Management of fungal corneal ulcer in rural areas of tropical countries

Suppurative corneal ulcer is a common problem in the tropical developing countries. A limited range of antibiotics is available but antifungal agents are usually completely unavailable there. Microbiological facilities are not available to identify the causal organisms. In addition ignorance, poverty, and illiteracy cause patients to use harmful traditional eye medicines, leading to blindness. In this study 3 have explored the use of chlorhexidine gluconate which should be cheap. In vitro I have tested fungal isolates from Ghana and India against chlorhexidine, povidone iodine, propamidine, polyhexamethylene biguanide (PHMB) and econazole by placing the drugs in wells in Sabouraud's dextrose agar media in petridishes. PHMB and propamidine showed no activity against the majority of fungi. Chlorhexidine showed a good dose related response. Econazole proved the most effective. In a pilot study chlorhexidine showed the best response compared with natamycin, povidone iodine and econazole. A masked randomised trial of three concentrations of chlorhexidine compared with 5[percent] natamycin, showed that 0.2[percent] chlorhexidine gave the best results without any toxicity. Another masked randomised trial in another country compared 0.2[percent] chlorhexidine with 2.5[percent] natamycin. 0.2[percent] chlorhexidine showed the better response both in severe and non-severe ulcers. In vitro, I have tested chlorhexidine against different species of bacteria and showed good response both in Gram positive and Gram negative bacteria. Chlorhexidine has already been prescribed for the treatment of Acanthamoeba keratitis. It is also active against Chlamydia trachomatis. The method I applied here for fungal sensitivity testing is simple and cheap. Chlorhexidine is also cheap, stable in the tropical temperature and has already been used as an antiseptic and as a preservative for more than 40 years. I therefore suggest that chlorhexidine may be a useful first line agent in any suppurative corneal ulcer when microbiological facilities and antifungal agents are not available