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Ophthalmia Neonatorum

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Ophthalmia Neonatorum PREGLED REVIEW Gynaecol Perinatol 2014;23(4):121–126 *Department of Ophthalmology, Clinical Hospital Dubrava; **University of Zagreb, School of medicine; ***General Hospital Karlovac; ****Special Hospital for Medical Rehabilitation Stubi~ke Toplice OPHTHALMIA NEONATORUM Snje`ana Ka{telan*, Ema Kasun**, @eljko [tajcer***, Boris Kasun**** Review article Key words: neonatal conjunctivitis, aetiology, clinical features, treatment, prophylaxis SUMMARY. Ophthalmia neonatorum (ON) or neonatal conjunctivitis is an acute mucopurulent infection of the conjunctivae occurring within 28 days of life. It is a relatively common disease affecting 1.6% to 12% of all newborn infants with an increase up to 23% in developing countries. ON can be divided into noninfectious and infectious categories. The most common noninfectious cause is chemical conjunctivitis whilst the infec- tious category includes bacterial, chlamydial and viral infections with chlamydia being the most common. Affected newborns present with a purulent, mucopurulent or mucoid discharge from one or both eyes, in- jected conjunctiva and lid swelling. In some cases there may also be an association with systemic infection. The time of onset of conjunctivitis as well as conjunctival scraping can aid in the diagnosis of the specifi c aetiology. A number of prophylactic antibiotic or antiseptic agents have been used to prevent ON namely 1% silver nitrate ophthalmic drops, 0.5% erythromycin or 1% tetracycline ophthalmic ointment and recently a 2.5% povidone-iodine ophthalmic solution. Despite this fact ON still remains a significant cause of ocular mor- bidity, blindness and even death in underdeveloped countries. The organisms causing ON are transmitted mainly from the mother’s birth canal during delivery. In countries where the incidence of ON is very low, an alternative prophylaxis strategy is the introduction of prenatal screening and treatment of infected mothers, forgoing routine neonatal prophy- laxis and conducting a follow-up of infants after birth for the possible development of infection. Introduction Generally ON can be divided into noninfectious and infectious categories. The most common noninfectious Ophthalmia neonatorum (ON), also called neonatal is chemical conjunctivitis whilst the infectious category conjunctivitis is an acute mucopurulent infection of the 1,2 includes bacterial, chlamydial and viral causes with conjunctivae occurring within the first 28 days of life. chlamydia being the most common.5,9 Furthermore in- It is a relatively common disease caused by chemical, fectious agents which the infant may acquire as it passes bacterial or viral processes affecting 1.6% to 12% of all through the birth canal include Streptococcus sp., Sta- newborn infants with a marked increase even up to 23% phylococcus sp., Escherichia coli, Pseudomonas sp., in developing countries.3,4 The prevalence of ON varies Klebsiella pneumoniae, Haemophilus sp., Neisseria in different parts of the world and it dependent mainly 5 upon socioeconomic conditions, the level of knowledge gonorrhea, and herpes simplex. The time of onset of regarding general health, the standard of maternal conjunctivitis as well as conjunctival scraping can aid in healthcare as well as the implementation of prophylac- the diagnosis of the specific aetiology of the neonatal tic programmes.3–5 conjunctivitis (Table 1). In differential diagnosis of ocu- lar inflammation in infants dacryocystitis neonatorum Prior to the 1880s ON was the primary cause of neo- and preseptal celulitis also need to be taken into consid- natal blindness observed in 60–73% of cases with the eration.3,4 most frequent agent being Neisseria gonorrhoeae pres- ent in over 10% of live births.5,6 In 1881, Dr Carl Sieg- ON is considered as an ophthalmic emergency. The mund Franz Credé, a German obstetrician introduced neonatal conjunctiva is particularly vulnerable to infec- the application of ocular prophylaxis with 2% silver ni- tion due to the lack of immunity and the absence of lo- trate at birth resulting in a dramatic reduction in the in- cal lymphoid tissue at birth. Affected newborns present cidence of neonatal gonococcal conjunctivitis from 10% with a purulent, mucopurulent or mucoid discharge to 0.3%.5,7 Today in industrialized countries due to a from one or both eyes within the first month of life and lower prevalence of sexually transmitted diseases (STD) typical symptoms of injected conjunctiva and lid swell- in pregnant women and the use of prophylaxis at birth, ing. In some cases there may also be an association with blindness caused by ON has become uncommon.6 Since systemic infection which further endangers the in- prophylaxis itself carries a certain risk for the