1

Eye and Vision Assessment

Nicole Quinn, OD, FAAONew England College of Optometry

Pediatric Health Assessment ConferenceBoston Children’s Hospital

August 16, 2017

No financial disclosures

Acknowledgment:

Kathy Majzoub, RN, MBAPrevent Blindness AmericaDirector, Northeast Region

Overview• Ocular Diagnoses Encountered By School Nurses

Conjunctivitis (Bacterial, Viral, Allergic) Contact Lens Related Red Eye Chalazion & Hordeolum Eye Trauma: Foreign Body, Abrasions, Chemical Exposure,

Contusions Sports Related Eye Injury Refractive Error: Hyperopia, Myopia, Astigmatism Strabismus Amblyopia

• Eye and Vision Assessment and Screening

2

Ocular Diagnoses Encountered By School Nurses

Conjunctivitis• “Pink Eye”

• Common cause of red, irritated eyes

• Inflammation of the thin, transparent membrane that covers the white part of the eye 

• Types– Viral: Contagious!– Bacterial: Contagious!– Allergic: NOT Contagious!

3

Conjunctivitis• Bacterial

– Key Signs & Symptoms• Mucous discharge (usually yellowish); crusty eye lids, often

stuck shut in morning; often starts unilaterally

– Treatment: Refer for treatment with topical antibiotic, hygiene precautions to prevent transmission to others

http://www.medscape.org

Conjunctivitis• Viral

– Key Signs & Symptoms• Tearing, burning• History of URI or sick

contact• Tender preauricular

lymph node• May start unilaterally

– Treatment• Usually self-limited• No effective treatment

for most types

http://www.theeyepractice.com.au

Conjunctivitis• Management of Contagious Conjunctivitis

– Referral for diagnosis and treatment– Precautions to prevent spread

• Avoid touching eyes• Frequent hand washing• No sharing of pillows and towels• No school until resolved

– For bacterial, antibiotic for at least 24 hours– For viral, until eyes are no longer red (usually over a

week)

– Do not cover eye during treatment

4

Conjunctivitis

• Allergic– Key Signs & Symptoms: Itching; history of seasonal

allergies; usually both eyes affected– Treatment: eliminate inciting agent; frequent

washing of hair, clothes, pillows; cool compresses; OTC and prescription topical medication, oral antihistamines

http://www.geteyesmart.org/eyesmart/diseases/conjunctivitis.cfm

Contact Lens-Related Red Eye• Contact lens wearers are

more likely to get severe eye infections– Red flags: eye pain,

sensitivity to light, mucous discharge, white spot on eye

– Remove contact lens immediately

– If symptoms persist, must be evaluated by an eye doctor ASAP to rule out corneal ulcer (can lead to permanent vision loss)

www.medicinenet.com

Contact Lens-Related Red Eye• Preventing eye infections in contact

lens wearers– No sleeping in contacts– No swimming– No tap or bottled water– No saliva– No sharing contacts (even colored contacts with

no prescription)– Wear contacts no longer than 12 hours per day– Use cleaning solution NOT saline solution for

disinfecting contacts

5

Hordeolum (Stye)• Infection of oil producing

glands in eye lid• Key Signs & Symptoms

– Red, tender bump on eye lid

• Treatment– Usually self-limited– Lid hygiene, warm

compresses– If multiple or severe,

refer for medication

http://www.health.state.mn.us/divs/fh/mch/webcourse/vision/chalazion.cfm

Chalazion• Bump on eye lid caused

by chronic infection of eye lid glands

• Key Signs & Symptoms– Palpable bump on eye

lid, NOT tender• Treatment

– Warm compresses– If large, consider

referral for medication or surgical removal

http://www.health.state.mn.us/divs/fh/mch/webcourse/vision/chalazion.cfm

Eye Trauma

• 1/3 of all eye injuries happen in children under 17 years of age– 75% in males

• Commonly associated with– Sports– Paintball– Fireworks– UV Exposure

• Child with monocular vision must useeyeglasses for protection

6

Sports Related Eye Injury

• 25 percent of estimated 2.4 million eye injuries that occur in the United States each year happen during sports and recreational activities

