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Pediatric Eye Conditions                 Vishakh Nair         M.Optom,FIACLE(Australia)        Sr.Faculty. Doctor of Optom...
Essential Pediatric Skills•   Knowledge of Growth and Development•   Development of a Therapeutic Relationship•   Communic...
Equipment       What’s in Your setting?• Airway support  equipment, Ambu-bags• Stethoscope &  Sphygmomanometer• Pen Light•...
The single most important part of the health assessment is……the
History    Bio-graphic Demographic     Past Medical History•   Name, Date of Birth, Age    •Allergies                     ...
Review of Systems• Ask questions about each system• Measurements: weight, height, head  circumference, growth chart, BMI• ...
Physical Assessment• General               •   Heart• Skin, hair, nails     •   Abdomen• Head, neck,           •   Genital...
H E E N THead       Eyes              Ears                     Nose                            Neck                       ...
HEENT: Head & Neck, Eyes, Ears,       Nose, Face, Mouth & Throat• Head: Symmetry of skull and face• Neck: Structure, movem...
Cranial NervesC1 - SmellC2 - Visual acuity, visual fields, fundusC3, 4, 6 - EOM, 6 fields of gazeC5 - Sensory to face: Mot...
Glasgow Coma Scale                1              2              3               4             5           6               ...
• To see clearly, light rays  must be bent or refracted by  the cornea and lens so they  can focus on the retina (layer  o...
Children’s Vision• Approximately 75%  of learning comes  through the eyes• Good vision is  critical to a child’s  early ed...
Vision Examinations for ChildrenThe Eye experts recommends that children get a comprehensive eye exam:At 6 months of age...
Some Signs of Poor Vision• Trouble seeing the blackboard• Difficulty reading /loses place often• Jerky eye movements• Freq...
Some signs of poor vision (cont.)• Tilts the head when looking at  something• Over-sensitive to light• Covers one eye whil...
Fixation and Following of light should be looked for and          documented before 4 months of age  Fixation should be C...
Corneal light reflexes in an infant
In hospital Electrophysiologicalmeasures such as the VisualEvoked potential (VEP) may beused. VEPs are electrical signalsp...
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 te...
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.
LEA Symbol Charts
Examination Visual Acuity in          Children• Children > 6 years old• Use standard Snellen  Chart at 20 ft (6 mtrs)• Mos...
Snellen Chart & Tumbling E
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...
Color Vision Tests
Color Vision Test• Equipment:   – Occluder   – Pseudo-Isochromatic     Test Plates• Referral Criteria   – Student fails if...
creening the red reflex- Bruckners test The quality of red reflex should be assessed by pediatriciansefore discharging new...
Assessment of Red Reflex Gross difference in the quality of red reflex of both eyesis indicative of refractive errors and...
Monocular Behavioral Test Vision R.E. < Vision L.E.
Pupillary Examination• Direct penlight into eye while patient  looking at distance• Direct  – Constriction of ipsilateral ...
Summary of steps in eye exam•   Visual Acuity•   Pupillary examination(PERRLA)•   Visual fields by confrontation•   Extrao...
Refractive Errors –Myopia,Hyperopia,Astigmatism
Amblyopia•   Amblyopia: poor vision in an eye    that did not develop normal sight    during early childhood;    sometimes...
AMBLYOPIA• Reduced Central Vision in the absence of an  organic cause• Pathophysiology:   – Obstruction of visual axis   –...
Causes of amblyopia• Cloudiness in the normally  clear eye tissues.• Cataract in one or both eyes  can lead to amblyopia; ...
Treating Amblyopia•   Weaker eye must be made    stronger; child must be made to    use the weak eye.•   Patching: patch p...
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 o...
Cover Test
MANAGEMENT OFSTRABISMUS PATIENT   • Visual Acuity   • External Exam   • Motility   • Refraction   • Funduscopy   • Neurolo...
LACRIMAL DRAINAGE APPARATUS• Absence or stenosis of puncta &/or canaliculi• Nasolacrimal Duct Obstruction (Up to 4% of inf...
LACRIMAL DRAINAGE APPARATUS• Congenital Dacryocele: Probing• Dacryocystitis:        Systemic  Antibiotics
INFANTILE GLAUCOMA• Rare: 1/10,000 Live Births• Sporadic (80-90%) or Familial (A.R.) (10-20%)• Bilateral but Asymmetric in...
LEUKOCORIA• Retinoblastoma• Cataract• Retrolental:          Vitreous Hemorrhage, R.O.P.,          P.H.P.V.• Retino-choroid...
