World Journal of Pharmaceutical Research Janani Et Al

World Journal of Pharmaceutical Research Janani et al. World Journal of PharmaceuticalSJIF Impact Research Factor 8.074 Volume 8, Issue 1, 1685-1691. Review Article ISSN 2277– 7105

A REVIEW OF XEROPHTHALMIA DUE TO VITAMIN-A DEFICIENCY WITH AYURVEDIC MANAGEMENT

Dr. N. Janani1*, Dr. Miral. D. Patel2, Dr. S. Md. Nihaluddin3, Dr. Shivkant Sharma4

1,2,3Final Year PG Scholar, Department of Shalakya Tantra, Parul University, Parul Institute of Ayurveda, Limda, Vadodara, Gujarat, India. 4Assistant Professor, Department of Shalakya Tantra, Parul University, Parul Institute of Ayurveda, Limda, Vadodara, Gujarat, India.

ABSTRACT Article Received on 05 Dec. 2018, Xerophthalmia is the most common ocular manifestation of vitamin A

Revised on 26 Dec. 2018, deficiency. Vitamin A deficiency and Xerophthalmia are widely Accepted on 16 Jan. 2019

DOI: 10.20959/wjpps20191-14152 considered to be problems of developing countries. Indeed, more than 60 such countries are recognised by the WHO as suffering from an aggregated 5 Million new cases of Xerophthalmia, one quarter million *Corresponding Author resulting in blindness, every year. In this condition excess intake of Dr. N. Janani Final Year PG Scholar, vitamin A is necessary. In Ayurveda, there is no direct reference for Department of Shalakya vitamins and minerals but our Aacharyas mentioned Chakshushya Tantra, Parul University, aaharas, oushadhis, rasayana therapy which promotes eyesight and Parul Institute of Ayurveda, prevention of Netra rogas. Limda, Vadodara, Gujarat,

India. KEYWORDS: VitaminA deficiency, Xerophthalmia, cakshushya

dravyas, rasayana chikitsa.

INTRODUCTION

Ocular manifestations of vitamin A deficiency, particularly night blindness, have been recognised since antiquity. Animal research and clinical observations early in the twentieth century indicated that vitamin A was important for numerous bodily functions. Humans deficient in vitamin A grew poorly, suffered more persistent or severe infections, and

subsequently developed characteristic ocular manifestations termed “Xerophthalmia or Dry eye.[1] ”Vitamin A deficiency precipitated by Protein Energy Malnutrition & other disease

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such as diarrhoea, measles, malaria in children which either causes increased utilization or mal-absorption of vitamin A and ultimately blindness.

Xerophthalmia The term Xerophthalmia is reserved (by a joint WHO and USAID Committee, 1976) to cover all the ocular manifestations of vitamin A deficiency, including not only the structural changes affecting the conjunctiva, cornea and occasionally retina, but also the biophysical disorders of retinal rods and cones function.[2]

The rhodopsin system in the rod cells of retina is much more sensitive to deficiency than is the iodopsin system in the cone cells. As a result, rod function is impaired early on, resulting when sufficiently marked in impairment of night vision.[3] Impairment of cone function (i.e., day vision and color vision) is rarely seen clinically. In 1982, WHO introduced new Xerophthalmia classification is as follows.

XN- Night blindness; X1A- Conjunctival Xerosis; X1B- Bitot’s spot; X2- Corneal Xerosis; X3A- Corneal Ulceration/ Keratomalacia ( < 1/3 corneal surface) ; X3B- Corneal Ulceration/ Keratomalacia ( > 1/3 corneal surface ); XS- Corneal scar due to Xerophthalmia; XF- Xerophthalmic fundus.[4]

Source and Metabolism of vitamin A[5] Vitamin A or retinol, is a fat-soluble substance found in liver and in egg yolk and dairy products. Carotenoids a potential provitamin A precursor that can be converted to retinol are present in green leafy vegetables, yellow fruits. 1 IU of Vitamin A is equivalent to 0.3µg of retinol, 0.55µg of retinyl palmitate, 0.6µg of β-carotene, 1.2µg of other provitamin carotenoids. Some 50-90% of ingested retinol is absorbed in the small intestine and transported to the liver where it is stored as retinyl palmitate. When needed, it is released to blood stream as retinol then utilised by target cells, such as retinal photoreceptors, epithelial lining throughout the body. When vitamin A intake is ≤ 180- 450µg/ day of retinol, liver storage is drained to maintain serum retinol at a normal level (well above 0.7µmol/litre or 200µg/litre).

