It is often said that the Mahabharata is
a complete encyclopedia. In this communication, we explore a case of
neuro-ophthalmology, as described in the epic. Bhagadatta, the King of
Pragjyotisha, took part in the Mahabharata, fighting on the side of the
Kauravas. Riding his war elephant, Supratika, he was one of the most feared
generals of the war1.
Bhagadatta, is described as an old man, with a
wrinkled face and drooping eyelids. To prevent these from obstructing his
vision, he tied thin folds of a silken handkerchief over his forehead. On the
12th day of the 18-day long Mahabharata war, Bhagadatta fought with Bhima. He
had almost defeated him, when Lord Krishna and Arjuna came to support their
brother. Arjuna aimed his arrows at the King’s handkerchief, tearing it and
blinding him successfully. This allowed Arjuna to kill Bhagadatta and
Supratika, and contributed to the victory of the Pandavas1.
This nugget from our history raises significant
issues. The author of the Mahabharata, Rishi Ved Vyas, was astute and
discerning enough to note the wrinkles and drooping eyelids of one of the
characters. He described them accurately, including details about how
Bhagadatta managed his limitation.
Did the elderly King have third nerve palsy?2
Or was it myasthenia gravis? Was it a congenital anomaly, or an event
associated with old age? The seemingly bilateral and symmetrical nature of
eyelid drooping suggests an ischemic or metabolic etiology, rather than a
localized lesion. The commonest cause of eyelid droop is senility3,
also known as senile involution. There is no mention of a diurnal variation in
the severity of Bhagadatta’s symptoms. However, the explanation that he became
almost blind towards the end of the day, suggests that he may have had
myasthenia gravis. Table 1 lists other possible differential diagnoses of
drooping eyelids.
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Table 1. Differentials of Bhagadatta’s Condition
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Etiology
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Bilateral
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Eyelid crease margin
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Other clinical feature
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Congenital abnormality of the levator muscle
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Sometimes
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Crease often absent
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Associated with amblyopia, strabismus
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Oculomotor nerve palsy
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Rarely
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Normal
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Impaired extraocular movement in ipsilateral eye; may be due to aneurysm
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Myasthenia
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Sometimes
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Normal
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Variable; associated with fatigue
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Aponeurotic ptosis
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Sometimes
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Often increased
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Isolated ptosis
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Horner’s syndrome
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Rarely
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Normal
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Ipsilateral miosis
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Myopathy
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Yes
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Normal
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Orbicularis oculi, other extraocular or bulbar muscles may be affected
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Epics and classic literatures are a useful
platform to explore and learn the complexity of medicine in an interesting and
fun-filled manner4.
1.
Krishnamacharya NVR. The Mahabharata. Tirupati: Tirumala Tirupati Devasthanams. 2nd Edition, 2012.
2.
Farber SE, Codner MA. Evaluation and management of acquired ptosis. Plast Aesthet Res. 2020;7:20.
3.
Avdagic E, Phelps PO. Eyelid ptosis (Blepharoptosis) for the primary care practitioner. Disease-a-Month. 2020;66(10):101040.
4.
Kalra B, Baruah MP, Kalra S. The Mahabharata and reproductive endocrinology. Indian J Endocrinol Metab. 2016;20(3):404-7.