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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$t. o". S.S.P
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Contents
•
Introduction• Sharira (Applied anatomy)of Shukla Mandala
(conjunctiva)
Arma%Pterygium&
• Nidana(etiology)
• Purva rupa(premonitory symptoms)
• Rupa(signs symptoms)
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• Samprapti(pathogenesis)
• Sadhya sadhyata(prognosis)
• !hikitsa (treatment)
•
Nidana parivarjana(prevention)
• !onclusion
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Introduction
• Arma(Pterygium) is a Netra roga comes under
Shukla gata rogas Acc to Acharya Susruta("")
and #ag$hata("%)&
• Acc to Susruta's classification of treatments for
eye diseases Arma comes under "" chedya
(e*cision) netra rogas&
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• +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&
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ar ra $$ eAnatomy&o" Shukla Mandala
%conjunctiva&
• Acc to Susruta the .rishna Mandala is /"0%rd'
of transverse diameter of eye the Shukla
Mandala is remaining /10%rd' of transverse
diameter&
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• +he Shukla Mandala having its $oundaries 2ith
vartma and .rishna Mandalas&
• +he Shukla Mandala is predominant of 3ala
maha$hauta (2ater element)&
• +he diseases pertaining to Shukla Mandala are
/""' acc to Susruta 4 /"%' acc to #ag$hata(sirotpata and siraharsha are considered as
Shukla Mandala gata rogas)&
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• Conjunctiva5 is a translucent mucus
mem$rane 2hich lines the posterior surface of
the eye lids and anterior aspect of the eye$all&
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• -ur main concentration is on 'ul'ar
conjunctiva 2hich is the site for Pterygium&
• It is thin transparent and lies loose over the
underlying structures and thus can $e movedeasily&
•
It is separated from anterior sclera $yepiscleral tissue and tenon's capsule& At the
lim$us the epithelium of conjunctiva $ecomes
continuous 2ith that of cornea&
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• +he histology of $ul$ar conjunctiva having
/%'layered epitheliumcontains go$let cellsadenoid layercontains lymphocytes fi$rous
layer 2hich contains vessels and nerves of
conjunctiva&
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• Glands o" conjunctiva5 /1' types Mucin
secreting glands(secrets mucus 2hich is
essential for 2etting conjunctiva cornea)
and Accessory lacrimal glands&
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• (lood su$$ly of conjunctiva $y arteries
derived from peripheral arterial arcade
marginal arcade of the eye lid and anterior
ciliary arteries&
• #eins from conjunctiva drains into venous
ple*us of eye lids and anterior cilliary veins&
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•
6ateral and medial lym$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&
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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.
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• 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&
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• 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&
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• 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 $ad to eye and especially
aggravate Pitta dosha&(A&7&ut&80")
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• According to Modern *$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$undance of dust&
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• Purva ru$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&
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• Sasoolam vartmakosheshusukapurnabhameva
cha- pain in lids and seems studded 2ith
$ristles of 2orms&
• Vihanyamanam rupe va kriyaswakshi yatha
pura- sensory impairment of faculty of eyes in
detecting colour closing and opening&
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• !u$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 $lue in colour and e*tended onconjunctiva&
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• Shuklarma- mrudu..saswetam samamihavardhate chiram- smooth 2hite and spreds
gradually for a long time&
• Lohitarma- yanmamsam..padmabham..-fleshy
gro2th resem$ling red lotus on conjunctiva&
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• 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$".%.Ut.&'(&)*
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•
In case of Snavyarma it resem$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&
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•
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 $ut may also occur on temporal
side&
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• Sym$toms:
• cosmetic intolerance may $e the only issue
other2ise asymptomatic condition in early
stages&
• >oreign $ody sensation may $e e*perienced&
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• ?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&
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• 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&
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• 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&
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• /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&
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• !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&
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• 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 $urns&
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Pterygium Pseudo$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 $e passedunder the neck
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• Com$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&
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• 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&
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• Sam$ra$ti %$athogenesis&:
• According to Ayurveda5
• Siranusaribhirdoshairvigunairudhwamagataih
- the disease causing pathogenic factors
(doshas) reaches eye through its circulation&
•
+ayante netrabhgeshu rogah paramadarunah-2hich causes sevier eye diseases&
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•
Dosha5 Prastharyarma AdhimamsarmaSnavyarma sannipataja(v&p&k)shuklarma
kaphakshtajarmaRakta&
• Dushya5 raktarasa&
•
Sthana5 Shukla Mandala&
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•
According to modern o$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&
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• 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 $o2man's layer and
superficial stroma are destroyed&
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• Sadhya sadhyata%$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&
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• Chikitsa %treatment&
•+he Armas 2hich are tanu.&thindhooma&&smoky avilam&&dusty rakta&&red and
dadhinibham.&looks like curd& Are to $e treated
on the lines of Sukra 2hich is a cornealopacity&(su& vag&)
•
Medical treatment 5• +riphala !hurna given along 2ith or 2ith out
ghee depending on the condition(vag)&
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• +iktaka ghritas for snehana (oleation) do
rakthamokshana ($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&)
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• 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
$e operated&
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• Pre o$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$$ed&
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• Operative procedure
•
"pangam prekshyamanasya badisena samahitah-muchundyad( suchisutrena va ask
the patient to look to2ards his outer canthus
lift the Arma 2ith hook and then catch it 2ith
forceps0suturing tread&
• Vartmani grahayedhridam- the eye lids are
dra2n tightly&
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• Ullikhan mandalagrena tikshnena parisodhayet-vimuktamsarvatachapi
krishnachuklachamandalat- the fla$$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&
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• /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&
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• hindyadvakrena sastrenavartma
suklantamasritam- then it should $e e*cised
2ith sharp edge of scalpel up to the point
2here lids unite 2ith conjunctiva&
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• Post o$erative $rocedure5
• Pratisaranamakshnostu tatah
karyamanataram- after completion of
surgery the part should $e ru$$ed 2iththe
alkali prepared 2ith stalks of $arleyBpo2der of trikatu Bpo2der of Saindhava
salt&
• After that duly fomented and $andaged.