PRESENTATION OF RETINOBLASTOMA •   Leukocoria •   Strabismus (Poor Vision) •   Proptosis, Photophobia, “Red Eye” •   Famil...
OPTIC NERVE Swelling• Papilledema:   (+) Ophthalmoscopy, Normal V.A.,• Papillitis or Optic Neuritis:   (+) Ophthalmoscopy,...
Optic Nerve Hypoplasia• Poor Vision, Nystagmus   Small, Pale Nerve Head   CNS defects may or may not be associated   (M.R....
OPTIC ATROPHY• Acquired  – Orbital and/or Intracranial Tumor  – From Papilledema or Hydrocephalus  – Retinal Dystrophy
Retinopathy Of Prematurity.
SCREENING   Retinopathy Of Prematurity• High Risk: B.W.: < 1,500 GM; <32 week GA• Low Risk: B.W.: 1,500 - 2,500 GM (O 2 Rx...
INTERNATIONAL     CLASSIFICATION OF R.O.P.• Stage I:     Demarcation Line• Stage II:    Ridge• Stage III:   Ridge and Neov...
OCULAR TRAUMA• Iritis• Hyphema      Rebleed      Glaucoma      Sickle Cell• Internal Injury      Lens: Dislocation, Catara...
VITAMIN A DEFICIENCY•  Xerophthalmia   Bitots spots   Night blindness   Corneal Xerosis   Corneal ulcer[Keratomalacia...
Cataracts in Paediatric patients• Opacity in lens• Can be: Visually significant or not          Stable or Progressive     ...
Classification : Acquired               cataracts• Systemic diseases : Diabetes mellitus                   : Myotonic dyst...
Congenital cataracts: Bilateral•   Genetic Mutation : Autosomal Dominant•   Metabolic         : Galactosaemia             ...
Evaluation• Screen newborns with red reflex test• History : Family            Maternal infections• Examination: systemic d...
Ocular examination• Formal estimate of vision not possible in neonate  Special tests: Preferential looking test, visually ...
The visually significant            cataract• In central visual axis, bigger than 3mm• Posterior cataract• No clear zones ...
Treatment• Surgery: Cataract extraction and intraocular lens            implantation for visually significant cataract• By...
Pseudophakic eye
Topical Drugs Used for                Diagnosis:             Fluorescin Dye• Fluorescein strip:                           ...
Anesthetics• Example:   – Propracaine Hydrochloride 0.5% (Alcaine)   – Tetracaine 0.5%• Uses:   –   Anesthetize cornea wit...
Mydriatics (pupil dilation)•    Two classes:    1. Cholinergic-blocking ( parasympatholytic)    2. Adrenergic-stimulating ...
Cycloplegics (pupil dilation+paralysis•   Action  of accommodation)    –   Dilate by paralyzing iris sphincter muscle    –...
We KnowIt’s a Jungle Out There!
The Power of Nursing Never doubt how vitally important you are;  never doubt how important your work is – and never expect...
Resources•   AllAboutVision.com•   CheckYearly.com•   ChildrensVision.com•   InfantSEE™•   Prevent Blindness America•   Ey...
Peadiatric Eye Conditions
Peadiatric Eye Conditions
Peadiatric Eye Conditions
Peadiatric Eye Conditions
Peadiatric Eye Conditions
Peadiatric Eye Conditions
Peadiatric Eye Conditions
Peadiatric Eye Conditions
Peadiatric Eye Conditions
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Peadiatric Eye Conditions

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Peadiatric Eye Conditions

  1. 1. 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.
  2. 2. 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
  3. 3. Equipment What’s in Your setting?• Airway support equipment, Ambu-bags• Stethoscope & Sphygmomanometer• Pen Light• Pulse Ox & Cardiac Monitor• Nebulizer• Otoscope / Opthalmoscope• O2
  4. 4. The single most important part of the health assessment is……the
  5. 5. 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?
  6. 6. 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
  7. 7. Physical Assessment• General • Heart• Skin, hair, nails • Abdomen• Head, neck, • Genitalia, Tanner Scale, lymph nodes • Rectal• Eyes, ears, nose, • Musculoskeletal: feet, throat legs, back, gait• Chest, Tanner Scale
  8. 8. H E E N THead Eyes Ears Nose Neck Throat
  9. 9. 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
  10. 10. 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
  11. 11. 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
  12. 12. • 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.
