JOURNAL OF AYURVEDA

CASE REPORT
Year
: 2022  |  Volume : 16  |  Issue : 2  |  Page : 161--169

One-and-a-half syndrome and its management with Ayurvedic treatments: A case report


Manjusree Radhakrishnan Parappurathu1, Aravind Kumar2, Krishnendu Sukumaran2, Kavya Rama Varma2,  
1 Senior Medical Officer, Sreedhareeyam Ayurvedic Eye Hospital and Research Center, Ernakulam, Kerala, India
2 Department of Clinical Research, Sreedhareeyam Ayurvedic Research and Development Institute, Ernakulam, Kerala, India

Correspondence Address:
Aravind Kumar
Sreedhareeyam Ayurvedic Research and Development Institute, Nelliakkattu Mana, Kizhakombu, Ernakulam, Kerala
India

Abstract

Introduction: One-and-a-half syndrome is a condition characterized by horizontal gaze palsy and internuclear ophthalmoplegia. Its risk factors include conditions that predispose to pontine lesions and demyelinating conditions. The symptoms include blurred vision, diplopia, and oscillopsia. Management is addressing the underlying symptom and relieving the symptoms. The case of a 46-year-old hypertensive male who was diagnosed with one-and-a-half syndrome and who underwent inpatient management at an allopathic hospital is presented here. He initially approached Sreedhareeyam's OP division and was prescribed medicine and inpatient management. Main Clinical Findings: On examination, he had blurred vision, diplopia, and one-and-a-half syndrome. Intervention: He underwent an inpatient Ayurvedic protocol comprising of oral medicines, external therapies, and eye exercises. Outcome: Results at discharge and at three subsequent follow-ups demonstrated gradually improved ocular movements and relief of symptoms. Conclusion: This case illustrates that Ayurveda treatments may be explored for this condition.



How to cite this article:
Parappurathu MR, Kumar A, Sukumaran K, Varma KR. One-and-a-half syndrome and its management with Ayurvedic treatments: A case report.J Ayurveda 2022;16:161-169


How to cite this URL:
Parappurathu MR, Kumar A, Sukumaran K, Varma KR. One-and-a-half syndrome and its management with Ayurvedic treatments: A case report. J Ayurveda [serial online] 2022 [cited 2022 Sep 26 ];16:161-169
Available from: http://www.journayu.in/text.asp?2022/16/2/161/349767


Full Text



 Introduction



One-and-a-half syndrome presents with a combination of ipsilateral conjugate horizontal gaze palsy (one) and ipsilateral internuclear ophthalmoplegia (a half).[1] Causes include vascular, traumatic, infiltrative, neoplastic, and inflammatory conditions that predispose to pontine lesions, demyelinating conditions, malignancies, and rarely infectious causes.[2] Common presentations are with diplopia, blurred vision, and oscillopsia. Diagnostic parameters include ocular motility assessment, differential diagnoses with ocular myasthenia gravis, and neuroimaging, especially magnetic resonance imaging (MRI) scanning, to rule out brainstem lesions. Management entails targeting the underlying cause and employing methods for ameliorating the symptoms. This report describes the Ayurvedic management of a case of one-and-a-half syndrome. Written informed consent was obtained before documenting the case.

 Case Report



Patient information

A 46-year-old hypertensive male presented with blurring of vision, double vision, and distorted vision for 15, January 2021. At 3:30 pm on that day, the patient suddenly developed numbness in his hands associated with weakness of the right side of his body, left-sided facial deviation, and restricted right eyeball movement. He immediately consulted a neurologist who diagnosed him with horizontal one-and-a-half syndrome and internuclear ophthalmoplegia. Computed tomography (CT) of the brain showed acute hemorrhaging in the posterior aspect of the pons. Electrocardiography showed normal sinus rhythms and no ST-T changes, and an echocardiogram showed normal cardiac walls and chambers and good left ventricular systolic functions, and no regional wall motion abnormalities and pulmonary arterial hypertension. He was admitted in the Neurology department from January 15, to January 27, 2021. Where he was given symptomatic management. An MRI brain taken on January 25, 2021 showed bleeding in the dorsal pons and midbrain and a hypertension-related cavernoma [Figure 1]. On February 1, 2021, the patient approached Sreedhareeyam Hospital's OP consultation center and started taking Ayurvedic medicines. He was advised admission the following month. His past history is significant for a cerebrovascular accident (CVA) and hypertension, for which he is currently under medication. His mother has had a history of both hypertension and CVA. His personal history and social history was normal. He was taking Biotor (1 tablet after dinner), Nicardiaa (1 tablet twice a day after food), Colihenz P (1 tablet after dinner), Rabican (1 tablet after breakfast), Ciplox (1 tablet twice a day after food), and Refresh Drops (1 drop in both eyes twice a day). Cardiovascular, gastrointestinal, renal, and nervous systems are all normal, and his vital signs were normal.{Figure 1}

