapna, suppression of natural urges like ashru, vayu, vinmutra, nidra,

vamana, sukshmekshanam, danta vigharshanam, ratri bhojanam, aatapa sevana,

prajalpanam, vamana karma, exposure to smoke, dust, heat and cold, krodha, klesha,

shoka, bhaya, atimaithuna.

Sadhyasaadhyata:

अयवगध ततसभयं सवध्मभवद्मं ऩटरभवचश्रतभ।् क्रष च्रं द्पवतधमे यवचग स्मवत्त्रषतधमे मवप्मभषच्मते॥

(Su.S. Ut. 17/53)

Prathama patalagata timira which has not attained ragatwa is sadhya, dwitiya

patalagata timira which has not attained ragatwa is krichhrasadhya and tritiya

patalagata timira which has attained ragatwa is yapya.





Modern Aspect

Disease Review107,108,109,110

The term cataract is used loosely to mean the occurrence of an optical

discontinuity in the lens of such magnitude as to cause a noticeable dispersion of light.

Cataracts are considered clinically significant when opacification interferes with visual

function.

Etymology:

The word cataract means a waterfall or floodgate. It is derived from Latin word

cataracta. In Greek, the root word is “katarhaktes” which means broken water; Its

alternative sense in Latin of "portcullis" probably was passed through French to form the

English meaning “eye disease” (early 15century.), on the notion of “obstruction” (to

eyesight).111

Definition:

Opacity in the lens or its capsule, whether developmental or acquired, is called a

cataract.

As per WHO, Cataract is clouding of the lens of the eye which prevents clear

vision.

WHO says, though most of cases of cataract are related to the ageing process,

occasionally children can be born with the condition, or a cataract may be

developed after eye injuries, inflammation, and some other eye diseases.

Etiological factors of cataract:

Age, systemic diseases, dermatological diseases, physical factors and toxic agents

are the basic causes of the cataract.





Age:

Usually Above 50 years

Heredity

UV radiation- Early onset and maturation

Dietary factors -Diet deficient in proteins , amino acids, vitamins &

essential elements

Severe dehydration -Diarrhoea, Cholera, Smoking

Systemic diseases:

Diabetes mellitus, galactosaemia, alport syndrome, lowe‟s syndrome and down

syndrome are the common systemic disorders which can cause loss of transparency of

lens.

Dermatological diseases:

Atopic dermatitis

Icthyosis

Physical factors:

Trauma

Electric Shock

Radiation-Infrared, X-ray, UV-Radiation

Toxic agents:

Gold, Iron, Copper

Pathogenesis:

Following mechanisms lead to opacification or loss of transparency of lens-

Oxidative damage to membranes & proteins, hydration, denaturation of lens

proteins, opacification of lens fibres with fibrous metaplasia, epithelial opacification,

accumulation of pigmented molecules, disturbance of osmotic balance, formation of





deposits of extracellular materials and failure of ion pumps can leads to the opacification

of lens.

Cataract is caused by the degeneration and opacification of the lens fibres already

formed, the formation of aberrant lens fibres or deposition of other material in their place.

The loss of transparency occurs because of abnormalities of lens proteins and consequent

disorganisation of the lens fibres. Any factor, physical or chemical, which disturbs the

critical intra and extra cellular equilibrium of water and electrolytes or deranges the

colloid system within the fibres tend to bring about opacification. Aberrant lens fibres are

produced when the germinal epithelium of the lens loses its ability to form normal fibres.

Biologically, three factors are evident in the process of cataract formation. In the early

stages of cataract, particularly the rapidly developing forms, hydration is a prominent

feature so that frequently actual droplets of fluid gather under the capsule forming

lacunae between the fibres, and the entire tissue swells (intumescence) and becomes

opaque. To some extent, this process may be reversible and thus opacities formed may

clear up. The second factor is denaturation of lens proteins. If the proteins are denatured

with an increase in insoluble proteins, a dense opacity is produced, a process which is

irreversible; opacities thus constituted do not clear up. Such an alteration occurs typically

in the young lens or the cortex of adult lens where metabolism is relatively active. It is

rarely seen in the older and inactive fibres of the nucleus. Here the usual degenerative

change is rather of third type, one of slow sclerosis. Clinically, when the first process is

predominant the condition is called a soft cataract and third is described as a hard

cataract.112





Classification:

A. Etiological classification

I. Congenital and developmental cataract

II. Acquired cataract

1. Senile cataract

2. Traumatic cataract

3. Complicated cataract

4. Metabolic cataract

5. Electric cataract

6. Radiational cataract

7. Toxic cataract- i. Corticosteroid-induced cataract

ii. Miotics-induced cataract

iii. Copper (in chalcosis) and iron (in siderosis) induced cataract.

8. Cataract associated with skin diseases (Dermatogenic cataract).

9. Cataract associated with osseous diseases.

10. Cataract with miscellaneous syndromes- i. Dystrophica myotonica

ii. Down's syndrome.

iii. Lowe's syndrome

iv. Treacher - Collin's syndrome

B. Morphological classification

1. Capsular cataract: i. Anterior capsular cataract

ii. Posterior capsular cataract





2. Subcapsular cataract: It involves the superficial part of the cortex (just below the

capsule): i. Anterior subcapsular cataract

ii. Posterior subcapsular cataract

3. Cortical cataract: It involves the major part of the cortex.

4. Supranuclear cataract: It involves only the deeper parts of cortex (just outside the

nucleus).

5. Nuclear cataract: It involves the nucleus of the crystalline lens.

Senile cataract

Factors affecting age of onset, type and maturation of senile cataract:

It is also called age related cataract and is the commonest type of acquired

cataract. It affected equally persons of either sex usually above the age of 50 years. This

condition is usually bilateral but almost always one eye is affected earlier than the other.

Classically the senile cataract occurs in two forms, the cortical (soft) cataract and nuclear

(hard) cataract. The cortical senile cataracts start as cuneiform or cupuliform. In general

the predominant form can be given as cuneiform (75%), nuclear (25%) and cupuliform

(5%).

Etiology:

Senile cataract is essentially an ageing process. Though its precise

etiopathogenesis is not clear, the following etiopathogenic factors are to be considered.

Heredity

It plays a considerable role in incidence, age of onset and maturation of

cataract in different races and families.





Exposure to Ultraviolet irradiation

More exposure to UV radiation from sunlight has implicated for early onset

and maturation of senile cataract. Recently from animal experiments it has

been confirmed that UV radiation between 290 and 320mm could induce lens

opacification.

It has been proposed that prolonged exposure to UV-rays may initiate

photooxidative damage in the lens. The mechanisms are:

Near UV-light is absorbed by tryptophan.

Tryptophan in sunlight is converted in to N-formyl-kynurenine.

Both these compounds can act as photosensitizers and lead to production of

the free radical single oxygen.

This free radical single oxygen regulates the function of critical lens

enzymes such as Na+/K

+ ATP-ase and lead to lens swelling and

opacification.

Other free radicals generated by near UV-light such as hydrogenperoxide

have been implicated in the dysfunction of hexokinase, an enzyme central to

glucose utilization in lens.

Lipid peroxidation may also play a role in cataractogenesis. Fattyacids can

ultimately produce the compound malondialdehyde, a well known cross

linking agent, which can attach enzymes and membrane components.

Oxygen increasees the rate of photo-oxidation and vitamin E, ascorbic acid

and glutathione reduces the effects of light damage.





Dietary factors

Diet deficient in certain proteins, amino acids, vitamins (riboflavin, vitamin E,

vitamin C), and essential elements have also been blamed for early onset and

maturation of senile cataract.

Dehydrational crisis:

An association with priorepisode of severe dehydrational crisis (due to

diarrhoea, cholera etc.) and age of onset and maturation of cataract is also

suggested.

Smoking: has also been reported to have some effect on the age of onset of

senile cataract. Smoking causes accumulation of pigmented molecules-3

hydroxykynurinine and chromophores, which lead to yellowing. Cyanates in

smoke cause carbamylation and protein denaturation.

Causes of presenile cataract:

The term presenile cataract is used when the cataractous changes similar to senile cataract

occur before 50 years of age. Its common causes are:

Heredity

As mentioned above because of influence of heredity, the cataractous changes

may occur at an earlier age in successive generations.

Diabetes mellitus

Age related cataract occurs earlier in diabetics. Nuclear cataract is more

common and tends to progress rapidly.





Myotonic dystrophy

Associated with posterior subcapsular type of presenile cataract.

Atopic dermatitis

It may be associated with presenile cataract (atopic cataract) in 10% of the

cases.

Mechanism of loss of transparency

It is basically different in nuclear and cortical senile cataracts.

Cortical senile cataract

Its main biochemical features are decreased levels of total proteins, amino

acids and potassium associated with increased concentration of sodium and

marked hydration of the lens, followed by coagulation of proteins.

Nuclear senile cataract

In nuclear senile cataract usual degenerative changes are intensification of the

age related nuclear sclerosis associated with dehydration and compaction of

the nucleus resulting in a hard cataract.

It is accompanied by a significant increase in water insoluble proteins.

However, the total protein content and distribution of cations remain normal.

There may or may not be associated deposition of pigment urochrome and/or

melanin derived from the amino acids in the lens.





Stages of maturation

1. Maturation of the cortical type of senile cataract

a) Stage of lamellar separation:

The earliest senile change is demarcation of cortical fibres owing to their

separation by fluid.

This phenomenon of lamellar separation can be demonstrated by slit-lamp

examination only. These changes are reversible.

b) Stage of incipient cataract:

In this stage early detectable opacities with clear areas between them are seen.

Two distinct types of senile cortical cataracts can be recognized at this stage:

i. Cuneiform senile cortical cataract

It is characterised by wedge-shaped opacities with clear areas in between.

These extend from equator towards centre and in early stages can only be

demonstrated after dilatation of the pupil. They are first seen in the lower

nasal quadrant. These opacities are present both in anterior and posterior

cortex and their apices slowly progress towards the pupil.

On oblique illumination these present a typical radial spoke-like pattern of

greyish white opacities.

On distant direct ophthalmoscopy, these opacities appear as dark lines

against the red fundal glow. Since the cuneiform cataract starts at periphery

and extends centrally, the visual disturbances are noted at a comparatively

late stage.





ii. Cupuliform senile cortical cataract

Here a saucer shaped opacity develops just below the capsule. Usually in the

central part of posterior cortex (posterior subcapsular cataract), which

gradually extends outwards. There is usually a definite demarcation between

the cataract and the surrounding clear cortex.

Cupuliform cataract lies right in the pathway of the axial rays and thus

causes an early loss of visual acuity.

c) Immature senile cataract (ISC):

In this stage, opacification progresses further. The cuneiform or cupuliform

patterns can be recognised till the advanced stage of ISC when opacification

becomes more diffuse and irregular. The lens appears greyish white but clear

cortex is still present and so iris shadow is visible. In some patients, at this stage,

lens may become swollen due to continued hydration. This condition is called

„intumescent cataract'. Intumescence may persist even in the next stage of

maturation. Due to swollen lens anterior chamber becomes shallow.

d) Mature senile cataract (MSC):

In this stage, opacification becomes complete, i.e., whole of the cortex is

involved. Lens becomes pearly white in colour. Such a cataract is also labelled as

„ripe cataract‟

e) Hypermature senile cataract (HMSC):

When the mature cataract is left in situ, the stage of hypermaturity sets in. The

hypermature cataract may occur in any of the two forms-





i. Morgagnian hypermature cataract

In some patients, after maturity the whole cortex liquefies and the lens is

converted into a bag of milky fluid. The small brownish nucleus settles at the

bottom, altering its position with change in the position of the head. Such a

cataract is called Morgagnian cataract. Sometimes in this stage, calcium deposits

may also be seen on the lens capsule.

ii. Sclerotic type hypermature cataract:

Sometimes after the stage of maturity, the cortex becomes disintegrated and the

lens becomes shrunken due to leakage of water. The anterior capsule is wrinkled

and thickened due to proliferation of anterior cells and a dense white capsular

cataract may be formed in the papillary area. Due to shrinkage of lens, anterior

chamber becomes deep and iris becomes tremulous (iridodonesis).

2. Maturation of nuclear senile cataract

In it, the sclerotic process renders the lens inelastic and hard, decreases its ability to

accommodate and obstructs the light rays. These changes begin centrally and slowly

spread peripherally almost up to the capsule when it becomes mature; however, a very

thin layer of clear cortex may remain unaffected. The nucleus may become diffusely

cloudy (greyish) or tinted (yellow to black) due to depositionof pigments. In practice,

the commonly observed pigmented nuclear cataracts are either amber, brown

(cataracta brunescens) or black (cataracta nigra) and rarely reddish (cataracta rubra) in

colour.





Management of cataract:

Cataract treatment essentially consists of its surgical removal. As discussed in

need for study, until surgery is taken up, in peculiar circumstances, certain non-surgical

measures may be of help. These include-

Non-surgical measure:

1. Treatment of cause of cataract

In acquired cataracts, thorough search should be made to find out the cause of

cataract, treatment of the causative disease, many a time it may stop progression and

sometimes in early stages may cause even regression of cataractous changes and thus

defer the surgical treatment. Some common examples include:

Adequate control of DM, when discovered

Removal of cataractogenic drugs such as cortico-steroids, phenothiazenes and

strong miotics, may delay or prevent cataractogenis

Removal of irradiation (IR or x-rays) may also delay or prevent cataract

formation.

Early and adequate treatment of ocular diseases like uveitis may prevent

occurrence of complicated cataract.

2. Measures to delay progression

Many commercially available preparations containing iodide salts of calcium and

potassium are being prescribed in abundance in early stages of cataract (especially

in senile cataract) in a bid to delay its progression. However, till date no

conclusive results about their role are available. Role of Vitamin E and aspirin in

delaying the process of cataractogenesis is also mentioned.





3. Measures to improve vision in the presence of incipient and immature

cataract

This may be of great solace to the patient. They include-

Refraction, which often changes with considerable rapidity, should be corrected at

frequent intervals.

Arrangement of illumination- Patients with peripheral opacities (pupillary area

still free), may be instructed to use brilliant illumination. Conversely,in the

presence of central opacities, a dull light placed beside and slightly behind the

patient„s head will give the best result.

Use of dark goggles in patients with central opacities is of great value and comfort

when worn outdoors.

Mydriatics: The patients with small axial cataracts frequently may benefit from

pupillary dilatation. This allows the clear paraxial lens to to participate in light

transmission, image formation and focusing. Mydriatics such as 5%

phenylephrine or 1% tropicamide; 1 drop BID in the affected eye may clarify

vision.

Role of diet and nutrition:

Diet and nutrition has an important role in the treatment of cataract. They not only

prevent progression but also reverse the process, thereby helping in early stages of

cataract. Their probable function can be studied on following basis:

Protection from free radical damage: maintaining glutathione levels, Vitamin C,

Vitamin B2, Vitamin E, selenium, α- lipoic acid, N- acetyl cysteine, garlic and

melatonin.





Protein protection: VitB6, acetyl-N- carnosine, amino guanidine

Lens metabolism support: Bioflavonoids, inositol, carnosine

Ocular environment support: Carotenoids, COQ 10, potassium and magnesium.

Levels at which these phyto-chemicals take an important role in protecting the

damage process are:

a) During the process of glycation: they bind to the sugar molecules

exhibiting chaperone activity, inhibits the activity of AR enzymes,

inhibits the formation of AGE‟s there by reduction in free radical

formation, protecting the normal proteins from the toxic effects of

existing AGE‟s

b) In lipid peroxidation: acts on membrane function (fatty acid break down)

and cellular structure (changes in proteins), restores mitochondrial

dysfunction, chaperone activity, lipid solubility nature of these

phytochemicals helping in drug penetration.

c) In UV irradiation: acts on inhibiting DNA strand breakage and repair,

preventing photooxidative stress, inhibition of nonenzymatic glycation,

maintaing the tryptophan levels, maintaining the levels of photochemicals

in 3HKG.

d) In aging: maintaining the levels of glutathione. Here they act preventive

rather than curative.

e) In oxidative damage: preventing the reduction of oxidative damage

resistant cells, scavenging activity of byproducts of lipid peroxidation,





glycation, UV radiation,regeneration and stimulation of glutathione,

membrane protection from damaging effects of byproducts of oxidative

damage etc, stimulation of NADPH.

f) In protein metabolism: in preventing mutation of protein phakinins,

maintaining normalcy of protein metabolism.

g) In maintenance of low pH: as H2O2 inhibitors, maintaining higher levels

of connexin α- 8 proteins, which abolishes sensitivity to low pH

h) Maintaining patency of aquaporin / removing blockage: maintaining

microcirculation, free radical generation inhibition from changes in

membrane and fibers.

Surgical management

Indications of cataract surgery

1. Visual improvement

It is the most common indication for cataract surgery and it is indicated when the

cataract develops to a degree sufficient to cause difficulty in performing daily

essential activities. Legal prescription of visual acuity in certain jobs also necessitates

the need for surgery.

2. Medical indication:

Sometimes patients may be comfortable from the visual point (due to useful vision

from the other eye or otherwise) but may be advised cataract surgery due to medical

grounds such as:





Lens induced glaucoma,

Phacoanaphylactic endophthalmitis

Retinal diseases like diabetic retinopathy or retinal detachment, treatment of

which is being hampered by the presence of lens opacities.

3. Cosmetic indication:

Sometimes patient with mature cataract may insist for cataract extraction (even with no

hope of getting improvement in vision), in order to obtain a black pupil.





Anjana Review

सेक आश्च्मोतन ंपऩण्डध त्रफडवरस्तऩािं तथव ऩषटऩवको अन्जनं च एसब् कल्ऩ नेत्रभषऩवचयेत।्

(Sha.S. Ut. 13/1)

For treating eye disorders many topical treatments are explained by Ayurvedic

scientist these topical treatments are known as Kriyakalpas which includes various

procedures like Seka, Aaschyotana, Pindi, Bidalaka, Tarpana, Putapaka and Anjana.

