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Bacteriological study on corneal
ulcers in the eye outpatient clinics,
Great River Eye Hospital, Benghazi
Abdelsalam A. Geilani;
Abeir baltomer;
Soumeendra Sahoo.
Department of Ophthalmology, Great
River Eyes Hospital, Faculty of Med-
icine, Garyounis University, Benghazi,
Libya.
ABSTRACT
Objectives: The aim of the present study was to investigate the types
of organisms causing bacterial corneal ulcer and their sensitivity to
various antibiotics.
Patients and Methods: During the study period of September 2006
to January 2007, a total of 22 patients with corneal ulcers (6
males and 16 females) were recruited prospectively from the eye
outpatient clinics of Great River Eye Hospital, Benghazi. Corneal
scrapings were collected from each corneal ulcer patient before
any antimicrobial therapy started. Isolation of bacteria and their
antimicrobial sensitivity was detected in laboratory attached to the
hospital.
Results: In the present study there were 6 males (27.3%) and
16 females (72.7%). The patients age ranged between 18-65
years. Bacterial cultures were positive in 15 (68.2%) patients.
Ten cultures were positive for Staphylococcus aureus (45.4%), 2
(9.1%) for Streptococci, 2 (9.1%) for Pseudomonas and 1 (4.5%)
for Staphylococcus epidermidius. Mixed growth was detected in 2
(9.1%) patients. No growth was found in 5 (22.7%) patients. All
isolates were sensitive to ciprofloxacin as well as gentamycin and
tobramycin.
Conclusion: Staphylococcus aureus was found to be the major
offending organism that caused corneal ulcer in the present
study. Antibiotics like fluoroquinolone in form of commonly used
ciprofloxacin was found to be highly sensitive to the bacterial
growths. But at the same time gentamycin and tobramycin were
equally effective. These two antibiotics can be used as first line
treatment in bacterial corneal ulcer so as ciprofloxacin.
Correspondence and reprint request: Abdelsalam A Geilani,
Department of ophthalmology
Faculty of Medicine, Garyounis University
Benghazi, Libya
Phone & Fax: 061- 9090642
Email: a_geilani1@yahoo.com
Received : 21/ 2/ 2007, Accepted : 15 / 6/ 2007
Key words:
Corneal ulcer, infective keratitis,
microbial isolates, antimicrobial
therapy.
Original Article
THE LIBYAN JOURNAL OF
Infectious Diseases
The Ofcial Periodical of the Libyan National Center
for Infectious Diseases Prevention and Control
Vol. 1 No. 2 July - 2007
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INTRODUCTION
Being the most anterior part of the
eyeball, the cornea is exposed to atmosphere
and hence prone to get infected easily. Most
of the bacteria can not easily penetrate
the intact corneal epithelium. Also other
protective mechanisms, like eye lid
movement and lysozymes in tear lm,
give additional protection. The disturbance
in this system usually results in infective
keratitis or commonly called corneal ulcer.
This condition usually progreses very fast to
produce severe morbidity and needs prompt
treatment. Bacterial corneal ulcers generally
follow a traumatic break in the corneal
epithelium, thereby providing an entry for
bacteria (1). The traumatic episode may be
minor, such as a minute abrasion from a small
foreign body, or it may result from such causes
as tear insufciency, malnutrition, or contact
lens use. Increased use of soft contact lenses
in recent years has led to a dramatic rise in the
occurrence of corneal ulcers, particularly those
due to Pseudomonas aeruginosa (2). Moreover,
some systemic diseases like diabetes mellitus
and rheumatoid disorders make cornea prone
for ulceration.
In the present study we investigated the types
of bacterial isolates from corneal scrapings and
their antibiotic sensitivity; in order to know
the common organisms producing bacterial
ulceration and to suggest the efcacy of
commonly used topical antibiotics.
MATERIALS AND METHODS
This was a cross sectional prospective study
in which 22 patients were recruited. The patients
were selected from the outpatient clinics of the
Great River Eye Hospital, Benghazi. Only the
cases showing clinical signs of bacterial ulcer
and reporting rst time after their present episode
were recruited for study. The patients who had
received topical ocular therapy elsewhere were
excluded from the study.
The demographic data and medical history
were taken from each patient including
age, gender, occupation, history of diabetes
mellitus, history of trauma or foreign body
entering eye, use of contact lens and long
term use of steroids or any other drugs.
Patients who already started with topical
antibiotics were excluded from the study.
Corneal scrapings were collected from all
patients using sterile Kimura spatula after
using preservative free topical anesthetic. The
scraping was done gently from the margin
as well as from the base of the ulcer. Those
with contact lenses, the contact lenses were
also send for bacteriological study along with
corneal scrapings.
The materials were then inoculated in various
culture media like blood agar (debrinated
sheeps blood which detect hemolytic activity),
chocolate agar (heat denatured sheeps blood
and nutrients which is the best medium for
hemophilus and nisseria), thioglycolate broth
(Sodium thioglycolate which is a general culture
media improving the anaerobic growth). The
CLED medium plates were cultured at 37C
and observed for a period of at least 48 hours.
Gram staining was performed in all patient`s
samples.
