Chapter 6
Neonatal Conjunctivitis (Ophthalmia Neonatorum)
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Neonatal conjunctivitis is defined as conjunctivitis presenting before 1 month of age (Fig. 1).1 Generally it can be divided into noninfectious and infectious categories. The most common noninfectious cause is a chemical conjunctivitis induced by silver nitrate solution used for prophylaxis against infectious conjunctivitis. Bacterial, chlamydial, and viral infections are major causes of infectious neonatal conjunctivitis; chlamydia is the most common.2,3 Other infectious agents that the infant may acquire as it passes through the birth canal during include, Streptococcus spp., Staphylococcus spp., Escherichia coli, Haemophilus spp., Neisseria gonorrhea, and herpes simplex.2 The time of onset of the conjunctivitis as well conjunctival scraping can aid in the diagnosis of the specific etiology of the neonatal conjunctivitis Table 1.

Fig. 1. Neonatal conjunctivitis.


Time of Onset (Days after Birth) Etiology (Clinical Presentation) Conjunctival Scraping
0–2Chemical (mild lid edema with watery discharge)Minimal reactive cells to few PMN
2–7Gonococcal (severe lid swelling with purulent discharge)Many reactive cells with gram negative intracellular diplococci
3–10Chlamydial (variable lid swelling with serous or purulent discharge)Many reactive cells with Giemsa stain for basophilic cytoplasmic inclusion bodies or direct immunofluorescent assay
4–7Bacteria (Staphylococcus, Streptococcus, Haemophilus purulent discharge)Gram stain for bacteria
3–14Herpes simples virus (serous discharge with dendritic keratitis or geographic ulcers)Variable reactive cells with multinucleated giant cells


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Laboratory studies for neonatal conjunctivitis are essential for proper management and diagnosis. Initial culture on chocolate agar or a Thayer-Martin test for N. gonorrhoeae should be obtained as well as blood agar for other bacteria. Chlamydial infection can be ruled out with a conjunctival scraping Giemsa stain for intracytoplasmic inclusion bodies or direct immunofluorescent antibody assay. In herpetic conjunctivitis, gram stain may reveal multinucleate giant cells or Papanicolaou smear may show eosinophilic intranuclear inclusions in epithelial cells. Culture for herpes simplex virus also can be indicated if a corneal epithelial defect is present or the diagnosis cannot be made on ocular examination alone with presence of vesicular lesions.4
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Topical 1% silver nitrate, 0.5% erythromycin, and 1% tetracycline are considered equally effective for prophylaxis of ocular gonorrhea and chlamydial ophthalmia in newborn infants.5–6 Recent studies indicate that 2.5% povidone-iodine solution also may be effective in preventing neonatal ophthalmia and appears to cause less chemical conjunctivitis as compared with either silver nitrate or erythromycin.7 Specific treatment for chemical conjunctivitis is not necessary, with spontaneous resolution in 2 to 3 days.

Specific treatment for infectious neonatal conjunctivitis is based on the clinical picture and the findings on Gram, Giemsa, and Papanicolaou stains. Most bacterial conjunctivitis respond quickly to topical antibiotic treatment; erythromycin, or bacitracin ointment for gram-positive organisms; gentamicin or tobramycin drops for gram-negative organisms; and fortified topical antibiotics for Pseudomonas.8

Gonococcal conjunctivitis can progress rapidly. It presents with severe purulent conjunctivitis with lid edema and chemosis (Fig. 2). This organism can penetrate intact corneal epithelium and cause rapid ulceration and perforation. Acute neonatal conjunctivitis should be treated as gonococcal conjunctivitis until culture results become available, after which the treatment can be altered based on laboratory results. Treatment before laboratory results should include topical erythromycin ointment and penicillin G intravenous (IV) or intramuscular (IM) third-generation cephalosporin. Because of the prevalence of penicillin-resistant N. gonorrhoeae, the treatment of choice for this organism is a systemic, third-generation cephalosporin such as ceftriaxone 30 to 50 mg/kg per day in divided doses IV or IM, not to exceed 125 mg.9,10 Irrigation of the affected eyes with saline until discharge is eliminated may be useful. In addition, a single dose of cefotaxime 100 mg/kg IM is an alternative treatment.11 The mother and her sexual contacts also should be treated. A pediatrician should be consulted for possible extraocular involvement.12

Fig. 2. Gonococcal conjunctivitis.

