Ophthalmia neonatorum

01OverviewDefinition, clinical context and the essential points that orientate the chapter.

The phrase sticky eye describes an observation, not a diagnosis. A well newborn with intermittent crusting, a white conjunctiva and a clear cornea may have impaired tear drainage. A red conjunctiva, swollen lids or purulent discharge changes the assessment because infection can extend beyond the visible ocular surface. Examine the baby as well as both eyes, and do not let an apparently local complaint bypass neonatal observations or a feeding history.

Neonatal conjunctivitis has several causes with different treatment requirements. Gonococcus can rapidly injure the cornea; chlamydia may persist at respiratory mucosal sites; herpes may accompany central nervous system or disseminated infection. A single empirical eye preparation cannot cover these risks. Community clinicians should seek immediate ophthalmic assessment of suspected ophthalmia neonatorum, with paediatric involvement determined by the likely organism and the infant's condition. Within hospital, investigation and antimicrobial treatment proceed together.

Precise prescribing depends on the infant's current weight, gestation, postnatal age, renal function and the formulation actually available. The neonatal regimens below are labelled to their source. The BASHH chlamydia guideline published in August 2026 covers people aged 16 years and over and explicitly directs younger patients to its children's guidance; its adult doxycycline recommendation must not be transplanted into neonatal care.

Key points

Ophthalmia neonatorum means conjunctival inflammation in the neonatal period, usually defined as the first 28 days.
Simple stickiness without conjunctival redness or other infection signs is a different clinical problem.
Onset helps prioritise organisms but cannot safely exclude gonococcus, chlamydia or herpes.
Gonococcal conjunctivitis threatens the cornea and needs systemic antibiotics urgently.
Chlamydial conjunctivitis needs systemic treatment even when topical treatment improves discharge.
Take conjunctival cells for chlamydial testing and urgently request gonococcal microscopy and culture.
Neonatal herpes can cause severe disease without visible vesicles or a known maternal history.
Macrolide treatment requires counselling about infantile hypertrophic pyloric stenosis and a clear clinical review plan.

02AetiologyUnderlying causes, associations and risk factors, with why each one matters.

Perinatal bacterial exposure

Chlamydia trachomatis and Neisseria gonorrhoeae can reach the conjunctiva around delivery from an infected genital tract. Maternal infection may be asymptomatic, so the absence of a recognised antenatal diagnosis does not remove this possibility.

Other bacterial and viral causes

Staphylococci, streptococci and other bacteria can produce neonatal conjunctivitis. Herpes simplex is particularly important because an ocular presentation may accompany more extensive infection and its clinical signs can be subtle.

Noninfective contributors

Tear drainage obstruction and chemical irritation can cause discharge or redness that resembles infection. They require distinction from true infectious conjunctivitis rather than automatic attribution of every sticky neonatal eye to a sexually transmitted organism.

03PathophysiologyThe causal sequence from the underlying abnormality to symptoms and harm.

1
Inflammation and discharge
Infection of the conjunctival surface recruits inflammatory cells and increases vascular permeability. Redness, swelling and discharge therefore reflect a tissue response; the volume of visible material alone does not establish the organism or disease extent.
2
Corneal invasion
Gonococcal infection can involve the cornea and lead to ulceration, thinning and perforation. Clearing discharge temporarily can improve visibility without interrupting the underlying destructive process, which explains the need for urgent systemic treatment.
3
Reservoir beyond the conjunctiva
Chlamydial infection can coexist in the nasopharynx and subsequently cause respiratory illness. Improvement confined to the ocular surface does not demonstrate eradication of these sites or remove the risk of later pneumonia.
4
Herpetic dissemination
Neonatal herpes may remain confined to skin, eyes and mouth or involve the brain and other organs. The absence of skin lesions does not show that infection is localised, and classification requires systemic investigation.

04Clinical features and red flagsSymptoms, examination findings, patterns of presentation and time-critical warnings.