Among them Anjana is a simple, highly effective and widely practiced form of treatment

modality.

It is assumed that they possess the potency to combat the targeted tissues involved

in pathology and some have the ability to cross the blood-aqueous, blood vitreous and

blood-retinal barriers.

Table No. 11 Kriyakalpas mentioned by various Acharyas

Kriyakalpa Cha.S. Su.S.

A.S. A.H. Y.R. B.P. Sha.S. G.N.

Seka - + - - + + + +

Aschyotana + + + + + + + +

Pindi - - - - + + + +

Bidalaka + - + - + + + +

Tarpana - + + + + + + +

Putapaka - + + + + + + +

Anjana + + + + + + + +

Etymology of Anjana:

The word Anjana is derived from the „Anj‟ dhatu +„lyut‟ pratyaya.





Definition of Anjana:

अनन्द्क्त अनेन इतत अन्जनभ।् 113 (Vachaspatyam)

That which spreads in the eye is called Anjana.

An act of applying ointment or pigment.

Black pigment or Collyrium applied to the eyelashes or the inner coat of the

eyelid.

That which cause Vyaktekarana (manifestation) of Dosha.

That which creates movement of Dosha.

The word anjana means both, a substance which is used for application into eyes and

procedure of applying anjana into eyes. For easy understanding the material used for

doing the procedure of anjana is termed as anjana dravya and the procedure of

applying anjana dravya is termed as anjana karma.

Anjana karma is a procedure of application of medicinal pastes or powders to the

inner side of lower lid, either with the help of an applicator ie. Anjana shalaka or by

the finger tip from kaneenaka sandhi to apanga sandhi. 114

Indications of Anjana:

व्मक्तरूऩेषष दोषेषष शषद्धकवमस्म केवरे नेत्र ेएव न्द्स्थते दोष ेप्रवप्त्भन्जनभवचयेत।्

(Su.S. Ut. 18/51)

Acharyas have mentioned anjana in following condictions:

Based on dosha

Anjana can be applied in pitta, kapha, rakta and vata dosha predominant eye

diseases.





Based on avastha of dosha

Anjana should be applied only when dosha show their lakshanas clearly

(vyaktarupeshu dosheshu). It should be applied when the dosha show pakva

linga, i.e. when they manifest their lakshanas clearly. Sushruta had used the term

vyakta roopa of dosha to indicate this condition. It can also be done when the

doshas, i.e pitta, kapha, rakta gets ghanatva (Solidification).

Based on Treatment order

It should be done only after purification therapies of the body (kaya shodhana),

i.e. after performing, vamana, virechana, nasya, vasti and rakta mokshana, which

should be according to the condition of the dosha and vyadhi. This implies that

anjana karma has to be done when the doshas which have been vitiated in the

whole body is initially removed by kaya shodhana procedures and the vitiated

doshas are left only in the eyes.

Based on the Asraya of Dosha

Anjana should be applied only when doshas are present only in the eyes or the

features of dosha dushti are limited only to the eye.

Based on Lakshana

It should be performed when symptoms like edema (shopha), Sliminess or

Stickiness (paichilya), itching (kandu), fatigue (mlanata), Redness (raga), foreign

body sensation (gharshana) and watering (asru) has decreased.

Based on Ritu

In hemanta and shishira ritu, it should be performed at noon (madhyahna), in





summer (greeshma ritu) at morning or evening and during rainy season (varsha

kala) when the sky is clear.

Contra-indications Anjana:

Application of anjana at night, during sleep, madhyahna and when the eyes are

fatigued by strong rays of sun. 115

Kruddha, Bheeta, Shankita, Shokita, Shranta, Ashitamatra, Virikta,

Dhoomapeeta, Madyapeeta, Datta nasya, Ratrijagarita, Vegarudita, Pipasita,

Jwarita, Chardita, Netrabhihata, Shirorujarta, Shirasnata, Uditha aadityeshu.116

Materials required for Anjana karm:

1) Anjana paatra

2) Anjana shalaka

3) Gharshana shila

Anjana paatra- Anjana patra is the container used for storing anjana dravyas. Material

for selecting the anjana is determined based on its purpose. 117

Table No. 12 Container used for storing Anjana dravyas

Type of Anjana Paatra

Madhura Suvarna paatra

Amla Rajata paatra

Lavana Mesha shringamaya paatra

Kashaya Tamra or Loha paatra.

Katu Vaidoorya paatra

Tikta Kamsya paatra.





Anjana Shalaka- Anjana shalaka or collyrium probe is a metalic cylindrical rod of 8

angulas in length. It‟s both ends should be Mukulakara (shaped like a bud) and its

circumference should be Kalaaya parimandala (equal to that of a pea). 118

Table No. 13 Type of Anjana shalaka. 119

Type of Anjana Type of Shalaka

Lekhana Tamra, Loha or Ashma

Ropana Hastha, Loha

Prasadana Svarna

Snehana Swarna, Rajata

Gharshana shila-

It is used to rub the varti anjana.

Classifications of Anjana:

Various classification of anjana mentioned by Acharyas:

Table No. 14 Classification of Anjana based on karma

Su.S. A.S. A.H. Y.R. B.P. Sha.S.

Lekhana Lekhana Lekhana Lekhana Lekhana Lekhana

Ropana Ropana Ropana Ropana Ropana Ropana

Prasadana

Snehana

Prasadana

Drishti-

prasadana

Snehana

Snehana

Snehana





Table No. 15 Classification of Anjana based on Rasa, Guna and Karma

Types Su.S. A.S. A.H. Y.R. Sha.S.

Lekhana Amla,

Lavaa,

Katu,

Tikta,

Kashaya

Amla,

Lavana,

Katu,

Tikta,

Kashaya

Kashaya,

Amla

Lavana,

Katu

Kshara,

Teekshna,

Amla

Kshara,

Teekshna,

Amla

Ropana Kashaya,

Tikta,

Sneha

Tikta,

Kashaya,

Sneha

Tikta Kashaya,

Tikta,

Sneha

Kashaya‟

Teekshna

Prasadana Madhura,

Sneha

Madhura,

Sheeta,

Sneha

Madhura,

Sheeta

- Madhura,

Sneha

Snehana - Sneha - Madhura,

Sneha

-

Table No. 16 Classification of Anjana based on kalpana

Type Su.S. A.S. A.H. Y.R. B.P. B.R. Sha.S. C.D. G.N. V.S.

Gutika/

vatika/

Varti

+

+

+

+

+

+

+

-

+

+

Rasakriya + + + + + + + - + +

Choorna + + + + + + + - + +

Acharya Sushruta has mentioned that the strength of the Gutika anjana is more

than rasakriya anjana and strength of rasakriya anjana is more than choorna

anjanas.

Acharya Dalhana has indicated gutikanjana in severe, rasakriyanjana in

intermediate and choornanjana in mild diseased conditions. 120





Types of Anjana

1. Lekhananjana: 121

Selection: It is done according to the dosha vitiation of the disease and it is of

pancharasas ie. “madhura rasa varjita.”

Dosha Selection of rasa

Vata -Amla and Lavana rasa dravyas

Pitta -Tikta and Kashaya rasa dravyas

Kapha -Katu, Tikta and Kashaya rasa dravyas

Raktaja -Tikta and Kashaya rasa dravyas

If vitiated doshas are more in number then 2 or more types of rasa dravyas in

combination can be selected accordingly.

Action: The mode of action of lekhananjana described in Sushruta Samhita is as

follows. Properly applied lekhanajana enters into the eye lids, blood vessels of the

eye, ducts of ashru and “shringataka marma”. Then it causes sravana (flow out)

of vitiated doshas through the mouth, nose and the eyes itself.

Indication: Shukla-Armaadi

Time of application: Morning

Samyak lakshnas of Lekhananjana: 122

There will be Clarity of vision (vaishadyata), Lightness of eyes (laghutva),

stoppage of tear secretion (anasravi), easy movement of eyes (kriyapatu), eyes

become comfortable as before (sunirmalam) and pacification of adverse effects of

anjana (sa shanta upadrava).





Athiyoga of Lekhananjana:

Squinting of eyes (jihma netra), daruna netra, discoloration of eyes (dur varna),

srastam, severe dryness (ati rooksha), syandana.

Managemant of athiyoga:

Santarpana karma should be adopted in management of atiyoga to pacify vata

dosha.

Heenayoga of Lekhananjana:

If lekhananjana application is insufficient then the doshas get vitiated more

(Ugrataradosha).

Managemant of heenayoga:

The vitiated doshas can be eliminated by dhooma, nasya and again application of

anjana.

2. Ropananjana

Ropana anjana should be prepared with drugs having kashaya, tikta rasa along with

sneha dravyas such as ghee. Due to sneha and sheeta it does varnapradana, dristi bala

vardhana. 123

Action: By the virtue of sneha and sheethalata it does varnya karma and

dristibala vardhana.

Indications: Pitta and rakta vyadhis

Time of administration: Night

Atiyoga and heeneyoga and their management are similar to that of Prasadana

anjana. 124





3. Drishtiprasadananjana / prasadana anjana:

It should be prepared with madhura rasa and with lot of sneha dravyas. It imparts

tone and vigour to the eye sight and should be used with advantage for all soothing

purposes connected with eyes. 125

Indications: Vataja Rogas, Srotoshodhana, Rookshata of eyes, Vataja timira and

after Lekhananjana.

Time of application: Evening

Samyak lakshnas of drishtiprasadananjana: 126

Samyak lakshnas of prasadananjana are snehavarnabalopetam, prasannam and

doshavarjitam.

Athiyoga of drishtiprasadananjana:

Guruta, avilata, atisnigdhata, ashru, kandu and doshasamutklishta are mentioned

as athiyoga of drishtiprasadananjana.

Managemant of Athiyoga:

It can be treated by using doshahara (ie.kaphahara), rooksha and mrudu (ie.

sheeta veerya) medications and can be achieved by virechana nasya, dhoomapana,

kavala and lekhananjana also.

Heenayoga of drishtiprasadananjana:

In heenayoga disease will not subside, dryness, roughness will persist.

Managemant of Heenayoga:

In such conditions anjana should be continued. Bramhana nasya, Netra trapana is

employed if necessary.





Pratyanjana:

Application of prasadananjana to the eyes which have become fatigue by the

application of choorna and teekshna anjanas will derive the name „Pratyanjana‟. 127

Complications of anjana:

Applying anjana when there is loss of sleep produces inability for work; when

applied during or after exposure to heavy breeze, produces loss of strength of eye and

vision; when troubled by dust and smoke, it gives rise to red colour, exudation and severe

pain to eye (adhimantha); when applied at the end of Nasya it produces swelling and

pain; when applied during diseases related to head, it produces headache. 128

Anjana matra:

Matra of anjana has mentioned by acharyas as follow:

Table No. 17 Anjana matra as per Acharya Sushruta 129

Table No. 18 Anjana matra as per Acharya Vagbhata 130

Teekshna Pinda Harenumatra

Mrudu Pinda Two Harenumatra

Teekshna Rasakriya Vella matra (vidanga matra)

Mrudu Rasakriya Two vella matra.

Teekshna Choorna Two Shalaka

Mrudu Choorna Three Shalaka

Lekahananjana Harenu matra

Prasadananjana one and half harenu matra

Ropananjana Two harenu matra





Table No. 19 Anjana matra as per Sharangadhara samhita: 131

Gutikanjana

Teekshna dravyas Harenu matra

Madhyama dravyas 1 ½ Harenu matra

Mrudu dravyas 2 Harenu

Choornanjana

Vairechanika 2 Shalakas

Mrudu 3 Shalakas

Snehana 4 Shalakas

Rasakriyanjana

Uttama matra 3 Vidangas

Madhyama matra 2 Vidangas

Heena matra 1 Vidanga

ANJANA KALA:

Table No. 20 Anjana kala as per Sharangadhara (Rutu anusara anjana kala) 131

Hemantha and shishira ritu Madhyaahna

Greeshma and sharad ritu Poorvahna or Aparahna

Varsha ritu On clear day when no clouds on sky

Vasantha ritu, Na atyushna Any time

Table No. 21 Anjana kala as per Acharya Sushruta (Doshanusara anjana kala) 132

Kaphaja vikara Madhyahna

Vataja vikara Saayam

Pittaja vikara Nishi





Drug review

In the present study Triphala Choorna was taken up for internally with Ghrita as

Anupana and Krishnadi varti for Anjana karma in the management of Timira w.s.r. to

senile immature cataract.

[A] Triphala choorna:

कल्क: क्ववथोऽथवव चूिां त्रत्रपरवमव तनषेपवतभ ्। भधषनव हपवषव ववऽपऩ सभस्तततयवन्तकृत ्।।

(Vangasena Netrarogadhikar-291, Chakradatta 59/102-103, Gadanigraha Netradhikar-3/229)

[B] Krishnadi varti:

कृष्िवऩथ्मे क्रभवद्वधृ्दे बङृ्गयवजसयप्रषते । छवमवशषष्के हत् सद्मन्द्स्तसभयं ववपऩ मोन्द्जते ॥ (Vangasena, Netrarogadhikar-309)

[C] Others Dravyas:

Goghrita used as anupana

Madhu for rubbing varti





1. Haritaki: 133,134,135,136,137,138

Table No. 22 Details of Haritaki

Botanical name Terminalia chebula Retz

Family Combretaceae

Synonyms Abhaya, Pathya, Kayastha,Putana, Haimavati, Avyatha,

Chetaki, Shiva, Vayastha, Rohini

Vernacular names English: Chebulik myrobalan

Hindi: Harre, Harad, Harar

Bengali: Haritaki

Kannada: Alalekai, Karakkayi

Malayalam: Katukka

Telugu: Karaka, Karakkaya, Karitaki

Rasa panchaka Rasa: Lavana varjita pancharasa, mainly kashaya

Guna: Laghu, ruksha

Veerya: Ushna

Vipaka: Madhura

Karma: Chakshushya, Lekhana, Shothahara, Vranashodhana,

Vranaropana, Nadibalya, Deepana, Pachana, Anulomana,

Hridya, Rasayana, Mriduvirechana

Doshaghnata Tridoshahara

Rogaghnata Shotha, prameha, netra roga, krimi, hrdroga

Useful part Fruit

Chemical

Composition

Anthraquinone glycoside, chebulinic acid, chebulagic acid,

tannic acid, terchebin, tetrachebulin, vitamin c.

Pharmacological

action

Anti-microbial, anti-fungal, anti-bacterial, anti-stress, anti-

spasmodic, anti-oxidant, hypoglycaemic, cardiotonic,

hypolipidaemic





2. Vibhitaki: 139,140,141,142,143,144

Table No. 23 Details of Vibhitaki

Botanical name Terminalia bellerica Roxb.

Family Combretaceae

Synonyms Akshaphala, Karshaphala, Kalidruma, Kaliyugalaya

Vernacular names English: Beleric Myrobalan

Hindi: Bahera

Bengali: Bayada, Baheda

Kannada: Tare kayi, Shanti kayi

Malayalam: Tannikya

Telugu : Thanikkaya

Rasa panchaka Rasa: Kashaya

Guna: Ruksha, Laghu

Veerya: Ushna

Vipaka: Madhura

Karma: Chakshushya, Shothahara, Vedanasthapana,

Raktastambhaka, Deepana, Anulomana, Krimighna, Rechana,

Bhedana, Kaphaghna,

Doshaghnata Kapha-pittahara

Rogaghnata Netra roga, Jvara, Hrdroga, Raktanishthivana, Pratishyaya,

Kasa, Shwasa

Useful part Fruit, Seed

Chemical

Composition

Chebulagic acid, gallic acid, fructose, galactose, ẞ-sitosterol,

rhamnose, mannitol

Pharmacological

action

Purgative, Anti-fungal, Anti-histaminic, Anti-bacterial, anti-

spasmodic, hepatoprotective, Anti-stress, Broncho-dilatory,

CNS stimulant





3. Amalaki: 145,146,147,148,149,150

Table No. 24 Details of Amalaki

Botanical name Embelica officinalis Linn

Family Euphorbiaceae

Synonyms Abhaya Dhatri, Sheetaphala, Vayastha

Vernacular names English: Indian gooseberry

Hindi: Amalki, Anvla

Bengali: Amalki, Anvla

Kannada: Amalaka, Nelli

Malayalam: Nelli

Telugu: Usiri

Rasa panchaka Rasa: Lavana varjita pancharasa, amla pradhana

Guna: Laghu, ruksha, sara

Veerya: Sheeta

Vipaka: Madhura

Karma: Dahaprashamana, Chakshushya, keshya, medhya,

deepana, anulomana, rechana, stambhana, kaphaghna,

rasayana

Doshaghnata Tridoshahara

Rogaghnata Netra roga, drishtimandya,indriyadaurbalya, agnimandya,

raktapitta, dourbalya, daha, shotha

Useful part Fruit

Chemical

Composition

Vitamin C, carotene, riboflavin, linolic acid, phyllemblin,

ellagic acid, terchebin, indole acetic acid, phyllemblic acid

and salts

Pharmacological

action

Anti-oxidant, anti-microbial, hypolipidaemic, anti-

inflammatory, hepatoprotective





4. Pippali: 151,152,153,154,155,156

Table No. 25 Details of Pippali

Botanical name Piper longum Linn

Family Piperaceae

Synonyms Krishna, Magadhi, Vaidehi, Chapala, Kana, Krukara,

Katubeeja, Tikshna, Ushna

Vernacular names English: Long pepper

Hindi: Pipli, Pipal

Bengali: Pipli, Pipul

Kannada: Hipli, Tippali

Malayalam: Tippali, Magadhi

Telugu: Pipallu, Pipilli

Rasa panchaka Rasa: Katu

Guna: Laghu, Snigdha, Teekshna

Veerya: Anushnasheeta

Vipaka: Madhura

Karma: Rasayana, Raktavardhaka, Shirovirechana, Medhya,

Deepana, Vatanulomana, Shoolaprashamana, Balya,

Raktashodhaka.

