eMedicine Specialties > Ophthalmology > Conjunctiva

Conjunctivitis, Neonatal

Kalpana K Jatla, MD, Private Practice, Clarity Eye Center
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

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.

Differential Diagnoses

Other Problems to Be Considered

Congenital dacryostenosis

Workup

Laboratory Studies

• Laboratory studies for neonatal conjunctivitis should include the following:
  • Conjunctival scraping Gram stain and either Giemsa or calcofluor white stains
  • Culture on chocolate agar and/or Thayer-Martin for N gonorrhoeae
  • Culture on blood agar for other bacteria
• Rule out chlamydial infection with a conjunctival scraping Giemsa stain for intracytoplasmic inclusion bodies or, preferably, a direct immunofluorescent antibody assay.
• A culture for HSV is indicated if a corneal epithelial defect is present or if vesicles are present on the eyelids or other parts of the body, and if the diagnosis cannot be made on ocular examination.

Histologic Findings

Chemical conjunctivitis - Neutrophils, occasional lymphocytes on Gram stain

Bacterial conjunctivitis - Bacteria, neutrophils on Gram stain

Chlamydial conjunctivitis - Neutrophils, lymphocytes, plasma cells on Gram stain; basophilic intracytoplasmic inclusions in epithelial cells on Giemsa stain

Herpetic conjunctivitis - Lymphocytes, plasma cells, multinucleate giant cells on Gram stain; eosinophilic intranuclear inclusions in epithelial cells on Papanicolaou smear

Treatment

Medical Care

• Prophylaxis
  • According to the 1997 Red Book, topical 1% silver nitrate, 0.5% erythromycin, and 1% tetracycline are considered equally effective for prophylaxis of ocular gonorrhea infection in newborn infants.¹ Each is available in single-dose tubes.
  • Studies indicate that 2.5% povidone-iodine solution also may be useful in preventing neonatal ophthalmia, but a product for this purpose is not commercially available.
  • Silver nitrate appears to be the best agent in areas where the incidence of penicillinase-producing N gonorrhoeae (PPNG) is significant. Neonates born to mothers with active gonococcal infection should receive a single IM injection of aqueous penicillin G.
  • A study showed that topical tetracycline and silver nitrate reduced the incidence of chlamydial ophthalmia neonatorum but did not eradicate the nasopharyngeal colonization or pneumonia. Such treatments possess the potential for not treating disseminated disease, so systemic treatment is required for gonococcal, chlamydial, and herpetic ophthalmia neonatorum.
• Medical treatment
  • Specific treatment is available for the various causes of neonatal conjunctivitis. Preliminary presumptive treatment pending culture confirmation should be based on the clinical picture and the findings on Gram, Giemsa, and Papanicolaou stains.
  • To confirm the presence of a sexually transmitted disease in the neonate, examine and treat the mother and her sexual partner(s). If necessary, therapy can be modified when the results of culture and sensitivity are known.
  • Bacterial conjunctivitis rarely fails to respond to treatment.
  • Emphasize that prompt treatment of gonococcal conjunctivitis is important, since this organism can penetrate an intact corneal epithelium and rapidly cause corneal ulceration. Because of the rapid progression of gonococcal conjunctivitis, patients with acute neonatal conjunctivitis should be treated for gonococcal conjunctivitis until culture results are available; the treatment is altered according to the laboratory results.
  • The treatment prior to laboratory results should include topical erythromycin ointment and IV or IM third-generation cephalosporin.
  • Pediatric consultation is indicated.
• Chemical conjunctivitis: Treatment is not necessary. Lubrication with artificial tear preparations may ease mild discomfort.
• Bacterial conjunctivitis
  • Erythromycin or bacitracin ointment for gram-positive organisms
  • Gentamicin or tobramycin drops for gram-negative organisms
  • Fortified topical antibiotics for Pseudomonas
  • IV penicillin G for N gonorrhoeae
  • Because of the prevalence of penicillin-resistant N gonorrhoeae, the treatment of choice for this organism is topical erythromycin ointment and systemic, third-generation cephalosporin (ceftriaxone 30-50 mg/kg/d in divided doses IV or IM, not to exceed 125 mg).
  • Infants with gonococcal ophthalmia should have their eyes irrigated with saline frequently until the discharge is eliminated. A single dose of cefotaxime (100 mg/kg IV or IM) is an alternative treatment.
• Chlamydial conjunctivitis
  • This infection is treated with oral erythromycin (50 mg/kg/d divided qid).
  • Topical treatment alone is ineffective. Topical erythromycin ointment may be beneficial as an adjunctive therapy.
  • Since the efficacy of systemic erythromycin therapy is approximately 80%, a second course sometimes is required.
• Herpetic conjunctivitis
  • Neonates with a suspected herpetic simplex infection should be treated with systemic acyclovir to reduce the chance of a systemic infection.
  • An effective dose is 30 mg/kg/day IV divided tid, but most experts recommend higher doses (45-60 mg/kg/d).
  • The recommended minimal duration is 14 days, but a course as long as 21 days may be required.
  • Infants with neonatal HSV keratitis should receive a topical ophthalmic drug, most commonly 1% trifluridine drops or 3% vidarabine ointment.

