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Year : 1973  |  Volume : 21  |  Issue : 3  |  Page : 121-125

Epidemic keratoconjunctivitis with corneal involvement (clinical observation of 375 cases)

Medical College Hospital, Rohtak, India

Correspondence Address:
B S Chohan
Medical College Hospital, Rohtak
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Source of Support: None, Conflict of Interest: None

PMID: 4500003

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How to cite this article:
Chohan B S, Sharma J L, Chandra P. Epidemic keratoconjunctivitis with corneal involvement (clinical observation of 375 cases). Indian J Ophthalmol 1973;21:121-5

How to cite this URL:
Chohan B S, Sharma J L, Chandra P. Epidemic keratoconjunctivitis with corneal involvement (clinical observation of 375 cases). Indian J Ophthalmol [serial online] 1973 [cited 2021 May 8];21:121-5. Available from: https://www.ijo.in/text.asp?1973/21/3/121/31396

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Table 4

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Table 2

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Table 1

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Epidemic keratoconjunctivitis is a highly communicable and distinct clinical entity encountered all over the world. 375 cases were studied in the department of ophthalmology of Medical College, Rohtak from March, 1970 to- Dec. 1972. Our observations are presented in this paper.

  Material and Method Top

Cases were selected out of the O.P.D. attendance of the department. Each case was interrogated with particular reference to epidemiology. General physical examination, oblique illuminiation and slit lamp examina­tion of the eyes were done in every case.

  Observations Top

Epidemiological Aspect.

The morbidity index of the disease was negligible during the present study. All the neighbouring states around Haryana were affected by the epidemic. Reports of this condition named as "Eye flu" were daily pouring from Delhi, Uttar Pradesh, Rajasthan and Punjab simultaneous to its spread in Haryana. In Haryana the incidence of the disease was highest during the months of May, June and July. From August onward it regressed rapidly as shown in [Table - 1].

The disease was equally common amongst males and females, however, the incidence was more in males amongst factory and mill workers. Large families, schools, colleges, vegetable shops and private clinics run by general medical practitioners and unhygienic congested living were detected as the common sources of contamination.

The mode of transmission of infec­tion in the majority of cases was infected fingers and fomites touching the eyes. Close contacts during daily working and crowded conditions added to the spread of this disease. The disease was equally common amongst urban and rural folks. Sporadic cases of the disease were observed till Dec., 1972. The disease was highly contagious and in 68 families all the members of the family were affected. Nutrition, social status and occupation did not play any role in order to check or eliminate this disease.

Clinical Aspect

The average duration of illness has been shown in [Table - 3]. The disease was bilateral in all the cases observed till Dec., 1970, but there­after unilateral as well as bilateral involvement of eyes were noticed as shown in [Table - 4]. In bilateral involvement, the second eye was usually affected after an interval of 4 to 24 hours. The complaints of foreign body sensation and sandy feeling in the eyes were universal in all the patients. 148 patients com­plained of intense itching prior to sandy feeling. Blepherospasm, photo­phobia, watery to mucopurulent dis­charge were the common complaints in the majority of the cases. Mode­rate to severe pain in the eyes was complained of by 34 patients. The interval between foreign body sensa­tion and the appearance of conjunc­tival congestion varied from 2 hours to 24 hours. The attacks of irritability were noticed at an interval of 2 days to 3 days until the disease disappeared.

