|Year : 1955 | Volume
| Issue : 3 | Page : 54-58
The eye in protective vaccination
SN Cooper, RJ Patel
S N Cooper
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Cooper S N, Patel R J. The eye in protective vaccination. Indian J Ophthalmol 1955;3:54-8
Protective vaccination is now an established form of preventive medicine which is gaining in importance every day. Once in a while one comes across a case which sets him, wondering whether such protective measures breed a hidden form of danger particularly for the eyes. A peep into the case histories of five of our patients may raise a doubt, in this direction.
| Case Reports|| |
Miss V. S., aged 16, was tested for tuberculin sensitivity prior to B.C.G. vaccination on 30-6-51. The test was positive, to 0.1 cc. of 1 in 100,000 and she was given only liver and vitamin Biz injections for "weakness". On 23-8-51, a "white spot" appeared in the left cornea after which she developed defective vision in that eye. On examination she had a ciliary flush and commencing deep keratitis in the left eye, her vision dropping to 6/12. All laboratory investigations and examinations for an infective focus in the body were negative. The condition progressed till the vision got reduced to finger counting at 2 meters.
Slit-lamp examination showed infiltration of the cornea in the deeper layers in the lower and outer quadrant with deep vascularization and thickening of the substantia propria. As no active tuberculous focus or any other cause for the same could be detected, it was considered a case of deep keratitis due to hypersensitivity to tuberculin. Under a course of desensitizing doses of tuberculin of which she received 14 injections in the course of three months, and cortisone locally, a gradual improvement in her condition resulted. A placenta grafting was done in the eye with the hope of clearing the residual opacity. A month later on 5-2-52, she got an attack of left maxillary sinusitis with no worsening of the ocular condition. The sinus condition cleared under the use of Sulphonamides by mouth. Her vision had improved to 6/9, and has continued to remain so. Previously in 1946 her vision was 6/5 in both the eyes with correction.
Master R. P., aged 16, was tested for sensitivity to tuberculin prior to B.C.G. a month before he came for examination. His Mantoux was strongly positive and had resulted in a hard nodule at the site of injection. No B.C.G. vaccination was therefore given. When he came under our attention on 24-4-55, he was complaining of defective vision for the last two days. On examination he had bilateral uveitis and his vision had dropped to 6/24 in each, eye.
On slit lamp examination he had an A.C. flare, vitreous opacities, more in the left eye, and a clear view of the fundus could not be obtained because of these opacities. As best as could be made out there was slight "beading" of the lower temporal arteries in both the eyes. All other laboratory tests were negative. A course of penicillin (400,000) and dihydro-streptomycin (1.0 gm.) injection was given for 12 days followed by a course of isoniazid tablets. Tuberculin injections were given once a week.
Even with the first desensitizing dose of old tuberculin that we ordinarily start with-0.1 cc. of 1 in 100,000 dilution-he got a mild febrile reaction and so we had to reduce the desensitizing dose to 0.1 cc. of a I in 1,000,000 dilution.
There was a complete recovery within 43 days, the vision being restored to 6/6 in each eye, with disappearance of the opacities in the media and of beading on the arteries. The desensitizing dose was continued for 12 more injections in the course of which the hard nodule in the skin of the preliminary Mantoux test dissolved completely.
Z.T. aged 35, volunteered for a Mantoux at a time when this test was done in his establishment during a B.C.G. campaign. His test was considered negative and was recommended to take a B.C.G. shot. Somehow he hesitated and approximately three weeks after the Mantoux he developed an exudative detachment of the retina, in the right eye. His myopia was in the neighbourhood of 11D, but previous to that his vision was 6/6 with correction, with very few myopic degenerative changes. With an operation for detachment and a course of tuberculin injections during the convalescence he made an uneventful recovery.
N. K., aged 62, an athlete and well-built, had suffered a traumatic detachment of the retina in 1931 in the left eye. He was operated successfully but ultimately developed a cataract in that eye which again was removed successfully.
