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Herpes Simplex Keratitis. Branched dendritic lesion seen on the cornea in a patient with HSV. (Photo contributor: Lawrence B. Stack, MD.)

The authors acknowledge the special contribution of Marc E. Levsky, MD, and Paul DeFlorio, MD, for portions of this chapter written for the previous editions of this book.


Clinical Summary

Neonatal conjunctivitis is acquired either during birth with passage through the mother’s cervix and vagina, or from cross-infection in the neonatal period. Presenting symptoms for Neisseria gonorrhoeae infection include a hyperacute bilateral conjunctivitis with copious purulent discharge, lid swelling, chemosis, and preauricular adenopathy.

More common etiologies include Chlamydia trachomatis, viruses (herpes simplex), and bacteria (Staphylococcus aureus, Streptococcal pneumoniae, Haemophilus species). For chlamydial conjunctivitis, the clinical features range from mild swelling with a watery discharge to marked lid swelling with a red and thickened conjunctiva with a blood-stained discharge. Fluorescein staining of herpes simplex conjunctivitis demonstrates epithelial dendrites.

Management and Disposition

With any form of neonatal conjunctivitis, Gram stain and culture are indicated. Scrapings of the palpebral conjunctiva are more likely to be rewarding than examination of the discharge itself. Begin treatment in the emergency department (ED) and admit newborns with suspected gonococcal conjunctivitis. Evaluate concurrently for C trachomatis, since coinfection is common.

Treatment for chlamydial conjunctivitis is based upon a positive diagnostic test. While culture is the gold standard, nucleic acid amplification tests, despite lacking FDA approval, are reported to perform similarly. Untreated disease can result in corneal and conjunctival scarring. Bacterial neonatal conjunctivitis that is neither gonococcal nor chlamydial may be treated with erythromycin antibiotic ointment and should be reevaluated in 24 hours.

Herpes simplex conjunctivitis is treated with intravenous (IV) acyclovir and topical trifluridine. Despite the appearance of a localized herpes infection, there is high risk for central nervous system (CNS) or disseminated infection.

Evaluation of the newborn’s parents should be undertaken in neonatal conjunctivitis due to Gonococcus, Chlamydia, or herpes simplex virus (HSV).


Neonatal Conjunctivitis (Ophthalmia Neonatorum). Copious purulent drainage in a newborn with neonatal gonococcal conjunctivitis. (Reprinted with permission of the American Academy of Ophthalmology. Eye Trauma and Emergencies: A Slide-Script Program. San Francisco, 1985.)


Neonatal Conjunctivitis. Thick purulent drainage in a newborn diagnosed with neonatal gonococcal conjunctivitis. (Photo contributor: David Effron, MD.)


Neonatal Conjunctivitis. A purulent discharge is seen in this newborn. Management includes excluding Neisseria and Chlamydia. (Photo contributor: Kevin J. Knoop, MD, MS.)

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