eMedicine Specialties > Ophthalmology > Conjunctiva

Conjunctivitis, Neonatal

Author: Kalpana K Jatla, MD, Private Practice, Clarity Eye Center
Coauthor(s): Robert William Enzenauer, MD, MPH, Professor, Department of Ophthalmology, Hamilton Eye Institute, University of Tennessee Health Science Center; Feng Zhao, MD, PhD, Staff Physician, Department of Ophthalmology, Emory Cartersville Medical Center
Contributor Information and Disclosures

Updated: Nov 17, 2008

Introduction

Background

By definition, neonatal conjunctivitis presents during the first month of life and may be aseptic or septic.

Aseptic neonatal conjunctivitis most often is a chemical conjunctivitis that is induced by silver nitrate solution, which is used for prophylaxis of infectious conjunctivitis. Chemical conjunctivitis is not as common anymore because of the use of erythromycin ointment in place of silver nitrate solution for the prophylaxis of infectious conjunctivitis.

Bacterial, chlamydial, and viral infections are major causes of septic neonatal conjunctivitis, Chlamydia being the most common infectious agent. Infants may acquire these infective agents as they pass through the birth canal during the birth process.

Pathophysiology

The conjunctiva (a thin translucent mucous membrane) can be divided into palpebral, bulbar, and fornical, based on the location. The conjunctiva contains nonkeratinizing, squamous epithelium and a thin, richly vascularized substantia propria (containing lymphatic vessels and cells, such as lymphocytes, plasma cells, mast cells, and macrophages). The conjunctiva also has accessory lacrimal glands and goblet cells.

The pathology of neonatal conjunctivitis is influenced by the anatomy of the conjunctival tissues in the newborn. The inflammation of conjunctiva may cause blood vessel dilation, chemosis, and excessive secretion. This reaction tends to be more serious due to the following: lack of immunity, absence of lymphoid tissue in the conjunctiva, and absence of tears at birth.

Frequency

United States

The incidence of infectious neonatal conjunctivitis ranges from 1-2%, depending on the socioeconomic character of the area.

The epidemiology of neonatal conjunctivitis has changed since silver nitrate solution was introduced to prevent gonococcal ophthalmia.

Chlamydia has been reported as the most common infectious agent that causes ophthalmia neonatorum in the United States (incidence is 6.2 per 1000 live births).

In contrast, the incidence of gonococcal ophthalmia neonatorum has been reduced dramatically, from 100 per 1000 live births to 3 per 1000 live births.

International

As in the United States, incidence of ophthalmia neonatorum in many other countries also decreased after silver nitrate solution was used.

In Europe, incidence fell from 10% of births to less than 1%.

The incidence was less than 7 per 1000 live births in 1943 in England.

A higher incidence of ophthalmia neonatorum exists in developing countries. In a Nairobi hospital, the incidences of gonococcal and chlamydial conjunctivitis were 40 per 1000 and 80 per 1000 (per live newborn), respectively. More than 50% of newborns in Nairobi had concurrent gonococcal conjunctivitis. Prophylaxis was not administered at birth in this area. The prevalence of gonorrhea also was high among antenatal attenders in African countries, ranging from 4-15%.

Mortality/Morbidity

Mortality is due to systemic involvement. No published information is available on mortality.

Antibiotics have significantly altered the prognosis of neonatal conjunctivitis, especially with Neisseria gonorrhoeae infection. A previous study showed that from 1906-1911, 24% of children who were admitted to American schools for the blind had a visual disability that resulted from ophthalmia neonatorum. In contrast, only 0.3% of these children were blind secondary to gonococcal conjunctivitis from 1958-1959.

Race

No published information is available on racial differences.

Sex

No published information is available on sex differences.

Age

This condition presents during the first month of life.

Clinical

History

Although clinical presentations vary with etiology, it is difficult to determine the exact cause of neonatal conjunctivitis on clinical grounds alone. Significant overlap in clinic presentations may be present.

• Incubation period
  • Chemical conjunctivitis secondary to silver nitrate solution application usually occurs in the first day of life, disappearing spontaneously within 2-4 days.
  • Gonococcal conjunctivitis tends to occur 3-5 days after birth but can present later.
  • Chlamydial conjunctivitis usually has a later onset than gonococcal conjunctivitis; the incubation period is 5-14 days.
  • The incubation period for other nongonococcal, nonchlamydial conjunctivitis is longer, according to a previous report.
  • Herpetic conjunctivitis usually occurs within the first 2 weeks after birth.
• Clinical presentation of gonococcal conjunctivitis
  • Gonococcal conjunctivitis tends to be more severe than other causes of ophthalmia neonatorum; there is a classic presentation of purulent conjunctivitis, which usually is bilateral.
  • Corneal involvement has been reported, including diffuse epithelial edema and ulceration that may progress to perforation of the cornea and endophthalmitis.
  • Patients also may have systemic manifestations (eg, rhinitis, stomatitis, arthritis, meningitis, anorectal infection, septicemia).
• Clinical presentation of chlamydial conjunctivitis
  • The presentation of chlamydial conjunctivitis may range from mild hyperemia with scant mucoid discharge to eyelid swelling, chemosis, and pseudomembrane formation.
  • Blindness, although rare and much slower to develop than in gonococcal conjunctivitis, is not due to corneal involvement as in gonococcal conjunctivitis; eyelid scarring and pannus (as in trachoma) cause it.
  • A follicular reaction does not occur because newborns have no requisite lymphoid tissue present in the conjunctiva.
  • Like gonococcal conjunctivitis, chlamydial conjunctivitis also may be associated with extraocular involvement, including pneumonitis, otitis, and pharyngeal and rectal colonization.
• Clinical presentation of neonatal conjunctivitis due to other agents
  • Neonatal conjunctivitis due to other microbial agents usually is milder.
  • Herpes simplex keratoconjunctivitis usually presents in infants with generalized herpes simplex with corneal epithelial involvement or vesicles on the skin (which surround the eye). Serious systemic complications, such as encephalitis, may occur in these neonates due to their poor immunologic response.

