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Clinical Practice

Herpes simplex ophthalmia neonatorum: a sight-threatening diagnosis

Nimra Maqsood and Usman Mahmood
British Journal of General Practice 2020; 70 (699): 513-514. DOI: https://doi.org/10.3399/bjgp20X712973
Nimra Maqsood
Consultant ophthalmologist with a special interest in paediatric ophthalmology, Hull Royal Infirmary, Eye Hospital, Hull.
Roles: Clinical fellow in ophthalmology
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Usman Mahmood
Consultant ophthalmologist with a special interest in paediatric ophthalmology, Hull Royal Infirmary, Eye Hospital, Hull.
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  • Relative frequencies of ophthalmia neonatorum and congenital nasolacrimal duct obstruction
    Thomas Weatherby
    Published on: 04 January 2021
  • Ophthalmia neonatorum and the role of primary care
    Douglas GJ McKechnie and Edward Snelson
    Published on: 02 October 2020
  • Published on: (4 January 2021)
    Relative frequencies of ophthalmia neonatorum and congenital nasolacrimal duct obstruction
    • Thomas Weatherby, Foundation doctor, North West Anglia NHS Foundation Trust

    I appreciate the useful article from Maqsood and Mahmood on the identification and diagnosis of herpes simplex ophthalmia neonatorum.1 As McKechnie and Snelson suggest in their response, a key differential for ‘sticky eye’ in the neonate is congenital nasolacrimal duct obstruction.2

    A large cohort study of all children in Olmsted County, Minnesota found that the prevalence of congenital nasolacrimal duct obstruction was 11.3%. Of these cases, over 90% were identified in primary care.3

    Ophthalmia neonatorum however is comparatively rare. A survey sent to members of the American Association of Paediatric Ophthalmology and Strabismus, found that most ophthalmologists encountered fewer than five cases per year. Of these cases, the most common causative organism was Chlamydia trachomatis.4

    The diagnostic challenge for the general practitioner is clear. While they will see numerous cases of congenital nasolacrimal duct obstruction, they will rarely encounter ophthalmia neonatorum. From the literature it appears that herpes simplex ophthalmia neonatorum is relatively uncommon even for specialists working in a more selected population.

    Given this difficulty, the pragmatic approach of referral of all cases suspicious for infection, as suggested by McKechnie and Snelson, is prudent. Prompt secondary care assessment would then allow timely and effective treatment to prevent sight threatening compl...

    Show More

    I appreciate the useful article from Maqsood and Mahmood on the identification and diagnosis of herpes simplex ophthalmia neonatorum.1 As McKechnie and Snelson suggest in their response, a key differential for ‘sticky eye’ in the neonate is congenital nasolacrimal duct obstruction.2

    A large cohort study of all children in Olmsted County, Minnesota found that the prevalence of congenital nasolacrimal duct obstruction was 11.3%. Of these cases, over 90% were identified in primary care.3

    Ophthalmia neonatorum however is comparatively rare. A survey sent to members of the American Association of Paediatric Ophthalmology and Strabismus, found that most ophthalmologists encountered fewer than five cases per year. Of these cases, the most common causative organism was Chlamydia trachomatis.4

    The diagnostic challenge for the general practitioner is clear. While they will see numerous cases of congenital nasolacrimal duct obstruction, they will rarely encounter ophthalmia neonatorum. From the literature it appears that herpes simplex ophthalmia neonatorum is relatively uncommon even for specialists working in a more selected population.

    Given this difficulty, the pragmatic approach of referral of all cases suspicious for infection, as suggested by McKechnie and Snelson, is prudent. Prompt secondary care assessment would then allow timely and effective treatment to prevent sight threatening complications.

    References
    1. Maqsood N, Mahmood U. Herpes simplex ophthalmia neonatorum: a sight-threatening diagnosis. Br J Gen Pract 2020, DOI: https://doi.org/10.3399/bjgp20X712973.
    2. McKechnie DG, Snelson E. Ophthalmia neonatorum and the role of primary care. Br J Gen Pract 2020, DOI: https://doi.org/10.3399/bjgp20X713621
    3. Sathiamoorthi S, Frank RD, Mohney BG. Incidence and clinical characteristics of congenital nasolacrimal duct obstruction. Br J Ophthalmol 2019;103(4):527–9.
    4. Zloto O, Gharaibeh A, Mezer E, Stankovic B, Isenberg S, Wygnanski-Jaffe T. Ophthalmia neonatorum treatment and prophylaxis: IPOSC global study. Graefes Arch Clin Exp Ophthalmol 2016; 254(3):577–82.

