PEDIATRIC VISION OR HEARING DISORDERS
- congenital or acquired unevenness of the curvature of the cornea
Disorders That Interfere w Vision
Refractive Vision
- light rays do not always focus onto the retina accurately as the
child grows older > hyperopia
o hyperopia begins to diminish at 5 yrs of age, if hyperopia
remains, child needs medical interventions
- light rays can also focus at a point in front of the retina > myopia
o tends to be familial; 10% of school-age children
hyperopia
- light rays do not always focus onto the retina accurately as the
child grows older
o focusing on close objects w strong accommodation
o tx: glasses w convex lens
myopia
*often progresses into the teen years, when it plateaus and remains for life
- focuses on objects by squinting and rubbing their eyes > changes
shape of eye globe
o similar Ssx: tearing, red-rimmed eyes, pressing on eyes
o tx: glasses w concave lenses
Therapeutic Management
- contact lenses
o 5 year olds are capable of putting them in and taking out
o 12 year olds can be relied to appropriate care for lenses
- Laser in situ keratomeleusis (LASIK)
o Incision under the cornea to change the contour of the
eye globe
o Postop: disturbed tear function for 1 or more mos →
prevent surface damage w artificial tears or ointments
Astigmatism
- light rays coming to the retina to not be all refracted in the same
way >> an uneven quality of vision
o if given page of print, they may see only half the letters
Signs & Symptoms
- headache and vertigo after doing close work
- deceptively normal on vision screening tests
o able to see all of the numbers on a chart by tilting head
TX: corrective lenses or contact lenses (smooths out curvature of cornea)
Nystagmus
- rapid, irregular eye movement, either vertically or horizontally
- not a disease but symptoms of underlying disease
- occurs with vision-impairing lesions (congenital cataracts)
- also occurs as a neurologic sign if there is a lesion of the
cerebellum or brainstem
Amblyopia
- subnormal vision in one eye; the child may be using only one eye
for vision while “resting” the other eye
- if progresses severely: central vision fails to develop > functionally
blind in one eye
o one eye focuses more readily than the other, they come
to depend on only the easily focused eye
- can also develop from strabismus
Assessment: screened w preschool E chart at routine health visits
o 20/50 vision (normal for preschool age) in one eye, and
the other eye shows lessened vision
Therapeutic Management
* correctable if treated during the preschool period
* prognosis for correction is considerable diminished after 6 years of age
o May not be possible after 9 or 10 yrs of age
 - good eye is covered by a patch held firmly in place
o initially, child may develop headaches or dizziness and
notice poor depth perception
o removed for 1 hour each day
- levodopa in addition to occlusion therapy
- Atropine: for pupil dilation and blurred vision when dropped into
the better eye
Color Vision Deficit (Color Blindness)
- inability to perceive color correctly
- one of the sets of cones of the retina that perceive red, green, or
blue is absent
o inability to distinguish red from green or blue from
yellow
o some are unable to see any colors
- inherited as a sex-linked disorder and occurs in about 8% of boys
- high incidence w hemophilia, congenital nystagmus, or g6pd
- no therapy for color deficit
Structural Problems Of The Eye
Coloboma
- congenital incomplete closure of the facial cleft; may involve:
o only the lower eyelid (notch in lid),
o iris, giving it the shape of a keyhole, rather than a circle
o ciliary body, the lens, the choroid, the retina,
o and the optic nerve
- Children w retina and optic nerve coloboma will have some vision
impairment in the affected eye
Hypertelorism
- congenital condition involving abnormally wide-spaced eyes
- associated with chromosomal abnormalities: Waardenburg’s
syndrome (also involves congenital hearing impairment)
- Detecting true hypertelorism:
o measure distance between the pupils and compared
with standards for the child’s age
Signs & Symptoms
- white forelock of hair, different-colored irises, and eyebrows that
tend to grow together in the center line
- newborn: broad-bridged nose c/a wide-spaced eyes, can hear no
sound
Ptosis
- inability to raise the upper eyelid normally so the eyelid always
remains slightly closed
- may be congenital (frequently hereditary and bilateral) or
acquired (usually unilateral)
- may be a result of injury to the third cranial nerve (neurogenic) or
to the lid or levator muscle
- always rule our myasthenia gravis
Signs & Symptoms
- dilated pupil
- Inability to rotate the eye globe upward, medially, or downward
- Weakness of accommodation (looking at near objects)
- tend to wrinkle their forehead and raise their eyebrows more
than usual in an attempt to lift the eyelid further
- cock their heads back to see under the lowered lid
Therapeutic Management
- correction surgery
o if ptosis obstructs vision, surgery must be done ASAP to
prevent amblyopia
Strabismus
- unequally aligned eyes (cross-eyes) caused by unbalanced muscle
control; hereditary
Signs & Symptoms
- the resting position of one eye may be divergent (turned out) or
convergent (turned in)
- One pupil may be higher than the other (vertical strabismus)
- may be monocular (same eye deviates constantly) or alternating
strabismus (one eye and then the other deviates)
- exotropia (eye turning out), esotropia (eye turning in), or
hypertropia (eye turning up)
Assessment
- if infant demonstrate strabismus past 6 weeks of age
o referred for diagnosis and treatment
- Infant demonstrate a constant strabismus before 6 wks of age
o need referral right away
- detected best when children examine a nearby object
o when they read small print, they turn both eyes medially,
or converge
o if farsighted in one eye, they turn the affected eye in
more than the other (strabismus)
o if one eye is nearsighted, they will not need to turn
that eye in as far as the other one (divergence)
latent strabismus
- able to maintain fusion, the strabismus is not overt
o w maintaining fusion, they experience eye strain
o headaches; tired, irritated eyes; nausea and vomiting
pseudostrabismus
- often close one eye or tilt their head to decrease the double
vision
- may tilt their head so much they appear to have a torticollis, or
“wry neck”
- cannot see well and may be too young to describe what is
happening to them but are fussy
Therapeutic Management
* eye correction for strabismus must be done before 6 years of age
- If the fusion mechanism is weak:
o eye exercises (orthoptics)
- If eyes are diverging with attempted convergence r/t hyperopia or
myopia:
o glasses to correct the basic visual defect
- If the misalignment is caused by unequal muscle strength:
o injection of botulinum toxin into the eye muscle
o eye muscle surgery (post-op: adm antibiotics ointment
for 2 to 3 days, eye patch not required)

