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
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!