Original Investigation
Conjunctival Bacterial Flora in Nasolacrimal Duct Obstruction and Its Changes After Successful Dacryocystorhinostomy Surgery Bahram Eshraghi, M.D.*, Babak Masoomian, M.D.*, Ali Izadi, M.D.*, Zohreh Abedinifar, M.S.*, and Khalil Ghasemi Falavarjani, M.D.† *Eye Research Center, Department of Ophthalmology, Farabi Eye Hospital, Tehran University of Medical Sciences, Tehran, Iran; and †Department of Ophthalmology, Rassoul Akram Hospital, Iran University of Medical Sciences, Tehran, Iran
Purpose: To evaluate the results of conjunctival culture in patients with nasolacrimal duct obstruction (NLDO) and its changes after successful dacryocystorhinostomy surgery. Methods: In this prospective study, 71 adult patients with NLDO and 41 age- and sex-matched controls without NLDO were evaluated. The patients were divided in 2 groups based on clinical examination; group A with purulent regurgitation and group B without purulent regurgitation. Dacryocystorhinostomy surgery was performed, and the silicon tube was inserted in patients with upper lacrimal drainage system stenosis and when the lacrimal sac or nasal mucosal flap was inadequate for suitable anastomosis. Before surgery, microbiologic specimens were taken from the conjunctiva. Postoperative conjunctival sampling was continued weekly until the culture became negative or the colony count reached to the range of the control group. Results: There were 38 and 33 patients in groups A and B, respectively. Silicone tube was inserted for 17 patients (23.9%). The culture was positive for bacterial growth in all cases. The conjunctival culture in the control group was positive in 17 eyes (41.4%). The mean count of colonies in a sample unit was 5274 ± 6300, 1167 ± 1504, and 9.5 ± 1.5 for group A, group B, and controls, respectively. The mean time of normalization of specimens was 3.3 ± 1.3 weeks (range 1–7). Pathogenic bacterial growth, higher colony counts, the presence of silicone tube, and purulent regurgitation were significantly associated with longer normalization time (p = 0.007, p = 0.0001, p = 0.0001, and p = 0.01, respectively). Conclusions: This study suggests that after successful dacryocystorhinostomy surgery, a waiting period of 7 weeks is enough for conjunctival bacterial cultures to become negative or reach the level of the normal eyes. (Ophthal Plast Reconstr Surg 2014;30:44–46)
N
asolacrimal duct obstruction (NLDO) is one of the commonly encountered problems in ophthalmic clinical visits.1 Stasis and secondary infection lead to acute and chronic dacryocystitis with epiphora and purulent discharge. Complete obstruction of nasolacrimal duct is usually treated by
Accepted for publication August 21, 2013. The authors have no financial or conflicts of interest to disclose. Address correspondence and reprint requests to Khalil Ghasemi Falavarjani, M.D., Eye Research Center, Department of Ophthalmology, Rassoul Akram Hospital, Sattarkhan-Niayesh St., Tehran 14456-13131, Iran. E-mail: [email protected] DOI: IOP.0000000000000006
44
dacryocystorhinostomy (DCR) surgery.1,2 NLDO and chronic dacryocystitis have been reported to be risk factors for endophthalmitis after intraocular surgery.3–5 Intraocular surgery should be delayed until obstruction is removed by DCR surgery.2 There are few articles about the bacteriology of conjunctival flora in chronic dacryocystitis in comparison with healthy people.6–8 To the best of the authors’ knowledge, there is only 1 published article defining the time of normalization of conjunctiva flora after DCR surgery.6 The main goal of this study was to determine the time required for the conjunctival flora to normalize after successful DCR surgery.
