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Year : 1985  |  Volume : 33  |  Issue : 1  |  Page : 3-8

Blepharo conjunctivitis-a clinico microbiological and experimental study

Dr. Rajendra Prasad Centre for Ophthalmic Sciences 411 India Institute of Medical Sciences, India

Correspondence Address:
Y Dayal
Dr. Rajendra Prasad Centre for Ophthalmic Sciences, A.I.I.M.S, New Delhi-110 029
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Source of Support: None, Conflict of Interest: None

PMID: 4077201

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How to cite this article:
Dayal Y, Venkateswarlu K, Mahajan V M. Blepharo conjunctivitis-a clinico microbiological and experimental study. Indian J Ophthalmol 1985;33:3-8

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Dayal Y, Venkateswarlu K, Mahajan V M. Blepharo conjunctivitis-a clinico microbiological and experimental study. Indian J Ophthalmol [serial online] 1985 [cited 2022 Jun 29];33:3-8. Available from: https://www.ijo.in/text.asp?1985/33/1/3/27322

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Blepharo-conjunctivitis is a subacute or chronic inflammation of lid margins. As the meeting place of skin and conjunctiva, this region tends to share in the affections of either, while the complexity of its follicular and glandular structures provides ready access and prolonged hospitality to the organisms. The condition is notorious for its chronicity and may last a life time. Its etiology is usua­lly complex and treatment may be exceptio­nally difficult and protracted. Besides bacteria yeasts and viruses an held responsible[1], for its causation. A large number of predisposing factors like irritation, lashes acting as re­ceptacles for dust and bacteria, poor hygienic surroundings, metabolic disturbances and associated diseases of the glands and adnexa are known to contribute substantially. Clini­cally two forms of the disease are seen. Staphylococci the prime offenders play a primary role in the ulcerative form and a secondary role in the squamous type[2],[3],[4]. The resultant suppurative process around the hair follicles followed by healing results in scarring leading to complications like trichiasis, tylosis, styes, madarosis and keratitis. The present work is an attempt to study etiopathogenesis in 24 cases of blepharo-conjunctivitis and to experimentally produce an identical disease in rabbits.

  Material and methods Top

1. Clinical

Subjects Twenty four cases of blopharo­-conjunctivitis were chosen. They were ques­tioned and examined for associated ailments. Thorough ocular examination was done.

Method of culture. Scrapings from lid margins were investigated for bacterial culture and sensitivity, and for Pityrosporum ovale. The latter was cultured in Sabouraud's medium overlaid with olive-oil[5], Treatment was instituted after the report was ready. Post-treatment scrapings were examined every week for 4 weeks.

Treatment For treatment, patients were divided into groups A, B and C. Groups A and B consisted of cases whose cultures were positive. Group A patients were advised only the sensitive antibiotic whereas group B cases were prescribed betnesol ointment also. Group C comprised of bacteriologically sterile cases and were advised only 2% salicylic acid ointment. All ointments were applied 6 hourly on the lid margins. All the patients were advised the following treatment at home :­

I . Hot fomentation for 5 minutes twice a day

2. Lid massage for 5 minutes twice a day

3. Cleaning of lid margins

4. Those having dandruff, were advised to have head bath with selsun sham­poo thrice a week.

The cases were followed up for 4 weeks,

II. Experimental Study

Materials. Staphylococci were identified and typed by the method of Baird-Parker[6]. The sensitivity of the strains to penicillin, tetracycline. chloramphenicol, streptomycin, erythromycin, gentamycin, framycetin and cloxacillin was tested by the disc diffusion technique.

