Ophthalmia Neonatorum

Inflammation of the conjunctiva occurring within the first month of life, also termed ophthalmia neonatorum. The underlying causes range from benign, self-limiting chemical irritation to serious bacterial and viral infections. These can cause permanent visual impairment or, in disseminated infection, systemic illness.

Timing of onset relative to birth provides substantial diagnostic guidance toward the likely cause. Prompt, accurate diagnosis and treatment are essential given the time-critical nature of several of the more serious causes, most notably gonococcal conjunctivitis.

Classification and pathophysiology

• Chemical conjunctivitis, historically associated with silver nitrate prophylaxis (now largely superseded by other prophylactic agents in contemporary practice), presents within the first day of life. It reflects a direct, self-limiting irritant reaction rather than infection.
• Gonococcal conjunctivitis is acquired through passage through an infected birth canal and typically presents within the first two to five days of life. It is the most urgent, sight-threatening cause, given the organism's capacity to penetrate an intact corneal epithelium. It carries substantial risk of corneal perforation and permanent visual loss if not promptly, aggressively treated.
• Chlamydial conjunctivitis is similarly acquired through passage through an infected birth canal. It typically presents somewhat later, between five and fourteen days of life, and is the commonest identifiable infective cause of neonatal conjunctivitis in many contemporary populations.
• Chlamydial infection carries additional relevance given the risk of associated chlamydial pneumonia developing in the subsequent weeks of life if the underlying infection is not adequately treated.
• Other bacterial causes include Staphylococcus aureus and Streptococcus pneumoniae. Each requires specific consideration according to the clinical presentation.
• Herpes simplex virus conjunctivitis typically presents within the first two weeks of life. It carries particular importance given its association with disseminated neonatal herpes simplex virus infection.

• Conjunctival erythema and discharge, ranging from mild and watery through to copious and purulent, represents the shared, core presenting feature across the various underlying causes, with the specific timing of onset relative to birth, together with the character of the discharge, providing important diagnostic guidance.
• Gonococcal conjunctivitis characteristically presents with marked eyelid oedema together with copious, purulent discharge, developing rapidly and often affecting both eyes, with the potential for rapid progression to corneal involvement if not promptly treated, representing a genuine ophthalmological emergency.
• Chlamydial conjunctivitis typically presents with a more indolent, though still purulent, discharge together with conjunctival erythema, generally less acutely severe in its presentation compared with gonococcal disease, though still warranting prompt treatment given both the direct ocular consequence and the risk of subsequent pneumonia.
• Herpes simplex virus conjunctivitis may present with vesicular skin lesions on the eyelid margin in addition to conjunctival involvement, and should prompt specific, urgent consideration of broader disseminated infection given its serious, systemic implications.
• A relevant maternal history of untreated gonorrhoea or chlamydia infection, or genital herpes, together with the specific timing of symptom onset relative to birth, provides essential diagnostic context.

• Conjunctival swabs for Gram stain and culture, together with specific nucleic acid amplification testing for gonorrhoea and chlamydia, are the essential diagnostic investigations for any infant presenting with a compatible clinical picture.
• There is substantial clinical overlap between the various possible causes. Accurate, organism-specific diagnosis is directly relevant to appropriately targeted treatment.
• Where herpes simplex virus infection is suspected, specific viral testing of any conjunctival or skin lesion sample, together with full assessment for evidence of broader disseminated infection, is essential.
• Given the time-critical nature of gonococcal conjunctivitis specifically, empirical treatment covering this organism should be initiated promptly on clinical suspicion in any infant with a compatible, severe presentation, without awaiting definitive microbiological confirmation.

• Gonococcal conjunctivitis requires immediate treatment with intravenous or intramuscular ceftriaxone, together with frequent saline eye irrigation to remove accumulated purulent discharge. It is an urgent intervention given the substantial risk of rapid corneal involvement and permanent visual loss if treatment is delayed.
• Chlamydial conjunctivitis is treated with oral erythromycin or azithromycin. Systemic, rather than purely topical, treatment is essential to also address the risk of subsequent chlamydial pneumonia. Topical treatment alone is considered inadequate for this specific infection.
• Herpes simplex virus conjunctivitis requires systemic intravenous aciclovir, following the specific principles and dosing, together with topical ophthalmic antiviral treatment and urgent ophthalmological assessment given the risk of associated keratitis.
• Chemical conjunctivitis requires no specific treatment beyond supportive measures, given its self-limiting nature, resolving spontaneously within a short period.
• Universal prophylaxis at birth, using topical erythromycin or an equivalent agent applied to both eyes shortly after delivery, is an important, standard preventive measure in many healthcare settings.
• Appropriate antenatal screening and treatment of maternal gonorrhoea, chlamydia, and genital herpes is the most effective overall strategy for preventing this condition.
• Treatment of the affected infant's parents for any identified, relevant sexually transmitted infection, together with appropriate contact tracing and partner notification, is an essential, integral component of full management extending beyond the infant alone.