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REVIEW ARTICLE
Year : 2010  |  Volume : 31  |  Issue : 1  |  Page : 93-100 Table of Contents     

A comprehensive review of cataract (Kaphaja linganasha) and its surgical treatment in Ayurvedic literature


1 Dept. of Shalakya, I.P.G.T. & R.A., Paprola, Himachal Pradesh, India
2 Dept. of SRPT, R. G. Govt. P. G. Ayu. College, Paprola, Dist. Kangra, H.P. 176 115, India
3 Shalakya, India

Date of Web Publication7-Aug-2010

Correspondence Address:
K S Dhiman
Institute for Post Graduate Teaching and Research in Ayurveda, Gujarat Ayurved University, Jamnagar and Rajiv Gandhi Govt. P. G. Ayurvedic College, Paprola, Himachal Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0974-8520.68197

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   Abstract 

Ayurveda the science of life, since its origin is serving the mankind throughout in health & disease state of life. Shalakyatantra, one of its specialized branch deals with the science of Ophthalmology, Otorhinolaryngology, Orodental surgery & Head; was contributed and developed by Rajrishi Nimi, the King of Videha , who was a colleague of Atreya, Punarvasu, Dhanwantri, Bharadwaja, Kashyapa etc. The available literature related to this speciality is reproduced from original text of Nimitantra in Uttartantra of Sushruta samhita. So Rajrishi Nimi deserves all the credit and regards for Shalakyatantra and for being the first eye surgeon on this earth. The fact regarding the technique of cataract surgery adopted by ancient surgeons is still a matter of debate. Most of the medical fraternity accepts cataract surgery of ancient surgeons as couching procedure but after going through forth coming pages, the prevailing concept will prove to be a myth. It started with extra capsular extraction through small incision during the period of Sushruta Samhita but later shifted to couching like technique by Acharya Vagbhatta. Secondly, the objective of this literary research paper is to find proper co-relation of the disease cataract to those mentioned in Ancient Ayurvedic classic. Linganasha has been inadvertently taken as cataract but this is neither logical nor in accordance with classics. We find detailed description of cataract's differential diagnosis, indications, contra- indications, pre/intra/post operative procedures and complication in ancient texts of Ayurveda. Not only this, vivid description of treatment of various complications of cataract surgery are also given. Needless to say, no other surgically treatable diseases & its complications except Kaphaja Linganasha are given this much attention.

Keywords: Linganasha, Shalaka, Vedhana, Daivakrita, Lekhana, Aschyotana, Lepa, Seka


How to cite this article:
Dhiman K S, Dhiman K, Puri S, Ahuja D. A comprehensive review of cataract (Kaphaja linganasha) and its surgical treatment in Ayurvedic literature. AYU 2010;31:93-100

How to cite this URL:
Dhiman K S, Dhiman K, Puri S, Ahuja D. A comprehensive review of cataract (Kaphaja linganasha) and its surgical treatment in Ayurvedic literature. AYU [serial online] 2010 [cited 2020 Feb 23];31:93-100. Available from: http://www.ayujournal.org/text.asp?2010/31/1/93/68197


   Introduction Top


Linganasha is a technical descriptive term in Ayurvedic literature, which means loss of vision. (Dalhan) [1] . Two varieties of Linganasha- loss of vision have been described i.e. reversible and irreversible or curable and in-curable. On the other hand linganasha as a whole can be classified [2] as follows:



Endogenous linganasha is described vividly on anatomical and etiological grounds and is said to be the end stage of Timira, a serious disease of the visual apparatus. On anatomical descriptive grounds, when the vitiated body humours reach/invade 4 th /last patal/layer of the eye ball (nucleus of the lens), then patient's vision is obstructed, pupil is covered by vitiated body humours then patient perceives only bright illuminating objects that too when the eye (Posterior segment) is normal. This stage of Timira; invading 4 th patal (Lens) is labelled as linganasha (Cataract). According to the etiological classification, linganasha is again the 3 rd stage of disease Timira, 2 nd being Kaach-(ISC).

