Conjunctivitis (in the neonate)

Ophthalmia neonatorum is literally, an infection of the newborn eye. It is usually a conjunctivitis; rarely a penetrating keratitis

• Ophthalmia neonatorum, also known as neonatal conjunctivitis, describes conjunctivitis occurring within the first 28 days of life (1)

Causes include:

• from maternal genital tract:
  • Neiserria gonorrhoeae
  • Chlamydia trachomatis
  • Group B beta-haemolytic streptococci
• from cross infection:
  • Staphylococcus aureus
  • Coliforms
  • Pseudomonas aeruginosa
    
    
• clinical features
  • all cases of neonatal conjunctivitis present with discharge, conjunctival redness, and lid swelling, but the severity and timing of these features vary according to the aetiology
    • examination of an infant with any of these signs should include visualisation of the lids, cornea, and tarsal and bulbar conjunctiva under direct illumination
    • instillation of fluorescein drops by the primary care practitioner is not necessary
    • if the conjunctiva is red and inflamed, infection can be assumed
      
      
  • if the baby is otherwise well then eye swabs should be sent as follows:
    • for bacterial and viral culture. Also microscopy (looking for intracellular gonoccoci) and chlamydia (e.g. via immunofluorescence)
    • clearly, if the baby is otherwise unwell, a full sepsis screen is indicated
      
      
• treatment depends on cause - all cases of neonatal conjunctivitis are investigated for both gonococcal and chlamydia infection

A review suggests (3):

• consider neonatal conjunctivitis in all infants presenting with eye discharge within the first 4 weeks of life
• carefully examine the conjunctiva: if red, refer to hospital eye services for same day review
  • NICE recommends urgent referral to ophthalmology for all cases of "sticky eye with redness in a neonate"
    
    
• investigations and treatment for suspected neonatal conjunctivitis in primary care are not necessary and may interfere with subsequent microbiology sampling
  
  
• eye discharge with normal conjunctiva is likely due to congenital nasolacrimal duct obstruction

Notes:

• not all neonatal eye discharge is due to conjunctivitis, however, with congenital nasolacrimal duct obstruction being a common and benign cause of sticky eyes in newborns
  • distinguishing these conditions when babies present to primary care services helps avoid unnecessary referrals to secondary care and undue distress for new parents.

Reference:

• Manasseh G S L, Amarakoon S, Photiou V, Arruti N, Borman A D. Approach to conjunctivitis in newborns BMJ 2022; 376 :e068023 doi:10.1136/bmj-2021-068023