Eye Discharge Redness and Conjunctivitis

Neonates with red eyes are most likely suffering from conjunctivitis. Neonatal conjunctivitis occurs in 1.6 to 12 percent of newborns during the first month of life. The chemical irritation from antimicrobial prophylaxis against bacterial infection is the most frequent cause, followed by Chlamydia trachomatis infection. Other important pathogens in this setting are H. influenzae and Streptococcus pneumoniae. Neisseria gonorrhoeae is no longer a major cause of neonatal conjunctivitis in the United States because of mandated use of neonatal ocular prophylaxis. The failure rate of antimicrobial prophylaxis is 1 percent. However, because N. gonorrhoeae can damage the eye severely, it is important to always test for this pathogen as the possible cause of neonatal conjunctivitis. Viruses rarely cause isolated neonatal conjunctivitis as an isolated problem. They usually cause conjunctivitis as part of a generalized viral syndrome affecting many organs. For example, herpes simplex virus causes neonatal keratoconjuctivitis as part of a generalized viremia with infection at other sites such as skin, mucous membranes, or with disseminated disease. The finding of vesicles anywhere on the body in association with neonatal conjunctivitis suggests the possibility of herpes simplex infection.

An important consideration in the evaluation of neonatal conjunctivitis is the time of onset. Chemical conjunctivitis secondary to ocular prophylaxis usually occurs on the first day of life. Gonococcal conjunctivitis generally has its peak time of onset between 3 and 5 days after birth. By the end of first week of life and throughout the first month of life, Chlamydia becomes the most frequent cause of conjunctivitis. It is important to note that these times of onset assume rupture of amniotic membrane at or near the time of delivery. The conjunctiva can be inoculated before birth by an ascending bacterial infection.

Chlamydial conjunctivitis can vary in severity, ranging from mild-to-severe hyperemia with a thick mucopurulent discharge and psuedomembrane formation. Gonococcal conjunctivitis can present as typical bacterial conjunctivitis. However, in its full-blown form, it presents as hyperacute conjunctivitis with profuse discharge. There often is severe edema of both lids. In marked contrast to other forms of bacterial conjunctivitis, N. gonorrhoeae has the capacity to invade superficial layers of the conjunctiva, causing ulceration of the cornea. If it is not treated, it can result in the loss of eye from corneal complications.

A Gram stain and culture should always be obtained in instances of neonatal conjunctivitis to make certain that the conjunctivitis is not due to N. gonorrhoeae. Since isolation of C. trachomatis requires specialized tissue cultures, proper technique should be employed in collecting those specimens (e.g., Dacron swabs) and specimens for antigen detection.

Gonococcal opthalmia neonatorum is treated best with ceftriaxone (25 to 50 mg/kg per day intravenously or intramuscularly, not to exceed 125 mg) given once or a single dose of cefotaxime (100 mg/kg intravenously or intramuscularly). When disseminated disease is suspected, the duration of treatment is 7 days. Cefotaxime is recommended for hyperbilirubinemic infants. If meningitis is documented, treatment should be continued for 10 to 14 days. Infants with gonococcal opthalmia should have their eyes irrigated with saline solution immediately and at frequent intervals until the discharge is eliminated. Topical antibiotic treatment alone is inadequate and is unnecessary when recommended systemic antibiotic treatment is given.

Chlamydial conjunctivitis and pneumonia in young infants are treated with oral erythromycin (50 mg/kg/day in four divided doses] for 14 days. Oral sulfonamides may be used after the immediate neonatal period for infants who do not tolerate erythromycin. Topical treatment of conjunctivitis is ineffective and unnecessary. Since the efficacy of erythromycin therapy is approximately 80 percent, a second course is sometimes required. A specific diagnosis of C. trachomatis infection in an infant should prompt the treatment of the mother and her sexual partners.

The neonate with a red eye and irritability may also be suffering from a corneal irritation or abrasion, usually due to an eyelash. Acute glaucoma, although rare, also presents as a red, teary eye. In these instances, the cornea may be stained or cloudy, the anterior chamber shallow, and the intraoccular pressure increased. Prompt opthalmologic referral of all suspected cases of glaucoma is mandatory. Infectious causes should be treated (Iable l12:6) and follow-up care ensured.454 4 and 48

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