Timira with special reference to cataract and its prevention & ayurvedic mangement

Timira with special reference to cataract and its prevention & ayurvedic mangement

1. SENILE CATARACT & ITS MANAGEMENT 1

2. INTRODUCTION ANATOMY OF LENS APPLIED PHYSIOLOGY CATARACTOGENESIS SENILE CATARACT CLASSIFICATION OF CATARACT MANAGEMENT OF CATARACT COMPLICATIONS OF CATARACT CONTENTS INTRODUCTION TO TIMIRA NIDANA & SAMPRAPTI LAKSHANAS OF TIMIRA SADHYASADHYATA CHIKITSA PREVENTIVE MEASURES DISCUSSION CONCLUSION REFERENCES 2

3. INTRODUCTION Cataract is one of the common eye disorders encountered in ophthalmological practice, which is caused due to degeneration and opacification of crystalline lens. Clinical features range from mild diminution of vision to loss of vision until only perception of light remains, as the opacification proceeds further until the entire lens is involved. Cataract is responsible for 50% of blindness in the world. It affects 12 to 15 million persons predominantly adults world wide. In India, approximately 38 million persons become blind from cataract each year. Timely management is essential to prevent subsequent blindness caused due to it. 3

4. The word cataract is derived from the Greek word ‘ katarraktes ’ which means ‘waterfall'. The view of the objects is similar to that, seen through a waterfall or a water droplet due to clouding of the lens. 4

5. ANATOMY OF LENS Transparent Biconvex Crystalline structure Placed between iris and the vitreous Diameter is 9-10 mm Thickness varies with age; At birth : 3.5 mm At extreme of age 5 mm weight varies from: 135 mg (0-9 years) to 255 mg ( 40-80 years of age) It has got two surfaces: Anterior surface Posterior surface 5

6. 1.Lens capsule 2.Anterior epithelium 3.Lens fibers i.Nucleus ii.Cortex 4.Suspensory ligaments of lens i.Anterior fibers ii.Middle group of fibers iii.Posterior fibers STRUCTURE OF LENS 6

7. The crystalline lens is a transparent structure playing main role in the focusing mechanism for vision. Its physiological aspects include : i . Lens transparency ii. Metabolic activities of the lens iii. Accommodation The eye works in the same principle as that of a camera. APPLIED PHYSIOLOGY 7

8. i . Avascularity ii. Tightly-packed nature of lens cells iii. The arrangement of lens proteins iv. Semipermeable character of lens capsule v. Pump mechanism of lens fiber membranes that regulate the electrolyte and water balance in the lens maintaining relative dehydration Lens transparency 8

9. Chemical composition of the lens vis -a- vis aqueous humour and the chemical exchange (pump-leak mechanism) between them. Values are in m moles/kg of lens water unless otherwise stated. Metabolism 9

10. The term cataract is used to mean the occurrence of an optical discontinuity in the lens of such magnitude as to cause a noticeable dispersion of light. Factors responsible for lens opacification : i . Hydration ii. Denaturation of lens proteins iii. Slow sclerosis . CATARACTOGENESIS 10

11. CLASSIFICATION OF CATARACT MORPHOLOGICAL ETIOLOGICAL CONGENITAL OR DEVELOPMENTAL ACQUIRED CATARACT 1.Capsular cataract 2.Subcapsular cataract 3.Cortical cataract 4.Supranuclear cataract 5.Nuclear cataract 6.Polar cataract 1.Senile cataract 2. Traumatic cataract 3. Complicated cataract 4.Metabolic cataract 5.Electric cataract 6.Radiational cataract 7.Toxic cataract 8.Dermatogenic cataract 9.Cataract associated with osseous diseases 10.Miscellaneous syndrome associated cataract. 11

12. ACQUIRED CATARACT i . In acquired cataract, opacification occurs due to degeneration of the already formed normal fibres . ii. In general any factor, physical, chemical or biological, which disturbs the critical intra and extracellular equilibrium of water and electrolytes or deranges the colloid system within the lens fibres , tends to bring about opacification . 12

