## Clinical Diagnosis **Key Point:** Gram-negative diplococci in acute purulent conjunctivitis with severe pain and photophobia is pathognomonic for *Neisseria gonorrhoeae* (gonococcal conjunctivitis). ## Management Strategy **High-Yield:** Gonococcal conjunctivitis is an ophthalmologic emergency requiring aggressive systemic and topical therapy to prevent corneal perforation and permanent vision loss. ### Rationale for Correct Answer The combination of: - Topical fluoroquinolone (e.g., ofloxacin or moxifloxacin) for local control - Systemic cephalosporin (ceftriaxone 1 g IM single dose OR cefixime 400 mg PO) for eradication **Clinical Pearl:** Systemic therapy is mandatory because topical antibiotics alone cannot achieve adequate aqueous humor and systemic concentrations. Cephalosporins are first-line due to increasing fluoroquinolone resistance in *N. gonorrhoeae*. **Warning:** Do NOT rely on topical therapy alone—this risks corneal involvement and perforation within 24–48 hours if untreated systemically. ### Adjunctive Measures - Frequent saline irrigation to remove purulent material - Cycloplegic drops (cyclopentolate) to relieve ciliary spasm and pain - Systemic NSAIDs for pain control - Screen for other STIs (chlamydia, syphilis, HIV) and partner notification ## Differential Consideration | Feature | Gonococcal | Chlamydial | Bacterial (other) | |---------|-----------|-----------|-------------------| | Onset | Acute (1–3 days) | Subacute (5–14 days) | Acute (1–2 days) | | Discharge | Copious, purulent | Mucopurulent, scanty | Purulent | | Pain | Severe | Mild–moderate | Mild–moderate | | Gram stain | Gram-negative diplococci | Intracellular (Gram-negative) | Gram-positive or negative cocci/rods | | Systemic therapy | **Mandatory** | Oral doxycycline | Topical often sufficient | [cite:Harrison 21e Ch 137] 
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