Arma

Pterygium

Presenter :Dr. Pancha janya kumar .Deevi

II yr Shalakya P.G scholar.
Moderator : Dr. CH. Rama Devi.
Asso.Prof. P.G Shalakya, Dept. of. 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)
Chikitsa (treatment)
Nidana parivarjana(prevention)
Conclusion

Introduction
Arma(Pterygium) is a Netra roga comes under
Shukla gata rogas Acc to Acharya Susruta(11)
and Vagbhata(13).
Acc to Susrutas classification of treatments for
eye diseases, Arma comes under 11- chedya
(excision) netra rogas.

 This presentation includes detailed surgical

description of Acharyas regarding
Arma(Pterygium) and its advantages &
disadvantages to current time.
The observed Post surgical complications &
their management by our Acharyas, their
utilization in current day post surgical
complications observed by Ophthalmic
surgeons.

Sharira (Applied
Anatomy)of
Shukla Mandala
(conjunctiva)
Acc to Susruta the Krishna Mandala is 1/3 rd
of transverse diameter of eye, the Shukla
Mandala is remaining 2/3rd of transverse
diameter.

 The Shukla Mandala having its boundaries with

vartma and Krishna Mandalas.
The Shukla Mandala is predominant of Jala
mahabhauta (water element).
The diseases pertaining to Shukla Mandala are
11 acc to Susruta 13 acc to Vagbhata
(sirotpata and siraharsha are considered as
Shukla Mandala gata rogas).

 Conjunctiva: is a translucent mucus

membrane which lines the posterior surface of
the eye lids and anterior aspect of the eyeball.

 Our main concentration is on bulbar

conjunctiva which is the site for Pterygium.
It is thin transparent and lies loose over the
underlying structures and thus can be moved
easily.
It is separated from anterior sclera by
episcleral tissue and tenons capsule. At the
limbus the epithelium of conjunctiva becomes
continuous with that of cornea.

 The histology of bulbar conjunctiva having

3layered epithelium-contains goblet cells,
adenoid layer-contains lymphocytes & fibrous
layer which contains vessels and nerves of
conjunctiva.

 Glands of conjunctiva: 2 types- Mucin

secreting glands(secrets mucus which is
essential for wetting conjunctiva & cornea)
and Accessory lacrimal glands.

 Blood supply of conjunctiva by arteries

derived from peripheral arterial arcade &
marginal arcade of the eye lid and anterior
ciliary arteries.
Veins from conjunctiva drains into venous
plexus of eye lids and anterior cilliary veins.

 Lateral and medial lymphatics drain into

preauricular and submandibular lymph nodes
respectively.
A circum corneal zone of conjunctiva is
supplied by branches from long ciliary nerves,
rest is supplied by the branches from lacrimal,
infra & supra trochlear, supra orbital and
frontal nerves.

Arma(Pterygium)
Nidana(etiology): According to Ayurveda
Ushnabhitaptasya jala pravesatentering into water after exposure to heat.
Doorekshanat- looking at distant objects.
Swapna viparyaya- irregular sleeping habit.

 Prasakta samrodhana soka kopaweeping, grief and anger in excess.

Klesabhigatadatimaithunachafatigue, blow and excess of coitus .
Suktaranalamlakulattamashanishevanathtaking beverages of acidic nature, horse gram
and black gram.

 Vegavinigrahacha- voluntary suppression of any

of nature call.
Swedadrajodhumanishevanacha- excess of
sweating, exposure to dust and smoke.
Chardervighatath- suppression of vomiting.
Vamanatiyogath- emesis in excess.
Bhashpagrahat- suppression of tears.

 Sookshmanireekshanacha- looking at minute

things.
All these are causative factors for eye diseases
by aggravating doshas of the body.(Su.ut.1/2122)
Achakshushayirhi prayena pittanusarinahathe deeds which are bad to eye and especially
aggravate Pitta dosha.(A.H.ut.8/1)

 According to Modern Ophthalmology:

Etiology of pterygium is not definitely known.
But the disease is more common in people
living in hot climates.
The most accepted view is that it is a response
to prolonged effect of environmental factors
such as exposure to sun (UV rays),dry heat,
high wind and abundance of dust.

 Purva rupa(premonitory symptoms) : acc to

Ayurveda
Avilam sasamrambhamasrupurnopadehavatcloudiness of vision, slight inflammation,
lacrimation, mucus accumulation.
Gurushatodaragadhyairjushtamchavyakta
lakshanaih- heaviness, pricking pain, redness
and un manifested features.

 Sasoolam vartmakosheshusukapurnabhameva
cha- pain in lids and seems studded with
bristles of worms.
Vihanyamanam rupe va kriyaswakshi yatha
pura- sensory impairment of faculty of eyes in
detecting colour, closing and opening.