• Every 13 minutes an ER treats a sports-related eye injury

Eye Trauma

• Common symptoms

– Eye pain

– Feels like something is in eye

– Red eye

– Tearing

– Sensitivity to light

– Swelling, bruising or laceration of eyelid

• Careful history is essential in determining the type and severity of injury and the most appropriate treatment and follow‐up

Eye Trauma: Foreign Body

www.consultantlive.com

www.eyecasualty.co.uk

• Rinse eye with sterile saline• Refer for additional treatments

Ex. Removal, topical antibiotic

7

Eye Trauma: Corneal Abrasion

• Scratched cornea

• Very painful

• Treatment

– Generally, not recommended to cover eye

– Refer for topical antibiotics

– Control painwww.insighteyespecialists.com

Eye Trauma: Chemical Exposure

• IMMEDIATELY, rinse eye with sterile saline – If no sterile saline

available, then use running water

– May need to rinse for 20-30 minutes

• Refer to evaluate extent of damage

www.sharecare.com

Eye Trauma: Contusions• “Black Eye”

• Bruising of eye lid, usually due to blunt trauma

• Look for damage to eye structures

– Subconjunctival hemorrhage (bleeding under conjunctiva)

– Hyphema (bleeding inside eye)

photoree.com

casereports.bmj.com

8

Orbital Fracture

• Signs & Symptoms

– Swollen, tender eye lid

– Eyes not moving in all directions; pain during eye movement

– Double vision

– Numbness, creptius

• Treatment

– Refer for complete eye exam and imaging (usually CT)

http://www.bheyelids.com/before_and_after_orbital_fractures_photos.asp

Penetrating Ocular Injuries

• Signs & Symptoms

– Pain, reduced vision, loss of fluid from eye

– Contents of eye outside of globe

– Abnormal pupil shape, hyphema

• Do not put pressure on eye

• Do not remove penetrating object

• Transfer to ER 

http://webeye.ophth.uiowa.edu/eyeforum/trauma.htm

Tips for School Nurses: Eye Trauma

• Thorough history is essential

• Use observational skills to determine type and extent of injury

• Tools needed to evaluate/assist patient

– Sterile saline to rinse eyes

– Visual acuity chart: has vision been affected?

– Light to better observe eye structures

• Establish a plan for emergency and non‐emergency referrals

9

Vision Screening• Without early detection and

treatment, vision deficits in childhood can lead to– Permanent vision loss– Learning difficulties– Delayed sensory, motor,

cognitive & social-emotional development

• Screening is designed to detect the most common vision problems in children– Refractive error– Strabismus– Amblyopia

Screenings do not detect ALL vision problems so pay attention to the ABC’s and refer, if necessary

ABC’s: Appearance

• Crossed or misaligned eyes

• Watering eyes

• Red-rimmed, encrusted or swollen eyelids

• Drooping eyelid

• Sties or infections

• Presence of white pupil

• Possible eye injury

ABC’s: Behavior

• Squinting or frowning

• Tilting head to one side

• Excessive blinking or eye rubbing

• Closing or covering one eye

• Body rigid when looking far

• Thrusting head forward or backward

10

ABC’s: Complaints

• Headaches, nausea or dizziness

• Blurred or double vision

• Burning, scratchy, painful or itchy eyes

• Blurry vision at looking up after close work

• Unusual sensitivity to light

“Normal” Vision

• Ideally, light enters the eye and focuses exactly on the retina, allowing clear vision

• If this occurs, no glasses are needed

Refractive ErrorIf light entering the eye does not focus on the retina, blurry

vision occurs. Corrective lenses are prescribed to compensate for the refractive error in the eye’s visual system.

