Parents bring their 5 day old baby in to Paeds ED. He has had sticky eyes since birth and they don’t seem to be getting better. The baby seems otherwise well. What should you advise?
Sticky eyes aren’t always conjunctivitis
Sticky eyes are very common in the neonatal period and often start in the first 24 hours after birth. If the conjunctiva itself look normal and are not inflamed, then no treatment is needed. Parents should be encouraged to gently wipe the eyelid (from inside to outside) with some saline-soaked gauze a few times a day.
This usually sorts things out within a few days, but if it persists, then consider treating with chloramphenicol drops (0.5%). Both eyes should be treated, even if only one is sticky.
Blocked nasolacrimal ducts are a common cause. Also consider other non-infectious causes such as corneal abrasion, glaucoma, or a foreign body.
What do I need to know about blocked tear ducts?
Some babies are just born with a blocked tear duct, and this usually opens and self-resolves after a few weeks or months. The main symptom is watery eyes (even when the baby is not actually crying), and it can lead to sticky eyes. Managements should be with parents wiping gently with gauze (as above).
If the duct is still blocked by one year, then sometimes it needs a procedure to open it.
What if the conjunctiva are inflamed?
Conjunctivitis will present with conjunctival erythema, lid oedema, and a purulent discharge. If this is present then send an eye swab and start chloramphenicol treatment. Chloramphenicol should treat most common causes of neonatal conjunctivitis including strep, staph, or haemophilus.
The causes we need to worry about more are Chlamydia trochomatis, and Neisseria gonorrhoea. Also consider HSV infection.
Tell me more about chlamydia and neisseria…
Chlamydia has a longer incubation period and onset is usually at 5-14 days of life. It can start in one eye only but usually spreads to both eyes and presents as purulent discharge with lid oedema. Note if there is maternal PROM then chlamydial conjunctivitis can present earlier. Vertical transmission rates are up to 66% and 25% of babies born to mothers with chlamydia get infections with a quarter of these being pneumonia and the rest with conjunctivitis. Babies with suspected chlamydia should have an eye swab sent, be commenced on 0.5% chloramphenicol drops, and oral erythromycin (or azithromycin). If untreated, 1 in 5 babies with chlamydia conjunctivitis will develop pneumonia.
Gonococcal eye infection is less common, and has a 2-5 day incubation period. If a baby presents in the first 5 days of life with a bilateral purulent discharge and tense lid oedema, then consider gonococcal infection. Swabs should be sent for (urgent) gram stain and culture, and the baby should be started immediately on IV cefotaxime. Chloramphenicol drops can also be given. Complications include corneal ulceration, meningitis, or sepsis.
Keep other causes in the back of your mind e.g. pseudomonas and HSV. HSV presents in the first two weeks of life with associated systemic or skin infections.
Eye Infections, Particularly Chlamydial Neonatal Clinical Guideline, Royal Cornwall Hospital, 2019
Ophthalmia neonatorum, College of Optometrists, https://www.college-optometrists.org/guidance/clinical-management-guidelines/ophthalmia-neonatorum.html
Protocol for management of neonatal conjunctivitis – https://www.networks.nhs.uk/nhs-networks/staffordshire-shropshire-and-black-country-newborn/documents/Conjunctivitis%202009-11.pdf