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Year : 2021  |  Volume : 9  |  Issue : 2  |  Page : 71-74

Study of prevalence of preventable keratitis, seasonal variation, and microbiological etiology along with quack practice in a Tertiary Eye Care Center in Maharashtra - Central India

1 Consultant and In Charge Head Cornea, Cataract and Refractive Services, Jalna, Maharashtra, India
2 Shri Ganapati Netralaya, Jalna, Maharashtra, India

Date of Submission28-May-2019
Date of Decision06-May-2021
Date of Acceptance25-May-2021
Date of Web Publication31-Jul-2021

Correspondence Address:
Namrata Kabra
Shri Ganapati Netralaya, Devalgaonraja-Mantha Road, Jalna - 431 203, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jcor.jcor_31_19

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Purpose: The purpose of the study is to evaluate the prevalence of preventable keratitis, seasonal variations, and microbiological etiology along with quack practices presented at a Tertiary Eye Care Center in Maharashtra (Central India), over a period of 1 year. Materials and Methods: A retrospective study of microbiology of corneal scraping reports in infectious keratitis cases from July 17, 2017 to June 17 2018. Incidence of bacterial and fungal keratitis and culture growth were analyzed for seasonal pattern. Type and frequency of quack practice in the patients were analyzed as well. Results: Among the 795 infectious keratitis cases, culture growth was positive in 322 (40.5%) samples; 258 (80.1%) and 64 (19.9%) were of fungal and bacterial etiology, respectively. The predominant fungal organism was Fusarium Spp. (61.2%) and the predominant bacteria organisms were Streptococcus spp. and Nocardia with (28.1/%) each. Seasonal statistics showed peak in infectious keratitis in rainy seasons with higher incidence of fungal keratitis. It was seen that in 50% of the participants, trauma was the predisposing factor. Six percent of the patients had a history of quack practice from which 53% removed the foreign body with the tip of the tongue. Conclusions: Infectious keratitis is a common problem in central India, with fungal being the most common etiology with surge in rainy season. A significant number of patients still prefer traditional ways of treatment hence awareness and basic knowledge can prevent blindness caused by preventable infectious keratitis.

Keywords: Infectious keratitis, quack, seasonal

How to cite this article:
Kabra N, Mussaji S, Hande SG. Study of prevalence of preventable keratitis, seasonal variation, and microbiological etiology along with quack practice in a Tertiary Eye Care Center in Maharashtra - Central India. J Clin Ophthalmol Res 2021;9:71-4

How to cite this URL:
Kabra N, Mussaji S, Hande SG. Study of prevalence of preventable keratitis, seasonal variation, and microbiological etiology along with quack practice in a Tertiary Eye Care Center in Maharashtra - Central India. J Clin Ophthalmol Res [serial online] 2021 [cited 2023 Mar 24];9:71-4. Available from: https://www.jcor.in/text.asp?2021/9/2/71/322791

  Introduction Top

Corneal blindness is a major public health problem globally, and infectious keratitis is one of the major causes.[1] The epidemiological pattern and causative agents for infective keratitis vary from country to country and also from region to region within the same country.[2]

In a vast agricultural country like India, particularly in rural areas where primary health care and referral systems are weak, minor eye injuries sustained in agricultural farms often lead to infectious corneal ulceration which are usually preventable and hence causing loss of vision. Alongside with the lack of primary health care, some urban areas and many of the rural areas have quacks still practicing the traditional ways to treat such minor injuries causing a higher risk for corneal ulceration. Volume of quack practice is high due to lack of knowledge and awareness.

The aim of this study was to evaluate the prevalence of preventable keratitis, the seasonal variations, and microbiological etiology along with quack practices presented at a Tertiary Eye Care Center in Maharashtra (Central India), over a period of 1 year from July 17, 2017, to June 17, 2018. There was also an attempt to search for the predisposing factor for the development of keratitis such as trauma and quack practice. Effort was taken to identify the specific organism in culture-positive cases.

  Materials and Methods Top

A retrospective study was carried out to attain the outcome; participants were selected from a time period of July 17, 2017–June 17, 2018. Institutional ethics committee clearance was sought. Records of patients with a diagnosis of corneal ulcer who underwent corneal scraping were retrieved within the time given, and each record was searched and filtered out on the basis of history given and corneal scrapings. Patients who presented with corneal ulcer and underwent corneal scraping were included in the study. On the other hand, patients who denied corneal scrapping were excluded from the study.

The patient records included a thorough and complete ophthalmological examination including visual acuity and refraction, slit-lamp examination, and fundus evaluation which were, however, not included specifically in this project. Corneal scrapings were taken under slit-lamp magnification with strict aseptic precautions which were further subjected to gram stain and potassium hydroxide mount if necessary. Culture reports were retrieved from microbiology laboratory of our hospital at the next follow-up of patient at 1 week.

  Results Top

A total of 795 patients were included in the study. Within a time period of 1 year, there were 85,599 number of patients which presented at the primary eye care center, out of which 795 underwent corneal scrapings and culture growth was retrieved for the same.

