} PENICILLIN IN MUCO-PURULENT

CONJUNCTIVITIS I k .J

By S. T.(PUTTANNA, b.sc., m.b., b.s., d.o.m.s. (Lond.)

Department of Ophthalmology, McGann Hospital, Shimoga

Mucopurulent conjunctivitis is still a

problem in our country. It occurs in definite

epidemics every year during the summer

months, the maximum incidence being in June, July and August, as seen in the seasonal incidence chart. The incidence fades away gradually to its minimum in November, then shows a gradual increase till March, then a slow fall till May and then a rise. The disease is contagious and is transmitted directly by the discharge from person to person. In addition the eye flies which are prevalent during the season are said to be the transmitters of the disease from eye to eye. The disease is very common in poor families living in insanitary surroundings. It affects all the members of the family invariably due to insanitary habits

especially among the poor who use common face towels. It also breaks out in school children, if proper precautions are not taken. ? Hence, the importance of instructing the parents not to send their children with sore-eyes to schools.

Muco-purulent conjunctivitis affects both sexes and all ages, the maximum incidence being in the age group between 1 and 5 years. The incidence is lowest under one year showing that children under one year are relatively more resistant to infection than adults. Again the

Feb., 1951] MUCO-PURULENT CONJUNCTIVITIS: PUTTANNA 39

incidence falls considerably in adults over .16

years as seen in the age incidence chart. When the disease occurs in the new-born, especially during the epidemics, smear examination is of

immense value in differentiating it from

ophthalmia neonatorum.

The disease is caused by the usual patho- gens, the commonest being Koch-Weeks' bacillus, pneumococci, streptococci and staphylococci. The micro-organisms seen in 200 smear examina- tions are tabulated below (table I):?

Table I

1 Koch-Weeks' bacillus 2 Pneumococci 3 Streptococci 4 Staphylococci 5 Mixed flora containing staphy-

lococci, streptococci, pneumo- cocci and B. xerosis.

6 No organisms

15 25 10 12

116

22

Cultures were not done due to want of proper facilities at the hospital.

The mucopurulent- conjunctivitis is treated

by frequent washing out of the conjunctival sac with a simple eye lotion, boric or saline, and applying sterile vaseline to the lids to prevent sticking of the lids in earlier cases. As the

attendants do not follow the instructions of

frequent washing at home and believe in washing once or twice a day in the out-patient depart- ment, it has been customary to apply silver nitrate 1 per cent solution to the everted lids and then wash the conjunctival sac with eye lotion and apply antiseptic drops like argyrol 25 per cent or protargol 20 per cent and smear the lids with unguentum flava 1 per cent. With this mode of treatment the condition clears up in 1 to 2 weeks. Relapses are common in some cases. Other modes of treatment have been tried by others like turmeric drops instillation into the

eye and using a cloth dipped in turmeric to wipe the affected eye; and like instillation of freshly prepared toddy drops into the eyes. (Dr. S. Y. Rao and Dr. M. B. S. Rao, Department of

Ophthalmology, Krishnarajendra Hospital, Mysore, who have reported favourable results.) The value of penicillin drops in other

ophthalmic conditions like ophthalmia neona-

torum, purulent ophthalmia and hypopyon ulcers tempted me to use these drops in this condition.

Clinical results.?1. Control group of 20 cases of one-day duration were selected. In this series no medicaments were used except washing

Cases Of Hucopuhulmt Conjunctivitis By Months. Cases Of Mucopuhulmt Conjunctivitis Bv Months.

( S?A50ivni. btc.iac.ic e) tC?

AGE INCIDENCE CHARJ

I

5cak ?= 1"- 50

II si ? fiC,? Ju?' ?

AGE INCIDENCE CHARJ

40 THE INDIAN MEDICAL GAZETTE [Feb., 1951

twice a day and simple sterile vaseline to the lids. The condition cleared up in 10 to 15 days. No complications were observed.

2. Twenty cases of one-day duration were treated with cocaine 1 per cent one drop, silver nitrate 1 per cent application to the lids, wash and instillation of argyrol 25 per cent drops and unguentum flava to the lids. The redness, smarting and conjunctival discharge continued as usual and the condition cleared up in 8 to 10

days. No complications were seen. 3. Twenty cases of one-day duration were

treated with cocaine 1 per cent, silver nitrate 1 per cent application to the lids, penicillin drops 5,000 units per cc. instilled twice a day with

unguentum flava to the lids. The condition cleared up in 8 to 10 days.

