OPHTHALMIA NEONATORUM

Ophthalmia neonatorum, also known as neonatal conjunctivitis, refers to any eye infection occurring within the first 28 days of a newborn’s life.

Flowchart 1: Etiology of ophthalmia neonatorum.

[Flowchart Description: The flowchart visually categorizes the causes of ophthalmia neonatorum into Bacterial, Chemical, and Viral etiologies. Bacterial causes are further divided into Sexually Transmitted (Chlamydia trachomatis, Neisseria gonorrhoeae) and Non-sexually Transmitted bacteria (Staphylococcus aureus, Streptococcus species, Haemophilus influenzae, Pseudomonas, and other species). Chemical causes include 1% silver nitrate solution, topical erythromycin, and gentamicin prophylaxis. Viral causes are listed as Adenovirus, herpes simplex, and enterovirus.]

Pathophysiology:

Inflammation of the conjunctiva leads to redness, dilation of blood vessels, tearing, and discharge. This inflammatory response is often more pronounced in newborns because of factors such as reduced tear production, immature immune system function, lower levels of protective lysozyme activity, and the limited presence of lymphoid tissue within the conjunctiva. Furthermore, newborn tears lack significant levels of immunoglobulin IgA, a key antibody in mucosal immunity.

Etiology:

• Bacterial Infections: Bacterial pathogens are a primary cause of septic neonatal conjunctivitis. Historically, Neisseria gonorrhoeae was the most prevalent bacterial agent, typically associated with sexually transmitted infections in the mother. Other bacterial causes include:

  1. Chlamydia trachomatis (most frequent overall): Onset typically between 5-14 days after birth.

  2. Neisseria gonorrhoeae: Usually presents earlier, between 3-5 days after birth.

  3. Staphylococcus aureus

  4. Pseudomonas aeruginosa

  5. Streptococcus species (including S. haemolyticus, S. pneumoniae)

  6. Other bacterial organisms like Klebsiella, Proteus, Enterobacter, Serratia, and Eikenella corrodens.

• Viral Infections: Viruses can also induce ophthalmia neonatorum, although they are less common than bacterial causes. Viruses known to cause neonatal conjunctivitis include herpes simplex virus, adenovirus, and enteroviruses.

• Chlamydial Infection: Chlamydia trachomatis is a sexually transmitted bacterium that can be passed from mother to infant during childbirth. Infants born to mothers with untreated chlamydial infection have a significant risk (30-50%) of developing ophthalmia neonatorum. Chlamydia trachomatis can also colonize the respiratory system, potentially leading to pneumonia in some infants.

• Chemical Conjunctivitis: Aseptic neonatal conjunctivitis can result from exposure to certain chemical agents. Historically, silver nitrate solution was used for prophylaxis against gonococcal ophthalmia, but it has been largely replaced by erythromycin ointment or povidone-iodine in many settings. Chemical conjunctivitis is now less frequently observed due to this shift in prophylactic practices.

Presentation/Clinical Manifestations of Ophthalmia Neonatorum:

Clinical signs and symptoms can vary depending on the specific causative agent, but common features generally include:

• Eyelid Swelling: Often the initial presenting sign, with severity ranging from mild eyelid puffiness to significant edema that can make opening the eyes difficult.

• Discharge:

  • Purulent discharge (thick, yellow-green) is typically associated with bacterial infections.

  • Chlamydial infections may initially present with a less purulent, watery discharge that can subsequently become purulent over time.

• Conjunctival Redness (Hyperemia): The conjunctiva appears inflamed and noticeably red.

• Photophobia (Light Sensitivity): The infant may exhibit increased crying or discomfort when exposed to bright light.

• Corneal Involvement: In severe cases, the cornea (the transparent front surface of the eye) can become cloudy or ulcerated, potentially leading to permanent visual impairment or blindness. This is particularly concerning with gonococcal infections.

  • Bilateral Symptoms: Typically affects both eyes.

  • Eyelid Edema: Swelling of the eyelids can hinder proper examination of the ocular surfaces.

  • Mucopurulent Conjunctivitis: Characterized by discharge that transitions from watery to increasingly purulent, especially in chlamydial infections.

  • Conjunctival Edema (Chemosis): Swelling of the conjunctiva itself.

  • Conjunctival Pseudomembrane: In severe cases, a false membrane may form on the conjunctival surface.

  • Corneal Involvement: Particularly prominent in Neisseria gonorrhoeae infections, potentially leading to corneal perforation.

  • Epithelial Edema, Superficial Keratitis, and Possible Corneal Ulceration: Signs of corneal surface damage.

Ophthalmia Neonatorum: Prevention and Management

Prevention: Preventive strategies are focused on minimizing the risk of infection before, during, and after birth.

1. Antenatal (During Pregnancy):

• Regular Screening for Vaginal Infections: Implement routine screening during prenatal care to detect vaginal discharges indicative of infections such as gonorrhea and chlamydia.

• Treatment of Vaginal Infections: Ensure prompt and appropriate antibiotic treatment for any identified vaginal infections in pregnant women using suitable antibiotics.