Consultations

Pediatrician or pediatric infectious specialist

Medication

The goals of pharmacotherapy are to reduce morbidity and to eliminate the infection.

Antimicrobial agents

Suppress the growth of other microorganisms and eventually may destroy them.

Erythromycin (E-Mycin, Eryc, Ery Tab)

Treats C trachomatis infection. Systemic treatment is necessary. Topical antimicrobial therapy not necessary (but may help) if systemic therapy given.

Dosing

Adult

Pediatric

Syrup: 50 mg/kg/d PO divided qid for 14 d
0.5% ophthalmic ointment: Apply 0.5-1 cm to each conjunctival sac tid/qid for 3 wk

Interactions

Potentiates the effects of astemizole, carbamazepine, corticosteroids, cyclosporine, digoxin, ergot alkaloids, terfenadine, theophylline, triazolam, valproate, and warfarin, probably by interfering with cytochrome P450-mediated metabolism of these drugs

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Prolonged use may give rise to overgrowth of nonsusceptible organisms

Tetracycline, 1% ophthalmic ointment (Sumycin)

A bacteriostatic derivative of polycyclic naphthacene carboxamide is an alternative for chlamydial infection.

Dosing

Adult

Pediatric

Apply 0.5-1 cm to each conjunctival sac qid for 3 wk

Interactions

May reduce effects of penicillins

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Use during tooth development (last one half of pregnancy through age 8 y) can cause permanent discoloration of teeth

Penicillin G (Pfizerpen)

The choice for penicillin-susceptible N gonorrhoeae infection. Interferes with synthesis of cell wall mucopeptide during active multiplication, resulting in bactericidal activity against susceptible microorganisms.

Dosing

Adult

Pediatric

100,000 U/kg/d IV divided qid for 7 d
Topical antibiotic agents are not required (but may be helpful) when systemic therapy given, although saline lavage of the eyes is optional

Interactions

Probenecid can increase effects of penicillin; coadministration of tetracyclines can decrease effects of penicillin

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

History of significant allergies and/or asthma; caution in impaired renal function

Bacitracin (Baciguent, AK-Tracin)

Ointment for gram-positive cocci. Prevents transfer of mucopeptides into growing cell wall, inhibiting bacterial growth.

Dosing

Adult

Pediatric

Apply to each conjunctival sac q4h for 7 d

Interactions

None reported

Contraindications

Documented hypersensitivity; vaccinia, varicella, epithelial herpes simplex keratitis, mycobacterial infections, fungal diseases of the eye; patients using steroid combinations after uncomplicated removal of a corneal foreign body

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Ophthalmic ointments may delay healing of corneal epithelia; in deep seated infections of the eye, supplement with systemic medications; prolonged use may result in overgrowth of nonsusceptible organisms

Ceftriaxone (Rocephin)

For penicillinase-producing N gonorrhoeae. Third-generation cephalosporin with broad-spectrum, gram-negative activity; lower efficacy against gram-positive organisms; higher efficacy against resistant organisms. Arrests bacterial growth by binding to one or more penicillin binding proteins.

Dosing

Adult

Pediatric

25-50 mg/kg IV/IM qd for 7 d

Interactions

Probenecid may increase ceftriaxone levels; coadministration with ethacrynic acid, furosemide, and aminoglycosides may increase nephrotoxicity

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Adjust dose in renal impairment; caution in breast-feeding women and allergy to penicillin

Cefotaxime (Claforan)

An alternative treatment for N gonorrhoeae. Arrests bacterial cell wall synthesis, which in turn inhibits bacterial growth.
Third-generation cephalosporin with gram-negative spectrum. Lower efficacy against gram-positive organisms.

Dosing

Adult

Pediatric

100 mg/kg IV/IM single dose

Interactions

Probenecid may increase cefotaxime levels; coadministration with furosemide and aminoglycosides may increase nephrotoxicity

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Caution in history of GI disease, particularly colitis; reduce total daily doses in patients with renal insufficiency

Gentamicin (Garamycin, Gentacidin)

Systemic gentamicin is another alternative for penicillinase-producing N gonorrhoeae. Topical gentamicin also is used for other gram-negative bacterial infections.

