Open Journal of Ophthalmology, 2012, 2, 21-25 Published Online May 2012 ( 21
The Causes of Distress in Paediatric Outpatients Receiving
Dilating Drops*
Nashila Hirji#, Sophie Jones, Graham Thompson
St. George’s Hospital, London, England.
Received January 1st, 2012; revised February 19th, 2012; accepted March 4th, 2012
Background/Aims: Paediatric outpatients are often dilated with cyclopentolate drops. These cause discomfort and dis-
tress, which may impede subsequent examination. We aimed to determine the distress caused by cyclopentolate drops,
and other factors in the clinic environment. Methods: Over an 8 week period, questionnaires were issued to guardians
of all paediatric outpatients aged under 10 years receiving cyclopentolate. The childrens’distress was graded on a scale
of 1 - 10 (1 = no distress, 10 = severe distress). Waiting time and ease of examination were recorded. Data was analysed
using Stata statistics, and significant differences were reported at the P < 0.05 level. Results: The 72 children were
g r o up e d a s u n d er 4 y e ar s ( n = 4 3 , G ro u p A ), a g e d 4 - 7 y e ar s ( n = 1 9 , G r ou p B ), a n d a ge d 7 - 10 years (n = 10, G roup C) .
Median distress levels at home (baseline), on arrival, on dilation, and on examination were as follows: Group A; 1, 2, 7,
6 respectively; Group B; 1, 1, 6, 2 and Group C; 1, 1, 4.5, 1. All age groups were significantly more distressed on ex-
amination compar ed to baseline. D istress scores on examination were significantly greater for Group A, in keeping with
the greatest number of suboptimal examinations. Guardians reported that a prolonged waiting time and bright examina-
tion lights also contributed to distress. Conclusions: This study confirms th at cyclopentolate causes significant distress
in young children, and in 45% of very young children, the examination is difficult. Proxymetacaine prior to cyclopento-
late is a possible solution, but other distressing factors should also be addressed for optimal outcomes.
Keywords: Paediatric; Cyclopentolate; Proxymetacaine Hydrochloride; Dilating Drops
1. Introduction
Cycloplegic examination is a key element in the assess-
ment of children presenting to ophthalmology outpatients.
It is most often achieved using cyclopentolate 0.5% or
1% depending on age. However, this drug is disliked by
children due to the stinging it produces on instillation.
Children receiving the drop commonly become dis-
tressed, and their resultant tearful and uncooperative be-
haviour can lead to significant difficulty in subsequent
examination. Additionally, paediatric distress can con-
tribute to a frightening env ironment in the clinical settin g,
and may have long-term harmful effects on the doc-
tor-patient rel a t i onship.
A previous study demonstrated that instillation of
proxymetacaine hydrochloride 0.5% prior to cyclopento-
late resulted in less traumatic cyclopleg ia in children [1].
This was further supported by a second study, which
showed a significant reduction in the total discomfort
with cyclopentolate administered after premedication
with proxymetacaine, compared with the use of cyclo-
pentolate instilled after placebo [2]. However, the authors
of this study suggested that other factors may also con-
tribute to the distress experienced by children attending
ophthalmology outpatien ts, and until now, this aspect has
remained unexplored.
Since the use of proxymetacaine prior to cyclopento-
late is often not standard practice, our study aimed to
determine the degree of distress caused by cyclopentolate
drops. In addition, we investigated other factors that may
lead to distress in the pa ediatric outpatient setting.
2. Patients and Methods
Over an 8 week period, all children under the age of 10
years requiring cycloplegic examination in a paediatric
ophthalmology outpatient clinic were assessed. Each re-
ceived our standard dilating regime of cyclopentolate
drops 0.5% or 1% (Minims, Smith and Nephew Pharma-
ceuticals, UK), and phenylephrine 2.5% drops (Minims,
Smith and Nephew Pharmaceuticals, UK) in addition for
those children with very dark eyes. Questionnaires were
*This study received no specific grant from any funding agency in the
ublic, commercial or no
-for-profit sectors.
The authors declare no competing interests.
#Corresponding author.
Copyright © 2012 SciRes. OJOph
The Causes of Distress in Paediatric Outpatients Receiving Dilating Drops
issued to the guardians of all children on arrival in clinic.
The questionnaires required the guardians to grade the
child’s distress on a scale of 1 - 10 (1 = no distress, 10 =
severe distress), at 4 points during the day: at home (prior
to coming to clinic); on arrival in the department; on re-
ceiving the cyclopentolate drops; and on examination.
The time of arrival and time at which the patient eventu-
ally saw the doctor were documented, enabling the wait-
ing time to be calculated. Guardians were also requested
to document other factors they felt may have contributed
to their child’s distress during their visit. In addition,
each doctor in the clinic recorded whether the child was
easy to examine (adequate examination performed), dif-
ficult to examine (subop timal ex aminatio n perfor med) , or
Statistical analysis of the data was performed using
Stata statistics. All medians with ranges are repo rted, and
significant differences are reported at the P < 0.05 level.
