1. Eye abnormalities in the neonate

2. Ophthalmia Neonatorum
Definition: conjunctival inflammation in the first month of life
Chemical
Secondary to application of silver nitrate (90% infants), povidone-iodine solution, erythromycin 0.5%, or tetracycline 1%
We use Erythromycin
Bacterial
Chlamydia trachomatis, Neisseria gonorrhoeae, , Staphylococcus aureus, Streptococcus pneumoniae, Escherischia coli, and other gram negative bacteria
Viral
Herpes simplex virus

3. Prevention of bacterial ophthalmia
Prenatal treatment of mothers with culture positive chlamydia or gonorrhea
Application of one of the following within 1 hour of birth:
Silver nitrate
Preferred in areas where there is a high percentage of penicillinase-producing strains of N. gonorrhoeae
2.5% povidone-iodine solution
Not used here but is an inexpensive option for developing countries
Erythromycin 0.5% ointment or tetracycline 1% ointment
All of these drugs are equally effective in combating most bacterial eye infections including N. gonorrhoeae

5. Treatment
The drugs used to prevent neonatal ophthalmia can cause chemical conjunctivitis especially silver nitrate.
Conjunctival erythema, edema, drainage, and sometimes periorbital edema
Transient, resolving in 36 hours
Gentle wiping of the eyes with sterile cotton soaked with sterile saline or water can help

7. N. Gonorrhoeae presentation and treatment
Conjunctival erythema, purulent exudate, lid edema presenting at 1-4 days of birth; corneal clouding or perforation can occur
These babies can also get rhinitis, scalp infections, sepsis, arthritis, and meningitis
A gram stain and appropriate cultures (plating on Thayer-Martin agar) of the exudate should be obtained
If the gram stain is positive for gram negative diplococci, obtain BCx and CSF cx on baby and cervical cx on mom. The Red Book recommends testing the infant for chlamydia, syphilis, and HIV.
Start cefotaxime IV bid for seven days or ceftriaxone x 1 (if not jaundiced) for sole conjunctivitis, and for days for disseminated disease. Contact precautions for infant’s secretions for 24 hours after treatment started. Frequent saline irrigations of the eyes should be performed. Have OB treat mom and her partner(s).

8. Presentation and diagnosis of Chlamydia trachomatis
Most common cause of newborn infectious conjunctivitis
Usually shows up 5-14 days after birth with mild to severe conjunctival erythema, eyelid swelling, and purulent exudate
The conjunctiva can be scraped and Giemsa stained to reveal basophilic inclusion bodies, it is diagnostic but only 22-95% sensitive depending on who’s doing the test. More commonly you’ll get a direct fluorescent antibody (DFA), enzyme immunoassay (EIA), or DNA probe tests on the conjunctival secretions. If positive, test baby for HIV, GC, and syphilis.
Babies born to chlamydia-positive moms should not be treated unless they have chlamydia conjunctivitis despite the fact that 20-50% of these babies will develop it. Good follow-up must be ensured for these babies
Watch for signs of chlamydia pneumonia—crackles on exam, diffuse infiltrates on xray, eosinophilia, positive direct antigen test

9. Treatment of Chlamydia
Oral erythromycin base or erythromycin ethylsuccinate (50mg/kg/day divided qid) for 14 days
A second course may be necessary because efficacy is only 80%
There has been an association between oral erythromycin and the development of pyloric stenosis before 6 weeks of age, but further research is needed
Parents should be counseled of this risk and cases of pyloric stenosis in infants given erythomycin should be reported to MedWatch –the FDA Adverse Event Reporting System (

11. Herpes eye infections
Often transmitted during delivery from a mom actively infected with HSV or by direct contact with an infected individual
Starts as conjunctivitis with vesicles on and inflammation of the eyelid that will lead to inflammation and ulceration of the cornea aka dendritic keratitis in 50% of patients
Can be seen using a cobalt blue filter light over a penlight; prompt referral to an ophthalmologist is necessary

12. Chorioretinitis
The choroid is part of the uveal tract which is the inner vascular tract of the eye and is close to the retina
Chorioretinitis is inflammation of the choroid and retina that can lead to visual impairment, retinal detachment or glaucoma

