arma pterygium

7/17/2019 Arma Pterygium

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Arma - Pterygium

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

Moderator : Dr. C. !ama Devi.

Asso.Pro". P.G Shalakya# De$t. o". S.S.P



Contents

•

Introduction• Sharira (Applied anatomy)of Shukla Mandala

(conjunctiva)

Arma%Pterygium&

• Nidana(etiology)

• Purva rupa(premonitory symptoms)

• Rupa(signs symptoms)



• Samprapti(pathogenesis)

• Sadhya sadhyata(prognosis)

• !hikitsa (treatment)

•

Nidana parivarjana(prevention)

• !onclusion



Introduction

• Arma(Pterygium) is a Netra roga comes under

Shukla gata rogas Acc to Acharya Susruta("")

and #ag$hata("%)&

• Acc to Susruta's classification of treatments for

eye diseases Arma comes under "" chedya

(e*cision) netra rogas&



• +his presentation includes detailed surgical

description of Acharyas regardingArma(Pterygium) and its advantages

disadvantages to current time&

• +he o$served Post surgical complications

their management $y our Acharyas their

utili,ation in current day post surgical

complications o$served $y -phthalmic

surgeons&



ar ra $$ eAnatomy&o" Shukla Mandala

%conjunctiva&

• Acc to Susruta the .rishna Mandala is /"0%rd'

of transverse diameter of eye the Shukla

Mandala is remaining /10%rd' of transverse

diameter&



• +he Shukla Mandala having its $oundaries 2ith

vartma and .rishna Mandalas&

• +he Shukla Mandala is predominant of 3ala

maha$hauta (2ater element)&

• +he diseases pertaining to Shukla Mandala are

/""' acc to Susruta 4 /"%' acc to #ag$hata(sirotpata and siraharsha are considered as

Shukla Mandala gata rogas)&



• Conjunctiva5 is a translucent mucus

mem$rane 2hich lines the posterior surface of

the eye lids and anterior aspect of the eye$all&



• -ur main concentration is on 'ul'ar

conjunctiva 2hich is the site for Pterygium&

• It is thin transparent and lies loose over the

underlying structures and thus can $e movedeasily&

•

It is separated from anterior sclera $yepiscleral tissue and tenon's capsule& At the

lim$us the epithelium of conjunctiva $ecomes

continuous 2ith that of cornea&



• +he histology of $ul$ar conjunctiva having

/%'layered epitheliumcontains go$let cellsadenoid layercontains lymphocytes fi$rous

layer 2hich contains vessels and nerves of

conjunctiva&



• Glands o" conjunctiva5 /1' types Mucin

secreting glands(secrets mucus 2hich is

essential for 2etting conjunctiva cornea)

and Accessory lacrimal glands&



• (lood su$$ly of conjunctiva $y arteries

derived from peripheral arterial arcade

marginal arcade of the eye lid and anterior

ciliary arteries&

• #eins from conjunctiva drains into venous

ple*us of eye lids and anterior cilliary veins&



•

6ateral and medial lym$hatics drain into preauricular and su$mandi$ular lymph nodes

respectively&

• A circum corneal ,one of conjunctiva is

supplied $y $ranches from long ciliary nerves

rest is supplied $y the $ranches from lacrimalinfra supra trochlear supra or$ital and

frontal nerves&



Arma%Pterygium&

• )idana%etiology&5 According to Ayurveda

• Ushnabhitaptasya jala pravesat-

entering into 2ater after e*posure to heat&

• Doorekshanat looking at distant o$jects&

• Swapna viparyaya- irregular sleeping ha$it.



