INTRODUCTION:

CASE REPORT:

A four years girl child came to Kashiba Gorhondas hospital, Baroda, medical OPD with the complaints of watery eyes, redness of the lower eyelid, itching of the eyes, intolerable pain and excessive crying. Doctor identified and done physical examination of the eye and they recognised it is due to the infection of the eye related to kajal. Later they diagnosed as kajal irritant syndrome of eye. The doctor advised and given painkiller and antibiotics.

ON EXAMINATION:

· Redness of the eye

· Inflammation of lower eyelid

· Twitching of eyes

· Blephritis

· Conjunctivitis

· Itching

Kajal is traditionally made by mixing galena (lead sulphide) and other ingredients, giving it the deep black colour. Synonymous with beauty and mystery, Surma (Soorma) Kohl or Kajal have defined and transformed the women’s makeup arena for centuries. A staple cosmetic for almost every woman, Kohl or Kajal and Soorma as it is known in India, has held great importance for women of all ages and from all kinds of cultural backgrounds.

The term kohl has been derived from the Arabic name ‘Kuhl’, and has Biblical references in Hebrew as well. Even though the terminology for kajal has an Arabic origin, this substance was first used in Egypt during the Protodynastic period in 3100 B.C. Kohl was used by ancient Egyptians as a form of adornment for the eyes, and also as a cure for any eye ailment. They believed that Kohl could protect the eyes from the harsh sun rays, and therefore large amounts were used to line the upper and lower lash lines. This was known as ‘Galena eye paint’. Apart from being widely used in ancient Egypt, Kohl was also used by several African tribes, who used it not only for their eyes, but for drawing distinct lines around the forehead, nose and other body parts as well.

MEANING OF KAJAL:

Kajal is nothing however a burnt residue of any oil burnt. whereas it’s thought-about that home-baked kajal is safe for babies, it’s a debatable issue as a result of the residue left once burning the oil is high in carbon and carbon is additionally not safe for sensitive eyes of a baby. (Nimish Patel Blogger | IT Project Manager)

Kajal is something, in the context of this question, that's used as a make-up application. Generally smeared under one's eyes. It's black in colour. It's prepared from natural ingredients and soot. It's called kohl in English. It's different from mascara which is applied on the eyelashes.

DEFINITION OF KAJAL AND KAJAL IRRITANT SYNDROME:

‘Kajal’ (Kohl) is a popular eye care product and its use has been reported since ancient times. Kohl (surma) has been defined as an eye preparation in ultra fine form of specially processed “Kohl Stone” (galena) incorporated with some other therapeutically active ingredients.

Application of ‘Kajal’ (also known as kohl or surma) is a common practice in Indian families. Although concerns about its safety have been raised, its use in paediatric age is very prevalent.

KAJAL IRRITANT SYNDROME:

Kajal irritant syndrome is a one type of infectious syndrome that occurs in the eye due to applying kajal in child’s eye its due to because of store-bought kajal has high levels of lead and other chemicals like galena, minimum, amorphous carbon, magnetite, and zincite.

The beliefs and practices with respect to use of ‘Kajal’ in children attending a tertiary care paediatric hospital in northern India are described.

It has been claimed to keep the eyes cool and clean, improve vision and strengthen the eyes. It has also been used for the prevention and treatment of eye diseases such as blepharitis, cataract, conjunctivitis etc. It is also said to ward off an ‘evil eye’.

However, in the recent studies, research has said that kajal is not safe for babies. Most medical experts and healthcare organizations recommend against the use of kajal for babies.

INCIDENCE AND PREVELENCE RATE:

One hundred consecutive children under 12 years of age of both genders and all religions (65% Hindus, 30% Muslims, and 5% other religions) were examined for use of ‘Kajal’. Eighty-six children had been applied ’Kajal’. Of these, 48 were girls and 38 were boys. Most of the children were under five years of age. On interview, the following information was collected.

· 64% mothers were educated up to class 12^th and more;

· 90% mothers applied ‘Kajal’ simply due to the advice of their elders;

· More than 50% parents did not know the advantage of applying ‘Kajal’. Some reasons cited included that it a) increases the size of eyes; b) improves eye sight; and c) protects the eyes against diseases.

· No mother who applied ‘Kajal’ could enumerate any disadvantage of using Kajal.

· About 80% respondents used ‘Kajal’ made at home. Most commonly, soot of the flame of an oil based lamp was mixed with some oil or eye ointment. Rest of the parents used commercially available ‘Kajal’.

· Of mothers not using ‘Kajal’, most did not have any reason for not using it while some said it was harmful to eyesight.

COMPOSITIONS OF KAJAL:

Most commercially produced ‘kajal’ contain high levels of lead. Studies have revealed that ‘Kajal’ comprises of galena (PBS), minimum (Pb₃O₄), amorphous carbon, magnetite (Fe₃O₄), and zincite (ZnO).

