CHAPTER 50 VISION AND HEARING

of the left side - makes the object appear 3

dimensional

Health Promotion and Risk Management • Have difficulty learning to ride a bicycle
and have great difficulty driving a car safely

• All newborns should be screened for
hearing in the first few days of life
for depth perception, is a specially
• Vision can be assessed in these early days
by eliciting a blink reflex and the ability to
• Stereo-fly or random dot test, a simple test
constructed picture of a large fly made of
colored dots

follow a moving object

• Providing anticipatory guidance to parents Accommodation

about safety measures to prevent • Accommodation is the adjustment the eye
accidental injury is a major nursing makes when focusing on a close image

responsibility
• To focus on a close object, the ciliary
• Supplement verbal explanation with tactile bodies of the eye contract, changing the
and visual aids as appropriate and allow curvature of the lens

child to use drawings, writings or gestures • The action of the ciliary body allows
to respond and communicate
accommodation but also cause the eye to
• Mild Vitamin A Deficiency - leads to loss of converse ad the pupil to constrict\

night vision
• test: ask a child to follow a penlight as it
• Severe Vitamin A Deficiency - occur from moves in toward the nose

an adolescent eating disorder can lead to

blindness
Disorders that Interfere with Vision

Vision Refractive Errors

• Vision occurs because the light rays reflect • The largest category of vision defects in
from an object through the corneas, children

aqueous humors, lenses and vitreous • Light refraction - refers to the manner in
humors to the retinas
which light is bent as it passes through the
• Retinas - studded with rods, which are lens

instrumental for night vision and movement • normally, this bending causes a ray of light
in the visual field
to fall directly on the retina

• Cones - register daylight and color vision

• Hyperopia (farsightedness) - vision is blurry
• Fovea Centralis (center of the macula) - an at a close range and clear at a far range

area of closely packed cones on the retinas • Normal hyperopia of a preschooler needs
where color is best perceived
no correction

• Each eye globe must develop good central • Myopia (nearsightedness) - the light rays
and peripheral vision
focus at a point in front of the retina

• Each eye globe must develop good central • Children with myopia need corrective
and peripheral vision - fusion must occur
(concave) lenses to enable them to see at a
• Single binocular vision - both eyes together distance

must interpret a visual image as one • Laser surgery (LASIK) to permanently

image, fusing visual perception into a change the contour of the cornea and
single image
correct refractive vision errors

• Infants with poor eye alignment cannot • Contact lenses are a big responsibility, they
establish singe binocular vision but have require conscientious cleaning or changing
diplopia
to prevent eye irritation or infection

Stereopsis Laser in Situ Keratomileusis (LASIK)

• Stereopsis - depth perception, or the ability • Laser surgery for correction of myopia

to locate an object in relative to other • Making an incision under the cornea to

objects
change the contour of the eye globe so
• The right eye sees more of the right side of that the light rays fall more accurately on
an object, whereas the left eye sees more the retina

Astigmatism
day to prevent amblyopia from developing

• Is a congenital or acquired unevenness of in the non amblyopic eye

the curvature of the cornea

- administration of levodopa in addition to

• Causes light rays coming to the retina to occlusion therapy may also be

not be all refracted in the same way; the prescribed as this almost immediately

result is an uneven quality of vision

improves vision in the poorer eye

• Have difficulty reading or following written - atropine, causes pupil dilation and

instructions
blurred vision when dropped into the

• May report headache and vertigo after better eye

doing close work

• Corrective lenses for close work relieve the Color Vision Deficit (Color Blindness)

symptoms and restore functional vision

• The inability to perceive color correctly

• Contact lenses may be even more helpful, • Occurs because one of the sets of cones
because they actually smooth out the of the retina that perceive red, green, or
curvature of the cornea
blue is absent

