Open Journal of Ophthalmology, 2012, 2, 26-30 Published Online May 2012 (
Risk Factors for Conjunctival Microorganism Colonization
in Adults Undergoing Intraocular Surgery*
Orly Halachmi-Eyal1#, Yoram Keness2, Yaron Lang1, Daniel Briscoe1,3, Dan Miron3,4
1Department of Ophthalmology, Afula, Israel; 2Clinical Microbiology Laboratory, Afula, Israel; 3Ruth and Bruce Rappaport School
of Medicine, Haifa, Israel; 4Pediatric Infectious Disease Consultation Service, Ha’Emek Medical Center, Afula, Israel.
Received January 16th, 2012; revised February 18th, 2012; accepted March 14th, 2012
Purpose: To assess prevalence of and risk factors for conjunctival colonization and types of organisms among adults
undergoing elective intraocular surgery. Setting: Ha’Emek Medical Center, Afula, Israel. Methods: A prospective study
conducted in the Ophthalmology Department at Ha’Emek Medical Center, Afula, Israel between May 1, 2006 and Au-
gust 31, 2007. Included were adults undergoing elective intraocular surgeries. Conjunctival cultures were obtained from
the lower fornix, prior to application of prophylactic decolonization treatment and were processed using routine micro-
biological techniques. Demographic, socioeconomic and medical data of our patient cohort were obtained from all par-
ticipants. Results: Cultures were obtained from 501 patients. (Mean age 69.7 ± 12.0 years) of whom 52.1% were fe-
males. In 208 patients (40.5%) bacteria grew in conjunctival cultures, one type in 175 (34.9%) one, and two types in 28
(5.6%). In none fungi were isolated. Coagulase negative Staphylococcus was the most frequent bacteria isolated. By
multivariate analysis, significant risk factors for conjunctival bacterial colonization were spring/summer seasons (OR:
1.64, CI: 1.15 - 2.36, P < 0.007), and showering on the day of the operation (OR: 1.73, CI: 1.11 - 2.69, P < 0.01). Conclu-
sions: In addition to previously known risk factors for conjunctival microorganism colonization, the present study
found showering on the morning of the operation, possibly related to bacteria on towels or in the eyelids and lashes, and
time of year (spring/summer) perhaps resulting from higher temperature and humidity related to the presence of con-
junctival bacteria to be significant in adults undergoing intraocular surgery.
Keywords: Conjunctiva; Culture; Bacteria; Coagulase Negative Staphylococcus; Cataract; Shower; Climate
1. Introduction
The pathogenesis of post-operative endophthalmitis (POE)
is associated in most parts with penetration of microor-
ganisms (mostly bacteria) from the conjunctiva into the
eye ball during the ocular surgical procedure. The most
common pathogens associated with in POE are coagulase
negative staphylococcus (CNS) (70%), Staphylococcus
areus (24%), gram negative rods (6%), Propionibacte-
rium acnes, Pseudomonas aeroginosa, and Hamophilus
influenza [1].
Data regarding colonization of microorganisms in the
conjunctival sac prior to ocular surgery are scarce. In a
previous paper we published our conjunctival culture
results in comparing prospectively two methods of pre-
operative prophylaxis [2]. The aim of the present study
was to identify risk factors and to assess their prevalence
in reference to conjunctival colonization as well as to
determine types of organisms found among adult patients
undergoing elective intraocular surgery.
There is a known correlation between conjunctival
bacterial detection and co-existence of an ocular surface
disease, (i.e. blepharitis and conjunctivitis). Chronic im-
munocompromised disease conditions and indiscriminate
use of antibiotics and corticosteroids are associated with
fungal growth. Hot climate was also shown to be associ-
ated with increased prevalence of bacterial recovery from
the conjunctiva [3].
