SHUKTIKA - ARJUNADr. Pranav Bhagwat

Reader, dept. of Shalakyatantra,

Gomantaka ayurveda college,

Shiroda, Goa.

SHUKTIKA

• Colour :• Consistency :• Shape :

Shyava i.e. blackish whiteMamsa-likeShell-like: oblong or oval

(Dalhana)

These are multiple spot-like structures .

Shyava: syu: pishitanibhashcha bindavo ye/

Shuktyabha: sitanayane sa shuktisaudnya:// (su ut 4/6)

It is a Shuklagata, Pittaja, Sadhya

Vyadhi.

• Gadanigraha (netra-66)• Bhavaprakasha (Madhya 4/16)• Yogaratnakara (netra-66)

= Sushruta’s opinion

Dalhana comments :- shuktyabha : iti jalashuktiriva kincit deerrgha: shuklamandale ye bindava :

According to Vagbhata-

Pittam kuryaat site bindoon asita-shyaava-peetakan/

Malaaktaadarshatulyam vaa sarvam shuklam adaaharuk/

Roga: ayam shuktikaasandnya: sashakrudbhedtrudjwara://

( A.S.U. 13/12.)

INDU TIKA:INDU TIKA:

Pittam kruddham site bhaage asitadivarnaan bindun tilakalakaan kuryaat/ athavaa sarvam shuklam malaliptadarpanasadrusham kuryaat/ ubhayatraaapi daaharuk

abhava:/ etat ubhayamapi shakrutbhedadiyogannaamna shuktika iti rogo bhavati /

Pittam kuryaat site bindoon asita-shyaava-peetakan/

Malaaktaadarshatulyam vaa sarvam shuklam adaaharuk/

Roga: ayam shuktikaasandnya: sashakrudbhedtrudjwara://

( A.S.U. 13/12.)

Inference

SUSHRUTA

• Can be corelated with Xerosis.

• Can be considered as part of systemic disease.

• pigmentary lesion of conjunctiva and sclera

• including malignant melanoma, primary acquired melanosis,

naevus,

• Like a dirty mirror- xerosis.

• when we include general symptoms - viral hepatitis,

liver disorders.

VAGBHATA

XEROSIS

• Dry lustreless condition of conjunctiva due to deficiency of mucin.

XEROSIS

• Types:- two.• 1) - as a sequel of local ocular disease• 2) - associated with general condition.

The first type occurs due to –• scarring of the conjunctival epithelium and glands

following trachoma, burns, diphtheria, pemphigoid- starts as a spot and continue to affect whole conjunctiva or cornea.

• Prolonged exposure to air – due to ectropion or proptosis.

• Xerosis has nothing to do with lacrimal apparatus. It depends more on the secretory activity of conjunctiva. (Goblet cells )

xerosis

• The second general type --a milder form,

-- usually found in children due to lack of vitamin A in diet and accompanied by night blindness.

• (vita. A daily requirement is 5000 I. u. /day-

chief sources – milk, egg, carrots.

Stored in liver.).

Character of xerosis

• A small triangular, white patch, little away from limbus in the horizontal meridian, usually on temporal side first.

• is covered with foamy substance due to gas produced by corynebacterium xerosis. (bitot’s spots).

• When patients looks towards affected side wrinkling of bulbar conjunctiva at the site.

• When the child is marasmic, disease associated with nyctalopia and keratomalacia.

Treatment

• Prevention:• 1) vit A 2 lac U every 6 months from the age of 6 months

to 3 years• 2)diet containing green leafy vegetables etc. • Curative:• Vit A IM 1 lac U per day on alternate day for 3 weeks.• Oral vit. A • Artificial tears • Topical antibiotics• Dark glasses

Pigmentory lesions of conjunctiva

NEVUS RACIAL MELANO

SIS

OCULAR MELANOCYTOSIS

PRIMARY ACQUIRE

D MELANO

SIS (PAM)

MALIGNANT

MELANOMA

Onset First 2 decades. Can show changes during

puberty

Congenital, dark

individuals

Congenital,Can be

associated with

Naevus of Ota

40-50 yrs, in fair

skins, high chances of conversion

to Ca.

