Ophthalmia Neonatorum

Classification & Key Features

Clinical Presentation

Gonococcal ophthalmia neonatorum with characteristic copious purulent discharge

Ophthalmia neonatorum showing mucopurulent discharge and periorbital edema

Etiology in Detail

1. Chemical

• Caused by prophylactic agents (classically silver nitrate; now erythromycin ointment).
• Self-limited, resolves within 24–36 hours; no treatment needed.

2. Gonococcal

• Acquired during passage through an infected birth canal.
• Onset 2–7 days; presents with intense bilateral chemosis and copious purulent discharge.
• The organism can penetrate intact corneal epithelium → rapid corneal ulceration and perforation if untreated.
• Half of untreated patients develop corneal clouding (major cause of blindness).
• Gram stain: gram-negative intracellular diplococci.
• Must evaluate for disseminated disease (joints, CNS, blood, CSF).

3. Chlamydial

• Most common infectious cause; C. trachomatis is a leading cause overall.
• Onset 7–14 days; bilateral mucopurulent discharge with eyelid edema and palpebral injection.
• May form pseudomembranes with bloody discharge in severe cases.
• Systemic complications: chlamydial pneumonia, rhinitis, otitis media.
• Diagnosis: Giemsa stain (intracytoplasmic basophilic inclusion bodies in epithelial cells), PCR, ELISA, DNA hybridization.

4. Other Bacterial

• Organisms: S. aureus, S. epidermidis, H. influenzae (non-typeable), E. coli, Pseudomonas.
• Non-typeable H. influenzae is uniquely severe — requires hospitalization, full septic workup, and parenteral antibiotics.
• All others: topical antibiotics usually sufficient.

5. Herpes Simplex (Viral)

• Rare but devastating; caused by HSV-2 > HSV-1.
• Onset 14–28 days; corneal dendrites → geographic ulcer.
• Risk of keratitis and disseminated neonatal HSV (encephalitis, multi-organ failure).
• Maternal history of herpes infection may be absent.
• Steroid drops are strictly contraindicated.

Differential Diagnosis

• Dacryocystitis: Swelling/erythema below the inner canthus
• Nasolacrimal duct obstruction: Chronic tearing without true conjunctivitis
• Congenital glaucoma: Tearing + corneal haze + buphthalmos

Workup

1. History: Maternal STI history, prenatal cultures
2. Ocular exam with fluorescein staining (assess corneal involvement)
3. Conjunctival scrapings for Gram and Giemsa stain
4. Cultures: Blood agar + chocolate agar (in 2–10% CO₂ for gonococcal)
5. Chlamydial PCR/immunofluorescent antibody test
6. Viral culture (if HSV suspected — moisten swab, roll along palpebral conjunctiva)
7. Systemic evaluation by primary care/paediatrics

Treatment

Chemical

• Discontinue offending agent; preservative-free artificial tears if needed; reevaluate in 24 hours.

Gonococcal

• Hospitalize; ophthalmology consult.
• Ceftriaxone 25–50 mg/kg IV/IM (max 125 mg) single dose, or cefotaxime 100 mg/kg IV/IM single dose.
  • Use cefotaxime if hyperbilirubinemia is present or disseminated infection suspected (requires longer course).
• Saline irrigation of conjunctiva and fornices until discharge clears.
• Treat both parents for gonorrhoea and chlamydia.

Chlamydial

• Oral erythromycin 50 mg/kg/day in 4 divided doses × 14 days + erythromycin ophthalmic ointment QID.
• Alternative: azithromycin 20 mg/kg/day orally × 3 days.
• Topical therapy alone is not effective — systemic treatment is mandatory.
• Treat mother and partners (doxycycline 100 mg BD × 7 days; azithromycin 1 g single dose if breastfeeding/pregnant).
• All neonates with chlamydial infection should also be evaluated for N. gonorrhoeae.

Other Bacterial

• Topical bacitracin-polymyxin ointment usually sufficient.
• Non-typeable H. influenzae: admit + parenteral antibiotics.

Herpes (Viral)

• Hospitalize; full septic evaluation including LP with HSV PCR of CSF.
• IV acyclovir 20 mg/kg every 8 hours for 14–21 days.
• Topical antivirals: 1% trifluridine, 0.1% iododeoxyuridine, or 0.15% ganciclovir.

Unknown Etiology (empirical)

• Erythromycin ointment QID + erythromycin elixir 50 mg/kg/day in 4 divided doses for 2–3 weeks.

Prophylaxis

• Erythromycin 0.5% ophthalmic ointment (agent of choice in most countries)
• Silver nitrate 1% aqueous solution (historical; being phased out)
• Tetracycline 1% ophthalmic ointment

The Canadian Paediatric Society advises against routine prophylaxis; the American Academy of Pediatrics continues to recommend it for all newborns. Povidone-iodine 0.5% is an emerging alternative — less toxic, inexpensive, and effective, but not yet widely adopted.

Key Complications

Recent Evidence