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British Columbia Reproductive Care Program

Newborn Guideline 11
EYE CARE AND PREVENTION OF OPHTHALMIA NEONATORUM

INTRODUCTION

Ophthalmia neonatorum presents as an inflammation of the conjunctiva in an infant younger than
30 days of age.1 Most ophthalmia infections in the neonatal period are acquired during vaginal
delivery and reflect the sexually transmitted diseases prevalent in the community.2 In 1881
Crede recommended eye prophylaxis with topical 1% silver nitrate for newborns to prevent
gonorrheal ophthalmia.3 Subsequently, this recommendation was widely practiced for almost a
century.
Although Chlamydia trachomatis is currently the most common organism causing ophthalmia
neonatorum in North America, complications from gonococcal ophthalmia are more severe,
appear more rapidly, and are more likely to cause blindness. The transmission rate for gonorrhea
from an infected mother to her newborn is 30-50%.4,5,6 Prenatal screening and treatment of
maternal sexually transmitted diseases and newborn eye prophylaxis has had a major effect on
the prevention of neonatal gonococcal ophthalmia. 7,8
In British Columbia today, the Health Act Communicable Disease Regulation requires that “a
physician, or other qualified person, assisting at the birth of a baby must within one hour of the
birth treat the eyes of the baby with a prophylactic solution of 1% tetracycline, 0.5%
erythromycin, or 1% silver nitrate dispensed in single use containers.” 9
CAUSES 10
• Chlamydial
• Neisseria gonorrhoeae (most important bacteria by its potential to damage vision)
RISK FACTORS11

• Premature rupture of membranes
• Documented or suspected sexually transmitted disease • Local eye injury during delivery Eye Care and Ophthalmia Neonatorum


EFFICACY OF PROPHYLACTIC AGENTS

Three prophylactic agents can be utilized in the newborn to prevent opthalmia neonatorum:
erythromycin, tetracycline, or silver nitrate. Several studies have looked at the efficacy of each
agent.12-16 Most studies have found that all three agents effectively prevent gonococcal
conjunctivitis, but results are conflicting as to whether the agents are effective in preventing
chlamydial disease. One of the studies found that the use of povidone-iodine as an eye
prophylactic was more effective in preventing infectious conjunctivitis (including cases caused
by chlamydia) than were the other three agents.17 More research on the use of povidone-iodine
is needed before conclusive evidence can be presented.

EYE PROPHYLAXIS ADMINISTRATION

1. Under the British Columbia Health Act Communicable Disease Regulation (1995), a
physician, midwife, or other qualified person assisting at the birth of a baby must within one hour of the birth treat the eyes of the baby with a prophylactic solution of 1% tetracycline hydrochloride, 0.5% erythromycin or 1% silver nitrate dispensed in single use containers.18,19,20 The Family-Centred Maternity and Newborn Care National Guidelines state that treatment may be delayed for up to 2 hours after birth to enable parent-infant contact and initial stabilization of the baby.21 Neither the guideline or the Act provide any reference for the time interval recommendation. Note that the Family-Centred Maternity and Newborn Care National Guidelines do not take precedence over the B.C. Health Act Communicable Disease Regulation, and in B.C. prophylactic treatment must be administered within one hour of birth. Policies should be developed which facilitate both bonding and compliance. 2. For those very premature babies whose lids are fused at the time of birth, apply the prophylactic agent without separating the eyelids. 3. When 1% tetracycline hydrochloride or 0.5% erythromycin is used, a line of ointment 1 to 2 cm long is placed in each lower conjunctival sac, if possible covering the whole lower conjunctival area. Care is needed to prevent injury to the eye or the eyelid from the tip of the tube. Gently massage the closed eyelids to help spread the solution to all areas of the conjunctiva.23 4. When 1% silver nitrate is used, two drops of solution are placed in each lower conjunctival sac, a single ampoule being used for each eye. Gently massage the closed eyelids to help spread the solution to all areas of the conjunctiva. Advise the parents that transient chemical conjunctivitis may occur.22 5. After 1 minute any excess ointment or drops should be gently wiped from the eyelids and surrounding skin with sterile cotton.24,25 6. The eyes should not be irrigated after instillation of a prophylactic agent.26,27,28 Eye Care and Ophthalmia Neonatorum

REFUSAL OF EYE PROPYLAXIS TREATMENT
The parents may refuse eye prophylaxis. Should both parents, or if the father is not
available, the mother refuse eye prophylaxis, a written statement declining the prophylaxis is
required29.