2. Materials and Methods
The current study was conducted between May 1st 2006
and August 31st 2007 in the Ophthalmology Department
at Ha’Emek Medical Center, Afula, Israel. The study was
approved by the local Internal Review Board and written
informed consent was obtained from each patient prior to
*Synopsis: The present study found showering on the morning of the
operation, and warm season to be significantly related to bacteria yield
in conjunctiva cultures in adults undergoing intraocular surgery.
#Corresponding author. Included were patients >18 years old attending an
Copyright © 2012 SciRes. OJOph
Risk Factors for Conjunctival Microorganism Colonization in Adults Undergoing Intraocular Surgery 27
elective intra-ocular surgery. Patients undergoing emer-
gency treatment, with pre-existing primary or secondary
immune-compromised conditions, those being treated
with local or systemic antibiotic or steroidal agents, de-
bilitated patients, or those suffering from inter-current
local or systemic infectious disease were excluded. Pa-
tients with chronic renal failure treated with dialysis were
also excluded. Demographic and socioeconomic data
included gender, age, place of residence (urban/rural),
work place (indoor/outdoor), level of formal education,
the season of the operation day and showering on the
morning of the operation. Medical data were obtained
including drug and drops intake, presence of hyperten-
sion, anemia, diabetes, heart, kidney, hormonal, pulmo-
nary and mental diseases as well as the season, and
showering on the morning of the operating day.
2.1. Workup
Conjunctival baseline cultures were obtained approxi-
mately two hours before the operation (prior to the ap-
plication of any prophylactic therapy). We obtained two
smears from the lower conjunctival fornix of each patient
by using Copan transwab applicators in an Amies trans-
port medium that was seeded on a chocolate agar at bed-
side. Specimens were processed according to routine
microbiological methods [4]. Transwab specimens were
further seeded on selective and enriched agar cultures for
aerobe bacteria and fungi and were incubated for 48 - 72
hours before microorganism colonization was recorded.
Routine microbiology methods were used for identifica-
tion of the microorganisms isolated and determination of
their susceptibility patterns [4].
Patients were generally treated with diclofenac sodium
1 mg/ml (Voltaren® Ophtha, Novartis, Switzerland) one
drop instilled 3 times/day for three days prior to the sur-
gery, in such a way that the last drop was applied on the
evening before the operation.
2.2. Statistical Analysis
The prevalence of particular bacteria was computed per
1000 cultures. Χ2 tests were used to assess the risk of
categorical data. Ordinal regression analysis with a logit
link was used to obtain an estimate of the common odds
ratio for the significant variables. Test of parallel lines
was performed.
3. Results
Five hundred and one subjects were included in the study
of whom 261 (52.1%) were female. The mean age was
69.7 ± 12.0 (range 18 - 92). Overall, 233 bacteria were
isolated in 203 (40.5%) patients’ conjunctival sacs. In
175 patients, one or more (34.9%) bacterial isolates were
retrieved. In 28 (5.6%) subjects two bacterial isolates
were retrieved. No cultures showed isolated fungi. The
most prevalent bacteria was CNS, isolated in 170 (33.9%)
patients (Table 1 ).
Significant factors for growth of at least one type of
organism in culture analyzed by univariate and stepwise
regression multivariate analysis are shown in Table 2.
Showering on the morning of the operation and spring/
ummer seasons were both significant risk factors for re-
trieving one or more bacteria in culture. No other vari-
ables were statistically significant factors associated with
Table 1. Microorganisms isolated in the conjunctival sac in 501 patients.
