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Comparative Study of Bacterial Status from Conjunctival Sac of the Elder

Comparative Study of Bacterial Status from Conjunctival Sac of the Elder

陨灶贼允韵责澡贼澡葬造皂燥造熏灾燥造援 5熏晕燥援 3熏 Jun.18, 圆园12 www.IJO.cn 栽藻造押8629原愿圆圆源缘员苑圆 8629-83085628 耘皂葬蚤造押ijopress岳员远猿援糟燥皂 窑ClinicalResearch窑 Comparative study of bacterial status from conjunctivalsacoftheelderQiangminorityand HanpeoplewithdryeyeinSichuan,

Foundation item: SichuanProvincialHealthMinistry sac,orthecompositionofbacteriaspeciesandstrains,orthe ResearchFund,China(No.080302) compositionof betweentwoethnic 1DepartmentofOphthalmology, SichuanAcademyof populations. MedicalSciencesandSichuanProvincialPeople'sHospital, ·CONCLUSION:Therewasnosignificantdifferenceofbacterial Chengdu610072,SichuanProvince,China positiverateinconjunctivalsacfromtheelderofQiang 2 MianyangWanjiangOphthalmologicHospital, minorityandHanpeoplewithdryeye,butthespeciesof 621000,SichuanProvince,China bacteriaweredifferent. 3DepartmentofClinicalLaboratory,SichuanAcademyof ·KEYWORDS:conjunctivalsac;bacteria;dryeye MedicalSciencesandSichuanProvincialPeople'sHospital, DOI:10.3980/j.issn.2222-3959.2012.03.18 Chengdu610072,SichuanProvince,China 4 HospitalofTraditionalChineseMedicineAffiliatedto Medical College, Luzhou 646000, ZhangY,LiuZR,ChenH,DongWJ,FanYC,YuH,WangGJ,Li Province,China YC,CaoK.Comparativestudyofbacterialstatusfromconjunctival sacoftheelderQiangminorityandHanpeoplewithdryeyein 5TheFourthPeople'sHospitalofZigongCity. Sichuan,China. 2012;5(3):343-347 643000,SichuanProvince,China Correpondenceto: YueZhang.DepartmentofOphthalmo- logy,SichuanAcademyofMedicalSciencesandSichuan INTRODUCTION ryeyeisacommondiseaseinthemiddleageand ProvincialPeople'sHospital,Chengdu610072,Sichuan elderpeople,especiallyintheelderwomenwhois Province,[email protected] D Received:2011-08-23Accepted:2012-05-15 susceptibletotheenvironmentfactors.Therearesome normalfloraexistedintheconjunctivalsac,whichis exposedtotheoutsideandsusceptibletoenvironmental Abstract factors.Fewreportsinchinacanbefoundaboutthe ·AIM:Tocomparethestatusofbacteriaintheconjunctival relationshipbetweendryeyeandconjunctivalsac,andthere sacfromtheelderQiangminorityandHanpeoplewithdry isnoreportonthebacteriastatusfromtheconjunctivalsac eyesinSichuan,China. ofethnicminoritypeopleinChina,neitherfromethnic ·METHODS:Totalof54elderQiangpeoplewithdryeyes Qiangminority(oneofthe55minoritiesinChina).Qiang (108eyes)wereexaminedbyclustersampling.Inthesimilar minoritywithapopulationofabout200000aremainlyin habitationregionofHanpeople,80(160dryeyes)Han theupperreachesofMinjiangRiverinSichuanAbaTibetan peoplewereanalyzedasthecontrolgroup.Thebacteriawas andQiangAutonomousregion(includingPrefectureof separatedfromtheinferiorpalpebralconjunctiva,then Maoxian,Wenchuan,LiCounty,Blackwater,Songpan)and inoculatedonbloodplatefor48hoursandidentified. BeichuanQiangAutonomousCountyinMianyangCity. ·RESULTS:Totally24strainsofbacteriawereculturedin Amongthoseareas,BeichuanQiangAutonomousCountyin eitherQiangminorityorHancpopulationswith3strainsof MianyangCityisthelargestregionfortheQiangminority themexistedinbothethnicgroups.Thecommonestbacteria settlements. inconjunctivalsacintwoethnicgroupswerenon-pathogenic Itisunknownwhetherthedifferentethnicpeoplewithdry bacterium.Thecompositionof inHan eyewillexhibitadifferentbacteriastateintheconjunctival people(54.1%)wassignificantlyhigherthanthatinQiang minority(27.4%)( 2=11.6721, =0.0006).Thepercentage sacornot.Thepurposeofthestudyistocomparethe of inQiangpeoplewashigher bacteriaintheconjunctivalsacbetweentheelderQiang thanthatinHanpeople( 2=18.6442, =0.0000).However, minorityandHanpopulationwithdryeyeinMianyangcity, therewasnosignificantdifferencebetweenQiangminority Sichuan,China.However,asinQiangminorityareathe andHanpeopleeitherinbacterialpositiverateinconjunctival proportionofHanpeopleisquitelow,wehavetoselectthe