METHODS This study was a prospective case control study. The study was approved by the ethics committee of the Farabi Eye Hospital. A total of 71 adult patients, with complaint of epiphora secondary to NLDO with or without pus reflux, were included. Exclusion criteria were any extraocular disease leading to ocular infection including significant eyelid disorders, history of surgery for nasolacrimal drainage system, use of topical medications, systemic immunosuppression, and active symptomatic infection in other sites of the body. A complete ophthalmic examination including evaluation of lacrimal drainage system was performed. Patients were divided in 2 groups based on clinical examination. Group A were the patients with purulent reflux. Group B were the patients with NLDO without pus reflux. All patients had unilateral nasolacrimal system problems. A control group of 41 cataract surgery candidates, without any past ocular history and with normal ophthalmic examination except for cataract was prepared. Standard external DCR was performed for all patients. Silicone intubation was performed in patients with upper lacrimal drainage system stenosis and when the lacrimal sac or nasal mucosal flap was inadequate for suitable anastomosis. Postoperative systemic antibiotic (cephalexin 500 mg every 6 hours for 5 days) and topical antibiotic (chloramphenicol 0.5% every 6 hours for 10 days) were prescribed. Conjunctival specimens were obtained bilaterally from all patients preoperatively and from 1 side of control group. All the procedures were performed by 1 surgeon (B.E.). The culture procedure was according to the previously described method.6 Briefly, samples were obtained by rolling a dry sterile swab against the lower conjunctival sac with great care to avoid the contact with eyelid margin and eyelashes. Each swab was immediately placed in a tube containing 1 ml thioglycollate medium. After 3 hours of incubation, the blood agar, chocolate agar, and eosin methylene blue agar plate were inoculated with 0.1 ml incubated medium for aerobic and anaerobic cultures. After the incubation period of 48 hours, colonies were differentiated and enumerated by standard bacteriologic laboratory techniques. Postoperative conjunctival specimens were obtained
Ophthal Plast Reconstr Surg, Vol. 30, No. 1, 2014
Ophthal Plast Reconstr Surg, Vol. 30, No. 1, 2014
Conjunctival Bacterial Flora and Dacryocystorhinostomy Surgery
Isolated organisms and the colony count in patients with nasolacrimal duct obstruction before dacryocystorhinostomy surgery and the normalization time after surgery
Cases with purulent regurgitation (group A) Cases without purulent regurgitation (group B) p
Mean ± SD of colony Normalization count in a sample unit time (wk)
No. patients
No. and type of isolated organisms (%)
38 (53.5%)
Staphylococcus epidermidis 10 (26.3%) Streptococcus viridians 10 (26.3%) staphylococcus aureus 5 (13.2%) klebsiella 4 (10.5%) diphtheroids 3 (7.9%) Staphylococcus saprophiticus 2 (5.3%) Bacillus cereus 2 (5.3%) Haemophilus 1 (2.6%) Mixed 1 (2.6%) S. epidermidis 14 (42.4%) S. viridians 6 (18.1%) S. aureus 4 (12.1%) Diphtheroids 2 (6.1%) S. saprophiticus 2 (6.1%) B. cereus 1 (3%) S. pneumoneae 1 (3%) Mixed 3 (9.1%) 0.4
33 (46.5%)
5274 ± 6300
3.8 ± 1.3
1167 ± 1504 0.001
2.6 ± 1.04 0.0001
Seven weeks after dacryocystorhinostomy surgery, all conjunctival bacterial cultures in 71 patients with nasolacrimal duct obstruction were negative or reached the level of the normal eyes.
