Pediatric eye disorders can affect vision development in children. A childhood eye exam evaluates visual acuity, ocular alignment and structure, and eye health. The exam includes tests of the red reflex, pupil response, and visual focus and tracking. Common childhood eye conditions include strabismus, amblyopia, and infections like conjunctivitis. Early detection through regular eye exams is important to address any vision problems and prevent long-term amblyopia.
3. Eye development starts in the 3-week embryo
The initial 3 years of life is the critical period for
eye development
Normal adult visual capacity develops at 3 years
of age
After the early puberty, the anterior posterior
diameter of the eye, remains unaltered in healthy
subjects
The refractive status of the eye may still change
in adults due to aging processes
Eye Development
6. CHILDHOOD EYE EXAMINATION
Red Reflex
Test
Cover, Cover-
Uncover, and
Alternate Cover
Tests
Corneal
Light Reflex
Fixation and
Alignment
Pupillary
Response
External Ocular
Examination
Visual Acuity
History
7. History
Personal or family histories of risk factors
for eye and vision problems are assessed for
Risks include premature birth, Down
syndrome, cerebral palsy, and a family
history of strabismus, amblyopia,
retinoblastoma, childhood glaucoma,
childhood cataracts, or ocular or genetic
systemic disease
8. Eye Charts
Each eye to be tested independently and
opposite eye occluded to discourage peeking.
Most children do not have 20/20 vision until
after 6 years of age, but at any age, visual
acuity should be approximately equal
between the eyes.
The visual acuity test is used to determine the
smallest letters you can read on a
standardized chart (Snellen chart) or a card
held 20 feet (6 meters) away.
Visual Aquity
11. Visual Acuity Norms for
Children 2.5 to 6 Years of Age
Age
(months)
Norms
30 to 35 Approximately 20/60
(6/20) or better
36 to 47 20/50 (6/15) or better
48 to 59 20/40 (6/12) or better
60 to 72 Approximately 20/30
(6/10) or better
12. External Ocular Examination
Involves examination of the
external portion of the eye,
including
• eyelids,
• orbits,
• conjunctiva,
• sclera,
• cornea,
• iris
13. External Ocular Examination
Inspect for excessive tearing, watery or
purulent discharge, photosensitivity,
conjunctival infection, and gross structural
abnormalities.
Lacrimal duct obstruction is recognized
when pressure over the lacrimal sac
produces mucus in an eye.
Childhood glaucoma presents with tearing
accompanied by corneal redness, corneal
clouding, photosensitivity, and enlarged
eyes.
14. Pupils measured for size
and symmetry in light &
darkness
03
Assessed using
a bright light
01
Room darkened
before declaring
a response
02
Pupillary Response
15. Fixation and Alignment
By 2 months of age, a child should
be able to fix and follow an object.
If strong binocular fix and follow
not seen by 3 months of age, refer
Ocular alignment should be
assessed to identify strabismus
Children as young as six weeks should have
some response to an examiner’s face.
16. In a corneal light reflex test, the child’s
attention is attracted to a target (a light or a
brightly colored object), while a light in front
of the child is directed at the child’s eyes.
The light’s reflection will be symmetric in
each pupil by four to six months of age in
patients with normally aligned eyes.
1. Corneal Light Reflex
17. Hirschberg test
It gives rough objective estimate of the angle of a manifest
squint. Useful in young or uncooperative patients or when
fixation in deviating eye is poor.
Procedure:
Patient made to fixate at point light held at a distance of
33cm .
Deviation of corneal light reflex from the centre of pupil
noted in the squinting eye.
1 mm of deviation ≅ 7○
. (1○
= 2 prism dioptre)
The angle of squint is 15 ○
& 45 ○
when the corneal light
reflex falls on the border of pupil and limbus, respectively.
19. 2. Cover, Cover-Uncover, and Alternate
Cover Tests
Cover
test
Uncover
test
Cover-
Alternate
Cover
test
20. Cover Test
Child’s attention
is attracted to a
target
Step 1
Vision of one eye
is then occluded
Step 2
Tested (uncovered) eye is
observed for movement from
a deviated position and back
Step 3
Untested eye is
uncovered & tested
eye is observed again
for any misalignment.
Step 4
21. Cover-Uncover Test
A cover is placed over one eye for 1 – 2
seconds while the child’s attention is
called to the target
1
2 Cover is removed rapidly, & previously
covered eye is observed for movement
from deviated position back to fixation
on the target
22.
23. Alternate Cover Tests
The cover is held over one eye for a few
seconds, then moved rapidly over the other eye
and held for a few seconds, then moved back to
cover the first eye.
This is repeated several times, and
each time the cover is moved, the
previously covered eye is observed
for any “refixation” from a deviated
to a normal position.
Step
1
Step
2
24. Red Reflex Test
The ophthalmoscope is used in a
darkened room
Each red reflex viewed individually
12 to 18 inches (approximately 30 to
45 cm) from the patient’s eyes
Both red reflexes simultaneously at a
distance of 2 to 3 feet (approximately
0.6 to 0.9 meters).
25. Red Reflex Test
A symmetric orange-red light
should reflect from each fundus.
Any abnormal finding (e.g.,
asymmetry of color or
occurrence of dark or white
spots) is a reason for referral to
an ophthalmologist.
28. Infantile
hemangiomas
Most common eyelid tumors in
infancy. Bright red or purple
appearance.
Blanch with pressure.
Undetected at birth.
Enlarge in first 12 months followed by a slow
involution during the first decade.
29. Infantile
hemangiomas
Vision loss is related to
amblyopia because of induced
astigmatism or visual
deprivation due to ptosis.
Steroid treatment (intralesional
and/or oral) is the first line of
therapy.
