CRITICAL ANALYSIS OF KAPHAJA LINGANASHA ALONG WITH MODERN CORRELATION

2. Therapeutic approach to Kaphaja
Linganasha
Dr.Vidyashree H T
2nd year pg scholar

3. Contents
 Introduction
 Kaphaja linganasha – its Clinical features
 Surgerical approach – Indications
 Contraindications
 Pre – operative measures
 Operative procedure
 Post operative measure
 Management of complications
 Understanding of Cataract – Brief Anatomy &
physiology of lens
 Definition of cataract, etiology, pathogenesis &
symptoms.

4.  Detail about age related (senile ) cataract.
 Management of cataract
 Surgical management of cataract and its
complications
 Discussion
 Conclusion

5. Introduction
 Linganasha is a technical descriptive term in
ayurvedic literature, which means loss of vision.
 Two varieties of Linganasha – loss of vision have
been described as reversible and irreversible or
curable and in-curable.
 On the other hand linganasha as a whole can be
classified as follows –

6.  Linganasha
(loss of vision)
Endogenous
Exogenous
Anatomical Aetiological
1.Sanimitaja
description description
2.Animitaja
4th patala vitiated 1.Vataja
3.Abhigataja
Stage of timira 2.Pittaja
(traumatic)
3.Kaphaja
4.Raktaja

7.  Endogenous linganasha is described vividly on
anatomical and etiological grounds and is said to
be the end stage of Timira, a serious disease of
the visual apparatus.
 On anatomical descriptive grounds, when the
vitiated body humors reach / invade 4th /last
patala (whole of lens fibres leaving behind
capsule), then patient’s vision is obstructed, pupil
is covered by vitiated body humours then patient
perceives only bright illuminating objects that too
when the eye (posterior segment) is normal.
 This stage of timira ; invading 4th patala (lens) is
labelled as linganasha(cataract). According to the
etiological classification, linganasha is again the
rd nd

8.  The clinical picture is as per the
vitiating/causative body humours. Among these
pathologically classified linganasha only Kaphaja
Linganasha(KL) is curable rest all being incurable
but a misconception about the surgical procedure
is still prevailing.
 The Western medical literature considers that
surgical procedure depicted in our ancient
surgical treatise Sushruta Samhita is couching
i.e. displacing the mature cataractous lens in the
capsular bag into the vitreous cavity
 This fact is partially expounding the ayurvedic
view point. The available description therein is
very similar to that of extra capsular cataract
extraction that too with a small incision. On the
other hand,the later surgeon Achrya vagbhata’s

9. Kaphaja linganasha

10. Clinical picture
In kaphaja linganasha there will be,
 Complete obstruction of vision, the patient can
only perceive bright light objects.
 Pupillary circle appears to be thick, smooth and
white in color like a white drop of water (fluid)
moving on lotus leaf.
 Pupil constricts in sun and dilates in shade/Dark
(+ve pupillary reaction).
 Pupillary circle is mobile or changes its shape on
ocular massage.
These clinical features of kaphaja linganasha
invading fourth patala (lens) exactly simulate the
picture of mature / hypermatue senile cortical
(cuneiform)cataract, the white and soft cataract.

11. Exogenous variety of linganasha (vision loss)-
 Sanimittaja and Animittaja types are classified
according to known and unknown (idopathic)
exogenous causes respectively.
 In both these varieties the pupillary circle remains
clear, like natural one, i.e. jet black in color.
 Both are incurable.
 Trauma also leads to irreversible loss of vision.

12. Surgical approach
Indications for surgery :
 Well developed kaphaja linganasha i.e fully
matured or hypermature cortical cataract with
clinical features mentioned above.
 Uncomplicated cataract ;
i.e following six complications of kaphaja
linganasha are to be avoided before surgical
intervention.
1.Avartaki – pupillary circle appears like whirlpool,
in reddish white color.
2.Sharkara – when linganasha –cataract appears
like that of coagulated milk i.e calcified cataract.

