Aetiology

Ophthalmia Neonatorum (ON) (conjunctivitis of the newborn) occurs within the first month of life. It is a bacterial, chlamydial or viral infection acquired during passage through an infected birth canal. Since April 2010 it is no longer a notifiable disease in the UK.

Historically, the commonest agent was Neisseria gonorrhoeae (also known as ‘gonococcus’, and a cause of sexually-transmitted disease). The use of silver nitrate drops as prophylaxis was introduced in the C19, although abandoned in the UK in the 1950s. The USA continues to recommend universal ocular prophylaxis based on the relatively high prevalence of gonococcal infection in the general population, and many other countries have also continued with prophylaxis. 

Gonococcal ON develops in approx. 30-50% of newborns exposed to gonococcal infection during delivery

Nowadays a more usual agent, also sexually acquired by the mother, is Chlamydia trachomatis. Babies born to women with untreated chlamydial infection at delivery have a 30-50% chance of developing ON. Chlamydia trachomatis can also colonise the respiratory tract. This causes pneumonitis 1-3 months after birth, which in 50% of cases may be preceded by conjunctivitis.

The incubation period is usually as follows:

• C. trachomatis: 5-14 days
• N. gonorrhoeae: 3-5 days

The prevalence of ON differs in different parts of the world and is dependent mainly upon socio-economic conditions, level of knowledge about general health, standard of maternal healthcare as well as the type of prophylactic programme used. UK incidence is:

• C. trachomatis: 6.9 per 100,000 live births
• N. gonorrhoeae: 3.7 per 100,000 live births

In low income countries, very much higher incidences have been reported

Other bacteria that cause ON include Haemophilus, Streptococcus, Staphylococcus and Pseudomonas species

Viral infections (less common) can be caused by herpes simplex virus, adenovirus or enterovirus

The neonatal conjunctiva is particularly vulnerable to infection because of the lack of immunity and the absence of local lymphoid tissue at birth

Predisposing factors

Infection of the maternal birth canal as the result of sexually-transmitted disease
This infection may be asymptomatic, especially in the case of C. trachomatis

Symptoms of ophthalmia neonatorum

(Usually described by mother):

• redness
• discharge (may be profuse)
• swelling of lids (may be severe)
• symptoms usually bilateral

Signs of ophthalmia neonatorum

Lids

• oedema (may impede examination of ocular surfaces)

Conjunctival features

• mucopurulent conjunctivitis – in C. trachomatis infection discharge is initially watery, progressing to a copious purulent discharge. 
• Danger of infection of clinician when prising open lids (use of sterile disposable gloves recommended during examination)
• NB: in neonatal C. trachomatis infection there are no follicles as in adults, because of the neonate’s lack of lymphoid tissue
• conjunctival oedema (‘chemosis’)
• conjunctival pseudomembrane in severe cases

Corneal features

• cornea can be involved, especially in N. gonorrhoeae infection. This organism can pass through intact corneal epithelium. Perforation may result
• epithelial oedema with superficial keratitis and possible ulceration
• signs usually bilateral; may be asymmetrical

Differential diagnosis

• By definition, conjunctivitis occurring within the first month of life is ON
• Congenital obstruction of the nasolacrimal duct(s) is often associated with epiphora, discharge and recurrent conjunctivitis (see Clinical Management Guideline on Nasolacrimal Duct Obstruction)

Management by optometrist

Practitioners should recognise their limitations and where necessary seek further advice or refer the patient elsewhere

GRADE* Level of evidence and strength of recommendation always relates to the statement(s) immediately above

None

None

Management category

A1: emergency (same day) referral to ophthalmologist; no intervention ON may result in a severe and progressive conjunctivitis with corneal complications and be associated with potentially serious systemic infection

Possible management by ophthalmologist

Diagnosis

• conjunctival cultures for bacteria (N. gonorrhoeae requires special media)
• conjunctival scraping for Gram stain (bacteria) and Giemsa stain (for C. trachomatis)
• Polymerase Chain Reaction (PCR)

Treatment

Bacterial conjunctivitis

• systemic penicillin G or a cephalosporin for N. gonorrhoeae
• topical erythromycin sometimes given in addition
• other topical antibiotics, including azithromycin or chloramphenicol
• frequent irrigation until discharge ceases

Chlamydial conjunctivitis

• systemic erythromycin
• topical azithromycin

Herpetic conjunctivitis

• systemic and topical antiviral, e.g. aciclovir

Evidence base

*GRADE: Grading of Recommendations Assessment, Development and
Evaluation (see www.gradeworkinggroup.org)

Sources of evidence

Darling EK, McDonald H A meta-analysis of the efficacy of ocular prophylactic agents used for the prevention of gonococcal and chlamydial ophthalmia neonatorum J Midwifery Womens Health 2010;55:319-27

Kapoor VS, Evans JR, Vedula SS. Interventions for preventing ophthalmia neonatorum. Cochrane Database of Systematic Reviews 2020, Issue 9. Art. No.: CD001862

Malik ANJ, Gilbert C. Cochrane corner: interventions for preventing ophthalmia neonatorum. Eye (Lond). 2022;36(2):356-357

Manasseh GSL, Amarakoon S, Photiou V, Arruti N, Borman AD. Approach to conjunctivitis in newborns. BMJ. 2022;376:e068023.

Matejcek A, Goldman RD Treatment and prevention of ophthalmia neonatorum. Can Fam Physician. 2013;59(11):1187-90

McAnena L, Knowles SJ, Curry A, Cassidy L. Prevalence of gonococcal conjunctivitis in adults and neonates. Eye (Lond). 2015;29(7):875-80

Moore DL, MacDonald NE; Canadian Paediatric Society, Infectious Diseases and Immunization Committee. Preventing ophthalmia neonatorum. Can J Infect Dis Med Microbiol. 2015;26(3):122-5

Opthalmia neonatorum
Version 12                                                                                                                       
Date of search 18.05.22
Date of revision 29.05.22
Date of publication 20.12.22
Date for review 17.05.24