KASTURBA GANDHI NURSING COLLEGE

SRI BALAJI VIDYAPEETH, SBV CAMPUS

Pillaiyarkuppam, Puducherry – 607402

SEMINAR
ON
EYE DISORDER

SUBMITTED TO SUBMITTED BY
MRS. Sherin Nithya. S D. Venkatesaperumal
Associate Professor M.Sc Nursing
Dept of Child Health Nursing IInd Year
Kgnc Kgnc

Submitted on :07/01/2022

EYE DISORDER
Introduction:

Vision is essential to a child’s development and quality of life. Almost three

fourth of a child’s learning is accomplished through vision. The world health
organization ( WHO) estimates that 19 million children world wide are affected by
eye disorders. A medical consultation is very important for preventing visual and
eye disorders are providing the correct treatment. Over the 80% of all eye
disorders can be prevented or cured.

Eye disorder and visual impairments can cause social and economic difficulties,
particularly in developing countries. Children in developing countries suffer from
blindness almost four times more often than children in developed countries.

Anatomy and physiology of eye

 The human eye is a complex anatomical device that remarkably demonstrates the
architectural wonders of the human body. Like a camera, the eye is able to refract
light and produce a focused image that can stimulate neural responses and enable
the ability to see.

The eye is essentially an opaque ball filled with a water-like fluid. In the front of
eyeball is a transparent opening known as the cornea. The cornea is a thin
membrane that has a refraction index of approximately 1.38. The cornea serves
dual purpose of protecting the eye and refracting light as it enters the eye. After
light passes through the cornea, a portion of it passes through an opening known as
the pupil. Rather than being an actual part of the eye's anatomy, the pupil is merely
an opening. The pupil is the black portion in the middle of the eyeball. Its black
appearance is attributed to the fact that, the light that pupil allows to enter the eye
is absorbed on the retina ( and elsewhere ) and does not exit the eye

Like the aperture of a camera, the size of pupil can be adjusted by dilation of the
iris. The iris is the colored part of eye- being blue for some people and brown for
others (and so forth). It is a diaphragm that is capable of stretching and reducing
the size of the pupil opening. In bright-light, the iris adjusts its size to reduce the
pupil opening and limit the amount of light that enters the eye. In dim-light
situations. the iris adjusts so as to maximize the size of the pupil and increase the
amount of light that enters the eye. Light that passes through the pupil opening will
enter the crystalline lens. The crystalline lens is made up of layers of a fibrous
material that has an index of refraction of roughly 1.40. Unlike the lens on a
carnera, the lens of the eye is able to change its shape and thus serves to fine-tune
the vision process. The lens is attached to the ciliary muscles. These muscles relax
and contract in order to change the shape of the lens. By carefully adjusting the
lens shape, the ciliary muscles assist eye in the critical task of producing an image
on the back of the eyeball.

The inner surface of the eye is known as the retina. The retina contains the rods
and cones that serve the task of detecting the intensity and frequency of the
incoming light. An adult eye is typically equipped with up to 120 million rods that
detect the intensity of light and about 6 million cones that detect the frequency of
light. These rods and cones send nerve impulses to the brain. The nerve impulses
travel through a network of nerve cells. There are as many as one million neural
pathways from the rods and cones to the brain. This network of nerve cells is
bundled together to form the optic nerve on the back of the eyeball. Each part of
the eye plays a distinct part in enabling humans to see.

Normal Development of Eye

The eye starts developing at about 22 days of gestation. This development is not
complete at birth. However, the newborn is able to focus on object at a distance of
3 feet. Sensitivity to brightness develops rapidly in the first 2 months of life and
infant displays blink reflex. By 4-6 months of age the infant has visual
accommodation (ability of the eye to focus clearly on objects at will distances)
equal to an adult. 'Binocularity' (fixing of two ocular images into one picture) is
also established by 6 months of age. "Visual acuity' (clearness or sharpness of
image) changes with age, from 20/50 at 18 months to 20/20 at 4 years of age. At
birth, the color of iris is blue or light grey in fair newborns and brown in dark
newborns. Permanent eye color may not appear until 1 year of age.
Classification of eye disorder:

They are mainly two classification of eye disorder

Eye disorder

Infectious and Non Inflammatory

inflammatory conditions conditions

1. Conjunctivitis 1. Cataract
2. Ophthalmia Neonatorum 2. Glaucoma
3. Retinitis 3. Ptosis
4. Stye ( HORDEOLUM) 4. Refractory error
5. Keratomalacia
6. Retinopathy of prematurity

INFECTIOUS AND INFLAMMATORY CONDITIONS

1. Conjunctivitis
Definition:
Conjunctivitis ( pink eye ) is an inflammation of the conjunctiva of
eye

Etiology
 Conjunctivitis during childhood is caused due to allergy or infection by bacteria
or virus.

