Ophthalmia Neonatorum: A Review

Surina Mittal

Introduction

“Pink eye” is a common ophthalmic presentation across patients of all age groups, however, can indicate a serious infection in neonates. Ophthalmia neonatorum (ON) is a conjunctivitis which presents within the first 28 days of life (1). ON typically manifests in the neonate due to the incidence of a maternal sexually transmitted infection (STI) (2). Early recognition and treatment of ON is essential, as the infection can lead to blindness in the affected neonate (1,2).

UK national guidelines emphasise the importance of distinguishing ON from benign neonatal conjunctivitis (3); infection with Neisseria gonorrhoeae can destroy the neonatal cornea within 24 hours if left untreated (1). Other causes of ON, such as Chlamydia trachomatis and Herpes Simplex Virus (HSV), carry a risk of disseminated disease and progression to neonatal sepsis (1). Therefore, confidently recognising ON is often both sight-saving and lifesaving for the affected newborn child.

Epidemiology

There is a significant range in the incidence of ON across the globe, ranging from an incidence of 1.36% in high-income countries, to around 6.90% in those of lower income (4). Such discrepancies in ON incidence can be attributed to a number of factors, including differences in antenatal STI screening, varying methods of childbirth delivery, and differing neonatal care practices (5).

Since the introduction of routine maternal STI screening and decreasing general incidence of STIs, there has been a significant reduction in the overall incidence of ON (2). Despite an overall reduction in incidence, isolated cases of ON continue to arise, particularly among mothers of a younger maternal age or with a limited access to antenatal services, or simply due to untreated STIs (4).

Globally, the leading cause of ON is Chlamydia trachomatis, which is responsible for up to 40% of cases (6). Neisseria gonorrhoeae, though less common, causes a much more severe and rapidly destructive presentation of ON (6). Similarly, ON due to HSV infection is a rare but highly morbid and life-threatening condition, with an up to 50% risk of fatality from disseminated disease in patients treated with antiviral therapy (6).

Pathophysiology

Ophthalmia neonatorum arises primarily during childbirth from the transmission of pathogens through the infected birth canal (7). Non-infectious causes of ON, such as chemical irritation from prophylactic agents such as silver nitrate, are now much less common due to changes in clinical practice (8).

Clinical Features and Management

The different causative organisms of ON can result in a range of clinical presentations, with the timing of symptom onset being a key factor in establishing the responsible organism.

Though symptoms and signs can overlap, different causative organisms usually give rise to distinct clinical presentations, requiring specific treatment therapies (Table 1).

Age of symptom onsetLikely causative organismClinical presentationManagementOcular ComplicationsSystemic Complications
0 – 1 daysChemical irritation (6)Mild, clear discharge, mild redness (6)Supportive care and topical lubricants (9)Minimal, transient ocular surface redness and excess tear production (9)None
2 – 5 daysNeisseria gonorrhoeae (6)Excessive purulent discharge and chemosis +/- corneal involvement (6)Emergency hospital admission for stat IV cefotaxime 100mg/kg, or 7-14 days IV cefotaxime 50mg/kg TDS if disseminated disease; Saline irrigation to clear discharge (9)Corneal ulceration and perforation; Endophthalmitis; Conjunctival scarring; Blindness (9)Disseminated infection; Sepsis; Meningitis; Arthritis
5 – 14 daysChlamydia trachomatis (6)Mucopurulent discharge and mild eyelid oedema (6)Urgent oral antibiotics (typically erythromycin); Hospital admission if suspicion of chlamydial pneumonitisChronic symptoms; Corneal scarring (9)Chlamydial pneumonitis; Otitis media; Rhinitis (9)
5 – 14 daysHerpes simplex virus (HSV) (6)Watery discharge, vesicular eyelid lesions (6)Emergency hospital admission for IV acyclovir 20mg/kg TDS for 14 days, or 21 days if disseminated disease (10)Keratitis; Scarring; Blepharoconjunctivitis; Corneal blindness (11)Encephalitis; Hepatitis; Pneumonitis; Multiple-organ failure (11)
3 – 7 daysOther bacteria (e.g. Staphylococcus aureus, Streptococcus pneumoniae, Haemophilus influenzae) (6)Variable purulent discharge, milder clinical presentation (6)Topical chloramphenicol eye drops or ointment (9)Mild bacterial conjunctivitis (9)None
Table 1: Causative organisms of ophthalmia neonatorum, their signs, symptoms and management. (Table 1).

All cases of suspected ophthalmia neonatorum should be referred urgently to the ophthalmology team (12). However, it is important to note red flag features which indicate a more serious or emergent referral. Red flag features include (12):

  • Rapidly worsening lid oedema or chemosis
  • Profuse purulent discharge
  • Corneal haze, ulceration, or perforation
  • Periocular vesicles (suggesting HSV)
  • Systemic signs of sepsis (fever, poor feeding, lethargy)

Investigations

If red flag symptoms or signs are present in the neonate, treatment should be initiated immediately and must not be delayed by investigations.