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Treatment[6] Individual Vitamin A dosage >1yr (immediately on diagnosis) 200,000 IU (orally)/ 100,000IU(IM) <1yr &<8kg 100,000 IU (orally) / 50,000 IU(IM) Pregnant / Non-pregnant women with XN, 10,000 IU for 2 weeks (daily dose ) X1A, X1B Corneal Xeropthalmia 200,000 IU (orally) / 100,000 IU (IM)

For Conjunctival xerosis artificial tears should be instilled every 3-4 hours. In the stage of Keratomalacia, full fledge treatment of bacterial corneal ulcer should be administered.

Prophylaxis[7] Individual Oral dose Timing 55mg retinyl 6-11 months Once every 4-6 months palmitate(100,000 IU) 110mg retinyl palmitate ≥12 months Once every 4-6 months (200,000 IU) 1375mg retinyl palmitate 1-3 times over the first 6 0-6 months (25000 IU) months of life Women of child bearing age 110mg retinyl palmitate Within 1 or 2 months of (mass dose) (200,000 IU) giving birth Pregnant and lactating 2.75-5.5 mg retinyl Daily women (repeated dose) palmitate (5000-10,000 IU)

Vitamin A rich foods[8] Sweet Dark-green Age group Carrots Mango potato Vegetables Children 0-5 months Breast feeding 6-11 months 11/2 tbsp 1 tbsp 1\3 cup ½ medium size 1-2 years 11/2tbsp 1 tbsp ½ cup ½ medium size 2-6 years 2 tbsp 11/2 tbsp ½ cup 2/3 medium size

Female ¼ cup Non- pregnant 21/2tbsp 1 cup 1 medium size ¼ cup Pregnant 21/2 tbsp 1 cup 1 medium size 1/3 cup Lactating ¼ cup 1 cup 2/3 medium size

Ayurvedic View Tridoshas plays an important role in proper functioning of eyes. Pittadosha specially Alochaka pitta responsible for good vision having a quality of roopaalocanata which is responsible for photochemical changes in retina.[9] Tarpaka kapha gives nourishment to eyes (aksha tarpaka) and regulate the tear film and surrounding which keeps the eye moist and lubricant.[10] Prana vata responsible for the proper functioning of visual pathway, Vyana vata

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responsible for nimesha and unmesha of eyelids.[11] If intake of vitamin A, Zinc, iron rich foods is low for prolonged periods, serum retinol level drop, cellular function is impaired results Xerophthalmia and deficiency like anemia, impaired resistance to infection and this leads to PEM. It can be correlated with Apatarpanajanya vyadhi mentioned by Caraka. Caraka mentioned deha, agni, varna, bala, oja kshaya.[12] It should be treated with sadhyosantarpana[13] which means excess intake of vitamin A, Zinc, iron rich food.

Aacharya Shusruta mentioned netra rogas that can be correlated with signs and symptoms of Xerophthalmia are as follows. Clinical features of Xerophthalmia Ayurvedic correlation Night Blindness Kaphavidagdahdrusti[14] Corneal and conjunctival Xerosis, Bitot’s Shuktika[15] spot Corneal ulcer or scar Savrana shukra[16] Xerophthalmic Fundus Linganasha[17]

Cakshushya Aaharas and oushadhis according to Ayurveda Many of the classics explained cakshushya food items and drugs which can be regularly used. Susruta Samhita quoted that a person who takes purana ghrita, asparagus (shatavari), snake gourd (patola), green gram, amalaki, yava, karavellaka, amaranth species(vatsuka, Tanduliya), flesh of vartaka regularly should not be afraid of the diseases.[18]

In Ashtanga Hridaya recommended that old grains like yava, Godhuma, Shali & Shastika, Kodrava, mudga with ghee is beneficial for the eyesight. Vagbhata highlighted dadima, draksha, saindhava, are cakshushya.[19]

Yogaratnakara mentioned madhura and tikta rasa are good for eyes.[20]

