GRAND WARD ROUND

03/08/2022
PREMAALOSHINEE THANABAL
Baby Y , 10 days’ old boy , born via SVD ( 38 weeks and 2 days )
• presented with right eye lid swelling for 2/7 ( at day 8 of life)
• associated with yellowish purulent discharge for 1/7
• no eye redness/ bleeding
• no fever
• no vomiting
• feeding as usual
• no incosolable cry
• no history of ill contact
• no family members with similar symptoms
• History of presenting illness
• The baby was brought to klinik kesihatan on
22/7/22 , for jaundice check-up.
• He was noted to have two episodes of hypotermia
there, hence referred to:
• Paeds team to rule out sepsis
• Ophthal team for ophthalmia neonatorum
• ANC:
• Premature rupture of membrane <18 H
UFEME(13/7/2022) : Not suggestive of urinary tract infection
High vaginal swab (13/7/2022): No growth
• Resolved anemia in pregnancy

• Mother details:
1. booked pregnacy
2. denies multiple sexual partner
3. throughout pregnacy denies any foul smelling discharge ,
4. no STD/ hep and hep c : negative / hiv : negative
 OCULAR Examination 22/07/2022
RE LE
unable to assess visual acuity VA able to follow light
No RAPD
swollen , erythematous , yellowish Lid Not swollen, minimal yellowish
purulent discharge ++,no vesicle lesion, discharge, no vescle lesion,
Everted: minimal pseudomembrane Everted: no pseudomembrane
Round/reactive Pupil Round/reactive
White, no chemosis Conjunctiva White, no chemosis
Clear, no stain uptake Cornea Clear
formed, no obvious hypopyon AC Formed, no obvious hypopyon
Clear Lens Clear
OD Pink CDR 0.2, Macula normal, Retina Fundus OD Pink CDR 0.2, Macula normal, Retina
flat flat
Investigation Results
Ix Result
FBC WCC: 21.1 ( predominant
neutrophil )
Hb 13.1, Plt 376
LFT normal
RP Normal
Blood No growth
c&s(22/7/22)
Eye swab c&s No growth
(22/7/22)
DIAGNOSIS
1.Bilateral eye ophthalmia neonatorum
2. TRO sepsis ( baby of mother PPROM )
MANAGEMENT
• G. Vigamox 2 Hourly Right Eye
• G. Vigamox 4 Hourly Left Eye
• Bilateral Eye Lid hygiene TDS
• Eye Swab C& S
• Blood c&s
• Iv Cefotaxime 145mg bd( 50mg /kg / dose )
 OCULAR Examination 23/07/2022
RE LE
unable to assess visual acuity VA able to follow light
No RAPD
swollen , erythematous , yellowish Lid Not swollen, minimal yellowish
purulent discharge reducing,no vesicular discharge, no vesicular eye lid lesion
eye lid lesion, Everted: minimal Everted: no pseudomembrane
pseudomembrane
Round/reactive Pupil Round/reactive
White, no chemosis Conjunctiva White, no chemosis

Clear, no stain uptake Cornea Clear , no stain uptake

formed, no obvious hypopyon AC Formed, no obvious hypopyon
Clear Lens Clear
OD Pink CDR 0.2, Macula normal, Retina Fundus OD Pink CDR 0.2, Macula normal, Retina
flat flat
 OCULAR Examination 25/07/2022
RE
unable to assess visual acuity VA
No RAPD
lids normal , no swelling , no vesicular Lid
eye lid lesion, not erythematous,
minimal discharge , Everted : no psm
LE
unable to assess visual acuity
Not swollen, minimal yellowish
discharge, no vesicular eye lid lesion
Everted: no pseudomembrane

Round/reactive Pupil Round/reactive

White, no chemosis Conjunctiva White, no chemosis

Clear, no stain uptake Cornea Clear

formed, no obvious hypopyon AC Formed, no obvious hypopyon
Clear Lens Clear
OD Pink CDR 0.2, Macula normal, Fundus OD Pink CDR 0.2, Macula normal,
Retina flat Retina flat
 OCULAR Examination 27/07/2022
RE LE
unable to assess visual acuity VA unable to assess visual acuity
No RAPD
lids normal , no more discharge , Lid normal
everted : no psm

Round/reactive Pupil Round/reactive

White, no chemosis Conjunctiva White, no chemosis

Clear, no stain uptake Cornea Clear

formed, no obvious hypopyon AC Formed, no obvious hypopyon
Clear Lens Clear
OD Pink CDR 0.2, Macula normal, Fundus OD Pink CDR 0.2, Macula normal,
Retina flat Retina flat
Throughtout the stay in NHDU, patient had no documented
temperature ,clinically improving and patient eye swelling and
discharge improved.
swab c&S(22/7/22): no growth
blood c&s( 22/7/22) : no growth
completed iv cefotaxime for 5 days
reduce g. vigamox bd bilateral eye
tca opthal clinic in one week
Discussion
Ophthalmia Neonatorum
• Ophthalmia neonatorum (ON), or neonatal conjunctivitis, is
defined as an acute, mucopurulent conjunctivitis occurring in
the first 4 weeks of life.

• Ophthalmia neonatorum --> occurring in 1% to 12% of

neonates.

• commonly gets transmitted during vaginal delivery, and it

correlates with severe complications
Characteristic

-eye discharge watery , mucopurulent in one or both eye

-swollen eyelids
-conjuctiva shows hyperemia or chemosis
DIAGNOSIS
• TIMING OF ONSET
-CHEMICAL IRRITATION : FIRST FEW DAYS
-GONOCOCCAL : FIRST WEEK
-STAPHYLOCOCCI AND OTHER BACTERIA : END OF THE FIRST WWEEK
- HSV : 1- 2 WEEKS
CHLAMYDIA: 1-3 WEEKS
 prophylatic
HISTORY medication

parental
ill contact of
symptoms of
conjuctivitis
sti

uncanalized
systemic illness
nasolacrimal
of child
duct
Predisposing Factor
• organism in vagina shed during delivery
• premature rupture of membrane
• long delivery
• low level igA
• trauma to epithelial barrier
• prophylaxis for gonorrohea ( antibiotic , silver nitrate )
----->( Silver nitrate effectively prevents gonococcal ophthalmia
neonatorum) high risk of developing chemical conjunctivitis
 euro

Ophthalmia neonatorum in a tertiary referral children’s hospital: A retrospective study

February 2021European Journal of Ophthalmology
national antimicrobial guideline 2019
 Gonococcal Conjunctivitis
• GC is also known as gonococcal ophthalmia neonatorum and is most
likely due to maternal transmission during birth
• associated with sexually transmitted infections (STIs)
• can lead to menigitis / blindness
• GC is due to ophthalmic infection with Neisseria gonorrhoeae, which
is a gram-negative diplococcus.
• GC often occurs during delivery and exposure to infectious vaginal
secretions.
• N. gonorrhoeae --> penetrate the epithelial cells of mucosal surfaces
such as the conjunctiva.
• bacteria can proliferate and induce pro-inflammatory mechanisms.
• N. gonorrhoeae ---> evading and even modulating immune responses,
which can potentially lead to disseminated infection, for example,
bacteremia or meningitis.
THANK YOU