Clinical findings

Unaided distant visual acuity (DVA) was LogMAR 0.477 in both eyes (OU– oculus uterque) and near visual acuity was N12 in his right eye (OD– oculus dexter) and N18 in his left eye (OS– oculus sinister). Pinhole acuity was not attempted here. A convex spherical lens measuring 0.75 diopters (D) and a cylinder of 0.5D with an axis of 90° was able to correct the visual acuity to LogMAR 0.301 OD, and a convex spherical lens of 0.75D corrected the visual acuity to LogMAR 0.301 OS. A 1.75D convex spherical lens corrected the NVA OU to N6. Ocular motility assessment showed restriction in horizontal and vertical movements OD and reduced adduction OS. Anterior segment examination was normal OU. Normal responses to direct, consensual, and near pupillary reflexes were observed OU. Posterior segment examination showed normal media, optic discs, background, and vasculature OU.

Dasavidha Pariksha (ten methods of examination) showed a somatic constitution (Prakrti) of Vata and Kapha; normal (Pravara) Sara (essence of functional tissues (Dhatus), compactness (Samhanana), measurement of body parts (Pramana), psyche (Sattva), habits (Satmya) digestion (Ahara Sakti), and capacity for exercise (Vyayama Sakti). He was categorized as Yauvana (young) in age.

Time line

The patient reported for one outpatient consultation on February 1, 2021. His inpatient management was from March 1 to 23, 2021. He reported for five follow-up consultations during the period of April– November 2021 [Table 1].{Table 1}

Diagnostic focus and assessment

A diagnosis of one-and-a-half syndrome was made based on the history and examinations. The condition was compared with Vatavyadhi (nervous disease) and Vataja Timira (blurring of vision due to Vata) as per Ayurveda. Routine hematological, biochemical, and serological assessments were normal. The patient submitted a negative result report of the COVID-19 reverse transcriptase polymerase chain reaction test prior to admission for therapy.

Therapeutic interventions

The patient was admitted for a course of inpatient Ayurvedic management comprising of oral medicines [Table 2], Sodhana Chikitsa (bio-purification) [Table 3] and local therapies for the eyes (Netra Kriyakalpa) and head [Table 4]. He was advised adherence to a healthy diet and lifestyle by the hospital's in-house dietician based on his previous history of CVA and hypertension. He was also trained in simple eye exercises (palming, throwing a ball, and slow eye movements) from the hospital's Yoga and Naturopathy division.{Table 2}{Table 3}{Table 4}

All medicines, except Neurodiet, were manufactured in Sreedhareeyam Farmherbs India, Pvt. Ltd., the hospital's GMP-certified drug manufacturing unit. Neurodiet was manufactured at The Diet Hub, based in Kochi, Kerala, India.

Follow-up and outcome

Unaided DVA at discharge improved to LogMAR 0.176 OD and 0.301 OS. A spherical lens of 0.75D with an cylinder of 0.5D and an axis of 90° improved the DVA to LogMAR 0 OU. NVA improved to N6 OU. Symptoms also showed reduction. Extraocular motility assessment demonstrated mild relief in eyeball movements OD and mild improvement in adduction OS. He reported for three follow-ups, in which unaided DVA improved to LogMAR 0.176 OU and eyeball movement OD and adduction OS gradually increased. In addition, symptoms gradually reduced. All findings were maintained at the fourth and fifth follow-ups. Posttherapeutic radiologic exams were advised, but the patient could not obtain them at present.

