Extern ConferenceOphthalmia Neonatorum

A 17-day-old female term newborn

• CC: purulent discharge from Rt eye for 3 days

• PI:

• 7 d PTA, Rt eye showed whitish-grey watery discharge and tear but no eyelid swelling was detected.

• 3 d PTA, Rt eyelids were red and swelled with occasional bloody-purulent discharge.

• She was treated by topical ATB and eye irrigation with sterile water but these symptoms did not improve.

• She had no fever, no drowsiness, no URI symptoms. She was breast-fed well.

Case presentation

• Birth history: G1P0A0, GA 38 wks, NL, Apgar 10,10 BW 3,090 g, length 50 cm, HC 33 cm

• There was no complication after delivery.

• History of pregnancy: • serology : neg • no maternal history of STD• amniotic membrane ruptured 7 hr before

delivery• mother had no fever or vaginal discharge.

• Family history: no genetic or contagious disease

• No history of drug allergy

• Vaccine: BCG, HBV1

History

Physical examination

BW 3,700 g (P50-75), length 54 cm (P75-90). HC 35 cm (P50)

V/S: T 36.8°C, P 168/min, R 40/min

GA: active and non-toxic child, not irritable, not pale, no jx, no dyspnea, no signs of dehydration

HEENT: pharynx and tonsils are not injected Rt eye: red and mildly swollen eyelid,

marked conjunctival injection with purulent and bloody discharge, clear cornea, EOM and VA cannot be evaluated Lt eye : normal

Physical examination

CVS: normal S1, S2, no murmur

RS: normal breath sound, no adventitious sound

Abd: soft, not tender, no hepatosplenomegaly

NS: normal movement, Brudzinski’s sign negative

Problem list

1. Unilateral purulent discharge (Rt eye)2. Mild eyelid swelling with marked conjunctival injection (Rt eye)

Differential Diagnosis

• Ophthalmia neonatorum (neonatal conjunctivitis)

• Neonatal dacryocystitis• Periorbital cellulitis

Ophthalmia neonatorum: in this patient

Pros• Age of onset• Clinical symptoms• Most common cause in newborn

Cons• No history of maternal infection or vaginal discharge

Differential Diagnosis

-Schachter, J, Grossman, M. Chlamydia. In: Infectious Diseases of the Fetus and Newborn, 5th ed, Remington, JS, Klein, JO (Eds), WB Saunders, Philadelphia 2001. p.769. -de Toledo AR, Chandler JW: Conjunctivitis of the newborn. Infect Dis Clin North Am1992 Dec; 6:807-13

Neonatal Dacryocystitis• onset 2-4 wk • Tenderness & swelling in medial canthal region• Epiphora most prominent • ± purulent D/C from puncta, cellulitis, conjunctivitis,

Differential Diagnosis

• Epiphora was not eminent• No tenderness & swelling in medial canthal region

In this patient

Lang, Gerhard K., Ophthalmology: a short textbook, 2000 Georg Thieme Verlag, Germany

Periorbital cellulitis• Local spread (preceded with URI) • Acute eyelid erythema and edema• Pain, epiphora• ± fever, conjunctivitis,

Differential Diagnosis

In this patient

• Mild eyelid edema• No Hx of URI, hordeolum, bug bite, trauma• Discharge more prominent than swelling

Malinow I, Powell KR: Periorbital cellulitis. Pediatr Ann 1993 Apr; 22:241-6

, leukocytosis

Causes Clinical symptoms

Associated findings

Neonatal conjunctivitis

Maternal infection

Discharge, conjunctivitis

Maternal STD

Neonatal dacryocystitis

Obstruction of lacrimal system

Epiphora, tenderness at epicanthal region

Nasal diseases

Periorbital cellulitis

Local spread Marked eyelid edema

URI

Differential Diagnosis

Approaching pediatric conjunctivitis

History

• Maternal/paternal infection during pregnancy

esp. STD

• Onset, severity, characters of discharge

• Associated symptoms, preceding illness

• Possible causes of illness (trauma, bug bites)

