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Introduction

Acharya Vagbhata emphasises the significance of vision, saying, "The eyes (organ of sight) are the most essential sense organ among the five others, especially for humans”.1 Every individual should make ongoing and consistent efforts to protect their vision during whole lifetime, because eye illness is far more serious than any other physical ailment since once eyesight is lost, a person is unable to do any routine tasks. Ophthalmology is addressed in detail in the Sushruta Samhita. The categorization of eye illnesses, as well as the surgical treatments used to treat them, are so well presented. The total number of eye illnesses is seventy-six. These seventy-six illnesses were categorised based on a variety of criteria such as-2

1. Dosha-wise: Vataja, Pittaja, Kaphaja, Raktaja, and Sannipataja.
2. According to the prognosis: Sadhya, Yapya, and Asadhya.
3. Site-specific: Sandhigata, Vartmagata, Shuklagata, Krishnagata, Sarvagata and Drishtigata.
4. Surgical Procedure: Chhedya, Lekhya, Bhedya, Vedhya, etc.

Vision-related diseases are researched under the umbrella term "Drushtigatarogas”. Twelve Drushtigatrogas were mentioned by Acharya Sushruta and twenty-seven by Acharya Vagbhata.3 This difference in the number may be because according to Sushruta, Timir, Kacha and  Linganasha are the progressive stages of the same disease. But Vagbhatta considers Timir, Kacha and Linganasha as separate clinical entities. One of them is Timir which occurred as a result of affliction of Abhyntar Patalas.4 The clinical features of Timir can be considered as errors of refraction. Out of the six Netra Patalas, described by Sushruta, the last four Patalas are related with eyeball antero-posteriorly, in which Timir Roga is said to be produced.5 It is also termed as "Paramdarunvyadhi," because of its gradual, irreversible nature, and its potential to cause complete or partial blindness.

Myopia, often known as short-sightedness, is the most common eye illness in the world, with significant social, educational, and economic consequences. According to four population-based studies, the prevalence of myopia in India is between seven to twenty seven percent and hyperopia is 22.9 percent which rises with school-age children and adolescent. It is estimated that across the world approximately 1.3 billion individuals are affected by some degree of visual impairment.6 According to WHO, 43% of the visual impairment is caused by untreated refractive error.7 Myopia was picked as a priority due of its importance as a worldwide public health problem. WHO's Vision 2020 aims to treat and prevent eye diseases and avoid blindness by 2028.8

Concept of Timir:

It is derived from ‘Timi Kledane Aardri BhavahaIti Yavatha’. Its etymology is “Tim+ Unadi” with suffix ‘Kirach’ (Shabdkalpadrum) which indicates increase of watery element in the eye.

The meaning of Timir according to Amarkosha is assumed as darkness.

The clinical features of Timir can be considered as errors of refraction. Out of the six Netra Patalas, described by Sushruta, the last four Patalas are related with eyeball antero-posteriorly, in which Timir Roga is said to be produced. According to Vagbhata, this occurs in the first two layers of the eyeball. When vitiated Doshas reach inside the eye through blood vessels and get located in the first Patala, there is indistinct vision of all objects. Vision becomes more disturbed when Doshas reach the second Patala. When vitiated Doshas are situated in first and second Patala, the disease is termed as Timir but when the vitiated Doshas affect the third Patala, it is termed as Kacha; and when it involves the fourth Patala, it is termed as Linganasha. If Doshas are in the 4th Patala, then there is absolute darkness.9 The part of clinical feature of Timir (First and  Second Patala) can be correlated with most important eye illness i.e., Myopia. When the vitiated Doshas invade first Patala, the patient complains of difficulty in seeing objects distinctly. This is the common complaint of myopia, hypermetropia, astigmatism. Thus one can correlate the Timir of first Patala with myopia easily. Myopia is due the length of the eyeball being too long, this causes light rays to focus at a point in front of the retina. Myopia is commonly referred as shortsightedness. It is mainly of 2 types:

1. Simple or Physiological myopia
2. Pathological/ Progressive or Degenerative myopia

Causative factors

Aharaj – Excessive Amla and Katu Rasa

Viharaj - Cold water bath, when the body is hot, cigarette smoking, suppression of lacrimation watching moving objects for a long, welding work and work in furnaces, Swapnaviparyaya, Atimaithuna, Kulatthamasha sevana, etc.10

Mansika - Chinta, Shoka, etc.

