Navya D P 2012

A COMPARATIVE STUDY ON THE EFFICACY OF PIPPALYADYA

ANJANA AND SHATAVARYADI CHURNA ABHYANTARA IN THE

MANAGEMENT OF ARMA”

By

Dr. Navya.D.P.

A dissertation submitted to the Rajiv Gandhi University of Health Sciences, Bangalore,

for the partial fulfillment of Degree

AYURVEDA DHANVANTARI

M.S. (SHALAKYA TANTRA)

Under the guidance of

Dr. B N Ramesh, M.D. (Ayu) (Shalakya)

Professor and HOD, Department of Post Graduate Studies in Shalakya Tantra, Government Ayurvedic Medical College, Bangalore.

DEPARTMENT OF POST GRADUATE STUDIES IN SHALAKYA TANTRA

GOVERNMENT AYURVEDIC MEDICAL COLLEGE DHANWANTRI ROAD, BANGALORE – 560 009

2011-2012

GOVERNMENT AYURVEDIC MEDICAL COLLEGE DEPARTMENT OF POST GRADUATE STUDIES IN SHALAKYA TANTRA

Dhanwantri Road, Bangalore – 560 009

CERTIFICATE BY THE GUIDE

This is to certify that the dissertation entitled “A COMPARATIVE STUDY

ON THE EFFICACY OF PIPPALYADYA ANJANA AND

SHATAVARYADI CHURNA ABHYANTRA IN THE MANAGEMENT

OF ARMA” submitted by Dr.Navya.D.P, for the degree of Ayurveda

Dhanvantari – M.S. (Shalakya Tantra) of the Rajiv Gandhi University of

Health Sciences, Bangalore, is a record of research work done by her under

my guidance and supervision during the period of the study in our department.

This dissertation has not previously formed the basis for the award of any

degree, diploma, associateship, fellowship or other similar titles.

I am recommending this dissertation for the above degree to the University

Assessment and approval.

Dr. B N Ramesh, M.D. (Ayu) (Shalakya)

Professor and HOD

Department of Postgraduate Studies in Shalakya Tantra,

Government Ayurvedic Medical College, Bangalore.

Date:

Place: Bangalore

GOVERNMENT AYURVEDIC MEDICAL COLLEGE DEPARTMENT OF POST GRADUATE STUDIES IN SHALAKYA TANTRA

Dhanwantri Road, Bangalore – 560 009

ENDORSEMENT BY THE HOD & PRINCIPAL

This is to certify that the dissertation entitled is “A COMPARATIVE

STUDY ON THE EFFICACY OF PIPPALYADYA ANJANA AND


OF ARMA” is a bonafide and genuine research work done by Dr.Navya.D.P

under the guidance of Dr. B N Ramesh, M.D. (Ayu) (Shalakya), Professor and

HOD, Department of Post Graduate Studies in Shalakya Tantra, Government

Ayurvedic Medical College, Bangalore.

Dr. B.N. Ramesh, M.D. (Ayu)

Professor and HOD,

Department of P.G.studies,

Shalakya Tantra,

Government Ayurvedic Medical college,

Bangalore.

Principal,

Government Ayurvedic Medical College,

Bangalore

Date:

Place: Bangalore

Date:

Place: Bangalore

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES

BANGALORE, KARNATAKA

DECLARATION BY THE CANDIDATE

I hereby declare that this dissertation entitled is “A COMPARATIVE

STUDY ON THE EFFICACY OF PIPPALYADYA ANJANA AND


OF ARMA”a bonafide and genuine research work carried out by me under

the guidance of Dr. B N Ramesh, M.D. (Ayu), Professor and HOD,

Department of Post Graduate Studies in Shalakya Tantra, Government

Ayurvedic Medical College, Bangalore.

Dr. NAVYA.D.P, B.A.M.S.

Date:

Place: Bangalore

COPYRIGHT

DECLARATION BY THE CANDIDATE

I hereby declare that the Rajiv Gandhi University of Health Sciences,

Bangalore, Karnataka shall have the rights to preserve, use and disseminate

this dissertation in print or electronic format for academic or research purpose.

Dr.NAVYA.D.P, B.A.M.S.

Date:

Place: Bangalore

© Rajiv Gandhi University of Health Sciences, Karnataka

i

Acknowledgement

I offer my prayers to Lord Ganesha and Lord Dhanwantri who enabled me to

complete the study without hassles.

Words cannot express the feelings but still they are the only medium of

expression for human beings. I would like to take this opportunity to express

my gratitude to all those who have rendered help in conducting this clinical

study and compiling this dissertation (research work).

It is with deep sense of gratitude and respect that I express my heartfelt

reverence to my guide Dr. B.N. Ramesh, M.D. (Ayu) (Shalakya) professor and

HOD, Department of P.G. Studies in Shalakya Tantra, GAMC, Bangalore for

his valuable guidance, constant encouragement, motivation, deep concern and

kind co-operation without which the work would not have been completed. I

hereby submit my thanks for all the encouragement and support given by him.

I sincerely thank Dr. H. T. Sreenivas, M.D. Principal, GAMC, Bangalore for

having provided me an opportunity to carry out this research work.

I express my heartiest gratitude to Dr. Sumitra .T. Gowda, MD (Ayu),

Professor, Department of P.G. Studies in Shalakya Tantra, GAMC, Bangalore

for her valuable timely suggestions and constant motivation.

I express my sincere gratitude to Dr. Suja. K. Sreedhar, MD (Ayu), Professor,

Department of P.G. Studies in Shalakya Tantra, GAMC, Bangalore for her

valuable suggestion and inspiration.

I express sincerely my gratitude to Dr. S. G. Mangalagi, M.D. (Ayu), and

Dr. K. Viswambhara, M.D. (Ayu) (Shalakya), GAMC, Bangalore, for their timely

suggestions and motivation throughout my study.

ii

I owe my sincere gratitude to Dr. Munnavar Pasha, MD (Ayu), Lecturer,

Department of Shalakya Tantra, GAMC, Bangalore for his constant guidance,

affection, valuable suggestions and motivation given throughout the study.

I also express my sincere gratitude to Dr. Mohan Kumari, Dr. Aravind,

Dr. Shobharani, and Dr. Rajeshwari for their valuable suggestion and

guidance throughout the work.

I acknowledge the valuable help and guidance rendered by Dr. Ashalatha,

HOD, Department of P.G. Studies in Dravyaguna, Dr. M Ramesh Professor,

Dr. Vijayasarathi, HOD, Department of P.G.Studies in Shalya tantra GAMC,

Bangalore.

I express my sincere thanks to lecturers Dr.Srilatha kamath, Dr.Nagaraj,

Dr.Narayan for their help and suggestion throughout my study.

I also express my sincere thanks to lecturers Dr.Ramya, Minto Opthalmic

Hospital for valuable suggestions and encouragement throughout my study.

I thank my seniors Dr. Suma, Dr.Veeresh, Dr. Nishitha, Dr. Manasa,

Dr. Bharati, Dr. Satish, Dr. Lokanath, Dr. Apeksha, Dr. Uma, Dr. Rekha

for their timely help.

I thank my P.G. colleagues and friends, Dr. Gayathri, Dr. Chandrashekar,

Dr. Chiranjeevi, Dr. Santosh, Dr. Vivek, Dr. Sharan, for their kind help and

co-operation throughout the work.

I also wish to thank my Junior P.G. Colleagues and friends, Dr. Akshata.

Dr.Jayashree, Dr.Sahana, Dr.Sneha, Dr.Ameena, Dr.Bhavya, Dr. Keshavan

for all the kind help and support they have given during my study.

iii

I also wish to thank my PG friends Dr.Rashmi, Dr. Vanishree, Dr. Shridhar,

Dr. Nandakaishor, Dr. Manjunath, Dr Kamlesh, Dr.Mukund, Dr. Radika S.M,

Dr. Nazira, Dr.Poornima, Dr.Sushendra, Dr.Kusum, Dr. Radika, Dr.Triveni

and all others for their support in my work.

I wish to thank my friends Dr.Pallavi.G, Dr.Swaroopa and Geetha M.S.for

their kind help and suggestions throughout my studies.

I thank my parents Mrs. Jayarathna, Mr. Puttaiah, my husband Vijay, my

brother Lokesh and family members for their love and affection, blessings and

constant moral support shown on me, which helped me to complete my study

successfully.

I thank V4U, The Print Paradise for their printing and binding work.

Last but not the least, I render my sincere thanks to all my patients, without

whose co-operation, the work would not happen.

Date:

Place: Dr. Navya.D.P.

iv

ABSTRACT

Arma is the Shuklagata roga. Arma can be correlated to Pterygium based on the

character of growth. Pterygium is a common ocular-surface disorder capable of

causing significant visual impairment & cosmetic deformity. At present surgical

treatment is the only satisfactory approach, recurrence after surgical excision is

common & recurred lesions grow more aggressively than the primary lesions. The

ayurvedic approach of the disease mainly concentrates on preventing the progression

of the disease. With this aim clinical study was undertaken.

The objectives of the study are to evaluate the efficacy of Pippalyadya anjana in the

management of Arma, to evaluate the efficacy of Shatavaryadi churna in the

management of Arma, to evaluate the efficacy of Narikela rasakriya anjana in the

management of Arma and To establish the significance of the efficacy of pippalyadya

anjana and Shatavaryadi churna by comparing it with the efficacy of Narikela

rasakriya anjana in the management of Arma, which is an established study.

In present study 45 patients were randomly selected and divided into 3 groups, with

15 patients each. Group A patients were treated with Pippalyadya Anjana for 48 days.

Group B were treated with Shatavaryadi Churna internally for 48 days and Group C

with Narikela Rasakriya Anjana for 48days.

Subjective parameters like Redness, Watering, Foreign body sensation and objective

parameters like Length and Thickness were adopted. These were suitably graded to

assess the results that were statistically analysed.

RESULTS

In the present study, Group A showed moderate response& both Group B and

Group C have shown a mild response to the treatment. The details of clinical

observations and results are discussed in the complete work presented here forth.

v

LIST OF ABBREVIATIONS

A.hru Astanga Hrudayam

A.sam Astanga Sangraha

Bh.pr Bhavaprakasha

Bhai.rat Bhaishajya Ratnavali

Ca.sam Caraka Samhita

Cha Chakradutta

Dal Dalhana

M.Ni. Madhava nidana

Su. Sushruta Samhita

Sa.y Sahasra yoga

Sha.sam Sharangadhara Samhita

Yr Yogaratnakara

Dwi.kh Dwiteeya Khanda

Ma.kh Madhyama Khanda

Pu.kh Purva Khanda

Tri.kh Triteeya Khanda

Su. Sutrasthana

Ni Nidanasthana

Sha Shareerasthana

Vi Vimanasthana

Chi Chikitsa sthana

Ut Uttarardha / Uttarasthana

Tri.sth Triteeya sthana

vi

Sl.

No.

CONTENTS Page

No. 1. INTRODUCTION 1-3

2. OBJECTIVES OF THE STUDY 4

3. REVIEW OF LITERATURE

Historical / Ayurvedic Review 5-37

Modern Review 38-60

4. DRUG REVIEW 61-78

5. PROCEDURE REVIEW 81-90

6. METHODOLOGY 91-96

7. OBSERVATIONS AND RESULTS 97-124

8. DISCUSSION 125-142

9. CONCLUSION 143-144

10. SUMMARY 145-146

11. BIBLIOGRAPHY 147-151

12. ANNEXURE 152-156

vii

LIST OF TABLES

Sl.

No. NAME OF THE TABLE

Page

No.

1. Showing Classification of Eye diseases on the basis of Adhistana 20

2. Showing Nidana of Netra vikaras according to various authors 23

3. Showing Classification of Arma 27

4. Showing Difference between True & Pseudopterygium 55

5. Showing Age Wise incidence of 45 patients 98

6. Showing Incidence of sex 99

7. Showing Religion Wise Distribution 100

8. Showing Occupation Wise Distribution 101

9. Showing Status Wise Distribution 102

10. Showing Diet Wise Distribution 103

11. Showing Place Wise Distribution 104

12. Showing Distribution of Chronicity 105

13. Showing Incidence of Nidana 106

14. Showing Incidence of Affected side of eye 107

15. Showing Incidence of Site of Arma 108

16. Showing Incidence of Different Parameters 109


18 Showing Incidence of Different Parameters 111

19 Showing Individual study of the parameters in Group A 112

20 Showing Individual study of the parameters in Group B 113

21 Showing Individual study of the parameters in Group C 115

22 Showing Comparative Study of the Overall effect of Treatment in

Group AC 116

23 Showing Comparative Study of the Overall effect of Treatment in

Group BC

118

24 Showing Comparative Study of the Overall effect of Treatment in 119

viii

Group AB

25 Showing the overall assessment of the results in the Groups 121

26 Showing the overall assessment of the treatment in Percentage 122

27 Showing the percentage of recurrence in all groups 123

LIST OF DIAGRAMS AND FIGURES

No. NAME OF THE FIGURE Page

No.

1. Showing Parts of Conjunctiva and Conjunctival glands 39

2. Showing Conjunctival fornices 41

3. Showing Microscopic structure of conjunctiva 43

4. Showing Goblet cell density in different parts of conjunctiva 45

5 I PIPPALADYA ANJANA INGREDIENTS 79

6 II SHATAVARYADI CHURNA INGREDIENTS 80

7 Procedure of Anjana karma 89

LIST OF FLOW CHARTS

Sl.

No. NAME OF THE FLOW CHART

Page

No.

1. Showing Arma samprapthi 127

2. Showing pterygium pathogensis 128

3. Showing Probable Mode of Action of Tarpana 140

ix

LIST OF CHARTS

No. NAME OF CHART Page

No.

1. Showing Age Wise incidence of 45 patients 98

2. Showing Incidence of sex 99

3. Showing Religion Wise Distribution 100

4. Showing Occupation Wise Distribution 101

5. Showing Status Wise Distribution 102

6. Showing Diet Wise Distribution 103

7. Showing Place Wise Distribution 104

8. Showing Distribution of Chronicity 105

9. Showing Incidence of Nidana 106

10. Showing Incidence of Affected side of eye 107

11. Showing Incidence of Site of Arma 108




15. Showing Individual study of the parameters in Group A 113

16. Showing Individual study of the parameters in Group B 114

17. Showing Individual study of the parameters in Group C 116

18. Showing Comparative Study of the Overall effect of Treatment in

Group AC 117


Group BC 119


Group AB 120

21. Showing the overall assessment of the results in the Groups 122

22. Showing the overall assessment of the treatment in Percentage 123

23 Showing the percentage of recurrence in all groups 124

A Study on Arma

Department of PG Studies Shalakya Tantra, GAMC, Bangalore Page 1

INTRODUCTION

It is very difficult to imagine the existence of mankind without eyesight. Thus one has

to admit the sayings - ―SARVENDRIYANAM NAYANAM PRADHANAM.‖

Eyes are the most important and beautiful among five sensory organs. It is said that

80% of the knowledge we gain is through our eyes. It is needless to mention here the

worth and praise about the eyes. Even though our eyes are one of the most important

organs in our body, people neglect to care about them and rarely pay attention until

there is some serious vision threatening problem.

Every person should try to protect his eyes throughout his life because the world is

useless since the day is as good as night for persons who are blind, though they might

possess plenty of wealth.

Arma is the Shuklagata roga, described in classical texts of Ayurveda. Clinical

features of arma are mamsavrudhi originating from Kaninika Sandhi, Apangasandhi

or from both sandhis towards the drustimandala causing loss of vision.

Disease Pterygium mentioned in modern science has its similarties with Arma based

on its site of manifestation, clinical presentation, & surgical method of management;

hence it is apt to correlate Arma with Pterygium.

Pterygium which is common ocular surface disorder characterized by triangular fold

of conjunctiva encroaching upon the cornea from either side within the interpalpebral

fissure.

A Study on Arma


In a 30-year (1971 to 2001) survey by the Cornea and External Disease Clinic of the

Department of Ophthalmology and Visual Sciences, University of the Philippines–

Philippine General Hospital (UP–PGH), Pterygium ranked eighth among the 10

leading conditions seen in the clinic and third among the most common

noninfectious conditions.

The pathogenesis of Pterygium is not fully understood. Various studies have

implicated environmental factors, such as ultraviolet light, chronic irritation. Recent

studies have also provided evidence implicating genetic components, antiapoptotic

mechanisms, cytokines, growth factors, extracellular matrix remodeling,

immunological mechanisms in the pathogenesis of the disease.

Pterygium has a moderate to high prevalence 300 above & below equator.

Pterygium is fairly common in our country, which is located within the tropics.

Basically the treatment of pterygium is surgical, but medical management can be tried

in cases where the pterygium is in early stage.

Cosmetic intolerance also forces the patient to turn towards surgical management

which is not devoid of complication.

These have only evoked passing interest in the treatment of pterygium. There is no

proper effective medical management & surgical management is the only line of

treatment in conventional system of medicine. Recurrence is commonest in either

method of treatments. Hence, these hindrances of modern science have stressed upon

the need for the study for effective measure which can cure the condition and prevent

recurrence.

Hence keeping these lacunae of modern medicine treatment for Arma, in mind this

study has been taken up.

A Study on Arma


Even with appreciable advancement in the field of medical science many ocular

problems are left out without any hopes of remedy. Under such circumstances

research in allied medical science is desired to aim at prevention, maintenance &

curative aspect of eye management.

In Ayurveda all the Acharyas have said about Lekhananjana for the treatment of

Arma which is in early stage and having thin membrane. When the growth encroaches

to Krishnamandala then it is surgically removed.

Kriyakalpas are the main mode of management in all types of nethra rogas and

Anjana is one of the simple yet very effective method of treatment in Arma. Keeping

its importance in nethra roga prevention, acharyas have adviced for regular use of

anjanas, which protects the eyes from diseases affecting especially from kapha. For

the medical management of Arma Anjanas especially Lekhnanjanas are extensively

quoted by our acharyas. Pippalyadya Anjana is also one of the lekhanajana yoga.

Pterygium is a degenerative condition. The subconjunctival tissue undergoes elastotic

degeneration and proliferates as vascularised granulation tissue, which causes the

further progression of the disease; hence use of antioxidant has received much

attention as a part of medical management. The rasayana approach provides drugs

having antioxidant activity, regenerative, adaptogenic effects etc, which may be

judiciously used to tackle degenerative problems of the eye.

Considering the above factors, in this present study an effort has been made to

evaluate the comparative efficacy of pippalyadya anjana & shatavaryadi churna

internally in the management of arma & also to evaluate its comparative effects with

Narikela Rasakriya anjana which has been established.

A Study on Arma


OBJECTIVES OF THE STUDY:

1. To evaluate the efficacy of Pippalyadya anjana in the management of Arma.

2 To evaluate the efficacy of Shatavaryadi churna internally in the management

of Arma.

3 To evaluate the efficacy of Narikela rasakriya anjana in the management of

Arma

4 To establish the significance of the efficacy of Pippalyadya anjana by

comparing it with the efficacy of Narikela rasakriya anjana in the management

of Arma, which is an established study.

5 To establish the significance of the efficacy of Shatavaryadi churna internally

by comparing it with the efficacy of Narikela rasakriya anjana in the

management of Arma, which is an established study.

A Study on Arma


HISTORICAL REVIEW: AYURVEDA

The History is the witness of the times. It tells us about the past time and how

the development and evolution of the mankind occurs. It helps to reveal hidden

facts and ideas of concerned subject. It also assists to pave pathway for future, but

these facts can be put together with structure to know what these facts are supposed to

tell us.

Description of Arma is available in detail in all Samhitas. The detailed description is

available in Sushruta samhita Uttaratantra 4th

chapter Suklagataroga Vijnaneeya

Adhyaya.

Astanga Sangraha has explanation of Arma in 13th

and 14th

chapters of Uttarasthana

and in Astanga Hridaya at 10th

and 11th

chapters of uttarasthana.

References of Arma as quoted by Acharya Nimi and Videha are compiled by Dalhana

in his commentary ‗Nibandhasangraha‘ on Sushruta samhita uttaratantra 4th

chapter.

Arma is also explained in Bhavaprakasha Madhyama Khanda 63rd

Chapter, in

Netraroga chikitsaadhikara of Yogaratnakara, Chikitsasara sangraha of Vanagasena in

71 chapter and in Gadanigraha 3rd

Chapter.

Madhavakara has explained about Arma at 59th

chapter of Madyama Kandha and

Chakrapanidatta has explained the chikitsa of Arma in Netraroga Chikitsadhyaya.

References about netra roga and its chikitsa in detail are available in Sahasrayoga and

Chikitsa manjari.

A Study on Arma


HISTORICAL REVIEW: MODERN36

Hippocrates (469BC) suggested the use of eye drops containing lead, zinc,

copper, iron, bile juices, urine & maternal milk.

Celso (50AC) & Galeno (131AC) also suggested a topical treatment with a

solution of white wine, vinegar and in more serious forms, the physical

removal.This was done by passing a thread underneath the growth & allowing

it to slide over the sclera surface with a to & fro movement as far as the medial

canthus; then when the pterygium was detached from the underlying sclera, it

was cut with scissors.

Other indications were given by Palo Egineta (660AC) and the Arab Asicenna

(1037AC) who suggested cutting the pterygium with scissors.

In 18th

century, it was fashionable to treat pterygium with copper sulphate. In

the 19th

century with silver nitrate & lead acetate & atropine was added to

encourage the healing of the associated corneal ulcer.

In 19th

century saw the advent of surgery of pterygia.

Scarp (1802) removal of the head from the cornea using forceps, section of a

portion of the body (3-4mm) & subsequent concentric excision of the detached

tissue as far as the limbus.

In 20th

century MC Reynolds (1902) who presented a modified Desmarres

technique which placed the head of the pterygium in a conjunctival pouch.

A Study on Arma


NETRA RACHANA SHAREERA

xÉuÉåïÎlSìrÉÉhÉÉÇ lÉrÉlÉÇ mÉëkÉÉlÉqÉç||

CHAKSHURENDRIYA occupies the key position among the other gyanendriyas.

The netra guhas shelter the two netras that are among the nine external openings in

the body.

Vyutpatti / Derivation of Netra:

lÉå§| - lÉÏrÉiÉå lÉrÉÌiÉ uÉÉlÉålÉåÌiÉ | CÌiÉ cÉ¤ÉÑ: || 2 ( p. 622 )

The word Netra is derived from the root ―Ni‖ which means to guide or to lead. Netra

means chakshu or visual sensory faculty which is guiding in nature.

According to Moneir Williams, the word Netra means guide, leader or eye which is

the guiding organ. 5 (P.568-569)

Chakshu-

cÉ¹å mÉvrÉirÉlÉålÉåÌiÉ | cÉ¤É + cÉ¤Éå: ÍvÉgcÉ EhÉÉÇ | CÌiÉEÍxÉ: xÉ cÉ ÍvÉiÉç |

ÍvÉiuÉÉiÉç ZrÉgÉÉSåvÉÉpÉÉuÉ: SvÉïlÉåÎlSìrÉqÉç | 2( P. 415)

The root chaksh with unadi suffix us in the absence of khyanjadesha forms the word

chakshu, meaning darshanendriya or organ of sight.

cÉ¤ÉÑxÉç – cÉ¤É – kÉÉiÉÔlÉÉqÉlÉåMüÉjÉïiuÉÉiÉç SvÉïlÉå MüUhÉå EÍxÉ | 1 (p.2842)

The term Chakshu is derived from the root ‗Chaksh‘ denoting ‗Darshana‘ (Sight) and

‗Karana‘ (Organ responsible for sight).

A Study on Arma


Nirukti / Definition:

cÉ¹å ÃmÉÇ ÃmÉuÉliÉÇ cÉ mÉëMüÉvÉrÉiÉÏÌiÉ cÉ¤ÉÑiÉgcÉÉåpÉrÉlÉrÉaÉÉåsÉMüÉÍkÉ¹ÉlÉqÉåMüqÉåuÉ|| 8(Cha.S.Su.8/ 8 p. 56)

Chakshu is that sensual faculty situated in both the eye balls, which is responsible for

vision.

Synonyms:

sÉÉåcÉlÉÇ lÉrÉlÉÇ lÉå§ÉqÉÏ¤ÉhÉÇ cÉ¤ÉÑU¤ÉÏhÉÏ|

SØaSØ¹Ï.........|| 5(sh 93 pg 235)

The other synonyms include- lochanam, nayan, akshi, druk, drishti.