14. Leukocoria the white eye
Glaucoma
It is congenital if it presents in the first three years of life
Defined as elevated pressure in the eye often secondary to a problem in the draining apparatus of the eye (the trabecular meshwork) that causes damage to the optic nerve
Presents with tearing, photophobia, and blepharospasm and often leukocoria; you may also notice a bulging eye
If you can exam the fundus, you may see cupping of the optic nerve
Can be associated with Sturge-Weber syndrome, Marfan syndrome, congenital rubella, secondary to retinopathy of prematurity, and many other syndromes

17. Leukocoria Cataracts Simply put, any opacification of the lens
Infectious causes
Toxoplasmosis, HSV,rubella, syphilis, CMV
Metabolic causes
Galactosemia (cataracts may be reversible with galactose-free diet)
May be seen in infants of diabetic mothers
Lowe syndrome (oculocerebral renal syndrome)
Often presents with bilateral cataracts at birth
Storage disorders
Chromosomal problems (Trisomies)
Drugs such as steroids
Treatment may be removal of the cataract with correction of vision; ophthalmology should be involved early in care

18. Cataract secondary to deposit of dulcitol in galactosemia: oil droplet appearance

21. Leukocoria keep checking for that red reflex
Retinoblastoma
Occasionally diagnosed at birth but more frequently between 1 and 2 years of life
Bilateral involvement accounts for 25-35% of cases and age of diagnosis is usually 12 mos; unilateral tumors are diagnosed on average at 21 mos of age
Most common presenting sign is leukocoria and the second most common sign is strabismus
Immediate referral to an ophthalmologist is necessary; often cured if confined to the eye

23. Esotropia and Exotropia
Congenital esotropia (inward deviation of the eye) occurs before 6 months of age and is more common than congenital exotropia (outward deviation of the eye
Test by using the corneal light reflex and cover-uncover test
Treated with patching or Botox and correction of visual acuity

26. Coloboma
Describes a defect such as a hole, notch, gap, etc. and can occur just about anywhere in the eye including the iris/pupillary margin, eyelid, lens, or fundus
Can be associated with Trisomy 13, 18, and 4p- syndromes as well as CHARGE (coloboma, heart, atresia choanae, retarded growth, gu anomalies, ear anomalies), Goldenhar syndrome, Rubinstein-Taybi and many others
Also associated with CMV and maternal use of thalidomide and LSD

27. Eyelid coloboma in Goldenhar syndrome

29. Horner’s syndrome
Characterized by enophthlamos, miosis, ptosis, and ipsilateral anhidrosis of the face
May be congenital which can be associated with vertebral anomalies, or present at birth (known as oculosympathetic paresis) secondary to birth trauma often in association with Klumpke brachial palsy or the result of a lesion in the brain stem, cervical spinal cord, or sympathetic plexus near the carotid artery
Horner syndrome presenting later in child’s life should prompt you to think of a tumor in the mediastinum or cervical area such as neuroblastoma
Recommend calling ophthlamology; they may instill a cocaine, phenylephrine, or hydroxyamphetamine solution in the eyes to discern oculosympathetic paresis.

30. Heterochromia Can be normal
Can be part of an autosomal dominat syndrome associated with a white forelock, sensorineural hearing loss, and lateral displacement of the lateral canthi
Also associated with trauma, inflammation, tumor, or Horner syndrome

31. Aniridia Minimal iris tissue present
Very rare presenting in 1 in 64,-96,000 births
High risk of cataracts and glaucoma
High risk of Wilms’ tumor
Need screening renal U/S q 3-6 mos until 5 years of age

32. Neonatal vision the miracle of sight
At 28 weeks, a baby will blink when a bright light is shone into the eyes
At 32 weeks, a baby will keep its eyes closed until the light is removed
At 37 weeks, a baby will turn its head and eyes towards a soft light
At term, a baby can fix and follow a brilliant target; their visual acuity is 20/150 to 20/400
One reference stated vision is 20/20 by 6 mos of age while another stated by 2-3 yrs of age