Refractive errors cause vision disturbances from alterations in the path of light rays through the eye. They usually result from an abnormally shaped orb; the orb may be flattened or elongated (Table 55-1). Refractive errors are often discovered when a child squints, frowns, or moves objects so they are more easily seen. Reports from the child or a teacher may also alert parents. Legal blindness is defined as a correction of 20/200 or worse in the better eye or a visual field of 20 degrees or less.

School nurses routinely test children’s vision and, in fact, annual vision screening is offered to children throughout the United States. The U.S. Preventive Services Task Force (2011) has recommended that vision screening begin early in the preschool years (at 3 years of age) to identify amblyopia and other associated vision alterations Several states in the United States mandate that a child have an approved vision screening test (administered by a trained examiner) within the year prior to entering kindergarten. The HOTV matching test, Lea symbols, and the “tumbling E” test are comparatively effective as screening measures for preschool age children (Chou, Dana, & Bougatsos, 2011). Evidence suggests that vision screening tests, which can include photoscreening or autorefraction testing, can accurately identify vision problems in young children (Chou et al., 2011). School nurses have used various methods of notifying families of children who do not pass a school vision screening (e.g., telephone call to parents, letter brought home by the child, letter mailed home). However, the parent is responsible for follow-through with a visit to a specialist. Nurses need to be aware that some parents, for a variety of reasons, do not take the child for a follow-up comprehensive eye examination; for this reason, nurses in other settings must ask for details about the child’s vision and previous vision testing.

Corrective lenses are used to improve the child’s vision. Encourage the parent to look for impact-resistant eyeglasses with spring-loaded frames, which are less likely to bend or warp. Fitting glasses to an infant or young child can be challenging; the goal is to choose shatter-resistant lenses in a type of frame that can be closely fitted to prevent easy dislodging during activity. Infant frames often have elasticized straps to keep them properly positioned. Teach the parent, and child if appropriate, to always store the glasses in a case when not being used. Special directions for cleaning must be followed to avoid scratching the lenses.

Both gas-permeable and soft contact lenses provide an alternative for children old enough and responsible enough to care for contacts independently. The nurse needs to teach parents and children about appropriate care of corrective lenses and should educate parents and children about recognizing and intervening with vision problems early.

Protective eyewear made of shatterproof polycarbonate, should be worn by all who participate in sports that have risk for eye injury. A variety of prescription sports glasses are available for athletes. Protective eyewear should be selected according to the sport and the relative risk for injury (American Academy of Ophthalmology, 2011).

Amblyopia, or “lazy eye,” one of the most common causes of diminished vision in children, results from a variety of eye alterations seen in children whose visual acuity is impaired. Various reports state that the prevalence of amblyopia is between 2% and 4% of children (USPSTF, 2011).When both eyes are unable to focus simultaneously, the brain suppresses the image from the deviating eye to avoid double vision (diplopia). Amblyopia frequently accompanies strabismus, as well as other eye conditions such as congenital cataract and severe refractive error. If the underlying eye condition is untreated in a child younger than 4 years (the critical period for development of the visual cortex), permanent loss of vision from amblyopia can result; amblyopia can be treated in the older child, but it is more resistant to treatment approaches at that time (Olitsky, Hug, Plummer, et al., 2011). Because the child loses binocular vision, depth perception may also be impaired. Early detection and treatment of strabismus or other underlying causes of amblyopia are essential to prevent loss of vision.

Two primary approaches, penalization (blurring) and occlusion, are used to correct amblyopia, and each is designed to alter or obscure vision in the stronger eye to force the child to use the amblyopic eye. Atropine, which is a cycloplegic (paralyzes the ciliary muscles to dilate the eye), most often is used to blur the vision in the stronger eye. Wearing eyeglasses in which the lens over the stronger eye creates blurring has a similar effect (Doshi & Rodriguez, 2007).

Wearing lenses corrective for refraction error can improve amblyopia in some children (Stewart, Moseley, & Fielder, 2011). Patching, combined with use of corrective lenses, has been demonstrated to have better outcomes than wearing corrective lenses alone for treatment of amblyopia caused by strabismus (Taylor & Elliott, 2011). Patching is used primarily to correct amblyopia and is used mostly during the preschool years when the visual cortex is developing. In this treatment, the normal eye is patched so that the child is forced to use the weaker eye. The schedule for patching is individualized. Recent evidence suggests that some children will respond well to a patching regimen that does not require 24 hour occlusion, but as little as 2 to 4 hours of daily use (Olitsky et al., 2011; Stewart et al., 2011). The patching regimen is prescribed by the ophthalmologist. Cooperation with the patching regimen is essential. Teaching should explain the reasons for patching or corrective lenses, the expected results of wearing the patch or lens, correct placement of the patch, the number of hours per day the patch or lens is to be worn, and the expected length of treatment (see Patient-Centered Teaching: Information about Eye Patching). The child needs to understand that wearing the patch or lens is not negotiable. The nurse often must teach parents strategies for dealing with resistant behaviors.

Glaucoma is a condition in which the intraocular fluid pressure of the eye is increased. This pressure increase, if left untreated, leads to atrophy of the optic disk and, ultimately, blindness. Glaucoma is a significant cause of blindness in children (Aponte, Diehl, & Mohney, 2010).

