GONOCOCCAL OPHTHALMIA - sti.bmj.com · GONOCOCCAL OPHTHALMIA ByA. E. W. McLACHLAN,M.B., D.P.H., and...

VII

GONOCOCCAL OPHTHALMIA

By A. E. W. McLACHLAN, M.B., D.P.H., andG. M. THOMSON, M.B., D.P.H.

THE importance of the early diagnosis and promptinstitution of treatment in the prevention of cornealdamage in ophthalmia neonatorum is well recognised.Purulent gonococcal eye infections resulting at somelater period of life from inoculation from genito-urinaryfoci or from some unknown source present at least equal,if not even greater, dangers to sight. The relativeinfrequency of occurrence of the latter group, and, inthe absence of an admitted genital infection, failure toconsider the possibility of a gonococcal aetiology may,however, lead to delay' in the recognition of the truecause with consequent risk of visual impairment. Theoccurrence since I936 of 6 cases of purulent gonococcalophthalmia-in three instances before recognition of theassociated genital infection, and in three instancessporadic, i.e., without concomitant genital infection-resulting in the complete loss of sight of one eye in eachof 2 cases and a slightly marked nebula in a third,emphasises the seriousness of this condition.

CASEs ASSOCIATED WITH BUT OCCURRING BEFOREDIAGNOSIS OF GENITAL GONORRHCEA

(i) Tf. 4042. Female, aged i8 years. Single.Reported March I2th, I936.For one month had noticed slight inconstant irritation

of left eye (? toxic conjunctivitis from genital gonorrhoea).Five days previously the irritation of the eye becamemore marked and a slight serous discharge was noticed;forty-eight hours later marked pain and sero-purulentdischarge, gradually becoming worse. On admission:marked photophobia, profuse purulent discharge, cedemaof upper and lower eyelids, slight chemosis, cornea clear.Right eye unaffected. Smears showed the presence ofpus and gonococci in conjunctival secretion. Progress

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BRITISH JOURNAL OF VENEREAL DISEASES

under treatment satisfactory. Patient discharged onMay I5th, I936, no comeal damage. The genito-urinaryinfection cleared up without complications under routinetreatment. W.R. found to be + +, and patient stillunder observation for syphilis.

(2) Tf. 5537. Female, aged 43 years. ReportedDecember 2ISt, I936.

Eight days previously had noticed irritation of lefteye with slight photophobia; twenty-four hours laterslight discharge gradually becoming worse. On thefourth day, because of severe pain and discharge, she

FIG. i.-End result of Case 2-dense corneal leucoma and complete lossof vision of left eye.

consulted a doctor who advised her to report to hospitaland prescribed an eye-wash. The eye improved slightlywith treatment, but after twenty-four hours again becameworse and patient finally reported to hospital. Onadmission: profuse purulent discharge, marked cedemaof both eyelids, the upper overhanging the lower, corneacloudy and slight chemosis. Smears, Pus, + + Gc + +in conjunctival secretion. Subsequent progress: despitetreatment, a central perforation of the cornea occurred andpatient was finally discharged on February 27th, I937, witha dense leucoma almost completely covering the cornea.Course of concomnitant gonorrhoea uneventful (Fig. i).

(3) M. I552 Male, aged 38 years. Reported October26th, I938.

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Six days previously had noticed irritation of righteye; discharge commenced forty-eight hours later,gradually becoming purulent; slight pain and photo-phobia. On examination profuse purulent dischargefrom right eye, marked cedema of both lids, the upperoverhanging the lower; marked fleshy chemosis. Corneapresented a slightly ground glass appearance. Smears,Pus + Gc +. W.R. negative, Gc F.T. negative. Underroutine local treatment plus M. & B. 693 the con-dition rapidly subsided, the eye being pus-free in threedays and the cedema of the lids almost completelyresolved. The fleshy chemosis, however, persisted, andhad not completely resolved until the middle of the thirdweek ; patient was discharged from hospital on November26th, I938. End result: superficial nebula, slightlyhollowed out, in upper part of cornea. Some smallperipheral nebulke at the outer limbus on the level of themain nebula. No sign of any involvement of the deeperlayers of the cornea. No traces of any corneal nebula inlower corneal hemicircle. The genital gonorrhoea wascompletely cleared up by the M. & B. 693 adminis-tration without local treatment.

Cases i and 2 admitted the presence of a vaginal dis-charge for some indefinite time before the occurrence ofthe eye infection, but had disregarded it as. the symptomswere slight. Case 3 had noted a slight symptomlessurethral discharge for ten days before the commencementof the purulent conjunctivitis.

SPORADIC CASES, i.e., WITHOUT CONCOMITANTGENITAL INFECTION

(4) T. 7454. Male, aged 26 years. Single. ReportedOctober 2ist, I937.Three days previously had felt irritation of both eyes;

one day later noted discharge at first serous, but rapidlybecoming purulent. On examination, purulent dischargefrom both eyes, slight cedema of lids, no chemosis, corneaclear. Smears, Pus, + + in both eyes, Gc + in right eye,not demonstrated in left eye. W.R. negative, Gc F.T.negative. Under treatment the condition cleared uprapidly, and patient was discharged from hospital onNovember gth, I937, with no corneal damage. Sourceof infection ascribed to dirty lavatory towel.

