Purpose
To evaluate the role of protein energy malnutrition and immunization profile in cases of atraumatic microbial keratitis in preschool children.
Design
Retrospective case analysis.
Methods
Case records of all children 5 years of age and younger with atraumatic microbial keratitis treated at the Dr Rajendra Prasad Centre for Ophthalmic Sciences, New Delhi, India, between January and December 2006 were reviewed retrospectively. Main parameters evaluated were age, degree of protein-energy malnutrition, immunization profile, microbiologic profile, and final outcome.
Results
Fifty-four consecutive children were enrolled during the study period. The mean age was 33.69 ± 21.91 months (range, 3 to 60 months). Mean weight on presentation was 10.57 ± 3.87 kg (range, 4 to 17 kg), with an average protein-energy malnutrition grade of 1.77 ± 0.74. The immunization for age was complete in 43 (80%) children. Severe protein-energy malnutrition was associated with the occurrence of bilateral keratitis ( P < .001) and incomplete immunization ( P < .001). Positive bacterial culture results were obtained in 44 (82%) cases, with Staphylococcus species being the most prevalent isolate (33/44; 75%). Cases requiring emergency corneal transplantation (24%) were associated with severe protein-energy malnutrition ( P < .00) and bilaterality ( P < .00). In multivariate analyses, cases without severe protein-energy malnutrition were 36% less likely to undergo any kind of surgical intervention (odds ratio, 0.64; 95% confidence interval, 0.04 to 0.91).
Conclusions
Our study highlights the association of protein-energy malnutrition and immunization profile with the occurrence of atraumatic microbial keratitis in preschool children. Most of these cases required corneal transplantation surgery to preserve the ocular integrity and to restore vision.
Microbial keratitis is a serious cause of ocular morbidity in pediatric age groups. It is of utmost importance because children have a greater number of potential seeing years as compared with other older groups. The magnitude of the problem assumes larger proportions because it is difficult to diagnose and manage these cases. Most of the published studies have identified trauma as the most common predisposing risk factor for the occurrence of microbial keratitis in children. Previously, Vajpayee and associates found that incomplete immunization status and poor socioeconomic status may be associated with the cause of corneal ulceration in children younger than 12 years. At our center, we usually encounter many cases with bacterial keratitis in the preschool age group in those with poor nutritional status and incomplete immunization. In this study, we retrospectively evaluated the clinical and microbiologic profile of cases of atraumatic keratitis in this age group with particular emphasis on the probable association of nutritional and immunization status.
Methods
Case records of children 5 years of age and younger, who sought treatment for infectious keratitis at the Cornea Services, Dr Rajendra Prasad Centre for Ophthalmic Sciences, New Delhi, India, between January and December 2006 were reviewed retrospectively. The study was conducted according to the guidelines laid down in the Declaration of Helsinki, and all procedures were approved by the Institutional Review Board of the hospital. Written informed consent was obtained from the parents or the next of kin. Cases with antecedent history of any kind of trauma were not included in this study. A detailed medical history and history of immunization of the affected child was elicited from the parents or next of kin. The National Immunization Schedule followed by the government of India was used to determine the immunization status. A child was regarded as being immunized for age if he or she had completed the National Immunization Schedule ( http://www.whoindia.org/EN/Section6/Section284/Section286_508.htm ). Children who had never been immunized or who had not received immunizations recommended for their age were regarded as nonimmunized or partially immunized, respectively.
