SRI VENKATESHWARA AYURVEDIC COLLEGE

MHHNR
ॐ नमो भगवते वासुदेवाय धन्वन्तरये अमृतकलश हस्ताय सवाा मय ववनाशनाय त्रैलोक्यनाथाय श्री महाववष्णववे नम ||
“ MALNUTRITIONAL EYE DISORDERS

DEPARTMENT OF SHALAKHYA TANTRA

”
PRESENTED BY:
M Hari Hara Nath Reddy
FINAL YEAR, BAMS
SRI VENKATESHWARA AYURVEDIC COLLEGE
  INTRODUCTION
 NUTRIENTS ESSENTIAL FOR HEALTHY EYES
 XEROPHTHALMIA
• Definition
CONTENTS • Classification
• Treatment
• Prevention
 OTHER MALNUTRITIONAL EYE DISORDERS
 AYURVEDIC ASPECT
 INTRODUCTION

ग्राह्यं च रूपस्य मुखस्य शोभा, प्रत्यक्ष बोधस्य च हे तु भूतम् |

तवमस्त्र वदक् कमा सु मागादवशा , नेत्रं प्रधानं सकले न्द्रियाणाम् ||
The Eye is an Indriya which perceive forms, which adorns the face, which is
source of direct knowledge, which guides to avoid wrong deeds. Hence the eye is
most important of all the sense organs.
Definition :
The human eye is a sense organ that reacts to light and allows vision. Rod and
Cone cells in the retina are photo receptive cells which are able to detect visible
light and convey information to brain.
 VITAMIN A

VITAMIN D
NUTRIENTS VITAMIN E
ESSENTIAL VITAMIN B
FOR
VITAMIN C
HEALTHY
EYES LUTEIN & ZEAXANTHIN

OMEGA 3 FATTY ACIDS

ZINC
 VITAMIN - A

 Vitamin A is a group of unsaturated nutritional organic compounds that includes retinol, retinal, retinoic acid and
several provitamin A carotenoids (most notably beta-carotene).
 Chemical formula : C20H30O
 Functions :
✓ Scotopic and Photopic Vision
✓ maintaining immune system
✓ acts as hormone like growth factor
✓ gene transcription and protein formation
✓ promotes development of epidermal cells
 Storage Form : Retinol (alcohol)
 Active Form : Retinal ( Aldehyde)
 ROLE OF “VITAMIN-A” IN VISION

SCOTOPIC VISION / NIGHT VISION PHOTOPIC VISION / COLOR VISION

➢ Rods are responsible for scotopic vision. ➢ Cones are responsible for photopic vision.
➢ Rhodopsin / Visual purple is the photo ➢ Porphyropsin, Iodopsin and Cyanopsin are the
sensitive pigment present in Rods. photo sensitive pigments present in Cones.
➢ Rhodopsin is a conjugated protein made of ➢ Pigments present in Cones are conjugated
proteins made of
Protein part : Scotopsin / opsin
Protein part : Photopsin
Chromophore : Retinal
Chromophore : Retinal
 WALD VISUAL CYCLE

Resynthesis Photochemical changes

Light
Rhodopsin Bathorhodopsin Lumirhodopsin
Energy

Metarhodopsin I

Metarhodopsin II
(active Rhodopsin)

Scotopsin
Phototransduction
Retinal isomerase

11-cis retinal All-trans retinal

Dehydrogenase NADH 2

All-trans retinol
11-cis retinol
(vitamin A)
Retinol isomerase
 VITAMIN A - DEFICIENCY

Primary Deficiency Secondary Deficiency

 Inadequate intake of provitamin A carotenoids  chronic mal-absorption of lipids.

from fruits & vegetables.
 impaired bile production and release.
 Inadequate intake of preformed Vitamin A
 chronic exposure to oxidants, such as cigarette
from animal products.
smoke, and chronic alcoholism.
 Early weaning from breast milk
 poor use of vitamin A from low-fat diets.
 Zinc deficiency

Vitamin A deficiency is "the leading cause of preventable childhood blindness", according to UNICEF
Recommended Dietary Allowance (RDA)

