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Introduction

In Ayurveda, Abhishyanda is main cause of all diseases of Netraroga. Sjogren syndrome is due to aqueous deficiency. It is an autoimmune chronic inflammatory disease with multi system involvement. (1) It is typically occurred in women between the age group of 40 to 60yrs.Incidence is 3 - 6 per 100,000 per year; and its estimated prevalence is upto 3% of population. (2) Female:Male ratio is 9:1 with average age of onset between 40 - 60 years. In primary sjogren’s syndrome, patients present with sicca complex, a combination of keratoconjuctivitis and xerostomia (dryness of mouth). (3) In secondary sjogren’s syndrome, patients present with dry eye, dry mouth. These all are associated with an autoimmune disease, commonly present rheumatoid arthritis.

Pathophysiology -Ayurvedic samprapti-      viatiated (Kupit) Doshas moves upward direction towards the eyes, invades through various channels and lead to malfunctioning of various sub-structures of eye.Vitiated Doshas propogates through the channels or vessels (siras) towards the head regions. They enter various part of the eye such as lids, conjunctiva, sclera, cornea, iris, pupil, choroid ciliary body, and retina causes diseases of eye. Pathogenesis of Abhishyanda: As given mentioned in Sushrut uttartantra.1-20-21.

Samprapti(pathogenesis) is the process which occurs in the body in between Nidana Sevana and the stage of Rupa of the diseases. The knowledge of the disease process is important from the treatment view point, because without proper knowledge of “Anshaansha kalpana” of Dosha, one cannot get success in the treatment, hence the knowledge of samprapti is essential to cure the disease. (4-5) Maximum importance has been given by all the Acharyas on the stage of Pathogenesis as it helps in the presentation of the disease. Samprapti Ghataka, Dosha - vata pradhana, Tridosha dushti. Dushya - Rasa and Rakta, Agni –ras rakt dhatu, Srotasa dushti- Rasavaha and Raktavaha, Rogamarga - Madhyama marg, Adhishthana – Sarvaakshi, Srotasa dushti- Rasavaha. Abhishyanda is in four types vataja, pittaja, kaphaja ,raktaja mentioned in Sushrut uttartantra. (5-6.)

