Neonatal Conjunctivitis (Ophthalmia Neonatorum) – An Overview

Neonatal conjunctivitis, medically known as Ophthalmia Neonatorum, is a disease of the eye occurring in newborn babies. It is majorly caused by an infection acquired by the baby either during the childbirth or soon after. It is more common in developing countries, particularly in Asia and Africa. This article outlines the various causes, treatment options and the preventive measures of neonatal conjunctivitis.

What is Ophthalmia Neonatorum?

Ophthalmia neonatorum is conjunctivitis in babies who are less than a month old. Conjunctivitis is typically the inflammation of the conjunctiva or the inner surface of the eyes caused due to an infection. Newborn babies pick up the infection from the mother or from their surroundings soon after birth. It is one of the most common types of eye disorders in newborns and is completely treatable if diagnosed on time. However, in some severe cases, there are chances of permanent scarring that can even lead to blindness.

Causes of Neonatal Conjunctivitis

The causes of neonatal conjunctivitis can be classified based on whether it is the infectious type or the non-infectious type. The infectious type is caused by one or more types of infection, while the non-infectious or aseptic type is caused by the contact of a chemical substance.

1. Infectious ON

Infectious ON can be caused by either bacterial or viral infections. The child picks up the infection from the mother while passing through the birth canal during delivery. The chances of infection are high if it is a face presentation(face-first or chin-up position in the womb) delivery or a forceps-assisted delivery. In some rare cases, the child may acquire the infection from an infected amniotic fluid during a membrane rupture. The causes of infections include the following:

• Bacterial: Bacteria like the Chlamydia and N. gonorrhoea are among the most common causative agents of neonatal conjunctivitis. It accounts for nearly 70% of the infectious ON cases. A mother who has sexually transmitted diseases carries these bacteria in her vagina and transmits them to the baby during birth. Other bacteria associated with infectious ON are Staphylococcus aureus, Streptococcus haemolyticus, and Streptococcus pneumonia. The instances of infectious conjunctivitis have declined over the years due to advanced pregnancy screening and a decrease in the prevalence of sexually transmitted diseases.
• Viral: The herpes simplex virus (HSV 2) is a less common cause of infectious neonatal conjunctivitis.

2. Non-Infectious ON

Prophylactic silver nitrate is used in newborns to prevent the spread of gonorrhoeal infection. This silver nitrate has a tendency to irritate the conjunctiva of the newborn’s eyes and can lead to serious forms of sterile conjunctivitis. Chloramphenicol, erythromycin and neomycin are safe alternates for silver nitrate and many doctors have reduced the usage of this harmful chemical.

Signs and Symptoms

Babies who have neonatal conjunctivitis show one of the following symptoms within the first one month of their birth,

• Discharge from the conjunctiva- A classical symptom of conjunctivitis is a white discharge that can contain mucus, pus or both, from the conjunctiva
• Swollen eyelids that give the eye a closed appearance
• pain or tenderness in the eyeball
• irritation, redness and continuous tear discharge (Chemical conjunctivitis)
• excessive oedema of the conjunctiva
• preseptal cellulitis
• Periocular vesicles and superficial punctate keratitis in the case of viral infection

The symptoms start appearing within five days of birth in the case of a gonorrhoeal infection, while it takes anywhere from five days to 28 days after birth, for conjunctivitis caused by a chlamydial infection.

Diagnosis

Once the symptoms start to show in the newborn baby, the doctor carries out a couple of tests to confirm the diagnosis,

• Discharge culture: Since the discharge from the eye carries the causative organism, a culture of the fluid is done on artificial medium. The growth of the bacteria or virus confirms the diagnosis of an infectious ON. Further study is also carried out to exactly determine the causative organism.
• Eye examination: Fluorescein examination of the eye can be helpful for doctors in estimating the extent of conjunctivitis. Normal physical examination of the eye can also give a first-hand idea of the disease.
• Maternal examination: If the doctor suspects a bacterial or viral infection as the cause of conjunctivitis, the mother is examined for any sexually transmitted diseases.
• Case history: A thorough analysis of the time of onset can help in the correct diagnosis, as each type of neonatal conjunctivitis has a unique time of onset.

Complications

Prompt treatment with antibiotics, usually bring down the infection and minimizes any chances of complications. However, in case of lack of proper treatment, the following complications may occur in the child,

• pseudomembrane formation
• the thickened palpebral conjunctiva
• peripheral pannus formation
• opacification of the cornea
• staphyloma
• perforation of the cornea
• endophthalmitis
• corneal oedema
• permanent blindness

Some systemic complications like otitis, pneumonitis, pharyngeal and rectal colonization, meningitis, arthritis, etc. can also occur.

Treatment

The treatment given is usually aimed at reducing the infection and correcting the symptoms of conjunctivitis.

• Antibiotic course: Each type of infection is treated with a suitable antibiotic at age-appropriate dosages. Some severe cases of infection are supplemented with an oral intake of antibiotic in addition to the topical application. Usually, for bacterial infections 1% tetracycline or 0.5% erythromycin is used as the first line of therapy. 50 mg/kg of Ceftriaxone is given to babies with gonococcal infections.
• Saline lavage: Saline is used to wash the eye and clear the infectious discharge

Prevention

The prevention of neonatal conjunctivitis can be done by the following ways

• Identifying and treating the mother carrying the infection. Expecting mothers can be screened for any gonorrhoeal or chlamydial infection. If not during the pregnancy, at least before delivery a screening for these infections is mandatory.
• Maintenance of aseptic conditions during delivery and cleaning the eyes of the newborn with sterile material.
• In case of a known infection in the mother a caesarean operation is preferred over a vaginal delivery, to minimize the chances of the baby contracting the infection.
• Use of safe antibiotics like erythromycin for ocular infections in newborn, instead of silver nitrate drops.
• Babies who are born to mothers carrying the infection, but do not show signs of any conjunctivitis should be monitored closely for the development of any new signs.

The incidence of neonatal conjunctivitis has greatly reduced worldwide, except a few developing countries owing to the general increase in awareness and better access to medical services. With proper and timely medical treatment, neonatal conjunctivitis is completely curable and is rarely sight threatening.