OPHTHALMIA NEONATORUM

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OPHTHALMIA NEONATORUM
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OPHTHALMIA NEONATORUM

• Neonatal conjunctivitis in the first month of life

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OPHTHALMIA NEONATORUM

• The clinical presentation of conjunctivitis in
  the first 4 weeks of life is reported with widely
  varying frequencies in different parts of the
  world. For example, a large population receiving
  1 silver nitrate prophylaxis in Los Angeles,
  California, had a frequency of 0.14,whereas a
  population in Norway had a frequency of 18.9,and
  another population in Kenya had a frequency of
  17.8.3 These studies are also examples of the
  variability of etiologic causations. It appears
  likely that Crede's important observations and
  the subsequent introduction of silver nitrate
  prophylaxis were in a population with
  predominantly gonococcal conjunctivitis with a
  frequency approaching 10.

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History

• At the turn of this century, many children
  admitted to schools for the blind in the United
  States had bilateral opacified corneas after
  gonococcal ophthalmia neonatorum. The widespread
  use of 1 silver nitrate prophylaxis after
  Crede's Credé's publication of his observations
  has made this cause of blindness rare. Many
  countries, including the United Kingdom and
  Sweden, have discontinued mandatory prophylaxis,
  as have many hospitals in the United States that
  are not required by state law to instill silver
  nitrate or another agent.

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History

• A randomized, double-masked clinical trial
  comparing silver nitrate, erythromycin, and no
  eye prophylaxis in newborns not at risk for
  gonococcal infections demonstrated that both
  antimicrobial agents lower the rate of
  conjunctivitis but that any of the three choices
  are reasonable for infants born to women
  receiving prenatal care and who are screened for
  sexually transmitted diseases during pregnancy.

Credé CSR Die Verhutung der Augenentzundung der
Neugeborenen. Acta Gyankol Gyänkol 18367, 1881
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OPHTHALMIA NEONATORUM

• Neonatal conjunctivitis in the first month of
  life
• PREDISPOSING FACTORS
• Organisms in vagina shed during delivery
• Premature rupture of membranes
• Long delivery
• Few tears and low levels of IgA
• Trauma to epithelial barrier
• Prophylaxis (antibiotics, silver nitrate)

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AETIOLOGY OF NEONATAL CONJUNCTIVITIS

• The microbial causes of neonatal conjunctivitis
  that are probably acquired from the birth canal
  are N. gonorrhoeae, C. trachomatis, and herpes
  simplex virus.
• The organisms that cause the remaining cases of
  neonatal conjunctivitis are almost certainly
  acquired sometime after delivery and are not
  prevented by ocular prophylaxis. Most are
  bacterial and include Staphylococcus aureus,
  Staphylococcus epidermidis, Streptococcus
  pneumoniae, Streptococcus group D, other
  Streptococcus sp, Pseudomonas sp, Serratia sp,
  Klebsiella sp, and Enterococcus sp. In many
  instances, an organism is not isolated.
• Infants who receive silver nitrate prophylaxis
  may develop a chemical conjunctivitis that is
  transient and distinguishable from infectious
  conjunctivitis.

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Modern Prophylaxis

• The shedding of some microorganisms from the
  cervix during the third trimester is well
  documented. For example, 7 to 20 of women shed
  cytomegalovirus,7 and approximately 12 shed
  Chlamydia.
• Some women shed herpes simplex virus type 2
  (HSV-2) during pregnancy even in the absence of
  typical genital lesions.
• If the screening of all pregnant women cannot be
  accomplished, the World Health Organization1has
  suggested screening women at high risk for
  delivering a baby who could develop neonatal
  conjunctivitis and the accompanying systemic
  involvements.

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CHEMICAL

• CAUSES TREATMENT-
• Silver nitrate, antibiotics
• Onset in hours, lasts 24 hours

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Chlamydia

• Chlamydia is a major sexually transmitted
  pathogen. The CDC estimates that there are 3
  million new cases of chlamydial infection
  annually.
• The incidence of chlamydial infection seems to be
  directly related to the level of sexual activity
  and to geography.
• Handsfield and co-workers23 reported a prevalence
  approaching 25 in young, indigent, inner-city
  populations. Although the percentages of
  infection are higher in urban areas, chlamydial
  infections are widespread and cross all social
  strata, occurring in 4 to 10 of pregnant women
  nationwide.
• The direct and indirect costs of these infections
  approach 1 billion per year.

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Chlamydia

• Infants whose mothers have untreated chlamydial
  infections antepartum have a 30 to 40 chance of
  developing chlamydial neonatal conjunctivitis
  postpartum.
• In addition, 10 to 20 of these children develop
  pneumonia related to Chlamydia.
• Perinatal chlamydial exposure may also cause
  localized infection in the nasopharynx, middle
  ear, vagina, and rectum.

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CHLAMYDIA

• Is the commonest infectious cause
• 4-10 pregnant women infected
• Presents at 5-14 days
• 40 neonates infected - watery conjunctivitis
  becoming purulent, papillary reaction (no
  follicles in newborn), /- pseudomembranes,
  corneal scarring
• Complications
• pneumonia, otitis media, rhinitis, GIT infection.
• DIAGNOSIS
• ELISA, Giemsa, culture, direct immunofluorescent
  antibodies (fastest). PCR
• TREATMENT
• Neonate- 50mg/kg erythromycin in 4 divided doses
  for 3 weeks, topical G tetracycline 1
• Adults- 250mg QDS erythromycin for 3 weeks
• Prophylaxis- Oc tetracycline or Oc erythromycin
  within 1hr after birth

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GONOCOCCAL CONJUNCTIVITIS

• N. gonorrhoeae is a gram-negative diplococcus.
  Humans are its only known reservoir. Gonococci
  have the ability to penetrate intact epithelial
  cells, and once inside the cell, they divide
  rapidly.
• Typically, the clinical picture of neonatal
  conjunctivitis related to N. gonorrhoeae includes
  the development of a hyperacute conjunctivitis
  associated with marked lid edema, chemosis, and
  purulent discharge, beginning 24 to 48 hours
  after birth. Conjunctival membranes may be
  present. With a delay in diagnosis, corneal
  ulceration may occur and can rapidly progress to
  perforation.
• Septicemia and meningitis are possible systemic
  involvements.