13. 3.Rajimati – when cataract’s anterior surface is
seen with linings i.e anterior capsular calcification
or hard cataract.
4.Chinnamshuka – pupil is irregular with tears,
charred colored and painful; i.e cataract with
uveitis and posterior synechiae.
5.Chandraki – pupillary area reflects off white color
and its shape like that of moon with bell metal like
shining i.e cataract with retinal detachment.
6.Chatraki – the pupillary area is multicolored like
that of mushroom i.e in posterior segmental
pathologies.

14. Contraindications for surgery ;
1. Related to cataract ( kaphaja linganasha )
 Pupillary appearance-
- Half moon shaped pupil –posterior subluxated lens
- Drop of lens – anterior dislocation of lens
- Pearl shaped – shrinked lens
- Hard cataract
- Irregular shaped
- Having streaks – calcified
- Thin from the centre
- Multicolored
- Blood or abnormal material in pupillary area
 Painful eye
 Immature cataract

15.  Related to patient –
- Those patients who are contraindicated for
venesection ( sira vyadha) blood letting i.e, having
generalised swelling throughout the body, anaemia,
abdominal distension, age of <16years, pregnant
women with edema, old age, post partum stage,
without snehana and swedana, neurological and
bleding disorders etc.,
- Patients suffering from hyperglycemia, sinusitis,
bronchitis, indigestion, vomiting, headache, otalgia,
ocular pain and edema.
 Related to time and place-
- Excessive hot or cold season / atmosphere.
- Cloudy or windy atmosphere.

16. Pre-operative steps / measures;
 Preparation of patient ;
- snehana (oleation)
- Swedana ( sudation)
- Virechana ( medicated purgation)
- Ghrita mixed food
- Tarpana of head-by abhyanga (massage)
- He should be given nasya of mamsarasa on
previous night.
- Pt should not take food on the day of surgery.
- The operation theatre should be checked for all
the necessary equipments or medicines.

17.  The day should be normal one without excessive
heat or cold.
 The place of surgery should be devoid of
excessive flow of wind.
 There should be good illumination.
 The room where surgery will be done should be
made clean and smooth by watering.

18. Preparation andcollection of requiredmaterials ;
1.Yava- vakra shalaka having following qualities;
a. Length – 8 angula; i.e 6 inches.
b. Wrapped in center with thread for proper grip.
c. Thickness equal to thumb.
d. Both ends shaped like flower- bud.
e. Made of copper, silver / gold.
2. Vetas patra shastra for scleral incision.
3.Stri stanya /goat/ cow milk.

19. 4.Eranda patra.
5.Arrangement for heating.
6. Ghrita
7.Kashaya from vatahara drugs e.g. eranda patra
and dashamoola kwatha.
8.Ghrita medicated with yasti madhu kashaya.
9.Vastra patta ( bandage)
10. Pichu (cotton)
11.Cloth for poultice ( sudation)
12.Calm, brave, strong, devoted attendants to hold
and assist the patient during the procedure.

20. Operative procedure
 Fix a particular date and time for the operation
and pray prayers to god.
 Make the patient sit in O.T with extended legs,
hands resting on seat, hyper extended neck-
facing sun(light) in the forenoon. the attendants
should make patient stable. The patient has to
constantly see his own nose.
 The surgeon should sit in front of the patient knee
bent. The eye should be given mild sudation by
the surgeon’s breath (bashpa swinnam).

21.  Surgeon should hold the shalaka(linganasha
vedhani shalaka) steadily in right hand(gripped
with thumb, index and middle finger) and enter
the left eye at daiva krita chidra i.e. keyhole(2/3rd
parts from krishna-shukla sandhi and 1/3rd parts
from the apanga sandhi in interpalpebral space).
 The shalaka should be introduced in the eyeball
by rotatory movements; a specific sound of entry
of shalaka inside the eye is experienced which
follows a drop of water (aqueous humour)
through the vedhana site.