Describe onset and progression

Ask the exact day symptoms began, whether one eye became both, how quickly discharge returns and whether cleaning changes the appearance. Gonococcal disease often begins from birth to day five; chlamydial disease commonly appears around days five to fourteen but may present later. These overlapping patterns guide tests rather than provide exclusion rules.

Inspect more than the discharge

Record conjunctival redness, lid swelling, discharge character and corneal clarity in each eye. Note whether the examination was limited by swelling or cooperation. A report that the eyes look normal after wiping is incomplete unless the conjunctiva and cornea were actually inspected.

Assess the whole infant

Check temperature, breathing, perfusion, alertness, feeding and hydration. Examine for skin or mucosal lesions and ask about cough, abnormal movements and joint swelling. A neonate with systemic illness requires emergency paediatric management even if the eye initially appears to be the only focus.

Take a sensitive exposure history

Review delivery, maternal infection or treatment, antenatal records when available and possible herpes contact after birth. Use neutral language and provide privacy. The answer informs testing and care for the mother and infant; it is not a basis for blame or an assumption about relationships.

Red flags requiring action

Copious discharge that rapidly returns after cleaning, particularly during the first few days after birth.
Corneal opacity, an epithelial defect, apparent thinning, or inability to inspect the cornea adequately.
Lethargy, temperature instability, reduced feeding, respiratory difficulty, seizures or abnormal perfusion.
Periocular vesicles or mucosal lesions, including eye symptoms with a possible herpes exposure.
A tender red swelling below the medial canthus or rapidly spreading eyelid inflammation.

05InvestigationsWhat to request, why it matters and how to interpret it.

Investigation order

Read from the initial assessment onwards. Tests may run in parallel in urgent care; first-line, preferred, confirmatory, definitive and gold-standard labels appear only when the chapter explicitly states them.

01
Urgent conjunctival microscopy and bacterial cultureFirst step
Why
Identify a likely gonococcal infection and recover organisms for susceptibility testing.
Interpretation and limitations
Request an urgent Gram stain explicitly and chase the preliminary result the same day. Intracellular Gram-negative diplococci strongly support gonococcal infection and justify treatment while culture is pending. A negative preliminary result does not independently overrule a strongly concerning clinical presentation.
02
Chlamydial and gonococcal nucleic acid testing
Why
Detect organisms that require specific systemic treatment and contact management.
Interpretation and limitations
Collect an appropriate conjunctival cellular sample rather than pus alone, using the laboratory's recommended swab and transport system. Request both organisms when indicated because coinfection is possible. Automatic neonatal testing panels vary by laboratory and should never be assumed from the infant's age alone.
03
Specialist corneal examination
Why
Determine whether infection has damaged the corneal surface or deeper ocular structures.
Interpretation and limitations
Ophthalmology assesses clarity, epithelial integrity and any ulceration or thinning, using suitable examination techniques. An obscured cornea is a limitation requiring resolution, not a negative finding. Examination and appropriate irrigation should support, rather than postpone, antimicrobial treatment.
04
Systemic bacterial and herpes investigations
Why
Assess dissemination and direct the required treatment duration and intensity.
Interpretation and limitations
A febrile or unwell infant may require blood cultures and lumbar puncture when clinically safe. For suspected neonatal herpes, obtain lesion and mucosal PCR samples, blood HSV PCR, full blood count, liver tests and coagulation, with CSF assessment under the neonatal protocol. Do not delay aciclovir or sepsis treatment while waiting for samples or results.

06Differential diagnosisRealistic alternatives and the features that help distinguish them.

Congenital nasolacrimal obstruction

Intermittent watering and crusting with a white conjunctiva favour impaired drainage. New redness, significant lid swelling, corneal change or an unwell infant requires reassessment because obstruction can coexist with infection.

Dacryocystitis or dacryocystocele

A focal swelling below the medial canthus suggests lacrimal sac disease rather than uncomplicated conjunctivitis. Tenderness, spreading erythema or systemic features indicate infection; neonatal nasal extension can also interfere with feeding and breathing.

