opthalmia um ppt
TRANSCRIPT
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OPHTHALMIA NEONATORUM
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OPHTHALMIA NEONATORUM
Neonatalconjunctivitis in the
first month of life
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OPHTHALMIA NEONATORUM
The clinical presentation of conjunctivitis in thefirst 4 weeks of life is reported with widelyvarying frequencies in different parts of theworld. For example, a large populationreceiving 1% silver nitrate prophylaxis in Los
Angeles, California, had a frequency of0.14%,whereas a population in Norway hada frequency of 18.9%,and anotherpopulation in Kenya had a frequency of17.8%.3 These studies are also examples ofthe variability of etiologic causations. Itappears likely that Crede's importantobservations and the subsequent
introduction of silver nitrate prophylaxis werein a population with predominantlygonococcal conjunctivitis with a frequencyapproaching 10%.
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History
At the turn of this century, many children admitted toschools for the blind in the United States had bilateralopacified corneas after gonococcal ophthalmia
neonatorum. The widespread use of 1% silver nitrateprophylaxis after Crede's Cred's publication of hisobservations has made this cause of blindness rare.Many countries, including the United Kingdom and
Sweden, have discontinued mandatory prophylaxis, ashave many hospitals in the United States that are notrequired by state law to instill silver nitrate or anotheragent.
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History
A randomized, double-masked clinical trialcomparing silver nitrate, erythromycin, and noeye prophylaxis in newborns not at risk forgonococcal infections demonstrated that bothantimicrobial agents lower the rate ofconjunctivitis but that any of the three choicesare reasonable for infants born to women
receiving prenatal care and who are screenedfor sexually transmitted diseases duringpregnancy.
Cred CSR: Die Verhutung der Augenentzundung der Neugeborenen. ActaGyankol Gynkol 18:367, 1881
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OPHTHALMIA NEONATORUM
Neonatal conjunctivitis in the first month of life
PREDISPOSING FACTORS Organisms in vagina shed during delivery
Premature rupture of membranes
Long delivery
Few tears and low levels of IgA
Trauma to epithelial barrier
Prophylaxis (antibiotics, silver nitrate)
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AETIOLOGY OF NEONATALCONJUNCTIVITIS
The microbial causes of neonatal conjunctivitis that are probablyacquired from the birth canal are N. gonorrhoeae, C. trachomatis,and herpes simplex virus.
The organisms that cause the remaining cases of neonatalconjunctivitis are almost certainly acquired sometime after deliveryand are not prevented by ocular prophylaxis. Most are bacterial andinclude Staphylococcus aureus, Staphylococcus epidermidis,Streptococcus pneumoniae, Streptococcus group D, other
Streptococcus sp, Pseudomonas sp, Serratia sp, Klebsiella sp, andEnterococcus sp. In many instances, an organism is not isolated.
Infants who receive silver nitrate prophylaxis may develop achemical conjunctivitis that is transient and distinguishable frominfectious conjunctivitis.
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CHEMICAL
CAUSES & TREATMENT:-
Silver nitrate, antibiotics
Onset in hours, lasts 24 hours
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Chlamydia
Infants whose mothers have untreatedchlamydial infections antepartum have a 30% to
40% chance of developing chlamydial neonatalconjunctivitis postpartum.
In addition, 10% to 20% of these childrendevelop pneumonia related to Chlamydia.
Perinatal chlamydial exposure may also causelocalized infection in the nasopharynx, middleear, vagina, and rectum.
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CHLAMYDIA Is the commonest infectious cause
4-10% pregnant women infected
Presents at 5-14 days 40% neonates infected :- watery conjunctivitis becoming purulent,
papillary reaction (no follicles in newborn), +/- pseudomembranes,corneal scarring
Complications: pneumonia, otitis media, rhinitis, GIT infection.
DIAGNOSIS
ELISA, Giemsa, culture, direct immunofluorescent antibodies
(fastest). PCR TREATMENT
Neonate- 50mg/kg erythromycin in 4 divided doses for 3 weeks,topical G tetracycline 1%
Adults- 250mg QDS erythromycin for 3 weeks
Prophylaxis- Oc tetracycline or Oc erythromycin within 1hr after birth
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GONOCOCCALCONJUNCTIVITIS
N. gonorrhoeae is a gram-negative diplococcus. Humans are itsonly known reservoir. Gonococci have the ability to penetrate intact
epithelial cells, and once inside the cell, they divide rapidly. Typically, the clinical picture of neonatal conjunctivitis related to N.
gonorrhoeae includes the development of a hyperacuteconjunctivitis associated with marked lid edema, chemosis, andpurulent discharge, beginning 24 to 48 hours after birth.