- flat, broad-bridged noses, a narrow interpupillary distance, and an

epicanthal fold or oval shaped palpebral fissures
o less white sclera visible in the inner margin of the eye
than normally > eye appears to be turned in
- cover test reveals condition
o covered eye will not move after being uncovered.
o It only appears to be turned medially because of the
obscured sclera at the inner canthus
- Hirshberg’s test

Concomitant Strabismus

- Most usual type found in children

- All the muscles of the eye are functioning but are not functioning
together
- Deviation is equally apparent in all directions of gaze

Paralytic strabismus

- c/a by paralysis of a muscle or nerve due to birth injury or lesion

- eyes appear straight except when they are moved in the direction
of the paralyzed muscle
- double vision occurs, and the crossed eye is evident
Infection or Inflammation Of The Eye

Stye Inclusion blennorrhea Keratitis

Chalazion Acute catarrhal conjunctivitis Periorbital cellulitis

Blepharitis marginalis Herpetic conjunctivitis Dacryostenosis

Conjunctivitis Allergic conjunctivitis Dacryocystitis

Traumatic Injury to Eye
Signs & Symptoms
- acute pain immediately after the incident
- eyes tear and sensitive to light, blinks rapidly
- have fear of not being able to see clearly
- eyelid edema forms quickly
Assessment
- visualize the inner surface of the lower lid and the bottom half of
the eye globe
o press firmly on the lower lid with your fingertip until it
turns out
- inner surface of the upper lid and the upper portion of the eye
globe
o evert upper eyelid, ask child to look downward
o Grasp the eyelashes and gently stretch the upper eyelid
downward
- MRI: excellent method for documenting internal eye damage
after an injury
Contusion Injuries
Therapeutic Management
- few drops of a topical anesthetic instilled into the eye
o relieves pain; allow eye to opened for examination
o Explain child what is happening and that an examiner is
“just looking”
black eye:
o May not be able to open eyes immediately due to reflex
spasm
- Remove foreign body is removed by touching it with a moistened,
sterile, cotton-tipped applicator while the lid is everted
Tx:
- If the FOREIGN BODY IS METALLIC & has been in cornea for hours
> rust ring
- If a foreign object is relatively large > puncture of eye globe
o To be examined by ophthalmologist
o Surgery to explore depth to puncture; to save sight
- AFTER REMOVAL corneal ulceration or abrasion from the foreign
body will stain green and be readily apparent
o This is because conjunctiva was touched with a strip of
filter paper impregnated with fluorescein stain
- CORNEAL TISSUE REGENERATION:
o eye is washed with an antibiotic solution and then closed
and patched (patch should be left in place)
- complication: SYMPATHETIC IRITIS
o inflammation of the opposite eye; when ciliary body was
involved in injury
o blindness in noninjured eye
o prevention: corticosteroid & antibiotics: reduces
inflammation
o tx: removal of injured eye (enucleation)
- eye injury from blunt trauma
- eye & surrounding tissue hemorrhages and becomes edematous
- limited motion; dilated, fixed, or cloudy pupil; cloudy lens or
cornea; loss of vision in the eye; blood in anterior chamber
- inspect the eye globe, assess vision in the eye, fundoscopic exam
- Evaluate extraocular eye movements for adequate function
[if no eye injury present]

Foreign Bodies
- REMOVED by irrigation with a sterile normal saline solution or by
gentle wiping with a well-moistened, sterile, cotton-tipped
applicator after the eyelid is everted
o child will blink a few times after the upper lid is returned
to its place
o after a few minutes, child will report feeling “fine” again
- If a FOREIGN BODY ADHERES TO THE CORNEA: ophthalmologist
will remove it
- ice pack to the eye (20 minutes on, 20 minutes off, and repeat)
o Reabsorption of hemorrhage in the tissue surrounding
the eye will take place over the next 1 to 3 wks
Blowout fracture
- Limited eye movements or reports o diplopia
- fracture line is trapping intraorbital tissue and preventing the eye
globe from moving freely
Tx: refer to ophthalmologist; surgery
Eyelid Injuries - other surgery technique: laser therapy
- do not adm atropine sulfate before surgery
- accompany eye globe injuries or present after foreign body entry
- after surgery: restrict rough play activities for 1 week
complication: - follow up appointment for eye pressure assessment after 1 month

- deep eyelid laceration > permanent ptosis > cataract

- inner canthal laceration > dacryostenosis
o Tx: refer to ophthalmologist - marked opacity of the lens

causes

- dominantly inherited condition

Inner Eye Conditions
Congenital Glaucoma
- Increased IOP in the eye due to inadequate or blocked drainage of
aqueous humor
o Increased fluid content that accumulates causes the
globe of the eye to increase in size
o pressure in the eye globe continues to rise, compressing
and ultimately destroying the optic nerve
- gray to green color of the retina or red reflex after sight is lost
- mostly, condition is bilateral, recessive gene inheritance
Signs & Symptoms
- enlarged, edematous, hazy cornea
- tearing, pain, and photophobia
- eye globe may feel tense to finger palpation
- galactosemia
- result of steroid use or radiation exposure
- infants who contacted rubella prenatally
- if opacity is on anterior surface of lens: birth injury or contact
between the lens and the cornea during intrauterine life
- if opacity is on edge of lens: result of nutritional deficiency during
intrauterine life (rickets or hypocalcemia)
Signs & Symptoms
- white pupil opening (leukocoria)
- red reflex elicited by shining a light into the pupil appears white
infant: lack of response to a smile or inability to reach, grasp an object, nystagmus
older children: blurred vision because of cataract formation
Therapeutic Management

