Neonatal Conjunctivitis Workup

  • Author: Emily A McCourt, MD; Chief Editor: John D Sheppard, Jr, MD, MMSc  more...
 
Updated: Jan 11, 2016
 

Approach Considerations

Laboratory studies for neonatal conjunctivitis should include the following:

  • Conjunctival scraping for Gram stain or Giemsa stain
  • Conjunctival scraping for polymerase chain reaction assay (PCR) to detect chlamydia and gonorrhea
  • Culture on chocolate agar and/or Thayer-Martin for N gonorrhoeae
  • Culture on blood agar for other bacteria
  • Culture of corneal epithelial cells for HSV if cornea is involved; PCR should also be considered in cases of possible HSV conjunctivitis
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Culture and Histology

Bacterial cultures on blood and chocolate agar are indicated in every case of neonatal conjunctivitis and remain the criterion standard despite newer diagnostic methods.

Since Chlamydia bacteria are obligate intracellular organisms, the culture specimens need to contain epithelial cells and not just exudative material. PCR is generally accepted as the most useful test for chlamydial conjunctivitis owing to its high sensitivity.[11]

In cases in which gonorrhea is suspected, the agar should be inoculated immediately since Ngonorrhoeae is very sensitive to moisture and temperature changes.

Laboratory evaluation for the presence of HSV infection is indicated if a corneal epithelial defect is present, if vesicles are present on the eyelids or other parts of the body, and if the diagnosis cannot be made on ocular examination. The presence of HSV in tissue culture remains the criterion standard in the diagnosis of HSV, despite a high false-negative rate. HSV infections may be more rapidly diagnosed with PCR, and PCR testing for HSV is more sensitive than viral culture.[11] Laboratory evaluation for suspected HSV becomes more important in neonatal disease because the clinical presentation may be highly atypical in an immunologically immature newborn.

Cytologic findings for various forms of conjunctivitis are as follows:

  • Chemical conjunctivitis - Neutrophils, occasional lymphocytes on Gram stain
  • Bacterial conjunctivitis - Bacteria, neutrophils on Gram stain
  • Gonococcal conjunctivitis - Neutrophils, Gram-negative intracellular diplococci 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, but with low sensitivity 
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Newer Diagnostic Techniques

Nucleic acid amplification tests such as polymerase chain reaction (PCR) and transcription-mediated amplification (TMA) are more sensitive than culture in detecting chlamydial and gonorrheal organisms.[8, 3]

PCR assays may have a higher sensitivity and similar specificity in diagnosing neonatal chlamydial conjunctivitis, compared with conventional methods.[12]

PCR for HSV from conjunctival scrapings has high sensitivity and specificity, but it is expensive, not always readily available, and is usually reserved for the diagnosis of encephalitis. Direct florescent antibody (DFA) studies are useful for rapid detection, have high sensitivity and specificity, and can be used to type the virus.[7]  

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Contributor Information and Disclosures
Author

Emily A McCourt, MD Assistant Professor of Pediatric Ophthalmology and Adult Strabismus, Children's Hospital Colorado, University of Colorado Denver School of Medicine

Emily A McCourt, MD is a member of the following medical societies: American Academy of Ophthalmology, American Association for Pediatric Ophthalmology and Strabismus, American Society of Cataract and Refractive Surgery

Disclosure: Nothing to disclose.

Coauthor(s)

Feng Zhao, MD, PhD Private Practice, Allatoona Eye Institute

Feng Zhao, MD, PhD is a member of the following medical societies: American Academy of Ophthalmology, American Medical Association, Georgia Society of Ophthalmology, American Society of Cataract and Refractive Surgery, International Society of Refractive Surgery

Disclosure: Nothing to disclose.

Robert William Enzenauer, MD, MPH, MBA, MSS Professor, Department of Ophthalmology, University of Colorado School of Medicine; Chairman, Department of Ophthalmology, Children's Hospital

Robert William Enzenauer, MD, MPH, MBA, MSS is a member of the following medical societies: American Academy of Pediatrics, American Association for Pediatric Ophthalmology and Strabismus, American Association for Physician Leadership, American Academy of Ophthalmology

Disclosure: CLEAR DONOR: Received consulting fee from Clear Donor for consulting; Partner received salary from Clear Donor for employment.