343 BacterialstatusfromconjunctivalsacofQiangminorityandHanpeople HanpeopleinFuchengdistrictofMianyangcity,foritis Theparticipantsunderwenteyeexaminations,which thenearestareatoBeichuanQiangAutonomousCountyand includedmeasurementofbest-correctedvisualacuity, showsasimilargeographicandenvironmentconditionto observationforsignsofdryeyes,slit-lampassessmentof Beichuan.Inthisstudy,thebacteriaintheconjunctivalsac anteriorsegmentandlens,andfundusevaluation. fromtheelderpeopleofQiangminorityandHanwere Ophthalmologistsconductedtheeyeexaminationsaccording compared. toastandardizedprotocol.Thedryeyeexaminations MATERIALSANDMETHODS includedBUT,FSS,Schirmertest(ST)andslit-lamp Subjects IntheearlyNovember,2009,theclusterrandom assessmentofanterior segment.Theophthalmologists samplingmethodwasusedinBeichuanQiangAutonomous performingtheeyeexaminationsweremaskedastodryeye CountyandMianyangFuchengDistrict.TheelderQiang informationfromthequestionnaire.Allthesurveyed minority(over40yearsold) in BeichuanQiang participantshadnohistoryoftopicaluseofantibioticseye AutonomousCounty,Mianyangcitywassurveyedand dropswithinthreedays. comparedwiththeelderHanpeoplewithdryeyein Schirmer test A5mm 35mmfilterstrip( 玉 伊 FuchengDistrict,Mianyangcity. JingmingNewTechnologicalDevelopmentCo.,Ltd., Methods Tianjin,China,rangeofwettingwasfrom0-30mm)was Samplingmethods Beforethesurvey,wegotthefull thenplacedtemporallyinbotheyesfor5minutes.The supportsfrom localgovernments andcorrelated participantwasencouragedtoclosehis/hereyesbutallowed constitutions.Thestandardtrainingwasgivenforoneweek toblinknormally.After5minutes,thestripwasremoved, totheteamhowtocarryonthesaccusconjunctivasecretion andtheamountofwettingwasrecorded.Tearsoakedfilter selectionvaccinationbythespecialistfromlaboratory paperwetlength<10mm,suspectedpositivefordryeye; medicinedepartment.Thepilotstudywasconductedoutside <5mmispositive. thestudyarea.Totally216individualsfromanothercounty BUT BUTwasmeasuredbyapplyingaslightlymoistened nearbywereexaminedandtheresultswereexcludedfrom fluorescentstriptotheinferiorfornixwhiletheparticipant thisstudy.Pilottestingshowedthatthequestionnairewas lookedup.Theparticipantwasaskedtoblinkseveraltimes easilyadministered,understandable,andculturallyacceptable. andthenholdtheeyesopen.Thetearfilmwasthen Ateamofophthalmologists,administrativepersonnel,and examinedwiththeaidofthecobaltbluefilterontheslit enumeratorsfromthevillagesandthemedicalworkersof lampwhiletheparticipantrefrainsfromblinking.Thetime thetownshipclinics(theyalsoactedastranslators) thatelapsesbeforethefirstdryspotorlineappearsinthe performedthedatacollection.Theteamwasequippedwith cornealfluorescentlayeristhetearfilmbreakuptime.BUT twovehicles,SnellenEchart,twoslitlampmicroscopes(66 wasrepeatedthreetimesforeacheye,andtheaveragetime Vision-TechCo.,,YZ-5E,Crane,China),a wasrecorded. binocularindirectophthalmoscope(Keeler,Windsor,UK) FSS Thefluorescentsodiumpaperwasplacedinthe withaVolk20Dlens,aPerkinshand-heldtonometer conjunctivalsacandthecornealstainingsituationwas (Clement-Clarke Ltd.,Essex, UK),andtwopower examinedundertheslit-lamp.Thegradingmethodwas generatorsforlocationswithoutelectricity. stipulatedas0:nostaining;1:1-5spotsstaining;2:5-10 