30. Epibulbar
dermoids
Choristomas (congenital dermoids)
are masses of normal tissue found in
an abnormal location
Induce astigmatism and cause
refractive amblyopia
May be excised to improve cosmetic
appearance and avoid amblyopia
33. Colobomas
Characterized by an inferior or
ventrally located gap in one or
more tissues, extending
between the cornea and the
optic nerve
34. Colobomas
May be unilateral or bilateral
Clinical spectrum of
congenitally reduced ocular
size (microphthalmia), and in
severe cases, absence of one
or both eyes (anophthalmia)
35. Persistant fetal vasculature
(persistant hyperplastic primary
vitreus)
◙ Failure of
regression of a
component of fetal
vessels within the
eye
◙ Leads to
impairment of
vision
Crossed eyes
(strabismus),
abnormal eye
movements
(nystagmus) and
“lazy eye”
(amblyopia) are
common features
37. Ptosis
Drooping of upper eyelid covering >
2mm of the cornea below the upper
limbus is called ptosis
May be congenital or acquired
Can induce sensory
deprivation amblyopia
Surgical correction:
Mild cases - age of 3-4 years.
Severe cases - early surgery
required to prevent amblyopia.
38. Entropion
Inversion of lid margin due to congenital
or scarring
Eyelid skin and eyelashes
to rub against the eye
Friction
Discomfort and
irritation to the cornea
39. Entropion
Surgical entropion repair:
⁃ Eyelid tightening: This procedure
shortens the eyelid (called a lateral
tarsal strip) to tighten the lid.
⁃ Retractor reinsertion: This procedure
is used to tighten the lid retractor
(muscle that opens and closes the
lid).
40. Ectropion
Outward turning of the lid margin
as a result of inflammation, burns or
trauma is called ectropion
Ectropion leaves the eye too
exposed. The eye can become dry,
irritated, and even infected.
It is either congenital or acquired
41. Blephrospasm
▲It is the repetitive or
spastic closure of
eyelids secondary to
trichiasis, keratitis or
conjunctivitis
42. Blepharitis
▲Inflammation of the lid margin due to
staphylococcal or seborrheic infection
▲Characterized by itching, irritation and watering of
the eyes due to blocked meibomian glands
▲Flaky skin around the
eyes with crusty debris
covering the eyelids,
loss of eyelash
44. The infections occur in
two clinical forms;
Preseptal
cellulitis
Orbital
cellulitis
Causes:
Skin trauma, sinusitis, lacrimal sac
infections and rarely remote
infections
47. Orbital cellulitis
Infection of the
orbital tissues
posterior to
the orbital
septum
Begins deep
to the orbital
septum
Caused by
extension of
infection from
adjacent
sinuses
48. Orbital cellulitis
Symptoms
swelling & redness of eyelid
conjunctival hyperemia &
chemosis
pain with eye movements
decreased visual acuity
fever
50. Ophthalmia Neonatorum
Inflammation of the conjunctiva within
the first month of life is classified as
ophthalmia neonatorum (neonatal
conjunctivitis).
Associated with catarrhal,
purulent or mucoid discharge
from one or both eyes,
conjunctival infection, edema
and erythema of the lids.
52. Common causes of Ophthalmia Neonatorum with
time of onset and typical characteristics
Type Time of
onset
Characteristics
Chemical (e.g.,
silver
nitrate drops)
Within hours
of
instillation
⁃ Self-limiting, mild, serous
discharge (occasionally
purulent)
⁃ Lasts 24–36 hr
Chlamydia
trachomatis
5–14 days ⁃ Mild-moderate, thick, purulent
discharge Erythematous
conjunctiva, with palpebral
more than bulbar involvement
53. Common causes of Ophthalmia
Neonatorum with time of onset and typical
characteristics
Type Time of
onset
Characteristics
Neisseria
gonorrhoeae
24–48 hr ⁃ Hyperacute, copious,
purulent discharge
⁃ Lid swelling and chemosis
common
Bacterial
(nongonococcal)
After 5 days ⁃ Variable presentation,
depending on organism
54. Common causes of Ophthalmia
Neonatorum with time of onset and typical
characteristics
Type Time of
onset
Characteristics
Herpetic Within 2
weeks
⁃ Conjunctiva only mildly
infected
⁃ Serosanguinous discharge
⁃ Vesicular rash on lids
sometimes seen
⁃ Systemic herpetic disease
present
56. Pathophysiology
Infection due to entry of
microorganism or
chemical
Blood vessels
dilate
Formation of new blood
vessels around the papillae
Formation of numerous
polymorphs in the
epithelium
Purulent discharge
and exudate
formation in eye
57. Clinical Features
Eyelids are
tense and
swollen
Conjunctiva is
congested and
swollen
Excessive tearing or turbid
and thick discharge from eyes
58. • Tetracycline, erythromycin
ointments or povidone-iodine
drops can be used for
prophylaxis
• Saline lavage hourly till
discharge is needed
• Systemic intravenous
antibiotics may be needed.
Treatment
59. Prevention
Proper antenatal care of pregnant women.
Treatment of infected vaginal discharge during
pregnancy.
Use of aseptic techniques while delivery and in care
of newborn.
Cleaning of each eye with sterile swabs dipped in
sterile water, as soon as the head is delivered and
instillation of Chloramphenicol eye drops in each eye
as a prophylactic measure.
60. Conjunctivitis
Conjunctivitis is inflammation of
conjunctiva characterized by red
eyes with or without discharge
and itching
Etiology is almost always
bacterial in children. It can
also be viral or allergic
61. Pathophysiology
Microbes enter the eye on
contact with infected object
Inflammation
of eye
Dilation of blood
vessels of eye
Swelling, redness,
exudates and
discharge
62. Clinical Features
Redness of eye
(hyperemia)
Tearing and
itching in eyes
Exudation
Other symptoms may include:
→Photophobia
→Pseudoptosis (drooping of
upper eyelid)
→Periorbital cellulitis
→Pain in eye
→Fever
Viral infection fever, sore
throat and runny nose
64. Bacterial Conjunctivitis
• Caused by bacteria
• Causes serious damage to the eye if
left untreated
• Symptoms include redness, dryness
of eyes and skin around it and
mucoid purulent discharge.