The clinical picture is as per the vitiating / causative body humours. Among these pathologically classified linganasha only Kaphaja linganasha (KL) is surgically curable rest all being incurable [3],[4],[5],[6],[7],[8],[9],[10],[11],[12],[13],[14],[15] but a misconception about the surgical procedure is still prevailing. The western medical literature considers that surgical procedure depicted in ancient surgical treatise Sushruta Samhita is couching [1],[14] i.e. displacing the mature catractous lens in capsular bag into the vitreous cavity. This fact is partially expounding the Ayurvedic view point because the said treatise encompassing the view point of Rajrishi Nimi of Videha Kingdom holds a very different explanation. The available description therein is very similar to that of extra capsular cataract extraction that too with a small incision. On the other hand in the later surgeon Acharya Vagbhatta's (5 th AD) technique is very near to the of couching.

To explore the facts in this regards and to put forth the correct view point of Ayurveda this literary research was under taken.

Aims and Objects

  1. To review the literature on KL and cataract to establish their relation.
  2. To explore there from the surgical method & procedure adopted by ancient scholars.



   Material and Methods Top


Classical literature on the subject from Ayurvedic and western system of medicine were explored thoughly and where felt necessary help of Sanskrit grammar scholars was taken. The collected classical material was compared and put forth in a systematic manner in the coming pages.[Figure 1]
Picture 1: Kaphaja Linganasha

Click here to view


Clinical picture of Kaphaja linganasha [4] is as follows

  • Complete obstruction of vision; the patient can only perceive bright light /object.
  • Pupillary circle appears to be thick, smooth, and white in color like a white drop of water (fluid) moving on lotus leaf.
  • Pupil constricts in sun and dilates in shade/dark (+ve Pupillary reaction).
  • Pupillary circle is mobile/changes its shape on ocular massage.


These clinical features of Kaphaja linganasha invading fourth patala (Lens) exactly simulate the picture of mature/hypermature senile cortical (Cuneiform) cataract, the white and soft cataract.

Exogenous variety of Linganasha (Vision loss)-Sanimitaja and Animitaja types are classified according to known and unknown (idiopathic) exogenous causes respectively. In both these varieties the pupillary circle remains clear, like natural one i.e. jet black in colour [5] . Both are incurable. Trauma also leads to irreversible loss of vision.

Indications for surgery

1. Well developed Kaphaja linganasha i.e. fully mature/hypermature cortical cataract with clinical features mentioned above.

2. Uncomplicated cataract [16] e.g. Avartaki etc. following Six complications of Kaphaja linganasha are to be avoided before surgical intervention:

  1. Avaratki: Pupillary circle appears like whirlpool, hyper- reactive, of reddish white colour.
  2. Sharkara: Where linganasha-cataract appears like that of coagulated milk i.e. calcified cataract.
  3. Rajimati: When cataract's anterior surface is seen with linings i.e. anterior capsular calcification or hard cataract.
  4. Chhinanshuka: Pupil is irregular, with tears, charred coloured and painful; i.e. cataract with uveitis and posterior synechiae.
  5. Chandraki: Pupillary area reflects off- white color and its shape is like that of moon; i.e. cataract with retinal detachment.
  6. Chhatrki:The pupillary area (Cataract) is multicolored like that of mushroom i.e. posterior segmental pathologies.


Contra- indications of surgery

A) Related to cataract (Kaphaja Linganasha[6])



  • Pupillary Appearance:
    • Half moon shaped pupil-posterior subluxated lens
    • Drop of sweat-anterior dislocation of lens
    • Pearl shaped-shrinked lens
    • Hard cataract
    • Irregular shaped
    • Having streaks-calcified
    • Thin from the centre.
    • Multicolored
    • Blood or abnormal material in pupillary area
  • Painful eye
  • Immature cataract.


B) Related to patient[17]:

Those patients who are contraindicated for venesection-blood letting i.e.

  • Having anasarca, anaemia, hemorrhoids, abdominal distension, <16 yrs, pregnant woman with oedema, old age, post partum stage, without oleation and sudation, after Pancha Karma therapy, neurological & bleeding disorders, diarrhoea, dysentery and apprehensive to surgery [8] .
  • Patients suffering from excessive polydypsia (Hyperglycemic) sinusitis, bronchitis, indigestion, vomiting, headache, otalgia, ocular pain, and oedema [8] .


