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Diabetic Retinopathy – An Ayurvedic Approach By Dr. Manu Vairasseri, BAMS, M.S(Ay)

The advent of globalization has brought dramatic changes in human lifestyle all over the world. These changes brought about alteration in the staple food habits and levels of physical activities of the indigenous population which were suitable to the persisting environment of the particular geographic region and gave way to a set of non-communicable diseases like Diabetes mellitus- which on due course took the embodiment of an epidemic. The epidemic nature of these diseases is being driven by powerful forces like demographic ageing, rapid unplanned urbanization, and the globalization of unhealthy lifestyles. In large parts of the developing world, non-communicable diseases (NCDs) are detected late, when patients need extensive and expensive hospital care for severe complications or acute events.

Ayurvedic classics narrate that even the descend of Ayurveda sastra (Ayurveda avatarana) has happened during such a drastic lifestyle change, that wreak havoc to the lives of the sages ever since they adopted the gramya lifestyle, which has an implication on the responsibility of Ayurvedic community in addressing such life-style diseases. The citation of Ayurveda avatarana is merely an example to imply that the system had an eye on such diseases quite before any other medical system had a voice in the scenario. Prameha, considering the aetiopathogenesis, is described as an Annapaanakriyajatha roga in Ayurvedic perspective. The term lifestyle disease attributed to Diabetes mellitus seems to be mere translation of the above Sanskrit term. Ekasthaana asana rathi – physical inactivity is another important nidana for prameha.

DM is a microvasculopathy involving different organ systems arising out of the disruption in equilibrium of fluid dynamics which in turn could be translated as a sarva dehika abhishynda - rasavaha sira rodha (increased plasma viscosity and platelet aggregation leading to microvascular occlusion). The pathogenesis is no longer dissimilar in case of a diabetic eye disease. There is an invariable Netrabhishyanda when we consider aetiopathogenesis of Diabetic retinopathy in Ayurvedic perspective. Maadhavakara has said that anything which increases kapha dosha is a prameha hetu. Any ahara or vihara which increases snigdha, guru, manda, slashna, mritsna and sthira gunas of kapha dosha acts as a prameha hetu. Same is the nidana for abhishyanda which in turn leads to all kinds of netrarogas. Madhura,amla, lavana, snigdha, guru, picchila, seethala aharas, navadhanya, sura, anoopa mamsa, ikshu, guda and gorasa act as nidana for prameha and abhishyanda simultaneously. Ekasthana and aasana priyata (sedentary habits), vidhi varjitha sayana and similar viharas lead to vyanadushti as well. Thus both stasis of rasa dhathu due to kaphakara ahara janya abhishyanda and vyana dushti due to sedentary habits together leads to srotosanga and there by kha vaigunya which in turn manifest as prameha vyadhi.

                                                  Samprapthi of PramehaSAMPRAPTHI OF PRAMEHA.PNG
                         																																																																																																																																																																											

While Vagbhataacharya explains about samprapthi of netra rogas, he says that dosha kopa created due to sarva roga nidana ascends to netra via siras when they get kha vaigunya at netra and produces diseases at vartma, sandhi, sita, krishna, drishti and/or sarvakshi. . In any prameha rogi there will be dosha dushti at koshta and at the level of different dhatus depending upon the guruthwa of nidanaghatakaas. But, for dosha dushti to reach netra there should be kha vaigunya or sthaanika dushti at netra level which is caused by achaksushya aharas and viharas.