  13. 13. 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
  14. 14. Vision Examinations for ChildrenThe Eye experts recommends that children get a comprehensive eye exam:At 6 months of ageAt 3 years of ageBefore beginning 1st gradeEvery 1-2 years thereafter as indicated
  15. 15. Some Signs of Poor Vision• Trouble seeing the blackboard• Difficulty reading /loses place often• Jerky eye movements• Frequent blinking /watering• Squinting / Redness / Rubbing
  16. 16. 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
  17. 17. Fixation and Following of light should be looked for and documented before 4 months of age  Fixation should be Central, Steady and Maintained
  18. 18. Corneal light reflexes in an infant
  19. 19. 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’.
  20. 20. OptokineticNystagmus Presence or absence ofnystagmus on gentlerotation of OKN drumquantifies visual acuityin babies
  21. 21. 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
  22. 22. Vision testing - 3-5 years of age Matching optotypes
  23. 23. Children may be asked to identifyletters or pictures either by naming or matching them with a key card.
  24. 24. LEA Symbol Charts
  25. 25. 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
  26. 26. Snellen Chart & Tumbling E
  27. 27. Examples of visual acuity charts:(A) Snellen, (B) HOTV, (C) Lea, (D) Allen
  28. 28. 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
  29. 29. Color Vision Tests
  30. 30. Color Vision Test• Equipment: – Occluder – Pseudo-Isochromatic Test Plates• Referral Criteria – Student fails if does not correctly identify the number on the card
  31. 31. creening the red reflex- Bruckners test The quality of red reflex should be assessed by pediatriciansefore discharging newborn babies.
  32. 32. Assessment of Red Reflex Gross difference in the quality of red reflex of both eyesis indicative of refractive errors and strabismus
  33. 33. Monocular Behavioral Test Vision R.E. < Vision L.E.
  34. 34. Pupillary Examination• Direct penlight into eye while patient looking at distance• Direct – Constriction of ipsilateral eye• Consensual – Constriction of contralateral eye
  35. 35. Summary of steps in eye exam• Visual Acuity• Pupillary examination(PERRLA)• Visual fields by confrontation• Extraocular movements• Inspection of – lid and surrounding tissue – conjunctiva and sclera – cornea and iris• Anterior chamber depth• Lens clarity• Tonometry• Fundus examination – Disc – Macula – Vessels
  36. 36. Refractive Errors –Myopia,Hyperopia,Astigmatism
  37. 37. 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.
  38. 38. AMBLYOPIA• Reduced Central Vision in the absence of an organic cause• Pathophysiology: – Obstruction of visual axis – Strabismus – Anisometropia – Severe Ametropia
  39. 39. 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.
  40. 40. 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.”
  41. 41. DIAGNOSIS OF STRABISMUS• Corneal Light Reflex• Cover-Uncover Test Strabismus vs Pseudostrabismus
  42. 42. 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.
  43. 43. Cover Test
  44. 44. MANAGEMENT OFSTRABISMUS PATIENT • Visual Acuity • External Exam • Motility • Refraction • Funduscopy • Neurologic Exam
  45. 45. LACRIMAL DRAINAGE APPARATUS• Absence or stenosis of puncta &/or canaliculi• Nasolacrimal Duct Obstruction (Up to 4% of infants) < 6 m.o.: Topical Antibiotics and Massage > 8 m.o.: Probing (office vs. OR) Balloon Dilatation > 2 years, Downs: Silastic Intubation
  46. 46. LACRIMAL DRAINAGE APPARATUS• Congenital Dacryocele: Probing• Dacryocystitis: Systemic Antibiotics
  47. 47. INFANTILE GLAUCOMA• Rare: 1/10,000 Live Births• Sporadic (80-90%) or Familial (A.R.) (10-20%)• Bilateral but Asymmetric in 80%• Signs and Symptoms: - Epiphora, Photophobia and/or Blepharospasm• Primary; Secondary: Aniridia, Sturge Weber Syndrome, Rubella, Steroid-Induced, Aphakia, Uveitis...