occur- fant.1,3,10 Since most cases of infectious conjunctivitis rence of chemical conjunctivitis some developing coun- occur due to transfer of infection in the birth canal dur- tries have discontinued its routine use. Conversely this ing delivery the presence of STDs in the mother is the may consequently led to the risk of re-emergence of main risk factor for gonococcal or chlamydial ON. these sight threatening infections.8 However the infection may also be spread by people 121 Gynaecol Perinatol 2014;23(4):121–126 S. Ka{telan et al. Ophthalmia neonatorum Table 1. Aetiology and clinical characteristic of neonatal conjunctivitis Corneal Aetiology Time of onset Clinical presentation Affected eye involvement Chemical First 24 hours Mild lid oedema, mild serous discharge (occasionally purulent), bilateral No of life self limited, lasts 2–4 days Chlamydia 5–14 days Variable lid swelling, mild to moderate thick, serous or purulent Unilateral No trachomatis discharge, erithematous conjunctiva with palpebral more than or bilateral (Rarely eyelid bulbar involvment scarring or pannus) Neisseria 2–5 days Hyperacute, severe lid swelling, chemosis, copious, purulent bilateral Oedema, ulcer, gonorrheae discharge perforation Bacterial 4–28 days Subacute, variable presentation, depending on organism, mostly mainly Mostly no lid swelling purulent discharge unilateral Pseudomonas-corneal perforation Herpes simplex 1–14 days Mildly injected conjunctiva, serosangvineous discharge,corneal Unilateral Dendritic or virus epithelial defects, possible vesicular rush on lids or bilateral geographic ulcers handling the baby soon after birth and more rarely dur- sults. In the management of ON corneal examination is ing pregnancy due to transplacental passage.1,3,6,10 essential in order to exclude keratits or corneal ulcer. In some cases infectious conjunctivitis may be associated Incidence with systemic complications which must also be ex- cluded.6,9,10 Now days Chlamydia is the most common single cause of infective neonatal conjunctivitis accounting for 2–40% of cases whilst Neisseria gonorrhoeae is report- Laboratory tests ed in less than 1% of cases. Incidence of these two Laboratory studies for neonatal conjunctivitis are es- pathogens has notably declined in the last two decades sential for proper management and diagnosis. Samples as a result of decreased prevalence of STD in the popu- for testing should be obtained from the inner side of the lation and the improvement of prenatal screening and eyelid after its evertion. Sampling the exudates is not care. Herpes simplex is the cause of ON in less than 1% adequate since this technique increases the risk of a of cases whilst non-sexually transmitted bacteria such false-negative test result. Initial culture on chocolate as Staphylococcus, Streptococcus, Haemophilus spe- agar or a Thayer-Martin test for Neisseria gonorrhoeae cies and other Gram-negative bacteria account for the majority of the remaining ON cases (30–50%).3–5 Apart should be obtained as well as blood agar for other bac- from the infectious forms ON also includes chemically teria. Chlamydial infection can be ruled out using con- induced conjunctivitis occurring in 10–90% of new- junctival scraping Giemsa stain for intracytoplasmic borns who have been subjected to the instillation of pro- inclusion bodies or direct immunofluorescent antibody phylactic agents mostly silver nitrate. Cases of chemical assay. Diagnostic tests which reveal bacterial genomes conjunctivitis are decreasing as silver nitrate prophy- based on polymerase chain reactions are also available laxis is being replaced by other agents namely 1% tetra- and useful in laboratory testing. In herpetic conjunctivi- cycline and 0.5% erytromxcin ophthalmic ointments.3,6 tis Gram stain may reveal multinucleate giant cells and Papanicolaou smear may show eosinophilic intranucle- Although ON in developed countries no longer repre- ar inclusions in epithelial cells. Culture for herpes sim- sents such a significant public health problem the World plex virus can also be beneficial for diagnostic purpos- Health Organization (WHO) Vision 2020 »The Right to 1,3,4,7,10 Sight, Global Initiative for the Elimination of Avoidable es. Blindness« has found that ON is still one of the major causes of blindness in low-income countries.11 In this Clinical features and treatment study conjunctivitis affected 17% of neonates which is consistent with other reports from developing countries Chemical conjunctivitis where the rates are even higher such as in Kenya where Chemical conjunctivitis accounts for most cases of the incidence is 23%.12 Iran cites incidence ranging ON presenting with mild irritation, tearing and redness from 4.9% to 21.7%, with India reporting 0.5 to 33%. 4 Neonatal conjunctivitis in the United States of America within
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