EVOLUTION OF INDRIYAS

iÉ§ÉÉlÉÑqÉÉlÉaÉqrÉÉlÉÉÇ mÉgcÉqÉWûÉpÉÔiÉÌuÉMüÉU xÉqÉÑSÉrÉÉiqÉMüÉlÉÉqÉÌmÉ

xÉiÉÉÍqÉÎlSìrÉÉhÉÉÇ iÉåeÉ¶É¤ÉÑÌwÉ ..................iÉixuÉpÉÉuÉÉÌ²pÉÑiuÉÉgcÉ ||8(Cha.S.Su.8/14 P.57)

The sense faculties are to be inferred (rather than directly perceived).They consist of

five mahabhutas.However, the visual, auditory, olfactory, gustatory and tactile

faculties are specially dominated by tejas, akasha, prithvi, ap and vayu respectively.9

(p.168-69)

iÉ§É uÉæMüÉËUMüÉSWûƒ¡ûÉUÉ¨ÉæeÉxÉ xÉWûÉrÉÉ¨ÉssÉ¤ÉhÉÉlrÉåuÉ LMüÉSzÉ CÎlSìrÉÉhrÉÑimÉ±iÉå ||6(S.S.Sha.1/4 P.338)

The eleven indriyas (five organs of senses and five organs of action and mind) are

created out of vaikarika ahankara with all its qualities with the help of Taijasa

ahankara Rupa (form), rupendriya (organ of sight) are derived from the qualities of

teja mahabhuta. 6(S.S.Sha.1/4 P.338)

A Study on Arma


EMBROYLOGICAL DEVELOPMENT OF NETRA

iÉ×iÉÏrÉå qÉÉÍxÉ xÉuÉåïÎlSìrÉÉÍhÉ xÉuÉï…¡ûÉuÉrÉuÉ¶É rÉÉæaÉmÉ±ålÉÉÍpÉÌlÉuÉïiÉïiÉå| 8(Cha.S.Sha.4/11 P.318)

During the third month, all the senses and limbs along with their organs manifest

themselves simultaneously.

iÉjÉÉ MüTüU£üuÉÉÌWûlÉÉÇ xÉëÉåiÉxÉÉÇ qÉWûÉpÉÔiÉÉlÉÉÇ cÉ mÉëxÉÉSÉÌSÎlSìrÉÉÍhÉ|

iÉåwuÉÌmÉ cÉ lÉå§É zsÉåwqÉhÉÈ mÉëxÉÉSÉiÉç zÉÑYsÉqÉhQûsÉÇ iÉiÉç ÌmÉiÉ×eÉqÉç|

AxÉ×eÉÈ M×üwhÉqÉhQûsÉÇ iÉiÉçqÉÉiÉ×eÉqÉç, qÉkrÉå SØÌ¹qÉhQûsÉÇ iÉSÒpÉrÉÉiqÉMüqÉç|| 10(A.S.Sha.5/48-49 P.304)

Sense organs are formed from the channels carrying Kapha, Raktha and mahabhootas.

In eyes, Shuklamandala is formed from essence of Kapha and is a Pitruja Bhava

(Paternal in origin) while the Krishnamandala is formed from Raktha and is maternal

in origin. The middle portion, the Drushtimandala is derived from both (paternal and

maternal).

NETRA AKRITI / SHAPE:

xÉÑuÉ×¨ÉÇ aÉÉåxiÉlÉÉMüÉUÇ xÉuÉïpÉÔiÉaÉÑhÉÉå°uÉqÉç 6(S.SUt.1/11 P.596)

Eye ball is round resembles the teat of cow in appearance and originates from all the

five elements with their attributes.

NETRA PRAMANA

ÌuÉ±É²rÉ…¡ÓûsÉoÉÉWÒûsrÉÇ xuÉÉ…¡Óû¸ÉåSUxÉÇÍqÉiÉqÉç|

²rÉ…¡ÓûsÉÇ xÉuÉïiÉÈ xÉÉkÉïÇ ÍpÉwÉXçlÉrÉlÉ oÉÑ¯ÒSqÉç|| 6(S.SUt.1/10 P.596)

Taking central part of the patients own thumb as one finger unit, the eye ball

dimension should be known by clinicians which measure two finger units from before

backwards and two and half from side to side.

A Study on Arma


lÉå§É AÉrÉÉqÉÌ§ÉpÉÉaÉliÉÑ M×üwhÉqÉhQûsÉqÉÑcrÉiÉå||

M×üwhÉÉiÉç xÉmiÉqÉÍqÉcNûÎliÉ SØÌ¹Ç SØÌ¹ÌuÉzÉÉUSÉÈ|| 6(S.SUt.1/13 P.596)

Krishnamandala measures 1/3rd

of the eyeball. Dristimandala is 1/7th

of the

krishnamandala.

In Aturopakramaneeya chapter of Sushruta Samhita sutrasthana (35th

chapter)

pramana of dristi is mentioned as 1/9th

part of Krishnamandala. According to Dalhana,

pramana of Dristimandala differs from persons to mahapurusha.

CONSTITUTION OF NETRA

mÉsÉÇ pÉÑuÉÉåÅÎalÉiÉÉå U£üÇ uÉÉiÉÉiÉç M×üwhÉÇ ÍxÉiÉÇ eÉsÉÉiÉç ||

AÉMüÉvÉÉS´ÉÑqÉÉaÉÉï¶É eÉÉrÉliÉå lÉå§|oÉÑSèoÉÑSå |

SØÌ¹Ç cÉÉ§É iÉjÉÉ uÉ¤rÉå rÉjÉÉ oÉëÔrÉÉÌ²vÉÉUS: || 6(S.SUt.1/11-12 P.596)

Mamsa dhatu is made up of or originated from Prutvi mahabhuta, Rakta composed of

Agni, Krishnamandala of Vata, and Shweta mandala of Jala mahabhoota. The

Ashrumarga is composed of Akasha mahabhuta.

PARTS OF NETRA (NETRA BHAGA):-

qÉhQûsÉÉÌlÉ cÉ xÉlkÉÏÇ¶É mÉOûsÉÉÌlÉ cÉ sÉÉåcÉlÉå |

rÉjÉÉ¢üqÉÇ ÌuÉeÉÉlÉÏrÉÉiÉç mÉgcÉ wÉOè cÉ wÉQåûuÉ cÉ || 6(S.S.Ut.1/14 P.596)

Eye consists of mandalas, sandhi and patalas which are five, six and six in number

respectively.

MANDALAS:

mÉgcÉ lÉå§Éå cÉ¢üuÉSÉliÉUiÉ: qÉhQûsÉÉÌlÉ ||10 ( Indu.A.S. Sha.5/50 p.304

The consecutive circular layers of the eyes are termed as mandalas.They are 5 in

number:

A Study on Arma


mÉ¤qÉuÉiqÉïµÉåiÉM×üwhÉSØ¹ÏlÉÉÇ qÉhQûsÉÉÌlÉ iÉÑ |

AlÉÑmÉÔuÉï iÉÑ iÉå qÉkrÉÉ¶ÉiuÉÉUÉåÅlirÉÉ rÉjÉÉå¨ÉUqÉç ||6(S.S.Ut.1/15 P.596)

The mandalas are pakshma, varthma, shweta, Krishna and Dristi.Successively the four

are in the centre while in the reverse order they are in periphery.

The five mandalas are:

1. Pakshma – circle of eye lashes;

mÉ¤qÉÉÍhÉ uÉiqÉïaÉiÉ UÉåqÉqÉÉÍsÉMüÉ || 6 ( dal.S.S.Ut.16 / 2 p.624)

Pakshma is the garland of hair present in varthma.

2. Vartma – circle of eye lids;

Vartmas form two outer patalas. 6 (S.S.Ut.1/17 p.596)

iÉ§É cÉ rÉSè oÉÉ½Ç mÉOûsÉÇ iÉSÕkuÉïkÉÉåpÉåSålÉ ²å uÉiqÉïlÉÏ || 10 ( Indu.A.S. Sha.5/50 p.304)

Upper and lower eye lids jointly form two vartma (bahya) patalas.

lÉå§ÉaÉÉåsÉMüÉuÉUMüÇ ÌlÉqÉåwÉÉålqÉåwÉÉ´ÉrÉÇ mÉOûsÉ²rÉÇ uÉiqÉï EcrÉiÉå ||15 (Srikantadatta. M.K, M.N..59/76 p.317)

Vartma are the two patalas which cover the eye balls and give ashraya for nimesha

and unmesha i.e, opening and closing of eye lids.Two nimeshini siras in varthma

performs the function of nimesha and unmesha. 6 (S.S.Ut.3/25 p.600)

Vartma patala gives shelter to 21 diseases according to Sushruta.6 (su.s.ut.1/44 p.598)

and 24

diseases according to Vagbhata 11(A.H.Ut.8/25 p.706)

3. Shweta mandala- White layer of the eye; Shweta mandala is the seat of 11

diseases of the eye 6(S.S.Ut.1/44p.598)

and 13 diseases according to Vagbhata 11(A.H.Ut.10/19

p.810)

4. Krishna mandala- Krishnamandala is the portion, which lies in the centre of

shuklamandala.It is about 1/3rd

of the eyeball.

A Study on Arma


It is the seat of four eye diseases 6(S.S.Ut.1/44p.598)

and 5 diseases according to Vagbhata

11(A.H.Ut.10/31 p.611)

5. Drishti mandala –

qÉxÉÔUSsÉqÉÉ§ÉÉÇ iÉÑ mÉgcÉpÉÔiÉmÉëxÉÉSeÉqÉç |

ZÉ±ÉåiÉ ÌuÉxTÑüÍsÉXçaÉÉpÉÉÍqÉ®ÉÇ iÉåeÉÉãÍpÉUurÉrÉæ: ||

AÉuÉ×iÉÉÇ mÉOûsÉålÉÉ¤hÉÉåoÉÉï½ålÉ ÌuÉuÉUÉM×üÌiÉqÉç |

vÉÏiÉxÉÉiqrÉÉÇ lÉ×hÉÉÇ SØÌ¹qÉÉWÒûlÉïrÉlÉÍcÉliÉMüÉ: ||

6(S.S.Ut.7/3-4 p.605)

The experts of eye describe Drishti (pupil) as masuradala matra, originated from the

essence of panchamahabhutas, resembling glow-worm and spark, shining with

constant light, covered with the outermost layer of eyes, appearing like a hole and

suited to cold.

SØÌ¹¶É UÉåqÉMÔümÉ¶É lÉ uÉkÉïliÉå MüSÉcÉlÉ|| 6(S.S.Sha.4/60 p.360)

Vision and pores of the hair follicles never grow or increase in their number or size is

the definite opinion of lord Dhanwantari.

NETRA SANDHI

Sandhis are junctional areas between two mandalas.

mÉ¤qÉuÉiqÉïaÉiÉ: xÉÎlkÉuÉïiqÉïvÉÑYsÉaÉiÉÉåÅmÉU: |

vÉÑYsÉM×üwhÉaÉiÉxiuÉlrÉ: M×üwhÉSØÌ¹aÉiÉÉåÅmÉU: ||

iÉiÉ: MülÉÏlÉMüaÉiÉ: wÉ¸¶ÉÉmÉÉXçaÉ: xqÉ×iÉ: ||6 (S.S.Ut.1/16 p.596)

There are six sandhis in netra:

1.Pakshmavarthmagatha sandhi – Junction between eye lashes and lids.

2.Varthmashuklagatha sandhi- the fornices(between eye lid and white circle).

3.ShuklaKrishnagatha sandhi- The Limbus.

A Study on Arma


4.Krishnadrishtigatha sandhi- Margin of the pupil.

5.Apanga- Outer canthus.

Apanga is situated at the end of eye brows.

AmÉÉXçaÉ MühÉïÌSÍvÉ – apanga is situated towards the ear. 10 ( Indu.A.S. Sha.5/50 p.304)

6.Kaninika-Inner canthus

MülÉÏÌlÉMüÉaÉiÉÉå lÉÉxÉÉxÉqÉÏmÉåÅuÉÎxjÉiÉ: || 6 (dal.S.S.Ut.1/16 p.596)

Is the junction of medial end of the eyelids near the nose.

PATALAS:

mÉOûsÉ – SØ¹åUÉuÉUMüqÉç | cÉ¤ÉÑwÉÉ mÉUSÉ CÌiÉ pÉÉwÉÉ ||3 (p.18)

Patala means an enclosing membrane of the eye.

According to Moneir Williams- patala means veil, cover, a film over the eyes, an

enclosing membrane (of the eyes).5(p.597)

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

of width of dristi.10

(Indu.A.S.Sha.5/50 p.30)

²å uÉiqÉïmÉOûsÉå ÌuÉ±ÉccÉiuÉÉrÉïlrÉÉÌlÉ cÉÉÍ¤ÉÍhÉ |

eÉÉrÉiÉå ÌiÉÍqÉUÇ rÉåwÉÑ urÉÉÍkÉ: mÉUqÉSÉÂhÉ: || 6 (Su.Ut.1 / 17 p.596)

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

in which Timira, a most formidable disease occurs.7 ( p..8 &9)

iÉåeÉÉåeÉsÉÉÍ´ÉiÉÇ oÉÉ½Ç iÉåwuÉlrÉiÉç ÌmÉÍvÉiÉÉÍ´ÉiÉqÉç |

qÉåSxiÉ×iÉÏrÉÇ mÉOûsÉqÉÉÍ´ÉiÉÇ iuÉÎxjÉ cÉÉmÉUqÉç ||

mÉgcÉqÉÉÇvÉxÉqÉÇ SØ¹åxiÉåwÉÉÇ oÉÉWÒûsrÉÍqÉwrÉiÉå ||6(Su.Ut.1 / 18 p.g596)

A Study on Arma


Out of them the outer most subsists in the tejas (fire) and the jala (water), the next

one in the muscle, the third patala in the meda and the last one in asthi. Their

thickness is said to be equal to 1/5th

of the pupil.

1. Tejojalashritha patala :

Is the outer most among the four patalas.

A§É iÉåeÉÉåvÉoSålÉÉsÉÉåcÉMü iÉåeÉ: xÉqÉÉ´ÉrÉÇ ÍxÉUÉaÉiÉÇ U£üÇ oÉÉå®urÉqÉç |

eÉsÉÇ iuÉaaÉiÉÉå UxÉ kÉÉiÉÑ: ||6 (dal.S.S.Ut.1 / 18 p.596)

Dalhana interprets the word teja as Alochaka teja (pitta) present in blood of blood

vessels and jala as Rasa dhatu present in twak.

oÉÉ½Ç cÉÉÍ´ÉiÉqÉalrÉqpÉxÉÏ AalrÉqpÉxÉÏcÉÉÍ¤ÉiÉqÉç| iÉÉprÉÉÇ iÉSÉmrÉÉÌrÉiÉqÉç |8 ( Indu.A.S. Sha.5/50 p.304)

Bahya patala is supported by Agni and Ambhasi. This patala is nourished by Rasa and

Rakta dhatus.

2. Pishitashrita / Mamsashritha: It is supported by mamsa dhatu.

3. Medoshrita patala: It is supported by Medo dhatu.

4. Astyashrita patala: It is supported by Asthi and particularly by Kalakasthi.6

(dal.S.S.Ut.7/3-4 p.606)

AKSHI BANDHANA:

ÍxÉUÉhÉÉÇ MühQûUÉhÉÉÇ cÉ qÉåSxÉ: MüÉsÉMüxrÉ cÉ ||

aÉÑhÉÉ: MüÉsÉÉiÉç mÉU: vsÉåwqÉÉ oÉlkÉlÉåÅ¤hÉÉå: ÍxÉUÉrÉÑiÉ: ||6 (S.S.Ut.1 / 19 p.596)

Eye balls are held in the position by the inherent properties of the vessels, tendons, the

adipose tissue and the kalakasthi as well as by the lining mucus membrane along

with its vessels next to the black portion.

Here sira denotes both sira and dhamani and kandara includes snayu. 6 (dal S..Ut.1/19 p.596)

A Study on Arma


SIRA AND DHAMANI:

There are thirty eight siras, out of which 8 siras carry vata, 10 pitta, 10 kapha and 10

rakta, to the eye.6 (S.S.sha.7/7 p.377)

Sixty five siras are present in the eye; among them two siras does the function of

opening and closing the eyes.11 (A.H.sh.3/29 p.391)

There are two dhamanis carrying rupa or visual impulses and two other dhamanis one

in each eye carrying tears.6 (S.S.sha.9/5 p.384)

PESHI AND SNAYU:

There are two muscles in the eye.6 (S.S.sha.5/37 p.368)

Two snayus are present in the eyes.10 (Indu.A .S.Sha .5/75 p.307)

ASTHI AND SANDHI:

Asthi: Akshikosha or orbital cavity contains tarunasthi. 6(S.S.sha.5/20,p.366),10(A.S.sha.7/65p.306)

Sandhi: There are two joints in the lids of the eyes. 6(S.S.sha.5/26 p.366), 10(A .S. Sha.5/69 p.306)

MARMA:

1. Apanga- two apanga marmas,(Sira marma,measuring half angula ) are situated on

the outer side of the orbits below the lateral end of eyebrows. Injury to them causes

blindness or diminished vision.6 (S.S.sha. 6/27 p.374)

2.Avartha- two avartha marmas (Sandhi marma, measuring half angula ) lie above

the eyebrows, injury to these marmas also results in blindness or diminished

vision.6(S.S.sha.6/27 p.374)

A Study on Arma


NETRA KRIYA VIJNANA (PHYSIOLOGY OF VISION)

iÉ§É cÉ¤ÉÑ ´ÉÉå§É .................. mÉgcÉåÎlSìrÉÉÍh ||8(Cha.S.Su. 8/ 8 p.56)

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

Chakshu or visual faculty is only one. 8(Chakrapani, Cha. S.Su. 8/ 8 p. 56)

AÉiqÉåÎlSìrÉ qÉlÉÉåÅjÉÉïlÉÉÇ xÉÌ³ÉMüwÉÉïiÉç mÉëuÉiÉïiÉå |

urÉYiuÉÉ iÉSÉiuÉå rÉÉ oÉÑÌ®: mÉëirÉ¤ÉÇ xÉÉ ÌlÉÂcrÉiÉå || 8(Cha. S.Su. 11/20 p. 71)

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

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

(perception or direct observation).9(p.211)

qÉlÉ: mÉÑU:xÉUÉhÉÏÎlSìrÉÉhrÉjÉïaÉëWûhÉ xÉqÉjÉÉïÌlÉ pÉuÉÎliÉ ||. 8(Cha.S..Su. 8/ 7 p.56)

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

are motivated by mind.

mÉgcÉåÎlSìrÉoÉÑ®rÉ: cÉ¤ÉÑoÉÑï®rÉÉÌSMüÉ: iÉÉ: mÉÑlÉËUÎlSìrÉåÎlSìrÉÉjÉïxÉiuÉÉiqÉ xÉÌ³ÉMüwÉïeÉÉ:,

¤ÉÍhÉMüÉ ÌlÉ¶ÉrÉÉÎiqÉMüÉ, CirÉåiÉiÉç mÉgcÉmÉgcÉMüqÉç/ 8(Cha. S.Su.8/ 12 p.56)

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.

CÎlSìrÉ – SvÉïlÉåÎlSìrÉ .

CÎlSìrÉÉjÉï – ÃmÉ

CÎlSìrÉ SìurÉ – iÉåeÉÉåqÉWûÉpÉÔiÉ

CÎlSìrÉÉÍkÉ¹ÉlÉ - cÉ¤ÉÑ

CÎlSìrÉoÉÑÌ® - cÉ¤ÉÑoÉÑÌ®

A Study on Arma


These perceptions are momentary in the sense that they fade away soon; even

though sense perception fades 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. 9(167-168)

xÉiÉÉÇ cÉ ÃmÉÉhÉÉqÉÌiÉ xÉÌ³ÉMüwÉÉïiÉç .................. mÉëirÉ¤ÉÉlÉÑmÉsÉÎokÉ: ||8(Cha. S.Su.11/8 p.69)

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

proximity, over distance, obstruction, weakness of senses, diversion of mind,

confusion with other similar objects, over shadowing and over minuteness.

CÎlSìrÉåhÉÉåÎlSìrÉÉjÉÉïÇ iÉÑ xuÉÇ aÉ×ºûÉÌiÉ qÉÉlÉuÉ:|

ÎxjÉiÉÇ iÉÑsrÉrÉÉåÌlÉiuÉÉ³ÉÉlrÉålÉÉlrÉÍqÉÌiÉÎxjÉÌiÉ:||6 (S.Sha.1/15 p.342)

iÉåeÉxÉÇ cÉ¤ÉÑxiÉæeÉxÉqÉåuÉ ÃmÉqÉÉS¨Éå|6 (dal.S.Sha.1/15 p.342)

Human beings have the perception of the objects of indriyas by that particular indriya

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 objects both are

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

other characters like sound etc. Rupa is the adhibhuta, God Surya is adhidaiva of

chakshu which is adhyatma (pertains to soul).6 (S.Sha.1/7 p.339)

qÉlÉ: wÉ¹ÉlÉÉÍqÉÎlSìrÉÉhÉÉÇ §ÉÏÍhÉ §ÉÏÍhÉ ÌuÉmÉëM×ü¹ xÉÌ³ÉM×ü¹uÉ×̈ ÉÏÌlÉ |

qÉlÉ¶É¤ÉÑ: ´ÉÉå§ÉÍqÉÌiÉ ÌuÉmÉëM×ü¹uÉ×¨ÉÏÌlÉ, bÉëÉhÉÇ UxÉlÉÇiuÉÌaÉÌiÉ xÉÌ³ÉM×ü¹uÉ×¨ÉÏÌlÉ || 21(K.S.Sha.1/3 p.110.,111)

Among six indriyas including manas, three perform functions with remoteness and

three with proximation. Amongst these, manas, eyes and ears function with

remoteness, while nose, tongue and skin function with proximity.

A Study on Arma


The Role of Alochakapitta in Visual Perception:

AÎalÉUåuÉ vÉUÏUå ÌmÉ¨ÉÉliÉaÉïiÉ: ................. SvÉïlÉqÉSvÉïlÉqÉç ................. 8(Cha.S.Su.12/1 p. 80)

It is Agni alone represented by Pitta which is responsible for vision or loss of vision

depending on its normal or abnormal state.

SvÉïlÉÉSvÉïlÉå lÉå§ÉaÉiÉxrÉÉsÉÉåcÉMüxrÉ | 8(chakrapani, Cha. S.Su 12/11 p. 80)

Alochakapitta present in netra is responsible for vision or loss of vision.

rÉSØwrÉÉÇ ÌmÉ¨ÉÇ iÉÎxqÉ³ÉÉsÉÉåcÉMüÉÅÎalÉËUÌiÉ, xÉ ÃmÉ aÉëWûÉhÉÉÍkÉM×üiÉ:||6 (S.S.Su.21/10. p.101)

Pitta which is located in the eye is known as Alochakagni. Its function is to form the

image of an external object presented to the eye.

ÃmÉÉsÉÉåcÉlÉiÉ: xqÉ×iÉÇ SØMçxjÉqÉÉsÉÉåcÉMüÇ |10 ( A.H.Su.12/14 p.194)

Alochakapitta is situated in the eye and its function is rupagrahana or forming images

presented to it.

iÉ§ÉÉsÉÉåcÉMüÉå lÉÉqÉ uÉwÉïvÉÏiÉÉiÉmÉ mÉëuÉ×®: | xÉ Ì²ÌuÉkÉ: cÉ¤ÉÑuÉæïvÉåÌwÉMüÉå oÉÑÌ®uÉæïvÉåÌwÉMü¶ÉåÌiÉ |

......................ÉæïvÉåÌwÉMüÉå lÉÉqÉ rÉÉå pÉëÔuÉÉåqÉï±å ´É×ÇaÉÉOûMüxrÉ:oÉÑÌ®uÉæïvÉåwrÉqÉÑimÉÉSrÉiÉÏÌiÉ| 20 (B.S.4/5 p.206)

Bhela has mentioned two aspects of alochakapitta viz. chakshurvaisheshika and

buddhirvaisheshika. He has quoted atreya punarvasu, as saying that alochaka is that

which is excited by varsha (rain), sheeta (cold) and atapa (sun). The

chakshurvaisheshika alochaka pitta begins its function after the co-relation of atma

and manas, when the object has made contact with it, leading to the production in

chitta, the knowledge of the characteristics, form, color etc of such things as flowers,

fruits, leaves etc.

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

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

enables concentration, responses and cognition.

A Study on Arma


Role of other doshas in visual perception:

uÉÉrÉÑ ................... xÉuÉåïÎlSìrÉÉhÉÉqÉÑ±ÉåeÉMü: xÉuÉåïÎlSìrÉÉjÉÉïlÉÉqÉÍpÉuÉÉåRûÉ .................||8(Cha. S.Su.12/ 8 p. 246)

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

respective objects.

