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 Table of Contents  
Year : 2014  |  Volume : 1  |  Issue : 3  |  Page : 138-141

Is topical kohl ophthalmic application associated with neonatal aseptic or bacterial conjunctivitis?

1 Department of Paediatrics, Ahmadu Bello University Teaching Hospital Zaria, Kaduna State, Nigeria
2 Department of Ophthalmology, Ahmadu Bello University Teaching Hospital Zaria, Kaduna State, Nigeria

Date of Submission17-Apr-2014
Date of Acceptance08-Jul-2014
Date of Web Publication17-Aug-2014

Correspondence Address:
Abdulkadir Isa
Department of Paediatrics, Ahmadu Bello University Teaching Hospital Zaria, Kaduna State
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/2384-5147.138942

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Background: Aseptic conjunctivitis is a recognized type of neonatal conjunctivitis which is commonly attributed to noninfective etiological agents such as chemicals, among which prophylactics used in the prevention of ophthalmia neonatorum (ON) are themselves well documented agents of aseptic neonatal conjunctivitis. In Nigeria, routine use of prophylactics in the prevention of ON remains uncommon. However, certain ophthalmic care practices with potentials for aseptic ON abound in the various communities. This study was, therefore, undertaken with a view of evaluating the role of kohl in conjunctivitis among newborns aged 0-28 days. Materials and Methods: A retrospective review of 123 neonates who presented with features of ON to the Ahmadu Bello University Teaching Hospital Zaria was conducted. Information regarding the use of kohl and the results of microscopy, culture and sensitivity evaluation of their conjunctival swabs and scrapings were extracted among others. Results: Thirty-one (25.2%) of the reviewed 123 neonates who presented with features of ON had sterile cultures of specimens obtained from their conjunctivae. Fifty-eight (47.2%) had kohl applied, while none received prophylaxis for ON. Kohl application was not significantly associated with culture isolation (P = 0.41). Conclusion: There was the prevalent use of kohl in newborns with ophthalmia. The study did not find enough evidence associating use of kohl in the etiology of ON and, therefore, calls for more extensive studies to investigate the possible relationship to enable informed policy articulation on its use or otherwise in the newborns.

Keywords: Aseptic conjunctivitis, kohl, neonate, ophthalmia neonatorum, purulent conjunctivitis

How to cite this article:
Isa A, Elsie S, Nuhu OW. Is topical kohl ophthalmic application associated with neonatal aseptic or bacterial conjunctivitis?. Sub-Saharan Afr J Med 2014;1:138-41

How to cite this URL:
Isa A, Elsie S, Nuhu OW. Is topical kohl ophthalmic application associated with neonatal aseptic or bacterial conjunctivitis?. Sub-Saharan Afr J Med [serial online] 2014 [cited 2024 Mar 2];1:138-41. Available from: https://www.ssajm.org/text.asp?2014/1/3/138/138942

  Introduction and literature review Top

By definition, neonatal conjunctivitis or ophthalmia neonatorum (ON) characterized by edema of the eyelids, conjunctival discharge and hyperemia of the inferior palpebral conjunctiva, presents during the first 28 days of life and may be septic or aseptic. [1],[2] Septic neonatal conjunctivitis is infective in origin and can be caused by a wide range of microorganisms ranging from mainly bacteria to viruses and rarely fungi. These organisms are acquired in utero via ascending infection from cervix and vagina; at delivery during passage through infected birth canal or via postpartum contact. [1],[2] Aseptic neonatal conjunctivitis, on the other hand, is of noninfective origin and has often been related to chemical conjunctivitis that results from reaction to prophylactic agents instilled into the eyes of the newborn at birth to prevent bacterial ON. [1] Silver nitrate solution remains the most documented cause of aseptic neonatal conjunctivitis and has been reported to occur in 10-100% of neonates who received this prophylaxis during the first 24 h of life. [3],[4] It presents as a mildly purulent conjunctivitis, which usually resolves within 48 h. [1],[2],[3],[4]

In Nigeria, traditional newborn care practices include among others the application of kohl locally known as "kwalli" to the eyes of the newborn. In older infants, children and women reasons for applying kohl ranged from beautification to protection and treatment of various eye ailments. [5],[6],[7] Compositions of products used as kohl, both refined and crude are greatly varied and include metals such as lead, aluminum, antimony, carbon, iron, and zinc compounds, while others contain camphor and menthol. [7],[8],[9],[10],[11],[12] In the adult population, the use of some of these agents have been attributed to numerous complications. [10],[11],[12],[13] The use of such agents has inherent potentials of inducing chemical irritation to the delicate neonatal conjunctivae and may possibly serve as a medium of introducing infection if contaminated or potentiate dissemination when it induces inflammation.