13. SENILE CATARACT Also called as ‘age-related cataract’, this is the commonest type of acquired cataract affecting equally persons of either sex usually above the age of 50 years. Senile cataract is almost universal in varying degrees in persons over 70 years of age. It affects 12 to 15 million persons worldwide. The condition is usually bilateral, but almost always one eye is affected earlier than the other. Types: i . Cortical senile cataract ii. Nuclear senile cataract 13

14. Smoking Steroids Dietary factors 14

15. With increasing age (Senility) Decrease in the function Of active transport pump Mechanism of lens Reduced oxidative reactions Reversal of Na+/K+ ratio Decreased level of amino acids Hydration of the lens fibers Decreased synthesis of Proteins in lens fibers Denaturation of lens protein Opacification of cortical lens fibers PATHOGENESIS 15

16. 16 DIABETIC CATARACT

17. Anterior subcapsular cataract lies directly under the lens capsule and is associated with fibrous metaplasia of the lens epithelium. Posterior subcapsular cataract lies just in front of the posterior capsule and manifests a vacuolated granular appearance on oblique slit-lamp biomicroscopy and appears black on retroillumination . Subcapsular cataract 17

18. Starts as an exaggeration of the normal ageing changes involving the lens nucleus. often associated with myopia due to an increase in the refractive index of the nucleus The nucleus appears yellowish due to deposition of urochrome pigment in early stages. Later it changes to brown . Such cataracts are of hard consistency. Nuclear cataract 18

19. Cortical cataract may involve the anterior, posterior or equatorial cortex. The opacities start as clefts and vacuoles between lens fibres due to hydration of the cortex.(Stage of lamellar separation) Subsequent opacification results in typical cuneiform or radial spoke-like opacities(incipient cataract) Cortical cataract 19

20. CATARACT MATURITY Immature cataract is one in which the lens is partially opaque. Mature cataract is one in which the lens is completely opaque. 20

21. Hypermature cataract has a shrunken and wrinkled anterior capsule due to leakage of water out of lens. Morgagnian cataract is a hypermature cataract in which liquefaction of the cortex has allowed the nucleus to sink inferiorly. 21

22. It is uncommon It is characterized by striking, polychromatic, needle-like deposits in the deep cortex and nucleus. which may be solitary or associated with other opacities. Christmas tree cataract 22

23. CLINICAL FEATURES Coloured halos Symptoms Glare or intolerance to bright light Uniocular polyopia Black spots Image blur, distortion of images and misty vision Loss of vision 23

24. Signs Visual acuity testing : Depending upon the location and maturation of cataract, visual acuity ranges from 6/9-PL+. Test for iris shadow . 24

25. Distant direct ophthalmoscopic examination : A reddish yellow fundal glow is observed in the absence of any opacity in the media. Slit lamp examination : Grading of nuclear hardness, size, shape, colour pattern. 25

26. Grade of hardness Description of Hardness Colour of nucleus Grade I Soft White or greenish yellow Grade II Soft-medium Yellowish Grade III Medium-hard Amber Grade IV Hard Brownish Grade V Ultra hard (rock-hard) Blackish Grading of nucleus hardness on slit-lamp biomicroscopy 26

27. Slit-lamp biomicroscopic grading of cataractous lens 27

28. 28 COMPLICATIONS OF CATARACT Subluxation or dislocation of the lens Phacoanaphylatic uvietis Lens induced glaucoma

29. MANAGEMENT OF CATARACT Treatment of cataract essentially consists of its surgical removal. 29

30. INDICATIONS OF SURGERY: 1.For visual improvement. 2.Medical indications: i . Lens induced glaucoma ii. Phacoanaphylatic endophthalmitis iii. Retinal diseases. 3.Cosmetic indications. 30

31. PREOPERATIVE EVALUATION 1.General medical evaluation of the patient 2.Ocular examination i . Visual status assessment ii. Examination of pupil 3.Anterior segment evaluation 4.Intra ocular pressure(IOP) 5.Examination of lids, conjunctiva and lacrimal apparatus 6.Fundus examination 7.Macular function tests 8.Objective test for evaluating retina 9.Keratometry and biometry 31

32. PREOPERATIVE MEDICATIONS AND PREPARATIONS 1.Consent 2.Scrub bath, care of hair and marking of the eye 3.Preoperative antibiotics and disinfectants 4.IOP lowering 5.Mydriasis ANAESTHESIA 1.Cataract extraction can be performed under general or local anesthesia. 2.Local anesthesia is preferred whenever possible. 32