VATAJ ABHISHYAND- Vataja Abhishyanda is characterized by Nistoda [Pricking pain], Sangharsha [Foreign body sensation], Shishirashruta [Watery discharge/ Cold lacrmation], Alpa Shopha [Mild chemosis], Vishushka Bhava [Feeling of dryness], Parushya [Dryness] etc which are very similar to the most of signs and symptoms of the SJOGREN SYNDROME (6,7,8).So,Vataja Abhishyanda can be co-related with SJOGREN’S SYNDROME. In the current era human beings are highly exposed to pollution. SJOGREN’S SYNDROME -Sjogren’s syndrome is an autoimmune disorder caused by the lymphocytic infiltration of exocrine glands resulting in glandular dysfunction, preferentially of the salivary and lacrimal glands. It can be classified into two types, namely 1. Primary Sjogren’s syndrome and 2. Secondary Sjogren’s syndrome. Primary Sjogren’s syndrome occurs in the absence of other autoimmune diseases and is characterized by keratoconjunctiva sicca means dry eyes and xerostomia (dry mouth), collectively called the sicca syndrome. In contrast, secondary Sjogren’s syndrome presents along with other autoimmune diseases such as rheumatoid arthritis and systemic lupus erythematosus. The prevalence of Sjogren syndrome is estimated to be approximately 3% in subjects 50 years or older, with a female to male ratio of 9:1. Conditions associated with Sjogren’s Syndrome include rheumatoid arthritis, lupus erythematosus and scleroderma. The clinical manifestations are often vague and mistakenly interpreted and attributed to other medical conditions or iatrogenic disorders. (10,11,12) As such, incorrect diagnosis of Sjogren’s syndrome is common and approximately half of all patients are thought to be undiagnosed. Primary Sjogren’s syndrome occurs in the absence of other autoimmune diseases and is characterised by keratoconjunctiva sicca means dry eyes and xerostomia (dry mouth), collectively called the sicca syndrome. In contrast, secondary Sjogren’s syndrome presents along with other autoimmune diseases such as rheumatoid arthritis and systemic lupus erythematosus. The prevalence of Sjogren syndrome is estimated to be approximately 3% in subjects 50 years or older, with a female to male ratio of 9:1. Conditions associated with Sjogren’s Syndrome include rheumatoid arthritis, lupus erythematosus and scleroderma. The clinical manifestations are often vague and mistakenly interpreted and attributed to other medical conditions or iatrogenic disorders. As such, incorrect diagnosis of Sjogren’s syndrome is common and approximately half of all patients are thought to be undiagnosed. This study aims to review the etiology of Sjogren’s syndrome, highlight aspects that contribute to the pathophysiology of the disease and vataja abhishyand to explore treatment options that target different mediators of pathogenesis. Pathology features; include focal accumulation and infiltration by lymphocytes and plasma cells with destruction of lacrimal and salivary glandular tissues. Clinical features- symptoms of sjogren’s syndrome includes -1) Irritation 2) foreign body sensation.3) feeling of dryness 4) Ocular discomfort. Classification criteria according to America and Europe department –Oral symptoms (if any), Occular symptoms (if any), Oral signs can be investigated by-Salivary Sialography, Parotid Sialography, Salivary flow (must be <1.5ml in 15 mins. This study aims to review the etiology of Sjogren’s syndrome, highlight aspects that contribute to the pathophysiology of the disease and Vataja Abhishyand to explore treatment options that target different mediator of pathogenesis. Pathology features; include focal accumulation and infiltration by lymphocytes and plasma cells with distruction of lacrimal and salivary glandular tissues. Clinical features- symptoms of sjogren’s syndrome includes, 1) Irritation 2) foreign body sensation 3) feeling of dryness 4) Ocular discomfort. Classification criteria according to America and Europe department –Oral symptoms (if any), Occular symptoms (if any), Oral signs can be investigated by-Salivary Sialography,Parotid Sialography, Salivary flow (must be <1.5ml in 15 mins. Occular signs can be investigated by –Schirmer’s test (<5mm in 5 min) and Floroscein staining- must get positive. (6)

TREATMENT-

As for the cure of the sjogren syndrome disease, there is at present no definitive treatment. Artificial tears, lubricant eye drop are only treatment, for arthritis only NSAIDS drug can be used,for dry mouth only sip of water can take ,this modern treatment is expensive & it should be lifelong & ayurveda can provide better relief in such manifestation . As for the cure of the sjogren syndrome disease, there is at present no definitive treatment. Artificial tears, lubricant eye drop are only treatment, for arthritis only NSAIDS drug can be used,for dry mouth only sip of water can take ,this modern treatment is expensive & it should be lifelong & ayurveda can provide better relief in such manifestation . Modern science dosen’t have any effective and definite treatment on this disease. In ayurveda, there is no direct reference, while searching solution for Sjogren’s syndrome. In such condition where the name of disorder such as sjogren syndrome is not mention in ayurveda, Acharya advised to study pathophysiology of disorder & management of the patient logically. Some similar symptoms of sjogren’s syndrome shows some disease like Vataja Abhishyanda. General line of treatment explained by our Acharyas for Vataja Abhishyanda are Snehan swedan , Snigdha Aanapana, Snehavirechana, Basti, Siravedhana, Tarpana, Putpaka , Dhoompana, Nasya, Aschyotana  and Sneha Parisheka. Acharya Sushruta has recommended ‘Kriyakalpa’ for the management of Vataja Abhishyanda , along with other forms of treatment. The term Kriyakalpa refers to the treatment , which can be applied for almost all types of eye diseases; and it comprises of Tarpana , Putapaka, Anjana, Ashchyotana and Seka . Among these Ashchyotana is a simple, safer, most economical procedure, which is indicated in the initial stage of the eye diseases. The drugs having Vatashamaka, Vedanasthapana, Vranaropana and Chakshushya properties may be helpful in the treatment of the disease Vataja Abhishyanda. Snehan-Snehan is a process wherein the body is lubricated with the help of oil or medicated ghee (clarified butter). The person is advised to consume medicated oil or ghee in large quantities. After this, the person is instructed to observe restrictions such as drinking only lukewarm water throughout the day, eating only when hungry and refraining from sleeping during day time. Even the food has to be very simple - as advised by the doctor.Snehan is a pre cursor to the main procedure of panchakarma. Abhyantarsnehana-This process comprises consumption of prescribed amounts of warm herbal ghee. The ghee is consumed first thing in the morning. The dose is increased gradually, depending on your body's requirements. The patient is unable to eat until the ghee is digested, which is signalled by return of the patient's appetite.In order to prepare for the main eliminative procedures, the patient receives internal and external oleation each day. The time needed for the oleaginous substances to reach all the dhatus takes 5 - 7 days. Hence these treatments can continue for up to 7 days. There are signs which indicate that the snehan therapy has been successful. For example, the skin displays a soft and shiny appearance and feels slightly luctuous. After this shodhan as to be followed. Due this shodhan, obstruction in srotas will be relieved and normal functions of eye will get improved.