Dosing

Adult

Pediatric

Systemic use: 5 mg/kg/d IM divided bid for 7 d
Topical use: Apply to each conjunctival sac q4h for 7 d

Interactions

Coadministration with other aminoglycosides, cephalosporins, penicillins, and amphotericin B may increase nephrotoxicity; aminoglycosides enhance effects of neuromuscular blocking agents thus prolonged respiratory depression may occur
Coadministration with loop diuretics may increase auditory toxicity of aminoglycosides; possible irreversible hearing loss of varying degrees may occur (monitor regularly)

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Narrow therapeutic index (not intended for long-term therapy); caution in renal failure (not on dialysis), myasthenia gravis, hypocalcemia, and conditions that depress neuromuscular transmission; adjust dose in renal impairment

Tobramycin (AKTob, Tobrex)

Ointment or drops for gram-negative bacilli. Interferes with bacterial protein synthesis by binding to 30S and 50S ribosomal subunits, which results in a defective bacterial cell membrane.
Available as a solution, ointment, and lotion.

Dosing

Adult

1-2 gtt to the affected eye qid

Pediatric

<2 years: Not established
>2 years: Administer as in adults

Interactions

Effects of this drug are decreased when used concurrently with gentamicin

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Do not use in deep-seated ocular infections or in those that may become systemic; prolonged use of antibiotics, may result in bacterial or fungal overgrowth of nonsusceptible organisms

Silver nitrate 1% ophthalmic solution

Has been used to prevent gonorrheal ophthalmia neonatorum.

Dosing

Adult

Pediatric

Instill 2 gtt 1% solution into conjunctival sac immediately after birth

Interactions

Sulfonamide preparations are incompatible with silver preparations

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Handle solutions carefully because they tend to stain skin and utensils; a mild chemical conjunctivitis should result from a properly performed Crede's prophylaxis using silver nitrate; a more severe chemical conjunctivitis occurs in less than or equal to 20% of cases

Povidone-iodine ophthalmic solution 2.5%

An antibacterial agent with broad antibacterial and antiviral activity. No bacteria are known to be resistant to povidone-iodine. Povidone-iodine is far less expensive and less toxic than agents currently used to prevent neonatal conjunctivitis.

Dosing

Adult

Pediatric

1 gtt of 2.5% solution to both eyes within 20 min of birth

Interactions

None reported

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Conjunctival hyperemia may occur

Antiviral agents

Therapy of viral infections begins with mechanical debridement of the involved rim along with a rim of normal epithelium. This is followed by the topical instillation of antiviral medications such as vidarabine, trifluridine, and acyclovir.

Vidarabine ointment (Vira-A)

Topical idoxuridine that interferes with early steps of viral DNA synthesis.
This ointment may stay in an infant's eye better than trifluridine drops, which tend to be rapidly cried out.

Dosing

Adult

Pediatric

1/4 inch in conjunctival sac 5 times/d until reepithelialization or 7 d

Interactions

None reported

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Corneal toxicity may occur; no viral resistance to vidarabine reported but possible

Acyclovir (Zovirax)

Inhibits activity of both HSV-1 and HSV-2. Patients experience less pain and faster resolution of cutaneous lesions when used within 48 h from rash onset. May prevent recurrent outbreaks.

Dosing

Adult

Pediatric

30 mg/kg/d PO for 10 d

Interactions

Concomitant use of probenecid or zidovudine prolongs half-life and increases CNS toxicity of acyclovir

Contraindications

Documented hypersensitivity or intolerance

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Caution in renal failure or when using nephrotoxic drugs

1% Trifluridine ophthalmic solution (Viroptic)

A purine nucleoside, the DOC for herpes simplex keratitis, which is superior to either vidarabine or idoxuridine. Trifluridine has better penetration and is more effective. Inhibits viral replication by incorporating into viral DNA in place of thymidine. If no response in 7-14 d, consider other treatments.

Dosing

Adult

Pediatric

1 gtt q2h or 9 times/d until reepithelialization or 7 d

Interactions

Concomitant use of probenecid or zidovudine prolongs half-life and increases CNS toxicity of acyclovir

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Corneal toxicity may occur; caution in renal failure or when using nephrotoxic drugs

Follow-up

Further Outpatient Care

• Follow up in 1 day to ensure that the patient responds to treatment.

Inpatient & Outpatient Medications

• Discharged patients should continue the treatment, according to clinical presentations and available culture results. Treatment may be modified later per culture results.
• Avoid eye patching.

Deterrence/Prevention

• Wearing gloves and frequent hand washing is necessary to reduce transmission.

