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Course: Pediatric Nursing

Topic: Nursing Care of Child With Eye Disorders IV

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Module Goals

Learners will be able to:

Define retinopathy of prematurity, congenital cataract, and vision loss.
List signs/symptoms of the above eye disorders in children.
Identify related diagnostic procedures.
Describe evidence-based management of the above eye disorders.
Discuss the nursing management of a child with the above eye disorders.

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Visual Disorders in Children

Retinopathy of prematurity
Congenital cataract
Vision loss

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Retinopathy of Prematurity (ROP)

An eye disease affecting some infants born before 31 weeks or who weigh less than 3 pounds at birth.

Caused by abnormal blood vessel growth in the retina.

National Eye Institute, 2022

American Academy of Ophthalmology,2022

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Retinopathy of Prematurity (ROP): Stages

5 different stages of ROP

Stages 1 and 2:

Usually resolves without treatment
Monitor infants carefully for worsening

Stage 3:

Some may resolve without treatment
Others may need treatment to prevent abnormal blood vessels from damaging the retina and causing retinal detachment

National Eye Institute, 2022

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Retinopathy of Prematurity (ROP): Stages (Continued)

5 different stages of ROP

Stage 4 :

Infants have partially detached retinas and need treatment

Stage 5:

The retina detaches completely
Even with treatment, infants may have vision loss or blindness

National Eye Institute, 2022

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Retinopathy of Prematurity (ROP): Symptoms

There are no signs of ROP that may be seen

If an infant had ROP that caused damage:

Eyes wander, shake, or make other unusual movements
Eyes don’t follow objects
Pupils look white
Trouble recognizing faces

National Eye Institute, 2022

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Retinopathy of Prematurity (ROP): Symptoms (Continued)

Instant who had ROP are also more likely to have other eye problems as they get older:

Retinal detachment
Nearsightedness
Amblyopia (lazy eye)
Strabismus (Crossed eyes)

National Eye Institute, 2022

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Retinopathy of Prematurity (ROP): Risk

Infants born before 30 weeks of pregnancy or weigh less than about 3 pounds at birth
Also more likely to develop ROP if they have:

Too much oxygen therapy to treat breathing problems
Infections
Medical problems with their heart, lungs, or brain

National Eye Institute, 2022

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Retinopathy of Prematurity (ROP): Causes

The blood vessels of the retina start to develop in the fourth month of pregnancy and finish developing around the due date.
If an infant is born very early, these blood vessels may stop developing normally.
The retina then develops new blood vessels that are abnormal (called retinal neovascularization).
The retinal neovascularization may pull the retina up off the back of the eye (type of retinal detachment).

National Eye Institute, 2022; Medlineplus, n.d

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Retinopathy of Prematurity (ROP): Diagnosis

Eye examination:

A dilated eye exam a few weeks after birth (usually between weeks 4 to 9)

Treatment:

Laser treatment
Injections (anti-VEGF drugs)
Eye surgery: 2 types of retinal surgery

Scleral buckle surgery
Vitrectomy

National Eye Institute, 2022

American Academy of Ophthalmology,2022

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Laser treatment. Infants with advanced ROP may need laser treatment on the sides of the retina. This treatment may help keep ROP from getting worse and help protect the child’s vision

Injections. Doctors may also inject medicines called anti-VEGF drugs into the infant’s eye. These medicines work by blocking the growth of blood vessels

Surgery:

Scleral buckle surgery. The doctor places a flexible band around the sclera (the white part of the eye). The band supports the detached retina until the eye starts growing normally, then the doctor removes it.
Vitrectomy. The doctor makes small openings in the eye wall to remove most of the vitreous (the gel-like fluid that fills the eye) and replace it with saline solution. The doctor then removes the scar tissue on the retina. They may also do laser treatment to treat the retina and seal it in position

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Retinopathy of Prematurity (ROP): Nurses Role

Focus on reducing risk factors:

Quiroga & Moxon, 2017

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Retinopathy of Prematurity (ROP): Nurses Role

Oxygen Monitoring:

Ensure the concentration of oxygen is optimum by setting the alarms on oxygen monitors and respond quickly.
Maintain oxygen saturation within the targets for 24-hour care (88% and 95%).

