|Year : 1955 | Volume
| Issue : 1 | Page : 1-9
Angular conjunctivitis with associated dermatitis
Ophth. Dept., King Edward Memorial Hospital, Bombay, India
S M Sathe
Ophth. Dept., King Edward Memorial Hospital, Bombay
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Sathe S M. Angular conjunctivitis with associated dermatitis. Indian J Ophthalmol 1955;3:1-9
"One of the manifestations of angular conjunctivitis is an eczematous condition of the surrounding skin varying in intensity from a slight scurfiness to a well marked area of redness and maceration, associated with considerable itching and smarting" (Duke Elder). In King Edward Memorial Hospital in a period of 15 months, 31 cases of angular conjunctivitis with associated skin lesions were studied. These were treated with 1 % zinc drops locally and in addition vitamin A injections intramuscularly for the skin condition. This has considerably reduced the usual resistant nature of this condition.
Vitamin A has been termed the anti-infective vitamin. It is anti-infective only to the extent that when it is given to an individual suffering from a deficiency of vitamin A it increases the power of the epithelial surfaces to resist local infection. Wolbach and Howe, as quoted by Bicknell and Prescott (1953), found that the specific tissue change due to deprivation of fat soluble vitamin A is replacement of various epithelia by stratified squamous keratinizing epithelium. This replacement of a specialized epithelium by a primitive type leads to a lowered local resistance to infection. The basal layer of the epithelium begins to form stratified, epithelium. The basal layer of cells always remains unchanged and from it regeneration starts if treatment is undertaken. The signs and symptoms which follow vitamin A deficiency are more variable than those which follow other vitamin deficiencies. L. Nicholls (1933) has described a case of vitamin A deficiency which showed a superficial dermatitis around the eyes and the mouth. The absence of wide recognition of the effect of vitamin A deficiency in man may be due to the irregularity of the signs and symptoms and may explain the anomalous observation on infection following this deficiency.
The recognised manifestations of vitamin A deficiency in the skin and eyes are as follows:
Skin-Toad skin or Phrynoderma (Nicholls and Lowenthal).
This insidious onset of a dry rough skin is the first cutaneous symptom of deficiency of vitamin A in all ages. Increased pigmentation and itching have been reported.
Eyes-The earliest sign is a slight impairment of dark adaptation followed later by night blindness. The first change in the eye is xerophthalmia followed by keratomalacia in children. Prolonged mild deficiencies lead to Bitot's spots, asthenopia and a peculiar keratitis, reported by Bluementhol. Follicular conjunctivitis in children is caused by vitamin A deficiency according to some authorities. In children the eyes and in adolescents the skin chiefly suffer.
Bacteriology of Angular Conjunctivitis
The causative organism of angular conjunctivitis is of little general interest and hence bacteriologists have not studied it intensively. On the other hand ophthalmologists find the organism very important but have given little attention to it because of the special techniques required in its study. Morax (1896) published a short paper in which he recorded all the essential points of a disease which he named "conjunctivite aigue". The following month in the same year Axenfeld presented his independent investigations at the International Congress of Heidelberg 1896 calling the condition `chronic diplobacillary conjunctivitis'. The organism soon became known as Morax Axenfeld diplobacillus. Eyre (1900) applied the name lacunatus because of its tendency to form lacunae or pits in Loeffler's solid medium. Later when Axenfeld observed acute cases the name diplobacillary conjunctivitis seemed generally more preferable. He considered the infection among the commonest and most widespread of all infections. This can readily be understood when we consider the extraordinary contagiousness and chronicity of the condition. Persons of every age and race may be affected but the adults especially the aged and debilitated are attacked most commonly. The organisms may reach the eye from the upper respiratory passages and from the nose, the infection travelling in a retrograde fashion or more likely may be carried to the eyes by handkerchief or soiled fingers. Steen and Berdal described chronic rhinosinusitis caused by Morax Axenfeld bacillus. Slight alkalinity of the tears is conducive to the growth of the organism. However there is something in the tears of the nature of an antiprotease which checks the activity of the bacillus. -If the protease which the organism elaborates reaches the unprotected skin it will digest it; otherwise the organism exists on the surface of the epithelium without causing any clinical symptoms.