C) Related to time and place[17]:

  • Excessive Hot or cold season/atmosphere.
  • Cloudy or windy atmosphere.


Pre-operative steps/measures:

Preparation of patient[9]:


  1. Snehan (Oleation).
  2. Swedan (Sudation).
  3. Virechana (Medicated purgation).
  4. Ghrita mixed food.
  5. Tarpana of head-by abhyanga (massage).


Preparation and collection of required materials[7]:



  1. Yav-vakra shalaka [18] having following qualities:
    1. Length-8 angul; i.e.6 inches.
    2. Wrapped in center with thread for proper grip.
    3. Thickness equal to thumb.
    4. Both ends shaped like flower-bud.
    5. Made up of copper, iron/gold.
  2. Vetas-patra Shastra for Scleral incision.
  3. Mother's milk/Goat/Cow milk.
  4. Ricinus communis leaves.
  5. Arrangement for heating.
  6. Ghrita.
  7. Decoction of vata-pacifying drugs e.g. R.communis leaves and roots, Dashamoola Kwatha.
  8. Ghrita medicated with Glycyrrhiza glabra decoction
  9. Vastra Patta (Bandage).
  10. Pichu (Cotton).
  11. Cloth for poultice (sudation).
  12. Calm, brave, strong, devoted attendants to hold & assist the patient during the procedure.
[Figure 2]
Picture 2: Yav-vakra shalaka

Click here to view


Operative procedure[7]:

  • Fix a particular date and time for the operation and pay prayers to the God.
  • Make the patients sit in O.T. with extended legs, hands resting on seat, hyper extended neck-facing sun (light) in the forenoon. The attendants should make patient sTable
  • Surgeon should sit in front of the patient at a convenient height and posture.
  • Eye to be operated upon is given mild sudation and lids fixed with thumb and index fingers. Patient is asked to continuously look towards his nose.
  • Surgeon should hold the shalaka (linganasha vedhani shalaka) steadily in Right Hand (Gripped with thumb, index and middle finger) and enter the left eye at Daiva Krita Chhidra i.e. keyhole (2/3 parts from Krishna-shukla sandhi and 1/3 parts from the Apang sandhi in the interpalpebral space). The Shalaka should be introduced in the eyeball by rotatory movements; a specific sound of entry of Shalaka inside the eye is experienced which follows a drop of water (Aqueous humour) through the vedhana site.
  • Steadily pushing forward & manipulating the shalakya until it reaches the drishti mandala (papillary aperture) i.e. on ant surface of the cataractous lens so that lekhana karma is completed under direct vision.

    Shalaka is to be gripped in left hand for operation on right eye.
  • Hold the entered shalaka in situ and irrigate the eye with mother's milk (Human milk) and apply mild sudation on the closed eye with Vata pacifying leaves e.g. R. communis leaves. This will prevent redness, discharge and pain.
  • There after assuring the patient, push the shalaka to the centre of pupil through rotatory movements. Incision at vedhana site (key hole) should be given before entry of Shalaka (as suggested by a traditional Netra vaidhya in National seminar on netra chikitsa-96 held at GAMC Bangalore).
  • With the tip of the shalaka in pupillary aperture, Kaphaja Linganasha (Cataract) should be scraped properly to disintegrate the organized material.

    To remove this disintegrated cortical/ nuclear matter, Close the nasal cavity opposite to the operated eye and ask patient to forcefully sneeze out through the open nare (ipsilateral to the eye being operated) while keeping the shalaka inside the eye. This will aid drainage of the liquefied cortical matter (by increasing the JVP and in turn increasing IOP.)