  48. 48. LEUKOCORIA• Retinoblastoma• Cataract• Retrolental: Vitreous Hemorrhage, R.O.P., P.H.P.V.• Retino-choroidal: Coloboma, Toxoplasmosis, Retinal Detachment
  49. 49. PRESENTATION OF RETINOBLASTOMA • Leukocoria • Strabismus (Poor Vision) • Proptosis, Photophobia, “Red Eye” • Family History
  50. 50. OPTIC NERVE Swelling• Papilledema: (+) Ophthalmoscopy, Normal V.A.,• Papillitis or Optic Neuritis: (+) Ophthalmoscopy, Decreased V.A.• Retro-bulbar Neuritis (-) Ophthalmoscopy, Decreased V.A.,* Pseudopapilledema
  51. 51. Optic Nerve Hypoplasia• Poor Vision, Nystagmus Small, Pale Nerve Head CNS defects may or may not be associated (M.R.I., Endocrine Eval)
  52. 52. OPTIC ATROPHY• Acquired – Orbital and/or Intracranial Tumor – From Papilledema or Hydrocephalus – Retinal Dystrophy
  53. 53. Retinopathy Of Prematurity.
  54. 54. SCREENING Retinopathy Of Prematurity• High Risk: B.W.: < 1,500 GM; <32 week GA• Low Risk: B.W.: 1,500 - 2,500 GM (O 2 Rx)• Examine at: 4-6-weeks of age, Before Discharge
  55. 55. INTERNATIONAL CLASSIFICATION OF R.O.P.• Stage I: Demarcation Line• Stage II: Ridge• Stage III: Ridge and Neovascularization Stage IV: Partial Retinal Detachment• Stage V: Total Retinal Detachment* Plus Disease: Posterior Pole, Retinal Vascular Dilatation and Tortuosity
  56. 56. OCULAR TRAUMA• Iritis• Hyphema Rebleed Glaucoma Sickle Cell• Internal Injury Lens: Dislocation, Cataract Vitreous Hemorrhage Retinal Hole, Edema• Conjunctival and Corneal Foreign Body/Abrasion
  57. 57. 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
  58. 58. 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
  59. 59. Classification : Acquired cataracts• Systemic diseases : Diabetes mellitus : Myotonic dystrophy : Atopic dermatitis : Neurofibromatosis• Ocular diseases : Chronic anterior uveitis : High myopia : Fundus dystrophies eg Retinitis pigmentosa• Drugs : Corticosteroids : Chlorpromazine• Trauma : Blunt : Sharp
  60. 60. Congenital cataracts: Bilateral• Genetic Mutation : Autosomal Dominant• Metabolic : Galactosaemia : Lowe : Hypoparathyroidism :• Infective : TORCH organisms• Chromosomal : Trisomy 21 (Down) : Trisomy 18 (Edward) : Trisomy 13 (Patau)• Skeletal : Hallerman-Streiff : Nance-Horan• Ocular anomalies : Aniridia : Anterior segment dysgenesis syndrome• Idiopathic : in 50%
  61. 61. 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)
  62. 62. 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
  63. 63. 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
  64. 64. 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
  65. 65. Pseudophakic eye
  66. 66. Topical Drugs Used for Diagnosis: Fluorescin Dye• Fluorescein strip: Orange yellow dye – water soluble Cobalt blue light Eye with corneal ulcer Orange becomes green
  67. 67. Anesthetics• Example: – Propracaine Hydrochloride 0.5% (Alcaine) – Tetracaine 0.5%• Uses: – Anesthetize cornea within 15 sec, last 10 mins – Remove corneal foreign bodies – Perform tonometry – Examine damaged corneal surface• Side effects: – Allergy: local or systemic – Toxic to corneal epithelium ( inhibit mitosis, migration)
  68. 68. Mydriatics (pupil dilation)• Two classes: 1. Cholinergic-blocking ( parasympatholytic) 2. Adrenergic-stimulating (sympathomimetic) Iris sphincter constrict pupil Pupillary dilator muscles
  69. 69. Cycloplegics (pupil dilation+paralysis• Action of accommodation) – Dilate by paralyzing iris sphincter muscle – Cycloplegia by paralyzing ciliary body muscles• Tropicamide Cyclopentolate • Max pupil dilatation 30 min Complete Cycloplegia • Effect diminishes 4-5 hrs • Used for refracting children • Side effects: – Rare – Nausea / vomiting – Pallor vasomotor collapse• Other examples: 1. Homatropine hydrobromide 1% or 2% 2. Atropine sulfate 0.5% or 1% 3. Scopolamine hydrobromide 0.25% or 5% (last 1-2 wks)
  70. 70. We KnowIt’s a Jungle Out There!
  71. 71. 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.
  72. 72. Resources• AllAboutVision.com• CheckYearly.com• ChildrensVision.com• InfantSEE™• Prevent Blindness America• Eyedidntknowthat.com

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