Highlights

• Significant Improvement in Ptosis: A single dose of Opium 1M led to a notable reduction in ptosis and diplopia severity within 30 days, nearly restoring normal eyelid position as well as vision clearity.
• Chronic Condition Post-Trauma: The patient experienced chronic ptosis and diplopia following a road traffic accident, highlighting the potential of Homoeopathic treatment in cases where conventional therapies have failed.
• Opium 1M as a Therapeutic Option: The case underscores the potential efficacy of Opium 1M in managing post-traumatic nerve-related symptoms, suggesting further exploration in similar chronic conditions.

Introduction

Ptosis and diplopia are common sequelae of cranial nerve injury [1], often resulting from trauma such as road traffic accidents (RTAs). These conditions can significantly impact a patient's quality of life, affecting both functional vision and cosmetic appearance. Conventional treatments, including physical therapy and pharmacological interventions, often offer limited relief, particularly in chronic cases. Homeopathy, with its individualized and holistic approach, presents an alternative therapeutic option, especially for conditions with a neurological basis.

This case report presents the therapeutic response of a 35-year-old male patient with chronic right-sided ptosis and diplopia, which developed after an RTA. Despite undergoing multiple allopathic treatments, including steroids and nerve stimulants, the patient experienced minimal improvement. A single dose of Opium 1M, a Homoeopathic remedy traditionally indicated for trauma-related conditions [2-4], was administered, leading to significant improvement in ptosis and diplopia. The report explores the effectiveness of this treatment, highlighting the potential role of homeopathy in managing chronic post-traumatic conditions where conventional therapies have been insufficient.

Patient Information:

- Age: 35 years

- Gender: Male

- Occupation: Contractor (Painter)

- Medical History: Head Injury leading to right-sided Ptosis and Diplopia following a road traffic accident (RTA) one year ago.

Previous Treatments:

Multiple sessions of physical therapy, various allopathic medications including steroids and nerve stimulants, with limited improvement in ptosis and diplopia.

- Other Medical Conditions: No other significant medical history, no known allergies.

- All investigations are attached at the end of the report.

Clinical Presentation:

- After experiencing six months of amnesia, followed by a period of ongoing memory weakness, treatment was initiated, leading to noticeable improvement in memory.

- Primary Complaints: Persistent drooping of the right eyelid (ptosis) and double vision (diplopia), impairing vision and causing cosmetic and functional concerns.

- Duration: Both ptosis and diplopia present since the accident.

- Associated Symptoms: Occasional headaches, eye strain, and mild discomfort around the right eye.

Examination Findings:

- Visual Acuity: 20/20 in both eyes.

- Right Eye: Marked ptosis with the upper eyelid covering more than half of the pupil.

- Left Eye: Normal eyelid position and function.

- Extra-ocular Movements: Full range of motion in both eyes, although diplopia was noted on upward and lateral gaze.

- Pupil Reaction: Right pupil was not responding to light.

- Neurological Examination: No other focal neurological deficits.

- Neurological Examination indicated 3rd nerve palsy.

Objective Criteria for Staging of Ptosis:

Ptosis is classified based on the margin-reflex distance (MRD) [5] as follows:

- Mild Ptosis: MRD 2-4 mm

- Moderate Ptosis: MRD 0-2 mm

- Severe Ptosis: MRD less than 0 mm (eyelid covers the pupil)

Diagram 1 [6].

In this case, the patient exhibited severe ptosis with the right upper eyelid covering more than half of the pupil, indicating an MRD of less than 0 mm.

CT Scan Findings:

• Few hemorrhagic contusions with surrounding perilesional edema are seen in the splenium of the corpus callosum, left occipital lobe. Sellar and parasellar regions are unremarkable.
• No evidence of bony fracture is noted.

• Parietal horn of the left lateral ventricle appears effaced and shows intraventricular hemorrhage.

• Mucosal thickening is seen in bilateral ethmoid sinuses.

MRI Findings:

• Few focal areas of altered signal intensity seen in the right high parietal lobe, right frontal lobe, left parietal lobe, left temporal lobe, and splenium of the corpus callosum. These areas appear hyperintense on T2/FLAIR images, showing blooming artifacts on SWI images. Few of them show diffusion restriction on DWI and ADC images, suggestive of hemorrhagic contusions with diffuse axonal injury.
• Left lateral ventricle appears effaced and shows T2/FLAIR hyperintense signal intensity.

• Intraventricular hemorrhage noted.

• FLAIR hyperintense signal intensity observed in sulcal spaces of bilateral fronto-parietal lobes.

Figure 1: MRI scan on the first instance showing multiple hemorrhagic contusions with diffuse axonal injury, along with intraventricular hemorrhage and FLAIR hyperintense signal intensities in the sulcal spaces of the bilateral fronto-parietal lobes.

Homoeopathic Intervention:

- Medication: Opium 1M

- Dosage: Single dose

- Selection Justification: Opium is indicated for conditions following trauma, particularly where there is nerve involvement and symptoms of shock. A high potency (1M) was chosen due to the chronic nature of the condition [7,8].

Treatment and Follow-Up:

- Day 0 (Baseline): Administered a single dose of Opium 1M.

- Day 1-3: No noticeable change in ptosis or diplopia. The patient reported no adverse effects.

- Day 4-7: The patient began to notice a slight elevation of the right eyelid. There was a mild decrease in the heaviness and discomfort previously experienced. Diplopia remained unchanged.

