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Introduction

Ptosis is abnormally low positioned eyelid that leads to defective vision. It can occur in all age group. Ptosis can either be congenital or acquired. Acquired ptosis can arise from a variety of underlying mechanisms and is broadly classified into myogenic, neurogenic, aponeurotic, mechanical, and traumatic types. (1)

Depending on the amount of eyelid covering the cornea it can be minimal (1-2 mm), moderate (3-4mm), severe (>4mm), and complete. (2) In ayurveda ptosis may be corelated to vatahatha vartma, a disease mentioned by acharya vaghbata in Astnga Hridaya uttaratantra, vartma roga vijnana. (3) Acharya susruta has also said about vatahataha vartma which do not exhibit the features of ptosis so there is difference in opinion on the features of vatahata vartma by both the acharyas. (4)

Vatahata vartma said by Acharya vaghbata exhibit the core feature of ptosis which is drooping of eyelid. Dosha involved in the manifestation of vatahata vartma is vata, here the vata vitiation can be due to dathukshaya leading to kevala vata dushti or due to avarana of vata by other doshas leading to the obstruction of normal movement of vata.(5) Differentiating between avarana and dathu kshaya is the fundamental principle in the management of any disease related to vata kopa. Almost all classical text considers vatahatha vartma asadhya,(6,7) but in clinical practise many of the vatahata condition respond to ayurveda management, so treatment should not be neglected. Re-validation of the cause specially the site of lesion and prognosis is a must in the present scenario. Mere observation of eyelid drooping is insufficient to determine whether the vitiated Vata is due to Avara?a or Dhatu K?aya. A thorough evaluation of the nidana (etiological factors) plays a crucial role in accurately assessing the underlying do?ic involvement and pathogenesis for example acharya susruta while explaining vata rogas like Ardita indicated vamana considering the avaranatwa,(8) Similarly, studies in cases of Bell’s palsy have suggested Vamana as a potential Sodhana therapy in conditions interpreted as Kapha-avarudha Vata.(9)

Therefore, in the management of Vatahata Vartma, both Nidana and the involved Do?a must be carefully assessed to determine whether the condition is due to Kevala Vata or Avara?a Vata, so that appropriate treatment can be planned accordingly.

CASE REPORT

70yr female with history of hypertension since 1 year on medication, presented to Government ayurveda college tripunithura shalakyatantra department OPD on 20/06/2023 with complete closure of right eye since 14 April 2023, foreign body sensation right eye and blurring of vision BE since 3 months. The patient had a history of a fall due to giddiness two months prior (14 April 2023), during which she sustained blunt trauma to the right side of the face. There were no external wounds noted, and radiological evaluation revealed no evidence of fracture and was admitted to a tertiary care hospital with a diagnosis of right oculomotor nerve palsy with essential hypertension. She remained unconscious for three days, and upon regaining consciousness, she noticed inability to open the right eye; however, she did not seek any treatment for this condition.

Her Cerebral Angiography dated 20/04/2023 showed small blister aneurysm in the supraclinoid segment of the right internal carotid artery (ICA), and Flow diverter placement was advised; however, the procedure was not undertaken.

 The emergency treatment summary dated 22/04/2023 revealed the following findings:

• Right ICA–PCOM blister aneurysm
• Right oculomotor nerve palsy
• Mild head injury with left cerebral contusion and subarachnoid hemorrhage in the left ambient cistern
• Second-degree atrioventricular (AV) block
• Post-traumatic vertigo
• Essential hypertensionTop of Form

Examinations Done for Ptosis

Head posture: straight, erect

Facial symmetry: normal with both eyebrows at same level

Lacrimal apparatus:  skin visible over with lacrimal apparatus, redness and swelling absent bilateral

Eye ball: Proptosis absent bilateral

Conjunctival: Congestion, chemosis, follicle, pterygium absent bilateral

Sclera: within normal limit with no discolouration bilateral

Cornea: size, shape normal with no corneal opacity bilateral

Pupil: no abnormality with brisk pupillary reflex bilateral

Anterior chamber:  normal not shallow not deep bilateral

Discussion

The clinical presentation closely resembles Vatahata Vartma, described by Acarya Vagbha?a in Astanga hridaya, Uttara Tantra. The disease is described as asadhya in classical texts, this prognosis is likely based on complete structural or irreversible nerve damage. However, in the present era, with improved understanding of do?a–dhatu involvement, early intervention, and integrative therapeutic approaches, functional improvement and symptomatic relief can be achieved.

In this case, the initial etiological factor was trauma, which resulted in a mild head injury with left cerebral contusion subarachnoid

haemorrhage in the left ambient cistern. From an Ayurvedic perspective, the predominant dosa involved at this stage can be considered Rakta–Pitta, owing to the hemorrhagic component and vascular insult.

