LABORATORY EXAMINATION IN THE ETIOLOGICAL DIAGNOSIS OF EYE FOR INFECTION

WINARTO
DEPT. of OPHTHALMOLOGY FAC. of MEDICINE, DIPONEGORO UNIVERSITY / DR KARIADI HOSPITAL

S E MARAN G

INTRODUCTION
Indogenous Microflora of Human Eye
1. Sites with normal flora : a. Function : - part of innate immunity - contribute to body normal function b. If disturb dysfunction causes a diseases e.g.: skin (palpebra), conjunctivae, cornea, lacrimal system.

2. Steril sites : e.g. COA, COP, vitreous, subcutaneous tissue, subconjungtival tissue

Site with normal flora

TIDAK MEMPENGARUHI

TAJAM PENGLIHATAN

Hordeolum eksternum

Hordeolum internum

Kalazion

Kalazion Jaringan granuloma pada tarsus inferior

Selulitis (anterior) palpebra

Palpebra bengkak Tanda radang pada palpebra

EMERGENCY

DAPAT MEMPENGARUHI

TAJAM PENGLIHATAN

Trikiasis
Silia atas tumbuh ke arah dalam : kornea atau konjungtiva Kornea atau konjungtiva teriritasi Akibatnya terjadi Keratitis atau Konjungtivitis

Konjungtivitis bakteri
Konjungtivitis bakteri Sekret mukopururulen Konjungtiva kemotik Injeksi konjungtiva

Keratitis marginal

Abses berbentuk cincin di tepi kornea Jernih antara keratitis dan limbus

KERATITIS
Pemakai lensa kontak

DECORATIVE / COSMETIC

Konjungitivitis purulenta
Konjungtivitis purulenta gonorrhoe : Konjungtiva kemotik dan kasar Sekret purulen

EMERGENCY

Konjungtivitis virus
Konjungtivitis virus Injeksi konjungtival Sekret sereous Perdarahan subkonjungtiva ( subakut )

Herpes zooster oftalmikus

Herpes zoster oftalmikus

Stadium
penyembuhan

Keratitis dendritik
Infiltrat dengan batas seperti cabangcabang Disebabkan Herpes simpleks

Trakoma
Konjungtivitis trakoma Folikel pada konjungtiva tarsal
Panus Infiltrat limbus atas Neovaskularisasi di atas

Keratitis lagoftalmos
Lagoftalmos pada penderita eksoftalmus goiter Keratitis di bagian bawah akibat mata tidak tertutup waktu tidur

Ulkus sentral
Ulkus dengan neovaskularisasi dari limbus

EMERGENCY

Ulkus atau abses kornea + hipopion

Kemotik + injeksi siliar Abses kornea Hipopion di dalam bilik mata depan

EMERGENCY

Endoftalmitis

Injeksi siliar Massa supuratif di dalam bilik mata depan

EMERGENCY

Nebula kornea
Kekeruhan tipis pada kornea Batas kabur Tanda radang negatif

Leukoma kornea

Kekeruhan dengan - Batas tegas - Mata tenang

Clinical Diagnosis / Suspicion:

Infection ?

Inflammation ?

Clinical Diagnosis / Suspicion:

Infection
1. Bacteria 2. Fungus 3. Virus

Clinical Diagnosis / Suspicion:

Infection
1. Bacteria 2. Fungus 3. Virus

1. 2. 3. 4. 5.

Isolation Susceptibility test Antigen detection Immunologic respons Molecular diagnosis

