**4. Neonatal conjunctivitis**

Neonatal conjunctivitis also known as ophthalmia neonatorum is inflammation of the con‐ junctiva occurring in the first month of life. This condition is caused by a number of differ‐ ent pathogens. These include bacteria, viruses and chemical agents. In recent times prophylaxis has led to decreased morbidity in the developed world. However, it is still a significant cause of ocular morbidity, blindness and even death in the developing world.

#### **4.1. Epidemiology of neonatal conjunctivitis**

The incidence of ophthalmia neonatorum is dependent on many different factors. The main risk factor for ophthalmia neonatorum of infective origin is the presence of a sexually trans‐ mitted disease in the mother. The organism usually infects the neonate through direct con‐ tact as it passes through the birth canal. Therefore, incidence is high in areas with high rates of sexually transmitted disease [34]. Prolonged rupture of membranes at the time of delivery is also thought to increase the risk of infection. It is also dependent on socioeco‐ nomic factors; incidence varies in highly developed countries with good prenatal care com‐ pared to the developing parts of the world [35]. The offending pathogens vary geographically due to the differences in the prevalence of maternal infection and the use of prophylaxis. In US and Europe the incidence has been reported 1-2% depending on the so‐ cioeconomic character of the area. However in other parts of the world the incidence is re‐ ported to be as high as 17%. In recent studies in Pakistanthe incidence has been 17% and in Kenya as high 23% [36, 37].

There has been a sharp decrease in the incidence of ophthalmia neonatorum in the past few decades in the developed countries due to many reasons. In 1800s, prophylaxis (silver ni‐ trate) for ophthalmia neonatorum in the developed countries was used for the first time. Since then there has been gradual decrease in incidence. Better prenatal care has also led to detection and treatment of sexually transmitted diseases hence reduction in the risk of trans‐ mission to new-borns during birth.

#### **4.2. Aetiology of neonatal conjunctivitis**

Ophthalmia neonatorum can be broadly divided into two types, septic and aseptic. The aseptic type (chemical conjunctivitis) is generally secondary to the instillation of silver ni‐ trate drops for ocular prophylaxis. Septic neonatal conjunctivitis is mainly caused by bacteri‐ al and viral infections. Causes include [38]:

From maternal genital tract:

**•** Bacterial

Fortunately, the treatment is very effective for fungal infections. Although hospital admis‐ sion is required in patients affected with keratitis, topical amphotericin B or natamycin, sub‐

Neonatal conjunctivitis also known as ophthalmia neonatorum is inflammation of the con‐ junctiva occurring in the first month of life. This condition is caused by a number of differ‐ ent pathogens. These include bacteria, viruses and chemical agents. In recent times prophylaxis has led to decreased morbidity in the developed world. However, it is still a significant cause of ocular morbidity, blindness and even death in the developing world.

The incidence of ophthalmia neonatorum is dependent on many different factors. The main risk factor for ophthalmia neonatorum of infective origin is the presence of a sexually trans‐ mitted disease in the mother. The organism usually infects the neonate through direct con‐ tact as it passes through the birth canal. Therefore, incidence is high in areas with high rates of sexually transmitted disease [34]. Prolonged rupture of membranes at the time of delivery is also thought to increase the risk of infection. It is also dependent on socioeco‐ nomic factors; incidence varies in highly developed countries with good prenatal care com‐ pared to the developing parts of the world [35]. The offending pathogens vary geographically due to the differences in the prevalence of maternal infection and the use of prophylaxis. In US and Europe the incidence has been reported 1-2% depending on the so‐ cioeconomic character of the area. However in other parts of the world the incidence is re‐ ported to be as high as 17%. In recent studies in Pakistanthe incidence has been 17% and in

There has been a sharp decrease in the incidence of ophthalmia neonatorum in the past few decades in the developed countries due to many reasons. In 1800s, prophylaxis (silver ni‐ trate) for ophthalmia neonatorum in the developed countries was used for the first time. Since then there has been gradual decrease in incidence. Better prenatal care has also led to detection and treatment of sexually transmitted diseases hence reduction in the risk of trans‐

Ophthalmia neonatorum can be broadly divided into two types, septic and aseptic. The aseptic type (chemical conjunctivitis) is generally secondary to the instillation of silver ni‐ trate drops for ocular prophylaxis. Septic neonatal conjunctivitis is mainly caused by bacteri‐

conjunctival miconazole and oral ketoconazole are proven effective antifungals.

**4. Neonatal conjunctivitis**

34 Common Eye Infections

Kenya as high 23% [36, 37].

mission to new-borns during birth.

