Year : 1981 | Volume
: 29 | Issue : 4 | Page : 401--405
Madan Mohan, G Mukherjee
Dr. Rajendra Prasad Centre for Ophthalmic Sciences A.I.I.M.S., New Delhi, India
Dr. Rajendra Prasad Centre for Ophthalmic Sciences A.I.I.M.S., New Delhi - 29
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Mohan M, Mukherjee G. Meibomian keratitis.Indian J Ophthalmol 1981;29:401-405
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Mohan M, Mukherjee G. Meibomian keratitis. Indian J Ophthalmol [serial online] 1981 [cited 2020 Jan 25 ];29:401-405
Available from: http://www.ijo.in/text.asp?1981/29/4/401/30940
Keratitis caused by specific organisms and its management by specific antibiotics is well documented in the literature. In some cases exact etiology cannot be established inspite of repeated smear and culture examination. Acute keratitis can become chronic and, or non responsive to specific therapy. Management of such cases is a challenge to ophthalmologist.
METHOD AND MATERIAL
Cases of keratitis acute and chronic, non responsive to specific therapy were studied for their etiopathogenesis and management. 2095 cases of keratitis were seen in the cornea clinic (1974-1978) at Dr. Rajendra Prasad Centre for Ophthalmic Sciences. 1588 cases (75.79%) were due to specific organisms [Table 1] and 507 cases (24.21 %) were of nonspecific keratitis. 395 cases (18.85%) of specific sub-acute & chronic keratitis and 301 cases (14.37%) of nonspecific chronic keratitis were associated with meibomitis i.e., a total of 696 cases (33.22%) showed poor to no response to the medical treatment. In all these cases further detailed investigations were carried out. pH of conjunctival secretion, break up time (B.U.T.) of tear film, Schirmer's Test and microbiological study were carried out. Cases of keratitis which failed to respond to medical treatment were subjected to therapeutic keratoplasty and corneal buttons were studied by culture and histopathological examination.
Out of 395 cases of specific keratitis 136 cases (34.44%) were of bacterial, 41 cases (10.38%) viral, 163 cases (41.26%) fungal and 55 cases (13.92%) mixed infection [Table 1].
In the group of nonspecific keratitis of 301 cases, in 109 cases (36.22%) staph. albus could be isolated. Diphtheroid 16 (5.32%), Micrococci 14 (4.65%), Mixed organisms 18 (5.98%) could also be isolated from the corneal scrappings. No organisms could be detected in 101 cases (33.55%), 43 cases (14.28%) were of dry eyes and culture were sterile [Table 2]. Sensitivity to antibiotics were studied, pattern of antibiotics sensitivity has been shown in [Table 3].
pH was acidic in 158 cases (59.84%) of specific keratitis and 185 cases (61.46%) of nonspecific keratitis, normal in 63 cases (23.86%) of specific keratitis and 69 (22.92%) cases of nonspecific keratitis, Alkaline in 43 cases (16.28%) of specific Keratitis and 47 cases (15.61%) nonspecific [Figure 1].
In dry eye group of 43 cases Schirmers test revealed subnormal response in 37 cases (86.04%) and marked deficiency in 6 cases (13.96%) [Figure 1]. Break up time of Tear film revealed subnormal (Less than 30 sec.) in 34 cases (79.06%) and poor (i.e. less than 20 sec.) in 9 cases (20.94%) [Figure 1]. Corneal sensitivity was normal in all cases.
85 non responsive cases were subjected to therapeutic keratoplasty and corneal buttons were subjected to bacterial and mycotic culture, a detailed histopathological studies by various special stains were carried out. Results are shown in [Table 5].
All these cases were sterile on culture examination. Histopathology of 26 cases showed signs of acute keratitis with loss of substance and few blood vessels. Other 59 cases showed signs of chronic keratitis with vascularisation and thickening of cornea, no organisms could be seen.
Basic principle of management were directed on the following lines.
(i) To combat infection by suitable antibiotic based on sensitivity studies even for the so-called saprophytic organism.