4. Twenty cases of one-day duration were treated with simple wash, penicillin drops 5,000 units per cc. instilled 4 times a day with peni- cillin eye ointment to the lids. The condition cleared up in 6 to 8 days.

5. One thousand one hundred and five cases of bilateral conjunctivitis of various types and severity were treated with hourly penicillin drops 5,000 units per cc. supplemented with penicillin eye ointment applied twice a day. No wash

being used in all these cases and penicillin drops were stopped during the sleeping hours.

Results are given in table II :?

Table II

Results with the local use of penicillin drops 5,000 units per cc. in 1,105 cases of bilateral

conjunctivitis

Age group

Under 1 year

1 to 5 years

6 to 16 years

Adults over

16 years.

Total

Num- ber of cases

63

559

324

159

1,105

Sex

Male

35

285

172

93

Female

28

274

152

66

Marked improve-

ment, SMARTING, DISCHARGE and

SWELLING CON-

SIDERABLY

REDUCED IN 48 TO 72 HOURS

48 hours

585 520

34

280

159

84

557

72 hours 4 days

6

72

44

22

144

Moderate IMPROVE-

MENT IN 4 TO 5 DAYS

No improve- ment

5 days

7

48

34

12

5

28

19

13

101 65

11

131

68

28

238

b o 03 rl

?>"2 CD d

I?I +3 eS

73

28

13

Complications

117

Ulcer cornea .. 2

Sub-conjunctival echimosis .. 1

Ulcer cornea .. 2

Relapse after one week .. 1

(cleared up in 2 days).

Limbal ulcer 10

Iritis ? ? 1

Relapse after 12 days ;?

1

(cleared up in 4 days).

Sensitivity to

penicillin .. 2

Superficial punc- tate keratitis 2 after the con- dition cleared up.

Iritis left eye 1

Ulcer cornea .. 2

Limbal ulcer left

eye .. 1

Associated conditions

Trachoma 1

Trachoma 4

Trachoma 2

26

17 cases of 3 days' duration with penicillin (10,000 units per cc.) showed marked improvement in 3 days. 12 cases of 4 days' duration with penicillin (10,000 units per cc.) showed marked improvement in 3 days. 7 cases of 1 week's duration with penicillin (10,000 units per cc.) showed marked improvement in 3 days. 2 cases of 2 weeks' duration with penicillin (10,000 units per cc.) showed marked improvement in 4 days.

Feb., 1951] MUCO-PURULENT CONJUNCTIVITIS : PUTTANNA 41

When the condition is under control as

revealed by objective improvement such as

diminution in swelling of the lids, redness and conjunctival discharge, the drops are instilled

every 4 hours for a period of 48 hours. Sanitary measures like frequent cleansing of the hand and use of separate face towels should be rigidly followed by other members in the family to

prevent the spread of the disease.

6. One hundred and two right eye and 149 left eye infections were also treated with hourly penicillin drops (except during sleeping hours) and penicillin eye ointment. In these cases

instillation of penicillin drops to the unaffected eye prevented it from being infected. The results are given in tables III and IV. Comment.?The clinical results show the

decided value of penicillin in muco-purulent

Table III *

Results with the local use of 'penicillin 5,000 units per cc. in 102 right eye injection<

Age group

Under 1 year 1- to 5 years 6 to 16 years

Adults over

16 years.

Total

Sex

Num- ber of cases

Male

2 20 10

35

45

17

15

102 42

Female

2

10 18

30

60

Marked improve-

ment, SMARTING, DISCHARGE AND

SWELLING CON-

SIDERABLY

REDUCED IN 48 TO 72 HOURS

48 hours

2 4 15

20

41

72 hours

17

Moderate IMPROVE-

MENT IN 4

TO 5 DAYS

4 days

13

5 days

No IMPROVE- MENT

? S3 P

8 9

11

28

bp-g

5 6

10

21

Complications Associated conditions

Limbal ulcer .. 1

Iritis .. 1

Superficial punc- tate keratitis 2

(after the con- dition cleared up).

