Opthalmia um PPt

8/2/2019 Opthalmia um PPt

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OPHTHALMIA NEONATORUM


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Neonatalconjunctivitis in the

first month of life


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The clinical presentation of conjunctivitis in thefirst 4 weeks of life is reported with widelyvarying frequencies in different parts of theworld. For example, a large populationreceiving 1% silver nitrate prophylaxis in Los

Angeles, California, had a frequency of0.14%,whereas a population in Norway hada frequency of 18.9%,and anotherpopulation in Kenya had a frequency of17.8%.3 These studies are also examples ofthe variability of etiologic causations. Itappears likely that Crede's importantobservations and the subsequent

introduction of silver nitrate prophylaxis werein a population with predominantlygonococcal conjunctivitis with a frequencyapproaching 10%.


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History

At the turn of this century, many children admitted toschools for the blind in the United States had bilateralopacified corneas after gonococcal ophthalmia

neonatorum. The widespread use of 1% silver nitrateprophylaxis after Crede's Cred's publication of hisobservations has made this cause of blindness rare.Many countries, including the United Kingdom and

Sweden, have discontinued mandatory prophylaxis, ashave many hospitals in the United States that are notrequired by state law to instill silver nitrate or anotheragent.


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History

A randomized, double-masked clinical trialcomparing silver nitrate, erythromycin, and noeye prophylaxis in newborns not at risk forgonococcal infections demonstrated that bothantimicrobial agents lower the rate ofconjunctivitis but that any of the three choicesare reasonable for infants born to women

receiving prenatal care and who are screenedfor sexually transmitted diseases duringpregnancy.

Cred CSR: Die Verhutung der Augenentzundung der Neugeborenen. ActaGyankol Gynkol 18:367, 1881


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Neonatal conjunctivitis in the first month of life

PREDISPOSING FACTORS Organisms in vagina shed during delivery

Premature rupture of membranes

Long delivery

Few tears and low levels of IgA

Trauma to epithelial barrier

Prophylaxis (antibiotics, silver nitrate)


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AETIOLOGY OF NEONATALCONJUNCTIVITIS

The microbial causes of neonatal conjunctivitis that are probablyacquired from the birth canal are N. gonorrhoeae, C. trachomatis,and herpes simplex virus.

The organisms that cause the remaining cases of neonatalconjunctivitis are almost certainly acquired sometime after deliveryand are not prevented by ocular prophylaxis. Most are bacterial andinclude Staphylococcus aureus, Staphylococcus epidermidis,Streptococcus pneumoniae, Streptococcus group D, other

Streptococcus sp, Pseudomonas sp, Serratia sp, Klebsiella sp, andEnterococcus sp. In many instances, an organism is not isolated.

Infants who receive silver nitrate prophylaxis may develop achemical conjunctivitis that is transient and distinguishable frominfectious conjunctivitis.


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CHEMICAL

CAUSES & TREATMENT:-

Silver nitrate, antibiotics

Onset in hours, lasts 24 hours


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Chlamydia

Infants whose mothers have untreatedchlamydial infections antepartum have a 30% to

40% chance of developing chlamydial neonatalconjunctivitis postpartum.

In addition, 10% to 20% of these childrendevelop pneumonia related to Chlamydia.

Perinatal chlamydial exposure may also causelocalized infection in the nasopharynx, middleear, vagina, and rectum.


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CHLAMYDIA Is the commonest infectious cause

4-10% pregnant women infected

Presents at 5-14 days 40% neonates infected :- watery conjunctivitis becoming purulent,

papillary reaction (no follicles in newborn), +/- pseudomembranes,corneal scarring

Complications: pneumonia, otitis media, rhinitis, GIT infection.

DIAGNOSIS

ELISA, Giemsa, culture, direct immunofluorescent antibodies

(fastest). PCR TREATMENT

Neonate- 50mg/kg erythromycin in 4 divided doses for 3 weeks,topical G tetracycline 1%

Adults- 250mg QDS erythromycin for 3 weeks

Prophylaxis- Oc tetracycline or Oc erythromycin within 1hr after birth


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GONOCOCCALCONJUNCTIVITIS

N. gonorrhoeae is a gram-negative diplococcus. Humans are itsonly known reservoir. Gonococci have the ability to penetrate intact

epithelial cells, and once inside the cell, they divide rapidly. Typically, the clinical picture of neonatal conjunctivitis related to N.

gonorrhoeae includes the development of a hyperacuteconjunctivitis associated with marked lid edema, chemosis, andpurulent discharge, beginning 24 to 48 hours after birth.

