A 6-day-old girl is admitted to the hospital because of profuse yellowish drainage from both eyes. The infant was born at home after a 36-week gestation age to an 18-year-old mother. Maternal screens were not obtained during pregnancy due to poor prenatal care. On exam, the infant had profuse purulent drainage from both eyes with significant eyelid edema (Figure 72-1). Gram stain of the purulent drainage revealed gram-negative diplococci, consistent with Neisseria gonorrhoeae infection (Figure 72-2). Blood and cerebrospinal fluid cultures were negative. The infant was treated with one dose of intravenous ceftriaxone and frequent eye irrigations and recovered completely.

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  Neonatal conjunctivitis (Ophthalmia neonatorum) occurs in the first month of life, and may be infectious or noninfectious (chemical) in origin. Knowledge of the differential diagnosis is essential in early diagnosis and management.

Ophthalmia neonatorum, inclusion (chlamydial) conjunctivitis.

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  Most infectious causes are acquired by the neonate during vaginal delivery.

  
  
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  The risk of a newborn acquiring Chlamydia trachomatis from the infected mother is estimated to be 50 percent; up to half of these may develop conjunctivitis.¹

  
  
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  The incidence of gonococcal conjunctivitis has decreased dramatically since the introduction of newborn antimicrobial ocular prophylaxis.²

  
  
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  Skin, eye, and mouth disease represents up to 45 percent of cases of neonatal herpes simplex infection,³ which may present as neonatal conjunctivitis.

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  The most common cause of neonatal conjunctivitis is Chlamydia trachomatis; Other causative agents include N gonorrhoeae and Herpes simplex virus (HSV).⁴

  
  
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  The role of bacterial agents other than C trachomatis, N gonorrhoeae, and HSV in the etiology of neonatal conjunctivitis is controversial; organisms such as Staphylococcus aureus, Group B Streptococci, and Haemophilus influenzae, which are occasionally isolated from newborns with conjunctivitis have been isolated from the conjunctivae of asymptomatic newborns.¹

  
  
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  Although rare, nosocomial neonatal conjunctivitis due to Pseudomonas aeruginosa can occur, and is related to prolonged stay in the neonatal intensive care unit.⁵

  
  
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  Chemical conjunctivitis is a noninfectious cause of neonatal conjunctivitis, which most commonly occurs secondary to silver nitrate infant prophylaxis.

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  Maternal infection with C trachomatis, N gonorrhoeae or HSV, especially during vaginal delivery, is the most important risk factor.⁴

Clinical Features

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  Signs and symptoms vary from mild erythema and watery eye discharge to severe eyelid swelling and purulent eye drainage, sometimes with chemosis (conjunctival edema) and formation of pseudomembranes (Figures 72-1 to 72-4).^4,6,7

  
  
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  Systemic signs or symptoms may indicate disseminated gonococcal infection, disseminated HSV infection, or sepsis.^3,6

  
  
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  N gonorrhoeae causes very severe infection and may lead to ulceration and scarring of the eye if untreated.

  
  
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  Gonococcal conjunctivitis presents early in life (2 to 7 days of life), while conjunctivitis secondary to C trachomatis and other pathogens usually presents in the second week of life.⁷

  
  
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  Chemical conjunctivitis usually occurs in the first 24 hours of life, and has been associated with eye prophylaxis with silver nitrate, which is no longer available for use in the US.⁷

  
  
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  Neonatal HSV conjunctivitis may be the presenting feature of neonatal HSV infection involving the skin, eyes, and mucous membranes.³