Ali Al-Kaff, MD; Ali Al-Rajhi, MD; Khalid Tabbara, MD; Adnan El-Yazigi, PhD, FCP From the King Khaled Eye Specialist Hospital (Drs. Al-Kaff and Al-Rajhi), Department of Ophthalmology, College of Medicine, King Saud University (Dr. Tabbara), and Biological and Medical Research Department, King Faisal Specialist Hospital and Research Centre (Dr. El-Yazigi), Riyadh. Address reprint requests and correspondence to Dr. Al-Kaff: c/o Medical Library, King Khaled Eye Specialist Hospital, P.O. Box 7191, Riyadh 11462, Saudi Arabia. Accepted for publication 24 March 1992. Kohl is a traditional powder-like mixture used as an eyeliner and to treat eye disease in many Middle and Far East countries. We studied kohl use among 360 individuals selected at random in Riyadh, Saudi Arabia. Kohl was used by 13% of males and 26% of females, especially the elderly and illiterate. Forty. percent of females with children applied kohl to the eyes of their children during the first postnatal month. Analysis of five commercially available traditional kohl samples showed that some preparations have a high ph and a high lead concentration (88%), indicating that most preparations are lead-based rather than antimony-based. It is interesting to find that some kohl preparations have a weak antimicrobial effect against Streptococcus, Staphylococcus and Proteus species. The use of lead-based kohl is still a common and serious practice and should be discouraged, especially in children. The role of traditional kohl use in the pathogenesis of common ocular external diseases prevalent in Middle and Far East countries merits investigation. A Al-Kaff, A Al-Rajhi, K Tabbara, A El-Yazigi, Kohl-The Traditional Eyeliner: Use and Analysis. 1993; 13(1): 26-30 Kohl has been known and used traditionally in the Middle and Far East as an eyeliner since antiquity. It has been used as a cosmetic by women and some men and has even been applied to the eyes of children and umbilicus of newborns. Kohl has been used also for treating and preventing ocular diseases. Pure kohl contains antimony sulfide and trisulfide as its main constituents. The source of kohl is a shiny, dark stone known in Arabic as "ithmed", which translates to antimony in English. In Urdu, the word "surma" refers to both antimony and kohl. Ithmed may be ground to a powder ready for use as an eyeliner. Kohl may comprise ithmed alone, or in combination with other materials such as camphor, menthol, almond seeds, essence wood, or ash. Due to the scarcity of ithmed, many manufacturers have substituted galena (lead sulfide), which has almost the same color and shiny surface as ithmed. Other manufacturers add charcoal or other vegetable ashes to the preparation. This has resulted in a wide variety of commercially available preparations, either in the form of stone, powder, finger rods, or pencils. Several reports have implicated kohl as the cause of lead poisoning among children [1 4]. Blood lead levels of children using kohl were found to be much higher than those of European children who did not use kohl [4]. Samples of kohl available in Saudi Arabia have also been studied for their microbial content and were found to be heavily contaminated with Bacillus species, gramnegative bacilli, and a number of fungi [5]. In addition, Hannan et al analyzed various commercial brands of kohl for potential carcinogens and have classified both mutagenic and nonmutagenic preparations [6]. The investigators found that brands lacking mutagenic properties were mostly antimony-based and contained no organic material. There are no reports on the prevalence of traditional kohl use and the sociocultural basis for its use. The
antimicrobial effect of kohl has not yet been reported. In order to investigate this important public health problem, we undertook the following study. Patients and Methods We selected at random 360 individuals, including patients attending King Khaled Eye Specialist Hospital (KKESH) during the period of October - December 1988, patients' relatives, and employees working at the hospital. Individuals were asked to respond to a multiple-choice questionnaire on age, sex, marital status, education, use of kohl, and whether kohl was ever applied to the eyes of children or infants in the household. Chemical Analysis of Kohl Samples Five of the most commonly used preparations of traditional kohl were selected and purchased from the local market. The preparations were stone kohl and the following powder forms: Ka-Noor, kohl Noori (imported from India), brown kohl, and kohl Samah (made locally in Saudi Arabia). We also selected at random one of the commonly used modern pencil eyeliners (an Italian product) for comparison. An equal weight of each preparation (20 mg) was prepared for analysis in powder form by grinding the stone and pencil forms. A standard weight was then tested for ph and solubility in water. The ph value of two samples (one traditional kohl preparation