                                  Pathogenesis of Diabetic retinopathyPrameha.PNG







Thus sarvadehika abhishyanda inturn leads to netrabhishyanda that hamper the fluid dynamics in sookshmasrotases in netra(retinal microvascular occlusion) which interferes with the normal gathi of vyana carrying rasadhathu. Vyanavaigunya manifests as abnormal vyasa of sookshmasrotases in netra(microaneurysms, venous dilation, increased vascular permeability) further causing the vimarga gamana of contents to the space outside the srotases(exudates and retinal haemorrhages). This causes relative soumyadhathukshaya at the required site(retinal ischaemia). Cosequently vata-pitta vridhi occurs and causes uncalled for srotovibhajana(vascular proliferation)

                          Ayurvedic perspective on pathological changes in DR DR Samprapthi.PNG







Classification of DR and corresponding fundus features

Non Proliferative Diabetic Retinopathy Micro aneurysms - Micro aneurysms are saccular out pouchings formed by dilatation of capillary wall. They appear as minute round dots, occasionally arranged like clusters of grapes at the ends of small vascular twigs. Intra retinal haemorrhages - These deep dot and blot haemorrhages occur as a result of bleeding from ruptured micro aneurysms, capillaries, venules. Their shape is dependent upon their location within retinal layers. Hard exudates - They are composed of lipoprotein and lipid-filled macrophages located mainly within the outer plexiform layer. Hyperlipidemia, especially triglyceridemia may increase the likelihood of exudate formation. They are waxy yellow lesions with relatively distinct margins, often arranged in clumps and/or rings at the posterior pole, typically surrounding leaking microaneurysms or areas of capillary non perfusion. Cotton wool spots – These are neuronal debris resulting from axonal damage due to ischaemia of retinal nerve fibres Venous beading and loops - These represent focal areas of venous dilatation with apparent thinning of vessel wall. Intra Retinal Microvascular Abnormalities (IRMA) - are arteriolar-venular shunts that run from retinal arterioles to venules, thus bypassing the capillary bed and are therefore often seen adjacent to areas of marked capillary hypo perfusion.

Preproliferative Diabetic Retinopathy Ischemic changes superimposed on background diabetic retinopathy produce a preproliferative DR. PDR is characterized by neovascularisation on or within one disc diameter of the disc (NVD) and/or new vessels elsewhere (NVE) in the fundus.


Diabetic macular oedema Diabetic maculopathy (foveal oedema, exudates or ischaemia)is the most common cause of visual impairment in diabetic patients, particularly type 2.

Diffuse retinaloedema is caused by extensive capillary leakage, andlocalized oedema by focal leakage from microaneurysms and dilated capillary segments.

Advanced diabetic eye disease Haemorrhage may be preretinal (retrohyaloid, intragel or both. Intragel haemorrhages usually take longer to clear than preretinal haemorrhages because the former are usually the result of a more extensive bleed. Tractional retinal detachment is caused by progressive contraction of fibrovascular membranes over areas of vitreoretinal attachment. Rubeosis iridis (iris neovascularization) may occur in eyes with PDR, and if severe may lead to neovascular glaucoma.


Laboratory investigations - Blood sugar levels (HbA1C), Lipid profile


Ophthalmological investigations Visual acuity Fundus examination – Ophthalmoscopy, slit lamp biomicroscopy, fundus photography Fundus fluorescein angiography(FA) Optical Coherence tomography (OCT)


Ayurvedic Management

a)Control of the primary disease (Prameha chikitsa) is a quintessential step in prevention, delaying the progression and in treatment of DR.

b) In presence of active retinal or vitreous haemorrhage, attempt should be made to control the haemorrhage. •Sirolepa, mukhalepa, and vidalaka with seetha dravyas like chandana, lodhra, yashtimadhu,usheera, amalaki etc. •Pratimarsa with Durva swarasa and ajaksheera •Sekam with ajaksheera processed with raktapittasamana dravyas like yashti, chandana, lodhra, manjishta etc. •Chandanadi varthi may be made in to Aschyotana form with ajaksheera •Internal administration of rakthapittasamana drugs like vasaguloochyadi kashya,Dura swarasa, laksha gulgulu gilika etc. must be considered. •Virechana with avipathi choorna

