OPHTHALMIA NEONATORUM

Ophthalmia neonatorum is the name given to bilateral inflammation of the conjunctiva occurring in an infant, less than 30 days old. It is a preventable disease usually occurring as a result of carelessness at the time of birth. As a matter of fact any discharge or even watering from the eyes in the first week of life should arouse suspicion of ophthalmia neonatorum, as tears are not formed till then.
Etiology
Source and mode of infection
Infection may occur in three ways: before birth, during birth or after birth.

1. Before birth infection is very rare through infected liquor amnii in mothers with ruptured membrances.

2. During birth. It is the most common mode of infection from the
  infected birth canal especially when the child is born with face presentation or
with forceps.
3. After birth. Infection may occur during first bath of newborn or from soiled clothes or fingers with infected lochia.

Causative agents
1. Chemical conjunctivitis It is caused by silver nitrate or antibiotics used for prophylaxis.

2. Gonococcal infection was considered a serious disease in the past, as it used to be responsible for 50 per cent of blindness in children. But, recently the decline in the incidence of gonorrhoea as well as effective methods of prophylaxis and treatment have almost eliminated it in developed countries. However, in many developing countries it still continues to be a problem.

3. Other bacterial infections, responsible for ophthalmia neonatorum are Staphylococcus aureus, Streptococcus haemolyticus, and Streptococcus pneumoniae.

4. Neonatal inclusion conjunctivitis caused by serotypes D to K of Chlamydia trachomatis is the commonest cause of ophthalmia neonatorum in developed countries.

5. Herpes simplex ophthalmia neonatorum is a rare condition caused by herpes simplex-II virus.

Clinical features
Incubation period
It varies depending on the type of the causative agent
as shown below:

Causative agent         Incubation period
1. Chemical                 4-6 hours

2. Gonococcal             2-4 days

3. Other bacterial         4-5 days

4. Neonatal inclusion
conjunctivitis               5-14 days

5. Herpes simplex        5-7 days

Symptoms and signs (Fig. 1)
1. Pain and tenderness in the eyeball.
2. Conjunctival discharge. It is purulent in gonococcal ophthalmia neonatorum and mucoid or mucopurulent in other bacterial cases and
neonatal inclusion conjunctivitis.
3. Lids are usually swollen.
4. Conjunctiva may show hyperaemia and chemosis. There might be mild papillary response in neonatal inclusion conjunctivitis and herpes simplex
ophthalmia neonatorum.
5. Corneal involvement, though rare, may occur in the form of superficial punctate keratitis especially in herpes simplex ophthalmia neonatorum.

Fig. 1. Ophthalmia neonatorum.

Complications
Untreated cases, especially of gonococcal ophthalmia neonatorum, may develop corneal ulceration, which may perforate rapidly resulting in corneal
opacification or staphyloma formation.

Treatment
Prophylactic treatment is always better than curative.
A. Prophylaxis needs antenatal, natal and postnatal
care.
1. Antenatal measures include thorough care of mother and treatment of genital infections when suspected.
2. Natal measures are of utmost importance, as
mostly infection occurs during childbirth.

• Deliveries should be conducted under hygienic conditions taking all aseptic measures.
• The newborn baby's closed lids should be thoroughly cleansed and dried.

3. Postnatal measures include :

• Use of either 1 percent tetracycline ointmentor 0.5 percent erythromycin ointment or 1 percent silver nitrate solution (Crede's method) into the eyes of the babies immediately after birth.
• Single injection of ceftriaxone 50 mg/kg IM or IV (not to exceed 125 mg) should be given to infants born to mothers with untreated gonococcal infection.

B. Curative treatment. As a rule, conjunctival cytology samples and culture sensitivity swabs should be taken before starting the treatment.
1. Chemical ophthalmia neonatorum is a self-limiting condition, and does not require any treatment.

2. Gonococcal ophthalmia neonatorum needs prompt treatment to prevent complications.
i. Topical therapy should include :

• Saline lavage hourly till the discharge is eliminated.
• Bacitracin eye ointment 4 times/day. Because of resistant strains topical penicillin therapy is not reliable. However in cases with proved penicillin susceptibility, penicillin drops 5000 to 10000 units per ml should be instilled every minute for half an hour, every five minutes for next half an hour and then half hourly till the infection is controlled.
• If cornea is involved then atropine sulphate ointment should be applied.

ii. Systemic therapy. Neonates with gonococcalophthalmia should be treated for 7 days with one of the following regimes:

• Ceftriaxone 75-100 mg/kg/day IV or IM, QID.
• Cefotaxime 100-150 mg/kg/day IV or IM, 12hourly.
• Ciprofloxacin 10-20 mg/kg/day or Norfloxacin 10 mg/kg/day.
• If the gonococcal isolate is proved to be susceptible to penicillin, crystalline benzyl penicillin G 50,000 units to full term, normal weight babies and 20,000 units to premature or low weight babies should be given intramuscularly twice daily for 3 days.

3. Other bacterial ophthalmia neonatorum should be treated by broad spectrum antibiotic drops and ointments for 2 weeks.

4. Neonatal inclusion conjunctivitis responds well to topical tetracycline 1 per cent or erythromycin 0.5 per cent eye ointment QID for 3 weeks. However,
systemic erythromycin (125 mg orally, QID for 3 weeks should also be given since the presence of chlamydia agents in the conjunctiva implies colonization of upper respiratory tract as well. Both parents should also be treated with systemic erythromycin.

5. Herpes simplex conjunctivitis is usually a self limiting disease. However, topical antiviral drugs control the infection more effectively and may prevent
the recurrence.