• Topical flouroquinolone and
erythromycin may be used for
treatment
Bacterial Conjunctivitis
Types of conjunctivitis
65. Types of conjunctivitis
Viral Conjunctivitis
• Caused by virus like the
common cold virus
• Very contagious
• Symptoms include redness of
the eye, periodic itching and
increased lacrimation
• Clear up on its own in few days
without treatment
Viral Conjunctivitis
66. Allergic conjunctivitis
• Caused by irritants such as pollen and
dust
• May be seasonal or flare up year
round
• Symptoms include redness of the eye,
itching, swelling of the conjunctiva
and the eyelids
• Antihistamine drops are used to
relieve symptoms
Allergic conjunctivitis
Types of conjunctivitis
67. Difference between bacterial conjunctivitis
and viral/allergic conjunctivitis
Features Bacterial conjunctivitis Viral/Allergic
conjunctivitis
Symptoms Bacterial cases will
always have discharge.
Allergic cases will always
have prominent itching
Presence
and nature
of
discharge
Bacterial infections will
have a purulent,
yellow-green
discharge
Viral cases will have
serous or mucoid
discharge. Allergic cases
will have serous
discharge with excessive
tearing.
68. Features Bacterial
conjunctivitis
Viral/Allergic conjunctivitis
Laterality Bacterial cases
can be either
unilateral or
bilateral.
Viral and allergic conjunctivitis
occur almost always bilateral.
Systemic
associations
-
Viral conjunctivitis might be
associated with upper respiratory
infections. Allergic conjunctivitis
might be seen with upper
respiratory allergic symptoms.
69. Difference between bacterial conjunctivitis
and viral/allergic conjunctivitis
Features Bacterial conjunctivitis Viral/Allergic conjunctivitis
Treatment First-line therapy for
bacterial conjunctivitis is
topical flouroquinolone.
In many cases
Polysporin, erythromycin
or trimethoprim/sulfa is
effective.
Viral conjunctivitis is self-
limited.
For allergic cases topical
antihistaminic drops are
effective.
70. Nursing Management
Prevention
Apply cold compress on the eye
Reduce exposure to light
Prevent rubbing of the eye
Acetaminophen
If caused by bacterial agents
− Clean eye with sterile water and cotton
swabs
− Apply antibiotic ointment or eye drops
− Use of dark glasses if photophobia present
71. Nursing Management
Family Teaching
Good hand washing
after touching the eye
Separate towel, sheet and
pillow case for infected child
Dropper should not touch
child’s eyes during
medication instillation
73. Congenital anomalies that
affect cornea
Megalocornea: It is
symmetric non-
progressive enlargement
of cornea. It is associated
with refractive error
Microcornea: It is a rare
condition characterized
by small isolated cornea.
It may be associated with
congenital cataract,
glaucoma, etc
74. Congenital anomalies
that affect cornea
Microphthalmos:
Microphthalmos is
defined as the
developmental arrest of
all ocular structures
Anophthalmos:
Anophthalmos is the
complete failure of the
eye development
75. Keratitis
Keratitis is an inflammation and
swelling of the cornea characterized by
oval shaped corneal infiltrations
surrounded by corneal edema,
conjunctival hyperemia, ocular pain
and photophobia
76. Types of Keratitis
Non-
infectious Infectious
Caused by an
eye injury, by
wearing
contact lenses
too long or by
a foreign body
in the eye
Caused by bacteria,
viruses, fungi and
parasites. Main
causative
organisms are
staph aureus, staph
epidermis & strep
pneumonia.
78. Treatment
Infectious
Mild cases - eye drops (antibiotic,
antiviral or antifungal, determined by
the cause of the infection)
Advanced infections - oral medications
Non-infectious
For mild discomfort - artificial tears.
Severe cases - a bandage contact lens
and anti-inflammatory eye medications
82. Classification of Optic Neuritis
Papillitis: characterized by hyperemia and
edema of the optic disc, associated with
peripapillary flame-shaped hemorrhages.
Neuroretinitis: is characterized by papillitis
in association with inflammation of the
retinal nerve fibre layer and a macular star.
Retrobulbar neuritis: the optic nerve head
is normal in retrobulbar neuritis, because
the optic nerve head is not involved
83. Papilloedema
Papilloedema is swelling
of the optic nerve head
secondary to raised
intracranial pressure
It is nearly always
bilateral, although it
may be asymmetrical.
Headaches, deterioration of
consciousness, nausea and
vomiting
Diplopia due to 6th
nerve palsy
SIGNS AND SYMPTOMS
99. Presence of dilatation and
tortuosity of retinal vessels at
posterior pole of eye.
Associated with papillary
rigidity and vitreous haze.
Plus disease frequently leads to
vessel contraction and scar
formation, which in turn, leads
to macular displacement.
Plus disease
101. In India, babies with
GA<34 weeks or Birth weight
<1700g
Birth weight <2000g (if GA not
known)
Sick preterm babies are screened at
the neonatologists’ discretion
102. To avoid confusions about the timing
of first screening it is recommended
that the first ROP screening should be
done strictly
• before “day 30” of post-natal life
• by “day 20” of life in smaller babies
(<30 weeks and/or birth weight
<1200 g).
103. Role of Nurses in ROP Screening
Record wt and GA at birth.
Monitor wt gain during NICU
admission.
Select babies eligible for screening.
Counsel the parents regarding
screening procedure.
Dilate eyes 1 hour before
examination using a topical agent.
104. Role of Nurses in ROP Screening
Keep the baby NPO one hour prior to
procedure.
Position the baby comfortably, take
adequate pain control measures.
Ensure hand washing, use sterile articles
only during procedure.
Monitor vital signs.
Documentation of procedure, fix next
appointment.
105. Treatment of ROP
Peripheral retinal
ablation of
avascular retina
Argon laser
photocoagulation
Follow up of the child for development
of vision, refractive status and
strabismus till preschool age
106. Prevention of ROP
Antenatal steroids
Judicious
oxygen therapy
Judicious use of
blood transfusions
Other
interventions
108. Definition
Cataract is the
opacification of the
crystalline lens. A
cataract is any
cloudiness or
opacity of the
natural lens of the
eye, which is
normally crystal
clear.
Incidence
Approx 3 /10,000
children
Variable
throughout the
world.