33. TYPES OF SURGICAL TECHNIQUES 1.Intracapsular cataract extraction (ICCE) 2.Extracapsular cataract extraction (ECCE): Different techniques of ECCE are :Conventional ECCE Manual SICS Phacoemulsification “Conventional large incision ECCE, though still being performed by many surgeons, is being largely replaced by small incision cataract surgery (SICS) and phacoemulsification techniques” 33

34. MANUAL SMALL INCISION CATARACT SURGERY Anterior chamber is entered b) capsulorrhexis c) prolapse of nucleus into anterior chamber d) expression of nucleus (e) cortical cleanup (f) IOL in place 34

35. PHACOEMULSIFICATION (a) Corneal incision (b) capsulorrhexis (c) hydrodissection (d) nucleus is grooved (e) nucleus is cracked (f) each nuclear quadrant is emulsified and aspirated 35

36. a)Cortical lens matter is pulled centrally and aspirated (b) viscoelastic is injected into the capsular bag (c) incision is enlarged (d) IOL is inserted (e) IOL is dialled (f) sideports are hydrated 36

37. 37 POSTOPERATIVE MANAGEMENT AFTER CATARACT OPERATION 1.The patient is asked to lie quietly upon the back for about three hours and advised to take nil orally. 2. For mild to moderate postoperative pain injection diclofenac sodium may be given. 3. Next morning bandage is removed and eye is inspected for any postoperative complication. 4. Antibiotic-steroid eye drops are used for four times, three times, two times and then once a day for 2 weeks each. 5. Final spectacles are prescribed after about 8 weeks of operation.

38. COMPLICATIONS OF CATARACT SURGERY Corneal oedema Postoperative endophthalmitis Uveitis Posterior capsular opacification Cystoid macular oedema IOL Dislocation 38

39. PCO (Posterior capsular opacification ) or AFTER CATARA C T 39

40. INTRODUCTION TO TIMIRA Timira is one among the Drishtigata rogas mentioned in Ayurvedic classics and is derived as timi kledane aardri bhava : iti yavat :, which means increased moisture in the visual apparatus . Kacha and linganasha are the successive stages of timira where in the patient experiences blurred vision and other visual disturbances and if timira is not treated properly gradually it leads to kacha and neglecting kacha will end up in linganasha (Complete loss of vision). 40

41. SAMANYA NIDANA Ushnabhi taptasya Jalapraveshat Kopa Samrodhana Swapna viparyaya Shoka 41 Angni suryadi tejasam avalokanat

42. Dhooma nishevana Abighata Kulatha Masha Pitta prakopaka ahara Amla ahara Madhyapana Katu ahara 42

43. SAMPRAPTI OF TIMIRA Achakshushya nidana Vitiation of doshas with predominance of pitta Urdhwagamana of doshas through siras Sthanasamsraya of doshas in patalas of drishti Timira 43 (Ah.Ut.8.1-2)

44. TIMIRA LAKSHANAS Prathama patala gata timira सिराभिरभिसम्प्राप्य विगुणो आभ्यन्थरे भृशम् | प्रथमे पटले दोषो यस्य दृष्टौ व्यवस्थितः ||६|| अव्यक्तानि स रूपाणि सर्वाण्येव प्रपश्यति |७| (Su.Ut.7.6) Doshas when aggravated , travel through the siras and get localised in the Prathama patala . Person sees all objects hazy. 44

45. Dwiteeya patala gata timira दृष्टिर्भृशं विह्वलति द्वितीयं पटलं गते || मक्षिका मशकान् केशाञ्जालकानि च पश्यति | मण्डलानि पताकांश्च मरीचीः कुण्डलानि च | परिप्लवांश्च विविधान् वर्षमभ्रं तमांसि च | दूरस्थान्यपि रूपाणि मन्यते च समीपतः || समीपस्थानि दूरे च दृष्टेर्गोचरविभ्रमात् | यत्नवानपि चात्यर्थं सूचीपाशं न पश्यति || (Su.Ut.7.7) 45

