ophthalmia%20neonatorum
OPHTHALMIA NEONATORUM
Ophthalmia neonatorum is conjunctivitis occurring in a newborn during the first month of life.
It is also called neonatal conjunctivitis.
Organisms causing neonatal conjunctivitis are usually acquired from the infected birth canal of the mother during vaginal delivery, though some may acquire the infection from their immediate surroundings.
It is one of the leading cause of blindness in infants via corneal ulceration and subsequent opacification or perforation and endophthalmitis.

Diagnosis

  • Laboratory diagnosis is important in identifying the causative agent & appropriate treatment

Classification

  • Identifying the specific cause & clinical presentation of ophthalmia neonatorum is essential in deciding the treatment to be given to the infant
Aseptic (Non-Infectious)
  • Usually connotes to chemical conjunctivitis
  • Classically secondary to silver nitrate instillation for ocular infection prophylaxis
  • Time of onset: 1-36 hrs postpartum
  • Usually disappears w/ withdrawal of offending agent or spontaneously in 2-4 days
  • Clinical presentation:
    • Mild, transient conjunctival injection w/ tearing
    • Lid swelling associated w/ redness of the eyes
    • Rarely, lacrimal stenosis
Septic (Infectious)
  • Bacterial, chlamydial or viral infection acquired during passage through an infected birth canal
  • Due to the lack of immunity & absence of local lymphoid tissue at birth, the neonatal conjunctiva is particulalry vulnerable to infection
Chlamydial neonatal conjunctivitis
  • Genital serovars type D-K of Chlamydia trachomatis is the most frequent cause of neonatal conjunctivitis
  • Also called inclusion conjunctivitis
  • Time of onset: 5-14 days postpartum
  • Colonization of the eye w/ C. trachomatis after birth does not always result in infection
  • Clinical presentation:
    • Eyelid edema
    • Bulbar conjunctival injection
    • Initially the discharge is watery then becomes mucopurulent discharge
    • No follicles
    • Pseudomembrane formation
    • Severe cases may result in conjunctival scarring & peripheral corneal pannus w/ corneal scarring
    • Hemorrhagic eye discharge is a highly specific sign of neonatal chlamydial conjunctivitis
  • Infantile pneumonia may occur if it is left untreated
    • Untreated cases may persist for 3-12 months
  • Other extraocular involvement: Nasopharyngeal, rectal & vaginal colonization
Gonococcal neonatal conjunctivitis
  • Usual cause is the gram-negative diplococcus Neisseria gonorrhoeae that can penetrate an intact epithelium causing epithelial edema & corneal ulceration
    • More severe than chlamydial neonatal conjunctivitis as it can progress to corneal perforation, endophthalmitis & blindness if unrecognized & untreated
  • Incubation period: 2-5 days
  • Time of onset: 24-48 hours postpartum
    • Can present later (> 7 days) if a topical antibiotic was used
    • Can occur earlier in cases of premature rupture of membranes
  • Clinical presentation:
    • Severe hyperacute purulent discharge
    • Marked eyelid edema
    • Marked chemosis
    • Marked builbar conjunctival injection
    • Pre-auricular lymphadenopathy
  • Other extraocular involvement: Stomatitis, arthritis, rhinitis, septicemia, meningitis & anorectal infection

Laboratory Tests

Cultures
  • Indicated in all cases of suspected neonatal conjunctiviits
  • Chlamydia trachomatis culture specimens should contain conjunctival cells & not exudate only
    • Obtained from the everted eyelid using a dacron-tipped swab
  • Neisseria gonorrhea cultures is best done using blood agar, chocolate agar &/or Thayer-Martin media
  • Viral cultures are not routinely used to establish a diagnosis
Histology
  • Smears for cytology & special stains are recommended in cases of suspected infectious neonatal conjunctivitis
  • Conjunctival scrapings for gram stain & giemsa stains should be obtained from the palpebral conjunctiva of all infants w/ neonatal conjunctivitis
  • Gonococcal neonatal conjunctivitis has gram negative intracellular kidney bean-shaped diplococci in conjunctival smears
  • Chlamydial neonatal conjunctivitis shows intracytoplasmic inclusion bodies in Giemsa stain
  • Herpetic conjunctivitis has eosinophilic intranuclear inclusions
Enzyme-Linked Immunosorbent Assay (ELISA)
  • Highly sensitive & specific for diagnosing chlamydial cause of neonatal conjunctivitis w/ results obtained w/in several hours
Direct Immunofluorescence Test
  • Gold standard for diagnosing chlamydial infections
    • Shows the presence of an impressively large number of punctate, fluorescing chlamydial elementary bodies, resembling “star-spangled sky at night”
Microimmunofluorescence assay
  • For detection of Chlamydia trachomatis immunoglobulin (IgG) & immunoglobulin (IgM) antibodies
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