111. Classification of pediatric cataract
Congenital/Infantile
cataract
Cataract present at birth or which occurs during
the first year of life
Manifestations:
• Usually bilateral
• Visible clouding of
lens
• Varying impairment of
vision
• Maybe found with
amblyopia
113. Classification of pediatric cataract
Acquired/Juvenile Cataract
Cataract that occurs after the first year of
life
Manifestations:
• Visible clouding of
lens
• Varying impairment
of vision
114. Classification of pediatric cataract
Acquired/Juvenile Cataract
Causes:
• Eye trauma (contusion,
foreign body and
penetrating injury)
• Child abuse
• Steroid induced
• Radiation, drug effects
(tetracyclines,
chlorpromazine)
• Hypo - and
hypervitaminosis ‘D’
• Juvenile onset
diabetes mellitus
• Hypoglycemia
• Hypocalcemia
115. Types of pediatric cataracts
A lamellar cataract is the opacification of a
lamella (an ovoid layer of cortex) which
causes cloudiness between the nuclear and
cortical layers of the lens
Lamellar
cataract
116. Types of pediatric cataracts
Nuclear
cataract
A nuclear cataract is cloudiness of the
center part of the lens. They can be dot-
like or can be quite dense. They
generally measure 2-3.5 mm and can
be associated with microphthalmia.
117. Types of pediatric cataracts
Posterior
sub
capsular
cataract
A posterior sub capsular cataract is a thin
layer of cloudiness that affects the back
surface of the lens cortex, just inside the
capsule. This type of cataract can often be
associated with medication use such as
steroids
118. Types of pediatric cataracts
Anterior polar cataract is a small, usually
central opacity of the front part of the lens
capsule. Anterior polar cataracts generally
do not grow during childhood and are
typically not visually significant. They are
often managed without surgery
Anterior
polar
cataract
119. Types of pediatric cataracts
A posterior polar cataract is a central
opacity at the back of the lens. In this type
of cataract, the opacity is in the capsule
itself.
Posterior
polar
cataract
120. Types of pediatric cataracts
Traumatic
cataract
A traumatic cataract results from either a
blunt or penetrating force that damages the
lens. The cataract can form shortly after the
trauma or months to years after the injury.
In children, traumatic anterior lens capsule
rupture quickly results in a hydrated white
cataract.
121. Signs and symptoms
A pupil that looks white when a flashlight is
shone into it
Eyes that aren’t in the right position
(misaligned)
Rhythmic eye movements that can't be
controlled (called nystagmus).
Cloudy or blurry vision
Trouble seeing
Lights that look too bright or have a glare
Seeing a circle of light around an object (halo)
122. Diagnosis
Red reflex test in
newborn
screening:
If no red reflex, or
a weak one, is
seen, it may mean
there's cloudiness
in the lens.
Vision tests for
older babies
and children:
This includes
visual acuity
tests and pupil
dilation
123. Management
Surgical removal of a
cataract
Restoration
of focusing
power
Contact
lenses
Intraocular
lenses
Glasses
Treat amblyopia by patching the good
eye to stimulate vision in affected eye
Antibiotic & steroid eye
ointments
124. Nursing Management
Preoperative Phase
History and
physical
assessment
Antibiotic eye
drops
Dilating eye
drops
Anticholinergics
: Mydriatics and
cycloplegics.
125. Nursing Management
Postoperative Phase
Antibiotics and
steroid eye
ointments
Aseptic eye care
with eye patch and
eye shield for
several days to
prevent injury
Sedation for 24
hours to
prevent crying
Prevention of
vomiting & ↑
IOP
126. Health Promotion
Wear sunglasses
Avoid unnecessary radiation –
Adequate antioxidant
vitamins
Good nutrition
Educate about disease
process and treatment options
Teach signs and symptoms of
infection
128. Definition
Glaucoma is a group of heterogenous disease
marked by high intraocular pressure (IOP) that
damages the optic nerve which can cause a
rapid loss of vision or even blindness.
129. Childhood glaucoma is defined by 2 of
the following features:
1.Intraocular pressure (IOP) greater
than 21 mmHg
2.Presence of optic disc cupping
3.Corneal findings of Haab striae
(breaks in Descemet's membrane
leading to scarring)
130. Childhood glaucoma is defined by
2 of the following features:
4. Corneal edema
5. Increased corneal diameter of
greater than 11mm in newborns,
greater than 12 mm in children less
than 1 year of age, and diameter
greater than 13 mm in any age.
131. Definition and Terminology
Juvenile glaucoma: Occurs after
the age of three to teenage years.
Related to age of onset
Congenital glaucoma: The glaucoma that
exists at birth, and usually before birth
Infantile glaucoma: Glaucoma that
occurs from birth until 3 years of age
132. Definition and Terminology
Related to development pattern
Developmental glaucoma: This term broadly
encompasses all glaucomas resulting from
abnormal development of the aqueous outflow
system. This may or may not be associated with
systemic anomaly
133. Definition and Terminology
Secondary developmental
glaucoma: This refers to
glaucoma resulting from
damage to aqueous outflow
system due to
maldevelopment of some
other portion of the eye, e.g.
eye with dislocated lens
Related to development pattern
Primary
developmental
glaucoma: This
is the glaucoma
resulting from
maldevelopment
of aqueous
outflow system
138. Types of glaucoma
Most prevalent type of
glaucoma is open-angle
glaucoma.
The trabecular meshwork is
partially blocked, but the
drainage angle formed by the
cornea and iris remains open.
Open-angle glaucoma
139. Types of glaucoma
As a result, the pressure in
the eye increases.
The optic nerve is damaged
by this pressure.
It happens so slowly that one
can lose vision before
understanding anything is
wrong.
140. Types of glaucoma
When the iris bulges forward,
it narrows or blocks the
drainage angle produced by
the cornea and iris, causing
angle-closure glaucoma.
Fluid cannot circulate through
the eye and pressure rises.
Angle-closure glaucoma
141. Types of glaucoma
People with small drainage
angles are more likely to develop
angle-closure glaucoma.
Angle-closure glaucoma can
develop quickly (acute angle-
closure glaucoma) or gradually
(progressive angle-closure
glaucoma/chronic angle-closure
glaucoma).
