Staphylococcal Blepharitis and Blepharokeratoconjunctivitis in Southeast Asia: Microbiological Profile and Antibiotic Sensitivity Patterns

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Sy, George Michael N. Sosuan, Ruben Lim Bon Siong This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9046143/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 8 You are reading this latest preprint version Abstract Purpose To describe the clinical and microbiological profile of patients with staphylococcal blepharitis and blepharokeratoconjunctivitis (BKC) in a Philippine tertiary hospital, determine antibiotic susceptibility patterns, and evaluate associations between bacterial species, resistance profiles, and disease severity. Methods This single-center prospective observational study included 30 patients (60 eyes) clinically diagnosed with staphylococcal blepharitis or BKC. Detailed clinical history, slit-lamp examination, and visual acuity measurements were documented. Eyelid margin swabs were obtained for organism identification and antibiotic susceptibility testing. Associations between microbiologic data and clinical presentation were analyzed using Kruskal–Wallis, Mann–Whitney U, and Spearman correlation tests. Results Twenty-seven patients (90%) yielded positive cultures and 34 staphylococcal isolates were identified. All isolates were Staphylococcus species, most commonly Staphylococcus epidermidis (47.1%), over half of which were methicillin-resistant. No methicillin-resistant Staphylococcus aureus was detected. High resistance rates were observed for penicillin and erythromycin, while fluoroquinolones and aminoglycosides demonstrated excellent antimicrobial sensitivity. No significant associations were found between bacterial species, antibiotic resistance patterns, and clinical presentation. Corneal involvement was found to have significantly worse visual acuity and a higher symptom burden positively correlated with more clinical signs. Conclusion Staphylococcal species and antibiotic resistance patterns did not correlate with disease severity or clinical presentation. Disease severity appears to be more strongly driven by bacterial toxin production, delayed consultation, and host susceptibility. Aminoglycosides remain highly effective for treatment. Although methicillin-resistant Staphylococcus epidermidis was common, it did not confer worse clinical outcomes. Staphylococcal blepharitis staphyloccocal blepharokeratoconjunctivitis microbiological profile resistance patterns Figures Figure 1 INTRODUCTION Staphylococcal blepharitis is defined as inflammation of the lid margin presenting with scaling, crusting, and erythematous eyelid margins with collarette formation at the base of the cilia. It is a relatively common ocular condition caused by bacterial colonization of the lids, primarily by Staphylococcus species. One significant complication arising from chronic staphylococcal blepharitis is blepharokeratoconjunctivitis (BKC), which is defined as a chronic and recurrent inflammatory disease of the eyelids characterized lid margin inflammation and telangiectasia, fibrin-crusts and scales (collarettes), tylosis, madarosis, trichiasis, papillary and follicular conjunctival hypertrophy, punctate epithelial erosions, and marginal infiltrates, among others. While staphylococcal blepharitis is relatively benign, progression to BKC becomes a more serious concern as it can cause long-term visual impairment.( 1 ) A local Philippine study describing the clinical profile and corneal complications of staphylococcal blepharitis reported a predominance among females and clustering in the 0–20-year age group. Corneal involvement occurred in 60% of patients, with nearly half experiencing delayed consultation or initial misdiagnosis.( 2 ) Standard management includes warm compresses, lid hygiene, and prolonged topical antibiotic therapy to reduce antigenic load and prevent recurrence.( 3 ) However, while clinical data is available, no local studies have examined the specific bacterial pathogens associated with staphylococcal blepharitis or characterized their antibiotic sensitivity patterns. This information is critical to determine whether current treatment protocols are still appropriate in the setting of evolving resistance. Staphylococcus aureus and Staphylococcus epidermidis are the leading bacterial pathogens in many ocular infections. The Staphylococcus substudy of the Asia Cornea Society Infectious Keratitis study highlighted rising antimicrobial resistance among these species, including the increasing emergence of methicillin-resistant strains (MRSA and MRSE), which pose significant therapeutic and public health challenges.( 4 , 5 ) Available literature also reports increasing resistance to erythromycin and penicillin among blepharitis isolates.( 6 ) Despite these trends, no Philippine data currently exists regarding the incidence of MRSA or MRSE in staphylococcal blepharitis. This study aims to describe the bacteria found in the lids of patients clinically diagnosed with staphylococcal blepharitis and staphylococcal blepharokeratoconjunctivitis, as well as, report their antibiotic sensitivity patterns. Specific objectives of this study include to determine the demographic and clinical profile of patients diagnosed staphylococcal blepharitis and blepharokeratoconjunctivitis, and to correlate the strains and sensitivity/resistance patterns to clinical presentation and severity. METHODOLOGY This single-center prospective observational study included 60 eyes of 30 patients clinically diagnosed with staphylococcal blepharitis or blepharokeratoconjunctivitis at the External Disease and Cornea Clinic of the University of the Philippines Manila - Philippine General Hospital between July 2025 and November 2025, using consecutive sampling. A total of 34 microbial isolates were collected from the 30 patients. Patients were eligible if they were clinically diagnosed by an External Disease and Cornea specialist with staphylococcal blepharitis or blepharokeratoconjunctivitis and provided informed consent (or parental consent for minors, with assent for ages 7–17 years). Inclusion required the presence of clinical signs of staphylococcal blepharitis, with or without conjunctival or corneal involvement. Exclusion criteria were the use of topical antibiotics for blepharitis within the preceding 2 weeks and coexisting allergic conditions like allergic conjunctivitis and vernal keratoconjunctivitis. All patients underwent history taking and examination with a slit-lamp biomicroscope. The following data were collected: age, gender, laterality, presenting symptoms, disease onset, and previous episodes or treatments. Uncorrected and best corrected visual acuity in LogMAR was noted. Slit lamp examinations findings that were gathered include lid margin findings (fibrin/crusts/collarettes, margin erythema/telangiectasia, ulceration, tylosis, trichiasis, distichiasis, madarosis, poliosis, hordeolum, chalazion, meibomitis/plugged MGs), conjunctival findings (redness, discharge, follicles, papillae), and corneal findings (neovascularization, pannus, marginal ulcer/infiltrates, phlycten, punctate keratitis, central corneal ulcer, lipid keratopathy, descemetocele, corneal perforation). These findings were documented using both written records and clinical photographs. After the clinical evaluation, specimens from the eyelid margins were collected. Sampling was performed by an External Disease and Cornea fellow. The swabbing was performed prior to application of any topical medications like anesthesia, fluorescein, or antibiotic. The eyelid margin (both upper and lower) was gently rubbed using a sterile flocked nylon swab from the nasal side outwards three times, focusing especially on areas with signs of inflammation, crusting, or discharge. Separate swabs were used for each eye. Specimens were placed in sterile containers, labeled, and transported immediately to the central microbiology laboratory. Samples were subjected to Gram staining and cultured on 5% sheep blood agar, MacConkey agar, and chocolate agar (10% CO₂), incubated at 35–37°C for 24 hours. Depending on organism growth, species identification and antimicrobial susceptibility testing were performed using either the automated Vitek 2 Compact system (BioMérieux, France) or manual biochemical methods for fastidious organisms. The antibiotics tested were ciprofloxacin, trimethoprim-sulfamethoxazole, gentamicin, penicillin G, vancomycin, moxifloxacin, clindamycin, erythromycin, levofloxacin, oxacillin, tetracycline, linezolid. Methicillin resistance was determined using oxacillin susceptibility. The data was encoded in a password-protected Excel file accessible solely to the primary investigator (PI). The patients’ identities were not included and were replaced with identification numbers to ensure privacy protection. Data was personally collected and encoded by the PI. Descriptive statistics were used to summarize patient demographics, clinical characteristics, and microbial distributions. Correlation and comparative analyses were performed using the Kruskal–Wallis test, Spearman rank correlation, and Mann–Whitney U test, with statistical significance set at p < 0.05. For analyses involving visual acuity, patients with unrelated ocular conditions potentially affecting vision (e.g., glaucoma, retinal disease) were excluded from those specific tests. The study was approved by the University of the Philippines Manila Research Ethics Board with UPMREB Code 2025-0401-01. It was carried out in accordance to the Data Privacy Act of 2012 and the 7th version of the Declaration of Helsinki. RESULTS During the five month data collection period from July to November 2025, a total of 30 patients were included in the study. Table 1 demonstrates the demographic characteristics of the patient population. All patients (100%) had bilateral disease, resulting in a total of 60 affected eyes. The mean age at diagnosis was 25.27 ± 16.25 years with an age range of 9 to 71 years old. Majority of the patients were within the 11 to 20 (40%) age range, followed by the 21 to 30 (23.3%) age range. Majority of the patients were female (63.3%), while the rest were male (36.7%). Among the affected eyes, 51.7% presented with blepharokeratoconjunctivis, 16.7% with blepharoconjunctivitis, and 31.7% with blepharitis alone. Table 1. Demographic Characteristics of the Population. Summary Measures N = 30 patients (%) Age in years 0 to 10 11 to 20 21 to 30 31 to 40 41 to 50 51 to 60 61 to 70 >70 3 (10%) 12 (40%) 7 (23.3%) 5 (16.7%) 0 0 2 (6.7%) 1 (3.3%) Gender Male Female 11 (36.7%) 19 (63.3%) Laterality Unilateral Bilateral 0 30 (100%) Diagnosis Blepharokeratoconjunctivitis Blepharoconjunctivitis Blepharitis 31 (51.7%) 10 (16.7%) 19 (31.7%) Of the 30 patients, 27 yielded positive eyelid margin cultures, resulting in a 90% culture positivity rate. The microbiological profile of the isolates is seen in Table 2. A total of 34 isolates were identified; the number exceeded the number of patients because some individuals had different organisms isolated from each eye. When only a single isolate was obtained, the organism was assumed to be present in both eyes for analysis. The most common isolate was Staphylococcus epidermidis accounting for 47.1% of all isolates. Among these, 56.3% were found to be methicillin-resistant while the remaining 43.8% were methicillin-sensitive. The other isolates were Staphylococcus hominis (14.7%), Staphylococcus haemolyticus (11.8%), Staphylococcus aureus (8.8%), Staphylococcus arlettae (5.9%), Staphylococcus equorum (2.9%), Staphylococcus lugdunensis (2.9%), Staphylococcus capitis (2.9%), and Staphylococcus warneri (2.9%). There were no organisms aside from Staphylococcus isolated from the specimens. Table 2. Microbiological Profile of Isolates. Summary Measures Eyelid Margin Culture (30 patients) Positive Negative 27 (90%) 3 (10%) Microbiological Profile (34 isolates) Staphylococcus epidermidis Staphylococcus hominis Staphylococcus haemolyticus Staphylococcus aureus Staphylococcus arlettae Staphylococcus equorum Staphylococcus lugdunensis Staphylococcus capitis Staphylococcus warneri 16 (47.1%) 5 (14.7%) 4 (11.8%) 3 (8.8%) 2 (5.9%) 1 (2.9%) 1 (2.9%) 1 (2.9%) 1 (2.9%) Staphylococcus epidermidis (16 isolates) Methicillin sensitive Methicillin resistant 7 (43.8%) 9 (56.3%) Multidrug resistance (34 isolates) Multidrug resistant isolates Non-multidrug resistant isolates 17 (50%) 17 (50%) The antibiotic susceptibility patterns are illustrated in Figure 1. There is a very high resistance of 88% to Penicillin G. Approximately half of the isolates were also resistant to Oxacillin and Erythromycin. The commonly used ophthalmologic fluoroquinolones Moxifloxacin and Levofloxacin still demonstrate good sensitivity of about 80%. The current treatment protocol of staphylococcal blepharitis in the Philippines involves chronic use of Tobramycin eye ointment. However, Tobramycin was not available in the sensitivity panel. Hence, Gentamicin was used as a substitute and it exhibits excellent sensitivity at 97% among the isolates. Multidrug resistance is defined as non-susceptibility to at least one agent in three or more drug classes.