Indian Academy of Pediatrics (IAP)

STANDARD
TREATMENT
GUIDELINES 2022

Ophthalmia
Neonatorum
Lead Author
Arvind Shenoi
Co-Authors
Tunu Gadi, Sachin Shah

Under the Auspices of the IAP Action Plan 2022

Remesh Kumar R
IAP President 2022
Upendra Kinjawadekar Piyush Gupta
IAP President-Elect 2022 IAP President 2021
Vineet Saxena
IAP HSG 2022–2023
© Indian Academy of Pediatrics

IAP Standard Treatment Guidelines Committee

Chairperson
Remesh Kumar R
IAP Coordinator
Vineet Saxena
National Coordinators
SS Kamath, Vinod H Ratageri
Member Secretaries
Krishna Mohan R, Vishnu Mohan PT
Members
Santanu Deb, Surender Singh Bisht, Prashant Kariya,
Narmada Ashok, Pawan Kalyan
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Ophthalmia Neonatorum
Introduction

;; Ophthalmia neonatorum refers to any conjunctivitis occurring in the first 28 days of life.
;; It can be a sight-threatening condition of the eye seen in the first 4 weeks of life. Reported
incidence in India is 0.5–33%.

Flowchart 1: Etiology of ophthalmia neonatorum.

Etiology
 Ophthalmia Neonatorum

TABLE 1: Signs and symptoms of ophthalmia neonatorum.

Time of
Causative agent Signs and symptoms appearance Special consideration
Chlamydia trachomatis Minimal mucopurulent 5–14 days after Most common cause of
(chlamydial ophthalmia) discharge to severe birth late onset conjunctivitis
eyelid edema with Maternal cervix or
copious discharge and urethra serves as
pseudomembrane reservoir of the organism
formation Chlamydia pneumonitis
may accompany
neonatal conjunctivitis
Neisseria gonorrhoeae Severe eyelid edema, 2–5 days after Most virulent infectious
Signs and Symptoms

(gonococcal ophthalmia) profuse mucopurulent birth, earlier cause of ophthalmia

discharge, chemosis, in premature neonatorum
corneal ulceration, and rupture of
blindness, if untreated membrane
Chemical Mildly red eye with 6–8 hours after Disappears
some swelling of instillation spontaneously after
eyelids following topical of topical 48 hours
prophylaxis prophylaxis
Herpes simplex (herpetic Red eye, serosanguinous Appears Rare cause. Can
keratoconjunctivitis) discharge, vesicles on lid anytime during be associated with
margin or skin, and hazy the first 2 weeks generalized herpes
cornea due to edema of life simplex infection
Presence of
dendritic keratitis is
pathognomonic
Pathogenic bacteria Conjunctival redness Within 72 hours Most common cause of
Coagulase-negative and discharge of birth conjunctivitis
Staphylococcus Occurs in vaginal
Alpha-hemolytic deliveries
Streptococcus Premature rupture of
Haemophilus influenzae membranes is a risk
Streptococcus pneumoniae factor
Staphylococcus aureus Midwife examination is
Pseudomonas species another risk factor
Escherichia coli species

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 Ophthalmia Neonatorum

;; Complete history:
•• History of time of appearance of symptoms and signs
•• History of risk factors, e.g., maternal sexually transmitted disease (STD), premature rupture of
membrane, prolonged delivery, midwife interference, and unclean vaginal examination.
;; Examination:
•• Conjunctivitis (discharge, edema/erythema of lids, and conjunctival hyperemia)

Evaluation
•• Discharge (purulent in bacterial, watery or serosanguinous in viral, and greenish in
Pseudomonas infection)
•• Unilateral eye involvement in Staphylococcus aureus, Pseudomonas, and viral conjunctivitis
•• Red reflex
•• Systemic examination—look for systemic sepsis, abscess, cellulitis, and disseminated infection.
;; Eye discharge Gram stain and culture in Thayer Martin media and chocolate agar for bacteria,
especially if gonococcal ophthalmia is suspected.
;; Conjunctival scraping polymerase chain reaction (PCR), Giemsa staining, or direct fluorescent
antibody staining for chlamydial ophthalmia.
;; Conjunctival swab PCR for suspected herpetic infection. Blood and cerebrospinal fluid (CSF)
analysis to exclude central nervous system (CNS) and disseminated disease.

If there is a high degree of suspicion of ophthalmia neonatorum but lack of confirmatory test,
start treatment for both chlamydial and gonococcal ophthalmia to prevent sight-threatening
complications (Table 2).

TABLE 2: Treatment for ophthalmia neonatorum.