    Show Less
    Competing Interests: None declared.
  • Published on: (2 October 2020)
    Ophthalmia neonatorum and the role of primary care
    • Douglas GJ McKechnie, Academic Clinical Fellow in Primary Care, University College London
    • Other Contributors:
      • Edward Snelson, Consultant in Paediatric Emergency Medicine, Sheffield Children’s NHS Foundation Trust

    We thank Maqsood and Mahood for their article on herpes simplex keratitis in neonates,1 which includes pointers on distinguishing HSV keratitis from other infective causes. While this is an interesting clinical point, we feel that it lacks a primary care perspective. “Sticky eye” is a common presentation in newborns, and is usually due to immature nasolacrimal duct formation, which requires no treatment unless it fails to improve by 1 year of age. Ophthamia neonatorum, whether bacterial or viral, requires urgent secondary care input for full assessment and treatment.2 As discussed in the article by Maqsood and Mahood, eye infections in the newborn are unlikely to present with features that clearly distinguish benign infections from more significant causes. While the frequency with which HSV causes eye infections in newborns is not stated, we presume that it is uncommon enough that many general practitioners will not see a case during their career. It is difficult to have a high index of suspicion for such a specific yet infrequently occurring event. We therefore suggest that primary care practitioners need only to distinguish infective from non-infective causes of ocular discharge in neonates, and urgently refer all neonates with suspected infection, while avoiding unnecessary treatment for a newborn with a blocked tear duct.

    References
    1. Maqsood N, Mahmood U. Herpes simplex ophthalmia neonato...

    Show More

    We thank Maqsood and Mahood for their article on herpes simplex keratitis in neonates,1 which includes pointers on distinguishing HSV keratitis from other infective causes. While this is an interesting clinical point, we feel that it lacks a primary care perspective. “Sticky eye” is a common presentation in newborns, and is usually due to immature nasolacrimal duct formation, which requires no treatment unless it fails to improve by 1 year of age. Ophthamia neonatorum, whether bacterial or viral, requires urgent secondary care input for full assessment and treatment.2 As discussed in the article by Maqsood and Mahood, eye infections in the newborn are unlikely to present with features that clearly distinguish benign infections from more significant causes. While the frequency with which HSV causes eye infections in newborns is not stated, we presume that it is uncommon enough that many general practitioners will not see a case during their career. It is difficult to have a high index of suspicion for such a specific yet infrequently occurring event. We therefore suggest that primary care practitioners need only to distinguish infective from non-infective causes of ocular discharge in neonates, and urgently refer all neonates with suspected infection, while avoiding unnecessary treatment for a newborn with a blocked tear duct.

    References
    1. Maqsood N, Mahmood U. Herpes simplex ophthalmia neonatorum: a sight-threatening diagnosis. Br J Gen Pract 2020; 70(699):513-514..
    2. NICE. Scenario: Who should I refer to ophthalmology? Management, Conjunctivitis - infective | CKS. [cited 2020 Sep 25]. Available from: https://cks.nice.org.uk/topics/conjunctivitis-infective/management/who-should-i-refer-to-ophthalmology. 

    Show Less
    Competing Interests: None declared.
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British Journal of General Practice: 70 (699)
British Journal of General Practice
Vol. 70, Issue 699
October 2020
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Herpes simplex ophthalmia neonatorum: a sight-threatening diagnosis
Nimra Maqsood, Usman Mahmood
British Journal of General Practice 2020; 70 (699): 513-514. DOI: 10.3399/bjgp20X712973

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Herpes simplex ophthalmia neonatorum: a sight-threatening diagnosis
Nimra Maqsood, Usman Mahmood
British Journal of General Practice 2020; 70 (699): 513-514. DOI: 10.3399/bjgp20X712973
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    • INTRODUCTION
    • HERPES SIMPLEX VIRUS
    • CLASSIFICATION
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