अक्षिपाक (Akshipaka) also known as Uveitis; is defined as the inflammation of uveal tissue.
इसका वर्णन सुश्रुत संहिता उत्तरतंत्र अध्याय 6 और अध्याय 12 व अष्टांग हृदय उत्तरतंत्र अध्याय 15 में किया है।
सशोफ अक्षिपाक:-
“कुण्डूपदेहाश्रुयुतः पक्वोदुम्बरसन्निभः। दाहसंघर्षताम्रत्वशोफनिस्तोदगौरवैः। जुष्टो मुहुः स्रवेच्चास्त्रमुष्णशीताम्बु पिच्छिलम्। संरम्भी पच्यते यश्च नेत्रपाकः स शोफजः।।” (सु.उ. 6/21)
- नेत्र में खुजली होना, मल का जमना, अश्रुस्राव होना, नेत्र पके हुए गूलर फल के समान दिखाई देना।
- नेत्र में दाह संघर्ष, ताम्र वर्णता, शोफ, सूई चुभोने की सी पीड़ा।
- भारीपन तथा कभी गरम, कभी ठण्डे, पिच्छिल स्राव का बार-बार निकलना, संरंभ और पाक होना।
- यह त्रिदोषज व्याधि है, इसमें शोफ, तीव्र पीड़ा, दाह, अत्यधिक स्त्राव होता है।
- आंख का श्वेत भाग पके हुए गूलर फल के समान।
- नेत्र से बार-बार कभी उष्ण, कभी शीतल, कभी पिच्छिल, कभी निर्मल, कभी गाढ़ा स्त्राव निकलता है।
अशोफ अक्षिपाक:-
“शोफहीनानि लिङ्गानि नेत्रपाके त्वशोफजे ।।”(सु.उ. 6/22)
- अशोक अक्षिपाक (Akshipaka) के लक्षण सशोफ अक्षिपाक के समान ही होते हैं, परंतु शोथ नहीं होता ।
- आ. वाग्भट् ने “अल्पशोफ” के नाम से वर्णित किया है तथा इसे शोफ रहित कहा है।
साध्यासाध्यता:-
सशोफ और अशोफ अक्षिपाक (Akshipaka) साध्य त्रिदोषज रोग हैं।
सशोफ और अशोफ अक्षिपाक की चिकित्सा:-
“सशोफश्र्चाप्यशोफश्र्च द्वौ पाकौ यौ प्रकीर्तितौ । स्नेहस्वेदोपपन्नस्य तत्र विद्ध्वा सिरां भिषक्।। सेकाश्र्चयोतननस्यानि पुटपाकाश्र्च कारयेत् ॥”(सु.उ. 12/38)
- सशोफ और अशोफ अक्षिपाक (Akshipaka) में जो रोग कहे गये हैं उनमें प्रथम रोगी को स्नेहन, स्वेदन करा के सिरावेध द्वारा अशुद्ध रक्त का मोक्षण कर देना चाहिए।
- वहाँ सेक, आश्च्योतन, नस्य, पुटपाक करना चाहिए।
“सर्वतश्चापि शुद्धस्य कर्तव्यमिदमञ्जनम् ॥” (सु.उ. 12/39)
रोगी का सर्वप्रकार से शोधन कर दिया हो अर्थात् वमन, शिरोविरेचन से ऊर्ध्व संशोधन तथा विरेचन से अधः संशोधन कर दिया हो उसके नेत्रों में निम्न अंजन लगाना चाहिए।
“ताम्रपात्रस्थितं मांस सर्पि: सैन्धवसंयुतम् । मैरेय वाऽपि दध्युत्तरकमेव वा।।” (सु.उ. 12/40)
- अंजन विधि = 1 तांबे के पात्र में घृत तथा सैंधव लवण मिश्रित कर भर दे तथा एक मास प्रयन्त ढक के रख दें अथवा मैरेय, दही या दही के ऊपर की मलाई या दही का पानी, इन्हें 1 मास तक ताम्र पात्र में भरकर रखें।
- इस तरह महीना भर बाद उस पात्र और द्रव को खरल में पीसकर अंजन कर लें।
- सैंधव लवण, सोंठ के चूर्ण को घृत में मिलाकर एक मास तक रख दें। फिर उसे स्त्री दूध के साथ मिलाकर आश्च्योतन और अंजन के रूप में प्रयोग करें।
Uveitis
- Uveal tissue constitutes the middle vascular coat of the eyeball.