(4) Among the isolates in our cohort, 50% were found to be multidrug resistant. The most common reason for consult was blurring of vision (33.3%) followed by eye redness (20%) and lid mass (20%). Other reasons were itching (14.4%), incidental (10%), and discharge (3.3%). The most common reported symptoms were tearing (55%), recurrent chalazia/hordeolum (48.3%), and redness (43.3%). The other presenting symptoms are illustrated in Table 3. The mean time from onset to consultation was 19.98 ± 24.38 months and had a very large range from 12 hours to 9 years. Almost half of the patients (43.3%) sought consult more than 1 year after onset of symptoms. The most common reasons for delay in consult included asymptomatic or minimal symptoms (36.7%), financial constraints (16.7%), logistical concerns (16.7%), and perceived non-urgency (13.3%). Only one-third of patients were treatment-naïve while the remained had previously been treated with various medications including antibiotic ± steroid eye ointment, antibiotic ± steroid eye drops, lubricants, oral antibiotics, and other unrecalled eye drops. Table 3. Clinical History Parameters of the Population. Summary Measures N = 30 patients (%) Chief Complaint Blurring of vision Redness Lid mass Incidental Itching Discharge 10 (33.3%) 6 (20%) 6 (20%) 4 (13.3%) 3 (10%) 1 (3.3%) Onset Less than 1 month 1 to 6 months 6 to 12 months More than 1 year 7 (23.3%) 5 (16.7%) 5 (16.7%) 13 (43.3%) Reason for delay Asymptomatic Financial constraints Logistical concerns Perceived non-urgency Self-medicated Prior consult elsewhere 11 (36.7%) 5 (16.7%) 5 (16.7%) 4 (13.3%) 3 (10%) 2 (6.7%) Previous treatment None Antibiotic ± steroid eye ointment Antibiotic ± steroid eye drops Lubricants Oral antibiotics Unrecalled eye drops 10 (33.3%) 6 (20%) 6 (20%) 3 (10%) 1 (3.3%) 4 (13.3%) Symptoms (N = 60 eyes) Tearing Recurrent hordeolum/chalazion Redness Photophobia Itching Grittiness Blurring of vision Discharge Pain 33 (55%) 29 (48.3%) 26 (43.3%) 24 (40%) 23 (38.3%) 17 (28.3%) 15 (25%) 10 (16.7%) 10 (16.7%) Out of 60 eyes, 8 eyes were excluded due to presence of other ocular conditions that could affect visual acuity, including infectious keratitis scars, previous keratoplasties, panuveitis, amblyopia with strabismus, and rhegmatogenous retinal detachment. Visual acuity frequencies are demonstrated in Table 4 according to the World Health Organization visual impairment classification.(7) The mean uncorrected visual acuity (UCVA) of the affected eyes was 0.46 ± 0.39 logMAR, with a median of 0.30 logMAR. Most eyes (51.9%) had minimal or no visual impairment (logMAR ≤0.3), while 11.5% had mild impairment (logMAR 0.31–0.5). Moderate impairment (logMAR 0.51 –1.0) was present in 30.8% of eyes, and severe impairment (logMAR >1.0) in 5.8%. The mean best-corrected visual acuity (BCVA) of the affected eyes was 0.22 ± 0.27 logMAR, with a median of 0.15 logMAR. Most eyes (75%) had normal or minimal impairment (logMAR ≤0.3), 13.5% had mild impairment (logMAR 0.31–0.5), 9.6% had moderate impairment (logMAR 0.51–1.0), and 1.9% had severe impairment (logMAR >1.0). Table 4. Visual Acuity of the Population (in logMAR). Summary Measures N = 52 eyes (%) Uncorrected visual acuity logMAR ≤ 0.3 logMAR 0.31 — 0.5 logMAR 0.51 — 1.0 logMAR >1.0 27 (51.9%) 6 (11.5%) 16 (30.8%) 3 (5.8%) Best corrected visual acuity logMAR ≤ 0.3 logMAR 0.31 — 0.6 logMAR 0.61 — 1.0 logMAR >1.0 39 (75%) 7 (13.5%) 5 (9.6%) 1 (1.9%) The most common presenting lid signs were fibrin/crusts/collarettes (96.7%), margin erythema/telangiectasia (63.3%), and meibomitis/plugged meibomian glands (50.%). The most common presenting conjunctival signs were papillae (35%), redness (30%), and follicles (26.7%). The most common presenting corneal signs were pannus (25%), corneal scar/haze (25%), and neovascularization (21.7%). The rest of the presenting signs are illustrated in Table 5. Table 5. Frequency of Presenting Signs of the Population. Summary Measures N = 60 eyes (%) Eyelid Fibrin/crusts/collarettes Margin erythema/telangiectasis Plugged meibomian glands Chalazion Tylosis Trichiasis Ulceration Distichiasis Poliosis Hordeolum Madarosis Abscess 58 (96.7%) 38 (63.3%) 30 (50%) 16 (26.7%) 14 (23.3%) 7 (11.7%) 5 (8.3%) 3 (5%) 1 (1.7%) 1 (1.7%) 0 0 Conjunctiva Papillae Redness Follicles Discharge 21 (35%) 18 (30%) 16 (26.7%) 3 (5%) Cornea Corneal scar/haze Pannus Neovascularization Punctate keratitis Phlycten Margin ulcer/infiltrates Lipid keratopathy Central corneal ulcer Descemetocele Corneal perforation 15 (25%) 15 (25%) 13 (21.7%) 10 (16.7%) 9 (15%) 4 (6.7%) 4 (6.7%) 2 (3.3%) 0 0 To compare the clinical presentation in terms of uncorrected visual acuity, best corrected visual acuity, symptoms, lid signs, conjunctival signs, and corneal signs with the different bacterial isolates, a Kruskal-Wallis test was performed and no significant differences (p > 0.05) was seen across the various Staphylococcal species. When the same clinical presentation factors were compared with antibiotic resistance patterns using Spearman correlation, no significant correlations were identified (p > 0.05). However, using Spearman correlation, it was noted that the presence of corneal signs was significantly and positively associated with uncorrected and best corrected visual acuity with p = 0.004 and p = 0.001, respectively. This suggests that as corneal involvement increases, the visual acuity tends to be worse. The same test also suggested that there was a significant positive correlation between presenting symptoms and lid signs (p = 0.002), conjunctival signs (p = 0.002), and corneal signs (p = 0.009), indicating that patients with more extensive clinical findings tended to report more symptoms. When comparing methicillin-resistant Staphylococcus epidermidis (MRSE) and methicillin-sensitive Staphylococcus epidermidis (MSSE), the Mann-Whitney U test indicated that MSSE appears to have significantly more symptoms (p = 0.036) and conjunctival signs (p = 0.005) compared to MRSE. The UCVA, BCVA, lid signs, and corneal signs were similar between MRSE and MSSE. Fisher’s exact test was used to compare the antibiotic susceptibility patterns between MRSE and MSSE and demonstrated similar susceptibility profiles across all tested antibiotics except for Oxacillin (p = 0.001), which is expected as this was the antibiotic used to determine methicillin resistance. Finally, no significant differences in clinical presentation were observed between isolates classified as multidrug-resistant and those that were not. DISCUSSION This study characterizes both the clinical and bacteriologic profile of staphylococcal blepharitis and blepharokeratoconjunctivitis (BKC) in a Philippine tertiary hospital. When compared with the previously published local cohort by Lim Bon Siong, et al., majority of the parameters are comparable as illustrated in Table 6 .( 2 ) Notable differences included a higher proportion of bilateral disease in the present cohort and an older mean age among eyes with corneal involvement. This suggests that there is minimal change in clinical presentation of the disease entity over time in this local setting. Table 6 Comparison of Clinical Profile between this cohort and Lim Bon Siong, et al. n Sy, et al, (2025) Lim Bon Siong, et al. (2023) 60 eyes of 30 patients 99 eyes of 55 patients Mean age Median age 25 years old 20 years old 27 years old 19 years old Gender predilection 63% female, 37% male 67% female, 33% male Bilaterality 100% 80% Mean time from onset to consult 19.98 ± 24.38 months 18.36 ± 25.69 months Previous treatment 67% prior consult/treatment 33% no previous consult 67% prior consult/treatment 33% no previous consult Top 3 reasons for consult Blurring of vision Redness Lid mass Corneal opacity Eye redness Blurring of vision Mean UCVA (logMAR) 0.46 ± 0.39 (20/55) 0.43 ± 0.51 (20/55) Corneal involvement Mean age 31 of 60 eyes (51.7%) 26.03 years 32 of 55% (58%) 17.83 years Lid findings Fibrin, crusts, collarettes (97%) Lid erythema, telangiectasia (63%) Plugged MGs (50%) Fibrin, crusts, collarettes (79%) Lid erythema, telangiectasia (27%) Tylosis (11%) Conjunctival findings Papillae (35%) Redness (30%) Follicles (27%) Redness (49%) Papillae (46%) Follicles (12%) Corneal findings Pannus (25%) Corneal scar/haze (25%) Neovascularization (22%) Neovascularization (40%) Phlycten (33%) Pannus formation (31%) Staphylococci are normal residents of the lid margin and their presence is not inherently pathologic. Previous local and international studies evaluating lid margin and conjunctival isolates of patients undergoing routine cataract surgery have consistently shown the presence of Staphylococcus epidermidis and coagulase-negative Staphylococcus in 60–90% and Staphylococcus aureus typically follows at 1–12%. ( 8 , 9 ) Their studies have also found non- Staphylococcus species present including Streptococcus, Micrococcus, Corynebacterium, Bacillus , and Klebsiella. A previous local study by Cham et al. ( 9 ), conducted in the Philippines, similarly demonstrated good sensitivity of these isolates to gentamicin, tobramycin, ofloxacin, and moxifloxacin, but noted poor sensitivity to erythromycin. In this cohort, all isolates were found to be Staphylococcus and no other bacterial genera were identified. Consistent with previous local and international data, there was demonstrated good sensitivity to fluoroquinolones and aminoglycosides and poor sensitivity to erythromycin. Notably, in comparison with the prior local study ( 9 ) conducted approximately 15 years earlier suggests an increasing trend in erythromycin resistance, rising from 30% in 2009 to 47% in the present study. Susceptibility patterns for other antibiotics evaluated in both studies remained largely comparable over time. When assessing isolates from adult patients diagnosed with blepharitis, coagulase-negative Staphylococcus still predominates with rates up to 89%. ( 6 , 10 , 11 ) Meanwhile, in pediatric belpharokeratoconjunctivitis cases, Staphylococcus aureus isolates comprise the majority at 75–93%. ( 12 , 13 ) The majority of eyes included in this cohort were cases of blepharokeratoconjunctivitis but coagulase-negative Staphylococcus still predominated. There were only 3 Staphylococcus aureus isolates in this cohort with varying degrees of severity and varied age distribution from 15 to 70 years old. The study conducted by Viswalingam et al concluded that Asian and Middle Eastern children appear to be more severely affected.( 12 ) The Asian participants from that study were mostly of Indian or Sri Lankan descent. Little data is available on the Southeast Asian population in particular. One study from Singapore performed a retrospective case series of 51 patients with pediatric blepharokeratoconjunctivitis. Their study concluded that patients in Asia appear to have a more severe clinical presentation and advocates for early recognition and management.