Neonatal Conjunctivitis

The Acute Red Eye

Red, sticky, watery eyes in newborns have a large number of causes and whose presentation may overlap.

Mild eye infections (sticky eyes) are very common in the newborn, and sometimes secondary to a blocked nasolacrimal duct which may cause reddened swelling in the region of the lacrimal sac (dacrocystitis). Purulent conjunctivitis, which may be either a congenital or acquired infection, is found in about 2% of cases.

The following organisms are usually implicated, from which anticipate rapid clinical response with frequent normal-saline eye toilet +/- topical chloramphenicol or neomycin eye drops (once conjunctivitis has settled somewhat, antibiotic ointment may be used):

• S. aureus
• E. coli
• Pseudomonas sp.
• Streptococcus sp.
• Diphtherioids

But it is the chlamydial trachoma and gonococcal ophthalmia neonatorum infections that remain the most serious, requiring prompt recognition (urgent Gram stain + culture of swab specimen) and systemic treatment:

• Chlamydia trachomatis (30%)
  • Fails to respond to topical antibiotics
  • If left untreated, there is a risk of pneumonitis
  • Giemsa stain of conjunctival scrapings for intranuclear inclusions
  • Local application of tetracycline ointment +/- systemic (non-tetracycline) antibiotic (e.g. erythromycin 10 mg/kg PO q 6-hourly and eye toilet
  • Investigate and treat the mother and her partner
• N. gonorrhoea (ophthalmia neonatorum) — uncommon but an ocular emergency because of the risk of corneal perforation: purulent discharge with marked lid oedema (‘pus under pressure’)
  • Gram-negative intracellular diplococci on urgent stain
  • Local irrigation with crystalline penicillin in normal saline solution and systemic penicillin for 10 days
  • Ceftriaxone 50 mg/kg (max 125 mg) STATIM
  • Admit if septic and give IV Ceftriaxone 50 mg/kg (max 2g) q 6-hourly
  • Investigate and treat the mother and her partner

Other cause of conjunctivitis: allergic, chemical, viral (e.g. herpes simplex), and in Kawasaki disease.

• Bacterial – pus is generally present
• Viral – generally, there is watery discharge
• Allergic – history of atopy and ‘itchy eyes’

Finally, consider other causes of a red eye—corneal ulceration, corneal / conjunctival foreign body, pre-septal and orbital cellulitis.

Manage older children according to aetiology:

• Bacterial: chloramphenicol eye drops, 2 hourly by day and ointment at night
• Viral: usually clears spontaneously (neomycin eye drops if query bacterial)
• Herpes simplex conjunctivitis: suspect if there are lid vesicles and check for corneal ulceration. Treat with 4-hourly acyclovir ointment and refer to an ophthalmologist
• Allergic:
  • astringent (phenylephrine 0.125% or naphazoline 0.1%)
    • topical antihistamine (antazoline 0.5%)
      • ophthalmologist for topical steroids or sodium cromoglycate

Corneal Ulceration

Present with pain, photophobia, lacrimation, and blepharospasm and diagnosed with fluorescein staining, after  installation of local anaesthetic. The cause is either:

1. Trauma (with / without foreign body)
   1. chloramphenicol ointment (1%) and pad
   2. review in 24 hours
   3. If not healed in 48 hours, refer to ophthalmology.
      1. if healed, continue chloramphenicol ointment twice daily for a week
2. Herpes simplex (dendritic ulcer)
   1. acyclovir eye ointment: 1 cm inside lower conjunctival sac five times a day for 14 days
   2. refer to ophthalmology

Pre-septal (periorbital) and Orbital cellulitis

Erythematous, swollen lids (frequently prevents eye from opening) in a febrile, unwell child:

• Separate the lids (+/- Desmarres’ lid retractor) to exclude proptosis and limitation of eye movement (i.e. orbital cellulitis, commonly associated with sinusitis)
• Proptosis may be so severe that it prevents lid closure and corneal exposure may result
• Bilateral orbital (or pre-septal) cellulitis may be associated with cavernous sinus thrombosis
• Admit all + IVI antibiotics
• Orbital cellulitis à Ophthalmology and ENT à urgent CT à urgent drainage (to prevent permanent loss of vision)

Watering Eyes

This common problem of childhood is due either to poor tear drainage (nasolacrimal duct obstruction is the commonest cause of watery eyes and discharge that persists after the first 2 weeks of life) or over-production of tears (eye irritation from foreign body, corneal ulcer, conjunctivitis, infantile glaucoma).

Blocked nasolacrimal duct manifests with mucopurulent discharge and watery eye, worse on waking and the conjunctiva is not inflamed. It usually resolves spontaneously, due to an opening of the lower end of the duct. Topical neomycin may help if infection is troublesome (avoid repeat courses of chloramphenicol). If not settled by 12 months of age, refer to ophthalmology for probing. If occurring in the first two weeks of life or associated with visible dilation of lacrimal sac and bluish discoloration of overlying skin, refer immediately to the Emergency Department.

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References

1. Tudehope, Thearle. A Primer of Neonatal Medicine. Brooks Waterloo, 1989 (North Ryde)
2. John, E. Neonatal Handbook. June, 2000
3. Royal Children’s Hospital, Melbourne Australia. Paediatric Handbook, 6^th Blackwell Science, 2000 (Carlton South)

Further

Bae C, Bourget D. Periorbital Cellulitis. [Updated 2020 Nov 19]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK470408/.

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Downloads

NW Newborn Clinical Guideline – Neonatal Conjunctivitis. Available at http://www.adhb.govt.nz/newborn/Guidelines/Infection/NeonatalConjunctivitis.htm.