• Prasakta samrodhana soka kopa-

2eeping grief and anger in e*cess&

• Klesabhigatadatimaithunacha-

fatigue $lo2 and e*cess of coitus &

• Suktaranalamlakulattamashanishevanath-

taking $everages of acidic nature horse gram

and $lack gram&



• Vegavinigrahacha- voluntary suppression of any

of nature call&

• Swedadrajodhumanishevanacha- e*cess of

s2eating e*posure to dust and smoke&

• hardervighatath- suppression of vomiting&

• Vamanatiyogath emesis in e*cess&

• !hashpagrahat suppression of tears&



• Sookshmanireekshanacha- looking at minute

things&

•

All these are causative factors for eye diseases $y aggravating doshas of the $ody&(Su&ut&"01"

11)

• "chakshushayirhi prayena pittanusarinaha-

the deeds 2hich are $ad to eye and especially

aggravate Pitta dosha&(A&7&ut&80")



• According to Modern *$hthalmology:

• +tiology of pterygium is not definitely kno2n&

9ut the disease is more common in people

living in hot climates&

• +he most accepted vie2 is that it is a response

to prolonged effect of environmental factorssuch as e*posure to sun (:# rays)dry heat

high 2ind and a$undance of dust&



• Purva ru$a%$remonitory sym$toms& : acc to

Ayurveda

• "vilam sasamrambhamasrupurnopadehavat-

cloudiness of vision slight inflammationlacrimation mucus accumulation&

•

#urushatodaragadhyairjushtamchavyaktalakshanaih heaviness pricking pain redness

and un manifested features&



• Sasoolam vartmakosheshusukapurnabhameva

cha- pain in lids and seems studded 2ith

$ristles of 2orms&

• Vihanyamanam rupe va kriyaswakshi yatha

pura- sensory impairment of faculty of eyes in

detecting colour closing and opening&



• !u$a%signs , sym$toms&: acc to Ayurveda

• Armas are /;' types depending upon their

signs and symptoms&

• Prastharyarma- shuklabhage vistirnam tanu

rudhiraprabham sa nilam-2hich is thin

reddish $lue in colour and e*tended onconjunctiva&



• Shuklarma- mrudu..saswetam samamihavardhate chiram- smooth 2hite and spreds

gradually for a long time&

• Lohitarma- yanmamsam..padmabham..-fleshy

gro2th resem$ling red lotus on conjunctiva&



• Adhimamsarma- visthirnam mrudu

bahalamyakrit prakasam syavam- soft thick

dark $ro2n like liver and spread on

conjunctiva&

• Snavyarma- pisitamupaiti vridhimetat..

kharamrapandu- rough pale and fleshy

gradual gro2th on conjunctiva& (su&ut&<0%=)

• In case of Prastharyarma #ag$hata says it

gro2s very fast- "suvridhi$".%.Ut.&'(&)*



•

In case of Snavyarma it resem$les snayu$tendon* $".%.Ut.&'(&)*

•

In case of Adhimamsarma sushkasrukpindavat syavamdark $ro2n in

colour like a dried $lood clot&

• +he Arma 2ill form either nasal or temporal

side 2as said only $y #ag$hata 2hile

e*plaining the surgery&



•

According to modern *$hthalmology5Pterygium a 2ing shaped fold of conjunctiva

encroaching upon the cornea from either side

2ithin the interpalpe$ral fissure&

• Demogra$hy5 usually seen in old age M#

may $e unilateral or $ilateral usually present

on nasal side $ut may also occur on temporal

side&



• Sym$toms:

• cosmetic intolerance may $e the only issue

other2ise asymptomatic condition in early

stages&

• >oreign $ody sensation may $e e*perienced&



• ?efective vision occurs 2hen it encroaches the

pupillary area or due to corneal astigmatisminduced $y fi$rosis in the regressive stage&

