Vision/Hearing Peds - Ch 50

Refractive Errors

• improper focusing of light on the retina

• Caused by how light bends (Refraction) through the eye lens

• Very common in school-aged children

Normal Vision

• Light rays focus directly on the retina

• Produces clear vision

Hyperopia

• Farsightedness

• Light focuses behind the retina

• Vision:

  • Near = blurry

  • Distance = clear

Hyperopia - In Children

• Common in preschoolers → normal developmental finding

• Usually improves by ~5 years of age

• No correction needed in early childhood screening unless persistent

Hyperopia - If Persistent (School-Age)

• Symptoms:

  • Headaches

  • Dizziness during close work

• Requires referral

Hyperopia - Treatment

• Convex lenses (glasses)

Myopia

• Nearsightedness

• Light focuses in front of the retina

• Vision:

  • Near = clear

  • Distance = blurry

Myopia - Onset & Course

• Typically begins around age 8

• Progresses during childhood

• Stabilizes (plateaus) in adolescence

Myopia - Symptoms

• Difficulty seeing:

  • Blackboard

  • Distant signs

  • Sports (e.g., baseball)

• Behaviors:

  • Squinting

  • Eye rubbing

  • Blinking

  • Tearing

Myopia - Risk Factors/Screening

Risk Factors

• Genetics (higher risk if both parents affected)

• Environmental influences

Screening

• Annual screening recommended for at-risk children

Myopia - Treatment

• Concave lenses (glasses)

Signs of Possible Refractive Errors

• Eye rubbing

• Squinting

• Excessive blinking

• Tearing

• Complaints of poor vision

Contact Lenses

• Can be used even in young children

• Children ≥5 years can learn insertion/removal

• Independent care usually reliable by ~12 years

Considerations

• Require strict hygiene

• Risk of irritation or infection if not maintained properly

Glasses Safety

• Use shatterproof (safety) lenses

• Children may initially resist wearing them

Refractive Surgery

• Includes:

  • LASIK

  • PRK

Key Points

• Rare in children (eyes still developing)

• Generally recommended ≥21 years

• Requires:

  • Patient cooperation during procedure

  • Avoiding eye rubbing post-op

Postoperative Care

• Risk:

  • Flap displacement (especially in children)

  • Dry eyes

• Treatment:

  • Artificial tears or ointments

Nystagmus

• Rapid, involuntary eye movements

• Can be:

  • Horizontal

  • Vertical

• Not a disease → a symptom of an underlying condition

Nystagmus - Associated Conditions

• Eye-related:

  • Optic nerve hypoplasia

  • Albinism

  • Congenital cataracts

  • Retinopathy of prematurity

• Neurologic causes:

  • Lesions of:

    • Cerebellum

    • Brain stem

Nystagmus - Clinical Significance

• May indicate:

  • Visual impairment

  • Neurologic disorder

Nystagmus - Management

• Immediate referral to primary care provider

• Follow-up with ophthalmologist

Amblyopia

• Abnormal visual development → loss of central vision

• Usually unilateral, rarely bilateral

• Most common cause of impaired vision in children

• (“Lazy Eye”)

Amblyopia - Pathophysiology

• Brain suppresses input from one eye → reduced visual development

• If untreated → permanent vision loss (functional blindness) in affected eye

Amblyopia - Critical Period

• Must treat before age 7

• After this → central vision:

  • Fails to develop OR

  • Previously developed vision deteriorates

Amblyopia - Causes / Risk Factors

Refractive Errors

• Myopia

• Hyperopia

• Astigmatism = irregular curvature → distorted vision

Other Causes

• Strabismus (most common cause)

• Ptosis (drooping eyelid covering cornea)

Amblyopia - Strabismus (Related Condition)

• One eye deviates while the other focuses forward

• Types:

  • Esotropia (inward)

  • Exotropia (outward)

• Leads to:

  • Suppression of one image

  • Development of amblyopia

Amblyopia - Assessment / Screening

• Screen all children ages 3–5 at least once

• Use tools like preschool E chart

Typical Finding

• One eye normal (e.g., 20/50 for preschool)

• Other eye significantly worse (e.g., 20/100)

Important Points

• Ongoing screening throughout childhood

• Early detection → better outcomes

• Gaps exist:

  • ~40% of children in U.S. not screened

  • Higher risk in underserved populations

Amblyopia - Most Effective Age for Treatment

• Best: <7 years

• Still some benefit: 7–13 years

Amblyopia - Main Treatments

• Corrective lenses (glasses)

• Eye patching (occlusion therapy)

  • Patch strong eye → forces use of weak eye

Amblyopia - Patching Details

• Improves vision in weaker eye

• Initial effects:

