Neonatal Conjunctivitis: An Overview

Introduction

The eyes are the window to our minds. Any damage to the eye affects the person's confidence significantly. Adults are prone to numerous infections like cataracts, glaucoma, hyphema, and diabetic retinopathy. Same way, neonates also (newborns less than one month) acquire eye infections. Neonatal conjunctivitis, also called ophthalmia neonatorum, is commonly seen in babies and is caused due to infection or irritation. It needs immediate care; otherwise, it will lead to blindness. Conjunctivitis means inflammation of the conjunctiva (connective tissue covering the eyeball) of the eye. It is common in both male and female infants. This article will explain the condition and management in detail.

What Causes Neonatal Conjunctivitis?

The causative agents are grouped into infectious and non-infectious types.

Infectious Factors:

• Neisseria gonorrhoeae.

• Chlamydia.

• Herpes simplex virus.

• Streptococcus pyogenes

• Streptococcus pneumoniae.

Neisseria gonorrhoeae and chlamydia are the most critical factors causing neonatal conjunctivitis. The child acquires the infection while getting birthed through the birth canal.

Non-infectious Factors:

• Blockage of tear ducts.

• Chemicals like silver nitrate.

What Are the Types of Neonatal Conjunctivitis?

Based on the causative agent, neonatal conjunctivitis is divided into,

• Gonococcal conjunctivitis.

• Chlamydial conjunctivitis.

• Chemical conjunctivitis.

• Herpetic conjunctivitis.

What Are the Symptoms of Neonatal Conjunctivitis?

• Swollen eyelids.

• Pain

• Discharge from the eyes (mucoid, purulent, or mucopurulent).

• Dilation and redness of the vessels of the conjunctiva.

• Chemosis (swelling of the eyelid tissue).

What Are the Risk Factors of Neonatal Conjunctivitis?

• HIV infections in mothers.

• Infections are present in the mother's birth canal.

• Trauma to the ocular structures during delivery.

• Infant's contact with infectious organisms.

• Silver nitrate chemical exposure.

• Poor hygiene maintenance during the delivery.

• Exposure to infectious aerosols from healthcare workers posts delivery.

• Mechanical ventilators.

What Are the Clinical Presentations of Neonatal Conjunctivitis?

Latent Period of Neonatal Conjunctivitis:

• Silver nitrate chemical-caused conjunctivitis occurs on the first day after birth and resolves in two-four days.

• Herpes-induced conjunctivitis occurs within two weeks after birth.

• Neisseria gonorrhoeae causing conjunctivitis occurs two to seven days after birth.

• Chlamydia-causing conjunctivitis occurs a bit later than Neisseria conjunctivitis.

Clinical Features of Neonatal Conjunctivitis:

Neisseria Gonorrhoeae: It causes the most severe form of conjunctivitis in neonates. It presents with features like:

• Bilateral purulent discharge.
• Corneal layer involvement.
• Conjunctival chemosis (eye irritation causing blister).
• Rhinitis.
• Stomatitis.
• Blindness.

Chlamydia:

• Dilation and redness of conjunctival blood vessels - hyperemia.
• Swelling of the eyelids.
• Chemosis.
• Corneal opacifications (scarring of the corneal layer).
• Pneumonitis.

Herpes Simplex Virus: Here, the infection will be milder compared to others.

• Involvement of corneal epithelium.

How to Diagnose Neonatal Conjunctivitis?

1. Physical Examination:

The presentation of the case varies based on the causative agent. Inflamed blood capillaries and eyelid swelling, and purulent discharge are commonly seen in all cases.

• Gonococcal Conjunctivitis: The patient presents with eyelid edema, purulent discharge, swelling of the eyelids, and chemosis.

• Chlamydial Conjunctivitis: Signs of peripheral pannus (growth of blood vessels into the cornea), opacification of the cornea, watery discharge in the early stages, and purulent discharge later. It can be unilateral or bilateral and rarely severe.

• Chemical Conjunctivitis: Overflow of tears is the most common sign. If the silver nitrate that caused the irritation is highly concentrated, then eyelid swelling, permanent damage to the conjunctiva, and chemosis. Chemical conjunctivitis cases are no longer reported because of replacing silver nitrate with other safety solutions.

• Herpetic conjunctivitis: Non-purulent discharge, unilateral or bilateral, an infection spread to the central nervous system, blister in the skin or eyelid margin, and geographic ulcers (most common sign).

2. Laboratory Tests:

Preferred tests to diagnose the condition are:

• Gram stain or Giemsa stain with conjunctival scrapings.

• Polymerase chain reaction with conjunctival scrapings to detect gonorrhea and chlamydia.

• Chocolate agar culture to see Neisseria gonorrhoeae.

• Polymerase chain reaction and culture of corneal epithelial cells to detect herpes simplex virus.

Nucleic acid amplification tests like transcription-mediated amplification are new techniques showing promising results.

What Are the Common Differential Diagnoses?

Neoplastic conjunctivitis can be misunderstood as a few other eye infections due to the presence of similar signs and symptoms.

Those conditions are:

• Congenital glaucoma (primary and secondary).

• Nasolacrimal duct obstruction.

• Infectious keratitis.

• Orbital cellulitis.

• Preseptal cellulitis.

• Dacryocystitis.

How to Manage Neonatal Conjunctivitis?

Management of neonatal conjunctivitis varies with the causative agent. Firstly, the causative agent should be finalized with the laboratory tests obtained. Suppose a sexually transmitted disease is found to be the cause. In that case, the mother has to undergo tests to confirm it, and the child has to be screened for other sexually transmitted diseases like HIV and syphilis.

1. First-Line Treatment:

Firstly, even before the lab results arrive, neonates will be treated with topical Erythromycin and intravenous or intramuscular cephalosporins. Gonococcal infections cause severe damage, so prompt treatment is needed. When a neonate comes with conjunctivitis, the treatment should be started for gonococcal infection, and once the lab results are out, treatment can be altered.

2. Medical Management:

• Gonococcal Conjunctivitis: Irrigation to remove a purulent discharge, intramuscular or intravenous ceftriaxone, topical application of Erythromycin, and topical application of atropine (corneal involvement) are advised. Treatment is needed for seven to fourteen days based on severity. The patient should stay under observation.

• Chlamydial Conjunctivitis: Oral Erythromycin for 14 days is found to be more effective than topical application.

• Herpetic Conjunctivitis: It is treated with systemic acyclovir to prevent systemic complications.

• Chemical Conjunctivitis: Only eye drops are prescribed. It will resolve on its own.

3. Follow Up:

Patients under treatment for neonatal conjunctivitis will show signs of improvement daily. Follow-up is necessary to prevent complications.

What Are the Complications of Neonatal Conjunctivitis?

Complications occur only if the infection is left untreated for a longer time.

• Peripheral corneal ulceration leading to corneal perforation might occur if Neisseria gonorrhoeae causing neonatal conjunctivitis is left untreated.

• Endophthalmitis, followed by death, occurs if pseudomonas infection is left untreated.

• Corneal scarring and corneal ulceration occur in herpes simplex conjunctivitis.

How Is the Prognosis of Neonatal Conjunctivitis?

The prognosis is generally good with proper and timely treatment. The use of antibiotics in treating Neisseria gonorrhoeae has shown tremendous improvement. Mortality is not reported commonly. Only if the infectious agent enters the bloodstream, mortality chances can increase.

Conclusion

Screening the mother for diseases that can cause neonatal conjunctivitis and knowing the status will decrease the chances of attack. Though the condition might seem scary, medical treatment has proven promising. Still, prevention is better than cure.