Gonorrhea of the eye

Gonorrhea is a human venereal disease that primarily affects the mucous membranes of the genitourinary organs.

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Causes and epidemiology of gonorrhea of the eyes

The disease is caused by the gram-negative diplococcus Neisseria. The source of infection is a person with gonorrhea. The transmission route is mainly contact. Gonorrhea of the eyes can develop in adults suffering from gonorrhea of the urogenital tract, as a result of the infection being carried into the conjunctival cavity, in persons who are in contact with patients if they do not observe hygiene rules. Cases of gonorrhea of the eyes have been described in health care workers who have served such patients. Newborns are infected mainly when passing through the birth canal of a mother suffering from gonorrhea. Intrauterine metastatic infection is extremely rare. Gonorrhea can also develop in children as a result of infection being carried in from outside by contaminated hands, linen, care items, etc.

Pathogenesis of gonorrhea of the eyes

Gonococci, getting on the mucous membrane, quickly multiply and after 3-4 days penetrate the subepithelial tissue through the intercellular spaces, causing local inflammation, manifested by conjunctivitis. Hematogenous dissemination, accompanied by the multiplication of gonococci in the blood, intoxication and metastases to various organs, is currently extremely rare. A certain part of hematogenous complications in gonorrhea (arthritis, uveitis) is caused by transient bacteremia. In it, gonococci are only mechanically transported by the bloodstream, without multiplying in the blood and not staying in it for a long time, but quickly settle in tissues and organs. In the body, especially in chronic gonorrhea, immunobiological shifts occur, leading to autoallergy. Autoaggression can play a certain role in the pathogenesis of post-gonorrheal diseases. Late toxic, toxic-allergic eye lesions are caused not by the effect of gonococcal endotoxin, as was previously believed, but by the addition of a secondary infection (virus, pneumococcus, etc.). Thus, uveitis, sometimes combined with joint damage, occurs 2-4 weeks or more after the end of treatment, when the gonococci have already disappeared. In this regard, they are considered allergic reactions of the body with a high degree of sensitization to any of the infectious agents.

Symptoms of gonorrhea of the eyes

The incubation period lasts from several hours to 3 weeks, usually 3-5 days. Clinically, eye damage in gonorrhea most often manifests itself as conjunctivitis. A distinction is made between gonorrheal conjunctivitis in newborns (gonoblennorrhea) and adults.

Gonoblenorrhea of newborns begins on the 2nd-3rd day after birth. The appearance of the first signs of the disease after 4-5 days indicates the introduction of infection from the outside. In most cases, the disease is bilateral from the very beginning; less often, first one eye is involved in the process, and then the other. In the clinical course of untreated gonoblenorrhea, 4 stages are distinguished. The first stage - the infiltration stage - is characterized by the appearance of a watery discharge from the conjunctival cavity and rapidly increasing hyperemia of the mucous membrane. From the 2nd day of the disease, edema of the eyelids appears, their skin becomes tense, it is difficult to open the palpebral slit, it is impossible to evert the eyelids. The conjunctiva of the eyelids is hyperemic, edematous, its surface is shiny, smooth, sometimes covered with fibrinous films, bleeds easily. The discharge at the height of the first stage becomes serous-bloody. On the 3rd-5th day, the second stage - suppuration - begins. The swelling and hyperemia of the eyelids decrease, they become soft. The conjunctiva of the eyeball remains edematous and surrounds the cornea with a ridge. The discharge is abundant, thick, purulent, yellow. This stage lasts 1-2 weeks, then passes into the third stage - proliferation. The amount of pus decreases, it becomes liquid, greenish. Hyperemia and swelling of the conjunctiva are less pronounced, as a result of the growth of papillae, roughness appears on the surface. The fourth stage - the stage of regression - is characterized by the disappearance of swelling and hyperemia of the conjunctiva. Follicles, papillary growths last much longer, disappearing only by the end of the 2nd month. A common complication of gonoblenorrhea is corneal damage, which can develop with insufficient treatment. Corneal complications arise as a result of deterioration of its trophism due to compression of the vessels of the marginal loop network by edematous conjunctiva, as well as due to maceration of the corneal epithelium by pus, toxic effects of gonotoxins and gonococci themselves, and the addition of a secondary infection. Corneal damage develops in the 2nd-3rd week; of the disease, very rarely at an earlier date. In this case, the cornea becomes diffusely cloudy. In its lower part or in the center, a gray infiltrate appears, which quickly turns into a purulent ulcer. The ulcer spreads along the surface of the cornea and into the depths, often leading to perforation with the subsequent formation of a simple or fused leukoma.

Less often, the infection penetrates into the eye and causes the development of panophthalmitis.

