Year : 1990 | Volume
: 38 | Issue : 2 | Page : 66--69
Clinicobacteriological correlates of congenital dacryocystitis
Umesh Bareja, S Ghose
R.P. Centre for Ophthalmic Sciences, AIIMS, New Delhi, India
7/97, Gents Hostel, AIIMS, Ansari Nagar, New Delhi - 110 029
One hundred and fourteen eyes with congenital dacryocystitis have been studied clinically and bacteriologically. Gram positive cocci constituted the major bacterial isolates (57.9%) with streptococcus pneumoniae predominating (28.9%). The most effective antibiotic was cloxacillin with an overall efficacy of 77%. Normal conjunctival flora was sterile in majority (75%) of cases. Positive cases showed preponderance of gram positive cocci (21.6%) with staphylococcus albus (13.3%) being the major isolate. Normal nasal flora revealed diphtheroids (alone or in combination) to be the commonest bacteria (62.1%). A statistically significant correlation was not observed between the normal conjunctival or nasal flora and flora from the affected eyes.
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Bareja U, Ghose S. Clinicobacteriological correlates of congenital dacryocystitis.Indian J Ophthalmol 1990;38:66-69
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Bareja U, Ghose S. Clinicobacteriological correlates of congenital dacryocystitis. Indian J Ophthalmol [serial online] 1990 [cited 2022 Jan 22 ];38:66-69
Available from: https://www.ijo.in/text.asp?1990/38/2/66/24534
Most of the earlier studies concerning microbiological aspects of dacryocystitis have been devoted to the adult variety of this disease in which chemotherapeutics play a relatively minor role for management , Only a few studies are available reporting on congenital dacryocystitis , A previous study at this centre showed staphylococcus and pneumococcus as the commonest organisms respectively with unusual and alarming sensitivity patterns . The present study has been undertaken to know the change in pattern, if any, of bacteria in congenital dacryocystitis and their antibiotic sensitivities, to guide the clinician better in his choice of medication.
SUBJECTS AND METHODS
The study was conducted on 114 eyes in 87 cases of congenital dacryocystitis (27 bilateral) referred to the Paediatric Ophthalmology Clinic at our Centre. An attempt was made to evaluate children with an early age of presentation. Those cases who had been surgically interfered with were excluded.
The material for microbiological analysis was taken from the affected eye either in the form of discharge regurgitating from the lacrimal sac, or the conjunctival discharge itself if there was no regurgitation on pressure over the sac. It was collected in the laboratory and streaked immediately on blood agar medium to be incubated at 37 0C for 48 hours.
The conjunctival swab of the fellow normal eye in the 60 unilateral cases was also similarly studied. Nasal swabs were taken from the ipsilateral nostril in unilateral cases and from the nostril corresponding to the more affected side in bilateral cases. Only aerobic cultures were done. Bacteria were identified by standard laboratory procedures and their culture and sensitivity tested by disc diffusion technique .
Pneumococci isolated were typed by Quellung's reaction by a set of diagnostic antisera prepared by the Statens Seruminstitute, Copenhagen, Denmark.
Specific treatment in the form of topical antibiotic drops as indicated by the culture and sensitivity results was instituted, following local sac massage and cleansing of the discharge. In case the initial swab from the affected eye was sterile on culture, the child was put on chloramphenicol eye drops 
During the course of conservative medical treatment, swabs were repeated from the eye when considered clinically necessary and the topical antibiotic altered if so indicated by the subsequent sensitivity reports. If the dacryocystitis did not respond by the age of 6 months; or after 6 weeks of conservative therapy if the child presented initially at or over 6 months of age, then probing and syringing under general anaesthesia was undertaken. After complete subsidence of symptoms following medical (or surgical) treatment, final swabs were taken from the eye and nose and their culture and sensitivity patterns again analysed.
The bacterial isolates from the 114 eyes studied with congenital dacryocystitis are shown in [Table 1]. Their antibiotic sensitivity patterns are depicted in [Table 2]. Our analysis of the pneumococcal typing has been reported elsewhere  with serotypes B3 and I46 being the commonest.
The conjunctival flora obtained from the normal fellow eye in 60 unilaterally affected cases are analysed in [Table 3]. The interrelationship between the isolates from the affected eye and contralateral normal fellow eye is explained in [Table 4].
[Table 5] details the nasal flora of the 87 patients and their correlation with the ocular flora of affected eyes is evaluated in [Table 6].
Of the 114 eyes initially studied in 87 patients, 100 eyes could be adequately followed up. Of these 100 eyes, 81 responded excellently to conservative medical management, as indicated by in vitro sensitivity reports. Fifteen eyes were cured with a single probing. Two more eyes required a repeat probing once to achieve satisfactory results. Only 2 eyes had to be advised a dacryocystorhinostomy later after a repeat probing had also failed.
