Neonatal Conjunctivitis : Symptoms, Causes, Diagnosis and Management

Neonatal Conjunctivitis : Symptoms, Causes, Diagnosis and Management

Neonatal conjunctivitis (Ophthalmia neonatorum) is defined as a conjunctival inflammation that occurs during first month of life after birth. Various causes have been implicated such as bacterial, viral including chemical conjunctivitis. Complications may be mild such as hyperaemia with scant conjunctival discharge to permanent scarring leading to even blindness.

Neonatal conjunctivitis may be septic or aseptic:

Septic neonatal conjunctivitis:

Viral and bacterial infections are the leading causes of septic neonatal conjunctivitis. Chlamydial conjunctivitis (caused by Chlamydia trachomatis serotypes D-K) is the most common infective cause of neonatal conjunctivitis. Infective agents causing neonatal conjunctivitis may be transmitted to infant during delivery through birth canal. Simple bacterial conjunctivitis may be caused by organisms like Staphylococcus aureus. Herpes simplex virus (HSV) type 2 may cause blepharoconjunctivitis and may involve cornea leading to keratitis.

Aseptic conjunctivitis:

Silver nitrate solution (1 %) is used for prophylaxis (prevention) of infectious conjunctivitis (Credé’s method). Aseptic neonatal conjunctivitis is commonly caused by the use of silver nitrate solution resulting in chemical conjunctivitis. Less commonly, Neonatal conjunctivitis may also be caused by antibiotics as well, which are used for prevention of infection. Chemical conjunctivitis is less common owing to the use of antibiotic such as erythromycin eye ointment in place of silver nitrate solution for the prophylaxis of infective conjunctivitis.

Healthcare providers and parents should wash hands frequently to prevent transmission of infection. Sexually transmitted infections such as Chlamydia, gonorrhoea and herpes simplex should be treated before the birth of infant through vaginal route.

The development of neonatal conjunctivitis in infant is influenced by the structure of conjunctival tissue. Inflammation may cause dilatation of blood vessels, discharge from eyes or chemosis (swelling) of conjunctiva. These changes tend to be more severe due to poor immunity, lack of immunoglobulin A (IgA), lack of tears at birth, decreased lysozyme activity and absence of lymphoid tissue in the conjunctiva.


Manifestations of neonatal conjunctivitis depend upon the aetiological agent and its incubation period (period between infection of an individual by a pathogen and the manifestation of the illness).

Incubation period:

–       Chemical conjunctivitis: Chemical conjunctivitis usually takes place on the first day of life following exposure to an irritant like silver nitrate solution. It resolves spontaneously within 2-4 days.

–       Chlamydial conjunctivitis: The incubation period for chlamydial conjunctivitis varies from 5-14 days.

–       Gonococcal conjunctivitis: Gonococcal conjunctivitis tends to manifest from 2-7 days after infection. It can present later as well in some cases.

–       Miscellaneous non-chlamydial and non-gonococcal conjunctivitis: The incubation period for miscellaneous non-chlamydial and non-gonococcal conjunctivitis also varies from 5-14 days like chlamydial conjunctivitis.

–       Herpes simplex conjunctivitis: Conjunctivitis due to Herpes simplex usually occurs within first two weeks after birth and has an incubation period of about 6-14 days.

Symptoms of common causes of conjunctivitis are:

Chemical conjunctivitis:

Chemical conjunctivitis present with:

–       Mild redness of eyes.

–       Slight swelling of eyes.

Chlamydial conjunctivitis:

–       Redness of eyes.

–       Swelling of eyelids.

–       Purulent discharge.

Gonococcal conjunctivitis:

–       Red eyes.

–       Swelling of eyelids.

–       Profuse purulent discharge.

Miscellaneous Non-chlamydial non-gonococcal conjunctivitis:

–       Red eyes.

–       Swelling of eyelids.

–       Some purulent discharge.

Herpes simplex conjunctivitis:

–       Moderate redness of eyes.

–       Swelling of eyelids.

-Non-purulent or sero-sanguinous (containing serum or blood) discharge.


The main causes of neonatal conjunctivitis are:

Chemical conjunctivitis:

Neonatal conjunctivitis is commonly caused due to post-delivery use of ophthalmic silver nitrate given for the prophylaxis of ocular infection.

Bacterial conjunctivitis:

Bacteria causing neonatal conjunctivitis are:

–       Chlamydia trachomatis (serotypes D-K).

–       Neisseria gonorrhoeae.

–       Staphylococcus aureus.

–       Staphylococcus epidermidis.

–       Streptococcus haemolyticus.

–       Pneumococcus.

–       Pseudomonas aeruginosa.

Chlamydia trachomatis is the most common infectious cause of neonatal conjunctivitis.

Gonococcus causes most serious of neonatal conjunctivitis.

Pseudomonas, although rare, may lead to potentially blinding complications such as corneal ulceration and even perforation.

Other bacteria which may infect are – Klebsiella, Proteus, Serratia or Enterobacter.