Age Male Female Pregnancy Lactation

0–6 months 400 mcg RAE 400 mcg RAE
7–12 months 500 mcg RAE 500 mcg RAE
1–3 years 300 mcg RAE 300 mcg RAE
4–8 years 400 mcg RAE 400 mcg RAE
9–13 years 600 mcg RAE 600 mcg RAE
14–18 years 900 mcg RAE 700 mcg RAE 750 mcg RAE 1,200 mcg
RAE
19–50 years 900 mcg RAE 700 mcg RAE 770 mcg RAE 1,300 mcg
RAE
51+ years 900 mcg RAE 700 mcg RAE

Retinol activity equivalents (RAE)

 VITAMIN A DEFICIENCY – OCULAR MANIFESTATIONS
XEROPHTHALMIA
DEFINITION :
 Xerophthalmia (from Ancient Greek "xērós" meaning "dry"
and "ophthalmos" meaning "eye") is a medical condition in
which the eye fails to produce tears.
 Xerophthalmia usually implies a destructive dryness of the
conjunctival epithelium due to dietary vitamin A deficiency.
 It is a rare condition in developed countries, but still causing
much damage in developing countries.
Signs and sytmptoms:
➢ Itching of eye
➢ Dryness of eye
➢ pain and burning sensation
➢ Certain periods of blurred or reduced vision
➢ Night blindness
➢ Corneal ulcers
 Epidemiology

 Xerophthalmia is probably the only vitamin deficiency disease to reach epidemic levels and
cause major concerns to the public health personnel.
 The World Health Organization (WHO) estimated that about 254 million children have Vitamin
A deficiency and 2.8 million children have xerophthalmia.
 It is the most common cause of childhood blindness, with 350,000 new cases every year.
Studies have shown that xerophthalmia not only causes blindness, but also affects growth,
general morbidity, and mortality.
 It has been noted that approximately 45% of the world's population of children with Vitamin A
deficiency and xerophthalmia are from South and Southeast Asia
 Risk Factors

• Low socioeconomic status

• Malnutrition
• Maternal malnourishment (affects Vitamin A concentration in breastmilk)
• Zinc deficiency: inadequate zinc can depress the hepatic synthesis of retinol-
binding protein (RBP), which is required for metabolism of retinol from the
liver.
• Zinc may also play a role in the conversion of beta-carotene to retinol via the
enzyme 15-15’-dioxygenase.
• Co-existing measles or other respiratory/diarrheal illness
 World Health Organization classified xerophthalmia into
following stages:
XN-Night blindness

X1A-Conjunctival xerosis

X1B-Bitot’s spots
CLASSIFICATION
X2-Corneal xerosis

X3A-Corneal ulceration/keratomalacia, involving less than one-third

of the cornea
X3B-Corneal ulceration/keratomalacia, involving more than one-third
of the cornea

XS-Corneal scar due to xerophthalmia

XF-Xerophthalmic fundus
 XN – NIGHT BLINDNESS

Definition:
 Night blindness is defined as the loss of vision when light in the environment becomes dim. It is
otherwise called nyctalopia or defective dim light (Scotopic) vision.
 It is a symptom of several eye diseases. Night blindness may exist from birth, or be caused by injury or
malnutrition (vitamin A deficiency). It can be described as insufficient adaptation to darkness.
Why rods are affected First ?
➢ A process called dark adaptation typically causes an increase in photopigment amounts in response to
low levels of illumination.
➢ This occurs to an enormous magnitude, increasing light sensitivity by up to 100,000 times its sensitivity
in normal daylight conditions.
➢ VAD affects vision by inhibiting the production of rhodopsin, the photopigment responsible for sensing
low-light situations.
➢ When VAD prevents the body from producing sufficient amounts of retinal, a decreased amount of
rhodopsin is produced and night blindness results.
 COMPARISION

Normal vision Nyctalopic vision

 X1A-Conjunctival xerosis

Definition :
 Desiccation of the conjunctiva due to a vitamin A
deficiency.
Aetiology :
➢ Vitamin A deficiency results in keratinization of the
superficial epithelial cells of the eye. Degeneration of
the goblet cells causes the surface of the conjunctiva
to lose it lustre.
➢ The keratinized epithelial cells die and are swept into
the palpebral fissure by blinking, where they
accumulate and create characteristic white Bitot’s
spots.
 X1B - BITOT’S SPOTS