Pranavayu attends the function of chakshuradi sense organs. 11(A.H.Su.12/ 4 p.193)

Vyanavayu is responsible for closing and opening of the eyes.11 (A.H.Su.12/ 7 p.193)

ÍvÉU: xÉÇxjÉÉåÅ¤ÉiÉmÉïhÉÉiÉç iÉmÉïMü: || 11(A.H.Su.12/ 17 p.195)

Akshitarpana is the function of tarpaka kapha which is present in shira.

A Study on Arma


NETRA ROGA SANKYA AND CLASSIFICATION

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

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

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

to Vagbhata and Sharngadhara there are 94 types of netrarogas,while Bhavaprakasha

and Yogaratnakara have mentioned 78 and 76 types of netravikaras respectively.

Table 1: Classification of eye disaeases on the basis of adhistana:

Adhistana Sushrutha Astanga

Sangraha

Astanga

Hridaya

Madhava

Nidana

Yogarat

nakara

Karala &

Chakrapani

Sandhi 9 9 9 9 9 9

Vartma 21 24 24 21 21 27

Shukla 11 13 13 11 11 13

Krishna 4 5 5 4 4 6

Dristi 12 27 27 12 12 16

Sarvaja 17 16 16 17 17 25

Bahya 2 - - 2 2 -

Total 76 94 94 78 78 96

A Study on Arma


DISEASE REVIEW

Description of Arma is available in detail in all Samhitas. The detailed description is

available in Sushruta samhita Uttaratantra 4th

chapter Suklagataroga Vijnaneeya

Adhyaya.

Astanga Sangraha has explanation of Arma in 13th

and 14th

chapters of Uttarasthana

and in Astanga Hridaya at 10th

and 11th

chapters of uttarasthana.

References of Arma as quoted by Acharya Nimi and Videha are compiled by Dalhana

in his commentary ‗Nibandhasangraha‘ on Sushruta samhita uttaratantra 4th

chapter.

Arma is also explained in Bhavaprakasha Madhyama Khanda 63rd

Chapter, in

Netraroga chikitsaadhikara of Yogaratnakara, Chikitsasara sangraha of Vanagasena in

71 chapter and in Gadanigraha 3rd

Chapter.

Madhavakara has explained about Arma at 59th

chapter of Madyama Kandha and

Chakrapanidatta has explained the chikitsa of Arma in Netraroga Chikitsadhyaya.

References about netra roga and its chikitsa in detail are available in Sahasrayoga and

Chikitsa manjari.

Sushruta explains 11 different types of diseases which are occurring in shuklamandala

of eye.The Prastari arma, Shuklarma, Kshtajarma, Adhimamsarma, Snayuarma, and

Shuktika, Arjuna, Pistaka, Sirajala, Sirapidaka and Balasagrathitha.

Acharya Vagbhata adds Sirotpata and Siraharsha to the shuklamandala vikaras.Thus

he describes thirteen rogas in shuklamandala.

A Study on Arma


Nirukti:-

The term Arma originated from ―Ru‖ dhatu along with ―Manain‖ pratyaya means

always growing.22

―Iyarthi gacchathi ithi Arma‖ – the gradually spreading extra membrane in shukla

mandala (mamsa vruddhi) is known as Arma.22

NIDANA

EwhÉÉÍpÉiÉmiÉxrÉ eÉsÉmÉëuÉåzÉÉiÉç

SÕUå¤ÉhÉÉiÉç xuÉmlÉÌuÉmÉrÉïrÉÉiÉç cÉ|

mÉëxÉ£üxÉÇUÉåSlÉ MüÉåmÉ zÉÉåMü

YsÉåzÉÉÍpÉbÉÉiÉÉiÉç AÌiÉqÉæjÉÑlÉÉiÉç cÉ||

zÉÑ£üÉUlÉÉsÉÉqsÉ MÑüsÉijÉqÉÉwÉ-

ÌlÉwÉåuÉhÉÉiÉç uÉåaÉÌuÉÌlÉaÉëWûÉiÉç cÉ|

xuÉåSÉSjÉÉå kÉÔqÉÌlÉwÉåuÉhÉÉiÉç cÉ

cNûSåï:ÌuÉbÉÉiÉÉiÉç uÉqÉlÉÉÌiÉrÉÉåaÉÉiÉ

oÉÉwmÉaÉëWûÉiÉç xÉÔ¤qÉÌlÉUÏ¤ÉhÉÉiÉç cÉ

lÉå§ÉåÌuÉMüÉUÉlÉç eÉlÉrÉÎliÉ SÉåwÉÉ: ||6 (S.S.Ut.1 / 26-27 p.597)

Sudden plunging into water after exposure to heat, excessive staring at distant objects,

abnormal sleeping habits, continuous weeping, anger/grief/suffering, injury to head,

excessive sexual intercourse, excessive use of vinegar and sour gruels, kulatta and

masha, pulses, suppression of physiological calls of nature, excessive perspiration,

smoking, suppression of excessive vomiting, suppression of tears, concentrating on

minute objects.

A Study on Arma


Table No-2: Showing nidana of Netra vikaras according to various authors

Causative factors S.S M.N B.P Y.R V.S H.S

Sudden plunging into water after exposure to

heat.

+ + + + + -

Excessive staring at distant objects + + + + + -

Abnormal sleeping habits + + + + + -

Continuous weeping + + + + + -

Anger/grief/suffering + + + + + -

Injury to head + + + + + +

Excessive sexual intercourse + + + + + -

Excessive use of vinegar and sour gruels + - + - - -

Kulatta and masha pulses + - + - - -

Suppression of physiological calls of nature + + + + + -

Excessive perspiration + + + + + -

Smoking + + + + + -

Suppression of excessive vomiting + + + + + -

Suppression of tears + + + + + -

Concentrating on minute objects + + + + + +

Intake of fluids at night - + - + + -

Alcohol - + - + + -

Appearance of unusual features during season - + + + + -

Travelling at high speed - - + - - -

Excessive intake of ushna, kshara and katu food

articles

- - - - - +

A Study on Arma


Other causes of Netra vikaras:

Dalhana has mentioned avak and uchrita shira shayana i.e, sleeping with the head at a

too low or too higher level, ritu viparyaya, jvaropata as some of the causes of

eyediseases.6 (S.S.Ut.1 /26-27)

Yogaratnakara adds these:

Excessive intake of fluids, excessive intake of alcoholic drinks, by physical contact,

by inhaling and coming in contact with a respired air, eating together, using the same

bed, seat, garlands, beds, clothes, cosmetics, one can be infected by the following

diseases, kusta (skin disease), jwara (fever), sosha (wasting), netrabhisyanda

(conjunctivitis). So netrabhisyanda is infectious in nature.

PURVA RUPA:

iÉ§ÉÉÌuÉsÉÇ xÉxÉÇUqpÉqÉ´ÉÑhMüQÕûmÉSåWûuÉiÉç ||

aÉÑÃwÉÉÇiÉÉåSUÉaÉÉ±æeÉÑï¹Ç cÉÉurÉ£üsÉ¤ÉhÉæ: ||

xÉvÉÔsÉÇ uÉiqÉïMüÉåwÉåwÉÑ vÉÔMümÉÔhÉÉïpÉqÉåuÉ cÉ ||

ÌuÉWûlrÉqÉÉlÉÇ ÃmÉå uÉÉ Ì¢ürÉÉxuÉÍ¤É rÉjÉÉ mÉÑUÉ |

SØ¹èuÉæuÉ kÉÏqÉÉlÉç oÉÑkrÉåiÉ SÉåwÉåhÉÉÍkÉÌ¸iÉÇ iÉÑ iÉiÉç || 6 (S.S.Ut.1 /21 p.597)

Dirtiness, congestion, lacrimation, itching, stickiness, heaviness, burning sensation,

pricking pain, redness etc are the prodromal features of the eye diseases. There may

be feeling as if the cavity of the eye lids is full of painful bristles, impairment in

vision or function of the eyes as compared with what they were before. As soon as the

above features are seen, the intelligent clinician should regard that (eye) to have

become afflicted with doshas.

Depending upon the dosha undergone Sthanasamshraya, poorvaroopa shows such

A Study on Arma


Doshic lakshanas like- iÉÉåSÉÌS = uÉÉiÉ ÍsÉ…¡Çû

FwÉÉÌS = ÌmÉ¨É ÍsÉ…¡Çû

aÉÑÂiuÉÉÌSÍpÉ: = MüTü ÍsÉ…¡Çû

UÉaÉÉÌS = U£ü ÍsÉ…¡Çû

These are just sensation but not appeared. If neglected, they get exhibited. Hence,

iÉ§É xÉÇpÉuÉqÉÉxÉÉ± rÉjÉÉSÉåwÉÇ ÍpÉwÉÎaeÉiÉqÉç|

ÌuÉSkrÉÉ³Éå§ÉeÉÉ UÉåaÉÉ oÉsÉuÉliÉÈ xrÉÑUlrÉjÉÉ||.6 (S.S.Ut.1 /24 p.597)

Treatment should be aimed at this stage as further all netrarogas become balavattara.

SAMPRAAPTI/ PATHOGENESIS

ÍxÉUÉlÉÑxÉÉUÏÍpÉ: SÉåwÉæ: ÌuÉaÉÑhÉæ: FkuÉïqÉÉaÉiÉæ:|

eÉÉrÉliÉå lÉå§ÉpÉÉaÉåwÉÑ UÉåaÉÉÈ mÉUqÉSÉÂhÉÉÈ|| 6 (S.S.Ut.1 /20 p.597)

The vimargagamana of the increased doshas through Urdhwagaami siras results in

various complicated diseases of netra. When they get localized in Shuklamandala due

to its susceptibility because of weakness caused by one or more nidanas results in any

of 11 SHUKLAMANDALAGATA ROGAS.

1. Prastari arma 2. Shukla arma

3. Kshtajarma 4. Adhimamsa arma

5. Snayu arma 6. Shuktika

7. Arjuna 8. Pistaka

9 .Sirajala 10. Sirapidaka

11. Balasagrathitha

A Study on Arma


Acc to Vagbhata -13

1.Prastari arma 2.Shuklarma 3.Shonitarma 4.Adhimamsarma5.Snayuarma 6.Shuktika

7.Arjuna 8.Pistaka 9.Sirajala 10.Sirapidaka 11.Balasagrathitha 12.Siraharsha

13.Sirotpata

ROOPA

mÉëxiÉÉËU mÉëÍjÉiÉÍqÉWûÉqÉï zÉÑYsÉpÉaÉå

ÌuÉxiÉÏhÉïÇ iÉlÉÑ ÂÍkÉUmÉëpÉÇ xÉlÉÏsÉqÉç||6 (S.S.Ut.4 /4 p.601)

Prastari arma (pterygium) arising in the white portion is extensive, thin, having

bloody lustre & bluish.This is caused by tridosha & is curable.

zÉÑYsÉÉZrÉÇ qÉ×SÒ MüjÉrÉÎliÉ zÉÑYsÉpÉÉaÉå

xÉµÉåiÉÇ xÉqÉÍqÉWû uÉkÉïiÉå ÍcÉUåhÉ||6 (S.S.Ut.4 /4 p.601)

Sukla arma appearing in white portion is soft, whitish & even & has delayed growth.

It is caused by kapha & is curable.

rÉlqÉÉÇxÉÇ mÉëcÉrÉqÉÑmÉæÌiÉ zÉÑYsÉpÉÉaÉå

mÉ©ÉpÉÇ iÉSÒmÉÌSzÉÎliÉ sÉÉåÌWûiÉÉqÉï||6 (S.S.Ut.4 /5 p.601)

The fleshy tissue having lotus-like lustre & growing in the white portion is known as

raktarma. This is caused by rakta & is curable.

ÌuÉxiÉÏhÉïÇ qÉ×SÒ oÉWûsÉÇ rÉM×üimÉëMüÉzÉÇ

zrÉÉuÉÇ uÉÉ iÉSÍkÉMüqÉÉÇxÉeÉÉqÉï ÌuÉ±ÉiÉç|| 6 (S.S.Ut.4 /5 p.601)

Adhimamsa is extensive, soft, thick, liver-like or blackish. This is caused by sannipata

& is curable.

A Study on Arma


zÉÑYsÉå rÉiÉç ÌmÉÍzÉiÉqÉÑmÉæÌiÉ uÉ×Î®qÉåiÉiÉç

xlÉÉruÉqÉåïirÉÍpÉmÉÌPûiÉÇ ZÉUÇ mÉëmÉÉhQÒû|| 6 (S.S.Ut.4 /6 p.601)

Fleshy tissue rough & pale, growing in white portion is known as ‗Snayu arma‘.

Both Sushruta and Vagbhata described five varieties of Arma and a lot of

resemblance is seen in all aspects such as names, etiology and description except in

the name of Shonitarma. Sushruta named this disease as Kshatajarma or Lohitarma.

Table No-3: Showing Classification of Arma & laxanas explained according to

various authors

TYPES OF ARMA

SUSHRUTHA

VAGBHAT

BHAVAPRAKASH

YOGARATNAKARA

PRASTHARIARMA

COLOUR

NATUREOFTHEGROWTH

NATURE OF THE MASS

DOSHA

ÂÍkÉUmÉëpÉ, xÉÌlÉsÉÉ

ÌuÉxiÉÏhÉï

iÉlÉÑ

Ì§ÉSÉåwÉ

zrÉÉuÉ sÉÉåÌWûiÉ

AzÉÑuÉ×®rÉ

qÉ×SÒ

§ÉSÉåwÉwith U£ü

zrÉÉuÉ U£üÌlÉpÉÇ

ÌuÉxiÉÏhÉï

iÉlÉÑ

Ì§ÉSÉåwÉ

SHUKLARMA

COLOUR

NATUREOFTHEGROWTH

NATURE OF THE MASS

DOSHA

zÉÑYsÉ xÉµÉåiÉ

uÉkÉïiÉå ÍcÉUåhÉ

qÉ×SÒ

MüTü

zÉÑYsÉ

ÍcÉUuÉ×®rÉ

AÍkÉqÉÉÇxÉMüqÉç

MüTü

zÉÑYsÉ xÉµÉåiÉ

uÉkÉïiÉå ÍcÉUåhÉ

qÉ×SÒ

MüTü

A Study on Arma


KSHATAJA/LOHITHARMA

COLOUR

NATUREOFTHEGROWTH

NATURE OF THE MASS

DOSHA

mÉ©pÉÉÇ

mÉëcÉrÉqÉÑmÉæÌiÉ

U£ü

mÉ©pÉÉÇ

AÍkÉqÉÉÇxÉ

zsÉ¤hÉÇ

U£ü

mÉ©pÉÉÇ

qÉ×SÒ

U£ü

ABHIMAMSARMA

COLOUR

NATUREOFTHEGROWTH

NATURE OF THE MASS

DOSHA

rÉM×üimÉëMüÉzÉ

zrÉÉuÉ ÌuÉxiÉÏhÉï

qÉ×SÒ oÉWûsÉÇ

xÉÍ³ÉmÉÉiÉeÉ

AxÉ×Mçü ÌmÉhQû zrÉÉuÉ

mÉ×jÉÑ

zÉÑwMü oÉWûsÉÇ


rÉM×üÍ³ÉpÉÇ

mÉ×jÉÑ qÉ×SÒ

oÉWûsÉÇ


SNAYUARMA

COLOUR

NATUREOFTHEGROWTH

NATURE OF THE MASS

DOSHA

mÉëmÉÉhQÒû

uÉ×Î®qÉåiÉiÉç

ZÉUÇ

Ì§ÉSÉåwÉeÉ

xlÉÉuÉxÉÍ³ÉpÉÇ

ÎxjÉUÇ

qÉÉÇxÉÉRÇûrÉ

Ì§ÉSÉåwÉeÉ

SADHYASADHYATA

Sadhyasadhayata gives the clear picture of prognosis of the disease. It depends upon

many factors like nature of diseases, severity of diseases, vaya, prakruti, bala of

patient etc. Arma is chedana sadhya vyadhi

CHIKITSA

The first and foremost method of treatment of Arma is Chedana. Procedure of surgery

described by Sushrutha and Vagbhata.They explained all the pre and post operative

aspects also.According to modern medical science surgery is only treatment for this

disease. But Ayurveda prescribes certain Anjanas for the treatment in addition to the

surgery.It is widely used in early stage of Arma to prevent the speedy growth of the

A Study on Arma


membrane.This is highly beneficial after the surgical treatment for the successful

prevention of growth after surgery.

Anjana are mainly of lekhana properties which can gradually taper the thickness of

the membrane and thereby preventing the growth and also reduces the size.

AqÉï cÉÉsmÉÇ SÍkÉÌlÉpÉÇ lÉÏsÉÇ U£üqÉjÉÉÌmÉ uÉÉ|

kÉÔxÉUÇ iÉlÉÑ rÉŠÉÌmÉ zÉÑ¢üuÉ¨ÉSÒmÉÉcÉUåiÉç||

cÉqÉÉïpÉÇ oÉWûsÉÇ rÉ¨ÉÑ xlÉÉrÉÑqÉÉÇxÉbÉlÉÉuÉ×iÉÇ|

Nåû±qÉåuÉ iÉSqÉï xrÉÉiÉç M×üwhÉqÉhQûsÉaÉÇ cÉ rÉiÉç|| 6 (S.S.Ut.15 /17-18 p.623)

Arma which is small, curd-like, blue or red, grey and thin should also be treated like

sukra. Alpam-inextent; dahinibham-suklarma; nilam-prastari, raktam-lohitarma; tanu-

snayvarma; ‗ca‘ & ‗api‘ indicate mamsarma. Thus arma of five types should be

treated with scarping collyrium like sukra.

Arma which is leathery, thick & densely covered with fibres & fleshy tissue and has

reached the black circle i.e, Krishna mandal should be excised verily.

AqÉÉåï£Çü mÉgcÉkÉÉ iÉ§É iÉlÉÑ kÉÔqÉÉÌuÉsÉÇ cÉ rÉiÉç|

U£üqÉç SÍkÉÌlÉpÉÇ rÉŠ zÉÑ¢üuÉ¨ÉxrÉ pÉåwÉeÉqÉç|| 11 (A.H.Ut.11 /13 p.813)

Among the five varieties of Arma described that which is thin, turbid like smoke, red

& which resembles curds are to be treated in the same manner as of Sukra.

A Study on Arma


ARMA CHEDANA:

POORVA KARMA:-

ÎxlÉakÉÇ pÉÑ£üuÉiÉÉå ½³ÉqÉÑmÉÌuÉ¹xrÉ rÉ¦ÉiÉ:|

xÉÇUÉåwÉrÉ¨ÉÑ lÉrÉlÉÇ ÍpÉwÉMçü cÉÔhÉæïxiÉÑ sÉÉuÉhÉæ||6 (S.S.Ut.15 /3 p.622)

After shareera shodhan.patient is given oleus substances to eat or drink and made

to sit comfortably.Then the physician should do the arma shithalikarana by putting

powder of saindhava in the eye.After the eye is properly enraged,it should be

fomented quickly and movements made.

According to Astanga hrudaya-saindhava macereted with juice of bijapura is applied

as an eyesalve.

Astanga sangrahakara advises intake of peya,vilepi,mamsarasa after oleation therapy;

then made to perform auspicious rites,then to lie on a comfortable bed with his face

up,head slightly bent down; the eyes are then given mild fomentation with cotton

swab dipped in warmwater; saindhava mixed with the juice of bijapura is put into the

eye;and then the eyelid is massaged by the thumb till balasa grathita develops; by this

method of enraging the eye,the muscular over-growth becomes moveable;during the

conduct of this act an attendant should hold the head of the patient.

PRADHANA KARMA

iÉiÉ: xÉÇUÉåÌwÉiÉÇ iÉÔhÉïÇ xÉÑÎxuÉ³ÉÇ mÉËUbÉOûÏiÉqÉç||

AqÉï rÉ§É uÉsÉÏeÉÉiÉÇ iÉ§ÉæiÉssÉaÉrÉåÎ°wÉMçü ||

AmÉÉ…¡Çû mÉëã¤ÉqÉÉhÉxrÉ oÉÌQûzÉãlÉ xÉqÉÉÌWûiÉ:||

qÉÑcÉÑhŽÉÅÅSÉrÉ qÉåkÉÉuÉÏ xÉÔcÉÏxÉÔ§ÉãhÉ uÉÉ mÉÑlÉ:||

A Study on Arma


lÉ cÉÉåijÉÉmÉrÉiÉÉ Í¤ÉmÉëÇ MüÉrÉïqÉprÉÑ³ÉiÉÇ iÉÑ iÉiÉç||

zÉx§ÉÉoÉÉkÉpÉrÉÉŠÉxrÉ uÉiqÉïlÉÏ aÉëÉWûrÉå¬ØRûqÉç||

iÉiÉ: mÉëÍzÉÍjÉsÉÏpÉÔiÉÇ Ì§ÉÍpÉUåuÉ ÌuÉsÉÎqoÉiÉqÉç||

EÎssÉZÉlqÉhQûsÉÉaÉëåhÉ iÉÏ¤hÉãlÉ mÉËUzÉÉåkÉrÉåiÉç||

ÌuÉqÉÑ£Çü xÉuÉïiÉ¶ÉÉÌmÉ M×üwhÉÉcNÒûYsÉÉŠ qÉhQûsÉÉiÉç||

lÉÏiuÉÉ MülÉÏlÉMüÉåmÉÉliÉÇ ÍNûl±É³ÉÉÌiÉMülÉÏlÉMüqÉç||

cÉiÉÑpÉÉïaÉÉÎxjÉiÉå qÉÉÇxÉå lÉÉÍ¤É urÉÉmÉÌ¨ÉqÉ×cNûÌiÉ||

MülÉÏlÉMüuÉkÉÉSxÉëÇ lÉÉQûÏ uÉÉÅmrÉÑmÉeÉÉrÉiÉå||

WûÏlÉcNãûSÉiÉç mÉÑlÉuÉ×ïÎkSÇ zÉÏbÉëqÉåuÉÉÍkÉaÉcNûÌiÉ|| 6 (S.S.Ut.15 /4-9 p622)

The patient is asked to look towards apanga sandhi.Then the physician should hold

the arma at the place where it has wrinkles,catch it with badisha yantra and

muchundiyantra again with the help of suchi and sutra it should be raised but should

not be lifted too much suddenly;at the same time the lids should be held firmly to

avoid surgical injury.Thus when loosened being held with all the three,it should be

lifted and all its connection are removed with sharp mandalagra shastra and freed

fully from black & white circles. It should be taken near the inner canthus & excised

not touching inner canthus.If one fourth of the tissue remains there is no risk to eyes

but if inner canthus is injured, it may cause haemorrhage or sinus.If inadequate

excision there will be quick growth once again.

AqÉï rÉ‹ÉsÉuÉSè urÉÉÌmÉ iÉSmrÉÑlqÉÉerÉï sÉÎqoÉiÉqÉç||

ÍNûl±É²¢åühÉ zÉx§ÉåhÉ uÉiqÉïzÉÑYsÉÉliÉqÉÍ´ÉiÉqÉç||6 (S.S.Ut.15 /10 p.622)

A Study on Arma


Arma which has spread like a net & situated at the end of vartma & shukla should be

lifted up, pulled and cut with the sharp curved instrument.

According to Astanga hrudaya, while cutting, the inner canthus & tear ducts being

protected; injury to the inner canthus leads to profuse flow of tears through the tear

ducts.In case the arma is more developed towards the outer canthus, the patient should

be asked to look towards the inner canthu & then the cutting done suitably.

According to Astanga sangraha arma is cut by mandalagra shastra or by vruddhipatra

shastra.

AqÉï iÉÑ NåûSlÉÏrÉÇ M×üwhÉmÉëÉmiÉÇ pÉuÉå±SÉ||

oÉÌQûzÉÌuÉ®Ç xÉqÉÑ³ÉqrÉ Ì§ÉpÉaÉÇ cÉÉ§É uÉeÉïrÉåiÉç||14(B.R.N.R.Chi 65/133 p.997)

According to Bhaishajya ratnavali arma should be cut leaving one third of it behind

at kaninika.

PASCHAT KARMA:-

mÉëÌiÉxÉÉUhÉqÉ¤hÉÉåxiÉÑ iÉiÉ: MüÉrÉïqÉlÉliÉUqÉç||

rÉÉuÉlÉÉsÉxrÉ cÉÔhÉãïlÉ Ì§ÉMüOûÉãsÉïuÉhÉxrÉ cÉ||

xuÉåSÌrÉiuÉÉ iÉiÉ: mÉÉ¶ÉÉ¯klÉÏrÉÉiÉç MÑüzÉsÉÉã ÍpÉwÉMçü||

SÉãwÉiÉÑïoÉsÉMüÉsÉ¥É: xlÉåWÇû S¨uÉÉ rÉjÉÉÌWûiÉqÉç||

uÉëhÉuÉiÉç xÉÇÌuÉkÉÉlÉÇ iÉÑ iÉxrÉ MÑürÉÉïSiÉ: mÉUqÉç||

§rÉWûÉlqÉÑ̈ uÉÉ MüUxuÉåSÇ S¨uÉÉ zÉÉãkÉlÉqÉÉcÉUåiÉç||6 (S.S.Ut.15 /11-13 p.622)

Thereafter eyes should be rubbed with powder of yavanala, trikatu &

saindhavalavana; followed by fomentation. Skilled physician should anoint the eye

and apply bandage considering the strength of the doshas, rutu & kala.Then vrana

A Study on Arma


chikitsa should be done; after three days the bandage should be removed, the wound

fomented with hand and cleaned.