>50 yrs (but can be

any age)

Location Interpalpebral area

Limbus>bulbar>palpeb

ral conjunctiva

Bulbar conjunctiva

Anywhere (usually bulbar

conjuctiva)

Anywhere

PIGMENTARY LESIONS OF CONJUNCTIVADIFFERENTIAL DIAGNOSIS OFMELANOCYTIC LESIONS

NEVUS RACIAL MELANOS

IS

OCULAR MELANOC

YTOSIS

PRIMARY ACQUIRE

D MELANOSIS (PAM)

MALIGNANT

MELANOMA

Colour Brown or yellow

Brown gray Brown Brown or pink

Depth Substantia propria

Epithelium Episclera/scleral

Epithelium/

substantia propria

Substantia propria

Cyst Present~ 50%

None None None Vascular nodule

Margins Well defined

Ill defined Ill defined Illdefined well defined

Laterally Unilateral Bilateral Usually unilateral

unliateral Unilateral

Conclusion

1. Pigmented lesions of the conjunctiva comprise a large and varied

spectrum of conditions that include benign and malignant melanocytic lesions.

2. Whilst conjunctival nevi are the most common

Melanocytic lesions, the clinical features of these pigmented

conditions occasionally overlap and cause diagnostic confusion.

3. Clinical inspection and photodocumentation on regular intervals

is utilized to monitor pigmented lesions.

4. A conjunctival biopsy can confirm diagnosis.

Treatment

TREATMENT OF SHUKTIKA ACCORDING TO AYURVEDA

• Sushruta-• Doshhaiadhastaat shuktikaayaam apaaste

sheetairdravyairanjanan kaaryamaashu//

(Su.u.11/14)

Dalhana says• Adhastaat apaaste doshaihi virechanena iti/

• Anjana of vaidurya, sphatika, pravala,mukta,shankha,raupya,suvarna along with sharkara and honey.

Conclusion.

• Sushruta has understood the degenerative condition of conjunctiva and hence used ratnas,upratnas and superior dhatus for anjana.

• The advocacy of virechana also points towards involvement of yakruta (raktavaha srotas ) here the point should be noted that virechana cannot be given in Vagbhata’s Shuktika as it already has shakruta bheda.

Vagbhata (A.S.U.14/6)

• says- shuktikaam pittaabhishhyandavat saadhayet //

Treatment of pittabhishandhya includes ( A.S.U.19) • 1)ghruta pana with sharkara or tiktaka

ghruta/mahatiktaka ghruta/guggula tiktaka ghruta.• 2) aschotana-kashaya of poundarika,

amalaka,darbha,dashamula,shatavari,manjistha, talispatra,yasthi,darvi along with sugar and stanya.

• 3)seka-lepa- described here are anti inflammatory which are not useful in this condition.

• 4) anjanas described here are also rujaghna dahraghna and hence not useful in this condition

• 5) rasakriya of 50 parts of darvi and 1 part of sariva, yasthi, kakoli, nisha,draksha, manjistha,lodhra, usher,chandana, kashmari, sunishannaka. This is useful in all pittarogas.

• 6)nasya- kalka of sariva+sharkara+kashmari swarasa, nasya-yashti kalka triturated in ikshu rasa .

• 7)Tarpana and putapaka similar to savrana shukla-cream should be taken from kshirapaka of mamsa of jaangala animals, pigeons, hens etc. along with sheeta, jevaniya drugs and this cream is subjected to kshirpaka with kalka of chandana, madhu etc. For putapaka veshavar of kukkuta along with sheeta, jeevaniya drugs, honey and ghee should be used.

• 8) Siravedha. –saarvadehika pittadushti.

Conclusion.

• The treatment described by Vagbhata has the action of raktaprasadana along with pitta shamana. This imparts arrest of transformation in nature of tissues- metaplasia -which is useful in acquired melanosis.

• Fat soluble contents.• Jeevaneeya action.

Chakradatta (59/195)

Recommends following treatment-• koumbha-sarpi(puraana ghrita) paana .- chakshushya• Virechana. • Alepa.• parisheka by madhura sheeta dravyas .• anjana same as Sushruta with addition of chandana.

• Vrunda madhava, Bhaishajya Ratnavali, Gadanigraha follow Chakradatta.

Conclusion-

• Sushruta, Chakradatta and others – Xerosis.• Vagbhata- Xerosis + pigmentations.

ARJUNA.