Bahya Snehan-This procedure employs a specific form of massage (abhyanga). The therapist applies herbal oil to the skin before starting the massage. There is great significance to the strokes used in bahya snehan, for they regulate the movements of five types of vata. It also improves circulation.     It is helpful in vataj netra vyadhi.

Swedan(Sushrut chiktsa 32-26)-In netra vyadhi swedan is avoided, but sevral condition swedan can be given in netra vyadhi with expert supervision  .Mostly sarvang swedan can be prefer for netra vyadhi.For ocular swedan,mild swedan can be applied.

Tarpan-(Sharangdharuttartantra 11-31/yogratnakar page 386) Tarpan means giving strength to the eyes. The medicated ghee is poured over the eyelids in an enclosure built around the eye out of wheat flour. It is said to be an excellent treatment to improve vision and clarity of the mind. This treatment aims to provide optimum rejuvenation to eyes. Dough of Urad (black gram) is put around the eye ball in such a way that a dam like appearance is seen. Then herbal medicated healing ghee is put in this groove to lubricate the eye and surrounding areas which will be kept warm for 30 – 35 minutes. This provides improved vision with beautiful eyes and strengthening of eye tissues. This treatment aims to provide optimum rejuvenation to eyes. Dough of Urad (black gram) is put around the eye ball in such a way that a dam like appearance is seen. Then herbal medicated healing ghee is put in this groove to lubricate the eye and surrounding areas which will be kept warm for 30 – 35 minutes. This provides improved vision with beautiful eyes and strengthening of eye tissues.

Benefits:1) Cleanses eyes by removing dust from the cornea.2) Moisturizes the dryeye.3) Improvises blurred vision.4) Reduces burning of eyes.5) Aids in the improvement of eye disturbances and thus improves clarityof the mind.