( 14 ) No other published studies from the Southeast Asian region was available at the time of this report. Based on the findings in this study, it appears that bacterial species does not correlate with clinical presentation and severity. The pathogenesis of this disease is more likely due to the direct toxic effects of staphylococcal products and host hypersensitivity reactions.( 15 ) Valenton et al . was one of the first to establish the key role of toxin production in the context of staphylococcal blepharitis. They found that even in the absence of the more pathogenic S. aureus, S. epidermidis can still produce blepharokeratoconjunctivitis symptoms due to its ability to produce this dermonecrotic toxin. ( 16 ) Staphylococcus aureus has been demonstrated to produce several virulence factors. Of particular note is the production of alpha toxin, a pore-forming cytotoxin that induces cell lysis.( 17 ) This toxin is absent in Staphylococcus epidermidis except in rare strains. Other virulence factors of Staphylococcus aureus include beta toxin, gamma toxin, Panton-Valentine leucocidin, enterotoxin, proteases, and lipases. This myriad of factors contribute to the more aggressive clinical presentation such as ulcerative blepharitis, punctate epithelial keratitis, and papillary conjunctivitis.( 18 , 19 ) Meanwhile, Staphylococcus epidermidis can produce lipases, biofilm, and delta toxin, which presents as more chronic low-grade inflammation and meibomian gland dysfunction.( 16 ). Therefore, it appears that Staphylococcus aureus is more aggressive and immune-driven while Staphylococcus epidermidis is more chronic and with less adaptive immune reaction. The predominance of coagulase-negative Staphylococcus in this cohort may partly explain the absence of very severe manifestations such as descemetocele formation or corneal perforation. Host susceptibility may also contribute to the disease pathogenesis. Immunogenetic factors such as variations in innate immunity and inflammatory response, combined with early colonization by virulent bacteria and an immature immune system, can cause an imbalance in ocular flora and contribute to recurrent, persistent inflammation.( 20 ) Many clinical findings in BKC are immune-mediated rather than from direct bacterial invasion. Epithelial keratitis is caused by toxic mechanisms. Marginal ulcers and infiltrates are an immune antigen-antibody reaction, as evidenced by the absence of Staphylococcus upon culturing these lesions.( 19 ) Lastly, phlyctens are well-known to be due to delayed type hypersensitivity.( 21 ) The more robust inflammatory response observed in younger patients likely explains the particular severity and chronicity often seen in pediatric BKC.( 22 ) In addition, the substantial delay in consultation observed in this and prior local cohorts likely contributes to prolonged inflammation and cumulative ocular surface damage, influenced by perceived non-urgency, prior misdiagnosis, and socioeconomic barriers..( 2 ) Another goal of this study was to determine whether current local treatment protocols remain appropriate in the context of evolving antibiotic resistance. The standard local regimen involves prolonged use of topical antibiotic ointment, most commonly tobramycin-based preparations.( 3 ) This study demonstrates that the isolates still had excellent sensitivity to gentamicin, which was used as a substitute for tobramycin due to availability issues. Previous studies have confirmed that gentamicin and tobramycin are comparable in terms of clinical outcomes, antibacterial effects, and safety profile. ( 23 , 24 ). The in vitro susceptibility of bacterial ocular isolates to these two aminoglycoside antibiotics also found that they were comparable for most organisms except for Staphylococcus aureus , where tobramycin had a significant higher susceptibility.( 25 ) Together with previous data on lid margin isolates demonstrating good aminoglycoside sensitivity, these results support the continued use of tobramycin in the management of staphylococcal blepharitis and BKC.( 8 , 9 ) In contrast, erythromycin showed sensitivity in only about half of the isolates in this cohort and literature reports sensitivity to be as low as 9%, warranting caution in its empiric use.( 6 ) While there were no methicillin-resistant Staphylococcus aureus (MRSA) isolates identified, more than half of the Staphylococcus epidermidis were methicillin resistant (MRSE). The presence of MRSE, however, did not correlate with worse clinical outcomes or increased severity. This is supported by the study of Schecter, et al where they found that MRSE isolates were more likely to be multidrug resistant but had no significance with treatment.( 26 ) One limitation of this study is its relatively small sample size, reducing the power to detect statistically significant associations. However, this was partly mitigated by its prospective design and high culture positivity rate. As a single center study conducted in a tertiary hospital where patients tend to present later and more severe disease, there may be limited generalizability to the broader population. Finally, molecular testing to identify specific bacterial toxins and an expanded antibiotic panel could have further strengthened this study. Despite these limitations, this study was able to provide microbiological data from a tertiary referral center that correlates with clinical findings. Moreover, the analysis of antibiotic sensitivity patterns has relevance beyond blepharitis since ocular flora from the eyelids is the source of a significant proportion of other ocular infections like keratitis and endophthalmitis. CONCLUSION The specific staphylococcal species and their antibiotic resistance patterns did not correlate with clinical presentation or disease severity. Instead, disease severity appears to be related to bacterial toxin production, delayed consultation, and individual host susceptibility. Aminoglycosides continue to show excellent sensitivity, whereas erythromycin demonstrates increasing resistance. No MRSA isolates but MRSE was present in a substantial proportion, though with minimal clinical impact. Declarations Funding source: none The investigators declare no conflict of interest relevant to the conduct of the proposed study. Author Contributions P.S. performed data collection and analysis, conducted the literature review, and drafted the manuscript. R.L. and G.S. conceptualised and designed the study, supervised the research, and critically revised the manuscript. All authors reviewed and approved the final version of the manuscript. Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. Competing Interests The authors declare no competing interests. Ethics Approval and Consent to Participate This study was approved by the University of the Philippines Manila Research Ethics Board (UPMREB Code 2025-0401-01). Written informed consent was obtained from all participants or their guardians. Data Availability The datasets generated during and/or analysed during the current study are available from the corresponding author on reasonable request. References Jones SM, Weinstein JM, Cumberland P, Klein N, Nischal KK. Visual Outcome and Corneal Changes in Children with Chronic Blepharokeratoconjunctivitis. Ophthalmology. 2007 Dec;114(12):2271–80. Lim Bon Siong R, Pablito Jr, Sosuan G. Clinical profile and corneal complications of staphylococcal blepharitis at the Philippine General Hospital. Acta Med Philipp. 2023;57(2). doi:10.47895/amp.v57i2.5611 Lim Bon Siong R, Cua IY, Tan RR. External Disease and Cornea Handbook Second Edition . Quezon City (Philippines): St. Luke’s Medical Center; 2025. Khor WB, Periayah MH, Lakshminarayanan R, Prajna V, Garg P, Sharma N, Young A, Nishida K, Kinoshita S, Tan AL, Tan DTH. The antibiotic resistance profiles of Staphylococcus in the Asia Cornea Society Infectious Keratitis Study. Int Ophthalmol. 2025;45:309. doi:10.1007/s10792-025-03667-3 Harford DA, Greenan E, Knowles SJ, Fitzgerald S, Murphy CC. The burden of methicillin-resistant Staphylococcus aureus in the delivery of eye care. Eye (Basingstoke). 2022 Jul 1;36(7):1368–72. de Paula A, Oliva G, Barraquer RI, de la Paz MF. Prevalence and antibiotic susceptibility of bacteria isolated in patients affected with blepharitis in a tertiary eye centre in Spain. Eur J Ophthalmol. 2020 Sep 1;30(5):991–7. World Health Organization. World report on vision. Geneva: World Health Organization; 2019. Ratnumnoi R, Keorochana N, Sontisombat C. Normal flora of conjunctiva and lid margin, as well as its antibiotic sensitivity, in patients undergoing cataract surgery at Phramongkutklao Hospital. Clin Ophthalmol. 2017;11:237-241. doi:10.2147/OPTH.S109247. Cham TL, Valenton MJ, Bon Siong RL. Ocular bacterial flora and antibiotic sensitivity among Filipino patients undergoing routine cataract surgery. Philipp J Ophthalmol. 2009;34(1):22-26. Teweldemedhin M, Gebreyesus H, Atsbaha AH, Asgedom SW, Saravanan M. Bacterial profile of ocular infections: A systematic review. Vol. 17, BMC Ophthalmology. BioMed Central Ltd.; 2017. Mudassar S, Bano A, Shahid M, Asghar F, Waheed F, Javed N. Microbiological evaluation of blepharitis: a case-controlled study. BioSci Rev. 2024;6(3):35-48. doi:10.32350/bsr.63.02 Viswalingam M, Rauz S, Morlet N, Dart JKG. Blepharokeratoconjunctivitis in children: Diagnosis and treatment. British Journal of Ophthalmology. 2005 Apr;89(4):400–3. Gupta N, Dhawan A, Beri S, D’Souza P. Clinical spectrum of pediatric blepharokeratoconjunctivitis. Journal of AAPOS. 2010 Dec;14(6):527–9. Teo L, Mehta JS, Htoon HM, Tan DTH. Severity of pediatric blepharokeratoconjunctivitis in Asian eyes. Am J Ophthalmol. 2012;153(3):564–570.e1. doi:10.1016/j.ajo.2011.08.038. Rodríguez-García A, González-Godínez S, López-Rubio S. Blepharokeratoconjunctivitis in childhood: corneal involvement and visual outcome. Eye (Lond). 2016;30(3):438–446. doi:10.1038/eye.2015.249. Valenton MJ, Okumoto M. Toxin-producing strains of Staphylococcus epidermidis (albus), isolates from patients with staphylococcic blepharoconjunctivitis. Arch Ophthalmol. 1973;89:186-189. Shen J, Yasir M, Willcox M. Staphylococcal exotoxins in ocular infection with focus on enterotoxins. Microbiol Res. 2025;299:128258. doi:10.1016/j.micres.2025.128258. Seal D, Ficker L, Ramakrishnan M, Wright P. Role of staphylococcal toxin production in blepharitis. Ophthalmology. 1990;97(12):1684-1688. doi:10.1016/S0161-6420(90)32361-8. Tetz MR, Klein U, Völcker HE. Staphylococcus-associated blepharokeratoconjunctivitis: clinical findings, pathogenesis and therapy. Ophthalmologe. 1997;94(3):186-190. doi:10.1007/s003470050099 Ortiz-Morales G, Ruiz-Lozano RE, Morales-Mancillas NR, Paez-Garza JH, Rodriguez-Garcia A. Pediatric blepharokeratoconjunctivitis: a challenging ocular surface disease. Surv Ophthalmol. 2025;70(3):516-535. doi:10.1016/j.survophthal.2025.01.006 Ficker L, Ramakrishnan M, Seal D, Wright P. Role of cell-mediated immunity to staphylococci in blepharitis. Am J Ophthalmol. 1991;111(4):473-479. doi:10.1016/s0002-9394(14)72383-9 Ali A. Pediatric Blepharokeratoconjunctivitis: An Update. Canadian Eye Care Today . 2024 Jun 18;3(2):47–50. Leibowitz HM, Hyndiuk RA, Smolin GR, Nozik RA, Hunter GJ, Cagle GD, Davis DS. Tobramycin in external eye disease: a double-masked study vs gentamicin. Curr Eye Res. 1981;1(5):259-266. doi:10.3109/02713688108999445 Cagle G, Davis S, Rosenthal A, Smith J. Topical tobramycin and gentamicin sulfate in the treatment of ocular infections: multicenter study. Curr Eye Res. 1981;1(9):523-534. doi:10.3109/02713688109069178 Moeller CTA, Castelo Branco B, Yu MCZ, Farah ME, Höfling-Lima AL. Alterations in ocular pathogen susceptibility to gentamicin and tobramycin. Arq Bras Oftalmol. 