• Inherited as a sex-linked disorder and

Nystagmus
occurs in about 8% of boys

• A rapid, irregular eye movement, either • May be associated with exposure to

vertically or horizontally
occupational solvents during pregnancy

• It is not a disease itself but rather a • Involve the inability to distinguish red from
symptom of an underlying disease green or blue from yellow

condition
• Color plates or discs can be used to detect
• Seen in children with vision-impairing color deficits in children as young as
lesions such as congenital cataracts
preschool age

• Occurs as a neurologic sign if there is a • No therapy for color vision deficit, but the
lesion of the cerebellum or brainstem
condition should be detected early

Amblyopia
Structural Problems of the Eye
• “lazy eye”or subnormal vision in one eye
Coloboma

• The child may be using only one eye for • Is the congenital incomplete closure of the
vision while “resting” the other eye
facial cleft

• Occur in children who have refractive error • May involve only the lower eyelid (there is a
in one eye that is significantly different from notch in the lid)

that of the other eye or children with • May involve the iris, giving it the shape of a
astigmatism
keyhole, rather than a circle

• Because one eye focuses more readily • May involve the ciliary body, the lens, the
than the other, they come to depend on choroid, the retina and the optic nerve

only the easily focused eye

• Children with retina and optic nerve
• Can also develop from strabismus (crossed coloboma will have some vision
eye)
impairment in the affected eye

• Assessment

- children should be screened by vision

Hypertelorism

testing with a preschool E chart at

• Is a congenital condition involving
routine health visits
abnormally wide-spaced eyes

- 20/50 vision (normal for preschool age) in

• This condition is associated with
one eye
chromosomal abnormalities, most notably
- 20/100 other eye showed lessened
Waardenburg’s syndrome, which also
vision
involves congenital hearing impairment

• Therapeutic Management
• Have a white forelock of hair, different
- correctable if treated during the
colored irises and eyebrows that tend to
preschool period
grow together in the center line

- the good eye is covered by a patch held

firmly in place

- the patch is removed after 1 hour each

Ptosis
an invading lesion

• The inability to raise the upper eyelid • Therapeutic management

normally so the eyelid always remains - depends on the cause of problem

slightly closed
- fusion mechanism is weak: eye

• May be congenital (frequently hereditary exercises (orthoptics)

and bilateral) or acquired (usually unilateral)

- eyes are diverging with attempted

• May be a result of injury to the third cranial convergence because of farsightedness

nerve (neurogenic) or to the lid or levator or nearsightedness: the child needs

muscle
glasses to correct the basic visual defect

• Children may exhibit:

- misalignment causes by unequal

1. A dilated pupil
muscle strength: eye muscle surgery;

2. Inability to rotate the eye globe upward,

injection of botulinum toxin into the eye

medially or downward
muscle may be tried first as temporary

3. Weakness of accommodation (looking

therapy or as an adjunct to surgery

at near objects)

• Myasthenia gravis must always be ruled Infection or Inflammation of the Eye

out as a cause of bilateral ptosis
(book page 1494-1495)

• Children with ptosis tend to wrinkle their

forehead and raise their eyebrows more Traumatic Injury to the Eye
than usual in an attempt to lift the eyelid • The primary cause of vision disorders in
further.
children today is ocular trauma, caused by
missiles such as dirt or sand, baseballs,
Strabismus
pieces or broken plastic toys, or flying
• The movement of each eye globe is glass in car accidents that strike or even
controlled by extraocular muscles
enter the eye globe

• Strabismus is unequally aligned eyes • Fights with other children, cigarette burns,
(cross-eyes) caused by unbalanced muscle sports injuries, fingernail scratches, and
control
burns from fireworks are also causes

