|Year : 1984 | Volume
| Issue : 1 | Page : 17-20
Epidemic gonococcal ophthalmia in adults in Tanzania
JLF Sangawe, AT Mtanda
Department of Ophthalmology Muitimbli Medical Centre, P. O. Box 65000, University of Dares Salaam, (Tanzania)
Deptt. of Ophthalmology, Muitimbli Medical Centre, University of Dares Salaam, Tanzania
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Sangawe J, Mtanda A T. Epidemic gonococcal ophthalmia in adults in Tanzania. Indian J Ophthalmol 1984;32:17-20
Gonococcal ophthalmia neonatorum has now fallen in Western countries to an incidence of 1% with improved hygienic and therapeutic measures (Jones et al, 1957). In adults, the infection is almost always transmitted accidentally from the genitals to the eyes either through the contaminated fingers or inanimate objects.
Due to the social and economic changes in our society and the relative sexual freedom of adolescents in the towns, there is an increase in venereal infections. The incidence of gonococcal ophthalmia in adults in this country is unknown. In the Muhimbili Medical Centre reports, there have been two cases of gonococcal ophthalmia in adults reported in seven years (1975 to 1981). In this paper we report twenty-two cases seen at the same hospital within a period of two months in 1982.
| Materials and methods|| |
Twenty-two patients with copious purulent conjunctivitis were seen at the Muhimbili Medical Centre eye clinic within a period of two months. All of them lived in the city of Dares Salaam.
The patients presented with similar symptoms of sandy sensation or foreign body like sensation in the eye (eyes) followed within a very short period with redness, profuse conjunctival discharge and marked swelling of the eyelids. A few complained of pain in the eyes.
The male patients admitted of having dysuria and pus discharge per urethra one to three weeks prior to the onset of the conjunctivitis. All of them except one had received treatment from the nearest dispensaries or privately run clinics for the venereal infection. However, for various reasons, they received inadequate treatment so that by the time we saw them they still had profuse discharge per urethra. The female patients on the other hand, denied having any foul discharge per vagina or dysuria. Neither of them had sought nor received any treatment.
All the patients except one male had received some form of treatment for conjunctivitis which was inadequate.
At the eye clinic, the visual acuity of each patient was recorded and a detailed examination of the eyes performed. Immediate Gram stain and culture/sensitivity tests of the conjunctival discharge, urethral discharge (in the males) and cervical discharge (in the females except in one young girl) were carried out After these procedures, the eyes were cleaned with wet cotton swabs and penicillin eye drops (100,000 units/ml).instilled in both eyes and then the patients admitted to the eye ward where intensive treatment was given in the form of frequent cleaning of the conjunctival discharge, hourly instillation of penicillin eye drops and intramuscular procaine penicillin (1.2 mega units for 5 days). One patient with impending corneal perforation had conjunctival flap operation performed.
| Observations|| |
Sex wise distribution of cases is shown in [Table - 1][Table - 2]. All of them except one 41h years female girl, were young adults between 17-45 years of age.
All the patients had swollen lids, copious purulent conjunctival discharge and chemotic conjunctiva which formed a cup like rim around the limbus. The cornea was involved in twenty eyes (45.5%). Eleven of these were corneal ulcers and nine corneal perforations [Table - 3]. Most of the ulcers were marginal, involving the upper quadrant (12 O' clock position)and lower- quadrant (6 0' clock position). The perforations also occurred at these sites. In one eye, the cornea had two perforations [Figure - 1] and in another, all of the corneal tissue was totally destroyed [Figure - 2]. Conjunctival flap was performed in one eye to prevent impending corneal preformation.
Gram stained smears showed-pus cells and Gram negative diplococci both intracellularly and extracellularly. The cultures from conjunctiva, urethra and cervix were positive or Neisseria gonorrhea. The organisms were sensitive to the commonly used antibiotics i.e. penicillin, chloramphenicol and tetracycline.
The intensive topical penicillin drops and systemic penicillin rapidly improved both the ocular and the genital infections. By the third day all had marked improvement. Most of the patients were discharged on the 5th to 15th day after onset of therapy except for four patients who remained in the ward for a longer period. One month after discharge their visual acuity was taken and using the World Health Organisation (WHO) Classification of visual impairment and blindness the uniocular visual acuity was as shown in [Table - 4].
