Ophthalmia neonatorum — branching viva

Opening — the three-day-old with a profuse purulent eye

Examiner: A three-day-old term infant is referred from the postnatal ward with profuse thick yellow-green discharge from the right eye and marked bilateral lid oedema. He was born vaginally to a mother with no documented sexually-transmitted-infection screening. Talk me through your immediate thoughts and actions. [12]

Candidate should cover: the diagnosis of gonococcal ophthalmia neonatorum based on the day 2 to 5 onset window, the profuse purulent discharge and lid oedema; recognition that it is sight-threatening because Neisseria gonorrhoeae can ulcerate and perforate the cornea within hours; and immediate management — admit, swab, begin frequent saline irrigation and give single-dose ceftriaxone before culture returns. [1]

Branch 1 — drug choice and the jaundiced neonate

Examiner: Your intern asks whether you should wait for the Gram stain. He is also visibly jaundiced. How do these two facts change your plan? [11]

Candidate should cover: never waiting for culture in suspected gonococcal ophthalmia — treat on suspicion; the standard single dose of ceftriaxone 25 to 50 mg per kilogram (maximum 250 mg); the switch to cefotaxime in the jaundiced, premature neonate or one on calcium-containing fluids, because ceftriaxone displaces bilirubin and forms calcium-ceftriaxone precipitates; and urgent ophthalmology review. [1] [4]

Branch 2 — the ten-day-old with a staccato cough

Examiner: Now a different infant: a ten-day-old with bilateral mucopurulent discharge for four days and a repetitive staccato cough, afebrile and feeding. What changed, and what will you do? [6]

Candidate should cover: the day 5 to 14 onset window and mucopurulent discharge pointing to chlamydial ophthalmia; the staccato cough signalling evolving afebrile chlamydial pneumonia; definitive treatment with oral erythromycin 50 mg per kilogram per day for 14 days systemically; and the rationale that topical therapy clears the eye but cannot eradicate nasopharyngeal carriage or prevent the pneumonia. [5] [6]

Branch 3 — vesicles, prophylaxis and the public-health response

Examiner: Finally, a neonate with periocular vesicles and a watery eye. What must you exclude at the slit lamp, and how do you manage it? And having seen these cases, what are the two durable public-health interventions? [7]

Candidate should cover: HSV keratoconjunctivitis with a dendritic ulcer on fluorescein — never give topical steroid until excluded; intravenous aciclovir with topical antiviral and evaluation for central-nervous-system and disseminated disease; and the two durable interventions — ocular prophylaxis at birth (erythromycin or tetracycline ointment, or 2.5% povidone-iodine) preventing gonococcal but not chlamydial disease, and screening and treating the mother and her partner. [3] [9]