Love Almost Made Him Blind: The Role Of Penetrating Keratoplasty In Gonococcal Corneal Perforation

To present a rare case of severe gonococcal keratoconjunctivitis in a young male patient, leading to corneal melting and requiring urgent penetrating keratoplasty. This case highlights the importance of early recognition and aggressive management to prevent complications and preserve vision.

Retrospective analysis of clinical data, imaging, and surgical video from a patient evaluated at a tertiary ophthalmology center. The case was managed at the Department of Ophthalmology, Unidade Local de Saúde de São João, Porto, Portugal.

A 22-year-old male initially diagnosed with conjunctivitis in left eye (OS) at another hospital, due to worsening symptoms, presented to our emergency department with eyelid edema, purulent discharge, chemosis, diffuse conjunctival hyperemia, tarsal membranes, and a corneal epithelial defect without anterior chamber reaction. The membranes were removed and he was treated with topical ofloxacin 2/2 hours, cyclopentolate 2id and chloramphenicol+prednisolone ointment at bedtime. Four days later, patient returned with worsening symptoms and onset of similar symptoms in the right eye (OD). In OS severe corneal melting (>3mm) and a shallow anterior chamber was observed. Upon further questioning, he disclosed recent unprotected sexual activity.

A systemic workup for sexually transmitted infections (STIs) and microbiological analysis of secretions confirmed Neisseria gonorrhoeae. With collaboration of the Infectious Diseases, patient was hospitalized and treated with intramuscular ceftriaxone 1g, oral moxifloxacin 400mg id and doxycycline 100mg 2id. Topical fortified antibiotics were administered hourly in the OS, while the OD received topical ofloxacin. Due to progressive corneal melting, urgent penetrating keratoplasty was performed. One-year post-surgery, the corneal graft remained clear with no signs of rejection or recurrence. Best-corrected visual acuity improved from counting fingers preoperatively to 0.7 with contact lenses.

Gonococcal keratoconjunctivitis is a rare but aggressive ocular infection with the potential for rapid corneal melting and vision loss. It’s an emerging concern due to the resurgence of STIs and can manifest without genital symptoms. Early microbiological diagnosis and prompt systemic and topical treatment are critical. This case underscores the importance of considering gonococcal infection in sexually active individuals presenting with hyperacute conjunctivitis and highlights the role of corneal transplantation in severe cases. Multidisciplinary collaboration between Ophthalmologists and Infecciologists is crucial for optimizing patient outcomes and preventing further complications.