Ophthalmology
Question 266 of 300
A 17 year old girl presents to the Emergency Department with her 3 day old daughter. She is concerned by a change in the babies eyes. The mother has not engaged with maternal services during and after the birth. What is the most likely diagnosis?
Answer:
The two major causes of infective neonatal conjunctivitis which should be excluded as priority are Chlamydia trachomatis and Neisseria gonorrhoea. Prompt diagnosis is key in establishing treatment and minimising potential complications. Time of onset varies with likely pathogen:- Non-infectious
- First 24 hours, usually self-limiting
- Neisseria gonorrhoeae
- Presents from birth to 5 days post-birth
- Chlamydia trachomatis (more common than gonorrhoea)
- Presents from 5 days to 14 days post-birth
Ophthalmia Neonatorum
Ophthalmology
Last Updated: 12th February 2021
A ‘sticky eye’ is a relatively common problem in infancy and ophthalmia neonatorum refers to any conjunctivitis (defined as conjunctival inflammation) occurring within the first 28 days of life. It is often due simply to a blocked lacrimal duct but may also be caused by a variety of bacterial and viral pathogens.
Causes
- Non-infective
- Blocked lacrimal duct
- Irritants
- Bacterial infection
- Chlamydia trachomatis
- Neisseria gonorrhoea
- Haemophilus influenzae
- Staphylococcus aureus
- Streptococcus pneumonia
- Group A and B streptococci
- Moraxella catarrhalis
- Escherichia coli
- Pseudomonas species
- Viral infection
- Herpes simplex
- Adenovirus
Presentation
Conjunctivitis is a clinical diagnosis that presents with inflammation of the conjunctiva causing conjunctival erythema, blood vessel dilation and tearing. It can involve the eyelid causing swelling and/or the cornea and lacrimal apparatus causing serous or purulent discharge.
The two major causes of infective neonatal conjunctivitis which should be excluded as priority are Chlamydia trachomatis and Neisseria gonorrhoea. Prompt diagnosis is key in establishing treatment and minimising potential complications. Time of onset varies with likely pathogen:
- Non-infectious
- First 24 hours, usually self-limiting
- Neisseria gonorrhoeae
- Presents from birth to 5 days post-birth
- Chlamydia trachomatis (more common than gonorrhoea)
- Presents from 5 days to 14 days post-birth
- Other bacteria
- Presents from 4 - 5 days post-birth but can be any time
- Herpes simplex virus
- Presents from 1 - 2 weeks post-birth
General management
- No conjunctival inflammation
- If there is no conjunctival inflammation or other signs of infection then no antibiotics are required.
- Advise regular cleansing of the affected eye(s) with sterile water or 0.9% saline, wiping from nose to outer aspect of eye in a single motion, discarding swab or cotton pad following this. A fresh swab or pad should be used if further cleansing is required. This should be done 4 to 6 hourly for 2 to 3 days. Daily firm massage of the nasolacrimal ducts is recommended: advise parents to use a clean index finger to press downwards on the side of the nose from the corner of the eye to the nostril.
- If no improvement (discharge persisting for greater than 48 hours) delayed antibiotic prescription may be indicated. A swab must be taken prior to commencement of any antibiotic treatment. Common organisms should respond to topical chloramphenicol, and both eyes should be treated.
- Conjunctival inflammation or purulent discharge
- If the infant’s eye looks inflamed or if the discharge is purulent, empiric treatment with topical chloramphenicol eye ointment should be commenced pending culture.
- An extremely purulent discharge in the first few days of life should prompt consideration of Neisseria gonorrhoeae.
- When a sticky eye has not responded to empiric antibiotic ointment, swabs should be sent to the virology laboratory to exclude Chlamydial infection.
Specific infections
- Neisseria gonorrhoeae
- Transmission
- Vertical transmission rates are high with positive conjunctival cultures occurring in 30-50% of cases. It is therefore prudent to treat prophylactically babies born to mums positive for gonorrhoea.
- Presentation
- Gonococcal conjunctivitis usually develops in the first 5 days after birth and is rapidly progressive; presentation in the second week suggests postnatal exposure. Most affected neonates have profuse purulent conjunctivitis and oedema of the eyelid.
- Pharyngeal colonisation occurs in up to 15% of infants with gonococcal conjunctivitis and carries a risk of haematogenous spread to distal sites. Any infant with proven eye involvement should be assessed for evidence of joint, mucosal surface (rhinitis, stomatitis or anorectal involvement) or CNS infection.
- Investigation
- An urgent eye swab should be taken and urgent gram stain requested, with preliminary results available and chased the same day. The presence of Gram negative diplococci is highly suggestive of gonococcal infection and should prompt treatment pending formal cultures.
- Definitive diagnosis is made by subsequent bacteriological culture or Nucleic Acid Amplification Test (NAAT). It is advisable to test for Chlamydia at the same time as both infections may be present. Appropriate cultures should also be obtained from the mother if neonatal infection is suspected and/or confirmed.
