Opthalmia neonatorum

Sep 4, 2016,

OPHTHALMIA NEONATORUM

Abstract

Ophthalmia neoatorum, because of it’s high association with serious systemic disease is still an important public health issue worldwide. 

As of April 2010,neonatal conjunctivitis is no longer a notifiable disease [1] ,but the incidence of neonatal conjunctivitis still remains high in African .

This review aims to buttress the economic important of ophthalmia neonatorum & the relevance of prevention in limiting blindness and other Complications. 

INTRODUCTION:

Ophthalamia neonatorum[ON]; or acute conjunctivitis of the newborn presents as inflammation of the conjunctiva in an infant within the first 30 days of life. [12]

▷ It is the most common eye infection occurring in the first 28 days of life [1].

▷ It is characterized by purulent eye discharge, redness of conjunctiva, swelling of eyelids and corneal involvement with potential to cause blindness if left untreated.[1]

▷ The baby’s eye are contaminated during passage through the birth canal from a mother infected with Nesseria gonorrhoea or Chlamydia trachomatis.

EPIDEMIOLOGY:

▷ In the absence of preventive measures it is estimated that gonococcal ophthalmia neonatorum will develop in approximately 28% of infants born to women with gonorrhea. [2].

▷ Neonatal conjunctivitis is usually transmitted to the newborn by passage through the mother’s infected cervix at the time of delivery and reflects the sexually transmitted disease prevalent in the community. It may be spread, however, by people handling the baby soon after birth. [5].

▷ The incidence of infectious neonatal conjunctivitis ranges from 1-2%, in the US depending on the socioeconomic character of the area. [11]. 

▷ The epidemiology of neonatal conjunctivitis changed when silver nitrate solution was introduced in the 1800’s to prevent gonococal opthalmia.[11].

▷ As in the United States, the incidence of ophthalmia neonatorum in many other countries decreased after silver nitrate solution came into use. In Europe, the incidence fell from 10% to less than 1%. [11].

▷ Higher incidence of neonatal conjunctivitis still found in certain regions of the world, particularly in developing countries. [12].

▷ Incidence of neonatal conjunctivitis remains high in Africa. [12].

AETIOLOGY [1,3,6,7,8,9,10]

The aetiology of acute conjunctivitis of the newborn can be:

(1) Infectious (2) Non infectious or chemical.

Infectious causes include: (a) Bacterial (b) Viral

Bacterial causes

1. Chlamydia trachomatis

2. Neisseria gonorrhea

3. Staphylococcus aureus

4. Escherichia coli

5. Websiella specie

6. Pseudomas aeruginosa

7. Haemophilus influenza

8. Streptococccus pneumonia

9. Enterobacter species

10. Staphylococus epidermitis

11. Proteus

                             Viral causes

1. Herpes virus

2. Human immunodeficiency virus (Hiv)

                        Non-infectious/chemical causes

                                        Induced by agents used for prophylaxis.[6]

E.g silver nitrate solution.

                     Risk/ Predisposing factors [3,5,6,7]

1. Premature rupture of membranes

2. Maternal vaginitis

3. Prolonged labour

4. Local eye trauma during birth

5. Untrained birth attendant interference

6. Gestation less than 36 weeks [prematurity]

7. Low levels of lysozymes and immunoglobin in neonatal conjunctiva

8. Poor hygienic delivery conditions

              Pathophysiology

▷ Inflammation of conjunctiva causing erythema due to blood vessel dilatation, tearing and drainage.[12].

▷ This reaction tends to be more serious due to reduced tear secretion, decreased immune function, decreased lysozyme activity and relative absence of lymphoid tissue of the conjunctiva [12]

▷ Neonatal tears also lack immunoglobin A.