Complications

• If untreated, corneal ulceration may occur in N gonorrhoeae infection and rapidly progress to corneal perforation.
• When unrecognized and not immediately treated, Pseudomonas infection may lead to endophthalmitis and subsequent death.
• Pneumonia has been reported in 10-20% of infants with chlamydial conjunctivitis.

Prognosis

• Neonatal conjunctivitis usually responds to appropriate treatment, and the prognosis generally is good.

Patient Education

• Educate parents or care providers to wash their hands frequently to prevent transmission.
• For excellent patient education resources, visit eMedicine's Eye and Vision Center. Also, see eMedicine's patient education article Pinkeye.

Miscellaneous

Medicolegal Pitfalls

• Failure to recognize or treat gonococcal conjunctivitis
• Failure to provide preventive measures in newborns
• Failure to exclude other potential causes of acute red eye (eg, preseptal cellulitis, orbital cellulitis)

Special Concerns

• Consider the risk of transmission of chlamydia, gonococcus, herpes, and streptococcus to the fetus during the birth process. Obtain cervical cultures (if indicated), and manage appropriately.
• Newborns with conjunctivitis are at risk for secondary infections, such as pneumonia, meningitis, and septicemia, which can lead to sepsis and death.
• Infants with a potentially sexually transmitted disease, such as gonorrhea or chlamydia, should undergo evaluation for other sexually transmitted diseases, such as syphilis and HIV, as should the mother and her sexual partner(s).

Multimedia

Media file 1: Severe purulent discharge and eyelid edema in a newborn with gonococcal conjunctivitis (confirmed with Gram stain and culture).

Media file 2: Cloudy cornea without ulcer in neonatalgonococcal conjunctivitis.

References

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Keywords

neonatal conjunctivitis, ophthalmia neonatorum, infectious conjunctivitis, conjunctiva

Contributor Information and Disclosures

Author

Kalpana K Jatla, MD, Private Practice, Clarity Eye Center
Kalpana K Jatla, MD is a member of the following medical societies: American Academy of Ophthalmology
Disclosure: Nothing to disclose.

Coauthor(s)

Robert William Enzenauer, MD, MPH, Professor, Department of Ophthalmology, Hamilton Eye Institute, University of Tennessee Health Science Center
Robert William Enzenauer, MD, MPH is a member of the following medical societies: American Academy of Ophthalmology
Disclosure: Hamilton County Medical Society Salary Consulting

Feng Zhao, MD, PhD, Staff Physician, Department of Ophthalmology, Emory Cartersville Medical Center
Feng Zhao, MD, PhD is a member of the following medical societies: American Academy of Ophthalmology, American Society of Cataract and Refractive Surgery, and International Society of Refractive Surgery
Disclosure: Nothing to disclose.

Medical Editor

Gerhard W Cibis, MD, Clinical Professor, Director of Pediatric Ophthalmology Service, Department of Ophthalmology, University of Kansas, Kansas City
Gerhard W Cibis, MD is a member of the following medical societies: American Academy of Ophthalmology, American Association for Pediatric Ophthalmology and Strabismus, and American Ophthalmological Society
Disclosure: Nothing to disclose.

Pharmacy Editor

Simon K Law, MD, PharmD, Assistant Professor of Ophthalmology, Jules Stein Eye Institute; Chief of Section of Ophthalmology Surgical Services, Department of Veterans Affairs Healthcare Center, West Los Angeles
Simon K Law, MD, PharmD is a member of the following medical societies: American Academy of Ophthalmology, American Glaucoma Society, and Association for Research in Vision and Ophthalmology
Disclosure: Nothing to disclose.

Managing Editor

Christopher J Rapuano, MD, Professor, Department of Ophthalmology, Jefferson Medical College of Thomas Jefferson University; Co-Chairman of the Cornea Service, Co-Chairman of Refractive Surgery Department, Wills Eye Institute
Christopher J Rapuano, MD is a member of the following medical societies: American Academy of Ophthalmology, American Society of Cataract and Refractive Surgery, Eye Bank Association of America, Pennsylvania Medical Society, and Philadelphia County Medical Society
Disclosure: Allergan Honoraria Speaking and teaching; Allergan Consulting fee Consulting; Alcon Honoraria Speaking and teaching; Inspire Honoraria Speaking and teaching; RPS Ownership interest Other

CME Editor

Lance L Brown, OD, MD, Ophthalmologist, Affiliated With Freeman Hospital and St John's Hospital, Regional Eye Center, Joplin, Missouri
Disclosure: Nothing to disclose.

Chief Editor

Hampton Roy Sr, MD, Associate Clinical Professor, Department of Ophthalmology, University of Arkansas for Medical Sciences
Hampton Roy Sr, MD is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, and Pan-American Association of Ophthalmology
Disclosure: Nothing to disclose.

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