c) In presence of macular oedema •Sirolepa, mukhalepa should be done with sophasamana dravyas like dasamoola •Sophasamana vidalakas with mukkadi •Takradhara •Internal administration of dasmoolam ksahyam, punarnavadi kashyam,Ardhavilwam kashyam, chandraprbha gulika etc. •Virechana with erandataila

d) After the management of acute haemorrhage and macular oedema resort to the classical line of netra chikitsa- •Ghritapana- Triphala ghrita, Mahatripahala ghrita, Padoladighrita •Virechana – Erandataila and ksheera •Nasya – Durvaswarasa and ajaksheera •Takradhara •Anjana – Pasupatha varthi/ chandanadi varti+ honey •Tarpana may be done with jeevaniya ghritam, satahwadi ghritam or durvaghritam only after remission of macular oedema, exudates and haemoerrhages to a considerable extent •Putapakam may be done with jeevaniyagana dravyas and ajamamsa.


Charakaacharya has emphasized that bahudrava sleshma is dosha vishesha in prameha. Because of the similarity in gunas it first vitiates medo dhatu followed by the dushti of kleda, sweda, rasa and mamsa dhatus. In the next stage there is dushti of pitta dosha and rakta dhatu. In the final stage dhatu ksheenata creates vayu kopa which in turn vitiates vasa and majja dhatus. The same involvement of doshas can be seen in pathogenesis and progression of Diabetic Retinopathy. Thus it may be observed that dosha predominance varies from kapha to pitta and then to vata in successive stages of Diabetic Retinopathy. Mainly kaphaadhika thridosha kopa is seen in Back ground or early DR, Pitta raktaadhika in Pre Proliferative and Proliferative DR and Vataadhika in Advanced DR though there is involvement of all doshas and rakta in all stages.

Therefore to conclude the treatment should be a logical combination of vatanulomana, kapha-pitta-rakta samana, prameha chikitsa,urdhwagaraktapitta chikitsa, thimira chikitsa and abhishyanda chikitsa.

Diabetic Retinopathy – An Ayurvedic Approach[edit]

By Dr. Manu Vairasseri, BAMS, M.S(Ay)

The advent of globalization has brought dramatic changes in human lifestyle all over the world. These changes brought about alteration in the staple food habits and levels of physical activities of the indigenous population which were suitable to the persisting environment of the particular geographic region and gave way to a set of non-communicable diseases like Diabetes mellitus- which on due course took the embodiment of an epidemic. The epidemic nature of these diseases is being driven by powerful forces like demographic ageing, rapid unplanned urbanization, and the globalization of unhealthy lifestyles. In large parts of the developing world, non-communicable diseases (NCDs) are detected late, when patients need extensive and expensive hospital care for severe complications or acute events.

Ayurvedic classics narrate that even the descend of Ayurveda sastra (Ayurveda avatarana) has happened during such a drastic lifestyle change, that wreak havoc to the lives of the sages ever since they adopted the gramya lifestyle, which has an implication on the responsibility of Ayurvedic community in addressing such life-style diseases. The citation of Ayurveda avatarana is merely an example to imply that the system had an eye on such diseases quite before any other medical system had a voice in the scenario. Prameha, considering the aetiopathogenesis, is described as an Annapaanakriyajatha roga in Ayurvedic perspective. The term lifestyle disease attributed to Diabetes mellitus seems to be mere translation of the above Sanskrit term. Ekasthaana asana rathi – physical inactivity is another important nidana for prameha.

