Research Article

Use of traditional eye medicines by patients

with corneal ulcer in India
Pankaj Choudhary, Charudatt Chalisgaonkar, Neera Marathe, Sujata Lakhtakia
Department of Ophthalmology, Shyam Shah Medical College, Rewa, Madhya Pradesh, India.
Correspondence to: Pankaj Choudhary, E-mail: [email protected]

Received March 29, 2015. Accepted March 31, 2015

Abstract

Background: Instillation of traditional eye medicines (TEMs) into the eye is one of the causes associated with poor visual
outcome and corneal blindness.
Objective: To determine the use of TEM and factors for its use in patients with corneal ulcer.
Materials and Methods: This prospective study was conducted on 189 new patients with corneal ulcer attending cornea
clinic of Gandhi Memorial Hospital, Rewa, Madhya Pradesh (India). After complete eye examination, information was
collected for use of TEM, sociodemographic profile, symptoms necessitating its use, and complication. Necessary
treatment was given and final visual outcome was noted. Lab investigations were performed to identify organism.
Result: TEM was used by 38% subjects, especially females and subjects residing in rural areas were found to be signifi-
cantly associated with its use. Majority of TEM users were farmers (51.4%). The most common symptom was poor vision
(66.7%) for use of TEM. Breast milk (40%) and plant products (29%) were most commonly applied TEMs. Central and
entire corneal involvement was found to be significantly high among TEM users. Scarring and perforation occurred in
70.8% and 31.9% TEM users, respectively. No significant difference was found between organism identified and the
use of TEM. Visual acuity up to 6/18 was found to be higher among non-TEM users (23.9%) as compared to TEM
users (9.7%). At presentation, 38.9% TEM users had already lost their vision. Significant difference was found between
presenting visual acuity and final visual acuity achieved in both groups.
Conclusion: Intensive health education is needed for encouraging the uptake of eye care services, particularly in rural areas.
KEY WORDS: Traditional eye medicines, corneal blindness, corneal ulcer, primary eye care

Introduction mately 6.8 million people have been estimated to have vision
less than 6/60 in at least one eye due to corneal diseases;
Corneal diseases are among the major causes of vision of these, about a million have bilateral involvement.[3,4] The
loss and blindness in the world today, after cataract and glau- burden of corneal disease in our country is reflected by the
coma.[1] Cataract and corneal diseases are major causes of fact that 90% global cases of ocular trauma and corneal ulcer-
blindness in countries with less-developed economies.[2] Ac- ation leading to corneal blindness occur in developing coun-
cording to the World Health Organization, in India, approxi- tries.[5] The prevalence of corneal blindness varies from coun-
try to country and even from one population to a nother. Its
epidemiology is complicated and encompasses a wide variety
Access this article online of infectious and inflammatory eye diseases. As trachoma and
Website: http://www.ijmsph.com Quick Response Code: vitamin A deficiency become less common, s uppurative kera-
titis is becoming the major cause of corneal blindness in the
DOI: 10.5455/ijmsph.2015.29032015206
developing world.[6] Whereas contact lens use is a major risk
factor for corneal ulceration in the developed world, a high
prevalence of fungal infections, agriculture- related trauma,
and use of traditional eye medicines (TEMs) is unique to the
developing world.[7,8]

International Journal of Medical Science and Public Health Online 2015. 2015 Pankaj Choudhary. This is an Open Access article distributed under the terms of the
Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), allowing third parties to copy and redistribute the material in any medium
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 Choudhary et al.: Use TEM by patients with corneal ulcer in India

