What is Ophthalmia Neonatorum?
Ophthalmia neonatorum is a kind of eye inflammation, similar to pink eye, spotted in newborns. It happens in about 1-12% of infants (see Image. Ophthalmia Neonatorum). This condition is generally passed on during childbirth, and it’s associated with severe risks such as eye ulcers and perforation, which could lead to permanent blindness. This potential severe outcome lead the U.S. Preventive Service Task Force to update guidelines about using antibiotics in all newborns to prevent ophthalmia neonatorum. These guidelines are aimed at reducing the chance of passing on an infection called gonococcal infection, which can happen in up to half of the cases when preventive treatment isn’t given.
In 2010, the Centers for Disease Control and Prevention (CDC) came up with guidelines for dealing with sexually transmitted infections, recommending preventive treatment using ointment (0.5% erythromycin) or azithromycin solution 1% (if plenty of erythromycin isn’t available) as part of standard newborn care to prevent ophthalmia neonatorum. This preventive treatment is both effective and affordable. The guidelines also include routine screening and proper treatment, as well as screening of pregnant women’s partners during the first three months of pregnancy. Screening later in the pregnancy is also suggested for women who may be more susceptible to the infection such as those with more sex partners or women who are 24 years old or younger. Silver nitrate used to be an effective prevention for gonococcal ophthalmia neonatorum, but it is no longer in use because it could lead to chemical conjunctivitis, similar to pink eye, in about half of the cases. [1][2]
What Causes Ophthalmia Neonatorum?
It has been found that various germs are responsible for causing this eye disease, such as Chlamydia trachomatis, Neisseria gonorrhoeae, viruses, and bacteria from the digestive system and skin.
The reason for newborn’s conjunctivitis, also known as “ophthalmia neonatorum,” can be divided into bacteria from sexual and nonsexual sources, viruses, and chemicals. The bacteria Neisseria gonorrhoea is linked to less than 1% of eye infection cases around the world. However, up to 48% of babies born to mothers with this bacteria may develop newborn conjunctivitis. In rare circumstances, meningitis and septicemia- severe and life-threatening blood infections, can develop if this is not treated or if treatment is inadequate.
Non-sexually transmitted bacteria, like Staphylococcus aureus, Streptococcal species, gram-negative bacteria, and Haemophilus, are responsible for 30 to 50% of newborn conjunctivitis cases.
Two common viruses, the Adenovirus and the herpes simplex virus, are also known to often cause conjunctivitis, also known as “pinkeye.”
Risk Factors and Frequency for Ophthalmia Neonatorum
Before 1880, a condition called ophthalmia neonatorum, mostly caused by a bacteria called Neisseria gonorrhoeae, was the top cause of permanent blindness in newborn babies. The first use of silver nitrate as a preventative at birth was by Dr. Crede in 1881. After it started being used, the cases of this eye disease caused by N. gonorrhoeae dropped from 10% to only 0.3%.
In the US, ophthalmia neonatorum brought on by N. gonorrhoeae occurs in roughly 0.3 out of 1,000 live births. Another bacteria, Chlamydia trachomatis, causes this condition in about 8.2 out of 1,000 cases.
Signs and Symptoms of Ophthalmia Neonatorum
Neonatal conjunctivitis, or pink eye in a newborn, is a condition that requires careful diagnosis due to the variety of possible causes. The timing and characteristics of the symptoms can provide clues about the cause, but symptoms like swelling, redness, and discharge might be present regardless of the cause.
Some causes like Chlamydia trachomatis and Neisseria gonorrhoeae are infections the baby can get during birth. If the doctor suspects these are causing the conjunctivitis, they will look into the mother’s medical history, specifically any infections during pregnancy. They also screen for other sexually transmitted infections, including HIV.
The timing of symptom onset can play a key role in treatment. For example, conjunctivitis that starts within 24 hours after birth may be due to chemicals used during delivery. Symptoms include redness, swelling, eyelid puffiness, and discharge. Whereas, Gonococcal conjunctivitis occurs between 2 to 5 days after birth, and is known for its thick, pus-like discharge, extreme swelling, and eyelid puffiness.
Chlamydia-induced conjunctivitis is usually seen 5-14 days after birth and can affect one or both eyes. It starts with a lot of discharge that eventually becomes filled with pus, along with swelling of the eyelids.
- Neonatal conjunctivitis due to birth-acquired infections
- Symptoms begin within 24 hours for chemical causes
- Symptoms appear between 2-5 days for Gonococcal conjunctivitis
- Chlamydia-induced conjunctivitis symptoms show up 5-14 days after birth
Herpes simplex caused conjunctivitis is less common, accounting for less than 1% of cases. However, it’s important to watch out for it in newborns experiencing one-sided swelling, bloody-to-pus-like discharge, sores around the eyelids or mouth, and swollen lymph nodes. It’s important to catch this early as it can lead to serious issues like widespread infection and inflammation of the brain and spinal cord if not treated.
Testing for Ophthalmia Neonatorum
If your doctor suspects your baby may have ophthalmia neonatorum, which is an eye infection, they’ll need to confirm what’s causing the infection. This requires getting a sample of the discharge from the eye. The sample is then sent to a lab to be examined under a microscope (a process known as Gram stain) and grown in certain conditions (on Thayer-Martin media and chocolate agar) to see if any bacteria, specifically N. gonorrhoeae, grow. This step is crucial as it helps doctors provide the right treatment for your baby, preventing complications and ensuring the best possible recovery.
