3/17/2025

PreClinical Program 2 : Neuroscience Module

MICROBIOLOGY OF
EYE INFECTIONS
Dr. Farah Al-Marzooq
MBChB, MMedSc, PhD

Assistant professor
Department of Microbiology and Immunology
email : [email protected]

OBJECTIVES
- Recognize the major infections of the eye
- List the common infectious agents involved in eye infections
- Explain the diagnostic approaches, and the antimicrobial therapy for these
infections
- Explain the development of blindness in trachoma and onchocerciasis

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BLEPHARITIS
▪ Blepharitis: inflammation of the eyelids, usually involving the lid margins.

Anterior blepharitis: involves the lid skin, base of eyelashes, and eyelash follicles
Posterior blepharitis (meibomitis): involves the meibomian glands.

Infectious blepharitis:
Main causative pathogen: Staphylococcus aureus
• scaling, yellow crusts, erythema of lid margins

Blepharitis associated with inflammatory skin

conditions, e.g. seborrheic dermatitis
• usually associated with the dandruff of the scalp
• white small scales on the eyelashes.

HORDEOLUM
Hordeolum: acute infection of sebaceous glands of the lid,
usually caused by Staphylococcus aureus

▪ External hordeolum (stye) : infection of the

sebaceous glands of Zeis at the base of the
eyelashes
▪ a painful pustule that points to the lid margin

▪ Internal hordeolum : infection of meibomian

gland within the tarsal plate of the eyelid
▪ lid swelling, erythema, and tenderness

Chalazion (MEIBOMIAN CYST): a sterile granulomatous reaction to inspissated

sebum within an obstructed meibomian gland → non-tender nodule within the lid

Treatment of eye lid infections:

• Eyelid hygiene + warm compresses
• Topical antibiotics : e.g. erythromycin ointment 4

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CONJUNCTIVITIS
▪ Conjunctivitis : inflammation of the conjunctiva
▪ Commonly known as pink eye → inflammation
causes congestion of the small blood vessels in
the conjunctiva

▪ Caused by Viruses or Bacteria

• Viral conjunctivitis → more prevalent in adults • Bacterial conjunctivitis → more prevalent in children

MICROBIAL CAUSES OF CONJUNCTIVITIS

Viruses
Organism Comments
Adenovirus Very common
Pharyngoconjunctival fever (Adenovirus type 3, 4, and 7):
• classic clinical presentation → triad of pharyngitis + fever +
subsequent conjunctivitis (acute follicular conjunctivitis)
Epidemic keratoconjunctivitis (Adenovirus types 8, 19, and 37):
• more severe than pharyngoconjunctival fever
• sub-conjunctival hemorrhages and conjunctival membranes in
Follicular conjunctivitis
some patients

Herpes simplex virus • acute follicular conjunctivitis or keratoconjunctivitis

• vesiculating periocular skin lesions

Enterovirus 70, Acute haemorrhagic conjunctivitis:

Coxsackievirus A24 • sub-conjunctival hemorrhage
• fast-onset eye pain + tear formation + photophobia.
• highly contagious → outbreaks reported around the world
Acute haemorrhagic 6
conjunctivitis

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MICROBIAL CAUSES OF CONJUNCTIVITIS

Bacteria
Organism Comments
Chlamydia trachomatis
Types A–C → Cause of TRACHOMA and commonly blindness
Types D–K → Cause of inclusion conjunctivitis
→ Infection of newborn via birth canal → Opthalmia
neonatorum
→ In adults with STD chlamydia

Neisseria gonorrhoeae Infection of newborn via birth canal → Opthalmia

neonatorum
→ In adults with STD gonorrhea
Staphylococcus aureus • Acute (mucopurulent) conjunctivitis
Streptococcus pneumoniae • Sticky eye in neonates
Haemophilus influenzae

Non-infectious causes of Conjunctivitis:

Chemicals, irritants and allergies may cause inflammation of the conjunctiva
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CONJUNCTIVITIS
Clinical features: ʚ Eye irritation or discomfort but NO significant pain UNLESS there
is involvement of the CORNEA
→ Kerato-conjunctivitis (cornea + conjunctiva)
ʚ Sticking of the lids → likely to be secondary to a bacterial infection
ʚ
Bacterial → Mucopurulent discharge

Viral → Serous (watery) discharge

ʚ discharge

ʚ In some cases : patients report photophobia (light sensitivity).

ʚ preauricular nodes enlargement in viral and chlamydial
infections.

