Eye Infections in Children

Etiology:

• Bacterial Infections: Bacterial infections are one of the major causes of septic neonatal conjunctivitis. The most common bacterial agent historically was Neisseria gonorrhoeae, which is a sexually transmitted infection. Others,

1. Chlamydia trachomatis (most common): 5-14 days
2. Neisseria gonorrhoeae: 3-5 days
3. Staphylococcus aureus
4. Pseudomonas aeruginosa
5. Streptococcus spp. (including S. haemolyticus, S. pneumoniae)
6. Other bacteria include Klebsiella, Proteus, Enterobacter, Serratia, and Eikenella corrodens.

• Viral Infections: Viral infections can also cause ophthalmia neonatorum, although they are less common than bacterial infections. Viral agents that can lead to neonatal conjunctivitis include herpes simplex virus, adenovirus, and enterovirus.
• Chlamydial Infection: Chlamydia trachomatis is a sexually transmitted infection that can be acquired by the mother and transmitted to the newborn during delivery. Babies born to women with untreated chlamydial infection have a 30-50% chance of developing ophthalmia neonatorum. Chlamydia trachomatis can also colonize the respiratory tract, leading to pneumonitis in some cases.
• Chemical Conjunctivitis: Aseptic neonatal conjunctivitis can be caused by exposure to certain chemicals. In the past, silver nitrate solution was used for prophylaxis, but it has been replaced by erythromycin ointment or povidone iodide in many places. Chemical conjunctivitis is becoming less common due to these changes

Presentation/Clinical Manifestations of Ophthalmia Neonatorum:

The presentation varies depending on the causative agent, but common features include:

• Eyelid swelling: Often the first sign, varying in severity from mild edema to significant swelling that may make it difficult to open the eyes.
• Discharge: Purulent (thick, yellow-green) discharge is characteristic of bacterial infections, while chlamydial infections may present with a less purulent, watery discharge that can become purulent later.
• Conjunctival redness (hyperemia): The conjunctiva will appear inflamed and red.
• Photophobia (light sensitivity): The infant may cry when exposed to light.
• Corneal involvement: In severe cases, the cornea (the transparent front part of the eye) can become cloudy or ulcerated, leading to permanent vision impairment or blindness. This is particularly true with gonococcal infections.
• Bilateral symptoms, affecting both eyes.
• Edema (swelling) of the eyelids, which may impede examination of the ocular surfaces.
• Mucopurulent conjunctivitis, characterized by a watery discharge that progresses to a copious purulent discharge in the case of chlamydial infection.
• Conjunctival edema (chemosis).
• Conjunctival pseudomembrane in severe cases.
• Corneal involvement, especially in cases of Neisseria gonorrhoeae infection, which can lead to corneal perforation.
• Epithelial edema, superficial keratitis, and possible corneal ulceration.

Ophthalmia Neonatorum: Prevention and Management

Prevention: Prevention strategies target reducing the risk of infection before, during, and after birth.

1. Antenatal (During Pregnancy):

• Regular screening for vaginal infections: Conduct regular examinations to detect vaginal discharges indicative of infections like gonorrhea and chlamydia.
• Treatment of vaginal infections: Ensure prompt and appropriate treatment of any identified vaginal infections in pregnant women using appropriate antibiotics.
• Management of high-risk pregnancies: Address conditions that may increase the risk of premature labor or prolonged rupture of membranes.
• Prevention and management of anemia: Address maternal anemia, as it can weaken the immune system and increase the risk of infection.
• Health education: Educate mothers on the importance of hygiene, including handwashing, perineal cleanliness, and avoidance of touching the eyes unnecessarily.

2. Intrapartum (During Labor):

• Sterile technique: Maintain strict sterile techniques during labor and delivery. All personnel should practice thorough hand hygiene.
• Avoid unnecessary eye swabbing: Avoid routine swabbing of the baby’s eyes during delivery unless absolutely necessary, as this can introduce infection. If swabbing is deemed necessary (e.g., for assessment), use separate sterile swabs for each eye, cleaning from the inner canthus outward.
• Isolation of infected mothers: Isolate mothers with purulent vaginal discharge to prevent transmission.
• Prophylactic antibiotics for prolonged rupture of membranes: Consider prophylactic antibiotics for mothers with prolonged rupture of membranes (PROM) exceeding 12 hours to reduce the risk of neonatal infection.

3. Postnatal (After Birth):

• Hand hygiene: Healthcare providers should perform thorough handwashing before and after handling newborns.
• Eye cleaning: Cleanse the baby’s eyes with sterile water or half-strength saline solution using a separate sterile cotton swab for each eye, cleaning from the inner to the outer canthus. Discard swabs after use.
• Avoid contact with birth fluids: Prevent the baby’s face from coming into contact with amniotic fluid.
• Educate mothers: Instruct mothers on proper hand hygiene before handling the baby and avoid touching the baby’s eyes.
• Prophylactic eye drops (during epidemics): In areas experiencing outbreaks of ophthalmia neonatorum, consider prophylactic eye drops (e.g., 1% silver nitrate or 10% sulfacetamide) immediately after birth. This practice is debated and requires careful consideration of potential side effects and local guidelines.

Management of Ophthalmia neonatorum:

Aims of Management:

The primary aims of management are to:

1. Eradicate the infection.
2. Prevent corneal damage and scarring.
3. Preserve vision.
4. Prevent transmission to others (e.g., other family members).

Management in a Maternity Centre (Limited to Mild Cases ONLY – Referral is usually necessary):

• Admission and Isolation: Admit the baby and isolate them to prevent infection spread. Position the baby on its side with the affected eye downward. Use mosquito nets to protect the baby from flies. Separate and disinfect all used materials before sending them to the laundry.
• Eye Cleaning: Cleanse the eyes with normal saline or cooled boiled water using a separate sterile swab for each eye.
• Topical Antibiotics: Apply antibiotic eye ointment (e.g., tetracycline or erythromycin) to both eyes. If ointments are unavailable, consider using diluted crystalline penicillin (see dosage instructions below).

