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POST GRADUATE SECTION
Year : 2019  |  Volume : 7  |  Issue : 1  |  Page : 31-34

Incidence of various causes of infectious keratitis in the part of rural central India and its visual morbidity: Prospective hospital-based observational study


Department of Ophthalmology, NKPSIMS and LMH, Nagpur, Maharashtra, India

Date of Submission06-Feb-2018
Date of Acceptance07-Dec-2018
Date of Web Publication12-Mar-2019

Correspondence Address:
Pratik Narendra Mohod
Jalapurti Colony, Vidhyut Nagar, VMV Road, Amravati, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jcor.jcor_16_18

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  Abstract 


Introduction: Infectious keratitis is potential causes for vision loss in India. Early recognition with prompt diagnosis and rapid institution of appropriate therapy will significantly improve visual prognosis. Aim: The aim of this study was to evaluate the incidence of various causes of infectious keratitis in this part of rural central India, predisposing factor and visual morbidity. Materials and Methods: This was a prospective observational hospital-based study conducted at the Department of Ophthalmology, at a tertiary care hospital, in the part of rural central India. Data related to socioeconomic status, predisposing factor, and course of disease was collected. Results were analyzed on the basis of history, slit lamp examination, and appropriate laboratory investigation. Results: During the period of January 2015 to February 2017 total 680 patients were examined in cornea specialty clinic, of which 88 were diagnosed with infective keratitis and were included in the study. Majority of patients of infectious keratitis were in between 41 and 60 (41%) age group followed by 21–40 (23%) and incidence in male was higher (61%) as compared to female. Prevalence of Fungal keratitis (59.09%) was higher than bacterial (19.31%) and viral (17.04%) in this part of India. Ocular trauma and occupational accidents were the most common (42%) among farmer. Majority of corneal ulcer (68%) healed, 11% had no change in ulcer status, 4% was progressed, and 10% perforated. About 53% had stable best-corrected visual acuity (BCVA) as compared to BCVA at the time of presentation and in 34% BCVA improved. Conclusion: Incidence of fungal corneal ulcer is higher among various causes of infectious keratitis in this part of rural central India. Agricultural injuries are the main predisposing factor for infectious keratitis in this region. Prompt diagnosis and early appropriate treatment on the basis of laboratory investigation can helps the community to reduce the burden of corneal blindness.

Keywords: Corneal ulcer, fungal, keratitis, prevalence


How to cite this article:
Mohod PN, Nikose AS, Laddha PM, Bharti S. Incidence of various causes of infectious keratitis in the part of rural central India and its visual morbidity: Prospective hospital-based observational study. J Clin Ophthalmol Res 2019;7:31-4

How to cite this URL:
Mohod PN, Nikose AS, Laddha PM, Bharti S. Incidence of various causes of infectious keratitis in the part of rural central India and its visual morbidity: Prospective hospital-based observational study. J Clin Ophthalmol Res [serial online] 2019 [cited 2019 Sep 15];7:31-4. Available from: http://www.jcor.in/text.asp?2019/7/1/31/253988



Corneal infection is the most common cause of monocular corneal blindness worldwide.[1] The ocular trauma and corneal ulceration results in 1.5–2 million new cases of corneal blindness annually.[2] As per recent worldwide lists on the causes of blindness, corneal scarring is the second-most common cause of blindness and visual disability in developing countries.[3],[4] Corneal blindness due to keratitis is a major public health problem in India. As per census 2011 and survey (rapid assessment of avoidable blindness) conducted by the Ministry of Health and Family Welfare 2006–2007 out of total population of 122 crores, 0.1% (1.22 lakh) are bilateral and 0.9% (10.98 lakh) are unilateral corneal blind in India.[5],[6] Twenty thousand new cases of corneal blindness are being added annually to the existing burden.[7] Infective keratitis caused by bacteria, fungi, viruses, and parasite results into potentially sight-threatening ocular infection. The most common causes of corneal blindness are infections made worse by the lack of proper nutrition due to poverty and illiteracy. Ulcerative keratitis must be considered as an ocular emergency. Early recognition with prompt diagnosis and rapid institution of appropriate therapy will significantly improve visual prognosis.

This study was undertaken to evaluate current status, the incidence of infectious keratitis in this part of rural central India and its visual morbidity.


  Materials and Methods Top


It was a prospective observational hospital based study conducted at the Department of Ophthalmology, at a tertiary care hospital, in rural central India. The study was conducted with the approval of the Institutional Ethics committee with proper consent taken from the patients. The study followed the tenant of the declaration of Helsinki.