ThequestionnaireofLü [1] wasusedinthisstudy.A spotsstaining;3:morethan10spotsstainingineach doortodoorvisitwasmadebytheteamandaquestionnaire quadrant.Andeachquadrantstainingwasclassified wascompletedaboutdemographicdata(name,age,gender, moderate,mediumandsevere3level. locality,economicsituation,medicalhistory,and Withthe education),lifestyle (smoking,alcoholintake),anddryeye Conjunctivalsecretioncollectionandculture symptoms.Thequestionsregardingdry-eyesymptoms platinumwireloops,theconjunctivalsecretionwastakento consistedofsixitems:(1)Didyoureyeseverfeeldry?(2) inoculateonthebloodagarculturemedium(AnTulv Didyoueverfeelagrittyorsandysensationinyoureyes? Bio-engineeringLimitedCompany,,China).The (3)Didyoureyeseveryhaveaburningsensation?(4)Were secretionwasculturedat35℃ for48hours.Ifthe youreyeseverred?(5)Didyounoticemuchcrustingon microorganismwasfoundfromtheculture,thenitwas yourlashes?(6)Didyoureyesevergetstuckshut? furthervaccinatedandseparatedbybloodagarculture Participantswhoreportedoneormoreofthesixdryeye medium.Thedetectionandidentificationofmicroorganism symptomsoftenorallthetimewereidentified. wasdoneinthelabdepartmentofSichuanProvincial Dryeyecriteriaandeyeexamination Criterionofdry People'sHospitalthroughVITEK2-compactautomatic eye [2] includes:Patient'ssymptomofdryeye,positive microorganismanalyzer,ontheEgyptianAPIappraisal SchirmerItest(5mm/5min)；positivetear-filmbreakuptime board. test(BUT) (<10s)曰positivecornealfluorescentstaining StatisticalAnalysis Thecollecteddatawereenteredintoa score(FSS)(score>1).Thepatientwasdiagnosedasdryeye computerprocessingsystembydesignatedprofessionals withanyoftheabovesymptoms,twopositivetestsand performingthesametaskstoensureconsistency.SPSS medicalhistory. Version15.0 (StatisticalPackageforSocialSciences,Inc, 344 陨灶贼允韵责澡贼澡葬造皂燥造熏灾燥造援 5熏晕燥援 3熏 Jun.18, 圆园12 www.IJO.cn 栽藻造押8629原愿圆圆源缘员苑圆 8629-83085628 耘皂葬蚤造押ijopress岳员远猿援糟燥皂 Chicago,Illinois,USA)wasusedforstatisticalanalysis. < Table 1 Percentage of bacterial positive culture from 0.05wasconsideredtobestatisticallysignificant.The conjunctiva in Qiang and Han people with dry eye Groups n Positive Negative Positive rate % positiverateandthecompositionwerecomparedby Qiang 108 62 46 57.4 Chi-squaretest.Thekindsofbacteriawereanalyzedby Han 160 98 62 61.2 Wilcoxonranksumtest. Total 268 160 108 59.7 RESULTS 2 DemographicInformation Dryeyewasdiagnosedin54 X = 0.396, P =0.529. patients （108eyes）outof210Qiangminoritypersons Table 2 Composition of single bacteria and multi-bacteria in surveyedinthisstudyandconjunctivalsecretionwas the saccus conjunctival from Qiang and Han with dry eye n(%) Groups Single bacteria Multi-bacteria Total culturedforbacteria.Amongthem,therewere17male(34 colony colony eyes),and37female(74eyes).Theageofpatientsranged Qiang 52(83.8) 10(16.2) 62 from41-84years,andtheaverageagewas60.2years. Han 86(87.7) 12(12.2) 98 Dryeyewasdiagnosedin80patients(160eyes)outof258 Total 138(86.2) 22(17.2) 160 2 Hanpersonssurveyedinthisstudyandconjunctival X =0.483, P= 0.487. secretionwasculturedforbacteria.Therewere40males Table 3 The number of bacteria species from Qiang and Han (80eyes)and40females(80eyes).Ageofpatientsranged Groups Positive eyes Number of species from41-85years,andtheaverageageis63.7years. Qiang 62 12 PositiveConjunctivalCultureRateforBacteriainthe Han 98 15 elderQiangMinorityandHanPeoplewithDryEye Z=-0.273. P =0.785. Therewasnosignificantdifferencebetweenthepositive Table 4 Gram positive and negative composition from Qiang culturerateinQiangminorityandHanpeople(Table1). minority