The most common bacterial causes are Hemophilus influenza, Streptococcus

pneumoniae and chlamydia.

Viruses that cause conjunctivitis are Adenovirus and Herpes virus.

Pathophysiology:

Microbes enter the eye on contract with infected object

Inflammation of eye

Dilation of blood vessels of eye

Swelling, redness, exudates and discharge

Clinical features

 Redness of the eyes

 Tearing and itching in eyes
 Exudation

Other symptoms includes

  Photophobia
 Pseudoptosis
 Periorbital edema
 Pain in eye
 Fever

Diagnostic evaluation

The diagnosis is made mainly on the basis of clinical features. A culture of the
drainage may be obtained to confirm the diagnosis

Management

Causes Associated symptoms Management

Viral Often associated with other  Hygiene

symptoms of generalized viral  Rest
illness

Bacterial Yellow, green or white pus  Antibiotic eye drops

with photophobia or ointment with
hygiene

Allergic Itching, other allergic features,  Antihistamine eye

watery discharge. drops
 Avoidance of
allergens
 Chemicals Watery discharge, onset of  Avoidance of
symptoms when exposed to irritating substances
cigarettes or other irritants.

Trauma Pain, photophobia and  Eye patch

increased tear production  Referral to
specialist

Prevention

If conjunctivitis is allergic or viral in origin, nursing management focuses

primarily on comfort measures. Following nursing care needs to be given,

 Apply cold compress on the eye.

 Reduce exposure to light.
 Prevent rubbing of the eye.
 Acetaminophen may be administered to relieve discomfort.

If conjunctivitis is caused by bacterial agents, nursing care includes:

 Clean the eye using sterile water and cotton swabs, from Inner canthus to
outer canthus
 Apply the prescribed antibiotic ointment or eye drops.
 Use of dark glasses is advised, in presence of photophobia.

Family teaching
  Advice the following ways to prevent transmission of infection to others
 Use good handwashing after touching the eye. .
 Use separate towel, sheet and pillow case for infected child.
 Do not allow the medicine dropper to touch child's eyes during medication
instillation.
 Discard old contact lenses (if child is using) and use new ones after infection
has resolved.

2. OPHTHALMIA NEONATRUM

Definition

Purulent discharge from eye of a newborn, within 21 days of birth is known as

ophthalmia neonatorum. Most cases develop this condition within 48-72 hours of
life. It is mostly bilateral.

Etiology

The organisms that may cause ophthalmia neonatrum are - Neisseria gonorrhoea,
Staphylococcus aureus, E. coli, Pseudomonas aeruginosa, certain viruses and
Chlamydia trachomatis,

Mode of Infection

The mode of infection include

a. Intrauterine infection

b. Infection during the process

c. Infection after birth

Pathology

Due to infection, the blood vessels dilate and there is formation of new blood
vessels around the papillae. Numerous polymorphs are present in the epithelium
which leads to purulent discharge and exudate Formation in eye.

Clinical Features

 Eyelids are tense and swollen.

 Conjunctiva is congested and swollen.
 Excessive tearing or turbid and thick discharge from eyes.

Management

A swab must be taken from purulent eye discharge and sent for culture and
sensitivity. Depending the result, the physician prescribes appropriate antibiotic
ointment or eye drops Crystatine Penicillin Chloramphenicol, Erythromycin
Gentamycin eye drops may be prescribed by the physician. Polymain is used for
pseudomonas infection..

Eye care
 The infected eye or eyes are cleaned with sterile swabs moistened with normal
saline. Each swab will be used once only for wiping the eye from inner canthus to
outer canthus Wash eyes as frequently possible with war sterile normal saline.

After cleaning of eyes, Instill crystalline penicillin eye drops.

Every minute for 1/2 hour

Every 5 minute for next 1/2 hour

Every 1 hour for 12 hours

Every 2 hourly for 3 days

In case of Gonococcal or Chlamydia infection, systemic antibiotic therapy is

required.