Subsequently, a right ICA–PCOM blister aneurysm developed, arising from the supraclinoid segment of the Internal carotid artery at or near the origin of the Posterior communicating artery on the right side these are strongly associated with sub arachanoid haemorrhage and in long standing hypertension. Due to its anatomical proximity to the Oculomotor nerve, the aneurysm exerted a mass effect, leading to compression of the nerve and resulting in ptosis.(10)

The drooping of the eyelid (ptosis) reflects Vata vitiation, as Vata governs neuromuscular activity and eyelid movements. Aneurysms cannot be considered as a manifestation of Vata alone, as the presence of structural obstruction (Srotorodha) indicates the concomitant involvement of Kapha. The initial pathological process likely involves Vata–Kapha, where Kapha contributes to structural alteration and obstruction of the vascular channels, while vitiated Vata induces dilatation and wall weakness. In later stages, particularly when rupture or haemorrhage occurs, Rakta dhatu becomes involved, reflecting vascular compromise and bleeding. The compressive mass effect of the aneurysm is also attributed to Kapha, as Kapha is associated with structural heaviness, obstruction, and space-occupying effects. The presence of sub arachanoid haemorrhage suggest significant involvement of pitta and rakta component.

Therefore, the condition may be better interpreted as Avara?a-janya Vatahata Vartma  rather than a presentation of Kevala Vata, since the Vata impairment is occurring due to avara?a by Kapha with association of rakta and pittaTop of Form.Bottom of Form The management strategy was designed to remove avara?a, Normalize Vata gati, nourish affected snayu and ma?sa dhatus, restore functional integrity of the eyelid. Udvartana was employed initially to alleviate Kapha avara?a, aiding in systemic and neurological stabilization. (11)

Takradhara was administered considering the involvement of Rakta dhatu, as subarachnoid hemorrhage was documented in the cerebral angiogram dated 22/04/2023. Takradhara was indicated for rakta pitta condition with association of kapha. (12)

Dhanyamladhara further facilitated avarana hara?a and improved peripheral circulation, particularly beneficial in post-traumatic neurological conditions. (13) Snehapana with Karpasasthyadi Sevya Taila and Indukanta Gh?ta provide Vata samanatwa, snigdhata, and bala vardhana, preparing the patient for Vamana.(14)

Although trauma was identified as the primary precipitating factor for the present condition, the patient had a significant history of Kapha-vardhaka nidanas, including day sleep, daily intake of milk, consumption of fish (three times per week), milk tea twice daily, and regular intake of idli–dosa as breakfast (four times weekly). These dietary and lifestyle factors indicate chronic Kapha aggravation contributing to srotorodha.(15)      

As the patient’s BMI was below 23 kg/m² and no clinical features of Kaphotklesha was observed, Sadyo Vamana was not undertaken. Additionally, Agni was found to be deranged and the patient had history of hypertension R?k?a?a therapy was administered initially to correct Agni, reduce srotorodha for minimising the risk of vascular stress during shodana.(16) Vamana is classically Kapha-hara, its use in this case was justified due to Kapha-avara?a of Vata, thereby facilitating unobstructed Vata movement. (17)

Following this, Yoga Vasti was administered as Vasti is considered Ardha Cikitsa for Vata disorders.  Bala Taila nourished snayu and majja dhatu, while Madhutailika Vasti provided Vata-Kapha samana and enhanced neuromuscular function.

Marsa Nasya with Karpasasthyadi Taila directly acted on urdhva jatrugata vikaras, particularly cranial nerves. Nasya is the prime therapy for disorders of the head and neck and plays a crucial role in improving neural conductivity as here the major cause was oculomotor nerve palsy. (18)

Tarpana and Putapaka with Triphala Gh?ta nourished ocular tissues, strengthened vartma ma?sa dhatu, and improved local circulation, thereby supporting eyelid function and ocular comfort. (19)

Conclusion

Ptosis is a condition causing drooping of eyelid, long term ptosis can cause chronic visual disturbance, ocular surface problems, cosmetic and psychological disturbances. Disease was corelated to vatahata vartma explained by acharya vaghbata. The condition is said to be asadhya in the classical texts but in the present scenario many patients are responding to ayurvedic management. Therefore, re-evaluation and revalidation of the disease entity and its prognosis are highly essential in the current context. Precise localization of the underlying cause ensures appropriate treatment planning and improves therapeutic outcomes. In Vatahata Vartma, the primary Do?a involved is Vata. However, for appropriate treatment planning, it is essential to determine whether the vitiation is due to Avara?a or Dhatu-k?aya. Proper differentiation between these two pathological mechanisms in the patient is crucial for selecting the most suitable line of management. In the present case, the primary clinical focus was ptosis. However, the associated conditions such as oculomotor nerve palsy, ICA–PCOM blister aneurysm, and subarachnoid hemorrhage indicated the involvement of multiple Do?as, Vata, Pitta, Kapha, along with Rakta. Follow-up of the patient was conducted periodically until July 2025. During this period, the patient remained clinically stable, comfortable, and did not report any fresh or recurrent symptoms.