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Corneal Ulceration, Measles, and Childhood Blindness in Tanzania

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Corneal Ulceration, Measles, and Childhood Blindness in Tanzania Br J Ophthalmol: first published as 10.1136/bjo.71.5.331 on 1 May 1987. Downloaded from British Journal of Ophthalmology, 1987, 71, 331-343 Corneal ulceration, measles, and childhood blindness in Tanzania ALLEN FOSTER' AND ALFRED SOMMER2 From the 'Eye Department, Mvumi Hospital, Dodoma, Tanzania, and the 2ICEPO, Dana Centre for Preventive Ophthalmology, Johns Hopkins Medical Institution, Baltimore, USA SUMMARY One hundred and thirty Tanzanian children with corneal ulceration were clinically examined to determine the cause of the ulceration. 37% of the ulcers were associated with recent measles infection and 38% of the children had bilateral ulceration. Herpes simplex virus infection was the commonest cause of ulceration in the series, but vitamin A deficiency was the major cause of bilateral ulceration, subsequent blindness, and mortality in this series. Other significant causes of childhood corneal ulceration were the use of traditional eye medicines, confluent measles keratitis, and ophthalmia neonatorum. We discuss the various mechanisms by which measles causes corneal ulceration, and the priorities in prevention and management of corneal ulceration in African children. Xerophthalmia, a term used to describe the ocular department of Mvumi Hospital in Central Tanzania findings caused by vitamin A deficiency, remains one between October 1981 and June 1985. of the six commonest blinding diseases in the world All the children were admitted to hospital and http://bjo.bmj.com/ today and the commonest cause of blindness in basic demographic and historical information docu- children.' 2 mented on a standard form. This included name, age, The problem of childhood blindness due to xero- sex, village of residence, date ulcer first noted, phthalmia has been well established in Indonesia3 history of measles, use of traditional eye medicines, and other parts of Asia."7 In Africa, however, recent diet, and history of night blindness. Ocular although 70% of blind school children are blind from examination with a handlight, lid speculum, fluor- corneal scarring,""' there is still uncertainty over the escein, and, in co-operative children, slit-lamp relative importance and interaction of factors such as microscopy was performed, and photographs were on September 28, 2021 by guest. Protected copyright. measles infection," vitamin A deficiency, 2-8 herpes taken of the corneal ulcers. Nutritional status was simplex keratitis,"' " and the use of traditional eye determined by comparing their weight for age against medicines82122 in causing childhood ulceration and the Harvard standards. The child was considered corneal blindness. normal (well nourished) if his weight for age was To investigate this problem we carried out a greater than 80% of standard, underweight if hospital based study with the aim of identifying by 60-80% of standard, and marasmic if less than 60% clinical means: (1) the major causes of corneal weight for age. ulceration in Tanzanian children, (2) the mechanisms For this special investigation serum samples were by which measles may lead to corneal ulceration, and drawn for chemical analysis on 41 consecutive cases (3) the major pathways leading to blindness from of the 130 cases in this report. They were also corneal scarring in children. obtained from three controls for each of the children with a diagnosis of measles-associated xerophthalmic Patients and methods corneal ulceration, matched on age, sex, and the presence of measles. The serum was kept frozen until One of us (AF) examined 130 children aged 4 days to shipment to Baltimore, where it was analysed by 10 years presenting with corneal ulceration to the eye high-performance liquid chromatography (HPLC). Corrcspondencc to Allen Foster, International Centre for Eye These values were not used in arriving at the clinical health, 27-29 Cayton Street, London ECI V 9EJ. diagnosis. 331 Br J Ophthalmol: first published as 10.1136/bjo.71.5.331 on 1 May 1987. Downloaded from 332 Allen Fosterand Alfred Sommer * --I- A<4~tz. .X l Fig. 2 Case 1. Right eye ofa 2-year-oldgirlfollowing nine days' treatment with IDU. The ulcerhas healed, leaving a superficial cornealscar. was continued or modified according to the protocol. At discharge a final diagnosis of the aetiology of the Fig. 1 Case 1. Right eye ofa2-year-old-girl, showing an corneal ulcer was made based on the history, the irregular corneal ulcer with severe corneal vascularisation. clinical appearance of the ulcer, and the response to specific therapy under supervision, as shown in the following case presentations. From the history and morphological appearance of the ulcer2 24 a provisional diagnosis was made. Case reports Specific treatment was then initiated according to the following protocol: CASE 1 Diagnosis Treatment A 2-year-old girl was admitted with a painful