Chemical conjunctivitis

Redness soon after an irritant exposure may be transient. The exposure history supports this explanation but should not override purulence, persistent inflammation, abnormal corneal findings or concern about the baby's general condition.

Congenital glaucoma

Watering accompanied by photophobia, blepharospasm, corneal haze or an enlarged cornea suggests glaucoma. Discharge is not a sufficient explanation for these structural signs, which need urgent ophthalmic assessment.

07ManagementImmediate care, first-line treatment, alternatives and escalation.

01TriageSeparate uncomplicated stickiness from inflammationFirst stepA newborn presents with ocular discharge in the community or postnatal setting.

1Assess general condition and inspect both conjunctivae and corneas before labelling the problem a blocked duct.
2For a well infant with no inflammation or other infection signs, explain gentle cleansing and arrange reassessment if symptoms persist or change.
3For conjunctival inflammation or purulent discharge, contact on-call ophthalmology immediately and agree the paediatric assessment route.
4If the baby is unwell or corneal disease is suspected, arrange hospital care immediately and communicate the concern directly to the receiving team.

02GonococcusTreat a corneal threat promptlyEarly profuse purulence or microscopy raises concern for gonococcal ophthalmia.

1Take urgent ocular specimens and involve senior paediatrics, ophthalmology and microbiology without waiting for final culture confirmation.
2Assess joints, mucosal sites and neurological or systemic signs before deciding that disease is isolated to the eye.
3Use the agreed neonatal systemic antibiotic regimen; the cited GGC pathway specifies intravenous cefotaxime for isolated ophthalmia.
4Irrigate with 0.9% sodium chloride to clear discharge and facilitate assessment; systemic therapy remains essential even when the eye looks cleaner.
5Arrange susceptibility review and confidential maternal sexual health assessment, with partner management through the appropriate clinical service.

03ChlamydiaEradicate infection beyond the eyeConjunctival testing or the clinical assessment supports neonatal chlamydial infection.

1Review respiratory symptoms, feeding and general condition, and start systemic treatment when indicated rather than relying on topical improvement.
2Choose the source-labelled neonatal macrolide course with paediatric and pharmacy advice, considering adherence and the available liquid preparation.
3Explain dose measurement, course completion and the need for prompt review of vomiting or feeding irritability because of pyloric stenosis risk.
4Arrange clinical follow-up and maternal assessment, and give specific advice to seek care for subsequent cough, breathing difficulty or poor feeding.

04HerpesStart antiviral treatment while classifying diseaseOcular findings or systemic illness raise a credible possibility of neonatal herpes.

1Urgently involve neonatology and ophthalmology, use appropriate infection control precautions and begin intravenous aciclovir without waiting for confirmation.
2Collect the neonatal herpes investigation set when safe, remembering that absent vesicles and an early negative test do not reliably exclude infection.
3Classify skin, eye and mouth disease separately from CNS or disseminated infection, because the minimum treatment duration differs.
4For CNS or disseminated disease, plan virological reassessment before stopping intravenous treatment and specialist follow-up including consideration of suppressive therapy.

Key medicines and prescribing safety5 treatments · regimens, roles and cautions

Provides systemic treatment for suspected or confirmed isolated gonococcal ophthalmia; saline irrigation accompanies treatment and topical antibiotics alone are insufficient.

Cefotaxime for isolated gonococcal ophthalmia

Neonatal regimen, not an adult dose: the cited GGC pathway specifies 100 mg/kg intravenously as a single dose for ophthalmia without systemic disease. This is specialist off-label use relative to the cited product's neonatal indications and divided-dose schedules.

Confirm current weight, gestation, renal function and the local neonatal monograph with pharmacy. BASHH separately lists 100 mg/kg intramuscularly, maximum 1 g; do not silently exchange source-specific routes. Exclude cephalosporin allergy and previous immediate or severe beta-lactam hypersensitivity. Never use a lidocaine-containing preparation intravenously or for this neonate. Follow specified injection or infusion rates; the single-dose plan does not treat disseminated infection or meningitis.