The conjunctival flora finally obtained from these 98 affected eyes after total subsidence of symptoms following medical treatment or probing is exhibited in [Table 7]. Nasal swabs similarly taken after complete cure are also analysed in [Table 8].
Bacteriology of congenital dacryocystitis acquires great significance in view of its bearing on the therapeutics of the disease. There have been only a limited number of studies in the literature which dwell exclusively upon bacteriology of this entity and its clinical significance,. Ours seems to be the first prospective study dealing with this problem in a systematic manner.
Thirty seven (32.5%) eyes with copious discharge did turn out to be sterile even on repeated culture [Table 1]. This could be often because of the use of various antibiotics before the patient presented to us, or the effect of topical drugs prescribed after our initial examination and swab. The possibility of the presence of organisms (as anaerobic bacteria) other than those for which cultures were done cannot however, be ruled out. The role of such anaerobic bacteria at present in ocular infections of children is still debatable ,,,.
In our present study, of the 77 out of 114 (67.5%) positive cultures obtained, Gram positive cocci constituted the commonest type of bacteria isolated (66 out of 77 or 85.7%, [Table 1]. Staphaureus with an isolation rate of 13% [Table 1] is well established as a pathogen ,. It exhibited a 93.3% in vitro sensitivity to cloxacillin [Table 2] and an excellent in vivo response also to 1 % or 2.5% drops depending on the child's age and tolerance. Twenty percent of the strains were found to be sensitive only to cloxacillin, supporting the belief that topical cloxacillin would at present be the drug of first choice in cases of staphylococcal infections. Although Staph.epidermidis (isolated in 11.4% cases, [Table 1]) has been assigned the role of a normal commensal of the conjunctive along with diphtheroids, a number of reports have appeared of its being pathogenic in postoperative ocular infections, blepharoconjunctivitis and corneal ulcers ,,,, Hence, it will be unwise to ignore these organisms any more as mere commensals. It has also been shown to be associated with congenital dacryocystitis . Thus, any ocular infection including congenital dacryocystitis should be routinely investigated for Staph.epidermidis and its sensitivity patterns. It was sensitive to cloxacillin in all our cases, although erythromycin, gentamicin and chloramphenicol were also effective in 80% [Table 2].
In our present study, the commonest organism isolated was Streptococcus pneumoniae (28.9%). It has always been a common isolate from various infections of the eye and in cases of congenital dacryocystitis . The most effective antibiotics against this important pathogen were found to be erythromycin (78.8%) followed by cloxacillin (72.7%) [Table 2]. It is clinically very significant that all the pneumococcal strains isolated were resistant to sodium penicillin G, an antibiotic to which these organisms used to be extremely sensitive only a few years ago. The possible clinical significance of serotyping pneumococci has been discussed else where .
The most effective single antibiotic in the present study was cloxacillin, exhibiting an overall efficacy of 77%. This is at slight variance with the previous study carried out at this centre where chloramphenicol was found to be the overall drug of choice, followed closely by gentamicin and cloxacillin . However, in case of gram negative organisms cultured, cloxacillin would not be recommended.
Repeat cultures during treatment were indicated in 6 out of the 98 eyes. In all of these, the organism at repeat culture was found to be different from the one isolated initially, thereby indicating that resistance to medical treatment in a particular case might be because of change of the organisms besides other factors.
There was an appreciable correlation between the clinical response and the microbiological analysis of the conjunctival flora after complete cure [Table 7] when compared with our initial data of isolates [Table 1].
A statistically significant correlation could not be obtained between the flora from unilateral dacryocystitis and the contralateral eye [Table 4]. Only 3 cases were found which carried similar organisms. Similarly, nasal flora had nothing in common with the flora of eyes affected with dacryocystitis [Table 5][Table 6].
There was essentially little difference between nasal flora at the beginning and after complete cure [Table 5][Table 8]. Isolation of different kinds of bacteria from the nasal cavity when compared to dacryocystitis or conjunctival flora, as well as the relative constancy, of nasal flora in the face of changing conjunctival flora indicate that nasal flora has probably no role to play in the causation of at least congenital dacryocystitis.
Our efforts in microbial analysis and its clinical correlation in vivo in congenital dacryocystitis not only offer the clinician the most suitable antibiotic for medical treatment to which the bacteria are sensitive, but also indicates the choice of antibiotic solution to be filled into the lacrimal system on the table after probing and to be used postoperatively . Occasionally, as in an episode of acute dacryocystitis, or when a false passage during probing is suspected, systemic antibiotics may become necessary. Here also, a prior culture and sensitivity would be greatly beneficial. The changing pattern of bacterial flora and antibiotic sensitivity even in the same area and institution necessitates careful individual culture and sensitivity of each affected eye, more than once during the course of treatment.
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