In 1947 he was operated for cataract in the right eye elsewhere. An intracapsular operation was done very successfully, but after the operation the eye continued to remain red and irritable and the vitreous was full of dust-like opacities. The vision could not be improved beyond 6/36. All foci of infection were searched for but nothing abnormal was detected.
It was during the temporary absence of the surgeon that we were shown the case for the first time. As the patient had already received penicillin (no other antibiotic was discovered then) and milk injections and because of a history of tuberculosis in the family we suspected an underlying tuberculous allergy and desired that the patient may be given desensitizing doses of old tuberculin. The attending general practitioner thought of doing a Mantoux first and when it was done the ocular condition got immediately worse, with severe pain in the eye, keratitis, and reduction of the vision to finger counting.
This was a definite focal reaction without much dermal reaction and confirmed our suspicion of a tuberculin hypersensitivity as the cause of his persistent irritation.
A course of tuberculin in desensitizing doses brought about a complete recovery within 5 weeks, the ultimate vision being 6/9 partial.
M. W., a European girl, aged 12 years, came on 24-5-56 with the following history. Every time she came to India she got an attack of keratitis which got cured on treatment with antibiotics. The last time when she came to India she went back to Kashmir directly, where she; got again a similar attack, but for lack of proper ophthalmic treatment facilities no anti-biotics were given till she came back to Bombay.
She was diagnosed as dendritic Keratitis and was treated elsewhere for about 2 weeks with cortisone and antibiotics with a little relief. On inquiring the history a. little further, it could be elicited that every time she came to India she was given Typhoid vaccination. At her last entry into India, before going to Kashmir she was also inoculated against typhoid and she got her ocular condition fifteen days later.
On 24-5-56 her tuberculin reaction was taken, and was very mildly positive. She was kept on cortisone applications locally, intensive vitamin therapy and penicillin and streptomycin injections. Not showing much improvement she was given ultra-violet irradiations (general) and applications of Beta rays over the cornea, 2,500 reps. over 4 days. The condition healed rapidly, and her vision came to 6/ 12 with - 4.01) with irregularity in the thickness of the cornea and superficial opacities. All other laboratory tests were negative. A Widal was not considered necessary as in the presence of a recent vaccination against typhoid, a Widal's test would have little significance.
| Comments|| |
The above five cases present some interesting points for consideration. The first two ocular conditions were caused by an attempt to discover the need for B.C.G. vaccination. In both these cases the Mantoux was strongly positive, in the second one it produced a fibrous lump at the side of injection. Evidently both these cases must have had a previous subclinical tuberculous infection of some kind from which they must have recovered, under power of their own resistance. In that process of offering resistance they developed a tissue hypersensitivity to tuberculin which became manifest when P.P.D., which does not contain the bodies of the tubercle bacilli but only their toxins, was injected intradermally to test their dermal sensitivity. In these two cases not only they developed a dermal reaction but also a delayed focal reaction in the eye, of different kinds in each eye, which will happen when the eye develops a hypersensitive state without actually suffering from the effects of it. Only when extra allergen is injected then the eye becomes involved in an allergic reaction.
The first case of interstitial keratitis took much longer to appear after the test and also to recover than the, second and in both these cases the recovery was almost complete,-vision better than 6/9 being returned to the affected eyes. It is a well-known fact that allergic scleral conditions, particularly scleritis, are comparatively rare but when they do occur are notorious for their slow recovery because of the comparatively avascular structure of the sclera. On the other hand uveal conditions are more common, at the same time more amenable to treatment.
Evidently the abundance of the vascular supply determines the frequency of a given allergic lesion and the facility it provides to treatment. An avascular structure like the cornea may offer the same transport difficulty to antigens and antibodies and other fighting forces as in the case of sclera. Allan Woods has commented on the same point in an attempt to explain the resistant nature of the cornea in developing immunity against the treponema in interstitial keratitis of congenital syphilis.
It is impossible to be dogmatic about Case III, and say that it followed a Mantoux test, nor is it possible to say that desensitization with tuberculin had anything to do with the ultimate successful termination of the operation. At the same time there is no way of proving that the detachment was not due to Mantoux. This case is presented only with a view to illustrate the possibility of obtaining a focal reaction in the eye without any dermal reaction (local) in the skin.
