Sushruta's Eye Surgery: Arma (Pterygium), Bhedya and Chhedya Karma in the Uttara Tantra

📖 24 min read · By Ayurveda Hub

Arma, Bhedya and Chhedya: When Sushruta Reached for the Knife

Ayurveda is usually pictured as a tradition of herbs, oils and gentle routine. Yet one of its two foundational texts is, at heart, a surgeon's manual. The Sushruta Samhita, attributed to Acharya Sushruta and the surgical school of ancient Kashi (Varanasi), is the reason Sushruta is so often called the "father of surgery." Its Sutrasthana sets out eight kinds of surgical action — the ashtavidha shastra karma: Chedana (excision), Bhedana (incision), Lekhana (scraping), Vedhana (puncturing), Eshana (probing), Aharana (extraction), Visravana (drainage) and Sivana (suturing). What is striking is where the text then applies these procedures: not only to the limbs and abdomen, but to the most delicate organ of all — the eye.

The eye belongs to Shalakya Tantra, the branch of Ayurveda dealing with diseases above the collar-bone (eye, ear, nose, throat and head), and it is treated at length in the Uttara Tantra, the "later section" of the Sushruta Samhita. There, Sushruta famously classifies seventy-six diseases of the eye (netra roga) and sorts them by how they must be managed. Many are handled with medicated drops, baths and salves — the gentle craft of kriya kalpa we covered in our guide to Ayurvedic eye treatment: Aschyotana, Tarpana and Anjana. But a particular group of eye diseases, the text says plainly, cannot be cured by medicine alone. They are the surgical eye diseases, and three short, vivid chapters are given to them.

The surgical chapters of the eye sit in the Uttara Tantra, the later section of the Sushruta Samhita, the text that earned Sushruta the title "father of surgery"

The three chapters divide the work cleanly by procedure:

• Chapter XIV — Bhedya-Roga-Pratishedha: eye diseases cured by Bhedya, incision — the lancing and draining of cysts and swellings such as Visa-granthi, Lagana, Anjana, Krimi-granthi and Upanaha.
• Chapter XV — Chhedya-Roga-Pratishedha: eye diseases cured by Chhedya, excision — above all Arma, the fleshy growth over the eye, along with Sira-Jala, Sira-Pidaka and Parvanika.
• Chapter XVI — Pakshma-kopa Pratishedha: diseases of the eyelashes and the lid, treated by a precise incision, suturing and, where needed, cautery.

Read together, these chapters are a window into a confident, careful surgical tradition — one that mapped the eye, named its diseases, chose the right operation for each, and (as we will see) was honest about risk. The purpose of this guide is to walk through that tradition respectfully, as heritage, while being completely clear that the medicine of the eye in the twenty-first century is a different and far safer world.

The Surgical Map of the Eye: Krishna-mandala, Shukla-mandala and Kaninaka

Before any operation, the text needs a vocabulary for where on the eye the surgeon is working — and Sushruta supplies one. The surface of the eye is mapped into zones, and the surgical chapters use these names constantly:

• Shukla-mandala — the white zone, the region of the sclera and the clear cornea (shukla means white).
• Krishna-mandala — the dark zone, the coloured circle of the iris and the surrounding sclerotic region (krishna means dark).
• Kaninaka — the pupil, the precious central aperture that must be protected at all costs.
• Apanga — the outer canthus, the corner of the eye toward the temple.
• Vartma — the eyelid; Pakshma — the eyelashes.

This is not decoration. The whole logic of Sushruta's eye surgery turns on this map. When he describes removing the growth called Arma, he tells the surgeon exactly how far to push and where to stop — from the Krishna-mandala and Shukla-mandala toward the edge of the Kaninaka, and not one step beyond, because to cut past the pupil is to risk haemorrhage, a draining sinus and lasting harm. The map is a safety system: it lets the text say, in effect, "this far is healing, that far is damage." It is the same anatomical care we saw in his account of the eye's structure and the fourteen causes of eye disease, explored in our piece on Sushruta's Aupadravika chapter and the panchabhautika anatomy of the eye.