Cakshushya drugs containing vitamin A[21] Drug Name English name Vitamin A content Go ghrita Cow’s ghee 1418 IU/100gm Go dugdha Cow’s milk 395 IU/100gm Nariksheera Breast milk 212 IU/100gm Kukkutanda Hen’s egg 1442 IU/100 gm Jangala mamsa Animal liver 17,997 IU/100gm Amra Mango 1262 IU/100gm Kharjaraka Carrot 16706IU/100gm Raktaluka Sweet potato 14,187 IU/100gm Shatavari Asparagus 756 IU/100gm Karavellaka Bitter gourd 471 IU/100gm

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Shigru Drumstick 7564 IU/100gm Draksha Grapes 100 IU/100gm Mudga Green gram 114 IU/100gm

Cakshusya rasayana described in different Samhitas[22] Charaka Samhita Shusruta samhita Ashtanga hridaya Jivaniya drug Bijaksaradi yoga-su.su- Triphala rasayana-A.S.su- yashtimadhu (ch.su.4/11) 46/325 12/47 Netra roga rasayana Vidanga tandula yoga(2nd) Mustadi yapana vasti- dronipravesikarasayana- su.chi- 27/8 A.S.ka-5/11 (ca.chi-1-4/7) Kanchuki vividha yoga- A.S.U.49/178 Shiva gutika-A.S.U.49/193

Swarna makshika- S.U.49/199 Sarpi guda- A.S.chi-7/52

Aacharya charaka explained about rasayana chikitsa in four padas. Abhayamalakeeyam Rasayana padam[23] Chyava prasha Balaindriyanam Cha.chi-1/73 Amalaka rasayana Indriyabala samudhita Cha.chi-1/75 Haritaki rasayana Sareeraindriya budhibala Cha.chi-1/76 Pranakameeyam Rasayana padam Sthirendriyam ca Amalaka ghrita Cha.chi-2/5 atibalendriyam Karaprachiteeyam Rasayana padam Amalakakashaya Brahma Indriya Balapradam Cha.chi-3/6 Rasayanam Lauhadi Rasayanam Ati Balendriyam Cha.chi-3/21 Ayurvedasamudhaneeyam Rasayana padam Dwiteeya indrokta Rasayana Indriya balapradam Cha.chi-4/27

Rasoushadhis[24] Chakshushyam Swarna (gold) Rasatarangini- 15/70 ayushpradam Yashada (Zinc) Nayanamaya nashakaram Rasatarangini- 19/120-123 Kasisa (ferrous sulphate) Netryam Rasaratna samuchaya-3/51 Samudraphena Chaksushya Rasatarangini- 12/113-114 Loha (iron) Nayanamayagnam Rasatarangini- 20/83-86 Swarnamakshika (copper pyrite) Chakshushyam Rasaratna samuchya-2/79-80 Gairika Netryam Rasaratna samuchaya-3/47 Srotonjana (antimony sulphate) Netryam Rasa ratna samuchaya-3/102 Kapardika (cowry) Netryam Rasa ratna samuchya-3/133 Abhraka (mica) Netryam Rasatarangini- 10/72 Tamra (copper) Netramayeshu uttamam Ayurveda prakasha-3/145 Vanga (tin) Chakshushyam Rasa chudamani- 14/134 www.wjpr.net Vol 8, Issue 1, 2019. 1689 Janani et al. World Journal of Pharmaceutical Research

DISCUSSION AND CONCLUSION Vitamin A deficiency is a common form of micronutrient malnutrition affecting 21.1% of preschool age children and 5.6% of pregnant women worldwide.

Nutrition plays an important role in Ayurveda. Ayurveda places special emphasis on aahara (diet) and anna (food) as means to good life, health and wellness. Healthy and wholesome food nourishes the mind, body and soul. Apatarpanajanyavyadhi is caused by ushna and ruksha guna. So Sadhyosantarpana chikitsa should be given which should be having vata shamaka property. Xerophthalmia is one of the cause of blindness, proper intake of rasayana and aahara in appropriate dose which are mentioned by our samhitas can easily overcome the deficiency of vitamin A.

ACKNOWLEDGEMENTS This work was done under the guidance of Dr. Rajeev Dole, Dr.Devdatt Dave, Dr.S.L. Pandya, Dr. Manjiri Keskar, Dr. Jay Shah, Dr.Eshwari Salian, faculties of Shalakya Tantra, Parul Institute Of Ayurveda.