Doshaghnata Kaphavatashamaka

Rogaghnata Shotha, Vedana, daurbalya, agnimandya, ajeerna, vibandha,

yakridvikara, pleehavikara, krimiroga, pandu, raktavikara,

kshaya

Useful part Fruit, Root

Chemical

Composition

Piperine, piplartine, Lignans, Longamide, piperlongumine,

Aristolactams, Dioxoaporphine, Sesamin Asarinine, Isobutyl

amide,

Pharmacological

action

Antibacterial, anti-inflammatory, insecticidal, CNS stimulant,

hypoglycaemic, antiulcerogenic, rejuvenative.





5. Bhringaraja: 157,158,159,160,161,162

Table No. 26 Details of Bhringaraja

Botanical name Eclipta alba (Linn.) Hassk

Family Asteraceae

Synonyms Markava, Bhringa, Angaraka, Kesharaja, Kesharanjana

Vernacular names English: Trailing Eclipta

Hindi: Bhamgra, Mochakand, Babri

Bengali: Kesuti, Keshori, Keshwari

Kannada: Garagada soppu

Malayalam: Kannunni, Kayyonni

Telugu: Galagara, Guntagalijeru

Rasa panchaka Rasa: Katu, Tikta

Guna: Ruksha, Laghu

Veerya: Ushna

Vipaka: Katu

Karma: Chakshushya, Shothahara, Vedanasthapana,

Vranashodhana, Vranaropana, Keshavardhana, Deepana,

Pachana, Pittarechaka, Rasayana, Balya.

Doshaghnata Kaphavatashamaka

Rogaghnata Granthi, Vrana, Netraroga, Shiroroga, Palitya,

Drishtimandya, Agnimandya, Raktavikara, Pandu, Shotha,

Dourbalya

Useful part Whole plant

Chemical

Composition

Ecliptal, flavanoids, Terthienyl-methanol, Xymethylene-2,

Glutamic acid, Phenylalanine, Cystine, Ecliptalbine

Pharmacological

action

Antiviral, Hepatoprotective, Antibacterial, Antioxidant, Anti-

catarrhal, Hypotensive, Analgesic, Antimyotoxic Antileprotic





6. Goghrita: 163,164,165,166,167

Table No. 27 Pharmacodynamic properties of Goghtrita

Nighantu Varga Rasa Guna Veerya Vipaka Doshaghnata

Dhanvantari Suvarnadi - - Sheeta Madhura Vata-Pitta

shamaka

Kaiyadeva Ghritavarga Madhura

Guru,

Mridu,

Slakshna

Sheeta Madhura Tridosha

shamaka

Raja nighantu Kshiradi Madhura Snigdha,

Guru

Sheeta Madhura Vata-Kapha

shamaka

Bhavaprakasha Ghrita

Varga

- Guru

Rochaka

Sheeta Madhura Tridosha

shamaka

Dravyaguna

Vigyana

Snehavarga Madhura Guru

Snigdha

Sheeta Madhura Vata-Pitta

shamaka

Karma of Goghrita:

Rasayana, Agnivardhaka Rasavardhaka, Balya, Ojavardhaka, Kantivardhaka,

Indriyabalavriddhikara, Buddhivardhaka, Vayahsthapana.

Rogaghnata of Goghrita:

Kshata, Daha, Vrana, Shosha, Shiroroga, Akshiroga, Murchha, Mada, Unmada,

Apasmara, Agnimandya, Jwara, Unmadahara.

Composition of Goghtrita:

Ghrita provides energy to body as it is more useful than the carbohydrates and proteins;

one gram of ghrita gives 9.3 calories. The chemical composition of ghrita is mentioned

below:





Table No. 28 Composition of Goghrita

Content Amount Content Amount

Tri -glycerides 97.098% Vitamin-A 2500 I.U (per 100 gm)

Di- glycerides 0.25-1.4% Vitamin –D 8.5x 10.7gm (per 100 gm)

Monoglycerides 0.16-0.038 % Vitamin-E 24x10.3gm ( per 100 gm)

Ketoacid glycerides 0.015-0.018 % Vitamin-K 1x10.4gm ( per 100 gm)

Glycerylesters 0.011-0.05% Myristic acid 21-23%

Free fatty acids 0.1-0.44% Oleic acid 27-27.5%

Phospholipids 0.2 -1.0% Sterols 0.22-0.41%

8. Madhu: 168,169,170

It is a viscid, saccharine substance, brown colour of an aromatic odour and of a

sweet acrid taste. After a time it becomes opaque and crystalline.

Table No. 29 Details of Madhu

Synonyms Madhu, Kshaudra, Makshik, Saradyam

Vernacular names English: Honey

Hindi: Shahad

Bengali: Madhu

Kannada: Jenutuppa

Malayalam: Ten

Telugu: Tene

Rasa panchaka Rasa: Madhura, Kashaya

Guna: Laghu, Ruksha, Sukshma

Veerya: Ushna

Vipaka: Madhura





Karma: Chakshushya, Vilekhana, Deepana, Lekhana, Varnya,

Srotovishodhana, Ropana, Yogavahi

Doshaghnata Kapha-Pittahara

Rogaghnata Netraroga, Atisar, Chardi, Trishna, Prameha, Kandu, Arsha,

Kamala, Galaroga, Daha.

Chemical

Composition

Glucose 84.9%, Formic acid, Sucrose 2.69%, Alkaloids

0.12%, Nitrogen 1.29%

Pharmacological

action

Antimicrobial, Anti-inflammatory, Minimises scarring

METHODOLOGY




Methodology

Null hypothesis

There is no added effect of Krishnadi anjana in the management of Timira w.s.r. to

Senile Immature Cataract.

Alternate hypothesis

There is an effect of Krishnadi anjana in the management of Timira w.s.r. to Senile

Immature Cataract.

Materials and methods

A. Source of data

1. Literary source

Classical Ayurveda texts, Modern literatures and Contemporary text books including

the Websites and Journals were reviewed to gather information about the disease,

therapy and the drugs.

2. Sample source

Patients with clinical features of Timira (Immature cataract) coming under the

inclusion criteria approaching the OPD and IPD of Shalakya Tantra, SKAMCH &

RC, Bengaluru were selected for the study.

The sample collection was initiated with post approval from the Institutional

Ethical Committee.

METHODOLOGY




3. Drug source

The identified raw drugs required for the preparation of Krishnadi varti anjana and

Triphala choorna were purchased from approved vendors. Post purchase, the raw drugs

were authenticated by the faculty of Dravya Guna, SKAMCH & RC, BENGALURU.

B. Method of collection of data

Study design

Randomized clinical study.

Sampling technique

The subjects who fulfilled the inclusion and exclusion criteria and complying with

the informed consent (IC) were selected using random sampling technique.

Sample size

A comparative clinical study where in 40 Patients diagnosed as Timira of either

sex were randomly assigned into two groups i.e., Group A and Group B

comprising of 20 patients each.

A case proforma containing all the necessary details pertaining to the study was

prepared.

The parameters considered for the study were scored as mentioned in the

proforma.

METHODOLOGY




Diagnostic criteria

Patients with lakshanas of Timira.

Clinical feature of senile immature cataract.

Diminished visual acuity up to 6/12 and N12.

Immature cataract confirmed by Ophthalmoscopy and Slit lamp biomicroscopy.

Inclusion criteria

Patients with lakshanas of Timira.

Patients with signs and symptoms of Senile immature cataract.

Patients in between the age group of 40 to 70 years.

Exclusion criteria

Post surgical cataract

Mature cataract

Sluggish pupillary reaction

Patients with systemic disorders that may interfere with the course of the study.

Associated with any inflammatory and infective ocular conditions.

METHODOLOGY




C. Intervention

The study was intervened in one treatment phase

Group Treatments Dose Duration

A 1. Krishnadi

anjana

-1 Harenu matra -Once daily at Morning for

48 days

2. Triphala

choorna Internally

-05 Grams with sufficient

amount of Go ghrita.

-Once daily at night after

food for 48 days

B 1. Triphala

choorna Internally

-05 Grams with sufficient

amount of Go ghrita

-Once daily at night after

food for 48 days

Assessment was done on 49th

day.

Duration of the study:

The total duration of the study in both the groups was 49days.

Method of preparation of medicaments required for the study:-

1. Krishnadi varti

Ingredients and Quantity:

Pippali tandula - 350 grams

Haritaki - 700 grams

Bhringaraja Swarasa - 4 litres (was extracted from fresh Bhringaraja panchanga-

fresh plant)

METHODOLOGY




Method:

A. Pre-preparatory procedure:

1) The raw drugs required for varti i.e. Pippali tandula and Haritaki were

washed thoroughly and allowed to dry up.

2) The procured Bhringaraja fresh plant was washed thoroughly and kept in the

clean vessel.

B. Preparatory procedure

1. Each of the drugs (Pippali tandula and Haritaki) were crushed and finely

powdered separately in a mixer grinder. Then a homogenous mixture was

prepared by adding these powders.

2. Bhringaraja plant was subjected to grinding using wet grinder until

Bhringaraja was completely grinded. The above paste of Bhringaraja was

placed in a clean cloth and allowed for squeezing by which Bhringaraja

swarasa was extracted and collected in a clean container.

3. The above mixture was subjected for bhavana using Bhringaraja swarasa.

4. The bhavana procedure was continued till it attained the form of kalka fulfil

the Subhavita lakshanas as per classics and then it rolled into varti aakar.

5. Each prepared varti was 2 inches long and about 5 grams weight.

C. Post-preparatory procedure:

1) The prepared vartis were dried in shade.

2) After complete drying, vartis were stored in a clean air tight container.

METHODOLOGY




2. Triphala choorna:

Ingredients and Quantity:

Amalaki - 5 Kgs

Haritaki - 5 Kgs

Vibhitaki - 5 Kgs

Method:

A. Pre-preparatory procedure:

1. The dry drugs required for Triphala choorna viz., as Amalaki, Haritaki and

Vibhitaki were thoroughly washed to remove the impurities and was dried

completely.

B. Preparatory procedure:

1. Each of the drugs were crushed separately using khalwa yantra and made

fine powder using mixture grinder.

2. The powders were sieved and a homogenous mixture was prepared by mixing

these powders.

C. Post-preparatory procedure:

The prepared choorna was stored in a clean air tight container.

METHODOLOGY




Procedure

Anjana karma:

The patients of Group A were subjected to Anjana karma with Krishnadi varti.

Materials required

1. Water

2. Madhu

3. Sterilized Steel bowl-2

4. Gharshana shila (sterile)

5. Anjana shalaka (sterile)

6. Sterile gauze-2

7. Sterile Cotton

Procedure

Poorva karma:

In a clean and well light room patient was seated comfortably with head rest.

The eye lids and area around the eyes were wiped with wet sterile gauze dipped

in water.

Pradhana karma:

Under aseptic precautions, the tapered end of the krishnadi varti was rubbed

against a gharshana shila with sufficient quantity of Madhu to get a soft paste.

The patient was asked to open the eyes widely and eye lids were pulled down

with thumb or index finger and the anjana paste was taken on a shalaka in the

dose of one Harenu and applied from Kaninika sandhi to Apanga sandhi in a jerk

free manner and the same is repeated for other eye.

METHODOLOGY




The patient was then advised to close his eyes and rotate the eye ball in clock wise

and anti clockwise direction once for the uniform spreading of medicine.

Paschat karma:

Wet cotton gauze was kept over each eye after closing, in order to soothe the

burning sensation due to the medicament applied.

When the burning sensation and lacrimation stopped, eyes were washed with

clean water.

Eyes were checked for any remnants of medicament or accumulated akshimala

and if present it was removed with sterile gauze in order to avoid any irritation to

the eyes.

Patient was advised to avoid exposure to dust and excessive eye strain.

Assessment Criteria:

Assessment criteria was designed based on subjective and objective parameters as

per the proforma by adapting a scoring pattern.

The clinical findings were noted in specially prepared case proforma and

assessment was done

Day 1-Before treatment (BT)

Day 49- After treatment (AT)

The parameters considered for the study were graded based on the scoring pattern

0-3 for subjective parameters and 0-6 for distant vision and near vision visual acuity for

the purpose of statistical analysis.

METHODOLOGY




Scoring index

Table No. 30 Scoring index

1. Avyaktadarshana (Blurriness of vision)

Score Criteria

0 Absent

1 Blurred vision present but can make out the features of an object

clearly

2 Blurred vision present but can make out the features of an object with

straining of the eyes

3 Blurred vision present and cannot make out the features of an object

2. Gocharavibhrama

Score Criteria

0 Can assess the distance

1 Can assess the distance for near objects easily and far objects on

straining the eyes

2 Can assess the distance for both near objects and far objects on

straining the eyes

3 Cannot assess the distance for either far or near objects on straining

the eyes

METHODOLOGY




3. Vihwala darshana (Visualization of non-existing things like dots, lines,

threads.)

Score Criteria

0 Absent

1 Perception on exposure to bright light but not disturbing the

visualization of objects

2 Perception on exposure to bright light and disturbing the


3 Perception on exposure to dim light and disturbing the


4. Dwidha-bahudha darshana (Diplopia /Polyopia)

Score Criteria

0 No diplopia/polyopia

1 Occasionally present in primary gaze or reading position

2 Frequently present in primary gaze or reading position

3 Continuous present in primary gaze or reading position

5. Glare

Score Criteria

0 Absent

1 Present in direct light

2 Present in reflected light

3 Present in dim light

METHODOLOGY




6. Distant vision (Snellen’s chart)

Score Criteria

0 6/6

1 6/9

2 6/12

3 6/18

4 6/24

5 6/36

6 6/60

7. Near vision (Jaegear’s chart)

Score Criteria

0 N6

1 N9

2 N12

3 N18

4 N24

5 N36

6 N60

Statistical Analysis:

For the statistical analysis the data obtained in both the groups were recorded,

presented in tabulations and drawings.

The Statistic Mean, Standard Deviation (SD), Standard Error of Mean (SEM) and

Standard Error of difference between two means (SE) were employed for descriptive

statistics.

To infer the clinical study and draw conclusion, paired ‘t’-test was applied for within

the group analysis and unpaired ‘t’-test was applied for between the group analysis.

SAMPLE SIZE OF ESTIMATION




Sample size of Estimation

A total number of 45 Patients of Timira w.s.r. to Senile Immature Cataract

fulfilling the inclusion criteria were registered for this clinical study. The observations of

the present study are elaborated below:

Number of Patients registered for the Study – 45

Number of Patients completed the Study – 40

Number of Patients discontinued in between the Study – 5

The observations recorded are presented under the following headings:

Observations on Demographic data.

Observations on Bala pramana pariksha.

Observations on Nidana and Lakshanas of Timira.

Age:

Graph No. 01 Distribution of patients based on Age

0

2

4

6

8

10

12

41-50 51-60 61-70

Group A

Group B

Table No. 31 Distribution of patients based on Age

Age in Years Group A % Group B % Total %

41-50 6 30 9 45 15 37.5

51-60 4 20 5 25 9 22.5

61-70 10 50 6 30 16 40

Total 20 100 20 100 40 100





In Group A, 6 (30%) patients belonged to the age group of 41–50years, 4 (20%) patients

belonged to the age group of 51–60years and 10 (50%) patients belonged to the age

group of 61–70years.

In Group B, 9 (45%) patients belonged to the age group of 41–50years, 5 (25%) patients

belonged to the age group of 51–60years and 6 (30%) patients belonged to the age group

of 61–70years.

Out of 40 patients, 15 (37.5%) patients belonged to the age group of 41–50years, 9

(22.5%) patients belonged to the age group of 51–60years and 16 (40%) patients

belonged to the age group of 61–70years.

Gender:

Table No. 32 Distribution of patients based on Gender

Gender Group A % Group B % Total %

Male 8 40 6 30 14 35

Female 12 60 14 70 26 65

Total 20 100 20 100 40 100

Graph No. 02 Distribution of patients based on Gender

In Group A, 8 (40%) patients were Males and 12 (60%) patients were Females.

In Group B, 6 (30%) patients were Males and 14 (70%) patients were Females.

0

5

10

15

Male Female

Group A

Group B





Out of 40 patients in both the groups, 14 (35%) patients were Males and 26 (65%)

patients were Females.

Religion :

Table No. 33 Distribution of patients observation on Religion

Religion Group A % Group B % Total %

Hindu 14 70 16 80 30 75

Muslim 6 30 4 20 10 25

Total 20 100 20 100 40 100

Graph No. 03 Distribution of patients observation on Religion

In Group A, 14 (70%) patients were Hindus and 6 (30%) patients were Muslims.

In Group B, 16 (80%) patients were Hindus and 4 (20%) patients were Muslims.

Out of 40 patients in both the groups, 30 (75%) patients were Hindus and 10 (25%)

patients were Muslims.

0

2

4

6

8

10

12

14

16

18

Hindu Muslim

GROUP A

GROUP B





Marital status :

Table No. 34 Distribution of patients based on Marital status

Marital status Group A % Group B % Total %

Married 20 100 20 100 40 100

Total 20 100 20 100 40 100

Graph No. 04 Distribution of patients observation on Marital status

In Group A, 20 (100%) patients were married.

In Group B, 20 (100%) patients were married.

Out of 40 patients in both the groups, 40 (100%) patients were married.

Educational status :

Table No. 35 Distribution of patients based on Educational status

Educational status Group A % Group B % Total %

Uneducated 3 15 4 20 7 17.5

Below graduation 11 55 10 50 21 52.5

Graduate 5 25 5 25 10 25

Post Graduate 1 5 1 5 2 5

Total 20 100 20 100 40 100

0

5

10

15

20

25

MARRIED UNMARRIED

GROUP A

GROUP B





Graph No. 05 Distribution of patients based on Educational status

In Group A, 3 (15%) patients were uneducated, 11 (55%) patients were below

graduation, 5 (25%) patients were graduate and 1 (5%) patient was post graduate.

