Definition

Gonococcal conjunctivitis, also known as neonatal gonococcal ophthalmia when it occurs in newborns, is an infection transmitted through contact between the eyes and infected genital secretions from someone with genital gonorrhoea. This infection occurs in neonates or newborns.

On physical examination, symptoms that may be found include the presence of pus in the eyes, adhesions on the conjunctiva, pain in the eyeball, swelling of the eyelids, and lymphadenopathy (swelling of lymph glands) caused by gonorrhoea.

However, gonococcal conjunctivitis can also occur in adults and is associated with sexually transmitted infections such as gonococcal urethritis and other sexually transmitted diseases. It is important to recognize and manage this medical condition properly to prevent blindness in patients. Although cases in adults are rare, they still need to be handled with care.

Worldwide, the incidence of gonorrhoea infection in newborns is less than 1%. In developed countries, the incidence tends to be lower due to the availability of screening options and better treatment. In the United States, the incidence of conjunctivitis in neonates is around 1-2%, with the incidence of neonatal gonococcal conjunctivitis being less than 1%.

Causes

Gonococcal conjunctivitis is caused by an infection with Neisseria gonorrhoeae, a gram-negative diplococcus bacteria. In neonates, the transmission of this infection occurs due to the continued development of gonococcal conjunctivitis during the birthing process and exposure to infectious vaginal fluid. This happens because the mucous membranes of the cervix and urethra of the infected mother can serve as a habitat for these bacteria.

In the adult population, transmission can occur directly through sexual contact with infectious fluids or indirectly through manual transmission or mites. However, indirect transmission tends to be rare because these bacteria cannot survive outside the human body for more than a few minutes.

There is also evidence suggesting that gonococcal conjunctivitis may potentially occur due to different species than gonococcus, unrelated to sexually transmitted infections.

Risk Factor

Several risk factors that increase the occurrence of gonococcal conjunctivitis include the birthing process in an infected mother and a history of gonorrhoeal sexually transmitted infections. Additionally, there are other factors that can increase the risk of gonococcal conjunctivitis, including:

• Engaging in sexual activity without using protection (condoms) 
• Using contact lenses with hands exposed to the bacteria causing the infection 
• Immunocompromised 
• A history of eye diseases 
• History of sexually transmitted infections 
• Alcohol and drug abuse

Symptoms

The incubation period from infection to symptom onset varies from 3 to 19 days. Some symptoms that may occur in gonococcal conjunctivitis include:

• Red eyes due to dilation of conjunctival blood vessels 
• Adhesion of the conjunctiva 
• Swelling of the eyelids 
• Visible discharge of pus from the eyes 
• Painful pressure on the eyeball 
• Swelling of lymph nodes in the preauricular (front of the ear) area

Diagnosis

The diagnosis of gonococcal conjunctivitis is established through medical interviews, physical examinations, and, when available and necessary, additional tests.

During the medical interview, the doctor will inquire about the current symptoms experienced by the patient. The existing symptoms can guide towards a specific disease, so it is essential to provide a comprehensive description of the symptoms along with when they started. This information is crucial for the doctor to establish a particular medical diagnosis. If the symptoms indicate gonococcal conjunctivitis, the doctor will proceed to physical examinations and additional tests.

In the physical examination, the doctor will conduct an assessment based on the patient's reported symptoms to find several clinical signs that are objective indicators of gonococcal conjunctivitis.

In cases of gonococcal conjunctivitis, the doctor may observe cloudy, yellowish, purulent discharge in both eyes, accompanied by redness and a sensation of pain or itching. The doctor may also identify adhesions on the eyelids due to accumulated eye discharge.

Additional tests help in confirming or ensuring the diagnosis of chronic conjunctivitis. Standard tests include cultures using chocolate agar or Thayer-Martin media and drug resistance examinations using samples of eye discharge. These tests are considered gold standards in confirming the diagnosis.

However, other tests, such as Gram staining with urine or urethral fluid samples, may also be performed to establish the presence of gonorrhoea in the genital area, supporting the possibility of transmission from the genital organs to the eyes through direct or indirect contact.

Management

For newborns suspected with gonococcal conjunctivitis, inpatient care is necessary, and consultation with an ophthalmologist is recommended. Patients with gonococcal conjunctivitis need to have the eye discharge cleaned through topical irrigation using normal saline solution.

The doctor will administer antibiotic injections to manage gonococcal conjunctivitis. This administration is typically a single dose or a one-time injection with a dosage adjusted according to the child's weight. Additionally, the use of antibiotic eye ointment may be considered to treat the potential concurrent chlamydial infection that may occur along with gonorrhoea in the eye organs.

Complications

Complications that may arise in cases of gonococcal conjunctivitis include abnormalities on the eye surface, such as:

• Swelling of the cornea (the clear outer layer of the eye)
• Thickening of the conjunctiva palpebra (eyelid)
• Formation of pannus (abnormal tissue)
• Opacification of the cornea (clouding of the cornea)
• Corneal perforation
• Endophthalmitis
• Visual impairment leading to blindness

Furthermore, involvement of systemic disorders as complications, such as arthritis, meningitis, anorectal infection, septicaemia, and death, is possible in cases of gonococcal conjunctivitis. The risk of complications can be minimized with early diagnosis and appropriate antibiotic therapy.

Prevention

Preventive measures to avoid gonococcal conjunctivitis, especially in newborns, include ensuring that the treatment undergone by the mother who is about to give birth has been completed and cured of gonorrhoea infection because the most common cause of this disease is a mother who has not fully recovered or completed treatment for gonorrhoea.

Additionally, it is necessary to ensure that there is no direct or indirect transmission by maintaining hygiene and not sharing personal items simultaneously. Sexual partners need to be educated and treated to avoid reinfecting each other. Sexual behaviour counselling is also necessary for adult cases with gonococcal conjunctivitis.

When to See a Doctor?

If you or your child experiences worsening symptoms suspected to be gonococcal conjunctivitis, it is advisable to consult an ophthalmologist. The doctor will conduct a medical interview, a physical examination, and specific diagnostic tests to determine the exact diagnosis of the underlying disease and provide appropriate management.

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