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Introduction

Ptosis is known as the drooping of the upper eyelid, and the patient usually presents with the complaint of the defect in vision and cosmesis. It can be congenital or acquired, or it can be neurogenic, myogenic, aponeurotic, mechanical, or traumatic in origin [1]. Ptosis is classified into congenital or acquired based on the age of presentation; the latter is usually further categorized into 5 types based on etiology [2]:

• Neurogenic: It results from defective innervation of the levator muscle of upper eyelid. For example, third nerve palsy, Horner syndrome, Marcus Gunn jaw-winking syndrome, multiple sclerosis, etc.

• Myogenic: Levator muscle myopathy or defect at its neuromuscular junction causes the myogenic ptosis which includes myasthenia gravis, ocular myopathy, simple congenital, blepharophimosis syndrome, etc.

• Mechanical: Levator function gets impaired due to the mass effect of some abnormal external structure such as neoplasm, chalazion, contact lens in the upper fornix, scarring, etc.

• Aponeurotic: Also known as Involutional ptosis, it results from a defective levator aponeurosis due to aging, trauma, or postoperative complication.

• Traumatic: Any kind of direct or indirect trauma to the eyelid leading to levator transection, cicatrization, eyelid laceration or orbital rooftop fracture with ischemia can cause ptosis.

Pathophysiology of Ptosis-

Levator palpebrae superioris (LPS) and Muller's muscle are two muscles of upper eyelid responsible for its elevation. LPS is the main elevator which is supplied by the oculomotor nerve. The levator palpebrae superioris muscle origin is the lesser wing of the sphenoid bone, it travels anteriorly above the superior rectus muscle, and attaches in multiple insertions: anteriorly into the upper eyelid skin, inferiorly on the anterior surface of the upper tarsal plate and to the superior conjunctival fornix. Muller's muscle is a smooth muscle also attached to the superior tarsal plate with sympathetic innervation, which is defective in ptosis of Horner syndrome. Loss of innervation of LPS and Muller's muscle causes neurogenic ptosis [3]. Levator muscle dystrophy causes simple congenital ptosis. On the other hand, involutional changes in the eyelid are the most common pathogenesis in adult ptosis. Deceasing tone and thinning of the levator muscle, due to aging, results in abnormal position of the eyelid. Disinsertion of the levator aponeurosis, or its dehiscence, after any trauma or surgery, can also lead to ptosis [4]. Main presenting complaint of patients with Ptosis is the visual disturbance ranging from mild to severe, which can be unilateral or bilateral along with cosmetic disfigurement [1]. 

In Ayurveda, Ptosis can be correlated with Vatahata Vartma which is a Vataja Vartmagata Roga which defines it as drooping of eyelid down, detached from its joint, without movement & is weak. As the name indicates Vatahata Vartma is caused by the vitiated Vata Dosha & it is a Asadhya Vyadhi.

Signs & symptoms as decribed in Ayurveda of Vatahata Vartma are Vimukta Sandhi (laxity & detachment of eyelid from its joint), Nishchestam (eyelid will be devoid of its activity, it will be open & fixed), Na Meelyate (eyelids cannot close & keep open), Sarujam (associated with pain in eyelids), Nirujam (devoid of pain in eyelids) [5]. Acharya Vagbhata also described similar symptoms of Vatahata Vartma & correlated it with Ptosis [6]. Treatment for this disease in Ayurveda is not described as it is Asadhya Vyadhi, still therapies like Shirodhara, Tarpan, Nasya, Netradhara, & other Vatshaman Chikitsa is practiced nowadays by Practitioners. Another such treatment therapy is Marma Pidan. Marma science emphasizes crucial points on the body surface known as Marmas. The occurrence of an injury at these vital points can potentially lead to disability, dysfunction, or even the termination of life. Intriguingly, Marmas serve as pivotal junctures where the entire spectrum of our physical and mental energy can be intentionally heightened, diminished, or redirected, facilitating transformative effects through the judicious application of Marma techniques. Considered as specialized pranic switches within the body, stimulating Marma points can lead to the balanced flow of Prana (life force) in different body parts, thereby yielding the desired therapeutic benefits [7]. This study aims to explore role of Apanga & Sthapani Marma in the management of Ptosis.

Aim & Objective-

This review aims to explore the role of Apanga and Sthapani Marma in the management of Ptosis.

Material & Methods-

A comprehensive review of classical Ayurvedic texts, research articles, and case studies will be conducted to gather information on the anatomical location, physiological significance, and therapeutic applications of Apanga and Sthapani Marma. The review will highlight the importance of these Marma points in regulating eyelid movement and tone.

Observation & Results-

Marmas are specific points in the body identified in Ayurveda that combine multiple tissues and serve as focal areas for healing and therapeutic interventions. Recognizing and treating Marmas can lead to significant improvements in health and recovery from various ailments.

Apanga Marma- Apanga specifically denotes the outer corner of the eye in Ayurvedic texts. It’s associated with particular Marmas that, when treated, can influence vision and overall well-being. Various anatomical structures lay beneath it, including blood vessels and nerves critical to eye function. Therapies involving stimulation of the Apanga Marma can alleviate issues related to eye strain, headaches, and visual defects, while promoting overall mental clarity and relaxation. Through gentle manipulation, therapeutic benefits include improved vision and a profound calming effect on the mind.