In Group B, 4 (20%) patients were uneducated, 10 (50%) patients were below

graduation, 5 (25%) patients were graduate and 1 (5%) patient was post graduate.

Out of 40 patients in both the groups, 7 (17.5%) patients were uneducated, 21 (52.5%)

patients were below graduation, 10 (25%) patients were graduate and 2 (5%) patients

were post graduate.

Socio economic status :

Table No. 36 Distribution of patients based on Socio economic status

Socio economic

status

Group A % Group B % Total %

Lower Class 6 30 7 35 13 32.5

Middle Class 11 55 12 60 23 57.5

Upper Class 3 15 1 5 4 10

Total 20 100 20 100 40 100

0

2

4

6

8

10

12

Uneducated Below graduation

Graduate Post Graduate

GROUP A

GROUP B





Graph No. 06 Distribution of patients based on Socio economic status

In Group A, 6 (30%) patients belonged to lower class, 11 (55%) patients belonged to

middle class and 3 (15%) patients belonged to upper class in socio-economic status.

In Group B, 7 (35%) patients belonged to lower class, 12 (60%) patients belonged to

middle class and 1 (5%) patient belonged to upper class in socio-economic status.

Out of 40 patients in both the groups, 13 (32.5%) patients belonged to lower class, 23

(57.5%) patients belonged to middle class and 4 (10%) patients belonged to upper class

in socio-economic status.

Habitat :

Table No. 37 Distribution of patients based on Habitat

Habitat Group A % Group B % Total %

Urban 20 100 19 95 39 97.25

Rural 0 0 1 5 1 2.5

Total 20 100 20 100 40 100

0

2

4

6

8

10

12

14

Lower Class Middle Class Upper Class

GROUP A

GROUP B





Graph No. 07 Distribution based on Habitat

In Group A, 20 (100%) patients belonged to urban area.

In Group B, 19 (95%) patients belonged to urban and 1 (5%) patient was from rural area.

Out of 40 patients in both the groups, 39 (97.25%) patients belonged to urban and 1

(2.5%) patient belonged to rural area.

Occupation :

Table No. 38 Distribution of patients based on Occupation

Occupation Group A % Group B % Total %

Housewives 12 60 14 70 26 65

Businessmen 3 15 3 15 6 15

Professionals 3 15 3 15 6 15

Drivers 2 10 0 0 2 5

Total 20 100 20 100 40 100

0

5

10

15

20

25

URBAN RURAL

GROUP A

GROUP B





Graph No. 08 Distribution of patients based on Occupation

In Group A, 12 (60%) patients were house wives, 3 (15%) patients were businessmen, 3

(15%) patients were professionals (Government/Private employee) and 2 (10%) patients

were drivers.

In Group B, 14 (70%) patients were house wives, 3 (15%) patients were businessmen

and 3 (15%) patients were professionals (Government/Private employee).

Out of 40 patients in both the groups, 26 (65%) patients were house wives, 6 (15%)

patients were businessmen, 6 (15%) patients were professionals and 2 (5%) patients were

drivers.

Diet:

Table No. 39 Distribution of patients based on Diet

Diet Group A % Group B % Total %

Vegetarians 9 45 12 60 21 52.5

Mixed 11 55 8 40 19 47.5

Total 20 100 20 100 40 100

0

2

4

6

8

10

12

14

16

Housewives Businessmen Professionals Drivers

Group A

Group B





Graph No. 09 Distribution of patients based on Diet

In Group A, 9 (45%) patients were vegetarians and 11 (55%) patients were consuming

mixed diet.

In Group B, 12 (60%) patients were vegetarians and 8 (40%) patients were consuming

mixed diet.

Out of 40 patients in both the groups, 21 (52.5%) patients were vegetarians and 19

(47.5%) patients were non-vegetarians.

Sleep:

Table No. 40 Distribution of patients based on Sleep

Sleep Group A % Group B % Total %

Sound 10 50 8 40 18 45

Disturbed 7 35 10 50 17 42.5

Delayed 3 15 2 10 5 12.5

Total 20 100 20 100 40 100

0

2

4

6

8

10

12

14

Vegetarians Mixed

Group A

Group B





Graph No. 10 Distribution of patients based on Sleep

In Group A, 10 (50%) patients had sound sleep, 7 (35%) patients had disturbed sleep

and 3 (15%) patients had delayed sleep.

In Group B, 8 (40%) patients had sound sleep, 10 (50%) patients had disturbed sleep and

2 (10%) patients had delayed sleep.

Out of 40 patients in both the groups, 18 (45%) patients had sound sleep, 17 (42.5%)

patients had disturbed sleep and 5 (12.5%) patients had delayed sleep.

Addictions :

Table No. 41 Distribution of patients based on Addictions

Addictions Group A % Group B % Total %

Smoking 3 15 1 5 4 10

Alcohol 1 5 0 0 1 2.5

Tobacco

chewing

2 10 1 5 3 7.5

Tea/Coffee 16 80 13 65 29 72.5

0

2

4

6

8

10

12

Sound Disturbed Delayed

Group A

Group B





Graph No. 11 Distribution of patients based on Addictions

In Group A, 3 (15%) patients were habituated to smoking, 1 (5%) patient was habituated

to alcohol, 2 (10%) patients were habituated to tobacco chewing and 16 (80%) patients

were habituated to tea/coffee.

In Group B, 1 (5%) patient was habituated to smoking, 1 (5%) patient was habituated to

tobacco chewing and 13 (50%) patients were habituated to tea/coffee.

Out of 40 patients in both the groups, 4 (10%) patient was habituated to smoking, 1

(2.5%) patient was habituated to alcohol, 3 (7.5%) patient was habituated to tobacco

chewing and 29 (72.5%) patients were habituated to tea/coffee.

Family history :

Table No. 42 Distribution of patients based on Family history

Family

History

Group A % Group B % Total %

Present 9 45 7 35 16 40

Absent 11 55 13 65 24 60

Total 20 100 20 100 40 100

02468

1012141618

Smoking Alcohol Tobacoo chewing

Tea/Cofee

GROUP A

GROUP B





Graph No. 12 Distribution based on Family history

In Group A, 9 (45%) patients had family history of cataract and 11 (55%) patients had

no family history of cataract.

In Group B, 7 (35%) patients had family history of cataract and 13 (65%) patients had

no family history of cataract.

Out of 40 patients in both the groups, 16 (40%) patients had family history of cataract

and 24 (60%) patients had no family history of cataract.

Chronicity :

Table No. 43 Distribution of patients based on Chronicity

Chronicity Group A % Group B % Total %

≤ 6months 1 5 3 15 4 10

>6months≤12months 3 15 2 10 5 12.5

>12≤18months 1 5 3 15 4 10

>18≤24months 3 15 1 5 4 10

>24months 12 60 11 55 23 57.5

Total 20 100 20 100 40 100

0

2

4

6

8

10

12

14

Present Absent

GROUP A

GROUP B





Graph No. 13 Distribution of patients based on Chronicity

In Group A, 1 (5%) patient had ≤6months of chronicity, 3 (15%) patients had

>6months≤12months of chronicity, 1 (5%) patient had >12≤18months of chronicity, 3

(15%) patients had >18≤24months of chronicity and 12 (60%) patients had more than

24months of chronicity.

In Group B, 3 (15%) patients had ≤6months of chronicity, 2 (10%) patients had

>6months≤12months of chronicity, 3 (15%) patients had >12≤18months of chronicity, 1

(5%) patient had >18≤24months of chronicity and 11 (55%) patients had more than

24months of chronicity.

Out of 40 patients in both the groups, 4 (10%) patients had ≤6months of chronicity, 5

(12.5%) patients had >6months≤12months of chronicity, 4 (10%) patients had

>12≤18months of chronicity, 4 (10%) patients had >18≤24months of chronicity and 23

(57.5%) patients had more than 24months of chronicity.

0

1

2

3

4

5

6

7

8

9

GROUP A

GROUP B





Bala pramana pariksha:

Table No. 44 Distribution of patients based on Bala pramana pariksha

Bala pramana

pariksha Group A Group B Total

Prakruti

Vata Pitta 5 6 11

25% 30% 27.5%

Vata Kapha 4 5 9

20% 25% 22.5%

Kapha Pitta 11 9 20

55% 45% 50%

Sara

Pravara 2 2 4

10% 10% 10%

Madhyama 15 15 30

75% 75% 75%

Avara 3 3 6

15% 15% 15%

Samhanana

Pravara 2 1 3

10% 5 7.5%

Madhyama 17 17 34

85% 85% 85%

Avara 1 2 3

5% 10% 7.5%

Pramana

Pravara 2 1 3

10% 5 7.5%

Madhyama 17 17 34

85% 85% 85%

Avara 1 2 3

5% 10% 7.5%

Satmya

Eka rasa 0 0 0

0% 0% 0%

Sarva rasa 9 12 21

45% 60% 52.5%

Vyamishra 11 8 19

55% 40% 47.5%

Satva

Pravara 2 1 3

10% 5% 7.5%

Madhyama 16 18 34

80% 90% 85%

Avara 2 1 3

10% 5% 7.5%





Abhyavaharana

shakti

Pravara 3 3 6

15% 15% 15%

Madhyama 10 9 19

50% 45% 47.5%

Avara 7 8 15

35% 40% 37.5%

Jarana shakti

Pravara 3 3 6

15% 15% 15%

Madhyama 10 9 19

50% 45% 47.5%

Avara 7 8 15

35% 40% 37.5%

Vyayama Shakti

Pravara 2 2 4

10% 10% 10%

Madhyama 14 13 27

70% 65% 67.5%

Avara 4 5 9

20% 25% 22.5%

Vaya Parihaani 20 20 40

50% 50% 100%

Graph No. 14 Distribution of patients based on Bala pramana pariksha

0

5

10

15

20

25

Pra

kru

ti-

Vat

a p

itta

Pra

kru

ti-V

ata

Kap

ha

Pra

kru

ti-K

aph

a P

itta

Sara

-P

rava

ra

Sara

-M

adh

yam

a

Sara

-Ava

ra

Sam

han

ana-

Pra

vara

Sam

han

ana-

Mad

hya

ma

Sam

han

ana-

Ava

ra

Pra

man

a-P

rava

ra

Pra

man

a-M

adh

yam

a

Pra

man

a-A

vara

Satm

ya-E

ka r

asa

Satm

ya-S

arva

rasa

Satm

ya-V

yam

ish

ra

Satv

a-P

rava

ra

Satv

a-M

adh

yam

a

Satv

a-A

vara

Ab

hya

varn

a Sh

akti

-Pra

vara

Ab

hya

varn

a-M

adh

yam

a

Ab

hya

varn

a-A

vara

Jara

na

Shak

ti-P

rava

ra

Jara

na

Shak

ti-M

adh

yam

a

Jara

na

Shak

ti-A

vara

Vya

yam

a Sh

akti

-P

rava

ra

Vya

yam

a Sh

akti

-M

adh

yam

a

Vya

yam

a Sh

akti

-Ava

ra

Par

ihaa

ni

GROUP A GROUP B





1. Prakruti:

In Group A, 5 (25%) patients belonged to Vata pitta prakruti, 4 (20%) patients belonged

to Vata kapha prakruti and 11 (55%) patients belonged to Kapha pitta prakruti.

In Group B, 6 (30%) patients belonged to Vata pitta prakruti, 5 (25%) patients belonged

to Vata kapha prakruti and 9 (45%) patients belonged to Kapha pitta prakruti.

Out of 40 patients in both the groups, 11 (27.5%) patients belonged to Vata pitta prakruti,

9 (22.5%) patients belonged to Vata kapha prakruti and 20 (50%) patients belonged to

Kapha pitta prakruti.

2. Sara:

In Group A, 2 (10%) patients were of Pravara sara, 15 (75%) patients were of

Madhyama sara and 3 (15%) patients were of Avara sara.

In Group B, 2 (10%) patients were of Pravara sara, 15 (75%) patients were of

Madhyama sara and 3 (15%) patients were of Avara sara.

Out of 40 patients in both the groups, 4 (10%) patients were of Pravara sara, 30 (75%)

patients were of Madhyama sara and 6 (15%) patients were of Avara sara.

3. Samhanana:

In Group A, 2 (10%) patients were of Pravara samhanana, 17 (85%) patients were of

Madhyama samhanana and 1 (5%) patient was of Avara samhanana.

In Group B, 1 (5%) patient was of pravara samhanana, 17 (85%) patients were of

Madhyama samhanana and 2 (10%) patients were of Avara samhanana.





Out of 40 patients in both the groups, 3 (7.5%) patients were of Pravara samhanana, 34

(85%) patients were of Madhyama samhanana and 3 (7.5%) patients were of Avara

samhanana.

4. Pramana:

In Group A, 2 (10%) patients were of Pravara pramana, 17 (85%) patients were of

Madhyama pramana and 1 (5%) patient was of Avara pramana.

In Group B, 1 (5%) patient was of Pravara pramana, 17 (85%) patients were of

Madhyama pramana and 2 (10%) patients were of Avara pramana.

Out of 40 patients in both the groups, 3 (7.5%) patients were of Pravara pramana, 34

(85%) patients were of Madhyama pramana and 3 (7.5%) patients were of Avara

pramana.

5. Satmya:

In Group A, 9 (45%) patients belonged to Sarva rasa satmya and 11 (55%) patients

belonged to Vyamishra satmya.

In Group B, 12 (60%) patients belonged to Sarva rasa satmya and 8 (40%) patients

belonged to Vyamishra satmya.

Out of 40 patients in both the groups, 21 (52.5%) patients belonged to Sarva rasa satmya

and 19 (47.5%) patients belonged to Vyamishra satmya.

6. Satva:

In Group A, 2 (10%) patients belonged to Pravara satva, 16 (80%) patients belonged to

Madhyama satva and 2 (10%) patients belonged to Avara satva





In Group B, 1 (5%) patient belonged to Pravara satva, 18 (90%) patients belonged to

Madhyama satva and 1 (5%) patient belonged to Avara satva.

Out of 40 patients in both the groups, 3 (7.5%) patients belonged to Pravara Satva, 34

(85%) patients belonged to Madhyama satva and 3 (7.5%) patients belonged to Avara

satva.

7. Abhyavaharanashakti:

In Group A, 3 (15%) patients had Pravara abhyavaharana shakti, 10 (50%) patients had

Madhyama abhyavaharana shakti and 7 (35%) patients had Avara abhyavaharana

shakti.

In Group B, 3 (15%) patients had Pravara abhyavaharana shakti, 9 (45%) patients had

Madhyama abhyavaharana shakti and 8 (40%) patients had Avara abhyavaharana

shakti.

Out of 40 patients in both the groups, 6 (15%) patients had Pravara abhyavaharana

shakti, 19 (47.5%) patients had Madhyama abhyavaharana shakti and 15 (37.5%)

patients had Avara abhyavaharana shakti.

8. Jarana shakti:

In Group A, 3 (15%) patients had Pravara jarana shakti, 10 (50%) patients had

Madhyama jarana shakti and 7 (35%) patients had Avara jarana shakti.

In Group B, 3 (15%) patients had Pravara jarana shakti, 9 (45%) patients had

Madhyama jarana shakti and 8 (40%) patients had Avara jarana shakti.





Out of 40 patients in both the groups, 6 (15%) patients had Pravara jarana shakti, 19

(47.5%) patients had Madhyama jarana shakti and 15 (37.5%) patients had Avara jarana

shakti.

9. Vyayama Shakti:

In Group A, 2 (10%) patients belonged to Pravara vyayama shakti, 14 (70%) patients

belonged to Madhyama vyayama shakti and 4 (20%) patients belonged to Avara vyayama

shakti.

In Group B, 2 (10%) patients belonged to Pravara vyayama shakti, 13 (65%) patients

belonged to Madhyama vyayama shakti and 5 (25%) patients belonged to Avara vyayama

shakti.

Out of 40 patients in both the groups, 4 (10%) patients belonged to Pravara vyayama

shakti, 27 (67.5%) patients belonged to Madhyama vyayama shakti and 9 (22.5%)

patients belonged to Avara vyayama shakti.

10. Vaya:

In Group A, all 20 (100%) patients belonged to Parihani avastha.

In Group B, all 20 (100%) patients belonged to Parihani avastha.

Out of 40 patients in both the groups, all 40 (100%) patients belonged to Parihani

avastha.





Nidana:

Table No. 45 Distribution of patients based on Nidana

Nidana Group A Group B Total %

No. of Pts. % No. of Pts. % No. of Pts. %

Swapna

viparyaya

10 50 12 60 22 55

Kopa 7 35 5 25 12 30

Shoka 3 15 6 30 9 22.5

Shukta Aranala

sevana

1 5 0 0 1 2.5

Amla rasa

atisevana

7 35 6 30 13 32.5

Vega dharana 11 55 9 45 20 50

Sookshma

nireekshana

8 40 6 30 14 35

Atapa sevana 4 20 4 20 8 20

Doorekshanat 3 15 4 20 7 17.5

Rajodhuma

nishevana

8 40 6 30 14 35

Graph No. 15 Distribution of patients based on Nidanas

0

2

4

6

8

10

12

14

Group A

Group B





In Group A, 10 (50%) patients had Swapna viparyaya, 7 (35%) patients had Kopa, 3

(15%) patients had Shoka, 1 (5%) patient had a habit of Shukta aranala sevana, 7 (35%)

patients had a habit of Amlarasa atisevana, 11 (55%) patients had Vegadharana

(majority had Mutra, Purisha & Nidra vegadharana), 8 (40%) patients had Sookshma

nireekshana, 4 (20%) patients had Atapa sevana, 3 (15%) patients had Doorekshanat and

8 (40%) had Rajadhuma nishevana as nidanas.

