Ординатура / Офтальмология / Английские материалы / Pediatric Ophthalmology for Primary Care 3rd edition_Wright, Farzavandi_2008

Chapter 13

Pediatric “Pink Eye”

Neonatal Conjunctivitis (Ophthalmia Neonatorum)

Neonatal conjunctivitis is a conjunctivitis occurring during the first month of life. Before the use of topical prophylaxis, ophthalmia neonatorum was a devastating disease associated with high morbidity. Routine topical prophy laxis with 1% silver nitrate, 1% tetracycline ointment, or 0.5% erythromycin ointment has dramatically reduced the incidence of ophthalmia neonato rum. Infections can be acquired from vaginal microorganisms during birth or from hand to eye contamination from hospital workers. An infection from the birth canal is usually associated with a vaginal delivery but also can occur after a Cesarean delivery if the amniotic membranes rupture prior to delivery.

The most common cause of red, watery eyes in the first few hours of life is chemical conjunctivitis secondary to silver nitrate prophylaxis. Most infants who receive silver nitrate prophylaxis will develop some degree

of chemical conjunctivitis. This occurs immediately after silver nitrate is administered, is self limited, and in most cases, lasts for less than a day. Infectious causes of neonatal conjunctivitis present later, usually at least 48 hours after birth, and include Chlamydia trachomatis, Neisseria gonor­ rhoeae, group B streptococcus, Staphylococcus aureus, Escherichia coli,

Haemophilus influenzae, and herpes simplex virus type 2. To a large extent, the etiology of the conjunctivitis can be determined by the time of onset of the conjunctivitis (Table 13 1). Another common cause of pink eye in

neonates is nasolacrimal duct obstruction with the discharge usually starting at 2 weeks of age (see Chapter 12).

Differential Diagnosis of Neonatal Conjunctivitis

In addition to neonatal conjunctivitis, other causes of a red, teary eye in a newborn include congenital glaucoma (Chapter 12), nasolacrimal duct

obstruction, dacryocystitis (Chapter 12), and in rare instances, endophthal mitis. Endophthalmitis is a devastating infection within the eye, often

160 Pediatric Ophthalmology for Primary Care

Table 13-1. Causes of Neonatal Conjunctivitis

resulting in blindness (also see Chapter 14). It is associated with vitreous inflammation that disrupts the red reflex. It is extremely rare, but a neonate can develop endophthalmitis from a blood borne infection originating from a contaminated indwelling catheter (author’s experience). Congenital glaucoma is characterized by clear tears, large cornea, and corneal edema.

Dacryocystitis is an infection of the lacrimal sac that causes a swelling in the medial canthal area of the lower lid, and should be distinguished from conjunctivitis.

Evaluation and Treatment of Neonatal Conjunctivitis (Table 13 2)

As for all newborns, the ophthalmic examination should start with the red reflex test. If the pathology is isolated to the conjunctiva and does not involve the cornea or intraocular structures, the red reflex should be nor

mal. Conditions such as endophthalmitis, congenital glaucoma, and corneal infections have an abnormal red reflex. An urgent consultation is indicated if the patient has significant lid swelling or a unilateral conjunctivitis (which may indicate herpes 2 keratitis), shows no improvement over a day or two, or has an abnormal red reflex. Consider an ophthalmology consultation for any neonate with conjunctivitis.

The initial workup for presumed infectious neonatal conjunctivitis includes conjunctival cultures on chocolate agar, Thayer Martin agar, and blood agar. Conjunctival scrapings should be obtained and examined by Gram stain, Giemsa stain, and indirect immunofluorescent antibody assay for chlamydia. If a herpes keratitis is suspected (unilateral conjunctivitis with corneal fluorescein staining), a corneal scraping for herpes culture should be obtained. A Venereal Disease Research Laboratories test for a concurrent congenital syphilis infection is advised for venereal neonatal conjunctivitis.