Some specific causes – Grahani Roga, Nasya Karma, Pinasa, Raktasrava, Constipation, Shiro Abhitapa, Marmaghata, etc.

Others - Genetic factors, biological variations in development of eye i.e. change in optical power of cornea and lens, increase in axial length of eyeball, etc.

• Dosha: Tridosha
• Dushya: Rasa, Rakta, Mamsa
• Agni: Mandagni leading to Ama formation
• Srotas: Rupavaha Siras mainly
• Srotodushti: Sanga and Vimarga Gamana
• Rogamarga: Madhyama as Shirah is the Pradhana marma
• Adhishthana: Drushti in general and Patalas in particular

Cinical Features of Timir

Vataja Timir - Objects appear as if they were moving, hazy, reddish in colour and tortuous in shape.

Pittaja Timir - Visualization of false flashes of the sun, glowworm, rainbow and the lightening. Bluish and blackish shades appear as variegated like the feathers of a peacock.

Kaphaja Timir - All objects are seen as glossy and white like the clouds.11

Raktaja Timir - Objects appear to be in various colours such as dark greenish, greyish, or blackish and smoky all around.

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Samprapti :

The pathological events of Timir begin with the increment of Doshas at their respective sites. The Vimarga Gamana of these increased Doshas through Siras towards Drishti and localization in Patalas is the main cause of Timir. The localization of Doshas in the Patalas further prevents the functional capacities of Patalas and leads to blurred vision or Avyakta Darshana. It further inhibits the nutritional supply by obstructing the channels responsible for it. The further progression leads to Vihwala Darshana due to the involvement of Pishitashrita and Medoashrita Patalas. The disease terminates into Linganasha, or the stage of absolute blindness. The Ashraya of the Malas in Indriya thus produces both Upaghata (destruction) and Upatapa (disease) in Chakshurendriya.

Samprapti Ghatakas:

Dosha: Tridosha

Dushya: Rasa, Rakta, Mamsa

Agni: Mandagni leading to Ama formation

Srotas: Rupavaha Siras mainly

Srotodushti: Sanga and Vimarga Gamana

Rogamarga: Madhyama as Shirah is the Pradhana marma

Adhishthana: Drushti in general and Patalas in particular

Cinical Features of Timir

Vataja Timir - Objects appear as if they were moving, hazy, reddish in colour and tortuous in shape.

Pittaja Timir - Visualization of false flashes of the sun, glowworm, rainbow and the lightening. Bluish and blackish shades appear as variegated like the feathers of a peacock.

Kaphaja Timir - All objects are seen as glossy and white like the clouds.11

Raktaja Timir - Objects appear to be in various colours such as dark greenish, greyish, or blackish and smoky all around.

Management of Timir:

Timir is a Drishti Mandala disorder that begins with mild visual problems. The pathology of Timir in various Patala describes visual disturbances caused by various biological and physiological factors. Timir's basic treatment plan entails avoiding aetiological causes and, more particularly, counteracting elevated Vata and other Doshas. The therapy for Timir is determined by the stage of the disease and the Doshas' dominance. Early on, the body should be cleaned with Langhana and Virechana.

Prophylactic measures :

Samanya chikitsa - According to Achrya Vagbhata, if Timir is not treated in its early stages, it might result in full blindness, hence it is critical to cure it as soon as possible. He suggested Snehana, Raktmokshna, Virechan, Nasya, and then Tarpana and other treatments. According to Acharya Sushruta, bodily cleansing should be done with the use of Langhana, Virechana, Nasya, and Basti in acute cases of eye illness, and then Abhishndokatakriyakalpa can be administered depending on the preponderance of Doshas.12 

Preventive measures - Person should consume Ghrita, Triphala, Shatawari, Patola, Mudga, Amalaki, and Yava (barley) regularly. Payasa prepared from Shatawari or that prepared similarly from amalaki or else barley meal cooked with sufficient quantity of Ghrita and the decoction of Triphala are the prophylactic measures to prevent Timir.