In Group B, 12 (60%) patients had Swapna viparyaya, 5 (25%) patients had Kopa, 6

(30%) patients had Shoka, 6 (30%) patients had a habit of Amlarasa atisevana, 9 (45%)

patients had Vegadharana (majority had Mutra, Purisha & Nidra vegadharana), 6 (30%)

patients had Sookshma nireekshana, 4 (20%) patients had Atapa sevana, 4 (20%)

patients had Doorekshanat and 6 (30%) had Rajadhuma nishevana as Nidanas.

Out of 40 patients in both the groups, 22 (55%) patients had Swapna viparyaya, 12 (30%)

patients had Kopa, 9 (22.5%) patients had Shoka, 1 (2.5%) patient had a habit of Shukta

aranala sevana, 13 (32.5%) patients had a habit of Amlarasa atisevana, 20 (50%)

patients had Vegadharana (majority had Mutra, Purisha & Nidra vegadharana), 14

(35%) patients had Sookshma nireekshana, 8 (20%) patients had Atapa sevana, 7

(17.5%) patients had Doorekshanat and 14 (35%) had Rajadhuma nishevana as nidanas.





Lakshanas:

Table No. 46 Distribution of patients based on Lakshanas

Lakshana Group A % Group B % Total %

Avyakta Darshana 20 100 20 100 40 100

Gocharavibhrama 8 40 7 35 15 37.5

Vihwala Darshana 11 55 10 50 21 52.5

Dwidha Bahudha

Darshana

14 70 12 60 26 65

Glare 16 80 17 85 33 82.5

Graph No. 16 Distribution of patients based on Lakshanas

In Group A, 20 (100%) patients had Avyakta darshana, 8 (40%) patients had

Gocharavibhrama, 11 (55%) patients had Vihwala darshana, 14 (70%) patients had

Dwidha bahudha darshana and 16 (80%) patients had glare.

0

5

10

15

20

25

Group A

Group B





In Group B, 20 (100%) patients had Avyakta darshana, 7 (35%) patients had

Gocharavibhrama, 10 (50%) patients had Vihwala darshana, 12 (60%) patients had

Dwidha bahudha darshana and 17 (85%) patients had glare.

Out of 40 patients in both the groups, 40 (100%) patients had Avyakta darshana, 15

(37.5%) patients had Gocharavibhrama, 21 (52.5%) patients had Vihwala darshana, 26

(65%) patients had Dwidha bahudha darshana and 33 (82.5%) patients had glare.

Visual acuity:

Table No. 47 Distribution of patients based on visual acuity- Distant

vision

Group A Group B Total

RE LE Total RE LE Total

6/12

6 7 13 7 6 13 26

30% 35% 32.5% 35% 30% 32.5% 32.5%

6/18

5 3 8 7 8 15 23

25% 15% 20% 35% 40% 37.5% 28.75%

6/24

4 4 8 3 2 5 13

20% 20% 20% 15% 10% 12.5% 16.25%

6/36

1 1 2 3 2 5 7

5% 5% 5% 15% 10% 12.5% 8.75%

6/60

4 5 9 0 2 2 11

20% 25% 22.5% 0% 10% 5% 13.75%





Graph No. 17 Distribution of patients based on visual acuity

-Distant vision

In Group A, 13 (32.5%) patients were having 6/12 visual acuity, 8 (20%) patients were

having 6/18 visual acuity, 8 (20%) patients were having 6/24 visual acuity, 2 (5%)

patients were having 6/36 visual acuity and 9 (22.5%) patients were having 6/60 visual

acuity.

In Group B, 13 (32.5%) patients were having 6/12 visual acuity, 15 (37.5%) patients

were having 6/18 visual acuity, 5 (12.5%) patients were having 6/24 visual acuity, 5

(12.5%) patients were having 6/36 visual acuity and 2 (5%) patients were having 6/60

visual acuity.

Out of 40 patients in both the groups, 26 (32.5%) patients were having 6/12 visual acuity,

23 (28.75%) patients were having 6/18 visual acuity, 13 (16.25%) patients were having

6/24 visual acuity, 7 (8.75%) patients were having 6/36 visual acuity and 11 (13.75%)

patients were having 6/60 visual acuity.

0

2

4

6

8

10

12

14

16

6/12 6/18 6/24 6/36 6/60

Group A

Group B





Table No. 48 Distribution of patients based on visual acuity-Near vision

Group A Group B Total

RE LE Total RE LE Total

N12

10 10 20

14 11 25

45

50% 50% 50%

70% 55% 62.5%

56.25%

N18

3 3 6 2 4 6 12

15% 15% 15%

10% 20% 15%

15%

N24 2 3

5 4 4

8 13

10% 15% 12.5%

20% 20% 20%

16.25%

N36 4 3 7 0 0 0 7

20% 15% 17.5% 0% 0% 0% 8.75%

N60 1 1 2 0 1 1 3

5% 5% 5% 0% 5% 2.5% 3.75%

Graph No. 18 Distribution of patients based on visual acuity-Near vision

0

5

10

15

20

25

30

N12 N18 N24 N36 N60

Group A

Group B





In Group A, 20 (50%) patients were having N12 visual acuity, 6 (15%) patients were

having N18 visual acuity, 5 (12.5%) patients were having N24 visual acuity, 7 (17.5%)

patients were having N36 visual acuity and 2 (5%) patients were having N60 visual

acuity.

In Group B, 25 (62.5%) patients were having N12 visual acuity, 6 (15%) patients were

having N18 visual acuity, 8 (20%) patients were having N24 visual acuity and 1 (2.5%)

patient was having N60 visual acuity.

Out of 40 patients in both the groups, 45 (56.25%) patients were having N12 visual

acuity, 12 (15%) patients were having N18 visual acuity, 13 (16.25%) patients were

having N24 visual acuity, 7 (8.75%) patients were having N36 and 3 (3.75%) patients

were having N60 visual acuity.

RESULTS




Results

The parameters considered for the Clinical study were subjected to Student’s

paired ‘t’ test to compare the Mean values within the groups and Unpaired ‘t’ test to

compare the Mean difference values between the groups. The differences in the mean

values were considered Highly Significant at p<0.01 and p<0.001, Significant at p<0.05

and Non- significant at p>0.05.

1. Avyakta darshana:

Table No. 49 Effect of treatment on Avyakta darshana within the groups

Within Group A

Group

A

Mean Mean

diff.

Paired „t‟- test

Before After SD SE t-

value

p

Value Re

BT-AT 2.35 0.8 1.55 0.510 0.114 13.580 <0.001 HS

Within Group B

Group

B

Mean Mean

diff.



value

p

Value Re

BT-AT 2.2 1.35 0.85 0.489 0.109 7.767 <0.001 HS

On Avyakta darshana, within the group analysis before treatment to after treatment, the p

value (< 0.001) revealed statistically highly significant in both the groups.

RESULTS




Table No. 50 Effect of treatment on Avyakta darshana between the groups

Phase

Group A Group B Unpaired „t‟ test

MD SD SEM MD SD SEM PSE t-

Value

p-

value Re

BT-AT 1.55 0.510 0.114 0.85 0.489 0.109 0.158 4.427 <0.001 HS

Graph No. 19 Effect of treatment on Avyakta darshana

On Comparing in between the groups, before treatment to after treatment the p- value

(<0.001) revealed highly significant differences statistically between the groups on the

effect of treatment on Avyakta darshana.

The t-value (13.580) of Group A was higher when compared with the t- value (7.767) of

Group B. Hence, the result on the effect of treatment on Avyakta darshana in Group A

was better than Group B.

1.55

0.85

0

0.2

0.4

0.6

0.8

1

1.2

1.4

1.6

1.8

BT-AT

Group A

Group B

RESULTS




2. Gochara vibhrama:

Table No. 51 Effect of treatment on Gochara vibhrama within the groups

Within Group A

Group

A

Mean Mean

diff.



value

p

Value Re

BT-AT 1.75 0.125 1.625 0.517 0.183 8.879 <0.001 HS

Within Group B

Group

B

Mean Mean

diff.



value

p

Value Re

BT-AT 1.857 1.428 0.428 0.534 0.202 2.120 <0.05 S

On Gochara vibhrama, within the group analysis before treatment to after treatment, the

p value (< 0.001) revealed statistically highly significant in Group A, before treatment to

after treatment, the p- value (<0.05) revealed statistically significant in Group B.

Table No. 52 Effect of treatment on Gochara vibhrama between the groups

Phase



Value

p-

value Re

BT-AT 1.625 0.517 0.183 0.428 0.534 0.202 0.272 4.389 <0.001 HS

RESULTS




Graph No. 20 Effect of treatment on Gochara vibhrama



effect of treatment on Gochara vibhrama.


Group B. Hence, the result on the effect of treatment on Gochara vibhrama in Group A


1.625

0.428

0

0.2

0.4

0.6

0.8

1

1.2

1.4

1.6

1.8

BT-AT

Group A

Group B

RESULTS




3. Vihwala darshana:

Table No. 53 Effect of treatment on Vihwala darshana within the groups

Within Group A

Group

A

Mean

Mean

diff.



value

p

Value Re

BT-AT 1.636 0.090 1.545 0.5222 0.157 9.813 <0.001 HS

Within Group B

Group

B

Mean

Mean

diff.



value

p

Value Re

BT-AT 1.6 1.2 0.4 0.516 0.163 2.449 <0.05 S

On Vihwala darshana, within the group analysis before treatment to after treatment, the

p- value (<0.001) revealed statistically highly significant in Group A, before treatment to

after treatment, the p value (<0.05) revealed statistically significant in Group B.

RESULTS




Table No. 54 Effect of treatment on Vihwala darshana between the groups

Phase



Value

p-

value Re

BT-AT 1.545 0.522 0.157 0.4 0.516 0.163 0.226 5.049 <0.001 HS

Graph No. 21 Effect of treatment on Vihwala darshana



effect of treatment on Vihwala darshana.


Group B. Hence, the result on the effect of treatment on Vihwala darshana in Group A


1.545

0.4

0

0.2

0.4

0.6

0.8

1

1.2

1.4

1.6

1.8

BT-AT

Group A

Group B

RESULTS




4. Dwidha bahudha darshana:

Table No. 55 Effect of treatment on Dwidha bahudha darshana within the groups

Within Group A

Group

A

Mean

Mean

diff.



value

p-

value Re

BT-AT 1.571 0.142 1.428 0.513 0.137 10.406 <0.001 HS

Within Group B

Group

B

Mean

Mean

diff.



value

p-

value Re

BT-AT 1.666 1 0.666 0.492 0.142 4.690 <0.001 HS

On Dwidha bahudha darshana, within the group analysis before treatment to after

treatment, the p- value (< 0.001) revealed statistically highly significant in both the

groups.

RESULTS




Table No. 56 Effect of treatment on Dwidha bahudha darshana between the groups

Phase



Value

p-

value Re

BT-AT 1.428 0.513 0.137 0.666 0.492 0.142 0.197 3.856 <0.001 HS

Graph No. 22 Effect of treatment on Dwidha bahudha darshana



effect of treatment on Dwidha bahudha darshana.


Group B. Hence, the result on the effect of treatment on Dwidha bahudha darshana in

Group A was better than Group B.

1.428

0.666

0

0.2

0.4

0.6

0.8

1

1.2

1.4

1.6

BT-AT

Group A

Group B

RESULTS




5. Glare:

Table no. 57 Effect of treatment on Glare within the groups

Within Group A

Group

A

Mean

Mean

diff.



value

p-

value Re

BT-AT 1.937 0.437 1.5 0.516 0.129 11.618 <0.001 HS

Within Group B

Group

B

Mean

Mean

diff.



value

p-

value Re

BT-AT 1.705 0.941 0.764 0.664 0.161 4.746 <0.001 HS

On Glare, within the group analysis before treatment to after treatment, the p- value

(< 0.001) revealed statistically highly significant in both the groups.

RESULTS




Table No. 58 Effect of treatment on Glare between the groups

Phase



Value

p-

value Re

BT-AT 1.5 0.516 0.129 0.764 0.664 0.161 0.206 3.561 <0.001 HS

Graph No. 23 Effect of treatment on Glare



effect of treatment on Glare.


Group B. Hence, the result on the effect of treatment on Glare in Group A was better

than Group B.

1.5

0.764

0

0.2

0.4

0.6

0.8

1

1.2

1.4

1.6

BT-AT

Group A

Group B

RESULTS




6. Distant vision:

Table No. 59 Effect of treatment on Distant vision within the groups

WITHIN GROUP A

Group

A

Mean

Mean

diff.

PAIRED „t‟- test


value

p-

value Re

BT-AT 3.65 1.95 1.70 0.563 0.089 19.066 <0.001 HS

Within Group B

Group

B

Mean

Mean

diff.



value

p-

value Re

BT-AT 3.20 2.07 1.13 0.607 0.096 11.718 <0.001 HS

On Distant vision, within the group analysis before treatment to after treatment, the p-

value (< 0.001) revealed statistically highly significant in both the groups.

RESULTS




Table No. 60 Effect of treatment on Distant vision between the groups

Phase



Value

p-

value Re

BT-AT 1.70 0.563 0.089 1.13 0.607 0.096 0.131 4.388 <0.001 HS

Graph No. 24 Effect of treatment on Distant vision



effect of treatment on Distant vision.


Group B. Hence, the result on the effect of treatment on Distant vision in Group A was

better than Group B.

1.7

1.13

0

0.2

0.4

0.6

0.8

1

1.2

1.4

1.6

1.8

BT-AT

Group A

Group B

RESULTS




7. Near vision:

Table No. 61 Effect of treatment on Near vision within the groups

Within Group A

Group

A

Mean

Mean

diff.



value

p-

value Re

BT-AT 3.1 1.675 1.425 0.500 0.079 18.000 <0.001 HS

WITHIN GROUP B

Group

B

Mean

Mean

diff.



value

p-

value Re

BT-AT 2.65 1.525 1.125 0.563 0.089 12.630 <0.001 HS

On Near vision, within the group analysis before treatment to after treatment, the p- value

(< 0.001) revealed statistically highly significant in both the groups.

RESULTS




Table No. 62 Effect of treatment on Near vision between the groups

Phase



Value

p-

value Re

BT-AT 1.425 0.500 0.079 1.125 0.563 0.089 0.119 2.517 <0.01 HS

Graph No. 25 Effect of treatment on Near vision



effect of treatment on Near vision.


Group B. Hence, the result on the effect of treatment on Near vision in Group A was

better than Group B.

1.425

1.125

0

0.2

0.4

0.6

0.8

1

1.2

1.4

1.6

BT-AT

Group A

Group B

DISCUSSION




Discussion

In any research work discussion plays an important role which sheds light on

logical analysis, reasoning and rational interpretations to ignite new ideas. Discussion

(Upanaya) on Shastra improves the knowledge and becomes the base of establishing the

concept or Conclusion (Nigamana). The theory is accepted only after the proper

reasoning (Tarka) of observations. Hence, here is an attempt to discuss on this topic.

The present study entitled “A comparative clinical study to evaluate the efficacy

of Triphala choorna with Krishnadi anjana and Triphala choorna in the management

of Timira w.s.r. to Senile immature cataract” was carried out on 40 patients with the

following objectives.

To evaluate the efficacy of Triphala choorna with Krishnadi Anjana in the

management of Timira w.s.r. to Senile Immature Cataract.

To evaluate the efficacy of Triphala choorna in the management of Timira

w.s.r. to Senile Immature Cataract.

To compare and evaluate the clinical efficacies of both the groups.

The discussion on the present study is done under the following headings:

DISCUSSION

Discussion on Selection of

Problem

Discussion on Review of Literature

Discussion on Disease

Discussion on Procedure

Discussion on Drugs

Discussion on Clinical study

Discussion on Observations

Discussion on Results

DISCUSSION




Discussion on selection of the problem:

Cataract is opacification of the lens of the eye which disturbs the clarity of the

vision. Although most cases of cataract are related to the ageing process, occasionally

children can be born with the condition, or a cataract may develop after eye injuries,

inflammation, drug induced and due to some other local, focal or systemic diseases.

Incidence and prevalence:

According to WHO “In spite of the progress made in surgical techniques in many

countries during the last ten years, cataract (47.9%) remains the leading cause of visual

impairment in all areas of the world, except for developed countries.”6 As per National

Programme for Control of Blindness of Govt. of India about 62.60% blindness is due to

cataract in India.7

Prevention and treatment

Development of Cataract can be prevented or delayed by avoiding exposure to

ultraviolet light and smoking. The additional risk factors considered are Diabetes mellitus

and high body mass index.

In modern system of medicine, the only definite management is lens extraction

once it reaches matured stage or complete opacification. Over 90% cataract surgeries are

successful9 but complications though rare are more serious which includes sensitivity to

anaesthesia, injury to the cornea & iris, vitreous loss, expulsive choroidal haemorrhage,

ocular infections, uveitis, retinal detachment, subluxation of lens, development of

posterior capsule opacification and loss of vision.

DISCUSSION




Ayurvedic management of cataract will be of great triumph in low economic

people who cannot afford surgery, in those patients when surgery becomes a

contraindication due to other factors, and in patients who are unwilling for surgery.

Therefore aiming these objectives Cataract in immature stage was selected for the present

study.

Discussion on review of literature

Discussion on disease review:

Timira is a disease included under Drishtigata vikaras by Ayurvedic scientists.

According to Acharya Sushruta the number of Drishtigata rogas is 12 and 27 as per

Acharya Vagbhata. Acharyas have rightly given the name „Timira‟ ie. „andhakara‟ as it

causes the visual impairment in the individual. The degree of blurredness may vary from

a lesser extent to a greater level depending upon the stage of the disease. As per Acharya

Sushruta, the involvement of first three netra patalas can be considered as Prathama,

Dwiteeya and Triteeya patalagata Timira respectively. Once the doshas reach the fourth

patala, there will be complete absence of vision, which is termed as Linganasha.

