The timing and manifestations of neonatal conjunctivitis are helpful in identifying the cause (Table 119-2). N. gonorrhoeaecauses severe conjunctivitis with profuse purulent discharge. Chlamydial conjunctivitis usually occurs in the second week of life but may appear 3 days to 6 weeks after delivery. There is mild to moderate inflammation with purulent discharge issuing from one or both eyes.
Cultures are not routinely obtained because bacterial conjunctivitis is usually self-limited or responds quickly to topical antibiotic treatment. If gonococcal conjunctivitis is suspected, especially in neonates, Gram stain and culture must be obtained. In these infants, blood and other sites of infection (such as cerebrospinal fluid) should be cultured. Additional testing for Chlamydia, human immunodeficiency virus (HIV), and syphilis should be performed on the mother and infant as necessary as well.
Distinguishing bacterial from viral conjunctivitis by presentation and appearance is difficult (see Table 119-1). Vesicular lid lesions, if present, suggest HSV. Hyperpurulent conjunctivitis characterized by reaccumulation of purulent discharge within minutes is characteristic of N. gonorrhea infection. The differential diagnosis is delineated in Table 119-3.
Blepharitis is associated with staphylococcal infections, seborrhea, and meibomian gland dysfunction. The child complains of photophobia, burning, irritation, and a foreign body sensation that causes the child to rub the eyes. Eyelid hygiene with an eyelid scrub routine is the initial step in treatment.
Hordeola are acute suppurative nodular inflammatory lesions of the eyelids associated with pain and redness. External hordeola or styes occur on the anterior eyelid, in the Zeis glands, or in the lash follicles and usually are caused by staphylococci. Internal hordeola occur in the meibomian glands and may be infected with staphylococci or may be sterile. If the meibomian gland becomes obstructed, the gland secretions accumulate, and a chalazion develops. Hordeola usually respond spontaneously to local treatment measures but may recur.
Dacryocystitis is an infection or inflammation of the lacrimal sac, which is usually obstructed, and is most commonly caused by Staphylococcus aureus or coagulase-negative staphylococci. A mucopurulent discharge can be expressed with
Chemical: silver
Variable (1%), Watery discharge 1–3 days No organisms on None None nitrate depending on use smear or culture of silver nitrate
CSF, Cerebrospinal fluid; DIF, direct immunofluorescence; HSV, herpes simplex virus; PCR, polymerase chain reaction.
Bacterial conjunctivitis Haemophilus influenzae, Mucopurulent unilateral or Topical antibiotics, parenteral Haemophilus aegyptius, bilateral discharge, normal ceftriaxone for gonococcus Streptococcus pneumoniae, vision, photophobia, conjunctival Neisseria gonorrhoeae injection and edema (chemosis);
Viral conjunctivitis Adenovirus, echovirus, Same as for bacterial infection; Self-limited coxsackievirus may be hemorrhagic, unilateral
Posterior uveitis (choroiditis) Toxoplasmosis, histoplasmosis, No signs of erythema, decreased Specific therapy for pathogen Toxocara canis vision