Arma - Pterygium

Presenter :Dr. Pancha janya kumar .DeeviII yr Shalakya P.G scholar.

Moderator : Dr. CH. Rama Devi. Asso.Prof. P.G Shalakya, Dept. of. S.S.P

Contents

• Introduction• Sharira (Applied anatomy)of Shukla Mandala

(conjunctiva)Arma(Pterygium)

• Nidana(etiology)

• Purva rupa(premonitory symptoms)

• Rupa(signs & symptoms)

• Samprapti(pathogenesis)

• Sadhya sadhyata(prognosis)

• Chikitsa (treatment)

• Nidana parivarjana(prevention)

• Conclusion

Introduction

• Arma(Pterygium) is a Netra roga comes under Shukla gata rogas Acc to Acharya Susruta(11) and Vagbhata(13).

• Acc to Susruta’s classification of treatments for eye diseases, Arma comes under 11- chedya (excision) netra rogas.

• This presentation includes detailed surgical description of Acharyas regarding Arma(Pterygium) and its advantages & disadvantages to current time.

• The observed Post surgical complications & their management by our Acharyas, their utilization in current day post surgical complications observed by Ophthalmic surgeons.

Sharira (Applied Anatomy)ofShukla Mandala (conjunctiva)

• Acc to Susruta the Krishna Mandala is ‘1/3rd’ of transverse diameter of eye, the Shukla Mandala is remaining ‘2/3rd’ of transverse diameter.

• The Shukla Mandala having its boundaries with vartma and Krishna Mandalas.

• The Shukla Mandala is predominant of Jala mahabhauta (water element).

• The diseases pertaining to Shukla Mandala are ‘11’ acc to Susruta – ‘13’ acc to Vagbhata

(sirotpata and siraharsha are considered as Shukla Mandala gata rogas).

• Conjunctiva: is a translucent mucus membrane which lines the posterior surface of the eye lids and anterior aspect of the eyeball.

• Our main concentration is on bulbar conjunctiva which is the site for Pterygium.

• It is thin transparent and lies loose over the underlying structures and thus can be moved easily.

• It is separated from anterior sclera by episcleral tissue and tenon’s capsule. At the limbus the epithelium of conjunctiva becomes continuous with that of cornea.

• The histology of bulbar conjunctiva having ‘3’layered epithelium-contains goblet cells, adenoid layer-contains lymphocytes & fibrous layer which contains vessels and nerves of conjunctiva.

• Glands of conjunctiva: ‘2’ types- Mucin secreting glands(secrets mucus which is essential for wetting conjunctiva & cornea) and Accessory lacrimal glands.

• Blood supply of conjunctiva by arteries derived from peripheral arterial arcade & marginal arcade of the eye lid and anterior ciliary arteries.

• Veins from conjunctiva drains into venous plexus of eye lids and anterior cilliary veins.

• Lateral and medial lymphatics drain into preauricular and submandibular lymph nodes respectively.

• A circum corneal zone of conjunctiva is supplied by branches from long ciliary nerves, rest is supplied by the branches from lacrimal, infra & supra trochlear, supra orbital and frontal nerves.

Arma(Pterygium)

• Nidana(etiology): According to Ayurveda • Ushnabhitaptasya jala pravesat-

entering into water after exposure to heat.

• Doorekshanat- looking at distant objects.

• Swapna viparyaya- irregular sleeping habit.

• Prasakta samrodhana soka kopa- weeping, grief and anger in excess.

• Klesabhigatadatimaithunacha- fatigue, blow and excess of coitus .

• Suktaranalamlakulattamashanishevanath- taking beverages of acidic nature, horse gram and black gram.

• Vegavinigrahacha- voluntary suppression of any of nature call.

• Swedadrajodhumanishevanacha- excess of sweating, exposure to dust and smoke.

• Chardervighatath- suppression of vomiting.

• Vamanatiyogath- emesis in excess.

• Bhashpagrahat- suppression of tears.

• Sookshmanireekshanacha- looking at minute things.

• All these are causative factors for eye diseases by aggravating doshas of the body.(Su.ut.1/21-22)

• Achakshushayirhi prayena pittanusarinaha- the deeds which are bad to eye and especially aggravate Pitta dosha.(A.H.ut.8/1)

• According to Modern Ophthalmology:

• Etiology of pterygium is not definitely known. But the disease is more common in people living in hot climates.

• The most accepted view is that it is a response to prolonged effect of environmental factors such as exposure to sun (UV rays),dry heat, high wind and abundance of dust.

• Purva rupa(premonitory symptoms) : acc to Ayurveda

• Avilam sasamrambhamasrupurnopadehavat- cloudiness of vision, slight inflammation, lacrimation, mucus accumulation.