 Rupa(signs & symptoms): acc to Ayurveda

Armas are 5 types depending upon their
signs and symptoms.
Prastharyarma- shuklabhage vistirnam tanu
rudhiraprabham sa nilam-which is thin
reddish blue in colour and extended on
conjunctiva.

 Shuklarma- mrudu..saswetam samamiha

vardhate chiram- smooth, white and spreds
gradually for a long time.
Lohitarma- yanmamsam..padmabham..-fleshy
growth resembling red lotus on conjunctiva.

 Adhimamsarma- visthirnam mrudu

bahalamyakrit prakasam syavam- soft, thick,
dark brown like liver and spread on
conjunctiva.
Snavyarma- pisitamupaiti vridhimetat..
kharamrapandu- rough, pale and fleshy
gradual growth on conjunctiva. (su.ut.4/3-7)
In case of Prastharyarma Vagbhata says it
grows very fast- Asuvridhi(A.H.Ut.10/17)

 In case of Snavyarma it resembles

snayu(tendon) (A.H.Ut.10/17)
In case of Adhimamsarmasushkasrukpindavat syavam-dark brown in
colour like a dried blood clot.
The Arma will form either nasal or temporal
side was said only by Vagbhata while
explaining the surgery.

 According to modern Ophthalmology:

Pterygium a wing shaped fold of conjunctiva
encroaching upon the cornea from either side
within the interpalpebral fissure.
Demography: usually seen in old age, M>F,
may be unilateral or bilateral, usually present
on nasal side but may also occur on temporal
side.

 Symptoms:
cosmetic intolerance may be the only issue
otherwise asymptomatic condition in early
stages.
Foreign body sensation may be experienced.

 Defective vision occurs when it encroaches the

pupillary area or due to corneal astigmatism
induced by fibrosis in the regressive stage.

Diplopia may occur occasionally due to

limitation of ocular movements.

 Signs: a triangular fold of conjunctiva

encroaching on the cornea in the area of
palpebral aperture usually on the nasal side,
but may also occur on the temporal side.

very rarely , both nasal and temporal sides are

involved-primary double pterygium.

 Parts of a fully developed pterygium:

Head-on the cornea
Neck-in the limbal area
Body- extended between
limbus &canthus
Cap- semi lunar whitish infiltrate just in front
of the head.

 Types: depending up on progression it may

be progressive or regressive pterygium.
Progressive pterygium: thick, fleshy and
vascular with a few infiltrates in the cornea, in
front of the head of the pterygium.

 Regressive pterygium: thin, atrophic,

attenuated with very little vascularity.
There is no cap but deposition of iron
(stocker's line) may be seen some times.

 Differential diagnosis:
Must be differentiated from
pseudopterygium. It is formed due to
adhesion of chemosed bulbar conjunctiva to
marginal corneal ulcer. It usually occurs
following chemical burns.

Pterygium
Etiology:
process

Pseudopterygium

degenerative

Inflammatory process

Age: usually occurs in

elder persons

Can occurs at any age

Site: always situated in

the palpebral aperture

Can occur at any site

Stages:
either
progressive regressive
or stationary

Always stationary

Probe test: probe cannot

be passed underneath

A probe can be passed

under the neck

 Complications: Cystic degeneration and

infection are infrequent. Neoplastic change to
epithelioma, fibrosarcoma or malignant
melanoma, may occur rarely.
Correlation between Ayurvedic
classification & Modern ophthalmic
classification:
Prastharyarma- can be compared with
Regressive pterygium.

 Shuklarma- can be compared with Stationary

pterygium.
Lohitarma- can be compared with
Progressive pterygium.
Adhimamsarma- can be compared with
Pseudopterygium.
Snavyarma- can be compared with Neoplastic
change of pterygium complications.

 Samprapti (pathogenesis):
According to Ayurveda:
Siranusaribhirdoshairvigunairudhwamagataih
- the disease causing pathogenic factors
(doshas) reaches eye through its circulation.
Jayante netrabhgeshu rogah paramadarunahwhich causes sevier eye diseases.

 Dosha: Prastharyarma, Adhimamsarma,

Snavyarma- sannipataja(v.p.k)-shuklarmakapha,-kshtajarma-Rakta.
Dushya: rakta&rasa.
Sthana: Shukla Mandala.

 According to modern ophthalmology:

The working hypothesis is that the UV
radiation causes mutations in the p53 tumor
suppressor gene, thus facilitating the
abnormal proliferation of limbal epithelium.