The binocular visual acuity with best correction is shown in [Table - 5] (18 patients retained normal vision, three had visual impairment and one became blind)
| Discussion|| |
The epidemic occurred primarily in the low socio-economic class living in the slums of Dar es Salaam. This is mainly due to the poor personal hygiene and the careless attitudes this "class of people" has on venereal infection.
As observed in this study, seventeen patients (77.3%) were single young adults and five (22.7%) were married. This reflects a high proportion of venereal disease among the teen-age and young adult population which is likely to increase the ocular spread in this age group.
A high proportion of the male patients received inadequate treatment for the gonococcal urethritis either because they had no money to buy the medicines or because there were no medicines available in the government dispensaries. Probably with improved personal cleanliness and adequate treatment of the gonorrhoeal infection this epidemic would not have occurred. In view of this it is essential that the existing health facilities should be improved to cope with VD problem in the susceptible areas.
The conjunctivitis was also mismanaged. Although all the patients except one got treatment before being referred to Muhimbil: Medical Centre, all of them were giver inadequate therapy. Many of the patients and Medical Personnel in the dispensaries/clinics were under the impression that the conjunctivitis was acute haemorrhagic conjunctivitis which was rampant in Dar e Salaam at that time. To make matters worse the local new,, papers carried an article urging people with conjunctivitis not to worry as the disease way self-limiting, thus misleading most of these patients to believe that the disease would clear without treatment
All the Neisseria gonorrhoea strains were sensitive to penicillin and other commonly used antibiotics. Although there have been a few reports of penicillin resistant gonococci (Snowe et al, 1973) none in were in this study. Therefore unless contraindicated a combination of parenterally and topically administered penicillin remains the drug of choice in this disease (Amstrong et al, 1976).
Gonococcal infection of the eye is usually a purulent conjunctivitis. Secondary corneal involvement may occur progressing from ulceration to perforation and even the loss of an eye (Duke-Elder, 1965 and Harden et al 1975).
To avoid corneal damage, the treatment of gonococcal ophthalmia must be started early and should be intensive. This is clearly demonstrated in this study whereby those patients who came to our clinic early and had intensive treatment escaped corneal damage. Because of the rapid progression of the disease to ocular perforation and blindness, specific chemotherapy should be based on the Gram stain without having to wait for culture results (Snowe et al, 1973).
The mode of transmission in this epidemic is by direct transfer of the organisms from the genital organs to the eyes by dirty hands etc rather than eye to eye transmission. This view is supported by the fact that most of the patients had associated gonococcal urethritis/cervicitis. The young girl (4' years) probably got the infection transferred to her eyes from her nurse-maid who had the infection. The two female patients in whom no gonococci were isolated could still have the infection inspite of negative culture results (Pearson 1957 and Amstrong et al 1976)
| Summary|| |
Twenty two cases of gonococcal ophthalmia in adults were seen in Muhimbili Medical Centre within a period of two months (Jan-March 1982). Corneal involvement was a common feature in those patients who presented late. None of the organisms isolated showed any resistance to penicillin and all the patients responded very well to this drug. The. mode of spread in these cases was by accidental transfer of the organisms from the genitals to the eyes rather than by eye to eye transmission. The epidemic probably does not represent an increase of gonorrhoea in the population but reflects the poor personal hygiene and inadequate treatment of this condition in the low socio-economic class in the slums of Dares Salaam.
| References|| |
Amstrong J.H., Zacarias F., and Rein M. 1976, Paediatrics 57:884.
Duke Elder, Sir Stewart 1965, Systems of Ophthalmology Vol 8 Pt 1 Pg. 310.
Harden AF. 1975, The Practitioner 214:636.
Pearson H.E. 1957, Am. J. Obstet Gynecol, 73:804.
Snowe RJ. and Wilfert C.M. 1973, Paediatrics, 51:110.
[Figure - 1], [Figure - 2]
[Table - 1], [Table - 2], [Table - 3], [Table - 4], [Table - 5]