Assessment - surgical removal of the cloudy lens then insertion of an internal

intraocular lens
- measured w tonometer o may be performed at age 3 mos if total lens is involved
o eye pressure tension > 12 – 20 mmHg o if not done before 6 mos: amblyopia
o if adm w anesthesia: caution child not to rub eyes 4 h post-op:
after examination o eye patching is not necessary unless infant is amblyopic
▪ corneal abrasion r/t corneal sensitivity triggered o sedative to help them rest for 24 hours
by eye rubbing o Introduce fluids cautiously; prevent vomiting (vomiting
Therapeutic Management increases IOP)
o If unusually restless, fussy, crying: notify MD ASAP
- goniotomy or trabeculotomy o Prevent crying (crying increases IOP)
o construction of new opening to canal of Schlemm o mydriatic agent to dilate the pupil and steroids to
o adm acetazolamide (Diamox): suppress aqueous humor prevent postop development of pupillary adhesions
 Hearing Loss Disorders of the Ear
a. conduction loss: interference with sound reaching the inner ear
- can occur if external canal is obstructed w cerumen or foreign
External Otitis
body, if the tympanic membrane is damaged or immobile,
or if the middle ear is filled with fluid (serous otitis media) - inflammation of the external ear canal
improvement of hearing w hearing aid - rarely threatens hearing or causes permanent damage
- causes discomfort: itching & extreme pain
b. nerve or sensorineural loss: inner ear or the 8th cranial nerve is - no history of a recent respiratory infection
affected
- results from diseases that affect the transmission of sound causes
sensation to the cerebral cortex or from a pathologic condition of
- hx of swimming
the cochlea
- foreign object pushed into ear canal
- may be congenital
- may be a result of drug therapy or infection (meningitis) Signs & Symptoms
- can occur from exposure to loud sound
- itching of the canal, then pain
- When the external ear is touched, the pain becomes acute
Hearing Impairment
- In some instances; Eardrum is inflamed
Causes
- moisture in the canal (from swimming) > inflammation >
- Treacher Collins syndrome, otosclerosis, osteogenesis imperfecta, secondary infection (Pseudomonas and Candida)
and Waardenburg’s syndrome - if fungal infection is present: entire canal is brown or black
- Prenatal rubella infection - if inflammation is from foreign body: white or gray debris
surround object, skin under object moist, red & eroded
- Slight hearing impairment: serous otitis media, trauma (from
inflating airbags), untreated acute otitis media w rupture of the Assessment
tympanic membrane
- Otoscopic exam: sharply localized, tender swelling of a furuncle,
Degrees of Hearing Impairment or the entire canal may be swollen shut and tender to the touch
- Weber test: should show that hearing is equal in both ears
<30 Slight Unable to hear whispered words, faint speech o tuning fork vibration that sounds louder in the affected
May not be aware of hearing difficulty ear: otitis media
Techniques to hear: leans forward, speaks loudly - Remove superficial debris in canal before examination
30 - 50 Mild Beginning speech impairment o do not irrigate until tympanic membrane intactness is
Difficulty hearing if not facing speaker; some difficulty confirmed
with normal conversation o removal by ear curette using extremely gentle pressure
55 - 70 Moderate may require speech therapy o securely restrain child; prevent turning of head
Difficulty with normal conversation o if debris is hard: oftened and loosened by touching it
70 - 90 Severe Difficulty with any but nearby loud voice with a hydrogen peroxide–soaked, soft, cotton applicator