In developing countries, information on sources and compositions of these substances are sparse, and information on their use in newborns remains unavailable. In Nigeria, there has not been any such documentation in newborns to the best of our knowledge. We, therefore, conducted a retrospective review of all newborns consulted and managed as cases of ON in a tertiary health facility in Northwestern Nigeria over a 6-month period to evaluate the role of kohl in conjunctivitis among newborns.

  Materials and methods Top

The study is a retrospective descriptive review of cases seen over a 6-month period at the Ahmadu Bello University Teaching Hospital (ABUTH) Shika Zaria, a tertiary hospital in Northwestern Nigeria. Information was extracted from data systematically collected on 123 neonates aged 0-28 days who presented with eye discharge with or without conjunctival hyperemia and or eyelid edema. Data on age, sex, kohl application, results of eye secretion microscopy and culture laboratory evaluation for bacteria and Chlamydia were reviewed. All swabs of eye secretion and conjunctival scrapings from subjects were analyzed in the microbiology laboratory of ABUTH. In the laboratory, conjunctival scrapings were fixed and stained with freshly prepared Giemsa solution from the stock solution in 1:40 using the standard technique while swab specimens collected were immediately inoculated onto chocolate, blood and McConkey's agars. To promote growth of any organism in the specimen, these plated culture media were incubated at 37°C over 24 h. The chocolate agar plates were incubated in 5% carbon dioxide using candle extinction jars. Isolates were subjected to secondary Gram-staining and biochemical testing. Antibiotic sensitivity testing was by standard disc diffusion technique.

Data obtained were analyzed using Epi Info version 3.5.0. Frequency tables and charts are used appropriately to illustrate data. Chi-square test was used to compare the frequencies of discrete variables and a P < 0.05 was considered as statistically significant in comparative analyses. Study approval was obtained from the medical ethical and scientific committee of ABUTH.

  Results Top

One hundred and twenty-three neonates with ON were reviewed. The age distribution at presentation is shown in [Figure 1]. The mean age at presentation was 13.2 ± 8.5 days. None of the neonates received silver nitrate prophylaxis for ON at birth. Sixty five (52.8%) of these neonates were females while fifty eight were males giving a male:female ratio of 1:1.1. A total of 58 (47.2%) of the 123 reviewed neonates had kohl application [Table 1] comprising twenty nine each accounting for 44.6% and 50% of the female and male neonates respectively. There was no significant sex difference in kohl application (χ2 = 0.36 and P = 0.59). Thirty one (25.2%) neonates had no organism isolated from their eye swabs or conjunctival scrapings and of these, 17 (55%) had kohl applied to their conjunctivae while the remaining did not. Kohl application, was not found to be significantly associated with the onset of symptoms within the first 24 h of life (P = 0.27). Forty-one (71%) of the 58 neonates who had kohl applied had organisms isolated from their conjunctivae, while the others had sterile cultures. On the other hand, 51 of the 65 neonates who had no kohl application had organisms isolated from their conjunctivae while 14 had sterile cultures. Kohl application was not significantly associated with culture isolation (P = 0.41). Thirty (24.4%) of the 123 neonates had received some form of treatment before presentation. Twenty-three (77%) of these 30 neonates received various types of topical and oral antibiotics, while the remaining 23% had breast milk applied topically. None of the neonates had kohl or other traditional concoction applied as a form of treatment for ON.
Figure 1: Age distribution of neonates with ophthalmia neonatorum

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Table 1: Kohl application versus age at onset of symptoms and isolate status in neonates with ON

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  Discussion Top

The use of kohl was found to be prevalent in this study as it was used on about half (47.2%) of the studied neonates. This shows significant use of this agent in newborns. There haven't been previous studies documenting the use of kohl in newborns in this part of the world. Though the study did not elicit the specific reasons for its use, it was, however, noted that none of the subjects had it applied as a therapy for ON. Other studies in women have documented beautification, protection from and treatment of eye ailments as reasons for use of kohl. [5],[6],[7] It could be speculated that the use of kohl in this study was probably for beautification or protection of the newborn's eyes from eye ailments possibly including ON. The documented risk [10],[11],[12] of high blood lead levels, toxicity and attendant sequelae to which users of kohl are exposed suggest that about half of our newborns may be potentially at risk. This is irrespective of their sex as it was found that the use of such agents, unlike in the adults where females were most users, was not sex related as its usage was not significantly related to sex of the neonate.

