Ophthalmia Neonatorum Summary

Definition

  • Conjunctivitis within first 28 days of life
  • Commonly due to blocked lacrimal duct
  • Can be bacterial or viral

Timing by Pathogen

  • Non-infectious: First 24 hours
  • Gonorrhoea: Birth to 5 days
  • Chlamydia: 5-14 days
  • Other bacteria: 4-5 days onwards
  • HSV: 1-2 weeks

General Management

  • No inflammation: Cleansing + massage
  • Inflammation/purulent: Topical chloramphenicol
  • Swab before antibiotics if delayed treatment

Gonorrhoea Management

  • Profuse purulent discharge
  • Urgent Gram stain + culture
  • IV Cefotaxime 100mg/kg single dose
  • Saline irrigation until discharge clears

Chlamydia Management

  • Systemic therapy always required
  • Oral erythromycin 14 days or azithromycin 3 days
  • Risk of pneumonia (10-20%)

Red Flags

  • Extremely purulent discharge (gonorrhoea)
  • Eyelid edema + systemic symptoms
  • No response to empiric treatment
  • Corneal involvement

Investigations

  • Swab for Gram stain + culture
  • NAAT for Chlamydia
  • Maternal screening if neonatal infection

Ophthalmia Neonatorum

Conjunctivitis in the first 28 days of life - diagnosis, management, and complications

Introduction

A 'sticky eye' is a relatively common problem in infancy and ophthalmia neonatorum refers to any conjunctivitis (defined as conjunctival inflammation) occurring within the first 28 days of life. It is often due simply to a blocked lacrimal duct but may also be caused by a variety of bacterial and viral pathogens.

Causes

Non-infective

  • Blocked lacrimal duct
  • Irritants

Bacterial Infection

  • Chlamydia trachomatis
  • Neisseria gonorrhoea
  • Haemophilus influenzae
  • Staphylococcus aureus
  • Streptococcus pneumonia
  • Group A and B streptococci
  • Moraxella catarrhalis
  • Escherichia coli
  • Pseudomonas species

Viral Infection

  • Herpes simplex
  • Adenovirus

Presentation

Conjunctivitis is a clinical diagnosis that presents with inflammation of the conjunctiva causing conjunctival erythema, blood vessel dilation and tearing. It can involve the eyelid causing swelling and/or the cornea and lacrimal apparatus causing serous or purulent discharge.

Priority pathogens: The two major causes of infective neonatal conjunctivitis which should be excluded as priority are Chlamydia trachomatis and Neisseria gonorrhoea. Prompt diagnosis is key in establishing treatment and minimising potential complications.

Timing of Onset by Pathogen

Pathogen Typical Onset
Non-infectious First 24 hours, usually self-limiting
Neisseria gonorrhoeae Birth to 5 days post-birth
Chlamydia trachomatis 5 days to 14 days post-birth
Other bacteria 4-5 days post-birth but can be any time
Herpes simplex virus 1-2 weeks post-birth

General Management

No Conjunctival Inflammation

  • No antibiotics required
  • Regular cleansing with sterile water or 0.9% saline
  • Wipe from nose to outer aspect of eye
  • Daily firm massage of nasolacrimal ducts
  • If no improvement after 48 hours, consider delayed antibiotic prescription

Conjunctival Inflammation or Purulent Discharge

  • Empiric treatment with topical chloramphenicol
  • Extremely purulent discharge in first few days → suspect gonorrhoea
  • If no response to empiric treatment → swab for Chlamydia
Cleansing Technique
  1. Use sterile water or 0.9% saline
  2. Wipe from nose to outer aspect of eye in single motion
  3. Discard swab/cotton pad after each wipe
  4. Repeat 4-6 hourly for 2-3 days
  5. Massage nasolacrimal ducts daily with clean index finger

Specific Infections

Neisseria gonorrhoeae

Transmission

  • Vertical transmission rates: 30-50%
  • Prophylactic treatment for babies of positive mothers

Presentation

  • Usually develops in first 5 days
  • Profuse purulent conjunctivitis
  • Eyelid edema
  • Pharyngeal colonization in 15% of cases
  • Risk of hematogenous spread

Investigation

  • Urgent eye swab for Gram stain (same day results)
  • Gram negative diplococci → highly suggestive
  • Definitive diagnosis by culture or NAAT
  • Test for Chlamydia simultaneously
  • Maternal cultures if neonatal infection suspected

Treatment

Condition Treatment
Ophthalmia without systemic disease Cefotaxime 100 mg/kg single dose IV + saline irrigation
Disseminated disease Cefotaxime 50 mg/kg IV TDS for 7 days (14 if meningitis)
Maternal infection - neonatal prophylaxis Cefotaxime 100 mg/kg IV single dose

Complications: Corneal ulceration, scarring, perforation leading to visual impairment.

Chlamydia trachomatis

Transmission

  • Overall transmission rate: 25%
  • Vaginal delivery: 67%
  • Caesarean section: <10%
  • Maternal treatment doesn't preclude neonatal infection

Presentation

  • Onset: 5-14 days (up to 60 days)
  • Often unilateral → bilateral
  • Serosanguineous → mucopurulent discharge
  • Eyelid swelling + conjunctival injection
  • 10-20% develop pneumonia

Investigation

Chlamydia detected by NAAT from conjunctival cells obtained by firmly swabbing everted lower eyelid.

Treatment

Systemic therapy always required - topical therapy doesn't eradicate nasopharyngeal carriage or prevent pneumonia.

Treatment Options

  • Oral erythromycin 12.5 mg/kg/dose QDS for 14 days
  • Oral azithromycin 20 mg/kg once daily for 3 days

Additional Measures

  • Maternal screening and treatment required
  • Eradication rate: 80-100% with systemic treatment

Complications: Symptoms may resolve spontaneously but untreated cases can persist for up to a year with corneal scarring. Systemic complications include pneumonitis, rhinitis, and otitis.

Chlamydial Pneumonia

Herpes Simplex Virus

  • Presents within first two weeks of life
  • Associated with systemic herpes infection or local skin lesions
  • Signs: eyelid edema, conjunctival injection, serosanguineous discharge
  • May be unilateral or bilateral
  • Discuss diagnosis and treatment with microbiologists if suspected