• Gurushatodaragadhyairjushtamchavyakta lakshanaih- heaviness, pricking pain, redness and un manifested features.

• Sasoolam vartmakosheshusukapurnabhameva cha- pain in lids and seems studded with bristles of worms.

• Vihanyamanam rupe va kriyaswakshi yatha pura- sensory impairment of faculty of eyes in detecting colour, closing and opening.

• Rupa(signs & symptoms): acc to Ayurveda

• Armas are ‘5’ types depending upon their signs and symptoms.

• Prastharyarma- shuklabhage vistirnam tanu rudhiraprabham sa nilam-which is thin reddish blue in colour and extended on conjunctiva.

• Shuklarma- mrudu..saswetam samamiha vardhate chiram- smooth, white and spreds gradually for a long time.

• Lohitarma- yanmamsam..padmabham..-fleshy growth resembling red lotus on conjunctiva.

• Adhimamsarma- visthirnam mrudu bahalamyakrit prakasam syavam- soft, thick, dark brown like liver and spread on conjunctiva.

• Snavyarma- pisitamupaiti vridhimetat.. kharamrapandu- rough, pale and fleshy gradual growth on conjunctiva. (su.ut.4/3-7)

• In case of Prastharyarma Vagbhata says it grows very fast- Asuvridhi(A.H.Ut.10/17)

• In case of Snavyarma it resembles snayu(tendon) (A.H.Ut.10/17)

• In case of Adhimamsarma- sushkasrukpindavat syavam-dark brown in colour like a dried blood clot.

• The Arma will form either nasal or temporal side was said only by Vagbhata while explaining the surgery.

• According to modern Ophthalmology: Pterygium a wing shaped fold of conjunctiva encroaching upon the cornea from either side within the interpalpebral fissure.

• Demography: usually seen in old age, M>F, may be unilateral or bilateral, usually present on nasal side but may also occur on temporal side.

• Symptoms: • cosmetic intolerance may be the only issue

otherwise asymptomatic condition in early stages.

• Foreign body sensation may be experienced.

• Defective vision occurs when it encroaches the pupillary area or due to corneal astigmatism induced by fibrosis in the regressive stage.

• Diplopia may occur occasionally due to limitation of ocular movements.

• Signs: a triangular fold of conjunctiva encroaching on the cornea in the area of palpebral aperture usually on the nasal side, but may also occur on the temporal side.

• very rarely , both nasal and temporal sides are involved-primary double pterygium.

• Parts of a fully developed pterygium:

• Head-on the cornea

• Neck-in the limbal area

• Body- extended between limbus &canthus

• Cap- semi lunar whitish infiltrate just in front of the head.

• Types: depending up on progression it may be progressive or regressive pterygium.

• Progressive pterygium: thick, fleshy and vascular with a few infiltrates in the cornea, in front of the head of the pterygium.

• Regressive pterygium: thin, atrophic, attenuated with very little vascularity.

• There is no cap but deposition of iron (stocker's line) may be seen some times.

• Differential diagnosis: • Must be differentiated from

pseudopterygium. It is formed due to adhesion of chemosed bulbar conjunctiva to marginal corneal ulcer. It usually occurs following chemical burns.

Pterygium Pseudopterygium

Etiology: degenerative process

Inflammatory process

Age: usually occurs in elder persons

Can occurs at any age

Site: always situated in the palpebral aperture

Can occur at any site

Stages: either progressive regressive or stationary

Always stationary

Probe test: probe cannot be passed underneath

A probe can be passed under the neck

• Complications: Cystic degeneration and infection are infrequent. Neoplastic change to epithelioma, fibrosarcoma or malignant melanoma, may occur rarely.

• Correlation between Ayurvedic classification & Modern ophthalmic classification:

• Prastharyarma- can be compared with Regressive pterygium.

• Shuklarma- can be compared with Stationary pterygium.

• Lohitarma- can be compared with Progressive pterygium.

• Adhimamsarma- can be compared with Pseudopterygium.

• Snavyarma- can be compared with Neoplastic change of pterygium complications.

• Samprapti (pathogenesis):• According to Ayurveda:

• Siranusaribhirdoshairvigunairudhwamagataih- the disease causing pathogenic factors (doshas) reaches eye through its circulation.

• Jayante netrabhgeshu rogah paramadarunah- which causes sevier eye diseases.

• Dosha: Prastharyarma, Adhimamsarma, Snavyarma- sannipataja(v.p.k)-shuklarma-kapha,-kshtajarma-Rakta.

• Dushya: rakta&rasa.

• Sthana: Shukla Mandala.

