Neonatal ophthalmia, or neonatal conjunctivitis, is an acute mucopurulent conjunctivitis occurring within the first 28 days of life and Chlamydia may be among the most frequent causes.
The causes
This form of conjunctivitis is a relatively common pathological condition that can be caused by chemicals, bacteria or viruses.
Neonatal ophthalmia affects between 1.6% and 12% of all newborns and up to 23% of newborns in developing countries.1
The causes and symptoms of neonatal ophthalmia can be classified into non-infectious and infectious.1
Conjunctivitis by Chlamydia trachomatis
The Chlamydia trachomatis is the most common cause of infectious neonatal conjunctivitis, accounting for between 2% and 40% of cases.1
The Chlamydia is the most common sexually transmitted bacterial infection in the world. The estimated global incidence of the infection is approximately 131 million new cases per year.
Although the Chlamydia trachomatis typically affects sexually active adults, it can be transmitted to infants by the infected mother during childbirth.
Approximately 30-50% of children born to a mother with active Chlamydia will develop neonatal conjunctivitis.2
Features
Neonatal conjunctivitis caused by Chlamydia trachomatis is an acute infection of the conjunctiva characterised by erythema, swelling and oedema of the eyelids and palpebral conjunctiva and purulent ocular discharge. It usually occurs 5-14 days after birth.2
Although it is generally a mild disease, complications such as scarring of the cornea or conjunctiva can occur if it is not treated promptly.
In addition, up to 20% of infants exposed to Chlamydia during delivery may develop pneumonia and in approximately 50% of them there is evidence of previous conjunctivitis.2
Neonatal ophthalmia is also still one of the main causes of blindness, especially in developing countries.1
Therapeutic approaches
For the treatment of infants with conjunctivitis by Chlamydia trachomatis, the World Health Organisation (WHO) guidelines for sexually transmitted diseases recommend using azithromycin in an oral formulation, 20mg/kg/day, one dose per day for 3 days.3
Azithromycin is preferred over erythromycin because of the potential risk of serious adverse events (such as pyloric stenosis) in infants treated with erythromycin.3
Prophylaxis for the prevention of neonatal conjunctivitis
Due to the potential complications associated with neonatal ophthalmia, many countries have implemented routine prophylaxis or preventive treatment for neonatal conjunctivitis.1
Agents currently used in the prevention of neonatal ophthalmia include1:
- 1% silver nitrate for topical use
- targesin (a compound of silver and protein)
- tetracycline at 1%
- topical macrolide antibiotics, including erythromycin 0.5% or azithromycin
- topical aminoglycosides, including gentamicin and tobramycin
- chloramphenicol
- fluoroquinolones, including ciprofloxacin
- iodopovidone at 1.25% or 2.5%
- fusidic acid
Neonatal screening
Several high-income countries have abandoned newborn eye prophylaxis and replaced it with routine prenatal screening and treatment of mothers with a sexually transmitted infection, resulting in a decrease in the incidence of neonatal Chlamydia and Gonorrhoea infections.2
The WHO guidelines for sexually transmitted diseases recommend, however, topical eye prophylaxis for the prevention of neonatal gonococcal and Chlamydia conjunctivitis for all newborns, also taking into account the symptoms of conjunctivitis.3
WHO Guidelines
The World Health Organisation (WHO) recommends that individual or sporadic cases of trachomatous-follicular inflammation be treated topically. The WHO also recommends topical treatment for intense trachomatous inflammation, but such systemic treatment must be considered. Trachomatous scars alone do not require treatment until they progress and cause trachomatous trichiasis.
Systemic treatment
For systemic treatment, a single oral dose of azithromycin 20 mg/kg (maximum 1 g) is effective from 78 to 95%. As an additional benefit, the use of oral azithromycin has been associated with a significant reduction in overall infant mortality. Alternatives include erythromycin 500 mg 2 times/day for 14 days or doxycycline 100 mg 2 times/day for 10 days (not to be used in pregnant or lactating women or children under 8 years of age).
Topical treatment
For topical treatment, tetracycline ointment 1% can be used on both eyes 2 times/day for 6 weeks.
Surgical treatment
The WHO recommends eyelid surgery for trachomatous trichiasis. If the corneal opacity has progressed to the central cornea, it is considered the stage of irreversible, untreatable blindness. In resource-rich nations a cornea transplant is required can restore sight. The procedure is complex, and the need for frequent and intensive care after treatment to prevent rejection and infection makes corneal transplantation impractical for many patients in most countries with limited resources.
On paediatric eye problems see also:
- Ocular chlamydia and antibiotic therapy - Oculista Italiano
- Retinopathy of the premature (ROP) - Oculista Italiano
- Counteracting poor visual development in children - Oculista Italiano
- Update on neonatal conjunctivitis - Oculista Italiano
- 1) Snježana Kaštelan et al, A Survey of Current Prophylactic Treatment for Ophthalmia Neonatorum in Croatia and a Review of International Preventive Practices, Med Sci Monit, . 2018 Nov 10;24:8042-8047. doi: 10.12659/MSM.910705.
- 2) Andrew Zikic et al, Treatment of Neonatal Chlamydial Conjunctivitis: A Systematic Review and Meta-analysis, J Pediatric Infect Dis Soc, . 2018 Aug 17;7(3):e107-e115. doi: 10.1093/jpids/piy060.
- 3) WHO Guidelines for the Treatment of Chlamydia trachomatis 2016
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