At the time of initial presentation, all cases underwent clinical evaluation, including obtaining clinical history and slit-lamp biomicroscopy (if possible). A general physical examination was carried out to detect any clinical signs of nutritional deficiency. The body weight was plotted against the corresponding age to determine the degree of protein-energy malnutrition according to the Road to Health Chart developed by the Indian Council of Medical Research, New Delhi, India. This chart is a modification of the original scale proposed by the World Health Organization. The Indian Council of Medical Research chart consists of 4 reference curves divided into 5 regions according to the weight-for-age value. The topmost curve represents more than 80% of the fiftieth percentile body weight in Indian population according to the child’s age. Children whose weights are above this curve throughout their preschool years are considered healthy. The next 3 curves denote 70%, 60%, and 50% of the fiftieth percentile body weight for the age of the cases falling in between these curves and are designated as protein-energy malnutrition grades 1, 2, and 3, respectively. Children whose weights are below the 50% curve are designated as grade 4 protein-energy malnutrition and suffering from severe malnutrition.
All cases with a corneal infiltrate with an overlying epithelial defect were labeled as having microbial keratitis. An examination under anesthesia was conducted for a detailed examination as well as to obtain corneal scrapings. Gram staining and potassium hydroxide wet mount were performed to examine corneal smears. The specimens obtained were inoculated on blood agar, chocolate agar, and Sabourad dextrose agar. The organisms were identified in the laboratory by performing Gram staining or preparations of colonies from the cultures. An indirect ophthalmoscopy or ultrasound B scan was performed to rule out any extension of the infection into the posterior segment in the affected eyes. Intensive topical antimicrobial therapy was started in the form of hourly fortified cefazolin 5% and tobramycin 1.3% eye drops after corneal scraping. Subsequent modifications in the choice and dosage of antibiotics were made according to culture results, sensitivity pattern, and clinical response.
All children received vitamin A supplementation at the time of presentation in the form of oral or parenteral dosage according to a World Health Organization-recommended protocol, that is, 200 000 IU on 2 consecutive days and 1 dose repeated after 2 weeks in patients older than 1 year and with body weight of more than 8 kg. Infants and children with a body weight less than 8 kg were given half the dosage. Infants younger than 6 months were given 50 000-IU doses for 2 consecutive days.
All patients were admitted for management. Subsequent examinations were performed under general anesthesia in very young and uncooperative children. Reduction in symptoms and size of infiltrate were used as the criteria for monitoring the healing of microbial keratitis. Surgical interventions in the form of emergency therapeutic corneal transplantation and elective penetrating keratoplasty were performed whenever required. Emergency corneal transplantation was performed in cases with corneal perforations and extensive corneal melting. Elective corneal transplantation was planned after the resolution of infection in cases with visually significant corneal scarring. The patients were discharged after complete resolution of the infection.
The main parameters evaluated in the study were age, gender, weight, degree of protein-energy malnutrition, immunization status (complete or incomplete), microbiologic profile, and final outcome (nonsurgical or surgical).
Statistical Analyses
Data Were Analyzed Using the Spss Statistical Software Version 17 (Spss, Inc, Chicago, Illinois, Usa). Protein-Energy Malnutrition Was Stratified Into Grades 1, 2, and 3, and Keratitis Status Was Dichotomized Into Unilateral and Bilateral. Similarly, Immunization Status Was Considered to Be Either Complete or Incomplete. Final Outcome Was Categorized Into Surgical and Nonsurgical Intervention. a P Value < .05 Was Used to Indicate Statistical Significance. Descriptive Statistical Analyses Were Performed to Characterize the Data. Univariate Analyses Using the Chi-Square Statistic for Categorical Data and the Student T Test or 1-Way Analysis Of Variance for Continuous Data Were Performed to Identify Factors That Differed Between Groups.
Results
Fifty-four consecutive children 5 years of age or younger with a presumed diagnosis of microbial keratitis were enrolled (35 males, 19 females). The mean ± standard deviation age was 33.69 ± 21.91 months (range, 3 to 60 months). Twelve cases (22%) had bilateral keratitis. The immunization for age was complete in 43 (80%) children. The mean ± standard deviation weight on presentation was 10.57 ± 3.87 kg (range, 4 to 17 kg), with an average ± standard deviation protein energy malnutrition grade of 1.77 ± 0.74 among the entire group.