According to Astanga hrudaya,after proper cutting,the eye should be smeared with

honey,vyosa & saindhava;next warm ghee is put in,then the eye is annointed with

honey & ghee mixed together and bandaged.On the third day it is removed & eye

washed with milk boiled with seeds of karanja.Next on fifth day it should be washed

with decoction of the two nisa,rodhra,patoli,yasti,kimsuka & buds of kuranta mixed

with honey.On the seventh day the bandage should be removed finally.

According to Astanga sangraha, ascertaining perfect haemostasis, saindhava mixed

with honey is applied on & off. Ash of yava plant may be used with madhu for same

purpose.Then eyes are washed with either cold water or warm water.Warmghritha or

mixture of ghirtha & madhu are put into the eye & then bandaged.

Shathadhoutha ghritha or paste of drugs which are sheetaveerya should be applied

over the head and feet of the patient.

He should adopt the activites prescribed in oleation therapy. From second day

onwards, warm decoction of madhuka with ghritha should be sprinkled both in the

morning & evening over the head & eye with the bandage intact for five days the

patient should consume ghee followed by drinking warm water. After ghee gets

digested, he should eat suitable food.

On the third day,the bandage should be removed & the eye given fomentation with

milk boiled with seeds of karanja.Decoction of lodhra,madhuka,kimsuka,patola & the

two haridra & buds of koranda added with honey be used for ascyotana & again

bandaged.

On the seventh day, the bandage is removed finally and patient directed to avoid

exposure to sun & sky.

A Study on Arma


MüUgeÉoÉÏeÉÉqÉsÉMüqÉkÉÑMæü: xÉÉÍkÉiÉÇ mÉrÉ:||

ÌWûiÉqÉÉ´crÉÉåiÉlÉÇ zÉÔsÉã ÎuSU»û: ¤ÉÉæSìxÉÇrÉÑiÉqÉç||

qÉkÉÑMüÉåimÉsÉÌMügeÉsMüSÕuÉÉïMüsMæü¤cÉ qÉÔkÉïÌlÉ||

mÉësÉåmÉ:xÉbÉ×iÉ: zÉÏiÉ: ¤ÉÏUÌmÉÌ¹: mÉëzÉxrÉiÉå||6 (S.S.Ut.15 /14-15 p.622-623)

If pain is noticed in the eyes milk boiled with the seeds of karanja, amalaki &

madhuka with madhu is ideal for ascyotana to be done twice a day.

Madhuka, utpala, kinjalka & durva made as paste with milk added with ghritha &

applied as cold poultice on the head is greatly beneficial.

According to Astanga sangraha, if there is swelling of the eyes dhoompana &

shirovirechana should be done.If the redness of the eye does not subside then

raktamokshana should be done. If there is discharge from the eyes nasya should be

administered.

sÉåZrÉÉgeÉlÉæUmÉWûUåSqÉïzÉåwÉÇ pÉuÉå±ÌS||6 (S.S.Ut.15 /16 p.623)

If there is residual of arma, it should be removed by lekhananjana.

SAMYAK LAKSHANAS OF LEKHANA:-

ÌuÉzÉÑ®uÉhÉïqÉÎYsÉ¹Ç Ì¢ürÉÉxuÉÍ¤É aÉiÉYsÉqÉqÉç||

ÍNû³ÉåÅqÉïÍhÉ pÉuÉåiÉç xÉqrÉarÉjÉÉxuÉqÉlÉÑmÉSìuÉqÉç||6 (S.S.Ut.15 /19 p.623)

When arma is excised properly, eye regains normal colour, function with ease,

relieved of fatigue & free from complications.

According to Astanga hrudaya

xÉqrÉMçü ÍNû³Éå pÉuÉåixuÉÉxjrÉÇ WûÏlÉÉÌiÉcNåûSeÉÉlÉç aÉSÉlÉç|

xÉåMüÉgeÉlÉmÉëpÉ×ÌiÉÍpÉeÉïrÉåssÉåZÉlÉoÉ×ÇWûhÉæ:|| 11(A.H.Ut.11/23 p.813)

A Study on Arma


Proper cutting leads to health; the diseases arising from inadequate or excess cutting

should be treated by proper seka, lekhananjana & brmhananjana.

A§É xÉqrÉMçü ÍNû³Éå uÉhÉïÌuÉzÉÑÎ®: xuÉxjÉiÉÉ cÉ|

WûÏlÉcNãûSÉiÉç mÉÑlÉuÉ×ï®Ï UÉaÉÉ´ÉÑmÉÉiÉmÉëMüÉzÉSzÉïlÉÉ¤ÉqÉiuÉÌS cÉ|

AÌiÉcNãûSÉSÍ¤ÉmÉÉMüxiÉqpÉxTÑüUhÉÉxÉëxÉëÑÌiÉÌiÉÍqÉUxÉÇUqpÉÌuÉoÉSèkSuÉiqÉÉïÌlÉ|

iÉåwÉÑ rÉjÉxuÉÇ SÉåwÉÉåSìåMüÉiÉç mÉëÌiÉMÑürÉÉïiÉç|16(A.S.Ut 14/21p.126)

If the cutting has been properly done, there will be transparency of colour and

normalcy.

If the cutting is inadequate, there will be recurrence, redness, more of tears, inability

to see light etc.

By over cutting, ulceration, loss of movement, throbbing pain, flow of blood,

blindness, anger and lids sticking together etc. These conditions should be treated

according to the doshas aggravated.

Nagara,manasila,ela,saindhava & sarkara each half karsha added to half- pala of

rasanjana liquefied by addition of honey and used as collyrium cures residual

arma,blindness due to aggravation of kapha & eye disease known as pilla.

According to Astanga hrudaya, the outer portion of any of triphala is macerated in

water put inside an earthen saucer with another saucer, their edges sealed, both

together are coated with mud, dried in sun & then placed inside a heap & cooked.Next

it is powdered nicely & soaked in the decoction of the other two drugs separately.This

ash is then mixed with the two lavana and macerated well.These three eye salves are

best lekhana says NIMI.

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Other yogas explained in the classics:-

Shankhadi Anjana

Shilanjana

Nayanasukhavarti

Chandrodayavarti

Samudraphenavarti

Guduchyadi Anjana

Marichyadi Churnanjana

PATHYA-APATHYA

AHARA:

Pathya : Purana ghrita, triphala, shatavari, patola, mudga, amalaki, yava, lohita shali,

whole grains like yava and godhuma, Cooked vegetables of jivanti, sunishannaka,

tanduleeya, vastuka, chilli, mulaka, meat of birds and wild animals, karkotaka,

karavella, vartaka, karira, shigru, tarkari.6(S.S.Ut. 17 / 50-51 p.690)

Yogaratnakara adds- peya, vilepi, tiktha and laghu ahara, shalitandula, godhuma,

saindhava, goghritha, gopaya, sitha, kshoudra, draksha, kustumburu, , surana, naveena

mocha, matsyakshi, punarnava to the above. 19(Y.R.N.R.Chi.sl.1-4 p.395)

Apathya: Masha, aranala, katuthaila, patra shaka, matsya, dadhi, phanita, vesavara,

pinyaka (oil cake), virudhaka (sprouts), ambupana, madhukapushpa, sura(alcohol),

ajangalamamsa, tambula, food and drinks which are amla, lavana, vidahi, teekshna,

katu, ushna and guru .19(Y.R.N.R.Chi.sl.5-7,10. p.395)

VIHARA:

Pathya: Manaso nivritti (withdrawing the mind from objects of senses.),

padabhyanga, sita jala prakshalana etc.

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Apathya: Krodha, shoka, maithuna, vata, vinmutra, nidra, vami, vegavarodha,

sukshmekshana (looking at minute objects), snana, atapa, prajalpana (excessive

talking), chardana. 19(Y.R.N.R.chi..Sl-6,. p.395)

(AOUSHADA) MEDICATION:

Pathya:

Anjana, nasya, padapuja (anointing, using foot wear etc), rudhirasriti (blood letting),

vishuddhi (purificatory therapies).11( .A. H .Ut. 13/99 p.825)

Yogaratnakara adds- aschyotana, langhana, sveda, pratisarana, prapoorana,

shastrakriya, and lepa to the above. 19(Y.R.N.R.Chi..sl.2. p.395)

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ANATOMY OF CONJUNCTIVA: 26

The conjunctiva is a translucent mucous membrane which lines the posterior surface

of the eyelids and anterior aspect of the eyeball.

The name conjunctiva (conjoin: to join) has been given to this mucous membrane

owing to the fact that it joins the eyeball to the lids. It stretches from the lid margin to

the limbus and encloses a complex space called conjunctival sac which is open in

front at the palpebral fissure.

PARTS OF CONJUNCTIVA

Conjunctiva can be divided into following parts:-

1. Palpebral conjunctiva: marginal, tarsal and orbital

2. Bulbar conjunctiva: sclera and limbal

3. Conjunctival fornix: superior, inferior, lateral and medial

1. PALPEBRAL CONJUNCTIVA

It lines the lids and can be subdivided into marginal, tarsal and orbital conjunctiva.

(i)Marginal conjunctiva – extends from the lid margin to about 2mm on the back of

the lid upto a shallow groove- the sulcus subtarsalis. It is actually a transitional zone

between skin and the conjunctiva proper.At the sulcus subtarsalis, the perforating

vessels pass through the tarsus to supply the conjunctiva. This sulcus is a common site

for lodgement of a conjunctival foreign body.

(ii)Tarsal conjunctiva- is thin, transparent and highly vascular. It is firmly adherent to

the whole tarsal plate in the upper lid. In the lower lid, it is adherent only to half width

of the tarsus.The tarsal glands are seen through it as yellow streaks. Tarsal

conjunctiva is a common site for the follicular and papillary reactions.

(iii)Orbital part-of palpebral conjunctiva lies loose between the tarsal plate and

fornix.Orbital conjunctiva of the upper lid is loose and lies over the muller‘s muscle.

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2 .BULBAR CONJUNCTIVA

It is thin, transparent and lies loose over the underlying structures and thus can be

moved easily. It is separated from the anterior sclera by episcleral tissue and Tenon‘s

capsule.Subconjunctival vessels and the anterior forming the pericorneal plexus can

be seen in the loose tissue under the bulbar conjunctiva. A 3mm ridge of bulbar

conjunctiva around the cornea is called limbal conjunctiva. In the area of limbus,the

conjunctiva,Tenon‘s capsule and the episcleral tissue are fused into a dense tissue

which is strongly adherent to the underlying corneo-scleral junction.It is the preferred

site for obtaining a firm hold(fixation) of the eyeball with the forceps during ocular

surgery. At the limbus, the epithelium of conjunctiva becomes continuous with that of

cornea.

Figure-1 Parts of Conjunctiva and Conjunctival Glands

3. CONJUNCTIVAL FORNIX

Conjunctival fornix is a continuous circular cul-de-sac, which is broken only on the

medial side by caruncle and the plica semilunaris.Conjunctival fornix joins the bulbar

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conjunctiva with the palpebral conjunctiva.It can be subdivided into superior, inferior,

medial and lateral fornices.

(i)Superior fornix- it extends from slightly above the upper border of the tarsal plate

to a distance about 10mm from the upper limbus and is thus located at level of

superior orbital margin.The extension of the fascial sheath of the levator and superior

rectus muscles is attached to the conjunctiva in the upper part of the superior fornix.It

helps in maintaining the recess of the superior fornix in the movements of the upper

lid.In the subconjunctival tissue of the superior fornix are present glands of Krause

and the Muller‘s muscle.A knife passed through the superior fornix,enters the fibrous

tissue between the levator and superior rectus muscle.A foreign body lodged in the

superior fornix can be seen after double eversion of the upper lid.

(ii)Inferior fornix – It extends from slightly below the lower border of the lower

tarsal plate to a distance about 8mm from the lower limbus and is located near the

inferior orbital margin.The extension of the fascial sheath of the conjunctival fold in

the lower fornix.It helps in maintaining the recess of the inferior fornix during

movements of the lower lid. Glands of Krause are lodged in the subconjunctival tissue

of the lower fornix. A knife passed through the lower fornix will enter the fibrous

tissue between the inferior rectus and inferior palpebral muscles and on further push it

hits the aponeurotic expansion from the inferior rectus and inferior oblique muscles.

(iii)Lateral fornix- It is a small cul-de-sac which extends to just behind the equator

of the eyeball and is about 14mm from the lateral limbus and about 5mm from the

lateral canthus.

(iv)Medial fornix- It is a shallow cul-de-sac in which lie the caruncle and plica

semilunaris dipped in the pool of tears called the lacus lacrimalis or tear-lake.

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Figure -2 Conjunctival fornices

STRUCTURE OF CONJUNCTIVA

Histologically conjunctiva consists of three layers, namely (1) Epithelium,

(2) Adenoid layer, and (3) Fibrous layer

1. Epithelium

(a)The layers of epithelial cells in conjunctiva vary from region to region and its

different parts are as follows

Marginal conjunctiva has 5 layered non keratinized stratified squamous type

of epithelium.The most superficial layer is of squamous cells, intermediate 3

layers of polyhedral cells and deepest layer of cylindrical cells.Goblet cells,

absent at mucocutaneous junction; begin to appear in this part of conjunctival

epithelium.

Tarsal conjunctiva has two- layered epithelium, superficial layer of cylindrical

cells and a deep layer of cubical cells in the upper lid.While the lower tarsal

conjunctiva is composed of 3-4 layers of cells which from deep to superficial

are layers of cubical cells, polygonal cells, elongated wedge-shaped cells and

the cone-shaped cells.

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Fornix and bulbar conjunctiva has three-layered epithelium, a superficial layer

of cylindrical cells, middle layer of polyhedral cells and a deep layer of

cuboidal cells.

Limbal conjunctiva is again many-layered (8 to 10) stratified squamous

epithelium. Most superficial are one to two layers of squamous

cells.Intermediate several layers are of polygonal cells and basal layer is of

small cylindrical or cubical cells.The limbal epithelium forms the papillae of

the limbal palisades of Vogt.The epithelium of palisade zone provides the

germinative zone for the corneal epithelium.

(b)Goblet cells are present in between the epithelial cells in all regions of

conjunctiva.

(c)Melanocytes are found in the conjunctiva at limbus, fornix, and caruncle and at

the site of entry of anterior ciliary vessels.

(d)Langerhans cells were originally described in humans as dendritic cells in the

basal corneal epithelium.Now it has been demonstrated that they are also present

in almost all parts of the conjunctiva.In fact,Langerhans cells appear to represent a

highly differentiated cell line from bone marrow related to monocyte-

macrophage-histiocyte series,which are present in the epidermis,mucous

membranes,thymus and lymph nodes.These cells stain positively for ATPase and

have no desmosomes.The Langerhans cells have surface receptors for the Fc

component of IgG,the third component of compliment and surface HLA-

DR(Ia)antigen.They are not phagocytic but function in antigenic

presentation,lymphokine and prostaglandin production,and stimulation of T-

lymphocytes.They are reported to be involved in allograft rejection of the

cornea,and in contact hypersensitivity of the skin.

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2. Adenoid layer

It is also called lymphoid layer and consists of fine connective tissue reticulum in the

meshes of which lie lymphocytes.This layer is most developed in the fornices and

ends at the subtarsal fold.It is not present since birth but develops after 2-3months of

life.For this reason,conjunctival inflammation in an infant does not produce follicular

reaction.

3. Fibrous layer

It consists of a meshwork of collagenous and elastic fibres.It is thicker than the

adenoid layer, except in the region of tarsal conjunctiva, where it is very thin.This

layer contains vessels and nerves of conjunctiva.It blends with the underlying Tenon‘s

capsule in the region of bulbar conjunctiva.

The adenoid layer and the fibrous layer are collectively known as the substantia

propria of the conjunctiva.

Figure -3 Microscopic structure of conjunctiva showing three layers

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THE CONJUNCTIVAL GLANDS

The conjunctiva contains two types of glands: the mucin secretory glands (goblet

cells, crypts of henle, and glands of Manz) and the accessory lacrimal glands (glands

of Krause and glands of Wolfring)

The mucin glands

1. Goblet cells. - These are unicellular mucous glands located abundantly within the

mucocutaneous junction and limbal conjunctiva.The goblet cells are formed from the

deepest cells (basal layer) of the conjunctiva and migrate towards the surface.These

cells are destroyed after discharging their content, the mucin.The density of goblet

cells is high in children and young adults.They are more numerous on the nasal side,

particularly in the bulbar conjunctiva and inferior fornix.

The conjunctival-associated lymphoid tissue (CALT) consists of T and B

lymphocytes, without plasma cells.Further, lymphoid aggregations corresponding to

the mucosal associated lymphoid tissue (MALT) of the gut and bronchi are also found

in the conjunctiva.

The goblet cells are round or oval in shape with an eccentric flattened nucleus near

the base of the cell. It contains a prominent Golgi apparatus with numerous mucus

pockets in the cytoplasm.

The mucin secreted by goblet cells lubricates and protects the epithelial cells of the

conjunctiva and the cornea and ensures the tear film stability by lowering the surface

tension.

The absence of tear fluid has no effect on the dessication, but destruction of the goblet

cells as in epithelial xerosis (hypovitaminosis A) and parenchymatous xerosis, leads

to dessication of the conjunctiva.The number of goblet cells is greatly increased in the

inflammatory conditions.

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2.Henle’s glands-Crypts of Henle are not true glands but folds of the mucous

membrane present in the palpebral conjunctiva between the tarsal plates and the

fornices.These are tubular structures with lumina of 15-30 µm which contains a few

goblet cells.These resemble Lieberkuhn‘s crypts in the large intestine.

3. Glands of Manz-These are found in the limbal conjunctiva in animals like pig, calf

or ox.Their existence in human beings is controversial.

Figure-4 Goblet cell density in different parts of conjunctiva

Acessory lacrimal glands

1. Glands of Krause-present in subconjunctival connective tissue of fornix, about 42

in upper fornix and 8 in lower fornix

2. Glands of Wolfring-present along the upper border of superior tarsus and along

the lower border of inferior tarsus

3. Rudimentary accessory lacrimal glands.

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THE PLICA SEMILUNARIS

It is a pinkish crescentric fold of the conjunctiva,present in the medial canthus.Its

lateral free border is concave which becomes less prominent on abduction but forms a

cul-de-sac about 2mm in depth when the eyeball is adducted.It is a vestigial structure

in human beings and represents the nictitating membrane (the third eyelid)of the

lower animals.

Microscopic structure –The epithelium of this part of the conjunctiva consists of 8 to

10 layer of cells with many goblet cells.The deepest layer is cylindrical instead of the

normal cubical.

The substantia propria is composed of loose connective tissue containing numerous

blood vessels,a lobule of fat,a few non-striated muscle and melanophores.

THE CARUNCLE

The caruncle is a small (5mm x 3mm) ,soft,ovoid,pinkish mass situated in the inner

canthus,just medial to plica semilunaris.In reality,it is a piece of modified skin (a part

of the margin of the lower lid which gets cut off due to development of the inferior

canaliculi)and so is covered with stratified squamous epithelium and contains sweat

glands,sebaceous glands and hair follicles.It differs from the skin by the presence of

accessory lacrimal glands of Krause,presence of plenty of goblet cells and absence of

keratinisation in the epithelium.The connective tissue underlying the caruncle is in

contact with the septum orbitale and the medial check ligament.

Blood supply is through the superior medial palpebral artery

Lymphatics drain into submandibular lymph glands.

Nerve supply is from the inferior trochlear nerve.

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BLOOD SUPPLY OF THE CONJUNCTIVA

Arteries supplying the conjunctiva are derived from three sources:-

(1)Marginal arcade of the eyelid

(2)Peripheral arterial arcade of eyelids

(3)Anterior ciliary arteries

1. The marginal arterial arcade

It is formed by anastomosis of medial and lateral palpebral arteries and lies in the

submuscular plane in front of the tarsal plate, 2mm away from the lid margin, in each

lid.The perforating branches from the marginal arterial arcade pierce the tarsus at the

sulcus subtarsalis to reach the conjunctiva, where they divide into marginal and tarsal

branches.The tarsal branches anastomose with the branches from the peripheral

arcade.

2. The peripheral arterial arcade

It is situated at the upper border of the tarsus in the upper lid.Its perforating branches

pierce the palpebral muscles to reach the conjunctiva and sends off descending and

ascending branches.

The descending branches supply the tarsal conjunctiva and anastomose with the

branches of the marginal arterial arcade at level of sulcus subtarsalis.

The ascending branches pass upwards and then bend round the superior fornix to

descend under the bulbar conjunctiva as posterior conjunctival arteries.At about 4mm

from the limbus,the posterior conjunctival arteries anastomose with the anterior

conjunctival arteries (branches of anterior ciliary arteries)forming the pericorneal

plexus.The posterior conjunctival vessels move with the movement of the bulbar

conjunctivitis,there is hyperaemia of the superficial conjunctival vessels derived from

the posterior conjunctival vessels.

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3. The anterior cilliary arteries

These are branches of muscular arteries (total7-2 from each rectus muscle except 1

from the lateral rectus).These arteries give off anterior conjunctival arteries just before

piercing the sclera at about 4mm from the limbus.

The anterior conjunctival arteries move forward towards the limbus at a plane deeper

than the posterior conjunctival arteries.These anastomose with each other forming a

series of arcades parallel to the corneal margin and also form the pericorneal plexus.

To summarize, the palpebral conjunctiva and fornices are supplied by branches from

the marginal and peripheral arcades of the eyelids. Bulbar conjunctiva is supplied by

posterior conjunctival arteries and anterior conjunctival arteries.

VENOUS DRAINAGE OF CONJUNCTIVA

The veins from the conjunctiva drain into the venous plexus of eyelids which in turn

drain into the superior or inferior ophthalmic veins.

A circumcorneal zone of veins about 5-6mm from the limbus drain into the anterior

ciliary veins.

LYMPHATICS OF THE CONJUNCTIVA

Conjunctival lymphatics are arranged in two layers: a superficial and a deep.

Lymphatics from the lateral side drain into preauricular lymph nodes and those from

the medial side into the submandibular lymph nodes.

NERVE SUPPLY OF CONJUNCTIVA

A circumcorneal zone of conjunctiva is supplied by branches from long ciliary nerves

which supply the cornea. Rest of the conjunctiva is supplied by branches from

lacrimal, infratrochlear, supratrochlear, supraorbital and frontal nerves.

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These nerves form a subepithelial plexus in the superficial part of substantia

propria.From this plexus, the fibres pass to form an intraepithelial plexus around the

base of the epithelial cells and send free nerve fibrils between these epithelial

cells.These nerves do not posses the myelin sheath.

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PTERYGIUM

Pterygium is a Greek word meaning WING

DEFINITION:-Pterygium is a wing shaped fold on conjunctiva encroaching upon the

cornea from either side within the interpalpebral fissure at the 3 or 9 o‘clock position

adjacent to the limbus.

AETIOLOGY:-36

There are several reviews explaining the etiology of pterygium

1) Radiational Factors-There is strong circumstantial evidence that exposure to

ultraviolet light is important in the etiology of pterygium.

2) Environmental Factors-Environmental irritative factors, such as heat, dry

atmosphere, high winds and abundance of dust are most frequently associated with

this condition.

Fuchs suggested that location of pterygium was related to the degree of exposure of

bulbar conjunctiva to sunny, smoky and dusty conditions.Chemicals irritants such as

fumes of oil wells have also been proposed.

Anderson postulated a causal relationship between temperature and

pterygium.Another is microtrauma caused by dust particles.

3) Tear film abnormality- The uneven spreading of tear film gives rise to dellen

formation, when cornea becomes dry & thin the epithelium desquamates and the

Bowmans membrane along with superficial stroma gets affected causing the

pterygium to progress.

4) Inflammation and Infection factors-It has been assumed that pterygium starts

with a corneal ulcer (Von Arlt), an episcleritis (Mannhardt, Boeckmann), trachoma

(Musabeili and Ismail-Zade) or other conjunctival infection.

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5) Degenerative factor-Hyaline & elastotic degeneration changes in the deeper parts

of the tissue.

