What Is Ophthalmia Neonatorum (ON)?
It is a variety of conjunctivitis seen in newborns, exclusively in those born through vaginal delivery. In severe cases, it can cause perforation and ulceration of the cornea (outer layer of the eye), ultimately leading to permanent blindness.
It is caused by the transmission of bacterial or viral infection from the infected mother (especially in the birth canal) to the baby during the delivery. Babies are particularly vulnerable to these infections due to their lack of immunity and lymphoid tissue at birth. It is a severely morbid condition, which is why the United States Preventative Task Force has issued new guidelines regarding the mandatory use of antibiotics in babies born with ophthalmia neonatal.
The guidelines are as follows-
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Prophylactic Erythromycin or Azithromycin ointment in babies born with the condition.
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Routine screening and necessary treatment for sexually transmitted diseases (STDs) for all pregnant women and their partners during the first trimester.
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Screening of high-risk pregnant women who are in their third trimester.
Previously silver nitrate was used to prevent bacterial ON, but due to its ability to cause chemical conjunctivitis, its use has been discontinued.
What Causes Ophthalmia Neonatorum?
The infection is transmitted from the mother at the time of the delivery. Different types of infections that can cause ON in newborns through the mother are-
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Sexually Transmitted Bacterial Infection- The most common sexually transmitted bacterial variants that cause ON are Chlamydia trachomatis and Neisseria gonorrhea.
Their chances of causing ophthalmia in the mother are almost zero to none, but they cause ON in almost 48 % of babies who are born to mothers who tested positive for STDs. If left untreated, ON will progress to meningitis (infection and inflammation of the brain) and septicemia (an infection that is spread to the entire body).
If the baby is born with ON, after diagnosis, the clinician will also screen the mother for human immunodeficiency virus (HIV).
The symptoms appear only after the completion of the incubation period of the causative agent. For gonorrhea, it is between 3 days to 5 days, and for Chlamydia, it is from 5 days to 15 days.
It is important to note the time of the onset of the symptoms because it plays an important role in planning the treatment.
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Non-Sexually Transmitted Bacterial Infection- The different non-sexually transmitted bacteria that can cause ON are Staphylococcus, Streptococcus, gram-negative bacteria, Hemophilus, etc. These account for 30 percent to 50 percent of all the ON cases.
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Viral Infection- The most common viruses that cause ON are the herpes simplex virus and the adenovirus. ON caused by viruses is relatively uncommon, but if the newborn has unilateral chemosis (eye irritation), serosanguineous discharge (secretions that contain blood and serum), and vesicular lesions, they should be evaluated for viral infections.
This will prevent further complications like meningoencephalitis and viral dissemination.
If the baby has erythema, chemosis, eyelid edema, discharge, etc, within 24 hours after birth, the clinician should suspect chemical conjunctivitis, which is caused due to the eye drops that are given to all babies to protect them from bacterial infection.
How Is Ophthalmia Neonatorum Diagnosed?
If the clinician suspects ON, the step is to confirm the diagnosis with the aid of investigations; the type of the test depends on the organism causing the ON, for example-
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A gram stain and culture are done in newborns suspected of bacterial infection. The sample is obtained from the eye discharge, and the culture medium used is either chocolate agar or Thayer-Martin media. This test is highly sensitive to N. gonorrhea and is an important tool when it comes to preventing potential complications.
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For suspected chlamydia infection, the recommended tests are polymerase chain reaction (PCR), direct fluorescent antibody-staining, and Giemsa-staining. The sample for these tests is obtained by scraping the epithelial cells near the conjunctiva.
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The standard diagnostic test for herpes-induced conjunctivitis is viral culture and PCR (for viral DNA detection)
If the early signs are missed and the condition has progressed, it will cause life-threatening conditions like meningitis, bacteremia, sepsis, etc. The investigations for these conditions will be conducted by using blood or cerebrospinal fluid.
What Are The Signs And Symptoms Of Ophthalmia Neonatorum?
The different signs and symptoms of ON are-
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Edema (swelling) of the eyelids is seen during the examination.
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Severe purulent (containing pus) discharged from the eyes is seen in case of gonorrheal infection.
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Watery discharge, which becomes copious and purulent later on, is seen in the case of Chlamydial infection.
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Corneal ulceration (ulcers in the cornea).
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Corneal perforation (perforations in the cornea).
Less commonly seen signs are-
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Cellulitis (skin infection).
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Rhinitis (inflammation of the eyes, ears, and throat).
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Otitis (inflammation of the ear).
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Pneumonitis (inflammation of the lungs).
Before reaching for definitive diagnosis, the clinician must examine for a blocked nasolacrimal duct to rule out any congenital obstructions that might cause the edema and discharge.
What Is The Treatment For Ophthalmia Neonatorum?
Treatment must start after the primary diagnosis and is always managed by a specialist.
The initial therapy includes starting the infant on broad-spectrum antibiotics or treatment for both gonorrhea and chlamydia before getting the investigative results. This usually gets rid of the infection, but if the initial infection recurs, chlamydia should be reconsidered by the clinician (even though the baby tested negative in the first test) as this bacteria is difficult to demonstrate in the laboratory and can be easily missed.
After the initial therapy, the treatment will depend on the type of infection causing ON; this includes-
Bacterial Infection- Treatment is guided by the investigations which determine the growth of the organism and by the extent of corneal involvement.
- Chlamydia Infection: The recommended treatment is Erythromycin- 50 mg/kg/day orally divided into four doses for a period of 14 days. Alternatively, Azithromycin can also be given at 20 mg/kg/day, one dose daily for three days.
The reason for systemic therapy instead of topical treatment is the presence of chlamydia symptoms in the eyes which invariably suggests its involvement in the respiratory tract.
- Gonorrhea Infection- Newborns with this infection will be hospitalized immediately with hourly saline lavage to remove the discharge. The antibiotic of choice is Ceftriaxone 25- 50 mg/kg IV (intravenous) or IM (intramuscular) in a single dose, not to exceed 125 mg.
Viral Infection- The newborn is hospitalized and treated with IV Aciclovir- 45 mg/kg/day to 60 mg/kg/day in divided doses for 14 days to 21 days, depending on the extent of the condition.
Conclusion:
It is a life-threatening condition that can be prevented by educating and counseling the would-be mothers about the importance of regular prenatal visits. If, unfortunately, the baby is affected, the clinician should start the treatment immediately after the initial diagnosis to control the infection; this will improve the chances of full recovery without any residual complications.