The following additional complaints pertaining to other systems of the body were also observed:

Sneezing - 150 cases

Rhinorrhoea - 273 cases

Frontal headache - 152 cases

Nausea and vomiting - 12 cases

Diarrhoea - 8 cases

Rise of temperature

upto 101°F. - 89 cases

Eruptions over the body - 10 cases

Proptosis resulting from marked swelling of the lids and chemosis was present in all the cases seen during 1970. The proptosis was mild to moderate when only one eye was involved as observed in sporadic cases of 1971 and 1972. *(Eye Movements of 11 patients were painful and restricted in all the directions). Conjunctival involvement was very similar in the majority of cases examined during 1970. Out of 300 cases 290 cases showed marked chemosis of palpeberal and bulbar conjunctiva. 250 cases showed pro­minent subconjunctival haemorrhages. Bloody discharge from the eyes was seen in 10 cases. The conjunctival congestion was mild to moderate in cases noticed during the years 1971 and 1972. Pseudomembrane forma­tion and hypertrophy of conjunctiva was found in 18 cases. There was as elevation of bulbar conjunctiva near the limbus in the majority of cases. The conjunctival congestion was mild to moderate in the cases seen during the years 1971 and 1972. Lids show­ed dark red colouration in 165 cases, violet red in 85 cases and bluish in 15 cases.

These lid changes were due to ecchymosis under the skin. Excoria­tion of lid skin near the medial angle of the eyes was found in 69 cases. Pain - and tenderness limited to superolateral orbital margin was experienced by 5 patients. Examina­tion of this area through conjunctiva revealed the involvement of lacrimal gland in these cases. The involvement of cornea varied with the cases reported during the years 1970, 1971 and 1972.

Following were the corneal changes observed during the years 1970, 1971 and 1972.

The duration of corneal changes varied from 1 week to 3 weeks in the cases examined during 1970, but during 1971 and 1972, the average duration of corneal changes was from 10 days to 30 days. Permanent opacities of cornea were seen in only two cases during 1970 and 20 cases in 1971 and 10 cases in 1972. The prognosis for ultimate vision remained good in the majority of cases. Corneal sensations remained normal in all the cases.

The condition responded very well to chloramphenicol eye drops. Corti­costeroids were also used in addition to chloramphenicol eye drops after a week of the onset of disease in 55 cases. Atropine eye ointment also proved helpful where corneal changes were prominently evident.

  Discussion Top

The epidemiology of the disease has been well established throughout its long history, particularly in eastern countries where subclinical infection is common. Common use of towels, Burma sticks and multiple personal contacts are the common sources of infection for transmission to others. Minor outbreaks of infection appear from time to time in hospitals, among families, school children and in ophthalmic clinics from the use of unsterilised tonometers, eye drops and fingers, to eye transmission. According to MITSUI, TANAKA AND YAMASHITA [9] children serve as a reservoir of the agent and also a vehicle for its trans­mission to their parents and relatives.

Clinical studies of various epidemics by different workers are clearly suggestive of variable nature of the disease. [2],[10],[8],[7],[13] This fact prompted us to study the epidemiology, clinical picture and effect of various treatments on this infection during 1970 epidemic in northern part of India. The present study has shown that young adults of the age ranging from 20 years to 40 years seem to be most affected. Its rarity under 12 years as advocated by majority of workers in this field has not been found in the present study. This epidemic affected children even upto the age of 2 years.

The disease was found to be equally common in both sexes in the present epidemic, however, in majority of epidemics males and females were affected in the ratio of 2 or 3 : 1. WIENER, [12] WRIGHT, [14] CHAMBERS, [3] ITUBURU [6] claimed that the disease reaches a peak during early winter months and tapers off towards spring but our study has revealed that the infection was at the peak during the summer months i.e. May, June and July. The conjunctival symptoms and signs in the present epidemic were very similar to previous reports. [1],[4],[11] . The disease remained as bilateral entity during 1970 and unilateral in 1971 and 1972, in large number of cases [Table - 4].

The occurrence of keratitis varied in different epidemics, corneal symptoms and signs predominate in some while conjunctival in others. The corneal involvement was cent percent during our observations, how­ever, the extent and character of involvement varied greatly in a large number of cases. Conjunctivitis of moderate to severe degree was present in almost every case. Besides the involvement of eyes, excessive sneez­ing, rhinorrhoea, frontal headache, nausea, vomiting, rise of temperature, diarrhoea and eruptions over the body disappearing after 2 days to 3 days were also present in our cases. Such findings have not been recorded by any of the previous workers. Frequent instillation of chloram­phenicol eye drops was proved to be very effective to this infection. Blepherospasm and photophobia were combated efficiently and effectively by atropine and corticosteroids eye drops and ointments. Orbital cellulitis and dacryoadenitis were also observ­ed in 5 cases and these findings have not been reported by any one in literature relating to epidemic kerato­conjunctivitis.