Bacteria Overall N (%*) As a sole isolate N (%) As a mixed isolate N (%)
CNS 170 (33.9) 145 (28.9) 25 (5.0)
Streptococcus viridans 14 (2.8) 0 (0) 14 (2.8)
Staphylococcus areus (methicillin sensitive) 10 (2.0) 9 (1.8) 1 (0.2)
Corynebacterium sp. 8 (2.0) 6 (1.2) 2 (0.4)
Proteus mirabilis 6 (1.2) 4 (0.8) 2 (0.4)
Bacillus sp. 5 (1.0) 3 (0.6) 2 (0.4)
Hemophilus sp. 4 (0.8) 2 (0.4) 2 (0.4)
Citrobacter diversus 4 (0.8) 1 (0.2) 3 (0.6)
Staphylococcus areus (methicillin resistant) 3 (0.6) 2 (0.4) 1 (0.2)
Others** 9 (1.8) 5 (1.0) 4 (0.8)
Overall 233 177 56
*Percent of all patients; **Diphtero id s , Streptococcus pneu monia, Ac inetobac ter sp. —2 isolates each, Morganella mor ganii, Pse udomonas sp., and Enterobacter
brevis—1 isolate each.
Copyright © 2012 SciRes. OJOph
Risk Factors for Conjunctival Microorganism Colonization in Adults Undergoing Intraocular Surgery
Table 2. Univariate and multivariate analysis for variables associates with any bacterial growth in conjunctival culture.
Univariate analysis Multivariate analysis
for independent variables
Variable (N value) Any bacterial
growth N (%) OR (95% CI) P OR (95% CI) P
Showering on the morning of operation
No (124)
Yes (335)
37 (29.8)
142 (42.4)
1.73 (1.11 - 2.69)=0.01 1.62 (1.03 - 2.54) =0.03
Autumn-Winter (254)
Spring-Summer (247)
88 (34.6)
115 (46.6)
1.64 (1.15 - 2.36)=0.007 1.50 (1.03 - 2.20) =0.03
Yes (183)
No (328)
117 (36.8)
86 (47.0)
0.66 (0.45 - 0.95)=0.03 0.67 (0.47 - 1.03) =0.07
bacterial yield in cultures. History of hypertension was
associated with lower rate of conjunctival bacterial colo-
nization by univariate analysis, only.
By univariate analysis significant risk factors for
mixed growth of bacteria in cultures were warm season
(OR: 1.66, 95% CI: 1.17 - 2.37, P < 0.02), showering on
the morning of the operation (OR: 1.72, 95% CI: 1.11 -
2.66, P < 0.05), and hypertension (OR: 0.64, P < 0.03).
Educational level tended to be a risk factor (P < 0.08).
Multivariate analysis using season, showering, blood
pressure and education level revealed that showering
(OR: 1.72, 95% CI: 1.11 - 2.66, P < 0.03), warm season
(OR: 1.53, 95% CI: 1.04 - 2.24, P < 0.03) and no formal
education (OR: 1.62, 95% CI: 1.01 - 2.60, P < 0.05) were
significant risk factors for mixed growth of bacteria
while hypertension was not (OR: 0.71, 95% CI: 0.48 -
1.05, P < 0.09).
4. Discussion
We previously published our results of conjunctival cul-
tures taken from healthy adults prior an elective in-
traocular surgery [2]. Bacteria were isolated from 40.5%
of the conjunctiva of adults, of which CNS was the most
prevalent occurring in 33.9% cases. In that prospective
double-blind controlled study we compared the effect-
tiveness of adding preventive treatment of Moxifloxacin
0.5% ophthalmic drops on Povidone-Iodine 5.0% solu-
tion alone for disinfection of the conjunctiva prior sur-
gery. We found that the addition of Moxifloxacin 0.5%
drops on the conventional treatment with Povidone-Io-
dine 5.0% prior the surgery, had no significant effect on
further reduction in the bacterial colonization rate from
the conjunctiva. In the current study, we looked at the
risk factors related to the presence of bacteria in conjunc-
tival cultures and we found showering on the morning of
the operation and spring/summer seasons were both sig-
nificant risk factors for conjunctival colonization.
In Ta ble 3, results of similar studies that examined the
rate and the bacterial type in conjunctival cultures are
presented. As seen in the table, positive cultures were
found to be between 20% and 80%; CNS was quite
abundant in the conjunctiva and derived from 30% - 80%
of normal cultures. This is in accordance with the results
of the Endophthalmitis Vitrectomy Study (EVS) [2] where
CNS was by far the most abundant bacteria in culture
positive post-operative endophthalmitis (POE), occurring
in 70% of cases.