Aseptic conjunctivitis that is noninfective, is commonly encountered with the use of prophylactic agents and presents within the first 24 h of life. In this review, none of the subjects had any form of orthodox ophthalmia prophylactics employed. However, 1 out of every 4 neonates had aseptic conjunctivitis. The possible use of kohl as a nonorthodox prophylactic may have been associated with aseptic conjunctivitis in the study subjects though, there wasn't enough evidence associating kohl application with conjunctivitis occurring from the 1 st day of life to suggest chemical conjunctivitis. This may have resulted from the unavailability of information on when specifically the commencement of kohl application began such that it is possible that conjunctival irritation may have begun within 24 h of its application at any age and not necessarily within the first 24 h of life. On the other hand though 71% of the neonates who had kohl applied had organisms isolated from their conjunctivae, suggesting that a high number of neonates in whom kohl was applied had infective conjunctivitis. However, when compared with 78% who did not have kohl applied but had positive isolates; the use of kohl was not found to be significantly associated with isolation of organisms. This implies that there was no sufficient evidence to associate the use of kohl with infective conjunctivitis in the study. It is possible however; that the kohl used was inherently contaminated with infective organisms or played a potential role in establishing infection in the conjunctiva but could not be significantly associated with infective conjunctivitis due to the study design. Being a retrospective review of data it was not possible to confirm whether those who did not have kohl applied ever had it applied then stopped, could not recall or denied its application particularly if they strongly felt blameworthy and these could have contributed to our finding. Conversely the fact that the culture for isolates in the conjunctival samples of the study subjects did not include viral cultures could also mean that some of the cases of aseptic conjunctivitis were possibly of viral etiology.

Overall being a retrospective review of cases it is limited in evaluating the association of kohl with ON. Employing a case control study design with a larger sample size evaluating in details the onset, pattern and reason of kohl use in the newborn coupled with culturing the kohl substance will be required to document possible association between use of kohl and ON.

  Conclusion Top

There was the prevalent use of kohl in newborns with conjunctivitis. The study did not find enough evidence associating use of kohl in the etiology of ON and, therefore, calls for more extensive studies to investigate the constituents of the prevalently used agents and evaluate their possible relationship with ON to enable informed policy articulation on their use or otherwise in the newborns.

  References Top

1.Mallika PS, Asok T, Aziz S, Faisal HA, Tan AK, Intan G. Neonatal conjunctivitis - A review. Malays Fam Physician 2008;3:77-81.  Back to cited text no. 1
2.Palafox SK, Jasper S, Tauber, Allyson D, Foster SC. Ophthalmia neonatorum. J Clin Exp Ophthalmol 2011;2:119.  Back to cited text no. 2
3.Isenberg SJ, Apt L, Del Signore M, Gichuhi S, Berman NG. A double application approach to ophthalmia neonatorum prophylaxis. Br J Ophthalmol 2003;87:1449-52.  Back to cited text no. 3
4.Credé. Reports from the obstetrical clinic in Leipzig. Prevention of eye inflammation in the newborn. Am J Dis Child 1971;121:3-4.  Back to cited text no. 4
5.Mohta A. Kajal (Kohl)-A dangerous cosmetic. Oman J Ophthalmol 2010;3:100-1.  Back to cited text no. 5
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6.Nnorom IC, Igwe JC, Oji-Nnorom CG. Trace metal contents of facial (make-up) cosmetics commonly used in Nigeria. Afr J Biotechnol 2005;4:1133-8.  Back to cited text no. 6
7.Al-Ashban RM, Aslam M, Shah AH. Kohl (surma): A toxic traditional eye cosmetic study in Saudi Arabia. Public Health 2004;118:292-8.  Back to cited text no. 7
8.Parry C, Eaton J. Kohl: A lead-hazardous eye makeup from the Third World to the First World. Environ Health Perspect 1991;94:121-3.  Back to cited text no. 8
9.al-Hazzaa SA, Krahn PM. Kohl: A hazardous eyeliner. Int Ophthalmol 1995;19:83-8.  Back to cited text no. 9
10.De Caluwé JP. Lead poisoning caused by prolonged use of kohl, an underestimated cause in French-speaking countries. J Fr Ophtalmol 2009;32:459-63.  Back to cited text no. 10
11.Alkhawajah AM. Alkohl use in Saudi Arabia. Extent of use and possible lead toxicity. Trop Geogr Med 1992;44:373-7.  Back to cited text no. 11
12.Al-Saleh I, Nester M, DeVol E, Shinwari N, Al-Shahria S. Determinants of blood lead levels in Saudi Arabian schoolgirls. Int J Occup Environ Health 1999;5:107-14.  Back to cited text no. 12
13.Nir A, Tamir A, Zelnik N, Iancu TC. Is eye cosmetic a source of lead poisoning? Isr J Med Sci 1992;28:417-21.  Back to cited text no. 13


  [Figure 1]

  [Table 1]


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