Viral infections may be:

–       Herpes simplex virus.

Risk factors for neonatal conjunctivitis are:

–       Maternal infections carried in birth canal.

–       Exposure of infant to infections.

–       Human immunodeficiency virus (HIV) infected mothers.

–       Ocular injury during delivery.

–       Inadequate ocular prophylaxis immediately after birth.

–       Premature babies.

–       Poor antenatal care.

–       Poor and unhygienic delivery conditions.

–       Post- delivery exposure to infection.


Diagnosis depends upon the clinical presentation and lab investigations.

Prompt diagnosis is necessary to institute appropriate treatment and thereby minimising potential serious complications of the disease.

Clinical manifestations of disease in newborn following birth, plays an important role in identifying the likely cause.

A thorough examination of the eye and periocular structures is crucial. Systemic manifestations of the disease should also be looked for an appropriate diagnosis.

Non-specific clinical features of neonatal conjunctivitis include:

–       Swelling of eyelids.

–       Conjunctival congestion (redness).

–       Watering from the eyes.

–       Mucoid or Mucopurulent discharge.

–       Chemosis (swelling) of conjunctiva.

Specific clinical features and clinical course of disease process may be:

Chemical conjunctivitis:

Chemical conjunctivitis results in mild conjunctival congestion with watering. It resolves spontaneously within 2-4 days.

More concentrated solution of silver nitrate may result in severe response with lid oedema, chemosis of conjunctiva, exudates, membrane or pseudo-membrane (formed by deposition of fibrin rich exudates) formation and permanent scarring leading to damage to conjunctiva or cornea.

Chlamydial conjunctivitis:

Presentation of chlamydial conjunctivitis may vary from mild hyperaemia with scant mucoid discharge to eyelid swelling, chemosis and even pseudo-membrane formation on conjunctiva.

Chlamydial conjunctivitis typically presents with unilateral or bilateral watery discharge, which later becomes copious and purulent with time.

Follicular reaction in conjunctiva does not occur because there is no requisite lymphoid tissue present.

Blindness is rare and much slower to develop and is due to corneal opacification being produced due to eyelid scarring and corneal pannus formation.

Chlamydial conjunctivitis may be associated with extraocular systemic manifestations such as pneumonitis, otitis or rectal/ pharyngeal colonisation.

Gonococcal conjunctivitis:

Gonococcal conjunctivitis has rapid onset and produces most serious conjunctivitis than the other causes of neonatal conjunctivitis and may be associated with severe lid oedema (swelling), acute conjunctivitis and chemosis. A conjunctival membrane may be present.

Classically, it leads to bilateral severe purulent conjunctivitis.

Involvement of cornea is the most serious ocular (pertaining to eye) complication of gonococcal conjunctivitis. Initially, superficial keratitis produces lacklustre corneal appearance. Gonococcal conjunctivitis may lead to diffuse epithelial oedema, opacification and corneal ulceration (particularly in periphery), which may progress to corneal perforation or endophthalmitis (inflammation inside the eye).

Gonococcal conjunctivitis may be associated with systemic manifestations such as stomatitis, rhinitis, arthritis, anorectal infection, meningitis or septicaemia.

Miscellaneous non-chlamydial and non-gonococcal conjunctivitis:

Non-chlamydial and non-gonococcal conjunctivitis may cause swollen lids, redness of eyes, chemosis with mucopurulent discharge, which are variable and often indistinguishable from other causes.

Pseudomonas conjunctivitis, though rare, can have devastating consequences, such as rapid progression to corneal ulceration and perforation. Untreated Pseudomonas keratitis (inflammation of cornea) may lead to endophthalmitis (infection inside eyeball) and may be life threatening.

Herpes simplex conjunctivitis:

Herpes simplex keratoconjunctivitis is characterised by unilateral or bilateral lid oedema, moderate conjunctival congestion, vesicles on periocular skin and non-purulent sero-sanguinous discharge. It may be associated with formation of conjunctival membrane.

Involvement of corneal epithelium shows typical signs of herpetic keratitis in the form of micro-dendrites or geographic ulcers.

There may be generalised serious systemic herpes simplex infection such as encephalitis (inflammation of brain) owing to poor immunological response in infants.

Laboratory diagnosis:

Laboratory tests for neonatal conjunctivitis includes following:

–       Conjunctival scraping for Gram stain or Giemsa stain.

–       Conjunctival scraping for polymerase chain reaction assay (PCR).

–       Culture on chocolate agar and/or Thayer-Martin medium.

–       Culture on blood agar.

–       Culture of corneal epithelial cells, if involved.

Laboratory tests specific for suspected infectious aetiology include:

Chlamydial conjunctivitis:

–       Conjunctival scraping for Gram stain and Giemsa stain. Conjunctival scraping is taken and eye exudate is not enough to look for Chlamydial conjunctivitis (caused by Chlamydia trachomatis), since the causative agent is obligate intra-cellular parasite.

–       Conjunctival scraping for polymerase chain reaction (PCR).