142. Classification of Childhood glaucoma
Primary glaucoma
Childhood glaucoma
Juvenile
open-angle
glaucoma
Congenital/
infantile
glaucoma
Secondary glaucoma
Associated c
̅
non-acquired
ocular
anomalies
Associated c
̅
non-acquired
systemic
disease
Associated with
an acquired
condition
After
congenital
cataract surgery
144. Symptoms Signs
• Photophobia • Buphthalmos (visible enlargement of
the eyeball detected at birth)
• Epiphora (excessive tearing/watering
of eyes)
• Corneal enlargement
• Blepharospasm (blinking or other
eyelid movements, like twitching, that
one can't control)
• Corneal edema
• Red eye • Breaks in Descemet’s membrane
(Haab striae)
• Irritability • Iris and pupillary abnormalities
• Cloudy cornea • Elevated intraocular pressure
• Enlarged cornea/eye • Visual impairment
• Poor vision • Myopia or astigmatism
• Asymptomatic • Optic nerve cupping
145. Treatment
Aim of treatment
The aim of pediatric glaucoma surgery is to reduce
IOP either by increasing the outflow of fluid from the
eye or decrease the production of fluid within the
eye.
Surgical treatments Laser
Therapy
Medical
treatments
Goniotomy
Trabeculotomy
Trabeculectomy
146.
147. Medical Therapy
• The treatment for glaucoma in older children
is generally medical, i.e. eye drops initially
and if these fail, surgery is considered.
• Anti-inflammatory and antibiotic drops are
used postoperatively
• When trabeculectomy is performed in children
an antimetabolite such as 5-fluorouracil (5-FU
for short) is very often used
148. Nursing Care
Assessment
Signs &
symptoms like
photophobia,
tearing, pain
and bump into
objects
Send the patient to
assess visual
acuity, visual
fields, IOP.
149. Nursing Care
Teach patient and family risks of glaucoma.
Stress on the importance of early detection,
ophthalmologic examination.
Administer medication to lower IOP.
Pre and post-operative teaching of the
patient and family are to be given.
Support for parents.
Educate parents on use of eye medications
to alleviate pain from disease and surgery.
151. A refractive error occurs when the eye does not
focus light correctly and it causes blurry vision.
The presence of any of the refractive disorders is
known as ametropia
REFRACTIVE DISORDERS
Myopia
(near-sightedness)
Hyperopia
(far-sightedness)
Astigmatism
152. Prevalence and Incidence
Myopia is most common refractive in the pediatric
population
WHO estimates refractive disorders to be 2-10% worldwide.
The prevalence is higher in the Far East.
The prevalence of astigmatism of 1 diopter or more is 50%
in infancy.
The prevalence decreases rapidly during the process of
emmetropization.
Only few children develop astigmatism greater than 1
diopter by 6 years of age
153. MYOPIA (NEARSIGHTEDNESS)
Myopia is an eye condition in which near
objects are seen clearly, but faraway objects
appear fuzzy or blurry.
154. In myopia, eye focuses incorrectly because its shape is
slightly abnormal.
A nearsighted eyeball has a long antero posterior
diameter.
The myopic child has excessive refractive power.
In myopia, eye focuses light entering the eye in front of the
retina instead of onto the retina.
According to the National Eye Institute (NEI), myopia is
usually diagnosed between the ages of 8 and 12 years when
eyes are growing at this age, so the shape of the eyes can
change.
155. Signs and symptoms
Blurry vision when
looking at faraway
objects
Headaches
Eyes that hurt
or feel tired
Squinting
158. • A hyperopic eye is shorter than normal and it is caused by
insufficient refractory power.
• Light from close objects cannot focus clearly on the retina.
If cornea is too flat, eye cannot focus correctly.
• About 75% of all neonates are hyperopic; but as they have a
greater accommodative ability, they overcome the error and
see objects at a nearer range.
• In hyperopia, eyes have to work hard to see anything up
close and causes eyestrain.
159. Symptoms
Headache after reading or other
tasks that require focusing on
something up close.
Tension
Fatigue
Blurry vision
up close
Squinting to
see better
Aching or burning
sensation around
eyes
161. ASTIGMATISM
When the focusing point is disrupted due to
variations in the curvature of the cornea or lens
at different meridians, the error is called
astigmatism
162. • Astigmatism is caused by an irregularly shaped
cornea, which causes light to refract or bend
incorrectly within the eye.
• With astigmatism, light rays do not refract (or bend)
properly as they enter the front of the eye. Vision is
blurry at near and far because light rays either fall
short of the retina or behind it. This results due to the
irregularity in curvature of the cornea which results in
different refractive power in some parts of the cornea
in comparison to other parts.
• It is possible to have astigmatism in combination with
myopia or hyperopia.
163. Symptoms
6 Squinting or holding
reading matter close
Eye discomfort
Blurry vision or areas
of distorted vision
Eyestrain and fatigue
Headaches
Eye rubbing to see
clearly
165. ANISOMETROPIA
Anisometropia refers to a difference in the
refractive status of the two eyes
It is the most important risk factor of amblyopia and
must be treated with caution
166. Types
Mixed anisometropia – one eye is myopic
and the other eye is hypermetropic ,it is also
called antimetropia
Simple anisometropia – one eye normal
and other eye myopic and hypermetropia
Compound anisometropia – both eye are either
hypermetropic or myopic ,but one is having higher
refractive power
167. Types
Simple
astigmatism
anisometropia –
one eye is
normal and
other has either
simple myopic
or
hypermetropic
astigmatism
Mixed
astigmatism
anisometropia –
One eyes has
hypermetropic
astigmatism and
the other eye has
myopic
astigmatism
Compound
astigmatism
anisometropia –
when both eyes
has astigmatic
but if unequal
degree
170. PRESBYOPIA
Presbyopia is a result of changes to the eye lens, the lens
hardens or thickens and becomes less flexible, making it
unable to change its shape and focus on images
Depending on the severity of the changes to the lens, both
short and long-distance vision may be affected
171. Symptoms
Excess strain in the eyes post reading a book
Throbbing headaches after attempting to view objects
nearby
Feeling tired and exhausted after working with things in
close focus
Requiring much brighter light to view things that are
nearby
Inability to read the small print
Blurred vision
Frequent squinting of eyes while trying to focus on
close objects
173. NURSING CARE OF A CHILD WITH
REFRACTIVE ERRORS
Assessment
History and observation,
examination, investigation and
diagnostic procedure in eye.