→ Conjunctivitis can start in one eye and then progress to the other 8

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CONJUNCTIVITIS

• Diagnosis:
▪ mostly clinical ▪ Conjunctival swabs:
▪ Bacteria → Gram stain + culture
▪ Viruses → PCR

• Treatment
1. Cleanliness - frequent washing of the eyes with warm saline or clean water.
2. Control of infection:
• Acute bacterial conjunctivitis : broad-spectrum topical agent such as fluoroquinolone (ciprofloxacin)
• Viral conjunctivitis spontaneously resolves within days to weeks 9

OPHTHALMIA NEONATORUM (CONJUNCTIVITIS OF THE NEWBORN)

▪ exposure to pathogens during passage through infected birth canal during a vaginal
delivery:
① Gonococcal conjunctivitis : caused by ② Inclusion (chlamydial) conjunctivitis :
Neisseria gonorrhoeae, that causes the STD caused by Chlamydia trachomatis (Types D–
gonorrhea K), that causes the STD chlamydia.
▪ Infection begins about 2 to 5 days after ✓ Infection begins about 5 days to 2 weeks
birth. after birth
✓ 1/10 of the infected infants present with
or develop pneumonia

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Intracytoplasmic inclusion bodies

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OPHTHALMIA NEONATORUM (CONJUNCTIVITIS OF THE NEWBORN)

Clinical features :
✓ Red eyes
✓ Swelling of the eyelids
✓ Discharge (thicker in Gonococcal conjunctivitis)
✓ Sticking of the lids.
✓ It is bilateral usually
✓ If untreated → scarring of the cornea or conjunctiva→ blindness

Diagnosis : Treatment: antibiotics (topical + systemic)

Swab from the infected conjunctiva • Gonococcal conjunctivitis : ceftriaxone
→ Gram stain and culture for Neisseria • Chlamydial conjunctivitis : azithromycin or
gonorrhoeae (Gram-negative diplococci) erythromycin
→ Giemsa stain: Detection of inclusion bodies
+ nucleic acid amplification tests for
Chlamydia trachomatis

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TRACHOMA
▪ Causative agent : Chlamydia trachomatis (types A–C)
▪ Trachoma is the leading infectious cause of blindness worldwide
→ endemic in parts of Africa and Asia in a hot, dry climate

▪ Ocular trachoma is a chronic

Chlamydia trachomatis infection →
involves the epithelium of both the
conjunctiva and the cornea.

▪ Transmission :
✓ flies
✓ contaminated fingers
✓ contaminated objects, such as
towels or face cloths

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TRACHOMA
▪ Clinical features:
▪ first affects young children
▪ mild irritation of the eyes
▪ discharge of pus and/or mucus
▪ Repeated trachoma infections can
result in more severe symptoms:
✓ blurred vision
✓ severe eye pain
✓ photophobia
✓ intense itchiness in the eyes –
caused by the eyelashes turning
back onto the surface of the eye Steps in Chlamydia trachomatis pathogenesis leading to blindness
(entropion)

• As the condition progresses, the "turned in" eyelashes will begin to scar the cornea →
known as trichiasis.
• The scarring will cause vision to become increasingly cloudy → If untreated → complete
loss of vision. 13

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WORLD HEALTH ORGANIZATION GRADING SCHEME FOR TRACHOMA

❶ Trachomatous inflammation—follicular (TF):

≥5 follicles in the upper tarsal conjunctiva

❷ Trachomatous inflammation—intense (TI):

Pronounced inflammatory thickening of the tarsal conjunctiva, which obscures half of the normal
deep tarsal vessels.

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WORLD HEALTH ORGANIZATION GRADING SCHEME FOR TRACHOMA

❸ Trachomatous conjunctival scarring (TS):

The presence of easily visible scars (white lines) in the tarsal conjunctiva.

❹ Trachomatous trichiasis (TT):

At least one eyelash rubs on the eyeball.

❺ Corneal opacity (CO):

Easily visible corneal opacity present over the pupil

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TRACHOMA

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TRACHOMA
▪ Diagnosis: clinical + lab
▪ Conjunctival fluid and swab
✓ Detection of inclusion bodies in
stained preparations
✓ PCR for Chlamydia trachomatis

▪ Treatment:

✓ Tetracycline
✓ Erythromycin
✓ Azithromycine

"SAFE" International efforts to

eliminate trachoma as a blinding
disease 17

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KERATITIS
▪ Microbial keratitis → infection of the cornea
▪ vision-threatening condition
Microbial causes :
✓ Bacteria → most common cause of infectious keratitis.
• Gram-positive bacteria, such as Staphylococcus and Streptococcus spp.
• Gram-negative bacteria, such as Pseudomonas aeruginosa:
• bacterial keratitis among contact lens users
• via contaminated eye drops
• following trauma
✓ Viruses → herpes simplex virus, varicella-zoster virus, and adenovirus.
✓ Fungi → Less common → Candida albicans, Aspergillus
• should be suspected after trauma
✓ Parasites → Acanthamoeba
• exposure to relatively high concentration of free-living amoebae
• swimming in lakes or in a spa while wearing contact lenses
• improper disinfection of contact lenses
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Contact lens wearers with red eye or increasing pain → suspect keratitis
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KERATITIS
▪ Clinical features:
▪ Pain — cornea is richly supplied by ophthalmic division of the trigeminal nerve
▪ corneal sensation is reduced → in diseases associated with damage to the corneal nerves
→ herpes simplex or herpes zoster.
▪ Photophobia
▪ Lacrimation — excessive reflex tear production
▪ Red eye — conjunctival hyperaemia
▪ In severe cases → pus settles at the bottom of the anterior chamber → hypopyon.
▪ Viral HSV:
▪ Skin lesion (vesicles) + regional lymphadenitis (preauricular lymph nodes)
▪ Greyish haze or loss of clarity
▪ Impairment of visual acuity due to corneal opacity.