(Low level or high level of oxygen may cause ROP)

Quiroga & Moxon, 2017

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Retinopathy of Prematurity (ROP): Nurses Role

Nutrition:

Essential for the normal growth and development and helps to reduce the risk of infection and ROP.

Infection Prevention:

Hand washing (when entering the unit, before and after each procedure).
Careful skin preparation before placing venous venous access devices
Limit visitors.

Quiroga & Moxon, 2017

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Retinopathy of Prematurity (ROP): Nurses Role

Maintain Temperature:

Preterm infants are not able to shiver if they become cold and compensate by consuming more oxygen, which increases their oxygen requirements.
Control the surrounding environment

Incubators, or hats and warmed cots
Kangaroo mother care

Quiroga & Moxon, 2017

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Retinopathy of Prematurity (ROP): Nurses Role

Supportive Care:

Reduce stress by reducing noise and bright lights and position infants in comfortable position and their limbs are supported.
Encourages breastfeeding.

Health Education:

Hand hygiene
Breastfeeding
Routine eye exams

Quiroga & Moxon, 2017

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Critical Thinking Question

The nurse is taking care of a child diagnosed with retinopathy of prematurity.

Which client symptom supports this diagnosis?.

An eye that wanders inward and upward
Leukoria
Painful swelling near the inside corner of the eye
Rainbow-colored halos around lights

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Pediatric Cataract

Clouding of the lense of the eyes
One of the leading causes of treatable childhood blindness
May lead to amblyopia
Early recognition, diagnosis helps to prevent complications
May be unilateral or bilateral

Gupta & Patel, 2021

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Pediatric Cataract: Causes

Idiopathic
Intrauterine infection: TORCH, rubella
Drug induced: corticosteroids
Metabolic disorders: Hypocalcemia, hypoglycemia
Trauma: Accidental, non-accidental, radiation
Other ocular diseases: Microcornea
Renal diseases
Skeletal diseases

Gupta & Patel, 2021

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Etiology

Causes of pediatric cataracts are diverse and may range from being idiopathic to being associated with systemic disorders. They may be unilateral or bilateral based on etiology. A majority of unilateral and some bilateral cases are idiopathic.

Idiopathic
Intrauterine infection (TORCH infections- toxoplasma, CMV retinitis, rubella, HSV)
Drug-induced

Corticosteroids

Metabolic disorders

Galactosemia
Galactokinase deficiency
Hypocalcemia
Hypoglycemia

Trauma

Accidental
Non-accidental
Radiation
Laser photocoagulation

Other associated ocular diseases

Microphthalmia, Microcornea
Aniridia
Persistent hyperplastic primary vitreous (PHPV)
Peter anomaly
Corneal guttae
Coloboma

Inherited without systemic abnormalities

Autosomal dominant (most common)
Autosomal recessive (mostly seen in families with a history of consanguinity)
X-linked

Associated with systemic abnormalities

Chromosomal abnormalities

Trisomy 21
Turner syndrome
Trisomy 13
Trisomy 18
Cri-du-chat syndrome

Cerebro-oculofacial-skeletal syndrome (COFS)
Mitochondrial abnormalities

Complex I deficiency

Renal disease

Lowe syndrome

Skeletal disease

Smith-Lemli-Opitz
Conradi syndrome
Weill-Marchesani syndrome

Syndactyly, polydactyly, or digital abnormalities

Bardet-Biedl syndrome
Rubenstein-Taybi syndrome

Central nervous system abnormalities

Zellweger syndrome
Meckel-Gruber syndrome

Cardiac disease

Hypertrophic cardiomyopathy

Dermatological

Cockayne syndrome
Rothmund-Thomson
Atopic dermatitis
Incontinentia pigmenti
Progeria
Ichthyosis
Ectodermal dysplasia

Dental Anomalies

Nance-Horan syndrome
Lenz syndrome

Causes of bilateral congenital cataracts:

Idiopathic
Intrauterine infection (TORCH infections- toxoplasma, CMV retinitis, rubella, HSV)
Multisystem genetic disorder
Inborn errors of metabolism
Endocrinopathies
Trauma
Uveitic cataract

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Pediatric Cataract: Signs and Symptoms

Poor vision: Child has difficulty recognizing and following objects or people with their eyes.
Rapid uncontrolled eye movements or "wobbling" eyes – known as nystagmus.
Eyes pointing in different directions known as a squint
White or grey pupil.