Management

Organism First choice Adjunct Special considerations

Gonococcal As per WHO STI guidelines Normal saline ;; Isolate baby during first
Single dose of ceftriaxone irrigation of 24 hours of parental
injection IM 50 mg/kg/day eyes every antibiotic therapy
(maximum 150 mg) 1–2 hours ;; Consider treating for
Or Topical chlamydia due to high
Kanamycin 25 mg/kg antibiotic not rate of concomitant
(maximum 75 mg) IM necessary infection
single dose ;; Evaluate for disseminated
Or disease
Spectinomycin 25 mg/kg ;; Test for other STD
(maximum 75 mg) ;; Take ophthalmology
IM single dose consultation
Contd...

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 Ophthalmia Neonatorum

Contd...
Organism First choice Adjunct Special considerations
Chlamydial As per WHO STI guidelines Frequent ;; Neonatal prophylaxis
Azithromycin 20 mg/kg normal saline with topical antibiotics do
once daily for 3 days is irrigation of not prevent chlamydial
preferred over erythro­ eyes ophthalmia
mycin 50 mg/kg/day ;; For infants born to
orally in four divided mothers with chlamydia
doses for 2 weeks exposure, educate
family to monitor baby
for infection including
pneumonia
Management

Herpetic Parenteral acyclovir ;; Seek ophthalmology

20 mg/kg three times consultation. Keratitis,
a day for 14 days (21 retinopathy and
days if disseminated or chorioretinitis can
CNS disease) along with develop
topical ganciclovir 0.15% ;; Evaluate and treat for
or 1% trifluridine five systemic herpes
times a day for 10–14 days ;; Isolate baby
Coagulase-negative Ophthalmic drops— ;; Most common cause of
Staphylococcus tobramycin or gentamicin conjunctivitis
Alpha-hemolytic × three to four times a day ;; Occurs following vaginal
Streptococcus × 7 days delivery
Haemophilus influenzae
Streptococcus
pneumoniae
Staphylococcus aureus
Pseudomonas species
Escherichia coli species
(CNS: central nervous system; STD: sexually transmitted disease; STI: sexually transmitted infection)

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 Ophthalmia Neonatorum

Prevention for Ophthalmia Neonatorum

;; Silver nitrate prophylaxis for gonococcal ophthalmia neonatorum has been
recommended in areas where incidence of maternal gonorrhea infection is high.
;; 1% silver nitrate solution (Credé’s method), 0.5% erythromycin ointment, 1%
tetracycline hydrochloride, chloramphenicol 1% eye ointment, or 2.5% povidone
iodine (aqueous solution without alcohol) is used for prophylaxis.
;; However, it is not practiced in most parts of our country; the WHO STI guidelines
Prophylaxis

2017 recommend ocular prophylaxis for prevention of chlamydia and gonococcal

infection. This guideline suggests one of the above-mentioned agents for topical
application to both eyes immediately after birth.
;; Administration of colostrum into the eye has been shown in a small study to
reduce the incidence of neonatal conjunctivitis.
;; Avoid cross contamination by frequent hand washing.
;; Avoid eye patching.
;; Chemical conjunctivitis resolves spontaneously. May need artificial tears.

;; American Academy of Pediatrics. Gonococcal infections. In: Kimberlin DW, Brady MT, Jackson MA,
Long SS (Eds). Red Book: 2018 Report of the Committee on Infectious Diseases, 31st edition. Itasca,
IL: American Academy of Pediatrics; 2018. pp. 355.
Further Reading

;; Ghaemi S, Navaei P, Rahimirad S, Behjati M, Kelishadi R. Evaluation of preventive effects of colostrum

against neonatal conjunctivitis: a randomized clinical trial. J Educ Health Promot. 2014;3:63.
;; Kapoor VS, Evans JR, Vedula SS. Intervention for preventing ophthalmia neonatorum. Cochrane
Database Syst Rev. 2020;9(9):CD001862.
;; Mammooty NC, George M, Joseph J, Tawab A. Proportion of ophthalmia neonatorum following
prophylaxis with azithromycin eye ointment in newborns at a tertiary care centre in Central Kerala.
Int J Contemp Pediatr. 2021;8(10):1720-4.
;; Wadhwani M, D’Souza P, Jain R, Dutta R, Saili A, Singh A. Conjunctivitis in newborn—a comparative
study. Ind J Pathol Microbiol. 2011;54(2):254-7.
;; World Health Organization. WHO Recommendations on Newborn Health: Guidelines Approved by
the WHO Guidelines Review Committee. Geneva: World Health Organization; 2017.
;; Zikic A, Schünemann H, Wi T, Lincetto O, Broutet N, Santesso N. Treatment of neonatal chlamydial
conjunctivitis: a systematic review and meta-analysis. J Pediatric Infect Dis Soc. 2018;7(3):e107-15.