Hears vowels more easily than consonants or 2% acetic acid can be instilled into the canal and
Requires speech therapy for clear speech allowed to stand for a few minutes
May still hear loud sounds (jets/train whistles)
>90 Profound Hears almost no sound
Therapeutic Management
- if ear drops cannot flow back d/t to swollen canal: cotton wick
moistened with Burow’s solution
o cotton extending out into the auricle is kept moistened
by rewetting it for 24 hours with Burow’s solution
o reduces swelling and further tx can be initiated
- ear drops containing hydrocortisone and an antibiotic or an
antifungal mixture (w additional alcohol base)
o Hydrocortisone: reduces inflammation
o antibiotic or antifungal: reduces the infection
o alcohol base: dries external canal further
- if ear pain is present: acetaminophen or ibuprofen
- keep the ear canal dry, avoiding swimming and hair washing
during this time
o during shower: insert ear plugs into the external meatus
Impacted Cerumen
• Wax accumulation is rarely extensive enough to interfere w hearing
• Do not clean child’s ear w cotton-tipped applicators regularly
o May scratch the ear canal > invasion site for 2nd infection
o Pushes accumulated cerumen father into ear canal > true
plugging of wax
• Never put anything smaller than an elbow in a child’s ear
Therapeutic Management (for true plugging of cerumen)
- Commercial softeners
- dilute solution of hydrogen peroxide to dissolve cerumen
o may be done once ion a while but not regularly > may
moisten ear canal too much > external otitis
acute otitis media
- most prevalent disease of childhood after respi tract infections
- occurs most often in children 6 to 36 mos of age, again at 4 to 6 y
- higher incidence of otitis media in formula-fed infants
o fed in a more slanted position > milk enters eustachian
tube
- incidence higher in homes in which a parent smokes cigarettes
complications: permanent damage of middle ear > hearing impairment
Signs & Symptoms
- “cold,” rhinitis, and perhaps a low-grade fever for several days >>
fever of 38° C >> sharp, constant pain in one or both ears
- external canal is usually free of wax
- discomfort does not increase on manipulation of the auricle
- if mastoid process behind the ear feels tender to touch: infection
- Infants: extremely irritable and frequently pull or tug at the
affected ear
- Older children can verbalize reports of pain
- Risk for conductive hearing loss up to 6 mos after acute infection
o If a child still has a conductive hearing loss after 6 mos:
child to be examined again
Assessment
1. on otoscope
- tympanic membrane appears inflamed or reddened;
- may be seen bulging into the external canal
- light reflex of the otoscope will not be as definite as usual d/t
convex shape of the eardrum
- malleus and incus, can be visualized only poorly or not at all
2. on pneumatic examination: decreased mobility
3. tympanocentesis: obtain fluid for culture
Therapeutic Management
- antibiotic therapy is unnecessary and may add to bacterial
resistance
- analgesic and antipyretic: acetaminophen
- decongestant nose drops: to open the eustachian tubes and allow
air to be admitted to the middle ear { given for only 3 days )
o should be given longer than 3 days: rebound effect
(edema & increase in mucous membrane inflammation)
- for chronic or persistent otitis media: cephalosporin (effective
against Staphylococcus)
Otitis Media with Effusion
- result of chronic otitis media
- source of air to middle ear is shut off > middle ear epithelial cells
become secretory cells > middle ear filled w glue-like fluid
- involvement usually bilateral
- occurs most frequently in 3 to 10 y of age
Signs & Symptoms Cholesteatoma