Gonoblenorrhea of newborns should be differentiated from blennorrheal conjunctivitis, which is also accompanied by pronounced conjunctival symptoms and abundant purulent discharge. These conjunctivitis are caused by various pathogens: pneumococcus, pseudomonas and intestinal bacteria, staphylococcus, streptococcus, a large virus similar to the trachoma virus, etc. The diagnosis of gonorrheal conjunctivitis is finally established after a bacteriological examination of a smear from the conjunctiva. In this case, gonococci are found located intracellularly and extracellularly. Sometimes, in the clinical picture of gonoblenorrhea of newborns, gonococci are not detected, but cellular inclusions are found in the epithelial cells of the conjunctiva, similar to Prowazek bodies in trachoma. Blennorrhea with inclusions, which appears no earlier than a week after the child’s birth, is much easier than gonorrhea and does not cause complications in the cornea.

Gonoblenorrhea in children and adults

The clinical course of the disease goes through the same stages as neonatal gonoblenorrhea, but is more rapid. Complications from the cornea are frequent.

The prognosis for timely and correct treatment of gonoblenorrhea is favorable and becomes serious when the cornea is involved in the process. A. I. Pokrovsky describes the development of metastatic conjunctivitis with the generalization of gonorrheal infection. Metastatic conjunctivitis occurs extremely rarely and is manifested by a picture of catarrhal conjunctivitis (mild swelling of the mucous membrane of the eyelids and eyeball, sometimes pinpoint hemorrhages in the conjunctiva and a rash of small nodules at the limbus).

Gonorrheal iridocyclitis often develops months to years after treatment and is regarded as an allergic process.

Less common is metastatic iridocyclitis with fresh gonorrhea or reinfection. Iridocyclitis is often combined with arthritis, more often with monoarthritis of the knee joint. The process is predominantly one-sided, accompanied by severe pain, and a pronounced inflammatory reaction. In gonorrheal iridocyclitis, a characteristic serous-fibrinous exudate resembling a transparent, fluctuating gelatinous mass is found in the anterior chamber of the eye. Sometimes hyphema occurs and multiple synechiae are formed. With appropriate local and general treatment, the exudate quickly resolves, the anterior synechiae are easily torn, and visual functions, as a rule, are not affected.

Diagnosis of gonorrhea of the eyes

The etiologic diagnosis is based on the anamnesis and a specific clinical picture. The main diagnostic method is bacterioscopy. The discharge from the conjunctival cavity and urogenital tract is examined. Staining is done according to Gram, and preliminarily with methylene blue. If gonorrhea is suspected, when gonococci are not found bacterioscopically, a cultural method is used - sowing on a medium (meat-peptone agar). By the sowing method, gonococci are detected 4-6 times more often than by bacterioscopy. Serological studies, in particular the Bordet-Gengou reaction, have no diagnostic value in acute gonorrhea. Usually during this period it is negative, despite the presence of gonococci, due to the absence of antibodies. This reaction is used to recognize complications of gonorrhea (iridocyclitis, arthritis). In order to detect infection in hidden foci, various provocation methods are used: mechanical, chemical or biological. Biological provocation consists of intramuscular administration of 500 million microbial bodies of gonovaccine or in combination with 200 MPD of pyrogenal.

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Treatment of gonorrhea of the eyes

General (antibiotics, mainly penicillin series, sulfonamides, in chronic and latent forms - gonovaccine, pyrogenal) and local therapy are carried out. In case of gonorrheal conjunctivitis, local treatment consists of washing the conjunctival cavity with a solution of potassium permanganate 1: 5000, furacilin, instillation of antibiotic solutions, 30% solution of sodium sulfacyl, 2-3% solution of collargol. At night, it is advisable to apply an ointment with an antibiotic or sodium sulfacyl. If corneal ulcers appear, mydriatics and enzymes (trypsin, chymotrypsin, papaya) are additionally used. Treatment is stopped when clinical manifestations disappear and the conjunctival cavity is sterile. Repeated control bacterioscopic examinations of smears from the conjunctiva are mandatory. For the treatment of gonorrheal iridocyclitis, mydriatics are applied locally in drops, by electrophoresis, subconjunctivally, antibiotics (usually subconjunctivally), enzymes (trypsin, chymopsin, chymotrypsin). Usually, intensive desensitizing therapy is carried out (diphenhydramine, pipolfen, tavegil, diazolip, metaglobulin, etc.), corticosteroids are prescribed according to indications.

Prevention of gonorrhea of the eyes

Prevention of ocular gonorrhea consists of timely detection and treatment of patients with gonorrhea, compliance with personal hygiene rules. In order to prevent gonoblenorrhea in newborns, mandatory examination of pregnant women for gonorrhea is carried out and, if detected, timely and active treatment. Prevention of gonoblenorrhea in newborns and maternity hospitals is mandatory. In our country, the Matveyev-Crede method of prevention has become widespread. It consists of treating the eyelids with a cotton swab soaked in a 2% solution of boric acid, and then instilling 1-2 drops of a 2% solution of silver nitrate into each eye. Currently, each eye is instilled with freshly prepared 30% solution of sodium sulfacyl. After 2 hours, in the children's ward, 30% solution of sodium sulfacyl is instilled again. The drug should be one-day.