22.  Steadily pushing forward and manipulating the
shalaka until it reaches the drishti mandala
(pupillary aperture) i.e on anterior surface of the
cataractous lens so that lekhana karma is
completed under direct vision.
 Shalaka is to be gripped in left hand for operation
on right eye.
 Hold the entered shalaka in situ and irrigate the
eye with human milk and apply mild sudation on
the closed eye with vata pacifying leaves e.g.
Eranda patra. this will prevent redness, discharge
and pain.
 There after assuring the patient, push the shalaka
to the centre of pupil through rotatory
movements.

23.  With the tip of the shalaka in pupillary aperture,
kaphaja linganasha (cataract) should be scraped
properly to disintegrate the organized material. To
remove this disintegrated cortical/nuclear matter,
close the nasal cavity opposite to the operated
eye and ask the patient to forcefully sneeze out
through the open nare (ipsilateral to the eye being
operated)while keeping the shalaka inside the
eye.
 This will aid drainage of the liquefied cortical
mater ( by increasing the JVP and in turn
increasing IOP).

24.  Acharya vagbhata varies in its technique at this
step of surgical procedure.
 He is of the opinion that ask the patient to see
towards ground and gently push the cataract
downside without any delay, then ask the patient
to sneez (as above) so that cataract goes down
enough leaving the pupillary aperture ( Dristi
mandala) clear.
 If the cataract is not completely scraped and
extracted out or if it reoccurs ( after-cataract) then
irrigate the eye again with human milk, apply
sudation (as earlier) and rescrap the cataract (in
pupillary area).

25.  When by doing this procedure the pupil become
clear of all kapha/ white material- cataract ( like
sky clear of clouds) and patient starts seeing
finger, threads like objects then shalaka should
be slowly removed by rolling out movemrnts.
 Apply pure ghee in the eye and apply the
bandage.

26. Post operative measures
Regimen of patient :
 Place of patient’s rest: In a house/ ward which is
clean and tidy, made on suitable land, devoid of
dust, smoke, blowing wind and direct sunshine.
Bed should be comfortably with soft mattress
covered by clean bed sheet with pillow facing
east with some sharp weapon underneath it.
 Posture of patient in bed: If left eye is operated lie
in right lateral position or vice-versa and if both
are operated lie in supine position.
 Patient should listen to pleasing stories etc.

27.  Contraindications :
- For 3 days patients should avoid eructation,
sneezing, coughing, spitting, trembling and
excess movements.
- For 7 days head bath, heavy food, brushing ( can
use mouthwash/ manjan for oral hygiene),
adhomukh shayan ( lying in prone position).
 Diet :
- Light, easily digestible food in proper quantity.
- Semi-liquid diet mixed with trikatu, amalaki, ghee
and salt.
- Yavagu and vilepi.

28. - Soup of meat of animals of jaangal region e.g.
deer etc.
- Food along with medicated milk ( medicated by
vata-pacifying drugs).
 Massage of ghrita on head and feet everyday.

29. Wound care
 Open the bandage after 3 days.
 Irrigate eye with decoction of vata pacifying drugs
e.g.
- Milk cooked with soft leaves of eranda.
- Milk medicated with laghu pancha moola.
 Mild sudation of eyes to avoid the fear of vaata
prakopa.
 Bandage again.
 For 7 days, continue same steps of irrigation and
re-bandaging every day.
 Avoid the bandage on 7th or 10th day.

30. Iatrogenic and improper post-operative care
related complications;
 Raga (redness).
 Paka (inflammation).
 Vriddhi (growth).
 Daha (burning sensation).
 Granthi (cystic swelling).
 Vakra netra (squint due to muscle trauma).
 Adhimantha (secoundary glaucoma).

31. Measures taken in care of certain persistent
problems ;
 If pain and redness persists :
1.Aschyotana (medicated eye drops):
a. Goat’s milk medicated with Yasti, Draksha,
Lodhra & saindhava lavana.
b. Goat’s milk medicated with Yasti, Draksha,
Utpala, Kusta, Laaksha & Saindhava lavana.
2.Lepa (paste application on head and face):
a. Ghrita mixed with the paste of gairika, sariva,
durva, yava, and milk.
b. Juice of matulunga swarasa mixed with roasted
tila, white sarshapa.