According to Acharya Vagbhata, the disease Timira is produced when the vitiated doshas

are situated in the first and second patala. When the vitiated doshas affects the third

patala, it is termed as Kacha and when it involves the fourth patala, it is termed as

Linganasha.

As per Acharya Sushsruta, under drishtigata rogas Timira is considered as one

among 76 netra rogas. Prathama-dwithiya-triteeya patalagata timiras and Linganasha

are different stages of the disease Timira itself. Though Acharya Vagbhata has counted

DISCUSSION




six types of Timira among 92 types of netra rogas he has described the signs and

symptoms along with Linganasha in three stages- Timira, Kacha and Linganasha. This

fact again proves Timira as different stages of the same and its progressive pathology.

Clinical features of Timira:

Avyakta darshana

Avyakta darshana (Blurring of vision) produced due to affliction of first patala,

which is the cardinal feature of timira and immature cataract. Blurring of vision, which

can be corrected by glasses in early stages, but the power would change rapidly based on

type of cataract, so one of the initial symptom could be frequent change of glasses.

Gochara vibhrama

Patient will have difficulty to perceive distant and near vision due to the

accumulation of water droplets in the lens which attains opacification and patient

develops different refractive index which can be understood as gochara vibhrama.

Vihwala darshana

Visualization of nonexisting things like dots, lines, threads in front of eyes, are

one of the symptom of timira and immature cataract which occurs due to irregular opaque

areas in the lens.

Dwidha bahudha darshana

Uniocular polyopia, another early symptom, is the perception of double or

multiple folds of the objects seen. It is due to the irregular refraction by different parts of

lens as in intumescent stage that several images are formed of each object.

DISCUSSION




Causative factors

In Ayurvedic texts, general causative factors of eye diseases are explained

elaborately. Following nidanas play a contributory role in pathogenesis of Timira -

Aharaja nidanas:

Among the ahaaraja factors excessive consumption of Katu, Amla and Lavana

are the most harmful rasas for eyes. The chances of consumption of vidahi aharas of

these rasas in excess are more in this epoch as people are more fond of spicy foods, like

pickles, different spice powders, fried items, over cooked, half cooked, baked foods,

excess of meat, fish and alcohol, consumption of fermented food stuffs like breads, flat

bread, white bread, pan cakes and other foods mainly containing urad dal, refined flour

etc lead to vatadi kopa. As per Acharya Charaka, Timira is a nanatmaja vyadhi of vata

and pitta being a dominant dosha in netra can disturb the functioning of vision. They

both in turn lead to kaphadushti, as netra being an organ situated in kapha sthana. All

these food factors impair the metabolism of the body and also eye in particular.

Transparency of lens is maintained by the normal nutrition and if this normal nutritional

status is altered due to life style modification then there occurs a certain pathological

changes in the lens leading to opacity.

Viharaja nidanas:

Ushnaabhitaptasya jalapraveshaat

Immersion in cold water immediately after getting exposed to heat or sun is the

one of the causative factor for eye diseases. When body is too warm, the vessels

DISCUSSION




supplying the eye are dilated and the volume of fluids will be increased. Then if body

temperature is suddenly dropped, the vessels constrict and the vasculature is damaged.

These cause circulatory disturbances, which in turn affects the mechanism of nutrition

leading to eye diseases.

Doorekshanat

Looking at very distant object for a longer time cause strain to cilliary muscle that

alter accommodative power of the lens which disturbs the clarity of the vision.

Swapna viparyaya

Sleeping in day time and keeping awake at night results in aggravation of kapha

and vata respectively. This will lead to impairment of Jatharagni, which in turn disturbs

the lens metabolism leading to improper nutrition to lens. Eyes are modified to work in

the presence of light and to rest in the absence of light. There are two types of

photosensitive pigments to adjust, according to the presence and absence of light rays.

Among these two, cones functions mainly in the presence of light rays where as rods in

dim light. In the presence of light, the cones will be in active form and in the absence of

light cones will be in inactive form. Similarly rods become active when there is a dim

light. Working at night and sleeping during day time leads to derangement of this

mechanism, which in turn cause strain on the ocular system and result into various

diseases including Timira.

Kopa-Shoka-Klesha

The manasika nidanas like kopa-shoka-klesha will lead to pitta and vata vriddhi

respectively, that in turn may accelerate the oxidation process in the cellular level

DISCUSSION




including lens tissues, resulting in denaturation of proteins followed by opacification of

lens. These emotional factors also activate autonomic nervous system which in turn

leads to profound vasodialatation which may hamper the circulation and in turn the

metabolism of the lens.

Abhighata

Abhighata is a direct cause for Timira roga. Abhighata gives rise to the disease

first rather than any of the prodromal signs and symptoms either of systemic organ or

organ specific in nature. These damages directly results into the disease of the eye as

cataract.

Traumatic cataract is partly due to mechanical effects of the injury on the lens

fibres and largely due to the entrance of aqueous due to the damage to the capsule, either

secondary to the impairment of its semi permeability or often the result of actual tears.

Sometimes if they are covered by the iris, such tears are rapidly sealed at first with fibrin

and later by the proliferation of the subcapsular epithelium which secretes a new capsule.

In these cases the entrance of aqueous is stopped and the opacity of the lens may remain

stationary or even regress. Alternatively the tear may remain open and opacification may

progress to involve the entire lens.

Ati maithuna

Excessive indulgence in sexual activity results in shukra dhatu kshaya leading to

poorva dhatu kshaya which will hamper the nourishment of ocular tissues that accelerates

the degenerative process in lens may cause opacification of the lens.

DISCUSSION




Vegavinigraha

Suppression of urges like adhovaayu, kshudha, baashpa, chardi, mutra purisha

and nidra vitiates vata, which in turn develops various types of eye diseases as per the

classics. Among these fourteen urges nidra and ashru are directly connected with the eye.

Rajodhuma nishevana

Exposure to dust and smoke, including cigarette smoking is considered as harmful

for eyes by both i.e. Ayurveda and modern medicines. As per Ayurveda, smoking will

vitiate pitta because of its teekshana, ushna and laghu gunas, and ultimately lead to vata

prokopa and causes maximum rookshata of the body. Hence it can be considered as one

of the important factors in the causation of Timira. In the context of dhoomapaana,

Acharya explains that inhaling smoke through mouth and discharging through nostrils

will lead to impairment of vision.

Cigarettes contain thousands of chemical substances like formaldehyde, ammonia,

and hydrogen sulphide that act as irritants, carcinogens and inflammatory agents, all of

which can interfere with blood flow and damage eyes. Research has established smoking

as a definitive cause of serious, progressive disorders of the eye that can lead to partial or

total vision loss. Heavy smokers and those who smoke for an extended number of years

are particularly at risk of eye damage. Smoking is responsible for a prolonged attack on

the eyes that can lead to the development of cataracts in two ways. First of all, tobacco

smoke contains harmful free radicals that directly assault the eye, potentially damaging

lens proteins and the fibrous cell membrane in the lens. Secondly, smoking reduces the

DISCUSSION




body's levels of antioxidants and certain enzymes which may help to remove damaged

proteins from the lens.

Aatapasevana:

As per Ayurvedic classics Aatapasevana is a direct cause for Timira roga.

Acharya has insisted the use of umbrella as one of the pathya for netra in order to protect

them from sun light. Also, as per modern science, exposure to almost all types of heat

generating activities is known to produce cataract by causing damage to the lens

epithelium. The different radiations which induce cataract are infrared, X-ray, gamma

rays and UV-rays. People who have more exposure to sun light, those who work in glass

factories, inadequately protected technicians, patients those who treated for malignant

tumours and workers of atomic energy plants are more prone to develop radiation

cataract.

Sookshma nireekshana

Watching minute objects for longer duration cause strain to cilliary muscles

which will interfere with normal accommodation of the lens that will disturb the clarity of

the vision.

Samprapti

Vatadi doshas get vitiated due to indulgence in achakshushya nidanas and

become vimargagami, through the siras reach the upper part of the body pathologically

lodged in netra patalas, giving rise to Timira. The mandagni, further leads to the vitiation

of sthanika doshas. The dushyas (rasa, rakta, mamsa, meda and asthi) i.e. substrate

elements of patalas, also become weak and at the same time khavaiguņya of rupavaha

DISCUSSION




sira (favourable site for localization of vitiated doshas) and drishti patalas occurs.

Depending upon the involved patalas the various symptoms are produced.

Pathogenesis of cataract

Cataract mainly caused due to degenerative process. The most common factor is

age, and it may be of significance that as age progresses the semi permeability of the

capsule is impaired, the inactive insoluble proteins increase and the antioxidaive

mechanisms become less effective. The normal lens contains sulphydryl-containing

reduced glutathione and ascorbic acid (Vitamin C), both of which decrease with age.

Cataract is produced by the administration of toxic substances like naphthalene, lactose,

galactose, selenite, thallium etc. Cyanate from cigarette smoke causes protein

denaturation. Cataractous changes may follow the use of the anti cholinesterase group of

miotics and after prolonged use of corticosteroids. Physical factors like mechanical

trauma or radiant energy may also induce the formation of cataract.

Oxidative stress is a common problem that the lens deals with daily through

exposure to ultraviolet and other types of irradiation. Molecular oxygen is the cause of

most oxidative damage. Fortunately the lens‟s oxygen tension is very low. This protects

the lens proteins and lipids from oxidative damage. However the lens normally derives a

substantial proportion of its ATP from oxidative phosphorylation which generates free

radicals.

Lens has many anti-oxidant mechanisms to maintain its transparency. These

mechanisms include glutathione, thiol-transferase, catalase and super oxide dismutase.

DISCUSSION




With age, the efficacy of endogenous anti-oxidant defences decline and opacification of

the lens increases resulting in cataract.

Prognosis

Prathama and dweetiya patalagata timira are easily curable. Treetiya patalagata

timira is yapya and when the doshas reach to chaturtha patala all the Timira attain the

stage of asadhyata except that of kaphaja variety, which may be curable with the help of

surgical intervention. 158

According to conventional system of medicine, the only remedy is surgical management

which has success rate but posterior capsule opacification remains the most prevalent

long-term complication along with other post-operative complications like subluxation of

the lens, posterior sub-capsular cataract, cystoid macular oedema, retinal detachment and

others which will not benefit the surgery.

Discussion on procedure

Anjana:

Anjana is the one of ocular therapeutics of Ayuveda which is very helpful in the

treating various eye disorders timira is one among them. Application of anjana is

advisable both in healthy and diseased person. In healthy person as a part of dinacharya

and in case of diseased person there is a broad range of indications such as timira,

abhishyanda, adhimantha, arma, shuklagata rogas and krishnagata netrarogas. There

are different types of anjana depending on their mode of action. The basic aim of anjana

prayoga is, eye being an organ which is “tejomayam” ie., one which is predominant with

DISCUSSION




tejomahabhuta can easily get afflicted by kapha dosha and by anjana prayoga as a daily

regimen the accumulated kapha can be normalised. In a disease based on the condition

and the pathogenesis involved different types of anjanas has been explained and which

can be employed accordingly. The anjana used in Timira will be of lekhana among its

varieties ie. snehana, ropana, lekhana or prasadana. In case of cataract, the lekhana

anjana is helpful because the lens is hydrated and hard due to denaturated lens fibres.

Discussion on drug

Triphala choorna: 186, 187, 188

Triphala choorna contains haritaki, vibhitaki and amalaki. It has tridoshahara

property that helps to normalise the vitiated doshas which are pathologicaly lodged in the

netra patala and obstructs the vision. Chakshushya and rasayana properties of triphala

helped in delaying the aging process along with nourishing the ocular tissues. Deepana

property enhanced the agni which helps in maintaining normal metabolic reactions of the

lens. Triphala has anti-cataract property which helps in maintaining transparency of the

lens. It acts as a free radical scavenger and removes free radical which is helpful in the

arrangement of the lens fibres. Antioxidant property of triphala helps in delaying

degenerative process in the lens. Vitamin C helps in the maintaining the normal level of

glutathione which is very necessary for normal metabolism of the lens. All these are

beneficial in preventing the progression of cataract.

DISCUSSION




Krishnadi varti: 189

Krishnadi varti contains Pippali, Haritaki and Bhringaraja. It has been mentioned

to be useful in Timira in Ayurvedic classics, as the drug possess teekshna guna, ushna

veerya which are beneficial in samprapti vighatana of Timira.

The lekhana (scraping) property of the formulation helped to clear the hydrated lens.

Antioxidant property of ingredients helped in delaying the degenerative process.

Ingredients having Chakshushya, Rasayana, Balya properties helped in revitalizing and

restoring normal ocular functions. Cysteine present in Bhringaraja essential for

maintaining glutathian of the lens which is a vital factor for lens transparency. Deepana

property of ingredients enhanced the agni which helps in maintaining normal metabolic

reactions of the lens. Katu rasa of Bhringaraja is netra virechaka, removes Doshas from

ciliary muscles, also it has the property of Vedana sthapana, inturn remove strain of

ciliary muscles, thereby gives strength and helps in physiological accommodation.

The availability of drugs listed in the preparation was ease and economical. Hence it was

selected for the present study for assessing its efficacy in the management of Timira.

Goghrita: 220,221,222,223,224

In this clinical study goghrita was taken as anupana for triphala choorna which

has tridoshahara property that helped in normalising the pathologically lodged vatadi

dosha in ntra patala.

DISCUSSION




Rasayana, chakshusya, rasavardhaka, balya, indriyabalavriddhikara and

vayahsthapana properties of goghrita have delayed the degeneration process and

nourished the ocular tissues.

Madhu: 225,226,227

In this clinical study madhu was taken for rubbing the ajnana varti. Lekhana and

kaphahara property of madhu helped in removing of water droplets from the lens.

Sukshma, laghu and yogavahi gunas promoted deeper penetration of drugs and cross the

barriers. It has srotovishodhana property that cleared the minute channels and helped in

the exchange of nutrients from the aqueous humor. Chakshushya property helped in

nourishing the oclular tissues. It enhanced the agni that helped in maintaining the lens

metabolism which is important for lens transparency. It has property of minimising scar

so helped in the removing the opaque area on the lens which hampered the clarity of

vision.

Probable mode of action of anjana

As described in paribhasha, “anakti anena ithi anjanam” meant for the spreading

and propagation of anjana.

After application of anjana in inner surface of lower palpebral conjunctiva, it

comes in contact with tear and due to blinking of eyelids the drugs get mixed with tear.

The tear mixed drugs now come in contact with conjunctiva and cornea. Due to

hydrophilic nature of conjunctiva the drugs get directly absorbed through conjunctival

sac by the trans cellular pathway. The absorbed drugs through scleral route entered into

the aqueous humor and through aqueous humor reached lens. Due to liphophilic and

DISCUSSION




hydrophilic nature of krishnadi varti anjana the tear mixed drugs directly absorbed

through the cornea and entered into the aqueous humor and through aqueous humor

reached lens.

Application of Anjana

(Inner surface of lower palpebral conjunctiva)

Drugs mixed with tear

Absorbed through conjunctiva

(Due to hydrophilic nature of drugs)

Comes in contact with

cornea

Comes in contact with

conjunctiva

Absorbed through cornea

(Due to hydrophilic & lipophilic nature of drugs)

Through sclera entered in

aqueous humor Entered in aqueous humor

Lens

DISCUSSION




Discussion on clinical study

Discussion on observations

Age:

In this clinical study, more number of patients i.e., 40% patients belonged to the age

group of 61–70 years followed by 37.5% patients belonged to the age group of 41–50

years and 22.5% patients belonged to the age group of 51–60 years.

The concentration of glutathione falls with advancing age which maintains the lens

transparency and also metabolic activities of lens decrease with age. It may be a cause to

initiate cataract during the fourth decade of life. According to Ayurveda the Ishat-

parihani avastha starts after the age of 40 years. By the influence of Kala swabhava in

this period, Dhatukshaya and Indriya vishaya grahana asamarthya occurs which can

have an impact on aging lens.

Gender:

In this clinical study, more number of patients i.e., 65% were females and 35% were

males.

The present study supports the higher incidence of Timira- Cataract in females. Lens

capsule is made up of collagen. Recent researches have discovered that collagen

disorders are more often seen in females after the age of 40 years, this is due to the

imbalance in the oestrogen level affecting the collagen and hence resulting in higher risk

of Cataract in females. The higher incidence in females as seen in this study is thus

justifiable.

DISCUSSION




Religion:

In the present clinical study 75% of the patients were Hindus and 25% were Muslims.

There is no reference available that establishes the relation between religion and its

associated cultural practices with the incidence of Timira- Cataract. Thus no conclusion

can be drawn from this observation apart from geographical representation.

Marital status:

Here in this clinical study, all patients were married.

None of the studies on cataract reveal any relationship of marital status with the

incidence of Cataract. Hence no inference can be made based on this observation.

Educational status:

More number of the patients i.e., 52.5% were below graduation, 25% of patients were

graduates, 17.5% of patients were uneducated and 5% of patients were post graduates.

As there is no direct relationship between educational status and the incidence of

Cataract, no definite conclusion can be drawn in relation to education and Cataract.

Socio-economic status:

In present study more number of patients i.e., 57.5% belonged to the middle class

followed by 32.5% belonged to lower class and 10% were from upper class.

There is no evidence available regarding the relationship between socio-economic status

and the incidence of cataract.

The percentage of patients in the middle class and lower class were more, it is

possible that they might be taking low nutritious diet, which progresses the degeneration

of the lens leading to Cataract.

DISCUSSION




Habitat:

Here in this clinical study, 97.25% patients were from urban area and 2.5% were from

rural area.

The changing life style, dietary habits, working conditions and the environment in

urban population are the contributory factors to impair the lens metabolism which

increases the incidence of Cataract in urban area. Further as the study was conducted in

urban area no definite conclusion can be drawn.

Occupation:

In the occupational category 65% were housewives, 15% were businessmen, 15%

were professionals (Government/Private employee) and 5% were drivers.

