Epidemiology and etiology
Worldwide, the incidence of ophthalmia neonatorum is greater in areas with high rates of sexually transmitted disease and poor health care. The prevalence ranges from 0.1% in highly developed countries with effective prenatal and perinatal care to 10% in areas such as East Africa. Because a mother may have multiple sexually transmitted diseases, infants with one type of ophthalmia neonatorum should be screened for other such diseases. Public health authorities should be contacted to initiate evaluation and treatment of other maternal contacts in cases of sexually transmitted diseases.
Table 20-1 Common Causes of Conjunctival Hyperemia in Infants and Children
The causative organism usually infects the infant through direct contact during passage through the birth canal. Infection can ascend to the uterus, especially if there is prolonged rupture of membranes, so even with cesarean delivery, infants can be infected.
Ophthalmia neonatorum caused by Neisseria gonorrhoeae typically presents in the first 3–4 days of life. Patients may present with mild conjunctival hyperemia and ocular discharge. In severe cases, there is marked chemosis, copious discharge, and potentially rapid corneal ulceration and perforation (Fig 20-1). Systemic infection can cause sepsis, meningitis, and arthritis.
Gram stain of the conjunctival exudate showing gram-negative intracellular diplococci allows a presumptive diagnosis of N gonorrhoeae infection; treatment should be started immediately. Ophthalmia neonatorum from Neisseria meningitidis has also been reported. Definitive diagnosis is based on culture of the conjunctival discharge. Treatment of gonococcal ophthalmia neonatorum includes systemic ceftriaxone and topical irrigation with saline. Topical antibiotics may also be indicated if there is corneal involvement.
Chlamydia trachomatis is an obligate intracellular bacterium that can cause neonatal inclusion conjunctivitis. Onset of conjunctivitis usually occurs around 1 week of age, although it may be earlier, especially in cases with premature rupture of membranes. Eye infection is characterized by minimal to moderate filmy discharge, mild swelling of the eyelids, and hyperemia with a papillary reaction of the conjunctiva (Fig 20-2). Severe cases may be accompanied by more copious discharge and pseudomembrane formation. Chlamydial infection in infants differs from that in adults in several ways: in infants, membrane formation may occur, the amount of mucopurulent discharge is greater, and there is no follicular response.
Neisseria gonorrhoeae conjunctivitis.
(Courtesy of Jane C. Edmond, MD.)
Figure 20-2 Chlamydial ophthalmia neonatorum.
(Courtesy of Jane C. Edmond, MD.)
Chlamydial infections can be diagnosed by culture of conjunctival scrapings, polymerase chain reaction, direct fluorescent antibody tests, and enzyme immunoassays. Systemic treatment of neonatal chlamydial disease is indicated because of the risk of pneumonitis and otitis media. The treatment of choice is oral erythromycin, 50 mg/kg per day in 4 divided doses for 14 days. Topical erythromycin ointment may be used in addition to but not as a replacement for oral therapy.
Herpes simplex virus
Infection with herpes simplex virus (HSV) is usually secondary to HSV type 2 and typically presents later than infection with N gonorrhoeae or C trachomatis, frequently in the second week of life. See the discussion of congenital HSV infection in Chapter 28.
Chemical conjunctivitis refers to a mild, self-limited irritation and redness of the conjunctiva occurring in the first 24 hours after instillation of silver nitrate, a preparation used for ophthalmia neonatorum prophylaxis. This condition improves spontaneously by the second day of life.
Ophthalmia neonatorum prophylaxis
Originally, 2% silver nitrate was used as prophylactic treatment of gonorrheal ophthalmia neonatorum. However, it is not effective against C trachomatis and has largely been supplanted by agents that are effective against both N gonorrhoeae and C trachomatis, such as erythromycin and tetracycline ointments and 2.5% povidone-iodine solution. Silver nitrate is still used in some parts of the world.
Excerpted from BCSC 2020-2021 series: Section 10 - Glaucoma. For more information and to purchase the entire series, please visit https://www.aao.org/bcsc.