DM is a microvasculopathy involving different organ systems arising out of the disruption in equilibrium of fluid dynamics which in turn could be translated as a sarva dehika abhishynda - rasavaha sira rodha (increased plasma viscosity and platelet aggregation leading to microvascular occlusion). The pathogenesis is no longer dissimilar in case of a diabetic eye disease. There is an invariable Netrabhishyanda when we consider aetiopathogenesis of Diabetic retinopathy in Ayurvedic perspective. Maadhavakara has said that anything which increases kapha dosha is a prameha hetu. Any ahara or vihara which increases snigdha, guru, manda, slashna, mritsna and sthira gunas of kapha dosha acts as a prameha hetu. Same is the nidana for abhishyanda which in turn leads to all kinds of netrarogas. Madhura,amla, lavana, snigdha, guru, picchila, seethala aharas, navadhanya, sura, anoopa mamsa, ikshu, guda and gorasa act as nidana for prameha and abhishyanda simultaneously. Ekasthana and aasana priyata (sedentary habits), vidhi varjitha sayana and similar viharas lead to vyanadushti as well. Thus both stasis of rasa dhathu due to kaphakara ahara janya abhishyanda and vyana dushti due to sedentary habits together leads to srotosanga and there by kha vaigunya which in turn manifest as prameha vyadhi.

                                                  Samprapthi of PramehaSAMPRAPTHI OF PRAMEHA.PNG
                         																																																																																																																																																																											

While Vagbhataacharya explains about samprapthi of netra rogas, he says that dosha kopa created due to sarva roga nidana ascends to netra via siras when they get kha vaigunya at netra and produces diseases at vartma, sandhi, sita, krishna, drishti and/or sarvakshi. . In any prameha rogi there will be dosha dushti at koshta and at the level of different dhatus depending upon the guruthwa of nidanaghatakaas. But, for dosha dushti to reach netra there should be kha vaigunya or sthaanika dushti at netra level which is caused by achaksushya aharas and viharas.

                                  Pathogenesis of Diabetic retinopathyPrameha.PNG







Thus sarvadehika abhishyanda inturn leads to netrabhishyanda that hamper the fluid dynamics in sookshmasrotases in netra(retinal microvascular occlusion) which interferes with the normal gathi of vyana carrying rasadhathu. Vyanavaigunya manifests as abnormal vyasa of sookshmasrotases in netra(microaneurysms, venous dilation, increased vascular permeability) further causing the vimarga gamana of contents to the space outside the srotases(exudates and retinal haemorrhages). This causes relative soumyadhathukshaya at the required site(retinal ischaemia). Cosequently vata-pitta vridhi occurs and causes uncalled for srotovibhajana(vascular proliferation)

                          Ayurvedic perspective on pathological changes in DR DR Samprapthi.PNG







Classification of DR and corresponding fundus features

Non Proliferative Diabetic Retinopathy Micro aneurysms - Micro aneurysms are saccular out pouchings formed by dilatation of capillary wall. They appear as minute round dots, occasionally arranged like clusters of grapes at the ends of small vascular twigs. Intra retinal haemorrhages - These deep dot and blot haemorrhages occur as a result of bleeding from ruptured micro aneurysms, capillaries, venules. Their shape is dependent upon their location within retinal layers. Hard exudates - They are composed of lipoprotein and lipid-filled macrophages located mainly within the outer plexiform layer. Hyperlipidemia, especially triglyceridemia may increase the likelihood of exudate formation. They are waxy yellow lesions with relatively distinct margins, often arranged in clumps and/or rings at the posterior pole, typically surrounding leaking microaneurysms or areas of capillary non perfusion. Cotton wool spots – These are neuronal debris resulting from axonal damage due to ischaemia of retinal nerve fibres Venous beading and loops - These represent focal areas of venous dilatation with apparent thinning of vessel wall. Intra Retinal Microvascular Abnormalities (IRMA) - are arteriolar-venular shunts that run from retinal arterioles to venules, thus bypassing the capillary bed and are therefore often seen adjacent to areas of marked capillary hypo perfusion.

Preproliferative Diabetic Retinopathy Ischemic changes superimposed on background diabetic retinopathy produce a preproliferative DR. PDR is characterized by neovascularisation on or within one disc diameter of the disc (NVD) and/or new vessels elsewhere (NVE) in the fundus.