• According to modern ophthalmology:

• The working hypothesis is that the UV radiation causes mutations in the p53 tumor suppressor gene, thus facilitating the abnormal proliferation of limbal epithelium.

• It is a degenerative hyperplastic condition of conjunctiva.

• The subconuctival tissue undergoes elastotic degeneration and proliferates as vascularised granulation tissue under the epithelium, which ultimately encroaches the cornea.

• The corneal epithelium, bowman’s layer and superficial stroma are destroyed.

• Sadhya sadhyata(prognosis)

• According to Susruta all ‘5’ Armas are of chedana(excision) sadhyas, Vagbhata also said chedana but as a special treatment.

• According to Modern Ophthalmology surgical excision is the only satisfactory treatment.

• Chikitsa (treatment)• The Armas which are tanu..thin,

dhooma..smoky, avilam..dusty, rakta..red and dadhinibham..looks like curd. Are to be treated on the lines of Sukra which is a corneal opacity.(su. &vag.)

• Medical treatment : • Triphala Churna given along with or with out

ghee depending on the condition(vag).

• Tiktaka ghritas for snehana (oleation), do rakthamokshana (blood letting), Vamana (emesis), virechana (purgation) and seka (pouring medicated kashayas or oils over the eye).

• Nasya (nasal drops), Tarpanam (filling the conjuctival sac with oils),putapaka (filling the conjuctival sac with medicated liquids or juices), Lekananjanam (Collyrium having scraping property).(Su. & Va.)

• Surgical procedure of Arma according to Susruta:

• Indications for surgery: charmabham bahalam.. snayumamsaghanavritam.. krishnamandalagacha yat- skinny, thick, tendinous, muscular, hardened and encroaches cornea -these are the conditions which are to be operated.

• Pre operative procedure: snigdhambhuktavatohyannam upavishta- the patient should be asked to sit comfortly after taking a meal rich of fat.

• Samroshayettu nayam bhishak churnaistu lavanaih- the affected eye should be irritated with powdered rock salt.

• Tatah samroshitam turnam susvinnam parighattitam- after that the part should be fomented and rubbed.

• Operative procedure: • Apangam prekshyamanasya badisena

samahitah-muchundyad/ suchisutrena va – ask the patient to look towards his outer canthus lift the Arma with hook and then catch it with forceps/suturing tread.

• Vartmani grahayedhridam- the eye lids are drawn tightly.

• Ullikhan mandalagrena tikshnena parisodhayet-vimuktamsarvatachapi krishnachuklachamandalat- the flabby and pendent Arma is scraped with the sharp edge of scalpel like that with out leaving any of its contents attached to cornea and sclera.

• Nitva kaninikopantam chindyannatikaninikam-cahtur bhagasthite mamse na akshi vyapattimarhati- the inner canthus should be secured while scraping, even leave 1/4part of Arma but don’t hurt any other parts of eye during the procedure.

• In case of Netted Arma: Arma yajjalavad vyapi- tadapyunmarjalambitam- catch same as before with forceps.

• Chindyadvakrena sastrenavartma suklantamasritam- then it should be excised with sharp edge of scalpel up to the point where lids unite with conjunctiva.

• Post operative procedure:• Pratisaranamakshnostu tatah

karyamanataram- after completion of surgery the part should be rubbed with-the alkali prepared with- stalks of barley +powder of trikatu +powder of Saindhava salt.

• After that duly fomented and bandaged.

• The part should be treated like a wound and bandage is removed after 3 days and give fomentation with rubbed palms.

• The patient was given medicines and purifications depending up on his strength in accordance to time and season.

• The properties of successful surgery:

• Visudhavarnamaklishtam kriyaswakshi gataklamam…yatha swamanupadravam- the eye assumes its normal colour and function with out getting any complications and pain.

• According to Vagbhata the surgical procedure is same except-

• In preoperative procedure the Saindhava salt powder is wetted with lemon juice and then the paste is applied as Collyrium to eyes, there after the procedure is same as Susruta.

• In postoperative procedure: for pratisarana he doesn’t mention yavakshara -along with trikatu and honey.

• The part after rubbing is poured with lukewarm ghee- ushnena sarpisha siktam.

• Abhyaktam madhu sarpisha- then it is anointed with honey+ghee .

• According to modern ophthalmic Surgery:

• Indications for surgery: cosmetic reasons, progression of pterygium to pupillary area, Diplopia due to interference in ocular movements.

• Pre operative procedure:• Topical anesthesia – instillation of drops of

2-4%xylocaine or 1%amethocaine. One drop once in 4minutes for 4times.

• Eye is cleansed ,draped and exposed using universal speculum.

• Operative procedure: It is the latest and most effective technique.

• Head of the pterygium is lifted and dissected off the cornea very meticulously.

