Ocular Microbiology

Laboratory of Microbiology
Faculty of Medicine – Universitas Brawijaya
2015

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 Introduction
 Today we will discuss about:
◦ Basic aspects of microbial disease
 How does infection occurs? Host defense? Virulence factor?
◦ Organisms causing ocular infections
 Bacteria? Fungi? Virus?
◦ Clinical cases of ocular infections
 Infection of eyelid? Conjunctiva? Cornea? Etc.
◦ Diagnostic laboratory technique for
microbiologic examination

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Basic Aspect of Microbial Disease

Eye Infection
Basic aspects Organisms
of microbial causing ocular
disease infections

Diagnostic
Clinical cases Laboratory
of ocular Technique for
infections Microbiologic
Examination

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How does Infection Occur?
Immunity
Host
Risk
factor It is all
started
with
adherence!

Virulence
Environment Agent
Quantity

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Overview

Attach to the host /

Multiply / colonize
infection site

In order to cause disease,

pathogens must be able to:

Evade host immune Cause pathogenic

defense effect on host

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 Host

Host defense
Environment Agent

Nonspesific
Defense

Spesific
Defense

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 Host

Host defense
Environment Agent

Nonspesific
Defense Skin / mucosal integrity
and normal flora

Mechanical flushing 
tears and eyelids

Defensive substance, i.e.

lysozyme

Inflammatory cells

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 Host

Host defense
Environment Agent

Cell mediated immune

response

Humoral immune
response

Spesific Presence of memory

Defense
Specificity

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 Host

Virulence Factors
Environment Agent

Bacterial pili &

cell wall capsules

Extracellular
Surface
enzymes:
proteins /
coagulase,
specific
hyaluronidase,
receptors
protease, etc.

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Organisms Causing Ocular
Infections
Eye Infection
Basic aspects Organisms
of microbial causing ocular
disease infections

Diagnostic
Clinical cases Laboratory
of ocular Technique for
infections Microbiologic
Examination

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What organism cause Eye Infection?

Bacteria Fungi

Virus

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Examples of bacterial staining and culture media
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 Common causes of ocular infection
 Dermatoblepharitis, dacryocystitis, dacryoadenitis:
◦ Streptococcus & Staphylococcus
◦ Herpes simplex virus,Varicella-zoster virus

 Conjunctivitis:
◦ Streptococcus, Staphylococcus, Haemophilus influenzae,
Neisseria gonorrhoeae, Chlamydia trachomatis
◦ Adenovirus, Herpes simplex virus

 Keratitis:
◦ Adenovirus, Herpes simplex virus
◦ Streptococcus, Staphylococcus, Haemophilus influenzae,
Pseudomonas aeruginosa
◦ Candida albicans, Acanthamoeba sp.

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Common causes of ocular infection
 Endophthalmitis:
◦ Staphylococcus, Streptococcus, P. acnes, Bacillus sp.,
Haemophilus influenzae.

 Retinochoroiditis:
◦ Herpes simplex virus,Varicella-zoster virus
◦ Toxoplasma gondii

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Clinical Cases of Ocular Infections

Eye Infection
Basic aspects Organisms
of microbial causing ocular
disease infections

Diagnostic
Clinical cases Laboratory
of ocular Technique for
infections Microbiologic
Examination

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Intraocular

Clinical Cases
 Our eyes … …
Cornea

Eyelid
Conjunctiva

Gland

Conjunctiva
Gland

Cornea

Intraocular
Eyelid

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 Intraocular

Infections of Eyelids
Hordeolum Blepharitis
Cornea

Acute abscess of Very common cause of

ocular discomfort and
eyelid gland irritation
Conjunctiva

Typically caused by Caused by S. aureus

Staphylococcus
Gland

May extend to May associated w/

surrounding tissues marginal keratitis
Eyelid

Tx: warm compress, Tx: promote hygiene,

ab topical, incision ab topical
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 Intraocular
Cornea
Conjunctiva

Hordeolum Hordeolum incision

Gland
Eyelid

Preseptal Cellulitis
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 Intraocular

Infections of Conjunctiva
Cornea

Bacterial Conjunctivitis

• Common cause: H. influenzae, S.pneumonia,

Conjunctiva

S.aureus, and Moraxella catarrhalis

• Gonococcal conjunctivitis
• Chlamydial conjunctivitis and trachoma

Viral Conjunctivitis
Gland

Fungal Conjunctivitis
Eyelid

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 Intraocular

Viral Conjunctivitis
Cornea

 Mostly due to ADENOVIRUS.