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GONOCOCCAL

• Neisseria gonorrhoeae
• 75 bilateral
• Rare now due to antenatal screening
• (silver nitrate prophylaxis has been abandoned in
  the UK).
• Presents 1-2 days after birth
• Hyperacute purulent conjunctivitis /- corneal
  ulceration and perforation
• DIAGNOSIS
• Gram stain (intracellular diplococci), culture
• TREATMENT
• 50,000u/kg penicillin in 2 divided doses for 7/7
  or ceftriaxone 125mg stat IMI
• topical treatment unnecessary, but eyes should be
  kept clean

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Gonococcal conjunctivitis

• It appears likely that Crede's important
  observations and the subsequent introduction of
  silver nitrate prophylaxis were in a population
  with predominantly gonococcal conjunctivitis with
  a frequency approaching 10. Today, newborn
  gonococcal ocular infections are extremely
  uncommon in most populations. It has been
  estimated that there are perhaps a total of 2000
  cases of gonococcal neonatal conjunctivitis
  annually in the United States

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OTHER BACTERIAL

• Staphyloccus aureus, Strep. epidermidis,
  Streptococcus pneumoniae, E. coli, Pseudomonas,
  Haemophilus influenzae
• Usually at day 5
• DIAGNOSIS
• By gram and culture.
• TREATMENT
• Neosporin ophthalmic covers most
• If Haemophilus- need systemic ampicillin or
  cefuroxime as well

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Bacterial conjunctivitis

• Classically, the onset of bacterial
  conjunctivitis is described as occurring on the
  fifth day. However, it is now recognized that it
  can occur anytime in the immediate postpartum
  period. The clinical picture is similar to those
  already described. Lid edema, chemosis, and
  conjunctival injection and discharge are variable
  and often indistinguishable from the same signs
  seen with other causes of neonatal
  conjunctivitis.
• In evaluation of an infant with suspected
  bacterial conjunctivitis, one should look for
  evidence of local trauma to the conjunctiva or
  cornea, because loss of the epithelial protective
  barrier often plays an important role in
  pathogenesis. Obstruction of the nasolacrimal
  duct secondary to infection must also be sought
  if present and undetected, this may cause
  recalcitrant conjunctivitis.

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Herpes simplex virus

• Although either herpes simplex virus type 1
  (HSV-1) or type 2 (HSV-2) can cause neonatal
  conjunctivitis, up to 70 of neonatal herpetic
  infections have been attributed to the genital
  strain, HSV
• Most neonatal HSV-1 infections seem to be related
  to contact with active infections ("fever
  blister" or "cold sores") in the immediate family
  during the perinatal period.
• HSV-2 is usually transmitted during passage
  through the birth canal or by transplacental
  mechanisms.

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LABORATORY DIAGNOSIS

• The proper evaluation of neonatal conjunctivitis
  consists of immediate cytologic examination of
  conjunctival scrapings obtained with a metal
  spatula and appropriate microbial cultures.
  Gram-stained smears provide information regarding
  bacterial causes. Giemsa-stained smears provide
  information on possible causes on the basis of
  the inflammatory cell types present and the
  characteristics of any inclusion bodies . A
  Papanicolaou-stained smear provides evidence of
  herpes simplex virus infection.

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Chlamydia

• The successful specific identification of C.
  trachomatis is based on cultures in special
  laboratories and identification with fluorescent
  monoclonal antibodies. However, the testing is
  not widely available, it is expensive, and the
  results are not available for 2 to 3 days. A
  number of tests have now become available that
  specifically identify Chlamydia on conjunctival
  smears with use of specific antibodies. These are
  more sensitive than examination of Giemsa-stained
  smears and are quite rapid, but they may require
  specific laboratory equipment. For example, a
  direct immunofluorescent monoclonal antibody
  stain for identification of chlamydial antigens
  on cells of conjunctival smears has a sensitivity
  of 100 and a specificity of 94

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Herpes Simplex type 2

• Usually type II, within 2/52
• Vesicular blepharitis /- keratitis.
• Diagnosis
• Immunofluorescence, smears, culture.
• TREATMENT
• Topical / systemic acyclovir

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Herpes Simplex type 2

• Unless the patient has herpetic keratitis, there
  is no specific diagnostic clue. Findings include
  nonspecific lid edema, moderate injection of the
  bulbar conjunctiva, and usually nonpurulent,
  often serosanguineous, discharge. Microdendrites
  or geographic ulcers, rather than typical
  herpetic dendrites, are the most typical signs of
  corneal involvement in newborns. The exudate
  contains mononuclear cells or, if there is a
  conjunctival membrane, polymorphonuclear
  leukocytes.
• Clinical suspicion is enhanced by a maternal
  history of herpetic infection, the presence of a
  dendrite, or evidence of herpetic infection
  elsewhere on the body.

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OPHTHALMIA NEONATORUM

• The treatment of herpes simplex virus infections
  in newborns should be based on the extent of
  involvement. Systemic and central nervous system
  infections with herpes simplex virus can be
  devastating. Therefore, the relative merits of
  combined topical and systemic antiviral therapy
  deserve special consideration. Most authorities
  believe all patients with any neonatal herpes
  infections require systemic therapy.