from the operated side weekly until the result of the culture became negative or reached to the range of control group. The maximum colony count in the control group was 60 colonies of Staphylococcus epidermidis or Staphylococcus saprophyticus specimen in a sample unit which was considered as normal colonizing populations of flora. The success of the surgery was considered as absence of regurgitation, and the patency of lacrimal drainage system was confirmed by free fluid passage to the nasal cavity. Patients with surgical failure were excluded. In patients in whom the cultured organisms were similar to the control group (S. epidermidis or S. saprophyticus), the normalization time was considered as the interval between DCR surgery and the time that the culture results were below the range of control group (60 colonies in a sample unit). In others, the bacterial normalization time was defined as the interval between DCR surgery and the time that the culture results were negative. Data analyzed using a SPSS software (version 15, SPSS Inc., Chicago, IL, U.S.A.) and t test and chi-square test and correlation test were used for analysis. p
Conjunctival Bacterial Flora in Nasolacrimal Duct Obstruction and Its Changes After Successful Dacryocystorhinostomy Surgery Bahram Eshraghi, M.D.*, Babak Masoomian, M.D.*, Ali Izadi, M.D.*, Zohreh Abedinifar, M.S.*, and Khalil Ghasemi Falavarjani, M.D.† *Eye Research Center, Department of Ophthalmology, Farabi Eye Hospital, Tehran University of Medical Sciences, Tehran, Iran; and †Department of Ophthalmology, Rassoul Akram Hospital, Iran University of Medical Sciences, Tehran, Iran
Purpose: To evaluate the results of conjunctival culture in patients with nasolacrimal duct obstruction (NLDO) and its changes after successful dacryocystorhinostomy surgery. Methods: In this prospective study, 71 adult patients with NLDO and 41 age- and sex-matched controls without NLDO were evaluated. The patients were divided in 2 groups based on clinical examination; group A with purulent regurgitation and group B without purulent regurgitation. Dacryocystorhinostomy surgery was performed, and the silicon tube was inserted in patients with upper lacrimal drainage system stenosis and when the lacrimal sac or nasal mucosal flap was inadequate for suitable anastomosis. Before surgery, microbiologic specimens were taken from the conjunctiva. Postoperative conjunctival sampling was continued weekly until the culture became negative or the colony count reached to the range of the control group. Results: There were 38 and 33 patients in groups A and B, respectively. Silicone tube was inserted for 17 patients (23.9%). The culture was positive for bacterial growth in all cases. The conjunctival culture in the control group was positive in 17 eyes (41.4%). The mean count of colonies in a sample unit was 5274 ± 6300, 1167 ± 1504, and 9.5 ± 1.5 for group A, group B, and controls, respectively. The mean time of normalization of specimens was 3.3 ± 1.3 weeks (range 1–7). Pathogenic bacterial growth, higher colony counts, the presence of silicone tube, and purulent regurgitation were significantly associated with longer normalization time (p = 0.007, p = 0.0001, p = 0.0001, and p = 0.01, respectively). Conclusions: This study suggests that after successful dacryocystorhinostomy surgery, a waiting period of 7 weeks is enough for conjunctival bacterial cultures to become negative or reach the level of the normal eyes. (Ophthal Plast Reconstr Surg 2014;30:44–46)
N
asolacrimal duct obstruction (NLDO) is one of the commonly encountered problems in ophthalmic clinical visits.1 Stasis and secondary infection lead to acute and chronic dacryocystitis with epiphora and purulent discharge. Complete obstruction of nasolacrimal duct is usually treated by
Accepted for publication August 21, 2013. The authors have no financial or conflicts of interest to disclose. Address correspondence and reprint requests to Khalil Ghasemi Falavarjani, M.D., Eye Research Center, Department of Ophthalmology, Rassoul Akram Hospital, Sattarkhan-Niayesh St., Tehran 14456-13131, Iran. E-mail: [email protected] DOI: IOP.0000000000000006
44
dacryocystorhinostomy (DCR) surgery.1,2 NLDO and chronic dacryocystitis have been reported to be risk factors for endophthalmitis after intraocular surgery.3–5 Intraocular surgery should be delayed until obstruction is removed by DCR surgery.2 There are few articles about the bacteriology of conjunctival flora in chronic dacryocystitis in comparison with healthy people.6–8 To the best of the authors’ knowledge, there is only 1 published article defining the time of normalization of conjunctiva flora after DCR surgery.6 The main goal of this study was to determine the time required for the conjunctival flora to normalize after successful DCR surgery.