TEMs are a form of biologically based therapies or prac- the ethical use of human volunteers were followed during
tices that are instilled or applied to the eye or administered this research. Oral informed consent was obtained from the
orally to achieve a desired ocular therapeutic effect.[9] TEMs patients before enrollment into the study. An interviewer-
are crude or partially processed organic (plant and animal administered questionnaire was used during the study. All
products) or inorganic (chemical substances) agents or rem- new patients seen in the eye clinic during the study period
edies that are procured from either a traditional medicine were asked about the use of TEM.
practitioner (TMP; synonyms: traditional alternative medicine Patients demographics such as sex, age, occupation,
practitioner, traditional healer, spiritual healer) or nontradition- education, and rural/urban residence were recorded. The symp-
al medicine practitioners that could be the patient, relative, or toms necessitating the use of TEM, the type of TEM, history of
friend.[10,11] trauma preceding the use of TEM, complications, presenting
TEM use, either as sole first-line treatment or as an visual acuity, and final visual outcome were documented. The
adjunct used concurrently with conventional therapy, has visual acuity was recorded in terms of Snellen notation.
been associated with poor visual outcome of otherwise treat- A penlight exam was performed followed by fluorescein stain
able eye diseases in clinical ophthalmic practice. TEM-related with slit lamp bio-microscopy to detect corneal lesions. Ulcers
poor ophthalmic outcomes have been attributed to delay in were classified as peripheral, central, and those involving the
uptake of eye care services, damage to ocular and or adnexal whole cornea. Corneal scrapings were sent for Grams staining,
structures from TEM toxicity, and microbial contamination of and KOH mount culture sensitivity tests were performed, where
TEM agent or procedure.[1013] required. Systemic and local treatment was given.
Various studies on TEM have documented its use and Data were analyzed with SPSS software, version 13
have established inconsistent associations of its use with (SPSS, Chicago, IL) including calculation of frequency tables,
factors such as age, gender, educational status, rural res- proportion, percentage, and 2-test to determine the statistical
idence, occupation, socioeconomic status, cultural beliefs, significance of variables. The statistically significant level (p)
ignorance and access to health care, and time to presentation was set at 0.05.
for uptake of eye care services.[715] Although several studies The study was carried according to the ethical guidelines
in Africa have documented the use of TEM before presenting for biomedical research on human subjects (2000).
to the hospital, few studies have been conducted in Indian
subcontinent.
The study was conducted to determine the use of TEM
Results
and the types of TEM used by the patients of corneal ulcer
Total 189 subjects were interviewed for the use of TEM.
attending the eye clinic of the tertiary care hospital, Rewa,
Table 1 presents the use of TEM among subjects by their
Madhya Pradesh, India. The association of the use of TEM
sociodemographic characteristics. Of total 189 subjects,
with sociodemographic and clinical correlates was also
101 (53.43%) were males and 88 (46.57%) were females.
studied.
The use of TEM was documented in 72 (38%) subjects before
presenting to hospital. Significantly high proportion of females
Material and Methods were found to use TEM. Age of the subjects varied from
4 to 72 years. Half of the subjects (50.8%) belonged to the
This prospective study was conducted on 189 consecu- age group of 3050 years. Slightly high use of TEM was noted
tive patients presenting with first episode of corneal ulcer at in the age groups of <30 and >50 years, but this difference
the ophthalmic clinic of the Teaching Hospital, Shyam Shah was not found to be significant. Among TEM users, m ajority
Medical College, associated with Gandhi Memorial Hospital, (69.4%) belonged to the rural background. Very significant
Rewa, between January 2008 and December 2008. All app association was found between TEM use and rural/urban
licable institutional and government regulations concerning residence. Table 2 presents occupation of the TEM users.

Table 1: Sociodemographic characteristics of patients with corneal ulcer

Category (n) TEM user (n = 72) Non-TEM user (n = 117) 2-Value, p-value Significant/not significant
Gender
Male (101) 29 (40.3%) 72 (61.5%) 7.265, 0.007 Very significant
Female (88) 43 (59.7%) 45 (38.5%)
Age group (years)
<30 (41) 16 (22.2%) 25 (21.4%) 0.2397, 0.887 Not significant
3050 (96) 35 (48.6%) 61 (52.1%)
>50 (52) 21 (29.2%) 31 (26.5%)
Residence
Rural (102) 50 (69.4%) 52 (44.4%) 10.23, 0.0014 Very significant
Urban (87) 22 (30.6%) 65 (55.6%)

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 Choudhary et al.: Use TEM by patients with corneal ulcer in India

