Eye Got It!John Davis RN, MSN, FNP-BC

ALL people by nature desire to know. An indication of this is the delight we take in our senses; for even apart from their usefulness they are loved for themselves; and above all others the sense of sight.

Aristotle, first line of “Metaphysics”

Anatomy

Fundoscopy

Vocabulary Strabismus- (cross eye) when both eyes don’t look at the

same place at the same time.

Amblyopia- (lazy eye) is the loss or lack of development of central vision in one eye

Esotropia- Form of strabismus in which the eye turns inward.

Exotropia-Form of strabismus in which the eye turns outward.

Anisocoria- unequal pupil size

Dyscoria- irregular pupil shape

Leukocoria- white pupil

Proptosis- Bulging of the eye anteriorly out of the orbit

Diplopia- double vision

Ptosis- Drooping of the upper eyelid

Myopia- near-sightedness (objects that are near are clear, objects far away appear blurred)

Hyperopia- far-sightedness (objects that are far are clear, objects that are close are blurry)

Normal Developmental Timeline of Vision

Visual Acuity at birth is 20/800 to 20/1000

Visual Acuity at age 6 months is 20/40 to 20/80 Age 6 months to 3 years the child should be able to fixate and

follow a face, a toy or a light.

Visual Acuity at age 3 to 5 years is 20/40 or better No more than 1 line acuity difference between eyes

Visual Acuity at age 6 and older should be better than 20/40 Refer for visual acuity 20/40 and above

Should not have any acuity difference between eyes.

Visual acuity less than 20/40 is needed for admission to military, law enforcement, aviation industry, and commercial truck driving.

Myopia affects about 30% of the U.S. population

How to Assess the Eye

Check Visual Acuity Use a pinhole if student forgot glasses/contact lenses

Check Pupil Size- are they equal, anisocoria?

Check Tracking and Convergence

Inspect the lids

Inspect the conjunctivae- bulbar vs. palpebral

Cover Test- To assess for Strabismus / Amblyopia

With Lights Turned Down Check Pupil Response- Reactive to light? Afferent Pupillary

Defect- Optic Nerve or Retinal disorder

Hirschberg Test

Red Reflex

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Tracking Ocular Tracking is the name given to the ability of

the eyes to move smoothly, together, to follow an object moving horizontally and vertically. Important to assess after an eye injury for signs of

extraocular movement entrapment.

In education, tracking refers to eye movement along a fixed target, as in reading.

In the past, some children with central processing dysfunctions (learning disabilities) were suspected of difficulty with tracking as a result of, or associated with, a learning disability. There is no scientific evidence to support this notion.

Most educators no longer ascribe to this view.

Convergence

A normal response is a movement of both eyes nasally, with convergence of the two axes of the eyes.

An inability of the eyes to converge may be related to: Problem with extraocular

muscles

Neurological disorder

If abnormal- refer immediately to ophthalmology

Strabismus

Perform the cover-uncover test with children age three years and older.

Can be treated and corrected if detected within the first 10 years of life.

Treatment is attempted for older children as well but not always correctible.

Occurs in 5-7% of children.

May have persistent squinting, head tilting, face turning, awkwardness, or decreased visual acuity in one eye.

Treatment:

Correct refractive error if present.

Eye patching- good eye

Atropine drops

Surgical correction

Strabismus

Strabismus

Refer immediately if new onset strabismus develops in a school age child.

Need to rule out tumor: Glioma

Astrocytoma

Neuroblastoma

Medulloblastoma

Viral Conjunctivitis

Most commonly adenovirus.

Adenovirus does not have a lipid coat.

Usually watery discharge, occasionally purulent.

Tender swollen preauricular lymph node.

Contagious for 7-10 days.

Treat with artificial tears, frequent hand washing.

Bacterial Conjunctivitis

Usually caused by Staph aureus, Strep pneumo, or H. influenzae.

70% of staph resistant to erythromycin

Can treat with bacitracin, avoid neomycin (neosporin)

Purulent discharge

Eyes crusted shut

Can return to school after 24 hours of antibiotic treatment.

Allergic Conjunctivitis Almost always involves both

eyes.

Eyes are red and itchy

No preauricular lymph node swelling or tenderness

Allergic Shiners

Clear drainage or stringy mozzarella cheese looking drainage

Not contagious but uncomfortable

Ophthalmic anti-histamines and opthalmic mast cell stabilizers to treat

Subconjunctival Hemorrhage

Does it affect vision?

Is it painful? If no- you have your

diagnosis.

Broken blood vessel under the surface of the eye.

Can be caused by a strong sneeze or cough.

Harmless

Resolves in 10-14 days.

Orbital Cellulitis

Orbital Cellulitis

Ocular emergency

No history of injury

Eye is red, warm to touch, swollen, painful

Orbit has a direct line to the central nervous system via the optic nerve- child needs to be hospitalized for IV antibiotics.

Orbital Wall Fracture Ocular emergency

Check the extraocular movments of the eye.

If eye is trapped, consider orbital wall fracture and seek emergency care.

Assess vision- if decreased or vision loss seek emergency care.

If proptosis present or open/perforated globe suspected- shield the eye and seek immediate emergency care.

Retinoblastoma

Cancer of the retina

Typically develops before age 5

Leukocoria- white pupil

Absent red reflex

Particularly noticeable in photographs taken with a flash

Autosomal dominant- often family history of retinoblastoma

Curable when diagnosed early

Which part of the body has the thinnest layer of skin?

Hordeolum (Stye)

Hordeolum (Stye) Localized inflammatory swelling of one or more of

the glands of the eyelid

Mildly tender

May discharge purulent fluid

Exclude from school if draining until on antibiotics.

Treatment:Warm compresses

Massage

Topical antibiotics if pointing outward

Occasionally incision and drainage

Chalazion

Chalazion Chronic version of stye.

Meibomian gland is the main sebaceous gland of the eye.

If the meibomian gland becomes plugged or constipated- chalazion forms.

Treatment:

Warm Compresses

Massage

Oral antibiotics if infection is present as topical will not infiltrate the area.

If above treatment is not effective, surgical excision is necessary.

Cornea The cornea is a smooth, transparent, avascular structure that

covers the iris and joins with the sclera and conjunctival reflection at the limbus.

The cornea functions as a protective window, allowing light to pass in to the eye.

The cornea is richly innervated by the trigeminal, or fifth cranial, nerve and is therefore exquisitely sensitive to touch.

Corneal Ulcer

White or gray spot on the cornea

Very painful

Refer immediately

Causes: Contact Lense Wearers

Bacterial infection

Herpes simplex or zoster infection

Corneal abrasion (scratch on the eye) if it becomes infected

Chemical burn

Mydriasis

Thank you!