14.3 Ophthalmological and Otological Effects

TCO IV.A.12–13 tests ophthalmologic and otologic acute, chronic, and late effects. This is not the emergency intracranial-pressure (ICP) chapter. Papilledema is signposted. Here the nurse times platinum hearing loss, protects the cochlea from unacknowledged radiation, keeps audiology and school frequency-modulated (FM) systems on the map, and treats eye pain and photophobia as reportable—not as screen time.

A 3-year-old receiving cisplatin for hepatoblastoma, a 7-year-old after posterior-fossa radiation whose teacher says the child is not listening, and a teenager on high-dose cytarabine who skipped steroid eye drops are sensory-effect patients.

Platinum and radiation ototoxicity

Cisplatin and, to a lesser extent, carboplatin cause sensorineural ototoxicity. Injury starts at high frequencies (classically 8000 Hz and above on a pure-tone audiogram) and can march downward into the speech range. Young age, higher cumulative platinum, concurrent cochlear radiation, renal impairment, and prior hearing loss raise risk. The child may not report hearing loss. Toddlers stop turning to a whisper; school-age children crank the tablet, fail a hearing screen, or develop tinnitus. Vincristine is not the main ototoxin; it rarely causes other cranial-nerve palsies (ptosis, diplopia, vocal-cord or jaw problems) taught in the neurologic chapter. Do not skip platinum audiology because the vincristine jaw-pain talk already happened.

Radiation to the cochlea (posterior-fossa fields for medulloblastoma, nasopharyngeal or temporal fields, TBI) adds risk alone and synergizes with platinum. Do not invent a single cochlear gray threshold as ONCC fact. Teach field plus platinum plus serial testing.

Supportive audiology is the intervention: baseline and protocol-timed audiograms (or auditory brainstem response in infants who cannot condition), early hearing aids when indicated, and classroom FM systems so the teacher’s voice reaches the ear above noise. Preferential seating, captioning, and an individualized education program or 504 plan overlap the neurocognitive chapter; hearing loss is not inattention. Otoprotectants such as sodium thiosulfate appear on selected cisplatin protocols as ordered—do not add them yourself and do not quote an invented preservation rate.

A 7-year-old after cisplatin and posterior-fossa radiation who is failing spelling tests with a normal Glasgow Coma Scale still needs an audiogram. Processing-speed late effects and high-frequency loss can coexist; one does not cancel the other.

Eyes: steroids, cytarabine, GVHD, retinoblastoma, and papilledema

Corticosteroid cataracts (often posterior subcapsular) are a chronic and late lens effect of prolonged dexamethasone or prednisone. Blurred vision, glare, and declining chalkboard reading are clues. Ophthalmology follows; do not tell the family that pediatric cataracts cannot happen.

High-dose cytarabine causes chemical conjunctivitis and keratitis: photophobia, tearing, eye pain, and a child who refuses to open their eyes in a bright room. Prophylactic steroid eye drops (and sometimes saline rinses) start before the infusion and continue for the protocol window after. Missed drops are a nursing failure. Dim the lights, report pain, and do not label this as behavior. The chemotherapy chapter names the same drops; this section is the organ toxicity when they are skipped.

Chronic GVHD produces sicca—dry eyes, dry mouth—months after allogeneic HSCT. Artificial tears, humidification, and ophthalmology (including infection risk on a dry cornea) are the plan. This is the same sicca cluster named in the HSCT chapter; here the organ is the eye.

Retinoblastoma treatment can include enucleation, focal therapy, systemic or intra-arterial chemotherapy, and historically external-beam radiation. Visual outcome depends on laterality, intraocular group, and which eye was saved. After unilateral enucleation, the remaining eye is precious: eye protection, infection teaching, and prompt ophthalmology for new redness. Do not invent a single percentage of normal vision as ONCC fact. Bilateral disease is a lifelong visual-function problem, not only a tumor-staging problem from the solid-tumor chapter.

Papilledema (blurred optic disc, visual change, headache, morning vomiting) is a sign of increased ICP until proven otherwise—brain tumor, hydrocephalus, thrombosis. Signpost to the emergency ICP pathway. It is not a routine steroid-cataract clinic visit and not a reason to add extra dexamethasone at home.

Radiation retinopathy is a rare, delayed retinal vascular injury after orbital or cranial radiation. It is not an expected finding on day 1 of cranial radiation. New visual loss years later still needs ophthalmology rather than a shrug.

Nursing: what to report

Teach families and chart a short list. Report new hearing loss, tinnitus, photophobia, and eye pain the same day they appear during platinum, cytarabine, or GVHD windows—not at the next annual survivorship visit. Hold bright lights for keratitis, protect the residual eye after retinoblastoma treatment, and send the student who is not listening to audiology instead of a purely behavioral plan.

The CPHON product is an audiogram that was not deferred until conversational speech collapsed, an FM system on a school 504 plan, cytarabine drops that went in before the infusion, and a nurse who treats photophobia and tinnitus as organ toxicity rather than screen-time complaints.