Definition
 Bitot's spots are foamy frothy sharply
demarcated whitish spots on conjunctiva.
 The spots are a sign of vitamin A deficiency and
associated with drying of the cornea. In 1863,
the French physician Pierre Bitot (1822–1888)
first described these spots.
Aetiology:
 they are the buildup of keratin located
superficially in the conjunctiva of human's eyes.
They can be oval, triangular or irregular in
shape.
 X2-Corneal xerosis

Definition:
 Corneal xerosis is characterized by a dry, hazy appearance of
the cornea. It may start as superficial, punctate epithelial
lesions. This stage quickly progresses to the stage of corneal
melting or keratomalacia.
 Up to this stage, high-dose Vitamin A supplementation can
result in the full preservation of vision.
Aetiology:
 The damage to the cornea in vitamin A associated
xerophthalmia is quite different from damage to the retina at
the back of the globe.
 Corneal xerosis from hypovitaminosis A is specifically due
to lack of the hormone-like vitamin A metabolite retinoic
acid.
 X3A & 3B-Corneal ulceration/keratomalacia
Definition:
 Softening and ulceration of the cornea of the eye resulting from
severe systemic deficiency of vitamin A
Aetiology :
 Vitamin A is required to maintain specialized epithelia (such as in
the cornea and conjunctiva).
 lack of vitamin A leads to atrophic changes in the normal mucosal
surface, with loss of goblet cells, and replacement of the normal
epithelium by an inappropriate keratinized stratified squamous
epithelium. In addition, the substantia propria of the cornea breaks
down and liquefies, resulting in keratomalacia.
 The resulting cornea becomes totally opaque, which is one of the
most common reasons for blindness around the world, particularly
in developing countries.
 XS-Corneal scar due to xerophthalmia

Definition:
 Corneal Scarring. Corneal scarring refers to the scarring of the
cornea, from trauma, or infection or disease, which results
in impaired vision, or even blindness, in the affected eye.
 Corneal scarring results into visual opacity or visual impairment.
It will depend on the extent of corneal damage.
 Cornea is an important part in the eye for focusing the object on
the lens.
 A Scar on cornea will not allow certain amount of light to enter
the eye; this will depend on the intensity and severity of scarring.
 XF-Xerophthalmic fundus

Definition:
 Xerophthalmic fundus (fundus xerophthalmicus) is a
condition characterized by fine white, cream-colored,
or greyish dot-like, oval, or linear opacities in the
retina.
 It usually occurs among individuals with night
blindness, conjunctival xerosis and/or Bitot spots.
Aetiology :
➢ Prolonged deficiency of Vitamin A leads to anatomical
changes in rods and cones and finally the degeneration
of other retinal layers occurs.
➢ So retinal function can be restored, only if treatment is
given with Vitamin A before the visual receptors start
degenerating.
 Diagnosis

Diagnosis of xerophthalmia is based on clinical signs supplemented by a positive medical history.

It is always important to take a thorough dietary history, social history, and history of alcohol intake
in all cases of dry eyes.
Physical exam
Aside from the ocular exam, the physical exam should include assessments for body weight,
jaundice, and abdominal exam for hepatomegaly.
Blood tests
• Serum vitamin A/retinol (reference range: 20-60 mcg/dL). These levels can be normal due to maintenance
of circulating retinol levels by hepatic stores.
VAD-related ocular symptoms have been shown to develop at concentrations <10mcg/dL.
• Serum retinol binding protein (reference range: 30-75 mcg/ml).
• Serum zinc (reference range: 75-120 mcg/dL)
Other testing
• Dark adaptometry and night vision threshold tests

• Electroretinogram (ERG): Retinopathy from VAD is

associated with decreased amplitude

• Impression cytology: conjunctival specimens can be

viewed for the presence of goblet cells. A decrease in
normal amount is considered an effective measurement
of VAD.