1999;62(6):687-692. Schechter BA, Sheppard JD, Sanfilippo CM, et al. An evaluation of staphylococci from ocular surface infections treated empirically with topical besifloxacin: antibiotic resistance, molecular characteristics, and clinical outcomes. Ophthalmol Ther. 2020;9:159-173. doi:10.1007/s40123-019-00223-y Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Reviewers agreed at journal 01 May, 2026 Reviews received at journal 16 Apr, 2026 Reviewers agreed at journal 09 Apr, 2026 Reviewers agreed at journal 19 Mar, 2026 Reviewers invited by journal 17 Mar, 2026 Editor assigned by journal 12 Mar, 2026 Submission checks completed at journal 12 Mar, 2026 First submitted to journal 05 Mar, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9046143","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":607322767,"identity":"b4ff7575-43f4-4102-9c0d-35b1c38dcb6b","order_by":0,"name":"Patricia Kaye T. Sy","email":"data:image/png;base64,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","orcid":"","institution":"Philippine General Hospital","correspondingAuthor":true,"prefix":"","firstName":"Patricia","middleName":"Kaye T.","lastName":"Sy","suffix":""},{"id":607322768,"identity":"cc0d5654-0752-4417-87c3-4403fc2e4b67","order_by":1,"name":"George Michael N. Sosuan","email":"","orcid":"","institution":"Philippine General Hospital","correspondingAuthor":false,"prefix":"","firstName":"George","middleName":"Michael N.","lastName":"Sosuan","suffix":""},{"id":607322769,"identity":"2f07bb5c-1651-4fe3-a461-805744799f39","order_by":2,"name":"Ruben Lim Bon Siong","email":"","orcid":"","institution":"Philippine General Hospital","correspondingAuthor":false,"prefix":"","firstName":"Ruben","middleName":"Lim Bon","lastName":"Siong","suffix":""}],"badges":[],"createdAt":"2026-03-06 05:08:27","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9046143/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9046143/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":104997227,"identity":"00eb36a1-47b6-43b9-a450-cf2674da1971","added_by":"auto","created_at":"2026-03-19 16:21:22","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":71399,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eAntibiotic Sensitivity and Resistance Patterns (34 isolates).\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-9046143/v1/fb262001196a0ea2e50e93a8.png"},{"id":105035410,"identity":"b188af09-5991-4368-9735-5a7638f6596b","added_by":"auto","created_at":"2026-03-20 07:26:02","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":773508,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9046143/v1/dc64e20c-859e-4921-82ce-b6e28a4ad5e4.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Staphylococcal Blepharitis and Blepharokeratoconjunctivitis in Southeast Asia: Microbiological Profile and Antibiotic Sensitivity Patterns","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eStaphylococcal blepharitis is defined as inflammation of the lid margin presenting with scaling, crusting, and erythematous eyelid margins with collarette formation at the base of the cilia. It is a relatively common ocular condition caused by bacterial colonization of the lids, primarily by \u003cem\u003eStaphylococcus\u003c/em\u003e species. One significant complication arising from chronic staphylococcal blepharitis is blepharokeratoconjunctivitis (BKC), which is defined as a chronic and recurrent inflammatory disease of the eyelids characterized lid margin inflammation and telangiectasia, fibrin-crusts and scales (collarettes), tylosis, madarosis, trichiasis, papillary and follicular conjunctival hypertrophy, punctate epithelial erosions, and marginal infiltrates, among others. While staphylococcal blepharitis is relatively benign, progression to BKC becomes a more serious concern as it can cause long-term visual impairment.(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eA local Philippine study describing the clinical profile and corneal complications of staphylococcal blepharitis reported a predominance among females and clustering in the 0\u0026ndash;20-year age group. Corneal involvement occurred in 60% of patients, with nearly half experiencing delayed consultation or initial misdiagnosis.(\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) Standard management includes warm compresses, lid hygiene, and prolonged topical antibiotic therapy to reduce antigenic load and prevent recurrence.(\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) However, while clinical data is available, no local studies have examined the specific bacterial pathogens associated with staphylococcal blepharitis or characterized their antibiotic sensitivity patterns. This information is critical to determine whether current treatment protocols are still appropriate in the setting of evolving resistance.\u003c/p\u003e \u003cp\u003e \u003cem\u003eStaphylococcus aureus\u003c/em\u003e and \u003cem\u003eStaphylococcus epidermidis\u003c/em\u003e are the leading bacterial pathogens in many ocular infections. The \u003cem\u003eStaphylococcus\u003c/em\u003e substudy of the Asia Cornea Society Infectious Keratitis study highlighted rising antimicrobial resistance among these species, including the increasing emergence of methicillin-resistant strains (MRSA and MRSE), which pose significant therapeutic and public health challenges.(\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e) Available literature also reports increasing resistance to erythromycin and penicillin among blepharitis isolates.(\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e) Despite these trends, no Philippine data currently exists regarding the incidence of MRSA or MRSE in staphylococcal blepharitis.\u003c/p\u003e \u003cp\u003eThis study aims to describe the bacteria found in the lids of patients clinically diagnosed with staphylococcal blepharitis and staphylococcal blepharokeratoconjunctivitis, as well as, report their antibiotic sensitivity patterns. Specific objectives of this study include to determine the demographic and clinical profile of patients diagnosed staphylococcal blepharitis and blepharokeratoconjunctivitis, and to correlate the strains and sensitivity/resistance patterns to clinical presentation and severity.\u003c/p\u003e"},{"header":"METHODOLOGY","content":"\u003cp\u003eThis single-center prospective observational study included 60 eyes of 30 patients clinically diagnosed with staphylococcal blepharitis or blepharokeratoconjunctivitis at the External Disease and Cornea Clinic of the University of the Philippines Manila - Philippine General Hospital between July 2025 and November 2025, using consecutive sampling. A total of 34 microbial isolates were collected from the 30 patients.\u003c/p\u003e \u003cp\u003ePatients were eligible if they were clinically diagnosed by an External Disease and Cornea specialist with staphylococcal blepharitis or blepharokeratoconjunctivitis and provided informed consent (or parental consent for minors, with assent for ages 7\u0026ndash;17 years). Inclusion required the presence of clinical signs of staphylococcal blepharitis, with or without conjunctival or corneal involvement. Exclusion criteria were the use of topical antibiotics for blepharitis within the preceding 2 weeks and coexisting allergic conditions like allergic conjunctivitis and vernal keratoconjunctivitis.\u003c/p\u003e \u003cp\u003eAll patients underwent history taking and examination with a slit-lamp biomicroscope. The following data were collected: age, gender, laterality, presenting symptoms, disease onset, and previous episodes or treatments. Uncorrected and best corrected visual acuity in LogMAR was noted. Slit lamp examinations findings that were gathered include lid margin findings (fibrin/crusts/collarettes, margin erythema/telangiectasia, ulceration, tylosis, trichiasis, distichiasis, madarosis, poliosis, hordeolum, chalazion, meibomitis/plugged MGs), conjunctival findings (redness, discharge, follicles, papillae), and corneal findings (neovascularization, pannus, marginal ulcer/infiltrates, phlycten, punctate keratitis, central corneal ulcer, lipid keratopathy, descemetocele, corneal perforation). These findings were documented using both written records and clinical photographs.\u003c/p\u003e \u003cp\u003eAfter the clinical evaluation, specimens from the eyelid margins were collected. Sampling was performed by an External Disease and Cornea fellow. The swabbing was performed prior to application of any topical medications like anesthesia, fluorescein, or antibiotic. The eyelid margin (both upper and lower) was gently rubbed using a sterile flocked nylon swab from the nasal side outwards three times, focusing especially on areas with signs of inflammation, crusting, or discharge. Separate swabs were used for each eye. Specimens were placed in sterile containers, labeled, and transported immediately to the central microbiology laboratory.\u003c/p\u003e \u003cp\u003eSamples were subjected to Gram staining and cultured on 5% sheep blood agar, MacConkey agar, and chocolate agar (10% CO₂), incubated at 35\u0026ndash;37\u0026deg;C for 24 hours. Depending on organism growth, species identification and antimicrobial susceptibility testing were performed using either the automated Vitek 2 Compact system (BioM\u0026eacute;rieux, France) or manual biochemical methods for fastidious organisms. The antibiotics tested were ciprofloxacin, trimethoprim-sulfamethoxazole, gentamicin, penicillin G, vancomycin, moxifloxacin, clindamycin, erythromycin, levofloxacin, oxacillin, tetracycline, linezolid. Methicillin resistance was determined using oxacillin susceptibility.\u003c/p\u003e \u003cp\u003eThe data was encoded in a password-protected Excel file accessible solely to the primary investigator (PI). The patients\u0026rsquo; identities were not included and were replaced with identification numbers to ensure privacy protection. Data was personally collected and encoded by the PI.\u003c/p\u003e \u003cp\u003eDescriptive statistics were used to summarize patient demographics, clinical characteristics, and microbial distributions. Correlation and comparative analyses were performed using the Kruskal\u0026ndash;Wallis test, Spearman rank correlation, and Mann\u0026ndash;Whitney U test, with statistical significance set at p\u0026thinsp;\u0026lt;\u0026thinsp;0.05. For analyses involving visual acuity, patients with unrelated ocular conditions potentially affecting vision (e.g., glaucoma, retinal disease) were excluded from those specific tests.\u003c/p\u003e \u003cp\u003e The study was approved by the University of the Philippines Manila Research Ethics Board with UPMREB Code 2025-0401-01. It was carried out in accordance to the Data Privacy Act of 2012 and the 7th version of the Declaration of Helsinki.\u003c/p\u003e"},{"header":"RESULTS","content":"\u003cp\u003eDuring the five month data collection period from July to November 2025, a total of 30 patients were included in the study. \u0026nbsp;Table 1 demonstrates the demographic characteristics of the patient population. \u0026nbsp;All patients (100%) had bilateral disease, resulting in a total of 60 affected eyes. \u0026nbsp; The mean age at diagnosis was 25.27 \u0026plusmn; 16.25 years with an age range of 9 to 71 years old. \u0026nbsp;Majority of the patients were within the 11 to 20 (40%) age range, followed by the 21 to 30 (23.3%) age range. \u0026nbsp;Majority of the patients were female (63.3%), while the rest were male (36.7%). \u0026nbsp;Among the affected eyes, 51.7% presented with blepharokeratoconjunctivis, 16.7% with blepharoconjunctivitis, and 31.7% with blepharitis alone.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1. Demographic Characteristics of the Population.\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"441\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 251px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 190px;\"\u003e\n \u003cp\u003eSummary Measures\u003c/p\u003e\n \u003cp\u003eN = 30 patients (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 251px;\"\u003e\n \u003cp\u003eAge in years\u003c/p\u003e\n \u003cp\u003e0 to 10\u003c/p\u003e\n \u003cp\u003e11 to 20\u003c/p\u003e\n \u003cp\u003e21 to 30\u003c/p\u003e\n \u003cp\u003e31 to 40\u003c/p\u003e\n \u003cp\u003e41 to 50\u003c/p\u003e\n \u003cp\u003e51 to 60\u003c/p\u003e\n \u003cp\u003e61 to 70\u003c/p\u003e\n \u003cp\u003e\u0026gt;70\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 190px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e3 (10%)\u003c/p\u003e\n \u003cp\u003e12 (40%)\u003c/p\u003e\n \u003cp\u003e7 (23.3%)\u003c/p\u003e\n \u003cp\u003e5 (16.7%)\u003c/p\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003cp\u003e2 (6.7%)\u003c/p\u003e\n \u003cp\u003e1 (3.