and Han Strains(%) CompositionofSingleBacteriaandMulti-bacteriain Groups n G +ve G -ve theConjunctivalSacfromQiangMinorityandHan Qiang 73 58(79.5) 15(20.5) Han 110 103(93.6) 7(6.4) PeoplewithDryEye InQiangminorityandHanpeople, majoritywere thesinglebacteriacolony, andsmall X2= -08347,P= 0.004. proportionweremulti-bacteriacolony(Table2).Therewas nosignificantdifferencebetweenQiangandHanpeoplein stateoftheconjunctivalsacfrompatientswithdryeyeand thesingleandmulti-bacteria. normal population,whichshowedasimilarbacteria SpeciesofBacteriaCulturedfromtheConjunctivalSac distributionbetweenthenormaleyeanddryeyeineither inQiangMinorityandHanPeople InQiangminority, QiangminorityorHanpopulation,eveninotherethnic 12speciesofbacteriawerecultured,andinHanpeople15 population [3-5].Inthisstudyweobservedtheflorasof speciesofbacteriawerefound(Table3).Therewasno conjunctivalsacfromadifferentviewbycomparing significantdifference betweenQiangandHanpeople conjunctivalbacterialconditionsoftwodifferentethnic (Wilcoxonranksumtest). populationsinelderpatientswithdryeye.Wefoundthat GramPositiveandGramNegativeCompositionfrom therewerenosignificantdifferencebetweentheelderQiang QiangMinorityorHanPeople Totally398strainsof minorityandHanpeoplewithdryeyeinconjunctival bacteriawereisolated,and73strainsculturedfromQiang bacterialpositiverate,compositionbetweensinglestrain minority,111strainsfromHanpeople(including1fungus-- andmultiple-strains, numberofbacteriaspeciesin ).Bothtypesoforganismswereisolated conjunctivalsac.Owingtorestrictionsofmaterialsand significantlymoreofteninQiangminoritywhencompared culturemethod,anaerobicbacteriaandmostfungicouldnot toHanpeople(Table4). beculturedonthebloodplate.However, BacterialStrainsinQiangMinorityandHanPeople isolatedformconjunctivalsacfromHanpeoplewithdryeye DistributionofconjunctivebacteriainQiangminority wasfoundgrowingonbloodplate,althoughitbelongsto andHanpeoplewithdryeye and fungusspecies.Itisinterestingtonotethatbeingasthe wereisolatedmoreoftenin universallyacknowledgedandcommonest infectious bothpopulations(Table5). pathogensofocularsurfacediseases,weonlyfound3 ComparativeanalysisofdominantbacteriainQiang strainsof inHan,3strainsof minorityandHan Inbothpopulations inQiangminority,2strainsof speciesand wereshownasthe inQiangminority,andnone dominantbacteria,however inQiang mo-doublebacilliinthisstudy.Itisrationallytopostulate minorityshowedahighproportionupto17.8%,whilein thatthesepathogenicbacteriastrainswere"transientflora", Hannonewereisolated(Table6). ifthosepathogenicbacteriawereomitted,wecouldfindthat DISCUSSION thebacteriainconjunctivalsacfromtheelderQiang Inthepreviouspublicationswehavereportedthebacteria minorityandHanwithdryeyewerealmostnon-pathogenic

345 BacterialstatusfromconjunctivalsacofQiangminorityandHanpeople

Table 5 Conjunctive bacteria distribution in Qiang minority and Han with dry eye Bacteria Qiang Han Strains Percentage(%) Strains Percentage(%) Corynebacterium 20 27.4 60 54.1 Staphylococcus epidermidis 24 32.9 29 26.1 Intracellular bacteria Sphingomonas 13 17.8 0 0 Staphylococcus xylose 4 5.4 0 0 Streptococcus pneumoniae 3 4.1 0 0 Proteus 0 0 4 3.6 Micrococcu 0 0 3 2.7 Micrococcus luteus 2 2.7 0 0 Aeromonas short defects 2 2.7 0 0 Wolfowitz Staphylococcus 0 0 2 1.8 Staphylococcus haemolyticus 0 0 2 1.8 Staphylococcus aureus 0 0 2 1.8 Corynebacterium diphtheria 1 1.4 1 0.9 Staphylococcus squirrel 1 1.4 0 0 Strain variation Cook 1 1.4 0 0 Markov Corynebacterium 1 1.4 0 0 Adjacent particles Streptococcus 1 1.4 0 0 Coriolis Staphylococcus 0 0 1 0.9 Streptococcus angina 0 0 1 0.9 Road Deng aureus 0 0 1 0.9 Staphylococcus heads 0 0 1 0.9 Alcaligenes faecalis 0 0 1 0.9 Krusei 0 0 1 0.9 Total 73 100 111 100

