Chapter 35: Eye Disorders

Garzon Maaks: Burns’ Pediatric Primary Care, 7th Edition

MULTIPLE CHOICE

1. The primary care pediatric nurse practitioner (PNP) performs a vision screen on a 4-month-
old infant and notes the presence of convergence and accommodation with mild esotropia of
the left eye. What will the nurse practitioner do?
a. Patch the right eye to improve coordination of the left eye.
b. Reassure the parents that the infant will outgrow this.
c. Recheck the infant’s eyes in 2 to 4 weeks.
d. Refer the infant to a pediatric ophthalmologist.
ANS: D
Esotropia that continues or occurs at 3 to 4 months of age is abnormal, so the infant should be
referred to a pediatric ophthalmologist. The PNP does not determine whether an eye patch
should be used. Because it is abnormal at this age, the PNP will not reassure the parents that
the infant will outgrow this. Esotropia after 3 to 4 months of age must be evaluated by a
specialist and not reevaluated in 2 to 4 weeks.

2. During a well child exam on a 4-year-old child, the primary care pediatric nurse practitioner
notes that the clinic nurse recorded “20/50” for the child’s vision and noted that the child had
difficulty cooperating with the exam. What will the nurse practitioner recommend?
a. Follow up with a visual acuity screen in 6 months.
b. Refer to a pediatric ophthalmologist.
c. Re-test the child in 1 year.
d. Test the child’s vision in 1 month.
ANS: D
Children age 4 years and older who have difficulty cooperating with a vision screen should be
retested in 1 month; if they continue to have difficulty cooperating, they should be referred for
a formal examination. Children who are 3 years old should be re-evaluated in 6 months.

3. During a well child assessment of an infant, the primary care pediatric nurse practitioner (NP)
notes a dark red-brown light reflex in the left eye and a slightly brighter, red-orange light
reflex in the right eye. What will the nurse practitioner do next?
a. dilate the pupils and reassess the red reflex.
b. order auto-refractor screening of the eyes.
c. recheck the red reflex in 1 month.
d. refer the infant to an ophthalmologist.
ANS: D
Any asymmetry, dark or white spots, opacities, or leukokoria should be referred immediately
to a pediatric ophthalmologist. The PNP does not dilate pupils or order auto-refractor exams;
these are done by an ophthalmologist. Because retinoblastoma is a concern, any unusual
finding should be immediately referred.

4. The primary care pediatric nurse practitioner performs a Hirschberg test to evaluate what?
a. color vision
b. ocular alignment
 c. peripheral vision
d. visual acuity
ANS: B
The Hirschberg test, or corneal light reflex, assesses ocular mobility and alignment by looking
for symmetry of reflected light. Color vision testing is performed with Richmond pseudo-
isochromatic plates. Peripheral vision is tested by watching the child’s response to objects as
they are moved in and out of the visual fields. Visual acuity is performed using eye charts or
visual-evoked potential readings.

5. The primary care pediatric nurse practitioner applies fluorescein stain to a child’s eye. When
examining the eye with a cobalt blue filter light, the entire cornea appears cloudy. What does
this indicate?
a. The cornea has not been damaged.
b. There is too little stain on the cornea.
c. There is damage to the cornea.
d. There is too much stain on the cornea.
ANS: D
When fluorescein stain is applied and the entire cornea appears cloudy, it means that there is
too much of the stain. Damaged areas of the cornea should appear greenish after staining with
fluorescein dye.

6. A toddler exhibits exotropia of the right eye during a cover-uncover screen. The primary care
pediatric nurse practitioner will refer to a pediatric ophthalmologist to initiate which
treatment?
a. Botulinum toxin injection
b. Corrective lenses
c. Occluding the affected eye for 6 hours per day
d. Patching of the unaffected eye for 2 hours each day
ANS: D
Deviations are initially treated by patching the unaffected eye for 2 hours each day to force the
affected eye to move correctly. Botulinum toxin injection may be used with some deviations
but is not a first-line therapy. Corrective lenses alone improve amblyopia in 27% of patients.
The unaffected eye is patched; 2 hours per day is as effective as 6 hours per day.

7. The primary care pediatric nurse practitioner performs a well child examination on a 9-month-
old infant who has a history of prematurity at 28 weeks’ gestation. The infant was treated for
retinopathy of prematurity (ROP) and all symptoms have resolved. When will the infant need
an ophthalmologic exam?
a. At 12 months of age
b. At 24 months of age
c. At 48 months of age
d. At 60 months of age
ANS: A
Children who have a history of ROP requiring treatment, even if ROP has completely
resolved, will need yearly ophthalmologic follow-up. Less frequent follow-up is required for
children with ROP who did not require treatment.
 8. During a well-baby assessment on a 1-week-old infant who had a normal exam when
discharged from the newborn nursery 2 days prior, the primary care pediatric nurse
practitioner notes moderate eyelid swelling, bulbar conjunctival injections, and moderate
amounts of thick, purulent discharge. What is the likely diagnosis?
a. Chemical-induced conjunctivitis
b. Chlamydia trachomatis conjunctivitis
c. Herpes simplex virus (HSV) conjunctivitis
d. Neisseria gonorrhea conjunctivitis
ANS: B
C. trachomatis conjunctivitis usually begins between 5 to 14 days of life and causes moderate
eyelid swelling, palpebral or bulbar conjunctivitis, and moderate, thick, purulent discharge.
Chemical-induced conjunctivitis manifests as nonpurulent discharge. HSV is characterized by
serosanguinous discharge. N. gonorrhea causes acute conjunctival inflammation and
excessive purulent discharge.