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 251px;\"\u003e\n \u003cp\u003eGender\u003c/p\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 190px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e11 (36.7%)\u003c/p\u003e\n \u003cp\u003e19 (63.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 251px;\"\u003e\n \u003cp\u003eLaterality\u003c/p\u003e\n \u003cp\u003eUnilateral\u003c/p\u003e\n \u003cp\u003eBilateral\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 190px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003cp\u003e30 (100%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 251px;\"\u003e\n \u003cp\u003eDiagnosis\u003c/p\u003e\n \u003cp\u003eBlepharokeratoconjunctivitis\u003c/p\u003e\n \u003cp\u003eBlepharoconjunctivitis\u003c/p\u003e\n \u003cp\u003eBlepharitis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 190px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e31 (51.7%)\u003c/p\u003e\n \u003cp\u003e10 (16.7%)\u003c/p\u003e\n \u003cp\u003e19 (31.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eOf the 30 patients, 27 yielded positive eyelid margin cultures, resulting in a 90% culture positivity rate. \u0026nbsp;The microbiological profile of the isolates is seen in Table 2. \u0026nbsp;A total of 34 isolates were identified; the number exceeded the number of patients because some individuals had different organisms isolated from each eye. When only a single isolate was obtained, the organism was assumed to be present in both eyes for analysis. \u0026nbsp;The most common isolate was \u003cem\u003eStaphylococcus epidermidis\u003c/em\u003e accounting for 47.1% of all isolates. \u0026nbsp;Among these, 56.3% were found to be methicillin-resistant while the remaining 43.8% were methicillin-sensitive. \u0026nbsp;The other isolates were \u003cem\u003eStaphylococcus hominis\u0026nbsp;\u003c/em\u003e(14.7%), \u003cem\u003eStaphylococcus haemolyticus\u003c/em\u003e (11.8%), \u003cem\u003eStaphylococcus aureus\u0026nbsp;\u003c/em\u003e(8.8%), \u003cem\u003eStaphylococcus arlettae\u0026nbsp;\u003c/em\u003e(5.9%), \u003cem\u003eStaphylococcus equorum\u0026nbsp;\u003c/em\u003e(2.9%), \u003cem\u003eStaphylococcus lugdunensis\u003c/em\u003e (2.9%), \u003cem\u003eStaphylococcus capitis\u0026nbsp;\u003c/em\u003e(2.9%), and \u003cem\u003eStaphylococcus warneri\u0026nbsp;\u003c/em\u003e(2.9%). \u0026nbsp;There were no organisms aside from \u003cem\u003eStaphylococcus\u0026nbsp;\u003c/em\u003eisolated from the specimens.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2. Microbiological Profile of Isolates.\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"560\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 384px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 176px;\"\u003e\n \u003cp\u003eSummary Measures\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 384px;\"\u003e\n \u003cp\u003eEyelid Margin Culture (30 patients)\u003c/p\u003e\n \u003cp\u003ePositive\u003c/p\u003e\n \u003cp\u003eNegative\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 176px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e27 (90%)\u003c/p\u003e\n \u003cp\u003e3 (10%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 384px;\"\u003e\n \u003cp\u003eMicrobiological Profile (34 isolates)\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eStaphylococcus epidermidis\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eStaphylococcus hominis\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eStaphylococcus haemolyticus\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eStaphylococcus aureus\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eStaphylococcus arlettae\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eStaphylococcus equorum\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eStaphylococcus lugdunensis\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eStaphylococcus capitis\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eStaphylococcus warneri\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 176px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e16 (47.1%)\u003c/p\u003e\n \u003cp\u003e5 (14.7%)\u003c/p\u003e\n \u003cp\u003e4 (11.8%)\u003c/p\u003e\n \u003cp\u003e3 (8.8%)\u003c/p\u003e\n \u003cp\u003e2 (5.9%)\u003c/p\u003e\n \u003cp\u003e1 (2.9%)\u003c/p\u003e\n \u003cp\u003e1 (2.9%)\u003c/p\u003e\n \u003cp\u003e1 (2.9%)\u003c/p\u003e\n \u003cp\u003e1 (2.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 384px;\"\u003e\n \u003cp\u003e\u003cem\u003eStaphylococcus epidermidis\u0026nbsp;\u003c/em\u003e(16 isolates)\u003c/p\u003e\n \u003cp\u003eMethicillin sensitive\u003c/p\u003e\n \u003cp\u003eMethicillin resistant\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 176px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e7 (43.8%)\u003c/p\u003e\n \u003cp\u003e9 (56.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 384px;\"\u003e\n \u003cp\u003eMultidrug resistance (34 isolates)\u003c/p\u003e\n \u003cp\u003eMultidrug resistant isolates\u003c/p\u003e\n \u003cp\u003eNon-multidrug resistant isolates\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 176px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e17 (50%)\u003c/p\u003e\n \u003cp\u003e17 (50%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eThe antibiotic susceptibility patterns are illustrated in Figure 1. \u0026nbsp;There is a very high resistance of 88% to Penicillin G. \u0026nbsp;Approximately half of the isolates were also resistant to Oxacillin and Erythromycin. \u0026nbsp;The commonly used ophthalmologic fluoroquinolones Moxifloxacin and Levofloxacin still demonstrate good sensitivity of about 80%. \u0026nbsp;The current treatment protocol of staphylococcal blepharitis in the Philippines involves chronic use of Tobramycin eye ointment. \u0026nbsp;However, Tobramycin was not available in the sensitivity panel. \u0026nbsp;Hence, Gentamicin was used as a substitute and it exhibits excellent sensitivity at 97% among the isolates. \u0026nbsp;Multidrug resistance is defined as non-susceptibility to at least one agent in three or more drug classes.(4) \u0026nbsp;Among the isolates in our cohort, 50% were found to be multidrug resistant.\u003c/p\u003e\n\u003cp\u003eThe most common reason for consult was blurring of vision (33.3%) followed by eye redness (20%) and lid mass (20%). \u0026nbsp;Other reasons were itching (14.4%), incidental (10%), and discharge (3.3%). \u0026nbsp;The most common reported symptoms were tearing (55%), recurrent chalazia/hordeolum (48.3%), and redness (43.3%). \u0026nbsp;The other presenting symptoms are illustrated in Table 3. \u0026nbsp;The mean time from onset to consultation was 19.98 \u0026plusmn; 24.38 months and had a very large range from 12 hours to 9 years. \u0026nbsp;Almost half of the patients (43.3%) sought consult more than 1 year after onset of symptoms. \u0026nbsp;The most common reasons for delay in consult included asymptomatic or minimal symptoms (36.7%), financial constraints (16.7%), logistical concerns (16.7%), and perceived non-urgency (13.3%). \u0026nbsp;Only one-third of patients were treatment-na\u0026iuml;ve while the remained had previously been treated with various medications including antibiotic \u0026plusmn; steroid eye ointment, antibiotic \u0026plusmn; steroid eye drops, lubricants, oral antibiotics, and other unrecalled eye drops.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3. Clinical History Parameters of the Population.\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"493\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 289px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 204px;\"\u003e\n \u003cp\u003eSummary Measures\u003c/p\u003e\n \u003cp\u003eN = 30 patients (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 289px;\"\u003e\n \u003cp\u003eChief Complaint\u003c/p\u003e\n \u003cp\u003eBlurring of vision\u003c/p\u003e\n \u003cp\u003eRedness\u003c/p\u003e\n \u003cp\u003eLid mass\u003c/p\u003e\n \u003cp\u003eIncidental\u003c/p\u003e\n \u003cp\u003eItching\u003c/p\u003e\n \u003cp\u003eDischarge\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 204px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e10 (33.3%)\u003c/p\u003e\n \u003cp\u003e6 (20%)\u003c/p\u003e\n \u003cp\u003e6 (20%)\u003c/p\u003e\n \u003cp\u003e4 (13.3%)\u003c/p\u003e\n \u003cp\u003e3 (10%)\u003c/p\u003e\n \u003cp\u003e1 (3.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 289px;\"\u003e\n \u003cp\u003eOnset\u003c/p\u003e\n \u003cp\u003eLess than 1 month\u003c/p\u003e\n \u003cp\u003e1 to 6 months\u003c/p\u003e\n \u003cp\u003e6 to 12 months\u003c/p\u003e\n \u003cp\u003eMore than 1 year\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 204px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e7 (23.3%)\u003c/p\u003e\n \u003cp\u003e5 (16.7%)\u003c/p\u003e\n \u003cp\u003e5 (16.7%)\u003c/p\u003e\n \u003cp\u003e13 (43.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 289px;\"\u003e\n \u003cp\u003eReason for delay\u003c/p\u003e\n \u003cp\u003eAsymptomatic\u003c/p\u003e\n \u003cp\u003eFinancial constraints\u003c/p\u003e\n \u003cp\u003eLogistical concerns\u003c/p\u003e\n \u003cp\u003ePerceived non-urgency\u003c/p\u003e\n \u003cp\u003eSelf-medicated\u003c/p\u003e\n \u003cp\u003ePrior consult elsewhere\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 204px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e11 (36.7%)\u003c/p\u003e\n \u003cp\u003e5 (16.7%)\u003c/p\u003e\n \u003cp\u003e5 (16.7%)\u003c/p\u003e\n \u003cp\u003e4 (13.3%)\u003c/p\u003e\n \u003cp\u003e3 (10%)\u003c/p\u003e\n \u003cp\u003e2 (6.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 289px;\"\u003e\n \u003cp\u003ePrevious treatment\u003c/p\u003e\n \u003cp\u003eNone\u003c/p\u003e\n \u003cp\u003eAntibiotic \u0026plusmn; steroid eye ointment\u003c/p\u003e\n \u003cp\u003eAntibiotic \u0026plusmn; steroid eye drops\u003c/p\u003e\n \u003cp\u003eLubricants\u003c/p\u003e\n \u003cp\u003eOral antibiotics\u003c/p\u003e\n \u003cp\u003eUnrecalled eye drops\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 204px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e10 (33.3%)\u003c/p\u003e\n \u003cp\u003e6 (20%)\u003c/p\u003e\n \u003cp\u003e6 (20%)\u003c/p\u003e\n \u003cp\u003e3 (10%)\u003c/p\u003e\n \u003cp\u003e1 (3.3%)\u003c/p\u003e\n \u003cp\u003e4 (13.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 289px;\"\u003e\n \u003cp\u003eSymptoms (N = 60 eyes)\u003c/p\u003e\n \u003cp\u003eTearing\u003c/p\u003e\n \u003cp\u003eRecurrent hordeolum/chalazion\u003c/p\u003e\n \u003cp\u003eRedness\u003c/p\u003e\n \u003cp\u003ePhotophobia\u003c/p\u003e\n \u003cp\u003eItching\u003c/p\u003e\n \u003cp\u003eGrittiness\u003c/p\u003e\n \u003cp\u003eBlurring of vision\u003c/p\u003e\n \u003cp\u003eDischarge\u003c/p\u003e\n \u003cp\u003ePain\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 204px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e33 (55%)\u003c/p\u003e\n \u003cp\u003e29 (48.3%)\u003c/p\u003e\n \u003cp\u003e26 (43.3%)\u003c/p\u003e\n \u003cp\u003e24 (40%)\u003c/p\u003e\n \u003cp\u003e23 (38.3%)\u003c/p\u003e\n \u003cp\u003e17 (28.3%)\u003c/p\u003e\n \u003cp\u003e15 (25%)\u003c/p\u003e\n \u003cp\u003e10 (16.7%)\u003c/p\u003e\n \u003cp\u003e10 (16.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eOut of 60 eyes, 8 eyes were excluded due to presence of other ocular conditions that could affect visual acuity, including infectious keratitis scars, previous keratoplasties, panuveitis, amblyopia with strabismus, and rhegmatogenous retinal detachment. \u0026nbsp;Visual acuity frequencies are demonstrated in Table 4 according to the World Health Organization visual impairment classification.