· Commercial kajal is not safe for babies since it contains lead. The lead comes from the galena stone (kohl stone), which naturally contains the element. The FDA considers kajal as According to the U.S. Food and Drug Administration (FDA), store-bought or an illegal colour additive in the US.

Some researchers found that store-bought kajal has high levels of lead and other chemicals like galena, minimum, amorphous carbon, magnetite, and zincite. These chemicals might harm the baby’s eyes. One study has questioned the authenticity of such reports and has claimed that ‘Kajal’ is safe for use. US FDA does not permit its use in a cosmetic or in any other FDA-regulated product.

THE CORRECT WAY OF VIEWING KOHL/SURMA/KAJAL (ESPECIALLY ITHMID):

First of all, it is important to understand that the Arabic word “Kohl” refers to anything that is applied on the eyes, eyelashes and eyebrows. This is also the case with the words “Surma” and “Kajal” used in South Asia, or their Somali equivalent, “Indha-Kuul”. In this context anything made of any kind of substance can act as a Kohl, Kajal, Surma or Indha-Kuul.

Considering this wider meaning of the word, modern eyeliner and mascara products are a form of Kohl or Surma/Kajal/Indha-kuul. On a close studying of relevant Ahadith, it becomes apparent that saying Kohl is recommended and used by the prophet صَلَّى اللَّهُ عَلَيْهِ وَسَلَّمَ is sort of wrong. Almost all the Hadiths relating to the use of kohl explicitly refer to Ithmid kohl only. The prophet صَلَّى اللَّهُ عَلَيْهِ وَسَلَّمَ recommended and used Ithmid Kohl only. There is no evidence of the prophet recommending the practice of Kohl in general or the use of other types of Kohl. This is not to say that other substances that are used as a Kohl are haram and not allowed, but it is wrong to claim that this mere practice of applying these substances (Kohl) is a sunnah.

It is more specific than that the practice of applying various substances on the eyes and its surroundings for cosmetic and health purposes has been around well before the coming of Islam, and there are many different substances such as charcoal and that can be used to this end. One of the queens of ancient Egypt where Kohl was popular, used to have a grounded Frankincense as a Kohl. In modern times, various chemicals are used to make eye liners and mascara products, which are also a form of Kohl.

Therefore, It is important to make the distinction between Ithmid Koh, which is the Kohl used and recommended by the prophet صَلَّى اللَّهُ عَلَيْهِ وَسَلَّمَ and other types of Kohl.Secondly, and this is very important point for men in particular: Applying ithmid Kohl is not like you are applying a mascara or an eyeliner. Rather you should view it as using a miracolous substance that has been proven throughout centuries to be beneficial for eye health and maintaning optimum vision. Not only that, you are following a practice and an advice of your beloved صَلَّى اللَّهُ عَلَيْهِ وَسَلَّمَ whom following him only brings goodness and bliss.

WHY TO AVOID KAJAL:

List of problems caused by lead and other reasons to avoid Kajal.

1. According to the FDA, the use of commercial kajal could cause lead poisoning, which can increase the risk of developing anaemia and kidney problems. Lead poisoning might also cause neurological damage that may lead to seizures and coma.

2. The prolonged application of kajal might increase lead levels in the body, thus causing adverse effects on the brain and bone marrow.

3. Kajal is often applied with the fingertip. Observing poor hygiene while application could expose the baby’s eyes to pathogens.

SIGNS AND SYMPTOMS:

· Change in vision

· Pain, itching, burning

· Excessive watering

· Blurred vision, double vision (diplopia)

· Loss in field of vision, blind spots, floating spots

· Difficulty with vision at night

· Pain in bright light

· Frontal headache

· Halos around eyes

· Frequent reddening of eye-conjunctivitis

· Discharge, eye crusted on awakening

· Eyes feel dry – wearing contact lenses, glasses

· Regular medication

· History of glaucoma in family

· History of diabetes, hypertension

· Daye of last eye exam

DIAGNOSTIC TESTS FOR THE EYE:

· Ophthalmoscopy – examination of the fundus or interior of the eye done with the ophthalmoscope

· Retinoscopy – determine focusing power of each eye

· Tonometry – measures the intra ocular pressure

· Normal IOP – 10-2-mmHG

· Visual field examination – measures peripheral vision

· Slit lamp examination – binocular microscope magnifies the surface of the eye – iritis cataract ,

· Ultrasonography – determine pathologic changes – opaque lense, cloudy cornea, blood vitreous

· Retinal imaging produced high resolution image of the entire retina – diabetic retinopathy

· Retinal angiography – detects vascular changes and blood flow through retinal vessels. Water soluble dye used. Special camera used to detect appearance and distribution of dye in the retinal arteries, capillaries and veins.