When discussing the bacteriology of the Morax Axenfeld bacillus it is impossible to be dogmatic. It is well known in the field of bacteriology that microorganisms are capable of undergoing considerable variation, transgeneration and dissociations. This variation can occur in size, shape, staining reaction, cultural characteristics and pathogenecity. The variation may be permanent but usually is temporary or a reversible response induced by a change in the conditions under which the organism must grow and may be interpreted as being one of the most basic adaptive phenomena. The involutional forms vary considerably from long thin, filamentous forms to short cocci-bacilli and from Gram negative to Gram positive. They may be long and club shaped. The filamentous forms usually stain pale pink while the cocobacilli are fairly Gram positive. The organisms present in the nose differ in type from those found in the eye.
The average size of the organisms as seen in the conjunctiva is 1.5-2 µ broad and 2-3 µ. long. On culture it grows only on blood serum or agar containing serum or media with human body fluids. On blood serum with an alkaline reaction prepared by Loeffler's method small, moist, slightly sunken transparent colonies are seen. They can remain alive outside the body in dried secretion for a long time. In cases of conjunctivitis the organism is very easily found. It is extremely plentiful in scrapings or smears of secretion from the angles. Morax asserted that his diplobacillus possessed no pathogenic powers for laboratory animals either locally; subcutaneously or intraperitoneally. Apes and birds were also refractory. Human conjunctiva was affected after an incubation period of 4 days. A typical subacute conjunctivitis developed. Organisms could be shown from the discharge. The conjunctivitis responded to zinc treatment with complete cure. There is a high degree of contagiousness and a widespread susceptibility to this disease.
Mitsui and his associates (1951) have suggested that in severe cases of diplobacillary conjunctivitis zinc alone has no effect except to remove the diplobacillus from the smears, the signs and symptoms persist. The diplobacillus is a saprophyte of the human eye. The factors that make these organisms pathogenic are not clearly known. He has suggested vitamin B deficiency as one of the factors. In our series of cases as the skin was affected vitamin A was used as an adjuvant to zinc.
| Material and Method|| |
In the present study extending over a period of 15 months, 31 cases of a severe type of angular conjunctivitis were collected. The criteria for inclusion in the series, were as follows: -
(1) Clinical picture of a severe type of angular conjunctivitis.
(2) Presence of skin lesions round the eyes.
(3) Conjunctival scraping showing Gram negative diplobacilli.
Clinical picture in brief : A patient usually complains of itching, for a varying period with a history of repeated attacks. On clinical examination, the lids look oedematous, and the skin over it rough, dry and excoriated, more marked at the angles of the eyes. There may be dark pigmentation round the eyes. Scanty discharge is to be seen at the inner angles.
The conjunctival scraping was taken from the angles with a blunt knife and smear prepared on a slide. In a few cases, a skin scraping was taken with a cotton swab moistened with saline. The area chosen was the boundary line between the normal and the affected skin.
Both these were stained with Gram's method and examined under an oil immersion lens of the microscope. Gram negative diplobacilli were seen either lying free on the epithelial cells or entangled in fibrin threads. Hardly any leucocytes were seen in the smear. In most of the cases absence of any other organism was noted. The conjunctival smear was examined three times, before treatment, after 8 days and again after 15 days of treatment. According to the number of organisms seen the smear was graded +, + + or =+++. When an occasional diplobacillus was seen it was graded as +. When every field showed one or two diplobacilli + + and when a number of them used to be present in every field then it was labelled as +++.
The 31 cases were divided into three groups for treatment.
