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OPHTALMIA NEONATORUMIntroduction Definition- inflammation of the conjunctiva in the first 28 daysof life. Also known as Neonatal Conjunctivitis.
Epidemiology Before introduction of silver nitrate eye drops in the late 19thcentury, approximately 10% to 15% of newborns developedbacterial conjunctivitis. Current incidence varies by the availability of obstetric care. Annual rates of gonococcal and chlamydial conjunctivitis per 1,000 livebirths are approximately 0.3 and 5, respectively, in the United States but areten times greater in parts of Africa.
Epidemiology… The risk of corneal complications from ophthalmia neonatorum ishigher among the poor. Between 1,000 and 4,000 infants are blinded each year.
Predisposing Factors Organisms in vagina shed during delivery Premature rupture of membranes Long delivery Few tears and low levels of IgA Trauma to epithelial barrier Prophylaxis (silver nitrate)
Types…Aseptic – Chemical conjunctivitis mostly Silver nitrate - prophylaxis of infectiousconjunctivitis- Crede’s method ofprophylaxis not as common anymore because of the use of erythromycinointment
Types…Septic- Bacterial, chlamydial (the most common cause), and viral infections are majorcauses Acquired by passage through birth canal
Etiology Chemical or Microbial ChemicalSilver nitrate surface-active chemical, facilitating agglutinate gonococci and inactivating them. toxic to the conjunctiva, potentially causing a sterile neonatal conjunctivitis.
Etiology… MicrobialChlamydia trachomatis the most common infectious cause 4-10% pregnant women infected Infants whose mothers have untreated chlamydial infections antepartum have a 30% to 40%chance of developing chlamydial neonatal conjunctivitis postpartum. reservoir- maternal cervix or urethra
Etiology… Neisseria gonorrhea have the ability to penetrate intact epithelial cells, and once inside the cell, they divide rapidly. the most dangerous and virulent infectious cause must be absolutely excluded in every case serious consequences
Etiology…Other bacteria Staphylococcus aureus, Streptococcus pneumoniae, Streptococcus viridans, andStaphylococcus epidermidis. Escherichia coli, Klebsiella pneumoniae, Serratia marcescens, and Proteus,Enterobacter, and Pseudomonas species
Etiology…Herpes simplex can cause neonatal keratoconjunctivitis rare and is associated most often with a generalized herpes simplex infection
Incidence Gonococcal 40 per 1000LB Chlamydial 80 per 1000LB 50% has concomitant gonococcal infection Chemical Conjunctivitis- decreased with substitution of silvernitrate. Incidence from other causes is relatively rare.
Clinical Difficult to know cause on clinical ground only Significant overlap in presentation Main findings are erythema, chemosis & purulent eyedischarge Therefore Lab studies are Important
Clinical…Incubation Period Chemical conjunctivitis (silver nitrate)- 1st day of life- disappearspontaneously in 2-4 days Gonococcal- 3-5 days or later Chlamydial- 5-14 days Other bacteria- longer Herpetic- within 2wks
Clinical… Chemical Conjunctivitis mild, transient tearing Gonococcal Bilateral purulent conjunctivitis – classical (75%) More severe (hyperacute conjunctivitis) Chemosis and ulceration - perforation of cornea and endophthalmitis (inflmn. of ocular cavity & adj.structures) Rhinitis, stomatitis, arthritis, meningitis, anorectal infection, septicemia… Conjunctival membrane plus blindness
Clinical… Chlamydial From Mild hyperemia with scant mucoid discharge Eyelid swelling, chemosis and pseudo membrane formation unilateral or bilateral watery discharge which may become more copious and purulent later Blindness-rare and slower to develop-b/s of eyelid scarring and pannus (non suppurating inflamedlymph gland) Pneumonitis, pharyngeal and rectal colonization
Clinical… Other Bacteria Similar findings like edema of eye lids, chemosis and eye discharge. Pseudomonas is rare but can cause accelerated corneal ulceration andperforation; if left untreated endophthalmitis and death can occur.
Clinical…Herpes simplex- Keratoconjunctivitis, generalized herpes simplex, encephalitis (low immunity) nonspecific lid edema, moderate conjunctival congestion Non-purulent, unilateral or bilateral discharge Geographic ulcers around the skin of the eye are typical Conjunctival membrane may be there
Work Up Gram stain/ Geimsa stain of conjunctival scrapings (rule outChlamydia…intracellular inclusion bodies) Culture (Thayer-Martin/ chocolate/ blood Agar) Direct immunofluorescent antibody HSV culture if vesicles are present
Treatment Prophylaxis Antenatal - thorough care of mother and treatment of genital infectionswhen suspected. Cesarean Delivery Natal - Topical 0.5% silver nitrate, 1% tetracycline for gonococcalinfection
Treatment… Medical treatment Systemic treatment is mandatory as topical alone in not effective thoughhelpful acute neonatal conjunctivitis should be treated for gonococcalconjunctivitis until culture results are available
Treatment… Treatment prior to laboratory results Topical erythromycin ointment and IV or IM third-generation cephalosporin (ceftriaxone 30-50mg/kg/d IVor IM. Max 125mg)
Treatment… Chemical Conjunctivitis Eye is regularly flushed and the eyelids cleaned – symptoms disappearwithin 1 to 2 days
Treatment… Gonococcal Conjunctivitis Topical administration of broad-spectrum antibiotics (gentamicineyedrops every hour)+ Systemic penicillin (penicillin G iv 2 million IU daily)OR A single dose of ceftriaxone (75-100 mg/kg/day IV or IM QID for 7days) is an alternative treatment.
Treatment… Chlamydial Conjunctivitis Topical erythromycin eyedrops (5x/day)+ Oral erythromycin (50 mg/kg/d divided QID)Since the efficacy of systemic erythromycin therapy is approximately 80%,a second course sometimes is required.
Treatment… Herpetic Conjunctivitis Acyclovir eye ointment Systemic acyclovir 30 mg/kg/day IV TID, for 14 days up 21 days (insever cases)
Reference Ophthalmology.-.A.Pocket.Textbook.Atlas.2nd.ed.2007 Duanes.Ophthalmology.2007.Edition Wikipedia