RESULTS
A total of 22 patients were included in the
present study. There were six (27.3%) males and
16 (72.7%) females. The age ranged between
18- 65 years. Table 1 shows the pre-disposing
factors for corneal ulcers in the study group.
Six patients (27.3%) had a history of diabetes
mellitus, two patients (9.1%) were contact lens
users, two patients (9.1%) had a history of
trauma and removal of foreign body, and one
patient (4.5%) was a case of recurrent corneal
ulcer.
Positive bacterial cultures were found in
15 patients (68.2%). No bacterial growth
Bacteriological study on corneal ulcers
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was observed in 5 patients (22.7%) and in
two patients (9.1%) mixed bacterial growth
was detected. Staphylococcus aureus was the
commonest cultured bacteria. The isolates were
found susceptible to various commonly used
antibiotic preparations according to the disc
diffusion susceptibility testing. Antibiotics like
uoroquinolone in form of commonly used
ciprooxacin were found to be highly sensitive
to the bacterial growths. But at the same time
gentamycin and tobramycin were equally
effective. Table 2 shows the spectrum of isolated
bacteria of patient`s samples and its sensitivity
to the different antimicrobials.
DISCUSSION
Bacterial corneal ulcer always needs prompt
diagnosis and fast action in therapy. Sometimes
it remains as a challenge to ophthalmologists.
In the present study we recorded 69% samples
showing positive bacterial growth. This is
nearly matching the study done by Upadhaya
and coworkers (3) and Khanal and coworkers
(4) showing positive bacterial growth in 63%
and 67%, respectively. Other studies by Pichare
and coworkers (5) and Ly and coworkers (6)
reported positive bacterial growth in 39% and
42% of their patients, respectively. The lower
positive culture results in their cases might be
attributed to previous antimicrobial therapy.
We have excluded cases with history of taking
antimicrobial therapy before reporting us which
could explain a higher growth rate of bacterial
infection in our study. Negative bacterial growth
in 22% of our patients might have been due to
Table 1. Predisposing factors for corneal ulcers
in the studied group (n=22)
No of patients
(%)
Predisposing Factors
6 (27.3) Diabetes mellitus
2 (9.1) Contact lens wearer
2 (9.1) Ocular Trauma
1 (4.5) Recurrence corneal ulcer
11 (50) No predisposing factor
Table 3. The spectrum of isolated bacteria and its sensitivity
to the different antimicrobials in the studied population
Antimicrobial sensitivity
No of patients
(%)
Type of bacteria
Resistance High sensitivity
Fucidic acid Gentamycin
10 (45.5) Staphylococcus aureus Ciprooxacin
Tobramycin
Fucidic acid Ciprooxacin
2 (9.1) Streptococcius pyogenes
Tobramycin
Gentamycin
Chloramphenicol
Chloramphenicol Tobramycin
2 (9.1) Pseudomonas aerogenosa
Sulphonamide Gentamycin
Ciprooxacin
Tetracyclin
Fucidic acid Gentamycin
1 (4.5) Staphylococcus epidermidis Ciprooxacin
Tobramycin
Geilani A. et al.
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Bacteriological study on corneal ulcers
insufcient scraping material from ulcer sites.
Staphylococcus aureus was found to be the
major positive bacterial growth (45.4%) in the
isolates. Pseudomonas growth was found in
both cases of contact lens wearers among the
recruited cases. This nding is in accordance
with the work of Tabbara and coworkers (2).
In the present study we found that all
Gram positive and Gram negative organisms
were highly sensitive to commonly
available ciprooxacin eye drops as well
as to gentamycin and tobramycin. In our
setting the commonly used rst line topical
therapy in corneal ulcer was gentamycin or
ciprooxacin. The ndings of the present
study further suggest that the same regime
can be continued in patients with bacterial
corneal ulcers after corneal sample collection
for culture and sensitivity. Getting isolates
of fulminate microbial like Pseudomonas in
contact lens users indicates the need for more
health education to people on hygienic care
during contact lens use; so that such type of
corneal morbidity can be prevented.
In conclusion, Staphylococcus aureus was
found to be the major offending organism
that caused corneal ulcer in the present study.
Antibiotics like uoroquinolone in form of
commonly used ciprooxacin were found to be
highly sensitive to the bacterial growths. But at
the same time gentamycin and tobramycin were
equally effective. These two antibiotics can be
used as rst line treatment in bacterial corneal
ulcer so as ciprooxacin.
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Laroche L. Bacterial keratitis: predisposing factors,
clinical and microbiological review in 300 cases. Br J
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2. Tabbara KF, El-Sheikh HF, Abed B. Extended
wear contact lens related bacterial keratitis. BR J
Ophthalmol 2000; 84: 327 - 328.
3. Upadhya MP, Karmacharya PC, Koirala S, et al.
Epidemiologic characteristics, predisposing factors,
and etiologic diagnosis of corneal ulceration in Nepal.
Am J Ophthalmol. 1991; 15; 111 (1): 92 - 99.
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gnosis in ulcerative keratitis. Ophthalmic Res 2005;
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5. Pichare A, Patwardhan N, et al. Bacteriological and
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