Several types of glaucoma occur in children. Congenital glaucoma and infantile glaucoma occur during the first 3 years of life and are caused by a defect in the drainage network of the eye. Primary congenital glaucoma has a genetic origin, with an autosomal recessive inheritance pattern. Secondary glaucoma, which may be associated with other ocular anomalies, refers to disease that occurs after 3 years of age and may be the result of inherited disease (juvenile glaucoma) or may be acquired from infection, trauma, or cataract removal (acquired glaucoma) (Olitsky et al., 2011).

Clinical signs of glaucoma include excessive tearing, light sensitivity, blepharospasm (muscle spasm causing involuntary closing of the eyelid), and enlargement of the globe and cornea. Parents often note excessive tearing or corneal haziness caused by edema and bring the child in for clinical evaluation. The child may also be brought to the practitioner for what appears to be conjunctivitis (“pink eye”).

Physical examination includes an assessment of visual acuity, measurement of intraocular pressure (tonometry), assessment of corneal diameter and clarity, and an examination of the retina to assess for optic nerve cupping. Any infant with a visible iris diameter greater than 10.5 mm should be evaluated. If retinal edema is present, the light reflex is diffuse. Because young children may not be able to cooperate during an examination, they are often sedated. Intraocular pressure should be measured only under light sedation, however, because deeper sedation may alter readings (either high or low, depending on the agent used).

The preferred treatment for childhood glaucoma is surgery. Medications to clear the cornea may be used before surgery to allow better visibility. Surgery should be performed as soon as possible after diagnosis to prevent loss (or further loss) of vision. The goals of surgery are to increase the outflow of the aqueous humor from the anterior chamber by correcting the structural abnormality that is causing the decreased outflow, create a different route for the outflow (trabeculotomy), or decrease production of aqueous fluid (Olitsky et al., 2011). Medications such as cholinergic agents, beta-adrenergic blocking agents, or adrenergic agents may be indicated after surgery to maintain low intraocular pressure.

Prognosis varies from child to child. The earlier the glaucoma develops, the poorer the prognosis, because infants and children with early onset glaucoma usually have defects in the development of the anterior chamber of the eye that occurred during fetal development (Olitsky et al., 2011). In general, with prompt treatment most children attain appropriate vision. Decreased vision may result from damage to the optic nerve, opacity of the cornea or lens, or amblyopia resulting from refractive errors. Children with glaucoma must be followed closely over the long term to identify any rise in intraocular pressure quickly.

Nursing interventions are similar to those for any child having eye surgery. Postoperative nursing care includes monitoring for signs and symptoms of increased intraocular pressure (pain, nausea and vomiting, increased inflammation) and administering any ordered medications, such as miotic eyedrops (used to constrict the pupils) and antibiotic ointments or eyedrops. If the child’s eyes are patched, the nurse pays special attention to the resulting sensory deficits. The nurse also considers safety to be an issue when eyes are patched.

Parental education is essential to maintain the appropriate intraocular pressure and prevent complications (including blindness). Education includes the use of any prescribed medications, patching, and any other measures designed to correct refractive errors. The importance of returning for follow-up care should be emphasized. The child and caregivers should also be taught signs and symptoms of increasing intraocular pressure. Any signs of increasing intraocular pressure or infection should be immediately reported to the ophthalmologist. Because certain types of glaucoma can be related to genetic abnormalities, referral for genetic counseling may be indicated.

A cataract is an opacity, or loss of transparency, of the lens. Causes include an inherited tendency (usually an autosomal dominant trait), infection (e.g., rubella), trauma, or a metabolic imbalance; the cause of congenital cataracts is unknown (Davenport & Patel, 2011). Cloudiness of the lens may be noted during examination in the newborn nursery (indicated by a white instead of red reflex) or by the parents. Ophthalmoscopy may reveal a dark spot in the lens. Parents may note that the infant exhibits visual inattentiveness and come in for an evaluation. Other clinical signs include nystagmus and strabismus. The cataract alters vision because it does not allow a sharp, clear image to be formed on the retina.

Treatment for cataracts in most instances is the surgical removal of the opaque lens as soon as possible and optimally within 6 to 10 weeks of age (Davenport & Patel, 2011). The resultant hyperopia is then dealt with by using a contact lens or, in older children, an intraocular lens implant. Any resulting amblyopia must also be addressed. Glasses may also be used to correct the resultant vision problem, although these may be difficult to manage in infants and small children (Olitsky et al., 2011).

Amblyopia may be a consequence of congenital cataract. In this case, the normal eye may be patched after surgery to develop the weakened eye.

Postoperative interventions are directed toward avoiding increased intraocular pressure. Measures include preventing coughing, straining, vomiting, and touching the operative site. A patch and “hard shield” are usually in place after surgery to prevent injury to the operative site. To prevent edema and pressure on the site, the nurse should elevate the head of the bed slightly and position the child so that the affected eye is not in a dependent position. Monitor the child for signs and symptoms of infection (fever, drainage, redness). Medications, including antibiotics, mydriatics, and steroids, may be used after surgery.

Postoperative teaching includes how to insert, remove, and care for the child’s contact lens. Parents need to be taught the signs and symptoms of infection and increasing intraocular pressure. To provide visual stimulation to the affected eye and prevent further loss of vision, the importance of adhering to any prescribed patching regimen should also be emphasized. Finally, the nurse teaches the importance of returning for follow-up visits to ensure that the lens fits correctly, the vision correction is appropriate, and no signs and symptoms of complications are present. As with glaucoma, the occurrence of some cataracts has a genetic component, so referral for genetic counseling may be indicated.