Signed rank tests were used to compare distress scores at
different time points for each age group. A Kruskal Wal-
lis test was performed to compare distress scores be-
tween age groups at different time points. A two-sample
Wilcoxon rank-sum test was performed to compare the
distress score on examination between the different age
3. Results
A total of 72 consecutive patients were included in the
study (40 male, 32 female). 43 children were aged under
4 years (Group A), 19 ch ildren were aged between 4 and
7 years (Group B), and 10 ch ildren were aged between 7
and 10 years (Group C). The mean age was 4.4 years
(range 2 months - 10 years). Figure 1 illustrates the
variation in the level of distress displayed by children at
various points during their visit, with the distress level at
home taken as the baseline. The median distress levels at
home, on arrival, on dilation, and on examination were as
follows, with the range for the distress level at each time
point shown in brackets: Group A; 1 (1 [1 to 2]), 2 (3 [1
to 4]), 7 (4 [5 to 9]), 6 (5 [3 to 8]) respectively; Group B;
1 (0 [1 to 1]), 1 (3 [1 to 4]), 6 (4 [4 to 8]), 2 (3 [1 to 4])
and Group C; 1 (0 [1 to 1]), 1 (1 [1 to 2]), 4.5 (3 [3 to 6]),
1 (2 [1 to 3]). In all age groups, distress levels peaked on
receiving cyclopentolate, and decreased to a degree by
the time they saw the doctor. However, distress scores
were significantly greater on examination in comparison
to baseline for all age groups (P < 0.000 Groups A & B,
P < 0.047 Group C). Distress scores were significantly
greater in the youngest age group on examination when
compared to both older ag e groups (P < 0.001). Figure 2
summarises the distress levels displayed by the children
in the 3 age groups, and illustrates the variance in the
distress observed at various points during the visit, and at
home prior to arrival. Figure 3 shows the variation in
distress level with waiting time. In all age groups, mean
distress levels rose with increased waiting time, with this
trend being most marked in the youngest age group . Fig-
ure 4 demonstrates the proportion of children in each age
group deemed by the examining doctors to be “difficult
to examine” or “unexaminable”. Factors which guardians
felt contributed to their child’s distress during the visit
included discomfort caused by instillation of the dilating
drop (83.3%), a prolonged waiting time (51.4%), and the
use of bright lights during examination (20.8%).
4. Discussions
There is a significant paucity in the literature of studies
on paediatric distress with cycloplegic agents. Our pro-
spective clinical observational study demonstrates that
the use of cyclopentolate in paediatric patients causes
Figure 1 . Mean distress levels displayed by the 3 a ge groups at various points during the visit, and at home prior to arrival.
For all age groups, mean distress levels peaked on receiving cyclo pentolate drops, and this w as most marked in t he younger
age groups.
Copyright © 2012 SciRes. OJOph
The Causes of Distress in Paediatric Outpatients Receiving Dilating Drops 23
Figure 2. Summary of distress levels displayed by the 3 age groups. The box-and-whisker plot illustrates the variance in the
distress levels displayed by the 3 age groups at various points during the visit, and at home prior to arrival. For each set of
data, the bo ttom and top of the
t the 25th and 75th perc entile respective ly, and the ba nd near the middle of the
box represents the median. Th e ends of the whis k ers r ep res ent th e m in imu m a nd ma ximum valu es of the data.
Figure 3. Variation in mean distress levels displayed by the 3 age gro ups, with increasing waiting time. Across all age groups,
mean distress levels rose wit h increased waiting tim e. This trend was most marked in children und er the age of 4 years.
significant distress. Children in all age groups were sig-
nificantly more distressed on examination compared to
their baseline distress level recorded at home. Further-
more, the distress scores on examination were signifi-
cantly greater for the youngest age group, in keeping
with the greatest number of suboptimal examinations. A
suboptimal examination defeats the purpose of the ad-
ministration of cyclopentolate, and causes unnecessary
distress. Of note, the 3 children recorded as “difficult to
examine” or “unexaminable” in the 4 - 7 year age group
were all under the age of 5 years. To our knowledge,
there are no previously established scales for grading
paediatric distress on the instillation of eye drops, hence
the need for us to create our own in this study. With re-
gard to their reliability, our scales had a subjective ele-
ment in that guardians may vary in their opinions as to
what defined a particular level of distress. However, this
variable was controlled to an extent by the fact that each
Copyright © 2012 SciRes. OJOph
The Causes of Distress in Paediatric Outpatients Receiving Dilating Drops
Figure 4. Proportion of children in each age group deemed
to be “difficult to examine” or “unexaminable” by the ex-
amining doctor. A relatively large proportion of children
under the age of 4 years could not be satisfactorily exam-
ined. A smaller, though still significant, proportion of chil-
dren aged 4 - 7 years underwent a suboptimal examination.
guardian rated their child’s distress through the course of
the visit, therefore changes in distress levels for each
particular child could be reported fairly accurately. With
this in mind, there appeared to be a definite trend for an
increase in distress with instillation of the drops, across
age groups. We accept that manifestations of distress
may vary amongst children of different ages, making it
difficult to make direct comparisons of distress between
age groups. However, the practical outcome of difficulty
with the examination followin g the instillation of dilating
drops is our main finding in this study.