The treatment of a presumed infectious neonatal conjunctivitis prior to receiving laboratory results includes the use of topical erythromycin ointment and intravenous (IV) cefotaxime. Cefotaxime is preferred over

Table 13-2. Initial Evaluation and Treatment of Presumed Infectious

Neonatal Conjunctivitis

Evaluation

1.Red reflex test and ophthalmology consultation.

2.Conjunctival scraping and obtain Gram stain, Giemsa stain, and direct immunofluorescent assay for Chlamydia.

3.Conjunctival culture on blood agar, chocolate agar, and Thayer-Martin agar. Consider viral culture, especially in unilateral cases.

Therapy

Initial therapy prior to laboratory results is erythromycin topical ointment and IV cefotaxime. Consider trifluridine and IV acyclovir if herpes is suspected. Once the offending organism is identified, then specific treatment is given.

ceftriaxone because ceftriaxone binds with albumin and may result in hyperbilirubinemia in neonates. Antibiotic treatment should be given immediately after cultures are taken. Add topical trifluridine (Viroptic) every 2 hours and IV acyclovir if herpes is suspected. Once the laboratory results are known, therapy is tailored to treat the offending organism.

Specific Infectious Causes of Neonatal Conjunctivitis

Gonococcal Conjunctivitis

Gonococcal conjunctivitis occurs approximately 48 hours after birth. It may occur even earlier if rupture of the amniotic membranes occurs several hours prior to delivery. Typically, gonococcal conjunctivitis presents as a bilateral, purulent conjunctivitis with copious discharge and lid edema (Figure 13 1). N gonorrhoeae is one of the few bacteria that can penetrate intact corneal epithelium causing a corneal ulceration and even corneal per foration. The diagnosis is usually made by identifying Gram negative intra cellular diplococci on conjunctival scrapings and verifying by conjunctival culture. The treatment for gonococcal conjunctivitis is topical erythromycin ointment and IV cefotaxime. If indicated, parents should also be evaluated for possible treatment.

Chlamydial Conjunctivitis

Chlamydial conjunctivitis typically presents bilaterally, with mild to moder ate conjunctivitis, around 4 to 10 days after birth. Eyelid swelling and a tarsal conjunctival pseudomembrane may be present (Figure 13 2). A conjunc tival pseudomembrane is an accumulation of debris, not a true vascular tissue. The diagnosis of chlamydia is confirmed by conjunctival scrapings identifying cytoplasmic inclusion bodies in corneal epithelial cells (Giemsa stain) or by indirect immunofluorescence assay or culture. The treatment of choice for chlamydial conjunctivitis is topical erythromycin ointment and oral erythromycin 30 to 50 mg/kg per day for at least 2 weeks. Oral eryth romycin is used to remove chlamydia organisms from the nasopharynx to decrease the risks of chlamydia pneumonia that presents between 1 and 3 months of age. Parents should be warned of the possibility that chlamydial pneumonitis can occur after neonatal conjunctivitis (Chong et al). Parents are the source of the infection and should be treated with oral erythromycin or tetracycline for 2 to 3 weeks, even if they are asymptomatic.

Figure 13 1.

A, Two-day-old infant with culture-positive gonococcal conjunctivitis. Note the bilateral lid swelling (left > right). B, With lids everted, a severe conjunctivitis is noted.

Herpes Simplex Virus Type 2

Herpes simplex virus type 2 can cause neonatal conjunctivitis usually associ ated with a keratitis (corneal infection). Herpes keratoconjunctivitis occurs as an isolated eye infection but may be associated with systemic disease and encephalitis. The onset of herpes keratoconjunctivitis is usually between 1 and 2 weeks postpartum, presenting as a serous discharge with moderate conjunctival injection. In contrast to other infectious causes of neonatal

Figure 13 2.