- feeling of fullness or the sound of popping or ringing in their ears - lesion of the pars flaccida or upper portion of the tympanic
- muffled hearing and a feeling of pressure in the ear membrane > retraction cyst > necrosis w foul-smelling drainage
- drop in hearing of 20 to 40 dB o if retraction cyst is not discovered & surgically removed:
it grows gradually deeper and deeper > invades mastoid
Assessment (on ear examination) o complications: mastoiditis, meningitis, facial nerve
- level of fluid behind the tympanic membrane paralysis
o fluid line will be visible only if there is also a quantity of
air in the middle ear to contrast with
- malleus more prominent, displaced to a horizontal angle
o d/t to increasing thick fluid, eardrum retracts
- light reflex from the otoscope light becomes distorted
- w pneumatic otoscope: gentle introduction of air against the
eardrum produces no movement of the tympanic membrane
(abnormal finding)

Therapeutic Management

- if intensified by inflammation from an allergy: avoidance of the

allergen, hyposensitization
- for mild involvement: daily administration of an antihistamine or
a nasal decongestant
o shrink the mucous membrane of the eustachian tube >
supply air
- if eustachian tube is blocked w adenoids: removal of adenoids
- tympanocentesis unless tubal myringotomy is undertaken
- tubal myringotomy
o source of air can be supplied to the middle ear w Teflon
tubes inserted through tympanic membrane
(tympanostomy)
o tubes do not interfere w hearing because it is done at
point where tympanic membrane is not used for hearing
o Tubes tend to be extruded after 6 to 12 months
o When tubes are in place, WATER SHULD NOT ENTER THE
CHILD’S EARS
o Prefer bath than shower (shower allowed w ear plugs),
hair washing w ear plugs, swimming contraindicated
unless w ear plugs