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Course: Pediatric Nursing

Topic: Nursing Care of Child With Eye Disorders II

The Nurses International Community

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Module Goals

Learners will be able to:

Define subconjunctival hemorrhage, foreign body in eyes, corneal abrasion, and strabismus.
List signs/symptoms of above eye disorders in children.
Identify related diagnostic procedures.
Describe evidence-based management of above eye disorders.
Discuss the nursing management of a child with above eye disorders.

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Subconjunctival Hemorrhage (SCH)

Also called ‘Red-Eye’
Results from bleeding of the conjunctival or episcleral blood vessels and leaking into the subconjunctival space
Risk:

Elderly clients, especially those with underlying vascular disorders such as hypertension and diabetes
Younger clients tend to have more spontaneous or traumatic causes

Doshi & Noohani, 2022

Contact info: info@nursesinternational.org

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Subconjunctival Hemorrhage: Causes

Traumatic incidents
Use of contact lenses
Ocular surgeries
Local minor trauma such as eye rubbing or foreign body
Nonaccidental trauma: Traumatic asphyxia syndrome, normal vaginal delivery
Hypertension and other vascular disorders like diabetes
Spontaneous causes include elevated venous pressures such as coughing, vomiting, strenuous exercise/lifting
Menstruation

Doshi & Noohani, 2022

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Subconjunctival Hemorrhage: Signs and Symptoms

Usually there are no discomforting symptoms
May become aware of it in the mirror
In some cases, mild discomfort or foreign body-like sensation

Doshi & Noohani, 2022

Contact info: info@nursesinternational.org

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Subconjunctival Hemorrhage: Treatment and Management

Generally, no treatment indicated unless associated with a serious condition.
The blood is typically resorbed over 1-2 weeks depending on amount of extravasated blood.
Ice packs and artificial tears minimize tissue swelling and provide relief.
Emergent ophthalmology consultation to evaluate trauma.
Follow up monitoring: Advise caregivers to report abnormalities like decreased vision, eye pain, light sensitivity, recurrent subconjunctival hemorrhages.

Doshi & Noohani, 2022

Contact info: info@nursesinternational.org

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Subconjunctival Hemorrhage: Nurses’ Role

Monitor vital signs
Adjust medications
Apply cool pack if necessary
Monitor pain and swelling
Artificial tears may help if the eye feels ‘gritty’ or full
Educate client on subconjunctival hemorrhages and prognosis

(generally subsides within two weeks)

Doshi & Noohani, 2022

Contact info: info@nursesinternational.org

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What Would the Nurse Do?

The parents of a 7 years old child with subconjunctival hemorrhage asked the nurse what would happen to their child’s vision. What would be appropriate response by the nurse? (Select all that apply).

“Usually subconjunctival hemorrhage is harmless.”
“If trauma is the cause, it has to be assessed by the ophthalmologist.”
“We will need to monitor for the child for decreased vision, pain, light sensitivity.”
“Child might need to replace lens damaged due to the hemorrhage.”

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Foreign Body in Eyes

Any unexpected object logged in the conjunctiva or in the cornea

Objects might include

Dust, dirt, sand
Contact lenses, cosmetics, eyelashes
Sharps objects like glass piece, pencil lead, rusts
Plants
Insects

Children's Wisconsin; n.d.

University of Rochester Medical Center Rochester, n.d.

Better health Channel, 2020

The Children’s Hospital of Philadelphia, n.d.

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Foreign Body in Eyes: Signs and Symptoms

Sensation of a foreign object in the eye
Pain in the eye (specially while looking at the light)
Burning and irritation
Tearing of the eye
Excessive blinking
Rubbing the eye
Blurred vision or loss of vision in the affected eye
Bleeding into the white of the eye

Children's Wisconsin; n.d.

University of Rochester Medical Center Rochester, n.d.

Better health Channel, 2020

The Children’s Hospital of Philadelphia, n.d.

Contact info: info@nursesinternational.org

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Foreign Body in Eyes: Diagnosis

Usually diagnosed during complete medical history and physical examination of the eye
Local anesthetic drops in the eye may be used prior to exam
Fluorescein stain may be used to help confirm diagnosis and evaluate corneal abrasion
X-rays may be done to check the placement of the object (eyeball) or orbit

Children's Wisconsin; n.d.

University of Rochester Medical Center Rochester, n.d.

Better health Channel, 2020

The Children’s Hospital of Philadelphia, n.d.

Contact info: info@nursesinternational.org

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Foreign Body in Eyes: Treatment and Management

Removal of the foreign body by washing or extraction
Medicine: Antibiotic ointment or drops
Evaluation by an eye care provider
Eye patch for comfort
Tetanus vaccine
Referral to an ophthalmologist or optometrist for removal if needed
Follow up care after removal of foreign body

Children's Wisconsin; n.d.