A, Two-week-old infant with severe lid swelling caused by a chlamydia conjunctivitis. B, Everting the upper eyelid reveals a severe conjunctivitis and a conjunctival pseudomembrane. A pseudomembrane is an accumulation of cellular debris and fibrin, not a true vascular tissue.

conjunctivitis, herpes keratoconjunctivitis almost always presents as a uni lateral infection. Breakdown of the normal epithelial barrier can result in a secondary bacterial corneal ulcer (Figure 13 3). Early stages of the keratitis are detected by corneal fluorescein staining showing a geographic or den dritic pattern. The diagnosis is confirmed by viral cultures that may take up to 7 to 10 days to become positive. If herpes neonatal conjunctivitis is

suspected, the treatment of choice is topical trifluridine every 2 hours com bined with IV acyclovir. Topical antibiotics should be used to prevent a sec ondary bacterial infection.

Neonatal Conjunctivitis Prophylaxis

There has been some controversy about the best agents to use to prevent neonatal conjunctivitis. Studies have shown that the efficacy of 0.5% erythro mycin ointment, 1% tetracycline ointment, and 1% silver nitrate is approxi mately the same. The use of povidone iodine 2.5% in a single dose has been advocated for prophylaxis (Harrison et al). The advantages of povidone include effective coverage of a broad spectrum of bacteria and coverage for viruses such as herpes simplex and human immunodeficiency virus with little chemical irritation reaction.

Pediatric Conjunctivitis

Pink eye or conjunctivitis is a nonspecific finding that simply indicates con junctival inflammation. A variety of disease processes can cause conjunctival inflammation, including an extraocular foreign body, chemical toxicity, trauma, uveitis (Chapter 14), episcleritis (Chapter 14), allergic disease, viral or bacterial infections, and eyelid inflammation (blepharitis). Intraocular processes, including endophthalmitis (infection within the eye) and tumors associated with necrosis (such as retinoblastoma), can also produce conjunc tival inflammation and may present as conjunctivitis. The vast majority of children who present with pink eye, however, will have a benign, self limiting conjunctivitis. The most common causes of pediatric conjunctivitis are listed in Table 13 3. It is often difficult to determine the etiology of conjunctivitis based on the appearance of the eye. Even so, there are basic distinguishing features of the common causes of pediatric conjunctivitis (Table 13 4).

Evaluation and Treatment of Pediatric Conjunctivitis

Initial evaluation and treatment of pediatric pink eye should include a his tory and an ocular examination using I ARM (inspection, acuity, red reflex, motility—see Chapter 3). A history of friends or family members with conjunctivitis usually indicates a contagious origin, commonly a viral infec tion. Itching is an important symptom because it is the hallmark of aller gic conjunctivitis. Conjunctivitis associated with contact lens use may be

Table 13-3. Common Causes of Pediatric Conjunctivitis

1.Blepharitis

a.Staphylococcal

b.Meibomian gland dysfunction

2.Allergic conjunctivitis

a.Seasonal

b.Vernal

c.Atopic

3.Bacterial conjunctivitis

a.H influenzae

b.S pneumoniae

c.S epidermidis

d.S aureus

e.Corynebacterium

f.Moraxella catarrhalis

4.Viral conjunctivitis

aAdenovirus

b.Herpesvirus

c.Papovavirus (conjunctival warts)

d.Poxvirus (molluscum contagiosum)

e.Picornavirus

f.Paramyxovirus

5.Trauma (Chapter 23)

a.Foreign body

b.Corneal abrasion

c.Chemical burn

d.Subconjunctival hemorrhage

e.Trichiasis

6.Ocular inflammation (Chapter 14)

a.Juvenile rheumatoid arthritis

b.Sarcoidosis

c.Endophthalmitis

d.Episcleritis

7.Neoplasm

a.Conjunctival nevus

b.Lymphangioma

c.Retinoblastoma

secondary to an allergy to contact lens solutions or even more importantly, a vision threatening bacterial corneal ulcer. Conjunctivitis associated with contact lens use deserves an immediate ophthalmology referral.

As in the case of neonatal conjunctivitis, the red reflex test should also be performed on older children with conjunctivitis because an abnormal red reflex may indicate a serious disease process. Benign pediatric conjunctivitis