Dear editor

We read with great interest the study published by Srinivasan et al [1]. It sheds light over the primary management of an endemic problem, corneal ulceration, at the village level. We have a few comments to make.

The study suggests that there is no statistically significant difference in the rates of fungal corneal ulceration in patients with corneal abrasions with antifungal prophylaxis or with placebo. The role of prophylactic antibiotics for the prevention of bacterial corneal ulcers is yet unclear, even though a few studies have indicated a positive role [2]. We would like to note that in a rural and largely illiterate population like India, the mass prescription of an antibiotic drug is certain to lead to its improper use. Patients may resort to applying the medication for unrelated eye problems, encouraging complications and antibiotic resistance. Whether proper counseling can be done at the village health worker level remains to be seen.

Also, in the study, only 30% of patients with ocular injury had corneal abrasions. This protocol may lead to the under diagnosis of other findings not picked up fluorescein-blue light examination, retinal dialysis or angle recession to name a few. And the process of examination may instill a false sense of security in the rural patients, preventing them from seeking ophthalmologic care. The study provided for referral center evaluation, but it was not clear whether the authors recommend this as a part of the screening model.

The authors suggest that a rapid epithelialisation and a modest antifungal effect from the ointment base itself may be the reason for the reduced incidence of ulceration in their population. A true control population without any topical medications may have greatly facilitated in reaching a firm conclusion. However, to the best of our knowledge, the antifungal effect 1% chloramphenicol base has not been reported. And if the hypothesis were true, there remains no need to prescribe a blanket treatment for all corneal erosions, as rapid epithelialisation will prevent the development of corneal ulcer. An important fact, which cannot be sidelined, is that severe side effects like aplastic anemia and even death have been reported on topical application of chloramphenicol eyedrops [3-5].

In view of the above observations, we would advise all patients with ocular trauma to undergo an ophthalmologists’ detailed examination. Patients detected to have corneal abrasions may start antibiotic prophylaxis in the interim. However, an ophthalmologist’s evaluation must be the emphatic general policy. As the authors conclude, the unanswered questions may be solved by future studies.

References

1. Srinivasan M, Upadhyay MP, Priyadarsini B, Mahalakshmi R, Whitcher JP. Corneal ulceration in southeast Asia III: prevention of fungal keratitis at the village level in south India using topical antibiotics. Br J Ophthalmol. 2006 Dec;90(12):1472-5.

2. Maung N, Thant CC, Srinivasan M, Upadhyay MP, Priyadarsini B, Mahalakshmi R,Whitcher JP. Corneal ulceration in South East Asia. II: a strategy for the prevention of fungal keratitis at the village level in Burma.Br J Ophthalmol. 2006 Aug;90(8):968-70.

3. Brodsky E, Biger Y, Zeidan Z, Schneider M.Topical application of chloramphenicol eye ointment followed by fatal bone marrow aplasia.Isr J Med Sci. 1989 Jan;25(1):54.

4. Abrams SM, Degnan TJ, Vinciguerra V.Marrow aplasia following topical application of chloramphenicol eye ointment. Arch Intern Med. 1980 Apr;140(4):576-7.

5. Fraunfelder FT, Bagby GC Jr, Kelly DJ.Fatal aplastic anemia following topical administration of ophthalmic chloramphenicol.Am J Ophthalmol. 1982 Mar;93(3):356-60.