  Summary Top

  1. The infection spread like fire in northern India during 1970 and sporadic cases were seen in 1971 and 1972.
  2. The highest incidence of the disease was during the summer season.
  3. It involved both sexes equally and was more prevalent in young adults. However some cases in youngsters under 12 years were also seen.
  4. Congested and unhygienic environments in urban and rural areas were responsible for the rapid spread of such infection.
  5. The average duration of illness in the majority of cases was from 4 days to 21 days.
  6. It was mainly bilateral during the year 1970 and unilateral during 1971 and 1972.
  7. Besides the symptoms and signs of conjunctival and corneal inflamma­tions the general constitutional symptoms, such as frontal headache, nausea, vomiting, diarrhoea, rise of temperature and skin eruptions were also present in a large number of cases in the present epidemic.
  8. Proptosis due to mild orbital cellulitis was also present in 5 cases. Inflammation of lacrimal gland was noticed in 5 cases.
  9. The infection was highly res­ponsive to chloramphenicol eye drops. However, atropine and corti­costeroids instillation also helped to combat the corneal inflammation.

  References Top

Behr, C. and Zeissler, J.: Quoted by Hogan and Crawford. Am. J. Ophthal. 25: 1059-1077, 1942.  Back to cited text no. 1
Bietti, G. B. and Bruna, F.: Epidemic keratoconjunctivitis in Italy. Am. J. Ophthal. 43: 50-57, 1957.  Back to cited text no. 2
Chambers, E. R.: Keratitis punctata superficialis. Brit. Med. Jour. 1: 750­-751, 1931.  Back to cited text no. 3
Hobson, L. C.: Acute epidemic superficial punctate keratitis. Am. J. Ophthal. 21: 1153-55, 1938.  Back to cited text no. 4
Hogan, J. and Crawford, W.: Epidemic keratoconjunctivitis. Am. J. Ophthal. 25: 1059-1077, 1942.  Back to cited text no. 5
Iturburu, J. C.: Quoted by Hogan and Crawford. Am. J. Ophthal. 25: 1059-1077, 1942.  Back to cited text no. 6
Kirkpatrich, H.: An epidemic of macular keratitis. Brit. J. Ophthal. 4: 16-20, 1920.  Back to cited text no. 7
Kirwan, E.: Epidemic superficial punctate keratitis in Bengal. Proc. All India Oph. Soc. 3: 1, 1933.  Back to cited text no. 8
Mitsui, Y., Tanaka, C. and Yama­shita, K.: Change in the constitution with age and its influence on the clinical symptoms of conjunctivitis. Am. J. Ophthal. 39: 540, 1955.  Back to cited text no. 9
Sanyal, S.: Epidemic superficial keratitis. Am. J. Ophthal. 16: 390­393, 1933.  Back to cited text no. 10
Viswalingham, A.: Epidemic super­ficial keratitis in Malaya. Brit. J. Ophthal. 25: 313-324, 1941.  Back to cited text no. 11
Weiner, M.: Keratitis punctata superficialis with report of a case. Arch. of Ophthal. 38: 120-124, 1909.  Back to cited text no. 12
Weerekon, M.: Epidemic kerato­conjunctivitis in Ceylon. Brit. J. Ophthal. 40: 691-695, 1956.  Back to cited text no. 13
Wright, R. E.: Superficial punctate keratitis. Brit. J. Ophthal. 14: 257-­291, 1930.  Back to cited text no. 14


  [Table - 1], [Table - 2], [Table - 3], [Table - 4], [Table - 5]


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