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Original Article

Normal conjunctival flora and their antibiotic sensitivity in

Omanis undergoing cataract surgery
Belur R. Keshav, Somansu Basu1
Departments of Ophthalmology and 1Microbiology, Sur Regional Hospital, Sur, Oman

Purpose: To evaluate the normal conjunctival flora
and to ascertain their sensitivity to antibiotics.
Materials and Methods: Prospective study was
undertaken with 56patients scheduled for cataract
surgery. In each of these patients, conjunctival
swab was taken from both eyes before instilling any
antibiotic drops or local anesthetics and were sent for
culture sensitivity by inoculating the samples in blood
agar plates. The unoperated eyes served as controls
for the study. The results were tabulated and analyzed
by applying confidence intervals at 95% confidence
limits.
and included both operated and control eyes.
Coagulasenegative staphylococcus was isolated in
44eyes (81.5%). Maximum sensitivity was found
with vancomycin, gentamycin, chloramphenicol, and
ciprofloxacin and maximum resistance with fusidic
acid, penicillin, and oxacillin.
Conclusion: We conclude that coagulasenegative
staphylococcus are the most common bacteria isolated
from the conjunctival sac, and vancomycin followed by
gentamycin and ciprofloxacin are most effective against
normal conjunctiva l flora, and fusidic acid the most
ineffective of all the antibiotics tested.

Results: Of the 112eyes studied, positive cultures Keywords: Antibiotics, cataract surgery, conjunctival
were obtained from 54eyes (48.3%) preoperatively, flora, sensitivity

Introduction which is the administration of topical antibiotic drops at regular

Cataract surgery is one of the most frequently performed operations
in the world, with approximately 1.5million cases done in the
UnitedStates annually.[1] In Oman, unoperated cataract was the
cause of 35% of estimated blindness.[2] Endophthalmitis is one of
the most dreaded complications of cataract surgery. It may result
in permanent loss of vision if not recognized and treated properly.
Eye surgeons use several preand postoperative methods to
prevent the occurrence of endophthalmitis, the most common of
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DOI:
10.4103/0974-620X.94722
intervals.[3] Use of antibiotic prophylaxis preand postoperatively
in reducing the risk of endophthalmitis remains controversial.
There also are no standard guidelines on the type of antibiotic
to be used in this setting. Bacteria are the most common cause of
endophthalmitis. Knowing the organisms found most frequently in
the ocular flora and their antibiotic sensitivity may provide a better
guide in choosing an antibiotic for prophylaxis of postoperative
endophthalmitis. The most common site of the organism that
is known to cause endophthalmitis is the conjunctiva itself.[4]
Several studies have shown coagulasenegative staphylococcus
to be the most common organism causing endophthalmitis and
also the most common organism isolated among the conjunctival
flora.[5,6]
Although there are many published articles[35] from Western
countries pertaining to normal flora of the eye and their sensitivity
pattern to antibiotics, these data cannot be applied directly to
Omani patients, as several factors affect the type and sensitivity
and resistance patterns of bacteria. Moreover, this kind of a study

Copyright: 2012 Keshav BR and Basu S. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which
permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Correspondence:
Dr. Belur R. Keshav, P.O.Box823, pc411, Sur, Oman. Email: keshavraj2000@gmail.com

16 Oman Journal of Ophthalmology, Vol. 5, No. 1, 2012

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Keshav and Basu: Normal conjunctival flora and their antibiotic sensitivity