Prevention

Ophthalmia neonatorum can be prevent by following simple measures

 Proper antenatal care of pregnant women.

 Treatment of infected vaginal discharge during pregnancy.
 Use of aseptic techniques while delivery and in care of newborn.
 Cleaning of each eye with sterile swabs dipped in sterile water, as soon as
the head is delivered and instillation of Chloramphenicol eye drops in each
eye as a prophylactic measure.

Complications
 If the condition is not treated, there can be generalized haziness of cornea or
corneal ulcers, which may lead to blindness.

3. RETINITIS

Definition

Inflammation of retina is known as retinitis. It usually occurs in association with

inflammation of chore (choria-retinitis) or optic nerve (neuroretinitis). Primary
retinitis is rare.

Etiology

Primary retinitis may be an allergic reaction to some endogenous taxin, In few

cases, the toxin produced from some active or latent septic focus (like dental
sepsis, séptic tonsits) but in most of the cases it is tuberculoprotein from a latent
focus in lung or any lymph node.

Pathophysiology

Due to infection, Inflammation occurs

Exudate formation

Exudates pass through the brunch's membrane and reach retina.

 Exudates from retina reach the vitreous

Floating of black spots in front of eye and retina becomes edematous

Distortion of images and blurring of vision

Clinical Features

The child presents with the following clinical features

 Floating black spots in front of eye

 Metamorphopsia (distortion of image)
 Micropsia (objects appear smaller)
 Macropsia (objects appear bigger)
 Photopsia or subjective flashes of light due to retinal irritation .

Diagnostic Evaluation

The diagnosis of retinitis is established with the help of fundoscopy, which

shows

 Localized grey patch with blurred margins in retina.

 Few hemorrhagic spots or exudates on retina.
 If the grey patch is close to optic disc the disc margin becomes edematous.
 Vitreous humor is slightly hazy.
  If central area is affected, there is permanent defect of visual acuity with
central scotoma.

Management

 Management of retinitis is as follows

 Protect the eye from light by wearing dark goggles.
 Atropine eye drops are instilled thrice daily. .
 Eye care should be done using warm sterile water.
 Sub conjunctival or retro-bulbar injection of corticosteroid may be helpful in
arresting the inflammatory process.
 Sodium salicylate may be given for pain relief.
 Systemic antibiotics are prescribed to treat focal sepsis, if present anywhere
in the body.
 Antihistamines are helpful in allergic type.
 Systemic corticosteroids are effective in controlling inflammation.

4. STYE (HORDEOLUM)

Definition

Stye or hordeolum is an infection of the sebaceous glands near the eye lashes. A
pustule in the eyelash follicle is known as stye.
Etiology

A stye may be caused by bacterial or viral infection. It is most often caused by

staphylococcus infection.

Clinical Features

The clinical features of hordeolum are as follows

 Pustule in eyelash
 Pain and tenderness
 Localized swelling of eyelid
 Redness in eye

As hordeolum forms, it gets filled with purulent material and becomes red and
painful.

Management

Warm compress must be applied on eye, several times in a day.

Eye care is done frequently.

Antibiotic eye drops are instilled.

If the hordeolum does not resolve spontaneously, incision and drainage of purulent
material is to be done.

Prevention

This type of infection can be prevented by observing hand washing practice and
maintaining personal hygiene.
 NON INFLAMMATORY CONDITION OF EYE

1. Cataract

Definition

Cataract is the development of opacity in the crystalline lens of eye. As light can
not pass through the opacity, vision becomes blurred.

Incidence

Congenital cataract affect 1 in 250 newbornsf

Types

Cataract can be of the following types

i. Unilateral or bilateral
ii. Partial or complete
iii. Congenital or acquired

Causes

The causes of congenital or acquired cataract is

Cataract

Congenital or primary Acquired or Secondary

*Intrauterine infections in early mothers * Trauma

Of pregnancy like German measles and * uveitis

Toxoplasmosis * Glaucoma

*maternal malnutrition * Retrolental fibroplasia

*galactosemia

*Chromosomal anomalies like

Down syndrome

*Ocular malnutrition

*Mental retardation

Pathophysiology

The lens capsule is formed during the fourth and fifth week of gestation. It is a
clear membrane which allows light to enter the eye and refract the rays for a clear
image on retina. If there is any reason that interferes with lens development, the
lens becomes milky white and cloudy, obscuring light rays and thus vision.