Indication:Dry eyes syndrome,Burning in the eyes,Vataj diseases of eyes,Conjunctivitis-Pain in the eyes,Watering eyes, Night blindness,Squinting,
Myopia, Reduces Dark circles if regularly done.ASHCHOTANA (Vagbhat sutrasthan 23-1, Sushrut uttartantra 18-44). (12) The unique therapy of dropping medicines in liquid form on the eyes with the eyes kept open is known as ashchotan.Quite similar to the akshiseka the ashchotana therapy is also classified into three as snehana, ropana and lekhana ashchotana. Medicine that are bitter in taste are used in the snehana ashchotana.Cold medicines that are sweet in taste are used for the ropana ashchotana. Likewise warm medicines having ruksha (dry) property and are bitter in taste are used in lekhana ashchotana in general. PROCEDURE-Ashchotana therapy is done during the day time, employing this procedure at night is contraindicated. There is no any specific preparation of the patient to carry out this therapy. The patient is made to lie down on the treatment table in supine position. The body is draped up to the neck. Both the eyes are treated one after the other. The lower lid is retracted with one hand.The liquid medicine is poured drop by drop on the cornea of the eye from a height of 2 angula. While dropping the medicine the patient is asked to keep his eye open. In the cold weather warm medicine is dropped into the eyes, but in hot weather there is no need to make the medicines warm. Dose varies according to the type of ashchotana therapy. 8 drops are the dose of lekhana ashchotana. In case of ropana ashchotana 10 drops of the medicine is dropped into the eyes. Further in the snehana type of ashchotana 12 drops of the medicine is dropped into each eye.

DURATION OF ASHCHOTANA-Instillation of the medicines.It is left undisturbed for 100matra(30seconds)INDICATIONS: Aschotana is the first line of treatment in the eye diseases. Aschotana is contraindicated in night & should be done only during day time: Morning in Kaphaja diseases Afternoon in pittaja diseases Evening in vataja diseases

BENEFITS: This will relieve- Ruk, todha - Painful conditions .Kandu – Scratching. Kharsha - Irritation or foreign body sensation in eyes.Asru - Excessive watering.Dhaha - Burning sensation of eyes. Raga - Redness or congestion. Paka, sopha - Features of inflammation in eyes.

PROBABLE MODE OF ACTION: The drug mixes with tears, distributes uniformly over the eyes, giving lubrication, smoothening effect and surface which protect the eyes.               Virechan-Panchakarma therapy aims at the elimination of excessive Doshas from the body to maintain the state of health for a longer duration, while the Shamana therapy is for suppression of vitiated Doshas within the body. Virechana is one of the Panchakarma therapies, wherein purgation is induced by drugs and it specifically aims at the elimination of excessive Pitta Dosha from the body. Normally, after Virechanakarma, patient does not complain of having any signs and symtoms of               tiredness, giddiness and letharg like those present after diarrhea due to dehydration. Virechan is useful to remove excessive Doshas in sjogren syndrome.

Raktamokshan- It prevents skin diseases, swollen glands general swellings blood diseases. If done at regular interval, sira vedh and jalavkavcharan are useful in eye diseases too. In sjogren syndrome jalavkavcharan useful for raga and vishushkbhava complaints. In abhishyanda there is raktgat samata means kledopatti in the eyes.So sthanik raktmokshan helps to remove the dusht rakt. so, it is very much helpful in vataj abhishyand.as it is vyadhi.

Basti-Basti therapy means medicated enema. Basti is one of the five main panchakarma procedures for the loosened vata doshas are eliminated from the body through the rectum. (13) The vata is mainly located in the colon and bones. It is thus mainly used to treat vata dosha related conditions.During the treatment medicinal substances such as, herbal oils and decoctions in a liquid medium are administered into the rectum. Basti therapy is an effective treatment for people who wish to rejuvenate the body and provide it with strength and longevity. Moreover, diseases such as common cold, problems such as in netra vyadhi, constipation, distention, arthritis and backache can be treated with the help of basti therapy. Types of basti include niruha, anuvasan, karma, kaal, yoga, etc. In sjogren syndrome basti can give for arthritis, and removed kleda from eye.

Discussion

Ayurveda can also be useful in SJOGREN SYNDROME (dry eye) conditions. Treatment of VATAJA ABHISHYANDA in this paper to justify that ayurvedic treatment can be useful in DRY EYE conditions.

2. The study of literature reveals that ayurvedic treatment in vataja abhishyanda are the appropriate management in sjogren syndrome.so has best to be prescribed.

Conclusion

Based on the observation it is concluded that ayurvedic medicine is useful in the management of SJOGREN SYNDROME (DRY EYE conditions).