Table 6 Dominant bacteria in Qiang minority and Han Groups Total positive Corynebacterium Staphylococcus epidermidis Intracellular bacteria Sphingomonas eyes Positive eyes Positive rate Positive eyes Positive rate Positive eyes Positive rate Qiang 73 20 27.4 24 32.9 13 17.8

Han 87 60 54.1 29 26.1 0 0 X2 11.6721 0.6771 18.6442

P 0.001 0.411 0.000 The above results indicated that there were significant differences in dominant bacteria of Corynebacterium and Intracellular bacteria Sphingomonas between two populations. The positive rate of Corynebacterium in Qiang minority was significant higher than that in Han, Intracellular bacteria Sphingomonas is one of dominant bacteria in Qiang minority with dry eye while in Han it does not exist. There was no significant difference in Staphylococcus epidermidis between both populations. bacteria.Nevertheless,itshowedthatboththe species,amongwhichonly non-pathogenicbacteriaandtransientfloraconstitutethe and could ocularsurfacebacteriainpatientswithdryeye. befoundintwopopulations,whiletheremaining21species Althoughthenon-pathogenicbacteriabetweentheQiang ofbacteriaexistedeitherinHanorinQiangminority(Table5). minorityandHandidnotshowsignificantdifference,the Additionally,throughanalysisofdominantbacterialstrains differencesofconjunctivalflorasbetweentwoethnic whichoccupied3/4ofconjunctivalbacteriaofthetwo populationscouldstillbeseenfromthisstudy.FromTable ethnicpopulations,itrevealedthat was 1,thecompositionofgramnegativebacteriafromQiang dominantinHanpeoplewithaproportionupto54.1%, minoritywithdryeyewassignificanthigherthanthatfrom almosttwiceasthatfromQiangminority (27.4%); Hanpeople.Furthermore,thedistributionofbacteriaspecies meanwhilethedifferenceof composition wasalsodifferent(Table2).Bacteriainconjunctivalsacof wasnotstatisticallysignificant,butitrankedfirstinQiang QiangminorityandHanpeoplewithdryeyeconsistedof24 minorityasadominantstrain,while

346 陨灶贼允韵责澡贼澡葬造皂燥造熏灾燥造援 5熏晕燥援 3熏 Jun.18, 圆园12 www.IJO.cn 栽藻造押8629原愿圆圆源缘员苑圆 8629-83085628 耘皂葬蚤造押ijopress岳员远猿援糟燥皂 wasinhighproportioninQiangminoritybut withdryeye,aslongasnosignsofinfectionornoocular nonewasfoundinHanpeople. surgerytodestroythemicroenvironment,itisunnecessary Thedifferencescouldprobablybeexplainedbythetheory touseanti-bacterialeyedropstoavoidbreakingocular ofmicrobiology;itmeansmicroecologicalenvironmentof surfacemicroenvironmentequilibrium. humanconjunctivalsachadanabilityof"microecological ThisisthefirsttimeinChinatocomparethebacteriastate succession".Externalenvironment(naturalandsocial)and fromtheconjunctivalsacintheelderQiangminorityand hostinternalenvironmentcouldbringgeneticcharacteristic Hanpeoplewithdryeye.Itdemonstratedthebacteriastate changesinmicrobialcommunitiesresultinginreplacement inconjunctivalsacinelderQiangminorityandHanpeople. betweendominant speciesandnon-dominantspecies, Inthisstudywecouldconcludethattherewasnosignificant includingpathologicalsuccession,thatis,whenhumanor differencebetweenQiangminorityandHanpeopleineither animalswereinapathologicalstate,thenormalflora bacterial positiverateinconjunctivalsac,orthe bacteriaofsomespecificpartswouldhavesubsequent compositionofbacteriaspeciesandstrains,orthe [6] changes .Thesurveyedpeopleinthisstudycamefrom compositionofstaphylococcusepidermidisbetweentwo closeadministrativeregionswithsimilargeographical groups,buttheGrampositiveornegativespeciesofbacteria locationsandclimates,whichensuredthecomparisonwas and compositionweredifferent betweentwoethnic homogeneousinlocationandgeography.Thereby,the populations. differencesbetweenthetwogroupscouldbespeculated REFERENCES fromthedifferencesoflivingenvironments,livinghabits,or 1L F,QuJ.Theclinicaldiagnosisofdryeye. 