Ahara to improve eyesight - The cooked vegetables of Jivanti, Sunishannaka, Tanduliya, good quantity of Vastuka, Karavellaka, brinjal, tarkari, karira fruits, Shigru and artagala; all these vegetables cooked with Ghrita promote eyesight.13

Curative measures

Local - Acharya Sushruta has given a very beautiful and unique description of local application of drugs in several eye diseases by the name of ‘Kriyakalpa’. Sushruta and Vagbhatta have indicated Samshodhana karma which includes Virechana, Raktamokshana and Nasya. Kriyakalpa which includes Putapaka, Anjana,Dhooma, Tarpana, Shirovasti, Lepa and Seka. Great emphasis has been given to Anjana in the management of Drishtigata Rogas, as Anjana expels the localized Doshas from the eye. Lekhana Ashchyotana is more useful in eradicating the localized Doshas from the Netra Patalas.

Systemic - The systemic treatment of Timir begins with Siramokshana to relieve Rakta Dushti. Virechana is said to be ideal for Anulomana of Doshas specially vitiated Pitta, as eye is the sight of Pitta predominance for which Eranda Taila (Vataja Timir), Triphala Ghrita (Pittaja Timir) and Trivrita Ghrita (Kaphaja Timir) are indicated. Old Ghee kept in iron container is beneficial in Timir in all ways. A number of Nasya Prayogas are also described for Timir, as nose is a gateway of drug administration in case of Urdhvajatrugata Rogas.14 Triphala is said to be drug of choice in case of Timir with various Anupanas according to the involvement of Doshas.

Vishesh Chikitsa of Timir

Snehapanarthdrvya - In VatajTimir (Dashmuladi and triphalakalkasiddhghrita), Pittaj Timir (JivntyadiGana and TriphalasidhhGhrita); Kaphaj Timir (Vasadi, Triphala, Patol, Guduchi Kwathsidhh Ghrita).

Virechnadi Yoga - In Vataj Timir (use of Erand oil with lukewarm water or milk for Virechana), Raktaj and Pittaj Timir (Virechana with Triphla Ghrita), Kaphaja Timir (Virechana with Nishottarsidhha Ghrita).15

Nasyadi Yoga – Vataj Timir (Jivantyadi tail, Mudgparni, Shatavari), Pittaj Timir (Kaakolyadigana Aaushadhi), Kaphaj Timir (Jalaudhbhavadighrita Nasya),

Tarpandi Yoga - TriphalaGhrit, MahatriphladiGhrit, JeevantyadiGhrit, PatoladiGhrit, etc.

Discussion

Acharya Sushruta considered Timir as “ParamdarunVyadhi”, therefore if it is left untreated finally leads to blindness. Some clinical feature of Timir described by various scholars are blurred vision, haziness of vision, visualization of false images such as gnats, hairs, webs, circles, flags, mirages and ear rings, unable to locate the eye of needle, visualization of objects situated above and not, etc. In Ayurveda Acharya described number of treatment modalities in the form of Pathyakar Aahar-Vihar, Netrakarma, Kriyakalpa, Panchkarma, Chakshuya drugs and Rasayana yoga etc. Snehpanootar Virechana followed by Raktmokshna is the main line of treatment of Timir. Triphala appears to be Vatashamak, followed by Pittashamak Kaphashamaka by virtue of its Rasa, Guna, Virya, Vipak,h thus, Tridoshamaka effect of Triphala helps to disintegrate the pathology of the disease Timir.16

Conclusion

There are twelve Drushtigatroga explained by Acharya Sushruta and twenty seven by Acharya Vagbhata. Timir is one of them which occurred due to affliction of the fourth Abhyantar Patalas. The symptom of Timir is blurring of vision, which is cardinal symptom of refractive error. Despite the fact that contemporary medical research has achieved significant development and breakthroughs in the field of Ophthalmology, there are still certain challenges in treating refractive errors. But Ayurveda consider Timir as Aushadhi Sadhya which means it is medically curable if treated at early stage.