A child is not simply a miniature adult. Children’s eyes as well as their visual needs tend to differ from those of adults in a number of important ways: Vision is critical to a child’s early educational, functional, and social development. For the most part, children have different lifestyles than adults. Children spend more time outside than adults, experiencing up to three times more sun exposure. Children are the most physically active of any age group with a higher risk for sports-related eye injuries. Computer and video game use create special demands on vision. These differences make the approach to vision and eye care quite different in the child than in the older patient.
It can be difficult for kids to articulate a vision problem. (A more extensive list of telltale signs is available on the VCA’s Check Yearly See Clearly Website.) Although it is beneficial for parents to be aware of the indicators of a vision problem, they should also know that not all problems can be observed by them; and that only an eye doctor has the training and equipment to diagnose an issue.
In addition to the information available through Transitions, there are many other resources in the industry that offer information on kids’ eyesight: AllAboutVision.com is a consumer-focused Website owned by Access Media Group. The site's content is broadly-focused, but it has a guide for parents with useful information written by a team of journalists who have extensive experience in the eyecare field. CheckYearly.com , is another Website for consumers, sponsored by the Vision Council of America. While its content is not solely focused on kids either, it provides a section on kids’ eyes, an interactive “Kids Zone,” and a section for teachers with information on the “ABC's of Eyecare” and “What Students Should Know About Eye Care.” Sponsored by two eyecare practices located in Kansas, ChildrensVision.com is a Website that exists to educate parents and teachers about frequently overlooked vision problems in the hopes of helping those children who struggle unnecessarily because of undiagnosed vision disorders. The site provides many free articles that cover the full spectrum of children’s eye health needs and Opticianry / Optometry extensive materials. InfantSEE is a public health program designed to ensure that eye and vision care becomes an integral part of infant wellness care to improve a child's quality of life. Created by members of the American Optometric Association in partnership with The Vision Care Institute of Johnson & Johnson Vision Care, the program’s Website features information-packed sections for parents, doctors and the media. Since 1908, Prevent Blindness America has been the nation's leading volunteer eye health and safety organization with the sole mission of preventing blindness and preserving sight. The organization’s Website features tips for parents on taking their child to the eye doctor and keeping their eyes safe from injury, as well as home eye tests for children.
Peadiatric Eye Conditions
Pediatric Eye Conditions Vishakh Nair M.Optom,FIACLE(Australia) Sr.Faculty. Doctor of Optometry (OD), Ministry of Higher Education ,KSA.Ex- Associate Professor, Bharati Vidyapeeth University Medical College – Optometry Dept.
Essential Pediatric Skills• Knowledge of Growth and Development• Development of a Therapeutic Relationship• Communication with children and their parents• Understanding of family dynamics and parent-child relationships: IDENTIFY KEY FAMILY MEMBERS• Knowledge of Health Promotion & Disease Prevention• Patient Education and Anticipatory Guidance• Practice of Therapeutic and Atraumatic Care• Patient and Family Advocacy• Caring, Supportive & Culturally Sensitive Interactions• Coordination and Collaboration• CRITICAL THINKING
Equipment What’s in Your setting?• Airway support equipment, Ambu-bags• Stethoscope & Sphygmomanometer• Pen Light• Pulse Ox & Cardiac Monitor• Nebulizer• Otoscope / Opthalmoscope• O2
The single most important part of the health assessment is……the
History Bio-graphic Demographic Past Medical History• Name, Date of Birth, Age •Allergies •Past illness• Parents & siblings info •Trauma / hospitalizations• Cultural practices •Surgeries• Religious practices •Birth history• Parents’ occupations •Developmental• Adolescent – work info •Family Medical/Genetics Current Health Status •Immunization Status •Chronic illnesses or conditions •What concerns do you have today?
Review of Systems• Ask questions about each system• Measurements: weight, height, head circumference, growth chart, BMI• Nutrition: breastfed, formula, favorite foods, beverages, eating habits• Growth and Development: Milestones for each age group
HEENT: Head & Neck, Eyes, Ears, Nose, Face, Mouth & Throat• Head: Symmetry of skull and face• Neck: Structure, movement, trachea, thyroid, vessels and lymph nodes• Eyes: Vision, placement, external and internal fundoscopic exam• Ears: Hearing, external, ear canal and otoscopic exam of tympanic membrane• Nose: Structure, exudate, sinuses• Mouth: Structures of mouth, teeth and pharynx
Cranial NervesC1 - SmellC2 - Visual acuity, visual fields, fundusC3, 4, 6 - EOM, 6 fields of gazeC5 - Sensory to face: Motor--clench teeth,C5 & C7 - Corneal reflexC7 - Raise eyebrows, frown, close eyes tight, show teeth, smile, puff cheeks, taste--anterior 2/3 tongueC8 - Hearing & equilibriumC9 – say "ah," equal movement of soft palate & uvulaC10 - Gag, Taste, posterior 1/3 tongueC11 - Shoulder shrug & head turn with resistanceC12 - Tongue movement
Glasgow Coma Scale 1 2 3 4 5 6 N/A N/AEYES Does not Opens eyes Opens Opens eyes open eyes in response eyes in spontaneously to painful response stimuli to voice N/AVERBAL Makes no Incomprehen Utters Confused, Oriented, sounds sible sounds inappropri disorientated converses ate words normallyMOTOR Makes no Extension to Abnormal Flexion / Localizes Obeys movements painful stimuli flexion to Withdrawal to painful commands painful painful stimuli stimuli stimuli Source :Wikipedia
• To see clearly, light rays must be bent or refracted by the cornea and lens so they can focus on the retina (layer of light-sensitive cells lining the back of the eye).• Retina sends image to the brain through optic nerve.
