What is Neonatal Conjunctivitis (Ophthalmia Neonatorum)?
When a newborn baby has eye discharge, it’s usually due to a blocked tear duct (known as a congenital nasolacrimal duct obstruction) or inflammation of the eye’s outer layer due to chemical irritants or an infection (known as conjunctivitis). Newborn conjunctivitis, also known as ophthalmia neonatorum, tends to appear within the first four weeks of a baby’s life. It’s typically caught during delivery, making it the most common eye condition in newborns.
The usual signs are constant teardrops and a mucus-like discharge in the inner corner of the eye. Understanding the symptoms, assessment, and treatment of newborn conjunctivitis is important, emphasizing the role of a healthcare team working together to care for affected babies.
What Causes Neonatal Conjunctivitis (Ophthalmia Neonatorum)?
The cause of conjunctivitis (or pink eye) in newborn babies can vary depending on their age. However, infections caused by bacteria can emerge at any time. Here’s a short summary of what usually causes conjunctivitis at different stages of a baby’s first few days of life:
- During the first 24 hours after birth: Conjunctivitis can be caused by certain chemicals, such as silver nitrate drops, or medicines like erythromycin drops or gentamicin drops. These substances are often used to prevent eye infections.
- After 24 to 48 hours of life: Bacteria, particularly Neisseria gonorrhoeae (which causes gonorrhea) and Staphylococcus aureus, are most likely to cause conjunctivitis.
- From day 5 to day 14: The infection could be due to Chlamydia trachomatis, a bacterial strain that causes chlamydia.
- From day 6 to day 14: Herpes keratoconjunctivitis, an eye condition as a result of the herpes virus, can occur.
- From day 5 to day 18: Pseudomonas aeruginosa, a bacterium that can cause infections, might be the cause.
These are averages and this timeline can sometimes vary from child to child.
Risk Factors and Frequency for Neonatal Conjunctivitis (Ophthalmia Neonatorum)
Infectious neonatal conjunctivitis – a type of eye infection in newborns – happens in about 1% to 2% of cases. The main cause of this condition shifted after the introduction of a solution called silver nitrate in the 1800s, which was used to avoid gonococcal ophthalmia, a severe kind of eye infection. Today, the most common culprit of this condition in the US is ‘Chlamydia’. It accounts for between 2% and 40% of all cases of neonatal conjunctivitis.
On the other hand, the occurrence of gonococcal ophthalmia neonatorum has decreased significantly and now makes up less than 1% of neonatal conjunctivitis cases.
Signs and Symptoms of Neonatal Conjunctivitis (Ophthalmia Neonatorum)
Conjunctivitis, also known as pink eye, shows several key physical signs. It typically involves a discharge from the eye, swelling and redness of the eyelids, and increased blood supply in the white part of the eye. The nature of the discharge can provide clues to the cause of conjunctivitis. For instance, a thick, pus-like discharge can indicate a bacterial infection, while a water-like discharge might suggest a viral cause. Different bacteria lead to distinctive discharges; Gonorrhea often creates a heavy, pus-filled discharge, Pseudomonas may result in a greenish discharge, and Chlamydia often leads to a watery discharge that can later turn into a pus and blood-filled discharge.
In addition, the affected eye (or eyes) can also provide clues to the potential cause of the infection. Conjunctivitis that affects only one eye is commonly linked to bacteria such as S. aureus, P. aeruginosa, or viruses causing Herpes simplex or adenovirus. Conjunctivitis affecting both eyes is usually the result of an infection from N. gonorrhea or a reaction to eye drop medications. An infection from Chlamydia typically starts in one eye and then moves to the other eye within 2 to 7 days.
As part of a physical check for conjunctivitis, the doctor should look for a red glow when light is shone in the eye (red reflex), check for any sores on the eye surface, and feel for any swollen lymph nodes. Additionally, they should assess other symptoms that may hint at a respiratory or general body infection.
Certain factors can increase the risk of certain types of conjunctivitis, such as history of sexually transmitted infections (STIs) in the mother, which increases the risk of infections from Chlamydia and Gonorrhea. Babies born to mothers infected with HIV also have a heightened risk of getting neonatal conjunctivitis.
