Gonococcal Conjunctivitis

Gonococcal conjunctivitis is a hyperacute purulent conjunctivitis caused by Neisseria gonorrhoeae, an ophthalmic emergency.

• Neonatal form: acquired in the birth canal, onset 2 to 5 days after birth.
• Adult form: autoinoculation from genital infection or sexual contact, in sexually active adults; rare in children (consider abuse).
• The organism penetrates intact corneal epithelium, causing ulceration and perforation within 24 to 48 hours if untreated.
• Resistance is increasing (penicillin, tetracycline, fluoroquinolone resistance is widespread; ceftriaxone is the mainstay).

• Abrupt onset (within 12 to 48 hours) of copious thick purulent discharge that reaccumulates immediately after wiping, severe lid swelling, marked chemosis and conjunctival injection.
• Tender preauricular lymphadenopathy, sometimes with pseudomembrane.
• Pain, photophobia, reduced vision signal corneal involvement: peripheral infiltrate and ring ulcer, rapid melting, perforation, endophthalmitis.
• Neonate: bilateral lid oedema, purulent discharge; fever, disseminated disease (arthritis, meningitis, sepsis) in some.
• Adults: genital symptoms (urethral discharge, dysuria, cervicitis, pelvic pain) in many.

• Urgent conjunctival swab for Gram stain (Gram negative intracellular diplococci), culture on chocolate agar or Thayer-Martin medium in CO2, and nucleic acid amplification test. Request antimicrobial susceptibility.
• Fluorescein stain and slit lamp for corneal involvement; measure intraocular pressure only after cornea assessed.
• Genital, throat and rectal swabs for gonorrhoea and chlamydia; screen for HIV, syphilis, hepatitis B; test contacts.
• Neonate: blood cultures and lumbar puncture if systemic signs.

• Adults and adolescents (uncomplicated, no corneal involvement): ceftriaxone 1 g intramuscularly single dose (2 g if corneal involvement or severe disease, or intravenous 1 g daily for 3 days if keratitis) plus azithromycin 1 g orally single dose to cover chlamydia. Alternative if ceftriaxone is unavailable: cefixime 400 mg orally plus azithromycin; spectinomycin 2 g intramuscularly.
• Hospital admission for corneal involvement, and intravenous ceftriaxone 1 to 2 g daily for 3 to 7 days.
• Irrigate the conjunctival sac with sterile saline every 30 to 60 minutes until the discharge stops.
• Topical antibiotics are adjunctive: ciprofloxacin 0.3 percent or gentamicin 0.3 percent drops every 1 to 2 hours initially, then four times daily, according to susceptibility; cycloplegic (atropine 1 percent once or twice daily) for corneal involvement.
• Neonates: ceftriaxone 25 to 50 mg/kg (maximum 125 mg) as single intramuscular or intravenous dose; use cefotaxime 100 mg/kg single dose when hyperbilirubinaemia or when calcium containing infusions are running; treat disseminated infection for 7 days (10 to 14 days for meningitis). Treat mother and partner.
• Review daily until improving. Repeat ocular and genital testing as test of cure when resistance suspected.
• Partner notification, safer sex counselling, and abstinence until treatment is completed and symptoms resolved (7 days).
• Complications: corneal perforation requires urgent patch graft or keratoplasty.