6) Allergic factor- Hilgers (1960) postulated that prolonged exposure of bulbar

conjunctiva to solar radiation produces degenerative changes with formation of

denatured protein.These proteins may cause antigen-antibody reactions.

7) Neoplastic aetiology - initially suggested by Winther (1856), has received

considerable support (Schreiter, Redslob). It was based on the fact that, pterygium

shows a progressive growth, invasion of normal tissue and recurrence after its

removal.

8) Heredity factor- Heredity has an undoubted influence in the occurrence of

pterygia although its influence is not crucial.

9) Neutrophic factor – A neurotrophic condition of the conjunctiva so that it reacts

exaggeratedly to external irritants was suggested by Sapuppo (1953).

10) Other factors – Trophic changes leading to hyperplasia (Spyratos), associated

with malnutrition (Shreck and Carriker), or a deficiency of choline (Beard &

Dimitry), or a raised cholesterol (Holt); but a relationship with deficiency diseases or

with social status of the patient has been denied.

RISK FACTORS OF PTERYGIUM

Ultraviolet light exposure (both UV-A and UV-B) appears to be the most

significant factors in the development of pterygium including living in

subtropical and tropical climates. People living near the equator are often

affected.

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People who spend considerable time in the sun (for example, farmer,

fishermen, surfers, gardeners) are much more likely to have pterygium than

people living mostly indoors.

Engaging in occupations that require exposure to ultraviolet, for example

welders.

Other agents that may contribute to the formation of pterygia include

allergens, noxious chemicals and irritants (e.g, wind, dirt, dust, air pollution).

Incidence of pterygium

Geographical distribution – Pterygium is a disease of tropical & subtropical areas.

It is common between the altitude of 37o northand south of the equator.

PATHOLOGY

Pathologically Pterygium is a Degenerative and Hyperplastic condition of the

conjunctiva.

The subconjunctival tissue undergoes elastotic degeneration & proliferates as

vascularised granulation tissues under the epithelium, which ultimately encroaches the

cornea.The corneal epithelium, Bowmans layer & superficial stroma, are destroyed.

PARTS OF PTERYGIUM27

Head (Apical part present on the cornea)

Neck (Limbal part)

Body (Scleral part extending between limbus & the canthus)

Cap (The grey subepithelial fibrous tissue at the leading edge of the head)

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TYPES27

Progressive Pterygium

Regressive Pterygium/Stationary /Atrophic

PROGRESSIVE PTERYGIUM-

Thick fleshy with prominent vascularity.

Gradually increased in size and encroaching towards the centre of cornea.

Opaque infiltrative spot (cap) is seen just in front of apex of the pterygium.

REGRESSIVE PTERYGIUM

Thin attenuated with poor vascularity.

No opaque spot is seen.

Duke Elders Classification36

Progressive (Pterygium crasum, vasculosum, carnosum)

When the growth is continuous, fleshy and vascular.

Regressive pterygium

When it ceases to grow, the vascularity disappears.The pterygium becomes

thin, grey, membranous and anaemic.

SYMPTOMS

Redness

Irritation

Watering

Foreign body sensation

Mild photophobia

Diminished vision due to covering of papillary area, diplopia due to limitation of

movements of eye ball in later condition.

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SIGNS

Triangular fold of conjunctiva seen encroaching on cornea.

Type 128

- extends less than 2mm onto cornea. A deposit of iron (Stocker line) may be

seen in the corneal epithelium anterior to the advancing head of the pterygium.

Type 228

- involves upto 4mm of the cornea and may be primary or recurrent following

surgery.

Type 328

- encroaches onto more than 4mm of the cornea and involves the visual axis.

Visual acuity normal, affected because of covering of pupillary area.

DIFFERENTIAL DIAGNOSIS30

Pinguecula

Pseudopterygium

Squamous cell carcinoma

Conjunctival intra epithelial neoplasia

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Table No-4: DIFFERENCE BETWEEN TRUE PTERYGIUM AND

PSEUDOPTERYGIUM27

PTERYGIUM PESUDOPTERYGIUM

ETIOLOGY Dengerative process Inflammatory process

AGE Usually occurs in elderly

persons

Can occur 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

MANAGEMENT OF PTERYGIUM

The management of Pterygium can be grouped as follows

a) Medical management

b) Surgical management

c) Combined Medical and Surgical management

d) Management of recurrent Pterygium

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MEDICAL MANAGEMENT

Basically treatment of Pterygium is surgical. But medical management can

be tried in cases where in the Pterygium is early small or inactive with minimal

vascularization and not encroached cornea.

1) HYALURONIDASE:

Hyaluronic acid is the connective tissue ground substance. It is very much needed for

forming new connective tissue in Pterygium.

When hyaluronidase is given subconjunctivally at this stage, it depolymerises the

hyaluronic acid which affects the connective tissue metabolism resulting in regression

or arrest of growth of the Pterygium.

Hylase is commercially available in the form of an odourless, freeze dried powder in

ampoules containing 1500IU. For clinical use freshly prepared hylase and 0.5ml of

2% Xylocaine is given subconjunctivally to the upper border of the pterygium. This

causes ballooning of the pterygium away from the sclera.The injection are repeated at

weekly intervals for 5-6 weeks.

2) CORTICOSTEROIDS

In early cases of pterygium they act by inhibiting the fibrovascular and epithelial

proliferation, there by retarding the further growth of pterygium.

They also bring down the hyperaemia and reduces the bulk of pterygium .But

pterygium does not disappear.They are used in the form of topical drops and eye

ointments.

They are also recommended post operatively after pterygium surgery, to check the

recurrences.

3) LUBRICANTS

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4) Recent advances

Angiogenic mechanisms in the pathology of pterygium i.e, abundant expression of

VEGF in Pterygium, have lead to the development of anti-VEGF therapy aimed at

inducing regression of blood vessels & size of pterygium.

SURGICAL MANAGEMENT

INDICATION-

Defective vision because of

a) Induced astigmatism

b) Progressive pterygium involving the central region of cornea.

c) Diplopia due to interference in ocular movements

d) Cosmetic reasons

e) Severe irritation not relieved by medical therapy.

TECHNIQUE27

After topical anaesthesia, eye is cleaned, draped & exposed using universal

eye speculum.

Head of the Pterygium is lifted & dissected off the cornea very meticulously.

The main mass of the pterygium is then separated from the sclera underneath

& the conjunctiva superficially.

Pterygium tissue is then excised taking care not to damage the underlying

medial rectus muscle.

Haemostasis is achieved & the episcleral tissue exposed is cauterized

thoroughly.

Next step differs depending upon the technique adopted as follows:-

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Simple excision with closure of the wound, the conjunctiva is sutured back to

cover the sclera.

Bare sclera method- Some part of conjunctiva is excised and its edges are

sutured to the underlying episcleral tissue leaving some part of sclera near the

limbus.

Free conjunctival membrane graft may be used to cover the bare sclera.

Amniotic membrane graft is used

Mucous membrane from lip.

This procedure is more effective in reducing recurrences.Free conjunctiva

from the same or opposite eye may be used as a graft.

Limibal conjunctival autograft transplantation to cover the defect after

pterygium excision is the latest & most effective technique in the management

of pterygium.

Recurrence of the pterygium after surgical excision is the main problem; however it

can be reduced by any of the following measures

Post operative Beta irradiations.

Post operative use of anti mitotic drugs such as Mitomycin-C

COMPLICATION33

Iatrogenic damage to the rectus muscles

Persistent epithelial defect

Infection

Corneal scarring

Recurrence of pterygium

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RECURRENCE RATE OF PTERYGIUM SURGERY

Bare sclera technique – 40%

Excision with mitomycini C intraoperative application – 10%

Conjunctival autograft - 8%

Mitomycin C + Conjunctival autograft – 5%

PREVENTION

The best method of preventing pterygium is to regularly wear UV 400 rated

sunglasses when outdoors in sunny conditions.

Sunglasses with a wrap around design provide better protection than those with large

gaps between the sunglasses frame and the skin around the eyes.

Wearing a hat with a wide brim provide valuable additional protection.

GREATER PREDILICATION ON NASAL SIDE:-

1) Normal flow of tears is from temporal to nasal side, towards puncti & carries dust

particles of the conjunctival sac & accumulates it in lacus lacrimalis.These

concentrated dust particles may cause greater irritation of nasal conjunctiva.

2) Greater exposure of nasal interpalpebral conjunctiva to U.V. radiation.

3) There are two anterior ciliary arteries on the nasal side & only one on the temporal

side. It is considered that due to this fact, any irritant will lead to greater hyperaemia

on the nasal side & results in pterygium on nasal side.

4) The predominance of pterygia on the nasal side is possibly a result of the sun's rays

passing laterally through the cornea, where it undergoes refraction and becomes

focused on the limbic area. Sunlight passes unobstructed from the lateral side of the

eye, focusing on the medial limbus after passing through the cornea. On the

contralateral (medial) side, however, the shadow of the nose medially reduces the

intensity of sunlight focussed on the lateral/temporal limbus.

http://en.wikipedia.org/wiki/Cornea

http://en.wikipedia.org/wiki/Corneal_limbus

http://en.wikipedia.org/wiki/Human_anatomical_terms#Anatomical_directions


http://en.wikipedia.org/wiki/Anatomical_terms_of_location#Other_directional_terms


http://en.wikipedia.org/wiki/Temple_%28anatomy%29

http://en.wikipedia.org/wiki/Corneal_limbus

A Study on Arma


FACTS ABOUT PTERYGIUM

A pinguecula may develop into pterygium.

Commonly found in individuals who spend a lot of time in the sun or

live in dry, windy, smoky, dusty, sandy tropical climates.

Reported to occur in males twice as frequently as in females.

One or both eyes may be involved.

Some pterygium grows slowly throughout a person‘s life while others

stop growing after a certain point.

Not dangerous (non- malignant) but can become uncomfortable.

Can eventually distort vision due to growth onto the cornea &

eventually even onto the central part of the eye blocking light from

entering.

Removing a pterygium surgically will take care of the problem.

Rate of recurrence is as high as 40% and they tend to come back bigger

and faster.

A Study on Arma


DRUG REVIEW

Acharya Charaka has considered dravya as one among the chikitsa chatushpada, thus

giving a vital role in treating the diseases. Without the knowledge of the dravya, the

knowledge of ayurvedic system of medicine becomes incomplete.

The yogas selected in the present study are ‗Pippalyadya Anjana‘ mentioned in Yoga

ratnakara, Netra Roga Nidana – Chikitsa Prakarana and ‗Shatavaryadi churna‘

mentioned in Yoga ratnakara, Netra Roga Nidana – Chikitsa Prakarana. Narikela

Rasakriyanjana mentioned in Sahasra yoga.

The Drugs of Pippalyadya Anjana:

PIPPALI

Botanical name - Piper longum

Family - Piperaceae

Synonyms - Kana, Krsna, Kola, Capala, Tiksna Tandula, Magadhi,

Vernacular names - English- Long pepper

Hindi- Pipala

Part used - Fruit

Pharmacodyamics - Rasa- Katu

Guna- Laghu, Snigdha, Teekshna, Pramathi

Veerya- Anushna sheetha

Vipaka-Madhura

Doshagnata- KaphaVata shamaka (shushka);

Pittashamaka (ardhra)

Chemical constituents - Piperine, Pipalatine Pipalatine alkaloid, Sesanin,

Pipalsetrol.

A Study on Arma


Action - chakshushya, rasaayana, deepana

Gana- Dipaniya, Kanthya, Asthapanopaga, Sirovirecanopaga (ch)

Pippalyadi, Urdhvabhagahara (su)

Pippalyadi (vag)

VIBHITAKI

Botanical name - Terminalia bellerica

Family - Combretaceae

Synonyms - Bibhitaka, Karshaphala, Kalidruma

Vernacular names - English name - Belleric Myrobolan.

Hindi name - Baheda, Bhaira

Kannada name - Tare Kayi, Santi Kayi.

Part used - Fruits, Seed.

Pharmacodynamics - Rasa - Kashaya

Guna - Laghu, Ruksha

Veerya - Ushna

Vipaka - Madhura

Doshagnata - Kapha Pittahara

Chemical constituents - Tannin and essential oils, saponins, - sitosterol, chebulagic

acid, ellagic acid, gallic acid, oxalic acid, oleic and linoleic acid.

Action - Chaksushya, Keshya, Krimighna, Charmarogahara, Deepana, Dhatuvardaka.

Gana – Jvarahara, Kasahara, Virechanopaga (Ch)

Triphala, Mustadi (Su)

Haritakyadi (Bh.P)

A Study on Arma


AMALAKI

Botanical name - Emblica Officinalis

Family - Euphorbiaceae

Synonyms - Vayasya, Dhatriphala, Amritaphala

Vernacular names - English name -EmblicMyrobolan, IndianGooseberry

Hindi name -Amla, Amalak

Kannada name -Nelli, Nellikai

Part used - Fruit

Pharmacodynamics - Rasa - Lavana varjita pancha rasa

Guna - Guru, Ruksha

Veerya - Sheeta

Vipaka - Madhura

Doshagnata - Tridoshahara

Chemical constituents - Tannins, Gallic acid, ellagic acid, Glucose, Vitamin C,

Proteins; sitosterol, diterpene, triterpene, flavonoid glucosides

Action - chakshushya, rasaayana

Gana - Jvaragna, kustagna, vayasthapana (Ch)

Amalakyadi, Parushakadi, Triphala (Su)

Parushakadi (Vag)

Research Works on antioxidant effect -

i). Ghosal et al., 1996 – Antioxidant effect is due to low molecular weight

tannins.

ii). Tewari et al., 1968 – By raising the total protein level and brings a positive

nitrogen balance.

A Study on Arma


HARITAKI

Botanical name - Terminalia Chebula

Family - Combretaceae

Synonyms - Abhaya, Pathya, Shiva, Vayastha

Vernacular names - English name - Chebulic myrobolan

Hindi name -Harad

Kannada name -Karakkayi, Alalekayi

Part used - Fruit

Pharmacodynamics - Rasa - Lavana varjita Pancha rasa

Guna - Laghu, Ruksha

Veerya - Ushna

Vipaka - Madhura

Doshagnata - Tridoshashamaka

Chemical constituents - Chebulinic acid, gallic acid, tannin, anthraquinone, lindric,

oleic, palmitic and stearic acids.

Action –Netraroga, Kustagna, Rasayana, Brumhana, Ropana, Shothahara,

srothovibandhahara

Gana – Jvaragna, Kustagna, Arshogna, Kasaghna (Ch)


Parushakadi (Vag)

Research works on antioxidant and adaptogenic activity –

Fu Naiwu et al., 1992 and Chem. Abstr. 1993, 119, 269367C

A Study on Arma


LAKSHA

Botanical Name: Laccifer (Tuchardia), Lacca Kerr (Lac producing insect)

Family- Coccideae

Part used- Lac (Lac resin).

Pharmacodynamics Rasa – Tikta, Kashaya

Guna – Laghu, Snigdha

Veerya – Usna, anushna

Vipaka – Katu

Doshagnata - Kaphapittanashaka, Pittaprashamana.

Chemical Constituents: Resin or Resinous matter, wax and coluring matter,

Pigment Laccin. Lac resin is composed of inter esters of hydroxyl fatty acid

derivatives; Aleuritic acid is the major constituent.

Action -Sandhaniya, Kasagna,

LODHRA

Botanical Name - Symplocos racemosa

Family - Symplocaceae

Synonyms - SambaraSthula, valkala, Rodhra, Aksibhaisajya, Kandahina

Vernacular names - English – Symplocos tree

Hindi-Lodhra

Kannada – Pachettu

Part used - Stem Bark, flower

Pharmacodynamics Rasa - Kashaya Tikta

Guna - Laghu Ruksha

Vipaka - Katu

Virya - Sheeta

A Study on Arma


Doshagnata - Kapha Pittahara.

Chemical Constituents: Symposide, epifzelechin, loturine, loturidine, colloturine etc.

Action - Chaksusya, Rakta sthambana, Vranaropaka.

Gana: Sonitasthapana, Sandhaniya, Kasaya skandha (ch)

Lodhradi, Nyagrodhadi gana (su)

Nyagrodhadi, Rodhradi (vag)

SAINDHAVA LAVANA

Latin Name: Sodium Chloride

Synonyms: Sindhu,Sindhuttha,Nadeya,

Sindhuja, Shiva,Manimantha.

Vernacular Names Sanskrit- Saindhava lavana

Kannada - Sendra lavana, sendhur lavana

Hindi -Sendhalon

English -Rock salt, sodium chlorate

Pharmacodynamics Rasa- Lavana, Susvadu (Ishad Madhura)

Guna- Tikshna Laghu, Snigdha, Sukshma, Vyavayi

Virya- Shita

Vipaka-Madhura

Doshaghnata-Tridoshara

Action Dipana, Pachana, Vrushya, Ruchya, Avidahi.

BHRUNGARAJA

Botanical name - Eclipta alba

Family - Compositae

A Study on Arma


Synonyms - Markava, Kesharaja, Kesharanjana, Bhrungara

Vernacular names - English name - Eclipta

Hindi name -Mochkand, Bhangra

Kannada name -Garga

Part used - Panchanga

Pharmacodynamics - Rasa - Katu, Tikta

Guna - Laghu, Ruksha,

Veerya - Ushna

Vipaka - Katu

Doshagnata - Kapha Vata hara

Chemical constituents - Ecliptine (alkaloid), Nicotine, -Carotene Saponins, Stigma

sterol, phytosterol-A, 5 amino acids – cystine, glutamic acid, phenylalanine, tyrosine

& methionine, fatty acids. Roots –stigmasterol, triterpenoid

Action -Chaksusya, Keshya, Twachya, Krimigna, Rasayana, Balya, Shirorogahara.

The Drugs of Shatavaryadi Churna:

SHATAVARI

Botanical name - Asparagus racemoses

Family - Liliacea

Synonyms - Satamuli, Satavirya, Suksamapatra, Atirasa.

Vernacular names- English-Pillipichara

Hindi-Satavare

Kannada- Majjige gadde

Part used- Tuberous roots.

Pharmacodynamics Rasa- Madhura, Tikta

A Study on Arma


Guna- Guru, Snigdha

Veerya- Sheeta

Vipaka-Madhura

Doshagnata-VataPitta shamaka

Chemical constituents

Sarsapogenin, 2Spirostanolic, 2Furostanolic, Sponins, Sitosterol.

Action-Chakshushya, rasayana

Gana-Balya, Vayahsthapana, Madhura skandha (ch)

Vidarigandhadi (su)

Vidarigandhadi (vag)

ELA

Botanical name - Elletaria Cardemomum

Family - Scitaminaceae

Synonyms - Dravidi, Triputa, Trti.

Vernacular names- English - Lesser Cardamom

Hindi - Choti Ilaychi

Kannada - Elakki

Part used - Fruit

Pharmacodynamics- Rasa - Katu, Madhura

Guna - Laghu, Rooksha

Veerya - Sheetha

Vipaka - Madhura

Doshagnata - tridosha shamaka

Chemical constituents - Stable oil 5%, Volatile oil 3%, Starch 3%, Mucin 2%,

Bhasma 6-10% Bhasma contains Manganese

A Study on Arma


Gana- Sirovirecana, Angamarda prasamana (ch)

Eladi (su)

Eladi, Caturjataka (vag)

VIDANGA

Botanical name - Embelia ribes

Family - Myrsinaceae

Synonyms - Vrishanasana, Chitratandula, Janthunashana

Veranacular names - English name - Babreng.

Hindi name -Baberung

Kannada name-Vayuvidanga

Part used - Berries (Fruit), Leaves and Root Bark

Pharmacodynamics - Rasa - Katu

Guna - Laghu, ruksha, teekshna.

Veerya - Ushna

Vipaka - Katu

Doshagnata - Kapha Vatahara

Chemical constituents - Alkaloids – Christembine, Flavonoids, Quinones – embelin,

vilangin which are the major active principles, proteins and saponins.

Action -Rasayana

Vidanga is the greatest Rasayana dravya. It gradually reduces the rigidity of the body,

improve circulation, agni and texture of the skin. Vidanga and iron formulations can

be used as very good rasayana.

A rasayana dravya -as quoted by sushruta

Gana - Krimigna, Kustagna, Truptigna (Ch)

A Study on Arma


Surasadi, Pippalyadi (Su)

Surasadi, Pippalyadi (Vag)

AMALAKI

Botanical name - Emblica Officinalis Gaertn

Natural order - Euphorbiaceae

Synonyms - Vayasya, Dhatriphala, Amritaphala

Vernacular names English name -EmblicMyrobolan, Indian Gooseberry

Hindi name -Amla, Amalak

Kannada name -Nelli, Nellikai

Part used - Furit

Pharmacodynamics - Rasa - Lavana varjita pancha rasa

Guna - Guru, Ruksha

Veerya - Sheeta

Vipaka - Madhura

Doshagnata - Tridoshahara

Chemical constituents - Tannins, Gallic acid, ellagic acid, Glucose, Vitamin C,

Proteins; sitosterol, diterpene, triterpene, flavonoid glucosides

Action - chakshushya, rasaayana

A Rasayana which acts on all dhatus

Gana - Jvaragna, kustagna, vayasthapana (Cha)


Parushakadi (Vag)

A Study on Arma


Research Works on antioxidant effect -

i). Ghosal et al., 1996 – Antioxidant effect is due to low molecular weight

tannins.

ii). Tewari et al., 1968 – By raising the total protein level and brings a positive

nitrogen balance.

PIPPALI

Botanical name - Piper longum

Family - Piperaceae

Synonyms - Kana, Krsna, Kola, Capala, Tiksna Tandula, Magadhi,

Vernacular names - English- Long pepper

Hindi- Pipala

Part used -Fruit

Pharmacodyamics Rasa- Katu

Guna- Laghu, Snigdha, Teekshna, Pramathi

Veerya- Anushna sheetha

Vipaka-Madhura

Dosha Karma- KaphaVata shamaka (shushka);

Pittashamaka (ardhra)

Chemical constituents- Piperine, Pipalatine Pipalatine alkaloid, Sesanin, Pipalsetrol

Action- chakshushya, rasaayana, deepana

Gana- Dipaniya,Kanthya, Asthapanopaga,Sirovirecanopaga(ch)

Pippalyadi,Urdhvabhagahara(su)

Pippalyadi (vag)

A Study on Arma


MARICHA

Botanical name - Piper nigrum

Family - Piperaceae

Synonyms - Usana, Krsna, Vellaja,Sakanga.

Vernacular names - English- Black pepper

Hindi-Kali Mirchi

Kannada- Karemanesu

Part used - Fruit

Pharmacodynamics Rasa- Katu

Guna- Laghu, Teekshna, Pramathi

Veerya- Ushna

Vipaka- Katu

Doshagata- KaphaVatahara

Chemical constituents- Piperine, alkaloid, Sesanin, Pipalsetrol

Action- chakshushya, Rasayana, deepana.

Gana- Dipaniya, Sirovirecanopaga(ch)

Pippalyadi (su)

Pippalyadi (vag)

MADHU

English name - Honey

Hindi name - Shehad

Kannada name - Jenutuppa

Pharmacodynamics - Rasa - Madhura, Kashaya

Guna - Laghu, Ruksha, Sukshma

Veerya - Sheeta

A Study on Arma


Vipaka - Madhura

Doshagnata - Kapha Pittahara

Chemical constituents – Glucose 84.9%, formic acid, sucrose 2.69%, alkaloids

0.12%, nitrogen 1.29%

Action - Vilekhana, Deepana, Srotovishodhana, Deepana

Yogavahi – pervades the minute srotas

GHRUTA

English name - Ghee (Cow‘s Ghee)

Hindi name - Ghee

Kannada name - Tuppa

Pharmacodynamics - Rasa - Madhura

Guna - Guru, Snigdha

Veerya - Sheeta

Vipaka - Madhura

Doshagnata - Pitta Vata hara

Action - Ojovruddhikara, Balya, Rasayana

The Drugs of Narikela Rasakriya Anjana

RASAANJANA/ DARUHARIDRA:

Botanical name - Berberis aristata

Family - Berberidacea

Synonyms - Daru nisa, Pita daru, Pacampaca, Katankateri, Parjani, Darvi

Vernacular names- English- Indian Berry

Hindi- Daruhaldi

Part used - Root, Stem, and Fruit.