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.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

John D Sheppard, Jr, MD, MMSc Professor of Ophthalmology, Microbiology and Molecular Biology, Clinical Director, Thomas R Lee Center for Ocular Pharmacology, Ophthalmology Residency Research Program Director, Eastern Virginia Medical School; President, Virginia Eye Consultants

John D Sheppard, Jr, MD, MMSc is a member of the following medical societies: American Academy of Ophthalmology, American Society for Microbiology, American Society of Cataract and Refractive Surgery, Association for Research in Vision and Ophthalmology, American Uveitis Society

Disclosure: Nothing to disclose.

Acknowledgements

Gerhard W Cibis, MD Clinical Professor, Director of Pediatric Ophthalmology Service, Department of Ophthalmology, University of Kansas School of Medicine

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.

Simon K Law, MD, PharmD Associate Professor of Ophthalmology, Jules Stein Eye Institute, University of California, Los Angeles, David Geffen School of Medicine

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.

Christopher J Rapuano, MD Professor, Department of Ophthalmology, Jefferson Medical College of Thomas Jefferson University; Director of the Cornea Service, Co-Director 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, Contact Lens Association of Ophthalmologists, Cornea Society, Eye Bank Association of America, International Society of Refractive Surgery, and Pan-American Association of Ophthalmology

Disclosure: Allergan Honoraria Speaking and teaching; Allergan Consulting fee Consulting; Alcon Honoraria Speaking and teaching; Inspire Honoraria Speaking and teaching; RPS Ownership interest Other; Vistakon Honoraria Speaking and teaching; EyeGate Pharma Consulting; Inspire Consulting fee Consulting; Bausch & Lomb Honoraria Speaking and teaching; Bausch & Lomb Consulting fee Consulting

References
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  3. American Academy of Pediatrics. Chlamydia Trachomatis. Pickering LK, Baker CJ, Kimberlin DW, Long SS, eds. Red Book: Report of the Committee on Infectious Diseases. 28th ed. Elk Grove Village, Ill: American Academy of Pediatrics; 2009. 255-9.

  4. American Academy of Pediatrics. Prevention of Neonatal Ophthalmia. Pickering LK, Baker CJ, Kimberlin DW, Long SS eds. Red Book 2009 Report of the Committee on Infectious Diseases. 28th ed. Elk Grove Village, Ill: American Academy of Pediatrics; 2009. 827-9.

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  8. American Academy of Pediatrics. Gonococcal Infections. Pickering LK, Baker CJ, Kimberlin DW, Long SS eds. Red Book 2009 Report of the Committee on Infectious Diseases. 28th ed. Elk Grove Village, Ill: American Academy of Pediatrics; 2009. 305-13.

  9. Gul SS, Jamal M, Khan N. Ophthalmia neonatorum. J Coll Physicians Surg Pak. 2010 Sep. 20(9):595-8. [Medline].

  10. Zuppa AA, D'Andrea V, Catenazzi P, Scorrano A, Romagnoli C. Ophthalmia neonatorum: what kind of prophylaxis?. J Matern Fetal Neonatal Med. 2011 Jun. 24(6):769-73. [Medline].

  11. Pediatric Conjunctivitis. Wright, Kenneth and Strube, Yi Ning. Pediatric Ophthalmology and Strabismus. Third. New York, NY: Oxford University Press; 2012. 633-636.

  12. Yip PP, Chan WH, Yip KT, Que TL, Kwong NS, Ho CK. The use of polymerase chain reaction assay versus conventional methods in detecting neonatal chlamydial conjunctivitis. J Pediatr Ophthalmol Strabismus. 2008 Jul-Aug. 45(4):234-9. [Medline].

  13. Gichuhi S, Bosire R, Mbori-Ngacha D, Gichuhi C, Wamalwa D, Maleche-Obimbo E, et al. Risk factors for neonatal conjunctivitis in babies of HIV-1 infected mothers. Ophthalmic Epidemiol. 2009 Nov-Dec. 16(6):337-45. [Medline].

  14. Prevention of Neonatal Ophthalmia. Pickering LK, ed. American Academy of Pediatrics. Red Book: 2012 Report of the Committee on Infectious Diseases. 29th Edition. Elk Grove Village, IL:

  15. McDonald M, Hardten D, Mah F, O’Brien T, Rapuano C, Schanzlin D, et al. Management of Epithelial Herpetic Keratitis: An Evidence-Based Algorithm. Optometric Management. Available at http://www.optometricmanagement.com/content/bl/2/b-l_treament-finalnb.pdf. Nov 11, 2012;

 
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