- It can be divided into 3 parts, namely Iris, Ciliary body & Choroid (Anterior to Posterior).
- The entire uveal tract is developmentally, structurally, functionally one indivisible structure.
Definition:-
Inflammation of the uveal tissue is called uveitis.
Classification:-
(A) Anatomical Classification :
- Anterior Uveitis =
- It is inflammation of the uveal tissue from iris upto pars plicata of ciliary body.
- It may be sub divided into –
- Iritis – infection predominantly affects the iris.
- Iridocyclitis – in which iris & pars plicata part of ciliary body are equally involved.
- Anterior cyclitis – in which pars plicata part of ciliary body is predominantly affected.
2. Intermediate Uveitis =
- It includes inflammation of the pars plana & peripheral part of the retina & underlying choroid.
- It is also called “Pars planitis“
3. Posterior Uveitis =
- It refers to inflammation of choroid (choroidity).
- Almost there is associated inflammation of retina & hence the term “chorioretinitis” is used.
4. Panuveitis =
- It is inflammation of the whole uvea.
- Sympathetic ophthalmitis.
- Vogt Koyanagi Harada’s disease.
(B) Clinical classification :
- Acute uveitis =
It has got a sudden symptomatic onset & disease lasts for about 6 weeks to 3 months.
2. Chronic Uveitis =
It frequently has an insidious & asymptomatic onset. It persists longer than 3 months to even years. Usually diagnosed when it causes defective vision.
3. Recurrent uveitis =
Characterized by repeated episodes, separated by inactive periods of >3 months without treatment.
(C) Pathological Classification :
(1) Suppurative or purulent uveitis
(2) Non suppurative uveitis –
- (Wood’s Classification) Further divided into 2 groups:-
- Non-granulomatous uveitis
- Granulomatous uveitis.
(D) Etiological Classification :
(1) Infective uveitis =
- Bacterial uveitis.
- Viral & fungal uveitis.
(2) Non- Infections uveitis =
- Immune- related uveitis
- Toxic uveitis
- Traumatic uveitis
- Uveitis associated with non-infective systemic disease.
- Idiopathic uveitis.
Etiology:-
- Infectious uveitis= Inflammation of the uveal tissue induced by invasion of the organisms. Infection, may be exogenous, secondary or endogenous. Types-
- Bacterial uveitis– It may be granulomatous. Eg: Tubercular, Leprotic, syphilitic.
- Viral uveitis– Herpes simplex, Herpes Zoster, Cytomegalovirus (CMV), AIDS, Dengue, Chikungunya.
- Fungal uveitis– Rare & may accompany systemic Aspergillosis, Candidiasis.
- Non-Infectious uveitis= Auto immune uveitis.
- HLA– associated systemic diseases with uveitis= include Ankylosing spondylitis.
- Other systemic diseases= Psoriasis, Diabetes mellitus, gout.
- Traumatic uveitis
- Idiopathic uveitis.
Pathology of Uveitis:-
- Suppurative uveitis –Purulent inflammation of the uvea is usually a part of endophthalmitis or panophthalmitis occuring as a result of exogenous infection by pyogenic organisms which includes- Staphylococcus, Streptococcus, Pneumococcus, Pseudomonas & Gonococcus.
- Non-granulomatous uveitis – may be an acute or chronic exudative inflammation of uveal tissue, usually occuring either due to a physical & toxic insult of the tissue, or as a result of different hypersensitivity reactions.