**4.2. Aetiology of neonatal conjunctivitis**

al and viral infections. Causes include [38]:

From maternal genital tract:

**4.1. Epidemiology of neonatal conjunctivitis**

	- **◦** *Herpes Simplex Virus (HSV)*

#### From cross infection:


**Figure 11.** A neonate suffering from gonococcal conjunctivitis

*Neisseria gonorrhoeae* - Congenital gonorrhoea infection is acquired intrapartum and it leads to ophthalmia neonatorum. *Gonococcal* ophthalmia neonatorum presents with a severe con‐ junctivitis and keratitis usually in the first 48 hours of life but it can be delayed up to 3 weeks. It is frequently bilateral. If untreated, it can lead to blindness. Systemic infection can cause meningitis, arthritis and sepsis.

*Chlamydia trachomatis* - Also known as trachoma-inclusion conjunctivitis or TRIC.This is usu‐ ally a benign, self-limiting, suppurative conjunctivitis due to *Chlamydia trachomatis* - sero‐ types D-K. Onset occurs around 1 week of age. Onset maybe earlier with premature rupture of membranes. It is characterised by mild swelling, hyperaemia and minimal to moderate discharge.

**Figure 12.** Typical presentation of a neonate suffering from herpetic conjunctivitis

*Other bacteria* -These bacteria make up 30-50% of all cases of neonatal conjunctivitis. The most commonly identified gram-positive organisms include *Staphylococcus aureus*, *Strepto‐ coccus pneumoniae*, *Streptococcus viridans*, and *Staphylococcus epidermidis*. Gram-negative or‐ ganisms, such as *Escherichia coli*, *Klebsiella pneumoniae*, *Serratia marcescens*, and *Proteus*, *Enterobacter*, and *Pseudomonas species*, also have been implicated.

*Herpes Simplex*- Herpes simplex virus (HSV) can cause neonatal keratoconjunctivitis. This is a rarer form of ophthalmia neonatorum presenting in the second week of life and can be as‐ sociated with a generalized herpes simplex infection.

*Chemical Conjunctivitis*- Classically, the most common cause of neonatal conjunctivitis is due to use of post-delivery use of ophthalmic silver nitrate used in the prophylaxis of ocular *Gonococcal* infections. There is a mild irritation, tearing and redness in a baby who has been administered prophylactic silver nitrate (used for the prevention of gonorrhoeal infection) within the preceding 24-48 hours. The incidence of chemical conjunctivitis in the United States has significantly decreased since replacement of silver nitrate with erythromycin oint‐ ment.

#### **4.3. Presentation of neonatal conjunctivitis**

Babies present with unilateral or bilateral purulent, mucopurulent or mucoid discharge from the eyes within the first month of life. Injected conjunctiva and lid swelling may also be present. There may be associated systemic infection.

**•** Bacterial conjunctivitis - often have a longer incubation period than for the other infective causes. Presenting with a sub-acute onset between the 4th and 28th day of life. Depending on the pathogen, there may be a mixed picture of a red eye with lid swelling and a vary‐ ing amount of purulent discharge. Specific types of bacterial infection:


#### **4.4. Differential diagnosis of neonatal conjunctivitis**

Every other potential cause of red eye needs to be excluded. The differentials include [39]:

**•** Dacryocystitis

**Figure 12.** Typical presentation of a neonate suffering from herpetic conjunctivitis

*Enterobacter*, and *Pseudomonas species*, also have been implicated.

sociated with a generalized herpes simplex infection.

**4.3. Presentation of neonatal conjunctivitis**

be present. There may be associated systemic infection.

ment.

36 Common Eye Infections

*Other bacteria* -These bacteria make up 30-50% of all cases of neonatal conjunctivitis. The most commonly identified gram-positive organisms include *Staphylococcus aureus*, *Strepto‐ coccus pneumoniae*, *Streptococcus viridans*, and *Staphylococcus epidermidis*. Gram-negative or‐ ganisms, such as *Escherichia coli*, *Klebsiella pneumoniae*, *Serratia marcescens*, and *Proteus*,

*Herpes Simplex*- Herpes simplex virus (HSV) can cause neonatal keratoconjunctivitis. This is a rarer form of ophthalmia neonatorum presenting in the second week of life and can be as‐

*Chemical Conjunctivitis*- Classically, the most common cause of neonatal conjunctivitis is due to use of post-delivery use of ophthalmic silver nitrate used in the prophylaxis of ocular *Gonococcal* infections. There is a mild irritation, tearing and redness in a baby who has been administered prophylactic silver nitrate (used for the prevention of gonorrhoeal infection) within the preceding 24-48 hours. The incidence of chemical conjunctivitis in the United States has significantly decreased since replacement of silver nitrate with erythromycin oint‐