A child tilts his head, rubs eyes,
squint, and walks into objects;
he or she holds things close to
face.
174. NURSING CARE OF A CHILD WITH
REFRACTIVE ERRORS
Nursing Diagnosis
• Alteration in visual perception of
patient, as a result of refractive error.
• Knowledge deficit, about treatment of
refractive error.
• Altered comfort as a result of refractive
error manifested by asthenopia.
175. NURSING CARE OF A CHILD
WITH REFRACTIVE ERRORS
Intervention
• Refer for vision testing.
• Use corrective lenses when caring for
child.
• As preventive measure educate
parents to be aware of signs and
symptoms and their meaning.
• Encourage vision testing at early stage
177. The deviation of visual axis
from normal alignment is
known as strabismus. The
visual line of each eye does
not simultaneously focus on
the same object due to lack
of muscle coordination
resulting in a crossed–eye
appearance.
Definition
178. Incidence
Strabismus occurs in 2–3% of all children.
Approximately half of these children have a
family history for the defect.
Transient strabismus is normal in first 4–6
months of life and is attributed to
physiologic hypermetropia.
180. Types
Paralytic or non-concomitant
• Occurs due to
weakness or
paralysis of one or
more extra ocular
muscles.
• There is limitation in
movement of eye
and diplopia occurs
Non-paralytic or concomitant
• The movements of
individual ocular
muscles are
present, but
coordination is
lacking.
• Diplopia does not
occur in this type
185. Nursing Management
Minimizing effects of vision loss
Minimize body image disturbance
Prevent injury.
Promote normal growth and
development
186.
187. Definition
Amblyopia is the medical term used when
the vision in one of the eyes is reduced
because the eye and the brain are not
working together properly. The eye itself
looks normal, but it is not being used
normally because the brain is favoring the
other eye. It is unrelated to an organic
cause. The condition is sometimes called
‘lazy eye’.
192. Clinical
Features
Diagnostic
Evaluation
Infants and children
with Amblyopia often
do not display any
symptoms. They may
occasionally over reach
for an object.
Visual acquity test
Amblyopia is usually
asymptomatic because the
good eye assumes the burden
of vision and the child is
unaware that there is a
problem. The child’s eyes are
examined periodically before
the age of 7 years.
196. Definition
Retinoblastoma is a
malignant glioma of the
retina.
It may be unilateral (70%)
or bilateral (30%).
It is a highly malignant
tumour arising from the
nuclear layer of the retina.
197. Incidence and
Prevalence
Predisposing
Factors
About 90 percent
cases are found in
less than 5 years of
age.
It is rare tumor,
though the most
common ocular
neoplasm of
childhood.
Usually congenital
in origin but
commonly
manifests itself
between 2 to 5
years.
Hereditary and
familial tendency
198. Etiology
The disease has a genetic predisposition in
majority of the cases.
The retinoblastoma gene is located on
chromosome 13.
The gene carries risk of osteosarcoma and
a secondary malignancy like a pineal tumor,
the so called “trilateral retinoblastoma”.
It usually develops in the posterior portion
of retina. About 25 per cent cases are
bilateral.
199. Forms of Retinoblastoma
Non-inheritable
Not passed down from
parents. This type of
retinoblastoma is caused
by mutations in the RB1
gene that occur by
chance after a child is
born. Usually unilateral
Heritable
The mutation in the RB1
gene passed from the
parent to the child, or it
may occur in the egg or
sperm before
conception or soon after
conception. Usually
bilateral
In
retinoblastoma
there is a
mutation in
the RB1 gene
201. Extension of the Tumour
When it grows towards the
choroids, it is known as
Glioma Exophytum.
When it grows towards the
vitreous humour, it is
Glioma Endophytum.
202. Extension of the Tumour
Quiescent Stage
Stage of Glaucoma
Stage of Extra-ocular Extension
Stage of Metastasis
205. Diagnosis
Confirmed by
fundoscopy to detect
leukocoria
CT scan to
determine the
extent of tumor
X-ray to detect
bone
involvement
CSF study, bone
marrow study to
identify the metastasis
206. Management
Enucleation may be
done in unilateral cases
Radiotherapy Chemotherapy Scleral plaque irradiation
Cryotherapy or
photocoagulation
214. THROAT ANATOMY AND PHYSIOLOGY
• Soft palate and vallecula
form a tongue and groove
and separates the oral
cavity from the nasal
cavity during the first 6
months of infancy when
most children are
primarily nasal breathers.
• Anterior placement of the
larynx
215. THROAT ANATOMY AND PHYSIOLOGY
• Shared passage for
eating and breathing.
• The tongue occupies
less of the oral cavity.
• The larynx sits lower in
the neck,
217. EXTERNAL OTITIS OR OTITIS EXTERNA
External otitis, or otitis
externa, refers to an
inflammation of the external
auditory canal. It is a painful
condition caused when
irritating or infective agents
come into contact with the
skin of the external ear.
218. Causes/Etiology
• Blockage of the
canal
• Absence of
cerumen due to
excess cleaning
• Trauma
• Alteration of pH
within the canal
Bacterial infection
Fungal infection
Pseudomonas
Aeruginosa
Staph Aureus
Aspergillus
219. Risk Factors
Hot and humid climates
Swimming
Diabetes Mellitus
Narrowing/obstruction of the
auditory canal
Over-cleaning leading to a
lack of wax in the canal
Wax build-up
Eczema
Trauma
220. Classification
Acute Otitis Externa:
• Lasts less than 6
weeks
• Typically due to
bacterial infection
Chronic Otitis Externa:
• Lasts more than 3
months
• Due to Allergies or
autoimmune diseases
221. Pathophysiology
Allergy, injury to external
auditory canal (EAC),
Trapped water, foreign bodies,
narrow canal, humid conditions
Retention of moisture
Multiplication and inhabitation by bacteria or fungi
Activation of inflammatory mediators and enzymes
Chemotaxis
Edema & pain Ear discharge
222. Clinical Manifestation
o Pain and discharge
from the EAC
o Aural tenderness
o Occasional fever
o Cellulitis
o Lymphadenopathy
o Pruritus
o Hearing loss
o Feeling of fullness in
the ear
On otoscopic
examination:
o Erythematous and
edematous ear canal
o Yellow or green, foul-
smelling discharge.
o Fungal infections –
visible hair like black
spores
224. Medical Management
Antibiotic ear drops or oral antibiotics
Corticosteroid ear drops (to help
decrease the swelling)
Pain medication
Keeping the ear dry, as directed.