and the modern eyeliner) was not determined because of the waxy nature and water insolubility of the samples. Lead and antimony concentrations in all six specimens were measured using electrothermal atomic absorption spectrophotometry at King Faisal Specialist Hospital and Research Centre laboratories, Riyadh. An accurately weighed amount of each specimen (i.e., 10 mg) was digested with 10 ml of concentrated nitric and sulfuric acids, (1:1, by volume), and the dried residue was ashed for six hours. The ash was dissolved in 2 ml of 0.05% nitric acid in deionized water by sonication for two minutes to yield absorbance values within the linear range for each element, then 10 µl was injected into the graphite furnace by the autosampler. The operating conditions of the instruments used were those recommended by the manufacturer (Varian Techtron Pty, Mulgrave, Victoria, Australia). Antimicrobial Effect of Kohl A 0.5 MacFarland standard suspension of bacteria was spread evenly over a 150-mm plate of Mueller-Hinton agar in the same manner used for antibiotic susceptibility testing. A 2 mm well was made in the agar in which 5 mg of kohl powder was placed. Plates were incubated in a non-co 2 incubator at 35-37 C for 18 to 24 hours. Other plates were incubated in a CO 2 incubator at room temperature. The effects of kohl on bacterial growth was graded according to the size of inhibition zone of bacterial growth around the kohl well. Absence of inhibition zone indicated no evidence of susceptibility, spotty growth within a small zone surrounding the kohl inoculum indicated slight inhibition, while a true sensitivity zone of no growth surrounding the kohl inoculum indicated susceptibility. Results There were 120 male and 240 female patients. Age and sex distribution is shown in Table 1. Ninety percent of the males were illiterate; of the females, 31% were illiterate, 28% had a secondary school education or less, and 41% had a university education. Sixteen males (13.3%) and 62 of the females (25.8%) were using traditional kohl; the other females were using modern eyeliner. Five percent (3/56) of females below the age of 20 years, 19.6% (22/118) of the middle-age females (20-40 years), and 56.0% (37/66) of the older females (above 40 years) used traditional kohl regularly. The use of traditional kohl was found more prevalent among illiterate females; 46 of 74 illiterate females (62.2%) compared to 8/61 (13.1%) of the females with elementary or secondary school education, and 8/97 (8.2%) of university educated females. This was found statistically significant when a chisquare analysis was performed (x 2 = 70.138 on two degrees of freedom, P < 0.0001). All the males and 38% of the females using traditional kohl applied it to the conjunctival culde-sac and the rest of females applied it to the lid margin. None of the males and 18% of the females shared the use of kohl from the same container. The frequency of kohl use among females and males of all age groups is shown in Table 2. The reasons given by users for traditional kohl use among males and females are shown in Table 3. When individuals were asked if they had any redness, irritation or problems related to the use of kohl, 18% of females answered positively and all males denied any problems. Fourteen of the females using traditional kohl wear contact lenses. Seven of them had
ocular irritation related to the use of kohl, which disappeared when kohl use was discontinued. Ninety-nine of the surveyed females have children and 40 (40.4%) had applied kohl to their children's eyes in early childhood. Of these, 62.5% (25/40) had applied kohl to the neonate eyes in the first postnatal week and 35.0% (14/40) had done so sometime during the first postnatal month. Chemical Analysis The ph range of the four tested kohl preparations was 6.10 to 10.90, and the solubility of the four samples in water was slight (0.02-0.03%). The contents of each of six samples tested for lead and antimony are shown in Table 4. Antimicrobial Effect The antimicrobial effect study of kohl samples has shown that Sample No. 1, the black stone kohl, had a slight inhibition zone for the growth of Proteus vulgaris and Staphylococcus aureus and a good inhibition zone (8 mm) for growth of Streptococcus pyogenes. Sample No.2, Kohl Ka Noor, had a slight inhibition zone for the growth of S. pyogenes. Sample No. 4, brown powder kohl had a slight inhibition zone for both S. pneumonia and S. pyogenes. No antimicrobial effects were found for the other samples. Table 1. Age and sex distribution of the study sample. Males (%) Females (%) Total no. 360 (100) 120 33 40 67 Age < 20 years 72 (20) 16 13 56 23 20-40 years 166 (46) 48 40 118 49 > 40 years 122 (34) 56 47 66 28 Table 2. Frequency of kohl use. Males Females Once daily or more 50% 73% One to four times weekly 13% 15% Rarely 37% 12% Table 3. Reasons for using kohl. Males (16) Females (62) Total (78) Reason (No.) No. (%) No. (%) No. (%) Cosmetic (1) 4 (25) 50 (80.6) 54 (69.2) Improve vision (2) 8 (50) 3 (4.8) 11 (14.1) Prophylaxis (3) 0 (0) 0 (0) 0 (0) Therapeutic (4) 0 (0) 1 (1-6) 1 (1-2) Religious belief (5) 0 (0) 2 (3.2) 2 (2.6) Nos. 1 and 5 0 (0) 2 (3.2) 2 (2.6) Nos. 2 and 5 4 (25) 2 (3.2) 6 (7.7) No answer 0 (0) 2 (3.2) 2 (2.6)