METHODS This study was a prospective case control study. The study was approved by the ethics committee of the Farabi Eye Hospital. A total of 71 adult patients, with complaint of epiphora secondary to NLDO with or without pus reflux, were included. Exclusion criteria were any extraocular disease leading to ocular infection including significant eyelid disorders, history of surgery for nasolacrimal drainage system, use of topical medications, systemic immunosuppression, and active symptomatic infection in other sites of the body. A complete ophthalmic examination including evaluation of lacrimal drainage system was performed. Patients were divided in 2 groups based on clinical examination. Group A were the patients with purulent reflux. Group B were the patients with NLDO without pus reflux. All patients had unilateral nasolacrimal system problems. A control group of 41 cataract surgery candidates, without any past ocular history and with normal ophthalmic examination except for cataract was prepared. Standard external DCR was performed for all patients. Silicone intubation was performed in patients with upper lacrimal drainage system stenosis and when the lacrimal sac or nasal mucosal flap was inadequate for suitable anastomosis. Postoperative systemic antibiotic (cephalexin 500 mg every 6 hours for 5 days) and topical antibiotic (chloramphenicol 0.5% every 6 hours for 10 days) were prescribed. Conjunctival specimens were obtained bilaterally from all patients preoperatively and from 1 side of control group. All the procedures were performed by 1 surgeon (B.E.). The culture procedure was according to the previously described method.6 Briefly, samples were obtained by rolling a dry sterile swab against the lower conjunctival sac with great care to avoid the contact with eyelid margin and eyelashes. Each swab was immediately placed in a tube containing 1 ml thioglycollate medium. After 3 hours of incubation, the blood agar, chocolate agar, and eosin methylene blue agar plate were inoculated with 0.1 ml incubated medium for aerobic and anaerobic cultures. After the incubation period of 48 hours, colonies were differentiated and enumerated by standard bacteriologic laboratory techniques. Postoperative conjunctival specimens were obtained
Ophthal Plast Reconstr Surg, Vol. 30, No. 1, 2014
Ophthal Plast Reconstr Surg, Vol. 30, No. 1, 2014
Conjunctival Bacterial Flora and Dacryocystorhinostomy Surgery
Isolated organisms and the colony count in patients with nasolacrimal duct obstruction before dacryocystorhinostomy surgery and the normalization time after surgery
Cases with purulent regurgitation (group A) Cases without purulent regurgitation (group B) p
Mean ± SD of colony Normalization count in a sample unit time (wk)
No. patients
No. and type of isolated organisms (%)
38 (53.5%)
Staphylococcus epidermidis 10 (26.3%) Streptococcus viridians 10 (26.3%) staphylococcus aureus 5 (13.2%) klebsiella 4 (10.5%) diphtheroids 3 (7.9%) Staphylococcus saprophiticus 2 (5.3%) Bacillus cereus 2 (5.3%) Haemophilus 1 (2.6%) Mixed 1 (2.6%) S. epidermidis 14 (42.4%) S. viridians 6 (18.1%) S. aureus 4 (12.1%) Diphtheroids 2 (6.1%) S. saprophiticus 2 (6.1%) B. cereus 1 (3%) S. pneumoneae 1 (3%) Mixed 3 (9.1%) 0.4
33 (46.5%)
5274 ± 6300
3.8 ± 1.3
1167 ± 1504 0.001
2.6 ± 1.04 0.0001
Seven weeks after dacryocystorhinostomy surgery, all conjunctival bacterial cultures in 71 patients with nasolacrimal duct obstruction were negative or reached the level of the normal eyes.
from the operated side weekly until the result of the culture became negative or reached to the range of control group. The maximum colony count in the control group was 60 colonies of Staphylococcus epidermidis or Staphylococcus saprophyticus specimen in a sample unit which was considered as normal colonizing populations of flora. The success of the surgery was considered as absence of regurgitation, and the patency of lacrimal drainage system was confirmed by free fluid passage to the nasal cavity. Patients with surgical failure were excluded. In patients in whom the cultured organisms were similar to the control group (S. epidermidis or S. saprophyticus), the normalization time was considered as the interval between DCR surgery and the time that the culture results were below the range of control group (60 colonies in a sample unit). In others, the bacterial normalization time was defined as the interval between DCR surgery and the time that the culture results were negative. Data analyzed using a SPSS software (version 15, SPSS Inc., Chicago, IL, U.S.A.) and t test and chi-square test and correlation test were used for analysis. p