Staphylococci were suspended in sterile saline and adjusted to contain 5 x 1012- orga­nisms per ml. Young adult healthy rabbits. pigmented and albino of either sex weighing between 1-2 kg were selected. All were exa­mined before experimentation to exclude the presence of any systemic or local disease. Only those whose conjunctival sacs were found sterile for bacteria were finally chosen Pilot Study. A pilot study was conducted by inoculating single or multiple doses of 0.1­0.2 ml of live bacterial suspension into the upper lid margin of the right eye while the left eye was similarly inoculated with sterile saline. Cultures were done periodically. Final Study. For the final experimental study, 2 strains of Staphylococcus aureus isolated from cases of blepharitis used on 4 rabbits. Three eyes per strain were the test eyes and the remaining eyes were inoculated with saline. Since the control eyes remained normal, the same were re-inoculated with dead organismal suspension of the same count. The bacteria were killed by keeping them in boiling water for 30 minutes. Each eye received 0.2 ml of the suspension at two sites in the upper lid margin. Re-isolates were similarly biotyped. At the height of the disease, the affected lids were studied histo­logically after H & E staining.

Four strains of Staph epidermidis isolated from patients with ocular disease were bioty­ped[6] and also similarly tested for their poten­tial to produce blepharitis in 8 rabbits The strain yielding positive findings was tested in another set of two rabbits.

  Observations Top


The age and sex-wise distribution of 24 cases is shown in [Table - 1]. Fifty per cent had symptoms for 1-2 years Twenty patients had bilateral involvement. Upper lid involvement was seen in all. Seventeen of them had squamous typ of blepharitis [Figure - 1][Figure - 2]. The association of these cases with refractive errors, dandruff and other conditions is depi­cted in [Table - 2][Table - 3]. Sixteen cases yielded Staph aureus. 12 from seborrhoeic variety and 4 from ulcerative. None of the cases grew Pityrosporum. The resistance pattern of sta­phylococci is compared with the results of previous years and is shown in [Table - 4]. Response to treatment in groups A, B & C patients is compared in graph I. Almost all the patients responded to the therapy by the 3rd week. The major decline in the incidence of bacterial positive cultures was by the 2nd visit.

Experimental: All the eyes infected with staph. aureus developed severe and acute form of blepharo-conjunctivitis [Figure - 3]. Ulcers developed at the margins But the disease lasted only for 5 days. Reisolates from the lid lesions had the same characteristics as the injected types. Histopathology revealed ulce­ration and diffuse infiltration with poly­morphs throughout the lids [Figure - 4]. Control lids remained normal clinically and histologi­cally.

None of the 4 strains of Staph. epidermidis (biotypes 4, 3, 1, 1) produced any lid lesion.

Only one strain consistently produced congestion of palpebral conjunctiva. The changes lasted only for 2 days. Histopatho­logy of the lids revealed the same findings in all the strains. Margins were normal.

Polymorphic infiltration seen throughout the lid was almost similar to Staph. aureus group [Figure - 5].

  Discussion Top

Clinical Study. The frequent occurrence of blepharitis in age group less than 10 years could be because infections are more commonly seen in children. It is clear from this study that associated conditions like dandruff, tonsillitis, pharyngitis. sinusitis have no role in the causation of blepharitis. Our finding however, contradicts the earlier con­cepts that dandruff and systemic septic foci are most commonly associated with it. Our observation that seborrhoea has no role in either type of blepharitis is further substantia­ted by our repeated failures to isolate P ovale even from a single case, even though an appropriate medium was employed through­out and 5 cases bad dandruff also. Our finding that lower lids are less often involved may be due to the constant cleaning of the lower lid margin with tear meniscus and also because its simple anatomy makes it less prone to infection. The frequent occurrence of bilateral cases cannot be explained on the basis of localised infection only unless syste­mic factors are also incriminated. More positive cultures in squamous blepharitis in our study are contrary to western reports[2]. This again supports our claim that seborrhoea has possibly no role in its causation. Similarly refractive errors do not seem to contribute to its etiology. Local associations like mada­rosis, styes, corneal opacities were also very rare.

Many of the Stash. aureus strains were sensitive to cloxacillin and chloramphenicol. Infective cases responded equally well to both the treatments i. e. with antibiotics alone or with antibiotics and steroids. This points out that frequent use of steroids for blepharitis by many people has no added advantage over specific therapy. Gradually increasing resis­tance to penicillin is a notable observation. Bacteriologically negative cases can always be treated with salicylic acid".