It is our opinion that the instillation of eye drops in
children is a skill, and some individual practitioners are
much better than others. Drops should be instilled
quickly and with confidence, and not provide a major
discussion point in the examination. In our clinics, drops
are instilled by orthoptists at th e end of their examination,
or by a specific paediatric ophthalmic nurse. The same
staff was used throughout our study.
Our work might support earlier studies advocating the
use of proxymetacaine as a premedication prior to the
instillation of cyclopentolate, in an attempt to reduce
discomfort [1,2]. This would be particularly beneficial in
younger children. The discomfort caused on instillation
of proxymetacaine is less than that caused by cyclopen-
tolate [2]. It has a rapid action, anaesthetising the eye in
less than 30 seconds, with an effect that lasts for 10 - 25
minutes [3]. This would allow for multiple instillatio ns of
cyclopentolate within a given time period if necessary.
However, there is a potential risk of ocular injury as a
result of the child rubbing h is or her eyes after the instil-
lation of proxymetacaine, and the anaesthetic is known to
have a higher incidence of contact allergy than other
topical anaesthetic agents [4]. Furthermore, as a pre-
medication, proxymetacaine would constitute an addi-
tional drop administered to the child, and if he or she
became distressed on its instillation, the chance to ad-
minister the dilating drop may then be lost. Therefore,
whilst proxymetacaine prior to cyclopentolate may prove
beneficial in reducing paediatric distress in clinic, it is
not an ideal solution. Two relatively recent studies have
advocated the use of cyclopentolate spray as opposed to
drops to achieve mydriasis in children [5,6]. These stud-
ies have demonstrated that both cyclopentolate spray and
drops have equal cycloplegic efficacy, but that the spray
is better tolerated by patients. Although most oph thalmic
units still use th e traditional cyclopentolate drops in ch il-
dren, a move to the use of the spray formulation may be
warranted if this can reduce paediatric distress, without
the need for the administration of an additional drug such
as proxymetacaine. Our study highlights other factors
which may also contribute to paediatric distress in the
clinic setting. These include a prolonged waiting time
and excessive use of bright lights by examining doctors.
Whilst a long wait is often unavoidable for patients at-
tending clinic, the resultant boredom and frustration for
paediatric patients may be alleviated by modifying the
waiting area to make it better suited to the needs of chil-
dren, and en listin g th e services of multi-disciplinary team
members such as paediatric nurses and play specialists
during the clinics to help maintain a positive environ-
ment. Increasing awareness amongst doctors in paediatric
clinics about the distress caused by excessive bright
lights may encourage them to use the minimum duration
and intensity of light necessary fo r an adequate examina-
tion, leading ultimately to a better assessment of the pa-
In summary, distress amongst paediatric outpatients is
multifactorial. Whilst a significant degree of the distress
may be attributable to the use of cyclopentolate, the use
of proxymetacaine as a premedication has its disadvan-
tages, and is not a perfect or sole solution. Our work
demonstrates that there are other factors which may con-
tribute to paediatric distress, and addressing these may
create a more positive experience for patients, their
guardians, and the healthcare professionals. Where pos-
sible, a multifaceted approach should be employed to
manage distress amongst paediatric patients, so as to en-
sure that the chances of performing a meaningful fundal
examination and refraction are maximised, and the trust
between the child and healthcare professionals is main-
[1] P. Shah, A. S. Jacks and G. G.Adams, “Paediatric Cyclo-
plegia: A New Approach,” Eye, Vol. 11, No. 6, 1997, pp.
845-846. doi:10.1038/eye.1997.216
[2] M. S. Sutherland and J. D. Young, “Does Instilling Pro-
xymetacaine before Cyclopentolate Significantly Reduce
Copyright © 2012 SciRes. OJOph
The Causes of Distress in Paediatric Outpatients Receiving Dilating Drops
Copyright © 2012 SciRes. OJOph
Stinging? The Implications of Paediatric Cycloplegia,”
British Journal of Ophthalmology, Vol. 85, No. 2, 2001,
pp. 244-245. doi:10.1136/bjo.85.2.238g
[3] C. W. Boozan and I. J. Cohen, “Ophthaine, a New Topi-
cal Anesthetic for the Eye,” American Journal of Oph-
thalmology, Vol. 36, No. 11, 1953, pp. 1619-1621.
[4] G. O. Rosenwasser, “Complications of Topical Ocular
Anesthetics,” International Ophthalmology Clinics, Vol.
29, No. 3, 1989, pp. 153-158.
[5] C. Y. Wong, D. S. Fan, C. B. Yu and D. S. Lam, “Topical
Mydriatic and Cycloplegic Spray for Chinese Children,”
Journal of Pediatric Ophthalmology and Strabismus, Vol.
40, No. 6, 2003, pp. 349-352.
[6] A. Chafai, S. Ajdnik, L. Lejeune and M. Cordonnier,
“Comparative Study of Cyclopentolate Drops versus Spray
in Cycloplegia in Children,” Journal Français dOph-
talmologie, Vol. 29, No. 8, 2006, pp. 896-899.