 It is a degenerative hyperplastic condition of

conjunctiva.
The subconuctival tissue undergoes elastotic
degeneration and proliferates as vascularised
granulation tissue under the epithelium, which
ultimately encroaches the cornea.
The corneal epithelium, bowmans layer and
superficial stroma are destroyed.

 Sadhya sadhyata(prognosis)
According to Susruta all 5 Armas are of
chedana(excision) sadhyas, Vagbhata also said
chedana but as a special treatment.
According to Modern Ophthalmology surgical
excision is the only satisfactory treatment.

 Chikitsa (treatment)
The Armas which are tanu..thin,
dhooma..smoky, avilam..dusty, rakta..red and
dadhinibham..looks like curd. Are to be treated
on the lines of Sukra which is a corneal
opacity.(su. &vag.)
Medical treatment :
Triphala Churna given along with or with out
ghee depending on the condition(vag).

 Tiktaka ghritas for snehana (oleation), do

rakthamokshana (blood letting), Vamana
(emesis), virechana (purgation) and seka
(pouring medicated kashayas or oils over the
eye).
Nasya (nasal drops), Tarpanam (filling the
conjuctival sac with oils),putapaka (filling the
conjuctival sac with medicated liquids or
juices), Lekananjanam (Collyrium having
scraping property).(Su. & Va.)

 Surgical procedure of Arma according to

Susruta:
Indications for surgery: charmabham
bahalam.. snayumamsaghanavritam..
krishnamandalagacha yat- skinny, thick,
tendinous, muscular, hardened and encroaches
cornea -these are the conditions which are to
be operated.

 Pre operative procedure:

snigdhambhuktavatohyannam upavishta- the
patient should be asked to sit comfortly after
taking a meal rich of fat.
Samroshayettu nayam bhishak churnaistu
lavanaih- the affected eye should be irritated with
powdered rock salt.
Tatah samroshitam turnam susvinnam
parighattitam- after that the part should be
fomented and rubbed.

 Operative procedure:
Apangam prekshyamanasya badisena
samahitah-muchundyad/ suchisutrena va ask
the patient to look towards his outer canthus
lift the Arma with hook and then catch it with
forceps/suturing tread.
Vartmani grahayedhridam- the eye lids are
drawn tightly.

 Ullikhan mandalagrena tikshnena

parisodhayet-vimuktamsarvatachapi
krishnachuklachamandalat- the flabby and
pendent Arma is scraped with the sharp edge
of scalpel like that with out leaving any of its
contents attached to cornea and sclera.

 Nitva kaninikopantam chindyannatikaninikamcahtur bhagasthite mamse na akshi

vyapattimarhati- the inner canthus should be
secured while scraping, even leave 1/4part of
Arma but dont hurt any other parts of eye
during the procedure.
In case of Netted Arma: Arma yajjalavad
vyapi- tadapyunmarjalambitam- catch same as
before with forceps.

 Chindyadvakrena sastrenavartma
suklantamasritam- then it should be excised
with sharp edge of scalpel up to the point
where lids unite with conjunctiva.

 Post operative procedure:

Pratisaranamakshnostu tatah
karyamanataram- after completion of
surgery the part should be rubbed with-the
alkali prepared with- stalks of barley
+powder of trikatu +powder of Saindhava
salt.
After that duly fomented and bandaged.

 The part should be treated like a wound and

bandage is removed after 3 days and give
fomentation with rubbed palms.
The patient was given medicines and
purifications depending up on his strength in
accordance to time and season.

 The properties of successful surgery:

Visudhavarnamaklishtam kriyaswakshi
gataklamamyatha swamanupadravam- the
eye assumes its normal colour and function
with out getting any complications and pain.

 According to Vagbhata the surgical

procedure is same except In preoperative procedure the Saindhava salt
powder is wetted with lemon juice and then
the paste is applied as Collyrium to eyes,
there after the procedure is same as Susruta.
In postoperative procedure: for pratisarana he
doesnt mention yavakshara -along with
trikatu and honey.

 The part after rubbing is poured with

lukewarm ghee- ushnena sarpisha siktam.
Abhyaktam madhu sarpisha- then it is
anointed with honey+ghee .

 According to modern ophthalmic Surgery:

Indications for surgery: cosmetic reasons,
progression of pterygium to pupillary area,
Diplopia due to interference in ocular
movements.
Pre operative procedure:
Topical anesthesia instillation of drops of
2-4%xylocaine or 1%amethocaine. One drop
once in 4minutes for 4times.

 Eye is cleansed ,draped and exposed using

universal speculum.
Operative procedure: It is the latest and most
effective technique.