(7) \u0026nbsp;The mean uncorrected visual acuity (UCVA) of the affected eyes was 0.46 \u0026plusmn; 0.39 logMAR, with a median of 0.30 logMAR. \u0026nbsp; Most eyes (51.9%) had minimal or no visual impairment (logMAR \u0026le;0.3), while 11.5% had mild impairment (logMAR 0.31\u0026ndash;0.5). Moderate impairment (logMAR 0.51 \u0026ndash;1.0) was present in 30.8% of eyes, and severe impairment (logMAR \u0026gt;1.0) in 5.8%. \u0026nbsp;The mean best-corrected visual acuity (BCVA) of the affected eyes was 0.22 \u0026plusmn; 0.27 logMAR, with a median of 0.15 logMAR. \u0026nbsp; Most eyes (75%) had normal or minimal impairment (logMAR \u0026le;0.3), 13.5% had mild impairment (logMAR 0.31\u0026ndash;0.5), 9.6% had moderate impairment (logMAR 0.51\u0026ndash;1.0), and 1.9% had severe impairment (logMAR \u0026gt;1.0).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 4. Visual Acuity of the Population (in logMAR).\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"475\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 271px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 204px;\"\u003e\n \u003cp\u003eSummary Measures\u003c/p\u003e\n \u003cp\u003eN = 52 eyes (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 271px;\"\u003e\n \u003cp\u003eUncorrected visual acuity\u003c/p\u003e\n \u003cp\u003elogMAR \u0026le; 0.3\u003c/p\u003e\n \u003cp\u003elogMAR 0.31 \u0026mdash; 0.5\u003c/p\u003e\n \u003cp\u003elogMAR 0.51 \u0026mdash; 1.0\u003c/p\u003e\n \u003cp\u003elogMAR \u0026gt;1.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 204px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e27 (51.9%)\u003c/p\u003e\n \u003cp\u003e6 (11.5%)\u003c/p\u003e\n \u003cp\u003e16 (30.8%)\u003c/p\u003e\n \u003cp\u003e3 (5.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 271px;\"\u003e\n \u003cp\u003eBest corrected visual acuity\u003c/p\u003e\n \u003cp\u003elogMAR \u0026le; 0.3\u003c/p\u003e\n \u003cp\u003elogMAR 0.31 \u0026mdash; 0.6\u003c/p\u003e\n \u003cp\u003elogMAR 0.61 \u0026mdash; 1.0\u003c/p\u003e\n \u003cp\u003elogMAR \u0026gt;1.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 204px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e39 (75%)\u003c/p\u003e\n \u003cp\u003e7 (13.5%)\u003c/p\u003e\n \u003cp\u003e5 (9.6%)\u003c/p\u003e\n \u003cp\u003e1 (1.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eThe most common presenting lid signs were fibrin/crusts/collarettes (96.7%), margin erythema/telangiectasia (63.3%), and meibomitis/plugged meibomian glands (50.%). \u0026nbsp;The most common presenting conjunctival signs were papillae (35%), redness (30%), and follicles (26.7%). \u0026nbsp;The most common presenting corneal signs were pannus (25%), corneal scar/haze (25%), and neovascularization (21.7%). \u0026nbsp;The rest of the presenting signs are illustrated in Table 5.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 5. Frequency of Presenting Signs of the Population.\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"474\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 270px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 204px;\"\u003e\n \u003cp\u003eSummary Measures\u003c/p\u003e\n \u003cp\u003eN = 60 eyes (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 270px;\"\u003e\n \u003cp\u003eEyelid\u003c/p\u003e\n \u003cp\u003eFibrin/crusts/collarettes\u003c/p\u003e\n \u003cp\u003eMargin erythema/telangiectasis\u003c/p\u003e\n \u003cp\u003ePlugged meibomian glands\u003c/p\u003e\n \u003cp\u003eChalazion\u003c/p\u003e\n \u003cp\u003eTylosis\u003c/p\u003e\n \u003cp\u003eTrichiasis\u003c/p\u003e\n \u003cp\u003eUlceration\u003c/p\u003e\n \u003cp\u003eDistichiasis\u003c/p\u003e\n \u003cp\u003ePoliosis\u003c/p\u003e\n \u003cp\u003eHordeolum\u003c/p\u003e\n \u003cp\u003eMadarosis\u003c/p\u003e\n \u003cp\u003eAbscess\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 204px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e58 (96.7%)\u003c/p\u003e\n \u003cp\u003e38 (63.3%)\u003c/p\u003e\n \u003cp\u003e30 (50%)\u003c/p\u003e\n \u003cp\u003e16 (26.7%)\u003c/p\u003e\n \u003cp\u003e14 (23.3%)\u003c/p\u003e\n \u003cp\u003e7 (11.7%)\u003c/p\u003e\n \u003cp\u003e5 (8.3%)\u003c/p\u003e\n \u003cp\u003e3 (5%)\u003c/p\u003e\n \u003cp\u003e1 (1.7%)\u003c/p\u003e\n \u003cp\u003e1 (1.7%)\u003c/p\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 270px;\"\u003e\n \u003cp\u003eConjunctiva\u003c/p\u003e\n \u003cp\u003ePapillae\u003c/p\u003e\n \u003cp\u003eRedness\u003c/p\u003e\n \u003cp\u003eFollicles\u003c/p\u003e\n \u003cp\u003eDischarge\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 204px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e21 (35%)\u003c/p\u003e\n \u003cp\u003e18 (30%)\u003c/p\u003e\n \u003cp\u003e16 (26.7%)\u003c/p\u003e\n \u003cp\u003e3 (5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 270px;\"\u003e\n \u003cp\u003eCornea\u003c/p\u003e\n \u003cp\u003eCorneal scar/haze\u003c/p\u003e\n \u003cp\u003ePannus\u003c/p\u003e\n \u003cp\u003eNeovascularization\u003c/p\u003e\n \u003cp\u003ePunctate keratitis\u003c/p\u003e\n \u003cp\u003ePhlycten\u003c/p\u003e\n \u003cp\u003eMargin ulcer/infiltrates\u003c/p\u003e\n \u003cp\u003eLipid keratopathy\u003c/p\u003e\n \u003cp\u003eCentral corneal ulcer\u003c/p\u003e\n \u003cp\u003eDescemetocele\u003c/p\u003e\n \u003cp\u003eCorneal perforation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 204px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e15 (25%)\u003c/p\u003e\n \u003cp\u003e15 (25%)\u003c/p\u003e\n \u003cp\u003e13 (21.7%)\u003c/p\u003e\n \u003cp\u003e10 (16.7%)\u003c/p\u003e\n \u003cp\u003e9 (15%)\u003c/p\u003e\n \u003cp\u003e4 (6.7%)\u003c/p\u003e\n \u003cp\u003e4 (6.7%)\u003c/p\u003e\n \u003cp\u003e2 (3.3%)\u003c/p\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eTo compare the clinical presentation in terms of uncorrected visual acuity, best corrected visual acuity, symptoms, lid signs, conjunctival signs, and corneal signs with the different bacterial isolates, a Kruskal-Wallis test was performed and no significant differences (p \u0026gt; 0.05) was seen across the various \u003cem\u003eStaphylococcal\u003c/em\u003e species. \u0026nbsp; When the same clinical presentation factors were compared with antibiotic resistance patterns using Spearman correlation, no significant correlations were identified (p \u0026gt; 0.05). \u0026nbsp; However, using Spearman correlation, it was noted that the presence of corneal signs was significantly and positively associated with uncorrected and best corrected visual acuity with p = 0.004 and p = 0.001, respectively. \u0026nbsp;This suggests that as corneal involvement increases, the visual acuity tends to be worse. \u0026nbsp; The same test also suggested that there was a significant positive correlation between presenting symptoms and lid signs (p = 0.002), conjunctival signs (p = 0.002), and corneal signs (p = 0.009), indicating that patients with more extensive clinical findings tended to report more symptoms.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/strong\u003eWhen comparing methicillin-resistant \u003cem\u003eStaphylococcus epidermidis\u003c/em\u003e (MRSE) and methicillin-sensitive \u003cem\u003eStaphylococcus epidermidis\u003c/em\u003e (MSSE),\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003ethe\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eMann-Whitney U test indicated that MSSE appears to have significantly more symptoms (p = 0.036) and conjunctival signs (p = 0.005) compared to MRSE. \u0026nbsp;The UCVA, BCVA, lid signs, and corneal signs were similar between MRSE and MSSE. \u0026nbsp;Fisher\u0026rsquo;s exact test was used to compare the antibiotic susceptibility patterns between MRSE and MSSE and demonstrated similar susceptibility profiles across all tested antibiotics except for Oxacillin (p = 0.001), which is expected as this was the antibiotic used to determine methicillin resistance. \u0026nbsp; Finally, no significant differences in clinical presentation were observed between isolates classified as multidrug-resistant and those that were not.\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eThis study characterizes both the clinical and bacteriologic profile of staphylococcal blepharitis and blepharokeratoconjunctivitis (BKC) in a Philippine tertiary hospital. When compared with the previously published local cohort by Lim Bon Siong, et al., majority of the parameters are comparable as illustrated in Table\u0026nbsp;\u003cspan refid=\"Tab6\" class=\"InternalRef\"\u003e6\u003c/span\u003e.(\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) Notable differences included a higher proportion of bilateral disease in the present cohort and an older mean age among eyes with corneal involvement. This suggests that there is minimal change in clinical presentation of the disease entity over time in this local setting.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab6\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 6\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of Clinical Profile between this cohort and Lim Bon Siong, et al.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003en\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSy, et al, (2025)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eLim Bon Siong, et al. (2023)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e60 eyes of 30 patients\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e99 eyes of 55 patients\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMean age\u003c/p\u003e \u003cp\u003eMedian age\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25 years old\u003c/p\u003e \u003cp\u003e20 years old\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e27 years old\u003c/p\u003e \u003cp\u003e19 years old\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGender predilection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e63% female, 37% male\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e67% female, 33% male\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBilaterality\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e100%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e80%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMean time from onset to consult\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e19.98\u0026thinsp;\u0026plusmn;\u0026thinsp;24.38 months\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18.36\u0026thinsp;\u0026plusmn;\u0026thinsp;25.69 months\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrevious treatment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e67% prior consult/treatment\u003c/p\u003e \u003cp\u003e33% no previous consult\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e67% prior consult/treatment\u003c/p\u003e \u003cp\u003e33% no previous consult\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTop 3 reasons for consult\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBlurring of vision\u003c/p\u003e \u003cp\u003eRedness\u003c/p\u003e \u003cp\u003eLid mass\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCorneal opacity\u003c/p\u003e \u003cp\u003eEye redness\u003c/p\u003e \u003cp\u003eBlurring of vision\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMean UCVA (logMAR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.46\u0026thinsp;\u0026plusmn;\u0026thinsp;0.39 (20/55)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.43\u0026thinsp;\u0026plusmn;\u0026thinsp;0.51 (20/55)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCorneal involvement\u003c/p\u003e \u003cp\u003eMean age\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e31 of 60 eyes (51.7%)\u003c/p\u003e \u003cp\u003e26.03 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e32 of 55% (58%)\u003c/p\u003e \u003cp\u003e17.83 years\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLid findings\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFibrin, crusts, collarettes (97%)\u003c/p\u003e \u003cp\u003eLid erythema, telangiectasia (63%)\u003c/p\u003e \u003cp\u003ePlugged MGs (50%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFibrin, crusts, collarettes (79%)\u003c/p\u003e \u003cp\u003eLid erythema, telangiectasia (27%)\u003c/p\u003e \u003cp\u003eTylosis (11%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eConjunctival findings\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePapillae (35%)\u003c/p\u003e \u003cp\u003eRedness (30%)\u003c/p\u003e \u003cp\u003eFollicles (27%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRedness (49%)\u003c/p\u003e \u003cp\u003ePapillae (46%)\u003c/p\u003e \u003cp\u003eFollicles (12%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCorneal findings\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePannus (25%)\u003c/p\u003e \u003cp\u003eCorneal scar/haze (25%)\u003c/p\u003e \u003cp\u003eNeovascularization (22%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNeovascularization (40%)\u003c/p\u003e \u003cp\u003ePhlycten (33%)\u003c/p\u003e \u003cp\u003ePannus formation (31%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003eStaphylococci\u003c/em\u003e are normal residents of the lid margin and their presence is not inherently pathologic. Previous local and international studies evaluating lid margin and conjunctival isolates of patients undergoing routine cataract surgery have consistently shown the presence of \u003cem\u003eStaphylococcus epidermidis\u003c/em\u003e and coagulase-negative \u003cem\u003eStaphylococcus\u003c/em\u003e in 60\u0026ndash;90% and \u003cem\u003eStaphylococcus aureus\u003c/em\u003e typically follows at 1\u0026ndash;12%. (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e) Their studies have also found non-\u003cem\u003eStaphylococcus\u003c/em\u003e species present including \u003cem\u003eStreptococcus, Micrococcus, Corynebacterium, Bacillus\u003c/em\u003e, and \u003cem\u003eKlebsiella.