Paediatric optometry beyond myopia

Dr Ebru Efem

B Vis Sci/M Optometry, M Orthoptics Director at iOptical
Clinical Educator Latrobe University

Zeinab Faki

BOptom MPH GradCertUniversityTeaching Manager Paediatric and Rehabilitative Services Australian College of Optometry

PART 1: THE PSYCHOSOCIAL IMPACT OF EYE DROPS

While eye drops are fundamental in paediatric eyecare, their administration often presents challenges, particularly for young patients. However, with practise, optometrists can develop ways to navigate these difficulties, foster cooperation in the clinic and provide parents strategies to ease the process at home.

Eye drops can be used to treat various eye conditions in children including allergies, infections and inflammation of the eyes. In addition, cycloplegic eye drops are a crucial part of paediatric eye assessments. For children under the age of 12 months, 0.5% cyclopentolate is used, and 1% cyclopentolate is used for those over the age of 12 months.¹

The use of this medication in clinic results in blurry near vision due to cycloplegia and glare sensitivity that comes with pupil dilation. These symptoms can increase anxiety in children and reluctance to participate in the eye examination.

Studies have shown that instillation of eye drops result in distress and negative clinician-patient relationship in at least 45% of children under the age of four years.²

In general, eye drop instillation can result in distress in many children which means poor cooperation and difficult examinations. There are a variety of reasons that may explain why eye drops are not favoured in the paediatric patient group. The burning physical sensation caused by the eye drops and the fundamental unfamiliarity of the instillation process are two of the often cited reasons.

In paediatric healthcare, use of restraint (also referred to as ‘clinical holding’ and ‘supportive holding’) is not uncommon.³ But restraint can negatively impact children by creating fear, anger, confusion and emotional stress. Additionally, there are long-term psychological consequences of restraint, including phobias, exacerbation of pain and a difficulty establishing relationships with healthcare professionals. So it’s vital that clinicians are aware of the psychosocial impacts of eye drops instillation and find fewer distressing approaches to invasive examinations including eye drop instillation.

In order to reduce stress for children when instilling eye drops, several helpful approaches can be adopted:

• Use of age-appropriate language to explain the procedure and the reason why the eye drop use is important. Understanding the purpose may help reduce fear and anxiety in children
• Demonstrating the technique of eye drop instillation on a toy to familiarise the child with the procedure
• Offering a reward such as stickers can help motivate the child to become more cooperative and be a method of distraction of fear
• Clinicians demonstrating calmness during the eye drop instillation process can increase trust and cooperation in children
• Working in step-by- step approach, and offering to review patient another day if the child is too anxious to continue with the examination

PARENTS AS ‘CLINICIANS’

Several eye conditions require eye drop use over a period of time. In these circumstances, the parent or caregivers become the responsible ‘clinicians’ in a home setting to instil eye drops for their children. For this reason, it is crucial to address the challenges that the parents face when administering the eye drops at home. The distress associated with eye drop instillation is not only confined to the child but also can extend to generate negative emotions in parents and caregivers.⁴

Parents resort to techniques such as distraction, role-play and reward to minimise distress and anxiety when instilling eye drops for their children at home. Overall, parents show dislike to using force to overcome their child’s reluctance to have eye drops as this creates tension between the child and the caregiver.

In order to support parents with instilling eye drops at home, clinicians can share useful tips to make the procedure less distressing for both the child and the parents/caregivers. Often, step-by step demonstration of technique for eye drop instillation reduces risk of incomplete medication delivery. In addition, written instructions are always helpful for parents to refer back to as required.

Discussing the challenges that the parent/ caregivers may face during eye drop instillation provides reassurance and an opportunity to discuss ways to overcome these challenges. By doing so, parents feel more relaxed and supported by the clinician, resulting in better compliance. Regular follow-up on the progress can also increase trust and rapport between the clinician and the parent.

EYE TESTS FOR CHILDREN WITH ASD

Autism spectrum disorder (ASD) is a neurode- velopmental disorder which results in social, communication and cognitive impairments. It is estimated that one in 40 people in Australia are diagnosed with ASD.⁵

Children with ASD often require a tailored approach during clinical examinations due to their sensory and communication challenges. Astigmatism, amblyopia and strabismus are common ocular conditions that present in children with ASD.⁶

Allowing the family to visit the practice prior to the examination may reduce stress and make the child with ASD feel more comfortable. It is also important to understand the needs of the patient. A discussion about their needs with parent/caregiver can help you, the patient and the parent/caregiver to better prepare for the examination.