IMMUNOLOGIC RESPONS
HUMORAL CELLULAR

IgG, IgM, IgA, IgE, IgD

Cytokines

DIAGNOSTICS

IMMUNOLOGIC (RESPONS) DETECTION

HUMORAL

IgG, IgM, IgA, IgE, IgD

1. Paired sera: acute and convalescence 2. Rises of titer 3. Endemic titer

DIAGNOSTICS

MICROBIOLOGY PROCESSES

INPUT

PROCESS

OUTPUT

GARBAGE IN

GARBAGE OUT

MICROBIOLOGY PROCESSES

INPUT

PROCESS

OUTPUT

CLINICAL SPECIMEN

MICROBIOLOGY PROCESSES

INPUT

PROCESS

OUTPUT

OPHTHALMO LOGIST
SPECIMEN COLLECTION

MICROBIOLOGY PROCESSES

INPUT

PROCESS

OUTPUT

CLINICAL MICROBIOLOGIST
SPECIMEN PROCESSING & REPORTING

MICROBIOLOGY PROCESSES

INPUT

PROCESS

OUTPUT

CLINICAL MICROBIOLOGIST OPHTHALMOLOGIST

SPECIMEN COLLECTION SPECIMEN PROCESSING & REPORTING

OPHTHALMOLOGIST communication

Request Form :

CLINICAL MICROBIOLOGIST

Microbiology lab. : 1. Administration

2. Specimen inspection
3. Lab. Examination 4. Report

Main objectives : to serve better to the patients

Clinical Diagnosis (Request form) Sample

MICROBIOLOGY EXAMINATION

Staining

Preliminary report

Morphology / microscopy

Isolation & identification

Susceptibility test Serology detection Rapid & mol. diagnosis

Final report Serology results

Species name Antibiogram

IgM & IgG

IF, PCR, RFLP, Blotting, etc

SPECIMEN COLLECTION
IS VERY IMPORTANT

PROPER SPECIMEN AVOID CONTAMINATION BEFORE ANTIBIOTICS TR/

Ulkus Kornea

LABORATORY EXAMINATION
Scrapping
Staining: Gram, KOH, Calcuflor white

Culture & Sensitivity test

BA, Chocolate agar, Mc Conkey

Fungus culture: SDA

Acanthamoeba culture: non nutrient medium

TYPE OF SPECIMENS
SWAB: - Conjungtivitis
SCRAPPING: - Conjungtivitis to study epithelial cells (inclusion bodies) - Corneal ulcers: - fungus - viral (HSV1) - acanthamoeba PUS: hordeolum

SKIN SCRAPPINGS: HSV1, mycoses

CORNEAL ULCER SPECIMEN

Local Analgesics: - suppressed bacteria - get more specimens

Limited specimens:
- culture : direct inoculation enrichment broth isolation - staining

STAINING
1. GRAM
Bacterial Morphology Gram (+) / (-) p.m.n. choose antibiotics
Inclusion bodies Cellular respons (pmn/lymphocyte) Viral / chlamydial infection Acute / chronic Allergy

2. GIEMSA

3. KOH

Filament, yeast, spores

HSV

4. Imm-Fluoresens

Corneal scraping (Masson trichrome) cyst of Acanthamoeba (arrow). Dendritiform epithelial lesions of patient with Acanthamoeba keratitis.

ISOLATION & SENSITIVITY TEST

CULTURE

Minimal using 2 type of media: - non inhibitory media - inhibitory media

Isolated colony

Identification
Colony morphology Staining Biochemical reaction, etc

Primary plating = isolation

Identification = Biochemistry reaction

Antibiotic Sensitivity Test Disc diffusion method : Sensitive

Intermediate sensitive
Resistant

Dilution method : MIC : minimum inhibitory concentration MBC : minimum bactericidal concentration

Causative organism
Conjungtivitis : S pneumoniae, S aureus

H influenzae
C trachomatis (inclusion & trachoma) Others : neisseria

Viral : adenovirus.
Keratitis : S pneumoniae, S aureus, S pyogenes Pseudomonas, Enterobacteriaceae, others Acanthamuba Viral : HSV, Herpes zoozter.

Endophthalmitis : S aureus, Pseudomonas, S pneumoniae

P acnes
N meningititids Others :

Periorbital sellulitis :
S aureus, S pyogenes, S pneumoniae, H influenzae Clostridium

WHEN TAKING SPECIMEN FOR CULTURE ??? x

AB culture

Immediate AB, culture if no respond

Bacteria die

Immediate culture, AB wait culture

Disease progress

Immediate culture & AB

Best choice