Placing a wick in the ear (a piece of
sponge may be placed in the child's ear
if there is a lot of swelling. This wick
helps the antibiotic drops work more
effectively in the ear canal).
225. Nursing Management
Avoid events that traumatize the external
canal such as scratching the canal with the
fingernail or other objects.
A cotton ball can be covered in a water
insoluble gel such as petroleum jelly and
placed in the ear as a barrier to water
contamination.
Infection can be prevented by using
antiseptic otic preparations after swimming
(eg, Swim Ear, Ear Dry).
EDUCATE
228. Management
If the occluding material is cerumen, management options
include watchful waiting, manual removal, and the use of
ceruminolytic agents followed by either manual irrigation
or the use of a low-pressure, electronic, oral irrigation
device.
The canal can be irrigated with a mixture of water and
hydrogen peroxide at body temperature.
Insects are killed before removal unless they can be
coaxed out by a flashlight or a humming noise.
229. Management
Lidocaine, a numbing agent, can be
placed in the ear canal for pain relief.
Mineral oil or diluted alcohol instilled
into the ear can suffocate the insect,
which is then removed with ear
forceps.
If the patient has local irritation, an
antibiotic or steroid ointment may be
applied to prevent infection and
reduce local irritation.
231. ACUTE AND CHRONIC OTITIS MEDIA
Chronic otitis media (COM): If an attack of
acute otitis media fails to heal, the
perforation and discharge may in some cases
persist. This leads to mixed infection and
further damage to the middle-ear structures,
with worsening conductive deafness
Acute otitis media (AOM) is an acute infection of the middle ear,
usually lasting less than 6 weeks
233. Risk factors
Crowed living conditions
Exposure to second hand smoke
Respiratory illness
Close contact with siblings those
who have cold.
Having Cleft Palate ( Abnormal
Position of muscles and tendons )
Premature birth
239. CHRONIC SUPPURATIVE OTITIS
MEDIA (CSOM)
Chronic suppurative otitis media is defined as chronic
inflammation of the middle ear and mastoid cavity
characterized by
1) Perforation of the tympanic membrane due to acute
infection or tympanotomy tube.
2) Recurrent discharge from the middle ear (otorrhea).
3) Prolonged duration (>2 weeks).
242. Classification
Tubotympanic/safe type: Atticoantral/unsafe type:
Associated with
tympanic membrane
perforation and
recurrent / persistent ear
discharge.
Episodes of URTI and
entry of water into the
middle ear are
precipitates
Associated with
presence of
cholesteatoma or
granulations
May cause life-
threatening
complications (brain
abscess, meningitis,
hydrocephalus etc.
244. Prevention
Preventive measures for CSOM are
described as HEAR
H- Hygiene of the ear
E- Early management of acute
otitis media
A - Antiobiotics
R - Raising awareness
245. TYMPANIC MEMBRANE
PERFORATION
A ruptured eardrum is a tear in the thin membrane that
separates outer ear from inner ear and when there is
abnormal opening or Perforation in tympanic membrane
247. Signs and Symptoms
Not able to recognize at first
Some may feel Air coming out
of their ear when they blow
nose.
Sudden sharp pain
Drainage from ear (Bloody,
Clear, Pus)
Ear Noise or buzzing
Hearing loss (Partial or
Complete)
Facial Weakness or dizziness
251. Clinical Manifestation
It may involve one or both ears and manifests as a
progressive conductive or mixed hearing loss.
Bone conduction is better than air conduction on
Rinne testing.
The audiogram confirms conductive hearing loss
or mixed loss, especially in the low frequencies.
253. MASTOIDITIS
Mastoiditis is a bacterial infection of the mastoid air
cells surrounding the inner and middle ear.
The mastoid bone, which is full of these air cells, is
part of the temporal bone of the skull.
254. Causes
Middle ear infection.
Cholesteatoma (a
growing collection of
skin cells) which blocks
ear drainage
256. Medical Management
• Antibiotic and steroid eardrop
for infection and inflammation,
e.g. Ciplox-D
• Ear-irrigation: For removing
purulent discharge
• Analgesics drugs: Aspirin,
Nimesulide.
257. Surgical Management
Mastoidectomy: It is a surgical
procedure that removes diseased
mastoid air cells
Myringotomy: It is a surgical
procedure in which a tiny incision is
created in the eardrum relieves
pressure caused by excessive
build-up of fluid or pus
258. Surgical Management
Mastoidectomy: It is a surgical
procedure that removes diseased
mastoid air cells
Myringotomy: It is a surgical
procedure in which a tiny incision is
created in the eardrum relieves
pressure caused by excessive
build-up of fluid or pus
259. Tympanoplasty: also called eardrum repair. It is the
surgical reconstruction of the perforated eardrum or the
small bones of the middle ear.