- Day 14: Further improvement in ptosis observed. The ptosis was less pronounced, and the patient reported a reduction in eye strain and headaches. Diplopia showed improvement to some extent.

- Day 30: Significant improvement in ptosis noted. The eyelid was nearly at a normal level, and the patient's vision was no longer obstructed by the ptosis. Diplopia showed some improvement but was still present on upward and lateral gaze. The patient experienced substantial relief in ptosis symptoms and reported an overall improvement in quality of life along with improvement of memory.

Figure 2: CT scan after four weeks of Homoeopathic treatment showing complete resolution of hemorrhagic contusions.

Adverse events:

No adverse events were observed within the case during the treatment.

Homoeopathic aggravation:

No Homoeopathic aggravation was noted in the case, and the medicines

produced amelioration within a few days of consumption.

Outcome and Evaluation:

- Objective Improvement: Photographic documentation and measurement of eyelid position showed a marked reduction in ptosis also repeat CT Scan showed marked improved changes.

- Subjective Improvement: The patient reported enhanced vision, less eye strain, and a significant reduction in diplopia, particularly in upward and lateral gaze. Additionally, there was a noted improvement in memory, which the patient had initially struggled with following the accident. These improvements contributed to a better overall quality of life, making daily activities less challenging.

Possible Causal Attribution:

The improvement in the patient's ptosis following the administration of Opium 1M can be potentially attributed to several factors:

Homoeopathic Action on Nerve and Muscle Function:

Opium 1M is traditionally used in homeopathy for conditions involving trauma, especially where there is nerve involvement and symptoms of shock. The remedy is believed to stimulate the body's self-healing mechanisms, potentially aiding in the recovery of nerve function and muscle tone [9], thereby reducing ptosis.

Chronicity and Specificity of Symptoms:

The chronic nature of the patient's symptoms, characterized by persistent ptosis and diplopia despite conventional treatments, aligns with the Homoeopathic principle of using higher potencies like 1M for deep-seated and chronic conditions. The selection of Opium 1M was based on the symptom picture post-trauma, which might have resonated well with the patient’s specific condition, leading to a therapeutic response.

Individualized Treatment Approach:

Homeopathy emphasizes an individualized approach, matching the remedy to the patient's specific symptoms and overall condition. The choice of Opium 1M was matched to the patient's presentation, which included not just the physical symptoms of ptosis and diplopia, but also the history of trauma and potential underlying shock or nervous system imbalance.

The possible causal attribution of the case was assessed using the MONARCH (Modified Naranjo Criteria for Homeopathy-Causal Attribution Inventory) criteria [10] and provided in Table 1 and 2.

This table 1 encapsulates the key elements of the case report as per the MONARCH criteria, ensuring that each aspect is addressed comprehensively.

Possible causal attribution by using the MONARCH criteria [11].

Table 2: Modified Naranjo Criteria for Homeopathy-Causal Attribution Inventory.

Inference:

The MONARCH criteria evaluation strongly suggests that Opium 1M had a beneficial effect on the patient's chronic ptosis, diplopia, and memory issues. The total score of 9 reflects a robust and credible improvement in symptoms, highlighting the potential efficacy of this Homoeopathic remedy in managing chronic conditions post-trauma. The absence of alternative causes and the presence of objective evidence further strengthen the case for attributing these improvements to the Homoeopathic intervention.

Discussion

The case demonstrates a significant positive response to a single dose of Opium 1M in treating chronic ptosis, diplopia, and memory issues post-trauma. The observed improvements suggest that high-potency Homoeopathic Opium can be effective in cases where conventional treatments have failed. The reduction in diplopia and enhancement in memory indicate that Opium 1M may have had a broader impact on the patient's neurological recovery, potentially addressing underlying nerve dysfunction or trauma-related factors contributing to these symptoms.

Consent: A written consent has been obtained from the patient.

Funding information: The study received no external funding

Considerations:

- The patient had no known allergies or other medications that could confound the treatment outcome.

- The follow-up period was adequate to observe the initial response; however, long-term follow-up is necessary to confirm the permanency of the improvement and further address diplopia.

Conclusion

A single dose of Opium 1M significantly improved chronic ptosis, diplopia, and memory in a patient post-RTA, suggesting its potential effectiveness where conventional treatments have failed. The enhancements in memory and overall quality of life further underscore the potential of Homoeopathic remedies in managing chronic post-traumatic conditions. CT scan of brain after four weeks of Homoeopathic treatment showing complete resolution of hemorrhagic contusions, thus further providing objective evidence of the action of potentised opium.

Future research should include controlled trials to validate these findings and explore optimized treatment protocols for comprehensive symptom management.

Recommendations for Future Research:

- Conduct randomized controlled trials to assess the efficacy of Opium 1M for ptosis and other trauma-related conditions.

- Explore the effects of different potencies and dosing regimens of Opium in chronic post-traumatic conditions.

- Investigate additional or complementary Homoeopathic or conventional treatments specifically targeting diplopia.

Follow-Up Plan:

- Immediate: Patient to continue daily activities and observe for any recurrence of symptoms.

- 3 Months: Follow-up visit to monitor the status of ptosis and diplopia, and any potential side effects.

- 6 Months and 12 Months: Further follow-up visits to ensure sustained improvement and manage any relapses if they occur. Additional treatments may be considered to address persistent diplopia.

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