32. c. Sariva, Yasti, Manjista, Talisapatra, Vidari mixed
with goat’s milk.
d. Paste of Daruharidra, Padmaka and Sunti.
3. Use of medicated ghrita orally, as nasal drops
and for irrigation. Ghrita medicated with
‘vatsakadi gana’.
4. Raktamokshana in the form of Siravedha after
snehana and swedana and agnikarma .
5. Adhimanta hara chikitsa ( acute angle closure G
& acute iridocyclitis).

33. Complications due to defect in shalaka;
( Improper surgical instruments )
Sl.
No
Defect in
Shalaka
Features
01. Brittle Ocular pain
02. Rough Intra ocular pain
03. Blunt tipped Big ocular wound
04. Very sharp Multiple wounds, intra ocular
wound
05. Irregular/une
ven
Lacrimation
06. Malleable Lacrimation
07. Very thin Anterior chamber dislocation
08. Blunt Pain, difficulty in procedure

34. Complication due to improper site of
vedhana & (surgical intervention) their
management;
Sl .
No
Site of puncture Features Management
01. Any site other
than daivkrit
chidra
-Injury to blood
vessels
-Haemorrhage
-Pain
-Seka of eye by
human milk &
ghrita medicated
with Yasti
kalka/kwatha.
-Agnikarma in
temporal region.
02. Puncture
towards
temporal side
- Pain
- Inflammation
- Redness
-Lacrimation
-Pricking
sensation
-Get torn from
above
-Swedana above
eyebrows
-Agnikarma
above eyebrows
-Intake of usna
ghrita
-Fasting
-Intake of Ghrita
& gomutra.

35. 03. Puncture very
near to shukla-
krishna sandhi
-Redness
-Inflammation
-Improper
healing
-Pupil gets
covered with
blood
-Medicated
purgation
-Netra seka by
luke warm
ghrita
-Blood letting
04. Puncture above
the indicated site
Increase in
ocular pain and
discomfort
-Netra seka by
luke warm
ghrita
- vata hara rx

36. 05. Puncture much
below the
indicated site
-Pain
- Lacrimation
- Redness
- slimy,
mucilaginous
discharge
after drawing
out shalaka
-Inflamation in
eyeball
-Netra seka
by luke warm
ghrita
- medicated
purgation
-Blood letting
- a/c
vagbhata the
condition is
incurable but
steps should
be taken to
prevent
eyeball from
suppuration

37. Latrogenic complication and management
Sl . N
o
Improper
movement of
shalaka
Features Management
01. Unstable
movement
-Constriction /
relaxation of
pupil
-piercing /
pricking pain
-Blood letting
by jalauka.
- Seka-
Ghritha
medicated
with leaves of
Yasti and
patola.
02. Excessive upward
movement
-Redness
-Excessive pain
-Fasting
- Seka with
luke warm
ghrita.

38. 03. Excessive
downward
movement
-Pain
-
Haemorrhag
e
-blood letting
Seka- Ghritha
medicated with
leaves of Yasti
and patola.
04. Pupil damage Haemorrhag
e
-Seka with –
ghrita manda
-Anuvasana
basti with
ghrita manda.
05. Piercing
opposite to
site of
puncture.
(damage of
ciliary body)
-
Haemorrhag
e
-
Chromatopsi
a
-Seka with
ghrita
-fasting
- Blood letting

39. Certain intraoperative complications of
linganasha (cataract) surgery & their
management;
Sl .
No
Complication Features Management
01. Sputan ( breaking of
the linganasha)
Cataract
breaks in
multiple
fragments on
being touched
by shalaka.
- Sudation by
poultice of
paste eranda
patra &
extraction of
broken pieces
one by one.
02. Avagalana ( falling
down)
Dislocation
into posterior
segment
-Seka by
human milk.
-Avapidana
nasya – sunti
& honey
-Blood letting
– by jalauka.