The physician, midwife or other qualified person, assisting at the birth must inform the
parents or mother, of the following before accepting a written statement:30
a) why the treatment is recommended, b) what advantages should be anticipated from the treatment, c) what problems may arise if the treatment is not given, and d) what side effects may arise from the treatment
REFERENCES

1. O’Hara, M. (1993). Ophthalmia neonatorum. Pediatric Clinics of North America, 40(4),
2. O’Hara, M. (1993). Ophthalmia neonatorum. Pediatric Clinics of North America, 40(4),
3. Whitcher, J. (1990). Neonatal ophthalmia: Have we advanced in the last 20 years? International Ophthalmology Clinics, 30(1), 39-41. 4. O’Hara, M. (1993). Ophthalmia neonatorum. Pediatric Clinics of North America, 40(4), 5. Hammerschlag, M. (1993). Neonatal conjunctivitis. Pediatric Annals, 22(6), 346-351. 6. Zanoni, D., Isenberg, S., & Apt, L. (1992). A comparison of silver nitrate with erythromycin for prophylaxis against ophthalmia neonatorum. Clinical Pediatrics, 31, 295-298. 7. O’Hara, M. (1993). Ophthalmia neonatorum. Pediatric Clinics of North America, 40(4), 8. Hammerschlag, M. (1993). Neonatal conjunctivitis. Pediatric Annals, 22(6), 346-351. 9. Government of British Columbia. (1995). Health Act Communicable Disease Regulation, B.C. Reg. 4/83, section 17. Victoria: Author. 10. Yetman, R. & Coody, D. (1997). Conjunctivitis: A practice guideline. Journal of Eye Care and Ophthalmia Neonatorum

11. Yetman, R. & Coody, D. (1997). Conjunctivitis: A practice guideline. Journal of 12. Zanoni, D., Isenberg, S., & Apt, L. (1992). A comparison of silver nitrate with erythromycin for prophylaxis against ophthalmia neonatorum. Clinical Pediatrics, 31, 295-298. 13. Hammerschlag, M., Cummings, C., Roblin, P., Williams, T., & Delke, I. (1989). Efficacy of neonatal ocular prophylaxis for the prevention of chlamydial and gonococcal conjunctivitis. The New England Journal of Medicine, 320,769-772. 14. Isenberg, S., Apt, L., & Wood, M. (1995). The controlled trial of povidone-iodine as prophylaxis against ophthalmia neonatorum. The New England Journal of Medicine, 332(9), 562-566. 15. Laga, M., Plummer, F., Piot, P., Data, P., Namaara, W., Ndinya-Achola, J., Nzanze, H., Maitha, G., Ronald, A., Pamba, H., & Brunham, R. (1988). Prophylaxis of gonococcal and chlamydial ophthalmia neonatorum. The New England Journal of Medicine, 318(11), 653 -657. 16. Bell, T., Grayston, T., Krohn, M., & Kronmal, R. (1993). Randomized trial of silver nitrate, erythromycin and no eye prophylaxis for the prevention of conjunctivitis among newborns not at risk for gonococcal ophthalmitis. Pediatrics, 92(6), 755-760. 17. Isenberg, S., Apt, L., & Wood, M. (1995). The controlled trial of povidone-iodine as prophylaxis against ophthalmia neonatorum. The New England Journal of Medicine, 332(9), 562-566. 18. Government of British Columbia. (1995). Health Act Communicable Disease Regulation, B.C. Reg. 4/83, section 17. Victoria: Author. 19. Canadian Paediatric Society. (1983). Recommendations for the prevention of neonatal ophthalmia. Canadian Medical Association Journal, 129, 554-555. 20. American Academy of Pediatrics & The American College of Obstetricinas and Gynecologists. (1997). Guidelines for Perinatal Care. (4th ed.). Illinois: Author. 21. Health Canada. 2000. Family-centred maternity and newborn care: National guidelines. 22. Canadian Paediatric Society. (1983). Recommendations for the prevention of neonatal ophthalmia. Canadian Medical Association Journal, 129, 554-555. 23. Canadian Paediatric Society. (1983). Recommendations for the prevention of neonatal ophthalmia. Canadian Medical Association Journal, 129, 554-555. Eye Care and Ophthalmia Neonatorum

24. Canadian Paediatric Society. (1983). Recommendations for the prevention of neonatal ophthalmia. Canadian Medical Association Journal, 129, 554-555. 25. American Academy of Pediatrics & The American College of Obstetricians and Gynecologists. (1997). Guidelines for Perinatal Care. (4th ed.). Illinois: Author. 26. Canadian Paediatric Society. (1983). Recommendations for the prevention of neonatal ophthalmia. Canadian Medical Association Journal, 129, 554-555. 27. Health Canada. 2000. Family-centred maternity and newborn care: National guidelines. 28. American Academy of Pediatrics & The American College of Obstetricians and Gynecologists. (1997). Guidelines for Perinatal Care. (4th ed.). Illinois: Author. 29. Government of British Columbia. (1995). Health Act Communicable Disease Regulation, B.C. Reg. 4/83, section 17. Victoria: Author. 30. Government of British Columbia. (1995). Health Act Communicable Disease Regulation, B.C. Reg. 4/83, section 17. Victoria: Author.

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