Gonorrheal conjunctivitis

Background

• Caused by Neisseria gonorrhoeae
• Usually spread from genital-hand-eye contact in the young sexually active population
• Neonates can acquire it from the birth canal

Clinical features

Typical "membranous" conjunctivitis, seen with gonorrheal conjunctivitis.

• Abrupt onset
• Copious purulent discharge (reforms quickly after wiping away)
• Marked conjunctival injection/chemosis
• Lid swelling
• Globe tenderness through closed lids
• Preauricular lymphadenopathy
• May or may not be associated with features of urethritis

Neonates

• 3-5 days postpartum
• Bilateral discharge
• May be localized to other organs (arthritis, meningitis, pneumonia) or may be disseminated

Differential Diagnosis

Conjunctivitis Types

• Viral conjunctivitis
  • Epidemic keratoconjunctivitis
  • Herpes zoster ophthalmicus
  • Herpes simplex keratitis
• Bacterial conjunctivitis
  • Gonorrheal conjunctivitis
  • Chlamydia conjunctivitis
• Allergic conjunctivitis
• Caustic keratoconjunctivitis

Evaluation

• Gram staining for gram-negative diplococci
• Cultures for Neisseria

Management

• Treatment for bacterial organisms is targeted toward S. aureus, S. pneumoniae, H. influenzae, Pseudomonas, N. gonorrhea, C. trachomatis
• Contact lens wearers should be given coverage for pseudomonas with one of the fluoroquinolone drops

Bacterial Conjunctivitis

• Counsel patient/family on importance of hand hygiene/avoiding touching face to prevent spread!
• Apply warm or cool compresses (for comfort and cleansing) every 4 hours, followed by instillation of ophthalmic antibiotic solutions

These options do not cover gonococcal or chlamydial infections

• Polymyxin B/Trimethoprim (Polytrim) 2 drops every 6 hours for 7 days OR
• Erythromycin applied to the conjunctiva q6hrs for 7 days OR
• Levofloxacin 0.5% ophthalmic solution 1-2 drops every 2 hours for 2 days THEN every 6 hours for 5 days OR
• Moxifloxacin 0.5% ophthalmic 1-2 drops every 2 hours for 2 days THEN every 6 hours for 5 days OR
• Gatifloxacin 0.5% ophthalmic solution 1-2 drops every 2 hours for 2 days THEN 1 drop every 6 hours for 5 days OR
• Azithromycin 1% ophthalmic solution 1 drop BID for 2 days THEN 1 drop daily for 5 days
• Chloramphenicol 0.5% ophthalmic solution 1 drop QID for 7 days

NB: levofloxacin is preferred for contact lens wearers for coverage of pseudomonas. Advise not to wear contacts for duration of treatment

Chlamydial

• Doxycycline 100mg PO BID for 7 days OR
• Azithromycin 1g (20mg/kg) PO one time dose
• Newborn Treatment: Azithromycin 20mg/kg PO once daily x 3 days or erythromycin PO 50 mg/kg/day in 4 divided doses for 14 days
  • Disease manifests 5 days post-birth to 2 weeks (late onset)

Gonococcal

• Due to increasing resistance, CDC recommends dual therapy with Ceftriaxone and Azithromycin (even if patient is negative for Chlamydia).
• Ceftriaxone 250mg IM one dose PLUS
• Azithromycin 1g PO one dose
• Newborn Treatment:
  • Prophylaxis: Erythromycin ophthalmic 0.5% x1
  • Disease manifests 1st 5 days post delivery (early onset)
  • Treatment Ceftriaxone 25-50mg IV or IM, max 125mg or cefotaxime single dose of 100 mg/kg (preferred if the patient has hyperbilirubinemia)
  • Also requires evaluation for disseminated disease (meningitis, arthritis, etc.)

• Eye irrigation (saline)
• Systemic antibiotics for gonorrhea
• Urgent referral to ophtho

Disposition

• Infant=Admit?
• Adult=Discharge
  • Unless evidence of complication or immunodeficiency

Complications

• Ulceration
• Perforation

See Also

• Conjunctivitis
• Sexually Transmitted Diseases (STD)

References

Mahmood AR, Narang AT. Diagnosis and management of the acute red eye. Emerg Med Clin N Am. 2008;26:35-55. [{Category:ID]]