  • Headaches

  • Dizziness

  • Poor depth perception

• Requires strict adherence

Important Rule

• Remove patch 1 hour daily

  • Prevents amblyopia in the good eye

Amblyopia - Other Treatments

• Refractive surgery (e.g., LASIK) if needed

• Medications:

  • Levodopa → NOT effective as adjunct therapy

Color Vision Deficit (Color Blindness)

• Inability to perceive colors correctly

• Caused by absence or dysfunction of retinal cones (red, green, or blue)

• Occurs in ~4%–8% of children

• More common in males (sex-linked inheritance)

Color Vision Deficit - Cause

• Genetic mutation affecting cone cells in the retina

• Inherited as a sex-linked disorder

Color Vision Deficit - Associated Conditions

• Hemophilia

• Congenital nystagmus

• Glucose-6-phosphate dehydrogenase deficiency

Color Vision Deficit - Types of Color Deficits

• Difficulty distinguishing:

  • Red vs. green (most common)

  • Blue vs. yellow

• Rare:

  • Complete inability to see any colors

Color Vision Deficit - Assessment / Diagnosis

• Can be detected in preschool-aged children

Testing Method

• Color plates/discs (e.g., Ishihara-type tests)

  • Normal vision: sees numbers/patterns

  • Deficit: sees unclear images or dots

Color Vision Deficit - Treatment

No cure or medical therapy

• Due to genetic cause

Color Vision Deficit - Management / Nursing Implications

Early identification is important to:

• Prevent frustration in school (color-based tasks)

• Promote safety awareness (e.g., traffic signals)

Strabismus

• Misalignment of the eyes due to imbalance of extraocular muscles

• One eye looks forward, the other deviates

• (Crossed Eyes)

• Occurs in ~1%–2% of children

• ~30% have a family history

Strabismus - Esotropia

eye turns inward

Strabismus - Exotropia

eye turns outward

Strabismus - Hypertropia

eye turns upward

Strabismus - Monocular

same eye always deviates

Strabismus - Alternating

either eye deviates

Strabismus - -tropia

constant/visible deviation

Strabismus - -phoria

appears only when tired or ill

Strabismus - Normal vs. Abnormal

• Occasional crossing is normal up to ~6 weeks

• Constant strabismus in infants → needs referral

Strabismus - Assessment

Observation

• Misaligned eyes at rest

• More noticeable when:

  • Child is tired

  • Child is ill

Strabismus - Associated Symptoms

• Headache

• Eye strain

• Fatigue

• Irritated eyes

• Nausea/vomiting

Strabismus - Special Tests

• Cover test

• Hirschberg test

  • a clinical method used to detect strabismus (eye misalignment) by observing where light reflects on the corneas

Strabismus - Pseudostrabismus

• Appears misaligned due to facial features

• Eyes are actually aligned

• Child outgrows it

Strabismus - Concomitant (Nonparalytic)

• Most common in children

• Eye deviation same in all directions

• Muscles work but are not coordinated

Strabismus - Nonconcomitant (Paralytic)

• Due to nerve or muscle paralysis

• Causes:

  • Birth injury

  • Lesion

Strabismus - Nonconcomitant (Paralytic) S/S

• Double vision (diplopia)

• Eye deviation in specific direction

• Child may:

  • Close one eye

  • Tilt head (may resemble torticollis)

  • Appear clumsy

Strabismus - Relation to Refractive Errors

• Farsightedness → can cause esotropia

• Nearsightedness → can cause exotropia

Strabismus - Complication

• Can lead to:

  • Amblyopia

• Due to suppression of vision in one eye

Strabismus - Treatment

Non-Surgical

• Glasses or contact lenses (correct refractive errors)

• Eye exercises (orthoptics)

Surgical

• Realigns extraocular muscles

• Used when muscle imbalance is primary issue

Strabismus - Postoperative Care

• Antibiotic ointment for 2–3 days

• Temporary:

  • Pain with eye movement

  • Nausea/vomiting

• Eye patching usually not required

Strabismus - Follow-Up

• Regular vision checks after surgery

• Ensure:

  • Eyes remain aligned

  • Vision remains equal

Infection & Inflammation of the Eye

Eye infections in children occur due to:

• Newborn exposure during vaginal delivery

• Poor hand hygiene (younger children)

• School/sports exposure (older children)

Eye Infection - Prevention

• Routine newborn care:

  • Antibiotic eye ointment after birth

• Education for caregivers:

  • Proper eye drop/ointment administration

  • Infection control (avoid spread)

  • Complete full course of antibiotics

Stye (Hordeolum)

• Infection of eyelid gland (usually Staphylococcus)

Stye (Hordeolum) - S/S

• Painful, red, localized swelling on lid

• Possible edema

• Tender lymph nodes

Stye (Hordeolum) - Treatment

• Warm, moist compresses (15–20 min, 4×/day)