Diagnostic Evaluation

Infants with a family history or prenatal history placing them at risk for cataract
should be assessed after birth. The opacity or cloudiness of lens can be seen with
naked eye. When the nurse does y examination using a penlight, it reveals absence
of red light reflex and white pupillary reflex
Management

The definitive treatment for cataract is surgical removal of the cataract from
affected eye. The affected lens is removed and artificial intraocular lens is put in
the affected eye.

The time at which cataract surgery is performed, is crucial to prognosis. If

cataract is noticeable at birth surgery must be done before 8 weeks of age, to
prevent irreversible visual impairment.

Post Operative Care

 After surgery the child needs eye patching or shielding for several days.
 Instillation of antibiotic and steroidal eye drops several times a day.

2. GLAUCOMA

Definition

Glaucoma is the condition of increased intra ocular pressure ( IOP), causing

gradual loss of sight.

Types

Glaucoma has two forms

1. Congenital or infantile glaucoma: It occurs in children under 3 years of age.

It may be present at birth.

2. Juvenile glaucoma: It affects children older than 3 years of age and is usually
secondary to some other disease.
Incidence and Etiology

Congenital or infantile glaucoma occurs in 1 out of 10,000 live births. It occurs

due to defect in the drainage system of eye. It is usually caused by a developmental
anomaly of the iridocorneal angle of eye known as trabeculodysgenesis.

Juvenile glaucoma occurs secondary to some other disease like retinoblastoma,

trauma to the eye etc.

Pathophysiology

Due to defective development of the trabecular meshwork, sufficient amount of

aqueous humor is not drained out of the intra ocular space. This leads to
accumulation of aqueous humor in the anterior chamber of eye, resulting in
increased intra ocular pressure. This increased pressure causes damage to the
ganglion cells of retina, leading to necrosis of the optic disc, which results in
blindness.

Clinical Features

 The clinical features of glaucoma are

 Excessive tearing (epiphora)
 Involuntary closing of eyelid
 Photophobia
 Enlargement of eyeball (Buphthalmos)
 Haziness or clouding of cornea
 Pain in the eyeball

Diagnostic Evaluation
Intra ocular pressure of eye is measured by tonometry. The normal pressure is 12
to 20 mm Hg. For measurement of intra ocular pressure in infants and young
children, anesthesia may be required. Assessment of corneal diameter and
examination of retina is done to assess any damage to optic nerve due to increased
pressure.

Management

The definitive treatment is surgery. Goniotomy or Trabeculotomy is done to open

the channel of outflow of aqueous humor from the anterior chamber of the eye,
thereby reducing Intra ocular pressure.

Post Operative Care

The post operative nursing care aims at the following.

 Management of Intra ocular pressure

 Management of pain
 Reducing fear and anxiety
 Teaching care givers about home management

These aims achieved by taking the following steps

1. Prevent increase of intra ocular pressure by preventing straining, crying and

getting startled.

2. Eye patch must be applied.

3. Administer the prescribed analgesic and antibiotics.

4. Educate the care givers about recognition of signs of increased intra ocular
pressure, signs of infection, Instillation of eye drops and need for follow up.

3. PTOSIS

Definition

Drooping of upper eyelid caused by weakness of ocular muscles is known as

ptosis. It occurs due to weakness of levator palpebrae or less frequently, the muller
muscles.

Etiology

Ptosis occurs in following conditions:

 Myasthenia gravis
 Eyelid injuries
 Third nerve palsy

Signs and symptoms

 Drooping eyelids
 Crossed eyes
 Double vision
 Eye and forehead fatigue
 Difficulty closing the eye or blinking
 Dry or watery eye
Diagnostic evaluation

Assessment of the child shows drooping of eyelid and impaired vision as the
eyelid covers the pupil

Management

The problem needs surgical correction to raise the eyelid and increase visual
field. Patching of the eye is needed post operatively for few days.

4.REFRACTORY ERRORS

Meaning

Refraction is the process by which the cornea and lens of the eye bend light rays
to focus on the retina. When the bending of rays and length of eyeball are
uncoordinated, the image does not fall on a single point on retina. This results in
refractory errors. When refraction is normal it is known as emmetropia.