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(5) Tf. 7820. Female, aged 3 years. ReportedDecember 3rd, I937.

Eight days previously " right eye started to oozepus "-treated with boric baths and fomentations. Sixdays later marked swelling of the right eyelids occurred,the left eye was discharging; medical advice was thensought. On examination, profuse purulent, slightlyhaemorrhagic discharge from right eye, marked cedemaof eyelids-upper overhanging the lower; cornea slightly

FIG. 2.-End result of Case 6-leucoma and anterior staphyloma:complete loss of vision of left eye.

opaque. Discharge and cedema less marked on left side,cornea clear. Smears, Pus + + and Gc + in smearsfrom both eyes. Blood, W.R. negative, Gc F.T. negative.Under treatment the condition improved rapidly, andafter eighteen days both eyes were practically pus-free.Discharged on thirty-second day after fourteen daysobservation. No corneal damage. No source of infectionascertained.

(6) A. IIo. Female, aged 27 years. Single. ReportedFebruary iith, I938.

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Five days previously noticed redness and slightdischarge of right eye, which rapidly became worse;three days later, swelling of eyelids. On examination,purulent discharge from left eye, marked oedema ofupper lid which overhung lower. Slight chemosis. Corneaopaque. Smears, Pus + + Gc + +. Blood, W.R.negative. Gc F.T. negative. Right eye unaffected.Twenty-four hours after admission, central perforationof the cornea occurred. The subsequent course of thedisease was protracted, the patient being discharged onthe ninety-eighth day with a dense corneal opacity andan anterior staphyloma. Sulphanilamide was exhibited,but was discontinued after the second dose because ofsevere vomiting. This patient ascribed the infection toa towel used in a railway toilet two days before theonset of the symptoms (Fig. 2).

INCIDENCEThe incidence of purulent gonococcal conjunctivitis, in

view of the accidental nature of the contagion, is difficultto assess. Table I, however, shows the local incidenceand end results since I936:

TABLE I

Gonococcal OphthalmiaTotal Number of

Cases of GonorrheeaYear under Treatment Associated with Spra. End Result of AffectedeInfectioui Sporadic Eye(s)

Male Feinale Male Femnale -lale Female

1936 I,304 293 - 2 - One eye infected ineach case. Recoveryin one, loss of sightin one.

1937 1,367 257 - I Both eyes infected inmale-recovery com-plete. Bilateral in-fection in female-recovery complete.

1938 1,423 256 I I Unilateral infectionin male - slightsuperficial nebulaeover upper portionof cornea. Uni-lateral infection infemale - completeloss of vision.

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CLINICAL COURSEThe clinical course is similar to, but frequently more

rapid and severe than that of ophthalmia neonatorum.Commencing with irritation, slight photophobia, con-junctival injection and scanty serous discharge, thecondition rapidly progresses to the characteristic pictureof severe pain, marked photophobia, profuse purulentdischarge, cedema of the eyelids, the upper one oftenoverhanging the lower and fleshy chemosis.When chemosis is marked the swollen conjunctiva may

overlap the corneal margin leading to retention of puswith consequent risk of marginal ulceration. Cornealclouding, ulceration and perforation may occur with theattendant sequele of macula, nebula, leucoma or staphy-loma formation, or panophthalmitis.Normally the line of closure of the eyelids falls opposite

the junction of the middle and lower thirds of the cornea.CEdema of the lower lid, as may be shown by experimentalinfiltration in the cadaver, may raise the level of the tarsalborder of the lower lid to above the level of the centreof the cornea and may also cause slight inversion of thisborder, while conjunctival cedema tends to limit thenormal upward rotation of the eyeball.The risk of pressure damage from the comparatively

rigid tarsal edge is increased by the pressure from theupper lid, while the upward drag of this lid may increasethe inversion of the lower. This sequence is illustratedby the occurrence in Case 3 of superficial nebuke abovethe level of the centre of the cornea. In the two casesin which perforation occurred this took place at the centreof the cornea-the area of least nutrition. It seemspossible that pressure from the tarsal edge of the lowereyelid may be an important factor in corneal damage.The minimal scarring of the cornea in Case 3 appears tobe due to the rapid control of the infection by M. & B.693. Pre-auricular adenitis with marked pain de-veloped in Case 6, but no other complications such asabscess of the eyelid, infection of the ethmoid air cells,lachrymal duct, orbital cellular tissue or meninges wereseen.

DIAGNOSISIn the early stages there is slight photophobia, con-

junctival injection and a scanty serous discharge as in2I8



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other bacterial infections. In toxic conjunctivitis dis-charge and cedema are slight and chemosis is absent. Alater accidental contagion superimposed on a toxicconjunctivitis may have occurred in Case i. Theimportance of microscopical examination of smears ofthe exudate in early cases is emphasised: in the majoritythe gonococcus is easily demonstrated. In advancedcases the clinical picture gives rise to little doubt as to theprobability of gonococcal infection.