University of Rochester Medical Center Rochester, n.d.

Better health Channel, 2020

The Children’s Hospital of Philadelphia, n.d.

Contact info: info@nursesinternational.org

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Foreign Body in Eyes: Care Advice at Home

Clean around the eye and face with a wet washcloth or moistened cotton swab
Position the side of the face over a pan of warm water
Have child try to open and close the eye while in the water

Use eye cup for flush
For younger children:

Fill a glass or pitcher with lukewarm tap water
Pour the water into the eye while holding child face up

Children’s Hospital Colorado, n.d

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Foreign Body in Eyes: Care Advice at Home

Pull the lower lid out by pulling down on the skin above the cheekbone for Particle Under the Lower Lid
For particle under upper lid, pull the upper lid out; draw it over the lower lid while the eye is closed

Children’s Hospital Colorado, n.d

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Critical Thinking Question

Which of the following are sign and symptoms indicate foreign body in the eye? (Select all that apply).

Pain in the eye
Tearing of the eye
Excessive blinking
Rubbing the eye
Bleeding into the white of the eye
Purulent discharge

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Corneal Abrasion

Superficial corneal defect due to scraping or rubbing of the corneal epithelium.
Usually caused by trauma or a foreign body

Characterized by

Normal vital signs
Visual acuity: Slightly blurred in affected eye
Diffuse conjunctival injection
Pupils react briskly to light
Presence of a foreign body under the upper or lower eyelid

Government of Canada, 2013

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Corneal Abrasion: Diagnostic Tests

Usually diagnosed in general physical examination of eye
Examination of visual acuity
Apply 1 to 2 drops of fluorescein stain to determine extent of damage

Government of Canada, 2013

Contact info: info@nursesinternational.org

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Corneal Abrasion: Treatment and Management

Pharmacologic Interventions

Instill topical anesthetic eye drop: Tetracaine 0.5% eye solution (Pontocaine), 2 drops, stat dose only
Instill a generous amount of antibiotic eye ointment (erythromycin) in the lower conjunctival sac

Government of Canada, 2013

Contact info: info@nursesinternational.org

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Corneal Abrasion: Treatment and Management

Client Education

On daily follow-up to ensure proper healing
Appropriate use of medications (type, dose, frequency, side effects)
Seeking medical help if pain increases or vision decreases before 24-hour follow-up
Wear protective glasses
No patch on the eye

Government of Canada, 2013

Contact info: info@nursesinternational.org

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Corneal Abrasion: Nursing Interventions

Be aware of the potentially negative consequences of corneal infections
Inspection of the cornea; report and document changes
Ensure the cleanliness of eyes
Lubricant eyes with prescribed ointment
Administer medications as prescribed
Support the child, caregivers/parents
Educate the parents on condition and self care at home

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What Would the Nurse Do?

A nurse suspects corneal abrasion in a 10 year of child brought in due to pain, irritation, and vision problems in the right eye. What intervention would the nurse anticipate in the management of this child? (Select all that apply).

Assess eye for presence of foreign body
Assess visual acuity
History taking for trauma to the eye
Wearing eye patch
Keeping eye clean, handwashing

Contact info: info@nursesinternational.org

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Strabismus

Also called ‘squint’, is a condition in which the eyes are misaligned
While one eye is directed at an object, the other eye may constantly or intermittently :

Turn in (esotropia)
Turn out (exotropia)
Turn up (hypertropia)
Turn down (hypotropia)

Sawers, Jewsbury, & Ali, 2017

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Strabismus in Children

Newborn may have a normal intermittent horizontal strabismus
Strabismus beyond the age of 3 months should be referred for further investigations
May be accompanied by abnormal motility of one or both eyes, double vision, decreased vision, ocular discomfort, headaches, or abnormal head posture

Children’s Health Queensland Hospital and Health Service, n.d.

Sawers, Jewsbury, & Ali, 2017

Contact info: info@nursesinternational.org

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Strabismus in Children: Consequences

Impair visual development of affected eye in children < age 7

Unless treated before age 7-8, becomes permanent.

Often causes reduced visual acuity called amblyopia (lazy eye) and impaired stereopsis (binocular depth perception).
May be stigmatised at school, and suffer from low self-esteem

Psychological effects continue to adulthood.

Family may worry about restrictions on career options for their child.

Children’s Health Queensland Hospital and Health Service, n.d.

Sawers, Jewsbury, & Ali, 2017

Contact info: info@nursesinternational.org

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Strabismus in Children: Red Flags

May be sign of serious pathology like retinoblastoma or intracranial tumour
Red flags that mandate urgent investigation by specialist:

Abnormal red reflex
Limited abduction
Double vision
Headaches
Nystagmus
Face turned to the side
Other neurological features- strabismus may be associated with neurological disease such as cerebral palsy

Children’s Health Queensland Hospital and Health Service, n.d.