46. When doshas invade the second patala vision becomes deranged. The person sees flies, mosquitoes, hairs, net, circles, flags, miraze , rings, different movements of stars, rain from the sky and darkness. 46

47. The person will not be able to see hole of the needle though makes great efforts. 47

48. Thritheeya patalagata timira ऊर्ध्वं पश्यति नाधस्तात्तृतीयं पटलं गते | महान्त्यपि च रूपाणि च्छादितानीव वाससा || कर्णनासाक्षियुक्तानि विपरीतानि वीक्षते | यथादोषं च रज्येत दृष्टिर्दोषे बलीयसि || अधःस्थिते समीपस्थं दूरस्थं चोपरिस्थिते | सन्ज्ञा पार्श्वस्थिते तथा दोषे पार्श्वस्थानि न पश्यति || समन्ततः स्थिते दोषे सङ्कुलानीव पश्यति | दृष्टिमध्यगते दोषे स एकं मन्यते द्विधा || द्विधास्थिते त्रिधा पश्येद्बहुधा चानवस्थिते | तिमिराख्यः स वै दोषः... | (Su.Ut.7.11) Dalhana . रागप्राप्तस्य च तिमिरस्य काच इति सन्ज्ञ || 48

49. When localised at all places he sees objects as through combined, when localised in the centre, he finds one object as two, two objects as three. 49

50. When doshas are moving from place to place he sees one object as many. 50

51. Chathurtha patalagata timira …………………….. चतुर्थं पटलं गतः || रुणद्धि सर्वतो दृष्टिं लिङ्गनाशः स उच्यते | तस्मिन्नपि तमोभूते नातिरूढे महागदे || चन्द्रादित्यौ सनक्षत्रावन्तरीक्षे च विद्युतः | निर्मलानि च तेजांसि भ्राजिष्णूनि च पश्यति || 51 (Su.Ut.7.15)

52. When the doshas invade the fourth layer they obstruct the sight totally. This disease is called Linganasha , in this disease tamas (darkness) envelops the person but still is able to see the moon, sun, stars, lightings etc. This linganasha is also known as Neelika and Kacha . 52 In kaphaja lingansaha ( mature cataract) the drishti mandala becomes thick, smooth, white like shanka , indu , looks like water droplet on leaf of lotus.

53. S adhyasadhyata Timira which is situated in the P rat hama patala and has not produced discoloration is curable . Situated in the dwiteeya patala and w h ich has become coloured is curable with difficulty. Timira of the third patala is said to be relievable only. Kaphaja linganasha is Shasthra sadhya अरागि तिमिरं साध्यमाद्यं पटलमाश्रितम् | कृच्छ्रं द्वितीये रागि स्यात्तृतीये याप्यमुच्यते|| (Su.Ut.17.53) 53

54. SAMANYA CHIKITSA OF TIMIRA दोषानुरोधेन च नैकशस्तं स्नेहास्रविस्रवणरेकनस्यैः| उपाचरेदञ्जनमूर्धबस्तिबस्तिक्रियातर्पणलेपसेकैः||४७|| Snehana Rakta mokshana Virechana Nasya Anjana Murdha basti B asti kriya Lepa Seka These therapies administered many times, suitable to the doshas is the mode of treatment 54 (Ah.Ut.13.47)

55. SL.No Dosha Drugs for virechana 1 Vataja timira Eranda taila with milk 2 Pittaja timira Go ghrita with milk Sarkara , ela , Trivrt churna with madhu 3 Kaphaja timira Kashaya prepared from Trivrt Puga , Abhaya , Shunti , Pippali , Trivrt and dantibija (A.S.Ut.16.19) VIRECHANA AUSHADHA CHIKITSA 55

56. SL.NO Dosha Drug compounds for Nasya 1 Vataja timira Anutaila 2 Pittaja timira Madhura ganasiddha ghrita of goat/sheep’s milk 3 Raktaja timira Madhura ganasiddha taila , Anutaila 4 Kaphaja timira Karanja katphaladi taila NASYA 56

57. Anjanas Yogas Ghrita Yogas Bhaskara churna Timirantakanjana Tuttanjana Aksha beejadi gutikanjana Vimalavarti Sukavati varti Chandrodaya varti Jeevanthyadi Ghrita Patoladhya Ghrita Triphala Ghrita Mahatriphala Ghrita ANJANA & GHRITA YOGA’S 57

