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Version 2, xy.06.10
Condition
Aetiology
Ophthalmia Neonatorum
Ophthalmia Neonatorum (ON) (conjunctivitis of the newborn) occurs within the
first 30 days of life. It may be infective or non-infective
Infective
Bacterial, chlamydial or viral infection acquired during passage through an
infected birth canal
Historically, the commonest agent was Neisseria gonorrhoeae (‘gonococcus’) and
the use of silver nitrate drops as prophylaxis was introduced in the C19.
Nowadays the usual agent is Chlamydia trachomatis. The prevalence of ON
differs in different parts of the world and is dependent mainly upon socioeconomic
conditions, level of knowledge about general health, standard of maternal
healthcare as well as the type of prophylactic program used. In the USA,
incidence is as follows:
Chlamydia: 6.2 per 1,000 live births
Gonococcus: 3 per 1,000 live births
Any data on the UK?
In developing countries, very much higher incidences have been reported
Other bacteria that can cause ON include Haemophilus, Streptococcus,
Staphylococcus and Pseudomonas species. ON can also complicate generalised
neonatal Herpes simplex infection
The neonatal conjunctiva is particularly vulnerable to infection because of the lack
of immunity and the absence of local lymphoid tissue at birth
The incubation period is usually as follows:
Chlamydia: 5-14 days
Gonococcus: 3-5 days
Predisposing
factors
Non-infective
Usually chemical conjunctivitis, induced by silver nitrate solution (used for
prophylaxis of infective conjunctivitis)
Infection of the maternal birth canal as the result of sexually-transmitted disease
This infection may be asymptomatic, especially in the case of C. trachomatis
Comments
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Symptoms
Signs
Differential
diagnosis
Symptoms (usually described by mother):
Redness sign rather than symptom?
Discharge (may be profuse in gonococcal infection)
Swelling of lids (may be severe)
Symptoms usually bilateral
Lids
Oedema may impede examination of ocular surfaces
Conjunctival features
Mucopurulent conjunctivitis – discharge may be profuse in gonococcal infection.
Danger of infection of clinician when prising open lids
NB in C. trachomatis infection there are no follicles as in adults, because of the
neonate’s lack of lymphoid tissue
Conjunctival oedema (‘chemosis’)
Conjunctival membrane in severe cases
Corneal features
Cornea can be involved, especially in gonococcal infection. Organism can pass
through intact epithelium
Signs usually bilateral; may be asymmetrical
By definition, conjunctivitis occurring within the first 30 days of life is ON
Management by Optometrist
NonNone
pharmacological
Pharmacological
None
A1: urgent referral to Ophthalmologist; no intervention
Management
category
ON may result in a severe and progressive conjunctivitis with corneal
complications and be associated with potentially serious systemic infection
Possible management by Ophthalmologist
Diagnosis
WF - I would suggest putting blocked Nasolacrimal
ducts in the differential diagnosis? It can be bilateral
and associated with a discharge and is of course
very much commoner than ophthalmia neonatorum.
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

Conjunctival cultures for bacteria (N. gonorrhoeae requires special media)
Conjunctival scraping for Gram stain (bacteria) and Giemsa stain (for
chlamydia)
 Polymerase chain reaction (PCR) studies
Treatment
Bacterial conjunctivitis
 Systemic penicillin G or a cephalosporin for N. gonorrhoeae
 Topical erythromycin sometimes given in addition
 Frequent irrigation until discharge ceases
 Topical antibiotics for other bacteria
Chlamydial conjunctivitis
 Systemic erythromycin
Herpetic conjunctivitis
 Systemic aciclovir
Evidence base
Recommendations for the prevention of neonatal ophthalmia by the Infectious
Diseases and Immunization Committee of the Canadian Paediatric Society (CPS)
Paediatr Child Health 2002;7(7):480-3 (reaffirmed in 2009)
Authors’ conclusion: as soon as possible after birth, all infants should receive
prophylaxis with silver nitrate, tetracycline or erythromycin, to reduce the risk of
neonatal ophthalmia due to N. gonorrhoeae. The use of these agents may also
provide some benefit in the prevention of ophthalmia due to other organisms. The
CPS also supports routine prenatal screening for N. gonorrhoeae and Chlamydia
trachomatis, and the treatment of identified infections during pregnancy
Centre for Evidence-based Medicine Level of Evidence = 1a
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This is interesting from Austria as it shows such a wide variety of practice in a developed country
Wien Klin Wochenschr. 2002 Mar 28;114(5-6):194-9.
Prophylaxis of ophthalmia neonatorum--a nationwide survey of the current practice in Austria.
Assadian O, Assadian A, Aspöck C, Hahn D, Koller W.
Division of Hospital Hygiene, Institute of Hygiene, University of Vienna Medical School, Vienna, Austria. [email protected]
Comment in:
Wien Klin Wochenschr. 2002 Mar 28;114(5-6):171-2.
The aim of this study was to analyze the current practice of Ophthalmia neonatorum prophylaxis in Austria. Questionnaires were sent to 107
hospitals with obstetric units, as well as to 490 registered community midwives, together looking after a yearly total of approximately 70,000
births. The overall return of the hospitals and midwives was 91.6% and 7.6%, respectively. RESULTS: Ophthalmia neonatorum prophylaxis is
being applied by 93.8% of all respondents (hospitals 96.9%, and community midwives 82.3%). The three most frequently applied substances
were Erythromycin (41.8%), Gentamicin (21.3%) and Silver nitrate (19.7%). Other substances were Tetracycline, Povidone-Iodine, Neomycin
and Chloramphenicol. The reported overall-observation of chemical conjunctivitis after application of a prophylactic agent was 42.3% (55/133),
typically after the use of Silver nitrate, Erythromycin or Tetracycline. The agent was determined by pediatricians (29%), in accordance to
governmental decree (15%), by hospital policy (12%), effectiveness against Chlamydia and Gonococci (9%), by pharmacists (3%) and
ophthalmologists (3%). 18% did not give any reason for the choice of agent. CONCLUSION: The rationale for prophylaxis and the substances
used in Austria show heterogeneity. Seven prophylactic agents are used, two antiseptics and five antibiotics. 25% of the routine applicants are
using substances (Gentamicin, Neomycin or Chloramphenicol) for which no evidence based efficacy for prophylaxis of Ophthalmia neonatorum
has been demonstrated through clinical trials. However, 83.5% of the maternity units do not want changes in their current routine, unless there
is a nation-wide agreement for Ophthalmia neonatorum prophylaxis.
------------------------------------Also http://archopht.ama-assn.org/cgi/content/full/128/1/136
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On the use of povidone iodine in a 2010 paper in Archives.