Fungal flora of the conjunctival sac in health and disease. Influence of topical and systemic steroids.

ALTHOUGH the role of fungi as ocular pathogens has become more widely recognized (Maddren, 1941; Sykes, 1946; Mendelblatt, 1953; Mitsui and Hanabusa, 1955-; Roberts, 1957; Haggerty and Zimmerman, 1958; Mikami and Stemmermann, 1958; Fine and Zimmerman, 1959; Chick and Conant, 1962; Currie, 1963; Ainley and Smith, 1965; Jelenkiewicz, 1965; Dominiczak, Branicka, and Lewenstam, 1965), relatively little attention has been given to the fungal flora of the healthy or diseased eye. Previous lengthy investigations conducted in Europe (Fazakas, 1935, 1953) and in the U.S.A. (Hammeke and Ellis, 1960) have shown some disparity in the frequency of occurrence of fungi in the healthy conjunctival sac; studies of smaller groups of patients (Mitsui and Hanabusa, 1955; Azevedo, 1962) are less conclusive owing to the small size and selectivity of the samples. Furthermore, some ocular mycoses may have an exogenous source, especially after surgery or trauma (Fine and Zimmerman, 1959) and an accurate knowledge of the species most likely to be encountered in the conjunctival sac is of more than academic interest. The first purpose of this paper, therefore, is to report the results of an investigation of the fungal flora of the clinically healthy conjunctivae of a large and representative sample of subjects in various age groups. Our second purpose is to study the variations of fungal flora in corticosteroid-treated patients. It is well documented that steroids reduce tissue resistance to a wide variety of bacterial, viral, and fungal agents (Zimmerman, 1950; Kligman, Baldridge, Rebell, and Pillsbury, 1951; Selye, 1951), and it would appear that the increase of ocular mycoses within recent years may be associated with the extensive use of systemic and topical corticosteroids and of broad-spectrum antibiotics (Hogan, Thygeson, and Kimura, 1954; Suie and Havener, 1963; McLean, 1963). Consequently, we have investigated the effects of (a) topical steroids, (b) topical steroids combined with antibiotics, and (c) systemic steroids, on the conjunctival flora of various groups of patients. The third section is concerned with the fungal flora of the eye in Sjogren's syndrome. The characteristically dry eye encountered in this syndrome (keratoconjunctivitis sicca) is associated with depletion of normal tear flow and impaired mechanical removal of foreign material, and may therefore be more susceptible to colonisation by microbial agents.