Clinical features: [6,12,13,15,17]

        Symptoms; usually bilateral

1. Redness of the eye

2. Eye discharge (may be profuse in gonococcal infection)

3. Swelling of lids

                    Signs

1. Lid oedema

2. Conjuctiva oedema[chemoris]

3. Mucopurulent eye discharge

4. Perforation of cornea/ulceration

     Investigation:

1. Conjuctival swabs for Herpes simplex and for Chlamydia[1] *Chlamydia is an obligate IC organism so it is important to sample conjuctival cells with any swabs.[2]

2. Take a sample of pus for culture and sensitivity.

3. Do a conjuctival scrape for urgent gram stain, culture and sensitivity: looking particularly for gram negative diplococcic i.e N. gonorrhea

4. Culture for HSV if vesicles present or is suspicious of viral aetiology including evidence of perinatal maternal exposure. [12]

NOTE; Conjuctival specimens for Chlamydia testing must include conjuctival epithelial cells because Chlamydia trachomatis is an obligate IC organism and exudates are not adequate for testing.

DIAGNOSIS

  Ophthalmia neonatorum can be diagnosed clinically by the presence of most common symptoms. Those symptoms are redness and swelling of the lining of the eyelid and a watery discharge from the eyes that may include pus or blood.[18].

▷ Diagnosis can be confirmed by conducting laboratory test carried out on the discharge to identify the specific infectious agent implicated.

▷ Prompt diagnosis is key n establishing proper treatment and minimizing potential serious complications of neonatorum ophthalmia.

Differential diagnosis

1. Congenital obstruction of the nasolacrimal duct occurs in 6% of nonates and is usually associated with edema of the inner canthus and matting of the eyelids.[5]. It is often associated with epiphora, discharge and recurrent conjunctivitis.[6].

2. Birth trauma.

3. Dacryocystitis: infection of the lacrimal sac with erythema and swelling of the inner canthus and nasal conjuctival injection. Purulent drainage can often be expressed from the punctum.[5].

4. Congenital glaucoma; accompanying early signs are tearing, photophobia, blepharospasm and fussiness. Later signs include cornel edema and corneal enlargement. Intraoccular kpa is elevated.[5].

5. Foreign body / corneal abrasion.

6. Preseptal / orbital cellulitis.

7. Keratitis: bacterial,fungal,herpes simplex.

      MANAGEMENT

▷ Specific treatment is available for the various causes of neonatal conjunctivitis.

▷ Preliminary presumptive treatment pending culture confirmation should be based on the clinical picture and the findings on Gram, Giemsa and papanioalaou stains [11]. This include topical erythromycin ointment and intravenous or intramuscular 3rd gen. cephalosporin. [11].

▷ Prompt treatment of gonococccal conjunctivitis is important since this organism can penetrate an intact corneal epithelium and rapidly cause corneal ulceration, because of the rapid progression of gonococcal conjunctivitis, patients with acute neonatal conjunctivitis should be treated for gonococcal conjunctivitis until culture results are available, then the treatment is altered according to laboratory results.[11].

Chemical conjunctivitis [12]

▷ No treatment required; supportive care only (may use artificial tears q.i.d.)

▷ Typically disappears spontaneously within 2-4 days.

Chlamydial conjunctivitis [11]

▷ In cases of chlamydial conjunctivitis, systemic treatment is necessary because of significant risk for life threatening pneumonia. [11]. 

▷ This infection is treated with oral erythromycin (50mg/kg/day divided q.i.d.) for 14 days.

▷ Topical erythromycin ointment is beneficial as an adjunctive therapy.

Gonococcal conjunctivitis. [11] 

▷ Topical irrigation with normal saline to remove mucopurulent discharge.

▷ Intravenous aqueous penicillin G 100000 units/kg/day in four divided doses or penicillin G benzathine 50000 units/kg/day or ceftriaxone 50mg/kg intramuscular as single dose for 7 days.

▷ Bacitracin or erythromycin ointment every 24 hours.

▷ Hospitalization and valuation for disseminated N. gonorrhea infection.

▷ Topical saline drops to remove discharge.

▷ Topical atropine if corneal involvement.

▷ All neonates with gonococcal conjunctivtis should also be treated for Chlamydia. Mother and sexual partner should be treated as well.

HSV keratoconjuctivitis. [11,12]

▷ Neonates with a suspected herpetic simplex infection should be treated with systemic acyclovir to reduce the chance of a systemic infection.

