Ophthalmia Neonatorum

Synonym: conjunctivitis of the newborn.

This is a conjunctivitis occurring in the first 28 days of life.¹ It is most commonly infective in origin: Neisseria gonorrhoeae, Chlamydia trachomatis, bacteria such as staphylococci, streptococci and viruses - notably the herpes simplex virus but may also occur as a reaction to chemical irritants. The latter is a self limiting condition lasting no more than 24 to 36 hours but infections need treatment. Neisseria or Chlamydial infections are also notifiable diseases.

• Incidence is about 3.1 per 1000 live births² although this varies according to the socioeconomic status of the area.³
• There is a high rate of transmission from infected mother to infant - up to 50% in the absence of prophylaxis.⁴

Babies present with a purulent, mucopurulent or mucoid discharge from one or both eyes within the first month of life. Look for injected conjunctiva, lid swelling and discharge.⁵ There may be associated systemic infection.

• Chemical conjunctivitis - there is a mild irritation, tearing and redness in a baby who has been administered prophylactic silver nitrate (used for the prevention of gonorrhoeal infection).
• Chlamydial infection - 5 to 14 days after birth: uni-/bilateral watery discharge which becomes copious and purulent later on.
• Gonorrhoeal infection - typically 3-5 days after birth but may occur later: acute conjunctival injection and chemosis, lid oedema and purulent discharge. There may be associated corneal ulceration and perforation.⁵
• Bacterial conjunctivitis - often (but not invariably) longer incubation period than for the other infective causes. Depending on the pathogen, there may be a mixed picture of a red eye with lid swelling and varying amount of discharge. Pseudomonas spp. infection is very rare but may be devastating and in disseminated cases, can ultimately lead to death.
• Viral conjunctivitis - usually 2 weeks after birth: uni-/bilateral serosanguinous discharge ± vesicular skin lesions.

A blocked nasolacrimal duct is common and results in a thick (sometimes copious) discharge which may be sticky or crusty. The eye is not red and the baby is otherwise well. The discharge may be intermittent and responds well to simple cleansing. Most babies' ducts clear as they grow, the majority being perfectly normal by 6-12 months of age.

These are carried out in the Eye Unit and will include:

• History - previous or concurrent sexually transmitted disease in the mother and results of any cervical cultures obtained during pregnancy.
• Ocular examination - penlight and fluorescein examination.
• Microbiology investigations - conjunctival swabs (obtained from the everted lid) and cultures including for chlamydial detection and viral cultures. The gram staining is requested urgently. Even if gonorrhoeal infection is strongly suspected, investigation for chlamydia should be carried out and vice-versa in the case of suspected chlamydial infection.
• Mother - she will need cervical swabs for gonorrhoea, chlamydia and viral infection and so will need to be seen at the genitourinary medicine clinic. There must also be efforts to trace contacts.⁵

Referral

The majority of neonates presenting with a sticky discharge have a benign cause - most frequently due to blocked nasolacrimal duct(s). Problems suggesting that referral is necessary include:

• If the conjunctiva is red, especially if the bulbar conjunctiva (overlying the sclera) is red.
• If the onset is sudden and severe.
• If the baby is distressed or unwell.
• If both eyes are affected.
• If there are suspicions of a possible maternal infection.
• If the mother or you are concerned.

If you suspect ophthalmia neonatorum, refer immediately. Early and appropriate treatment has long been recognised as the key to preventing consequent blindness.⁶

Initial therapy⁵

Prior to results from Gram staining (or if these are inconclusive), it is appropriate to start the infant on a broad spectrum antibiotic e.g. ofloxacin 0.3% q.d.s. for a week until the microbiology results have come back.

Chemical conjunctivitis

No treatment is required although some favour the use of preservative-free artificial tears q.d.s. These babies need early review (24hours) to confirm that this was indeed a case of chemical irritation as opposed to early infection.

Chlamydial infection

Oral erythromycin syrup (50 mg/kg/day in four divided doses) for 14 days. Topical treatment alone is not sufficient and is not necessary when systemic treatment is taken. The mother and her sexual partners will also need treating.

Gonorrhoeal infection

These babies need hospitalisation and evaluated for disseminated disease. There is no established treatment protocol but options include ceftriaxone (single dose: 25-50 mg/kg iv or im, no more than 125 mg total) or cefotaxime (single dose: 100 mg/kg iv or im). If there is penicillin or cephalosporin allergy, the infectious disease consultant will need to be involved. Additionally, these infants can be treated with bacitracin eye ointment 2-4 hourly and topical saline lavages to remove the discharge (q.d.s.). They should be concurrently treated for chlamydial infection as above.

Bacterial infection

Treatment should be guided by the organism grown. If there is corneal involvement, the baby may be hospitalised and treated as for microbial keratitis.

Viral infection

These babies should be hospitalised and treated with intravenous aciclovir (full term infants: 45-60 mg/kg/day in 3 doses for 14 days if limited disease and 21 days if disseminated disease) as well as topical antivirals.

• Keratitis
• Conjunctival scarring
• Superior corneal pannus
• Rarely - effects of overwhelming systemic infection (consider chlamydial pneumonia for example)
• Rarely - side effects of treatment such as the association between oral erythromycin and infantile hypertrophic pyloric stenosis (IHPS) reported in infants aged <6 weeks.⁷

If the initial infection recurs, Chlamydia should be reconsidered (even if the baby first tested negative).⁵

• Chemical irritation: good - full spontaneous recovery expected after 24-36 hours.
• Chlamydial infection: good - 80% fully recover after one course of treatment.⁷
• Bacterial infection: rarely fails to respond to appropriate treatment.³

The issue of prevention tends to relate to those infections acquired during vaginal deliveries in mothers known to have either chlamydial or gonorrhoeal infection. Traditionally, this has involved the use of 2% silver nitrate ophthalmic solution but more recently, there have been advocates of the additional application of 2.5% povidone-iodine ophthalmic solution. This remains the remit of specialist care.