Conjunctival membranes may be present. With a delay in diagnosis,corneal ulceration may occur and can rapidly progress toperforation.
Septicemia and meningitis are possible systemic involvements.
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Gonococcal conjunctivitis
It appears likely that Crede's importantobservations and the subsequent introduction ofsilver nitrate prophylaxis were in a population
with predominantly gonococcal conjunctivitiswith a frequency approaching 10%. Today,newborn gonococcal ocular infections areextremely uncommon in most populations. It has
been estimated that there are perhaps a total of2000 cases of gonococcal neonatalconjunctivitis annually in the United States
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OTHER BACTERIAL
Staphyloccus aureus, Strep. epidermidis, Streptococcuspneumoniae, E. coli, Pseudomonas, Haemophilusinfluenzae
Usually at day 5 DIAGNOSIS
By gram and culture.
TREATMENT
Neosporin ophthalmic covers most If Haemophilus:- need systemic ampicillin or cefuroxime
as well
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Bacterial conjunctivitis
Classically, the onset of bacterial conjunctivitis is described asoccurring on the fifth day. However, it is now recognized that it canoccur anytime in the immediate postpartum period. The clinicalpicture is similar to those already described. Lid edema, chemosis,and conjunctival injection and discharge are variable and oftenindistinguishable from the same signs seen with other causes ofneonatal conjunctivitis.
In evaluation of an infant with suspected bacterial conjunctivitis, oneshould look for evidence of local trauma to the conjunctiva orcornea, because loss of the epithelial protective barrier often playsan important role in pathogenesis. Obstruction of the nasolacrimalduct secondary to infection must also be sought; if present andundetected, this may cause recalcitrant conjunctivitis.
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Herpes simplex virus
Although either herpes simplex virus type 1 (HSV-1) ortype 2 (HSV-2) can cause neonatal conjunctivitis, up to70% of neonatal herpetic infections have been attributed
to the genital strain, HSV Most neonatal HSV-1 infections seem to be related to
contact with active infections ("fever blister" or "coldsores") in the immediate family during the perinatal
period. HSV-2 is usually transmitted during passage through the
birth canal or by transplacental mechanisms.
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LABORATORY DIAGNOSIS
The proper evaluation of neonatal conjunctivitisconsists of immediate cytologic examination ofconjunctival scrapings obtained with a metal
spatula and appropriate microbial cultures.Gram-stained smears provide informationregarding bacterial causes. Giemsa-stainedsmears provide information on possible causes
on the basis of the inflammatory cell typespresent and the characteristics of any inclusionbodies . A Papanicolaou-stained smear providesevidence of herpes simplex virus infection.
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Chlamydia
The successful specific identification of C. trachomatis is based oncultures in special laboratories and identification with fluorescentmonoclonal antibodies. However, the testing is not widely available,it is expensive, and the results are not available for 2 to 3 days. Anumber of tests have now become available that specifically identifyChlamydia on conjunctival smears with use of specific antibodies.These are more sensitive than examination of Giemsa-stainedsmears and are quite rapid, but they may require specific laboratoryequipment. For example, a direct immunofluorescent monoclonal
antibody stain for identification of chlamydial antigens on cells ofconjunctival smears has a sensitivity of 100% and a specificity of94%
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Usually type II, within 2/52
Vesicular blepharitis +/- keratitis.
Diagnosis
Immunofluorescence, smears, culture.
TREATMENT
Topical / systemic acyclovir
Herpes Simplex type 2
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OPHTHALMIA NEONATORUM
The treatment of herpes simplexvirus infections in newbornsshould be based on the extent ofinvolvement. Systemic and central
nervous system infections withherpes simplex virus can bedevastating. Therefore, therelative merits of combined topicaland systemic antiviral therapydeserve special consideration.
Most authorities believe allpatients with any neonatal herpesinfections require systemictherapy.