Incidence and Etiology

Refractory disorders are the most common type of visual disorders in children
that occur due to the following reasons

a. Abnormal curvature of refractive surfaces

b. Abnormal position of refractive surfaces

c. Abnormal anterio - posterior length of eyeball

d. Abnormal refractive index of refractive media of eyeball 1.e. lens (as in cataract)
and vitreous humor (after vitrectomy)

Types

The following Refractive disorders may be present in children

a. Myopia (Near sightedness)

b. Hyperopia (Far sightedness)

c. Astigmatism (Blurred vision)

A. Myopia ( Near sightedness)

Myopia is the condition in which the parallel rays from distant object
focus in front of retina.

Types

1. Congenital myopia: It is present at birth and may be unilateral or bilateral.

It is usually associate with convergent squint.
2. Simple myopia: This is the commonest type and is not associated with any
degenerative changes retina and choroid. It starts in early adolescence,
increases during school years and becomes stationary after the age of 25
years.
3. Progressive myopia: This type progresses rapidly and is accompanied by
degenerative changes in vitreous, choroids and retina.
Pathophysiology

When the length of eyeball in anterio-posterior axis is more due to over

development of the eye, or if the refractive index of lens is greater than normal or
if the curvature of cornea is greater than normal, it causes the light rays to focus in
front of retina.

Clinical Features

The clinical features of myopia are as follows:

 Dimness of vision for distant objects:- The child usually complains that
he/she can not see the writing on blackboard in school.
 If the defect is severe, apart from dimness of vision for distant objects, the
child complains of headache on reading.
 The child is seen holding books closely to eyes, while reading.

Management

The defect should be corrected by prescribing a concave lens; of appropriate

strength for the child Photorefractive keratectomy laser surgery may be used to
correct myopia.

B.HYPEROPIA (FAR SIGHTEDNESS)

Definition

Hyperopia is the condition in which parallel rays from a distant object focus
behind the retina. This is the most common refractory error.
Pathophysiology

When the length of eyeball in anterio-posterior axis is shorter than normal or if

the refractive index of lens is low or if the curvature of cornea is less than normal,
the light rays focus behind the retina resulting in difficulty with near vision.

Clinical Features

The Clinical features of hyperopia are as follows

 Diminished vision, both for near and distant objects.

 In less severe hyperopia, the child complains of reading problem.
 There may be headache, transient blurring of vision (particularly while
reading), pain in eyes, heaviness of eyelids and redness of eyes.

Management

This refractory error can be corrected by using convex lens of proper strength.

C.ASTIGMATISM

Definition

Astigmatism is the refractory error in which refraction differs in different

meridians of eye. In the horizontal meridian, the eye is emmetropic while in the
vertical meridian, it is hypermetropic or myopic.
Types

Irregular astigmatism: Here the rays of light are reflected very irregularly due to
irregular corneal curvature, as in case of corneal scar.

Regular astigmatism: In this type, the meridians of greatest and least curvature
are at right angles to each other. They are called principal meridians. It is of the
following types:

 Simple astigmatism: in this type, one meridian is emmetropic (normal

refraction) while other is either myopic or hypermetropic/ hyperopic.
 Compound astigmatism: In this type, both the meridians are either myopic
or hypermetropic/hyperopic.
 Mixed astigmatism: When one meridian is myopic and the other is
hyperopic, it is known as mixed astigmatism.

Pathophysiology

Astigmatism occurs when there is uneven curvature of the cornea or lens or

both, preventing light rays from focusing correctly on retina. It also occurs due to
dislocation of the lens.

Management

For the correction of regular astigmatism, cylindrical lens of proper strength is

prescribed. In case of irregular astigmatism, correction in eye sight can't be made
with cylindrical tens, but use of contact lens can be helpful.
 5. Keratomalacia

Definition

Keratomalacia is an eye disorder that involves drying and clouding of cornea

due to vitamin A deficiency

Causes

• Decreased vitamin A intake

• Poor metabolism ( eg. in case of celiac syndrome and ulcerative

colitis)

• Insufficient conversion, storage , absorption and transport of vitamin A

• Infants and children who are allergic to milk are at high risk

Pathophysiology

Lack of vitamin A

Atrophic changes in normal mucosal surface

Loss of goblet cells

Replacement of normal epithelium by inappropriate keratinized squamous

epithelium
 In addition substantia propria ofcornea breaks down and liquefies

Keratomalacia

Cornea becomes totally opaque

Blindness

Signs and Symptoms

• Highly perforated and soft cornea

• Wrinkling and cloudiness in cornea

• Corneal ulcers

• Changes in vision

• Decreased night vision

• Photophobia

• Corneal scar

• Dryness of ocular glands like lachrymal glands, cornea and conjunctiva

• Formation of bitots spots

Diagnostic evaluation

• History colleection

• Physical Examination

• Eye examination

• External appearance

• Visual acquity

• Eye movements

• Visual field

• Slit lamp examination of conjunctiva and cornea

• Blood studies (beta carotene and vitamin A levels)

