Hyperacute Conjunctivitis
Hyperacute conjunctivitis is a vision-threatening bacterial infection, most commonly caused by Neisseria gonorrhoeae, characterized by rapid onset of severe purulent discharge, marked eyelid edema, and high risk of corneal involvement that can progress to perforation within 24 hours if untreated. 1
Clinical Presentation
The hallmark features that distinguish hyperacute from other forms of conjunctivitis include:
- Copious purulent discharge that re-accumulates immediately after being wiped away 1
- Marked eyelid edema with severe bulbar conjunctival injection 1
- Rapid progression with symptom onset and worsening within hours to days 2
- Preauricular lymphadenopathy is commonly present 1
- Corneal involvement is the critical finding to detect—look specifically for superior corneal infiltrates or ulcers, which can rapidly progress to perforation 1
Causative Organisms
While Neisseria gonorrhoeae is the classic cause, other organisms can produce hyperacute presentations:
- N. gonorrhoeae is the most common cause in sexually active adults and neonates 1, 2
- N. meningitidis can cause primary meningococcal conjunctivitis with similar severity and systemic complications 3
- Beta-hemolytic streptococci rarely cause hyperacute presentations but have been documented 4
Age-Specific Considerations
In neonates, hyperacute conjunctivitis manifests within 1-7 days after birth (later if prophylactic antibiotics were used), representing ophthalmia neonatorum 1, 5
In sexually active adults, consider oculogenital transmission and screen for concurrent genital infection 1
In children, sexual abuse must be considered and documented with standard culture 1
Immediate Management
This is an ophthalmologic emergency requiring immediate systemic antibiotic therapy—topical treatment alone is insufficient. 1
The American Academy of Ophthalmology recommends:
- Obtain Gram stain and cultures before initiating treatment to confirm Gram-negative diplococci 3
- Initiate systemic antibiotics immediately upon clinical suspicion—do not wait for culture results 1
- Ceftriaxone 1g IM/IV is the first-line systemic therapy 1
- Add treatment for Chlamydia trachomatis as coinfection is common (azithromycin 1g orally single dose or doxycycline 100mg twice daily for 7 days) 1
- Consider saline lavage of the infected eye to reduce bacterial load 1
Critical Pitfalls to Avoid
- Delaying systemic antibiotics while waiting for culture results can result in corneal perforation and permanent vision loss 1
- Using topical antibiotics alone is inadequate for gonococcal conjunctivitis 1
- Missing corneal involvement on initial examination—always perform careful slit-lamp examination looking for superior corneal infiltrates 1
- Failing to treat sexual partners and screen for other sexually transmitted infections 1
- Not considering meningococcal disease when N. meningitidis is identified—systemic complications can be life-threatening and prophylaxis for close contacts is required 3
Follow-up
Patients require close monitoring within 24-48 hours to assess treatment response and evaluate for corneal complications 1. The CDC recommends retesting approximately 3 months after treatment for both gonococcal and chlamydial infections 1.