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EW FEATURE 48 Navigating the red eye • May 2018 Extensive conjunctival chemosis and swelling and a central corneal ulcer in a patient with Neisseria gonorrhoeae conjunctivitis Source: Vincent de Luise, MD Diagnosis continued from page 46 Streptococcus pneumoniae, Haemoph- ilus influenzae, and Staphylococcus aureus. Infections with S. pneumoniae and H. influenzae are more common in children, whereas S. aureus most frequently affects adults. Chronic conjunctivitis is pri- marily due to Chlamydia trachomatis. However, chronically ill or immuno- compromised patients can become colonized with other virulent bacteria responsible for chronic con- junctivitis. Staphylococcus aureus and Moraxella lacunata may also cause chronic conjunctivitis in patients with associated blepharitis. "Hyperacute bacterial conjuncti- vitis is primarily due to Neisseria gon- orrhoeae, which is a sexually trans- mitted disease," Dr. de Luise said. "Neisseria meningitidis can also cause hyperacute bacterial conjunctivitis and can lead to potentially fatal meningeal or systemic infection." Diagnosis According to Francis Mah, MD, La Jolla, California, "Hyperacute bac- terial conjunctivitis is accompanied by a copious amount of green or gray mucus. If you take a tissue and wipe some of it away, it is back im- mediately. It is typically unilateral, although it can be bilateral. There can also be significant eyelid edema and redness of the eye." According to Dr. de Luise, this condition is so dramatic that it can't be mistaken for another condition. "It's an explosive, rapid onset, severely purulent, pussy conjuncti- vitis. The patient comes to you and is weeping yellow discharge. I've seen it a few times in my career, but thankfully not very often. There are three things to remember when you see hyperacute bacterial conjunc- tivitis: It's sight-threatening, it's potentially life-threatening if it's not treated immediately, and it requires systemic treatment and hospital- neonate transmission during vaginal delivery. It is rare in neonates now because of the use of silver nitrate or erythromycin ointment on all neonates when they are born." Dr. Mah added that Neisseria gonococcus is one of the rare patho- gens that can penetrate a normal, intact corneal epithelium. "Nor- mally bacteria, viruses, fungi, and parasites can't go through a normal cornea. They can only get in if there is a scratch, a defect, dry spots, or something abnormal on the cornea. Neisseria gonococcus can go through a normal, intact corneal epithelium, so it can cause an ulcer or a perfo- ration. Other pathogens that can penetrate an intact cornea are Herpes simplex, Listeria, Neisseria meningiti- dis, and Acanthamoeba," he said. ization. Gonococcus and meningo- coccus, which are the bacteria that cause this hyperacute conjunctivitis, can lead to corneal ulceration or corneal perforation, which can lead to endophthalmitis, or what we call a panophthalmitis, meaning every layer of the eye is inflamed," he said. The causes of hyperacute bacte- rial conjunctivitis are almost always bacteria in the genus Neisseria. "Neisseria gonorrhoeae or its cousin Neisseria meningitidis are often re- sponsible," Dr. de Luise said. "Neisse- ria gonorrhoeae is a sexually trans- mitted disease that would result from direct genital to eye contact or genital to hand to eye contact. It can also occur through maternal to Dr. Mah noted that because Neisseria gonococcus is associated with a sexually transmitted disease, it is important to get the patient's history in this regard. Patients should be asked whether they or their partner have a history of sexu- ally transmitted diseases. Treatment According to Dr. Mah, it is import- ant to continue to remove the copi- ous amounts of discharge because it contains Neisseria. "One of the main treatments is to irrigate and wipe the eye. Fluoroquinolone drops are also effective. Another component is systemic treatment. Azithromycin and doxycycline can be given orally. Patients with gonorrhea usually use ceftriaxone intramuscularly. If a patient is allergic to ceftriaxone, 2 g of azithromycin can be given orally in a single dose. Gentamicin drops could also be used, especially in younger children," he said. Dr. de Luise added that if the cornea is intact, the patient can be treated as an outpatient with intramuscular ceftriaxone, 1 g. If the patient has Neisseria gonorrhoeae, they would need to be treated with intramuscular ceftriaxone and oral azithromycin (1 g orally). "If the physician diagnoses hyperacute bacterial conjunctivitis, this can be a sexually transmitted disease by Neisseria gonorrhoeae bacteria," Dr. de Luise said. "One should be worried about Neisseria gonorrhoeae, which is the gonococ- cus, or rarely Neisseria meningitidis, which is the meningococcus that causes meningitis. Neisseria menin- gitidis can cause a panophthalmitis and subsequent meningitis, which can be life-threatening if not treated promptly." Patients with gonorrhea have a high risk of concomitant chlamydial disease. "It's very common to have

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