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Introduction

Abducent nerve lies at the mid-level of pons, ventral to the floor of fourth ventricle. The fibres leave the brain stem ventrally at Ponto medullary junction.1 Abducent (sixth cranial) nerve results in lateral rectus muscle contraction. When palsy of this nerve occurs symptoms like diplopia, esotropia and limitation of abduction of affected side observed. Microvascular ischemia due to systemic diseases like diabetes mellitus and hypertension can result in abducent nerve palsy. In this condition complete or incomplete paralysis of lateral rectus muscle of eye leads to ocular deviation. Mononeuritis Multiplex is commonly associated with diabetes mellitus where asymmetrical, asynchronous, painful peripheral neuropathy develops. Damage to abducent nerve along with peripheral neuropathy results in hindrance of patient’s routine and eyesight.

One of the cause of abducent nerve palsy is systemic conditions like diabetes mellitus since many years may result in condition like mononeuritis multiplex which leads to damage of abducent nerve and peripheral neuropathy. Symptoms of abducent nerve palsy are horizontal diplopia which worsens while looking in the direction of affected eye, diplopia increases for distance than near (D > N). Esotropia of affected eye in primary gaze. Limitation of abduction of affected eye and compensatory face turn towards the affected eye. Visual acuity may or may not be reduced.2 According to ayurveda, this condition can be correlated with vataj nanatmaja vikara; jinmha & diplopia can be correlated with patalagata dosha dushti and can be treated like timira chikitsa. Acharya Sushruta explained trutiya patalagata dosha dushti and vagbhatacharya explained dwitiya patalagata dosha dushti. Symptoms can be correlated with timira and treated accordingly. Prameha janya timir vyadhi lakshana like vihwal drushti, makshika mashaka kesha jala pasl?yati, tamasa darshana and nasa akshi yuktani viparitani vikshate are observed.3 Nerve palsy can be clinically correlated with vata vyadhi lakshana like ardita and vata hara chikitsa can be given to the patient. Modern treatment modalities offer occlusion therapy, prism correction, botulinum toxin injection and surgical transposition of muscle.4 These treatments are expensive and having side effects. So developing ayurvedic treatment protocol as an alternative is necessary. Ayurvedic treatment aims on encountering disease pathogenesis from the root.

Aims and Objective:

This case report aims at developing ayurvedic treatment protocol to treat left abducent nerve palsy developed secondary to mononeuritis multiplex. Objective of this case report is to study the mode of action and potential role of ayurvedic therapeutics in treatment of trutiya patalagata dosha dushti (timira)

Chief complaints:

A 62 year old female patient; visited shalakya tantra OPD on 15th November 2023 with complaints of horizontal diplopia, limitation of abduction of left eye and mild esotropia in primary gaze and floaters since 2 months, known systemic history of diabetes mellitus since 11 years, hypertension since 7 years and mononeuritis multiplex since 6 months. Other associated symptoms were bilateral foot drop due to damage of nerves in lower limb. No history of trauma, stroke or recent travel.

Past History: History of Diabetes mellitus since 11 years. Hypertension since 7 years and mononeuritis multiplex since 6 months. Patient is on regular medication for the same.

Drug History: patient is on regular medication for diabetes mellitus Rx: Glimital M tablet SR 1BD. Tablet Amlo 5 1OD for hypertensive management. Tablet Nutrolin B Plus 1BD and Tablet Juviana plus 1HS as treatment of mononeuritis multiplex. No history of any drug allergy known till date. Family History: Paternal history-diabetes mellitus, which could be a potential factor for contributing patient's condition. Past surgical History: Right eye cataract surgery 9 years ago, left eye operated for cataract 3 years ago.

Ashtavidha Pariksha: •Nadi: 88/min •Mala: samyak •Mutra: 5-6 times/day •Jivha: Sama. •Shabda: samyaka • Sparsha: Anushnasheeta • Druk: Vikruti • Akruti: Madhyam

Ocular Examinations:

Diagnostic Assessment

Patient was advised to investigate Complete blood Count (CBC), Blood Sugar Level (BSL), MRI (brain and orbit) and 2D Echo was advised. In CBC reports, Erythrocytes Sedimentation Rate (ESR) was raised. BSL fasting and post prandial were raised hence hbA1C was advised. MRI reports ruled out space occupying lesion, vestibular schwannoma and pituitary adenoma. Ejection fraction was 60% in 2D Echo with mild tachycardia.

History of systemic metabolic disorder of diabetes mellitus, hypertension and mononeuritis multiplex with chief complaints like diplopia, lateral rectus restricted movement in left eye were clearly suggestive of left abducent nerve palsy. Ocular examination and laboratory investigation confirmed the diagnosis. No challenges were faced to confirm the diagnosis.

Ayurvedic therapeutic intervention Patient was advised dietary modulation to control diabetes mellitus and hypertension. Administration of nidana parivarjana.5 (avoiding disease causing factors) like lifestyle modification, following a balance diet, regular exercise along with medication to control systemic metabolic disorders in association with panchakarma and local treatment like kriyakalpa contributed to manage the disease prognosis.

Ayurvedic treatment like deepana, pachana, anulomana along with vata shamaka, chakshushya medication with local treatments like kriyakalpa are advised. Prameha hara internal medication along with shodhana (purfication) with panchakarma and kriyakalpa (local treatment) nourishes capillaries like sira, reduces shotha and enables self maintenance of system. Samanya chikitsa of timira mentioned as-6

Detailed ayurvedic treatment plan given is mentioned in table 9.

Result

Ayurvedic therapeutic intervention was administered for one month. Marked visual improvement with symptomatic relief and overall well being resulted in elimination of diplopia and abduction of left lateral rectus improved.

Follow up after 1 month revealed no recurrence of any symptom.

Result was obtained by assessment of subjective and objective criteria before treatment and after treatment as mentioned in table 8.

Discussion

Ayurvedic treatment was given for 1 month regularly and follow up was taken in the month of December. By understanding pathogenesis of disease; reversal of pathology by ayurvedic treatment achieved. Strength of this article is images were taken before treatment and after treatment which depicts marked improvement in left abducent nerve palsy. All the subjective and objective assessment criteria contribute to resolution of abducent nerve palsy in left eye.

Root cause of this condition is metabolic diseases like diabetes mellitus, hypertension and mononeuritis multiplex. This systemic disease was well treated by lifestyle modification, dietary modulation along with regular exercise and medication. 

Mode of action according to ayurveda-

Vitiated vata along with tridosha causes timira netra roga. Considering disease pathogenesis vata hara, prameha hara, tridosha shamana, rasayana and chakshushya treatment is prescribed.

Conclusion

Timely intervention to prevent further loss by ayurvedic treatment was achieved. Root cause of disease was well treated by ayurvedic treatment. Marked improvement in visual acuity with reduction in clinical symptoms were noticed within period of one month. Further complications were prevented. However further studies should be carried out to establish potential

ayurvedic treatment protocol for management of abducent nerve palsy secondary to mononeuritis multiplex.

Informed written consent

Informed written consent was taken from patient for publication of case report. It is made available for verification by editor of journal.

Author contribution

All authors have equally contributed in treating this patient, documentation work and development of manuscript.

Conflict of interest

To the best of our knowledge; all authors declare that this study was carried out in absence of any reason that could create potential conflict of interest.

Source of funding

None.