9. The primary care pediatric nurse practitioner performs a well baby assessment of a 5-day-old
infant and notes mild conjunctivitis, corneal opacity, and serosanguinous discharge in the right
eye. Which course of action is correct?
a. Administer intramuscular ceftriaxone 50 mg/kg.
b. Admit the infant to the hospital immediately.
c. Give oral erythromycin 30 to 50 mg/kg/day for 2 weeks.
d. Teach the parent how to perform tear duct massage.
ANS: B
The infant has symptoms consistent with human papillomavirus (HPV) conjunctivitis and
requires hospitalization for topical and systemic antiviral medications to prevent spread to the
central nervous system, mouth, and skin. IM ceftriaxone is given for gonococcal
conjunctivitis. Oral erythromycin is given for chlamydial conjunctivitis. Tear duct massage is
performed for lacrimal duct obstruction.

10. A preschool-age child who attends day care has a 2-day history of matted eyelids in the
morning and burning and itching of the eyes. The primary care pediatric nurse practitioner
notes yellow-green purulent discharge from both eyes, conjunctival erythema, and mild URI
symptoms. Which action is correct?
a. Culture the conjunctival discharge.
b. Observe the child for several days.
c. Order an oral antibiotic medication.
d. Prescribe topical antibiotic drops.
ANS: D
Young children with bacterial conjunctivitis may be treated with topical antibiotic drops.
Culturing the eyes is not necessary unless there is no improvement. While most cases of
bacterial conjunctivitis are self-limiting, using a topical antibiotic will hasten the return to day
care. Oral antibiotics are not indicated.

11. A 14-year-old child has a 2-week history of severe itching and tearing of both eyes. The
primary care pediatric nurse practitioner notes redness and swelling of the eyelids along with
stringy, mucoid discharge. What will the nurse practitioner prescribe?
a. Saline solution or artificial tears
b. Topical mast cell stabilizer
 c. Topical NSAID drops
d. Topical vasoconstrictor drops
ANS: C
This child has symptoms of allergic conjunctivitis. Topical NSAIDs work for acute symptoms
to reduce inflammation and may be used in children over age 12 years. Saline solution or
artificial tears are useful for milder symptoms. Topical mast cell stabilizers are useful for
chronic symptoms and maintenance therapy. Topical vasoconstrictors should be avoided
because of rebound hyperemia.

12. The primary care pediatric nurse practitioner observes a tender, swollen red furuncle on the
upper lid margin of a child’s eye. What treatment will the nurse practitioner recommend?
a. Culture of the lesion to determine causative organism
b. Referral to ophthalmology for incision and drainage
c. Topical steroid medication
d. Warm, moist compresses 3 to 4 times daily
ANS: D
The child has symptoms of hordeolum, or stye. Although these often rupture spontaneously,
warm, moist compresses may hasten this process. It is not necessary to culture the lesion
unless symptoms do not resolve. Referral to ophthalmology is made if the hordeolum does not
rupture on its own. Steroids are not indicated.

13. The primary care pediatric nurse practitioner is treating an infant with lacrimal duct
obstruction who has developed bacterial conjunctivitis. After 2 weeks of treatment with
topical antibiotics along with massage and frequent cleansing of secretions, the infant’s
symptoms have not improved. Which action is correct?
a. Perform massage more frequently.
b. Prescribe an oral antibiotic.
c. Recommend hot compresses.
d. Refer to an ophthalmologist.
ANS: D
Infants treated for a secondary bacterial conjunctivitis with lacrimal duct obstruction who do
not improve after 1 to 2 weeks of topical antibiotic therapy must be referred to an
ophthalmologist for possible lacrimal duct probe. Performing the massage more often or
applying hot compresses will not help clear the infections. Oral antibiotics are not indicated.

14. A preschool-age child is seen in the clinic after waking up a temperature of 102.2°F, swelling
and erythema of the upper lid of one eye, and moderate pain when looking from side to side.
Which course of treatment is correct?
a. Admit to the hospital for intravenous antibiotics.
b. Obtain a lumbar puncture and blood culture.
c. Order warm compresses 4 times daily for 5 days.
d. Prescribe a 10- to 14-day course of oral antibiotics.
ANS: A
This child has periorbital cellulitis and must be hospitalized because of having pain with
movement of the eye, indicating orbital involvement. LP is performed on infants under 1 year
of age. Warm compresses are used for mild cases. Oral antibiotics are not indicated.
15. A school-age child is seen in the clinic after a fragment from a glass bottle flew into the eye.
What will the primary care pediatric nurse practitioner do?
a. Refer immediately to an ophthalmologist.
b. Attempt to visualize the glass fragment.
c. Irrigate the eye with sterile saline.
d. Instill a topical anesthetic.
ANS: A
The PNP should never attempt to remove an intraocular foreign body or any projectile object
but should refer immediately to an ophthalmologist. Visualizing the object, irrigating the eye,
or instilling drops may further injure the eye.

16. A school-age child is hit in the face with a baseball bat and reports pain in one eye. The
primary care pediatric nurse practitioner is able to see a dark red fluid level between the
cornea and iris on gross examination, but the child resists any exam with a light. Which action
is correct?
a. Administer an oral analgesic medication.
b. Apply a Fox shield and reevaluate the eye in 24 hours.
c. Instill anesthetic eyedrops into the affected eye.
d. Refer the child immediately to an ophthalmologist.
ANS: D
This child has a traumatic injury with hyphema to the eye, and an ophthalmologist must
examine the eye to rule out orbital hematoma or retinal detachment. Any further attempt to
examine the child may result in further injury. A Fox shield is used once more serious injury is
excluded.