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Ophthalmia Neonatorum
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.
Babies present with a purulent, mucopurulent or mucoid discharge from one or both eyes within the first month of life. 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.
- 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 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 scrapings and cultures including for chlamydial detection and viral cultures. 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.
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.
Initial therapy
Prior to results from Gram staining (or if these are inconclusive), it is appropriate to start the infant on erythromycin ointment qds combined with systemic erythromycin (50 mg/kg/day) for 2 to 3 weeks.
Chemical conjunctivitis
No treatment is required although some favour the use of preservative-free artificial tears qds. 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 (50 mg/kg/day) 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 (qds). 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.5
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.
Document references
- Kunimoto DY, Kanitkar KD, Makar MS; The Wills Eye Manual (4th ed.) 2004 Lippincott, Williams and Wilkins
- Jarvis VN, Levine R, Asbell PA; Ophthalmia neonatorum: a study of a decade of experience at the Mount Sinai Hospital. British Journal Ophthalmol, 1987(71): 295-300
. - Jatla KK, Zhao F; Conjunctivitis, neonatal. eMedicine; June 2006.
- WHO - Ophthalmia neonatorum.
- Centers for Disease Control and Prevention (USA); Treatment guidelines: Ophthalmia Neonatorum Caused by C. trachomatis. Last updated 2002.
- Isenberg SJ, Apt L, Del Signore M et al.; A double approach to ophthalmia neonatorum prophylaxis. British Journal of Ophthalmoly, 2003; 87: 1449-1452.
DocID: 1539
Document Version: 22
DocRef: bgp25320
Last Updated: 10 Nov 2006
Review Date: 9 Nov 2008
Disclaimer: Patient UK has no control of the content of the above links. Inclusion does not imply endorsement by Patient UK.
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