An information sheet with pictures of equipment and step-by-step explanations of parts of the eye test can create familiarity and reduce overall anxiety. Dimming room lights, minimising loud noises and asking for assistance from family members where necessary can improve the overall experience. Direct communication with the child with ASD also helps build trust. Lastly, seeing the same clinician at each visit helps build rapport and reduce overall anxiety.

Children with ASD tolerate invasive tests better when they are given clear explanations which enables them to feel like they have more control. This is imperative particularly when the clinician needs to touch the patient by holding eye lids open when instilling eye drops.⁷

It’s important to explore the needs of patient and create a safe approach when attempting to perform invasive techniques. Building a rapport with patients with ASD, communicating clearly and allowing for extra testing time can reduce distress, improve overall cooperation.

PART 2: HYPEROPIA, AMBLYOPIA AND CYCLOPLEGIC AGENTS
Cycloplegic refraction requires careful time management by the optometrist, consent from the parents, and may limit a child’s near acuity on the day of testing. However, these small challenges are significantly outweighed by the benefits of having a more accurate eye examination.

It is well documented that cycloplegia plays a critical role in the diagnosis and management of childhood refractive errors. A number of studies have reported the importance of cycloplegic refraction in school aged children.^8,9

Cycloplegic refraction is considered the gold standard for refraction in young children. Without cycloplegia, there is increased risk of over-correcting myopia, under correcting hyperopia and reduced accuracy of astigmatic correction.

HYPEROPIA AND AMBLYOPIA

The published results of the Statewide Eyesight Preschooler Screening (StEPS) screening program through NSW found that uncorrected refractive error and amblyopia were still the most detected anomalies in school aged children detected through screening.¹⁰

In the case of amblyopia, the diagnosis requires the exclusion of ocular pathology as a cause of deprivation, and the confirmation of the most accurate refractive correction if refractive amblyopia is identified. These differentials are more accurately examined with cycloplegic agents.¹¹

In Australia, the prevalence of hyperopia at age six is estimated at 13% and by age 12, the prevalence is estimated at 5%.¹²

In children with hyperopia the exploration of the latent hyperopic prescription is of critical importance. The manifest hyperopia at a child’s presentation is only a small component of their total refractive error. Total hyperopia is defined as the combination of manifest hyperopia and latent hyperopia.

Without exploration of the latent component a correction for symptomatic hyperopia, refractive amblyopia and accommodative esotropia may be inefficient and prevent the child from realising their full visual potential.

The total hyperopia found can be defined as low, moderate or high as shown in Figure 2.

Not all hyperopic prescriptions require correction. Children with low-to-moderate hyperopia may be asymptomatic, have normal visual acuity, adequate binocular vision control and good stereoacuity. Moderate hyperopia is expected at birth, with most full-term infants seen to be mildly hyperopic.

Emmetropisation begins from early infancy with an increase in axial length and decrease in corneal curvature and lens power observed. The most rapid phase of this process occurs in the first year of life. By 12 months, infants with moderate-to-high residual hyperopia (greater than +3.50D) are up to 13 times more likely to develop strabismus by age four if left uncorrected.¹³

STRABISMUS

Prescription decisions should be based on evidence, specific to the child’s age, presentation and symptoms. The evidence is clear for presentations of strabismus, where the total hyperopic prescription should be prescribed in a child with a manifest accommodative esotropia.

In other presentations of hyperopia, clinical judgement can be made as to the required refractive correction. In making this decision, optometrists should consider the child’s symptoms, their visual needs at distance and near, their binocular vision including the presence of any significant phoria, risk of decompensating to a manifest tropia and risk of refractive amblyopia.

Furthermore, the effect of hyperopia on a child’s education continues to be an area of interest. A recent meta-analysis in 2022 looking at the impact of hyperopia on academic performance found that there is a statistically significant relationship with children having uncorrected hyperopia showing poorer educational performance than emmetropic children.¹⁴

When necessary, optical corrections for the hyperopic child should aim to reduce accommodative demand and to provide clear, comfortable vision and normal binocularity.¹⁵