STICKY EYES
History
Jenna is a 5-day-old girl who is brought to her GP because she has had sticky eyes for 2 days. The GP notes that there is a purulent discharge filling both eyes, and it is very hard to see the conjunctiva clearly. He refers her to the on-call paediatric team. She was born at term by normal vaginal delivery to a 19-year-old first-time mother after an uneventful pregnancy. Her birth weight was 2.75 kg (ninth centile). Her mother smoked throughout pregnancy and drank some alcohol. She had erratic attendance for antenatal care and had refused antenatal screening blood tests. She was discharged from hospital after 12 hours and the baby has been bottle-fed since.
Examination
Jenna looks healthy apart from swollen eyelids with profuse purulent discharge and erythematous conjunctiva. She weighs 2.8 kg. She is afebrile, with a heart rate of 140/min, a respiratory rate of 35/min, normal heart sounds and normal breath sounds. Her abdomen is soft and the liver is palpable 1 cm below the costal margin. Her anterior fontanelle is normotensive.
INVESTIGATIONS
Normal
Haemoglobin 13.3 g/dL 13.4–19.8 g/dL
White cell count 9.1 109/L 6–21 109/L
Platelets 353 109/L 170–500 109/L
C-reactive protein 11 mg/L 5 mg/L
Microscopy of pus from the eye – pus cells ; Gram-negative diplococci
Questions • What is the diagnosis? • How should the baby be managed? • What advice should be given to the mother?
Medicine
Jenna has ophthalmia neonatorum (neonatal conjunctival infection) caused by Neisseria gonorrhoeae. The differential diagnosis of sticky eyes in a neonate includes nasolacrimal duct obstruction, Chlamydia trachomatis, herpes simplex and other bacterial conjunctivitis (e.g. Staphylococcus aureus, Streptococcus pneumoniae). Inflammation of the conjunctiva is not seen in nasolacrimal duct obstruction, although the eyes may be sticky. Ophthalmia neonatorum is an emergency and requires prompt management to prevent permanent visual impairment and to treat possible systemic infection. In cases of ophthalmia neonatorum, it is essential to take adequate microbiological specimens and then commence prompt antibiotic treatment. Swabs for chlamydia are usually different from those used for other bacteria and it is necessary to look for both as chlamydia and gonococcal infections can coexist. Gonococcal ophthalmia neonatorum should be treated with intravenous ceftriaxone or cefotaxime and frequent eye irrigation with saline solution. Many experts would also add antibiotic eye drops. The neonate should be evaluated for disseminated infection, although this is unlikely in this infant, who is afebrile and appears systemically well. Ophthalmia neonatorum is a notifiable disease. Jenna’s mother should be told that this is a sexually transmitted infection (STI), which Jenna has almost certainly acquired from the birth canal. It can cause asymptomatic infection in women, but also causes symptomatic infection of the genital tract, pelvic inflammatory disease and perihepatitis. It is very important that she attends a genitourinary medicine clinic for treatment and screening for other STIs and considers discussing this with her partner(s). It is also important to have a more thorough discussion about her social circumstances and why she declined antenatal screening blood tests.
KEY POINTS
• Ophthalmia neonatorum requires prompt recognition and systemic treatment.
• Appropriate specimens must be sent for both gonococcus and chlamydia.
• The mother must be advised that she and her partner(s) will require screening.
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