Keratitis can lead to corneal scarring with new

blood vessel formation (neovascularization)
→ resulting in loss of vision
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KERATITIS
Lab diagnosis :
Corneal scrapings → should be performed for all
suspected cases of infectious keratitis
→ Gram’s stain, Giemsa stain, and cultures to identify
the organism.
→ PCR for Herpes simplex virus

Staining of the cornea by fluorescein stain:

To visualise the ulcer → fluorescein staining and a cobalt blue
light.

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KERATITIS

Hypopyon in a case of bacterial keratitis

Dendritic ulcers are common in recurrent

herpes simplex virus infection

Fungal corneal ulcer

showing a dry looking
ulcer and thick
hypopyon
Acanthamoeba keratitis
dendritic ulcer stained with fluorescein 21
& trophozoite.

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KERATITIS
▪ Treatment of infectious keratitis:

* Medical emergency
▪ Antimicrobial therapy should be initiated AFTER scrapings and cultures of
infectious keratitis.
▪ Bacteria → broad-spectrum antibiotics (topical + systemic)
▪ e.g: fluoroquinolone
▪ Fungi → Antifungal therapeutic agents (topical + systemic)
▪ e.g: amphotericin B and voriconazole
▪ Viruses as HSV → Antiviral drugs such as aciclovir
▪ Acanthamoeba → Topical anti-parasitic agent + chlorohexidine (0.02%)

▪ if uncontrolled: Surgical Management

▪ corneal transplantation may be necessary

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UVEITIS
• The uvea is a highly vascular layer that lines
the sclera
• Uvea is subdivided into:
- Anterior
➢ iris
➢ ciliary body :
i. Pars plicata → secretes
aqueous humour
ii. Pars plana

- Posterior (choroid)

Uveitis: inflammation of the uveal tissue

→ infectious or non-infectious (idiopathic, autoimmune)
can be viral, bacterial, fungal, and parasitic infection
Exogenous infections → trauma
Secondary infections → spread from other ocular tissues
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Endogenous infections → reach the eye through the blood stream

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UVEITIS
Category Inflamed parts of uvea Common microbial causes
Anterior uveitis • iris (iritis) • Herpes simplex virus
• anterior ciliary body : (90% of infectious
pars plicata (cyclitis) etiologies)
• both iris + anterior • Varicella-zoster virus
ciliary body • Syphilis
(iridocyclitis) • TB
• Lyme disease
Intermediate uveitis pars plana of the ciliary RARE, Lyme disease
body + periphery of choroid
Posterior uveitis • choroid (choroiditis) • Toxoplasmosis
Retinitis is included as a type of
• retina (retinitis) • Toxocara
uveitis even though the retina is not
• Both (chorioretinitis) • Herpes simplex virus
part of the uvea because the retina is
• Varicella-zoster virus
often involved when there is
• Cytomegalovirus
underlying choroidal inflammation
• Syphilis
• Candida
Panuveitis whole uvea • Syphilis
• TB 24
• Candida
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UVEITIS

Pus blood

Anterior synechiae Posterior synechiae 25

Adhesion With cornea Adhesion With lens
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UVEITIS
▪ Clinical features
▪ Anterior uveitis :
✓ Pain
✓ Redness
✓ Photophobia
✓ Blurred vision
✓ Increased lacrimation

Keratic precipitates in anterior uveitis

▪ Posterior uveitis :
✓ Blurred vision and floaters + NO symptoms of anterior uveitis

▪ Intermediate uveitis :
✓ Painless floaters and decreased vision (similar to posterior uveitis)
✓ Minimal photophobia

▪ Panuveitis
✓ may present with any or all of the above symptoms 26

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UVEITIS
▪ Diagnosis
▪ Clinical + slit-lamp examination + funduscopic
examination
▪ Lab diagnosis varies by etiology
▪ Serology : e.g : VDRL → syphilis
▪ PCR for viral causes

▪ Treatment :
▪ Specific treatment for the infection:
▪ Antimicrobial drugs:
▪ depends on the causative organism such as toxoplamosis, tuberculosis,
syphilis, HSV, etc.
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ENDOPHTHALMITIS
Infection of the aqueous or vitreous humor → mostly caused by bacteria or fungi
▪ Exogenous:
 Surgical trauma (post cataract surgery)
 Main causative agents (postoperative) are bacteria:
▪ Acute post-operative → Staphylococcus epidermidis
 Penetrating injury – often
▪ Bacteria → Bacillus cereus
▪ Fungi → Aspergillus and Fusarium.