• The main mass of pterygium is then separated from the sclera underneath and the conjunctiva superficially.

Pterygium 3 Techniques John A. Hovanesian Harvard Eye Associates, California.mp4

• Pterygium tissue is then excised taking care not to damage underlying medial rectus muscle.

• Haemostasis is achieved and the episcleral tissue exposed is cauterised thoroughly.

• Conjuctival limbal auto graft (CLAU) transplantation to cover the defect after pterygium excision.

• Post operative procedure:• Bandaged the operated eye.

• Topical steroid antibiotic drops, topical NSAIDS, artificial tears up to 6-8 weeks.

• Advice to wear dark sun glasses and to avoid exposure to sun.

• Advantages and disadvantages:• The signs indicated for medical management

acc to Ayurveda are very much useful in current times to prevent surgery.

• The rock salt+ citrus juice mixture – consists mineral Na, K..vitamin-c apart from this it is a good cleanser of surgical part.

• The instruments are changed but the procedure is same as said by Susruta.

• The grafting technique is not dealt by Susruta in eye, but he knows how to graft the nose.

• The post operative care said by Susruta offers good healing and prevent recurrence, by which he claims that the Armas are Sadhya rogas of eye.

• The pratisarana enhances healing process along with cauterisation.

• The mixture of ghee and honey is a good source of vitamins, lubrication and enhances healing.

• The ‘¼’th part of Arma is left to secure lacrimal passages and blood vessels , with the help of dilators the problem will be overcomed in current time.

• By explaining properties of successful surgery we suspect Susruta's success rate in excision of pterygium.

• Complications: these are observed due to improper surgery/improper post surgical management/immune response of the patient.

• Susruta observed complication during surgery by cutting Arma up to innercanthus, that is the reason he said to leave ‘1/4’th of Arma near to kaninika to secure lacrimal passages and blood vessels.

• At the same time improperly excised Arma will re grow, in that case Collyrium having scraping nature (lekhyanjana) to be used-Susruta.

• The post surgical pain management done with eye drops made up of milk (boiled with karanja+amalaki+yashti) and honey.

• A cold plaster prepared with paste of milk+ghee+yashti+polens of lotus+durvagrass is to be applied on the fore head.

• Vagbhata support the views of Susruta.

• Acc. to Modern ophthalmic surgery:• The recurrence of pterygium is 30-50% is the

main problem.

• Current technique of grafting is some what better to decrease the recurrence rate.

• Surgical excision with amniotic membrane graft and mitomycin-c (MMC) (0.02%)application may be required in recurrent pterygium.

• Though grafting gives relief from post surgical pain and discomfort , it may get rejected in some cases due to immune response.

• Pain , inflammation, irritation all are well managed by modern surgeons by keeping patient under antibiotics, steroids, NSAIDS, artificial tear solutions.

• Nidana parivarjana(preventive aspects):• Both the systems finally come to single

point prevention.

• Susruta's main notion regarding treatment is prevention.

• Acharyas’ clearly mention not to take certain diets in eye diseases –horse gram, black gram, beverages having sour taste etc.

• Advised to avoid situations which cause cry, anger, grief .

• Advised to avoid hurt to eye and excess of coitus.

• Advised to use umbrella and footwear.

• Advised to use Collyrium and massage soles with oil.

• Advised not to use hot water for head bath.

• Advised to take diet containing rich source of vitamin A &C.

• Advised to wear sun glasses to protect from sun light.

• Advised to avoid work in hot environment.

• These are some preventive measures to avoid Arma-pterygium.

• Conclusion:• Susruta clearly mentioned -excision has to be

done in pterygium encroaching cornea, means not to wait for further progression to the pupillary region and cause discomfort to vision which is a good carry point.

• The signs indicated for medical treatment also useful to prevent surgical intervention.

• Post surgical precautions and medications are also useful to prevent recurrence.

• Though it is a surgically curable disease , the recurrence rate of it alarms us better to prevent.

• Sankshepatah kriya yogo nidanaparivarjanam-Su.ut.20/1.

• References: • Susruta samhita uttara tantra 1st,4th,8th,15th

chapters.• Ashtanga Hridaya uttara sthana 7th,10th,11th

chapters.• Comprehensive ophthalmology 5th edition by

AK Khurana 4th and 24th chapters.• e_references-www.slideshare.net, appropriate

images & videos from Google search.

Acknowledgements

• Prof.& HOD PG Dept.of.S.S.P: Dr. M.Guru murthy.• Shalakya PG unit • Professor: Dr. T. Praveen kumar.• Associate professor: Dr. CH.Rama Devi.• Assistant professor: Dr. B.Badrinath Benarji.