Dosage of Diluted Crystalline Penicillin (If Ointments Unavailable – ONLY under direct medical supervision, and ideally as a temporary measure before hospital transfer):

1. 100,000 IU vial: Dilute with 4 ml sterile water. Use 5 drops in each eye every 5 minutes for 6 times, then 5 drops every 10 minutes for 6 times, then 5 drops every 30 minutes for 6 times, then 5 drops every hour for 3 days.
2. 500,000 IU vial: Dilute with 20 ml sterile water. Adjust dosage proportionately.

• Systemic Antibiotics (with strong caution, only when referral is significantly delayed and under medical supervision): Consider intramuscular crystalline penicillin 50,000 units/kg body weight every 12 hours for 7 days. This should be a last resort and is only acceptable if hospital transfer is delayed and a qualified medical professional has made the decision and is monitoring the infant’s response.
• Referral: Refer the patient to a hospital for definitive diagnosis (gonorrhea testing, culture and sensitivity) and treatment as soon as possible.

Referral: Refer all suspected cases of ophthalmia neonatorum, especially those with purulent discharge or corneal involvement, to a hospital.

• Assessment and Referral: Thoroughly assess the infant’s eyes. Any infant with suspected ophthalmia neonatorum, especially with purulent discharge or corneal involvement, requires immediate referral to a hospital with ophthalmology services. Do not attempt to manage significant cases in a maternity centre.
• Initial Cleaning (before referral): Gently cleanse the eyes with sterile saline or water to remove excess discharge. Use a separate cotton swab for each eye.

Management in Hospital:

• Diagnostic Testing: The physician will order an eye swab for culture and sensitivity to identify the causative organism.
• Eye Cleaning: Continue meticulous eye cleaning as previously described.
• Antibiotic Treatment: The physician will prescribe appropriate systemic and topical antibiotics based on the culture results. This may include intravenous antibiotics for severe infections. Penicillin may be used in gonococcal infections, as may other antibiotics like cefotaxime or ceftriaxone.
• Topical Antibiotic Ointments: Use Neomycin or tetracycline eye ointment to prevent eyelid adhesion.

Medical Management: Purulent discharge in the eyes of the newborn baby

→ Take history and examine

1. Rx for the baby:

• Always wear gloves.
• Cover the inflamed eye with gauze before opening for your protection.
• Clean the eye with saline or water.
• Apply tetracycline eye ointment hourly for 24 hours, then 8-hourly for 10 days.

PLUS:

• Ceftriaxone 125 mg IM stat.
• OR Erythromycin syrup 15 mg/kg body weight 6 hourly x 2/52.

2. Rx for the mother:

• Ceftriaxone 250 mg IM stat.
• PLUS: Erythromycin 500 mg for 7 days.

3. Rx for partners:

• Ciprofloxacin 500 mg stat.
• Septrin 5 tablets BD x3/7.

PLUS:

• Doxycycline 100 mg BD x7/7.
• OR Tetracycline 500 mg 6×7/7.

Educate on compliance:

• Schedule for a return visit.
• Provide mother and partner with condoms and counsel on risk reduction.

Incase of specific causative organisms;

Gonococcal Ophthalmia Neonatorum: 

• The infant should be isolated for the first 24 hours of treatment. 
• Eyes are irrigated every 1-2 hours with sterile isotonic saline until the discharge clears. 
• For culture-positive cases or severe infections, systemic antibiotic therapy is indicated. Ceftriaxone (25-50 mg/kg IV or IM) or cefotaxime (100 mg/kg IM or IV) is usually administered as a single dose for localized infection; a 7-day course is recommended for disseminated infection.

Chlamydial Ophthalmia Neonatorum: 

• Oral erythromycin suspension (40 mg/kg/day divided into four doses) is administered for 14 days. 
• Topical treatment alone is insufficient; systemic therapy is essential to prevent systemic spread.

Herpes Simplex Ophthalmia Neonatorum: 

• The infant requires isolation. Systemic acyclovir (20 mg/kg every 8 hours IV) for two weeks is the standard treatment. 
• Topical therapy with 3% vidarabine or 0.1% iododeoxyuridine ointment (five times daily for 10 days) may be added. 
• Severe cases necessitate immediate ophthalmological consultation.

Nursing Care (Maternity Centre and Hospital):

• General hygiene: Maintain meticulous hygiene, including handwashing, clean linens, and a clean environment.
• Eye care: Continue frequent eye cleaning as previously described.
• Comfort measures: Provide comfort measures to reduce the infant’s discomfort.
• Frequent eye cleaning: Gently cleanse the eyes with sterile saline or water every 2–4 hours, using a separate swab for each eye.
• Medication administration: Administer topical medications as prescribed, ensuring correct dosage and frequency.
• Monitoring: Closely monitor the infant’s response to treatment, including assessment of eyelid swelling, discharge, and corneal clarity.
• Pain management: Provide comfort measures as needed, such as cuddling and soothing techniques.
• Education: Educate the parents on the importance of adherence to the prescribed treatment regimen, proper eye cleaning techniques, and the need for follow-up appointments.

Complications:

• Corneal ulceration and scarring: This can lead to permanent visual impairment or blindness.
• Perforation of the cornea: A serious complication that requires surgical intervention.
• Endophthalmitis: Infection of the internal structures of the eye.
• Meningitis (rare, but possible, particularly with gonococcal infection): Infection of the membranes surrounding the brain and spinal cord.
• Sepsis: A life-threatening bloodstream infection.