Synonym: conjunctivitis of the newborn, neonatal conjunctivitis
Ophthalmia neonatorum refers to any conjunctivitis occurring in the first 28 days of life. It is most commonly infective in origin: bacterial causes include Chlamydia trachomatis, Neisseria gonorrhoeae, Staphylococcus aureus, Streptococcus pneumoniae and various other organisms. Less often there can be viral causes - notably the herpes simplex virus. It may also occur as a reaction to chemical irritants, and is a self-limiting condition lasting no more than 24 to 36 hours but infections need treatment.
In most cases ophthalmia neonatorum is a mild illness. The exception is that due to gonococcal infection, which can progress rapidly to corneal damage and permanent visual impairment.This may also cause systemic complications.Nevertheless, as of April 2010, ophthalmia neonatorum is no longer a notifiable disease.
Ophthalmia neonatorum affects 1-12% of infants in the western world.[2, 3]The precise figure varies according to the socio-economic status of the area. The figure goes up to 23% in developing countries. Originally, the term neonatal ophthalmia referred to conjunctivitis in the newborn caused by N. gonorrhoeae, but now the term is used for any conjunctivitis in this age group, irrespective of causative organism.
The main risk factor for ophthalmia neonatorum of gonococcal or chlamydial origin is the presence of a sexually transmitted disease in the mother. There is a high rate of transmission from infected mother to infant.
- Chlamydia is now the most common single cause of infective neonatal conjunctivitis, accounting for 2-40% of cases.
- N. gonorrhoeae now accounts for less than 1% of reported cases of neonatal ophthalmia.
- Incidence of these two pathogens has declined over a period of two decades, due both to decreased prevalence in the population and to the introduction of prenatal screening .
- Non-sexually transmitted bacteria such as Staphylococcus, Streptococcus and Haemophilus species and other Gram-negative bacteria, make up most of the remaining ophthalmia neonatorum cases (30-50%)..
- Chemical conjunctivitis from the instillation of silver nitrate accounts for the majority of the rest .
- Cases of chemical conjunctivitis are decreasing as silver nitrate prophylaxis is being replaced by other agents (see 'Prevention', below) which in turn, have reduced the incidence of gonococcal conjunctivitis.
Affected babies present with a purulent, mucopurulent or mucoid discharge from one or both eyes within the first month of life. They typically show injected conjunctiva and lid swelling. There may be associated systemic infection.
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) within the preceding 24-48 hours.
This usually (but not invariably) has a longer incubation period than for the other infective causes, presenting with a subacute onset between the 4th and 28th day of life. Depending on the pathogen, there may be a mixed picture of a red eye with lid swelling and a varying amount of purulent discharge. Specific common types of bacterial infection are:
- Gonorrhoeal infection - typically, 1-5 days after birth but it may occur later: hyperacute conjunctival injection and chemosis, lid oedema and severe purulent discharge. There may be associated corneal ulceration and perforation.
- Chlamydial infection - 5-14 days after birth (some report up to 28 days after birth): unilateral/bilateral watery discharge which becomes copious and purulent later on. There may be associated preseptal cellulitis and, less commonly, rhinitis, otitis and pneumonitis. The eyes are usually less inflamed than in the case of gonococcal infection.
Onset is acute, 1-14 days after birth: unilateral/bilateral serosanguinous discharge ± vesicular skin lesions. Other ocular features may include keratitis, anterior uveitis, cataract, retinitis and (rarely) optic neuritis. Uncommonly, systemic infection can cause jaundice, hepatosplenomegaly, pneumonitis, meningoencephalitis and disseminated intravascular coagulation.
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 functioning normally by 12 months of age.
These are generally carried out in a specialist eye unit under consultant direction and will include:
- History - previous or concurrent sexually transmitted disease in the mother and results of any cervical cultures obtained during pregnancy.
- Ocular examination - pen light and fluorescein examination.
- Microbiological investigations - conjunctival swabs (ideally obtained from the everted lid) and cultures including for chlamydial detection and viral cultures. The Gram staining is requested urgently where there is suspicion of gonococcal conjunctivitis. Even if gonorrhoeal infection is strongly suspected, investigation for chlamydia should be carried out and vice versa in the case of suspected chlamydial infection.
- Maternal investigations - the mother 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 sexual partners.
The majority of neonates presenting with a sticky discharge have a benign cause - most frequently due to blocked nasolacrimal duct(s). Features suggesting that referral is necessary are those suggestive of gonococcal involvement, and include:
- Conjunctival redness, especially if the bulbar conjunctiva (overlying the sclera) is involved.
- If the onset is sudden and severe.
- If the baby is distressed or unwell.
- If both eyes are affected.
- If maternal gonococcal infection is suspected.
- If the mother is concerned, or you are concerned.
If you suspect gonococcal infection, refer immediately. Early and appropriate treatment have long been recognised as the key to preventing consequent blindness.
Prior to results from Gram staining (or if these are inconclusive), it is appropriate to start the infant on a broad-spectrum antibiotic - eg, ofloxacin 0.3% qds for a week, or until the microbiological results have come back.
