ATLAS OF NEONATAL CONJUNCTIVITIS, OPHTHALMIA NEONATORUM
Clinical Summary
Neonatal conjunctivitis is acquired either during birth with passage through the mother’s cervix and vagina, or from cross-infection in the neonatal period. Presenting symptoms for Neisseria gonorrhoeae infection include a hyperacute bilateral conjunctivitis with copious purulent discharge, lid swelling, chemosis, and preauricular adenopathy.
More common etiologies include Chlamydia trachomatis, viruses (herpes simplex), and bacteria (Staphylococcus aureus, Streptococcal pneumoniae, Haemophilus species). For chlamydial conjunctivitis, the clinical features range from mild swelling with a watery discharge to marked lid swelling with a red and thickened conjunctiva with a blood-stained discharge. Fluorescein staining of herpes simplex conjunctivitis demonstrates epithelial dendrites.
With any form of neonatal conjunctivitis, Gram stain and culture are indicated. Scrapings of the palpebral conjunctiva are more likely to be rewarding than examination of the discharge itself. Begin treatment in the emergency department (ED) and admit newborns with suspected gonococcal conjunctivitis. Evaluate concurrently for C trachomatis, since coinfection is common.
Treatment for chlamydial conjunctivitis is based upon a positive diagnostic test. While culture is the gold standard, nucleic acid amplification tests, despite lacking FDA approval, are reported to perform similarly. Untreated disease can result in corneal and conjunctival scarring. Bacterial neonatal onjunctivitis that is neither gonococcal nor chlamydial may be treated with erythromycin antibiotic ointment and should be reevaluated in 24 hours.
Herpes simplex conjunctivitis is treated with intravenous (IV) acyclovir and topical trifluridine. Despite the appearance of a localized herpes infection, there is high risk for central nervous system (CNS) or disseminated infection.
Evaluation of the newborn’s parents should be undertaken in neonatal conjunctivitis due to Gonococcus, Chlamydia, or herpes simplex virus (HSV).
 |
| Neonatal Conjunctivitis (Ophthalmia Neonatorum). Copious purulent drainage in a newborn with neonatal gonococcal conjunctivitis |
 |
| Neonatal Conjunctivitis. Thick purulent drainage in a newborn diagnosed with neonatal gonococcal conjunctivitis. |
 |
| Neonatal Conjunctivitis. A purulent discharge is seen in this newborn. Management includes excluding Neisseria and Chlamydia. |
 |
| Neonatal Conjunctivitis. A scant crusty discharge is seen in this newborn who was diagnosed in follow-up with nasolacrimal duct obstruction. |
Pearls
1. The “rule of fives” may help predict the most likely bacterial cause.
0-5 days Gonococcus
5 days-5 weeks Chlamydia
5 weeks-5 years Staphylococcus, Streptococcus, Haemophilus
2. Blindness can result from gonococcal eye infection in the neonate because the organism can invade the cornea. It is one of the few emergency conjunctival infections.
3. Nasolacrimal duct obstruction is common (up to 20%) in newborns and may present with findings suggestive of conjunctivitis. It is a diagnosis of exclusion in the neonate.
4. Advise parents that infants treated with macrolides are at risk for developing hypertrophic pyloric stenosis.
COMMENTS