Diabetic macular oedema Diabetic maculopathy (foveal oedema, exudates or ischaemia)is the most common cause of visual impairment in diabetic patients, particularly type 2.

Diffuse retinaloedema is caused by extensive capillary leakage, andlocalized oedema by focal leakage from microaneurysms and dilated capillary segments.

Advanced diabetic eye disease Haemorrhage may be preretinal (retrohyaloid, intragel or both. Intragel haemorrhages usually take longer to clear than preretinal haemorrhages because the former are usually the result of a more extensive bleed. Tractional retinal detachment is caused by progressive contraction of fibrovascular membranes over areas of vitreoretinal attachment. Rubeosis iridis (iris neovascularization) may occur in eyes with PDR, and if severe may lead to neovascular glaucoma.


Laboratory investigations - Blood sugar levels (HbA1C), Lipid profile


Ophthalmological investigations Visual acuity Fundus examination – Ophthalmoscopy, slit lamp biomicroscopy, fundus photography Fundus fluorescein angiography(FA) Optical Coherence tomography (OCT)


Ayurvedic Management

a)Control of the primary disease (Prameha chikitsa) is a quintessential step in prevention, delaying the progression and in treatment of DR.

b) In presence of active retinal or vitreous haemorrhage, attempt should be made to control the haemorrhage. •Sirolepa, mukhalepa, and vidalaka with seetha dravyas like chandana, lodhra, yashtimadhu,usheera, amalaki etc. •Pratimarsa with Durva swarasa and ajaksheera •Sekam with ajaksheera processed with raktapittasamana dravyas like yashti, chandana, lodhra, manjishta etc. •Chandanadi varthi may be made in to Aschyotana form with ajaksheera •Internal administration of rakthapittasamana drugs like vasaguloochyadi kashya,Dura swarasa, laksha gulgulu gilika etc. must be considered. •Virechana with avipathi choorna

c) In presence of macular oedema •Sirolepa, mukhalepa should be done with sophasamana dravyas like dasamoola •Sophasamana vidalakas with mukkadi •Takradhara •Internal administration of dasmoolam ksahyam, punarnavadi kashyam,Ardhavilwam kashyam, chandraprbha gulika etc. •Virechana with erandataila

d) After the management of acute haemorrhage and macular oedema resort to the classical line of netra chikitsa- •Ghritapana- Triphala ghrita, Mahatripahala ghrita, Padoladighrita •Virechana – Erandataila and ksheera •Nasya – Durvaswarasa and ajaksheera •Takradhara •Anjana – Pasupatha varthi/ chandanadi varti+ honey •Tarpana may be done with jeevaniya ghritam, satahwadi ghritam or durvaghritam only after remission of macular oedema, exudates and haemoerrhages to a considerable extent •Putapakam may be done with jeevaniyagana dravyas and ajamamsa.


Charakaacharya has emphasized that bahudrava sleshma is dosha vishesha in prameha. Because of the similarity in gunas it first vitiates medo dhatu followed by the dushti of kleda, sweda, rasa and mamsa dhatus. In the next stage there is dushti of pitta dosha and rakta dhatu. In the final stage dhatu ksheenata creates vayu kopa which in turn vitiates vasa and majja dhatus. The same involvement of doshas can be seen in pathogenesis and progression of Diabetic Retinopathy. Thus it may be observed that dosha predominance varies from kapha to pitta and then to vata in successive stages of Diabetic Retinopathy. Mainly kaphaadhika thridosha kopa is seen in Back ground or early DR, Pitta raktaadhika in Pre Proliferative and Proliferative DR and Vataadhika in Advanced DR though there is involvement of all doshas and rakta in all stages.

Therefore to conclude the treatment should be a logical combination of vatanulomana, kapha-pitta-rakta samana, prameha chikitsa,urdhwagaraktapitta chikitsa, thimira chikitsa and abhishyanda chikitsa.