On the other hand in Case IV a definite hypersensitivity is established not only from the diagnostic Mantoux which gave a focal reaction but also from the therapeutic effect of tuberculin, in desensitizing doses. In the absence of streptomycin and cortisone in those- days the therapeutic value of tuberculin in this case remains unchallenged.
In the fifth case the patient's parents were inclined to believe that it was the change from a temperate to a tropical climate that was the cause of the keratitis. Amore careful history suggests that it was probably the effect of typhoid vaccination the patient received at each entry into India. In all previous attacks the condition aborted rapidly with the use of antibiotics. The last attack was so severe that a necrotic lesion of the cornea took place, starting with a dendritic pattern, and developing into an area of necrosis with diminished sensitivity.
The greater intensity of the final attack may be due to the delayed use of antibiotics under circumstances over which there was no control, or to the rendering of the patient more and more sensitive with each attack until at last the fatal attack on the cornea took place.
The perceptible improvement in this case took place about three weeks after the commencement of the inflammation in the eye and was simultaneous with the use of beta-rays and subconjunctival use of cortisone which was used previously only as a local application. This conjures up three possibilities for consideration.
(1) Assuming that this was due to a typhoidal lesion in the eye or an activation of allergy to typhoidal toxins due to a revaccination, could it be a natural termination of the pathological event, as we know the course of an average typhoidal infection is approximately three weeks.
(2) Could it be due to the cortisone that was injected subconjunctivally for the first time about 3 weeks after the lesion started, thus making the antibodies more readily available to the avascular cornea in its internal struggle for a cure ?
(3) Could it be due to the use of beta-rays ?
Taking the first possibility, it must be noted that in previous attacks the condition improved with antibiotics which were not specific for the B. typhosus group. In the final attack also chloromycetin was never used.
It must also be noted that the possible association with typhoid is a matter of assumption and there is no definite proof of the condition being typhogenic.
The first possibility however, cannot be ruled out. An actual typhoidal infection of the cornea is not known and the fact that it improved on the first two occasions with penicillin only further suggests that it may not be due to an actual typhoidal infection of the cornea.
An allergic manifestation from the toxins of the typhoid bacilli seems the more likely pathological event. As in interstitial keratitis of congenital syphilis, as commented previously, the cornea seemed to behave in exactly the same way by not getting immune with each attack. On the contrary it became more and more sensitive with each attack until at last the final attack seemed to be the worst of them all.
Yet another possibility is that the patient may have developed a sensitivity to other bacterial allergens, which sensitivity got precipitated by the vaccination and which got relieved by penicillin only in the first attacks. In the final attack penicillin and streptomycin had little effect.
As regards possibility (2), in our experience it has often been noted that in interstitial keratitis from other causes, improvement in the corneal condition begins with the subconjunctival injection of cortisone when it has persistently resisted the therapeutic effects of topical applications of the steroid. In some way subconjunctivally administered steroids appear to open the portals of the cornea to the available antibodies. This is held as an observation only but not as a clinical proof yet.
The value of application of beta-rays unfortunately becomes a matter of mere speculation as their application coincided with the use of cortisone subconjunctivally.
The conclusion one can arrive at in the fifth case is that the patient possibly developed a hypersensitive condition of the cornea from typhoid vaccination. Because of the peculiar difficulty of the cornea to retain immunity as opposed to other tissues of the body, she developed a progressively increasing hypersensitivity which resulted in a final attack with necrosis of the cornea when typhoid vaccination was given. Administration of cortisone subconjunctivally probably helped the mobilization and transport of antibodies to the cornea.
| Summary|| |
Three cases, one of deep keratitis, one of uveitis and one of detachment of the retina, probably following a Mantoux test are described. One case of exacer. bation of post operative uveitis immediately after a Mantoux appears to be the most convincing of them all. A fifth case is described in which a deep keratitis with ulceration of the cornea resulted, probably following a revaccination against typhoid.
The probable specific and non-specific allergic nature of these lesions is discussed.