• Possible antibiotic ointment

• Incision & drainage if needed

• Recurrent → evaluate for systemic issues (e.g., diabetes)

Chalazion

• Blocked meibomian gland → chronic nodule

Chalazion - S/S

• Painless, firm lump

• No redness or swelling

Chalazion - Treatment

• May resolve spontaneously

• Incision & drainage if persistent

• Surgery if causing ptosis (to prevent amblyopia)

Blepharitis Marginalis

Eyelid margin inflammation (often Staph)

Blepharitis Marginalis - S/S

• Red eyelid margins

• Yellow crusts on lashes

• Possible styes

Blepharitis Marginalis - Treatment

• Warm compresses

• Remove crusts

• Antibiotic ointment

• Systemic antibiotics if persistent

Conjunctivitis

• Inflammation of the conjunctiva

• Causes: bacterial, viral, fungal, neonatal infections

Conjunctivitis - S/S

• Red eyes

• Tearing

• Discharge

• Light sensitivity

Conjunctivitis - Treatment

• Antibiotic ointment (inner → outer canthus)

• Follow-up required

Inclusion Blennorrhea

• A type of Conjunctivitis

• Cause: Chlamydia

• Occurs 5–14 days after birth

Inclusion Blennorrhea - Treatment

• Systemic antibiotics (e.g., erythromycin)

Acute Catarrhal Conjunctivitis

• Often viral or bacterial (H. influenzae, S. pneumoniae)

• Pink Eye

Acute Catarrhal Conjunctivitis - S/S

• Red conjunctiva

• Purulent discharge

Acute Catarrhal Conjunctivitis - Treatment

• Antibiotic drops/ointment (7 days)

• Cool compresses

• Avoid spreading infection

Herpetic Conjunctivitis

• Caused by herpes simplex virus

Herpetic Conjunctivitis - S/S

• Vesicles on conjunctiva

• Fluorescein stain → bright green

Herpetic Conjunctivitis - Management

• Urgent ophthalmology referral

• Antivirals (e.g., idoxuridine)

• Avoid steroids

Allergic Conjunctivitis

Hypersensitivity reaction

Allergic Conjunctivitis -

• Itching

• Tearing

• Eyelid swelling

Allergic Conjunctivitis -

• Treat allergy

• Cool compresses

Keratitis

Corneal infection/inflammation

Keratitis S/S

• Severe pain

• Tearing

• Photophobia

• Redness

Keratitis - Management

• Urgent referral

• Risk:

  • Corneal scarring

  • Vision loss

Periorbital Cellulitis

• Infection of tissue around the eye

• Spread from skin injury (bite, scratch)

Periorbital Cellulitis - S/S

• Swelling around eye

• Possible eye/nerve damage

Periorbital Cellulitis -

• IV antibiotics

Dacryostenosis

• Blocked tear duct (common in newborns)

Dacryostenosis - S/S

• Tearing

• Lump at inner eye

• Usually unilateral

Dacryostenosis - Treatment

• Gentle massage (“milking” duct)

• Usually resolves by 6 months

• Probing if persistent

Dacryocystitis

Infection of nasolacrimal sac

Dacryocystitis - S/S

• Pain at inner canthus

• Eye pain

Dacryocystitis - Treatment

• Local + systemic antibiotics

• Possible duct probing

• Antihistamines if related to allergies

Traumatic Injury to the Eye

• Ocular injuries account for ~191,000 U.S. emergency visits annually

• Represent ~1/3 of all eye injuries

Common Causes

• Balls hitting the eye (most common)

• Racquet sports

• Falls

• Foreign bodies (e.g., dirt, glass)

Traumatic Injury to the Eye - CM

• Acute eye pain

• Tearing

• Photophobia (light sensitivity)

• Rapid blinking

• Blurred or lost vision

Behavioral Response

• Fear due to vision changes

• Reluctance to allow examination

Traumatic Injury to the Eye - Pain Management

• Use topical anesthetic drops if needed

• Helps:

  • Reduce pain

  • Allow eye to open for exam

Traumatic Injury to the Eye - Barriers to Examination

• Reflex eyelid spasm

• Rapid eyelid swelling (edema)

Traumatic Injury to the Eye - Eye Examination Techniques = Lower Eyelid

• Press downward to expose inner surface

Traumatic Injury to the Eye - Eye Examination Techniques = Upper Eyelid Eversion

1. Ask child to look downward

2. Grasp eyelashes

3. Pull eyelid downward

4. Place cotton-tipped applicator across lid

5. Flip eyelid upward over applicator

6. Hold in place gently

Important Precaution

• Do NOT apply pressure to the eye globe

  • Risk: worsening a penetrating injury