Abstract
Timira is a disease that can be attributed to wide range of clinical conditions starting from mild blurring of vision and having potential risk of permanent vision loss. According to the involvement of Dhatus (body elements) the condition can be grouped into two stages. The initial stage or Uttana, where the involvement of Dhatus is limited to Rasa, Rakta (blood), and Mamsa Dhatu (muscle tissue). When the Doshas are localized in the first and second Patala refractive error do happen and in presbyopia more emphasis is given to Mamsa Dhatu. In this study only Uttana stage of Timira was considered. The clinical study was done on 66 patients of Timira in two groups of four sub groups each of myopia, hypermetropia, astigmatism, and presbyopia. Group A was subjected to eye exercises (Bates method) and Group B was subjected to Trataka Yoga Kriya. After the enrolment of patients for this study, signs and symptoms were assessed both subjectively and objectively before, during, and after treatment. The study indicates that subjectively there are significant results in both the groups but objectively there is not much improvement.
Keywords: Eye exercises, refractive errors, Timira, Trataka Yoga Kriya
Introduction
Estimates of the number of people worldwide with refractive error range from 8 million to 2.3 billion.[1] But this figure seems to be subjective; because till today population-based study had not been carried out. Among this, majority of refractive errors are uncorrected. In 2006, refractive error program had been implemented in India. In 1990, papers published from India highlighted the fact that uncorrected refractive error was a significant cause of blindness and the major cause of impaired vision The fact became initiation for World Health Organization (WHO) to think about Vision 2020 global program – “The right to sight” – Refractive error can no longer be ignored as a target for urgent action.[2] Hence the main motto of Vision 2020 (current global initiative program by WHO) mandate to correct refractive errors with little infrastructures. Throughout the global survey in developing as well as developed countries myopic group being the main culprit in refractive errors.
Clinically asymptomatic retinal detachment is common in myopes, whereas asthenopic condition is more common among other refractive errors. Prevailing treatment modalities, that is, refractive surgeries are becoming popular option for reducing or eliminating refractive errors.
Age factor, cost of the treatment, complications like corneal dystrophies, dry eye, and prevalence of infection had limited its applications. Recent claims of genetic modulation therapy are under evaluation and its success rate is doubtful. While analyzing the etiology of refractive errors, today's life style, occupation, and unawareness of importance of eye have a great impact on ocular health.
Prevailing modality of treatment should be supplemented by some ocular strengthening therapy by which ocular health can be maintained and promoted search for such modality lead the investigators to Bates Eye exercise therapy, which is under-evaluated by modern science. However it is practiced in full pledged manner in many reputed institutes of India like School for perfect eyesight at Pondicherry and Moraji Desai institute of Yogic Science at New Delhi.
Meanwhile Trataka Yoga Kriya of our traditional system is practiced throughout India and believed to increase the eyesight. By keeping this concept in mind, to evaluate the role of this Nonpharmacological therapy in refractive error, a study was planned with following aims and objectives:
Aims and Objectives
To evaluate the role of eye exercises and Trataka Yoga Kriya on Timira w.s.r. to Ammetropia and Presbyopia.
Materials and Methods
Patients attending the OPD and IPD of Department of Shalakya Tantra, Institute for Post Graduate Teaching and Research in Ayurveda, Jamnagar hospital with signs and symptoms of Timira-Ammetropia and presbyopia were irrespective of their sex, religion, occupation, education, etc., A total of 66 patients (132 eyes) were recruited for the study. An elaborative case taking proforma was specially designed for the purpose of incorporating all aspects of the disease on Ayurvedic and modern parlance.
Sampling technique
A total of 66 patients were registered under two main groups with four sub groups of refractive error like myopia, hypermetropia, astigmatism, and presbyopia, respectively, (Group A – 32 patients, Group B – 34 patients) by random sampling method.
Inclusion criteria
Sign and Symptoms showing Prathama (first) and Dwitiya (second) Patalagata Timira.
Functional refractive errors in myopia, hypermetropia, astigmatism, and simple presbyopia.
Patients with asthenopic symptoms like headache, watering, ocular pain, and fatigue.
Exclusion criteria
Patients having any lenticular or corneal opacity and any other known ocular pathology.
Assessment criteria
The criteria for assessment were based on signs and symptoms of disease Timira described in Ayurvedic as well as modern texts, that is, refractive errors and presbyopia. All the objective parameters like retinoscopy, autorefractometer, ascan, keratometer were adopted to study the role in detail.
Grouping
Group A
A total of 32 patients were registered in this group (myopia – 10, astigmatism – 10, hypermetropia – 06, and presbyopia – 06). Here patients were subjected to perform group of eye exercises once daily for 3 weeks.
Group B
A total of 34 patients were registered in this group (myopia – 10, astigmatism – 11, hypermetropia – 07, and presbyopia – 06). Here patients were subjected to perform Trataka Yoga Kriya once daily (either in morning or in evening hours) for 3 weeks.