58. 58 सुजातं – Fully ripened or matured cataract नि: प्रेक्ष्यम् - Complete loss of vision कफोत्भवं – which is of kapha origin Uncomplicated cataract - following Six complications of Kaphaja linganasha are to be avoided before surgical intervention: a. Avaratki : Pupillary circle appears like whirlpool, hyper- reactive, of reddish white colour . b. Sharkara : Where linganasha -cataract appears like that of coagulated milk. INDICATION OF KAPHAJA LINGANASHA SHASTRA KARMA (Su.Ut.17.56)

59. 59 c. Rajimati : When cataract’s anterior surface is seen with linings. d. Chhinanshuka : Pupil is irregular, with tears, charred coloured and painful. e. Chandraki : Pupillary area reflects off- white color and its shape is like that of moon. f. Chhatrki :The pupillary area (Cataract) is multicolored like that of mushroom.

60. 60 CONTRAINDICATIONS Related to cataract ( Kaphaja Linganasha ) Pupillary Appearance: अर्धेन्दु - Half moon shaped pupil-posterior subluxated lens घर्माम्भु - Drop of sweat-anterior dislocation of lens बिन्दु मुक्ताकृति - Pearl shaped- shrinked lens स्थिरा – Hard cataract विषम - Irregular shaped राजीमान - Having streaks-calcified तनु मध्ये - Thin from the centre. बहुप्रभ – Multicolored सरुजो सलोहित: - Painful or red eye असञ्जात - Immature cataract. (Su.Ut.17.55)

61. 61 B) Related to patient: Those patients who are contraindicated for सिराव्यध . Suffering from: Thrishna Kasa Peenasa Ajeerna Vamana diseases of Karna , akshi,shira who is bheeru .

62. SHASTRA KARMA Purvakarma –In a weather which is neither too hot nor too cold ( नात्युष्णशीत) , the patient is s ubjected to oleation and sudation (स्निग्धस्विन्न) . Pradhanakarma - Patient comforted with good food, made to Sit in a place with good light in the morning, held tight by attendants. Physician sitting on a seat which is of knee height, should ask the patient to fix his gaze towards his own nose continuously.(स्व नासां पश्यत) 62 (Su.Ut.17.57)

63. 63 Surgeon should hold a barley-shaped salaka instrument. (यववक्त्राय शालक) Instrument should be h e ld be t ween thumb, middle finger and ind e x finger of his right hand. Puncture the eye ball towards the temporal canthus avoiding two parts of the white of the eye from cornea. (शुक्लभागौ द्वौ कृष्णानमुक्त्वा ह्यपान्गता ) ( Vaghbhata - कृष्णात् अर्धाङ्गुलम् मुक्त्वा तथा अर्धार्धं अपाङ्गत : - Leaving half angula of space from the border of black portion and quarter angula from the outer canthus )

64. The puncture should be made neither too high nor too low,nor at the sides and saving the network of veins it should then be directed towards the natural orif i ce. (नाधौ नोर्ध्वम् न पार्श्वाभ्यां छिद्रे दैवकृते तत:) Surge o n should operate with his right hand on the left eye and with his left hand on the right eye (दक्षिणेन भिषक स्वव्यं विध्येत् सव्येन चेतरेत्) 64

65. Proper puncturing is recognised by the production of a typical sound and by the out-flow of a drop of liquid. (aqueous humor) E ye should be irrigated with human milk and fomented with vata- hara leaves irrespective of dosha being stable or mobile. (संसिच्य विद्धमात्रं तु योषित्स्तन्येन कोविद:| स्थिरे दोषे चले वापि स्वेदयेदक्षि बाह्यत:) Lens should be punctured and scraped with the point of shalaka (शलकग्रेण तु ततो निर्लिखेदृष्टिमण्डलं) Patient should be made to blow out violently the kapha accumulated in the lens after closing the nostril of the opposite side. ( विध्यतो योअन्यपार्श्वे अक्ष्णस्तं रुध्दवा नासिका पुटं|| उच्छिङ्नेन हर्तव्यो द्रुष्टिमण्डल: कफ:) 65

66. 66 SAMYAK LIKHITA LAKSHANA When the drsti becomes as bright as the sun in a cloudless sky. When there is no pain, it should be regarded as properly scraped In a case of failure to expel the doshas or in case the doshas reappear therein, the whole process from oleation to puncturing should be repeated.