Surgical Management
260. Nursing Management
Nursing Diagnosis
High risk for infection related to tissue
destruction
Pain related to physical factors
Altered auditory sensory perception related
to partial/total perforation of tympanic
membrane
Impaired verbal communication related to
hearing deficit
High risk for trauma related to impaired
balance
261. Nursing Management
Interventions:
• Assess pain for location, intensity etc
• Administer analgesics as prescribed to relieve
pain
• Administer antibiotics as ordered
• Administer antipyretics as prescribed
• Provide plenty of fluids
• Use cool water sponging to reduce body
temperature
• Encourage patient and family to use signs of non-
verbal communication such facial expression
266. Pathophysiology
Allergen, drugs, infections and other causes
Production of immunoglobulins (IgE) and inflammatory
mediators (histamine, thromboxane, prostaglandins)
Nerve cell irritation Loss of mucosal integrity
Sneezing, itching,
vascular
engorgement
Rhinorrhea
272. Pathophysiology
Acute infection Destroys normal ciliated epithelium
Impairs drainage
from sinus
Pooling and stagnation of
secretions
Decreased mucocilliary
clearance
Inflammation, edema and
exudation
Blockage of
paranasal sinuses
Sinusitis and persistent
infection
273. Clinical Features
Acute bacterial sinusitis:
Nasal or postnasal discharge (of any quality)
Daytime cough (which may be worse at night)
Headache
Retro-orbital pain
Facial pain
Tenderness, redness and swelling of the cheek and
near inner canthus of the eye
Fever at least 102°F (39°C).
274. Clinical Features
Chronic bacterial sinusitis:
Persistent or recurrent attack of nasal or postnasal
discharge
Low grade fever
Malaise
Sniffing
Nose twitching
Mouth breathing
Epistaxis
Ear discharge
275. Diagnosis
Nasal examination showing
mucus or pus
X-ray of paranasal sinus
showing air- fluid filled
levels and complete
opacification
CT scan
Nasal swab culture
276. Management
Chronic bacterial
sinusitis:
Prolonged antibiotic
therapy, nasal drops of
oxymetazoline HCI,
breathing exercise, nose
blowing and radical sinus
surgery.
Acute bacterial
sinusitis:
Antibiotic therapy with
amoxicillin,
decongestants, mucolytic
agents, nasal drops and
avoiding contacts with
URI.
281. Non-surgical Management
• Fresh blood and clots
should be removed with
suction.
• Topical vasoconstrictors,
packing and cauterization
will stop the bleeding
effectively.
Surgical Management
• Arterial ligation,
submucosal resection
(SMR)/septoplasty
• Embolization of the
internal maxillary artery
in case of failed
surgery
Management
282. Preventive Measures
• To avoid nose-picking as much as possible.
• During the winter and allergic seasons, do not blow
the nose harshly but gently.
• When participating in any physical activities that can
harm the nose and head, wear a protective helmet for
safety measures.
• To avoid the consumption of excess alcohol and
smoking.
• Make use of saline nasal spray or saline nose drops
once or twice a day to keep the nose moisturized.
285. Etiology of Acute Pharyngitis
Rhinovirus
Adenovirus
Coronavirus
Parainfluenza virus
Bacterial Viral
Group A beta hemolytic
Streptococcus
Neisseria gonorrhoea
Corynebacterium
diphtheria.
286. Clinical Features
Viral pharyngitis:
• Fever
• Malaise
• Anorexia
• Sore throat
• Hoarseness of voice
• Conjunctivitis
• Coryza (inflammation of the mucous membrane in the
nose)
• Cough
• Diarrhea
287. Clinical Features
Bacterial pharyngitis
• Beefy, red swollen uvula
• petechiae on the palate; excoriated nares (especially in
infants) and a scarlitiniform (Scarlet fever) rash
• Sudden onset of sore throat
• Severe pain on swallowing
• Fever
• Headache
• Nausea
• Vomiting
• Abdominal pain
288. Diagnosis
• Streptococcal pharyngitis is
treated with oral
antimicrobial therapy
(penicillin, erythromycin or
amoxicillin) for 10-14 days.
• Supportive therapy includes
antipyretics, analgesics,
antitussives, bed rest and
saline gargles.
• Throat culture.
• Rapid antigen
detection tests.
Treatment
290. Causes
Bacteria cause 15-30 percent of
pharyngotonsillitis cases
The herpes simplex virus
Streptococcus pyogenes
Epstein-Barr virus (EBV)
Cytomegalovirus (CMV)
Adenovirus
Group B Strep is the cause for most bacterial
tonsillitis – strep throat
292. Treatment
Chronic tonsillitis:
Tonsillectomy is indicated
when there is recurrent
infections of >7 episodes per
year, peritonsillar abscess
and severe hypertrophy of
tonsils.
Acute tonsillitis:
Saline gargles
Analgesics
Antibiotics
295. Clinical Features
Acute adenoiditis:
Purulent rhinorrhea
Nasal obstruction
Mouth breathing
Epistaxis
Fever
Associated Otitis
Media
Nasal change in voice.
Chronic adenoiditis:
Persistent rhinorrhea
Postnasal drip
Malodorous breath
Associated otitis media >3
months
Open mouth
Drooling and mal-occluded
teeth (adenoid faces)
Pulmonary hypertension.
296. Treatment
Surgical: Adenoidectomy if recurrent rhinosinusitis or
severe adenoid hypertrophy occurs.
Conservative treatment:
includes nasal decongestants,
antihistaminic and antibiotic
therapy.
298. Nursing diagnosis
1. Ineffective airway clearance
related to postoperative
secretions Pain related operative
procedure.
2. Risk for deficient fluid volume
related to bleeding.
3. Deficient knowledge related to
home care.
299. Nursing Intervention
• Monitoring oxygen saturation especially
when they sleep. Observing bleeding for
initial 6 hours which is crucial for primary
bleeding.
• Prevention of bleeding from site of operation.
• Maintain IV access until discharge.
• Position the child in comfortable or prone
position turning the head to one side to allow
the drainage of secretions.
300. Nursing Intervention
• Measure and record intake and output hourly.
Assess skin turgor and moisture of mucous
membranes.
• Adequate rest and sleep.
• Soft non irritating diets and plenty of fluids.
• Avoid contacts with infected persons.
• Avoid use of straw to prevent injury to the site.
Practice nose breathing.
• Discourage excessive coughing and clearing the
throat.
302. CONCLUSION
Eye and ENT disorders in children are very
common though most are not life threatening.
But the anatomical structures involved are
important and most may make the child
physically challenged if left untreated. So it is
the duty of the community, parents and
health care workers to actively be involved in
the care of children with these disorders