• ?iplopia may occur occasionally due to

limitation of ocular movements&



• Signs: a triangular fold of conjunctiva

encroaching on the cornea in the area of

palpe$ral aperture usually on the nasal side

$ut may also occur on the temporal side&

• very rarely $oth nasal and temporal sides are

involvedprimary dou$le pterygium&



• Parts of a fully developed pterygium5

• 7eadon the cornea

• Neckin the lim$al area

• 9ody e*tended $et2een

lim$us canthus

• !ap semi lunar 2hitish infiltrate just in front

of the head&



• /y$es: de$ending u$ on $rogression it may

$e progressive or regressive pterygium&• Progressive $terygium5 thick fleshy and

vascular 2ith a fe2 infiltrates in the cornea in

front of the head of the pterygium&



• !egressive $terygium5 thin atrophic

attenuated 2ith very little vascularity&

• +here is no cap $ut deposition of iron

(stocker@s line) may $e seen some times&



• Di""erential diagnosis5

•

Must $e differentiated from$seudo$terygium& It is formed due to

adhesion of chemosed $ul$ar conjunctiva to

marginal corneal ulcer& It usually occurs

follo2ing chemical $urns&



Pterygium Pseudo$terygium

+tiology: degenerative process

Inflammatory process

Age: usually occurs inelder persons

!an occurs at any age

Site: al2ays situated inthe palpe$ral aperture

!an occur at any site

Stages: either

progressive regressiveor stationary

Al2ays stationary

Pro'e test: pro$e cannot $e passed underneath

A pro$e can $e passedunder the neck



• Com$lications5 !ystic degeneration and

infection are infreuent& Neoplastic change toepithelioma fi$rosarcoma or malignantmelanoma may occur rarely&

• Correlation 'et0een Ayurvedicclassi"ication , Modern o$hthalmicclassi"ication:

• Prastharyarma- can $e compared 2ith!egressive $terygium&



• Shuklarma can $e compared 2ith Stationary

$terygium.

• 1ohitarma can $e compared 2ith

Progressive $terygium.

• Adhimamsarma can $e compared 2ith

Pseudo$terygium&

• Snavyarma can $e compared 2ith )eo$lastic

change of pterygium complications&



• Sam$ra$ti %$athogenesis&:

• According to Ayurveda5

• Siranusaribhirdoshairvigunairudhwamagataih

- the disease causing pathogenic factors

(doshas) reaches eye through its circulation&

•

+ayante netrabhgeshu rogah paramadarunah-2hich causes sevier eye diseases&



•

Dosha5 Prastharyarma AdhimamsarmaSnavyarma sannipataja(v&p&k)shuklarma

kaphakshtajarmaRakta&

• Dushya5 raktarasa&

•

Sthana5 Shukla Mandala&



•

According to modern o$hthalmology5

• +he 2orking hypothesis is that the :#

radiation causes mutations in the p;% tumorsuppressor gene thus facilitating the

a$normal proliferation of lim$al epithelium&



• It is a degenerative hyperplastic condition of

conjunctiva&

• +he su$conuctival tissue undergoes elastotic

degeneration and proliferates as vascularised

granulation tissue under the epithelium 2hich

ultimately encroaches the cornea&

• +he corneal epithelium $o2man's layer and

superficial stroma are destroyed&



• Sadhya sadhyata%$rognosis&

• According to Susruta all /;' Armas are of

chedana(e*cision) sadhyas #ag$hata also said

chedana $ut as a special treatment&

• According to Modern -phthalmology surgical

e*cision is the only satisfactory treatment&



• Chikitsa %treatment&

•+he Armas 2hich are tanu.&thindhooma&&smoky avilam&&dusty rakta&&red and

dadhinibham.&looks like curd& Are to $e treated

on the lines of Sukra 2hich is a cornealopacity&(su& vag&)

•

Medical treatment 5• +riphala !hurna given along 2ith or 2ith out

ghee depending on the condition(vag)&



• +iktaka ghritas for snehana (oleation) do

rakthamokshana ($lood letting) #amana

(emesis) virechana (purgation) and seka

(pouring medicated kashayas or oils over the

eye)&

• Nasya (nasal drops) +arpanam (filling the

conjuctival sac 2ith oils)putapaka (filling the

conjuctival sac 2ith medicated liuids or juices) 6ekananjanam (!ollyrium having

scraping property)&(Su& #a&)



• Surgical $rocedure o" Arma according to

Susruta5

• Indications "or surgery: charmabham

bahalam.. snayumamsaghanavritam..

