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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 Version 2, xy.06.10 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. Version 2, xy.06.10 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 Version 2, xy.06.10 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 Version 2, xy.06.10 On the use of povidone iodine in a 2010 paper in Archives.