Comprehensive Eye Examination- A Systematic Approach

Eye patient has to be examined thoroughly for proper diagnosis so that appropriate management can be planned. What is healthy status or niramayata? How is disease generated? Charaka-Samhita, Sushruta-Samhita and Ashtanga-Hrudaya elaborated these points in their compendia. Some important points are discussed here:

3 Dosha, 7 Dhatu and 3 Mala should be maintained in homeostatic equilibrium for attaining healthy status. Their deviation on either side, vruddhi or kshaya, triggers genesis of disease. (Vruddhi means either aggrevation/vitiation or increase in one of the properties and kshaya means decrease in volume or one of the properties. Refer-S.Su.Ch.15, A.H.Su.Ch.1 & 11)

Etiological factors for vruddhi and kshaya of dosha:

Following different factors are responsible for disturbing the equilibrium between dosha, dhatu and mala which are responsible for genesis of disease.

  1. Unwholesome diet/edibles– 3 dosha, 7 dhatu and 3 mala undergo vruddhi/increase/aggrevation due to consumption of food materials having similar qualities/properties/rasa. They undergo kshaya/decrease by using food items with opposite qualities. 
  2. Injudicious behaviour/habits– These as well as ignoring sheet, ushna kala and desha i.e. geographical location are also responsible for genesis of disease.
  3. Ignoring seasonal regimen/rutucharya– not following seasonal regimen regularly is also responsible.
  4. Overuse, underuse or misuse of sense organs is also responsible.
  5. Wrong physical, mental or elocution deeds are also responsible. (asatmyendriyarthasanyoga / pradnyaparadha / parinama).  

Three/Four fold Specific methods of Tests of investigation:

Various general methods of collecting information about any disease are described in Nidanasthana but for collecting more deep and specific information; Three/Four fold methods are described by Charakacharya in Vimanasthana Ch.4– 2 and Sutrasthana Ch.11-17 as under-

  • Aptopadesha (Authoritative Testimony)
  • Patyaksha (Direct Observation)
  • Anumana (Inference)
  • Yukti/Reason (Later on rejected by Maharshi Aatreya in Vi.Ch.8)

Transmission of knowledge through highly educated, well acquainted, experienced and reliable teacher is Aptopadesha.

Practically witnessing the things with perception of sense organs or dnyanendriya through mann and atma is Pratyaksha pramana.

Judgement of things which are not perceivable by naked eye or by other sense organs but are probably derieved from the circumstances is called Anumana pramana.

Objects examined by eyes:

Physical size, shape, measurement, color, luster, body-health, abnormalities/diseases etc can be examined with eyes (Charaka Vimana 4-11). 

Types  of diseases:-  Nija and Agantu 

Types of adhishthana of diseases:– Sharira i.e. body and Mann i.e. mind

Prognosis i.e. sadhyasadhyatva:

Diseases 
Sadhya  Asadhya 
Sukhasadhya Kruchchrasadhya Yapya Anupakrama 

Information gathered from all the above points along with history and other points from following table will definitely help in confirming various hetu, purvarupa, rupa and samprapti of any ophthalmic  disease.

 

Table for examination of an Eye patient:

    1. Rungna samvedya lakshana/liga i.e.Symptoms
    2. Rugna itihasa or History of patient 
    3. Purvotpanna vyadhi or past history          
    4. Kula itihasa or Genetic/ family  history 
    5. Rugna parikshana or Examination of patient-

Trividha, Ashtavidha, Dashavidha Pariksha.