Gonococcal conjunctivitis:

–       Culture on chocolate agar or Thayer-Martin medium for bacteria Neisseria gonorrhoeae.

–       Conjunctival scraping for polymerase chain reaction (PCR).

Miscellaneous non-chlamydial and non-gonococcal bacterial conjunctivitis:

–       Culture on blood agar for the causative agent.

Herpes simplex conjunctivitis:

–       Culture for Herpes simplex virus (HSV).

–       Direct fluorescent antibody test.

–       Polymerase chain reaction (PCR).

Repeat cultures may be required if symptoms worsen or recur following treatment.

Transcription-mediated amplification (TMA) test is a nucleic acid amplification test like PCR. TMA and PCR are more sensitive than culture in detecting chlamydial and gonorrhoeal organisms.

Cytological findings for various forms of neonatal conjunctivitis are:

–       Chemical conjunctivitis: Gram stain shows neutrophils with occasional lymphocytes.

–       Chlamydial conjunctivitis:

Gram stain: Gram stain shows neutrophils, lymphocytes and plasma cells.

Giemsa stain: Giemsa stain shows basophilic intracytoplasmic inclusions in epithelial cells.

–       Gonococcal conjunctivitis: Gram stain shows neutrophils and Gram-negative intracellular diplococci.

–       Miscellaneous non-chlamydial and non-gonococcal conjunctivitis: Gram stain shows neutrophils and infective bacteria.

–       Herpes simplex conjunctivitis:

Gram stain: Gram stain shows lymphocytes, plasma cells and multinucleate giant cells.

Papanicolaou smear: Papanicolaou smear shows eosinophilic intra-nuclear inclusions in epithelial cells, but with low sensitivity.

Neonatal conjunctivitis should be differentiated from:

–       Congenital obstruction of nasolacrimal duct.

–       Dacryocystitis.

–       Bacterial keratitis.

–       Fungal keratitis.

–       Preseptal cellulitis.

–       Orbital cellulitis.

–       Congenital glaucoma.


Management should be carried out under medical supervision.

Prior to birth, obtain cervical (lower part of uterus) culture if indicated, to exclude the risk of transmission of chlamydial, gonococcal, herpetic and other bacterial organisms to the foetus during vaginal delivery. Infection should be managed appropriately or the newborn may be delivered through Caesarean section.

Preliminary management pending culture is based on clinical picture and findings on Gram stain, Giemsa stain and Papanicolaou smear.

Since gonococcal conjunctivitis can infect an intact corneal epithelium and may progress rapidly leading to ulceration, prompt treatment is necessary. Infants with acute neonatal conjunctivitis should be treated for gonococcal conjunctivitis and is later modified based on the culture report.

The treatment prior to laboratory result includes topical erythromycin and systemic cephalosporin.

Newborns with conjunctivitis having systemic manifestations or who are at risk of secondary infections such as pneumonia, meningitis or septicaemia should be treated intensively.

Infants and parents with potential sexually transmitted diseases, such as Chlamydia and Gonococcus, should be examined for other sexually transmitted diseases such as Human immunodeficiency virus (HIV) and syphilis.

Patching of eyes should not be done.

Chemical conjunctivitis:

Usually no treatment is necessary for chemical conjunctivitis.

Eye lubrication with artificial tears may be sufficient for mild features.

Chlamydial conjunctivitis:

Topical treatment alone is not sufficient.

Topical and systemic erythromycin is prescribed.

Systemic therapy is important in chlamydial conjunctivitis since topical therapy does not eradicate bacteria in nasopharynx, which may cause life-threatening pneumonia. Since the efficacy of systemic erythromycin is about 80%, a second course is required sometimes.

Infants are treated on outpatient basis but hospitalisation may be required in severe cases.

Gonococcal conjunctivitis:

–       Topical irrigation with normal saline to remove profuse mucopurulent or purulent eye discharge.

–       Systemic penicillin or ceftriaxone is needed.

–       Local application of erythromycin is given.

Hospitalisation may be required.

All neonates with gonococcal conjunctivitis are also treated for chlamydia. Both parents should be treated as well.

Miscellaneous non-chlamydial and non-gonococcal bacterial conjunctivitis:

–       Antibiotics such as gentamicin, tobramycin or ciprofloxacin may be used for Gram negative organisms and bacitracin may be used for Gram positive organisms.

Herpes simplex conjunctivitis:

–       Systemic acyclovir is prescribed to reduce the risk of systemic infection.

–       Topical anti-viral agents such as trifluridine eye drops, ganciclovir gel or vidarabine eye ointment may be prescribed.

–       Topical antibiotics may be needed in cases with significant epithelial defects to prevent secondary bacterial infections.


Prognosis of neonatal conjunctivitis is generally good as long as early diagnosis is made and prompt medical therapy is instituted.

Most cases of infectious neonatal conjunctivitis respond to appropriate therapy.

Morbidity and mortality increases in cases of systemic manifestations requiring hospitalisation and intensive monitoring.