Table 4. Lead and antimony contents of different kohl preparations. Sample no. Kohl brand Lead(%) Antimony (%) 1 Black stone 88 0 2 Ka-Noori 4.1 0.53 3 Kohal Noori 3 1.82 4 Brown powder traces 1.13 5 Samah powder 20 9.97 6 Pencil eyeliner 0 2.09 Discussion Although many women moved to the use of eyeliner as a result of public education programs and improved educational and socioeconomic status, traditional kohl continues to be used by many women and men in Saudi Arabia, especially among the elderly and illiterate. There is a false belief that all commercially available kohl is "ithmed," that is, antimony-based. Prophet Mohammed (PBUH), Peace Be Upon Him, had advised Moslems to use kohl originating from ithmed. Such a religious reason is an important factor for its common use among women and men and for its application to children's eyes. It is not surprising to find that the main reasons for kohl use among males is to improve vision. Lid surfaces tinted by such a black, shiny powder will result in more reflection of the incident light rays and, therefore, glare will be decreased. This is noticed particularly by males who are more exposed to the bright sun than the females who usually wear veils. It is interesting to note that 25% of males used it for cosmetic reasons. The most serious aspect of kohl use is its application to children's eyes and umbilicus. Added to the risks of ocular infection and septicemia due to contamination [5], application of lead-based kohl may lead to chronic lead poisoning if the kohl is absorbed from the nasolacrimal mucosa or by ingestion through sucking the contaminated fingers [7]. Such a practice is still followed by many women (40% in our study), even by those who do not use traditional kohl. Chronic lead poisoning can result in hypochromic and microcytic anemia, chronic encephalopathy, and renal damage [8]. Lead absorption has been found to be greater in children than in adults [9]. In addition, previous studies have reported that asymptomatic lead poisoning may cause significant and permanent impairment of the nervous system functions [10]. Frequent use of preparations with high-alkaline ph values is irritating to the corneal and conjunctival surface and will increase the risk of infection by breaking the continuity of the corneal and conjunctival epithelial layers, and by changing the tear ph, making it favorable for growth and adherence of various ocular pathogens on the ocular surface. There is poor solubility of kohl particulate in water; active substances in kohl, whether organic or inorganic, are therefore deposited on the conjunctival surface, the mucous membrane lining the nasolacrimal system, and in the upper gastrointestinal tract. The role of kohl in precipitating nasolacrimal duct obstruction is possible and should be studied. One strong belief of Middle Easterners is that kohl (ithmed) protects from and treats eye infections. It is interesting to find that some preparations of kohl have a weak antimicrobial effect. The antimicrobial effects of three preparations of kohl (Samples 1, 2, and 4) are mostly minimal with a slight inhibition zone, except against Streptococcus pyogenes, where an 8 mm inhibition zone was elicited. Such antibacterial effects can be explained by the high ph of these preparations. Kohl Sample No. 1 (black stone) has an antibacterial effect on three different organisms which may be explained by its high lead content (88%). It may be that the presence of other metals and organic substances in kohl play a role in the antibacterial effect. This finding, however, does not justify the use of kohl with its documented contamination. Such a finding may explain in part why using contaminated kohl does not cause significant clinical conjunctivitis among most of the users. In conclusion, kohl use is still a significant and serious public health problem in our community. Most commercially available kohl preparations in Saudi Arabia, which are also available in other Middle Eastern countries, are risky to use due to product contamination, high ph, and high concentrations of lead. Kohl use in children can lead to very serious general and ocular complications. Kohl may play a role in the external eye infections by its contamination and shared use. The role of kohl in the pathogenesis of some ocular surface diseases and infections prevalent among kohl users merits further study. Public education programs for this problem are needed, as well as government health policies for the control of importing and selling cosmetic eye products to the public.
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