Therapy
-
Bates method[3] of eye exercises are as follows:
- Sunning
- Eye wash
- Palming
- Candle light reading
- Shifting and Swinging
- Playing with ball
- Vaporization
- Cold pad
Trataka Yoga Kriya[4] includes both Bahiranga and Antaranga Trataka.
Follow-up
After completion of therapy, patients were followed-up for 1 month in order to observe any adverse effects of the therapy.
Statistical test
Based on observations, the data obtained were statistically analyzed in terms of mean, standard deviation, standard error, and unpaired ‘t’ test was considered at the level of P < 0.001 as highly significant, P < 0.01 as significant, and P < 0.10 as insignificant to assess the results.
Assessments of Overall Effect of Therapy
Subjective assessment
Cured: Total 100% relief in signs and symptoms and no recurrence during follow up study were considered as cured.
Marked improvement: More than 75% improvement in signs and symptoms was recorded as marked improvement.
Moderate improvement: Around 51-75% improvement in signs and symptoms was considered as moderate improvement.
Mild improvement: Around 26-50% improvement in signs and symptoms was considered as mild improvement.
Unchanged: Up to 25% reduction in signs and symptoms was noted as unchanged.
Objective assessment
Cured: Nearly 1D reduction in spherical or cylindrical dioptric power or complete remission.
Marked improvement: Nearly 0.75D reduction in spherical or cylindrical dioptric power.
Moderate improvement: Nearly 0.50D reduction in spherical or cylindrical dioptric power.
Mild improvement: Nearly 0.25D reduction in spherical or cylindrical dioptric power.
Unchanged: No reduction in spherical or cylindrical dioptric power.
Observations and Results
Out of 66 patients studied in this work, maximum patients (45.45%) were found in the age group of 16–30 years. Major number of patients were Hindus (86.36%). Maximum patients belonged to Vata-Pitta Prakruti (53.03%), showed sleep deprivation (71.21%) and were performing indoor activities (83.33%). Majority of patients were watching television (50%) and working on computers (59.09%) for 2-4 hours daily.
Effect of Therapy in Group A (Eye exercise group)
In myopic group, the percentage of relief in Durastha Avyakta Darshana (difficulty in distant vision) was 50% and Netrayasa (ocular fatigue) was relieved by 54%, which was statistically significant (P < 0.01), and 40% insignificant relief (P < 0.05) was observed in Kadachit Vyaktobhavati (transient gain of clarity of vision).
In astigmatic group, statistically insignificant 50% relief was observed in Durastha Avyakta Darshana, 62.5% in Shirobhitapa (brow headache), 60% in Netrasrava (watering), 54% in Netrayasa, and 75% in Suchipasam Na Pasyathi (difficulty in seeing small objects).
In hypermetropic group, statistically significant (P < 0.01) relief of 88% in Netradaha (burning senasation), 72% in Shirobhitapa, 66% in Netrasrava was observed. The relief in Durastha Avyakta Darshana (37%), and Vihwala Darshana (27%) was statistically insignificant (P < 0.05).
In presbyopic group, the percentage of relief in Netrayasa (62.5%) and Suchipasam Na Pasyathi (12.5%) was statistically insignificant (P < 0.05). The dioptric power was reduced by 25.95% in right eye and 22.15% in left eye, both the results being statistically insignificant (P < 0.05). Keratometric reading was reduced by 25.65% in right eye and 24.25% in left eye, both the results being statistically insignificant (P < 0.05). A scan reading was reduced by 12.65% in right eye and 12.15% in left eye, both the results were statistically insignificant (P < 0.05). Retinoscopic reading was reduced by 16.55% in right eye and 15.15% in left eye, both the results being statistically insignificant (P < 0.05).
Effect of Therapy in Group B (Trataka Group)
In myopic group, 35% relief in Durastha Avyakta Darshana, 55% each in Kadachit Vyaktobhavati and Netrasrava and 62% relief in Netrayasa was observed which was statistically insignificant (P < 0.05).
In astigmatic group, statistically insignificant (P < 0.05) relief in Durastha Avyakta Darshana (37.5%), Shirobhitapa (62.5%), and Netrasrava (54%) is observed.
In hypermetropic group, statistically significant (P < 0.01) relief in Shirobhitapa (58%), Netrasrava (50%) was seen. The relief in Netrayasa (57%), Durastha Avyakt Darshana (20%), and Suchipasam Na Pasyathi (16.6%) was statistically insignificant (P < 0.05).
In presbyopic group, the percentage of relief in Netrayasa (37.5%) and Suchipasam Na Pasyathi (12.5%) was statistically insignificant (P < 0.05). The dioptric power was reduced by 23.95% in right eye and 21.16% in left eye, both the results being statistically insignificant (P < 0.05). Keratometric reading was reduced by 27.85% in right eye and 25.35% in left eye, both the results which was statistically insignificant (P < 0.05). A scan reading was reduced by 18.25% in right eye and 17.65% in left eye, both the results being statistically insignificant (P < 0.05). Retinoscopic reading was reduced by 13.65% in right eye and 13.25% in left eye, both the results being statistically insignificant (P < 0.05).