krishnamandalagacha yat- skinny thick

tendinous muscular hardened and encroaches

cornea these are the conditions 2hich are to

$e operated&



• Pre o$erative $rocedure5

snigdhambhuktavatohyannam upavishta- the

patient should $e asked to sit comfortly aftertaking a meal rich of fat&

•Samroshayettu nayam bhishak churnaistulavanaih- the affected eye should $e irritated 2ith

po2dered rock salt&

• ,atah samroshitam turnam susvinnam

parighattitam- after that the part should $e

fomented and ru$$ed&



• Operative procedure

•

"pangam prekshyamanasya badisena samahitah-muchundyad( suchisutrena va ask

the patient to look to2ards his outer canthus

lift the Arma 2ith hook and then catch it 2ith

forceps0suturing tread&

• Vartmani grahayedhridam- the eye lids are

dra2n tightly&



• Ullikhan mandalagrena tikshnena parisodhayet-vimuktamsarvatachapi

krishnachuklachamandalat- the fla$$y and

pendent Arma is scraped 2ith the sharp edgeof scalpel like that 2ith out leaving any of its

contents attached to cornea and sclera&



• /itva kaninikopantam chindyannatikaninikam-

cahtur bhagasthite mamse na akshivyapattimarhati- the inner canthus should $e

secured 2hile scraping even leave "0<part of

Arma $ut don't hurt any other parts of eyeduring the procedure&

•

In case o" )etted Arma5 "rma yajjalavadvyapi- tadapyunmarjalambitam- catch same as

$efore 2ith forceps&



• hindyadvakrena sastrenavartma

suklantamasritam- then it should $e e*cised

2ith sharp edge of scalpel up to the point

2here lids unite 2ith conjunctiva&



• Post o$erative $rocedure5

• Pratisaranamakshnostu tatah

karyamanataram- after completion of

surgery the part should $e ru$$ed 2iththe

alkali prepared 2ith stalks of $arleyBpo2der of trikatu Bpo2der of Saindhava

salt&

• After that duly fomented and $andaged.



•

+he part should $e treated like a 2ound and $andage is removed after % days and give

fomentation 2ith ru$$ed palms&

• +he patient 2as given medicines and

purifications depending up on his strength in

accordance to time and season&



• /he $ro$erties o" success"ul surgery5

• Visudhavarnamaklishtam kriyaswakshi

gataklamam0yatha swamanupadravam- the

eye assumes its normal colour and function

2ith out getting any complications and pain&



• According to 2ag'hata the surgical

procedure is same e*cept• In preoperative procedure the Saindhava salt

po2der is 2etted 2ith lemon juice and then

the paste is applied as !ollyrium to eyes

there after the procedure is same as Susruta&

• In postoperative procedure5 for pratisarana he

doesn't mention yavakshara along 2ith

trikatu and honey&



•

+he part after ru$$ing is poured 2ithluke2arm ghee- ushnena sarpisha siktam&

•

"bhyaktam madhu sarpisha- then it isanointed 2ith honeyBghee &



• According to modern o$hthalmic Surgery:

• Indications "or surgery5 cosmetic reasons

progression of pterygium to pupillary area?iplopia due to interference in ocular

movements&

• Pre o$erative $rocedure5

• +opical anesthesia 4 instillation of drops of

1<C*ylocaine or "Camethocaine& -ne droponce in <minutes for <times&



• Dye is cleansed draped and e*posed using

universal speculum&

• *$erative $rocedure5 It is the latest and mosteffective techniue&

• 7ead of the pterygium is lifted and dissected

off the cornea very meticulously&

• +he main mass of pterygium is then separated

from the sclera underneath and the conjunctiva

superficially&

Pterygium 3 Techn iques John A. Hovanes ian Harvard Eye Associates, California.mp



• Pterygium tissue is then e*cised taking care

not to damage underlying medial rectusmuscle&

•

7aemostasis is achieved and the episcleraltissue e*posed is cauterised thoroughly&

•

!onjuctival lim$al auto graft (!6A:)transplantation to cover the defect after

pterygium e*cision&



• Post o$erative $rocedure5

• 9andaged the operated eye&

• +opical steroid anti$iotic drops topical

NSAI?S artificial tears up to E8 2eeks&

• Advice to 2ear dark sun glasses and to avoid

e*posure to sun&



• Advantages and disadvantages5

• +he signs indicated for medical management

acc to Ayurveda are very much useful incurrent times to prevent surgery&

• +he rock saltB citrus juice mi*ture 4 consists

mineral Na .&&vitaminc apart from this it is a

good cleanser of surgical part&

• +he instruments are changed $ut the procedure

is same as said $y Susruta&



• +he grafting techniue is not dealt $y Susruta

in eye $ut he kno2s ho2 to graft the nose&

• +he post operative care said $y Susruta offers

good healing and prevent recurrence $y 2hichhe claims that the Armas are Sadhya rogas of