 Discussion



The patient's condition was explored along the lines of Vatavyadhi, specifically Indriyagata Vata as told by Caraka Samhita[3] due to restricted eyeball movement. In addition, the patient's symptoms highlight the features observed in Vataja Timira. His previous CVA was analyzed in line with Avarana (occlusion) of Vata by Kapha. Some residual Kapha remaining after the CVA may have increased Vata and the resultant bleeding at the level of the pons and midbrain, leading to the subsequent involvement of the eyes. Thus, the treatment protocol (Cikitsa Krama) was aimed at reducing Kapha and Rakta first, and subsequently pacifying Vata.

Dhanadarasnadi Kvatha and Ananta Ghrta are proprietary medicines of Sreedhareeyam Farmherbs, Pvt. Ltd., that have the property of pacifying Vata, while at the same time not being too nourishing. Excess nourishment was kept in check by Triphala Guggulu,[4] which has the property to cleanse the metabolic channels and keep Kapha balanced. The Kvātha was administered with Dhānvantaram 101 Āvartana[5] as an adjuvant to further enhance the potency of the medicine. Neurodiet, the proprietary medicine of The Diet Hub, arrests neuronal degeneration and restores normal neuromuscular activity through its careful combination of potent herbo-mineral formulations indicated in Vātavyādhi. Vāta Gajāṅkuśa Rasa has the capacity to penetrate and open micro-channels and exert its activity through cellular mechanisms.[6] Samīra Pannāga Rasa is an arsenic-mercurial compound that has neuro-protective effects, as evidenced by studies demonstrating its efficacy in neurobehavioral and neuro-inflammatory lesions.[7] Mahā Vāta Vidhvansa Rasa has been shown to have a proclivity for managing neuro-degenerative conditions. Sūtaśekhara Rasa, by virtue of its indication in gastric disorders, increased digestion in this patient and caused nutrient-rich elements to reach the target tissues. Ekāṅgavīra Rasa has been shown to relieve CVAs with antioxidant and atherosclerotic properties of both itself and its processing liquid (Bhāvana Dravya). Mānasa Mitra Vaṭaka, with the presence of alkaloids, steroids, protein, tannins, phenols, flavonoids, saponins, amino acids, and glycosides, has been shown to prevent neurotoxicity and promote nerve regeneration.[8] Rasna Dasamula Ghrta was prescribed at the fourth and fifth follow-ups to further augment the effects of the medicines.

Ocular irrigation (Seka) and pressing of boluses to the eye (Avaguṇṭana) prepared the eye for receiving further treatments by enhancing vascular dilatation, stimulating peripheral nerves, and expelling obstructive toxins.[9] Sterile medicines used for Āścyotana (eye drops) promoted eyesight and relieved symptoms. Tarpaṇa was used for improving eyesight and stimulating the nerves. The use of lipid medicines for the head treatments was due to their neuro-protective and antioxidant properties, which enabled more robust stimulation and protection of the nerves. The use of a lipid medium to mix the paste was to further enhance the absorption and bioavailability of the medicines. Massage has been shown to increase serotonin and dopamine, facilitate increased cellular exchange, and enhance the elasticity of tissues, thus promoting nerve regeneration.[10] Gargling optimizes the conductivity of motor and sensory nerves, expels toxins, and improves digestion.[11] The continuous dripping of oil over the head may offer afferent inputs to the cerebral cortex, leading to a tranquilizing effect.[12]

Eye exercises have been proven to improve ocular motility and reduce ocular fatigue by improving accommodation and vergence.[13] These may be referred to as dynamic/isotonic exercises where both concentric and eccentric contractions of the extraocular muscles occur.[14] Regular eye exercise increases the amount of energy stores held in the muscle, and increase the proteins that are required to use these efficiently.[15]

 Conclusion



The challenges faced in this case were improving vision and relieving restricted ocular motility. The oral medicines normalized the internal physiology, the external treatments nourished and stimulated the nerves, and the ocular exercises stimulated movement in the muscles. Although positive results were obtained in this case, further management incorporating bio-purification (Śodhana) would need to be planned to achieve better results. The results obtained in this report may be validated using the large scale sample trials.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initial s will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Acknowledgment

The authors thank Sreedhareeyam Ayurvedic Eye Hospital and Research Center and Sreedhareeyam Farmherbs India, Pvt. Ltd. for their help in preparing this review article. The authors acknowledge the immense help received from the scholars whose articles are cited and included in references of this manuscript. The authors are also grateful to the authors, editors, and publishers of all those articles, journals, and books from where the literature for this article has been reviewed and discussed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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