▷ An effective dose is 60mg/kg/day intravenous divided t.i.d. for a minimum of 14 days, but a course as long as 21 days may be required.

▷ Vidarabine 3% ointment 5×1 day for 14-21 days can be added depending on the presence or absence of CNS involvement.

Other bacteria:

Gram (+) – Bacitracin ointment q.i.d. for 2weks

Gram (-) – Gentamycin, tobramycin or ciprofloxacin q.i.d. for 2 weeks.

Prevention

▷ Prevention through good prenatal care and treatment of chlamydial, gonococcal or herpetic infections during pregnancy remains the best preventive method.[12]

▷ Four prophylactic agents can be utilized in the newborn to prevent ophthalmia neonatorum:

1. 0.1% silver nitrate

2. 0.5% erythromycin

3. 1% tetracycline hydrochloride

4. 2.5% povidine-iodine

  TOPICAL PROPHYLAXIS

▷ According to the 2012 Red book, topical 0.5% erythromycin and 1% tetracycline are considered equally effective for prophylaxis of ocular gonorrhea infection in newborn infants [11].

▷ Topical silver nitrate, povidone-iodine, and erythromycin are all effective in the prevention of non-gonococcal non- Chlamydia neonatal conjunctivitis. [11]

▷ There is no agent that is currently effective in preventing the transmission of Chlamydia trachomatis from mother to baby.[11].

▷ 2.5% povidone iodine solution may also be useful in preventing neonatal ophthalmia and currently used in Europe although not currently approved in US. [12].

▷ Silver nitrate appears to be the best agent in areas where the incidence of penicillinase- producing N. gonorrhea is significant. [12].

▷ Neomycin and chloraphenicol are additional topical prophylactic options. [12].

        SYSTEMIC PROPHYLAXIS  

Infants with possible infection exposure in utero or during birth process should receive prophylaxis following birth in attempt to prevent ocular and systemic complications. [12]

 Other preventive measures include hand washing, techniques by peripartum and nursery staff.

 

 COMPLICATONS [5, 11, 13,14,15]

A. Occular complications

B. Systemic complications

Occular complications [5, 14]

1. Blindness

2. Corneal scarring

3. Corneal prforation

4. Inflammation of the iris

5. Symblepharon

6. Endophthalmtis

7. Corneal opacification

8. Staphyloma

9. Pseudo

Systemic complications [5, 11, 13]

1. Pneumonia

2. Meningitis

3. Otitis

4. Arthritis

5. Sepsis

Differential diagnosis 

1. Congenital nasolacrimal duct obstruction

2. Dacrocystitis

3. Congenital glaucoma

4. Preseptal/orbital cellulitis

5. Infectious keratitis

 

PROGNOSIS

Prognosis of neonatal conjunctivitis is good as long as there is early diagnosis and prompt adequate medical treatment.

- Mortality associated with ophthalmia neonatorum is due to systemic involvement of the infecting agent.

- Most cases of infectious neonatal conjunctivitis respond well to appropriate treatment [12] .

 

CONCLUSION 

Incidence of neonatal conjunctivitis remains high in African [12] 

Because of it’s high association with serious system disease, neonatal conjunctivitis is still an important public health issue worldwide.

Prenatal screening for gonorrheal and chlamydial infections, particularly among high risk women, should play a major role in the prevention of ophthalmia neonatorum [2] 

 

 

 

 

REFERENCES

1. Lucy Titcomb, ophthalmia neonatorum, Drugs and thereapeutic committee, Birmingham & midlands eye center May 2013.

2. Richard B. Goldbloom, Prophylatis for gonococcal and chlanydial ophthalmia neonatorum; periodic health examination, chapter 16,168-175.

3. Syeda shireen Hul, mahmood jamal & Nusrat Khan, Ophthalmia neonatorum; journal of the college of physicians and surgeons Pakistan – 2010, Vol 20(9); 596-598.