67. PASCHAT KARMA When the patient is able to visualise objects shalaka should be withdrawn. eye should be lubricated with ghrita and bandaged with cloth. Patient should lie down in supine position, in room free from disturbing agencies like dust, smoke , blasts of wind, sun etc Avoid Udgara , kasa , kshavathu , Shteevana , utkampana . Should follow the regimen prescribed for snehapana . 67 (Su.Ut.17.69)

68. 68 Every 3 rd day the eye should be washed with the Vata -all eviating decoctions . The eye should be fomented from 3 rd day onwards to avoid the danger of vata vitiation and this is followed for 10 days . Bandage should removed on 7 th day. Measures to improve the vision along with light diet. Avoid seeing minute and brilliant objects suddenly.

69. COMPLICATIONS OF SHASTRA KARMA राग: शोफो अर्बुदं चोषो बुद्बुदं शूकरक्षित || अधिमान्थादयश्चान्ये रोगा: स्युर्व्यधदोषजा: || अहिताचरतो वा अपि यथास्वम् तानुपाचरेत् || Redness Inflammation New growths Sucking pain Bubble like projections Squint Glaucoma 69 (Su.Ut.17.85)

70. 70 MANAGEMENT OF COMPLICATIONS Lepa on eye : 1.Durva, yava , gairika and sariva paste with ghee. 2.Sarshapa and tila macerated with the juice of matulunga . 3.Kheeraparni, sariva , tejapatra , manjishta,madhuyasti with goats milk. (AH.Ut.14.24 & 25) 2. Seka 1. Goats milk boiled with rodhra , saindhava , mrudvika and madhuka 2. Madhuka , utpala , kushta , draksha , laksha , and sita (AH.Ut.14.26 & 27)

71. PREVENTIVE MEASURES FOR CATARACT घृतं पुराणां त्रिफलं शतावरीं पटोलमुद्गमलकं यवानापि || निषेवमाणस्य नरस्य यत्नतो भयं सुधोरात्तिमिरन्न विध्यते || (Su.Ut.17.47) The peron who is (regularly) in the habit of taking Purana g hrita Triphala S h atavari Patola Mudga Amalaka Yava has no reason to fear about Timira 71

72. शतवरीपायसा एव केवलस्तथा कृतोवामालाकेषु पायस: || प्रभुतसर्पिस्त्रिफलोदकोत्तरे यवौदनो व तिमिरं व्यपोहति || (Su.Ut.17.48) Payasa prepared from: S h atavari Amalaki Y avodana cooked with sufficient quantity of g hrita and Triphala kashaya prevent Timira Prophylactic diet for cataract 72

73. 73 Eye wash Palming Prophylactic regimen for Timira (Gadadanigraha.3.363)

74. दोषोदयो नैव च विप्लुतिं गते द्रव्याणि नस्यदिषु योजयेत् बुधः || पुनश्च कल्पे अञ्जनविस्तर: शुभ:प्रवक्ष्यते अन्यस्तमपीह योजयेत् || When the symptoms of the vitiated doshas have just manifested but have not involved in the whole eye,Wise physician should treat them by Nasya with proper combination of drugs. Ben i ficial Anjana Treatment of early stage of timira 74 (Su.Ut.17.47)

75. HITA VIHARAS Chatra dharana Use foot-wear (Padatradharana) Not to gaze at sun Not to look at shinning object 75 Massage to soles (Padabhyanga)

76. HITA AHARA Matsyakshi ( Alternanthera sessilis ) Madhu (Honey ) Dadima (Pomegranate) Draksha (Grapes) Ksheera (Milk) Shigru ( Drum stick) 76 (Y.R.Netraroga.428-430 )

