• Conjunctival redness
• Swelling of conjunctiva and eyelids
• Purulent or mucopurulent discharge
• Vesicles on lids or adjacent skin (herpes simplex)

Differential diagnosis

• Sticky eye with blocked tear duct in which there is no inflammation of conjunctiva
• Congenital glaucoma in which there is corneal opacity
• Swelling of conjunctiva and eyelids as part of preseptal or orbital cellulitis

Bacterial

• Staphylococcus aureus 
• Haemophilus influenzae 
• Streptococcus pneumoniae
• Serratia spp, E. coli, Pseudomonas spp
• Neisseria gonorrhoeae – typical onset aged 0–5 days: mild inflammation with sero-sanguineous discharge to thick, purulent discharge with tense oedema of eyelids
• Chlamydia trachomatis – typical onset aged 5–14 days: mild-to-severe swelling with purulent discharge (may be blood-stained)

Viral

• Herpes simplex virus (HSV)

• 4–6 hrly eye toilet using sodium chloride 0.9% 
  • cooled, boiled tap water acceptable for home use

Conjunctivitis (see signs above)

• Swab all for:
  • Gram stain and bacterial culture and sensitivities
  • if other suspicions of HSV (e.g. vesicles etc.), swab for HSV PCR 
    • use dry swab/moistened with viral transport media 
    • place in dry tube/pot
  • swab using dry swab/moistened with viral transport media, and place in dry tube/pot (check for Chlamydia trachomatis and Neisseria gonorrhoeae PCR)
• Treat both eyes with:
  • frequent eye toilet as necessary
  • chloramphenicol 0.5% eye drops
  • fusidic acid 1% eye drops for Staphylococcus
• Presentation ≤24 hr of birth suggests gonococcal infection – inform consultant paediatrician
• If herpes suspected, begin treatment with aciclovir IV and aciclovir eye ointment while awaiting results

In severe non-resolving cases

• Take throat and eye swabs for viral PCR 
• If herpes suspected, look for other signs of herpetic infection
• Treat suspected herpes with aciclovir IV and topical for 14 days
• Refer to ophthalmology

Neisseria gonorrhoeae suspected

• Request urgent Gram stain and culture
• Assess baby for sepsis 
• Swab for PCR

Neisseria gonorrhoeae confirmed

• Give single dose ceftriaxone 25–50 mg/kg IV (maximum 250 mg) or if hyperbilirubinaemia or premature give cefotaxime 100 mg/kg IV 
• Refer to ophthalmology

Chlamydia

• If result positive treat: 
  • azithromycin 20 mg/kg IV single dose
  • and azithromycin eye drops twice daily for 3 days
• If maternal chlamydia treated successfully in pregnancy, baby does not require prophylactic treatment
  • if unsure, swab baby’s conjunctiva using nucleic acid amplification test (NAAT) swab 
  • if high risk, send bacterial swab for gonococcus and HIV antibody, HBsAg and HCV antibody from mother or baby

Gonococcal or chlamydia infection detected

• Refer mother and partner to genitourinary medicine for immediate treatment