4. Elizabeth K. Darling, thelen M.C Donald a meta-analysis of the efficacy of ocular prophylactic, agents used for the prevention of gonococcal & chlamydial ophthalmia neonatroum journal of midwifery & women’s health, 2010;55:319-327.

5. Janine G.tabas, ophthmia neonatorum, chapter 9

6. College of optometrists; ophthalmia neonatorum, chorical management guideline, version 8 22.07.13.

7. Newborn guideline II: Eye care and prevention of ophthalmia neonatorum; British coumbia reproductive care program: March 2001. Pg 1-5

8. Ernest SK, Ademyi A, Mokuolu O.A, onile B.O Oyewale B. neonatal conjunctivitis in Ilorin, Nigeria. Nigerian journal of paediatrics 2000;27:39.

9. Ulrich C. Schaller & Volker Klauss; is crede’s prophylaxis for ophthalmia neonatorum still valid:/ bulletin of the world health organization, 2001, 79(3) Ref. no 00-1032.

10. F. O olatunji; A case control study of opthalmia neonatorum in Kaduna II: causative agents & their antibiotic sensitivity; WAYM Vol. 23 No3,July-septemer, 2004:pg 215-220 neonatal conjunctivitis: emedcine ophthalmology. http:llemedcine.Medscape. Com/article/ 1192/90. 

11. Kevin M. Bowman; Neonatal conjunctivitis ; Eye wiki, 5 June 2011.

12. Neonatal conjunctivitis – Wikipedia, the free encyclopedia.

13. Neonatal conjuctivities- symptoms, Diagnosis, Treatment of neonatal conjunctivitis- The new York times, Tuesday May 20,2014.

14. Neonatal conjunctivitis; medline phis medical encyclopedia.

15. N. J. F. Buisman MD, T. abong Mwemba, G. Garrigue. J.P. Durand, J.S. Stima, Yh. M. Van Balen, Chlamydia opthlmia neonatorum in cameroom Documarta Ophthalnologica 1988 10/11/ Vol. 70, issuOPHTHALMIA NEONATORUM

Abstract

Ophthalmia neoatorum, because of it’s high association with serious systemic disease is still an important public health issue worldwide. 

As of April 2010,neonatal conjunctivitis is no longer a notifiable disease [1] ,but the incidence of neonatal conjunctivitis still remains high in African .

This review aims to buttress the economic important of ophthalmia neonatorum & the relevance of prevention in limiting blindness and other Complications. 

INTRODUCTION:

Ophthalamia neonatorum[ON]; or acute conjunctivitis of the newborn presents as inflammation of the conjunctiva in an infant within the first 30 days of life. [12]

▷ It is the most common eye infection occurring in the first 28 days of life [1].

▷ It is characterized by purulent eye discharge, redness of conjunctiva, swelling of eyelids and corneal involvement with potential to cause blindness if left untreated.[1]

▷ The baby’s eye are contaminated during passage through the birth canal from a mother infected with Nesseria gonorrhoea or Chlamydia trachomatis.

EPIDEMIOLOGY:

▷ In the absence of preventive measures it is estimated that gonococcal ophthalmia neonatorum will develop in approximately 28% of infants born to women with gonorrhea. [2].

▷ Neonatal conjunctivitis is usually transmitted to the newborn by passage through the mother’s infected cervix at the time of delivery and reflects the sexually transmitted disease prevalent in the community. It may be spread, however, by people handling the baby soon after birth. [5].

▷ The incidence of infectious neonatal conjunctivitis ranges from 1-2%, in the US depending on the socioeconomic character of the area. [11]. 

▷ The epidemiology of neonatal conjunctivitis changed when silver nitrate solution was introduced in the 1800’s to prevent gonococal opthalmia.[11].

▷ As in the United States, the incidence of ophthalmia neonatorum in many other countries decreased after silver nitrate solution came into use. In Europe, the incidence fell from 10% to less than 1%. [11].

▷ Higher incidence of neonatal conjunctivitis still found in certain regions of the world, particularly in developing countries. [12].

▷ Incidence of neonatal conjunctivitis remains high in Africa. [12].