The instruments of the eye chapters: the round-tipped Mandalagra scraper, the small Vadisa hook, a slender shalaka probe and a fine needle

The instruments, too, are named. A Vadisa is a small hook, used to catch and lift a growth or a hardened vein. A Mandalagra is a round-tipped, blunt-edged instrument for scraping and shaving tissue without gouging. A shalaka is the slender probe or rod that gives the whole branch its name (Shalakya). Honey and clarified butter (ghrita) appear again and again as the dressing of choice — soothing, and, as we now understand, mildly protective of a raw surface. Rock salt (Saindhava) is used to irritate or to draw; barley-alkali (Yava-kshara) and the three pungents (Trikatu) to clean and finish. With this map and this kit, Sushruta sets to work.

Bhedya Roga: The Eye Diseases Treated by Incision

Chapter XIV opens the surgical sequence with the diseases that call for Bhedya — incision. These are, broadly, the cysts, abscesses and contained swellings of the lids and the surface of the eye: lumps that have to be opened, drained and dressed. Sushruta names five and treats each in turn.

Visa-granthi is a suppurating cyst. The instruction is methodical: first foment the part (warm, softening application), then incise its puncture-like openings completely so that nothing pent-up remains, removing any swelling in the affected part. The opened part is then dusted with a fine powder of Saindhava (rock salt), Kasisa (green vitriol / iron sulphate), Magadhi (long pepper, Pippali), Pushpanjana and Manah-shila (realgar) with Ela (cardamom), pounded together. Honey and clarified butter are applied over the dusted part, and it is loosely bandaged so the parts can knit. (Here the text even preserves a scholarly disagreement: the commentators Vrinda and Chakradatta read a shorter version in which the wound is dusted with Saindhava alone — a reminder that these chapters came down through centuries of careful editors.)

Lagana is treated by an incision into the affected part, after which any of several drugs — Rochana, Yava-kshara, Tuttha (copper sulphate), Pippali — with honey are applied to the cut. In serious, large cases, Sushruta turns to cauterisation with alkali or fire. Anjana (a small lid cyst) is fomented; if it bursts on its own, it is pressed and rubbed (Pratisarana) with a paste of Manah-shila, Ela, Tagara and Saindhava in honey; if the surgeon must open it, he rubs it with honey and Rasanjana and then coats it with a warm collyrium made of lamp-black gathered from a burning flame. Krimi-granthi — literally a "worm-cyst," a parasitic or granulomatous lump — is incised, fomented, and treated with a thickened decoction (Rasa-kriya) of Triphala with Tuttha, Kasisa and Saindhava. Finally Upanaha, a Kapha-born swelling in the eye, is opened, rubbed with powdered Pippali and Saindhava in honey, then gently scraped (Lekhana) with the Mandalagra instrument.

One general rule from the chapter is worth keeping. In all of these incisable eye diseases, Sushruta says, until suppuration has actually set in, the eye should first be treated with Sneha (oleation) and then lightly fomented under a cover of tender leaves; oleation comes first in every case. Only once matter has formed does the work turn to opening and healing. It is patient, staged medicine — the very opposite of rushing in.

Arma (Pterygium): Sushruta's Operation for "Surfer's Eye"

If one operation deserves to be famous, it is this one. Chapter XV is devoted to the eye diseases cured by Chhedya — excision — and its great subject is Arma (also written Arman): a fleshy growth, described as a "manifest vegetation or polypus" that springs up on the eye and creeps across its surface. Generations of scholars have identified Arma with pterygium — the wing-shaped fold of fleshy tissue that grows from the inner corner of the eye over the white and, untreated, can reach toward the cornea. It is sometimes nicknamed "surfer's eye" because sun, wind and dust drive it, which is exactly why it remains common across India's bright, dusty plains and coasts to this day.

Arma is described as a fleshy "vegetation" that creeps over the surface of the eye — the condition modern scholars identify with pterygium, the wind-and-sun "surfer's eye"

What is astonishing is the precision of the operation Sushruta describes. It reads almost like a modern operative note:

