Critical

Purulent, mucopurulent, or mucoid discharge from one or both eyes in the first month of life with diffuse conjunctival injection.

Other

Eyelid edema and chemosis.

• Dacryocystitis: Swelling and erythema just below the inner canthus. See 6.11, Dacryocystitis/Inflammation of the Lacrimal Sac.

• Nasolacrimal duct obstruction: See 8.10, Congenital Nasolacrimal Duct Obstruction.

• Congenital glaucoma: See 8.13, Congenital/Infantile Glaucoma.

• Chemical: Seen within a few hours of instilling a prophylactic agent (e.g., silver nitrate). Lasts no more than 24 to 36 hours. Rarely seen now that erythromycin is used routinely. Topical gentamicin should be avoided since it is associated with a toxic reaction.

• Neisseria gonorrhoeae: Usually seen within 3 to 4 days after birth. May present with mild conjunctival hyperemia to severe chemosis, copious discharge, rapid corneal ulceration, or corneal perforation. Gram-negative intracellular diplococci seen on Gram stain.

• Chlamydia trachomatis: Usually seen within 1 to 2 weeks after birth. Presents with mild swelling, hyperemia, tearing, and primarily mucoid discharge. Can progress resulting in increased eyelid swelling and discharge. May form pseudomembranes with bloody discharge. Giemsa stain may show basophilic intracytoplasmic inclusion bodies in conjunctival epithelial cells, polymorphonuclear leukocytes, or lymphocytes. Diagnosis usually made with various molecular tests including immunoassay (e.g., ELISA, enzyme immunoassay, direct antibody tests), polymerase chain reaction (PCR), or DNA hybridization probe.

• Bacteria: Staphylococci (including methicillin-resistant Staphylococcus aureus), streptococci, and gram-negative species (e.g., Pseudomonas aeruginosa) may be seen on Gram stain.

• Herpes simplex virus: Initially asymptomatic. May present with a cloudy cornea, conjunctival injection, and tearing. Classic herpetic vesicles on the eyelid margins are not always seen. A corneal dendrite which rapidly progresses to a geographic ulcer may occur. Can see multinucleated giant cells on Giemsa stain.

1. History: Ocular medication administration? Previous or concurrent venereal disease in the mother? Were cervical cultures performed during pregnancy?

2. Ocular examination with use of fluorescein staining to look for corneal involvement.

3. Conjunctival scrapings for two slides: Gram and Giemsa stain.

   • Technique: Irrigate the discharge out of the fornices and place a drop of topical anesthetic (e.g., proparacaine) in the eye. Scrape the palpebral conjunctiva of the lower eyelid with a flame-sterilized spatula (once cooled) or with a fresh calcium alginate swab (dry or can be moistened with liquid broth media). Place scrapings on slide (or culture media).

    

4. Conjunctival cultures with blood and chocolate agars. Technique as described above.

5. Scrape the conjunctiva for the chlamydial immunofluorescent antibody test or PCR, if available.

6. Viral culture: Moisten the applicator and roll it along the palpebral conjunctiva. Place the end of the applicator directly into the viral transport medium and mix vigorously to achieve inoculation.

7. Systemic evaluation by primary care provider.

Initial therapy is based on the results of the Gram and Giemsa stains if immediately available. Therapy is then modified according to the culture results and clinical response.

1. No information from stains, no particular organism suspected: Erythromycin ointment q.i.d. plus erythromycin elixir 50 mg/kg/d in four divided doses for 2 to 3 weeks.

2. Suspect chemical (e.g., silver nitrate) toxicity: Discontinue offending agent. No treatment or preservative-free artificial tears q.i.d. Reevaluate in 24 hours.

3. Suspect chlamydial infection: Erythromycin elixir 50 mg/kg/d orally in four divided doses for 14 days, plus erythromycin ointment q.i.d. Alternatively, azithromycin 20 mg/kg orally for 3 days can be used. Topical therapy alone is not effective. If confirmed by culture or immunofluorescent stain, treat the mother and her sexual partners with one of the following:

   • Doxycycline 100 mg p.o. b.i.d. for 7 days (for women who are neither breastfeeding nor pregnant). If breastfeeding or pregnant, one of the following regimens may be used: azithromycin 1 g as a single dose, amoxicillin 500 mg p.o. t.i.d. for 7 days, or erythromycin 250 to 500 mg p.o. q.i.d. for 7 days.

   NOTE Inadequately treated chlamydial conjunctivitis in a neonate can lead to chlamydial otitis or pneumonia.

   NOTE All neonates with chlamydial infection should also be evaluated for N. gonorrhoeae infection.

4. Suspect N. gonorrhoeae:

   • Saline irrigation of the conjunctiva and fornices until discharge gone.

   • Hospitalize and evaluate for disseminated gonococcal infection with careful physical examination (especially of the joints). Blood and cerebrospinal fluid cultures are obtained if a culture-proven infection is present.

   • Ceftriaxone 25 to 50 mg/kg intravenously (i.v.) or intramuscularly (i.m.) (not to exceed 250 mg) as a single dose or cefotaxime 100 mg/kg i.v. or i.m. as a single dose. In penicillin-allergic patients or cephalosporin-allergic patients, an infectious disease consult is recommended. If sensitivities are not initially available, ceftriaxone is the treatment of choice. Systemic antibiotics sufficiently treat gonococcal conjunctivitis, and topical antibiotics are not necessary.

   • Topical saline lavage q.i.d. to remove any discharge.

   • All neonates with gonorrhea should also be treated for chlamydial infection with erythromycin elixir 50 mg/kg/d in four divided doses for 14 days.

   NOTE If confirmed by culture, the mother and her sexual partners should be treated appropriately for both gonorrhea and chlamydia infections.

   NOTE Isolation of the patient is recommended for Pseudomonas, herpes, and gonococcal conjunctivitis.

5. Gram-positive bacteria with no suspicion of gonorrhea and no corneal involvement: Bacitracin ointment q.i.d. for 2 weeks.

6. Gram-negative bacteria with no suspicion of gonorrhea and no corneal involvement: Gentamicin, tobramycin, or ciprofloxacin ointment q.i.d. for 2 weeks.

7. Bacteria on Gram stain and corneal involvement: Hospitalize, workup, and treat as discussed in 4.12, Bacterial Keratitis.

8. Suspect herpes simplex virus: The neonate (under 1 month of age), regardless of the presenting ocular findings, should be treated with acyclovir intravenously as well as with vidarabine 3% ointment five times per day  or ganciclovir 0.15% gel five times per day or trifluridine 1% drops nine times per day. Prompt initiation of intravenous acyclovir may prevent dissemination of the HSV infection and spread to the CNS. Topical therapy is optional when systemic therapy is instituted. In full-term infants, the dosage for acyclovir is 60 mg/kg/d divided into three doses. If infection is limited to the skin, eye, and mouth, it is administered intravenously for 14 days. Treatment duration is extended to 21 days if the disease is disseminated or involves the CNS. Consultation with a pediatric infectious disease specialist is recommended. For children with recurrent ocular lesions, oral suppressive therapy with acyclovir (20 mg/kg b.i.d.) may be of benefit.

1. Initially examine daily as an inpatient or outpatient.

2. If the condition worsens (e.g., corneal involvement develops), reculture and hospitalize. Therapy and follow-up are tailored according to the clinical response and the culture results.