\u003c/em\u003e A previous local study by Cham et al. (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e), conducted in the Philippines, similarly demonstrated good sensitivity of these isolates to gentamicin, tobramycin, ofloxacin, and moxifloxacin, but noted poor sensitivity to erythromycin. In this cohort, all isolates were found to be \u003cem\u003eStaphylococcus\u003c/em\u003e and no other bacterial genera were identified. Consistent with previous local and international data, there was demonstrated good sensitivity to fluoroquinolones and aminoglycosides and poor sensitivity to erythromycin. Notably, in comparison with the prior local study (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e) conducted approximately 15 years earlier suggests an increasing trend in erythromycin resistance, rising from 30% in 2009 to 47% in the present study. Susceptibility patterns for other antibiotics evaluated in both studies remained largely comparable over time.\u003c/p\u003e \u003cp\u003eWhen assessing isolates from adult patients diagnosed with blepharitis, coagulase-negative \u003cem\u003eStaphylococcus\u003c/em\u003e still predominates with rates up to 89%. (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e) Meanwhile, in pediatric belpharokeratoconjunctivitis cases, \u003cem\u003eStaphylococcus aureus\u003c/em\u003e isolates comprise the majority at 75\u0026ndash;93%. (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e) The majority of eyes included in this cohort were cases of blepharokeratoconjunctivitis but coagulase-negative \u003cem\u003eStaphylococcus\u003c/em\u003e still predominated. There were only 3 \u003cem\u003eStaphylococcus aureus\u003c/em\u003e isolates in this cohort with varying degrees of severity and varied age distribution from 15 to 70 years old.\u003c/p\u003e \u003cp\u003eThe study conducted by Viswalingam et al concluded that Asian and Middle Eastern children appear to be more severely affected.(\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e) The Asian participants from that study were mostly of Indian or Sri Lankan descent. Little data is available on the Southeast Asian population in particular. One study from Singapore performed a retrospective case series of 51 patients with pediatric blepharokeratoconjunctivitis. Their study concluded that patients in Asia appear to have a more severe clinical presentation and advocates for early recognition and management.(\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e) No other published studies from the Southeast Asian region was available at the time of this report.\u003c/p\u003e \u003cp\u003eBased on the findings in this study, it appears that bacterial species does not correlate with clinical presentation and severity. The pathogenesis of this disease is more likely due to the direct toxic effects of staphylococcal products and host hypersensitivity reactions.(\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e) Valenton \u003cem\u003eet al\u003c/em\u003e. was one of the first to establish the key role of toxin production in the context of staphylococcal blepharitis. They found that even in the absence of the more pathogenic \u003cem\u003eS. aureus, S. epidermidis\u003c/em\u003e can still produce blepharokeratoconjunctivitis symptoms due to its ability to produce this dermonecrotic toxin. (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e) \u003cem\u003eStaphylococcus aureus\u003c/em\u003e has been demonstrated to produce several virulence factors. Of particular note is the production of alpha toxin, a pore-forming cytotoxin that induces cell lysis.(\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e) This toxin is absent in \u003cem\u003eStaphylococcus epidermidis\u003c/em\u003e except in rare strains. Other virulence factors of \u003cem\u003eStaphylococcus aureus\u003c/em\u003e include beta toxin, gamma toxin, Panton-Valentine leucocidin, enterotoxin, proteases, and lipases. This myriad of factors contribute to the more aggressive clinical presentation such as ulcerative blepharitis, punctate epithelial keratitis, and papillary conjunctivitis.(\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e) Meanwhile, \u003cem\u003eStaphylococcus epidermidis\u003c/em\u003e can produce lipases, biofilm, and delta toxin, which presents as more chronic low-grade inflammation and meibomian gland dysfunction.(\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). Therefore, it appears that \u003cem\u003eStaphylococcus aureus\u003c/em\u003e is more aggressive and immune-driven while \u003cem\u003eStaphylococcus epidermidis\u003c/em\u003e is more chronic and with less adaptive immune reaction. The predominance of coagulase-negative \u003cem\u003eStaphylococcus\u003c/em\u003e in this cohort may partly explain the absence of very severe manifestations such as descemetocele formation or corneal perforation.\u003c/p\u003e \u003cp\u003eHost susceptibility may also contribute to the disease pathogenesis. Immunogenetic factors such as variations in innate immunity and inflammatory response, combined with early colonization by virulent bacteria and an immature immune system, can cause an imbalance in ocular flora and contribute to recurrent, persistent inflammation.(\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e) Many clinical findings in BKC are immune-mediated rather than from direct bacterial invasion. Epithelial keratitis is caused by toxic mechanisms. Marginal ulcers and infiltrates are an immune antigen-antibody reaction, as evidenced by the absence of \u003cem\u003eStaphylococcus\u003c/em\u003e upon culturing these lesions.(\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e) Lastly, phlyctens are well-known to be due to delayed type hypersensitivity.(\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e) The more robust inflammatory response observed in younger patients likely explains the particular severity and chronicity often seen in pediatric BKC.(\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e) In addition, the substantial delay in consultation observed in this and prior local cohorts likely contributes to prolonged inflammation and cumulative ocular surface damage, influenced by perceived non-urgency, prior misdiagnosis, and socioeconomic barriers..(\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eAnother goal of this study was to determine whether current local treatment protocols remain appropriate in the context of evolving antibiotic resistance. The standard local regimen involves prolonged use of topical antibiotic ointment, most commonly tobramycin-based preparations.(\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) This study demonstrates that the isolates still had excellent sensitivity to gentamicin, which was used as a substitute for tobramycin due to availability issues. Previous studies have confirmed that gentamicin and tobramycin are comparable in terms of clinical outcomes, antibacterial effects, and safety profile. (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e). The in vitro susceptibility of bacterial ocular isolates to these two aminoglycoside antibiotics also found that they were comparable for most organisms except for \u003cem\u003eStaphylococcus aureus\u003c/em\u003e, where tobramycin had a significant higher susceptibility.(\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e) Together with previous data on lid margin isolates demonstrating good aminoglycoside sensitivity, these results support the continued use of tobramycin in the management of staphylococcal blepharitis and BKC.(\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e) In contrast, erythromycin showed sensitivity in only about half of the isolates in this cohort and literature reports sensitivity to be as low as 9%, warranting caution in its empiric use.(\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eWhile there were no methicillin-resistant \u003cem\u003eStaphylococcus aureus\u003c/em\u003e (MRSA) isolates identified, more than half of the \u003cem\u003eStaphylococcus epidermidis\u003c/em\u003e were methicillin resistant (MRSE). The presence of MRSE, however, did not correlate with worse clinical outcomes or increased severity. This is supported by the study of Schecter, et al where they found that MRSE isolates were more likely to be multidrug resistant but had no significance with treatment.(\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eOne limitation of this study is its relatively small sample size, reducing the power to detect statistically significant associations. However, this was partly mitigated by its prospective design and high culture positivity rate. As a single center study conducted in a tertiary hospital where patients tend to present later and more severe disease, there may be limited generalizability to the broader population. Finally, molecular testing to identify specific bacterial toxins and an expanded antibiotic panel could have further strengthened this study. Despite these limitations, this study was able to provide microbiological data from a tertiary referral center that correlates with clinical findings. Moreover, the analysis of antibiotic sensitivity patterns has relevance beyond blepharitis since ocular flora from the eyelids is the source of a significant proportion of other ocular infections like keratitis and endophthalmitis.\u003c/p\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eThe specific staphylococcal species and their antibiotic resistance patterns did not correlate with clinical presentation or disease severity. Instead, disease severity appears to be related to bacterial toxin production, delayed consultation, and individual host susceptibility. Aminoglycosides continue to show excellent sensitivity, whereas erythromycin demonstrates increasing resistance. No MRSA isolates but MRSE was present in a substantial proportion, though with minimal clinical impact.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eFunding source:\u003c/strong\u003e none\u003c/p\u003e\n\u003cp\u003eThe investigators declare no conflict of interest relevant to the conduct of the proposed study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eP.S. performed data collection and analysis, conducted the literature review, and drafted the manuscript. \u0026nbsp;R.L. and G.S. conceptualised and designed the study, supervised the research, and critically revised the manuscript. \u0026nbsp;All authors reviewed and approved the final version of the manuscript.