1. Prepare the patient. First, the patient is built up with Sneha-predominating (oleaginous) food — oleation before surgery — and then seated comfortably and at ease.
2. Raise the growth. Powdered Saindhava (rock salt) is cast onto the growth to irritate and define it; the eyeball is fomented and gently rubbed by hand. The surgeon asks the patient to look toward the Apanga (the inner corner of the affected eye) so the growth turns up into view.
3. Secure it. The raised growth is caught with a hook (Vadisa) and held with a Muchundi instrument or a threaded needle. The text warns that it is dangerous to lift the eyelid suddenly, and that the two lids should be drawn firmly apart so they are not injured during the work.
4. Separate and remove. Made flabby and pendent by these three aids, the growth is shaved off with a sharp Mandalagra. Its root is carefully pushed apart from the Krishna-mandala and the Shukla-mandala toward the edge of the Kaninaka (pupil), and then removed.
5. Protect the pupil — and leave a margin. The Kaninaka must be guarded so it is not hurt. And in a detail that still impresses surgeons, Sushruta says a quarter-layer of the growth should be left behind: cut to that careful depth and the operation will not injure the eye; cut too deep, past the limit of the pupil, and you risk a haemorrhage and a sinus.

Then comes the most clinically shrewd sentence of all. The vegetation, Sushruta warns, "is sure to grow up again to its former size if it is cut off insufficiently." In a single line he names the central problem of pterygium surgery that ophthalmologists still wrestle with today: recurrence. Remove too little and it returns; remove too much and you damage the eye. The whole craft lies in that narrow margin — and Sushruta knew it.

None of this means you should ever think of an eye growth as a do-it-yourself matter — quite the reverse. The reason to admire Sushruta is that he treated the eye as something to be approached only by a trained, careful hand, with a clear map and a known stopping point. A pterygium today is assessed and, if needed, removed by an ophthalmologist in a sterile theatre, often with techniques that graft healthy tissue to lower the very recurrence Sushruta described. The ancient text is a tribute to human ingenuity; it is not a substitute for that care.

Sira-Jala and Sira-Pidaka: The Vessels and Growths of the Eye

Arma rarely travels alone. The same chapter deals with the diseased blood-vessels of the eye — the engorged, visible networks that accompany such growths. Sira-Jala is a "net" (jala) of hardened, thickened veins (sira) spreading over the surface; Sira-Pidaka are the small cysts or pimples that form on those diseased vessels. Sushruta's approach mirrors the Arma operation: the hardened veins are hung down with a hook (Vadisa) and scraped with the round-tipped Mandalagra; the vein-cysts, if they will not yield to medicine, are excised exactly as an Arma is, with the same instrument, followed by rubbing (Pratisarana) and scraping (Lekhana) judged according to the doshas involved.

A related growth, Parvanika, sits at the junction near the inner corner of the eye. Here Sushruta is especially cautious about the tear apparatus: only a quarter of the growth is kept apart while the upper three-quarters are secured with a hook and cut with a knife; even then, only half of that remaining quarter is carefully removed, because cutting too freely there can set up a lachrymal sinus and constant watering of the eye. Once more the lesson is restraint near vital structures — take what must be taken, and not a fraction more.

He also distinguishes look-alikes with a clinician's eye. An Arma that resembles curdled milk (Dadhi), or that looks blood-red, bluish or grey, is to be treated like a case of Shukrarman (a corneal opacity or film); one that is very thick, "like a piece of skin" and matted with fibres, or that sits on the Krishna-mandala, calls for excision. This is differential diagnosis in miniature: not every white or fleshy mark on the eye is the same disease, and not every one is cut. The judgement of which is which belonged to an examined, trained physician — as it does today.

Churna-Anjana: The Gem-and-Mineral Collyrium

After the cutting comes the dressing — and here Chapter XV offers one of the most beautiful passages in the whole of Ayurvedic ophthalmology: the recipe for Churna-Anjana, a powdered collyrium (eye-powder) for post-operative care. It reads like an inventory of a jeweller's drawer turned to medicine. Sushruta lists, in equal parts: Shankha (conch-shell), Samudra-phena (cuttle-fish bone or "sea-foam"), crystal, ruby, coral, Asmantaka, Vaidurya (lapis lazuli), pearl, iron, copper and Srotonjana (antimony). These are finely powdered, mixed, and — in a detail that fixes the image forever — stuffed into a ram's horn for storage. The physician applies it morning and evening, and the text calls it efficacious "in all types of Armans, Pidakas, Sira-jala" and the other growths of the eye.