Physical examination• eyelid eversion: hyperemia, follicles, papillae, membranes• Characters and amount of discharge (purulent, mucoid, watery, bloody) • Detailed eye exam if possible (EOM, VA, pupillary reaction, proptosis)• Preauricular lymphadenopathy• Systemic manifestation (fever, pneumonia, sinusitis, meningitis, arthritis)

Approaching pediatric conjunctivitis

Ophthalmia neonatorum

Ophthalmia neonatorum

• Neonatal conjunctivitis – during the first mo• Aseptic – chemical: silver nitrate• Septic – bacteria, chlamydia, virus

• Septic neonatal conjunctivitis• Neisseria gonorrhoeae (GC) – most serious• Chlamydia trachomatis – most common• Non-gonococcal, non-chlamydial

• Acquire during passing through the birth canal

Incidence

• One of the most common eye disease

in neonate • Incidence ranging from 1.6-12.0%

Weiss AH. Conjunctivitis in neonatal period. In Long S, Pickening LK, Prober CG (eds): Principle and practice of pediatric infectious disease, 2003, pp 486-89.

Clinical presentation

• Common findings:erythema and edema of the eyelidsconjunctival injectionchemosiswatery to purulent eye discharge

• More specific findings for different causative agents

Clinical presentationSilver nitrate

GC Chlamydia Herpes

Onset Day 1 Day 3-5 Day 5-14 Day 6-14

Character Transient, disappear in 2-4 days

Hyperacute, purulent

Acute, varying in severity

Corneal epith defects

Affected eye Bilat Bilat Uni or bilat Uni or bilat

Corneal involvement

No Edema, ulcer, perforation

No

(eyelid scarring, pannus)

Geographic ulcers

Extraocular No Maybe Maybe (pharyngeal colonization, pneumonitis, otitis)

Vesicles on the skin or lid margin, others

Adapted from: Weiss AH. Conjunctivitis in neonatal period. In Long S, Pickening LK, Prober CG (eds): Principle and practice of pediatric infectious disease, 2003, pp 486-89.

Investigation• When to perform?

• Look more severe• Persist than 2-3 days or progress• First appear after the first day of life

Cited from: Weiss AH. Conjunctivitis in neonatal period. In Long S, Pickening LK, Prober CG (eds): Principle and practice of pediatric infectious disease, 2003, pp 486-89.

Gram stainconjunctival exudate

Histologic study

Ophthalmia neonatorum

Chemical conjunctivitis

Bacterial conjunctivitis

Chlamydial conjunctivitis

Gram stain

neutrophils, lymphocytes

neutrophils, bacteria

neutrophils, lymphocytes, plasma cells

Provisionaldiagnosis

Gonococcal infection

Investigation for Chlamydial infection

• Conjunctival scraping for chlamydia• Giemsa stains from lower conjunctiva

• intracytoplasmic inclusion bodies• Do not collect from ocular discharge alone

• Culture• Non-culture method

• Direct immunofluorescent antibody assay• Nucleic acid amplification tests (PCR)

Chlamydial inclusion body

Management

1. If there are systemic symptoms, admit the patient for specific treatments and further investigation

2. Laboratory investigations include discharge G/S, cultures

3. IV or IM third-generation cephalosporin should be given before laboratory results

4. Topical ATB is not necessary5. Consult ophthalmologist

Specific treatment

1. Gonorrhea conjunctivitis (non-disseminated)

• Admit and separate patient from other babies

• Ceftriaxone 25-50 mg/kg/day IM single dose not to exceed 125 mg.

• Irrigated with NSS frequently until discharges disappear

• Treat parents

2. Chlamydia conjunctivitis

• Erythromycin oral 50 mg/kg/day qid for 14 days

• 0.5% erythromycin ointment tid/qid for 3 wks (unnecessary but may be adjunctive)

• Irrigated with NSS frequently until discharge disappear

• Treat parents

Red Book: 2006 Report of the Committee on Infectious Diseases. 27th ed.