Sawers, Jewsbury, & Ali, 2017

Teodorescu, 2015

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Strabismus in Children: Assessment/Diagnosis

Assessment should also focus on red flags for other serious conditions
History:

Age of onset
Frequency and direction of deviation
Child or parental concerns about vision
Birth history — including developmental history
Wearing of glasses and family history
Behavioral issues, history of ADHD or autism, etc.

Children’s Health Queensland Hospital and Health Service, n.d.

Sawers, Jewsbury, & Ali, 2017

Contact info: info@nursesinternational.org

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Strabismus in Children: Assessment/Diagnosis (Continued)

Examinations:

Visual acuity (VA)- usually older than 3yrs

If too young to check VA, ascertain whether the child may fix and follow – using a toy or a light

Cover test
Ocular motility
Fundus examination, red and white reflex
Pupillary reactions and sizes
Abnormal head posture

Children’s Health Queensland Hospital and Health Service, n.d.

Sawers, Jewsbury, & Ali, 2017

Contact info: info@nursesinternational.org

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Strabismus in Children: Management

Early intervention helps improve vision
Ophthalmologist may prescribe treatment /management:

Glasses
Patching of non-squinting eye (or blurring the vision per non-squinting eye with atropine drops)
Surgery

Children’s Health Queensland Hospital and Health Service, n.d.

Sawers, Jewsbury, & Ali, 2017

Contact info: info@nursesinternational.org

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Nursing Role in Management of Strabismus

Early referral of child with strabismus to ophthalmologist
Address child and family concerns
Assess for psychosocial impact on the child
Coordinate with child, family, and school teachers to assist child overcome negative psychosocial impact of strabismus

Contact info: info@nursesinternational.org

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What Would a Nurse Do?

Parents of the child with strabismus asks the nurse how strabismus may be treated. What would be appropriate response by the nurse ? (Select all that apply).

“It is best to treat strabismus before age of 9.”
“Depending on the cause, glasses or eye-patch may be prescribed.”
“Ophthalmologist may recommend surgery after thorough assessment of the eye.”
“If eye-patch is prescribed, it has to be worn in the affected eye for a month.”

Contact info: info@nursesinternational.org

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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

Contact info: info@nursesinternational.org

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References:

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

Better health Channel. (2020, August 20). Eye injuries - foreign body in the eye. https://www.betterhealth.vic.gov.au/health/conditionsandtreatments/eye-injuries-foreign-body-in-the-eye

Children’s Health Queensland Hospital and Health Service. (n.d.). Referral guideline – Strabismus (squint). https://www.childrens.health.qld.gov.au/referral-guideline-strabismus-squint/

Contact info: info@nursesinternational.org

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References:

Children’s Hospital Colorado. (n.d). Eye - Foreign Object. https://www.childrenscolorado.org/conditions-and-advice/conditions-and-symptoms/symptoms/eye-foreign-body-or-object/

Children's Wisconsin. (n.d.). Eye Trauma: Foreign bodies in the eye. https://childrenswi.org/medical-care/eye-program/eye-conditions/eye-trauma/foreign-bodies-in-the-eye

Domingo, E., Moshirfar, M., Zabbo, C.P. 9 2021, Jul 25). Corneal Abrasion. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK532960/

Contact info: info@nursesinternational.org

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References:

Doshi, R., & Noohani, T. (2022 Feb 23). Subconjunctival Hemorrhage. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK551666/?report=classic

Sawers, N., Jewsbury, H., & Ali,N. (2017). Diagnosis and management of childhood squints: investigation and examination with reference to red flags and referral letters. Br J Gen Pract, 67(654):42-43. https://bjgp.org/content/67/654/42

Teodorescu, L. (2015). Anomalous head postures in strabismus and nystagmus diagnosis and management. Rom J Ophthalmol,59(3):137-40. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5712957/

Contact info: info@nursesinternational.org

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References:

Government of Canada. (2013). Clinical Practice Guidelines for Nurses in Primary Care: Adult Care - Chapter 1 - Eyes. https://www.canada.ca/en/indigenous-services-canada/services/first-nations-inuit-health/health-care-services/nursing/clinical-practice-guidelines-nurses-primary-care/adult-care/chapter-1-eyes.html#c4

The Children’s Hospital of Philadelphia. (n.d.). Foreign Bodies in the Eye. https://www.chop.edu/conditions-diseases/foreign-bodies-eye

University of Rochester Medical Center Rochester. (n.d.). Foreign Bodies in the Eye in Children. https://www.urmc.rochester.edu/encyclopedia/content.aspx?contenttypeid=90&contentid=P02816

Contact info: info@nursesinternational.org

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