must be done regularly due to the dynamic nature of bacterial staphylococcus, 4eyes (7.4%) grew Streptococcus pneumoniae, and
resistance to antibiotics.[5] 2(3.7%) eyes grew Staphyloccus viridans, Staphylococcus aureus,
S.corynebacterium, S.proteus, and S.enterococci were grown in one
In Oman with a wide prevalence of trachoma in the past, resulting eye (1.8%) each [Table2]. When preoperative and postoperative
in alteration of ocular surface subtly in many individuals and cultures were analyzed and compared, it was found that 11eyes
markedly in some, the conjunctival flora may be different. And as (20.3%) were showing the same growth preand postoperatively,
is wellknown going by the various studies,[38] every region may 44.4% (95% CI: 30.76%57.24%) of eyes operated for cataract
have a different sensitivity pattern. showed growth preoperatively and no growth postoperatively,
and 33.3% (95% CI: 20.46%45.54%) of the unoperated eyes with
This study was undertaken to ascertain the normal conjflora growth preoperatively showed no growth [Table3]. As regards to
in the region and its sensitivity pattern and change following susceptibility pattern in case of all isolates, the organisms showed
preoperative prophylactic antibiotic use. high sensitivity to choramphenicol, 63% (95% CI: 50.125%
88%), gentamycin 74% (95% CI: 62.3%85.7%), ciprofloxacin
72% (95% CI: 60.2%83.98%), and vancomycin 83% (95% CI:
Materials and Methods
72.98%93.02%) and high resistance to penicillin, ampicillin,
fusidic acid, and oxacillin [Table4]. As regards to the sensitivity
A prospective study was conducted with patients who underwent
pattern in case of coagulasenegative staphylococci, the organisms
cataract surgery between February and August 2010. Hundred
were most susceptible to vancomycin, 97.72% (95% CI: 91.96%
and twelve eyes of 56patients admitted for cataract surgery in
102.04%), gentamycin, 86.36% (95% CI: 75.75%96.25%), and
Sur regional hospital, a secondary care center with state of the art
ciprofloxacin 84% (95% CI: 73.17%94.83%) and moderately
laboratory facilities, were enrolled in this study. The fellow eye
susceptible to chloramphenicol 68.1% (95% CI: 54.2%81.78%),
of these patients served as controls. Patients with ocular surface
augmentin 52.27% (95% CI: 37.24%66.76%), oxacillin 50% (95%
disease such as meibomitis, dry eye, and chronic dacryocystitis
CI: 35.23%64.77%), and methicillin 61.36% (95% CI: 49.59%
were excluded from the study. After obtaining consent, conjunctival
75.41%) and least susceptible to fusidic acid (29.5%; Table5).
swab was taken 1day before cataract surgery from both eyes before
Thus, coagulasenegative staphylococci showed maximum
applying any antibiotic or anesthetic drops. Specimen was taken
sensitivity to vancomycin followed closely by gentamycin and
from the inferior conjunctival fornix with sterilized loop without
maximum resistance to fusidic acid.
touching the eyelids. The sample was inoculated aseptically by
Cshaped streaking onto blood agar medium at the bedside. The
plates were then incubated at 37C for 48hours under standard
Discussion
aerobic conditions.[7] Any positive bacterial growth was further
Postoperative endophthalmitis is the most dreaded complication
identified and susceptibility testing done according to Kirby
of cataract surgery and conjunctival flora has been blamed to be
Bauers method using standard CLSI guidelines.[8] Conjunctival
swab was taken from both eyes and processed similarly on the
Table1: The number of eyes with growth and no
first postoperative day. Chloramphenicol eye drops four times a
growth (n=112)
day were instilled into the eyes of patients undergoing surgery
Growth status Number of eyes %
1day preoperatively, and iodine (5050dilution of 10% povidone
No bacterial growth 58 51.7
iodine) wash preoperatively was performed. No medications were
Bacterial growth 54 48.3
applied to the control eyes of these patients either preoperatively
or postoperatively.
Table2: Ocular flora in patients undergoing
Data obtained were subjected to statistical analysis by applying cataract surgery
confidence intervals (CIs) at 95% confidence limits. This study Organism Frequency (n=54) %
was evaluated and approved by the ethics review committee Coagulasenegative staphylococcus 44 81.5
Streptococcus pneumoniae 4 7.4
members of the Ministry of Health in South Sharqiya region
Staphylococcus viridans 2 3.7
Staphylococcus aureus 1 1.8
Results Cornybacterium sp. 1 1.8
Proteus sp 1 1.8
A total of 112eyes of 56patients from whom the conjunctival swabs Enterococci 1 1.8
were taken were analyzed. In this study, 19(33.9%) were males
and 37(66.1%) were females. The age group was 4080years. Table3: Postoperative growth status (n=54)
No bacterial growth was seen 51.7% eyes preoperatively (95%
Eye Same growth, n (%) Negative growth, n (%)
CI: 41.75%61.25%), while 48.3% (95% CI: 38.75%57.25%) Test 4(7.4) 24(44.4)
showed bacterial growth [Table1]. This included both control Control 7(13) 18(33.3)
and operated eyes. Of the 54eyes showing bacterial growth, Total 11(20%) 32(78)
81.5% (95% CI: 71.12%81.84%) grew coagulasenegative *1eye showed a different growth from the preoperative growth

Oman Journal of Ophthalmology, Vol. 5, No. 1, 2012 17

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Keshav and Basu: Normal conjunctival flora and their antibiotic sensitivity