Relation between the cataract and the occupation can be ascertained here. In house

wives exposure to heat while cooking acts as predisposing factor for netra rogas

especially Timira- Cataract. In professionals (Government/Private employee) and

business men kopa, kleshla, swapna viparyaya along with improper food habits like

intake of food at irregular timings and excess of junk foods were found to be the nidanas

which increases risk of cataract by disturbing the normal metabolism of lens. In drivers

more exposure to sunlight acts as a risk factor for Cataract.

These above mentioned Nidanas are causative factors for the eye diseases which are

mentioned by Ancient Ayurvedic Scientists and hence the data of present study supports

the same.

DISCUSSION




Diet:

More number of patients in this study i.e., 52.5% were consuming vegetarian diet and

47.5% were consuming mixed diet.

Intake of low protentious and minerals deficits diet causes earlier development of

Cataract and recent researches have proved that nutrition can prevent cataract, due to the

small sample size, no conclusion can be made based on this observation. The reasons

could be that many of the patients had faulty food habits like intake of food without

proper nutrients (proteins, vitamins and minerals) along with Adhyashana and

Vishamashana. The above said reasons hasten formation of Cataract.

Sleep:

More number of patients i.e., 45% were having sound sleep, 42.5% were having

disturbed sleep and 12.5% were having delayed sleep in this study.

Sound sleep and disturbed sleep depends on the Prakruti, Circumstances, Life style

and Stress. The disturbed sleep as discussed in the Nidana of Timira will impair the

metabolic reactions of the lens which accelerates the degenerative process and leads to

opacification of the lens.

Addiction:

In the present clinical study, majority of the patients (72.5%) had the habit of having

tea/coffee, 10% of the patients had the habit of smoking, 7.5% of the patients had the

habit of chewing tobacco and 2.5% of patients had the habit of consuming alcohol.

DISCUSSION




Acharya Vagbhata in the context of Dhumapana adhyaya quotes that, inhalation of

smoke through the mouth and leaving through the nose is highly harmful for the eyes and

could be a reason for timira.

Though the modern medical science has considered smoking and alcohol as the risk

factors for the manifestation of Cataract, this fact cannot be concluded in the study as

only 10% patients were addicted to smoking and 2.5% were addicted to alcohol,

registered for the study.

There are no such evidences available regarding impact of excess intake of tea/coffee

on changes in lens, it‟s just a part of observation.

Family history

In the present clinical study, 60% patients had no family history of cataract and 40%

had family history of cataract.

Heredity has a considerable role in the incidence, age of onset and maturation of

Cataract in different races and families. As 40% patients had family history of Cataract

the observation of the present study supports the same.

Chronicity:

In this clinical study, 57.5% of patients were having chronicity more than 24months.

Among others 12.5% were having the chronicity of >6months≤12months and 10% of the

patients were having chronicity of ≤ 6months, >12≤18months and >18≤24months.

This emphasizes the chronicity of cataract. Most of the patients neglect to visit the doctor

at early stages as it starts with mild blurrness of vision which does not hamper their

DISCUSSION




routine activities. With spectacles correction from optician, patients get improvement in

vision in early stages so they don‟t consult physician but when they experience more

blurrness of vision even with the spectacles then they consult physician.

Bala pramana pareeksha:

Prakruti:

In the present study 50% of the patients were of Kapha-pitta prakruti, 27.5%

were Vata-pitta prakruti and 22.5% were Vata-kapha prakruti.

Due to the small sample size, no definite correlation between Shareera prakruti and

occurrence of Cataract can be established.

Saara, Samhanana and Pramana:

In the present study observation on Sara, Samhanana, Pramana and Satmya shows:

75% of patients were of Madhyama sara, 15% of patients were of Avara sara

and 10% of patients were of Pravara sara.

85% of patients were of Madhyama samhanana, 7.5% of patients were of

Avara and Pravara samhanana.

85% of patients were of Madhyama pramana, 7.5% of patients were of Avara

and Pravara pramana.

Maximum number of patients belonged to Madhyama saara, Madhyama

samhanana and Madhyama pramana. The incidence of Cataract is more in individuals

who are poorly built with low height and low weight. Though this is an established fact,

such observations were not found in this clinical study.

DISCUSSION




Saatmya:

In the present study 52.5% of patients were of Sarva rasa satmya and 47.5% of

patients were of Vyamishra satmya.

No conclusive inference can be drawn from this observation to indicate the relation

between Satmya and incidence of Timira.

Satva:

More number of patients, i.e., 85% were having Madhyama satva followed by

7.5% were Avara satva and Pravara satva.

Since more number of patients had Madhyama satva, they were convinced to undergo

treatment for long duration of 48 days and were asked to follow the instructions.

Abhyavaharana shakti and Jarana shakthi:

In the present study 47.5% were having Madhyama abhyavaharana shakti, 37.5%

had Avara abhyavaharana shakti and 15% had Pravara abhyavaharana shakti.

In present study more number of patients i.e., 47.5% were having Madhyama

jarana shakti, 37.5% were having Avara jarana shakti and 15% were having

Pravara jarana shakti.

Maximum patients belonging to Madhyama and Avara Abhyavaranashakthi and

Jaranashakti indicates the relation between age, appetite and food intake which decreases

on increasing age. Agnimandya can impair the metabolic process which inturn disturbs

metabolism of the lens and accelerates the degenerative process causing loss of

transparency of the lens.

DISCUSSION




Vyayamashakti:

More number of patients i.e., 67.5.5% were having Madhyama vyayama shakti

followed by 22.5% of patients were having Avara vyayama shakti and 10% of patients

were having Pravara vyayama shakti.

There is no direct relationship between Vyayama shakti and Timira, hence no

conclusion can be drawn from this observation of the present study and has been just

considered as a part of the study‟s observations.

Vaya:

In this clinical study, all patients i.e., 100% belonged to Parihani avastha.

The abilities of human body will gradually reduce in every decade of life. The

visual efficiency, according to Sharangadhara samhita will start diminishing from the

age of sixty years. As per the contemporary science, the degenerative changes in lens

start as age advances, so the incidence of Cataract is more in the old age and loss of

transparency of lens occurs due to ageing and degenerating process. This justifies the

higher incidence of Cataract in old age patients.

Nidana:

In the present clinical study, the probable Nidanas recorded for the manifestation

of Timira possess the following percentages:

Swapna viparyaya (55%), Vegadharana (majority had Mutra, Purisha & Nidra

vegadharana) (50%), Sookshma nireekshana (35%), Rajodhuma nishevana (35%), Amla

rasa atisevana (32.5%), Kopa (30%), Shoka (22.5%), Atapa sevana (20%),

Doorekshanat (17.5%) and Shukta aranala sevana (2.5%).

DISCUSSION




As per the literatures, these are the causative factors of Netra rogas and the present

observation supports the same. Due to intake of above mentioned Nidanas, Vatadi doshas

becomes vitiated and pathologically lodge in Netra patalas causing Timira. These

causative factors may be responsible for altering the lens metabolism and increase the

oxidative stress of the lens. Hence the denaturation of lens proteins occurs and ultimately

manifests cataract.

Lakshanas

In the clinical study, all the patients i.e. 100% had Avyakta darshana, 82.5% of

patients had glare, 65% of patients had Dwidha bahudha darshana, 52.5% of patients

had Vihwala darshana, 37.5% of patients had Gocharavibhrama.

Avyakta darshana is the cardinal feature of Timira- Cataract. In Cataract opacification

of lens takes place. These opaque areas obstruct the rays of light coming from the objects

to reach the retina and hence blurriness of vision is seen as early symptom. The velocity

of light varies for different colours and due to increased scattering of light patients

develop glare. In opaque lens accumulation of water droplets causes irregular refraction

and hence double or multiple images are visualised by the patient. As per the literatures,

these are the common changes that occur in the lens as a result of ageing, and the present

observation supports the same.

DISCUSSION




Visual acuity- distant vision

In the clinical study, all the patients i.e. 100% had diminished visual acuity for distant

objects.

It is due to de-arrangement of lens fibres and opacity of lens which obstruct the rays

of light to reach retina hence visual acuity for distant objects becomes decreased.

Visual acuity- near vision

In the clinical study, all the patients i.e. 100% had diminished visual acuity for near

objects.

With advancing age, strength of ciliary muscles and accommodative power of opaque

lens decrease, so patients experienced difficulty in near vision.

DISCUSSION




Discussion on Results

1. Effect of treatment on Avyakta darshana

The effect of treatment on Avyakta darshana within the group, before treatment

and after treatment, the p value (<0.001) was statistically highly significant in both the

groups.

On comparing between the groups, before treatment to after treatment p value

(<0.001) was statistically highly significant.

Though both the groups showed good results, the t-value (13.580) of Group A

was higher when compared to the t-value (7.767) of Group B, concluding that the effect

of treatment on Avyakta darshana in Group A was better than Group B.

Cataract is caused by the degeneration and opacification of the lens fibres. There

is an accumulation of water droplets in between the fibres, which disturbs its arrangement

and leads to opacification of the lens. As age progresses glutathione content of the lens

decreases, which is an important factor to maintain the transparency of the lens by

controlling anti-oxidative process.

Anti-cataract property of Triphala delays the degeneration of the lens and

Vibhitaki in Triphala choorna helps to remove the accumulated water droplets due to its

Kaphahara property and maintain transparency of the lens.

Due to tikta, kashaya rasa and laghu, ruksha guna of Haritaki in Krishnadi varti, it acts

as lekhya and srotoshodhaka. By its lekhana (scraping) property it minimises the

opacification and by virtue of its srotoshodhaka property it helps to clear the hydrated

lens that would be the reason to form a better image on the retina.

DISCUSSION




However the effect of treatment in Group A was better than Group B probably

due to the added effect of Krishnadi anjana.

2. Effect of treatment on Gochara vibhrama

The effect of treatment on Gochara vibhrama within the group, before treatment

and after treatment, the p value (< 0.001) revealed statistically highly significant in Group

A, before treatment to after treatment, the p value (<0.05) revealed statistically significant

in Group B.


(<0.001) was statistically highly significant. The t-value (8.879) of Group A was higher

when compared to the t-values (2.120) of Group B thereby concluding, the effect of

treatment on Gochara vibhrama in Group A was better than Group B.

Patients had difficulty to assess the distance of an object which occurred due to

alteration in the accommodation caused by weak ciliary muscles and reduced

accommodative power of lens due to opacity.

Rasayana property of of Triphala choorna provides strength to ciliary muscles and Anti-

oxidant activity of Go ghrita minimises the degeneration of the lens which improves

accommodative power.

Ciliary muscles are made up of proteins. Cysteine of Bhringaraja in krishnadi

anjana being a building block of proteins helps to strengthen the ciliary muscles so that

there is an improvement in physiological accommodation. Lekhana (scraping) property of

Krishnadi anjana maintains transparency of the lens and improves physical

accommodation.

DISCUSSION




In both the groups Triphala choorna rejuvenates the ciliary muscles and provides

strength hence improvement is seen in both the groups. Due to added effect of Krishnadi

anjana Group A showed better results in comparison of Group B on Gochara vibhrama.

3. Effect of treatment on Vihwala darshana

The effect of treatment on Vihwala darshana within the group, before treatment

and after treatment, the p value (<0.001) revealed statistically highly significant in Group

A, before treatment to after treatment, the p value (<0.05) revealed statistically significant

in Group B.


(<0.001) was statistically highly significant. The t-value (9.813) of Group A was higher

when compared to the t-values (2.449) of Group B thereby concluding, the effect of

treatment on Vihwala darshana in Group A was better than Group B.

The vitiated doshas pathologically lodged in Netra patala cause the visualisation

of non-existing things in front of eyes like mosquitoes, flies, hair and net. Irregular

opaque areas on the lens obstructs the rays of light coming from an object which falls

abruptly on retina so patients visualise false moving objects in front of the eye.

Amalaki and Haritaki in Triphala choorna are Tridoshahara dravyas, they help to

remove the pathologically lodged Doshas from the Netra patalas.

Pippali in Krishnadi anjana due to its laghu and snigdha guna crosses the

lipophilic layer of the cornea and through aqueous humour reaches the lens and helps in

maintaining its transparency. Therefore patients got relief in Vihwala darshana in both

DISCUSSION




the groups. The effect of treatment on Vihwala darshana in Group A was better than

Group B probably due to the added effect of Krishnadi anjana.

4. Effect of treatment on Dwidha bahudha darshana

The effect of treatment on Dwidha bahudha darshana within the group, before

treatment and after treatment, the p value (<0.001) was statistically highly significant in

both the groups.



Though both the groups showed good results, the t-value (10.406) of Group A was higher

when compared to the t-value (4.690) of Group B, concluding that the effect of treatment

on Dwidha bahudha darshana in Group A was better than Group B.

In Cataract, cortical spoke opacities in conjunction with water clefts form radial

wedges containing a fluid of lower refractive index than surrounding lens, this is the

cause for diplopia and polyopia.

The Kaphahara property of Vibhitaki in Triphala choorna helps to remove the

accumulated water droplets from the lens fibres and provides uniform refractive index

which corrects the diplopia and polyopia.

Srotoshodhana property of Madhu which is used to rub the Krishnadi anjana

varti, clears the channels, provides uniform refractive index thus minimizes diplopia and

polyopia.

The effect of treatment on Dwidha bahudha darshana in Group A was better

than Group B probably due to the added effect of Krishnadi anjana.

DISCUSSION




5. Effect of treatment on Glare

The effect of treatment on Glare within the group, before treatment and after

treatment, the p value (< 0.001) was statistically highly significant in both the groups.

On comparing between the groups, before treatment to after treatment p value (<0.001)

was statistically highly significant.

Though both the groups showed similar effect, the t-value (11.618) of Group A


of treatment on Glare in Group A was better than Group B.

Glare is seen as a result of increased scattering of light rays through the opaque

lens.

The anti-cataract and scavenging property of Triphala choorna arrests the

degeneration process in the lens and removes free radicals thereby helps in maintaining

its transparency.

Lekhana property of Haritaki and antioxidant property of Bhringaraja in

Krishnadi anjana, minimizes the opacification of the lens hence scattering of light by

lens is reduced and improvement is seen in both the groups.

Group A was showed better result than Group B on Glare probably due to the

added effect of Krishnadi anjana.

6. Effect of treatment on Distant vision

The effect of treatment on Distant vision within the group, before treatment and

after treatment, the p value (<0.001) revealed statistically highly significant in both the

groups.

DISCUSSION






Though both the groups showed good results, the t-value (19.006) of Group A was higher

when compared to the t-value (11.718) of Group B, concluding that the effect of

treatment on Distant vision in Group A was better than Group B.

The concentration of glutathione falls with advancing age which is a vital for

maintaing the lens transparency by controlling its metabolic activities. Opacification of

lens occurs as a result of decreased metabolic reactions and increased degeneration.

These opaque areas of the lens obstruct the rays of light coming from an object so

patients develop blurrness of vision for distant objects.

Chakshushya and Rasayana properties of Triphala choorna nourishes the lens and

stops further degeneration. Glutathione and ascorbic acid of Amalaki in Triphala choorna

keeps the normal level of glutathione in the lens thereby maintain its transparency.

Lekhana (scraping) and srotoshodhaka properties of Haritaki in Krishnadi varti

anjana helps to clear the hydrated lens and minimizes the obstruction of the light rays.

Therefore improvement is seen in both the groups and the effect of treatment in Group A

was better than Group B probably due to the added effect of Krishnadi anjana.

7. Effect of treatment on Near vision

The effect of treatment on Near vision within the group, before treatment and

after treatment, the p value (<0.001) revealed statistically highly significant in both the

groups.

DISCUSSION






Though both the groups showed similar effect, the t-value (18.000) of Group A


of treatment on Near vision in Group A was better than Group B.

Altered physical and physiological accommodation makes deficient near vision.

With the advancing age, strength of the ciliary muscles and accommodative power of the

opaque lens decreases so patients experienced difficulty in near vision.

Ruksha, laghu guna of vibhitaki in Triphala choorna acts as Kaphaghna and

Shoshana helps in dehydration of lens, which is a prime factor in maintaining its

transparency. Ushna virya of Vibhitaki does Deepana and Pachana, enhances the

metabolic activities of the lens and increases the contractility thereby improves physical

accommodation.

Katu rasa of Bhringaraja in Krishnadi anjana is Netra virechaka, removes

Doshas from ciliary muscles, also it has the property of Vedana sthapana, inturn removes

strain of ciliary muscles, thereby gives strength and helps in physiological

accommodation.

In both the groups accommodative power is improving as the result of treatment

and Group A showed better result than Group B probably due to the added effect of

Krishnadi anjana.

CONCLUSION




Conclusion

Timira is one among Drushtigata netra rogas, which is commonly encountered in

the present clinical practice.

Kacha and Linganasha are the progressive stages of the disease Timira.

The lakshanas of Timira simulate to that of the clinical entity of Cataract.

Senile Cataract is a geriatric condition which initially can be reversed. With the

gradual development of opacifications, surgery becomes inevitable.

The study was conducted on 40 patients of Timira w.s.r. to Senile Immature

Cataract assigned into two groups- Group A and Group B, comprising of 20

patients.

The patients of Group A were subjected to internal administration of 5 grams

Triphala choorna once daily at night after food with sufficient amount of Go

ghrita as anupana along with Anjana karma with Krishnadi varti once daily at

morning. The patients of Group B were subjected to internal administration of 5

grams Triphala choorna once daily at night after food with sufficient amount of

Go ghrita as anupana.

In the course of study majority of the patients were females.

Predisposing factors described in modern texts and the Nidanas mentioned by our

ancient Acharyas are very much similar.

Nidanas like Swapana viparyaya and Vegadharana were observed more as

Nidana in the present study.