Hyperopia

Myopia

11

Refractive Error: Myopia (Nearsightedness)

• Distant objects blurred

• Increases through school-age years and stabilizes in early adulthood

• Unable to see people’s faces from a distance or read board at school

• May squint eyes to see better

Refractive Error: Hyperopia (Farsightedness)

• Objects blurrier at near than at distance

• Mild hyperopia is normal in young children and commonly decreases as the child grows

• Only when significant amount is present are corrective glasses prescribed at a young age

Refractive Error: Astigmatism• Irregular corneal shape

causes more than one point of focus in the eye

• Distorted vision distance and near

• May get headaches or eye strain; may squint to improve vision

12

Refractive Error• About 1 in 5 school‐aged children need glasses

– Hyperopia and astigmatism common in young children

– Myopia increases as children get closer to middle school age

• Screen children with their glasses or contact lenses on, if possible 

• Encourage compliance with glasses or contacts

Strabismus• Misalignment of the

eyes– May be present all the

time or intermittently– Eye may deviate

horizontally, vertically or both

– May be congenital or acquired

– May cause double vision– May cause amblyopia

StrabismusMisalignment leads to suppression of deviating eye

which results in amblyopia• Treatment is required to

straighten the eyes

• Glasses are often prescribed first to improve focusing and redirect the line of sight to support correct alignment

• If non-surgical treatment is unsuccessful, surgery may be needed to straighten the eyes

13

Amblyopia

• Amblyopia (“Lazy Eye”)– “amblyos” dull– “opia” vision

• Develops birth - 8 years

• Leading cause of blindness in children and adults under 45 years

• Any condition that causes the brain to receive images of unequal quality from the two eyes can lead to amblyopia

Amblyopia• Most common causes of amblyopia

– Refractive Error (especially if one eye has a significantly higher refractive error than the other)

– Strabismus (misalignment of eyes)– Deprivation (something blocking vision)

• Ex. Ptosis or Cataract

Amblyopia Treatment

Correct underlying vision problem (refractive error, cataract, strabismus, etc.)

Correct amblyopia by retraining the brain (ex. patching)

14

Vision Screening: Who and Where

According to the MA Mandate and AAP Guidelines:

All children beginning at birth are assessed by PCP

All children beginning at age 3 or 4 years have additional vision assessment through the use of screening protocols by PCP designee and annually thereafter

All children enrolled in Head Start beginning at age 3 years are evaluated using vision screening protocols (5% of MA preschoolers)

All children in public kindergarten, annually through elementary school, once in middle school, and once in high school, are evaluated with vision screening protocols by school nurse or designee

Primary Care Provider Bright Futures

• 0-3 Years: History, external, red reflex, light reflex, fixation, tracking, cover test

• 3-5 Years: All of the above AND visual acuity and stereopsis– Instrument-based

screening acceptable

• Age 6, 8, 10 years and three times during teen years

MA : Screening State or Exam State?

• MA: An Act Relative to Eye Examinations for Children, 2004: Within 30 days of start of K, child must show pass on vision screen or proof of eye exam conducted in previous 12 months. Children with Neurodevelopmental delay, and children who fail thevision screening, are referred for a comprehensive eye exam by an ophthalmologist or optometrist.

15

First Step: Screening or Exam?“Neurodevelopmental Delay”

MA School Health Manual

• Law requires proof of a comprehensive eye exam, performed by a licensed optometrist or ophthalmologist, for children diagnosed with neurodevelopmental delay

• Term “neurodevelopmental delay” may be subject to interpretation, but is likely to include children born pre-term or low birth weight and children with neurological disorders such as cerebral palsy, Down Syndrome, multiple handicaps or developmental delay

National Center for Children’s Vision and Eye Health

• Children who are at high risk, such as those born prematurely or with known neurodevelopmental disorders in any area (ex. hearing impairment, motor abnormalities such as cerebral palsy, cognitive impairment, autism spectrum disorders, and speech delay), should be referred directly to an eye care provider for further evaluation

THE O’s?