77. Ghrita (Ghee) Saindhava (Rock Salt) Mudga ( Mung Dal ) Patola Godhuma (Wheat) Rakta shali (Red rice) 77

78. Excessive exposure to sunlight, alcohol, smoking and dietary factors are the common etiological factors found in both cataract and timira . Hydration is one of the factors involved in catarctogenissis which is seen even in timira ( timi kledane aardri bhava ) Gradual painless loss of vision depending on different stages of maturity and visual disturbances like misty vision, polyopia , black spots in front of the eyes are common symptoms found in both of these diseases . DISCUSSION 78

79. Kaphaja linganasha shastra chikitsa resembles extra capsular small incision cataract surgery. Puncturing at daivikrita chhidra leaving 2 parts from the cornea shows that it is a very small, temporal scleral incision. Scraping the lens is similar to anterior capsulotomy . Blowing the nose by closing the opposite nostril was the method adopted to remove the cortical matter . 79

80. 80 Daivakrita Chhidra (Key hole) which is the junction of medial 2/3rd and lateral 1/3rd of the area between limbus and outer canthus in interpalpebral spaces,should be 6mm from limbus in temporal interpalpebral area and it corresponds with pars plana , the site which is least vascular and devoid of retinal tissue and also preferred site for intra ocular (posterior segment) approach to the eye ball. (A comprehensive review of Cataract ( Kaphaja Linganasha ) and its Surgical Treatment in Ayurvedic Literature K. S. Dhiman*, Kamini Dhiman**, Samita Puri***, Deepak Ahuja***)

81. Postoperative care mentioned in Ayurvedic classics like avoiding prone position, sneezing, coughing is similar to postoperative care of cataract surgery. Detailed description regarding selection of patient , preoperative, operative, postoperative procedures and management of complications in Ayurvedic classics shows systematic approach of ancient surgeons and also utmost care taken during surgery. PCO is one of the complications of cataract surgery and reappearance of doshas (after cataract) has been mentioned in Ayurvedic classics an account of murdhabhighata , vyayama , vyavaya , vamana , murchana , kopa and also when an immature cataract is pierced. 81

82. Complications of cataract surgery are many, which gives a scope for pharmacological intervention for prevention. Acharya Shusruta has stressed upon early management of Timira , so that the severity of the disease can be avoided. Various types of ahara and vihara mentioned for prevention of timira are available in our classics. Vitamin A, C, E, beta carotene, flavonoids and minerals like zinc present in chakshushya ahara have antioxidant activity, act as free radical scavengers and therefore prevent degeneration of lens fibres . 82

83. 82 Anticataract activity of herbal drugs like amalaki , triphala,vasa , shigru,guduchi,haridra , tulasi,palandu etc, due to antioxidant potential of their phytoconstituents , has been proved in many of the research works. Chief among them is triphala,which is chakshushya and has been indicated in Timira in various forms. Triphala is rich in polyphenols and tannins. By converting reactive oxygen free radicals to non-reactive products, polyphenolic contents in triphala are responsible for the antioxidant and radioprotection ability. (journal of pharmacognosy and phytochemisry,Pharmacological and therapeutic effects of triphala –A literature review-- Neethu S Kumar, Arun S Nair, Anju M Nair, Megha Murali)

84. CONCLUSION Cataract is the major cause of global blindness which can be prevented. Prevention can be achieved at different stages i . Primary prevention – Prevention of cataract occurring in the first place. ii. Secondary prevention – Prevention of vision loss after the occurrence of cataract, which includes, arresting progression of cataractogenesis to prevent further vision loss and timely surgery if the maturity has already occurred, for better vision and to avoid complications of hypermaturity . 84

85. Though the surgery is now safe and successful in the large majority of cases, it is not without its inherent problems and potential complications. Prophylactic measures for timira mentioned in Ayurvedic classics along with nidana parivarjana and suitable kriyakalpas will prevent age related eye diseases like cataract and will also delay its progression. These measures will contribute to reduction in percentage of global blindness and achievement of vision 20-20. 85

86. REFERENCES Anatomy and physiology of eye- A.K.Khurana Kanski clinical opthalmology Parsons diseases of the eye Text book of opthalmology - Dr.Santhakumari The shalakya tantra - Dr.Dingari lakshmana Text book of Shalakya tantra-Dr.Udaya shankar Ashtanga Hrudaya uthara sthana Susruta Samhita uttara tantra Yogaratnakara webmed.com wikipedia.com Youtube.com 86

87. 87