Sara Fatima Memon¹, Rameez Naqvi², Kashaf Zaidi³

1. University Hospitals Dorset NHS Foundation Trust
2. East Suffolk and North Essex NHS Foundation Trust
3. Bart’s and the London, School of Medicine and Dentistry

Applying Kajal, collyrium, surma or kohl to the eyes is a common practice in many parts of the world, particularly in the Indian subcontinent. The word Surma is derived from the Urdu word antimony, due to its original main constituents being antimony trisulfide and ore stibnite (1). However, due to the scarcity and expense of antimony, galena (lead sulphite) is commonly added to the composition (2–4).

Surma is not only used for its aesthetic appeal but also for its perceived medicinal properties. As a result, the practice spans across age groups and genders, with infants’ eyes commonly being lined with Surma as a customary practice. In fact, a recent clinical trial demonstrated a significant improvement in blepharitis-related signs and symptoms in eyes treated with Kohl compared witherythromycin ointment in staphylococcal blepharitis (5).

The most significant concern associated with the use of traditional Surma involves the addition of lead. Studies analysing the lead content of Surma preparations in various countries have shown it to be as high as 85%, owing to poor regulation during manufacturing  (1,6–8). The ocular surface spread of cosmetic products has been well-documented, often resulting in disruption of the lipid layer of the tear film and potential blockage of the Meibomian glands (2). The fine particles present in Surma can irritate the eye (2). Recently, Sharma et al. has described a case of a large particle comprised of  Surma powder in the lower palpebral conjunctiva, large enough to be seen as a radio-opaque fleck on CT scanning (9). Chakraborti et al. has described a more serious and unusual case of  Surma-induced conjunctival and scleral ulceration, necessitating an autologous lamellar scleral graft in a 60-year-old female, who applied the product in an attempt to alleviate mild itching symptoms (10). Further risks include allergic reactions, the risk of conjunctivitis using communal applicators and contaminated products, and periocular skin hyperpigmentation (11).

The implications for young children and infants are broader. Whilst absorption through the conjunctiva is unlikely, the most common route of lead ingestion in infants is orally through mouthing their fingers, which can occur following eye-rubbing (12). A study in California showed that the use of eye cosmetics imported from Pakistan was strongly correlated with elevated blood lead levels, with chemical evaluation of eye cosmetics used by these children revealing a high lead content (13). Goswami et al. found Surma to be associated with high blood lead concentration and a significant reduction of haemoglobin levels in children using Surma regularly in Kolkata (1). Furthermore, high levels of lead have been found in the cord blood of foetuses where the mothers regularly used Surma (6). Chronic lead poisoning may contribute to poor growth and impaired development, with severe cases causing seizures and death (14).

In response to health concerns, there has been a shift towards the production of safer, lead-free versions of Surma. However, the challenge remains in educating the public about the risks associated with traditional Surma and encouraging the use of safer alternatives. In the US, Surma is not approved by the Federal Drug Authority (FDA) and is a banned product with import restrictions. Similarly in the UK and Europe, cosmetic products containing lead, cadmium, and other heavy metals are prohibited from being sold. However, these products are still available to purchase from a variety of sources on the Internet, in addition to shops in parts of the UK that cater to ethnic-minority groups (8).

Eye care has been an integral part of child health and new-born care in the World Health Organization (WHO) guidelines. However, whilst advocating for general eye hygiene may be straightforward, discussions surrounding the use of Surma may be difficult owing to its deeply embedded roots in tradition, religion, and culture, along with its potential benefits as experienced by local communities. Public health initiatives and education are key in shifting towards safer practices, ensuring that this age-old tradition does not compromise the well-being of its users.

References

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3. Patel DK, Prasad S, Tripathi R, Behari JR. The level of polyaromatic hydrocarbons in kajal and surma of major Indian brands. Int J Cosmet Sci. 2009;31(3):177–82.
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