• In strabismus, the resting position of one • Assessment

eye may be divergent (turned out) or - in acute pain immediately after the

convergent (turned in)

accident

• One pupil may be higher than the other - vision may be blurred or lost in the

(vertical strabismus)
affected eye

• The strabismus may be monocular, in - most children are very reluctant to let

which the same eye deviates constantly, or anyone examine or tough their injured

it may be an alternating strabismus, in eye

which one eye and then the other deviates

• Assessment
Foreign Bodies

- infants’ eyes may only cross occasionally

• Sand or dirt that are loose on the
until 6 weeks of age
conjunctiva can be removed by irrigation
- exotropia (eye turning out)
with a sterile normal saline solution or by
- esotropia (eye turning in)
gentle wiping with a well-moistened,
- hypertopia (eye turning up)
sterile, cotton-tipped applicator after the
- a cover test reveals the true condition
eyelid is inverted

- concomitant (measures the same in all

• If a foreign body adheres to the cornea, it
directions of gaze)
needs to be removed by an
- non concomitant (greater in one direction
ophthalmologist

than in another; often called paralytic

• If the foreign body is metallic and has been
strabismus)
in contact with the cornea for a period of
- concomitant (nonparalytic) strabismus is
hours, a rust ring can form around the
the most usual type found in children
particle

- paralytic strabismus is caused by

• The eye is washed with an antibiotic
paralysis of a muscle or nerve, perhaps
solution and then closed and patched

from an injury, such as a birth injury, or

• Sympathetic iritis - inflammation of the photophobia (sensitivity to light), all

opposite eye, may result if the ciliary body difficult to identify in a newborn

was involved in a penetrating injury

- the eye globe may feel tense to finger

• Removal (enucleation)
- eye pressure is measured by means of a

tanometer, a pressure sensitive device

Contusion Injuries
that is placed against the anterior eye

• The eyelid and the surrounding tissue, globe and measured eye pressure by a

including the intraorbital tissue, beam of light directed toward the eye

hemorrhages and becomes edematous

• Therapeutic Management

• “Black eye” - the simplest form of - immediate surgery: goniotomy,

contusion injury
trabeculotomy, in which a new opening

• If there is no apparent eye injury, ocular to the canal of Schlemm is constructed

movement is good and vision is normal, - acetazolamide (Diamox) suppress the

the only treatment necessary is an ice pack formation of aqueous humor, may be

applied to the eye to minimize the swelling

used temporarily to reduce eye pressure

before surgery can be scheduled

Eyelid Injuries
Cataract

• May accompany eye globe injuries, or they • Marked opacity of the lens

may be the only finding present after a • Dominantly inherited condition

foreign body has struck the eye

• Caused by galactosemia, or inability to
metabolize the lactose in milk

Inner Eye Conditions • Few children develop cataracts as a result

Congenital Glaucoma
of steroid use or radiation exposure

• Glaucoma is increased intraocular pressure • Can be caused by trauma to the eye if the
in the eye globe caused by inadequate or lens is injured

blocked drainage of aqueous humor

• Anterior surface of the lens - birth injury or
• A developmental anomaly in the angle of possible contact between the lens and the
the anterior chamber prevents proper cornea during intrauterine life

drainage into the canal

• At the edge of the lens - result of nutritional
• Glaucoma occurs wen the Cana becomes deficiency during intrauterine life, such as
blocked
rickets or hypocalcemia

• The increased fluid content that • Infants who contact rubella prenatally ay
accumulates causes the globe of the eye develop opacity throughout the lens

to increase in size
• Assessment

• The pressure in the eye globe continues to - the pupil openning appears to be white

rise, compressing and ultimately (leukocoria)

destroying the optic nerve

- the red reflex elicited by shining a light

• Glaucoma (“gray”) gets its name from the into the pupil appears white

color of the retina or red reflex (which - older children may report blurred vision

appears to be green) in the eye after the because of cataract formation

sight has been lost

- infant: can be detected by lack of

• Assessment
response to a smile or inability to reach

- the condition is bilateral and is caused

and grasp a nearby object; nystagmus,

by inheritance of a recessive gene

being unable to focus the eye on objects

- symptoms begin to be noticeable shortly

- congenital glaucoma: lens may be

after birth
opaque because of edema

- occurs more in girls

• Therapuetic Management

- can occur after the eye trauma in older

- surgical removal of the cloudy lens,

children if there is scarring at the canal of

followed by the insertion of an internal

Schlemm
intraocular lens

- the cornea, which appears enlarged,

- if not done before 6 months of age,

may be edematous and hazy

amblyopia may result

- there may be tearing, pain and

- children will be given a mydriatic agent

to dilate the pupil and steroids to prevent

 postoperative development of pupillary

• Congenital sensorineural hearing loss
adhesions
occurs in 2 to 3 of every 1000 live births