Table 2: Occupation of the TEM users (n = 72) 48 patients (66.7%) followed by trauma in 21 (29.1%).
Occupation TEM users % Table 4 presents types of material used as TEM by the
subjects. Breast milk (29; 40%) and plant products (20; 29%)
Agriculture work 37 51.4
were most common materials applied as TEMs. Location,
Housewife and unemployed 11 15.3
complications, and microbial profile of the subjects are
Laborer 06 8.3
given in Table 5. Central and entire corneal involvement was
Student 08 11.1
found to be significantly high among TEM users. Significant
Service 03 4.2
association was found between complications experienced
Business/self-employed 05 7
Professional 02 2.8
and the use of TEM. Scarring and perforation occurred in
70.8% and 31.9% TEM users, respectively. Fungal organism
was isolated in 58.3% TEM users and in 52.1% non-TEM
Table 3: Symptoms leading to the use of TEM (n = 72) users, but no significant difference was found between organ-
Symptoms TEM users % ism identified and the use of TEM. Table 6 depicts the visual
Diminution of vision 48 66.7 acuity of subjects on presentation and final visual acuity after
Trauma, foreign body 21 29.1 the completion of treatment. Proportion of patients present-
Redness, itching, discharge, white spot 03 4.2 ing with visual acuity up to 6/18 was higher among non-TEM
users (23.9%) as compared to TEM users (9.7%). Before
presenting to the health-care facility, 38.9% TEM users had
Table 4: Type of material used as TEM (n = 72)
already lost their vision. Slight improvement in visual acuity
Type of TEM No % (up to 6/18) is achieved in both groups after treatment as
Breast milk 29 40 shown in Table6. The proportion of patients with visual acuity
Leafy matter 20 20 <6/18 was reduced slightly to 83.3% in TEM users and 69.2%
Honey 07 9 in non-TEM users after the treatment. Significant difference
Castor oil 05 7 was found between presenting visual acuity and final visual
Sugar water 04 5 acuity achieved in both groups.
Ghee 04 5
Othersa 03 4
Discussion
a
Cows urine (01), toothpaste (01), hens blood (01).
This study was conducted to document the usage of TEM
among patients presenting with corneal ulcer to a tertiary care
Farmers constituted the highest occupational group facility in central India. Our study reported the use of TEM
accounting for 37 (51.4%) whereas professional constituted in 38% subjects. This is comparable to a study conducted
the lowest group with 2 (2.8%). Table 3 documents the symp- in southern India in which 47.7% patients with corneal
toms leading to the use of TEM, which included pain, redness, ulcer used TEM before presenting to the hospital.[10] Another
discharge, itching, poor vision, trauma, and white spot. study carried out in Gujarat documented the use of TEM by
The most common symptom was poor vision found among 9.5% patients with corneal ulcer.[16] Large-scale use of TEM

Table 5: Location, complications, and microbial profile in patients of corneal ulcer (n = 189)
TEM users (n = 72) Non-TEM users (n = 117)
Location of ulcer (n)
Peripheral (90) 24 (33.3%) 66 (56.4%)
Central (77) 36 (50%) 41 (35.1%)
Entire (22) 12 (16.7%) 10 (8.5%)
2 = 9.957, df = 2, p = 0.0069; significant association
Complications
Scarring (118) 51 (70.8%) 67 (57.3%)
Perforation (29) 23 (31.9%) 6 (5.1%)
Secondary glaucoma (26) 10 (13.9%) 16 (22.2%)
Iridocyclitis, endophthalmitis, and panophthalmitis (16) 10 (13.9%) 06 (5.1%)
2 = 14.5, df = 3, p = 0.0023; significant association
Organism
Fungus (103) 42 (58.3%) 61 (52.1%)
Bacteria (86) 30 (41.7%) 56 (47.9%)
2 = 0.46, df = 2, p = 0.49; not significant

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 Choudhary et al.: Use TEM by patients with corneal ulcer in India