NHS, 2022

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Pediatric Cataract: Diagnosis

Newborn screening: Done within 72 hours of birth, again in 6-8 weeks old.

Vision Test (Children): Every 2 years until 16 years of age

NHS, 2022

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Pediatric Cataract: Treatment

Cataract Surgery:

Performed in hospital under general anesthesia
Needs hospital for overnight stay for close monitoring

Post Surgery

Pad or transparent shield will be placed over the child's eye to protect it
Eye Drops to reduce swelling and redness
Glasses or contact lenses
Wearing a patch over the operated eye

NHS, 2022

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Pediatric Cataract: Nursing Interventions

Check visual acuity
Teach parent/patient about cataracts and their treatment
Teach patient/parent about healthy diet
Educate about medication compliance
Monitor eye redness, eye pain
Detailed documentation

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What Would the Nurse Do?

Which discharge instructions should the nurse provide to the parents of a child diagnosed with cataracts? (Select all that apply.)

Recommend cool liquids and soft diet
Educate about medication compliance
Monitor eye redness, eye pain
Monitor oxygen saturation levels
Teach patient/parent about healthy diet

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Vision Loss in Children

Vision loss refers to the partial or complete loss of vision
May happen suddenly or over a period of time
Some types of vision loss never lead to complete blindness

Partial blindness- having very limited vision
Complete blindness- unable to see anything, cannot see light

Vision worse than 20/200, with glasses or contact lenses, are considered legally blind in most states in the United States

A.D.A.M. Medical Encyclopedia [Internet], 2020

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Vision Loss in Children: Causes

Inherited conditions related impaired development or degeneration of retina, optic nerve, melanin pigments.
Cataracts, glaucoma, nystagmus, cerebral visual impairments.
Brain injury, infections or degeneration of the eye.

Department of Communities, Child Safety and Disability Services, Queensland Government, 2014

A.D.A.M. Medical Encyclopedia [Internet], 2020

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Vision Loss in Children: Signs/symptoms

Heightened sensitivity to light, glare
Not reacting to bright light when a bright light is turned on
Getting closer to objects for clarification
Using other senses such as touch and hearing to support vision
Cautious approach when walking
Getting close to floor level to feel changes in ground surfaces before walking over them

Department of Communities, Child Safety and Disability Services,

Queensland Government, 2014

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Vision Loss in Children: Diagnostics

History:

Onset, severity, progression of visual symptoms
Family history of visual impairment
Impact of disorder on the child’s psychosocial functioning
Prior use of low vision aids, including glasses

Eye exams may include:

Visual acuity, visual fields, contrast sensitivity, refraction and accommodative capacity, color vision
Dilating eyes with eye drops to examine eye structures
Imaging scans of deeper eye structures

Department of Communities, Child Safety and Disability Services, Queensland Government, 2014

Bregman et al., 2022

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Vision Loss in Children: Management

Glasses with special absorptive filters and side shields for children sensitive to glare
Early intervention services that include:

Speech and language development
Educational and social development,
Positioning and mobility skills
Support to develop basic life skills (e.g. eating, drinking, bathing and dressing)

Occupational therapist may help enhance gross and fine motor abilities to maximize activities of daily living and independence

Department of Communities, Child Safety and Disability Services, Queensland Government, 2014

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Vision Loss in Children: Management (Continued)

Special attention to the psychosocial impact of low vision on a child critical for comprehensive and effective care.
Early intervention is associated with improved outcomes compared to low vision support initiated at school age.
Services for vision loss alleviate restrictions in social activities, sports, and other hobbies or leisure activities, thereby helping to improve quality of life.

Department of Communities, Child Safety and Disability Services, Queensland Government, 2014

Bregman et al., 2022

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Nurses Role in Management of Children with Vision Loss

Identify signs/symptoms of vision loss in child, quickly refer to ophthalmologist.
Ensure child and family’s concerns are addressed appropriately.
Inform and assist child and family to access the resources available in the community:

Services for vision loss

Rehabilitation centers, braille classes, mental health specialists

Support for child and family dealing with vision loss

Organizations, peer-support groups, etc

Bregman et al., 2022

Hadavanc et al., 2013

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What Would the Nurse Do?