All corneal scrapings underwent direct microscopy (DM), and culture growth was further analyzed. The DM findings were categorized into five groups: fungal, bacterial, mixed (both fungal and bacterial involvement), other (microsporoidal and Nocardia), and no organism. On DM out of 795 samples, 343 (43%) were noted to be fungal filaments, 286 (36%) were bacterial in nature, 116 (15%) had both fugal and bacterial components, and 33 (4%) samples were reported to have no organism.

The statistical data for culture growth showed that out of 795 samples, culture growth was seen in 322 (40.5%) samples. Out of which 258 (80.1%) were fungal species, 46 (14.3%) were bacterial species and 18 (5.6%) were other atypical growth which included Nocardia and its species (Nocardia asteroids). The remaining 473 (59.5%) showed no culture growth. The culture organisms under each are shown in [Table 1].
Table 1: Statistical analysis for the culture organisms

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Seasonal statistics showed that the maximum number of patients presented at the eye care center was in the rainy seasons which is between June and September (n = 340, 43%) followed by in summer which is between February and May (n = 231, 29%), and finally, the least patients were seen in winter between October and January (n = 224, 28%). The DM seen in each season is tabulated in [Table 2].
Table 2: Number and percentage of patients seen and direct microscopy findings for each season

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Predisposing factors were ruled out to evaluate the number of patients who had some form of trauma. The analysis showed that 400 (50%) had trauma as their predisposing factor, keratitis was caused in 28 (3%) patients due to systemic conditions such as high fever and nonocular Herpes Simplex/Herpes Zoster Virus infection, keratitis secondary to ocular conditions such as entropion, trichiasis, and conjunctivitis was seen in 17 (2%) patients, 4 (1%) patients had keratitis following eye surgeries such as penetrating keratoplasty, and the rest 355 (44%) had no known predisposing factor.

Most common organism on microscopy isolated from preexisting ocular conditions was suggestive of bacteria n = 13 (76.4%) in cases associated with preexisting ocular conditions. Whereas most common species could not be identified as there was no growth on culture in most of them.

Subdivision on type of trauma was further analyzed, it showed that 164 (41%) had a history of blunt trauma (example with hand, punch, and finger), 102 (26%) had some FB/particle gone into the eye, 96 (24%) had a history of trauma with some vegetative matter, 17 (4%) had a history of chemical injuries, 9 (2%) patients had a history of trauma with penetrating objects (example nail, thorn, and glass), 9 (2%) patients had trauma with unknown objects, and finally, 3 (1%) patients had a thermal injury.

The breakdown for DM and culture for blunt trauma are given in [Table 3], and the breakdown for DM and culture for trauma with vegetative matter are given in [Table 4]. Overall, we could not observe any specific association between mode of injury and particular organism except for the fact that fungus was more than bacteria on DM.
Table 3: Breakdown for direct microscopy and culture for blunt trauma

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Table 4: Breakdown for direct microscopy and culture for trauma with vegetative matter

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Out of the 795 patients, 47 (6%) patients had a history of quack practice. All of them had some form of traumatic history out of which 4 (8.5%) was of vegetative nature, and the kind of method used to remove the foreign particle from the eye was also noted and was seen that: 25 (53%) particles were removed with the tongue, 10 (22%) particles were removed with cotton wick, 5 (11%) particles were removed with butter, 1 (2%) particle were removed with garlic paste, 1 (2%) particle was removed with the help of a hollow tube, 1 (2%) particle was removed with milk, 1 (2%) particle was removed with water, 1 (2%) particle was removed by rubbing the eye, 1 (2%) particle was removed with the help of a sugar stone, and 1 (2%) particle was removed by some unknown method.

Out of these 47 patients, 25 (53.2%) patients had culture growth, 20 patients (80%) were fungal, and 5 patients (20%) were bacterial species.

The microbiology of those 25 patients who had foreign particles removed with tongue showed a culture growth in 15 patients (60%) out of which 11 (73.3%) were fungal and 4 (26.7%) were bacterial. The remaining 10 (40%) showed no culture growth.

  Discussion Top

Based on DM, it was seen that in Central Maharashtra, fungal etiology was predominant (43%) among infectious keratitis. A similar result by Bharathi et al. in a study in South India was found where their fungal etiology was 34.4%.[1] Other studies showed a similar incidence of fungal keratitis was 32% in East India and 38.9% in West India. However, in North India, the incidence was only 7.3% which differed from the rest.[3],[4],[5] This regional variation could be because fungal keratitis is expected to be more common in the tropical and subtropical regions than in the temperate regions. The predominant fungal species in this particular study were seen to be Fusarium solani, similar to the reports from South India.[1] However, this is in contrast with the Aspergillus spp. etiology seen in North India.[6] We also found that Nocardia and Streptococcus had an incidence of 28.1% each; however, this was not as significant as the 70% seen in South India.[1] This could also be due to the poor percentage of culture growth at the center for bacteria spp.