    Acharya Vagbhatta[26] varies in its technique at this step of surgical procdure. He is of the opinion that ask the patient to see towards ground and gently push the cataract downside without any delay, then ask the patient to sneez (as above) so that cataract goes down enough leaving the pupillary aperture (Drishti Mandala) clear.
  • If the cataract is not completely scraped and extracted out or if it re-occurs (After-cataract) then irrigate the eye again with mother's milk, apply sudation (asearlier) and rescrap the cataract (in pupillary area).
  • When by doing this procedure the pupil become clear of all kapha/white material-Cataract (like sky clear of clouds) and patient starts seeing fingers threads like objects then shalaka should be slowly removed by rolling out movemnts.
  • Apply pure ghee in eye and apply the bandage.
[Figure 3]
Picture 3: Linganasha Vedhana Procedure

Click here to view


Post Operative measures[8]:

A) Regimen of patient:

1. Place of patient's rest: In a House/ward which is clean and tidy, made on suitable land, devoid of dust, smoke, blowing wind and direct sunshine.

Bed should be comfortable, of proper length and width, so that patient can do movements comfortably, with, soft mattress covered by clean bed sheet with Pillow facing east with some sharp weapon underneath it.

2. Posture of patient in bed: If left eye is operated lie in right lateral position or vice-versa and if both are operated lie in supine position.

3. Patient should listen to pleasing stories etc.

4. Contraindications [11]:

  • For 3 days patients should avoid eructation, sneezing, coughing, spitting, trembling and excess movements.
  • For 7 days, head bath, heavy food, Datun (tooth Brush), but should take mouthwash/ manjan for oral hygiene, adhomukh- shayan (lying in prone position).


5. Diet [10],[19]

  1. Light, easily digestible food in proper quantity.
  2. Semi-liquid diet mixed with Trikatu (Zingiber officinale, Piper nigrum, Piper longum), Embelica officinalis, Sneha (Ghrita) and Salt.
  3. Porridge and Vilepi.
  4. Soup of meat of animals of Jaangal regions e.g. deer etc. and decoction of Leptadenia reticulata.
  5. Food along with medicated milk (medicated by Vata-pacifying drugs).


6. Massage of ghrita on head and feet everyday.

B. Wound care [11],[20]



  1. Open the bandage after 3 days
  2. Irrigate eye with decoction of Vata pacifying drugs e.g.
    1. Milk (or Ghrita) cooked with soft leaves of Ricinus communis.
    2. Milk medicated with Laghu Pancha moola.
  3. Mild sudation of eyes to allay the fear of Vata-alleviation.
  4. Bandage again.
  5. For 7 days, continue same steps of irrigation and re-bandaging every day.
  6. Avoid the bandage on 7 th or 10 th day.


C. Iatrogenic and Improper post-operative care related complications

  1. Raga (Redness).
  2. Paka (Inflammation).
  3. Vriddhi (Growth).
  4. Daha (Burning sensation).
  5. Granthi (Cystic swelling).
  6. Vakra netra (Squint due to muscle trauma).
  7. Adhimantha (Uveitis / Secondary glaucoma etc.)


D. Measures taken in care of certain persistent problems

1. If pain and redness persist [21] :



  1. Aschyotana (medicated eye drops):
    1. Goat's milk medicated with Glycyrrhiza glabra, Vitis vinifera, Symplocos racemosa and Saindhva lavana.
    2. Goat's milk medicated with Glycerrhiza glabra, Nelumbo nucifera, Saussurea lappa, Vitis vinifera, Laakh and Khaand.
    3. Goat's milk mixed with sandhava lavana.
  2. Lepa (paste-application on head and face):
    1. Ghrita mixed with paste of Geru, Hemidesmus indicus, Cynodon dactylon, Yava.
    2. Lemon juice mixed with roasted Sesamum indicun and Brassica compestris.
    3. Hemidesmus indicus, Glycerrhiza glabra, Rubia cardifolia, Cinnamon tamala, Ipomoea digitata, ground with goat's milk.
    4. Zingiber offcinale, Cedrus deodara, wood of Prunus cerasoides.
  3. Use of medicated ghrita orally , as nasal drops and for irrigation.Ghrita medicated with "Vatsakadigana".
  4. Siravedha (Venae puncture).
  5. Treat like Adhimantha- acute angle closure glaucoma and acute iridocyclitis.