A Study on Arma


Pharmacodyamics Rasa- Tikta, Kashaya

Guna- Laghu, Rooksha

Veerya- Ushna

Vipaka- Katu

Doshagata- Kapha Pitta shamaka

Chemical Constituents- Berberin, Oxyanthin, Umballitine

Action- Chakshushya

Gana- Arsoghna, lekaniya (ch)

Haridradi, Mustadi (su)

Haridradi, Mustadi (vag)

YASHTI MADHU

Botanical name - Glycyrrhiza glabra

Family - Leguminaceae

Synonyms - Klitaka, Madhuka, Jalajayasti, Madhuyasti

Vernacular names - English- Liquorice

Hindi- Mulethi

Part used - Root

Pharmacodyamics - Rasa- Madhura

Guna- Guru, Snigdha

Veerya- Seetha

Vipaka- Madhura

Doshagata- Tridosahara

Chemical Constituents- Glycyrrhizin, Glycyrrhetinic acid, Liquirtin, Glabrine

Action- Chakshushya, Rasayana

Gana- Jivaniya, Sonitasthapana, Kanthya, Vamanopaga.(ch)

A Study on Arma


Kakolyadi, Sarivadi, Anjanadi (su)

Sarivadi, Anjanadi (vag)

NARIKELA

Botanical name - Cocos nucifera

Family - Palmae

Synonyms - Nalikera, Trnaraja, Drdha phala, Tunga.

Vernacular names - English- Coconut tree

Hindi- Narial

Part used - Fruit, Flower, Oil, Root, Fruit shell

Pharmacodyamics - Rasa- Madhura

Guna- Guru, Snigdha

Veerya- Seetha

Vipaka- Madhura

Doshagata- Vatapittahara

Chemical Constituents - Phenol, p-cresol, Caproic acid, Crotonaldehyde, Furfural

Action- Balya, Brmhana

KARPURA

Botanical name - Cinnamomum Camphora

Family - Lauraceae

Synonyms - Ghanasara, Candraprabha, Sitabhra, Hima, Himavaluka

Vernacular names - English- Camphor

Hindi- Karpur

Part used - Niryasa

Pharmacodyamics - Rasa- Tikta, Katu, Madhura

Guna- Laghu, Ruksa

A Study on Arma


Veerya- Seetha

Vipaka- Katu

Doshagata- Tridosahara

Chemical Constituents - Campher, Campherol, Cineol, Pinene, Camphene,

Dipentene, Terpineol, Safrole, Reticuline.

Action- Chakshushya,

A Study on Arma


RESULT OF DRUG ANALYSIS

1. Name of the sample: PIPPALYADYA ANJANA

Description: The varthi is black in colour

Results of Analysis

Identity, purity and strength Found

Loss on drying at 110deg .C - 5.03% w/w

Total Ash - 19.14% w/w

Acid insoluble Ash - 3.56% w/w

Alcohol soluble extract - 44.19% w/w

Water soluble extract - 36.9% w/w

pH of 1% aqueous solution - 4.19

A Study on Arma


2. Name of the sample: SHATAVARYADI CHURNA

Description: The powder is light brown in colour, odour characteristic and bitter and

pungent in taste

Results of Analysis

Identity, purity and strength Found

Loss on drying at 110deg .C - 7.77% w/w

Total Ash - 3.6% w/w

Acid insoluble Ash - 0.59% w/w

Alcohol soluble extract - 17.568% w/w

Water soluble extract - 32.264% w/w

pH of 1% aqueous solution - 4.30

A Study on Arma


INGREDIENTS OF PIPPALYADYA ANJANA

PIPPALI AMALAKI HARITAKI

VIBHITAKI LODHRA LAKSHA

SAINDHAVA BHRINGARAJA SWARASA PIPPAYADYA ANJANA

A Study on Arma


INGREDIENTS OF SHATAVARYADI CHURNA

SHATAVARI AMALAKAASTHIBEEJA PIPPALI

VIDANGA MARICHA ELA

]

SHATAVARYADI CHURNA

A Study on Arma


PROCEDURE REVIEW

ANJANA:

Anjana is one among the kriyakalpas. It forms an important line of management.

iÉmÉïhÉÇ mÉÑOûmÉÉMü¶É xÉåMü AÉ¶rÉÉåiÉlÉÉgeÉlÉå|

iÉ§É iÉ§ÉÉåmÉÌS¹ÉÌlÉ iÉåwÉÉÇ urÉÉxÉÇ ÌlÉoÉÉåkÉ qÉå|| 6(Su.S.Ut.18/4 p.633)

Anjana is one of the topical drug administrations in netra rogas, which is usually

adopted after tarpanadi karma. Thus it can be an approach in advance stages of all eye

diseases.

NIRUKTI AND PARIBHASHA:

*AerÉiÉåÅlÉålÉ AlÉÑeÉç MüUhÉå srÉÑOèû| 1(pg94)

The word Anjana is derived from the root ‗anuj‘ added with ‗lyut‘ pratyaya.

*AlÉÌ£ü AlÉålÉ CÌiÉ AgeÉlÉ| 1(pg94)

To anoint or to smear with is anjana.

*qÉë¤ÉhÉÇ| aÉqÉlÉqÉç| urÉ£üÏMüUhÉÇ| 1(pg94)

That which spreads or propagates is Anjana.

*AlÉÌ£ü mÉëiÉÏcrÉÉÇ ÌSÍzÉ U¤ÉMüiuÉålÉ mÉëMüÉzÉiÉå rÉÈ| 1(pg94)

Anjana increases the brightness, protects the eye and enables to see in all directions

clearly.

*AgeÉlÉ zÉoSÉåÅprÉgeÉlÉåÅÌmÉ uÉiÉïiÉå, iÉSjÉïqÉ¤rÉgeÉlÉÍqÉirÉÑ£üqÉç| 8(Cha.S.Su.5/14 p.38)

Abhyanjana means akshi anjana

Thus anjana is a topical application of drugs into the eye in the form of a smooth paste

with the help of a shalaka or finger. This clears the defects in vision due to

accumulation of doshas, thus enhancing the power/function of vision.

A Study on Arma


INDICATION OF ANJANA:

urÉ£ü ÃmÉåwÉÑ SÉåwÉåwÉÑ zÉÑ®MüÉrÉxrÉ MåüuÉsÉå|

lÉå§É LuÉå ÎxjÉiÉå SÉåwÉå mÉëÉmiÉqÉgeÉlÉqÉÉcÉUåiÉç||6(S.S.Ut.18/51-52 p.636)

urÉ£ü ÃmÉåwÉÑ xÉÉqÉiÉÉ AmÉaÉqÉålÉ urÉ£üÉiqÉÃmÉ mÉëÉmiÉåwÉÑ|

According to this statement, anjana is never applied in saamaavastha. After Shirah

kaaya shodhana, when the doshas purely localize in eye, then anjana is applied to

remove it from this region.

mÉë¤ÉÉsrÉ xmÉ×zÉiÉÉÇ MüÉrÉïÇ xÉqrÉXçlÉå§ÉÉgeÉlÉÇ §rÉWûÉiÉç| 8(Cha.S.Chi 26/236 p.690)

lÉå§ÉgeÉlÉÇ §rÉWûÉÌSirÉ§É mÉëÉrÉÉåÅÍ¤ÉUÉåaÉÉhÉÉÇ §rÉWåûhÉ mÉÉMüÉiÉç §rÉWûÉÌSirÉÑ£üqÉç|

mÉÉMüsÉ¤ÉhÉÇ iÉl§ÉÉliÉUå- ― mÉëzÉxiÉuÉiqÉïiÉÉ cÉÉ¤hÉÉå: xÉÇUqpÉÉ´ÉÑmÉëzÉÉliÉiÉÉ|

qÉlSuÉåSlÉiÉÉ MühQÕûÈ mÉYuÉÉÍ¤ÉaÉS sÉ¤ÉhÉqÉç|| ‖

After a thorough wash anjana should be applied to netra, but only after 3 days of

vyaadhi utpatti. The 3 days indicates paaka kaala of netra rogas from saamavastha.

Reduction in watering, swelling of lids, pain, itching indicates paaka lakshana.

TYPES OF ANJANA:

A. Karma Bhedha: - According to the action: 6( Su.S.Ut.18/76 p.638)

1. Lekhana Anjana

2. Ropana Anjana

3. Snehana / Prasadana Anjana

Anjana prepared with tikta, kashaya, amla, katu, lavana and kshara dravyas are

used as lekhana anjana.

Anjana prepared from kashaya, tikta dravyas and oil or ghee is used as ropana

anjana.

A Study on Arma


Anjana prepared with madhura dravyas, oil and ghee, is used as snehana /

prasadana anjana.

B. Akruthi Bhedha:- According to the form they can be made into 3

types:6(Su.S.Ut.18/88 p.637)

1. Pindi or gutika

2. Rasakriya

3. Choorna

In conditions where the doshas are prabala Pindi / gutika anjana is used. In cases of

madhyama dosha, Rasakriya is used. Choorna is used in case of durbala dosha.

C. Based on Dravya Veerya:- According to Potency of Drug.

1. Mrudu anjana * Snehana

* Ropana

* Prasaadana

2. Teekshna anjana Lekhana

D. Based on Rasa: According to drug taste

Madhura anjana, Amla anjana, Lavana anjana, Katu anjana, Tiktha anjana,

Kashaya anjana

DOSE OF ANJANA:

According to Sushrutha 6(Su.S.Ut.18/59 p. 637)

Lekhananjana – 1 harenu

Ropananjana – 1 ½ harena

Snehana / Prasadananjana – 2 harenu.

According to Sharangadhara:

Gutikanjana with Tikshna (LEKHANA) - 1 harenu

(Pill form) Madhyama (ROPANA) - 1 ½ harenu

A Study on Arma


Mrudu (SNEHANA) - 2 harenu

Rasakriyanjana uttama matra - 3 vidanga

(Semisolid form) Madhyama matra - 2 vidanga

Heena matra - 1 vidanga

Choornanjana for virechana karma (LEKHANA) - 2 shalakas

(Powder form) for mrudu karma (ROPANA) - 3 shalakas

for snehana karma (SNEHANA) - 4 shalakas.

Each succeeding one is poorer in efficacy than the previous one.

Time for Application of Anjana:

Anjana is applied to the eyes when the doshas have become pakwa. According

to Sushrutha, anjana should be applied in the morning, noon and night according to

the dosha vitiated. In kaphaja vikara, it should be applied in the morning. In vataja

vikara it is applied in the evening. In pittaja vikara, it is applied during night.

According to Sharangadhara:

In hemantha & sishira ritu- afternoon

Grishma ritu - morning time

Sarat ritu - evening time

Varsha ritu - time when it is neither too cold nor too hot

(Having no clouds)

Vasantha rutu - at any time

♦ LEKHANADI ANJANA DRAVYAS:

iÉ§É mÉgcÉUxÉÉlÉç urÉxiÉÉlÉÉ±æMüUxÉuÉÎeÉïiÉÉqÉç|

mÉgcÉkÉÉ sÉåZÉlÉÇ rÉÑgerÉÉiÉç rÉjÉÉSÉåwÉqÉiÉÎlSìiÉÈ|| 6(Su.S.Ut.18/53 p. 636)

All 5 rasas excepting madhura rasa based on dosha has to be selected for lekhana

anjana.

A Study on Arma


In Vata dosha amla, lavana

Pitta dosha tikta, kashaya

Kapha dosha katu, tikta, kashaya

Rakta dosha pittavat

Sannipata combination of 2 or 3 rasas.

Definition of Lekhanaanjana:

sÉåZÉlÉÇ SÉåwÉxÉëÉuÉhÉÉlÉç lÉrÉlÉxrÉ ËU£üÏMüUhÉqÉç|

Lekhana brings about dosha sraavana and there by eye becomes clear from doshas.

Mode of action:

lÉå§ÉuÉiqÉïÍxÉUÉMüÉåzÉxÉëÉåiÉÈ zÉÚ…¡ûÉOûMüÉÍ´ÉiÉqÉç|

qÉÑZÉlÉÉxÉÉÍ¤ÉÍpÉSÉåïwÉqÉÉåeÉxÉÉ xÉëÉuÉrÉå¨ÉÑ iÉiÉç|| 6(Su.S.Ut.18/54 p.637)

The mode of action of lekhana anjana has an effect on the siras of netra palakas, netra

srothosas, and the Shringataka marmas. It brings out the vitiated doshas accumulated

in the eye and hence improves the vision.

♦ ROPANAANJANA:

MüwÉÉrÉÇ ÌiÉ£üMÇü uÉÉÅÌmÉxÉxlÉåWÇû UÉåmÉhÉÇ qÉiÉqÉç|

iÉiÉç xlÉåWûzÉæirÉÉSè uÉhrÉï xrÉÉSè SØ¹å¶É oÉsÉuÉkÉïlÉqÉç|| 6(Su.S.Ut.18/55 p 637)

Ropanaanjana should be prepared with drugs having kashaya,tikta rasas and

snehadravyas such as ghrutha. It is good for healing purpose.

Mode of action:

Due to sheeta veerya and snigdhata of grutha it improves colour and promotes vision.

A Study on Arma


♦ PRASAADAANJANA:

qÉkÉÑUÇ xlÉåWûxÉÇmÉ³ÉqÉgeÉlÉÇ iÉÑ mÉëxÉÉSlÉqÉç|

SØÌ¹SÉåwÉmÉëxÉÉSÉjÉïÇ xlÉåWûlÉÉjÉïÇ cÉ iÉÎ®iÉqÉç|| 6(Su.S.Ut.18/56 p.637)

Prasaadanjana should be prepared with the drugs of madhura rasa and with plenty of

ghrita in it. It imparts soothing of the doshas of vision and is beneficial for the unction

purpose also.

Pindi or gutikanjana should be used in severe diseases, rasakriyanjana in medium

diseases and choornaanjana in mild condition of doshas of the diseases.

Samyak Lakshanas of lekhananjana:

There will be clarity in vision, lightness, free from discharges, improved power of

vision, absence of secretion and eye will be free from complications. These are the

symptoms indicating proper action of lekhananjana.

Ati Yoga Lakshanas of lekhananjana:

Excessive lekhananjana results in the eye become crooked, hard, with abnormal

colour, drooping, too rough and discharges excessively.

Management:

Santarpana karma should be adopted for the management of atiyoga.For this, netra

tarpana is the ideal method of choice.Along with other vata- alleviating measures.

Hina Yoga Lakshanas of lekhananjana:

In case anjana is applied in less quantity, then the doshas will be vitiated in excess.

Management:

In such cases doshas can be eliminated by Nasya, Dhooma and Anjana therapy.

A Study on Arma


Contra – Indication for Anjana Application:

Anjana should not be applied to person suffering from shrama, udavarta,

vegavarodha, rodhana, .madyapana, Krodha, Bhaya, jwara, shiroroga.

In condition of nidrakshaya, if anjana is applied it leads to netra kriya hani. If anjana

is applied in places where there is excess of wind, it leads to loss of vision.If eye is

contaminated with dust and dirt it leads to srava and adhimantha. Applying anjana at

the end of nasya karma leads to netra shopha, shoola etc.In case of shirashoola

application of anjana will increase it.Anjana if applied soon after shirahsnana,

sheetakala, before sunrise one will not be able to achieve proper anjana lakshanas, as

the dosha in this period will be in vitiated condition.In case of ajeernasvastha, if

anjana is applied, it leads to doshavriddi, as there will be srotorodha.

During vegavastha,anjana prayoga leads to upadravas like raga,shopha,etc.Therefore

physician must take care of all the above condition to avoid complication.The above

contra-indication relates particularly to lekhanajana.

The symptoms should be treated with seka, aschotana, lepa, dhoomapana, kavala,

nasya with due regard to specific nature of deranged doshas.

Shalaka:

Shalaka is an instrument by which anjana is applied to the eye. The two sides

of the shalaka used resemble the mukula or mallikadi kusuma. It should be 8 angulas

in length and devoid of karkashata. The shalaka should be of copper (tamra) for

lekhana karma. In ropanaanjana finger is used as shalaka. Gold and silver shalaka are

used in Prasaadaanjana.

A Study on Arma


Anjana paatra.

The containers for storing the anjana should also be made of similar properties such as

gold, silver, horn, vaidurya, bell metal, copper and iron for storage of madhuradi

shadrasa yukta anjana respectively.

Anjana Vidhi:

urÉ£ü ÃmÉåwÉÑ SÉåwÉåwÉÑ zÉÑ®MüÉrÉxrÉ MåüuÉsÉå|

lÉå§É LuÉå ÎxjÉiÉå SÉåwÉå mÉëÉmiÉqÉgeÉlÉqÉÉcÉUåiÉç|| 6(Su.S.Ut.18/ 51-52 p .636)

When the clinical features of doshas have become manifest, the body of the patient

has been cleansed and the doshas have got localized in the eyeball proper, the

appropriate collyrium should be applied.

The lids of the affected eye should be drawn apart with the left hand of the physician

and anjana should be carefully applied by holding the shalaka in the right hand, and

by constant movement of the rod from the kaneenika to the apaanga and viceversa.

Taking care not to apply the anjana too less nor in excess or neither thick nor very

thin and applied with finger when it would be necessary to be used on the lids. The

collyrium which is meant to be applied on the lids only should be applied with fingers

alone. After application, the eyes are closed and the eyeball should be moved slowly

so that the anjana will spread uniformly.

Precautions to be taken:

The physician should not apply excessive collyrium towards the inner as well as the

outer ends of the palpebral fissure nor should he produce discomfort in the eye during

its application. Washing should not be done until the doshas are completely

eliminated because in such case the recurrence of doshas is likely to damage the

A Study on Arma


visual capacity. Opening and closing, blinking, squeezing and washing of the eyes

should not be done as the doshas may stagnate in the eyes.

PROCEDURE OF ANJANA KARMA

A Study on Arma


Churna kalpana:

Churna is a synonym of ‗Sushka Kalka‘.

AirÉliÉ xÉÔ¤qÉÇ rÉiÉç SìurÉÇ xÉÑÌmÉ¹Ç uÉx§ÉaÉÉÍsÉiÉqÉç|

iÉiÉç xrÉÉiÉç cÉÔhÉïÇ UeÉÈ ¤ÉÉåQûÈ iÉlqÉÉ§ÉÉ MüwÉï xÉÇÍqÉiÉÉ|| 18(Sh.S.Mk.6 p.137)

A dry powder, filtered through a fine cloth is called as Churna.

Types of choorna:

i) Sthula churna: Coarse powder – for Hima, Phanta, Kashaya

ii) Sookshma: Fine powder – for Vati, Lehya, Nasya

iii) Atyanta sookshma (vastra gaalita): very fine – for bhasmas, anjanas.

General method of preparation:

The drug, taken in completely dry form should be pounded well in ‗Ulookala yantra‘

(pounding machine) and sieved through different sized sieves, as per the need and

use.

Shelf life: 6months.

According to Shaarangadhara – 2 months.

General dose of Churna: 1 karsha=12 gms

Advantages of Powder form:

a) fixation of the dose is more easier

b) Powders are more stable than liquids, because chemical reactions take place more

rapidly in atmospheric conditions when the drugs are in liquid form.

c) The finer or smaller sized particles/powders dissolve more rapidly in the body

fluids than other solid dosage forms of medicament.

The rapid dissolution increases the blood concentration in shorter time, there by

the action is produced in a lesser time.

They are more economical compared to other preparations

A Study on Arma


METHODOLOGY

A definite protocol of the study is one among the basic requirement to be fulifilled in

a clinical study .The methodology followed in the present study consist the following

aspects

Aims and objectives

Source of data

Selection of patient

Inclusion and exclusion criteria

Study design

Treatment schedule and follow up

Assesment criteria

Assesment of response.

Aims and objectives

1. To evaluate the efficacy of Pippalyadya anjana in the management of Arma.

2. To evaluate the efficacy of Shatavaryadi churna internally in the management

of Arma.

3. To evaluate the efficacy of Narikela rasakriya anjana in the management of

Arma.

4. To establish the significance of the efficacy of Pippalyadya anjana by

comparing it with the efficacy of Narikela rasakriya anjana in the

management of Arma, which is an established study

5. To establish the significance of the efficacy of Shatavaryadi churna internally

by comparing it with the efficacy of Narikela rasakriya anjana in the

management of Arma, which is an established study

A Study on Arma


Source of data

Patients were selected from the out patient and in patient departments of Sri.

Jayachamarajendra Institute of Indian Medicine, Bangalore between December 2010

to Januray 2012.

Selection of patient

The selection was done on the basis of clinical examination. A careful clinical history

of all those patients complaining of Netra ragata, Ashrusrava and Toda were

considered.The patients were then subjected to a throrough, examination and after

establishing the diagnosis; the patients were taken for the clinical study.

Inclusion criteria

Patient aged below 15-55 years

Clinical features as per classics

Pterygium presented with or without Redness, Watering, and Foreign body

sensation.

Sex, either sex.

Pterygium which is limited to limbus

Exclusion criteria

Patient with any other systemic disease.

Pseudopterygium

The patient who had undergone excision of pterygium (recurred)

Study design

Group A- 15 Patients were subjected for Pippalyadi anjana.

Group B- 15 Patients were subjected for Shatavaryadi churna internally.

Group C-15 Patients were subjected for Narikela rasakriya anjana.

A Study on Arma


Procurement of the Drugs

The drugs for the Pippalayadya anjana and Shatavaryadi churna were procured from

the Sri Ayurvedic Centre Banagalore.

Preparation of the Drugs

Preparation of Pippalayadya anjana

Pippali, Triphala, Laksha, Lodhra, Saindhava are taken in equal quantity & pounded

in khalva yantra till it becomes fine powder.Vastraghalana is done to get fine

powder.This fine powder is taken, and then subjected to bhavana with sufficient

quantity of Bhringaraja swarasa till it become soft in consistency.This is then made

into varthi form of about 2cm length and dried in sun shade and preserved in air tight

container.

Preparation of Shatavaryadi churna

12 parts of shatavari, 10 parts of ela (seeds), 8 parts of vidanga, 6 parts of

amalakasthibija, 4 parts of maricha and 3 parts of pippali .All ingredients were taken

and powdered separately by using kalva yantra, sieved through a clean cotton cloth

(Kora cloth) .All the powders of the drugs were then thoroughly mixed together over

kalva yantra and then stored in airtight container.

Narikela rasakriya anjana was the market sample from The Nikhila Karnataka

central Ayurvedic pharma, Batch no MS-33

DURATION AND MODE OF ADMINISTRATION OF THE YOGAS

Group A: Pippalayadya anjana

Purvakarma – The patient is explained about the entire procedure, and then patient is

made to sit on a knee height chair comfortably

A Study on Arma


Pradhana karma: The eye of the patient is opened with left hand. Then holding the

shalaka dipped in anjana having harenu matra with right hand anjana is smeared from

kaneenika sandhi to apanga sandhi on the inner side of the eyelid uniformly. It was

applied once daily in the morning for 48days.

Paschat Karma: When tears start flowing out of the eye, the eye is washed with

lukewarm water or triphala kashaya.

Group B: Shatavaryadi churna

Patients were treated with Shatavaryadi Churna half karsha (6grams) with madhu and

ghrutha internally once daily at night for 48days.

Group C: Nairkela rasakriya anjana

Procedure is similar to group A, instead of pippalayada anjana Nairkela rasakriya

anjana was used once in morning for 48 days.

Follow up period:

A follow up period of 90 days was fixed to observe the possible recurrences in cases

where total relief was obtained by the treatment.

ASSESSMENT CRITERIA

Subjective parameters

1) Redness

Absence (0) - No redness

Mild (1) - Scanty redness

Moderate (2) - Moderate redness

Severe (3) - Severe redness.

2) Foreign body sensation

Absence (0) - No Foreign body sensation

Mild (1) - Occasional Foreign body sensation

Moderate (2) - Frequent Foreign body sensation

A Study on Arma


Severe (3) - Continous Foreign body sensation.

3) Watering

Absence (0) - No watering

Mild (1) - Occasional watering

Moderate (2) - Frequent watering

Severe (3) - Excessive watering.

Objective parameter

1) Length

Absence (0) - Begining of the growth (0.5cm)

Mild (1) - In between the canthus and limbus(0.75cm)

Moderate (2) - In between the canthus and limbus (1cm)

Severe (3) - Upto limbus (1.5cm).

2) Thickness

Absence (0) - Negligible growth

Mild (1) - Had clearly visible episcleral vessels under the body of

Pterygium (Atrophic)

Moderate (2) - Had partially visible episcleral vessels under the body of

Pterygium (Intermediate)

Severe (3) - Had totally obscured episcleral vessels underlying the body of

Pterygium (Fleshy).

A Study on Arma


ASSESSMENT OF RESPONSE

The net result obtained by various parameters of assessment both before and after

treatment was taken into consideration to assess the overall effect of the therapies.

Then they were graded in terms of percentage of relief in subjective and objective

parameters.

Good response/ improvement – More than 65% relief in objective and

subjective parameters.

Moderate response/ Improvement – 40-65% relief in objective and subjective

parameters.

Mild response/Improvement –15-40% relief in objective and subjective

parameters.

Poor response/Improvement – less 15% relief in objective and subjective

parameters

.