Seasonal statistics showed that there was a peak in the number of patients presenting with infectious keratitis in the rainy seasons that are from month June to September with a higher incidence of fungal keratitis. This could be due to high harvest time and infection from vegetative corneal injuries. This is similar to researches carried out in South India.[1],[7] Bacterial growth was higher during the summer; studies show that fungal and bacterial growth rates have optimum temperatures around 25°C–30°C, while at higher temperatures, lower values are found. This decrease is more drastic for fungi than for bacteria, resulting in an increase in the ratio of bacterial to fungal growth rate at higher temperatures.[8]

Trauma appeared to be the most common predisposing factors associated with infectious keratitis. Injury to the eye is an important predisposing factor. In the study, 50% of the patients presented with a history of some form of injury to the eye. This result was in agreement with a study that was carried out in North India where one-third of their patients had a definite history of corneal injury.[6],[9] Among which a significant number, 24% had a history of trauma with vegetative matter. However, the most common form of trauma was blunt trauma, i.e., 41%. The result of trauma with vegetative matter was similar to a research carried out in South India.[1]

It is of interest that patients usually present at the hospital after receiving some sort of quack treatment/medication at their native areas. This study showed that 6% of the total patients presented with some history of quackery. It was seen that from those 6%, half of the people removed some foreign body from the eye with the tip of the tongue. Medline and literature search showed no other study from Central India to study prevalence and pattern of quack practice. A study carried out in South India revealed that the most common traditional remedy used in the area was breast milk and only a few used the method of tongue.[10]

More than 700 bacterial species have been identified in oral cavity as a normal bacterial flora.[11] In addition, there are also a number of fungi found in the oral cavity including Aspergillus, Fusarium, and Candida.[12] That's why quack practice of ocular foreign body removal can result into infectious keratitis with varied causative organisms. In our study also, we found variety of culture growth in tongue application patients; these were Aspergillus, Bacillus Spp, F. solani, Nocardia, and Pseudomonas aeruginosa.

  Conclusions Top

This study concludes that infectious keratitis is a common problem in central India where fungal keratitis is more prevalent than bacterial keratitis with surge in rainy season. Since majority of population is involved in agricultural activities, susceptibility to encounter ocular trauma is high. Quack practices are still availed rampantly as a primary eye care following ocular trauma which increases the risk of development of microbial keratitis. Hence, knowledge and awareness programs about the risks and outcomes of both ocular trauma and quack practice, knowledge about personal protective equipment for eyes, and availability of primary eye care centers around the area can reduce the burden of preventable infectious keratitis and subsequent corneal blindness significantly.


We would like to thank Dr. Rushikesh Naigaonkar (Medical Director, Shri Ganapati Netralaya) to allow us to carry out the project at the premises. We also would like to acknowledge our colleagues who helped us in data collection.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Bharathi MJ, Ramakrishnan R, Vasu S, Meenakshi R, Palaniappan R. Epidemiological characteristics and laboratory diagnosis of fungal keratitis. A three-year study. Indian J Ophthalmol 2003;51:315-21.  Back to cited text no. 1
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Whitcher JP, Srinivasan M, Upadhyay MP. Corneal blindness: A global perspective. Bull World Health Organ 2001;79:214-21.  Back to cited text no. 2
Chander J, Sharma A. Prevalence of fungal corneal ulcers in Northern India. Infection 1994;22:207-9.  Back to cited text no. 3
Dutta LC, Dutta D, Mohanty P, Sharma J. Study of fugal keratitis. Indian J Ophthlmol 1981;29:407-40.  Back to cited text no. 4
Varenkar MP, Shubhangi B, Pinto MJ, Naik PA. Study of mycotic keratitis in Goa. Indian J Med Microbiol 1998;16:58-60.  Back to cited text no. 5
Saha R, Das S. Mycological profile of infectious Keratitis from Delhi. Indian J Med Res 2006;123:159-64.  Back to cited text no. 6
Lin CC, Lalitha P, Srinivasan M, Prajna NV, McLeod SD, Acharya NR, et al. Seasonal trends of microbial keratitis in south India. Cornea 2012;31;1123-7.  Back to cited text no. 7
Pietikäinen J, Pettersson M, Bååth E. Comparison of temperature effects on soil respiration and bacterial and fungal growth rates. FEMS Microbiol Ecol 2005;52:49-58.  Back to cited text no. 8
Talwar P, Sehgal SC. Mycotic infections of the eye in Chandigarh and neighbouring areas. Indian J Med Res 1978;67:929-33.  Back to cited text no. 9
Srinivasan M, Gonzales CA, George C, Cevallos V, Mascarenhas JM, Asokan B, et al. Epidemiology and aetiological diagnosis of corneal ulceration in Madurai, South India. Br J Opthalomol 1997;81:965-71.  Back to cited text no. 10
Aas JA, Paster BJ, Stokes LN, Olsen I, Dewhirst FE. Defining the normal bacterial flora of the oral cavity. J Clin Microbiol 2005;43:5721-32.  Back to cited text no. 11
Cui L, Morris A, Ghedin E. The human mycobiome in health and disease. Genome Med 2013;5:63.  Back to cited text no. 12


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


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