GROUP I- consisted of cases treated with a combined therapy. They were given intramuscular vitamin A injections 100,000 units, every alternate day for a total of 600,000 units. Zinc drops 1 % were given for local use, one drop to be instilled four times a day. Zinc was continued for a week after the completion of vitamin A injections.
Group II consisted of patients who were given only vitamin A injections for a varying period of 8-12 days. The response to this therapy was noted and subsequently zinc was added and the condition noted after 8 days.
Group III In this group, patients were given only zinc to be used locally for eight days and the response noted. Then vitamin A injections were given in addition, every other day. for a total of six injections. Zinc was continued throughout this period.
| Results and Discussion|| |
Age and Sex Incidence. As can be seen from [Table - 1], the maximum incidence appears in the 40-49 years age-group. No case was seen below the age of 10 years. Out of 31 cases more than half the cases were males.
Deficiencies in Diet : It is an impression though not an investigated or a proved fact that cases of this type are rare in nutritionally better class of people. Therefore it is likely that diet plays an important role in the causation of the disease. As cases in this series were collected from a free general hospital almost all were from a poor class, whose diet is rice and vegetables, occasionally supplemented by curds and meat. The fat soluble vitamins are present in the more expensive food stuffs such as eggs, milk, butter, liver, etc. which these people cannot afford. Therefore it might be expected that deficiencies of the fat soluble vitamins may be a contributory cause.
Duration of disease : As can be seen from [Table - 2], 22 cases out of 31 had the disease for more than a month with frequent exacerbations. No patient had the symptoms for less than 15 days. It is a well known fact that angular conjunctivitis is a chronic infection.
Quite a number of these 31 cases had received previous treatment elsewhere for varying periods without relief.
As can be noted in [Table - 3] all 17 cases responded to this combined treatment within a period of nine days except two cases, which required 11 days and one which required 13 days. All 17 cases were given a full course of 600,000 units of vitamin A and zinc locally for a week after the completion of vitamin A injections. One case (No. 14) however was given a total of 1.200,000 units of vitamin A as it was of a very severe type. The conjunctivitis responded first, then itching and lastly dermatitis. The second smear (taken after 8 days) was negative in all 17 cases.
From [Table - 4], one can see that 7 patients were treated with vitamin A injections to start with. All seven cases showed little improvement in the skin condition after a variable period of 8-12 days. The second smear was positive in all cases. Conjunctivitis and itching persisted in all cases. On addition of zinc all symptoms so also the skin lesions cleared up within 7 days. The third smear became negative. Zinc was continued for a further period of eight days.
[Table - 5] shows 7 cases out of a total of 31 that were treated first with only zinc drops locally. After eight days in all cases the second smear became negative. Conjunctivitis showed improvement. Itching persisted though little less than before. The skin condition remained the same in all 7 cases. On addition of vitamin A the skin had a healthy look in 7 days in 6 cases. In one case, (No. 7) there was no improvement even after giving 1,200,000 units of vitamin A along with zinc. The failure in treatment could not be accounted for.
The photometer test, to assess vitamin A deficiency could not be done as the eyes were in an irritable state.
All patients were asked to come for follow up 15 days after completing the treatment, or if they had another attack in between. But the response for follow up was comparatively poor.
Case Histories of Some Selected Cases
Typical case from Group I: (Case I [Table - 3])
A female aged 50 years came to the Eye Department of the K. E. M. Hospital with a complaint of itching and watering of both eyes for 8 days. On inquiry she gave history of a similar attack a few months back, but of a milder type than the present one. On clinical examination there was photophobia with scanty discharge at the angles. The lids looked oedematous, the skin over it was dry and eczematous. There was dark pigmentation round the eyes. The conjunctiva was congested at the angles. The conjunctival smear showed Gram negative diplobacilli entangled in fibrin threads and few lying free on the epithelial cells. There were hardly any leucocytes to be seen. A photo was taken and the following treatment started. Locally 1 % zinc drops four times a day and vitamin A injections intramuscularly. After 9 days of treatment her signs and symptoms disappeared. The conjunctival smear became negative in 8 days. All the six injections were given and zinc drops continued for a period of 8 days after the completion of injections.