• Liver biopsy: considered the gold standard for

evaluating total body vitamin A, although it is not
routinely used outside of the research setting due to
procedural risks.
 Prognosis

 Xerophthalmia signifies a severity of VAD that can cause mortality from malnutrition and
increased susceptibility to mucosal infections.
 Nearly 2/3 of children with keratomalacia die within months.
 Mortality in children with night blindness is triple the mortality found in children with
subclinical VAD.
 Mortality in children with both Bitot spots and night blindness is reported to be nine times that
of children with subclinical VAD.
 With prompt treatment of high-dose vitamin A, the early ophthalmologic signs, such as a rod
function, conjunctival xerosis, and night blindness, can resolve completely within about 2
months of supplementation, without long-term sequelae.
 Corneal xerosis and ulceration may also improve; however, they can lead to scarring and
permanent vision loss.
 Treatment

The treatment will be required for both the symptoms and the
deficiency.
 Eye drops containing artificial tear like preparations (help
renew the tear film and prevent dryness of eye)
 Air humidifiers (keeping the air in the room humid will help
prevent eye dryness as well)
 Wrap around glasses (this is extremely important, as the lack
of tear film will contribute to debris to enter the eye, causing
serious infections; plus, the wind can cause even more
dryness)
 Antibiotics are used to prevent secondary bacterial infections.
 In case of corneal ulcerations, the most recommended course
of treatment is the surgical intervention
 Recommended Vitamin A deficiency treatment regimens are described in the following table.

Vitamin A dosage (IU)

50,000 IU along with three doses of

Young infants 0-5 months (Severe mal-nutrition)
OPV/DPT
Older infants 6-11 months (Severe mal-nutrition) 100,000 IU for every 4-6 months
Children (males: 12 months or more;females
12 months to 12 years and 50 years or more) 200,000 IU for every 4-6 months
(Severe mal-nutrition)

Women (13-49 years) with night blindness 10,000 IU every day or 25,000 IU every
and/or Bitot's spots week for at least 3 months
Women (13-49 years) with active corneal
200,000 on days 1, 2, and 14
lesions
 Prevention

 Prophylaxis consists of periodic administration of Vitamin A supplements.

WHO recommended schedule, which is universally recommended is as
follows:
• Infants 6–12 months old and any older children weighing less than 8 kg
require 100,000 IU orally for every 3–6 months.
• Children over 1 year and under 6 years of age require 200,000 IU orally
for every 6 months.
• Infants less than 6 months old, who are not being breastfed require
50,000 IU orally should be given before they attain the age of 6 months
 Vitamin A rich food items

 Cod Liver Oil  Pumpkin

 Liver  Spinach
 Fish  Broccoli
 Milk  Beans
 Cheese  Citrus
 Egg  Tomatoes
 Sweet Potatoes  Mango
 Carrots  Apricot
 Capsicum  Curd
 VITAMIN - D

Vitamin D is a group of fat-soluble secosteroids responsible for increasing

intestinal absorption of calcium, magnesium, and phosphate, and many other
biological effects. In humans, the most important compounds in this group are
vitamin D3 (also known as cholecalciferol) and vitamin D2 (ergocalciferol)
 Benefits of vitamin D: Reduce the risk of macular degeneration.
 Food sources: Salmon, sardines, Mushrooms, milk, oranges, Eggs etc.,
 RDA: 400 IU per day for infants, children and adolescents, and higher daily
intakes for adults.
 The best source of vitamin D is exposure to sunlight.
 VITAMIN - E

Vitamin E is a group of eight fat soluble compounds that

include four tocopherols and four tocotrienols. Vitamin E
deficiency, which is rare and usually due to an underlying
problem with digesting dietary fat rather than from a diet low in
vitamin E.
 Benefits of vitamin E: When combined with carotenoids and
vitamin C, may reduce the risk of advanced AMD.
 Food sources: Almonds, sunflower seeds, Moringa etc;
 RDA: 15 mg for teens and adults (15 mg for women during
pregnancy and 19 mg when breast-feeding).
 VITAMIN – B complex

