Neonatal Eye Care

  • Posted by Dr. Jay Gordon

<span “>Many of my patients refuse neonatal eye care.  They do this after having read information on their own and discussing the issue at length with me during a prenatal visit in my office.

<span “>This is a controversial issue and the vast majority of doctors and experts recommend giving the treatment shortly after birth.  Nonetheless, there is research to suggest that this routine may not be necessary.

<span “>Obviously, this represents a minority point of view both in the hospital and in the pediatric community in general.

<span “>I have added my own emphasis to these articles.

<span “>Pediatrics 1993 Dec;92(6):755-60
Randomized trial of silver nitrate, erythromycin, and no eye prophylaxis for the prevention of conjunctivitis among newborns not at risk for gonococcal ophthalmitis. Eye Prophylaxis Study Group.
Bell TA, Grayston JT, Krohn MA, Kronmal RA

Department of Biostatistics, University of Washington, Seattle 98195.
OBJECTIVE. To compare the efficacy of commonly used forms of eye prophylaxis for newborns with no prophylaxis in the prevention of nongonococcal conjunctivitis. DESIGN. Randomized doubly masked clinical trial. SETTING. University of Washington Hospital and affiliated clinics, Seattle, between 1985 and 1990. SUBJECTS. The medical records of 8499 women were evaluated for possible participation; 2577 were eligible. Of the 758 enrolled, the infants of 630 were evaluable. INTERVENTION. Comparison of silver nitrate, erythromycin, and no eye prophylaxis given at birth for the prevention of conjunctivitis. MAIN OUTCOME MEASURES. Conjunctivitis during the first 60 days of life and nasolacrimal duct patency in the first 2 days of life. RESULTS. The frequency of impatent tear ducts at the 30- to 48-hour examination did not differ significantly by prophylaxis group. Among the 630 infants randomized and observed, 109 (17%) developed mild conjunctivitis. Sixty-nine (63%) of the cases appeared during the first 2 weeks of life. After 2 months of observation, infants allocated to silver nitrate eye prophylaxis at birth had a 39% lower rate of conjunctivitis (hazard ratio = 0.61, 95% confidence interval = 0.39 to 0.97), and those allocated to erythromycin had a 31% lower rate of conjunctivitis (hazard ratio = 0.69, 95% confidence interval = 0.44 to 1.07), than did those allocated to no prophylaxis. CONCLUSION. Silver nitrate eye prophylaxis caused no sustained deleterious effects and even provided some benefit to infants born to women without Neisseria gonorrhoeae. However, the effect was modest and against microorganisms of low virulence. The results suggest that parentalchoice of a prophylaxis agent including no prophylaxis is reasonable for women receiving prenatal care and who are screened for sexually transmitted diseases during pregnancy.

<span “>Pediatr Infect Dis J 1992 Dec;11(12):1026-30

<span “>Prophylaxis of ophthalmia neonatorum: comparison of silver nitrate, tetracycline, erythromycin and no prophylaxis.
Chen JY

Department of Pediatrics, Chung Shan Medical and Dental College Hospital, Taichung, Taiwan, Republic of China.
From November, 1989, to October, 1991, 4544 neonates were born at our hospital. Neonatal ocular prophylaxis immediately after birth was used with 1% tetracycline ophthalmic ointment in 1156 neonates, 0.5% erythromycin ophthalmic ointment in 1163 neonates and 1% silver nitrate drops in 1082 neonates. No prophylaxis for neonatal conjunctivitis was given to 1143 neonates. A total of 302 infants (6.7%) developed conjunctivitis during the first 4 weeks of life. Between December, 1991, and January, 1992, 425 neonates were born at our hospital and all were given 0.5% erythromycin ophthalmic ointment twice in the first 24 hours after birth for ocular prophylaxis. Thirty-one (7.3%) infants developed conjunctivitis during the neonatal period. The incidence rates of neonatal chlamydial conjunctivitis in the tetracycline, erythromycin, silver nitrate, no prophylaxis and erythromycin twice groups were 1.3, 1.5, 1.7, 1.6 and 1.4%, respectively. We conclude that neonatal ocular prophylaxis with erythromycin (one or two doses) or tetracycline or silver nitrate does not significantly reduce the incidence of neonatal chlamydial conjunctivitis compared with that in those given no prophylaxis.

<span “>5Am J Epidemiol 1993 Sep 1;138(5):326-32   
The bacterial etiology of conjunctivitis in early infancy. Eye Prophylaxis Study Group.
Krohn MA, Hillier SL, Bell TA, Kronmal RA, Grayston JT

Department of Epidemiology, School of Public Health and Community Medicine, University of Washington, Seattle.
The authors conducted this study to determine the etiologic agents of conjunctivitis in early infancy. From 1985 to 1990, 630 infants enrolled in a randomized, controlled, double-masked study of eye prophylaxis were observed for 60 days after delivery for signs of conjunctivitis. The following isolates were categorized as pathogens: Haemophilus influenzae, Streptococcus pneumoniae, Neisseria cinerea, Klebsiella pneumoniae, and Chlamydia trachomatis. Using conditional logistic regression for analysis of 97 infant pairs, the authors identified isolates categorized as pathogens almost exclusively among cases (odds ratio (OR) = 18.0, 95% confidence interval (CI) 2.3-128). Among the microorganisms which have not usually been regarded as pathogens in the etiology of infant conjunctivitis, Streptococcus mitis was the only microorganism associated with an increased risk of conjunctivitis (OR = 5.3, 95% CI 1.8-15.0).The findings concerning the species of bacteria most often associated with conjunctivitis, as well as the finding that method of delivery is unimportant, suggest that bacteria were transmitted to the infants’ eyes after birth and not from the birth canal.

<span “>14Pediatr Infect Dis J 1989 Aug;8(8):491-5
Failure of erythromycin ointment for postnatal ocular prophylaxis of chlamydial conjunctivitis.
Black-Payne C, Bocchini JA Jr, Cedotal C

Department of Pediatrics, Louisiana State University School of Medicine, Shreveport 71130.
Chlamydia trachomatis is the most common pathogen associated with conjunctivitis during early infancy in the United States. During a 13-month interval at our medical center 4834 infants were born, 311 of whom (6.4%) had conjunctival specimens tested for chlamydial antigen before the age of 12 weeks. In 44 (14% of all tested infants, 0.9% of live births) chlamydial antigen was present. Because the rate of asymptomatic maternal chlamydial endocervical colonization is estimated to be 26% at our institution (previous prospective study), we calculated a minimal failure rate for erythromycin ocular prophylaxis of from 7 to 19.5%. A subsequent case-control study revealed that mothers of infants with chlamydial conjunctivitis were more likely to be primiparous (P = 0.03) and experience longer duration of rupture of membranes before delivery (P = 0.046). We conclude that a substantial percentage of infants exposed to Chlamydia develop chlamydial conjunctivitis despite receiving erythromycin ocular prophylaxis.