Physical

Presentations for different organisms may vary. Typical findings may include erythema and edema of the eyelids and palpebral conjunctiva and/or purulent eye discharge during the external eye exam. Perform a Gram stain conjunctival smear in all cases.

• Chemical conjunctivitis
  • The clinical picture of chemical conjunctivitis is mild, transient tearing and conjunctival injection.
  • If the 1% silver nitrate used for neonatal conjunctivitis is provided in a large bottle, the solution can evaporate and become concentrated over time. More concentrated silver nitrate solution may result in more severe responses (eg, lid edema, chemosis, exudate, membranes or pseudomembranes, permanent damage to the conjunctiva or the cornea). This problem is obviated by using sealed, single-use ampules. Chemical conjunctivitis is becoming less common because of the substitution of erythromycin ointment in place of silver nitrate.
• Chlamydial conjunctivitis
  • Patients typically present with unilateral or bilateral watery discharge, which may become more copious and purulent later.
  • Although most cases are mild and self-limited, it occasionally may be severe. Pseudomembranes, thickened palpebral conjunctiva, significant peripheral pannus, and/or corneal opacification may be present.
• Gonococcal conjunctivitis
  • This type of conjunctivitis is the most serious, usually occurring 24-48 hours following birth. Typically, patients develop a hyperacute conjunctivitis, associated with marked lid edema, chemosis, and purulent discharge.
  • A conjunctival membrane may be present.
  • Corneal ulcer may occur and rapidly progress to perforation, if treatment is delayed.
• Other bacterial conjunctivitis
  • Various organisms (eg, gram-positive and gram-negative bacteria) have been identified.
  • Classic clinical pictures are lid edema, conjunctival injection, chemosis, and discharge, which are variable and often indistinguishable from signs of other etiologies.
  • Although it rarely causes neonatal conjunctivitis, Pseudomonas can lead to devastating consequences, such as rapid progression to corneal ulceration and perforation; if left untreated, it even can lead to endophthalmitis and subsequent death.
• Herpetic conjunctivitis
  • This type typically occurs within the first 2 weeks after birth.
  • Ocular involvement may follow systemic herpes infection or vesicular lesions on the skin or lid margins.
  • Patients may present with nonspecific lid edema, moderate conjunctival injection, and nonpurulent and often serosanguineous discharge, which may be unilateral or bilateral.
  • Microdendrites or geographic ulcers, rather than typical dendrites as seen in adults, are the most typical signs of herpetic keratitis in newborns.
  • Conjunctival membrane may be present.

Causes

The etiology can be chemical or microbial. Although several noninfectious and infectious agents can inflame the conjunctiva, the more common causes are silver nitrate chemical conjunctivitis and chlamydial, gonococcal, staphylococcal, and herpetic infections.

• Silver nitrate solution
  • In 1881, Crede's method of instilling a drop of 2% silver nitrate into a newborn's eyes was a major advance in preventing neonatal conjunctivitis.
  • Silver nitrate is a surface-active chemical, facilitating agglutinate gonococci and inactivating them. Ironically, silver nitrate was later found to be toxic to the conjunctiva, potentially causing a sterile neonatal conjunctivitis.
• Chlamydia trachomatis
  • This obligate intracellular parasite has been identified as the most common infectious cause of neonatal conjunctivitis.
  • The reservoir of the organism is the maternal cervix or urethra. Infants who are born to infected mothers are at high risk for developing an infection.
• Neisseria gonorrhoeae
  • This gram-negative diplococcus is potentially the most dangerous and virulent infectious cause of neonatal conjunctivitis.
  • Gonococci have the ability to penetrate intact epithelial cells and to divide rapidly inside the epithelial cells.
  • Gonorrheal conjunctivitis must be absolutely excluded in every case of neonatal conjunctivitis to avoid serious consequences.
• Other bacteria
  • The most commonly identified gram-positive organisms include Staphylococcus aureus, Streptococcus pneumoniae, Streptococcus viridans, and Staphylococcus epidermidis.
  • Gram-negative organisms, such as Escherichia coli, Klebsiella pneumoniae, Serratia marcescens, and Proteus, Enterobacter, and Pseudomonas species, also have been implicated.
• Herpes simplex
  • Herpes simplex virus (HSV) can cause neonatal keratoconjunctivitis, but it is rare and is associated most often with a generalized herpes simplex infection.
  • Most infants with such infection acquire the disease during the birth process. Therefore, caesarean delivery usually is considered when active genital disease is recognized at term.

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