B vitamins are a class of water-soluble vitamins that play important roles

in cell metabolism and synthesis of red blood cells. Though these vitamins share
similar names (B1, B2, B3, etc.), they are chemically distinct compounds that often
coexist in the same foods. In general, dietary supplements containing all eight are
referred to as a vitamin B complex.
 Vitamins B6, B9 and B12 This combination of vitamins can lower levels of
homocysteine, a protein in the body that may be associated with inflammation
and an increased risk of developing AMD.
 Riboflavin vitamin B2, As an antioxidant, riboflavin has the potential to reduce
oxidative stress in the body, including eyes., thus prevents cataract.
 Vitamin B3 niacin play a role in the prevention of glaucoma, a condition in
which the optic nerve of eye becomes damaged.
 Thiamine vitamin B1 effective at reducing the risk of cataracts.
 Salmon fish, Spinach, Liver, Eggs, Milk, Legumes, Chicken, Yogurt, Yeast, Sun
flower seeds are the foods rich in Vitamin B Complex
 VITAMIN - C

Vitamin C (also known as ascorbic acid and ascorbate). It is used

to prevent and treat scurvy. Vitamin C is an essential
nutrient involved in the repair of tissue, the formation of collagen,
and the enzymatic production of certain neurotransmitters. It is
required for the functioning of several enzymes and is important
for immune system function. It also functions as an antioxidant.
 Benefits of vitamin C: Reduce the risk of cataracts and macular
degeneration.
 Food sources: Citrus Fruits, Indian Goose berry, Bell Pepper,
cauli flower, Guava, Mangoes, broccoli etc.,
 RDA: 90 mg for men; 70 mg for women (85 mg during
pregnancy and 120 mg when breast-feeding).
 LUTEIN & ZEAXANTHIN

Lutein and zeaxanthin are part of the carotenoid family, a group

of beneficial compounds synthesized by plants.
 Both of these carotenoids can be found in the macula and retina
of your eyes, where they help filter potentially harmful blue
light, thus protecting your eyes from damage.
 Several studies suggest that these plant compounds prevent
cataracts and prevent or slow the progression of AMD.
 Food Sources: Dark Leafy Greens, Green Peas, Pumpkin,
Broccoli, Asparagus, Lettuce, Carrots, Pistachios.
 OMEGA 3 FATTY ACIDS

Omega−3 fatty acids, also called Omega-3 oils,

are polyunsaturated fatty acids.
➢ Types : α-linolenic acid (ALA), eicosapentaenoic
acid (EPA), docosahexaenoic acid (DHA)
➢ Benefits of omega-3 fatty acids: May help prevent macular
degeneration (AMD) and dry eyes.
➢ Food sources: Cold-water fish such as salmon, mackerel
and herring; fish oil supplements, freshly ground flaxseeds,
walnuts.
 ZINC

Zinc is an essential micronutrient for human metabolism that catalyzes more

than 100 enzymes, facilitates protein folding, and helps regulate gene expression.
Patients with malnutrition, alcoholism, inflammatory bowel disease, and
malabsorption syndromes are at an increased risk of zinc deficiency.
➢ Benefits of zinc: Zinc is a part of many essential enzymes, including
superoxide dis-mutase, which functions as an antioxidant, It also appears
to be involved in the formation of visual pigments in retina, For this
reason, zinc deficiency lead to night blindness. It also play a role in
reducing risk of advanced AMD.
➢ Food sources: Meat, Shellfish, Legumes, Seeds, Nuts, Dairy, Eggs, Whole
Grains, Some Vegetables, Dark Chocolate.
➢ RDA: 11 mg for men; 8 mg for women (11 mg during pregnancy and 12
mg when breast-feeding).
AYURVEDIC ASPECT
 ने त्र पाञ्च भौवतक्वमम्

सुवृतं गोस्तनाकारं सवव भूत गुणोध्भवम् |

पलं भुवो ऽग्नितो रक्तं वातात् कृष्णं ग्नसतं जलात् ||
आकाशात् अश्रु मागावश्च जायन्ते नयन बुद्बुदे ||
( सु .उ . 1/10-11 )
 दोष प्रधानत