Management

• Vitamin A Supplementation

• Mild to moderate deficiency : 10,000mcg of fat soluble vit A x 10 days

• Severe cases : 50,000mcg of fat soluble vit A for several weeks

• A single dose of 1lakh mcg vit A will prevent vit A deficiency in children
for about 6 months

Treatment of secondary cause if any

 • Fish liver oil
• Butter
• egg
• Green leafy vegetables
• Cod liver oil
• Carrot
• Pumkin
• Milk and milk products …etc

6. Retinopathy of prematurity
RETINOPATHY OF PREMATURITY (ROP) Babies born with a very low birth
weight have an increased risk of developing abnormal peripheral retinal blood
vessels that can cause the retina to become loose (detached retina), which can lead
to blindness.

Those babies who do not develop this problem in childhood still have an increased
risk of retinal detachment later in life, and should be seen regularly by an eye
doctor to check for retinal detachments.

Incidence

 66% of infant born with 1,250g

 82% of infant born with 1000 g

Causes and Risk factors

  Occurs in premature children
 Vitamin A deficiency

Risk factors

 Prematurity (< 32 weeks)

 Low birth weight (<1500g)
 Excess O2 supplementation

Pathophysiology

Full term normal child’s retina is completely vascular

Pre term child’s retina vascularity not complete, extend only up to ora serrata

At birth, child is exposed to hyperoxia

Hyperoxia causes vasoconstriction

Vaso obliteration

Peripheral retina do not develop blood vessels

Hypoxia
 VEGF produced

Neovascularization occurs at vascular and avascular junction of retina

New blood vessels contract due to fibrous tissue and pull the retina from retinal
pigment epithelium

Loss of vision

Oxygen saturation targets

For full term baby 95 – 100%

For Pre term baby 85 to 93%

Management

1. Laser therapy
2. Post laser therapy
 antibiotics and
 follow up care
3. Surgical treatment
 Endo laser photocoagulation
  Retinal detachment

Journal abstract

Neonatal Intensive Care Unit Based Screening Program For Retinopathy Of

Prematurity And Its Treatment In An Indian Population.

ABSTRACT:

The retrospective study was conducted to identify the risk factors and anatomical
out comes after the laser treatment in retinopathy of prematurity. In that they were
identified 1648 eyes screening was done, in that 418 eyes are high risk of
retinopathy of prematurity and 164 eyes are low risk. Here one fourth of the infants
show ROP and one tenth needed laser photocoagulation, the outcome of which
was excellent. Risk factors to ROP were anemia, oxygen supplementation,
increased number of blood transfusions, and septicemia.

Theory application:

Lydia Core, Care, Cure theory

Lydia hall was born in New York city on September 21,1906,

Summary

So for we are discussed about the eye disorder in that I have discussed about
definition, Incidence, causes, pathophysiology, signs and symptoms, diagnostic
evaluation, Medical and surgical management.

Conclusion:

Child with eye disorder can be face the more difficulties in the life period. Proper
medical and surgical treatment can be lead to increase the vision of child and
prevent the blindness.

Bibliography

 Hockenberry MJ, Rodgers CC, Wilson D. Study Guide for

Wong's Essentials of Pediatric Nursing-E-Book. Elsevier Health
Sciences; 2021 Mar 26.

 Parthasarathy A, Menon PS, Nair MK. IAP Textbook of pediatrics. Jaypee

Brothers Medical Publishers; 2019 Feb 4.

 Sharma R. Essential of pediatric nursing. Jaypee Brother Medical

Publisher (p) LTD. Page. 2013(460).

 Behrman RE, Kliegman RM, Jenson HB. Nelson textbook of pediatrics

17th ed. Saunders2000. 2004.

 Singh M. Care of the new born revised 8ed (2017). CBS Publishers &
Distributors Private Limited; 2017 Nov 30.
Net Reference:
 Priyadharshini. Eye disorders for child https://www.slideshare.net.
Nov19,2012
 Dr. sayeedur rumi Retinopathy of prematurity. Aug26,2018
 Rahu moothedan. Eye disorder https://www.slideshare.net. Feb.02,2017