Children’s Vision• Approximately 75% of learning comes through the eyes• Good vision is critical to a child’s early educational, functional, and social development
Vision Examinations for ChildrenThe Eye experts recommends that children get a comprehensive eye exam:At 6 months of ageAt 3 years of ageBefore beginning 1st gradeEvery 1-2 years thereafter as indicated
Some Signs of Poor Vision• Trouble seeing the blackboard• Difficulty reading /loses place often• Jerky eye movements• Frequent blinking /watering• Squinting / Redness / Rubbing
Some signs of poor vision (cont.)• Tilts the head when looking at something• Over-sensitive to light• Covers one eye while reading• Sits very close to the TV• Sees double• Poor concentration
Fixation and Following of light should be looked for and documented before 4 months of age Fixation should be Central, Steady and Maintained
In hospital Electrophysiologicalmeasures such as the VisualEvoked potential (VEP) may beused. VEPs are electrical signalsproduced in the visual systemwhen a target is seen. Thesesignals are recorded withelectrodes lightly attached tothe scalp at the back of thehead while the child watchespatterns on a computer screen.These visual acuity testsmeasure ’resolution acuity’.
OptokineticNystagmus Presence or absence ofnystagmus on gentlerotation of OKN drumquantifies visual acuityin babies
Preferential looking- teller acuity chartsYoung children or those with communication difficultiescan be tested using methods that don’t require thepatient to speak or point. Most commonly lookingresponses are assessed to estimate visual acuity
Vision testing - 3-5 years of age Matching optotypes
Children may be asked to identifyletters or pictures either by naming or matching them with a key card.
Examination Visual Acuity in Children• Children > 6 years old• Use standard Snellen Chart at 20 ft (6 mtrs)• Most common ocular condition in this age group is myopia – blurred vision at distance – can develop over several months
Examples of visual acuity charts:(A) Snellen, (B) HOTV, (C) Lea, (D) Allen
Color Vision Test• Detects difficulty in ability to recognize color• Children with color blindness are not actually blind to color, but simply have difficulty identifying and distinguishing between different colors• Color Deficiencies are usually hereditary and affect 1 in 12 boys but only 1 in 200 girls
Amblyopia• Amblyopia: poor vision in an eye that did not develop normal sight during early childhood; sometimes called “lazy eye.”• While usually only one eye is affected by amblyopia, both eyes can be “lazy.” Amblyopia is common, affecting 2 or 3 out of every 100 people• Best time to correct amblyopia is during infancy/early childhood.
AMBLYOPIA• Reduced Central Vision in the absence of an organic cause• Pathophysiology: – Obstruction of visual axis – Strabismus – Anisometropia – Severe Ametropia
Causes of amblyopia• Cloudiness in the normally clear eye tissues.• Cataract in one or both eyes can lead to amblyopia; surgery may be necessary. Cloudy corneas• Any factor that prevents a clear image from being focused inside the eye can lead to development of amblyopia.
Treating Amblyopia• Weaker eye must be made stronger; child must be made to use the weak eye.• Patching: patch placed over better- seeing eye to make child use and develop good vision in “lazy eye.”• Eyedrops: Atropine placed in better-seeing eye daily to blur vision; forces the child to use “lazy Patching the eye eye.”
DIAGNOSIS OF STRABISMUS• Corneal Light Reflex• Cover-Uncover Test Strabismus vs Pseudostrabismus
The corneal light reflex test involves shining a light onto the childs eyes from a distance and observing the reflection of the light on the corneawith respect to the pupil. The location of the reflection from both eyes should appear symmetric andgenerally slightly nasal to the center of the pupil. (A) Normal corneal light reflex.(B) Corneal light reflex in Esotropia. (C) Corneal light reflex in Exotropia.
VITAMIN A DEFICIENCY• Xerophthalmia Bitots spots Night blindness Corneal Xerosis Corneal ulcer[Keratomalacia] Treatment of Keratomalacia For children older than 1 year- oral vit A 200,000 IU on day one, 200,000 IU on second day and additional dose repeated 2-4 weeks later Less than 1 year – Half the above dose
Cataracts in Paediatric patients• Opacity in lens• Can be: Visually significant or not Stable or Progressive Congenital or Acquired Unilateral or Bilateral Partial or Complete• Congenital: incidence 6/10 000 10% of childhood blindness
Evaluation• Screen newborns with red reflex test• History : Family Maternal infections• Examination: systemic diseases or syndromes• Workup: Bilateral cases without known hereditary basis TORCH screen s-glucose s-calcium, phosphate Urine: reducing substances (galactosaemia) amino acids ( Lowe syndrome) haematuria (Alport syndrome)
Ocular examination• Formal estimate of vision not possible in neonate Special tests: Preferential looking test, visually evoked potentials• Density and position of cataract• Morphology• Associated ocular pathology• Indicators of severe visual impairment : No fixation Nystagmus Strabismus
The visually significant cataract• In central visual axis, bigger than 3mm• Posterior cataract• No clear zones in between• Retinal details not visible with direct ophthalmoscope• Nystagmus or strabismus present• Poor central fixation after 8 weeks
Treatment• Surgery: Cataract extraction and intraocular lens implantation for visually significant cataract• By 6 weeks of age• Bilateral cases: 1 week apart• Non visually significant cases : careful observation, possible pupillary dilation
The Power of Nursing Never doubt how vitally important you are; never doubt how important your work is – and never expect anyone to acknowledge it before you do. Every moment, in everything you do, you are making a difference. In fact, you are in the business of making a difference in other people’s lives.In that difference lies their healing and your power. Never forget it.