(ii) Correction of pH.
(iii) Mechanical expression of the meibomian secretion after hot fomentation.
(iv) Methyl cellulose solution to combat dryness of eyes.
(v) Vitamin A & D capsules O.D. for 2 weeks.
The following treatments were given in clinic and advised to be carried out at home: (i) Hot fomentation was given by dry or moist heat or by infra red heat for ten minutes. (ii) The eyes were washed with soda. bicarb. lotion 5 % twice daily for patients with pH less than 6.8 and boric acid lotion in cases of pH above 7.2. (iii) Lid massage was given under 4% topical lignocain hydrochloride using Mohan's lid clamp and lid spatula specially designed for the purpose [Figure 2]. The patient was advised to carry on lid massage three times a day by gently pressing the lid against eye ball to squeez out the secretions of meibomian glands (iv) Lid margins were painted with sodium sulphacetamide 30%. It was followed by sodium sulphacetamide 20% drops three times a day in cases where culture was sterile and proper antibiotics for other cases.
(v) Methyl cellulose (0.7%) drops were prescribed in cases with dry eyes (vi) Vitamin A and D capsules was given daily for 4 weeks.
Above treatment was given in the Clinic, daily or on alternate days, for 4 to 6 sittings. Home treatment was prescribed for 2 to 4 weeks. Results of the treatment of 696 cases of subacute & chronic keratitis with meibomitis are shown in the [Table 4]. 489 cases (70.26%) responded to the treatment and were cured, 150 cases (21.55%) became refractory. Out of 157 cases of nonspecific keratitis in which saprophytic organisms were cultured 91 cases responded to the treatment. 35 cases which had subnormal conjunctival secretions also responded to the treatment. However, 85 cases did not respond to above treatment were subjected to therapeutic keratoplasty and were cured. 6 patients of dry eye improved with soft contact lens.
Cases of subacute and chronic recurrent keratitis with meibomitis were studied for their etiopathogenesis and management.
In the present series a large number of cases of corneal ulceration and chronic keratitis had moderate to severe meibomitis. It was felt that meibomitis is one of the contributory factors in causation and non healing of keratitis. The cases of specific keratitis responded well to the specific antibiotic treatment for the first few days, but failed to bring about complete cure in cases where meibomitis was present. The initial response was due to control of infection. The slowing of progress and refractory chronic course suggests the role of meibomitis in delaying healing of keratitis.
These cases responded dramatically with the treatment suggested above. Many cases which would have lingered on with subacute or chronic keratitis could thus be cured by this treatment. Therapeutic keratoplasty is required in a small percentage of cases in nonspecific chronic keratitis if proper medical treatment is instituted.
It is also evident from this study that pH of the conjunctival secretion, (B.U.T.) are altered in cases of meibomitis. Saprophytic organisms like staphylococcus albus, micrococci and diphtheroids have been found more often in cases of chronic keratitis associated with meibomitis. It is not possible to say if these organisms are responsible for both pathology or whether these so called saprophytic organisms assume pathogenecity in the presence of meibomitis or altered tear film. The alterations are brought about by meibomitis in the pH of tear secretions and tear film constitution and its stability. We have observed that response to the treatment is dramatic when simultaneous, correction of pH tear film physiology and control of infection is attempted.
A shift of the acidic pH has been noted in majority of cases of chronic nonhealing keratitis, particularly those associated with meibomitis. Correction of pH to neutral level by Sod. bicarb. lotion helped in both symptomatic relief and early healing of keratitis.
Staphylococcus albus, diphtheroids and micrococci are known as saprophytic organisms in conjunctival sac. Their occurrence in large number of cases of keratitis raised doubt to their being purely of saprophytic nature. Specific treatment after culture and sensitivity test with antibiotics helped in rapid improvement.
A thorough investigation in chronic indolent keratitis is indicated to find out such factors. Appreciation of all these factors and their correction by suitable treatment gives satisfactory results.