Conjunctival membranes may be present. With a delay in diagnosis,corneal ulceration may occur and can rapidly progress toperforation.

Septicemia and meningitis are possible systemic involvements.


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Gonococcal conjunctivitis

It appears likely that Crede's importantobservations and the subsequent introduction ofsilver nitrate prophylaxis were in a population

with predominantly gonococcal conjunctivitiswith a frequency approaching 10%. Today,newborn gonococcal ocular infections areextremely uncommon in most populations. It has

been estimated that there are perhaps a total of2000 cases of gonococcal neonatalconjunctivitis annually in the United States


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OTHER BACTERIAL

Staphyloccus aureus, Strep. epidermidis, Streptococcuspneumoniae, E. coli, Pseudomonas, Haemophilusinfluenzae

Usually at day 5 DIAGNOSIS

By gram and culture.

TREATMENT

Neosporin ophthalmic covers most If Haemophilus:- need systemic ampicillin or cefuroxime

as well


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Bacterial conjunctivitis

Classically, the onset of bacterial conjunctivitis is described asoccurring on the fifth day. However, it is now recognized that it canoccur anytime in the immediate postpartum period. The clinicalpicture is similar to those already described. Lid edema, chemosis,and conjunctival injection and discharge are variable and oftenindistinguishable from the same signs seen with other causes ofneonatal conjunctivitis.

In evaluation of an infant with suspected bacterial conjunctivitis, oneshould look for evidence of local trauma to the conjunctiva orcornea, because loss of the epithelial protective barrier often playsan important role in pathogenesis. Obstruction of the nasolacrimalduct secondary to infection must also be sought; if present andundetected, this may cause recalcitrant conjunctivitis.


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Herpes simplex virus

Although either herpes simplex virus type 1 (HSV-1) ortype 2 (HSV-2) can cause neonatal conjunctivitis, up to70% of neonatal herpetic infections have been attributed

to the genital strain, HSV Most neonatal HSV-1 infections seem to be related to

contact with active infections ("fever blister" or "coldsores") in the immediate family during the perinatal

period. HSV-2 is usually transmitted during passage through the

birth canal or by transplacental mechanisms.


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LABORATORY DIAGNOSIS

The proper evaluation of neonatal conjunctivitisconsists of immediate cytologic examination ofconjunctival scrapings obtained with a metal

spatula and appropriate microbial cultures.Gram-stained smears provide informationregarding bacterial causes. Giemsa-stainedsmears provide information on possible causes

on the basis of the inflammatory cell typespresent and the characteristics of any inclusionbodies . A Papanicolaou-stained smear providesevidence of herpes simplex virus infection.


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Chlamydia

The successful specific identification of C. trachomatis is based oncultures in special laboratories and identification with fluorescentmonoclonal antibodies. However, the testing is not widely available,it is expensive, and the results are not available for 2 to 3 days. Anumber of tests have now become available that specifically identifyChlamydia on conjunctival smears with use of specific antibodies.These are more sensitive than examination of Giemsa-stainedsmears and are quite rapid, but they may require specific laboratoryequipment. For example, a direct immunofluorescent monoclonal

antibody stain for identification of chlamydial antigens on cells ofconjunctival smears has a sensitivity of 100% and a specificity of94%


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Usually type II, within 2/52

Vesicular blepharitis +/- keratitis.

Diagnosis

Immunofluorescence, smears, culture.

TREATMENT

Topical / systemic acyclovir

Herpes Simplex type 2


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The treatment of herpes simplexvirus infections in newbornsshould be based on the extent ofinvolvement. Systemic and central

nervous system infections withherpes simplex virus can bedevastating. Therefore, therelative merits of combined topicaland systemic antiviral therapydeserve special consideration.

Most authorities believe allpatients with any neonatal herpesinfections require systemictherapy.

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