• Management of High-Risk Pregnancies: Address conditions during pregnancy that may elevate the risk of premature labor or prolonged rupture of membranes.

• Prevention and Management of Anemia: Manage maternal anemia, as it can compromise the maternal immune system, potentially increasing the risk of infection.

• Health Education: Educate expectant mothers on the importance of hygiene practices, including handwashing, perineal hygiene, and avoiding unnecessary touching of the eyes.

2. Intrapartum (During Labor):

• Sterile Technique: Maintain strict sterile protocols during labor and delivery. All healthcare personnel should adhere to thorough hand hygiene practices.

• Avoid Unnecessary Eye Swabbing: Routine swabbing of the newborn’s eyes during delivery should be avoided unless clinically indicated, as this can introduce infection. If swabbing is necessary for assessment purposes, use separate sterile swabs for each eye, and cleanse from the inner canthus outwards.

• Isolation of Infected Mothers: Isolate mothers with purulent vaginal discharge to minimize the risk of transmission to the newborn.

• Prophylactic Antibiotics for Prolonged Rupture of Membranes: Consider prophylactic antibiotics for mothers experiencing prolonged rupture of membranes (PROM) exceeding 12 hours to reduce the risk of neonatal infection.

3. Postnatal (After Birth):

• Hand Hygiene: Healthcare providers must practice thorough handwashing before and after handling newborns.

• Eye Cleaning: Cleanse the baby’s eyes with sterile water or half-strength sterile saline solution using a separate sterile cotton swab for each eye, cleaning from the inner to the outer canthus. Discard swabs after each use.

• Avoid Contact with Birth Fluids: Prevent the baby’s face from direct contact with amniotic fluid or other birth fluids.

• Educate Mothers: Instruct mothers on proper hand hygiene before handling the baby and to avoid touching the baby’s eyes unnecessarily.

• Prophylactic Eye Drops (During Epidemics): In regions experiencing outbreaks of ophthalmia neonatorum, consider using prophylactic eye drops (e.g., 1% silver nitrate or 10% sulfacetamide) immediately after birth. This practice is debated and necessitates careful consideration of potential side effects and local guidelines.

Management of Ophthalmia Neonatorum

Aims of Management:

The primary goals for managing ophthalmia neonatorum are:

1. Eliminate Infection: To completely eradicate the causative pathogen.

2. Prevent Corneal Damage: To avoid injury and scarring of the cornea.

3. Preserve Vision: To protect and maintain the infant’s eyesight.

4. Prevent Transmission: To stop the spread of infection to others, including family members.

Management in a Maternity Centre (For Mild Cases ONLY – Referral is Usually Necessary):

• Admission and Isolation: Admit the infant and implement isolation measures to prevent further spread of infection. Position the baby on their side, ensuring the affected eye is facing downwards to aid drainage. Utilize mosquito nets for protection from flies. Ensure all used materials are kept separate and properly disinfected before laundering.

• Eye Cleaning: Regularly cleanse the eyes using normal saline or cooled, sterile boiled water, employing a fresh sterile swab for each eye to prevent cross-contamination.

• Topical Antibiotics: Administer antibiotic eye ointment (such as tetracycline or erythromycin) to both eyes, even if only one eye appears to be infected. If ointments are unavailable, consider using diluted crystalline penicillin, following the dosage instructions provided below.

  Dosage of Diluted Crystalline Penicillin (When Ointments Are Not Available – ONLY under direct medical supervision, and ideally as a temporary measure prior to hospital transfer):

  1. 100,000 IU vial: Dilute with 4 ml of sterile water. Instill 5 drops into each eye every 5 minutes for the initial 30 minutes (6 applications), then 5 drops every 10 minutes for the next hour (6 applications), followed by 5 drops every 30 minutes for 3 hours (6 applications), and finally 5 drops every hour for a total of 3 days.

  2. 500,000 IU vial: Dilute with 20 ml of sterile water. Adjust the dosage proportionally to maintain the intended concentration.

• Systemic Antibiotics: (Use with extreme caution, and only when hospital referral is significantly delayed and under strict medical supervision). Consider intramuscular crystalline penicillin at a dosage of 50,000 units/kg of body weight every 12 hours for 7 days. This should be considered a last resort and is only acceptable if hospital transfer is delayed, and a qualified medical professional has assessed the situation and is closely monitoring the infant’s response to treatment.

• Referral: Refer the infant to a hospital for a definitive diagnosis (including gonorrhea testing, culture and sensitivity tests) and appropriate treatment as soon as possible.

Referral: Refer all suspected cases of ophthalmia neonatorum, especially those exhibiting purulent discharge or corneal involvement, to a hospital without delay.

• Assessment and Referral: Conduct a thorough examination of the infant’s eyes. Any infant suspected of having ophthalmia neonatorum, particularly with purulent discharge or corneal involvement, necessitates immediate referral to a hospital equipped with ophthalmology services. Avoid attempting to manage significant cases within a maternity center setting.

• Initial Cleaning (before referral): Gently cleanse the eyes with sterile saline or sterile water to remove excessive discharge prior to referral. Utilize a separate sterile cotton swab for each eye.