Experimental: Experimental disease was an acute form of blepharo-conjunctivitis which had a self-limiting course. All our previous experiments have indicated that healthy rabbit eye is considerably resistant to microbial infections. In this study, both Staph. aureus and Staph. epidermidis produced either conjunctival or lid lesions or both but the disease was manifest only with the former. Histological picture of lids was however, identical in both. Our study confirms a similar study carried out earlier with bacteria free filtrates[7]. Repeated exposures to these organisms may have resulted in chronic lid lesions as is the case clinically.

While this study reveals that blepharitis is chiefly caused by Staph. aureus which when inoculated in the lid margins of rabbits, pro­duce their inflammation, it also shows that strains of Staph. epidermidis are also capable of evoking a similar but a less severe response This is not surprising as our earlier experi­mental studies have suggested that coagulase negative staphylococci are capable of produ­cing corneal pathology in rabbits and also similar lesions clinically[8]. Moreover, spora­dic cases of post-operative infections are also on record. It will be interesting to note here that nearly 30% of such strains have been shown to be dermonecrotoxic for rabbit skin. It therefore, does not seem wise to clinically dismiss Staph. epidermidis as irrele­vant if isolated repeatedly in sizeable numbers from an infected site. We wish to recommend routine investigation of all cases of corneal ulcers or post-operative infections, chronic cases of conjunctivitis and blepharitis for Staph. epidermidis as we do ourselves. Clinicians will save many eyes by timely application of appropriate antibiotics.

  Summary Top

An analysis of 24 clinical cases of blepha­ro-conjunctivitis showed that the disease was more common in children. Bilateral involve­ment of the upper lid was more frequent. Surprisingly none of the 17 cases of the sebor­rhoeic variety yielded Pityrosporum ovale though five had dandruff also. On the other hand Staphylococcus aureus was isolated from 12. From the remaining seven cases of ulce­rative blepharitis Staph. aureus grew in 4. Most of the strains were sensitive to cloxaci­llin and chloramphenicol. Infective cases responded to sensitive antibiotics. The addi­tion of steroids did not alter the results.

Two strains of Staph, aureus and four of Staph. epidermidis were tested for their ability to produce blepharo-conjunctivitis in rabbits. Clinical disease manifested only with the former. However, tissue sections of lids injected with all the 6 strains revealed diffuse polymorphonuclear infiltration with only minor quantitative differences. The control lids appeared clinically and histologi­cally normal. Reisolates had the same charac­teristics as those of the injected types.

  References Top

Duke Elder, S., 1974, System of Ophthalmology Ist ed., Henry Krympton, London 13; 205-233,  Back to cited text no. 1
Galin M., 1962, Arch. Ophthalmol. 67: 746,  Back to cited text no. 2
Smolin, G, and Okumoto, M , 1972, Arch.Ophthalmol. 95; 812.  Back to cited text no. 3
Thygeson, P., 1966, Amer. J. Ophthalmol., 68; 446  Back to cited text no. 4
Baird-Parker A. C., 1974, The basis for the present classification of Staphyococci and micrccocci, Ann. NY. Acad, Sci. 23t; 7.  Back to cited text no. 5
Maha:ac, V. M, Alexander, T. A., Jain, R. K., Agarwal, L. P. 1910. J. Clin. Pathol., 33; 1169.  Back to cited text no. 6
Valenton, M. J., Qeamoto., 1973, Arch. Ophthalmol. 89; 186  Back to cited text no. 7
Agarwal, L. P., Alexander, T. A., Mahajan, V. M., Ratnakar, K. S., 1979, East. Arch. Ophthalmol, 7; 1  Back to cited text no. 8


  [Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4], [Figure - 5], [Figure - 6]

  [Table - 1], [Table - 2], [Table - 3], [Table - 4]


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