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.\u003c/p\u003e\n\u003ch3\u003e\u003cstrong\u003eCompeting Interests\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e\n\u003ch3\u003e\u003cstrong\u003eEthics Approval and Consent to Participate\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eThis study was approved by the University of the Philippines Manila Research Ethics Board (UPMREB Code 2025-0401-01). Written informed consent was obtained from all participants or their guardians.\u003c/p\u003e\n\u003ch3\u003e\u003cstrong\u003eData Availability\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eThe datasets generated during and/or analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eJones SM, Weinstein JM, Cumberland P, Klein N, Nischal KK. Visual Outcome and Corneal Changes in Children with Chronic Blepharokeratoconjunctivitis. Ophthalmology. 2007 Dec;114(12):2271\u0026ndash;80.\u003c/li\u003e\n\u003cli\u003eLim Bon Siong R, Pablito Jr, Sosuan G. Clinical profile and corneal complications of staphylococcal blepharitis at the Philippine General Hospital. Acta Med Philipp. 2023;57(2). doi:10.47895/amp.v57i2.5611\u003c/li\u003e\n\u003cli\u003eLim Bon Siong R, Cua IY, Tan RR. External Disease and Cornea Handbook Second Edition\u003cem\u003e. \u003c/em\u003eQuezon City (Philippines): St. Luke\u0026rsquo;s Medical Center; 2025. \u003c/li\u003e\n\u003cli\u003eKhor WB, Periayah MH, Lakshminarayanan R, Prajna V, Garg P, Sharma N, Young A, Nishida K, Kinoshita S, Tan AL, Tan DTH. The antibiotic resistance profiles of \u003cem\u003eStaphylococcus\u003c/em\u003e in the Asia Cornea Society Infectious Keratitis Study. Int Ophthalmol. 2025;45:309. doi:10.1007/s10792-025-03667-3\u003c/li\u003e\n\u003cli\u003eHarford DA, Greenan E, Knowles SJ, Fitzgerald S, Murphy CC. The burden of methicillin-resistant Staphylococcus aureus in the delivery of eye care. Eye (Basingstoke). 2022 Jul 1;36(7):1368\u0026ndash;72.\u003c/li\u003e\n\u003cli\u003ede Paula A, Oliva G, Barraquer RI, de la Paz MF. Prevalence and antibiotic susceptibility of bacteria isolated in patients affected with blepharitis in a tertiary eye centre in Spain. Eur J Ophthalmol. 2020 Sep 1;30(5):991\u0026ndash;7.\u003c/li\u003e\n\u003cli\u003eWorld Health Organization. World report on vision. Geneva: World Health Organization; 2019.\u003c/li\u003e\n\u003cli\u003eRatnumnoi R, Keorochana N, Sontisombat C. Normal flora of conjunctiva and lid margin, as well as its antibiotic sensitivity, in patients undergoing cataract surgery at Phramongkutklao Hospital. Clin Ophthalmol. 2017;11:237-241. doi:10.2147/OPTH.S109247.\u003c/li\u003e\n\u003cli\u003eCham TL, Valenton MJ, Bon Siong RL. Ocular bacterial flora and antibiotic sensitivity among Filipino patients undergoing routine cataract surgery. Philipp J Ophthalmol. 2009;34(1):22-26.\u003c/li\u003e\n\u003cli\u003eTeweldemedhin M, Gebreyesus H, Atsbaha AH, Asgedom SW, Saravanan M. Bacterial profile of ocular infections: A systematic review. Vol. 17, BMC Ophthalmology. BioMed Central Ltd.; 2017.\u003c/li\u003e\n\u003cli\u003eMudassar S, Bano A, Shahid M, Asghar F, Waheed F, Javed N. Microbiological evaluation of blepharitis: a case-controlled study. BioSci Rev. 2024;6(3):35-48. doi:10.32350/bsr.63.02\u003c/li\u003e\n\u003cli\u003eViswalingam M, Rauz S, Morlet N, Dart JKG. Blepharokeratoconjunctivitis in children: Diagnosis and treatment. British Journal of Ophthalmology. 2005 Apr;89(4):400\u0026ndash;3.\u003c/li\u003e\n\u003cli\u003eGupta N, Dhawan A, Beri S, D\u0026rsquo;Souza P. Clinical spectrum of pediatric blepharokeratoconjunctivitis. Journal of AAPOS. 2010 Dec;14(6):527\u0026ndash;9.\u003c/li\u003e\n\u003cli\u003eTeo L, Mehta JS, Htoon HM, Tan DTH. Severity of pediatric blepharokeratoconjunctivitis in Asian eyes. Am J Ophthalmol. 2012;153(3):564\u0026ndash;570.e1. doi:10.1016/j.ajo.2011.08.038.\u003c/li\u003e\n\u003cli\u003eRodr\u0026iacute;guez-Garc\u0026iacute;a A, Gonz\u0026aacute;lez-God\u0026iacute;nez S, L\u0026oacute;pez-Rubio S. Blepharokeratoconjunctivitis in childhood: corneal involvement and visual outcome. \u003cem\u003eEye (Lond).\u003c/em\u003e 2016;30(3):438\u0026ndash;446. doi:10.1038/eye.2015.249.\u003c/li\u003e\n\u003cli\u003eValenton MJ, Okumoto M. Toxin-producing strains of \u003cem\u003eStaphylococcus epidermidis\u003c/em\u003e (albus), isolates from patients with staphylococcic blepharoconjunctivitis. Arch Ophthalmol. 1973;89:186-189.\u003c/li\u003e\n\u003cli\u003eShen J, Yasir M, Willcox M. Staphylococcal exotoxins in ocular infection with focus on enterotoxins. \u003cem\u003eMicrobiol Res.\u003c/em\u003e 2025;299:128258. doi:10.1016/j.micres.2025.128258.\u003c/li\u003e\n\u003cli\u003eSeal D, Ficker L, Ramakrishnan M, Wright P. Role of staphylococcal toxin production in blepharitis. Ophthalmology. 1990;97(12):1684-1688. doi:10.1016/S0161-6420(90)32361-8.\u003c/li\u003e\n\u003cli\u003eTetz MR, Klein U, V\u0026ouml;lcker HE. Staphylococcus-associated blepharokeratoconjunctivitis: clinical findings, pathogenesis and therapy. Ophthalmologe. 1997;94(3):186-190. doi:10.1007/s003470050099\u003c/li\u003e\n\u003cli\u003eOrtiz-Morales G, Ruiz-Lozano RE, Morales-Mancillas NR, Paez-Garza JH, Rodriguez-Garcia A. Pediatric blepharokeratoconjunctivitis: a challenging ocular surface disease. Surv Ophthalmol. 2025;70(3):516-535. doi:10.1016/j.survophthal.2025.01.006\u003c/li\u003e\n\u003cli\u003eFicker L, Ramakrishnan M, Seal D, Wright P. Role of cell-mediated immunity to staphylococci in blepharitis. Am J Ophthalmol. 1991;111(4):473-479. doi:10.1016/s0002-9394(14)72383-9\u003c/li\u003e\n\u003cli\u003eAli A. Pediatric Blepharokeratoconjunctivitis: An Update. \u003cem\u003eCanadian Eye Care Today\u003c/em\u003e. 2024 Jun 18;3(2):47\u0026ndash;50.\u003c/li\u003e\n\u003cli\u003eLeibowitz HM, Hyndiuk RA, Smolin GR, Nozik RA, Hunter GJ, Cagle GD, Davis DS. Tobramycin in external eye disease: a double-masked study vs gentamicin. Curr Eye Res. 1981;1(5):259-266. doi:10.3109/02713688108999445\u003c/li\u003e\n\u003cli\u003eCagle G, Davis S, Rosenthal A, Smith J. Topical tobramycin and gentamicin sulfate in the treatment of ocular infections: multicenter study. Curr Eye Res. 1981;1(9):523-534. doi:10.3109/02713688109069178\u003c/li\u003e\n\u003cli\u003eMoeller CTA, Castelo Branco B, Yu MCZ, Farah ME, H\u0026ouml;fling-Lima AL. Alterations in ocular pathogen susceptibility to gentamicin and tobramycin. Arq Bras Oftalmol. 1999;62(6):687-692.\u003c/li\u003e\n\u003cli\u003eSchechter BA, Sheppard JD, Sanfilippo CM, et al. An evaluation of staphylococci from ocular surface infections treated empirically with topical besifloxacin: antibiotic resistance, molecular characteristics, and clinical outcomes. Ophthalmol Ther. 2020;9:159-173. doi:10.1007/s40123-019-00223-y\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"journal-of-ophthalmic-inflammation-and-infection","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"joii","sideBox":"Learn more about [Journal of Ophthalmic Inflammation and Infection](http://joii-journal.springeropen.com)","snPcode":"12348","submissionUrl":"https://submission.nature.com/new-submission/12348/3","title":"Journal of Ophthalmic Inflammation and Infection","twitterHandle":"@SpringerOpen","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Staphylococcal blepharitis, staphyloccocal blepharokeratoconjunctivitis, microbiological profile, resistance patterns","lastPublishedDoi":"10.21203/rs.3.rs-9046143/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9046143/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003ePurpose\u003c/h2\u003e \u003cp\u003eTo describe the clinical and microbiological profile of patients with staphylococcal blepharitis and blepharokeratoconjunctivitis (BKC) in a Philippine tertiary hospital, determine antibiotic susceptibility patterns, and evaluate associations between bacterial species, resistance profiles, and disease severity.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThis single-center prospective observational study included 30 patients (60 eyes) clinically diagnosed with staphylococcal blepharitis or BKC. Detailed clinical history, slit-lamp examination, and visual acuity measurements were documented. Eyelid margin swabs were obtained for organism identification and antibiotic susceptibility testing. Associations between microbiologic data and clinical presentation were analyzed using Kruskal\u0026ndash;Wallis, Mann\u0026ndash;Whitney U, and Spearman correlation tests.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eTwenty-seven patients (90%) yielded positive cultures and 34 staphylococcal isolates were identified. All isolates were \u003cem\u003eStaphylococcus\u003c/em\u003e species, most commonly \u003cem\u003eStaphylococcus epidermidis\u003c/em\u003e (47.1%), over half of which were methicillin-resistant. No methicillin-resistant \u003cem\u003eStaphylococcus aureus\u003c/em\u003e was detected. High resistance rates were observed for penicillin and erythromycin, while fluoroquinolones and aminoglycosides demonstrated excellent antimicrobial sensitivity. No significant associations were found between bacterial species, antibiotic resistance patterns, and clinical presentation. Corneal involvement was found to have significantly worse visual acuity and a higher symptom burden positively correlated with more clinical signs.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eStaphylococcal species and antibiotic resistance patterns did not correlate with disease severity or clinical presentation. Disease severity appears to be more strongly driven by bacterial toxin production, delayed consultation, and host susceptibility. Aminoglycosides remain highly effective for treatment. Although methicillin-resistant \u003cem\u003eStaphylococcus epidermidis\u003c/em\u003e was common, it did not confer worse clinical outcomes.\u003c/p\u003e","manuscriptTitle":"Staphylococcal Blepharitis and Blepharokeratoconjunctivitis in Southeast Asia: Microbiological Profile and Antibiotic Sensitivity Patterns","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-03-19 16:21:17","doi":"10.21203/rs.3.rs-9046143/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewerAgreed","content":"86676159865158921385203932196961799968","date":"2026-05-01T11:48:25+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-16T12:50:34+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"143915104358655146715349409544109304697","date":"2026-04-09T23:55:45+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"59054178499517056628953284569140636512","date":"2026-03-19T09:34:30+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-03-17T05:10:28+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-03-12T16:43:54+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-03-12T16:43:26+00:00","index":"","fulltext":""},{"type":"submitted","content":"Journal of Ophthalmic Inflammation and Infection","date":"2026-03-06T04:54:43+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"journal-of-ophthalmic-inflammation-and-infection","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"joii","sideBox":"Learn more about [Journal of Ophthalmic Inflammation and Infection](http://joii-journal.springeropen.com)","snPcode":"12348","submissionUrl":"https://submission.nature.com/new-submission/12348/3","title":"Journal of Ophthalmic Inflammation and Infection","twitterHandle":"@SpringerOpen","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"d0b09663-cbb7-4e62-bada-22d4ddf41b62","owner":[],"postedDate":"March 19th, 2026","published":true,"recentEditorialEvents":[{"type":"reviewerAgreed","content":"86676159865158921385203932196961799968","date":"2026-05-01T11:48:25+00:00","index":22,"fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-03-19T16:21:17+00:00","versionOfRecord":[],"versionCreatedAt":"2026-03-19 16:21:17","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9046143","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9046143","identity":"rs-9046143","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}