A Study on Arma


OBSERVATIONS AND RESULTS

Fourty five Patients were selected and divided into 3 groups (Group A,B and C).

Containing 15 patients each. GroupA was treated with Pippalyadya anjana, GroupB

with Shatavaryadi Churna, Group C with Narikela rasakriya anjana. Subjective and

objective changes were considered for the assessment of the efficiency of research

work.

Data were collected as follows:

a. Demographic data

b. Data related to disease

c. Data related to response.

A Study on Arma


DEMOGRAPHIC DATA:

Table-5: Showing Age Wise incidence of 45 patients

Age In Years

Group A

Group B Group C Total

No of

Ptnts

% No of

Ptnts

% No of

Ptnts

% No of

Ptnts

%

15-24 00 00 00 00 00 00 00 00

25-34 01 06 03 20 01 06 05 11

35-44 07 47 04 26 06 40 17 38

45-54 07 47 08 54 08 54 23 51

Out of 45 patients selected for clinical study 00(0%) patients were between the age

group of 15-24years, 05(11%) patients were between the age group of 25-34years,

17(38%) between 35-44years, 23(51%)patients were between the age group 45-54

years of age.

Figure 1- Age wise distribution

5

10

15

20

25

30

35

40

45

50

55

15-24 25-34 35-44 45-54 Age in years

Per

cen

tage

Group A

Group B

Group C

Total

A Study on Arma


Table-6: Showing Incidence of sex

Sex

Group A


No of

Ptnts

% No of

Ptnts

% No of

Ptnts

% No of

Ptnts

%

Male 5 33 07 46 10 67 22 49

Female 10 67 08 54 05 33 23 51

Out of 45 patients selected for clinical trial 22(49%) were Male and 23(51%) were

Female.

Figure-2: Incidence of sex

A Study on Arma


Table-7: Showing Religion Wise Distribution

Religion Group A Group B Group C Total

No of

Ptnts

% No of

Ptnts

% No of

Ptnts

% No of

Ptnts

%

Hindu 14 94 13 88 13 88 40 89

Muslim 01 06 01 06 01 06 03 07

Christian 00 00 01 06 01 06 02 04

Out of 45 patients taken for clinical study 40(89%) were Hindus, 03(07%) were

Muslims, 02(04%) were Christian.

Figure 3-Incidence of Religion

0

10

20

30

40

50

60

70

80

90

100

Group A Group B Group C Total

Per

cen

tage

Hindu

Muslim

christian

A Study on Arma


Table-8: Showing Occupation Wise Distribution

Occupation Group A


No

of

Ptnts

% No of

Ptnts

% No of

Ptnts

% No of

Ptnts

%

Field Workers 05 34 04 26 02 13 11 24

House Wife 06 40 05 34 04 27 15 33

Outdoor Work 02 13 03 20 03 20 08 18

Office Work 00 00 03 20 04 27 07 16

Business 02 13 00 00 02 13 04 09

Out of 45 patients, 11(24%) were Fieldworkers, 15(33%) were Housewife, 08(18%)

were Outdoor work and 07(16%) were Office work, 04(09%) were Business men.

Figure 4-Incidence of occupation

0

5

10

15

20

25

30

35

40

45


Per

cen

tage

Fieldworker

Housewife

Outdoor

Officework

Business

A Study on Arma


Table-9: Showing Economic Status Wise Distribution

Economic

Status

Group A


No of

Ptnts

% No of

Ptnts

% No of

Ptnts

% No of

Ptnts

%

Upper

Class

00 00 01 06 00 0 01 02

Middle

Class

13 87 08 54 11 74 32 71

Lower

Class

02 13 06 40 04 26 12 27

Out of 45 patients, 1(02%) patients were of upper class category, 32(71%) were

middle class, 12(27%) patients were lower class.

Figure 5-Distribution of Patients based on Economic state

0102030405060708090

100


Pe

rce

nta

ge

Upper Class

Middle Class

Lower Class

A Study on Arma


Table-10: Showing Diet Wise Distribution

Diet Group A


No of

Ptnts

% No of

Ptnts

% No of

Ptnts

% No of

Ptnts

%

Vegetarian 06 40 07 46 05 33 18 40

Mixed 09 60 08 54 10 67 27 60

Out of 45 patients, 18(40%) were of vegetarians and 27(60%) patients were of mixed

diet.

Figure 6- Incidence of Diet

Vegetarian, 40%

Mixed, 60%

Incidence of Diet

Vegetarian

Mixed

A Study on Arma


Table-11: Showing Place Wise Distribution

Place Group A


No of

Ptnts

% No of

Ptnts

% No of

Ptnts

% No of

Ptnts

%

Urban 09 60 09 60 11 74 29 64

Rural 06 40 06 40 04 26 16 36

Out of 45 patients, 29(64%) patients were living in urban area, 16(36%) patients were

of rural basis.

Figure 7-Incidence of Place

0

10

20

30

40

50

60

70

80


Per

cen

tage

Urban

Rural

A Study on Arma


Table-12: Showing Distribution of Chronicity

Chronicity

(Years)

Group A


No of

Ptnts

% No of

Ptnts

% No of

Ptnts

% No of

Ptnts

%

0-1 10 68 09 61 07 48 26 58

1-2 01 06 03 20 02 13 06 13

2-3 01 06 02 13 02 13 05 12

3-4 03 20 01 06 02 13 06 13

4-5 00 00 00 00 02 13 02 04

Out of 45 patients, 26(58%) patients were between 0-1years chronicity,

06(13%) patients between 1-2years chronicity, 05(12%) patients between 2-3years

chronicity, 06(13%) patients between 3-4years chronicity, 02(04%) patients with

4-5years chronicity.

Figure 8- Distribution Of Chronicity

0

10

20

30

40

50

60

70


No

of

Pat

ien

ts 0-1

1-2

2-3

3-4

4-5

A Study on Arma


Table-13: Showing Incidence of Nidana

Nidanas Group A


No % No % No % No %

Dhoop sevana 04 27 08 53 01 06 13 29

Rajasevana 05 33 06 40 07 48 18 40

Marutasevana 00 00 00 00 00 00 00 00

Atigamana 01 06 00 00 00 00 01 02

Dhoomasevana 02 13 01 06 00 00 03 07

Out of 45 patients taken for clinical study, 13 patients (29%) had nidana of

Dhoopsevana, 18 patients (40%) had Rajasevana, 01 patient (02%) had Atigamana

and 03(07%) had Dhoomasevana.

Figure 9-Incidence of nidana

0

2

4

6

8

10

No

of

Pat

ien

ts

Group A

Group B

Group C

A Study on Arma


Table-14: Showing Incidence of Affected side of Eye

Affected

Eye

Group A


No of

Patients

No of

Patients

No of

Patients

No of

Patients

%

Only

Right

05 03

03 11 24

Only

Left

03 04 04 11 24

Both 07 08 08 23 52

Out of 68 eyes of 45 patients taken for the study, 11(24%) patient having Pterygium

affected to Right Eye only, 11(24%) patients having Pterygium affected to only Left

Eye and 23(52%) patients were having Pterygium affected to both of their eyes.

Figure 10-Incidence Right-Left Side Eyes

0

5

10

15

20

25

Right Eye only Left Eye only Both

No

of

Pat

ien

ts

Group A

Group B

Group C

Total

A Study on Arma


Table-15: Showing Incidence of Site Of Arma

Site Of

Arma

Group A


No of

Patients

No of

Patients

No of

Patients

No of

Patients

%

Medial

Canthus

15 15

15 45 100

Lateral

Canthus

00 00 00 00 00

Both

Canthus

00 00 00 00 00

Out of 45 patients, all 45 patients (100%) were having on medial canthus.

Figure 11-Incidence of Site of Arma

0

5

10

15

20

25

30

35

40

45

50

Medial Canthus Lateral Canthus Both Canthus

No

of

Pat

ien

ts

Group A

Group B

Group C

Total

A Study on Arma


Table-16: Showing Incidence of Different Parameters

Parameters Group A


No of

Patients

No of Patients No of Patients No of

Patients

%

Redness 14 15 15 44 98

Watering 11 09 10 30 67

Foreign

BodySensation

15 15 11 41 91

Out of 45 patients, 44 (98%) patients were having Redness, 30(67%) patients were

having Watering, 41(91%) were having Foreign body sensation.

Figure 12-Incidence of Different Parameters

0

5

10

15

20

25

30

35

40

45

50


No

of

Pat

ien

ts

Redness

Watering

Foreign Body sensation

A Study on Arma



Parameters Group A


No of

Patients

No of Patients No of Patients No of

Patients

%

Length 15 15 15 45 100

Thickness 15 15 15 45 100

Out of 45 patients, 45 (100%) patients were having Length, 45(100%) patients were

having Thickness.

.


0

5

10

15

20

25

30

35

40

45

50

Length Thickness

No

of

Pat

ien

ts

Group A

Group B

Group C

Total

A Study on Arma



Parameter


No of

Eyes

% No of

Eyes

% No of

Eyes

% No of

Eyes

%

Redness 21 95 23 100 23 100 67 99

Watering 15 68 14 61 15 65 44 65

Foreignbodysensation 22 100 23 100 17 74 62 91

Length 22 100 23 100 23 100 68 100

Thickness 22 100 23 100 23 100 68 100

Out of 68 eyes of 45 patients taken for clinical study, 67(99%) eyes were having

Redness, 44(65%) eyes were having Watering, 62(91%) eyes were having Foreign

body sensation, 68(100%) eyes were having Length, and 68 (100%) eyes were having

Thickness.


0102030405060708090

100110120

Pe

rce

nta

ge o

f N

um

be

r o

f Ey

es

Group A

Group B

Group C

Total

A Study on Arma


RESULTS

Table-19: Showing Individual study of the parameters in Group A

Paramet

er

Average Diffe

r

% of

diffe

r

SD SE df T

valu

e

P

value

Rema

rks

BT AT (d) % d

Redness 1.67 0.9

3

0.74 44.3 0.438 0.080 2

9

9.25 <0.00

1

HS

Watering 1.07 0.5 0.57 53.2 0.495 0.090 2

9

6.33 <0.00

1

HS

Foreign

body

sensation

1.93 1.0

7

0.86 44.5 0.347 0.063 2

9

13.6

5

<0.00

1

HS

Length 2.2 2.2 0 0 0 0 2

9

0 >0.05 NS

Thicknes

s

1.53 1.4 0.13 8.4 0.336 0.061 2

9

2.12 >0.05 S

1. Analysis of the Redness shows that mean score before treatment was 1.67

which reduced to 0.93, there was 44.3% of improvement in the symptom, with

t value 9.25 the result was statistically highly significant (p<0.001).

2. Analysis of Watering shows that mean value before treatment was 1.07 which

reduced to 0.5, there was a 53.2% improvement in the symptom, with t value

6.33 the result was statistically highly significant (p<0.001).

3. Analysis of the Foreign body sensation shows that mean value before

treatment 1.93 which reduced to 1.07, there was a 44.5% improvement in the

symptom, with t value 13.6 the result was statistically highly significant

(p<0.001).

4. Analysis of the Length shows that mean value before treatment 2.2 which

remained same 2.2, there was no change in the feature,with t value 0 the result

was statically not significant at (p> 0.05)

5. Analysis of the Thickness shows that mean value before treatment 1.53which

reduced to 1.4, there was a 8.4% of improvement in the sign, with t value 2.12

the result was statistically significant (p>0.05).

A Study on Arma


Figure 15-Individual study of parameters in Group A

0

0.5

1

1.5

2

2.5

Redness Watering Foreign body

sensation

length thickness

Mea

n V

alu

e

BT

AT

Table-20: Showing Individual study of the parameters in Group B

Paramet

er

Average Diffe

r

% of

diffe

r

SD SE df T

valu

e

P

value

Rema

rks

BT AT (d) % d

Redness 1.6 1.0

3

0.5 35.6 0.495 0.090 2

9

6.33 <0.00

1

HS

Watering 1.2 0.7

3

0.47 39.1 0.499 0.091 2

9

5.16 <0.00

1

HS

Foreign

body

sensation

2.07 1.3 0.77 37.1 0.421 0.077 2

9

10 <0.00

1

HS

Length 2.16 2.1

6

0 0 0 0 2

9

0 >0.05 NS

Thicknes

s

1.5 1.4

7

0.03 2 0.171 0.031 2

9

0.96

4

>0.05 NS

A Study on Arma



which reduced to 1.03, there was 35.6% of improvement in the symptom, with

t value 6.33 the result was statistically highly significant (p<0.001).






symptom, with t value 10 the result was statistically highly significant

(p<0.001).


remained same 2.16, there was no change in the feature,with t value 0 the

result was statically not significant at (p> 0.05)


reduced to 1.47, there was a 2% of improvement in the sign, with t value 0.964

the result was not statistically significant (p>0.05).

Figure 16-Individual study of parameters in Group B

0

0.5

1

1.5

2

2.5


sensation

length thickness

Mea

n V

alu

e

BT

AT

A Study on Arma


Table-21: Showing Individual study of the parameters in Group C

Paramete

r

Average Diffe

r

% of

diffe

r

SD SE df T

valu

e

P

value

Rem

arks

BT AT (d) % d

Redness 1.77 1.3 0.47 26.5 0.499 0.092 2

9

5.07 <0.00

1

HS

Watering 1.2 0.7

3

0.5 41.6 0.5 0.091 2

9

5.49 <0.00

1

HS

Foreign

body

sensation

1.37 0.8

7

0.5 36.4 0.5 0.091 2

9

5.49 <0.00

1

HS

Length 2.27 2.2

7

0 0 0 0 2

9

0 >0.05 NS

Thickness 1.7 1.6

7

0.03 1.7 0.171 0.031 2

9

0.96

4

>0.05 NS


which reduced to 1.3, there was 26.5% of improvement in the symptom, with t

value 5.07 the result was statistically highly significant (p<0.001).






symptom, with t value 5.49 the result was statistically highly significant

(p<0.001).


remained same 2.27, there was no change in the feature,with t value 0 the

result was statically not significant at (p> 0.05)


reduced to 1.67, there was a 1.7% of improvement in the sign, with t value

0.964 the result was not statistically significant (p>0.05).

A Study on Arma


Figure 17-Individual study of parameters in Group C

0

0.5

1

1.5

2

2.5


sensation

length thickness

Mea

n V

alu

e

BT

AT

INTER GROUP COMPARISON/ COMPARATIVE EFFECT OF

TREATMENTS:

Table 22: Comparison of effect of treatment on Parameters in ―Group A‖

and ―Group C‖:

Parameter Group Mean % of

differ SD SE

T-

Value

P-

Value Remarks

Redness A 0.733 44.3 0.639 0.116

1.78 <0.10 S C 0.466 26.5 0.507 0.092

Watering A 0.566 53.2 0.727 0.132

0.39 >0.05 NS C 0.5 41.6 0.572 0.104

Foreignbody

sensation

A 0.866 44.5 0.628 0.114 2.48 <0.01 HS

C 0.5 36.4 0.508 0.092

Length A 0 0 0 0

0 >0.05 NS C 0 0 0 0

Thickness A 0.2 8.4 0.484 0.088

1.76 <0.10 S C 0.033 1.7 0.182 0.033

A Study on Arma


1. Comparative analysis of effect of treatment on Redness between Group A&C,

with t-value 1.78, the result is statistically significant (p<0.10).However there

was 44.3% improvement in Group A and 26.5% improvement in the

Group C treatment individually.

2. Comparative analysis of effect of treatment on Watering between Group

A&C, with t-value 0.39, the result is statistically not significant

(p>0.05).However there was 53.2% improvement in Group A and 41.6%

improvement in the Group C treatment individually.

3. Comparative analysis of effect of treatment on Foreign body sensation

between Group A&C, with t-value 2.48, the result is statistically significant

(p<0.01).However there was 44.5% improvement in Group A and

36.4%improvement in the Group C treatment individually.

4. Comparative analysis of effect of treatment on Length between Group A&C,

with t-value 0, the result is statistically not significant (p>0.05).However there

was 0% improvement in Group A and Group C treatment individually

suggesting both having same effect.

5. Comparative analysis of effect of treatment on Thickness between Group

A&C, with t-value 1.76, the result is statistically significant (p<0.10).

However there was 8.4% improvement in GroupA and1.7% improvement in

the Group C treatment individually.

Figure 18-Comparision of Percentage of difference between Groups A& C

0

10

20

30

40

50

60


sensation

length thickness

per

cen

tage

of

relie

f

Group A

Group C

A Study on Arma


Table 23: Comparison of effect of treatment on Parameters in ―Group B‖

and ―Group C‖:


differ SD SE

T-

Value

P-

Value Remarks

Redness B 0.566 35.6 0.504 0.092

0.76 >0.05 S C 0.466 26.5 0.507 0.092

Watering B 0.466 39.1 0.571 0.104

0.22 >0.05 NS C 0.5 41.6 0.572 0.104

Foreignbody

sensation

B 0.766 37.1 0.626 0.114 1.81 <0.10 S

C 0.5 36.4 0.508 0.092

Length B 0 0 0 0

0 >0.05 NS C 0 0 0 0

Thickness B 0.033 2 0.182 0.033

0 >0.05 NS C 0.033 1.7 0.182 0.033

1. Comparative analysis of effect of treatment on Redness between Group B&C,

with t-value 0.76, the result is statistically not significant (p>0.05).However

there was 35.6% improvement in Group B and 26.5% improvement in the


2. Comparative analysis of effect of treatment on Watering between Group B&C,


there was 39.1% improvement in Group B and 41.6% improvement in the


3. Comparative analysis of effect of treatment on Foreign bodysensation between

Group B&C, with t-value 1.81, the result is statistically significant

(p<0.10).However there was 37.1% improvement in Group B and

36.4%improvement in the Group C treatment individually.

4. Comparative analysis of effect of treatment on Length between Group B&C,


was 0% improvement in Group B and Group C treatment individually



B&C, with t-value 0, the result is statistically not significant

(p>0.05).However there was 2% improvement in Group B and1.7%

improvement in the Group C treatment individually.

A Study on Arma


Figure 19-Comparision of Percentage of difference between Groups B& C

0

5

10

15

20

25

30

35

40

45


sensation

length thickness

pe

rce

nta

ge o

f re

lief

GroupB

Group C

Table 24: Comparison of effect of treatment on Parameters in ―Group A‖

and ―Group B‖:


differ SD SE

T-

Value

P-

Value Remarks

Redness A 0.733 44.3 0.639 0.116

1.21 >0.05 NS B 0.566 35.6 0.504 0.092

Watering A 0.566 53.2 0.727 0.132

0.59 >0.05 NS B 0.466 39.1 0.571 0.104

Foreignbody

sensation

A 0.866 44.5 0.628 0.114 0.61 >0.05 NS

B 0.766 37.1 0.626 0.114

Length A 0 0 0 0

0 >0.05 NS B 0 0 0 0

Thickness A 0.2 8.4 0.484 0.088

1.76 <0.10 S B 0.033 2 0.182 0.033

A Study on Arma


1. Comparative analysis of effect of treatment on Redness between Group A&B,


there was 44.3% improvement in Group A and 35.6% improvement in the

Group B treatment individually.

2. Comparative analysis of effect of treatment on Watering between Group

A&B, with t-value 0.59, the result is statistically not significant


improvement in the Group B treatment individually.

3. Comparative analysis of effect of treatment on Foreign bodysensation between

Group A&B, with t-value 0.61, the result is statistically not significant


improvement in the Group B treatment individually.

4. Comparative analysis of effect of treatment on Length between Group A&B,


was 0% improvement in Group A and Group B treatment individually



A&B, with t-value 1.76, the result is statistically significant (p<0.10).However

there was 8.4% improvement in GroupA and 2% improvement in the

Group B treatment individually.

Figure 20-Comparision of Percentage of difference between Groups A& B

0

10

20

30

40

50

60


sensation

length thickness

pe

rce

nta

ge o

f re

lief

Group A

GroupB

A Study on Arma


OVERALL ASSESSMENT OF THE RESULTS.

Table No. 25. Showing the overall assessment of the results in the groups.

Response

Group-A

Group-B

Group-C

No of patients

No of patients

No of patients

Good response

0

0

0

Moderate response

2

0

0

Mild response

19

19

16

Poor response

1

5

7

The study reveals that in groupA, 0 eye had good response, 2 eyes had moderate

response, 19 eyes had mild response and 1 eye had poor response.

In group B, 0 eye had good response, 0 eye had moderate response, 19 eyes had Mild

response and 5 eyes had poor response.

In group C, 0 eye had good response, 0 eye had moderate response, 16 eyes had

Mild response and 7 eyes had poor response.

A Study on Arma


Figure 21- Showing the overall assessment of the results in the groups.

0

2

4

6

8

10

12

14

16

18

20

Good Moderate Mild Poor

No

of

Pa

tie

nts

Group A

Group B

Group C

Table No. 26 Showing the over all assessment of the tretment in percentage:

Groups

GroupA GroupB GroupC

Percentage of relief

46% 36.8% 30%

The overall assessment of parameters shows 46% relief in Group A, 36.8%

relief in GroupB and 30% relief in Group C.

Group A showed moderate response to the treatment. Both Group B and Group C

have shown mild response.

A Study on Arma


Figure 22 - Showing the over all assessment of the tretment in percentage:

Group -A

Group -B

Group -C

46%

36.8%

30%

Table-27: Showing the percentage of recurrence in all the groups

PTERYGIUM Group A Group B Group C Total

No of

Patients

% No of

Patients

% No of

Patients

% No of

Patients

%

Recurrence 01 07 03 20 04 27 08 12

Non-

Recurrence

14 93 12 80 11 73 37 82

During 90 days follow up period 07% of Group A, 20% of Group B and 27% in

Group C had recurrence of complaints.

A Study on Arma


Figure-23: Showing the percentage of recurrence in all the groups

0

10

20

30

40

50

60

70

80

90

100

Recurrence Non-recurrence

07%

93%

20%

80%

27%

73%

Per

cen

tage

Pterygium

Group A

Group B

Group C

A Study on Arma


DISCUSSION

In every research work, discussion part is most important because it brings into light -

about the logical analysis, reasoning and rational interpretations to ignite new ideas,

which are helpful in filling the research gaps in the scientific world. Hence, here is an

attempt to discuss the concepts, observations and experiences in the clinical study.

The discussion is categorized into following ways for the ease of understanding.

1. Discussion on selection of the topic

2. Discussion on review of literature

3. Discussion on observations

4. Discussion on results

5. Discussion on drugs, their mode of action on the disease, Probable mode of

action anjana

1. Discussion on selection of the topic

Arma is a suklaghatha roga, characterized by mamsavruddhi in suklamandala. Hence

the classical approach towards the management of the disease would be Lekhana

anjana in early stages, when it encroaches the krishnamandala then it is removed by

chedana karma.

Pterygium though being symptomless & non troublesome condition if left untreated

may develop signs of inflammation followed by growth resulting in visual

disturbance.

The management of pterygium in early stage is through, application of topical

lubricants, anti-inflammatory & corticosteroids. All these are effective for a short

A Study on Arma


period & there are no proper effective medicaments & surgery is the only line of

treatment according to modern science. Recurrence rate is very high & cosmetic

appearance forces the patient to turn towards surgical management which is not

devoid of complication.

Ptreygium is more prevalent now a days & the reason for the same may be attributed

to the present day exposure to pollutants i.e, Heat, Smoke, and Dust.

A review into the pathodynamics of pterygium is suggestive of hyperplasia of

fibrovascular growth due to elastotic degeneration of subconjunctival tissue.

Hence simple & effective measures as suggested by our Acharyas when adopted act

definately on the pathological events that occur in genesis of pterygium i.e,

Lekhananjana on Hyperplastic tissue & Rasayana on regeneration of normal healthy

cells & there by prevent the further degeneration.

Though Pippalyadya anjana & Shatavaryadi churna have been indicated in the disease

of Arma, no studies have been undertaken. Hence the present study of Pippalayadya

anjana & Shatavaryadi churna Abyantra was taken up.

A Study on Arma


2. Discussion on Review of literature:

Arma is one of the shukalamandal roga explained by sushruta, Vagabhata

Madhavakara, Yogaratnakar, Bhava prakash. All the acharyas have the same opinion

about the seat of this disease, nidana & chikitsa prakarna. Arma is one among the 11

types of Shuklamandal roga. It is characterized by Mamsavruddi in suklabhaga.

It can be corrected with Pterygium in contemporary science, as both these

condition are diagnosed based on the character of the growth.

Nidana

The exact pathology of Arma is obscure but can be understood by Netra Samanya

Nidana.

Purvarupa also have not been mentioned for Arma, however Samanya Purvarupa

can be considered here.