Table 6: Visual acuity of the patients with corneal ulcer

Presenting visual acuity Final visual acuity
Visual acuity
TEM users (N = 72) Non-TEM users (N = 117) TEM users (N = 72) Non-TEM users (N = 117)
6/66/18 7 (9.7%) 28 (23.9%) 12 (16.7%) 36 (30.8%)
<6/186/60 12 (16.7%) 30 (25.6%) 7 (9.7%) 25 (21.4%)
<6/603/60 25 (34.7%) 27 (23.1%) 18 (25%) 21 (17.9%)
<3/60PL 24 (33.3%) 29 (24.8%) 28 (38.9%) 30 (25.6%)
No PL 4 (5.6%) 03 (2.6%) 7 (9.7%) 05 (4.3%)
p-Value 0.0276, significant 0.0125, significant

has been reported from Africa.[8,9,11,12,14,15] Courtright et al.[8] commonly used in India is human breast milk followed by plant
reported that 33.8% patients with corneal ulcers in rural extract.[8,10,16] In Africa, TEMs are more of plant than animal
Malawi used TEM before presentation to hospital. Singh[17] origin.[8,18,19] This difference might be attributed to prevailing
from Nepal reported that 57% patients with corneal ulcers cultural practices. Patients who reported TEM use were more
used TEM. Recent studies from Nigeria reported the use likely to have vision impairment (visual acuity <6/18) on pres-
of TEM by many new patients, 1.57% by Ukponmwan and entation (90.3%) as compared to non-TEM users (76.1%).
Momoh[18] and 5.9% by Eze et al.[19] A study conducted by Low presenting visual acuity among TEM users, apparently
Yorston and Foster[20] in Tanzania showed that 25% patients due to delays caused by prior TEM use, has been reported in
with corneal ulcers were associated with the use of TEM. various studies.[10,14,15,18,19] The proportion of patients with visual
The sociodemographic characteristics of the study sub- impairment was reduced slightly to 83.3% in TEM users after
jects showed that those who presented with ocular complaints various appropriate treatments. Poor visual outcome was also
were predominantly in the productive age group, which has seen more in patients who used TEMs than in those who did
adverse economic implications for the patient, the family, not use them.15 When various substances are applied, visual
and the country. Sociodemographic profile in our study is prognosis may be compromised further even after definitive
comparable with that of the studies conducted in India.[10,16] ophthalmic interventions have been offered. Generally,
Slight preponderance of TEM use was observed in less than the visual outcome of corneal ulcer depends majorly on other
30 years or older (>50 years); however, no difference was indices. Therefore, further studies are needed to evaluate
observed between the groups with regard to age. This is s imilar effect of additional factors such as duration and frequency of
to the study conducted in south India.[10] TEM use was found TEM instillation, trauma, and systemic illness. In this study,
to be significantly high among females in our study. However, 70.8% subjects who used TEM developed complications.
Prajna et al.[10] and Ukponmwan and Momoh[19] observed no Scarring followed by perforation were the most common com-
difference in age and sex among TEM users and non-TEM plications. Another study reported ocular complications in
users. TEM use by females has been attributed to inability 54.8% most common were corneal opacity.[19] Many studies
to access eye care services due to gender-related factors. indicated that HR/TEM is likely to have adverse effects on
As shown by our study, rural residence continues to be an the eye. Most of these traditional medications are often pre-
important risk factor for usage of TEM. Rural residence pared with alkaline or acidic solutions, resulting in high degree
imposes both geographic and economic barriers to access of corneal damage and scarring. Ocular complications such
eye care services. Illiteracy, poor socioeconomic status, as keratitis, endophthalmitis, and panophthalmitis were more
unawareness, physical distance to hospitals, and health
frequent in patients with a positive history of TEM than those
care and other barriers to access eye care are few facts for with a negative history. This finding is consistent with that
increasing use of HR/TEM.[21] The lack of access to hospi- of the study conducted in Tanzania.[20] TEM may also cause
tals due to geographic and economic barriers, proximity, corneal damage by introducing microorganisms into the eye,
and relative access to TEM through friends, relatives, and which lead to primary or secondary infection. The secondary
neighbors likely explains the preponderance of rural subjects infections are likely to be due to the unsanitary condition used
resorting to TEM. Half of the TEM users were engaged in agri- to make and instill TEM. Investigators from Tanzania[20] found
culture work. A large population of India resides in rural areas that corneal ulcers associated with the use of TEM were
and their main occupation is agriculture. These workers are more likely to cause dense scars. However, Lewallen and
exposed to trauma and a hot humid climate predisposes them Courtright[22] reported in their study that peripheral corneal
to ocular conditions such as abrasions, lacerations, allergies, ulcers were associated with the use of TEM. Our study showed
and bacterial conjunctivitis which is compounded by poverty diminution of vision followed by trauma as most common symp-
and lack of access to medical care. Hence, they are more tom necessitating the use of TEM. The study conducted in
likely to use TEM. Previous studies have similarly reported Nigeria also found poor vision as main symptom necessitating
farmers, traders, and artisans as people who frequently the use of TEM followed by inflammatory eye condition.[18]
use TEMs.[10,18,19] In contrast to practice in Africa, TEM most Prajna et al.[10] reported that patients with a history of trauma