Xerosis

Table IV

Results with the local use of penicillin 5,000 units per cc. in 149 left eye infections

group

Num- ber of cases

Sex

Marked improve- ment, SMARTING, DISCHARGE and

SWELLING CON-

SIDERABLY

REDUCED IN 48 TO 72 HOURS

Male Female 48 hours 72 hours

Under 1 year 1 to 5 years 6 to 16 years

Adults over

16 years.

2

27 2 .. i 1 12 15 14

56 28 28 24

64 39 25 30

Total . 149 81 68 ! 69 18

/

Moderate IMPROVE-

MENT IN 4

TO 5 DAYS

4 days 5 days

17 10

No IMPROVE- MENT

1 6 13

15

35

3

3>1 <D W

l-<

1 4 10

11

26

Complications Associated conditions

Limbal ulcer Ulcer cornea

Relapse Limbal ulcer Iritis

42 THE INDIAN MEDICAL GAZETTE [Feb., 1951

conjunctivitis. By and large, the clinical results with it are decidedly better than those with other modes of treatment. Moreover, the relief of

symptoms such as burning, itching and dis-

charge is noticed within 48 to 72 hours before

objective improvement is seen. The number of

cases sensitive to this drug are negligible as seen in the series. The drug should be stopped where the sensitivity is noticed. The drops are non- irritating and soothing in character. The use

of penicillin eye ointment 1,000 international units per gramme as?& supplement in the treat- ment is of marked value not only in preventing the sticking of the lids together but in main-

taining the concentration of the drug in the

conjunctival sac. Penicillin drops used twice or thrice a day are of no avail as it implies treating the infection for a minute and leaving it untreated for the rest of the time. This has been confirmed in 20 cases of one-day duration where penicillin drops were instilled 4 times a

day. The drops should be instilled every hour except during the sleeping hours (5,000 units per cc.) supplemented with penicillin eye ointment 1,000 international units per gramme to the lids twice a day. With this treatment the relief of symptoms will be marked in 48 to 72 hours and the condition clears up in another 2 to 3 days in the majority of cases. If, after 48 to 72 hours there is no marked improvement, it may be taken that the causative organism is not penicillin sensitive. As the bacteriological flora of the conjunctiva in such cases is usually of the mixed type as seen in table I and as most of the pathogens are penicillin sensitive, instilla- tion of penicillin drops will certainly produce beneficial results in at least controlling the

secondary organisms and inhibiting the activity of the causative pathogen. It is a known fact that the presence of some micro-organisms, e.g.

staphylococci, will enhance the pathogenicity of the causative organism. Hence, the use of peni- cillin will control the secondary infection and thus minimize the pathogenicity of the causative organism.

In severe infections of longer duration with intense swelling of the lids and plenty of con- junctival discharge, the drug has to be used in greater concentration, 10,000 units per cc.

Another advantage of this treatment is that no washing of the conjunctival sac is required which saves time and the discharge collected at the margins of the lids being wiped by swabs followed by instillation of penicillin drops and ointment. Furtl^er, the treatment can be followed easily at home. The drops should be freshly prepared every day and given to the attendants with proper instructions regarding instillation. In the dilution in which it is used, it is also economical.

Conclusions.?1. The bacteriological flora in

muco-purulent conjunctivitis is usually of a

mixed type as revealed by smear examinations in table I.

2. The disease is common in summer months and the maximum incidence being in June, July and August, children between 1 and 5 are

commonly affected. 3. In one thousand one hundred and five cases

of bilateral conjunctivitis treated with hourly penicillin drops, 701 showed marked improve- ment in 2 to 3 days and 166 showed moderate improvement in 4 to 5 days. In one hundred and two right eye infections

treated with hourly penicillin drops, 58 showed marked improvement in 2 to 3 days and 16 moderate improvement in 4 to 5 days.

In one hundred and forty-nine left eye infec- tions treated with hourly penicillin drops, 87 showed marked improvement in 2 to 3 days and 27 showed moderate improvement in 4 to 5 days.

4. Penicillin is highly beneficial in controlling the secondary infection and minimizes the

pathogenicity of the causative pathogen.

I wish to thank Dr. A. B. Renu, District Medical Officer, Shimoga, for his encouragement and kind permission to communicate this paper for publication. I also thank Dr. K. S. S. Appa, Physician, McGann Hospital, Shimoga, for his help in checking up the smears.