History
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 2-7 days after birth but can present later. [4]
The onset of chlamydial conjunctivitis is usually later than gonococcal conjunctivitis; the incubation period is 5-14 days.
The expected incubation period for other nongonococcal, nonchlamydial conjunctivitis is also 5-14 days. [4]
Herpetic conjunctivitis usually occurs within the first 2 weeks after birth and has an incubation period of approximately 6-14 days. [4]
Clinical presentation of gonococcal conjunctivitis
Gonococcal conjunctivitis tends to be more severe than other causes of ophthalmia neonatorum. The classic presentation is severe bilateral purulent conjunctivitis.
Corneal involvement, including diffuse epithelial edema, limbal ulceration adjacent to severe conjunctival chemosis, and diffuse opacification, may progress to perforation of the cornea and endophthalmitis.
Patients also may have systemic manifestations, including rhinitis, stomatitis, arthritis, meningitis, anorectal infection, and 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 generally not due to corneal involvement as in gonococcal conjunctivitis. Instead, eyelid scarring and corneal pannus can gradually progress to central corneal opacification by mechanisms reminiscent of trachoma.
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 is usually milder.
Herpes simplex keratoconjunctivitis often presents in infants with generalized herpes simplex infections, characterized by corneal epithelial involvement or vesicles on the periocular skin. Serious systemic complications, such as encephalitis, may also occur in these neonates owing 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. A Gram stain conjunctival smear should be performed in all cases. Eyelid edema and purulent discharge are seen in the image below.
Severe purulent discharge and eyelid edema in a newborn with gonococcal conjunctivitis (confirmed with Gram stain and culture).
Chemical conjunctivitis
The clinical picture of chemical conjunctivitis is mild with transient tearing and conjunctival injection.
If the 1% silver nitrate used for neonatal conjunctivitis is provided in a large bottle, the solution can evaporate or settle, thereby becoming more concentrated over time. More concentrated silver nitrate solution may result in more severe responses, including, lid edema, chemosis, exudate, membranes or pseudomembranes, and permanent cicatricial 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 alternative agents such as erythromycin ointment, tetracycline ointment, or povidone iodide 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, chlamydial conjunctivitis occasionally may be severe. Pseudomembranes, thickened palpebral conjunctiva, significant peripheral pannus, and corneal opacification may be present.
Gonococcal conjunctivitis
Gonococcal conjunctivitis is the most serious form of neonatal conjunctivitis with the most rapid onset, 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 ulceration may occur, particularly in the periphery, where massive limbal conjunctival chemosis traps inflammatory mediators and organisms, with rapid progression to perforation if treatment is delayed.
Other bacterial conjunctivitis
Various organisms, including gram-positive and gram-negative bacteria, have been identified in neonatal conjunctivitis.
Classic clinical pictures are lid edema, conjunctival injection, chemosis, and discharge, which are variable and often indistinguishable from signs of other etiologies.
Although rarely implicated in neonatal conjunctivitis, Pseudomonas can lead to devastating consequences, such as rapid progression to corneal ulceration and perforation. If left untreated, Pseudomonas keratitis even can lead to endophthalmitis and subsequent death.
Herpetic conjunctivitis
This type of neonatal conjunctivitis typically occurs within the first 2 weeks after birth.
Ocular involvement may follow systemic or central nervous system herpes infection, as well as vesicular lesions on the skin or lid margins.
Patients may present with nonspecific lid edema, moderate conjunctival injection, and a 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.
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Severe purulent discharge and eyelid edema in a newborn with gonococcal conjunctivitis (confirmed with Gram stain and culture).
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Cloudy cornea without ulcer in neonatal gonococcal conjunctivitis.