The Churna-Anjana of Chapter XV: conch, pearl, coral, crystal, lapis lazuli (Vaidurya) and antimony (Srotonjana), powdered and kept in a ram's horn

Why gems and shells? Part of the answer is mineral chemistry — antimony (the anjana / surma of tradition), conch and coral are calcareous and metallic substances that classical medicine across the world reached for in eye preparations. Part is the doctrine of prabhava, the specific, almost signature action a substance was held to carry. And part, surely, is reverence: the eye is the organ of light, and it is dressed with the things that hold light — pearl, crystal, lapis, ruby. Whatever the reasoning, the care is unmistakable. This is not a rough field dressing; it is a considered, almost ceremonial finish to a delicate operation.

It hardly needs saying, but it must be said: do not make or use any such preparation. Powdered minerals and metals near the eye are dangerous, and several of these substances are frankly toxic by modern understanding. The value of the passage is historical and cultural — a glimpse of how seriously, and how richly, an ancient tradition treated the healing of the eye. For the related family of medicated anjanas and eye-baths used in non-surgical care, see our guide to the seventy-six netra rogas and the origins of Tarpana and Anjana.

Pakshma-kopa (Trichiasis): The Eyelash Surgery

Chapter XVI turns from the surface of the eye to its fringe: the eyelashes (Pakshma) and the lid (Vartma). Pakshma-kopa is, literally, the "anger" or disorder of the eyelashes — the condition in which lashes turn inward and rub against the eyeball, scratching the cornea with every blink. Modern medicine knows it as trichiasis (often with an in-turned lid margin, entropion), and it is no small thing: left alone, in-turned lashes can scar the cornea and steal sight. It is among the world's oldest recorded causes of preventable blindness, and Sushruta describes an operation for it.

For Pakshma-kopa (trichiasis), Chapter XVI describes a precise lid incision sutured with horse's hair — an early answer to the in-turned lashes that can scar the eye

The method is exact. After oleation, and with the patient seated, the surgeon makes a cut "in the shape and size of a barley corn" in the eyelid, set horizontally parallel to the part of the eyeball lying between the Kaninaka (pupil) and the Apanga (outer corner) — leaving two parts of the lid below the eyebrow and one part above the lashes. He then diligently sutures the two edges of the incision with horse's hair. Honey and clarified butter are applied, and the wound is treated as an ordinary incidental ulcer. A piece of linen is tied round the forehead and the horse-hair stitching is attached to it — a neat traction dressing that lifts the lid margin and turns the offending lashes away from the eye. The stitches are removed once the edges have fully knit. (The text notes a refinement from Vagbhata, who in his Ashtanga Hridaya gives a parallel account and advises removing the stitching hair on the fifth day.)

Strip away the antique materials — horse-hair for suture, a linen brow-band for traction — and the principle is the one trichiasis surgery still uses: alter the lid margin so the lashes no longer touch the eye. That an operation built on that idea was written down well over a millennium and a half ago is part of why Sushruta is studied, not just admired. We trace that surgical legacy more widely in our overview of the Sushruta Samhita as one of the world's first surgical texts.

Agni Karma and Kshara: Cautery and Alkali in Eye Surgery

Two finishing tools run through all three chapters, and both deserve a careful, respectful word: Agni Karma (thermal cautery, the controlled use of heat) and Kshara (the application of a caustic alkali). When a growth on the inner lid is removed, Chapter XV has the surgeon rub the base with a powder of Saindhava, Kasisa (iron sulphate) and Pippali, then — after the bleeding has fully stopped — carefully cauterise the lid with a red-hot rod, and treat any stubborn root with a caustic alkaline preparation. For the larger cysts of Chapter XIV, too, "serious cases" are finished with alkali or fire.

Sushruta held cautery in high regard; elsewhere in the Samhita he calls heat-treatment superior for certain conditions because what it settles does not relapse. The reasoning is sound on its own terms — cautery seals bleeding vessels and destroys residual diseased tissue — and it echoes through surgery to this day in the form of electrocautery and thermal sealing. But the eye and its lids are the most delicate of fields, and these were procedures for the most skilled of hands. The text itself reflects this seriousness: it even records a debate over whether strong emetics and purgatives should be given internally afterwards to clear the doshas, with the great commentator Dalhana and the Panjika-kara arguing against the practice. A tradition that argues with itself about aftercare is a tradition taking aftercare seriously.

To keep these in perspective, it helps to remember that Sushruta's surgery did not happen in a vacuum. The tradition also described measures to dull pain and steady a patient before the knife — the herbal and wine-based "intoxicants" discussed in our piece on Sammohini and Sanjivani, the ancient idea of anaesthesia in Sushruta's surgery. Surgery, anaesthesia, instruments, aftercare: the pieces of a genuine operative culture are all here, applied even to the eye.