ARJUNA-

• This is a shuklagata vyadhi,• Raktaja, saadhya.• Sushruta says- ( Su. U. 4/7) Eko ya: shasharudhiropamastu bindu: shuklastho

bhavati tam arjunam vadanti/• Gadanigraha (3/netraroga/66) , yogaratnakara-

(netraroga/67), follow Sushruta.• Vagbhata says-(A.S.U.13/20)Neeruk shlakshno arjuno bindu: shashalohit lohita:/• Vagbhata has added painless lesion as an additional

feature.

SUBCONJUNCTIVAL ECCHYMOSIS

• Site- bulbarC. Since it is liable to injuries and also loose connective tissues are there.

• Colour – bright red, then blackish red.

Causes-

• direct trauma to the eye- posterior limit is visible.• Injury to orbit/head injury- appears within 12-24 hrs after

injury. Since the bleeding is from inside the orbit, therefore the posterior limit of the hemorrhage is not visible.

• Marked congestion of neck veins- whooping cough in children, severe compression of chest/neck

• Blood diseases- leukaemia, haemophilia, purpura.• HT/ aneurysm of local arterioles.• Acute inflammation of conjunctiva- -pneumococcal,

herpes simplex, leptospirosis, viral epidemic K-Citis.

• Acute febrile systemic infections- measles, yellow fever, subacute bacterial endocarditis, meningococcal septicaemia.

• Endometriosis.• Elderly people• idiopathic

DIFFERENTIAL DIAGNOSIS

Kaposi’s sarcoma (in AIDS cases, bluish red tumour, may be with similar lesion on eyelid and face)

TREATMENT

• Trivial condition• Hardly any treatment required.• Blood absorbs within 2-3 wks. Faster with hot

compresses• Astringent drops as placebo.

AYURVEDOKTA CHIKITSA

According to Sushruta:

(Su. U. 12/19-27)

Paittam vidhim ashshhena kuryaat arjunashantaye/

• The vidhi of pittaabhishhyanda should be follwed.

• Parisheka with ikshu, honey, sugar, stanya, darvi, yashti, saindhava

• Anjana with same

• Ashcyotana- Amla drugs. Also with sugar water, yashti, mastu, honey, amla, saindhava, beejapooraka, kola, dadimamla.

• Anjana-

• 1)sphatika, pravala, shankha, yashti, honey or 2)shankha, honey, sugar, samudraphena or 3)saindhava, honey, kataka or

4) rasanjana with honey or

5) kasis with honey.

• Lekhyanjana- lohadi dhatu, avasadana gana, 5 lavanas, etc.

• Putapaka at last.

According to Vagbhata (A.S.U.14/8)

Raktaabhishyandavat pratikuryaat/

• Ashchyotana- matulungaras+sugar or mastu• Anjana- 1)shankhanaabhi+ makshika or

2)samudraphena with sita or 3)sphatika, keshara, shankhanabhi, yashti, honey or 4)rasanjana with honey or 5) kasis with honey.

From raktabhishyanda chikitsa• If required siravyadha• Nasya- sharkara, stanya,neelotpala.

According to Vrundamaadhava (Netraroga/226/7/8)

• 1. Pittabhishyandavat.• 2. Anjanas with shankha with honey. kataka with saindhava. samudraphena with sugar.• 3. Purana with sita, honey tentu, mastu, yashti,

saindhava.

ChakradattaGadanigrahaYogaratnakaraBhaishajyaratnavali

Follow anjanas of Vrunda

Yogaratnakara advises aschyotana with sugar, mastu and honey.

Discussion & Conclusion

• Basic treatment principle- early absorption of extravasated blood to reduce anxiety of patient and

further prevention of recurrence. • yogas containing CaCO3, sugar, honey, kashaya

dravyas are used.• Here,. the question can be raised regarding use of amla

rasaa for ashchyotana and not kashaya rasa, though amla rasa is raktapittaprakopakara.

• The answer is- The amla rasa - ushna so drugs when instilled in eye get entry into capillaries and veinules and dilate them causing resorption of blood.(anumaana) The

similar use of amla dravyas are found for lepa in raktapitta chikitsa and pittaja jwara chikitsa..

(aapptopadesha.)• Lekhyanjana should be reserved for intractable cases

and generally not required.

• The topic is open for discussion.

• -dr. Pranav Bhagwat.