- Granulomatous uveitis – Granulomatous uveitis is a chronic inflammation of proliferative nature which typically occurs in response to anything which acts as an irritant foreign body, it be organic or inorganic material. The common organisms which excite this type of inflammation are those responsible for Tuberculosis, Leprosy, Syphillis.
Anterior Uveitis
It is inflammation of the uveal tissue from iris upto pars plicata of ciliary body.
Clinical features:-
- Symptoms =
- It may present as Acute or chronic anterior uveitis.
- In acute ant. uveitis main symptoms are= Pain, Photophobia, Redness Decreased vision, Lacrimation.
- In chronic uveitis, the eye may be white with minimal symptoms even in presence of signs of severe inflammation.
- Signs =
- Lid oedema – usually mild.
- Corneal sign :- It includes –
- Corneal oedema- is due to toxic endothelitis & raised IOP.
- Keratic precipitates (kps) – are proteinaceous cellular deposits occuring at back of cornea. Following types may be seen – may Mutton fat KPs, Fine KPs, Small & medium KPs, Old Kps.
- Posterior corneal opacity- may be formed in long -standing cases of iridocyclitis.
- Anterior chamber Sign :-
- Aqueous flare- It is the earliest sign, occurs due to leakage of protein particles into the aqueous humour from damaged vessels. In beam of light, these particles are seen as suspended & moving dust particles.
- Hypopyon – When exudates are heavy & thick, they settle down in the lower part of the anterior chamber as Hypopyon .
- Iris Signs :-
- Iris becomes muddy.
- Synechiae- Posterior synechiae, These are adhesions b/w the posterior surface of iris & anterior capsule of crystalline lens.
- Pupillary sign :-
- Narrow pupil.
- Irregular pupil shape.
Intermediate Uveitis
Inflammation involving pars plana, periphered retina, choroid.
Clinical features:-
Symptoms =
- Asymptomatic.
- Blurring of vision.
- Pain, Photophobia & redness are absent.
Signs =
- Low-grade flare
- Few KPs.
- Lens may show complicated Cataract in late stages.
- Snow ball or cotton ball opacities.
- Anterior viterous condensation.
Posterior Uveitis
Inflammation of choroid.
Clinical features:-
Symptoms =
- Painless condition.
- No photophobia & Lacrimation.
- Defective vision.
- Photopsia- (flashes of light, resulting due to irritation of rods and cones.)
- Black spots floating in front of eye.
- Micropsia.
- Macropsia.
Signs =
- No external signs.
- Viterous opacities- due to choroiditis usually that in its middle/ Posterior part.
Diagnosis:-
- Dilated fundus examination.
- ESR, CRP, TLC, DLC
- Lepromin test.
- X-Ray (Chest)
- Skin test→ tuberculin test.
- Urine examination.
Differential diagnosis:-
- Acute Red eye.
- Ocular Ischemic Syndrome.
- Retinoblastoma.
- Leukemia.
- Pigment dispersion syndrome.
Complications:-
- Complicated cataract
- Secondary glaucoma
- Early glaucoma
- Late glaucoma
- Choroiditis.
- Retinal Complications- Cystoid macular oedema and Macular degeneration.
- Papillitis.
- Band Shaped Keratopathy.
- Glaucoma
Treatment:-
- Steroids – used in Eye drops, by oral (tablets), Periocular injections, Intra venous infusion.
- Oral Steroid – Prednisolone tablet for 2 to 4 weeks.
- Dose= 60-80 mg/day.
- Intra venous steroid- Eg: Methylprednisolone.
- Immunosuppressant – when steroid is not responding.
- Cyclosporine A (2-5 mg/kg/day)
- Methotrexate (7.5-50 mg/week)
- Tacro limus (Prograf 500)
- Mydriatics → eye drops → eg: Atropine, cyclopentolate (2-3 weeks).
- They block nerve impulses to Pupillary sphincter and ciliary muscles relieving pain & photophobia.
- Hot fomentation -Reduces blood pain and circulation increases.