Table4: Susceptibility pattern of all the isolates

Sensitivity Gen Oxa Aug Cipro Vanco Pen Amp Met Cef Fuc Chl
Sensitive, N (%) 40(74) 23(43) 25(46) 39(72) 45(83) 2(4) 5(9) 28(51) 3(6) 14(26) 34(63)
Resistance, N (%) 14(26) 31(57) 29(54) 15(27) 9(17) 52(96) 49(91) 26(49) 51(94) 40(74) 20(37)
Gen: Gentamycin, Oxa: Oxacillin, Aug: Augmetin, Cipro: Ciprofloxacin, Vanco: Vancomycin, Pen: Penicillin, Amp: Ampicillin, Met: Methicillin, Cef: Cefuroxime,
Fuc:Fucidic acid, Chl: Chloramphenicol

Table5: Sensitivity pattern to coagulasenegative staphylococcus

Sensitivity Gen Oxa Aug Cipro Vanco Met Fuc Chl
Sensitive, N (%) 38(87) 22(50) 23(52) 37(84) 43(98) 27(61) 13(30) 30(68)
Resistance, N (%) 6(3) 22(50) 21(48) 7(14) 1(2) 17(39) 31(70) 14(32)
Gen: Gentamycin, Oxa: Oxacillin, Aug: Augmetin, Cipro: Ciprofloxacin, Vanco: Vancomycin, Pen: Penicillin, Amp: Ampicillin, Met: Methicillin, Cef: Cefuroxime, Fuc:
Fucidic acid, Chl: Chloramphenicol

the primary and most frequent source of bacteria. So evaluation of
the conjunctival bacterial flora and their sensitivity pattern is of
utmost importance. In our study, we were able to isolate bacteria in
54eyes (48.3%). In a study by Reza etal.,[5] the percentage isolation
was found to be 52.4%. Another study by Terence etal.[6] showed
the isolation was of the order of 80%. In both cases, the inoculation
was in blood agar and in the latter case the lid margin samples were
also taken which could be the reason for such a high positivity.
In our study, it is shown that 44% of eyes having growth
preoperatively and treated with perioperative iodine
and chloramphenicol preoperatively showed no growth
postoperatively, and 33% of the control eyes showing growth
preoperatively and not treated with iodine perioperatively showed
no growth postoperatively. The negative growth postoperatively
in control eyes is difficult to explain. More number of cases
treated with iodine showed negative growth postoperatively.
Although statistically nonsignificant (P=0.2342), there was a
trend suggesting that the practice of perioperatively washing eyes
with iodine is a step in the right direction. A larger study in this
regard may throw light on its significance in a better way.
The most common organism isolated in our study was
coagulasenegative staphylococcus (81.5%) which is in
confirmation with most of the studies.[58] In all these studies,
the isolation was above 80% with respect to coagulasenegative
staphylococcus, thus confirming that this bacteria is the most
common isolate in conjunctival bacterial flora worldwide.
With regards to sensitivity patterns particularly in case of CNS,
ciprofloxacin, gentamycin, vancomycin, and chloramphenicol
were found to be most effective. In a study by Terence etal.,[7]
almost identical sensitivity patterns were noticed. With respect to
the resistance pattern, the organism was least sensitive to fusidic
acid. Terence etal. found maximum resistance to polymyxin B,
but fusidic acid was not tested for in their study.
bacteria were shown to be isolated in insignificant numbers.
Perioperative conjunctival irrigation with iodine is an effective
way of reducing bacterial flora. This study may act as a guide to
choosing antibiotics for preoperative prophylaxis or postoperative
prophylaxis and treatment.
Acknowledgements
We wish to thank the doctors and paramedical staff of ophthalmology
and microbiology departments of Sur Hospital. We also wish to thank
Dr.PuneetJainHead, Department of Pathology, for his cooperation.
Last but not the least we are grateful to our executive director for his
cooperation. Finally, we wish to state that the study would not have been
possible without the help of the patients and relatives involved in the
study.
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In conclusion, our study is the first of its kind in Oman showing
nearly 50% positive growth with coagulasepositive staphylococci
predominating, which was most sensitive to vancomycin followed
by ciprofloxacin, gentamycin, and chloramphenicol. The other
Cite this article as: Keshav BR, Basu S. Normal conjunctival flora and
their antibiotic sensitivity in Omanis undergoing cataract surgery. Oman J
Ophthalmol 2012;5:16-8.
Source of Support: Nil, Conflict of Interest: No.

18 Oman Journal of Ophthalmology, Vol. 5, No. 1, 2012