Inclusion criteria were patients with infectious keratitis, also patients on the treatment of infectious keratitis with irregular follow-up.

Exclusion criteria were patients showing signs and symptoms of endophthalmitis and panophthalmitis. Patients from other than rural central area and treatment defaulter were excluded.

Data related to sociodemographic features were recorded. Appropriate history was taken to find out predisposing factors, previous treatment, and duration of symptoms. Visual acuity was recorded at the time of presentation. All patients were evaluated on slit lamp to record the size, depth, and location of ulcer along with an examination of margins, floor, and infiltrations.

Examination of ocular adnexa including lids, eyelashes, and lacrimal sac area was done. The sac syringing was done to check the patency of the lacrimal system, and random blood sugar was recorded to screen for diabetes mellitus in every patient. Corneal scraping was done in cases of large epithelial defect and involved visual axis. A nonpreservative topical anesthetic was instilled (proxymetacaine 0.5%). Scrapping was taken with a disposable scalpel blade. Loose mucus and necrotic tissue were removed before scraping. The margins and base of the lesion were scraped. The thin smear was placed on one or two glass slide for microscopy, including gram stain, Giemsa, acid-fast bacillus, calcofluor white.[8] Samples were plated onto culture media, routinely blood agar, chocolate, and sabouraud media were used and placed incubator. Standard antimicrobial therapy was given based on laboratory reports. Scraping may be delayed without treatment for 12 h if antibiotics have instilled previously. Viral keratitis cases were confirmed on basis of clinical findings, fluorescein and rose Bengal stain. If no improvement after 48 h then suspension of treatment for 24 h, re-scraping performed with inoculation on border range of media and additional staining techniques requested. Corneal biopsy was send for histology and culture.

No sign of healing after 7–8 days' label as nonhealing ulcer. For the purpose of analysis each case was then classified into either of Groups A–F, based on presenting best-corrected visual acuity (BCVA). Group A (6/6 to >6/18), Group B (6/24 to >6/60), Group C (5/60–1/60), Group D counting fingers, Group E hand movement (HM to PL), and Group F no perception of light (No PL). Visual acuity was compared at the time of presentation and after treatment. Statistical analysis was performed by EpiInfo 3.5.3 Analysis(CDC, Atlanta, GA, USA).


  Results Top


During the period of January 2015 to February 2017, a total of 680 patients were examined in cornea specialty clinic, of which 88 were diagnosed with infective keratitis and were included in the study. The mean age of the patient was 44 years. [Graph 1] shows majority of patients of infectious keratitis were in between 41 and 60 (41%) age group followed by 21–40 (23%) and incidence in male was higher than (61%) that of female. The left eye was slightly more commonly involved (54%) as compared to the right eye (46%).



Distribution of patient according to occupation shows majority cases (42.04%) were farmer followed by household work (29.54%) and laborer (15.90%). Miserable amount patients among business (2.27%), students/children (6.81%) and 3.40% were others [Graph 2].



The incidence of fungal keratitis (52 cases, 59.09%) was higher than bacterial (17 cases, 19.31%) and viral (15 cases, 17.04%), were as no growth and mix clinical presentation noted in 4 cases (4.54%). Out of 88, fresh cases were 42 (47.7%), 18 (20.4%) patients were on antimicrobial and those on steroid were 28 (31.8%).

Among all patients, majority of the patient had BCVA Group E (41) and Group D (23) followed by Group C (13) Group B (7) Group A (3) only 1 patient had No PL. It was found that most of the patients visited to our institute after 2–3 weeks (43.18%) of the initial symptom. About 34.09% visited on the 1st week and 22.72% visited after 4 weeks of initial complaints.

26.13% (23 cases) had significant vision-threatening complication noted at the time of presentation and during management. It includes perforation in 10.22% (9 cases) followed by secondary glaucoma occurred due to fibrinous exudates 6.81% (6 cases), iridiocyclitis 2.27% (2 cases), and adherent leukoma 2.27% (2 cases), were as 73.86% (65 cases) had less significant vision-threatening such as corneal scar, mild iridocyclitis, and mild raised intraocular pressure (IOP) which was controlled on topical anti-glaucoma medication.