Management[13]

Following line of treatment is followed in all these complications:

1. Lepa on eye (Enointing): For pacifying pain and redness.

  1. Luke warm paste of red ochre, Hemidesmus indicus, Cynodon dactylon, grinded finely in ghrita and milk and heated on fire.
  2. Luke warm paste of mild roasted Sesame indicum and Brassica campestris grinded with Citrus medica juice.
  3. Luke warm paste of Hemidesmus indicus, Cinnamomum tamala, Glycerrhiza glabra, and Rubia cardifolia in equal quantity ground with goat's milk.
  4. Luke warm paste of Berberis aristata, Zingibar officinale, Prunus cerasoides ground in milk.
  5. Luke warm paste of Vitis vinifera, Glycyrrhiza glabra, Saussurea lappa and Saindhava (Salt) ground with goat's milk.


2. Seka (ocular irrigation):

(A) For allaying pain and redness:

  1. Goat's milk boiled with paste/decoction of Glycyrriza glabra, Saindhava, Symplocus racemosa, Vitis vinifera.
  2. Goat's milk boiled with paste/decoction of Saussurea lappa, Vitis vinifera, Laakh, Glycyrrhiza glabra, Sugar, Saindhava, Nymphaea stellata.


(B) For allaying pain and burning sensation:

Goat's ghrita cooked with goat's milk along with. Paste/decoction of Prunus cerasoides, Uraria picta, Asparagus racemosus, Cyperus rotundus, Emblica officinalis.

3. Lepa, Anjana and Seka:

Goat's ghrita processed with goat's milk along with paste of vata pacifying Cedrus deodara etc. drugs and four time paste of "Kaakolyadigana" herbs should be used for anointing and irrigation.

4. Blood letting:

If ocular pain persists, then snehan (oleation), svedana (sudation) and blood letting from veins of temporal or frontal region.

5. Agnikarma (Moxibustion) on temporal or frontal area (above centre of respective eyebrow).[Table 1],[Table 2],[Table 3],[Table 4]
Table 1: Complications due to defect in Shalaka12&22 (Improper surgical instruments)


Click here to view
Table 2: Complication due to improper site of Vedhana14&23 (Surgical Intervention) & their Management


Click here to view
Table 3: Latrogenic complication and management24

Click here to view
Table 4: Certain intra operative complications of lingnasha (cataract) surgery & their management

Click here to view



   Discussion Top


Linganasha is one of the major causes of blindness, which can be either reversible or irreversible depending on its type. Kaphaja Linganasha is the only surgically treatable type, rest all being incurable. The indicated site of puncture/incision for linganasha/Cataract surgery is Daivakrita Chhidra (Key hole), which is the junction of medial 2/3 rd and lateral 1/3 rd of the area between limbus and outer canthus in interpalpebral space. On measuring this area with Vernier calliper, it is found to be 9 mm on an average. Thus the Daivkrita chhidra (natural point) should be about 6 mm away from the limbus on temporal interpalpebral area. These measurements correspond with Pars plana, the site which is least vascular and devoid of retinal tissue and also the preferred site for intra ocular (posterior segment) approach to the eyeball.

The shape of linganasha Vedhani shalaka is like the flower bud of Jasmine i.e. round, spindle shaped with narrow petiole like base. Such a shape ensures spontaneous and effortless exit of cortical matter from the sides of the neck of Shalaka through wound gap made by wide spindle shaped tip of the shalaka, when the scrapping is being done. This technique given in Sushruta Samhita (reproduced from Nimitantra) closely resembles to extra-capsular cataract extraction.

On the other hand description available in the Vagbhatta Samhita regarding this surgical step differs and is similar to the couching procedure.

After proper lekhana karma (scrapping), a JVP raising maneuver is done i. e closing Nostril opposite to the eye being operated and forcefully sneezing out through the ipsilateral nostril which consequently raises the IOP and facilitates spontaneous exit of scrapped/liquefied lens matter through the incision.

A detailed & critical account related to postoperative care & management of various complications (if arise) of cataract surgery has been given in Ayurveda literature which clearly emphasize that a utmost care in the selection of the patient, pre-operative, operative and post- operative as well as complications if any have been taken.


   Conclusion Top


Kaphaja Linganasha seems to be the proper word to be used for the eye disease- Cataract in modern medical science. Rajarishi Nimi, the king of Videha, who is the original contributor to the science of ophthalmology since the origin of Ayurveda, should be given a due credit that he rightly deserves.