• Causes include serious otitis media,
The Child Undergoing Eye Surgery trauma from such things as inflating
• Surgery for cataracts or glaucoma in airbags, and untreated acute otitis media
childhood is usually performed during the with rupture of the tympanic membrane

infant period
• Should be enrolled in special programs for
- helping a baby to adjust to a strange
hearing challenged children as soon as the
environment and encouraging parents or
hearing loss is discovered

a primary care person to spend as much

• An improvement in hearing usually can be
time with the infant as possible
achieved by use of a hearing aid (which
• Surgery for strabismus is often done during intensifies the level of sound waves)

the preschool period

• Children who have inner ear or nerve
- explain through the use of puppets or
deafness cannot expect this kind of
dolls
improvement

- talk about the child’s affected parts

• Acupuncture, often recommended to
being “fixed” or “made better”, never
parents by friends as therapy for nerve
“cut”
deafness, has no documented effect

The Hospitalized Child with a Vision Hearing Aids and Cochlear Implants

Disorder • Hearing aids pick up sound through a

• WHO defines vision impairment as testing microphone, convert the sound waves into
20/60 to 20/200 in the better eye on a electrical impulses, and amplify them
standard examination
across the tympanic membrane

• Powered by batteries that must be

• Blindness is defines as vision less than
20/200 or peripheral vision less than 10 changed periodically

degreed
• Designed to be as inconspicuous as

• Occurs because of Vitamin A deficiency, possible so that children will not feel self-
inadequately treated eye infections, conscious wearing them

corneal scarring, and diabetes

• Teach children to remove hearing aids
before washing their hair, showering, or
Structure and Function of the Ears swimming

• Hearing aids should be turned off when

Physiology of Hearing Loss

• Conduction loss

removed, to preserve the life of the

- if there is interference with sound
batteries

• Cochlear implants - mechanical devices

reaching the inner ear (difficulty with the

external canal, the tympanic membrane,

consisting of a microphone, a speech
or the ossicles)
processor, a transmitter/receiver, and an
- Conduction loss can occur if the external
arrangement of electrodes that send
canal is obstructed with cerumen (wax)
impulses from the receiver to the auditory
of foreign object
nerve

• Have the potential to replace a

• Nerve or sensorineural loss

- inner ear or the 8th cranial nerve is

nonfunctioning inner ear and create the
affected
ability to receive and interpret sounds in an
- results from diseases that affect the
ear that has sustained nerve damage

• Consist of an external portion that is

transmission of sound sensation to the

cerebral cortex or from a pathologic

surgically implanted under the skin

• Hearing is often reported as “muffled” but

condition of the cochlea

adequate

• Months of training are necessary to help a

Hearing Impairment

• 1 in 1000 children in the US are profoundly

child interpret these distorted impulses
hearing challenged
correctly

Speech Therapy
• Caution parents not to clean the child’s
• Learning sign language early is helpful ears with cotton-tipped applicators as a
because it allows children to express their regular practice, because they may scratch
needs early
the ear canal, causing an invasion site for
• By sign language, children decrease their secondary infection

need to learn to articulate speech sounds • Commercial softeners are available if

or to lip read and for this reason, learning cerumen accumulates to such extent that
sign language should not be encouraged
hearing is affected