Protein-Energy Malnutrition
At the time of presentation 44 (81.5%) cases had grade 1 (n = 22) or grade 2 (n = 22) protein-energy malnutrition. The degree of protein-energy malnutrition was associated with the laterality of keratitis ( P < .001) and immunization status of the patient ( P < .001). Severe protein-energy malnutrition was associated significantly with bilateral keratitis and incomplete immunization ( Table 1 ).
| Degree of Protein Energy Malnutrition | Grade 1 (n = 22; 40.7%) | Grade 2 (n = 22; 40.7%) | Grade 3 (n = 10; 18.5%) |
|---|---|---|---|
| Unilateral keratitis | 21/22 | 19/22 | 2/10 |
| Bilateral keratitis | 1/22 | 3/22 | 8/10 |
| Complete immunization | 21/22 | 21/22 | 1/10 |
| Incomplete immunization | 1/22 | 1/22 | 9/10 |
Unilateral versus Bilateral Cases
The cases were divided into unilateral (n = 42) and bilateral (n = 12) keratitis for further analysis. At the time of presentation, most cases (n = 42; 78%) had unilateral keratitis. We found no difference between these 2 groups for age (35.3 ± 23.3 months vs 28.0 ± 15.7 months; P = .31) and gender (29 males and 13 females in the unilateral group and 6 males and 6 females in bilateral group; P = .22). Only 25% (n = 3) of cases with bilateral keratitis were completely immunized for age as compared with 95% of cases (n = 40) with unilateral corneal ulcers ( P < .001). Mean weight was significantly higher (11.06 kg vs 8.83 kg; P = .03) and degree of protein energy malnutrition was significantly lower ( Table 1 ) at the time of presentation in the unilateral keratitis group.
Immunization Status
The immunization for age was complete in 43 (80%) children in our cohort. Immunization status was significantly associated with protein-energy malnutrition ( P < .001), with 81.8% (9/11) of those who were not completely immunized having severe protein-energy malnutrition. Similarly, keratitis was significant associated with protein-energy malnutrition, because 66.7% of those with bilateral keratitis were found to have severe protein-energy malnutrition ( P < .001).
Microbiologic Profile
Corneal scrapings were sent for microbiologic evaluation in all cases. Positive bacterial culture results were obtained in 44 (81.5%) cases, with Staphylococcus species being the most prevalent isolate (33/44; 75%; Table 2 ). None of the patients had a positive fungal or viral culture results. The rate of isolation of gram-positive bacteria (75%) was higher than that of the Gram-negative bacteria (25%). Of the gram-negative bacteria isolated, Pseudomonas species were the most common organism, present in 20% (n = 9) of the culture-positive cases (n = 44). Table 2 shows the results of the bacterial isolates from cultures in unilateral and bilateral keratitis. Cases with bilateral keratitis were associated with a significantly higher incidence of isolation of Pseudomonas aeruginosa from the bacterial cultures (chi-square, 18.5; P = .001). Further analysis showed that cases with severe protein-energy malnutrition were more likely to acquire Pseudomonas -associated keratitis ( P < .001; Table 3 ).
| Microorganism | Unilateral Keratitis (n = 42) | Bilateral Keratitis (n = 12) |
|---|---|---|
| Coagulase-negative Staphylococcus | 26 (61.9%) | 4 (33.3%) |
| Staphylococcus aureus | 1 (2.4%) | 2 (16.7%) |
| Pseudomonas aeruginosa | 3 (7.1%) | 6 (50%) |
| Enterobacteriaceae | 2 (4.8%) | 0 (0%) |
| Sterile | 10 (23%) | 0 (0%) |
| Protein Energy Malnutrition Grade | Sterile | Coagulase-Negative Staphylococcus | Staphylococcus aureus | Pseudomonas aeruginosa |
|---|---|---|---|---|
| 1 | 5 | 16 | 1 | 0 |
| 2 | 4 | 13 | 1 | 2 |
| 3 | 1 | 1 | 1 | 7 |
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