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Abstract
The authors present a case of severe gonococcal conjunctivitis associated with corneal perforation of the right eye in a 25-year-old homosexual man. Inpatient management and corneal grafting were required. The authors demonstrate that Neisseria gonorrhoea should be considered in the presence of purulent conjunctival discharge with a white patch on the cornea or reduced vision. Regardless of whether a patient has genital symptoms, they should be referred urgently to an ophthalmologist to ensure adequate treatment of this rare but sight-threatening complication.
- Neisseria gonorrhoeae
- corneal perforation
- HIV
- grafting
- corneal
- ophthalmia
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Introduction
The adult conjunctiva is susceptible to infection by Neisseria gonorrhoea (GC) by both direct and indirect contact. Once infection is established, the bacteria can quickly spread to the cornea leading to keratitis, ulceration, descemetocoele formation and ultimately perforation. The rapid identification and treatment of the infection are paramount, as these complications can occur within 24 h of infection.1
Case report
A 25-year-old man initially presented to the ophthalmologists via the emergency department. He reported 3 days of irritation and discharge from the right eye attributed to a chemical injury. Swabs were taken and he was treated with dexamethasone, chloramphenicol, ascorbic acid and cyclopentolate eye-drops.
Seven days later, the eye had become increasingly painful with intense conjunctival injection and copious purulent discharge (figure 1A). A corneal abscess had developed under the upper lid together with corneal melt and associated perforation (figure 1B). Unaided visual acuity was right eye 6/36 and left 6/4. Culture results from the initial visit were found to be positive for GC, which was resistant to ciprofloxacin and nalidixic acid. He was admitted by the ophthalmologists for intensive topical antibiotics.
Anterior segment photographs of a patient with gonoccocal keratitis: (A) on admission, 10 days after the onset of symptoms, there was copious pus and a superior corneal perforation; (B) after 2 days of systemic and intensive topical antibiotics, the infection began to settle, but necrotic stroma remained around the perforation. Tectonic corneal grafting was performed at 1 week. (C) One week postoperatively, the perforation was sealed. (D) Ten months later, the eye was white and quiet, sutures were removed, and he achieved an unaided visual acuity of 6/18.
The patient was referred to the genito-urinary (GU) service for a full GU sexual history and screening. The male was a sexually active homosexual. He reported a urethral discharge 4 weeks prior to his eye symptoms, which had resolved spontaneously. He was offered and accepted a full GU screen. This initially revealed urethral GC and a positive HIV point-of-care test. Subsequent results confirmed HIV-1 infection, urethral GC and Chlamydia.
The patient received initial treatment with ceftriaxone 250 mg intramuscularly and azithromycin 1 g by mouth. Intravenous ceftriaxone was continued for 7 days together with topical chloramphenicol and gentamicin hourly day and night (dexamethasone and cyclopentolate eye-drops). On day 7 of admission, once the eye was quieter, he underwent tectonic corneal grafting of the perforated area of cornea (figure 1C). A kidney-shaped lamellar graft was overlaid on the perforation and area of melt just inside the superior limbus.
During close outpatient follow-up, his vision in the affected eye improved to 6/18 unaided (6/5 pinhole) (figure 1D). He was found to have a CD4 count of 180 (22%).
Discussion
The presentation of gonococcal eye infection can have a similar initial presentation to the common infective forms of conjunctivitis. However, conjunctival swabs are not routinely taken, so the diagnosis of GC can initially be missed. In this patient, a swab was taken because the purulent discharge was inconsistent with the history of chemical injury. Sexual history taking is particularly important to identify patients most at risk of gonococcal eye infection.
GC infection of the eye has been reported both with and without concomitant anogenital infection.2 3 Patients may not readily associate their eye and genital symptoms. In this case in particular, there was a 4-week delay between the onset of genital and eye symptoms. The importance of considering the diagnosis is therefore paramount.
The British Association of Sexual Health and HIV (BASHH) does not have any recommendations for the treatment of GC eye in their current guidelines.4 For genital infection, WHO 2003 guidelines recommend ceftriaxone 125 mg intramuscularly stat5 while the American Centers for Disease Control (CDC) advise a 1 g dosage.6 The GC isolated in this case had confirmed sensitivity to third-generation cephalosporins, namely cefixime and ceftriaxone. For eye infections, topical antibiotics achieve much higher concentrations in the infected tissues than systemic treatments. Treatments four times a day are usually sufficient for conjunctivitis, but for corneal involvement, dual topical therapy hourly throughout the day and night is required.1 In this case, in view of the breach of the cornea, systemic treatment more akin to that for disseminated GC was employed.
Case reports of GC eye infection with associated corneal perforation have been previously described in the ophthalmology literature but not that of GU medicine. This case highlights both the potential severe complications of this infection, which should be treated immediately and followed up closely by ophthalmologists, and the shortcomings of current guidelines for its management.
Key messages
Early recognition and treatment of N gonorrhoea eye infection, wherever it may present, is paramount to prevent sight-threatening complications.
A sexual history is important in the management of patients with purulent eye discharge, as patients do not readily associate genital and eye symptoms.
The optimal antimicrobial management of this condition is unknown, and there is presently no UK guideline for its management.
Footnotes
Competing interests None.
Patient consent Obtained.
Provenance and peer review Not commissioned; externally peer reviewed.