Snehana and Aftercare: Protecting the Healing Eye

For all the drama of the knife, what may be most modern about these chapters is their insistence on care around the operation. Before surgery, the patient is oiled and fed (Snehana); the eye is softened with oleation and gentle fomentation. During surgery, the lids are protected, the pupil is guarded, a margin is left. After surgery, the wound is dressed with honey and ghee, bandaged, and — in a lovely touch — covered with tender leaves as a soft shield; the bandage is removed after three days and the part is then only mildly fomented with the warmth of the surgeon's own palms.

The text even prescribes soothing applications for pain: milk cooked with Karanja seed, Amalaka and Yashti-madhu (licorice) and mixed with honey, dropped into the eye morning and evening; and a cooling plaster of Yashti-madhu, lotus pollen (Utpala) and Durva grass for the scalp. Most striking of all, Sushruta closes the surgical chapter with a discipline of recovery: the patient should observe a strict regimen of diet and conduct for a full month after the operation. That instinct — that healing is a season, not an afternoon — is the same wisdom behind the gentle, non-surgical eye care the tradition is really built on.

The soothing, everyday side of the tradition: ghrita, cooling rose water and tender leaves — gentle care for the eye area, a world away from the knife

That gentler side is where most of us actually live. Tired, screen-strained eyes do not need surgery; they need rest, blinking, distance, sleep and simple comfort. A cool compress of clean rose water on closed lids is a time-honoured way to refresh the eye area at the end of a long day. A pure, fragrant rose water such as Gulab Jal suits exactly that ritual — dabbed on cotton and laid over closed eyes as a cooling compress, or used as a refreshing facial mist.

Heritage, Not Home Remedy: Reading Sushruta Today

So what do we do with chapters like these? The wrong reading — and an unsafe one — is to treat them as instructions. The right reading is to see them for the extraordinary historical document they are: evidence that, two thousand years and more ago, a medical tradition on the Indian subcontinent had mapped the surface of the eye, named its diseases, matched each to a specific operation, worried about the pupil and the tear ducts, anticipated the problem of recurrence, and built a whole culture of preparation and aftercare around the work. That deserves wonder. It is part of why modern researchers keep returning to these texts, a theme we explore in is Ayurveda scientifically proven? — the modern rediscoveries of Sushruta.

But wonder is not a treatment plan. The eye is unforgiving, and the gap between an ancient manuscript and a safe modern operation is filled with sterility, anaesthesia, magnification, microsurgery and centuries of hard-won knowledge about infection. A pterygium, a trichiasis, a lid cyst, a red or painful eye — each of these is, today, a routine matter for an ophthalmologist and a poor one for any home remedy. The honest tribute to Sushruta is not to copy his recipes but to share his seriousness: to take the eye seriously enough to have it cared for properly.

Where Ayurveda does speak to most of us day to day is in the unglamorous, genuinely useful side of eye wellness: protecting the eyes from the same dust, smoke, heat and glare the classics blamed; resting them from screens; sleeping enough; eating for general nourishment; and supporting overall vitality (rasayana). A traditional rasayana like Chyawanprash belongs to that broad, whole-body idea of nourishment — not as anything aimed at the eye specifically, but as part of the everyday, preventive spirit these texts ultimately serve. For the foundations of that gentle, non-surgical tradition of eye care, our companion guide to Ayurvedic eye care and the Sushruta approach to eye health is the natural next read.

Sushruta's eye surgery is, in the end, a story about respect — respect for a fragile organ, for the limits of what should be cut, for the patient's long recovery, and for the difference between knowledge and bravado. That respect is the part worth carrying forward. The instruments belong in a museum; the seriousness belongs in how we look after our eyes.

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Disclaimer: This article is for educational and historical purposes only and describes classical Ayurvedic texts. It is not medical advice, diagnosis or treatment, and nothing in it should be attempted. Eye conditions — including growths on the eye, in-turned eyelashes, redness, pain or any change in vision — require assessment by a qualified ophthalmologist. Never place any substance or instrument in or near the eye. Ayurveda Hub products are wellness preparations, not medicines for any disease. Always consult a qualified medical or Ayurvedic professional before acting on any traditional information.