If the initial infection recurs, chlamydia should be reconsidered (even if the baby first tested negative), as this organism is difficult to demonstrate in the laboratory and can be missed.
No treatment is required, although some favour the use of preservative-free artificial tears qds. These babies need early review (24 hours) to confirm that this was indeed a case of chemical irritation as opposed to early 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.
Oral erythromycin syrup (50 mg/kg/day in four divided doses) for 14 days. Topical treatment alone is not sufficient (and is not usually felt to be necessary when systemic treatment is taken). The presence of chlamydia in the eyes invariably indicates its presence in the respiratory tract too, which is a further reason for systemic therapy. The mother and her sexual partner(s) will also need treating.
Gonorrhoeal infection[5, 6]
These babies need hospitalisation and evaluation for disseminated disease. Hourly saline lavage is recommended to remove the discharge (qds). Additionally, these infants can be treated with bacitracin eye ointment 2- to 4-hourly (topical penicillins are unreliable due to resistance). If penicillin sensitivity is established then penicillin drops are also used. There is no established treatment protocol but options include ceftriaxone (single dose: 25-50 mg/kg intravenously (IV) or intramuscularly (IM), no more than 125 mg in total) or cefotaxime (single dose: 100 mg/kg IV or IM). Topical atropine is used for corneal involvement. If there is penicillin or cephalosporin allergy, the infectious disease consultant will need to be involved. Babies should be concurrently treated for chlamydial infection, as above.
These babies should be hospitalised and treated with IV aciclovir (full-term infants: 45-60 mg/kg/day in three doses. This is continued for 14 days if there is limited disease and 21 days if there is disseminated disease, which can be devastating) in addition to topical antiviral preparations.
The complications mainly relate to gonococcal conjunctivitis. Most other causes of conjunctivitis in the newborn are fairly benign. Gonococcal complications include:
- Conjunctival scarring.
- Superior corneal pannus.
- Side-effects of treatment (rarely), such as the association between oral erythromycin and infantile hypertrophic pyloric stenosis (IHPS) reported in infants aged <6 weeks.
- Permanent visual impairment.
Other bacteria can (rarely) have serious consequences:
- Overwhelming systemic infection may occur - eg, chlamydial pneumonia, disseminated herpes simplex.
- Pseudomonas spp. infection is very rare but may be devastating, causing keratitis; in disseminated cases, it can ultimately lead to death.
- Chlamydial infection: good - 80% fully recover after one course of treatment.
- Bacterial infection: rarely fails to respond to appropriate treatment.
- Viral infection: the ocular prognosis can be poor and the systemic sequelae may be fatal.
- Chemical irritation: good - full spontaneous recovery expected after 24-36 hours.
The issue of prevention relates mainly 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.However, this treatment does not prevent absolutely all cases, and it causes transient chemical conjunctivitis in a high proportion of babies (50-90%).As a result, erythromycin and tetracycline, which are slightly more effective, have also been used for prophylaxis against gonorrhoeal infection.[2, 10] More recently, there have been advocates of the additional application of 2.5% povidone-iodine ophthalmic solution which is more effective than the other agents, especially against chlamydial infection, and which does not appear to have systemic side-effects.
A meta-analysis looked at routine eye prophylaxis in all babies and concluded that, where the prevalence of maternal infection is low, it is probably not worthwhile due to the high failure rates of the prophylactic regime. This remains the remit of specialised care.
Further reading and references
Conjunctivitis - infective; NICE CKS, August 2012 (UK access only)
Chlamydia; Public Health England
Chlamydial Infections, Sexually Transmitted Disease Treatment Guidelines 2010; CDC Centers for Disease Control and Prevention
The Wills Eye Manual
Recommendations for the prevention of neonatal ophthalmia; Canadian Paediatric Society
Denniston AKO, Murray PI; Oxford Handbook of Ophthalmology, Oxford University Press, 2009
List of Notifiable Diseases; Public Health England under the Health Protection Act Regulations April 2010
Chlamydial and Gonococcal Infections in Infants and Children; Clinical Infectious Diseases Vol 53 Issue 3 p S99 - S102
Moorfields Manual of Ophthalmology
Chlamydial Infections, Sexually Transmitted Disease Treatment Guidelines 2010; CDC Centers for Disease Control and Prevention
Isenberg SJ, Apt L, Del Signore M, et al; A double application approach to ophthalmia neonatorum prophylaxis. Br J Ophthalmol. 2003 Dec87(12):1449-52.
Darling EK, McDonald H; A meta-analysis of the efficacy of ocular prophylactic agents used for the prevention of gonococcal and chlamydial ophthalmia neonatorum. J Midwifery Womens Health. 2010 Jul55(4):319-27.
Keenan JD, Eckert S, Rutar T; Cost analysis of povidone-iodine for ophthalmia neonatorum prophylaxis. Arch Ophthalmol. 2010 Jan128(1):136-7.
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