Management in Hospital:

• Diagnostic Testing: The attending physician will order an eye swab for culture and sensitivity testing to pinpoint the specific causative organism.

• Eye Cleaning: Continue meticulous eye cleaning procedures as previously outlined.

• Antibiotic Treatment: The physician will prescribe appropriate systemic and topical antibiotics based on the results of culture and sensitivity testing. This may involve intravenous antibiotics for severe infections. Penicillin remains a viable option for gonococcal infections, alongside other antibiotics like ceftriaxime or cefotaxime.

• Topical Antibiotic Ointments: Utilize Neomycin or tetracycline eye ointment to prevent eyelid adhesion and maintain lubrication.

Medical Management: Purulent discharge in the eyes of the newborn baby.

-> Take history and examine

1. Rx for the baby:

• Always wear gloves when handling the infant and their eyes.

• Cover the inflamed eye with gauze before opening the eyelids for your own protection.

• Clean the eye with saline or water gently to remove discharge.

• Apply tetracycline eye ointment hourly for the first 24 hours, then reduce frequency to every 8-hourly for a total of 10 days.

PLUS:

• Ceftriaxone 125 mg IM stat. as a single dose.

• OR Erythromycin syrup 15 mg/kg body weight 6 hourly x 2/52. administer for 2 weeks.

2. Rx for the mother:

• Ceftriaxone 250 mg IM stat. single intramuscular injection.

• PLUS: Erythromycin 500 mg for 7 days. oral administration for one week.

3. Rx for partners:

• Ciprofloxacin 500 mg stat. as a single oral dose.

• Septrin 5 tablets BD x3/7. twice daily for 3 days.

PLUS:

• Doxycycline 100 mg BD x7/7. twice daily for one week.

• OR Tetracycline 500 mg 6×7/7. six times a day for one week.

Educate on compliance:

• Schedule a follow-up return visit to monitor progress.

• Provide mother and partner with condoms and offer counseling on risk reduction for future infections.

In case of specific causative organisms:

Gonococcal Ophthalmia Neonatorum:

• Infant Isolation: Isolate the infant for the first 24 hours of treatment to minimize transmission risk.

• Eye Irrigation: Irrigate the eyes frequently, every 1-2 hours, with sterile isotonic saline until the discharge clears completely.

• Systemic Antibiotics: For culture-positive cases or severe infections, systemic antibiotic therapy is crucial. Ceftriaxone (25-50 mg/kg IV or IM) or cefotaxime (100 mg/kg IM or IV) is typically administered as a single dose for localized infection. A 7-day course is recommended for disseminated gonococcal infection.

Chlamydial Ophthalmia Neonatorum:

• Oral Erythromycin: Oral erythromycin suspension (40 mg/kg/day divided into four doses) is administered for a full 14 days.

• Systemic Therapy Essential: Topical treatment alone is insufficient for chlamydial infections; systemic therapy is critical to prevent systemic spread beyond the eyes.

Herpes Simplex Ophthalmia Neonatorum:

• Infant Isolation: The infant requires isolation precautions to prevent viral spread.

• Systemic Acyclovir: Systemic acyclovir (20 mg/kg IV every 8 hours IV) for two weeks is the standard treatment regimen.

• Topical Antivirals (Adjunctive): Topical therapy with 3% vidarabine or 0.1% iododeoxyuridine ointment (applied five times daily for 10 days) may be added as adjunctive therapy.

• Ophthalmological Consultation: Severe cases necessitate prompt and immediate ophthalmological consultation and co-management.

Nursing Care (Maternity Centre and Hospital):

• General Hygiene: Maintain meticulous hygiene standards, including frequent handwashing, use of clean linens, and maintaining a clean and sanitary environment.

• Eye Care: Continue frequent eye cleaning as previously described to remove discharge and prevent eyelid crusting.

• Comfort Measures: Provide comfort measures to reduce the infant’s discomfort, such as gentle swaddling and minimizing bright light.

• Frequent Eye Cleaning: Gently cleanse the eyes with sterile saline or sterile water every 2-4 hours, utilizing a separate sterile swab for each eye to prevent cross-contamination.

• Medication Administration: Administer topical and systemic medications exactly as prescribed, ensuring correct dosage and frequency of administration.

• Monitoring: Closely monitor the infant’s response to treatment, including regular assessment of eyelid swelling, discharge characteristics, and corneal clarity.

• Pain Management: Provide comfort measures as needed for pain relief, such as cuddling and soothing techniques.

• Education: Educate the parents thoroughly on the importance of adherence to the prescribed treatment regimen, proper eye cleaning techniques, and the necessity for scheduled follow-up appointments.

Complications:

• Corneal Ulceration and Scarring: This can result in permanent visual impairment or even blindness if left untreated or if severe.

• Perforation of the Cornea: A serious complication that necessitates urgent surgical intervention to repair.

• Endophthalmitis: Infection extending to the internal structures of the eye, potentially leading to severe vision loss.

• Meningitis: (Rare, but possible, particularly in cases of gonococcal infection). Infection of the membranes surrounding the brain and spinal cord, requiring intensive medical management.

• Sepsis: A life-threatening bloodstream infection, demanding immediate and aggressive treatment.