A prospective comparison between cyclopentolate spray and drops in pediatric outpatients

Evidence-Based Clinical Practice Guideline: Comprehensive Pediatric Eye and Vision Examination

Republished with written permission granted from the American Optometric Association, October 2, 2020.

Efficacy of a Cycloplegic Agent Administered as a Spray in the Pediatric Population

PURPOSE

To evaluate the efficacy and tolerability of cyclopentolate 1% administered as a spray in pediatric patients between 3 and 6 years old.

METHODS

In this prospective, randomized, parallel group study, healthy volunteers were randomly assigned to receive cyclopentolate 1% as a single drop or a single puff into closed eyes.

RESULTS

There were 61 patients included in the study; 31 received cyclopentolate 1% as drops and 30 received cyclopentolate 1% as spray. The mean age at presentation was 4.5 ± 1.07 years (range: 3 to 6 years) and 4.2 ± 1.06 years (range: 3 to 6 years) in the drops and spray groups, respectively. The distress level was significantly lower at the time of receiving cyclopentolate as a spray (P < .0001), with the exception of patients aged 6 years. There were no significant differences in pupil diameter between the two groups (P = .51), whereas 5 of 30 patients (16.6%) with dark irises who received cyclopentolate spray did not have adequate cycloplegia to allow for accurate refraction.

CONCLUSIONS

Cycloplegia achieved with cyclopentolate 1% administered as a spray may be an option in uncooperative children because it is less distressing compared to cyclopentolate 1% drops. However, physicians should be aware that cycloplegia obtained is only partially effective in children with dark irises. [J Pediatr Ophthalmol Strabismus. 2020;57(5):301-304.].

A Clinical Randomized Trial Comparing the Cycloplegic Effect of Cyclopentolate Drops Applied to Closed Eyelids Versus Open Eyelids

BACKGROUND AND PURPOSE

Adequate cycloplegia and dilation are required for refraction and fundus exam in children. Standard practice is to instill cycloplegic drops in the inferior cul-de-sac, and this is often traumatic for children. Our study assesses the use of cyclopentolate on closed lids as a method of instillation for ensuring complete cycloplegia.

PATIENTS AND METHOD

Ninety children presenting for annual refraction were enrolled. Three were excluded as they did not finish the testing. One drop of Alcaine^® and one drop of cyclopentolate HCL 1% were used in each eye. Cyclopentolate drops were placed on the inner canthus near the lid margin on the closed eye and directly onto the conjunctiva of the fellow eye.

RESULTS

Overall, 145/174 eyes (83%) were fully cyclopleged with one drop. The methods of instillation were equally successful (seventy-two indirect vs. seventy-three direct). Age, eye color, spherical refractive error, astigmatic refractive error, and presence of amblyopia on the study visit played no role in the success of either method. Dark irises where the pupil margin was clinically indistinguishable had the largest number of failures (n = 17/44) in comparison to light irises (12/130), but had an equal amount of failures for both direct and indirect methods.

CONCLUSION

Placing one drop of cyclopentolate HCL 1% on a closed eyelid had a success rate for complete cycloplegia that was equivalent to placing one drop directly on the cornea.

Pharmacodynamic profile of mydriatic agents delivered by ocular piezo-ejection microdosing compared with conventional eyedropper

AIM

Eyedroppers deliver medication volumes exceeding conjunctival absorptive capacity, causing spillage and risking ocular/systemic complications. We evaluated piezoelectric microdosing. Results/methodology: Subjects (n = 102) received precision microdroplet delivery of phenylephrine (2.5%) and tropicamide (1.0%): 1 × 1.5 μl, 1 × 6 μl or 2 × 3 μl of each (randomized 1:1:1), into one eye. Contralateral eyes received eyedropper doses of both drugs. Outcomes were pupil dilation (0-60 min) and patient satisfaction. Six-microliter microdosing achieved comparable, and 2 × 3 μl met/exceeded dilation speed and magnitude versus eyedropper. Separately, participants preferred piezoelectric saline self-delivery to eyedroppers, reporting better head-positioning comfort, reduced tearing/overflow and increased likelihood of adhering to ocular medication regimens.

CONCLUSION

Piezoelectric microdosing achieves comparable effects as eyedroppers delivering 4-17-fold larger doses. Microdosing may enhance patient adherence to ocular medication regimens while minimizing side effects.

The psychological impact of eyedrops administration in children

PURPOSE

To determine the psychological effects of eyedrops administration in children.

METHODS

Children requiring eyedrops for cycloplegic refraction were recruited in this cross-sectional study. Nurses administered eyedrops in 2-3 cycles spaced 5-10 minutes apart, and optometrists performed refraction 30 minutes after the last drop. Ophthalmologists, nurses, and optometrists rated the children's cooperation level at first review, after each eyedrop, at refraction, and at final review. Parents chose a personality type best describing their child, and monitored their child's anxiety using a modified Yale Preoperative Anxiety Scale (m-YPAS). Children were "uncooperative" if nurses noted significant distress during the first drop cycle.

RESULTS

A total of 298 children 2-12 years of age were included. Of these, 77 (26%) experienced pre-drop distress and 39 (13%) were uncooperative with drops. Compared to cooperative children, uncooperative children tended to be younger (2.0-4.9 years vs ≥8 years; OR, 4.11; 95% CI, 1.14-14.83; P = 0.031), male (OR, 2.55; 95% CI, 1.06-6.10; P = 0.036), have had a previous negative eyedrop experience (84.2% vs 25.3%; P < 0.001) and were more anxious (m-YPAS scores, 41.4 ± 22.0 vs 30.6 ± 12.6: P < 0.001). Children described as "demanding and aggressive" were more uncooperative than "timid and anxious" children. It took longer to instill drops (3.1 vs 1.3 minutes), and perform refraction (11.6 vs 7.2 minutes) in uncooperative children.

CONCLUSIONS

A small group of children were uncooperative with eyedrops and 26% experienced significant pre-drop anxiety. Factors such as age, sex, a previous negative eyedrop experience, and pre-drop anxiety, associated with uncooperativeness need to be considered when developing strategies to improve the eyedrops experience in children.