For infections due to Chlamydia trachomatis, another bacterium, doctors have a few more tools at their disposal. They can perform a polymerase chain reaction (PCR) test, which quite simply multiplies the DNA in the sample to make it easier to identify. They can also use a technique called direct fluorescent antibody staining, which helps to visualize the bacteria when looked at under a microscope. Lastly, they may also examine Giemsa-stained epithelial cells scraped from the eyeball’s surface, again, to visually confirm the presence of bacteria. Some doctors may recommend using nucleic acid amplification tests (also known as NAATs) from eye swabs when they suspect chlamydia infection. However, these tests are not approved by the Food and Drug Administration for diagnosing chlamydia on the eyeball’s surface.
In cases of herpes-caused conjunctivitis, doctors typically use a culture test (growing the virus in lab conditions) and PCR to identify its DNA.
Finally, if your baby is showing signs of an infection that’s affecting their entire body (like appearing generally unwell), the doctor may worry that the infection has spread to cause conditions like meningitis, bloodstream infections, joint infection, or sepsis. If this is the case, they’ll need to perform additional tests such as blood culture and testing of the cerebrospinal fluid (the fluid that surrounds the brain and spinal cord) for bacteria.
Treatment Options for Ophthalmia Neonatorum
When a newborn baby is suspected to have an eye infection, also known as neonatal conjunctivitis, doctors will make decisions based on initial examinations and potential complications. If the doctor is highly certain about the conjunctivitis and can’t immediately confirm the cause of the infection, immediate treatment for two common bacterial culprits (Chlamydia trachomatis and Neisseria gonorrhoeae) is recommended to prevent further complications.
If it’s confirmed that Neisseria gonorrhoeae, a type of bacteria, is causing the infection, doctors will start treatment right away. This often includes a hospital stay, and the standard treatment is a single dose of an antibiotic called ceftriaxone. Additionally, a saltwater solution is typically used to keep the eye clean. If Chlamydia trachomatis is identified as the cause, an antibiotic called erythromycin is taken orally for two weeks, and it can also be applied directly to the eye for added benefit.
If the eye infection is due to Staphylococcus bacteria or Pseudomonas, other bacteria, systemic (whole body) antibiotic treatment is required. For cases of conjunctivitis caused by the herpes simplex virus, antiviral medications are needed along with special eye drops, either ganciclovir or trifluridine, for 14 days. For these cases, a consultation with an eye specialist is necessary.
There are also guidelines for managing babies who are born to mothers infected with Chlamydia trachomatis, even if the babies don’t show symptoms. These babies should be closely monitored for signs of infection in their eyes or respiratory system. However, the administration of erythromycin to these asymptomatic babies is generally not recommended due to the risk of developing a condition called pyloric stenosis, a narrowing of the stomach’s exit that can block food from entering the small intestines.
What else can Ophthalmia Neonatorum be?
When trying to determine what’s causing certain eye symptoms, doctors consider several possibilities. These include:
- Dacryocystitis: an inflammation of the tear sac
- Congenital glaucoma: a rare type of glaucoma that occurs in babies
- Keratitis: inflammation of the cornea, the clear layer at the front of the eye
- Nasolacrimal duct obstruction: blockage of the tear duct
- Cellulitis: a skin infection
These conditions often have similar symptoms, making it difficult to pinpoint the exact cause. To help figure it out, doctors will usually do a thorough check-up, asking about any family history of eye diseases and the patient’s overall health history. A detailed physical exam is also part of this process. If the cause still isn’t clear after these steps, the doctor might refer the patient to an eye specialist for further examination.
What to expect with Ophthalmia Neonatorum
Before 1880, a condition called ophthalmia neonatorum, caused by a bacteria called Neisseria gonorrhoeae, was the leading cause of blindness in newborn babies. That’s why it’s so important to detect and treat this in infected mothers as early as possible; it can help to prevent permanent damage to the baby’s eyes. If this condition goes untreated or is not treated fully, it can lead to ulcers in the cornea (the clear part of the eye), perforation or tearing of the cornea, and even blindness. Every year, approximately 10,000 cases of blindness worldwide are a result of ophthalmia neonatorum.
On the bright side, the majority of cases of ophthalmia neonatorum caused by bacteria other than Neisseria gonorrhoeae are not as severe and have a good outlook. However, up to half of all babies born to mothers with a chlamydia infection could develop neonatal conjunctivitis, which is an inflammation of the eye. Out of these babies, 10% to 20% may also develop pneumonia.
A type of conjunctivitis caused by silver nitrate, a chemical sometimes used in eye drops, often gets better on its own without treatment.
Possible Complications When Diagnosed with Ophthalmia Neonatorum
If a baby’s eye condition is not treated promptly, there is a high risk of developing severe eye problems. These can include corneal ulcers, or open sores on the eye’s surface, as well as perforations, or holes, in the eye globe. This can lead to permanent loss of sight. Although it’s rare, there are instances where the disease can spread to other areas. Serious consequences such as meningitis, a dangerous infection surrounding the brain and spinal cord, sepsis, a life-threatening response to an infection, or even death may occur.
- Corneal ulcers
- Ocular globe perforations
- Permanent blindness
- Spread of disease
- Meningitis
- Sepsis
- Potential death
Preventing Ophthalmia Neonatorum
It’s very crucial for mothers to be aware of the importance of regular check-ups during pregnancy. These prenatal visits are not just routine appointments, but they also include essential tests such as screening for infections caused by Neisseria gonorrhoeae and Chlamydia trachomatis. These bacteria can cause serious health problems for both the mother and the baby if not treated. So, attending these regular appointments ensures that any such issues can be identified and addressed early on.
