Gonococcal conjunctivitis presents with explosive onset and very rapid progression of severe purulent conjunctivitis: massive exudation; severe chemosis; eyelid edema; marked conjunctival hyperemia; and, in untreated cases, corneal infiltrates, melting, and perforation. The organism most commonly responsible for hyperpurulent conjunctivitis is N gonorrhoeae (Fig 10-11). Gonococcal conjunctivitis is a sexually transmitted disease resulting from direct transmission of the organism, for example, from the genitalia to the hands and then to the eyes or from the mother to the neonate during vaginal delivery.
Gonococcal conjunctivitis is one of the few bacterial diseases associated with preauricular lymphadenopathy and the formation of conjunctival membranes. Keratitis, the principal cause of sight-threatening complications, has been reported to occur in 15%–40% of cases. Corneal involvement may consist of diffuse epithelial haze, epithelial defects, marginal infiltrates, and ulcerative keratitis that can rapidly progress to perforation.
Gonococcal conjunctivitis requires systemic antibiotic therapy, with topical ophthalmic antibiotics used as adjunctive therapy only. Current treatment regimens for gonococcal conjunctivitis reflect the increasing prevalence of penicillin-resistant N gonorrhoeae (PRNG) in the United States. Ceftriaxone, a third-generation cephalosporin, is highly effective against PRNG. Patients with gonococcal conjunctivitis without corneal ulceration may be treated on an outpatient basis with 1 intramuscular (IM) ceftriaxone (1 g) injection; patients with corneal ulceration should be admitted to the hospital and treated with intravenous (IV) ceftriaxone (1 g IV every 12 hours) for 3 consecutive days. Patients with penicillin allergy can be given spectinomycin (2 g IM) or oral fluoroquinolones (ciprofloxacin 500 mg or ofloxacin 400 mg orally twice daily for 5 days). When possible, fluoroquinolones should be avoided in children because of potential adverse effects on joint cartilage.
Erythromycin ointment, bacitracin ointment, gentamicin ointment, and ciprofloxacin solution have been recommended for topical therapy. Treatment of severe cases should include copious, frequent (every 30–60 minutes) irrigation of the conjunctival sac with normal saline to remove inflammatory cells, proteases, and debris that may be toxic to the ocular surface and contribute to corneal melting.
Up to one-third of patients with gonococcal conjunctivitis have been reported to have concurrent chlamydial venereal disease. Because of this frequent association, it is advisable to give patients supplemental oral antibiotics for treatment of chlamydial infection. Treatment regimens for chlamydia are discussed later in this chapter. Patients should be instructed to refer their sex partners for evaluation and treatment. Other sexually transmitted pathogens causing conjunctivitis include Chlamydia trachomatis, Treponema pallidum, human immunodeficiency virus, and herpes simplex virus (Table 10-4). For further discussion of syphilis, see BCSC Section 1, Update on General Medicine, and Section 9, Uveitis and Ocular Inflammation.
American Academy of Ophthalmology Cornea/External Disease Panel. Preferred Practice Pattern Guidelines. Conjunctivitis. San Francisco: American Academy of Ophthalmology; 2013. Available at www.aao.org/ppp.
Table 10-4 Sexually Transmitted Pathogens Associated With Conjunctivitis
Cortina MS, Tu EY. Antibiotic use in corneal and external eye infections. Focal Points: Clinical Modules for Ophthalmologists. San Francisco: American Academy of Ophthalmology; 2011, module 6.