Babies present with unilateral or bilateral purulent, mucopurulent or mucoid discharge from the eyes within the first month of life. Injected conjunctiva and lid swelling may also

**•** Bacterial conjunctivitis - often have a longer incubation period than for the other infective causes. Presenting with a sub-acute onset between the 4th and 28th day of life. Depending on the pathogen, there may be a mixed picture of a red eye with lid swelling and a vary‐

ing amount of purulent discharge. Specific types of bacterial infection:


#### **4.5. Investigations**

A definitive diagnosis of the cause of ophthalmia neonatorum is dependent on laboratory identification of the offending organism. The speed of progression of some of the causative agents makes it imperative to do a test which can identify the cause as soon as possible. Some of the laboratory tests that can be performed are as follows [40]:


#### **4.6. Management of neonatal conjunctivitis**

Prophylaxis- In 1881 for the first time silver nitrate was used as prophylactic treatment to reduce the incidence of ophthalmia neonatorum. Silver nitrate is specifically more effective against gonorrhoeal conjunctivitis. It inactivates gonococci by agglutination. It is not effec‐ tive against Chlamydial conjunctivitis. However silver nitrate use also led to mild conjuncti‐ val inflammation, tearing and redness which typically resolved within 48 hours. Chemical conjunctivitis is a self-limiting condition, therefore no treatment is required. However pres‐ ervative artificial tears have been used in some cases.

In recent times povidone-iodine drops are used as prophylaxis instead of silver nitrate [41]. These are shown to be more effective against *gonococcal* and *chlamydial* conjunctivitis and al‐ so less toxic. In US, erythromycin is being used as alternative to silver nitrate and povidoneiodine [42]. This is also well tolerated and effective against TRIC and gonococci agents.

Treatment -Treatment of neonatal conjunctivitis should initially be based on the history, clinical presentation and results of smears. This can later be adjusted when laboratory re‐ sults become available then specific therapy can be instituted.

The risk of transmission of chlamydial, gonococcal, herpetic, and streptococcal pathogens to the foetus during the birth process should be considered. If necessary, cervical cultures should be performed and managed appropriately. To confirm the presence of a sexually transmitted disease in the neonate, examine and treat the mother and her sexual partner. If necessary, therapy can be modified when the results of culture and sensitivity are known.

Bacterial conjunctivitis- Chlamydial conjunctivitis is treated with fourteen day course of twice daily oral erythromycin(50 mg/kg/d divided qid) [43, 44]. Systemic therapy is impor‐ tant in Chlamydia conjunctivitis, due to the high incidence of extra-ocular infection in neo‐ nates. It has shown to eliminate Chlamydial infection in 80-100% of patients. Topical erythromycin can be used as adjunct with the oral therapy. If there is failure to respond to this course the fourteen day course can be repeated before seeking alternative antibiotics [45].

Gonococcal conjunctivitis may be treated with intramascular or intravenous ceftriaxone 50 mg/kg/day or as a single dose treatment of 125mg [46]. Alternatively, cefotaxime 100mg can be given intramuscularly or 25 mg/kg given either intramuscularly or intravenously every 12 hours for 7 days [47].

Neonates with conjunctivitis caused by herpetic simplex virus should be treated with sys‐ temic acyclovir to reduce the chance of a systemic infection [48]. An effective dose is 60 mg/kg/day IV divided.The recommended minimal duration is 14 days, but a course as long as 21 days may be required.Infants with neonatal HSV keratitis should receive a topical oph‐ thalmic drug, most commonly 1% trifluridine drops or 3% vidarabine ointment.

#### **4.7. Complications of neonatal conjunctivitis**

Complications of neonatal conjunctivitis vary. There are two main types of complications, ocular and systemic complications. These can be prevented with prompt diagnosis and treatment. Ocular complications include pseudomembrane formation, peripheral pannus formation, thickened palpebral conjunctiva, cornealoedema, corneal opacification, corneal perforation, staphyloma, endophthalmitis, loss of eye, and blindness [49].

Systemic complications of chlamydia conjunctivitis include pneumonitis, otitis, and phar‐ yngeal and rectal colonization. Pneumonia has been reported in 10-20% of infants with chla‐ mydial conjunctivitis. Complications of gonococcal conjunctivitis and subsequent systemic involvement include arthritis, meningitis, anorectal infection, septicaemia, and death.

Ophthalmia neonatorum is a preventable cause of childhood blindness and with prompt di‐ agnosis, treatment and efforts on all levels, this can be eradicated.