Total Effect of Therapy
The present study shows that none of the patients were cured and markedly improved in eye exercises group and in Trataka group. By eye exercises, moderate improvement was observed in one patient (3.20%), mild improvement was observed in 20 patients (64.45%), and no improvement was observed in 10 patients (32.25%) of Timira. Whereas by Trataka, moderate improvement was observed in two patients (6.25%), mild improvement was observed in 18 patients (56.25%) and no improvement was observed in 12 patients (37.5%) of Timira.
Overall effect of therapies on subjective parameters
In subjective parameters, mild improvement that is 3.20% in Group A and 6.25% in Group B was seen. Moderate improvement that is 64.45% in Group A and 56.25% in Group B was observed. No change was observedin32.25% patients of Group A and 37.5% patients of Group B [Figure 1].
Figure 1.
Overall effect of therapies on subjective parameters
Overall effect of therapies on objective parameters
Moderate improvement was seen in objective parameters in 32.25% patients of Group A and 21.87% patients of Group B. No change was observed in 67.74% patients in Group A and 78.12% in Group B [Figure 2].
Figure 2.
Overall effect on objective parameters
This depicts that no considerable improvement was found in objective parameters in both the groups. In contrast, moderate to mild improvement was noted and observed in many of the subjective parameters like Shirobhitapa Netrasrava and Neytrayasa.
Discussion
Rajarishi Nimi explains the clinical manifestation of Timira according to the Dosha localization in different Patalas (layers of eye), a transient phase of clear vision, that is, Kadhachit Vyakto Bhavati[5] when Doshas get localized in the outermost Patala. In this study this feature was observed in patients having refractive error between 0.25 and 0.75D. While analyzing the Doshika involvement, most of the patients were having Kaphaja Timira Lakshana especially in the Myopic and Hypermetropic group and Vataja Timira lakshana were seen in the Astigmatic and Presbyopic group. Timira being Vataja Nananatamja disorder; myopia and hypermetropia are grouped under Vatakaphaja and astigmatism and presbyopia are under pure Vataja categories.
Eye exercise and Trataka Yoga Kriya, the basic concepts behind these are relaxation techniques. Relaxation of mind and eyes improves the vision. On analyzing the pathogenesis of vitiation of Rasa and Raktavaha Srotas, maximum concern was given to mental disturbance by ancient scholars. Similarly relaxation of mind was an essential prerequisite for the cure of the disease pertaining to the Srotasas.
Mode of action of eye exercises
Eye exercises have a great role to play in asthenopic features. For better understanding, asthenopic features can be divided into extra ocular asthenopia and intraocular asthenopia. Extra ocular asthenopia is due to following factors like forcing the medial rectus muscle during convergence, lid squeezing to get stenopic effect, and strain causes fatigue, which in turn leads to brow headache, ocular pain, reflex lacrimation, and referred ophthalmoplegia.
In the effort of clear vision, the blinking phenomenon also reduces, leading to non replacement of tear film, which leads to blurring of vision. The fatigue of lid muscles also cause reflex irritation of conjunctiva, leading to burning sensation and thereby patient develops the habit of rubbing the eyes frequently to relive the lid fatigue and irritation, which adds into the conjunctival hyperemia\chronic conjunctivitis. Whereas in case of intraocular asthenopia, ciliary spasm take place, which in turn leads to fatigue, ocular pain, and reflex features of lacrimation like burning sensation and watering.
Where as in Trataka Yoga Kriya, imagination power increases, functionally efficiency of extra ocular and intraocular increases by forcing them to work and enhances the metabolism of rods and cones through the mechanism of dark and light adaptation.
The sense organ, which is misused to the maximum extent is eye, that is, Mithya or Atiyoga of Chaksurendriya. In this era of changed life style and increased pace, it is the primary duty of Ayurvedic community to educate the society regarding the healthy use of this sense organ. A regular schedule in this regard for the prompt relaxation of eye is not only beneficial to such refractive problems but also can prevent many degenerative conditions. A schedule of optimum exercise improves Rasa, Rakta Samvahana as well as improves the efficacy of sense organ in their perception. A mild derangement of these Dhatus can completely be cured with these exercises. If the vitiation is moderate to severe, this can very well act as suitable supportive therapy. Actually the agenda behind this particular study was to popularize these two simple techniques, which can contribute to mankind in prevention of many eye diseases and provide relief to too many visual problems/asthenopic symptoms.
Conclusion
In Snellen's chart reading one line improvement was noted. There was moderate improvement in clarity of vision, contrast sensitivity, and fineness of objects. Though the degree of this improvement was almost similar in both the groups, a better relief was appreciated by patients of Trataka Yoga Kriya group. It is an encouraging finding that a non-pharmacological, low cost, relaxation technique can improve the quality of vision, by which it indirectly checks the progression of the disease condition. Both these techniques act as adjuvant therapy hence one should adopt pharmacological interventions (medical management), life style, and diet modifications to get a better result.
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