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I. PROBLEM

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A purulent eye discharge is noted in a 3-day-old infant. Eye discharge in a neonate is usually caused by conjunctivitis or congenital lacrimal duct obstruction. Neonatal conjunctivitis (ophthalmia neonatorum) is an inflammation of the surface or covering of the eye that presents with eye discharge and hyperemia in the first 4 weeks of life. It is the most common ocular disease in neonates. Most infections are acquired during vaginal delivery. In the United States the incidence of infectious conjunctivitis is 1–2%; in the world it is 0.9–21%. Congenital lacrimal duct obstruction (CLDO) (dacryostenosis) is a condition where there is a blockage of the lacrimal drainage system. It occurs in ∽5–6% of infants. The symptoms are persistent tearing and a mucoid discharge in the inner corner of the eye.

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II. IMMEDIATE QUESTIONS

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  1. How old is the infant? Age may be helpful in determining the cause of eye discharge. For conjunctivitis: in the first 6–24 hours of life, conjunctivitis is often due to ocular prophylaxis (usually silver nitrate drops; it may also be from tetracycline, erythromycin, or gentamicin). After 24–48 hours, a bacterial infection is most likely; the most common neonatal organisms are Neisseria gonorrhoeae (2–7 days but can present later) and Staphylococcus aureus (5–14 days). Chlamydia trachomatis conjunctivitis is usually seen after the first week of life (5–14 days) and often presents as late as the second or third week. Herpes conjunctivitis is seen 6–14 days after birth. Pseudomonas aeruginosa infections are typically seen between 5 and 18 days. Note: Bacterial infections can occur anytime. Lacrimal duct obstruction usually manifests at 2 weeks of age, but can be seen in the first few days to the first few weeks after birth.

  2. Is the discharge unilateral or bilateral? Unilateral conjunctivitis is most often seen with S. aureus, P. aeruginosa, and herpes simplex (HSV) and adenovirus. Bilateral conjunctivitis is seen with infection caused by N. gonorrhoeae or by the use of ocular prophylaxis. Chlamydia usually develops in one eye but affects the other after 2–7 days. Lacrimal duct obstruction usually causes unilateral discharge, but up to 20 % of infants have bilateral obstruction.

  3. What are the characteristics of the discharge (purulent vs watery)? Purulent discharge is more common with bacterial infection. A serous discharge is more common with a viral infection. Gonorrhea has a profuse purulent discharge. Greenish discharge is more characteristic of P. aeruginosa. Chlamydial infection can be watery early and purulent later, but a blood-stained discharge is typical. Herpes conjunctivitis usually has a nonpurulent and serosanguineous discharge. Lacrimal duct obstruction can cause watery tears in the corner of the eye or tears draining from the eyelid down the cheek. It can also cause a mucus or yellowish discharge in the eye.

  4. Did the infant receive eye prophylaxis? Prophylaxis is used to decrease the risk of developing ocular gonorrheal infection (prevent blindness) and it also decreases the risk of nongonococcal and nonchlamydial conjunctivitis ...

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