27 year old man with pain,swelling, and redness of the left eye for 2 days
Digital Journal of Ophthalmology 1996
Volume 2, Number 2
September 10, 1996
|The patient is a 27 year old white man with a history of pain, swelling, and redness of the left eye for two days. He also complained of general malaise. |
PMHx: Non contributory
SHx: Non contributory
FHx: Non contributory
|Vision: 20/20 OD, 20/40 OS |
Pupils: Normal OU, No APD
Motility: Full OU
External: Left preauricular adenopathy
Fundus examination: Normal disc, macula, vessels OU
General Physical Exam: The patient had a fever of 100.2 degrees Farenheit
Figures 1-2. These are views of the patients left eye, demonstrating marked conjunctival chemosis and hyperemia as well as purulent discharge.
Gram stain of the conjunctival discharge which demonstrates gram negative diplococci
|- Neisseria meningitidis |
- Neisseria gonorrheae
- S. pneumoniae
- S. pyogenes
|Diagnosis and Discussion|
The finding of Gram-negative diplococci on the Gram stain coupled with a subsequent history of genital tract complaints was highly suggestive of gonococcal disease. The diagnosis of Gonococcal Ophthalmia was confirmed by positive gonoccocal cultures performed on chocolate agar plates.
Gonococcal ophthalmia is a disease that occurs in neonates, adolescents, and young adults. One out of every 700-800 cases of gonococcal infection per year have ophthalmic involvement (or approximately 2000 cases per year). However, only about one-half of cases are actually reported. Transmission if FROM genitalia to hand to eye contact.
The pathogen is Neisseria gonorrheae, a gram negative diplococci which is microaerophilic. Man is this organism's only natural reservoir. Its pathogenicity is related to its ability to attach to epithelial surfaces and invade epithelial cells and white blood cells. (particularly polymorphonuclear cells). This organism is fastidious and can be grown in Thayer-Martin media or chocolate agar with incubation in a 5% CO2 environment.
Clinical signs include marked lid edema, conjunctival hyperemia, copious purulent exudate, and preauricular lymphadenopathy. Conjunctival membranes and pseudomembranes can also be seen. All or some of these signs can occur within 24 hours, hence the inclusion of this entity as a "hyperacute conjunctivitis". Symptoms can include pain and tenderness to palpation, and decreased visual acuity, often secondary to lid edema, copious exudate, and corneal involvement.
Recognition of this entity is an important first step towards management of the disease. It can be confused with hyperacute conjunctivitis caused by Neisseria meningitidis, which is also an aggressive disease, with early onset, and copious purulent exudate. However, N. meningiditis occurs much less often than N. gonorrheae. Acute conjunctivitis caused by S. pneumoniae, S. pyogenes, and fungal agents (and others) have an onset of hours to days and are characterized by a mucopurulent exudate. Organisms that produce a membranes such as C. diptheriae, and adenovirus can also lend some confusion, but they typically are less purulent and less aggressive in onset.
Prompt and effective management of gonococcal ophthalmia greatly affects the prognosis of the affected eye. Parenteral antibiotics are the cornerstone of disease therapy. They are used because of the virulence of the organism and the high risk of perforation and loss of the eye if lesser modalities are used. Dosing regimens have been more of a source of controversy than the antibiotics in use. Ceftriaxione is the first line intravenous antibiotic because of its efficacy against penicillinase producing Neisseria gonorrheae (PPNG), which approches 100%. Ceftriaxone has very good penetration in the aqueous humor. Some physicians in the past have advocated single dose IM ceftriaxone in this disease if no corneal involvement is present, while others contend that IV dosing is the most beneficial. Penicillin allergic patients may use Spectinomycin, a relative of the aminoglycosides, as an alternative. Topical antibiotics (such as Ciprofloxacin and Bacitracin) are a supplement, not a replacement for parenteral antibiotics. Other important steps in treatment include saline lavage (which decreases the toxin LOAD by removing inflammatory cells and necrotic debris), following culture results, and daily examination.
Concomitant treatment of other sexually transmitted diseases is important. Chlamydia trachomatis occurs in up to 30% of patients with gonococcal ophthalmia. Neither Ceftriaxone nor Spectinomycin is active against C. trachomatis. Doxycycline or tetracycline is the drug of choice for this organism. Syphilis can also be associated with gonococcal ophthalmia, in which case the drug of choice is penicillin. All of these entities are sexually transmitted diseases, and as such, should be reported and the patient's partner(s) should be treated.
Complications of gonococcal ophthalmia can include iritis, endopthalmitis, lid abscess, dacryoadenitis, and septicemia. However, the most important complication is corneal involvement. Up to 40% of infected patients have keratitis of some form, and of this GROUP ten percent will perforate (four percent total). Corneal findings include superficial punctate keratitis, peripheral subepithelial and stromal infiltrates, stromal thinning, and peripheral ulcerative keratitis (which progresses to thinning and perforation). Daily monitoring is essential in preventing these complications and aggressive therapy is required if complications arise.
|1) Ullman, Saul et al Gonococcal keratoconjunctivitis. Survey of Ophthalmology 32:199-120(1987) |
2) Albert, D. and Jakobiec, F: Principles and Practice of Ophthalmology, vol. 1. Philadelphia, WB Saunders, p. 164-5 (1994)