eye&

• +he pratisarana enhances healing process

along 2ith cauterisation&



• +he mi*ture of ghee and honey is a good

source of vitamins lu$rication and enhances

healing&

• +he /F'th part of Arma is left to secure

lacrimal passages and $lood vessels 2ith

the help of dilators the pro$lem 2ill $e

overcomed in current time&



•

9y e*plaining properties of successful surgery2e suspect Susruta@s success rate in e*cision of

pterygium&

• Com$lications5 these are o$served due to

improper surgery0improper post surgical

management0immune response of the patient&



• Susruta o$served complication during surgery

$y cutting Arma up to innercanthus that isthe reason he said to leave /"0<'th of Arma

near to kaninika to secure lacrimal passages

and $lood vessels&

• At the same time improperly e*cised Arma

2ill re gro2 in that case !ollyrium havingscraping nature (lekhyanjana) to $e used

Susruta&



• +he post surgical pain management done 2ith

eye drops made up of milk ($oiled 2ithkaranjaBamalakiByashti) and honey&

•

A cold plaster prepared 2ith paste ofmilkBgheeByashtiBpolens of lotusBdurvagrass

is to $e applied on the fore head&

• #ag$hata support the vie2s of Susruta&



• Acc. to Modern o$hthalmic surgery5

• +he recurrence of pterygium is %G;GC is the

main pro$lem&

• !urrent techniue of grafting is some 2hat

$etter to decrease the recurrence rate&

• Surgical e*cision 2ith amniotic mem$rane

graft and mitomycinc (MM!)(G&G1C)application may $e reuired in

recurrent pterygium&



• +hough grafting gives relief from post surgical

pain and discomfort it may get rejected insome cases due to immune response&

•Pain inflammation irritation all are 2ellmanaged $y modern surgeons $y keeping

patient under anti$iotics steroids NSAI?S

artificial tear solutions&



• )idana $arivarjana%$reventive as$ects&5

•

9oth the systems finally come to single point prevention&

•Susruta@s main notion regarding treatment is prevention&

•Acharyas' clearly mention not to takecertain diets in eye diseases 4horse gram

$lack gram $everages having sour taste etc&

Ad i d id i i hi h



• Advised to avoid situations 2hich cause cry

anger grief &

• Advised to avoid hurt to eye and e*cess of coitus&

•Advised to use um$rella and foot2ear&

• Advised to use !ollyrium and massage foot 2ith

oil&

• Advised not to use hot 2ater for head $ath&



• Advised to take diet containing rich source

of vitamin A !&

• Advised to 2ear sun glasses to protect from

sun light&

• Advised to avoid 2ork in hot environment&

• +hese are some preventive measures to avoid

Armapterygium&



• Conclusion:

•

Susruta clearly mentioned e*cision has to $edone in pterygium encroaching cornea means

not to 2ait for further progression to the

pupillary region and cause discomfort to vision

2hich is a good carry point&

•

+he signs indicated for medical treatment alsouseful to prevent surgical intervention&



• Post surgical precautions and medications

are also useful to prevent recurrence&

• +hough it is a surgically cura$le disease the

recurrence rate of it alarms us $etter to

prevent&

• Sankshe$atah kriya yogo

nidana$arivarjanam-Su.ut.3456.



• !e"erences:

• Susruta samhita uttara tantra "st<th8th";th

chapters&

• Ashtanga 7ridaya uttara sthana =th"Gth""th

chapters&

• !omprehensive ophthalmology ;th edition $y

A. .hurana <th and 1<th chapters&

• eHreferences222&slideshare&net appropriate

images videos from oogle search&



Ackno0ledgements

•

Pro"., *D PG De$t.o".S.S.P5?r& M&uru murthy&

• Shalakya PG unit

•Pro"essor5 ?r& +& Praveen kumar&

• Associate $ro"essor: ?r& !7&Rama ?evi&

• Assistant $ro"essor5 ?r& 9&9adrinath 9enarji&

arma pterygium

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