40. 03. Vistirna
(spreading )
Spreading/
dispersion
of liquefied
cataract
-Sudation on face by
cloth dipped in luke
warm water.
- Pratimarsha nasya
with ghrita manda
04. Utplavana
(leaping –up)
Dislocation
into
anterior
chamber
-Sudation on face by
cloth dipped in luke
warm water.
-frighten the patient
-Sprinkle cold water
-If linganasha is
stationary or mobile do
sudation by vata
pacifying group of
leaves.
-If problem persists;
snehapana ,sneha
nasya & blood letting,
agnikarma .

41. 05. Linata
(Disappear)
On being
scrapped by
shalaka,
linganasha
disappears in
pupillary
area.
-Sudation –
nadi sweda
by milk.
-Pratimarsha
nasya by
mixture of
ghrita, Yasti
choorna &
satapushpa
choorna .

42. Management ;
 Following line of treatment is followed in all these
complications:
1. Lepa on eye : for pacifying pain & redness.
a. Luke warm paste of gairika, sariva, durva are
grinded finely in ghrita & milk & heated on fire.
b. Luke warm paste of mild roasted tila & white
sarshapa grinde with matulunga swarasa.
c. Luke warm paste of sariva, tejapatra, yasti &
manjista in equal quantity ground with goats
milk.

43. 2. seka :
- For alleviating pain and redness:
a. Goats milk boiled with kalka/ kashaya of Yasti,
saindhava, Lodhra & Draksha.
b. Goats milk boiled with kalka/ kashaya of kusta,
saindhava, Laksha, yasti, sarkara, utpala &
Draksha.
- For alleviating pain and burning sensation:
Goats ghrita cooked with goats milk along with
paste / kashaya of shatavari, prithakparni,
mustaka, amalaka & padmaka.

44. 3.Lepa , anjana & seka :
Goat’s ghrita processed with goats milk along with
paste of vata pacifying devadaru etc. drugs & four
times paste of kaakolyadigana herbs should be
used for lepa & seka.
4. Blood letting :
If ocular pain persists, then snehana, swedana &
rakta mokshana from veins of temporal or frontal
region.
5. Agnikarma on temporal or frontal area.

45. Cataract

46. Definition :
Cataract is formed by the
degeneration and
opacification of the lens
fibres already formed, the
formation of abberant lens
fibres or deposition of other
material in their place.

47. Brief anatomy of lens :
 Lens is a biconvex, transparent, crystalline
structure, has ability to change its shape.
 Divides eye into anterior & posterior segments.
 It has 2 surfaces anterior
& posterior.
 Placed between iris and
vitreous in a saucer shaped
depression called patellar
fossa.

55. Etiology
 Eye injury
 Sun exposure
 Smoking
 Kidney disorders
 Diabetes mellitus
 Long term use of steroids
 Toxic substances
 Hereditary

56. Pathogenesis
 Degeneration
 Opacification
 Deposition of other material
 Abnormality of lens protein
 Disorganization of lens fibers

58. Symptoms
 Frequent change of glasses
 Reduced visual acuity gradual, progressive &
painless.
 Loss of ability to see objects in bright sunlight,
blinded by light of oncoming headlamps when
driving at night.
 Monocular diplopia or polyopia.
 Glare
 Colored haloes around light.
 Color shift (becomes more obvious after surgery)
 Visual field loss

63. Polyopia

64. Age related(senile)cataract
 Rare in persons < 50 years of age ( unless
associated with some metabolic disturbances
such as diabetes).
 Occurs equally in men and women.
 Usually bilateral.
 Considerable genetic influence in its incidence.
 Occurs in 2 forms
 Cortical cataract
 Nuclear or sclerotic cataract

66. Cortical cataract

70. Stages of maturation of cortical cataract:
 Etio – pathogenesis : Here the classical signs of
hydration followed by coagulation of proteins,
appear in the cortex.
 Stages ;
 Stage of lamellar separation
 Stage of incipient cataract
 Immature cataract
 Mature cataract
 Hypermature cataract
 Morgagnian cataract
 Intumescent cataract

77. Hyper mature cataract

78. Morgagnian cataract

79. Nuclear cataract
 Occurs soon after 40 years of age.
 It typically blurs distant vision more than near
vision.
 In maturity, the sclerosis may extend almost to
the capsule so that the entire lens functions as a
nucleus.
 On direct ophthalmoscopic examination,
- Fundus are hazy.
 Generally Hypermaturity does not occur in
nuclear cataract.