▪ Endogenous:
 Hematogenous spread from distant site.
 Candida albicans – leading fungi causing
endophthalmitis - > 50% cases
 Bacteria: Staphylococcus aureus, streptococci, Clinical features:
gram-negative bacilli ▪ Decreased vision
 Spread from eye infection → ▪ Eye pain
 keratitis-related endophthalmitis → infection of the ▪ Hypopyon
cornea extends into the aqueous 28
 most common etiology: Fusarium and Aspergillus

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ENDOPHTHALMITIS
▪ Diagnosis
▪ Suspected clinically → appearance of the eye + risk factor for endophthalmitis.
▪ Microbial identification:
▪ Exogenous cases, and some endogenous cases:
▪ vitreous → vitreous aspirate or vitrectomy for culture
▪ aqueous may also be cultured.
▪ Endogenous cases with positive blood cultures ➔ presumed to be due to the
same organism.

Treatment
• Acute endophthalmitis is a medical emergency →
delayed or inadequate therapy may result in
irreversible vision loss.
• Intra-vitreal antibiotics
• Broad-spectrum antibiotics or anti-fungal agents
• Vitrectomy (surgical débridement of the vitreous):
• in severe and resistant cases only
• in fungal endophthalmitis along with intravitreal +
systemic amphotericin B.
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Parasitic eye infections

Summarized list of the parasites infecting the eye
Organism Disease Route of infection
Toxoplasma gondii Chorioretinitis, blindness Infection in utero
(toxoplasmosis)
Toxocara canis Chorioretinitis, posterior pole Transmission by eggs passed
(ocular toxocariasis) granuloma, blindness by dogs
Echinococcus granulosus Distortion of the eye by Transmission by eggs passed
(hydatid disease) growth of larval tapeworm in by dogs
hydatid cyst
Onchocerca volvulus Sclerosing keratitis, Larvae transmitted by blood-
(river blindness) chorioretinitis feeding Simulium flies
Loiasis Inflammation of conjunctiva Larvae transmitted by blood-
and cornea feeding Mango flies

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ONCHOCERCIASIS
• world's second leading infectious cause of blindness

The parasite : The vector : blackfly:

Onchocerca volvulus Simulium damnosum

• The disease is called river blindness because the vector Simulium flies develop in
fast flowing rivers, and people living near these sites are most affected.
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• In regions of Africa, and Central America
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ONCHOCERCIASIS
▪ Clinical Presentation:
✓ Skin disease
pruritus, dermatitis, onchocercomata (subcutaneous nodules), and lymphadenopathies.
✓ Eye disease
▪ ranges from mild visual impairment to complete blindness.
▪ lesions of the anterior portion of the eye include:
▪ Punctate keratitis → acute inflammatory infiltrate surrounding dying microfilariae →
resolves without causing permanent damage.
▪ Sclerosing keratitis → ingrowth of fibrovascular scar tissue that may cause
subluxation of the lens and blindness.
▪ Anterior uveitis or iridocyclitis → may deform the pupil
▪ Chorioretinitis, optic neuritis, and optic atrophy may also occur.

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ONCHOCERCIASIS
▪ Diagnosis :
▪ Clinical +
▪ microfilariae in thin skin samples
▪ skin nodules : surgically removed and examined for adult worms.
▪ Slit-lamp examination : the larvae, or the lesions they cause, are visible.

▪ Treatment :
▪ Ivermectin → kills adult worms quickly and microfilariae over several weeks.
▪ Surgical removal of the skin nodules to eliminate the adult worms

▪ Prevention :
▪ eliminating black flies
▪ Vector control involves killing the larvae of the blackfly vectors using
environmentally safe insecticides. 33

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LOIASIS
▪ The eye worm Loa loa → a filarial worm endemic to African rainforests
▪ Vector : mango fly (Chrysops spp.)
▪ Larvae enter bite wound → microfilariae migrate in the blood → after several months : adult worms form in
subcutaneous tissues + eye.

Clinical features :
• asymptomatic for several months
• becomes evident when the adult worm
crosses the conjunctiva of the eye
• itchy swellings of the body known as Calabar
swellings (arms and legs and near joints).
Diagnosis :
• finding microfilariae in blood or by finding
worms in the skin or eyes.

Treatment :
• Diethylcarbamazine → the only drug that
kills microfilariae and adult worms
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• surgical removal of the worm

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