Paeds · ophthalmology
Ophthalmia neonatorum
Also known as Neonatal conjunctivitis · Ophthalmia neonatorum · Gonococcal ophthalmia neonatorum · Chlamydial ophthalmia neonatorum · Inclusion conjunctivitis of the newborn · Sticky eye of the newborn
Fellowship topic on ophthalmia neonatorum — conjunctivitis arising in the first 28 days of life. Covers the chemical, gonococcal, chlamydial and herpes simplex causes with their onset windows and discharge characters; the epithelial-invasive and intracellular pathophysiology that explains corneal perforation, chlamydial pneumonia and neonatal HSV dissemination; the swab and PCR work-up; the cause-specific systemic treatment of single-dose ceftriaxone for gonorrhoea, oral erythromycin for 14 days for chlamydia and intravenous aciclovir for HSV; birth ocular prophylaxis and maternal sexually-transmitted-infection screening; and ANZ, UK, US and Canadian guidance.
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Red flags
- A neonate with profuse purulent discharge and marked eyelid oedema in the first two to five days of life — gonococcal ophthalmia neonatorum that can ulcerate and perforate the cornea within hours; treat as a sight-threatening emergency, swab, irrigate and give single-dose ceftriaxone without waiting for culture
- A 5-to-14-day-old with mucopurulent discharge and a staccato cough — chlamydial ophthalmia neonatorum with evolving afebrile pneumonia; treat systemically with oral erythromycin, never with topical drops alone
- Periocular vesicles, a watery eye or a dendritic ulcer on fluorescein staining — herpes simplex keratoconjunctivitis that may be the first sign of disseminated or central-nervous-system neonatal HSV; give intravenous aciclovir and evaluate for systemic disease
- A red eye attributed to simple conjunctivitis when fluorescein reveals a corneal defect — keratitis, abrasion or HSV dendrite rather than conjunctivitis; refer urgently and never prescribe topical steroid for a dendritic ulcer
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Board mappings
- Neonatology and General Paediatrics: ophthalmia neonatorum — definition, the chemical, gonococcal, chlamydial and herpes simplex causes by onset window, and the red flags that demand urgent assessment
- Infectious diseases and neonatal prophylaxis: ocular prophylaxis at birth, maternal sexually-transmitted-infection screening and the rationale for systemic treatment
- Renewed curriculum — Neonatology and Infectious diseases: the intracellular and epithelial-invasive pathophysiology, the ceftriaxone versus cefotaxime choice in the jaundiced neonate, and the erythromycin and aciclovir systemic pathways
- Public health and the social determinants of eye disease: maternal screening, partner treatment and povidone-iodine prophylaxis in resource-limited settings
- General Paediatrics: recognition of the cornea-threatening gonococcal form and the systemic chlamydial and HSV complications, with the work-up of conjunctival swabs
- Public health: neonatal ocular prophylaxis, maternal and partner screening and treatment, and the safety-net for the discharged neonate
- Long Case / Structured discussion: a neonate with ophthalmia neonatorum — cause, investigation, cause-specific systemic treatment, complications and the maternal and public-health response
- Communication station: explaining to a parent why a newborn red eye is treated as an emergency and why the mother and partner must be screened and treated
- Level 2 / 3 — Neonatology and Infection: ophthalmia neonatorum by cause, the onset windows, the red flags and neonatal prophylaxis
- Public health and health improvement: universal ocular prophylaxis and maternal sexually-transmitted-infection screening
- Foundation of Practice (FOP): the causes and onset windows of ophthalmia neonatorum and the differential of a sticky eye in the newborn
- Applied Knowledge in Practice (AKP): cause-specific systemic antimicrobial choice, the ceftriaxone-versus-cefotaxime decision and the complications of chlamydial pneumonia and neonatal HSV
- History-taking and management: the newborn with conjunctivitis, the maternal history and the systemic treatment plan
- Communication: explaining the emergency nature of gonococcal ophthalmia and the need for maternal and partner screening and treatment
- Neonatology Content Outline: ophthalmia neonatorum — causes, onset windows, prophylaxis and the systemic treatment pathways
- Infectious Diseases: gonococcal, chlamydial and herpes simplex neonatal conjunctivitis, maternal screening and neonatal prophylaxis