REFERENCES 1. Alfred Sommer, Vitamin A deficiency and its consequences, 3rd edition, WHO Geneva, 1994; pg.01. 2. AK Khurana, Comprehensive Ophthalmology, 6th edition, Jaypee Brothers Medical Publishers (P) Ltd, New Delhi, 2015; pg-467. 3. Alfred Sommer, Vitamin A deficiency and its consequences, 3rdedition, WHO Geneva, 1994; pg.09. 4. AK Khurana, Comprehensive Ophthalmology, 6th edition, Jaypee Brothers Medical Publishers (P) Ltd, New Delhi, 2015; pg-467-468. 5. Alfred Sommer, Vitamin A deficiency and its consequences, 3rdedition, WHO Geneva, 1994; pg.03. 6. AK Khurana, Comprehensive Ophthalmology, 6th edition, Jaypee Brothers Medical Publishers (P) Ltd, New Delhi, 2015; pg- 469. 7. Alfred Sommer, Vitamin A deficiency and its consequences, 3rdedition, WHO Geneva, 1994; pg.44. 8. Alfred Sommer, Vitamin A deficiency and its consequences, 3rdedition, WHO Geneva, 1994; pg.38.

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9. Ashtanga Hridayam of Vagbhata,Sutrasthana12/13, English translation by B. Rama Rao, Vol 1,1st edition Chaukambha Visvabharathi, Varanasi, 2009; pg.158 10. Ashtanga Hridayam of Vagbhata,Sutrasthana12/13, English translation by B. Rama Rao, Vol 1,1st edition Chaukambha Visvabharathi, Varanasi, 2009; pg.158 11. Ashtanga Hridayam of Vagbhata,Sutrasthana12/13, English translation by B. Rama Rao, Vol 1,1st edition Chaukambha Visvabharathi, Varanasi, 2009; pg.157. 12. Charaka Samhita of Charaka Sutrasthana 23/36, English translation by Vaidya Bhagwan Dash, Vol 1, Chowkamba Krishnadas Academy, Varanasi, 2008; pg.399. 13. Charaka Samhita of Charaka Sutrasthana 23/36, English translation by Vaidya Bhagwan Dash, Vol 1, Chowkamba Krishnadas Academy, Varanasi, 2008; pg.400. 14. Sushruta Samhita of Sushruta, Uttaratantra 7/36, English translation by P.V.Sharma, Vol 3, Chowkambaha Bharati Academy, Varanasi, 2005; pg.145. 15. Sushruta Samhita of Sushruta, Uttaratantra 4/7, English translation by P.V.Sharma, Vol 3, Chowkambaha Bharati Academy, Varanasi, 2005; pg.126. 16. Sushruta Samhita of Sushruta, Uttaratantra 5/4, English translation by P.V.Sharma, Vol 3, Chowkambaha Bharati Academy, Varanasi, 2005; pg.129. 17. Sushruta Samhita of Sushruta, Uttaratantra 7/29-32, English translation by P.V.Sharma, Vol 3, Chowkambaha Bharati Academy, Varanasi, 2005; pg.143. 18. Sushruta Samhita of Sushruta, Uttaratantra 17/49-51, English translation by P.V.Sharma, Vol 3,1st edition, Chowkambaha Bharati Academy, Varanasi, 2010; pg.201. 19. Ashtanga Hridayam of Vagbhata,Uttarasthana16/61b-65, English translation by K.R. Srikantha Murthy,Vol 3,1st edition Chaukambha Visvabharathi, Varanasi, 2010; pg.201-2. 20. Yogaratnakara, Netra Roga Chikitsa, Uttarardha/132, English translation by Mss Babu, Vol2, 1st edition, Chaukambha Sanskrita Series Office, Varanasi, 2008; Pg-1103. 21. Available from https:// WWW.livestrong.com. 22. Sharma Ajay Kumar, Elements of Rasayan Therapy, Srisadguru Publications, 1st edition, 2005; pg.no-68. 23. Vikash M.D, Role of Rasayana in Netra Roga, Journal of Ayurveda and integrated Medical Sciences, Jan-Feb 2018; Vol 3, Issue 1. 24. Vikash M.D, Role of Rasayana in Netra Roga, Journal of Ayurveda and integrated Medical Sciences, Jan-Feb 2018; Vol 3, Issue 1.