Testing for Neonatal Conjunctivitis (Ophthalmia Neonatorum)
If you find that there’s a discharge from your eye, it could be a number of different things. Possibilities include an infection in your eye (conjunctivitis), a blocked tear duct present from birth, or something foreign that got into your eye. Other possibilities could include an infection around your eye or eyelid, an inward-turned eye lid, injury to your eye or scratch on your eye’s surface, inflammation of the tear sac (dacryocystitis), or eye inflammation (keratitis). Broken blood vessels in the eye following delivery, abnormalities of the tear system present at birth, diseases affecting the surface of the eye, signs of drug withdrawal in a newborn, and dangerously high eye pressure (congenital glaucoma) could also be the cause.
To understand the cause, your doctor will examine the area around your eyes and check for swelling in nearby lymph nodes. They’ll check both of your eyes and eyelids for any swelling or inflammation, and will look at the white part of your eyes for redness or swelling. They’ll also check for any ulcers and for the presence of the ‘red reflex’, which is the red glow you see when light shines into your eye. If your eye lids are red and swollen, there’s a whitish-yellow fluid discharge or the white part of your eye is red, it could be bacterial conjunctivitis, which is an infection of the eye.
To confirm, your doctor might take a sample of the eye discharge to check under a microscope and to grow in a lab, which will help identify any bacteria present. The lab can also determine the best medication to treat the identified bacteria. For suspicion of an infection with the bacteria ‘chlamydia’, a Giemsa stain test might be done. Nowadays, the diagnosis of chlamydia is more commonly made using nucleic acid amplification tests, which are cheaper and less labor-intensive than traditional tests. If a newborn baby is suspected of having a chlamydia infection, samples should be taken from both eyes and the back of the throat. As chlamydia is a bacteria that lives inside cells, the swab should also collect cells from the lining of the eye, if possible.
Usually, no imaging tests are needed. However, to check whether a blocked tear duct is the causing the discharge, your doctor might perform a Fluorescein dye disappearance test.
Treatment Options for Neonatal Conjunctivitis (Ophthalmia Neonatorum)
Some basic steps are important to manage any conjunctivitis condition like frequent hand washing, wearing gloves to prevent the spread of infection, rinsing the eye with sterile saline, and not covering the eye with a patch. Medical experts with knowledge in children’s infections and children’s eye health could also be consulted. If the cause of conjunctivitis is chemical exposure, it usually clears on its own within 2-3 days and using lubricating eye drops or artificial tears might provide some relief.
Gonococcal conjunctivitis, caused by the gonococcus bacteria, is considered a medical emergency. It can still occur even with preventive measures in babies born to mothers with an active gonococcal infection. It is primarily treated with a class of antibiotics called third-generation cephalosporins. The baby should be isolated during the first day of antibiotic therapy to prevent spread. It is also necessary to test for other infections like HIV and syphilis. Further assessment for other systemic infections, including arthritis, meningitis, sepsis, and anorectal infections is needed. Frequent rinsing of the eyes with saline solution helps and additional eye drops are usually not needed.
Chlamydial conjunctivitis occurs due to the Chlamydia bacteria and often needs systemic treatment, as localized (topical) treatments are generally ineffective. Treatment with one of two antibiotics, either erythromycin for 14 days or azithromycin for 3 days, is recommended. Often, a second course of antibiotics is required as there can be a recurrence of infection in one out of every five cases. Parents need to be informed that erythromycin, in some cases, can lead to a condition in infants known as pyloric stenosis, which affects the opening from the stomach into the intestines. Also, no preventive measures are recommended for babies born to mothers with Chlamydia exposure.
In case of herpetic conjunctivitis, caused by the herpes virus, both eye drop medication and systemic medication like acyclovir are often prescribed. It’s crucial to assess and treat the patient for systemic herpes infection. An eye specialist should perform an examination as eye complications like retinopathy (damage to retina), cataracts (clouding of lens) and chorioretinitis (inflammation of the inner eye) can develop.
It’s also advised to keep patients with Pseudomonas, herpes, and gonococcal conjunctivitis isolated to prevent the spread of infection. In case of a blocked tear duct, most cases resolve on their own. However, if the symptoms persist beyond 6 to 7 months, an ophthalmologist should evaluate the infant.
What else can Neonatal Conjunctivitis (Ophthalmia Neonatorum) be?
When trying to diagnose an eye-related issue, it’s important to eliminate several conditions that might cause similar symptoms. These conditions can include:
- Bacterial keratitis
- Dacryocystitis
- Fungal keratitis
- Happy simplex virus keratitis
- Nasolacrimal duct obstruction and epiphora
- Orbital cellulitis
- Preseptal cellulitis
- Primary congenital glaucoma
- Secondary congenital glaucoma
It’s essential to accurately diagnose the right condition, to initiate the correct treatment for the patient.