Basak Bostanci MD FEBO
Neonatal conjunctivitis
Conjunctivitis which occurs during
the first postnatal month
Causes are specific to this age group
Distinct from conjunctivitis
occurring in older infants.
Infants may
acquire infective
agents as they
pass through the
birth canal
Infection tends to • lack of immunity
be more serious • absence of lymphoid tissue in the
in neonates conjunctiva
owing to • absence of tears at birth
Patient education
• Educate parents or care
providers to wash their
hands frequently
• Educate pregnant
women on the
importance of regular
examinations to detect
and treat sexually
transmitted infections
Predisposing factors
• Exposure to STD-causing pathogens present in
the infected mother’s genital tract
• Neglecting to administer prophylactic anti-
microbial eye drops following birth
• Premature delivery
• Birth trauma
• Immun deficiency
Signs
• Critical. Purulent,
mucopurulent or
mucoid discharge from
one or both eyes with
diffuse conjunctival
injection.
• Other. Eyelid edema,
chemosis
Etiology
Chemical
Chlamydial
Bacterial
• Neisseria gonorrhoeae
• Other bacteria
Viral
Chemical
• Cause: Silver nitrate solution used for
prophlaxis of neonatal conjunctivitis (Crede's
method, 2% )
• Surface-active chemical that facilitates
agglutination and inactivation of gonococci
• Toxic to the conjunctiva causing a sterile
neonatal conjunctivitis
Chemical
• Within a few hours of instilling the silver
nitrate in the first day of life
• Lasts 24 to 36 hours
• Becoming less common owing to the use of
erythromycin ointment or povidone iodide for
prophylaxis of neonatal conjunctivitis
Neisseria gonorrhoeae
• potentially the most
dangerous and virulent
infectious cause of
neonatal conjunctivitis
• Usually seen within 3 to
4 days after birth
• May present with
severe chemosis,
copious discharge, rapid
corneal ulceration or
corneal perforation
Neisseria gonorrhoeae
• Acquired during birth from maternal cervical
and urethral mucosa
• Potentially blinding corneal and conjunctival
complications
• Patients also may have systemic
manifestations, including rhinitis, stomatitis,
arthritis, meningitis, anorectal infection and
septicemia
Cloudy cornea without ulcer in neonatal gonococcal conjunctivitis
Chlamydia trachomatis
• Usually presents within
first week or two of
birth
• Mild swelling,
hyperemia, tearing and
primarily mucoid
discharge.
• May form
pseudomembranes with
bloody discharge
Chlamydia trachomatis
• The reservoir of the organism is the maternal
cervix or urethra
• Infants who are born to infected mothers are
at high risk (approximately 25%-50%)
• Chlamydial pneumonitis may also accompany
neonatal conjunctivitis
Bacteria
• Gram-positive organisms include
Staphylococcus aureus, Streptococcus
pneumoniae, Streptococcus viridans and
Staphylococcus epidermidis
– 30-50% of all cases of infectious neonatal
conjunctivitis
• Gram-negative organisms also have been
implicated
Herpes simplex virus
• May present with a cloudy cornea, conjunctival
injection and tearing within the first two weeks of
life
• Classic herpetic vesicles on the eyelid margins are
not always seen
• Corneal ulcer may occur
• Caesarean delivery is strongly considered when
active genital disease is recognized
– risk of transmitting HSV to the neonate during vaginal
delivery is 25-60%
Epidemiology
• The incidence of ophthalmia neonatorum in
many countries decreased after silver nitrate
solution came into general use
• In Europe, the incidence fell from 10% of births
to less than 1%
• The rates of neonatal conjunctivitis vary in
different parts of the world
• In one hospital in Pakistan, the incidence of
neonatal conjunctivitis was reported at 17%
Complications
• N gonorrhoeae
infection: Corneal
ulceration / perforation
• Pseudomonas infection:
Endophthalmitis and
subsequent death
Complications
• Pneumonia reported in 10-20% of infants with
chlamydial conjunctivitis
• HSV keratoconjunctivitis can cause corneal
scarring and ulceration
• Disseminated HSV infection often includes
central nervous system involvement
Work-Up
• History: Previous or
concurrent venereal disease
in the mother? Were
cervical cultures performed
during pregnancy?
• Ocular examination with
use of fluorescein to look
for corneal involvement.
• Conjunctival scrapings for
two slides: Gram and
Giemsa stain.
Work-Up
• Conjunctival cultures with blood and
chocolate agars.
• Chlamydial immunofluorescent antibody test
or PCR, if available.
• Viral culture
• Systemic evaluation by primary care provider
Newer Diagnostic Techniques
Polymerase chain reaction (PCR) and transcription-
mediated amplification (TMA) more sensitive than
culture for chlamydial and gonorrheal organisms
Direct florescent antibody (DFA) studies useful for
rapid detection, have high sensitivity and specificity
Prophlaxis
• Topical 0.5%
erythromycin ointment
• Topical 1% tetracycline
ointment
• Topical silver nitrate %1
• Povidone-iodine 2.5%
Treatment
• Initial therapy is based on the results of the
Gram and Giemsa stains if they can be
examined immediately
• Therapy is then modified according to the
culture results and clinical response.
• No information from stains, no particular
organism suspected:
– Erythromycin ointment q.i.d. plus oral
erythromycin in four divided doses for 2 to 3 weeks
Treatment
Suspect chemical (e.g., silver nitrate) toxicity:
• Discontinue offending agent
• No treatment or preservative-free artificial
tears q.i.d.
Treatment
Suspect chlamydial infection:
– Erythromycin orally for 14 days, plus erythromycin
ointment q.i.d. or
– Azithromycin orally for 3 days or
– Tetracycline
– NOTE: Inadequately treated chlamydial
conjunctivitis in a neonate can lead to chlamydial
otitis or pneumonia
Treatment
• Suspect N. gonorrhoeae:
– Saline irrigation of the conjunctiva and fornices
until discharge is gone
– Hospitalize and evaluate for disseminated
gonococcal infection (especially examine joints)
– Ceftriaxone or cefotaxime intravenously or
intramuscularly as a single dose
Treatment
• All neonates with gonorrhea should also be
treated for chlamydial infection with oral
erythromycin for 14 days
• If confirmed by culture, the mother and her
sexual partners should be treated
appropriately for both gonorrhea and
chlamydia infections
Treatment
• Gram-positive bacteria with no suspicion of
gonorrhea and no corneal involvement:
– Bacitracin ointment q.i.d. for 2 weeks
• Gram-negative bacteria with no suspicion of
gonorrhea and no corneal involvement:
– Gentamicin, tobramycin, or ciprofloxacin ointment
q.i.d. for 2 weeks
Treatment
Suspect herpes simplex virus:
• Acyclovir intravenously
• Vidarabine 3% ointment 5*1 or trifluridine
drops 9*1
Differential Diagnosis
• Dacryocystitis: Swelling and erythema just
below the inner canthus
• Nasolacrimal duct obstruction
• Congenital glaucoma
Dacryocystocele
• Mild enlargement of
noninflamed lacrimal sac
in an infant
• Entrapment of mucus or
amniotic fluid in the
lacrimal sac and usually
unilateral
Dacryocystitis
• Infection of the lacrimal
sac
• Pain, redness and
swelling over the
lacrimal sac
• Tearing, discharge, fever
• Untreated lacrimal sac
infection may result in
orbital cellulitis.
Congenital glaucoma
• Enlarged globe (buphthalmos)
• Enlarged corneal diameter (horizontal corneal
diameter >12 mm before 1 year of age)
• Tearing, photophobia, blepharospasm,
corneal clouding
Thank you
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