Relevant investigations for ON include (3,6,9):

  • Bilateral conjunctival swabs to be sent for microscopy, culture and sensitivity testing (MC&S)
  • Nucleic acid amplication test (NAAT) for Neisseria gonorrhoeae and Chlamydia trachomatis
  • HSV PCR for suspicious conjunctival lesions or vesicular eyelid lesions
  • Full septic screen if any concern of systemic infection
  • X-ray imaging of chest if any suspicion of chlamydial pneumonitis

Prevention

The mainstay of ON prevention involves effective maternal STI screening, treatment and education, given the pathophysiology of disease development (2). In the UK, ocular prophylaxis for all neonates is no longer routine practice, and has instead been replaced by antenatal testing for gonorrhoea and chlamydia. Early treatment of maternal STIs prior to childbirth reduces the prevalence of ON. However, in many lower and middle-income countries, topical prophylactic agents continue to be used as per recommendations from the World Health Organisation (2,8,13). Prophylactic agents include topical erythromycin, tetracycline or povidone-iodine, and are typically used due to the absence of routine maternal STI testing in certain regions (13).

Cases of ON should trigger both maternal and paternal testing, due to the likely presence of STIs (10). Effectively managing infection is not only vital for essential treatment of the affected individuals but also will reduce the chance of ON in any future children due to untreated infection.

Conclusion

Ophthalmia neonatorum is a serious neonatal infection which demands rapid recognition and coordinated management in order to prevent complications which may result in sight loss, or even fatality. Though incidence has decreased in the UK with the implementation of routine antenatal testing, ON remains a global concern and continues to put many neonates worldwide at risk.

Early empirical treatment, urgent referral to ophthalmology, appropriate investigative testing, and simultaneous management of maternal and paternal infection are vital to reducing ON disease burden.

References

  1. Matejcek A, Goldman RD. Treatment and prevention of ophthalmia neonatorum. Canadian Family Physician (Internet). 2013 Nov;59(11):1187. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC3828094/
  2. ‌Moore DL, MacDonald NE. Preventing Ophthalmia Neonatorum. Canadian Journal of Infectious Diseases and Medical Microbiology (Internet). 2015;26(3):122–5. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4507834/
  3. Ashby J, Browne R, Dwyer E, Fifer H, Forsyth S, Hamlyn E, et al. BASHH National Guideline on the Management of Sexually Transmitted Infections and Related Conditions in Children and Young People (2021) (Internet). 2021. Available from: https://www.bashh.org/_userfiles/pages/files/resources/children_and_yp_2021.pdf
  4. ‌Asiamah R, Owusu G, Amoako PT, Amponsah R, Adator E, Kyei S. Epidemiology of ophthalmia neonatorum: a systematic review and meta-analysis. BMC pediatrics (Internet). 2025 Summer;25(1):31. Available from: https://pubmed.ncbi.nlm.nih.gov/39810179/
  5. Naik, N. Clinical Spectrum and Outcomes of Ophthalmia Neonatorum: A Prospective Observational Study. European Journal of Cardiovascular Medicine (Internet). 2025 Sep;15:11–7. Available from: https://healthcare-bulletin.co.uk/article/clinical-spectrum-and-outcomes-of-ophthalmia-neonatorum-a-prospective-observational-study-4122/
  6. Castro Ochoa KJ, Mendez MD. Ophthalmia Neonatorum (Internet). PubMed. Treasure Island (FL): StatPearls Publishing; 2021. Available from: https://www.ncbi.nlm.nih.gov/books/NBK551572/
  7. Vielmetti L, Hibbs S, Yoon H. Neonatal Visual Impairment: Etiologies, Screening, and Management. NeoReviews. 2025 Jun 1;26(6):e391–401.
  8. Moore DL, MacDonald NE. Preventing Ophthalmia Neonatorum. Canadian Journal of Infectious Diseases and Medical Microbiology (Internet). 2015;26(3):122–5. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4507834/
  9. Eye infections in the neonate: Ophthalmia Neonatorum and the management of systemic Gonococcal and Chlamydial infections | NHSGGC (Internet). Scot.nhs.uk. 2023. Available from: https://clinicalguidelines.scot.nhs.uk/ggc-paediatric-guidelines/ggc-paediatric-guidelines/neonatology/eye-infections-in-the-neonate-ophthalmia-neonatorum-and-the-management-of-systemic-gonococcal-and-chlamydial-infections/
  10. Maqsood N, Mahmood U. Herpes simplex ophthalmia neonatorum: a sight-threatening diagnosis. British Journal of General Practice. 2020 Oct;70(699):513–4. Available from: https://doi.org/10.3399/bjgp20X712973
  11. Fernandes ND, Arya K, Ward R. Congenital Herpes Simplex (Internet). PubMed. Treasure Island (FL): StatPearls Publishing; 2021. Available from: https://www.ncbi.nlm.nih.gov/books/NBK507897/
  12. Conjunctivitis – infective (Internet). NICE. Available from: https://cks.nice.org.uk/topics/conjunctivitis-infective/management/who-should-i-refer-to-ophthalmology/
  13. Kapoor VS, Evans JR, Vedula SS. Interventions for preventing ophthalmia neonatorum. Cochrane Database of Systematic Reviews. 2020 Sep 21. Available from: https://doi.org/10.1002/14651858.CD001862.pub4

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