AETIOLOGY [1,3,6,7,8,9,10]

The aetiology of acute conjunctivitis of the newborn can be:

(1) Infectious (2) Non infectious or chemical.

Infectious causes include: (a) Bacterial (b) Viral

Bacterial causes

1. Chlamydia trachomatis

2. Neisseria gonorrhea

3. Staphylococcus aureus

4. Escherichia coli

5. Websiella specie

6. Pseudomas aeruginosa

7. Haemophilus influenza

8. Streptococccus pneumonia

9. Enterobacter species

10. Staphylococus epidermitis

11. Proteus

                             Viral causes

1. Herpes virus

2. Human immunodeficiency virus (Hiv)

                        Non-infectious/chemical causes

                                        Induced by agents used for prophylaxis.[6]

E.g silver nitrate solution.

                     Risk/ Predisposing factors [3,5,6,7]

1. Premature rupture of membranes

2. Maternal vaginitis

3. Prolonged labour

4. Local eye trauma during birth

5. Untrained birth attendant interference

6. Gestation less than 36 weeks [prematurity]

7. Low levels of lysozymes and immunoglobin in neonatal conjunctiva

8. Poor hygienic delivery conditions

              Pathophysiology

▷ Inflammation of conjunctiva causing erythema due to blood vessel dilatation, tearing and drainage.[12].

▷ This reaction tends to be more serious due to reduced tear secretion, decreased immune function, decreased lysozyme activity and relative absence of lymphoid tissue of the conjunctiva [12]

▷ Neonatal tears also lack immunoglobin A.

Clinical features: [6,12,13,15,17]

        Symptoms; usually bilateral

1. Redness of the eye

2. Eye discharge (may be profuse in gonococcal infection)

3. Swelling of lids

                    Signs

1. Lid oedema

2. Conjuctiva oedema[chemoris]

3. Mucopurulent eye discharge

4. Perforation of cornea/ulceration

     Investigation:

1. Conjuctival swabs for Herpes simplex and for Chlamydia[1] *Chlamydia is an obligate IC organism so it is important to sample conjuctival cells with any swabs.[2]

2. Take a sample of pus for culture and sensitivity.

3. Do a conjuctival scrape for urgent gram stain, culture and sensitivity: looking particularly for gram negative diplococcic i.e N. gonorrhea

4. Culture for HSV if vesicles present or is suspicious of viral aetiology including evidence of perinatal maternal exposure. [12]

NOTE; Conjuctival specimens for Chlamydia testing must include conjuctival epithelial cells because Chlamydia trachomatis is an obligate IC organism and exudates are not adequate for testing.

DIAGNOSIS

  Ophthalmia neonatorum can be diagnosed clinically by the presence of most common symptoms. Those symptoms are redness and swelling of the lining of the eyelid and a watery discharge from the eyes that may include pus or blood.[18].

▷ Diagnosis can be confirmed by conducting laboratory test carried out on the discharge to identify the specific infectious agent implicated.

▷ Prompt diagnosis is key n establishing proper treatment and minimizing potential serious complications of neonatorum ophthalmia.

Differential diagnosis

1. Congenital obstruction of the nasolacrimal duct occurs in 6% of nonates and is usually associated with edema of the inner canthus and matting of the eyelids.[5]. It is often associated with epiphora, discharge and recurrent conjunctivitis.[6].

2. Birth trauma.

3. Dacryocystitis: infection of the lacrimal sac with erythema and swelling of the inner canthus and nasal conjuctival injection. Purulent drainage can often be expressed from the punctum.[5].

4. Congenital glaucoma; accompanying early signs are tearing, photophobia, blepharospasm and fussiness. Later signs include cornel edema and corneal enlargement. Intraoccular kpa is elevated.[5].

5. Foreign body / corneal abrasion.

6. Preseptal / orbital cellulitis.

7. Keratitis: bacterial,fungal,herpes simplex.

      MANAGEMENT

▷ Specific treatment is available for the various causes of neonatal conjunctivitis.

