Easing anxiety in difficult patients

Administration of oral midazolam can increase the speed and efficiency of measuring refraction and performing fundus examination in children with behavioural difficulties, according to Geraldine Comer MD, University Hospital Galway, Galway, Ireland. “This new service delivered by the medical ophthalmologist reduces the need for valuable theatre slots, in-patient bed use and consultant ophthalmic surgeon time. In addition, non-theatre examination reduces general anaesthesia risks and is cost-effective overall,” Dr Comer told the Annual Conference of the Irish College of Ophthalmologists in Galway, Ireland. Dr Comer and her associates reviewed the clinical notes of 12 children aged between three and eight years (mean age five years, three months) who underwent examination under sedation between December 2017 and March 2019. All children were also under the care of a paediatrician for developmental delay. Five children had autism. The patients received oral midazolam (0.5mg/kg), in either blackcurrant or apple juice, 30 minutes prior to instillation of cyclopentolate 1% and one hour prior to examination and refraction in the paediatric day ward. The maximum dosage is 15mg, as agreed in the 2018 protocol between ophthalmology and paediatrics departments. Three children who weighed more than 30kg were administered the maximum dose, 15mg. “We have noted that there is an increasing number of children with severe special needs, particularly autism, who were being seen in the paediatric orthoptic clinic and it was impossible to do an examination and incredibly distressing for the child, the parent and myself. Therefore, we wrote the protocol in conjunction with the paediatric department,” Dr Comer explained. ADEQUATE OCULAR EXAMINATION She noted that the onset of sedation was rapid and permitted adequate ocular examination in all cases. All children were admitted and discharged from the hospital within five hours. Furthermore, in two cases general systemic examination and blood tests were facilitated on the same day as the eye examination while the child was still under the effects of midazolam. No local or general adverse reaction was experienced by any of the 12 children. Moreover, none of the children required flumazenil to reverse the effects of the midazolam. “This non-invasive method of sedation has been successfully used by our ophthalmology department for children who would otherwise require general anaesthesia. The environment of the out-patient paediatrics treatment room is a calm, child-friendly and well-equipped space for children with special needs requiring an ophthalmology assessment,” Dr Comer concluded. Geraldine Comer: geraldinecomer@gmail.com

Tags: paediatric ophthalmology