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•
+he part should $e treated like a 2ound and $andage is removed after % days and give
fomentation 2ith ru$$ed palms&
• +he patient 2as given medicines and
purifications depending up on his strength in
accordance to time and season&
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• /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&
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• 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&
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•
+he part after ru$$ing is poured 2ithluke2arm ghee- ushnena sarpisha siktam&
•
"bhyaktam madhu sarpisha- then it isanointed 2ith honeyBghee &
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• 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 $rocedure5
• +opical anesthesia 4 instillation of drops of
1<C*ylocaine or "Camethocaine& -ne droponce in <minutes for <times&
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• Dye is cleansed draped and e*posed using
universal speculum&
• *$erative $rocedure5 It is the latest and mosteffective techniue&
• 7ead of the pterygium is lifted and dissected
off the cornea very meticulously&
• +he main mass of pterygium is then separated
from the sclera underneath and the conjunctiva
superficially&
Pterygium 3 Techn iques John A. Hovanes ian Harvard Eye Associates, California.mp
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• Pterygium tissue is then e*cised taking care
not to damage underlying medial rectusmuscle&
•
7aemostasis is achieved and the episcleraltissue e*posed is cauterised thoroughly&
•
!onjuctival lim$al auto graft (!6A:)transplantation to cover the defect after
pterygium e*cision&
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• 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&
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• 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&
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• +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 $y 2hichhe claims that the Armas are Sadhya rogas of
eye&
• +he pratisarana enhances healing process
along 2ith cauterisation&
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• +he mi*ture of ghee and honey is a good
source of vitamins lu$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 $e
overcomed in current time&
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•
9y e*plaining properties of successful surgery2e suspect Susruta@s success rate in e*cision of
pterygium&
• Com$lications5 these are o$served due to
improper surgery0improper post surgical
management0immune response of the patient&
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• Susruta o$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 $e used
Susruta&
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• +he post surgical pain management done 2ith
eye drops made up of milk ($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&
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• 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&
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• +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&
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• )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 $everages having sour taste etc&
Ad i d id i i hi h
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• Advised to avoid situations 2hich cause cry
anger grief &
• Advised to avoid hurt to eye and e*cess of coitus&
•Advised to use um$rella and foot2ear&
• Advised to use !ollyrium and massage foot 2ith
oil&
• Advised not to use hot 2ater for head $ath&
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• 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&
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• Conclusion:
•
Susruta clearly mentioned e*cision has to $edone in pterygium encroaching cornea means
not to 2ait for further progression to the
pupillary region and cause discomfort to vision
2hich is a good carry point&
•
+he signs indicated for medical treatment alsouseful to prevent surgical intervention&
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• Post surgical precautions and medications
are also useful to prevent recurrence&
• +hough it is a surgically cura$le disease the
recurrence rate of it alarms us $etter to
prevent&
• Sankshe$atah kriya yogo
nidana$arivarjanam-Su.ut.3456.
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• !e"erences:
• Susruta samhita uttara tantra "st<th8th";th
chapters&
• Ashtanga 7ridaya uttara sthana =th"Gth""th
chapters&
• !omprehensive ophthalmology ;th edition $y
A. .hurana <th and 1<th chapters&
• eHreferences222&slideshare&net appropriate
images videos from oogle search&
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Ackno0ledgements
•
Pro"., *D PG De$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&
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