Which of the following are true regarding vision loss?

Some type of vision loss never lead to blindness
Vision loss may be cured with early intervention
Cataracts, glaucoma, nystagmus may cause vision loss
Surgery is available option to treat blindness

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Red Flags

More than half of children with vision impairment also have at least one other developmental disability, such as intellectual disabilities, cerebral palsy, hearing loss, or epilepsy.

CDC, 2020

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Cultural Considerations

Religion, culture, beliefs, and ethnic customs may influence how families understand and use health concepts:

Health beliefs: In some cultures talking about a possible poor health outcome will cause that outcome to occur.
Health customs: In some cultures family members play a large role in health care decision-making.
Ethnic customs: Differing gender roles may determine who makes decisions about accepting & following treatment recommendations.

AHRQ, 2020

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Cultural Considerations (Continued)

Religion, culture, beliefs, and ethnic customs may influence how families understand and use health concepts:

Religious beliefs: Faith and spiritual beliefs may effect health seeking behavior and willingness to accept treatment.
Dietary customs: Dietary advice may be difficult to follow if it does not fit the foods or cooking methods of the family.
Interpersonal customs: Eye contact or physical touch may be ok in some cultures but inappropriate or offensive in others.

AHRQ, 2020

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References:

A.D.A.M. Medical Encyclopedia [Internet]. (2020, August 18). Blindness and vision loss. https://medlineplus.gov/ency/article/003040.htm#:~:text=Vision%20loss%20refers%20to%20the,never%20lead%20to%20complete%20blindness.

American Academy of Ophthalmology. (2022). What Is Retinopathy of Prematurity (ROP)?.https://www.aao.org/eye-health/diseases/what-is-retinopathy-prematurity

Andrews, M.M., Boyle, J.S. & Collings, J. W. (2020). Transcultural Concepts in Nursing Care (8th Ed.). Wolters Kluwer, Philadelphia, PA.

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References:

Bregman, J., Sohal,P., Mishra, S., & deBeaufort, H. (2022, January 12). Pediatric Low Vision. In:P. Kumar (Ed.). American Academy of Opthalmology. https://eyewiki.aao.org/Pediatric_Low_Vision

Centers for Disease Control and Prevention. (2020). What is it like to not be able to see? https://www.cdc.gov/ncbddd/kids/vision.html#:~:text=Vision%20impairment%20is%20not%20very,older%20people%20than%20in%20children

Quiroga A & Moxon S. (2017). Preventing sight-threatening ROP: the role of nurses in reducing the risk. Community Eye Health.30(99):53-54. PMID: 29434437; PMCID: PMC5806219 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5806219/

Contact info: info@nursesinternational.org

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References:

Department of Communities, Child Safety and Disability Services, Queensland Government. (2014). My child has vision impairment: Information for Queensland families of young children. https://www.publications.qld.gov.au/dataset/my-child-has-information-for-queensland-families-of-young-children/resource/8b459352-2505-4874-a794-c2cdf1717d9d

Gupta, P., Patel, B.C., (2021, Nov 2). Pediatric Cataract. StatPearls Publication. https://www.ncbi.nlm.nih.gov/books/NBK572080/

Hadavand, M.B., Heidary, F., Heidary, R., & Gharebaghi, R. (2013). Role of ophthalmic nurses in prevention of ophthalmic diseases. Med Hypothesis Discov Innov Ophthalmol, 2(4):92-5.https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4017631/

Contact info: info@nursesinternational.org

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References:

Medlineplus. (n.d). Retinopathy of prematurity. https://medlineplus.gov/ency/article/001618.htm

National Eye Institute. (2022). Retinopathy of Prematurity. https://www.nei.nih.gov/learn-about-eye-health/eye-conditions-and-diseases/retinopathy-prematurity#:~:text=Retinopathy%20of%20prematurity%20(ROP)%20is,the%20back%20of%20your%20eye

NHS. (2022, April 13). Overview: Childhood Cataract. https://www.nhs.uk/conditions/childhood-cataracts/

Nizami, A. A., Gulani, A. C., Redmond, S. B. (2022, May 8). Cataract (Nursing). StatPearls Publication. https://www.ncbi.nlm.nih.gov/books/NBK568765/

Contact info: info@nursesinternational.org

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