Ophthalmia neonatorum — structured clinical encounter

Candidate brief

You are the paediatric registrar on the postnatal ward. A three-day-old term boy has been referred with a 12-hour history of profuse, thick yellow-green discharge from the right eye that reaccumulates within minutes of cleaning, with marked bilateral lid oedema and chemosis and an intensely red eye. He was born by spontaneous vaginal delivery after an unbooked pregnancy with no documented antenatal sexually-transmitted-infection screening. On examination he is visibly jaundiced but afebrile and feeding. [12]

Task

Take the focused history, present your differential ranked by likelihood, justify your bedside and laboratory investigations, and outline your emergency management including the specific drug, dose and route. Be prepared to defend the drug-choice decision in this jaundiced infant, and to discuss the maternal and public-health response. A second infant — a ten-day-old with mucopurulent discharge and a staccato cough — will then be introduced for contrast. [1]

Discussion anchors

• Recognition and emergency: gonococcal ophthalmia neonatorum from the day 2 to 5 onset window, the profuse purulent discharge and lid oedema, and the risk of corneal ulceration and perforation within hours — admit, swab, irrigate and treat on suspicion. [1]
• Drug and dose: single-dose ceftriaxone 25 to 50 mg per kilogram (maximum 250 mg); switch to cefotaxime in the jaundiced or premature neonate or one on calcium-containing fluids, because of bilirubin displacement and calcium-ceftriaxone precipitation. [4] [11]
• Investigations: Gram stain and culture on chocolate and Thayer-Martin media, nucleic-acid-amplification for chlamydia and gonorrhoea, HSV PCR, fluorescein staining, and maternal and partner screening. [3]
• Contrast case: the ten-day-old with mucopurulent discharge and a staccato cough is chlamydial ophthalmia with evolving pneumonia — oral erythromycin 50 mg per kilogram per day for 14 days systemically, because topical therapy cannot prevent the pneumonia. [5] [6]
• Prophylaxis and HSV probe: birth prophylaxis prevents gonococcal but not chlamydial disease; a neonate with periocular vesicles and a dendritic ulcer needs intravenous aciclovir and evaluation for disseminated and central-nervous-system disease. [7] [3]