- Patient Care: cause-specific, systemic, evidence-based management of ophthalmia neonatorum with prompt recognition of the sight-threatening causes
- Systems-Based Practice and Population Health: universal ocular prophylaxis, maternal and partner screening and treatment, and antibiotic stewardship
- Medical Knowledge: the epithelial-invasive and intracellular pathophysiology, the corneal-perforation and pneumonia mechanisms, and the ceftriaxone, erythromycin and aciclovir pharmacology
- Medical Expert: ophthalmia neonatorum diagnosis, cause-specific systemic treatment and complications, including the neonatal HSV and chlamydial pneumonia risks
- Health Advocate and Collaborator: neonatal prophylaxis, maternal sexually-transmitted-infection screening and partner treatment, and Indigenous and remote-community eye health
- Communicator: explaining the emergency nature of gonococcal ophthalmia and the public-health response to families
Overview & Definition
A midwife calls you to the postnatal ward about a three-day-old boy whose right eye has been weeping thick yellow discharge since the morning, the lids now so swollen he cannot open them. Half an hour later a general-practitioner referral arrives: a ten-day-old with bloodstained mucopurulent discharge and a curious, repetitive cough. Both are ophthalmia neonatorum, but the first is a sight-threatening emergency and the second is a systemic infection in disguise. The fellowship skill is to read the day of life and the discharge and act on the cause, because the difference between them is measured in hours of corneal viability. [1] [12]
Ophthalmia neonatorum is any conjunctivitis — conjunctival inflammation with discharge — arising in the first 28 days of life. The name is old but the problem is current: worldwide it remains one of the commonest neonatal infections, and in settings without antenatal screening and birth prophylaxis it is still a leading preventable cause of childhood blindness. The conjunctiva of the newborn is immature, its tear film and immune defences underdeveloped, so organisms picked up during vaginal delivery invade readily and, for gonorrhoea, with devastating speed. [1] [2]
What makes the topic examinable is that the causes behave so differently. Gonorrhoea invades the conjunctival epithelium and can erode through the cornea within hours; chlamydia is an obligate intracellular organism that seeds the nasopharynx and descends to the lung; herpes simplex replicates in surface epithelium, forms a dendritic ulcer and may signal disseminated disease; and chemical conjunctivitis is simply the irritant effect of prophylactic drops. The clinical tool that separates them is the onset window and the character of the discharge, and it drives both the investigation panel and the systemic treatment — which is why a neonatal red eye is investigated and treated far more aggressively than conjunctivitis in an older child. [1] [3]
References12ShowHide
- [1]Castro Ochoa KJ; Gurnani B Ophthalmia Neonatorum (Neonatal Conjunctivitis). StatPearls, 2026.PMID 31855399
- [2]Asiamah R; Owusu G; Amoako PT; et al Epidemiology of ophthalmia neonatorum: a systematic review and meta-analysis. BMC Pediatr, 2025.PMID 39810179
- [3]Moore DL; MacDonald NE; Canadian Paediatric Society Preventing ophthalmia neonatorum. Paediatr Child Health, 2015.PMID 25838784
- [4]Curry SJ; Krist AH; Owens DK; et al Ocular Prophylaxis for Gonococcal Ophthalmia Neonatorum: US Preventive Services Task Force Reaffirmation Recommendation Statement. JAMA, 2019.PMID 30694327
- [5]Zikic A; Schunemann H; Wi T; et al Treatment of Neonatal Chlamydial Conjunctivitis: A Systematic Review and Meta-analysis. J Pediatric Infect Dis Soc, 2018.PMID 30007329
- [6]Zar HJ Neonatal chlamydial infections: prevention and treatment. Paediatr Drugs, 2005.PMID 15871630
- [7]Pinninti SG; Kimberlin DW Neonatal herpes simplex virus infections. Semin Perinatol, 2018.PMID 29544668
- [8]James SH; Kimberlin DW Neonatal herpes simplex virus infection: epidemiology and treatment. Clin Perinatol, 2015.PMID 25677996
- [9]Isenberg SJ; Apt L; Yoshimori R; et al Povidone-iodine for ophthalmia neonatorum prophylaxis. Am J Ophthalmol, 1994.PMID 7977595
- [10]Smith-Norowitz TA; Ukaegbu C; Kohlhoff S; Hammerschlag MR Neonatal prophylaxis with antibiotic containing ointments does not reduce incidence of chlamydial conjunctivitis in newborns. BMC Infect Dis, 2021.PMID 33731049
- [11]Belagal P Current alternative therapies for treating drug-resistant Neisseria gonorrhoeae causing ophthalmia neonatorum. Future Microbiol, 2024.PMID 38512111
- [12]Tan AK Ophthalmia Neonatorum. N Engl J Med, 2019.PMID 30625059