俟 probableinstinctgeneticcharacteristicsofdifferentethnic 2002;20(7):514-517 groups.Taking asanexample, 2ZhangHC,ZhouZL,ZhaoCR.TheDryeyerecordspointsthe wasreclassifiedinto graduationandtheartificialtearcurativeeffectappraisalresearch. when wasnewly 1994;12(01):25-27 establishedaccordingto16SrRNAsequenceanalysis,cells 3ZhangY,LiuZR,ChenH,CaoK,YuH,WangGJ,LiYC Comparative containingspecialcomponents (sphingosine,coenzyme studyofbacterialstatusonconjunctivalsacindryeyesandnormaleyesof Q10,andotherfeaturesbyYabuuchi [7] in1990.These theelderofQiangminority. 2011;42(6): bacteriapossessedaspecialmetabolic mechanismto 811-814 4DongWJ,ZhangY,LiuZR,ChenH,CaoK,YuH,WangGJ,LiYC. efficientlyadjustitsgrowthandresistancetoadverse Comparativestudyofbacterialstatusonconjunctivalfornixsacindryeyes environmentalchangessuchastolerancetopoornutrition, andnormaleyesofthemiddleageandtheelderofHannationalityin cold,ultravioletradiation;consequentlytheybehavedina Mianyangcity. 2011;31(10):965-968 [8] strongvitalityanddistributedwidelyinthenature .Some 5HoriY,MaedaN,SakamotoM,KohS,InoueT,TanoY.Bacteriologic membranesofthesestrainsalsohadpolymerchannelsand profileoftheconjunctivainthepatientswithdryeye. largeplasmids,whichcoulddegradepolymericorganic 2008;146(5):729-734 pollutants.Thebacteriawerecommonlypresentedonlyin 6LiLJ.Infectedwithmicro-ecology.Firstedition.:People's Qiangminoritywithdryeyebutnoneininfectious MedicalPublishingHouse2002:4-15 conjunctivalsac;itmightberelatedtothedifferenceof 7YabuuchiE,YanoI,OyaizuH,HashimotoY,EzakiT,YamamotoH. habitat.Howeveritneedsfurtherinvestigations.This ProposalsofSphingomonaspaucimobilisgen.nov.andcomb.nov., phenomenonalsoindicatedthattheinteractionsfromnatural Sphingomonasparapaucimobilissp.nov.,Sphingomonasyanoikuyaesp. nov.,Sphingomonasadhaesivasp.nov.,Sphingomonascapsulatacomb. healthymicroecologicalenvironmenttothehumanocular nov.,andtwogenospeciesofthegenusSphingomonas. surface-eventosomeunhealthydryeyewithalocal 1990;34(2):99-119 decreasedresistance(wereprotectiveandrepairable. 8HuJ,HeXH,LiDP,LiuQ ProgressinResearchofsphingomonas Althoughcoagulase-negativestaphylococcisuchas paucimobilis. 2007;13(03):431-437 havebeenasthemainpathogenic 9VaraprasathanG,MillerK,LietmanT,WhitcherJP,CevallosV, factorofocularsurfaceinfectionsinrecentyears [9,10],itis OkumotoM,MargolisTP,YinghuiM,CunninghamETJr.Trendsinthe stillthoughttobeawidespreadresidentbacteriainocular etiologyofinfectiouscornealulcersattheF.IProctorfoundation. surfaceotherthanapathogenicone [11].Itisveryinteresting 2004;23(04):360-364 thatLai [12] found may 10ZhangWH,PanZQ,WangZQ,JinXY,LuoSY,ZouY,WuYY,LiR. produceabeneficialeffecttotheepidermaltissueandits Commonpathogenspurulentchangesincornealulcer. lipoteichoicacidcouldinhibitthedermalinflammation.Itis 2002;38(01):8-12 11LiuZG.Studiesofocularsurfacedisease.Firstedition.Beijing:People's becauseofthesenormalflorasofbacteriaregularlysettled MedicalPublishingHouse2003:61-62 intheocularsurface,probably throughpromoting 12LaiY,DiNardoA,NakatsujiT,LeichtleA,YangY,CogenAL,Wu microeubiosisandinternalenvironmentstabilityeveninthe ZR,HooperLV,SchmidtRR,vonAulockS,RadekKA,HuangCM,Ryan dryeyethattheeyecouldstillremaininnon-infectedstate. 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