In the present study, 94 patients had infective keratitis, among these 6 patients were treatment defaulter hence 88 included in the study. Among those on prompt follow-up and appropriate treatment most of the corneal ulcer 68% healing, 11% no change in ulcer status only 4% progress and 10% perforate and also 34% improved, 53% stable there BCVA compare to BCVA at the time of presentation. Only 6% deteriorated mainly due to poor follow-up and compliance.


  Discussion Top


Clinical outcome in microbial keratitis and epidemiological patterns may be different from country to country and between different geographical regions within a country. In our study, Majority of patients of infectious keratitis were in between 41 and 60 (41%) age group followed by 21–40 (23%). Most of them were a farmer as this is the most common occupation of rural population in developing countries. This explains why agriculture trauma was the leading predisposing factor of corneal ulcer in developing countries.[9] This is in concurrence with that of Panda et al.,[9] Khare et al[10], Srinivasan et al.[11] and other studies[12],[13],[14] shows similar results.

Incidence was higher in males (61%) than that of females in our study. Male predominance was found in many studies,[10],[15] some has found it in the ratio as high as 1.6. This may be because males are more involved in outdoor activities and also males are preferred over females to seek medical advice.

Our study showed farming (42.04%) was the predominant occupation followed by household work (29.54%) and laborer (15.90%). Srinivasan et al.[10] showed that the majority of corneal ulcers were observed in the farmer. Vegetative trauma was the most common predisposing factor for the development of corneal ulcer representing 49% cases. Bharathi et al.[16] and other author also found the ocular trauma as a main predisposing factor for microbial keratitis.[10],[17] Twenty-five per cent of all patients with a history of trauma implicated wheat/maize stalks as the traumatic object. This was followed by tree branches and thorns, soil and rocks, vegetable matter, and animal products.

Out of the 88 patients with corneal ulcer, the cultures of 69 patients show positive microbial growth and 19 cultures were negative microbial growth, but out of these 15 clinically diagnosed with viral and rest 4 were mixed infection. The detection of fungal filaments in10% KOH mount has 90%–99% sensitivity.[18] While sensitivity and specificity of bacterial detection in gram stain are inferior to that of culture method.[19] Fungal isolates (59.09%) were more common in this study than bacterial isolates (42.08%), which was similar to the findings of Basak et al.[20],[21] Fusarium spp., followed by Aspergillus spp., was the most commonly isolated fungal pathogen in this study. Srinivasan et al.[10] show the similar to the findings, while other studies have reported Aspergillus spp. As the most common fungal pathogen isolated from patients with corneal ulcers.[20],[22],[23] This may be due to differences in the climate and natural environment of the areas studied.

Among ulcer of severe grade, perforation of the cornea (10.22%) was the most common complication followed by secondary glaucoma 6.81%, irdiocyclitis 2%, and adherent leukoma 2%. Whereas 73.86% (65 cases) had less significant vision-threatening such as corneal scar, mild iridocyclitis, mild raised IOP which was controlled on topical anti-glaucoma medication.

Lack of awareness and local treatment from nonophthalmologist were responsible for late presentation and severe complications.

Majority of patients came to our hospital were from the nearby rural region. Most of them take initial treatment from the local practitioner including paramedical and medical personnel, relatives, traditional healer, and even directly from drugstores. Patients' accessibility to eye care services is the main barrier for early consultation followed by cost, social belief, and ignorance about the disease. In the present study, 20.8% of patients were on steroid therapy at initial presentation and predisposed to fungal keratitis.

In our study, most of the patients had BCVA Group E (41) and Group D (23) followed by Group C (13), Group B (7), Group A (3), only 1 patient had No PL. It was found that most of the patients visited on 2nd–3rd week (43.18%) of presentation, 34.09% on the 1st week and 22.72% visited after 4 weeks of complaints. Similar results were noted in other studies.[9],[11]

On prompt follow-up and appropriate treatment most of the corneal ulcer 68% healing, 11% no change in ulcer status only 4% progress. Thirty-four percentage improved, 53% stable there BCVA compare to BCVA at time of presentation only 6% deteriorated mainly due to poor follow-up and compliance.


  Conclusion Top


Our study highlights that the incidence of fungal corneal ulcer is higher among various causes of infectious keratitis in the part of rural central India. Agricultural injuries are the main predisposing factor for infectious keratitis in this region. Prompt diagnosis and early appropriate treatment on the basis of laboratory investigation can helps the community to reduce the burden of corneal blindness. Community awareness of the risk factors and restriction of the abuse of topical corticosteroids or antibiotics plays a key role for control worsening of diseases.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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