Typical case from Group II (Case 5. [Table - 4])
A male aged 40 years complained of itching and burning oft and on for the last year and a half. On examination he had photophobia, lids looked swollen. The skin over it was pigmented, dry, rough and had an unhealthy look. The conjunctiva at the angles was congested. Both the conjunctival and skin scrapings showed Gram negative diplobacilli. On culture made on blood agar slope after a period of 48 hours small, translucent, sunken discrete colonies were seen. Smear from it showed Gram negative diplobacilli with plenty of involution forms. The patient was given six injections of vitamin A (600,000 units total). His skin condition showed some improvement but the symptoms persisted though the severity was less. The smear was also positive. With the addition of zinc for 8 days he felt much better. Smear became negative. During that time his vitamin A was continued. Total vitamin A he received was 1,200,000 I.U.
Typical case from Group III (Case 5, [Table - 5]).
A male aged 50 years complained of itching and watering for 8 days. He gave history of such repeated attacks for last 6 months. On examination lid borders looked thickened, there was madarosis. The skin over the lids was dry, rough and excoriated. There was dark pigmentation round the eyes. As a routine a conjunctival scraping and in addition a skin scraping was done. Both the smears showed Gram negative diplobacilli. The patient was given only zinc drops to be instilled locally four times a day. After 8 days the conjunctival smear became negative but the signs and symptoms persisted. Hence vitamin A was added. After three injections he felt much better, the skin had a healthy look. In all six injections were given.
| Conclusion|| |
(1) All cases of angular conjunctivitis do not show skin lesions. Probably vitamin A deficiency lowers the resistance of the skin to local infection by Morax Axenfeld bacillus. This, it may do by limiting the production of antiprotease in the tears.
(2) Severe type of cases do not respond to the usual zinc treatment. Zinc only makes the conjunctival sac free from the offending organisms.
(3) Vitamin A alone improves the skin condition little and the organisms are not removed from the conjunctiva.
(4) Only a combined treatment, with zinc locally and vitamin A injections intramuscularly, can severe cases of angular conjunctivitis be effectively treated.
I am indeed grateful to my Chief, Dr. C. B. Dhurandhar, Honorary Ophthalmic Surgeon, K. E. M. Hospital for his guidance and direction.
Further I thank the Dean, K. E. M. Hospital and Seth G. S. Medical College, Bombay, for permitting me to report the hospital case records.
| References|| |
Axenfeld, J. (1908) The Bacteriology of the Eye, Translated by A. McNab, p. 157, Bailliere, Tindall & Co., London.
Bicknell, F. and Prestcot, F. (1953), The Vitamins in Medicine, W. Heinemann Medical Books, Ltd., London.
Blumenthol, as quoted in 2.
Duke Elder, W. S. (1952), Text Book of
Ophthalmology. Vol. 5, Henry Kimpton, London, p. 4846.
Eyre (1900) as quoted in 6, p. 202.
Fedukowicz, H., & Horwich, H. (1953), Arch. of
Ophth., 49, 202.
Lowenthal, L. J. A. (1953), Arch. Dermat. Syph., 28, 700.
Mitsui, Y. Hinokuma, S. and Tanaka. C. (1951), Am. J. of Ophth. 34,
Nicholls, L. (1933), Ind. Med. Gaz. 68, 681.
Nicholls, L. (1934), Ind. Med. Gaz. 69, 241.
Steer & Berdal as quoted in 6, p. 205.
Wolbach, S. B. and Howe, P. R. (1925), J. Exp. Med.. 42, 753.
[Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4], [Figure - 5], [Figure - 6], [Figure - 7]
[Table - 1], [Table - 2], [Table - 3], [Table - 4], [Table - 5]