CONCLUSION




The effect of treatment was statistically assessed by Student’s paired t test to

analyse within the group and unpaired t-test to analyse between the groups. In

both the groups, within the group analysis, the effect of treatment was statistically

highly significant in Avyakta darshana, Dwidha bahudha darshana, Glare, visual

acuity for Distant vision and Near vision, and statistically significant in Gochara

vibhrama and Vihwala darshana.

Though both groups showed highly significant differences, within the group

analysis however on comparing the t- values in between the groups, the t-values

Group A was higher when compared to that of Group B which could be due to

added effects of Krishnadi varti anjana which proved beneficial.

Anjana karma is important procedure for treating diseases of eye. In the present

study, the bio availability of the drugs helps in Samparapti vighatana as they act

on the target tissues effectively. Thus procedure Anjana can be practised for

clinical success.

Triphala choorna has anti-cataract and anti-oxidant properties that help in

delaying the degenerative process of the lens.

Scope for further study:

Considering the doshaja variety of Timira in particular, same clinical study can

further be established.

Owing to the progressive nature of the disease it is recommended to have prolonged

duration of treatment and follow up.

As the sample size was small and the disease is chronic nature. It is recommended to

carry the study on larger sample size.

SUMMARY




Summary

Chapter-01:

In this chapter, a brief introduction of the present study which gives compact idea

regarding the disease, pathogenesis, treatment aspect and the utility of Triphala choorna

and Anjana karma in Timira is described.

Chapter- 02:

Objectives of the study:

In this chapter, objectives of the study have been mentioned.

Chapter -03:

Review of Literature:

This chapter contains review of literature pertaining to the disease, drug and procedure.

Review of Disease:

In this section, Ayurvedic description of Timira, historical review of Timira, etymology,

definition, Nidana, Samprapti, Samprapti ghataka, Poorvaroopa, Roopa, Sadhya

Asadhyata, Upashaya and Anupashaya, Samanya Chikitsa of Timira, Vishesha Chikitsa

of Timira, Pathya and Apathya are described in detail. It also contains detailed

description of Cataract- definition, synonyms, epidemiology, types, risk factors,

pathology, clinical features, diagnostic tests and treatment.

SUMMARY




Review of the procedure:

This section deals with the conceptual study of Anjana, in detail comprising of historical

review, etymology, definition, utility and importance, classification according to different

acharyas, procedure, matra, indications of Anjana, mode of action of Anjana, Samyak,

atiyoga and ayoga lakshanas.

Review of Drug:

This Section contains the detailed description of the ingredients of Triphala choorna,

Anjana karma and anupana.

Chapter- 04:

Methodology:

This chapter contains the description regarding the source of data, Method of collection

of data, study design, diagnostic criteria, inclusion criteria, exclusion criteria, intervention

and procedural details of Anjana.

Chapter-05:

Sample Size of Estimation:

The observation of the study in relation to age, sex, religion, marital status, educational

status, socio- economic status, occupation, diet, addictions, sleep, family history,

chronicity, balapramana pareeksha, nidanas and lakshanas are presented in both tabular

and diagrammatic form.

SUMMARY




Chapter-06:

Results:

The result of the study in relation to its effect on assessment parameters like Avyakta

darshana, Gochara vibhrama, Vihwala darshana, Dvidhabahudha darshana, Glare,

Distant vision and Near vision were assessed using scoring and grading pattern and were

statistically analyzed within the group and between the groups to draw a valid conclusion

and is represented both in tabular and graphical form.

Chapter -07:

Discussion:

This chapter contains details about the discussion on Anjana and its probable mode of

action, methodology, observations and results along with the logical reasoning.

Chapter-08:

Conclusion:

In this chapter, whole study is concluded by giving a brief description of the disease,

procedure, study design, observation and results.

Chapter- 09:

Summary:

This chapter contains brief explanation of the whole dissertation.

Chapter- 10:

References:

This chapter contains the references in Vancouver's style.

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Verse-164, Pg-44, Uttarkhanda, Chapter 13, Verse- 68-70, pp- 336, pg- 265.




REFERENCES



MANAGEMENT OF TIMIRA W.S.R. TO SENILE IMMATURE CATARACT” Page xvi


53, pp- 824, pg- 638.

133) Dr.J.L.N Sastri, Dravyaguna Vijnana, Chaukhambha Orientalia, Varanasi,

Reprint Edition 2014, Volume 2, pp- 1134, pg- 209.

134) Bapalal G. Vaidya, Nighantu Adarsa, Chaukhambha Bharathi Academy,

Varanasi, Reprint Edition 2013, Volume 1, pg- 550.



2007, Purva Khanda, Part-I, Haritakyadi varga, pp- 659, pg- 7.

136) Sri Narhari Pandit, Raj Nighantu, By Dr. Satish Chandra Sankhyadhar and Dr.

Deepika Sankhyadhar, Chaukhambha Orientalia, Varanasi, Edition 2012, pp-

1306, pg- 621.

137) P.C. Sharma, M.B. Yelne; Data base on medicinal plants used in Ayurveda,

Central council for research in Ayurveda & Siddha, New Delhi, Print 2001,

Volume 3, pg- 282.

138) The Ayurvedic Pharmacopoeia of India, Government of India Ministry of

Health and Family Welfare Department of AYUSH, New Delhi, Part 1,

Volume 1, pp- 171, pg- 60.


Reprint Edition 2014, Volume 2, pp- 1134, pg- 216.








1306, pg- 626.

REFERENCES



MANAGEMENT OF TIMIRA W.S.R. TO SENILE IMMATURE CATARACT” Page xvii



Volume 3, pg- 158.



Volume 1, pp- 171, pg- 33.


Reprint Edition 2014, Volume 2, pp-1134, pg- 221.








1306, pg- 598.



Volume 3, pg- 12.



Volume 1, pp- 171, pg- 7.








REFERENCES



MANAGEMENT OF TIMIRA W.S.R. TO SENILE IMMATURE CATARACT” Page xviii



1306, pg-197.



Volume 3, pg- 71.



Volume 4, pp- 167, pg- 105.







2007, Purva Khanda, Part-I, pp- 659, pg- 429.



1306, pg- 121.



Volume 2, pg- 112.



Volume 2, pp- 190, pg- 21.


Reprint Edition 2014, Volume 3, pg- 46.



2007, Purva Khanda, Part-I, Dugdha varga, pp- 659, pg- 775.

REFERENCES



MANAGEMENT OF TIMIRA W.S.R. TO SENILE IMMATURE CATARACT” Page xix



1306, pg- 841.

166) Vaidya. V.M. Gogte, Ayurvedic Pharmacology & Therapeutic uses of

medicinal plants, Dravyaguna vignyan, Chaukhambha publication, edition,

Reprint 2012, pg-841, pp- 765.

167) Inventory of Animal products used in Ayurveda Siddha and Unani, National

Bio-Resources Development Board, Department of Bio-Technology, Ministry

of Science and Technology Government of India, CCRAS, New Delhi, Print

2008, Part 1, pg- 54.


Reprint Edition 2014, Volume 3, pg- 51.

169) Vaidya. V.M. Gogte, Ayurvedic Pharmacology & Therapeutic uses of

medicinal plants, Dravyaguna vignyan, Chaukhambha publication, edition,

Reprint 2012, pg- 841, pp- 765.

170) Inventory of Animal products used in Ayurveda Siddha and Unani, National

Bio-Resources Development Board, Department of Bio-Technology, Ministry

of Science and Technology Government of India, CCRAS, New Delhi, Print

2008, Part 2, pg-507.

CONSENT FORM



MANAGEMENT OF TIMIRA W.S.R. TO SENILE IMMATURE CATARACT” Page xx

WRITTEN INFORMED CONSENT FORM

Certificate by Investigator

I certify that I have disclosed all the details about the study in the terms easily understood

by the patient.

Date: Signature of the investigator

PATIENT’S CONSENT FORM

I the undersigned,

Resident of ……………

Age: yrs. Education:

I am taking the treatment with the Ayurvedic drugs under the supervision of Dr. Santosh

Kumar Shaw, She has explained me the purpose of treatment and I have understood it. I

have come to the hospital on my own and the treatment is for my betterment.

Voluntarily and without any pressure I am willing to undergo this treatment as long as

Physician in-charge asked me to undergo. She has not offered me any rewards. She has

also not made assurance regarding the benefits of cure from this trail. I am aware of my

rights to opt out of the study at any point of time during the study period.

The meaning of the contents of this letter has been explained to me in my own language.

Name of the subject: Name & sign of the investigator

Signature/ thumb impression

Place:

Date:

Page xxi

CASE PROFORMA



MANAGEMENT OF TIMIRA W.S.R. TO SENILE IMMATURE CATARACT” Page xxii

CASE PROFORMA

SRI KALABYRAVESHWARASWAMY AYURVEDIC MEDICAL COLLEGE,

HOSPITAL AND RESEARCH CENTRE.

VIJAYANAGAR, BANGALORE-560040.

DEPARTMENT OF POST GRADUATE STUDIES IN SHALAKYA TANTRA

A COMPARATIVE CLINICAL STUDY TO EVALUATE THE

EFFICACY OF TRIPHALA CHOORNA WITH KRISHNADI

ANJANA AND TRIPHALA CHOORNA IN THE MANAGEMENT

OF TIMIRA W.S.R. TO SENILE IMMATURE CATARACT

GUIDE : Dr. Sujathamma K. M.D., (Ayu)

RESEARCH SCHOLAR : Dr. Santosh Kumar Shaw, B.A.M.S.

ATURA VIVARANA Sl.No:

Name : O.P.D No:

Age : I.P.D No:

Sex : M / F Ward :

Religion : H / M / C / O Bed No:

Educational status : UE / UG / GR / PG D.O.A:

Marital status : UM / M D.O.D:

Economic status : LC / MC / UC Occupation:

Postal address :

Place/ area : R / U Ph No:

Desha : Anupa / Jangala / Sadharana E-mail ID:

CASE PROFORMA



MANAGEMENT OF TIMIRA W.S.R. TO SENILE IMMATURE CATARACT” Page xxiii

Date of commencement of treatment:

Date of completion of treatment: Study Group – A/B:

PRADHANA VEDANA: Duration:

ANUBANDHA VEDANA: Duration:

VEDANAVRUTTANTHA

POORVA VYADHI VRUTTANTA:

CHIKITSA VRUTTANTA:

KAUTUMBIKA VRUTTANTA:

VAIYAKTIKA VRUTTANTA:

1] Ahara: Vegetarian / Non veg/ Lacto ova veg

2] Vyasana:

Beedi / Cigarette - Yes / No , If Yes no........../ day /week Duration

Alcohol - Yes / No , If Yes qnt....................../ day /week/month Duration

CASE PROFORMA



MANAGEMENT OF TIMIRA W.S.R. TO SENILE IMMATURE CATARACT” Page xxiv

Tobacco Chewing - Yes / No , If Yes qnt....../ day /week/month Duration

Coffee/Tea -Yes / No , If Yes qnt in ml/cups......../day Duration

Other-

3] Nidra: ......... Hours /day - Sound / Disturbed /delayed

Divaswapna- Yes / No ......... Hours/day, Daily/Occasional

Ratrijagarana- Yes / No ........ Hours /day, Daily /Occasional

Other-

4] Koshta: Mridu/Madhyama/Kroora

5] Mala Visarjana: Regular / Irregular / Constipation / Loose stool

Frequency ........./Day

Colour-

Consistency-

Other-

6] Mutravisarjana – Frequency: Day........times, Night.........../times

Colour -

Other -

7] Vegadharana – Yes/No, Suppression of............................ urge/s regularly/

occasional

VYAVASAYIKA VRUTTANTA:

Work- Sedentary / Labour / Travelling/ House makers

Working hrs / day

Day / Night

CASE PROFORMA



MANAGEMENT OF TIMIRA W.S.R. TO SENILE IMMATURE CATARACT” Page xxv

RAJOSAMBANDHI VRUTTANTA:

Menstrual cycle: …… Regular / Irregular

ROGI PAREEKSHA

DASHA VIDHA PAREEKSHA (Atura Balapramanapareeksha ) :

Prakriti :V / P/ K/ VP/ PK/ VK/ VPK

Sara :Pravara / Madhyama / Avara

Samhanana :Pravara / Madhyama / Avara

Pramana :Heena / Madhyama / Uttama

(Dairghya___ cms, Bhara___kgs)

Satmya :Eka rasa / Sarva rasa / Vyamishra

Satva : Shareerika- Pravara / Madhyama / Avara

Manasika- Pravara / Madhyama / Avara

AharaShakti :

Abhyavaharana Shakti- Pravara / Madhyama / Avara

Jarana Shakti- Pravara / Madhyama / Avara

Vyayama Shakti: Pravara / Madhyama / Avara

Vaya : Bala/ Madhyama/Vriddha

Vikruti :P/ M/ A

Hetu - Desha -

Kala - Dosha -

Bala - Dushya -

CASE PROFORMA



MANAGEMENT OF TIMIRA W.S.R. TO SENILE IMMATURE CATARACT” Page xxvi

SROTO PAREEKSHA:

General Physical examination:

1. Built and nourishment:

2. Pulse : / min, regular/irregular

3. B.P : / mm of Hg

4. Temperature : F

5. Respiratory rate : / min

6. Tongue :

7. Height : meter

8. Weight : kg

9. Pallor : P / A

10. Icterus : P / A

11. Clubbing : P / A

12. Cynosis : P / A

SYSTEMIC EXAMINATION :

Respiratory System :

Cardiovasular System :

Gastrointestinal System :

Nervous System :

CASE PROFORMA



MANAGEMENT OF TIMIRA W.S.R. TO SENILE IMMATURE CATARACT” Page xxvii

OCULAR EXAMINATION

1. VISUAL ACUITY TEST:

Without spectacles With spectacles

DV NV DV NV

Both eye

Right eye

Left eye

2. PIN HOLE OCCLUDER TEST:

Right eye

Left eye

3. REFRACTION CORRECTION:

Right Eye Left Eye

Sph Cyl axis V/A sph cyl axis V/A

DV

NV

CASE PROFORMA



MANAGEMENT OF TIMIRA W.S.R. TO SENILE IMMATURE CATARACT” Page xxviii

4. EXTRA-OCULAR EXAMINATION:

Right eye Left Eye

1. Eye ball

Position

Size

Ocular movements

2. Eye lid

3. Eye lashes

4. Lacrimal apparatus

Puncta

Nasolacrimal duct

5. Conjunctiva

Palpebral

Bulbar

Fornices

Sclera

Cornea

Size

Shape

Surface

Transparency

Anterior chamber

Iris

CASE PROFORMA



MANAGEMENT OF TIMIRA W.S.R. TO SENILE IMMATURE CATARACT” Page xxix

Pupil

Location

Size

Shape

Colour

Reflex

5. INTRA-OCULAR EXAMINATION

A) Slit lamp Examination

Left eye Right eye

Conjunctiva

Cornea

Anterior chamber

Lens

Colour pattern

Position

Capsule

Cortex

Nucleus

B) Direct Ophthalmoscopy (Examination of Fundus)

Left eye Right eye

a) Media

Corneal opacity

Lenticular opacity

CASE PROFORMA



MANAGEMENT OF TIMIRA W.S.R. TO SENILE IMMATURE CATARACT” Page xxx

b) Optic disc

Size

Shape

Cup-disc ratio

c) Retinal vessels

d) Macula Lutea

ROGA PAREEKSHA

NIDANA:

PURVARUPA:

RUPA:

SAMPRAPTI:

SAMPRAPTI GHATAKA:

Dosha- Udbhavasthana-

Dushya- Sancharasthana-

Agni- Adhishtana

Ama- Vyaktasthana-

Srotas-

Srotodusti -

CASE PROFORMA



MANAGEMENT OF TIMIRA W.S.R. TO SENILE IMMATURE CATARACT” Page xxxi

CHIKITSA:

Group Treatments Dose Duration

A

Krishnadi anjana 1 Harenu matra Once daily at Morning for

48 days

Triphala choorna

Internally

05 Grams with

ghrita

Once daily at night after

food for 48 days

B

Triphala choorna

Internally

05 Grams with

ghrita

Once daily at night after

food for 48 days

Samyak Lakshanas of Lekhana Anjana :

Observation DT AT

Vishada

Laghu

Anasraavi

Kriyaapatu

Samshanta upadrava

Nirmalam

Ayoga Lakshanas of Lekhana Anjana

Observations DT AT

Ugrataradosha

CASE PROFORMA



MANAGEMENT OF TIMIRA W.S.R. TO SENILE IMMATURE CATARACT” Page xxxii

Atiyoga Lakshanas of Lekhana Anjana

Observations DT AT

Jihmatwa

Daaruna durvarnata

Srasthatha

Rookshata

Syandana

ASSESMENT CRITERIA:

CRITERIA BT AT

Avyakta darshana

Gochara vibhrama

Viwhala darshana

Dwidhabahudha

drushti

Glare

Distant vision

Near vision

BT =Before Treatment.

AT =49th

day of treatment

Signature of HOD Signature of Guide Signature of Scholar

ANNEXURES



MANAGEMENT OF TIMIRA W.S.R. TO SENILE IMMATURE CATARACT” Page xxxix

ANNEXURES

Haritaki

Vibhitaki

Amalaki

Drugs used for Triphala choorna

Pippali

Haritaki

Bhringaraja

Drugs used for Krishnadi varti

ANNEXURES



MANAGEMENT OF TIMIRA W.S.R. TO SENILE IMMATURE CATARACT” Page xl

Goghrita used as anupana

Madhu for rubbing Anjana varti

ANNEXURES



MANAGEMENT OF TIMIRA W.S.R. TO SENILE IMMATURE CATARACT” Page xli

Preparation of Krishnadi varti

Pippali Tandula

Haritaki

Bhringaraja Plant

Wet Grinder

Varti

Varti container

ANNEXURES



MANAGEMENT OF TIMIRA W.S.R. TO SENILE IMMATURE CATARACT” Page xlii

Amalaki

Haritaki

Vibhitaki

Triphala choorna

Preparation of Triphala choorna

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