Pterygium 3 Techniques John A. Hovanesian Harvard Eye Associates, California.mp4

Head of the pterygium is lifted and dissected

off the cornea very meticulously.
The main mass of pterygium is then separated
from the sclera underneath and the conjunctiva
superficially.

 Pterygium tissue is then excised taking care

not to damage underlying medial rectus
muscle.
Haemostasis is achieved and the episcleral
tissue exposed is cauterised thoroughly.
Conjuctival limbal auto graft (CLAU)
transplantation to cover the defect after
pterygium excision.

 Post operative procedure:

Bandaged the operated eye.
Topical steroid antibiotic drops, topical
NSAIDS, artificial tears up to 6-8 weeks.
Advice to wear dark sun glasses and to avoid
exposure to sun.

 Advantages and disadvantages:

The signs indicated for medical management
acc to Ayurveda are very much useful in
current times to prevent surgery.
The rock salt+ citrus juice mixture consists
mineral Na, K..vitamin-c apart from this it is a
good cleanser of surgical part.
The instruments are changed but the procedure
is same as said by Susruta.

 The grafting technique is not dealt by Susruta

in eye, but he knows how to graft the nose.
The post operative care said by Susruta offers
good healing and prevent recurrence, by which
he claims that the Armas are Sadhya rogas of
eye.
The pratisarana enhances healing process
along with cauterisation.

 The mixture of ghee and honey is a good

source of vitamins, lubrication and enhances
healing.
The th part of Arma is left to secure
lacrimal passages and blood vessels , with
the help of dilators the problem will be
overcomed in current time.

 By explaining properties of successful surgery

we suspect Susruta's success rate in excision of
pterygium.
Complications: these are observed due to
improper surgery/improper post surgical
management/immune response of the patient.

 Susruta observed complication during surgery

by cutting Arma up to innercanthus, that is
the reason he said to leave 1/4th of Arma
near to kaninika to secure lacrimal passages
and blood vessels.
At the same time improperly excised Arma
will re grow, in that case Collyrium having
scraping nature (lekhyanjana) to be usedSusruta.

 The post surgical pain management done with

eye drops made up of milk (boiled with
karanja+amalaki+yashti) and honey.
A cold plaster prepared with paste of
milk+ghee+yashti+polens of lotus+durvagrass
is to be applied on the fore head.
Vagbhata support the views of Susruta.

 Acc. to Modern ophthalmic surgery:

The recurrence of pterygium is 30-50% is the
main problem.
Current technique of grafting is some what
better to decrease the recurrence rate.
Surgical excision with amniotic membrane
graft and mitomycin-c (MMC)
(0.02%)application may be required in
recurrent pterygium.

 Though grafting gives relief from post surgical

pain and discomfort , it may get rejected in
some cases due to immune response.
Pain , inflammation, irritation all are well
managed by modern surgeons by keeping
patient under antibiotics, steroids, NSAIDS,
artificial tear solutions.

 Nidana parivarjana(preventive aspects):

Both the systems finally come to single
point prevention.
Susruta's main notion regarding treatment is
prevention.
Acharyas clearly mention not to take
certain diets in eye diseases horse gram,
black gram, beverages having sour taste etc.

 Advised to avoid situations which cause cry,

anger, grief .
Advised to avoid hurt to eye and excess of coitus.
Advised to use umbrella and footwear.
Advised to use Collyrium and massage foot with
oil.
Advised not to use hot water for head bath.

 Advised to take diet containing rich source

of vitamin A &C.
Advised to wear sun glasses to protect from
sun light.
Advised to avoid work in hot environment.
These are some preventive measures to avoid
Arma-pterygium.

 Conclusion:
Susruta clearly mentioned -excision has to be
done in pterygium encroaching cornea, means
not to wait for further progression to the
pupillary region and cause discomfort to vision
which is a good carry point.
The signs indicated for medical treatment also
useful to prevent surgical intervention.

 Post surgical precautions and medications

are also useful to prevent recurrence.
Though it is a surgically curable disease , the
recurrence rate of it alarms us better to
prevent.
Sankshepatah kriya yogo
nidanaparivarjanam-Su.ut.20/1.

 References:
Susruta samhita uttara tantra 1st,4th,8th,15th
chapters.
Ashtanga Hridaya uttara sthana 7th,10th,11th
chapters.
Comprehensive ophthalmology 5th edition by
AK Khurana 4th and 24th chapters.
e_references-www.slideshare.net, appropriate
images & videos from Google search.

Acknowledgements
Prof.& HOD PG Dept.of.S.S.P:
Dr. M.Guru murthy.
Shalakya PG unit
Professor:
Dr. T. Praveen kumar.
Associate professor: Dr. CH.Rama Devi.
Assistant professor: Dr. B.Badrinath Benarji.