▷ Preliminary presumptive treatment pending culture confirmation should be based on the clinical picture and the findings on Gram, Giemsa and papanioalaou stains [11]. This include topical erythromycin ointment and intravenous or intramuscular 3rd gen. cephalosporin. [11].

▷ Prompt treatment of gonococccal conjunctivitis is important since this organism can penetrate an intact corneal epithelium and rapidly cause corneal ulceration, because of the rapid progression of gonococcal conjunctivitis, patients with acute neonatal conjunctivitis should be treated for gonococcal conjunctivitis until culture results are available, then the treatment is altered according to laboratory results.[11].

Chemical conjunctivitis [12]

▷ No treatment required; supportive care only (may use artificial tears q.i.d.)

▷ Typically disappears spontaneously within 2-4 days.

Chlamydial conjunctivitis [11]

▷ In cases of chlamydial conjunctivitis, systemic treatment is necessary because of significant risk for life threatening pneumonia. [11]. 

▷ This infection is treated with oral erythromycin (50mg/kg/day divided q.i.d.) for 14 days.

▷ Topical erythromycin ointment is beneficial as an adjunctive therapy.

Gonococcal conjunctivitis. [11] 

▷ Topical irrigation with normal saline to remove mucopurulent discharge.

▷ Intravenous aqueous penicillin G 100000 units/kg/day in four divided doses or penicillin G benzathine 50000 units/kg/day or ceftriaxone 50mg/kg intramuscular as single dose for 7 days.

▷ Bacitracin or erythromycin ointment every 24 hours.

▷ Hospitalization and valuation for disseminated N. gonorrhea infection.

▷ Topical saline drops to remove discharge.

▷ Topical atropine if corneal involvement.

▷ All neonates with gonococcal conjunctivtis should also be treated for Chlamydia. Mother and sexual partner should be treated as well.

HSV keratoconjuctivitis. [11,12]

▷ Neonates with a suspected herpetic simplex infection should be treated with systemic acyclovir to reduce the chance of a systemic infection.

▷ An effective dose is 60mg/kg/day intravenous divided t.i.d. for a minimum of 14 days, but a course as long as 21 days may be required.

▷ Vidarabine 3% ointment 5×1 day for 14-21 days can be added depending on the presence or absence of CNS involvement.

Other bacteria:

Gram (+) – Bacitracin ointment q.i.d. for 2weks

Gram (-) – Gentamycin, tobramycin or ciprofloxacin q.i.d. for 2 weeks.

Prevention

▷ Prevention through good prenatal care and treatment of chlamydial, gonococcal or herpetic infections during pregnancy remains the best preventive method.[12]

▷ Four prophylactic agents can be utilized in the newborn to prevent ophthalmia neonatorum:

1. 0.1% silver nitrate

2. 0.5% erythromycin

3. 1% tetracycline hydrochloride

4. 2.5% povidine-iodine

  TOPICAL PROPHYLAXIS

▷ According to the 2012 Red book, topical 0.5% erythromycin and 1% tetracycline are considered equally effective for prophylaxis of ocular gonorrhea infection in newborn infants [11].

▷ Topical silver nitrate, povidone-iodine, and erythromycin are all effective in the prevention of non-gonococcal non- Chlamydia neonatal conjunctivitis. [11]

▷ There is no agent that is currently effective in preventing the transmission of Chlamydia trachomatis from mother to baby.[11].

▷ 2.5% povidone iodine solution may also be useful in preventing neonatal ophthalmia and currently used in Europe although not currently approved in US. [12].

▷ Silver nitrate appears to be the best agent in areas where the incidence of penicillinase- producing N. gonorrhea is significant. [12].

▷ Neomycin and chloraphenicol are additional topical prophylactic options. [12].

        SYSTEMIC PROPHYLAXIS  

Infants with possible infection exposure in utero or during birth process should receive prophylaxis following birth in attempt to prevent ocular and systemic complications. [12]

 Other preventive measures include hand washing, techniques by peripartum and nursery staff.

