Ophthalmia neonatrum

Neonatal Conjunctivitis

1. OPHTHALMIA NEONATORUM Aelaf Aseged C2

2. OPHTALMIA NEONATORUM Introduction Definition - inflammation of the conjunctiva in the first 28 days of life. Also known as Neonatal Conjunctivitis .

3. Epidemiology Before introduction of silver nitrate eye drops in the late 19th century, approximately 10% to 15% of newborns developed bacterial conjunctivitis. Current incidence varies by the availability of obstetric care. Annual rates of gonococcal and chlamydial conjunctivitis per 1,000 live births are approximately 0.3 and 5, respectively, in the United States but are ten times greater in parts of Africa.

4. Epidemiology… The risk of corneal complications from ophthalmia neonatorum is higher among the poor. Between 1,000 and 4,000 infants are blinded each year.

5. 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)

6. Types 2 types Septic Aseptic

7. Types… Aseptic – Chemical conjunctivitis mostly Silver nitrate - prophylaxis of infectious conjunctivitis - C rede’s method of prophylaxis not as common anymore because of the use of erythromycin ointment

8. Types… Septic- Bacterial, chlamydial (the most common cause), and viral infections are major causes Acquired by passage through birth canal

9. Etiology Chemical or Microbial Chemical Silver nitrate surface-active chemical, facilitating agglutinate gonococci and inactivating them. toxic to the conjunctiva, potentially causing a sterile neonatal conjunctivitis.

10. Etiology… Microbial Chlamydia 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

11. 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

12. Etiology… Other bacteria Staphylococcus aureus, Streptococcus pneumoniae, Streptococcus viridans, and Staphylococcus epidermidis. Escherichia coli, Klebsiella pneumoniae, Serratia marcescens, and Proteus, Enterobacter, and Pseudomonas species

13. Etiology… Herpes simplex can cause neonatal keratoconjunctivitis rare and is associated most often with a generalized herpes simplex infection

14. Incidence Gonococcal 40 per 1000LB Chlamydial 80 per 1000LB 50% has concomitant gonococcal infection Chemical Conjunctivitis- decreased with substitution of silver nitrate. Incidence from other causes is relatively rare.

15. Clinical Difficult to know cause on clinical ground only Significant overlap in presentation Main findings are erythema , chemosis & purulent eye discharge Therefore Lab studies are Important

16. Clinical… Incubation Period Chemical conjunctivitis (silver nitrate)- 1st day of life- disappear spontaneously in 2-4 days Gonococcal - 3-5 days or later Chlamydial- 5-14 days Other bacteria- longer Herpetic- within 2wks

17. 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

18. 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 inflamed lymph gland) Pneumonitis, pharyngeal and rectal colonization

19. Clinical… Other Bacteria Similar findings like edema of eye lids, chemosis and eye discharge. Pseudomonas is rare but can cause accelerated corneal ulceration and perforation; if left untreated endophthalmitis and death can occur.

20. 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

21. Work Up Gram stain/ Geimsa stain of conjunctival scrapings (rule out Chlamydia…intracellular inclusion bodies) Culture (Thayer-Martin/ chocolate/ blood Agar) Direct immunofluorescent antibody HSV culture if vesicles are present

22. Treatment Prophylaxis Antenatal - thorough care of mother and treatment of genital infections when suspected. Cesarean Delivery Natal - Topical 0.5% silver nitrate, 1% tetracycline for gonococcal infection

23. Treatment… Medical treatment Systemic treatment is mandatory as topical alone in not effective though helpful acute neonatal conjunctivitis should be treated for gonococcal conjunctivitis until culture results are available

24. Treatment… Treatment prior to laboratory results Topical erythromycin ointment and IV or IM third-generation cephalosporin (ceftriaxone 30-50mg/kg/d IV or IM. Max 125mg)

25. Treatment… Chemical Conjunctivitis Eye is regularly flushed and the eyelids cleaned – symptoms disappear within 1 to 2 days

26. Treatment… Gonococcal Conjunctivitis Topical administration of broad-spectrum antibiotics (gentamicin eyedrops 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 7 days) is an alternative treatment.

27. 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.

28. Treatment… Herpetic Conjunctivitis Acyclovir eye ointment Systemic acyclovir 30 mg/kg/day IV TID, for 14 days up 21 days (in sever cases)

29. Reference Ophthalmology.-.A.Pocket.Textbook.Atlas.2nd.ed.2007 Duanes.Ophthalmology.2007.Edition W ikipedia

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