Other prevalent bacteria are Corynebacterium sp.,
Staphylococcus Aureus and Streptococcus viridance.
Corynebacterium sp. was scarcer in our study compared
to its prevalence in the literature [5], where it accounts for
up to 30% - 40% of the microorganisms in culture. Being
a facultative anaerobe, this may be related to the use of
aerobic bacteria agar, and will be discussed later.
Risk factors for conjunctival growth: Previously known
risk factors for retrieving bacteria from the conjunctiva
include: advanced age, local risk factors (chronic use of
topical medications, contact lens wear, blepharitis,
chronic eyelid or conjunctival inflammation) and systemic
risk factors (immunosuppression, diabetes, skin disorders,
asthma, autoimmune conditions and those taking immu-
nosuppressant medications) [6].
According to our findings, the time of year (spring/
summer) is a significant independent risk factor for con-
junctival colonization. Higher temperature and humidity
were shown to be related to the presence of conjunctival
bacteria [7]. Of 4432 patients studied in Madrid, Spain,
prevalent bacteria were CNS (>60%); Corynebacterium
sp. (>33%), Staphylococcus aureus (>8%), and other
Gram-positive bacteria (>2.5%) and other Streptococcus
sp. (>6%). Also, in this study, the incidence of rehospi-
talisation for endophthalmitis after cataract extraction in
warm months (May and June together) was 3.37 times
higher than in the other months. In another study, hot
climate was shown to be associated with the presence of
certain bacteria in the conjunctiva especially Staphyloc-
cocus Epidermidis in India [8].
Showering in the morning of the operation is also a
significant risk factor in our study. While this conclusion
Copyright © 2012 SciRes. OJOph
Risk Factors for Conjunctival Microorganism Colonization in Adults Undergoing Intraocular Surgery 29
Table 3. Studies assessing prevalence of bacterial growth in conjunctival culture obtained from adults (*CNSCoagulase
negative staphylococcus).
Reference N Overall positive cultures N (%) CNS* N (%) Other—relatively frequent (>10%) N (%)
Yang et al. [9] 133 61 (45.8) 25 (41) Staphlococcus aureus 23 (37.7)
Gram-positive rods 13 (21.3)
Leong et al. [10] 98 64 (65) 35 (55) Corynebacterium 40 (63)
Fernández et al. [11] 4432 3461.4 (78.1) 2521 (56.9) Gram positive bacteria 3236 (93.5)
Corynebacterium sp. 1055 (30.5)
Herde et al. [12] 686 126 (18.4) 109 (86.5)
Current study 501 233 (46.5) 170 (73)
Overall 5850
may seem unlikely, we assume that the reasons are re-
lated to bacteria that exist on towels or in the eyelids and
lashes (e.g. in chronic blepharitis), which can potentially
expose them to a large inoculum when rubbing their eye-
lids. Another reason might be related to lowering the
normal peri-ocular inoculum, enabling exposure to
pathogenic bacteria, but we could not found literature
that supported these parameters. A further study might be
required, specifically focusing on the technique of wash-
ing and drying the eyes.
5. Limitations of the Study
In our study, we excluded potential risk factors such as
chronic immune-compromised disease conditions and
indiscriminate use of antibiotics and steroids. We did
have difficulties in standardizing local risk factors such
as the presence of blepharitis or other ocular surface dis-
orders because of the large number of participants (both
patients and medical staff). Furthermore, because of
technical issues, only aerobic bacteria were analyzed at
the laboratory. The rationale for that was that aerobic
bacteria cause more than 94% of all POE cases [1] while
obligate anaerobes have a negligible role in endoph-
thalmitis. According to the EVS, Propionibacteria acnes
and Propionibacteria granulosum were the only obliga-
tory anaerobic bacteria isolated in the POE cases and
constituted just 0.6% of all the 323 confirmed growth
isolates. Furthermore, since both microorganisms need a
laboratory incubation period of more than 6 days, it was
impractical to culture every conjunctival specimen of the
more than 500 specimens for this extended period of time
under anaerobic conditions in order to retrieve a mere
<1% (0.6%) of the microorganisms.