Prophylaxis

• Baby that born from Gonorrhea-infected

mother

• Ceftriaxone 25-50 mg/kg/day (max 125 mg)

IM single dose stat or aqueous pen-G

100,000 U IV single dose

• The American Academy of Pediatrics and

the U.S. Centers for Disease Control(CDC)

1% silver nitrate solution

0.5% erythromycin ointment

1% tetracycline ointmentRed Book: 2006 Report of the Committee on Infectious Diseases. 27th ed.

16/4/50 (Day 1)

• Admit (consult ophthalmologist: r/o orbital

cellulitis)

• Observe clinical signs: sepsis

• RE: mild lid swelling, not tensed, erythema;

conjunctival injection with chemosis; purulent

bloody discharge wih pseudomembrane, full

EOM

Progression

16/4/50 (cont.)

• Investigation

• G/S of discharge: numerous PMN, no organism

• Giemsa staining of conjunctival scraping: pending

• Discharge culture for GC, bacteria, Chlamydia trachomatis: pending

• CBC: Hb 12.7 g/dL Hct 38.1% WBC 11640/mm3 N30.5% L 49.7% M16.2% E3.4% B0.2% plt 343000/mm3

Progression

16/4/50 (cont.)• Imp: Ophthalmia neonatorum,

suspected C. trachomatis conjunctivitis

• Start ATB covering GC and Chlamydia• Ceftriaxone 50 mg/kg/day iv over 30 min, single

dose

• Erythromycin Syr 50 mg/kg/day for 14 days

• Topical ATB : erythromycin ed. (Tobrex ed. instead)

• Evaluate and treat mother OPD Gynae

Progression

17/4/50 (Day 2)S: active child, afebrileO: RE: eyelid swelling, soft;

conjunctival injection with chemosis; purulent bloody discharge; normal cornea

A: not worseP: continue treatment18/4/50 (Day 3)• Giemsa stain (16/4/50): not appropriate specimen• Repeated conjunctival scaping for Giemsa• Zymar (Gatifloxacin) ed to RE q 2 hr (12.5 MKdose)

Progression

19/4/50 (Day 4)

• Afebrile

• RE: eyelid not swelling, conjunctiva-mildly injected, small amount of discharge, clear cornea

• Plan F/U OPD eye 1 week, with Giemsa stain result

Progression

• NB with conjunctivitis are at risk of systemic infection

• Hx of mother (ANC, STD, perinatal Hx) and child

• Complete PE

• Treat for GC if it cannot be ruled out and admit if there is evidence of systemic infection.

• Presumptive treatment is based on the clinical picture, G/S and Giemsa

• Systemic ATB, not just ATB eye drop, is recommended. (Chlamydia, GC, HSV)

• Evaluate and treat the parents.

Take home message

References1. American Academy of Pediatrics. Red Book: 2006 Report of the

Committee on Infectious Diseases. 27th ed. Elk Grove Village, IL:

American Academy of Pediatrics; 2006:401–411

2. de Toledo AR, Chandler JW: Conjunctivitis of the newborn. Infect

Dis Clin North Am1992 Dec; 6:807-13

3. Lang, Gerhard K., Ophthalmology: a short textbook, 2000 Georg

Thieme Verlag, Germany

4. Malinow I, Powell KR: Periorbital cellulitis. Pediatr Ann 1993

Apr; 22:241-6

5. Weiss AH. Conjunctivitis in neonatal period. In Long S,

Pickening LK, Prober CG (eds): Principle and practice of

pediatric infectious disease, 2003, pp 486-89.

6. Schachter, J, Grossman, M. Chlamydia. In: Infectious Diseases of

the Fetus and Newborn, 5th ed, Remington, JS, Klein, JO (Eds),

WB Saunders, Philadelphia 2001. p.769

Thank you for your attention