• Some physician dilute solution of hydrogen

Disorders of the Ear peroxide to dissolve cerumen

External Otitis

• The inflammation of the external ear canal

Acute Otitis Media

• Causes discomfort in the form of itching • Acute inflammation of the middle ear (otitis
and sometimes extreme pain
media) is the most prevalent disease of
• Assessment
childhood after respiratory tract infections

- recently been swimming (Swimmer’s ear)

• Most in males

- occur if a young child pushes a foreign

• There is a higher incidence of otitis media
object, such as peanut into the ear canal
in formula-dfed infants than those who are
- no history of recent respiratory infection
breastfed, because formula-fed infants are
- children first notice itching of the canal,
held in a more slanted position while
then pain
feeding, and this allows milk to enter the
- when the external ear is touched, the
eustachian tube

pain becomes acute

• Highest in winter

- the moisture in the canal left from

• Permanent damage can occur to middle
swimming has caused inflammation
ear structure, leading to hearing
- pseudomonas and candida are agents
impairment

- otoscopic examination
• Assessment

- fungal infection: the entire canal may

- occurs after a respiratory tract infection

appear brown or black

- “cold”, rhinitis, and perhaps low grade

- peanut: white or gray debris may

fever for several days, and a sharp,

surround the object

constant pain in one or both ears

- the skin under the object will be moist,

- infants: irritable and frequently pull or tug

red, and eroded

at the affected ear

• Therapuetic Management
- the external canal is usually free of wax

- differs according to the organism

because the warmth of the inflammation

causing the infection

and fever melts the wax and moves it

- if the canal is so swollen that ear drops

more readily out of the canal

cannot flow back into the canal: cotton

- the tympanic membrane appears

wick moistened with Burrow’s solution

inflamed or reddened on otoscopic

may be threaded into the canal

examination

- hydrocortisone: reduces inflammation

- tympanocentesis: (withdrawal of fluid

- antibiotic/antifungal: reduces infection

from the middle ear through the tympanic

membrane) may be performed by a

Impacted Cerumen
physician to obtain fluid for culture at the

• Cerumen (earwax) serves the important time of assessment

function of cleansing the external earl canal • Therapeutic Management

as it gradually moves outwards, bringing - cause by Streptococcus pneumoniae,

with it shed epithelial cells and any foreign Haemophilus influenzae (<5years) or

objects
streptococcus pyrogenes

• Wax accumulation rarely is extensive - most resolve spontaneously without

enough to interfere with hearing

therapy

• Cerumen serves a protective function, - antibiotic such as ampicillin or

however should not be removed routinely

amoxicillin

Otitis Media with Effusion

• Result of chronic otitis media

• Assessment

- muffled hearing and a feeling of pressure

in the ear

- a fluid line will be visible only if there is

also a quantity of air in the middle ear to

contrast with it

- pneumatic otoscope: gentle introduction

of air against the eardrum produces no

movement of the tympanic membrane (as

there would be normally)

• Therapeutic Management

- supplying air to the middle ear

- mild involvement: daily administration of

antihistamine or a nasal decongestant to

shrink the mucous membrane of the

eustachian tube may be enough to

achieve an air supply

- tympanocentesis

1. Tubal Myringotomy - a source of air can

be supplied to the middle ear by the
insertion of small plastic (Teflon) tubes
inserted through the tympanic membrane
(tympanostomy)

Cholesteatoma

• A lesion of the pars flaccida or upper

portion of the tympanic membrane

• A retraction cyst forms, and there is

necrosis of the pars flaccida with foul-
smelling drainage from the ear

• It can progress to mastoiditis, meningitis,

and possibly facial nerve paralysis if it is
not surgically removed

The Hospitalized Child with Hearing

Impairment
• A hearing loss greater than 49 dB is
sufficient enough to interfere with hearing
normal conversation and developing
language

• Always allow hearing-challenged children

to see you before you touch them as they
will not find this nearly as intrusive as being
touched without warning

• Do not underestimate the intelligence level

of hearing-challenged children