Systemic treatment for chlamydial conjunctivitis, including the extraocular reservoir that topical therapy does not reliably eradicate.

Erythromycin oral suspension for neonatal chlamydia

Neonatal GGC and BASHH regimen: 12.5 mg/kg per dose orally four times daily for 14 days, equivalent to 50 mg/kg per day. The cited erythromycin suspension includes eye infections and weight-based dosing up to this daily amount in children under two years; the neonatal course is specified by the clinical guidance.

Discuss infantile hypertrophic pyloric stenosis, particularly with exposure in the first two weeks, and arrange prompt assessment for vomiting or feeding irritability. Check macrolide allergy, liver function concerns, congenital or acquired QT prolongation, ventricular arrhythmia, hypokalaemia, hypomagnesaemia and interacting medicines. Erythromycin is contraindicated with these QT or electrolyte conditions and with domperidone. The cited 125 mg/5 mL product contains sorbitol and must not be given in hereditary fructose intolerance; verify concentration and measure with an oral syringe.

An alternative systemic chlamydial treatment when the neonatal team judges the shorter course appropriate after considering evidence and adherence.

Azithromycin oral suspension for neonatal chlamydia

Specialist off-label neonatal regimen in GGC and BASHH: 20 mg/kg orally once daily for three days. GGC reserves this alternative for substantive concerns about completing erythromycin. Current Zithromax licensing starts at six months for listed paediatric indications and does not cover neonatal conjunctivitis.

It also carries a reported pyloric stenosis risk after use during the first 42 days; advise urgent assessment for projectile vomiting or feeding irritability. Check macrolide allergy, QT risk, electrolyte abnormalities, interacting medicines and hepatic disease. Confirm the exact product and its excipients, reconstitution and concentration with pharmacy; do not assume that an older-child dose table applies to a neonate.

Urgent systemic antiviral treatment while neonatal herpes investigations establish the extent of disease; ophthalmology determines any additional local ocular treatment.

Aciclovir intravenous infusion for suspected neonatal herpes

Licensed neonatal regimen in the cited SmPC: 20 mg/kg intravenously every eight hours with normal renal function, for 14 days for disease limited to skin, eye and mouth, or 21 days for CNS or disseminated disease. Infuse each dose over at least one hour.

Exclude aciclovir or valaciclovir hypersensitivity, maintain appropriate hydration and monitor renal function, urine output and the infusion site. Modify dosing for renal impairment using the neonatal protocol, including review of other nephrotoxic drugs. Avoid rapid or bolus administration. CNS or disseminated disease needs the specialist virological stopping plan; a positive late CSF PCR requires continued treatment and reassessment.

A safety check when considering an alternative cephalosporin, rather than permission to substitute an adult gonorrhoea prescription.

Ceftriaxone: neonatal contraindication check

No interchangeable dose is provided: selection requires a neonatal specialist protocol because ceftriaxone has important neonatal contraindications even when a general gonorrhoea guideline lists it.

Contraindicated in premature neonates up to a postmenstrual age of 41 weeks. In full-term neonates up to 28 days it is contraindicated with hyperbilirubinaemia, jaundice, hypoalbuminaemia or acidosis, and when intravenous calcium is required or expected. Check serious beta-lactam hypersensitivity and product-specific preparation requirements with the neonatal pharmacist.

08ComplicationsImportant consequences, why they occur and why they matter clinically.

Permanent corneal damage

Ulceration, scarring and perforation may produce irreversible visual impairment. Subsequent optical deprivation can add amblyopia, so treatment success includes preserving a clear visual axis and arranging age appropriate visual follow-up.

Infection outside the eye

Gonococcal disease may involve joints, mucosal sites or the central nervous system. A single-dose regimen intended for isolated ophthalmia is inadequate when systemic infection requires a longer, specifically planned intravenous course.