red right http://bjo.bmj.com/ Herpes simplex Idoxuridine 0-1% drops hourly or 0-5% eye of at least two weeks' duration. There was no ointment, 5 times daily. had received Xerophthalmia Vitamin A 200000 IU oral stat, repeat history of measles infection, but she after 1 day and 1 week. chloramphenicol drops for one week to her right eye. Bacterial ulcer Chloramphenicol 1% drops hourly, On examination she was well nourished, with a with or without 20 mg subconjunctival normal left eye. The right eye showed an irregularly gentamicin. shaped linear ulcer in the inferonasal quadrant with Trachoma Tetracycline 1% ointment 3 times a day. Ophthalmia neonatorum Chloramphenicol 1% drops hourly, surrounding stromal oedema and marked vasculari- on September 28, 2021 by guest. Protected copyright. with tetracycline 1% ointment 3 times a sation. There were also several small areas of super- day. ficial staining temporally. There was no perforation Exposure keratopathy Tetracycline 1% ointment stat with eye pad for 1 day. (Fig. 1). She was treated with 0.5% idoxuridine Traditional eye medicines Chloramphenicol 1% drops hourly, (IDU) ointment five times a day and gradually with hydrocortisone 1% drops 3 times a improved. Treatment was stopped after nine days, day after 48 hours. leaving a residual partial-thickness, nasally situated The child continued to receive a normal diet from corneal scar (Fig. 2). Three days later a small area of the mother unless there was evidence of severe staining recurred which was successfully treated with undernutrition, in which case additional food was a further five days' course of IDU. given in the form of dried skimmed milk, eggs, and Diagnosis. Herpes simplex ulceration of the right oil. Children with diarrhoea received oral rehydra- cornea. tion therapy and children with respiratory infections received systemic antibiotics, usually procaine CASE 2 penicillin. Preparations containing multivitamins A 20-month-old boy was admitted on 14 April 1984 were not given. with a three-week history of measles. There was no After 24, 48, and 72 hours the child was re- history of night blindness, and the mother denied examined, and, depending on response to therapy using traditional eye medicines. On examination he and clinical appearance of the ulcer, the management was marasmic. The right eye showed limbus-to- Br J Ophthalmol: first published as 10.1136/bjo.71.5.331 on 1 May 1987. Downloaded from Corneal ulceration, measles, and childhood blindness in Tanzania 333 *.... "al. Fig. 5 Case3. Left eye ofan 18-month-old boy showing cornealxerosis and localised areas ofstromal necrosis. Fig. 3 Case 2. Right eye ofa20-month-old boy with measles and marasmus. There is limbs to limbus corneal necrosis pneumonia, at which time the right eye was develop- with a central cornealperforation. ing a staphyloma and the left eye was phthsical. Serum vitamin was 40 sg/l (normal 200 Rg/l or limbus corneal necrosis with perforation of the above), and serum albumin 29 g/l (normal 40 g/l). central cornea (Fig. 3). The left eye showed slough- Diagnosis. Postmeasles marasmus, with bilateral ing of the cornea with prolapse of iris and vitreous corneal ulceration due to vitamin A deficiency. (Fig. 4). The child was treated with oral vitamin A, frequent calorie-protein rich meals, and systemic CASE 3 http://bjo.bmj.com/ antibiotics. He died 10 days after admission of An 18-month-old boy was admitted on 24 October I on September 28, 2021 by guest. Protected copyright. Fig. 4 Case 2. Left eye ofa 20-month-old boy with measles Fig. 6 Case3. Same as Fig. 5, five days after treatment with and marasmus. There is complete sloughing ofthe cornea vitamin A. The cornea is now clear, and the areas ofstomal with prolapse ofiris and vitreous. necrosis have healed with scarformation. Br J Ophthalmol: first published as 10.1136/bjo.71.5.331 on 1 May 1987. Downloaded from 334 Allen Foster and Alfred Sommer vitamin A therapy, with improvement after 48 hours and healing with scar formation after five days (Fig. 6). Serum vitamin A was 20 ,ug/l (normal above 200 ,ug/l), and serum albumin 28 g/l (normal 40 g/l). Diagnosis. Corneal ulceration due to vitamin A deficiency. CASE 4 A 10-year-old girl was admitted with bilateral pain- ful red eyes following the use of traditional eye medicines. There was no history of measles and the patient was well nourished. The mother had paid for the traditional doctor to apply 'boiled green herbs' to the girl's eyes because her eyes were red and discharging pus. After the use of the traditional eye medicines her eyes became more painful and blind. On examination both eyes were very red with swollen lids. There were three areas of iris prolapse in the right eye (Fig. 7) and a small corneal perforation with .'...I iris prolapse in the superotemporal quadrant of the left eye (Fig. 8). The patient was treated with local antibiotics, and later hydrocortisone drops were Fig. 7 Case 4. Right eye ofa JO-year-old girl ajier application oftraditional eye medicines.
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