Chapter 58: Eye Discharge and Conjunctivitis

I. PROBLEM

A purulent eye discharge is noted in a 3-day-old infant. Eye discharge in a neonate is usually caused by neonatal conjunctivitis (also known as ophthalmia neonatorum) or congenital nasolacrimal duct obstruction (CNLDO or congenital dacryostenosis). Neonatal conjunctivitis (conjunctivitis occurring within the first 4 weeks of life) is an inflammation of the surface or covering of the eye that presents with eye discharge and hyperemia. It is the most common ocular disease in neonates. Etiology is chemical, bacterial, or viral. Most infections are acquired during vaginal delivery, but ascending infection can occur. In the United States, the incidence of infectious conjunctivitis is 1% to 2%, and in the world, it is 0.9% to 21%. Neonates with conjunctivitis require a thorough clinical and appropriate laboratory evaluation so appropriate treatment can be started as soon as possible if necessary. CNLDO is a membranous obstruction at the valve of Hasner, which is at the distal end of the nasolacrimal duct. Incidence is 6% to 20% in infants (studies show higher incidence in preterm infants when compared to full-term infants). The symptoms are persistent tearing and a mucoid discharge in the inner corner of the eye.

II. IMMEDIATE QUESTIONS

1. How old is the infant? Age may be helpful in determining the cause of eye discharge, noting that bacterial infections can occur anytime.

   1. First day of life. Conjunctivitis is most often due to ocular prophylaxis secondary to medications such as silver nitrate drops, tetracycline, erythromycin, gentamicin, povidone iodine solution, and chloramphenicol.

   2. 2 to 5 days old. Conjunctivitis is most often due to Neisseria gonorrhoeae (but can present earlier with premature rupture of membranes).

   3. 5 to 12 days old. Conjunctivitis is most often due to Chlamydia trachomatis. It is usually seen during this time and can present as late as the second or third week.

   4. 5 to 14 days old. Conjunctivitis is often due to other bacterial microbes. This includes pathogens from the skin, respiratory, gastrointestinal, or vaginal tract. See Table 58–3.

   5. 5 to 28 days old. Pseudomonas aeruginosa infections are typical during this time.

   6. 6 to 14 days old. Conjunctivitis can be due to herpes simplex virus (HSV).

   7. 2 weeks old. CNLDO usually manifests at 2 weeks of age but can sometimes be seen in the first few days to the first few weeks after birth.

2. Is the discharge unilateral or bilateral? Typical symptoms are persistent tearing and a mucoid discharge in the inner corner of the eye.

   1. Unilateral conjunctivitis is most often seen with Staphylococcus aureus, P aeruginosa, HSV, and adenovirus.

   2. Bilateral conjunctivitis is seen with infection caused by N gonorrhoeae or by the use of ocular prophylaxis.

   3. Unilateral, then bilateral. Chlamydia usually develops in 1 eye but affects the other after 2 to 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 (eg, purulent, serous, ...