Anatomical site- Apanga Marma specifically denotes the outer corner of the eye (tail of the eyebrow ends).

Marmaghat Lakshan- Injuries to this Marma can lead to blindness (Andhyatva) or vision defects (Drishti Upghata), highlighting its significance in ocular health and therapeutic applications.

Apanga Marma Pidan- For stimulation, sit upright and keep your eyes closed. Use the middle fingers to gently massage the Apanga Marma at the outer corner of the eye in circular motions, stopping briefly with light pressure at each point [8].

Categories in which Apanga Marma is included [9]-

i) Shiro-Greeva Gata Marma (Shiro = Head, Greeva = Neck).

ii) Siraa Marma - Apanga Marma is predominantly made up of Siraas i.e. blood vessels (veins). The other elements namely Asthi (Bones), Snayu (ligaments, tendons, nerves), Sandhi (bony joints) and Mamsa (muscles) are also present but in a lesser proportion.

iii) Vaikalyakara Marma - (Vaikalyakara - deformity forming) Apanga Marma when injured are said to produce deformity of the body.

As Ptosis is also having traumatic type in its etiology which can be correlated with Marmaghat Lakshan of Apanga Marma, stimulation of Apanga Marma by means like Marmapidan, Accupressure, Viddha Karma at the site, etc. can help regain its muscle tone & can regulate nervous system function by calming effect produced by its stimulation.

Sthapani Marma [10]- The Sthapani Marma is an important anatomical location found in the   glabella region, situated between the two eyebrows. Classified as a Sira Marma, this area    primarily consists of vascular structures.

Anatomical Site: Located between the two eyebrows or Superciliary Arches.

Type: Classified as a Sira Marma based on structural classification.

Number and Measurement: Singular in number, and Ardha Angula in Praman.

Structures under it are- Located anterior to this point are the supratrochlear artery, nerve, and vein. The supratrochlear artery branches from the Ophthalmic artery and anastomoses superiorly with the supraorbital artery. Injuries to this region can lead to profuse bleeding in the brain or subdural hemorrhages, potentially causing death.

Categories in which Sthapani Marma is included-

i) Shiro-Greeva Gata Marma (Shiro = Head, Greeva = Neck).

ii) Siraa Marma - Sthapani Marma is predominantly made up of Siraas i.e. blood vessels (veins).

iii) Vishalyghna Marma- Vayu dominant Marma points that may naturally dissipate after suppuration (Paaka).   

Marmaghat Lakshan- Injuries to the Sthapani Marma can lead to severe consequences like profuse bleeding and cranial hemorrhages. If a foreign object remains lodged in the area, it may prevent excessive bleeding and reduce the risk of death.

Sthapani Marma Pidan- This area contains vital vascular structures, including the supratrochlear artery, nerve, and vein, which are pivotal for maintaining blood supply to the brain. Stimulation of this Marma increases blood supply to the brain thereby improving nerve conduction. Found between the eyebrows, often referred to as the "third eye" in spiritual contexts, this point affects the pituitary gland, intuition, and mental health.

As in Neurogenic Ptosis, Sthapani Marma Pidan helps in improved nerve conduction, thereby can improve the symptoms of Ptosis.

Therefore, Marma Pidan of these 2 Marma’s i.e. Sthapani & Apanga can serve as a complementary therapy in the management of Ptosis (Vatahata Vartma).

Benefits of Marma Pidan in management of Ptosis [11]-

1. Pain relief- Marma therapy is highly effective in reducing pain. It can alleviate muscle tension, headaches.
2. Enhanced circulation- Marma therapy improves blood circulation which facilitates better oxygen & nutrient delivery to the eye structure.

1. Stress reduction- Marma therapy can induce deep relaxation, helping to calm the mind & reduce stress. This relaxation response can decrease the production of stress hormones, promoting sense of well-being.

1. Emotional healing- By releasing blocked energy, Marma therapy can also help in resolving emotional blockages leading to improved emotional health & resilience. It helps in improving nerve function which helps in healing & treating neurological disorders & improving overall neurovascular activity.

Discussion

Marma therapy, including massage (Marmapidan), acupressure, and other manual techniques, can be effectively used to stimulate these points and alleviate Ptosis symptoms. This review contributes to the existing body of knowledge on Ayurvedic management of Ptosis and highlights the potential of Marma therapy as a complementary or alternative approach.

Further research is warranted to explore the efficacy and safety of Marma therapy in the management of Ptosis.

Conclusion

Ptosis, or drooping of the eyelid, is a common condition that affects individuals worldwide. In Ayurveda, Ptosis can be correlated with Vatahata Vartma which is a Vataja Vartmagata Roga which defines it as drooping of eyelid down, detached from its joint, without movement & is weak.

In Ayurveda, Marma therapy has been utilized to manage various health conditions, including Ptosis. The results suggest that Apanga and Sthapani Marma play a crucial role in the management of Ptosis by enhancing eyelid strength, improving muscle tone, and regulating nervous system function.