Flow chart-1: Samprapti of Arma

Samprapti

Nidana sevana (Achakshusya factors)

Vitiation of Tridosha

Inturn Vitiates Rasa, Rakta, Mamsa

Sthana samshraya in sukla mandala

Vyakta sthana in Suklamandala

Manifestation of Arma

A Study on Arma


Flow chart-2: Depicting Pterygium Pathognesis

The Pathogensis of Pterygium is characterized by:-

Conjunctival epithelium is more prone to ultraviolet damage because it does not

have a protective coating known as keratin.

Because of chronic irritation due to U.V. rays results in elastotic degeneration.

The subconjunctival tissue undergoes elastotic degeneration & proliferates as

vascularised granulation tissue under the epithelium.

Loss of limbal epithelial basal stem cells leads to encroaching of conjunctival

vasculature on to cornea.

It is been postulated that the development of pterygium depends on a changed

angiogenic stimulator to inhibitor ratio.Pterygia contain drastically decreased

levels of pigment epithelium derived factors, an angiogenic inhibitor & elevated

VEGF (Vascular endothelial growth factors) levels hence there is proliferation of

vascularised granulation tissue.

It is also found that there is marked elevation of VEGF in pterygia compared with

normal conjunctival samples.

A Study on Arma


Chikitsa

The demarcation of Samprapti helps in planning the treatment. Arma is considered as

a Chedana sadhya Vyadhi. In early stages of the disease Lekhana Anjanas are used

and when it encroaches the krishnamandala, Chedana is the only option. Sushruta has

explained a special surgical procedure for the Arma Chedana.

Based on samprapthi or Arma & pathogensis of Pterygium, it can be managed by

exploring the following treatment principles.

Tridosha samaka.

Lekhana.

Rasayana.

Anti-VEGF drugs.

Chakshushya.

The main objectives of the treatment are:-

To reduce the symptoms.

To remove or scrape out the extra growth in the subconjunctiva.

To prevent the further degeneration.

3. Discussion on observations

By considering all the relevant points, the comparative clinical study was carried out

on 45 patients. The observations made during the study were discussed below.

Observations on General Points

Age

The incidence of disease Arma was observed to be higher in age group of

45-54(51%) followed by 35-44(38%) which indicates that incidence of disease is

more prevalent among the middle aged persons, it may be because of more exposure

to dust, sunlight, smoke & external atmosphere.

A Study on Arma


Sex

A higher prevalence was seen in females (51%) than in males (49%) may be because

females were very cautious of cosmetic appearance. However if the study was carried

out in larger sample size could be conclusive.

Religion

The incidence of patients of Hindu religion (80%) were more in the trial groups; this

may be because of the higher population of Hindus in the society.

Occupation

The incidence of housewife was higher (33%) followed by fieldworkers (24%),

outdoor work (18%), office work (16%) and business (9%); the reason is exposure to

heat. By this we can infer that working environment plays an important role in

causing Arma.

Economic status

The incidence of patients belonging to middleclass was higher (71%) in this study;

this is because of the larger middle class population in the society.

Diet

Out of 45 patients taken for the study, 40% were vegetarians and 60% were of mixed

diet variety. Since study sample is small relation with diet cannot be drawn.

Place

It is observed that incidence of arma is 64% in urban areas and 36% in rural area.This

shows it is more prevalent in urban area than the rural because of their maximum

exposure to the pollutants in urban areas.

Observations Related To Disease

Chronicity

Out of 45 patients, maximum number had the duration of 0-1yr (58%)

A Study on Arma


Incidence of nidana

The incidence of Rajasevana was higher (40%), followed by Dhoopsevana (29%),

Dhoomasevana (7%) and Atigamana (2%), this probabaly shows the relation

between exposure to outer atmosphere with the higher incidence of pterygium.

Affected side of Eye

A total of 23 patients (52%) had Pterygium in their both eyes. Only right eye was

affected in 11 patients (24%), and only left eye was affected in 11 patients (24%).

This indicates Pterygium can occur bilateral or unilateral.

Site of Arma

Out of 45 patients of Pterygium taken for the clinical study all the patients had

Pterygium in medial canthus. This is due to reasons said before for the greater

predilection on nasal side.

Incidence of parameters

Out of 68 eyes of 45 patients taken for the clinical study, 99% of eyes with redness

followed by 65% of eyes with watering, 91% of eyes with foreign body sensation,

100% with length & 100% with thickness was observed.

4. Discussion on Results

To evaluate the effect of treatment on individual parameters in Group A, Group B and

Group C paired t-test was applied and also to compare the efficacies between the

groups unpaired t-test was applied. The obtained results are discussed here.

Effect of therapy on individual parameter in Group A-B-C

1. Redness

In Group A—There was a 44.3% of improvement in the symptom with t-value 9.25,

which is statistically highly significant at p<0.0001.

A Study on Arma


In Group B—There was a 35.6% of improvement in the symptom with t-value 6.33,


In Group C—There was a 26.5% of improvement in the symptom with t-value 5.07,


Interpretation: All 3 Groups have shown statistically highly significant result

(p<0.0001) in treatment of Redness, and there is a higher percentage of success rate

(44.3%) in treating Redness by Pippalyadya anjana (Group A) than Shatavaryadi

churna (Group B) and Narikelarasakriya anjana (Group C) alone.

2. Watering

In Group A—There was a 53.2% of improvement in the symptom with t-value 6.33,


In Group B—There was a 39.1% of improvement in the symptom with t-value 5.16,


In Group C—There was a 41.6% of improvement in the symptom with t-value 5.49,



(p<0.0001) in treatment of Watering, and there is a higher percentage of success rate

(53.2%) in treating Watering by Pippalyadya anjana (Group A) than Narikela

rasakriya anjana (Group C) and Shatavaryadi churna (Group B)alone.

3. Foreign body sensation

In Group A—There was a 44.5% of improvement in the sign with t-value 13.65,


In Group B—There was a 37.1% of improvement in the sign with t-value 10, which

is statistically highly significant at p<0.0001.

A Study on Arma


In Group C—There was a 36.4% of improvement in the sign with t-value 5.49,



(p<0.0001) in treatment of Foreign body sensation, and there is a higher percentage

success rate (44.5%) in treating Watering by Pippalyadya anjana (Group A) than

Shatavaryadi churna (Group B) and Narikela rasakriya anjana (Group C) alone.

4. Length

In Group A—There was a 0% of improvement in the feature with t-value 0, which is

statistically not significant at p<0.05.

In Group B—There was a 0% of improvement in the feature with t-value 0, which is

statistically not significant at p>0.05.

In Group C— There was a 0% of improvement in the feature with t-value 0, which is

statistically not significant at p>0.05.

Interpretation: None of the Group is effective in reducing the length.

5. Thickness

In Group A—There was a 8.4% of improvement in the sign with t-value 2.12, which

is statisticallyt significant at p<0.05.

In Group B—There was a 2% of improvement in the sign with t-value 0.964, which

is statistically not significant at p>0.05.

In Group C—There was a 1.7% of improvement in the sign with t-value 0.964,

which is statistically not significant at p>0.05.

Interpretation: There is a statistically significant result (p<0.05),having 8.4% of

success rate in the clinical feature of thickness treated by Pippalyadya anjana (Group

A) than treatment with other two Groups which are statistically not significant

(p>0.05).Even though there is improvement by 2% in the clinical feature treated by

A Study on Arma


Shatavaryadi churna (Group B) and 1.7% improvement in the clinical feature treated

by Narikela rasakriya anjana (Group C) the result are not conclusive to say the effect

of treatment since the results are statistically not significant (p>0.05).

Here failure to give better reponse can be attributed to reason, since grade 2 & grade 3

Pterygium having thicker and greater amount of fibrovascular tissue compared with

those of the early stage, were taken for the study.

By reducing the thickness, vascularity will be reduced, in turn stops the

progression of the Pterygium.

Overall Comparative Effect of therapy between the Groups AC-BC-AB

1. Redness

Comparing the effect of treatment on Redness between Group A&C with t-value 1.78

shows statistically just significant result (p<0.10) between the two treatments. This is

obvious with success rate of improvement of 44.3% & 26.5% in the individual

treatments of Groups A&C respectively.

Comparing the effect of treatment on Redness between Group B&C with t-value

0.765 shows statistically not significant result (p>0.05) between the two treatments.

However there is a 35.6% & 26.5% of success rate of improvement in the individual

treatments of Groups B&C respectively.

Comparing the effect of treatment on Redness between Group A&B with t-value 1.12

shows statistically not significant result (p>0.05) between the two treatments.


treatments of Groups A&B respectively.

A Study on Arma


2. Watering

Comparing the effect of treatment on Watering between Group A&C with t-value



treatments of Groups A&C respectively.

Comparing the effect of treatment on Watering between Group B&C with t-value




Comparing the effect of treatment on Watering between Group A&B with t-value




3. Foreign body sensation

Comparing the effect of treatment on Foreign body sensation between Group A&C

with t-value 2.483 shows statistically significant result (p<0.01) between the two

treatments. This is obvious with success rate of improvement of 44.5% & 27.55% in

the individual treatment of Groups A&C respectively.

Comparing the effect of treatment on Foreign body sensation between Group B&C

with t-value 1.81 shows statistically significant result (p<0.10) between the two

treatments. However there is a 37.1% & 36.4% of success rate of improvement in the

individual treatments of Groups B&C respectively.

Comparing the effect of treatment on Foreign body sensation between Group A&B

with t-value 0.61 shows statistically not significant result (p>0.05) between the two

A Study on Arma


treatments. However there is a 44.5% & 37.1% of success rate of improvement in the

individual treatments of Groups A&B respectively.

4. Length

Comparing the effect of treatment on Length between Group AC & BC & AB with

t-value 0 shows statistically not significant result (p>0.05) between the treatments is

0.

5. Thickness

Comparing the effect of treatment on Thickness between Group A & C with t-value

1.76 shows statistically just significant result (p<0.10) between the two treatments.

This is obvious with success rate of improvement of 8.4% & 1.7% in the individual

treatments of Groups A & C respectively.

Comparing the effect of treatment on Thickness between Group B&C with t-value 0

shows statistically not significant result (p>0.05) between the two treatments.

However there is a 2% & 1.7% of success rate of improvement in the individual


Comparing the effect of treatment on Thickness between Group A&B with t-value

1.76 shows statistically just significant result (p<0.10) between the two treatments.

This is obvious with success rate of improvement of 8.4% & 2% in the individual


Overall assessment of the results in the groups

Good response-

After 48 days of the treatment, none of the eye of Group A, B & C showed good

response.

Moderate response

After 48 days of treatment, 2 eyes of Group A showed Moderate response

A Study on Arma


None of eye of Group B & C showed moderate response.

Mild response

After 48 days of the treatment, 19 eyes of Group A showed mild response,

19 eyes of Group B & 16 eyes of Group C showed mild response.

Poor response After 48 days of the treatment, 1 eye of Group A showed poor

response. 4 eyes of Group B & 7 eyes of Group C showed poor response.

Follow up- During the post treatment period of 90 days, 07% of patients from Group

A and 20% of patients from Group B and 27% of patients from Group C had

recurrence of the complaints suggesting a higher rate of recurrence in the treatment

with Narikela rasakriya anjana which indicates the necessity for a prolonged duration

of therapy.Even though the recurrence was seen it was observed that symptoms and

sign was not so severe as it was seen in the beginning of the treatment.This shows that

Pippalyadya anjana is more efficacious then other two yogas. Topical application

found more effective followed by internal medicine.

During the treatment period and follow up, the length of the pterygium remained the

same in all the three groups.

5. Discussion on Probable mode of action

Probable mode of action of Pippalyadya Anjana:-

The ingredients of Pippalyadya Anjana are –Pippali, Triphala, Laksha, Lodhra,

Saindhava lavana, Bhringaraja.

Pippali- having katu rasa, laghu, snigdha, teekshna, pramathi guna, anushna

sheetha veerya does lekhana action. By its madhura vipaka has rasayana and

chakshushya property also act has anti-inflammatory, anti-allergic, immune

stimulatory.

A Study on Arma


Pippali is a well known as a yogavahi; its benefits are increased bioavailability

& enchances the absorption of other active ingredients of the medicinal

compound.

The piperine of pippali is the best bioavalibality enchancer drug.

Triphala- Anti-oxidant, immunomodulatory, adaptogenic, capillary

strengthening. Vit-C and Vit-E present in Amalaki helps in inhibiting platelet

aggregation by thromboxane A2 synthesis have tridoshahara, srotho

vibandahara.

It is chakshushya and rasayana

Owing to katu.tikhta, kashaya rasa it does lekhana action.

In Triphala, Amalaki & Vibhitaki contain flavonoids which inhibit

angiogensis by regulating expression of VEGF, there by prevent the further

growth.

Triphala also contain Hyaluronidase, Hyaluronidase acts by depolymarising

the hyaluronic acid.

Hyaluronic acid is the connective tissue ground substance.It is very much

needed for forming new connective tissue in Pterygium as it forms the gel in

mesenchyme.When Hyaluronidase is given it depolymerises the hyaluronic

acid which affect the connective tissue metabolism resulting in the regression

or arrest the growth of Pterygium.

Laksha- Sandhaniya, snigha guna helps laksha to bind wound as a part of

regenerative process .Having kashya rasa, laghu snigha guna does lekhana

action.

Lodhra- styptic, cooling, anti-inflammatory and anti-microbial properties

A Study on Arma


having kashaya, tikta rasa, laghu ruksha guna, katu vipaka, sheetha virya is

kapha pittasamaka because of kashaya tikta rasa & ruksha guna has lekhana

property. It is also chakushushya.

Saindhava lavana-having tikshna,laghu,suskshmaguna penetrate in

Sukshma srotas also take other dravyas along with it & gives the best effect of

lekhana kriya hence commoly used as drug of pratisarana.

Bhringaraja- Ama nashaka, chakshuhya, rasayana, raktashodhana & effective

anti-inflammatory.Having katu vipaka & laghu ruksha guna & katu tikta rasa

does the lekhana & it is kaphavatashamaka.

Thus most of the ingredients of Pippalayadya Anjana have lekhana property

there by scrapes away the extra growth which is occurring on the

shuklamandala.

By virtue of their combined pharmacological action of tridhosha shamaka,

lekhana, raktashodaka chakshushya & rasayana.Formulation has a potency to

relieve the clinical features.

If we use drug having antiangiogensis property in the preparation of lekhana

anjana, it prevents vascularity & reduces the further growth & there by prevent

further complication.

A Study on Arma


Probable mode of action of Anjana:-

PIPPALYADYA ANJANA

(Applied to inner side of eye lid)

The anjana is administerd in suspension form & particles size is in

Nanometer, thus particles are retained in the conjunctival cul-de-sac,

This increases the contact time of the drug with the absorption surface.

Drugs are water soluble hence absorption will be more.

Transient microscopic hyperaemia in the vascularity of the conjunctiva

i.e, conjunctival capillaries. In response to this hyperaemia capillaries inturn

changes the permeability (i.e, structural intergerity of capillaries is altered)

for a short duration.This causes drugs to gain access into capillaries which

again interconnected with the vascular system of the eye.

The drug has acidic pH suggested from phytochemical analysis help in

enhancement of lekhana property.

Thus gradually scarpes the fibrovascular growth thereby desired

Therapeutic effect is obtained.

Flow chart-3: Probable mode of action of Anjana

A Study on Arma


Probable mode of action of Shatavaryadi Churna:-

Shatavaryadi churna: This yoga is mentioned by Yogaratnakara in Arma hence was

taken for the study for assessing the efficacy. The churna form of medicine is very

beneficial, as it is very easy for administration, easy for fixing the dose and better in

absorption.

The ingredients of Shatavaryadi churna are- Shatavari, Ela (seeds), Vidanga,

Amalakasthibija, Maricha and Pippali.

Shatavari- having madhura rasa, madhura vipaka & sheetavirya it is having Rasayana

property hence maintains the normal structure of cells & normal development.

It is an adaptogenic agent; adaptogenic property of shatavari is due to phytochemicals

Sarsapogenin, 8 fructo oligosaccharides. Rich in vitamin A, B6 & powerful

antioxidant.

Ela- a-pinene, b-pinene, limonene, p-cymene, terpinolene, methyl eugenol, terpineol

are the main phytochemicals present in the ela. These enhance the permeation effect

of various drugs. Antioxidants- phenolics and flavonoids.Have anti-inflammatory

activity, powder of cardamom seeds is specifically indicated for the treatment of

symptoms resulting from excess of heat.

Vidanga-the phytochemicals of vidanga contains sitosterol, benzoquinone. Quercitol

is flavonoids which acts as an antiangiogentic agent there by prevent the further

progression of fibrovascular growth & also has antioxidant property.

Pippali and Maricha best bioavalibality enhancer because of presence of piperine.

Oral supplementation of piperine leads to altered phase II enzymes and reduces

damage. Ethanol crude extracts of maricha possess potent antioxidant and free radical

scavenging; Maricha has many important functions in the ocular therapeutics.

A Study on Arma


The polysaccharides in maricha may help in immune enhancement. The piperine

alters the permeability characteristics. It acts on the hydrophobic portions of lipid in

membranes. This property is of importance in the (mode of action of kriyakalpas)

permeability/penetration of the drugs used topically.

Amalaki richest source of antioxidant also contain flavonoids which prevent

fibrovascular growth of Pterygium.It is tridosha shamaka and also Rasayana and

Chakshushya.

Madhu having ruksha guna & kashaya rasa does lekhana action.

Ghritha is yogavahi also has the property of samskarasaya anuvartana property.It can

penetrate into sookshma srotas. Thus can cross the barriers of absorptions.

Ghritha itself is a Rasayana.It is pittha vatahara, hence works towards the normalcy of

the doshas responsible for triggering the disease.

All the ingredients of Shatavaryadi churna possess chakshusya, rasayana & tridosha

samaka action.Long term administration would also help in retarding the progression

of the disease and helps in arresting the further degeneration of the tissue.

Probable mode of action of Narikela rasakriya Anjana:-

Narikela Rasakriya anjana having, Narikela Jala possesses Anti-inflammatory, Anti-

bacterial, Anti-neoplastic, Anti-oxidant property. Daru Haridra having Anti-

inflammatory, Anti-bacterial, Anti-tumour, Anti-oxidant property.

Most of the drugs are Chakshushya,having Katu,Tikta,Kashaya rasa,Laghu,Ruksha

guna and Tridoshagna and Rasayana property.These drugs act through Anti

inflammatory,Anti-bacterial,Anti oxidant properties.

A Study on Arma


CONCLUSION

The clinical features of Arma are closely related to Pterygium.

The occurrence of Pterygium is quite common, but most of the time it is

ignored.It should be treated in early stages if not treated at the earliest, will

gradually progress & leads to visual disturbances.

After observing the results of Group A, B &C, can come to the conclusion that

patients of GroupA who were treated with Pippalyadya anjana responded well.

All the three Groups were found to be effective in reducing the severity of the

symptoms like Redness, Watering & Foreign body sensation, and other

parameter like length did not produce any statistical significant result after

treatment in all the groups.

Thickness showed a statistically just significant result in patients of GroupA.

Overall assessment of result in percentage GroupA-44% ,Group B-37% &

Group C-33%.

By Lekhananjana Arma can be managed with conservative line of treatment in

the initial stage as told in the classics.

Shatavaryadi churna prevents the further degeneration and help in retarding

the progression of the disease.

Better results can be obtained, if patients do Nidana parivarjana.

No untoward effect was observed in any of the treatment groups.

Thus early diagnosis and adequate treatment of this definitely relieves the

patients from the disease without leading to much complication.

A Study on Arma


Recommendations for further study-

As the sample size was small and the disease is chronic nature. It is

recommended to carry the study on larger sample size.

Owing to the disease progressive nature it is recommended to have prolonged

duration of treatment and follow up.

A Study on Arma


SUMMARY

The present clinical study entitiled ― A Comparative study on the efficacy of

Pippalyadya Anjana and Shatavaryadi Churna Abyantara in the management of

Arma‖ was limited to 45 patients having the features of Pterygium attending the OPD

and IPD of Department of Shalakya Tantra and SJIIM Hospital, Bangalore.It was

divided into Group A,B &C consisting of 15 patients in each Group.

The reference of Pippalyadya Anjana & Shatavaryadi Churna is from Yoga Ratnakar

& Narikela rasakriya is from Sasharyoga.

The work is presented in two section.The first section deals with review of the

literature available on the diseases; the formulation & the therapies adopted.

Historical review consists of an attempt to collect the references about Arma in

various literature, netra rachana and shareera kriya & Nidana, Lakshana and chikitsa

of Arma.

Anatomy of conjunctiva, Pterygium definition, aetiology, incidence, pathology, types,

clinical features & management of Pterygium & greater predilication on Nasal side

are dealt in Modern Review.

The drug review,a brief note on the ingredients, properties, method of preparation &

application of the formulations are discussed.

The second section includes material & methods, the study design, source of data,

parameters for assessement of data .

Observations made during the study & the results of the data drawn after the study are

expressed in terms of diagrams & the comparsion between the two Groups have been

made statistically.

Observations made by the study along with Probable mode of action of drugs are

discussed.

A Study on Arma


Lastly the Conclusion drawn out of the clinical study and summary of the entire work

is dealt.

All the 3 Groups were found statistically siginificant. Group A showed overall higher

significance & better response compared to other two Groups.

BEFORE TREATMENT AFTER TREATMENT

(Group A ) (Group A)

A Study on Arma


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A Study on Arma


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A Study on Arma


ANNEXURE

CASE PROFORMA

Department of Postgraduate Studies in Shalakya Tantra G.A.M.C & H,

Dhanwantari Road Bangalore-560 009

Case No : Date :

Name : OPD No. :

Age : IPD No : Bed No

Sex : DOA :

Religion : DOD :

Occupation : Address :

Education : Marital Status :

Socioeconomic status: Provisional Diagnosis:

Pradhana vedana / chief complaint :

Duration

Redness


Watering

Discomfort

Anubandha vedana / Associated complaint :

Photophobia

Blurness of vision

Itching

Adhyatana vyadhi vrittanta / History of present illness :

Duration

Mode of onset – gradual / sudden

Course of illness – progressive/ receding/ stationary

Aggravating factor – sunlight/ dust/ wind/ smoke

A Study on Arma


Poorva vyadhi vrittanta / History of past illness :

Previous eye diseases & operation

Any treatment undergone.

Personal History :

Diet Sleep

Appetite Habit

Bowel

Micturition

Family History : H/O similar complaints

Occupational history:

Nature of work:- Travelling / Labour / agriculture

Astasthana pareeksha :

Nadi Mala

Mootra Jihwa

Shabda Sparsha

Drik Akriti

Vital signs :

Temperature

Pulse

Respiration

B.P.

Local examination:

Examination for the head posture

Examination of forehead

Examination of eyebrows - Level of eyebrow

Cilia

Examination of eyelids - Position

Movements of lids

Lid margin

Abnormalities of skin

A Study on Arma


Palpebral aperture

Examination of lacrimal apparatus – Puncta

Lacrimal sac

Regurgitation test

Lacrimal syringing

Examination of eyeball – Position

Visual axes of eyeball

Size of eyeball

Movement of eyeball

Examination of conjunctiva – Bulbar conjunctiva

Lower palpebral conjunctiva

Upper palpebral conjunctiva

Fornix

Signs - Discoloration

Congestion

Chemosis

Follicles

Papillae

Concretion

Foreign bodies

Membranous growth - Medial canthus

Lateral canthus

Both canthus

RE LE

Length – 0 - begining of the growth(0.5cm)

1- In b/w the canthus & limbus(0.75cm)

2- In b/w the canthus & limbus(1cm)

3- Upto limbus(1.5cm)

Thickness – 0- negligible growth

1- Had clearly visible episcleral vessels under the

body of pterygium(Atrophic)

2- Had partially visible episcleral vessels under the

body of Pterygium(Intermediate)

3- Had totally obscured episcleral vessels

underlying the body of pterygium(Fleshy)

Examination of sclera –Discoloration

Inflammation

Any other abnormality

A Study on Arma


Examination of cornea – Size

Shape

Surface

Transparency

Vascularity

Corneal sensation

Examination of anterior chamber –Depth

Examination of iris – Colour

Pattern

Any other abnormality

Examination of pupil- Number

Location

Size

Shape

Colour Papillary reactions

Examination of lens – Position

Transparency

Colour

Examination of Intraocular pressure- Digital method

Fundus examination – Disc

Blood vessels

Macular area

Visual acquity : D.V. N.V.

B.E

R.E

L.E

OBSERVATION B/F TREATMENT

Sever Moderate Mild Absent

Redness


Watering

Length

Thickness

Photographs

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OBSERVATION A/F TREATMENT ON 48TH

DAY

Sever Moderate Mild Absent

Redness


Watering

Length

Thickness

Photographs

Observation during follow up :

Signature of the Candidate Signature of the Guide

Navya D P 2012

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