6. Acknowledgements
The authors did not receive any financial support from
any public or private sources.
The authors have no financial or proprietary interest in
a product, method, or material described herein.
[1] D. P. Han, S. R. Wisniewski, L. A. Wilson, et al. , “Spec-
trum and Susceptibilities of Microbiologic Isolates in the
Endophthalmitis Vitrectomy Study,” American Journal of
Ophthalmology, Vol. 122, No. 1, 1996, pp. 1- 17.
[2] O. E. Halachmi, Y. Lang, Y. Keness and D. Miron, “Pre-
operative Topical Moxifloxacin 0.5% and Povidone-Io-
dine 5.0% versus Povidone-Iodine 5.0% Alone to Reduce
Bacterial Colonization in the coNjunctival Sac,” Journal
of Cataract Refractive Surgery, Vol. 35, No. 12, 2009, pp.
2109-2114. doi:10.1016/j.jcrs.2009.06.038
[3] M. G. Speaker and J. A. Menikoff, “Prophylaxis of Endo-
phthalmitis with Topical Povidone-Iodine,” Ophthalmol-
ogy, Vol. 98, No. 12, 1991, pp. 1769-1775.
[4] K. Todar, “The Bacterial Flora of Humans,” Online Text-
book of Bacteriology, University of Wisconsin-Madison,
Madison, 2002.
[5] U. Bachrach, J. Gurevitch, J. Landau and D. Birnbaum,
“The Flora of the Normal Conjunctiva of Healthy People
in Israel,” Acta Medica Orientalia, Vol. 12, No. 1, 1953,
pp. 3-10.
[6] H. M. De Kaspar, C. N. Ta, et al., “Prospective Study of
Risk Factors for Conjunctival Bacterial Contamination in
Patients Undergoing Intraocular Surgery,” European Jour-
nal of Ophthalmology, Vol. 19, No. 5, 2009, pp. 717-722.
[7] E. F. Rubio, “Climatic Influence on Conjunctival Bacteria
of Patients Undergoing Cataract Surgery,” Eye (Lond),
Vol. 18, No. 8, 2004, pp. 778-784.
[8] V. P. S. Tomar, O. P. Sharma and K. Joshi, “Bacterial and
Fungal Flora of Normal Conjunctiva,” Annals of Oph-
thalmology, Vol. 6, 1971, pp. 669-671.
[9] W. Yang, L. Kuang, F. Deng, et al., “Study on Bacterial
Strains in Conjunctival Sac before and after Intraocular
Surgery,” Eye Science, Vol. 15, No. 4, 1999, pp. 267-269.
[10] J. k. Leong, R. Shah, P. J. Mc Clusskey, et al., “Bacterial
Contamination of the Anterior Chamber during Phacoe-
mulsification Cataract Surgery,” Journal of Cataract and
Refractive Surgery, Vol. 28, No. 5, 2002, pp. 826-833.
[11] R. E. Fernández, “Conjunctival Bacteria of Patients Un-
dergoing Cataract Surgery: Changes in the Last 50 Years,”
Copyright © 2012 SciRes. OJOph
Risk Factors for Conjunctival Microorganism Colonization in Adults Undergoing Intraocular Surgery
Archivos de la Sociedad Española de Oftalmología, Vol.
79, No. 1, 2004, pp. 13-19.
[12] J. Herde, M. Tost, D. Wilhelms, et al., “Perioperative
Conjunctival Flora,” Klinische Monatsblätter für Augen-
heilkunde, Vol. 209, No. 7, 1996, pp. 13-20.
Copyright © 2012 SciRes. OJOph