Ophthalmology• Four years post undergraduate education (MD)• Four years internship/residency• One or two year optional fellowship: cornea,

pediatric/strabismus, glaucoma, retina, ocular immunology, etc.

Optometry• Four years post undergraduate education (OD)• One year optional residency: pediatric, geriatric, low

vision rehabilitation, vision therapy

Confidentiality? • HIPAA : doctors outside of school and school nurse can

communicate about child’s health condition without parent permission

• FERPA (school health staff operate under FERPA) does not allow school nurse to communicate health information that originates in school (for example vision screening results or results of physical exam that was completed at school) to doctors outside of school unless parent gives permission

• FERPA does allow school nurse to discuss health condition with classroom teacher and others as a “need to know” issue

• MA School Health Policy states that if an eye exam was done based on results of a school screening, the eye doctor is required to send exam results to the school and school health also requests that results be sent to the PCP

16

Screening At School

Head Start thru Grade 3

Vision Risk Factors – ABC’s

Distance Visual Acuity

ADD NEAR VISUAL ACUITY AT GRADE 1

Stereopsis Test for binocular vision

Instrument-based screening acceptable for 3-5 year-olds

Follow-up

Grade 4‐Grade 12

Vision Risk Factors – ABC’s

Distance Visual Acuity

Near Visual Acuity

Follow-up

IF CHILD WEARS GLASSES OR CONTACTS, BE SURE THEY ARE ON DURING SCREENING

Charts or Devices?• Visual Acuity Charts

– Which chart?• HOTV• LEA• SNELLEN• SLOAN

• Devices– Optec– Titmus– Spot*– PlusOptix*

Screen for refraction, strabismus

Measure Visual Acuity

Preschool, Kindergarten

Older Children

*PBA Approved Devices age 3-5 yrs

Distance Visual Acuity

• Visual Acuity Far: read a standardized eye chart at distance of 10 feet

• This is a monocular test—Good Occlusion Required

• Four of five symbols on a line must be identified correctly to pass that line

• A child who fails a distance visual acuity screening is referred for a professional eye exam

17

Distance Visual Acuity:Passing Lines

Age Passing Line

MA: 48 months and younger 20/40

MA: Older than 48 months 20/30

2 Line or Greater Difference in Acuity

RDE Stereopsis Test• In the child whose eyes are not

working together, the brain is unable to fuse the two images from each eye into one clear image

• Child must identify the card with the “E” four consecutive times at a distance of 48 inches– Must use polarized glasses– Test at correct distance!

Near Acuity-Add at 1st Grade

• LEA, HOTV, SNELLEN

• Distance: 14-16 inches (string)

• Allowed to miss one per line

• Passing line is 20/30

• Both eyes together

18

Red Flags for School Nurses:When to Refer to Eye Doctor

• When child is suspected of having contagious conjunctivitis, contact lens related red eye or sustains an eye injury

– Referral ASAP if vision loss,  eye pain, structural damage has occurred

• At diagnosis of “neurodevelopmental delay” or other diagnoses associated with vision problems

• Appearance, Behavior, Complaint related to vision

• Fail on MA Vision Screening Protocol

Resources

Healthy Eyes Eyeglass Program:  kmajzoub@preventblindness.org

For approved vision screening equipment:www.goodlite.com/Details.cfm?ProdID=502&category=7&Secondary=37www.schoolhealth.com/preventblindness

References‐www.childrensvisionmassachusetts.org‐www.nationalcenter.preventblindness.org‐www.preventblindness.org‐http://www.aao.org/eye‐health/tips‐prevention/injuries‐Gerstenblith AT, Rabinowitz MP. (2012) The Wills eye manual: office and emergency room diagnosis and treatment of eye disease. 6th edition. Philadelphia:Wolters Kluwer/Lippincott Williams & Wilkins.‐Kaiser PK, Neil J, Pineda III R. (2014) The Massachusetts eye and ear infirmary illustrated manual of ophthalmology. 4th edition. New York: Elsevier, Saunders.

Questions