Chlamydial conjunctivitis has a later onset than gonococcal conjunctivitis typically from 3 to 10 days after birth. It is much more indolent and less severe. Diagnosis is made by observing intracytoplasmic inclusion bodies by Giemsa stain or direct immunofluorescent assay, which has high sensitivity and specificity.13,14Treatment includes both topical erythromycin ointment and oral erythromycin 30 to 50 mg/kg per day divided in four doses. Typical treatment lasts for 2 weeks to prevent recurrence and secondary pneumonitis.15 Both parents also should be treated for chlamydia even if they are asymptomatic.16

Herpetic conjunctivitis can be the sole manifestation of a neonate infected with herpes simplex. Most cases of herpetic conjunctivitis are type II; however, up to 30% can be type I.17,18 Most present with later onset conjunctivitis with corneal keratitis usually presenting as microdendrites or small geographic ulcers. Treatment consists of topical trifluorothymidine 1% drops every 2 hour or 3% vidarabine ointment.19 In cases with systemic involvement (e.g., pneumonitis, septicemia, or meningitis), systemic acyclovir should be used.

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1. Grosskreutz C, Smith LBH: Neonatal conjunctivitis. Int Ophthalmol Clin 32:71, 1992

2. Rapoza PA, Quinn TC, Kiessling LA, Taylor HR: Epidemiology of neonatal conjunctivitis. Ophthalmology 93(4):456, 1986

3. Armstrong JH, Zacarias F, Rein MF: Ophthalmia neonatorum: a chart review. Pediatrics 57:884, 1976

4. Rapoza PA, Chandler JW: Neonatal conjunctivitis: Diagnosis and treatment. Am Acad Ophthalmol 1:1, 1988

5. Laga M, et al: Prophylaxis of gonococcal and chlamydial ophthalmia neonatorum. A comparison of silver nitrate and tetracycline. N Engl J Med 318(11):653, 1988

6. Hammerschlag MR, et al: Erythromycin ointment for ocular prophylaxis of neonatal chlamydial infection. JAMA 244(20):2291, 1980

7. Barsan PC: Specific prophylaxis of gonorrheal ophthalmia neonatorum. A review. N Engl J Med 274(13):731, 1966

8. Isenberg SJ, Apt L, Wood M: A controlled trial of povidone-iodine as prophylaxis against ophthalmia neonatorum. N Engl J Med 332(9):562, 1995

9. Hammerschlag MR: Neonatal conjunctivitis. Pediatr Ann 22(6):346, 1993

10. Rothenberg R: Ophthalmia neonatorum due to neisseria gonorrhoeae: Prevention and treatment. Sex Transm Dis 6(2 Suppl):628, 1979

11. Laga M, et al: Single-dose therapy of gonococcal ophthalmia neonatorum with ceftriaxone. N Engl J Med 315(22):1382, 1986

12. Lepage P, Bogaerts J, Kestelyn P, Meheus A: Single-dose cefotaxime intramuscularly cures gonococcal ophthalmia neonatorum. Br J Opthalmol 72(7):518, 1988

13. Ingram DL: Neisseria gonorrhoeae in children. Pediatr Ann 23(7):341, 1994

14. Rapoza PA, Quinn TC, Kiessling LA, Green WR, Taylor HR: Assessment of neonatal conjunctivitis with a direct immunofluorescent monoclonal antibody stain in Chlamydia. JAMA 255(24):3369, 1986

15. Hawkins DA, Wilson RS, Thomas BJ, Evans RT: Rapid, reliable diagnosis of chlamydial ophthalmia by means of monoclonal antibodies. Br J Ophthalmol 69(9):640, 1985

16. Harrison JR, et al: Chlamydia trachomatis infant pneumonitis. N Engl J Med 298:702, 1978

17. Schachter J, Grossman M, Sweet RL, et al: Prospective study of perinatal transmission of Chlamydia trachomatis. JAMA 255(24):3374, 1986

18. Nahmias AJ, Bisintine AM, Caldwell DR, Wilson L: Eye infections with herpes simplex viruses in neonates. Surv Ophthalmol 21:100, 1976

19. Whitley RJ, Nahmias AJ, Visitine AM, et al: The natural history of herpes virus infection of mother and newborn. Pediatrics 66:489, 1980

20. Whitley RJ, Mahmias AJ, Soong SJ: Vidarabine therapy of neonatal herpes simplex virus infection. Pediatrics 66(4):495, 1980

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