1004 International Journal of Medical Science and Public Health | 2015 | Vol 4 | Issue 7
 Choudhary et al.: Use TEM by patients with corneal ulcer in India

were more likely to use TEM than those without any such 7. Srinivasan M, Gonzales CA, George C, Cevallos V,
history. To conclude, our study documents the use of TEM Mascarenhas JM, Asokan B, et al. Epidemiology and aetiologic
predominantly by population living in rural areas and those diagnosis of corneal ulceration in Madurai, south India. Br J Oph-
who are engaged in agriculture work. Symptoms suggest thalmol 1997;81:96571.
8. Courtright P, Lewellan S, Kanjaloti S, Divala DJ. Traditional eye
the use of TEM for various ocular conditions. This suggests
medicines use among patients with corneal disease in rural
that the necessary human and material resources, needed Malawi. Br J Ophthalmol 1994;78:81012.
for the treatment of these leading eye conditions, should be 9. West AL, Oren GA, Moroi SE. Evidence for the use of n utritional
made available and accessible to all particularly rural popula- supplements and herbal medicines in common eye diseases.
tion. The use of TEM can further degrade visual outcomes in Am J Ophthalmol 2006;141(1):15766.
patients with minor or major ocular problems. A large propor- 10. Prajna VN, Pillai MR, Manimegali TK, Srinivasan M. Use of
tion of subjects presented with low vision and blindness due traditional eye medicines by corneal ulcer patients presenting
to either complications caused by TEM or underlying disease, to a hospital in South India. Indian J Ophthalmol 1999;47(1):
trauma, and so on. Further community-based studies are 1518.
needed to reveal other factors that play role in attaining final 11. Osahon AI. Consequences of traditional eye medication in
UBTH, Benin City. Nigerian J Ophthalmol 1995;3:514.
visual outcome. The prevalence of this preventable blindness
12. Mwanza JC, Kabasele PM. Corneal complications of traditional
can be reduced by intensive health education to the communi- local ocular treatment in the Democratic Republic of Congo. Med
ties, both urban and rural, about the dangers of TEM. Primary Trop (Mars) 2001;61(6):5002.
eye care workers have a very important role to play in the pre- 13. Fraunfelder FW. Ocular side effects of herbal medicines and
vention of blindness from TEM. They should be encouraged nutritional supplements. Am J Ophthalmol 2004;138(4):63947.
to be the first point of contact for ocular conditions. They must 14. Bialasiewicz A, Shenoy R, Thakral A, Al-Muniri AA, Shenoy U,
be trained to recognize minor ocular ailments and equipped Al-Mughari Z. Microbial keratitis: a 4 year study of risk factors
for treating it. Their contact with the community is important in and traditional/complementary medicine in Oman. Ophtha
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16. Kumar A, Pandya S, Kavathia G, Antala S, Madan M,
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17. Singh SK. Corneal ulcers in the eastern region of Nepal. Com
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Intensive health education is needed for encouraging the Middle East Afr J Ophthalmol 2010;17(4):31519.
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use by newly ophthalmic patients to a teaching hospital in
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