The detailed description of surgical procedure of the ancient eye surgeons of India is suggestive of small incision extra- capsular cataract extraction by temporal approach as per the description available in the Sushruta Samhita (view point of King of Videha-Rajrishi Nimi). On the other hand couching was a later development in the surgical technique of cataract around the period of Acharya Vagbhatta. Couching technique being easy and time saving, remained in practice till mid of the 20 th century in many tribal areas of the country.

Some surgeons opines this procedure as pars plana lensectomy; but in that case this should have been referred as AAharana karma ( extraction ) and there would have been no reference of Punah linganasha (after cataract) as an complication.

A comprehensive and systematic account of pre-operative preparation, operative, technique and postoperative care of the patients and the surgical wound has been given by the ancient surgeons. Besides this, various iatrogenic and postoperative care related complications has been vividly detailed along with their management. Thus the surgical treatment of cataract was selective, systematic and in continuous process of transition since its recognition as major catastrophe in the literature of Ayurveda.[28]

 
   References Top

1.Sushruta Samhita with Nibandhasangraha commentary of Dalhana, edited by Acharya Trivikramji Yadavaji, 1st Edition, 1997, Uttar. 7/15-17; Choukhambha Orientalia,Varanasi.   Back to cited text no. 1      
2.Ibid. (1), Uttar., 7/29-33 & 42-44 & 45.  Back to cited text no. 2      
3.Ibid. (1), Uttar., 7/29-33.  Back to cited text no. 3      
4.Ibid. (1), Uttar., 7/15 & 30-31.  Back to cited text no. 4      
5.Ibid. (1), Uttar., 7/ 42.   Back to cited text no. 5      
6.Ibid. (1), Uttar., 17/55.   Back to cited text no. 6      
7.Ibid. (1), Uttar., 17/57 & 17/84.   Back to cited text no. 7      
8.Ibid. (1), Uttar., 17/64 .  Back to cited text no. 8      
9.Ibid. (1), Uttar., 17/74.  Back to cited text no. 9      
10.Ibid. (1), Uttar., 17/70.   Back to cited text no. 10      
11.Ibid. (1), Uttar., 17/69.  Back to cited text no. 11      
12.Ibid. (1), Uttar., 17/82-83.  Back to cited text no. 12      
13.Ibid. (1), Uttar., 17/87-94.  Back to cited text no. 13      
14.Ibid. (1), Uttar., 17/73-79.  Back to cited text no. 14      
15.Sir Stewart Duke Elder, 1976, System of Ophthalmology; 2nd Edi.,Vol. XI-249; Hentry Kimpton Publisher, London.   Back to cited text no. 15      
16.Acharya V.J.Thakker, 1988, Ashtanga Sangraha -Shashilekha Commentary of Indu, Ist Ed.Uttar 15/17; CRAS, New Delhi.  Back to cited text no. 16      
17.Ibid. (15), Uttar., 17/3.  Back to cited text no. 17      
18.Ibid. (15), Uttar., 17/04.  Back to cited text no. 18      
19.Ibid. (15), Uttar., 17/7.  Back to cited text no. 19      
20.Ibid. (15), Uttar., 17/11.  Back to cited text no. 20      
21.Ibid. (15), Uttar., 17/10.  Back to cited text no. 21      
22.Ibid. (15), Uttar., 17/11.  Back to cited text no. 22      
23.Ibid. (15), Uttar., 17/20.  Back to cited text no. 23      
24.Ibid. (15), Uttar., 17/13.  Back to cited text no. 24      
25.Ibid. (15), Uttar., 17/15.  Back to cited text no. 25      
26.Ibid. (15), Uttar., 17/16-18.  Back to cited text no. 26      
27.Ibid. (15), Uttar., 17/10.  Back to cited text no. 27      
28.Madhava Nidana with Madhukosh Commentary by Sh. Vijay Rakshita & Shri Kantha Dutta,Netra Roga Nidana 59/62-64, edited by Acharya Sudarshana Shastry, 1st Edi.2005.  Back to cited text no. 28      


    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]


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