82. Management of cataract
 Early stage of hydration – due to diabetes –
control of casual condition .
 Opacification – control of general condition .
 Initial stage of cataract – adjustment of
illumination;
- In cortical cataract – bright illumination.
- In large central opacity – dull illumination – dark
glasses – very weak mydriatic drops are advised.

83. Surgical intervention
 Indication ;
 Cataract causing visual loss.
 Subluxation or dislocation.
 Coloboma, lenticonus, spherophakia.
 Lens induced complications such as;
- Phacolytic uveitis or glaucoma.
- Phacoanaphylactic endophthalmitis
- Phacomorphic glaucoma
- Lenticular tumour

84. Intracapsular cataract extraction (ICCE)

93. Techniques ( ECCE)
 Conventional ECCE
 ECCE by small incision cataract surgery or
small incision manual nucleus
fragmentation
 Lensectomy
 Phacoemulsification

107. Post operative complications
 Endophthalmitis
 Uveitis
 Corneal edema
 Astigmatism
 Retinal detachment
 Displacement of IOL
 Secondary glaucoma
 Posterior capsule opacification
 Exacerbation of diabetic retinopathy.

108. Discussion
 Linganasha is one of the major causes of
blindness, which can be either reversible or
irreversible depending on its type.
 Kaphaja linganasha is the only surgically
treatable type, rest all being incurable.
 The indicated site of puncture/ incision for
linganasha / cataract surgery is daivakrita
chhidra, which is the junction of medial 2/3rd and
lateral 1/3rd of the area between limbus and outer
canthus in interpalpebral space.
 On measuring this area with vernier calliper, it is
found to be 9mm on an average. Thus the
daivakrita chhidra should be about 6mm away

109.  These measurements correspond with pars
plana, the site which is least vascular and devoid
of retinal tissue and also preferred site for intra
ocular (posterior segment) approach to the
eyeball.
 The shape of linganasha vedhani shalaka is like
the flower bud of jasmine i.e round, spindle
shaped with narrow petiole like base. Such a
shape ensures spontaneous and effortless exit of
cortical matter from the sides of the neck of
shalaka through wound gap made by wide
spindle shaped tip of the shalaka, when the
scrapping is being done.
 This technique given in sushruta samhita closely

110.  On the other hand description available in the
vagbhata samhita regarding this surgical step differs
and is similar to the couching procedure.
 After proper lekhana karma (scrapping), a JVP raising
maneuver is done i.e. closing nostril opposite to the
eye being operated & forcefully sneezing out through
the ipsilateral nostril which consequently raises the
IOL& facilitates spontaneous exit of scrapped /
liquified lens matter through the incision.
 A detailed & critical account related to postoperative
care & management of various complications of
cataract surgery has been given in ayurveda literature
which is clearly emphasize that a utmost care in the
selection of the patient, pre-operative, operative &
post-operative as well as complications if any have

111. Conclusion
 Kaphaja linganasha seems to be the proper word
to be used for the eye disease cataract in modern
medical science.
 The detailed description of surgical procedure by
the ancient eye surgeons of India is suggestive of
small incision extra capsular cataract extraction
by temporal approach as per the description
available in su. Sam.
 On the other hand couching was a later
development in the surgical technique of cataract
around the period of Acharya Vagbhatta.
Couching technique being easy & time saving,
remainded in practice till mid of the 20th century in
many tribal areas of the country.

112.  some surgeons opines this procedure as pars
plana lensectomy; but in that case this should
have been referred as Aharana karma (extraction
) and there would have been no referance of
punah linganasha ( after cataract) as an
complication.
 Various iatrogenic & post-operative care related
complications are vividly detailed along with their
management.
 Thus the surgical treatment of cataract was
selective, systemic & in continuous process of
transition since its recognition as major
catastrophe in the literature of Ayurveda.