 Epidemic keratoconjunctivitis  serotypes 8,19
Conjunctiva

and 37
 Serotypes 3,7, and 11  less severe
pharyngoConjunctival fever.
 Signs
◦ eyelid oedema,
Gland

◦ follicular conjunctivitis,
◦ Conjunctival hemorrhage,
◦ pseudomembrane.
Eyelid

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 Intraocular

 Treatment is SUPPORTIVE
 artificial tears and cold compress
Cornea

 until spontaneous resolution which can take

up to 3 weeks.
Conjunctiva

 Topical steroids may relief symptoms and corneal

inflammation
Gland

Follicular reaction in Adenoviral conjunctivitis

Eyelid

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 Intraocular

Bacterial Conjunctivitis
Acute
Cornea


 Usually self limited
 Common cause: H. influenzae, S.pneumonia, S.aureus,
Conjunctiva

and Moraxella catarrhalis

 Signs :
◦ diffuse Conjunctival injections
◦ mucopurulent secretion
 Topical antimicrobial agents are effective
Gland

 Special cause:
◦ Neisseria gonorrhoeae
Eyelid

◦ Chlamydia trachomatis
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 Intraocular

Gonococcal keratoconjunctivitis
Cornea

• Neisseria gonorrhoeae (also causes venereal

Etiology genitourinary tract infection)
Conjunctiva

Gram stain of the • Gram- negative diplococci

discharge

Infection • occurs in neonates through the birth canal

• acute profuse purulent Conjunctival

Presented as discharge,
Gland

• severe eyelid oedema

Complication • Corneal ulceration and perforation

Eyelid

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 Intraocular
Cornea
Conjunctiva
Gland

Gonococcal keratoconjunctivitis: a. severe eyelid oedema;

Eyelid

b.profuse purulent discharge; c & d. corneal ulceration; e. ocular

perforation; f. Gram stain showing gram negative diplococci 24
 Intraocular

Gonococcal keratoconjunctivitis
Cornea

Bacterial • enriched media such as chocolate

culture agar.
Conjunctiva

• topical and systemic antibiotics

Treatment (Ceftriaxone i.m or i.v)

• should be hospitalized and

Patient quarantined
Gland

Supportive • Frequent irrigation of discharge is

tx also important to accelerate healing
Eyelid

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 Intraocular

Chlamydial Conjunctivitis
Inclusion conjunctivitis / swimming pool conjunctivitis
Cornea

small intracellular obligate bacteria

◦ Extracellular elementary body
C.trachomatis (infectious)
Conjunctiva

◦ Intracellular replicating reticular body

serotype D-K which
primarily cause
urogenital infection

• PCR
Special • Direct monoclonal fluorescent antibody microscopy
investigation:
Gland

• McCoy cell culture

• Topical tetracycline or erythromycin Chronic?

Eyelid

Treatment: • Doxycyclin 100 b.d. for 10 days

• Azithromycin 1 g single dose
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 Intraocular
Cornea
Conjunctiva
Gland

Chlamydial inclusion conjunctivitis: a. Large Conjunctival follicles;

b.marginal corneal infiltrates; c. monoclonal fluorescent antibody
microscopy; d. McCoy cell cultures showing inclusion bodies
Eyelid

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 Intraocular

Trachoma
C.trachomatis Currently trachoma is the leading
Cornea

serotype A, B, Ba, cause of preventable blindness in the

and C world
Conjunctiva

Risk factors of infection is overcrowding

population, poor hygiene, and poverty.

Fly is an important vector of

transmission
Gland

Direct transmission occur from eye or

nasal discharge
Eyelid

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 Intraocular
Cornea
Conjunctiva
Gland

Trachoma: a. Follicles at Conjunctiva; b. Herbert’s pit on upper

Eyelid

limbus; c. Corneal scarring and neovascularization; d & e.

subConjunctival sicatrix; f. Enteropion causing corneal opacification 29
 Intraocular

Trachoma (cont’d)
Cornea

Initial infection :
repeated
Conjunctiva

mild Complications blindness

infection
conjunctivitis,

 Complications are:
◦ Conjunctival scarring
Gland

◦ Trichiasis, cicatrical enteropion

◦ Severe corneal opacification and vascularization
Eyelid

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 Intraocular

Trachoma (Management)
Cornea

• Regular face washing

Supportive • Control of flies
Conjunctiva

• single dose Azithromycin 20 mg/kg

Antibiotics • Doxycyclin 2x 100 mg or Erythromycin
500 mg b.i.d. for 14 days
Gland

• If necessary to relieve trichiasis and

Surgery repair enteropion
Eyelid

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 Intraocular

Herpetic Eye Disease (1)

Etiology: Herpes Simplex Virus (HSV)
Cornea

 Common manifestation
• causes
infection at ◦ blepharoconjunctivitis,
Conjunctiva

HSV-1 face, lips, and

eyes ◦ dendritic keratitis
◦ corneal ulcer
 Droplet transmission
• causes  May establish a latent infection
genital
herpes, but  Treatment with antiviral:
Gland

HSV-2 rarely can be

transmitted ◦ Topical: Acyclovir 3% ointment
to eyes 5x/day
◦ Oral Acyclovir 5 x 400 mg
Eyelid

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 Intraocular
 Recurrent disease is
often encountered
because of reactivation,
Cornea

triggered by stimuli such

as fever, hormonal
Conjunctiva

HSV Blepharoconjunctivitis
change, UV radiation, or
trauma.
Gland
Eyelid

Dendritic keratitis stained with fluorescent

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 Intraocular

Herpetic Eye Disease (2)

Herpes Zoster Ophthalmicus (etiology: Varicella Zoster Virus/ VZV)
Cornea
Conjunctiva