ग्नपत्तं पक्त्यूष्म दशवनैः ||

क्षुत् तृट् रुग्नि प्रभा मे धा धी शौयव तनु मादव वैः ||
(अ . हृ. सू 11/2)
नाग्नभरामशय स्वेदो लसीका रुग्नधरं रसैः |
दृक् स्पशवनं ि ग्नपत्तस्य नाग्नभरत्र ग्नवशेषतैः ||
(अ . हृ. सू 12/2)
रूपालोिनतैः स्मृतम् । दृक्स्थमालोिकं
(अ . हृ. सू 12/14)
 अन्य दोष कमा

तं िलैः ।
उत्साहोच्छ्वासग्ननश्वासिे ष्टावे ग प्रवतवनैः ॥सम्यग्गत्या ि धातू नामक्षाणां पाटवे न ि । अनु गृाात्यग्नवकृतैः ,
(अ . हृ. सू 11/1)
प्राणोऽत्र मू धवगैः । उरैः कण्ठिरो बुद्धिहृदये द्धियग्नित्तधृ क् ष्ठीवन क्षवथू द्गारग्ननैः श्वासान्नप्रवे शकृ त्
(अ . हृ. सू 12/4)
व्यानो हृग्नद द्धथथतैः कृत्स्नदे हिारी महाजवैः ॥6॥गत्यपक्षे पणोत्क्षे पग्ननमे षो्े षणाग्नदकाैः ।
(अ . हृ. सू 12/6)
ग्नशरैः सं थथोऽक्षतपव णात् ॥तपव क ैः
(अ . हृ. सू 12/17)
 वपत्त X कफ

िक्षु स्तेजोमयं तस्य ग्नवशेषाच्छ्लेष्मतो भयम् |

(अ . हृ. सू 2/5)
 नेत्र रोग पथ्य

मु द्गा यवा लोग्नहत शालयश्च | पु ननववा माकवव काकमािी

लावो मयू रो वन कुक्कुटश्च पत्तूर शाकाग्नन कुमाररका ि |
कूमव ैः कुग्नलङ्गोऽथ कग्नपञ्जलश्च || द्राक्षा कुस्तु म्बुरु माग्नण मन्थ
लोध्रं वरा क्षौद्रम् उपानाहौ ि ||
कौम्भं हग्नवैः वन्य कुलत्थ यूषैः
पे या ग्नवलेपी लशु नं पटोलम् | नारी पयैः िन्दनं इन्दु खण्डं
वाताव कु ककोटक कारवे ल्लं ग्नतक्ताग्नन सवाव ग्नण लघू ग्नन िाग्नप |
नवीन मोिं नव मूलकञ्च || ग्नवजानता पथ्यग्नमदं प्रयु क्तम्
यथामलं दोष ियं ग्ननहद्धन्त ||

(भै . र . 64/ 267-271)

 आहार द्रव्य

कदली यवा
नागरङ्ग मु द्ग
कारवे ल्लकं कुक्कुट मां सं
मधु लशु न
वाताम वाताव क
उरुमान नव मू लकं
अक्षोडैः द्राक्षा
घृ तं कुस्तुम्बुरु
क्षीरं सन्धवं
दग्नध ग्नशग्रु
रक्त शाग्नल
 औषध द्रव्य

आमलकी पुननववा
ग्नवभीतकी ग्नतल
हरीतकी तुलसी
िक्षुष्या उदु म्बर
यग्नष्ट मधुकं दारु हररद्रा
अद्धिक पुराण घृत
गुडूिी कुमाररका
भृङ्गराज काकमािी
 आमवयक प्रयोग

 ग्नत्रफला + यष्टी मधु + घृ तं + मधु during राग्नत्र काल for good vision. (अ . हृ . उ 13/ 14-15)
 मत्स्य अण्ड cooked with भृ ङ्ग राज cures नक्तान्ध्य. (चक्र दत्त 59/172)
 हरीतकी every day early in the morning to cure all types of eye defects. (अ . हृ . उ 13/ 19)
 आश्चोतन with आमलकी स्वरस for good vision. ( भै . र . नेत्र रोगावधकार )
 औषध योग

 ग्नत्रफला घृ तं
 ग्नतल तल नस्य
 िक्षुष्या अञ्जन
 च्यवनप्राश अवलेह्य
कमलायत लोचन लोकपते ववजयीभव वेङ्कट शै लपते ॥

Thank you