- Treatment
- Ophthalmia neonatorum without systemic disease
- e.g. Cefotaxime 100 mg/kg, single dose, IV
- 0.9% Normal Saline irrigation until eye discharge clears
- Disseminated gonococcal disease
- e.g. Cefotaxime 50 mg/kg IV three times daily
- Treatment should continue for 7 days (or 14 days if meningitis is suspected or proven)
- Documented maternal infection: neonatal prophylaxis
- Asymptomatic infants born to mothers with known disease should be treated with e.g. a single dose of Cefotaxime 100 mg/kg IV after birth
- Ophthalmia neonatorum without systemic disease
- Complications
- Corneal involvement with ulceration and scarring is a serious complication of neonatal conjunctivitis which can occur even with treatment and will result in visual impairment. Perforation can also occur.
- Transmission
- Chlamydia trachomatis
- Transmission
- Overall transmission rate at delivery is around 25%, ranging from 67% for vaginal delivery to less than 10% for infants born by caesarean section. Apparently successful treatment of the mother during pregnancy does not preclude neonatal infection.
- When a mother is known to be infected with chlamydia, management of the infant should be expectant. In a symptomatic infant it would be reasonable to commence empiric treatment pending the result of eye swabs or NP secretions.
- Presentation
- Onset is usually around day 5 - 14 but may be as late as 60 days.
- Chlamydial eye infection often presents unilaterally and becomes a bilateral conjunctivitis. This may initially be serosanguineous but later becomes mucoid or mucopurulent in appearance. It is commonly associated with eyelid swelling and marked conjunctival injection.
- 10 - 20% of infected neonates develop pneumonia and infants may have feeding difficulties at initial presentation as a consequence of this.
- Investigation
- Chlamydia is detected in conjunctival cells by NAAT. Cells should be obtained by firmly swabbing the everted lower eyelid using a virology swab.
- Treatment
- Systemic therapy is always required. Although topical therapy may be clinically effective for treatment of the eye infection, it does not eradicate nasopharyngeal carriage or prevent subsequent pneumonia. Systemic treatment is effective with eradication in 80 - 100% of cases.
- Options include:
- Oral erythromycin 12.5 mg/kg/dose, four times daily, 14 days
- Oral azithromycin, 20 mg/kg, once daily, for 3 days
- Maternal screening and treatment will be required.
- Complications
- Symptoms may resolve spontaneously but infection in untreated or inadequately treated cases can persist for up to a year and may result in corneal scarring. Other systemic complications include pneumonitis, rhinitis and otitis.
- Chlamydial pneumonia presents as an afebrile respiratory illness with paroxysmal cough and wheeze. Symptoms can be very similar to viral bronchiolitis or whooping cough but infection may be atypical in preterm infants. Onset is usually between 2-12 weeks post delivery: antecedent conjunctivitis is not a prerequisite.
- Transmission
- Herpes simplex virus
- Herpes simplex virus may present within the first two weeks of life in association with systemic herpes infection or local skin lesions.
- Signs include eyelid oedema, moderate conjunctival injection, and non-purulent and often serosanguineous discharge, which may be unilateral or bilateral.
- If suspected, discuss diagnosis and treatment with microbiologists.
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- Biochemistry
- Blood Gases
- Haematology
| Biochemistry | Normal Value |
|---|---|
| Sodium | 135 – 145 mmol/l |
| Potassium | 3.0 – 4.5 mmol/l |
| Urea | 2.5 – 7.5 mmol/l |
| Glucose | 3.5 – 5.0 mmol/l |
| Creatinine | 35 – 135 μmol/l |
| Alanine Aminotransferase (ALT) | 5 – 35 U/l |
| Gamma-glutamyl Transferase (GGT) | < 65 U/l |
| Alkaline Phosphatase (ALP) | 30 – 135 U/l |
| Aspartate Aminotransferase (AST) | < 40 U/l |
| Total Protein | 60 – 80 g/l |
| Albumin | 35 – 50 g/l |
| Globulin | 2.4 – 3.5 g/dl |
| Amylase | < 70 U/l |
| Total Bilirubin | 3 – 17 μmol/l |
| Calcium | 2.1 – 2.5 mmol/l |
| Chloride | 95 – 105 mmol/l |
| Phosphate | 0.8 – 1.4 mmol/l |
| Haematology | Normal Value |
|---|---|
| Haemoglobin | 11.5 – 16.6 g/dl |
| White Blood Cells | 4.0 – 11.0 x 109/l |
| Platelets | 150 – 450 x 109/l |
| MCV | 80 – 96 fl |
| MCHC | 32 – 36 g/dl |
| Neutrophils | 2.0 – 7.5 x 109/l |
| Lymphocytes | 1.5 – 4.0 x 109/l |
| Monocytes | 0.3 – 1.0 x 109/l |
| Eosinophils | 0.1 – 0.5 x 109/l |
| Basophils | < 0.2 x 109/l |
| Reticulocytes | < 2% |
| Haematocrit | 0.35 – 0.49 |
| Red Cell Distribution Width | 11 – 15% |
| Blood Gases | Normal Value |
|---|---|
| pH | 7.35 – 7.45 |
| pO2 | 11 – 14 kPa |
| pCO2 | 4.5 – 6.0 kPa |
| Base Excess | -2 – +2 mmol/l |
| Bicarbonate | 24 – 30 mmol/l |
| Lactate | < 2 mmol/l |