 

 COMPLICATONS [5, 11, 13,14,15]

A. Occular complications

B. Systemic complications

Occular complications [5, 14]

1. Blindness

2. Corneal scarring

3. Corneal prforation

4. Inflammation of the iris

5. Symblepharon

6. Endophthalmtis

7. Corneal opacification

8. Staphyloma

9. Pseudo

Systemic complications [5, 11, 13]

1. Pneumonia

2. Meningitis

3. Otitis

4. Arthritis

5. Sepsis

Differential diagnosis 

1. Congenital nasolacrimal duct obstruction

2. Dacrocystitis

3. Congenital glaucoma

4. Preseptal/orbital cellulitis

5. Infectious keratitis

 

PROGNOSIS

Prognosis of neonatal conjunctivitis is good as long as there is early diagnosis and prompt adequate medical treatment.

- Mortality associated with ophthalmia neonatorum is due to systemic involvement of the infecting agent.

- Most cases of infectious neonatal conjunctivitis respond well to appropriate treatment [12] .

 

CONCLUSION 

Incidence of neonatal conjunctivitis remains high in African [12] 

Because of it’s high association with serious system disease, neonatal conjunctivitis is still an important public health issue worldwide.

Prenatal screening for gonorrheal and chlamydial infections, particularly among high risk women, should play a major role in the prevention of ophthalmia neonatorum [2] 

 

 

 

 

REFERENCES

1. Lucy Titcomb, ophthalmia neonatorum, Drugs and thereapeutic committee, Birmingham & midlands eye center May 2013.

2. Richard B. Goldbloom, Prophylatis for gonococcal and chlanydial ophthalmia neonatorum; periodic health examination, chapter 16,168-175.

3. Syeda shireen Hul, mahmood jamal & Nusrat Khan, Ophthalmia neonatorum; journal of the college of physicians and surgeons Pakistan – 2010, Vol 20(9); 596-598.

4. Elizabeth K. Darling, thelen M.C Donald a meta-analysis of the efficacy of ocular prophylactic, agents used for the prevention of gonococcal & chlamydial ophthalmia neonatroum journal of midwifery & women’s health, 2010;55:319-327.

5. Janine G.tabas, ophthmia neonatorum, chapter 9

6. College of optometrists; ophthalmia neonatorum, chorical management guideline, version 8 22.07.13.

7. Newborn guideline II: Eye care and prevention of ophthalmia neonatorum; British coumbia reproductive care program: March 2001. Pg 1-5

8. Ernest SK, Ademyi A, Mokuolu O.A, onile B.O Oyewale B. neonatal conjunctivitis in Ilorin, Nigeria. Nigerian journal of paediatrics 2000;27:39.

9. Ulrich C. Schaller & Volker Klauss; is crede’s prophylaxis for ophthalmia neonatorum still valid:/ bulletin of the world health organization, 2001, 79(3) Ref. no 00-1032.

10. F. O olatunji; A case control study of opthalmia neonatorum in Kaduna II: causative agents & their antibiotic sensitivity; WAYM Vol. 23 No3,July-septemer, 2004:pg 215-220 neonatal conjunctivitis: emedcine ophthalmology. http:llemedcine.Medscape. Com/article/ 1192/90. 

11. Kevin M. Bowman; Neonatal conjunctivitis ; Eye wiki, 5 June 2011.

12. Neonatal conjunctivitis – Wikipedia, the free encyclopedia.

13. Neonatal conjuctivities- symptoms, Diagnosis, Treatment of neonatal conjunctivitis- The new York times, Tuesday May 20,2014.

14. Neonatal conjunctivitis; medline phis medical encyclopedia.

15. N. J. F. Buisman MD, T. abong Mwemba, G. Garrigue. J.P. Durand, J.S. Stima, Yh. M. Van Balen, Chlamydia opthlmia neonatorum in cameroom Documarta Ophthalnologica 1988 10/11/ Vol. 70, issue 2y Pg 257-264.

16. Conjunctivitis (pink Eye) in newborn. National center for immunization & Respiratory disease ;CDC January 9,2014.e 2y Pg 257-264.

16. Conjunctivitis (pink Eye) in newborn. National center for immunization & Respiratory disease ;CDC January 9,2014.

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