MEDICAL MANAGEMENT:

· Assess eyes and vision

· Assess for signs of ear infection

· Instill drops and apply ointments to eyes as necessary.

· Administer medications as required

· Antibiotic drops or ointments are used to treat bacterial infections.

· Antihistamines, decongestants and steroids may also be given to relieve symptoms.

Teach parent to instill eye drops or apply ointments at home for continued treatment.

NURSING MANAGEMENT OF EYE INFECTIONS:

· Bacterial and viral conjunctivitis are spread through contact. Disinfect all equipment to prevent cross contamination to other patients.

· Obtain history from patient and parents, depending on patient’s age.

· Determine if others in the home have similar symptoms. Isolate patient from these family members.

· Does the patient attend school or daycare where it is easy to pick up germs and bacteria? How long has patient had symptoms?

· Apply warm compress over eye

· Make sure compress is moist and warm (not hot) to help relieve discomfort.

· Instill drops and apply ointments to eyes as necessary.

· Administer medications as required

· Antibiotic drops or ointments are used to treat bacterial infections.

· Antihistamines, decongestants and steroids may also be given to relieve symptoms.

· Encourage patient to remain home from school or daycare for approximately 7 days

· Pink eye infections are highly contagious and easily spread through contact. Isolating the patient from other children will prevent the continued spread of the illness.

· Educate patients and parents / caregivers of proper hygiene and how to prevent further spread of infection:

a. Avoid rubbing the eye(s)

b. Clean eye discharge with a tissue (dispose of carefully)

c. Do not share towels or clothing with others

d. Teach parent to instill eye drops or apply ointments at home for continued treatment

· Help patients and parents / caregivers understand the importance of proper care and hygiene to prevent spread of infection to other children or family members.

· Correct instillation of eye drops and correct administration of medications is imperative for optimal therapeutic benefit.

· We can also use home-made kajal but there is no medical evidence to prove that homemade kajal is safe for babies.

· Therefore, consult your baby’s paediatrician before using a homemade or store-bought kajal for your babies.

· Kajal has been conventionally used for centuries. But modern research has shown that the substance has potential hazards.

PHYSICAL ASSESSMENT:

· Observe for redness of conjunctiva, swelling, secretions, excessive tearing

· Change in visual acuity

· Note any squinting, tilting head

· Note ability to move eyebrows, eyes

· Intolerable cry and uncontrollable pain

NURSING DIAGNOSIS:

· Anxiety/fear related to loss of vision

· High risk of infection related to interruption of body surface

· High risk of injury related to visual limitations and unfamiliar environment

· Self-care deficit related to post operative period

· Knowledge deficit related to post-operative management, medications and follow up care.

INSTILLING EYE DROPS:

· Verify order

· Wash hands, give patient tissue

· Remove eye patch, gently cleanse with wet gauze

· Patient supine or head lifted up, look up

· Pull lower lid down

· Squeeze gtts in to conjunctiva sac

· Do not touch dropper to patient’s eye

· Put pressure with figure over lacrimal duct to decrease systemic absorption

· Ask patient to close eye gently and rotate eyeball to distribute medication. Do not squeeze eye shunt

· Apply new tape with non-allergic tape.

ADVERSE EFFECTS:

· Prolonged application may cause excessive lead storage in the body

· Affecting the brain and bone marrow

· Convulsions

· Anaemia

· Other eye related effects

COMPLICATIONS:

· To increased levels of lead in the blood stream

· At risk of lead poisoning

· Lead intoxication

· Anemia

· Growth retardation

· Low IQ.

· Convulsions

NURSING IMPLICATION:

· Scientific bodies of paediatricians, ophthalmologists and paediatric surgeons and nurses should interact with social leaders for education of public.

· Parent education by paediatricians, ophthalmologists and other primary health care providers.

· Display of educative material in the health care facilities like hospitals and clinics.

· Regulatory directions to manufacturers regarding compulsory testing of ‘Kajal’ for levels of lead and other heavy metals and certification.

· Banning of advertisements proclaiming unauthenticated advantages of ’Kajal’ in media.

· Community health nurses are playing an important role in providing health education regarding kajal irritant syndrome.

· Every hospital have to work together to prevent this issue.

· As a community health nurse we can distribute the pamphlet related to kajal and its effects to the public.

· Each nurse who is working in a hospital has to be aware of the kajal and its side effects.

· It is a nurse role to be educated to the parents who are bringing their child for medical seeking opinion.

REFERENCES:

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Received on 22.02.2020 Modified on 26.03.2020

Int. J. Nur. Edu. and Research. 2020; 8(3):358-362.

DOI: 10.5958/2454-2660.2020.00076.9