Virus travels
to sensory
Remain
Initial attack ganglia Herpes
dormant for Reactivation
of varicella, dorsal root zoster
decades
and cranial
nerve
Gland
Eyelid

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 Intraocular

Herpes Zoster Ophthalmicus

Cornea

Clinical • Painful erythema and maculo-

papular rash along the branches of
features: trigeminal nerve dermatome
Conjunctiva

Eye • Conjunctivitis
involvement • Keratitis (epithelial and stromal)
include: • Anterior uveitis
Gland

Postherpetic • May persist for months after cure

neuralgia
Eyelid

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 Intraocular
Cornea
Conjunctiva

Herpes Zoster Ophthalmicus

 Treatment:
◦ Oral acyclovir 5x 800 mg/day for 3-7 days
Gland

◦ Or famciclovir 3x 500 mg/day

◦ Symptomatic treatment of involved skin
Eyelid

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 Intraocular
How to Diagnose Herpetic Eye
Disease
Cornea

 Most often are made on clinical basis

Conjunctiva

◦ Anamnesis
◦ Physical Examination

 Viral culture can show a characteristic

cytopathic effect
Gland

 PCR is also available to detect viral DNA

Eyelid

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 Intraocular

Bacterial Keratitis
Cornea

 Uncommon in normal eye,

 Usually develops when ocular defense is
compromised e.g: epithelial defect
◦ Trauma of the eye
Conjunctiva

◦ May occur following damage because of contact lenses

 May occur via direct penetration of bacteria
through corneal tissue
Gland
Eyelid

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 Intraocular

Bacterial Keratitis (cont’d)

Example of common causal pathogen(s)
Cornea

most common cause of

P. aeruginosa keratitis in contact lens
wearers
S. aureus,
commensal organism that
S. pyogenes
Conjunctiva

can cause opportunistic

infection
S. pneumonia

N. gonorrhoeae,
Gland

H. influenzae, penetrate intact

epithelium
C. diphtheriae
Eyelid

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 Intraocular

Bacterial Keratitis
Cornea
Conjunctiva
Gland
Eyelid

Severe bacterial keratitis with ulceration 40

 Intraocular

Fungal Keratitis
Cornea

Fungal corneal
• Aspergillus or Fusarium sp.
infection can • Candida albicans
be caused by:
Conjunctiva

Should be considered as differential

diagnosis in cases of suppurative keratitis
Gland

• systemic antifungal such as

Treatment ketoconazole,
• topical Natamycin drops.
Eyelid

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 Intraocular

Acanthamoeba Keratitis
Cornea

• ubiquitous protozoa found in fresh water,

Acanthamoeba tap water, and soil.

Ocular • developing countries  ocular trauma

infection • developed countries  contact lens wear
Conjunctiva

Corneal infection can be severe and sight threatening

Gland

• dipropamidine and polyhexamethylene

Treatment: biguanide drops
Eyelid

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 Intraocular
Cornea

Fungal keratitis caused by Aspergillus sp. (a) and Candida albicans (b)
Conjunctiva
Gland

Achantamoeba keratitis
Eyelid

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 Eyelid Gland Conjunctiva Cornea Intraocular

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Intraocular
Endophthalmitis
severe infection of result of
penetrating
the intraocular injuries and ocular
structures
Cornea

surgery
Conjunctiva

diagnosing
etiology
Vitreous tap is usually required to obtain
specimens for microbial culture
Gland

The infection is visual threatening, and

sometimes eye removal is necessary
Eyelid

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Intraocular
Endophthalmitis

Most common • Staphylococcus, Streptococcus, P. acnes

(post surgery)
offending
Cornea

• Bacillus sp., Haemophilus influenzae.

organisms are (post trauma)
Conjunctiva

• given by intravitreal injection,

Antibiotics • comprising combined broad
Gland

therapy spectrum antibiotics, (e.g Tobramycin,

Ceftazidime, or Vancomycin).
Eyelid

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Diagnostic Laboratory Technique for
Microbiologic Examination
Eye Infection
Basic aspects Organisms
of microbial causing ocular
disease infections

Diagnostic
Clinical cases Laboratory
of ocular Technique for
infections Microbiologic
Examination

47
Diagnostic Laboratory Techniques

• Staining and microscopy

Microbiological examination
examination to • Culture techniques
assist diagnosis
comprise of • Antigen detection
• Nucleic acid detection

Appropriate specimen collection and handling is

important to produce accurate laboratory examination

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Diagnostic Laboratory Techniques

Conjunctival Corneal Another

specimens specimen swab
obtained
obtained with
using a
sterile swabs
Kimura taken for
and
spatula, sterile direct
inoculated
needle, or smearing /
into
surgical blade staining
appropriate
to get enough examination
solid media
corneal
or broth
scrapings

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Diagnostic Laboratory Techniques

viral and chlamydial bacterial and fungal

infections : infections, :
an appropriate specimens should be
tissue/cell culture is inoculated to blood,
selected for chocolate, and
examination Sabouraud’s agar and
thioglycolate broth.

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