PROGNOSISIn general the earlier the diagnosis is made the more

favourable the outcome. Any suggestion of cornealopacity or ulceration is of serious import as to thepreservation of vision. Since the utmost care should betaken to prevent corneal damage during irrigation orinstillation a skilled attendant is essential. Ulcerationinvariably follows injury and pressure on the eyeball inseparating the lids may cause rupture of the floor of theulcer.

PREVENTIVE ASPECTSThe eye may be infected by digital contamination in a

patient suffering from genital gonorrhoea; by directinfection of the clinician or nurse from ophthalmic orgenital gonorrhceal infections: or from contaminatedtowels, sponges or other toilet appliances. Digitalinfection of the eye is stated to be more common in malesthan in females and the right eye more frequently affectedin right-handed persons than the left. Cases i and 3support this rule-a left-handed female having a lefteye and a right-handed male a right eye involved. InCase 2, however, a right-handed female, the left eye wasinvolved.The necessity of impressing on patients affected with

genital gonorrhoea how to avoid contaminating the eyesis evidently well recognised and carried out as eyeinfections in practice are rare. Strict nursing precautionsand the provision of goggles for those treating cases ofophthalmia neonatorum are necessary. In 3 cases comingunder our notice in which there was a probability ofaccidental eye infection, immediate prophylaxis of Credetype following lavage proved successful. The avoidance

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of other than freshly laundered towels and the use ofstrictly personal toilet equipment obviate any risk ofsporadic contagion.

TREATMENTImmediately on admission to hospital the unaffected

eye must be protected with a Buller's shield. The eyesshould be kept discharge free by frequent lavage withweak antiseptic solutions such as I/20,000 Potass.Permang., i/6,ooo Mercurochrome, boric lotion or saline,at first at half-hourly intervals. Later, astringentlotions, such a I/2,000 zinc sulphanilate or zinc sulpho-carbolate, are indicated. Atropine drops are appliedonce daily and instillations of I/I,500 neutral flavine incastor oil or IO to 25 per cent. argyrol are given four-hourly, or more frequently in severe cases. Painting thepalpebral conjunctiva with I to 2 per cent. silver nitratesolution is favoured by many, but was not found necessaryin this series of cases.The introduction of sulphonamide compounds for

gonorrhceal infections has materially improved the out-look of purulent gonococcal conjunctivitis. In Case 3,and in two recent cases of ophthalmia neonatorum, treatedwith M. & B. 693, the results clinically and bacterio-logically were dramatic, the eye being pus-free in threedays. In view of the possibility of intolerance, as inCase 6, the routine local treatment should be commencedat once.

In the present series of cases vaccines were notemployed; these have been proved a valuable adjunctin the treatment of ophthalmia neonatorum. Operativemeasures were not required in our cases. Externalcanthotomy may have to be considered in cases in whichnarrowness of the palpebral fissure and cedema of thelids interfere with efficient lavage and especially whenchemosis and pus retention threaten marginal ulceration.

SUMMARY AND CONCLUSIONSSix cases of purulent gonococcal ophthalmia are

reported. In 3 cases infection of the eyes occurred beforerecognition of the associated genital infection: in theremaining 3 cases, without concomitant genitalgonorrhoea, the source of infection was not ascertained,but was ascribed in two instances to dirty lavatory towels.

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In each of 4 cases one eye alone was affected; in theremaining two the infection was bilateral.That a purulent gonococcal conjunctivitis remained

unilateral in 4 cases out of 6, despite the possibilities ofcontagion of the non-infected eye, is a striking feature andin sharp contradistinction to the commonly bilateral non-gonococcal forms of conjunctivitis.

Of the 8 eyes affected, complete loss of vision resultedin two, and a slightly marked nebula in a third.The seriousness of 'the condition, the necessity for

early bacteriological investigation of any suspiciousconjunctivitis, especially if unilateral, and the earlyinstitution of treatment are emphasised.

The in-patient care of Cases i and 2 was carried out byDr. Sydney Thompson to whom we are indebted for theclinical details covering this period: we are also indebtedto Mr. Alex MacRae for helpful advice and criticism.

(Since the above was written, a further case has comeunder our care. M. 270I, male, aged 34 years, right-handed. Reported on May I2th, I939, with genitalgonorrhoea. Treated with Albucid orally and per-manganate irrigations. Did not return till June iith,I939, when admitted to hospital with a purulent con-junctivitis of three days' duration. Stated that theurethral discharge had ceased in three days and hadconsidered himself cured despite an intermittent gleet.On examination: purulent discharge from left eye, slightchemosis, no corneal involvement. Pus + + Gc + +.Right eye clear. Slight muco-purulent urethral discharge,Pus + + Gc +. Under routine lavage and M. & B.693 the eye condition improved rapidly, and now onthe fifth day of treatment is pus- and organism- free.Under observation, and treatment for genital infection.)

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