Trividha parikshana Signs or vaidyasamvedya lakshana/features
A] Darshana pariksha Entire physical examination of patient is advisable followed by the examination of indriya. In this examination color of different parts of eye, size, shape, measurement and  abnormal findings, if any, should be noted down 
B] Sparshana pariksha It should be done to evaluate the consistency (hard/soft), tenderness, ballottement in case of abscess, intra ocular pressure etc.
C] Prashna pariksha History of patient and disease to evaluate different hetu; genetic history, age, education, occupation, economical status, addictions, habits, lifestyle, desha (geographical place), bala (strength) kala(season), agni, mental status, sleep, satmyasatmya (homologation), aahara (diet), vihara (regime) etc are assessed by asking appropriate questions. This information is useful for diagnosis of the disease.
D] Ashtavidha 

/dashavidha pariksha ( 8 /10 topics of investigations)

Nadi, mala, mutra, jivha, shabda, sparsha, druk, akruti etc are assessed by ashtavidha and dashavidha pariksha.(C.Vi.8-69 to 79)

6. Examination of Prakruti ( test of constitution )

7. Indreeya parikshana / Examination of eye

 

Right Left
1. Bhru
2. Mandala i. Pakshmamandala
ii. Vartma-mandala – Urdhva
                                        – adho 
iii. Shuklamandala 
iv. Krushnamandala – karnika (cornea)
        Tarakamandala / varnamandala (iris) 
v. Drushimandala – akara (size, shape ),  
        Sankocha-vistara (reaction) 
3. Sandhi i. Pakshma-vartmagata sandhi
ii. Vartma-shuklagata sandhi – urdhwa    / adho (Fornix)
iii. Shukla-krushnagata sandhi                  
iv. Krushna-drushtigata sandi
v. Kaninika sandhi / inner canthus
vi. Apanga sandhi / outer canthus.
4. Srava Rashi/Pramana-volume, density, odour, color
5. Other features

8. Nidana panchaka/vyadhi parikshana (A.H.Su. 1-22)-

  1. Hetu
  2. Purvarupa
  3. Rupa
  4. Upashayanupashaya
  5. Samprapti

9. Blood examination, urine examination, stool examination and other specific investigations etc.

10. Vyavachhedaka-nidana /Differential diagnosis

11. Vyadhi-vinishchaya /Final diagnosis

12. Sadhya-sadhytva /Prognosis

13. Upadrava i.e. complications

14. Chikitsa  / Management (A.H.Su. 4-27)- 

  • Shodhana chikitsa – vamana, virechana, basti, shirobasti, shirovirechana, nasya, dhumapana, snehanottara raktamokshana etc should be performed.
  • Shaman chikitsa – internal medicinal remedy in accordance with dosha along with different Kriyakalpa.

 Principles of Management to be undertaken- 

Avastha Sarvadihik (systemic)  chikitsa Sthanik chikitsa
1 Nidana parivarjana ——- ——-
2 Purvarupa-vasta Tikshna shirovirechana, kavalagraha, dhumapana, upavasa (except-vataja netraroga in which vata mitigating, chakshushya and snigdha measures are used.) Lepa/bidalaka, avachurnana, sechana/parisheka
3 Samavastha Langhana, dhumapana, use of madhura-tikta rasa; to be performed for 4 days. For amapachana- dipaka, pachaka drugs to be used; AVOID – ghrutapana, heavy foodstuff, kwathapana  and bathing Sechana,bashpa-sweda, lepa for 4 days
AVOID –anjana, purana (ashchotana)
4 Niramavastha a)Shodhana- snehana, swedana followed by raktamokshana, virechana, basti, vamana, nasya, dhumapana etc. according to bala of the patient.
b) Shaman chikitsa.
Shodhana, shaman of local dosha by raktamokshana, nasya, dhumapana followed by kriyakalpa like Tarpana, putapaka ashchotana, parisheka, anjana etc.
5 Surgery – if indicated-Purva-pradhana-pashchata karma
6 Upadrava – if any, to be managed accordingly
7 Pathyapathya – Dietary and other measures
8 Drushti-prasadanartha anjana
9 Swasthavrutta and Rasayana chikitsa

If a physician /surgeon follows a proper and systematic approach regarding nidana panchaka, laboratory investigations, vyavacchedaka-nadana, vyadhi-vinishchaya etc. then only the medical /surgical management of an eye disease will be successful. Moreover he should also tackle the complication, if any.