Delayed respiratory disease

Chlamydial pneumonia can present weeks after the eye complaint, sometimes without a previous recognised conjunctivitis. New cough, breathing difficulty or feeding deterioration therefore remains relevant after the ocular discharge has settled.

Herpetic neurological injury

Central nervous system or disseminated herpes can cause death or lasting neurological and ocular disability. Early clinical improvement does not independently justify stopping antiviral therapy before the required investigations and treatment course are complete.

09Monitoring and follow-upTreatment response, safety checks and longer-term review.

Record the response of the conjunctiva and cornea as well as discharge, with ophthalmic review frequency determined by severity. Worsening swelling or a new opaque corneal area requires immediate reassessment despite antibiotics.
Check that laboratory results have a named responsible clinician and that susceptibility or coinfection findings alter treatment promptly. An unreviewed result can leave the infant and mother with incomplete care.
For chlamydial infection, review adherence, feeding and respiratory symptoms clinically. The cited GGC pathway does not recommend routine early NAAT test-of-cure because nonviable organisms can remain detectable for weeks; persistent symptoms need specialist reassessment and a tailored testing or retreatment plan.
For prolonged aciclovir treatment, monitor renal function and hydration and follow the neonatal team's blood monitoring schedule. In CNS or disseminated herpes, the 2024 BASHH/RCOG pathway arranges blood and previously positive CSF PCR around days 17–20 before a planned day-21 stop; persistent positive CSF extends treatment.
Provide written escalation advice for vomiting, reduced feeding, fewer wet nappies, respiratory difficulty, fever, lethargy or recurrent eye inflammation. Agree who will review the baby and how the family can obtain urgent help.
After corneal damage or significant herpes disease, arrange ongoing ophthalmic and developmental follow-up. A visibly quiet eye does not establish normal visual development.

10Special situationsVariants, exceptions and circumstances that change the usual approach.

Timing supports probability

A two-day onset with heavy pus prioritises gonococcus, whereas later mucopurulent disease raises chlamydia. Nevertheless, the calendar cannot safely replace examination and sampling: prior treatment, different exposure timing and incomplete histories alter the observed presentation.

Systemic treatment needs systemic reasoning

Choosing a drug requires more than matching a positive eye swab. The same organism in an infant with meningitis or disseminated illness changes the route, dose schedule and duration; explicitly documenting the assessment for spread makes that decision reviewable.

Early improvement has limits

Cleaning reduces visible material, topical treatment may suppress local inflammation, and systemic therapy may rapidly improve symptoms. None of these observations independently proves eradication at another mucosal site or permits shortening a defined neonatal treatment course.

Protect confidentiality and the child

Possible perinatal transmission calls for sensitive maternal testing and sexual health care. It does not, by itself, establish sexual abuse of the infant. If separate safeguarding concerns arise, involve an experienced paediatric safeguarding clinician and follow the relevant pathway while continuing urgent medical treatment.

Known maternal infection needs a specific plan

An asymptomatic infant exposed to documented maternal gonorrhoea needs a neonatal prophylaxis plan. GGC instead advises observation for an asymptomatic infant exposed to maternal chlamydia, with prompt assessment and treatment if symptoms develop. These are organism-specific decisions, not a blanket policy for every discharge.

11Common pitfallsFrequent interpretation and management errors.

01
Treating every sticky eye as bacterial conjunctivitis without checking whether the conjunctiva is inflamed.
02
Waiting for final culture in a neonate with suspected gonococcal corneal infection or credible neonatal herpes.
03
Using topical therapy alone for chlamydial infection because the ocular discharge improves.
04
Confusing milligrams per kilogram per dose with milligrams per kilogram per day when prescribing erythromycin.
05
Applying adult sexual health drug regimens or older-child suspension tables to neonatal infection.
06
Interpreting a negative early herpes result or absent maternal symptoms as definitive exclusion.
07
Calling a persistent positive early chlamydial NAAT treatment failure without considering residual nucleic acid and the clinical response.