Procedural anxiety can be defined as any fear or worry that is experienced relating to medical interventions, procedures, or appointments. In ophthalmology, procedural anxiety is common enough, even with seemingly innocuous procedures, such as instillation of eye drops and measurement of intraocular pressure. In paediatric ophthalmology, procedural anxiety is more frequently encountered and can become a challenge or indeed a barrier to providing care to this patient group.
Dr Sandra Staffieri explores strategies to help ease the way for the child in your clinic.
As a 40-year veteran clinical orthoptist, I wouldn’t be able to calculate how many times I have instilled drops into a patient’s eyes. What I do know though, is that I have contributed to procedural anxiety. Procedural anxiety is well-recognised in paediatric oncology1 but only recently in ophthalmology in relation to children.2
One of the most significant findings in a recent study by Law and co-workers found that clinicians should be aware of the challenges parents face when administering eye drops and should include tips for distracting the child, restraining them, and reducing distress.3
I was well accustomed to a child not wanting to enter my consulting room for fear of having eye drops. They would either start to cry on hearing their name called or, rather than responding to my greeting with a “Hello” as they made their way from the waiting room, they’d ask, “Do I have to have eye drops today?”
What’s important for me, is that there’s a continuous learning, improvement, and development in the devices, techniques, and medication used to examine and treat children
Changing of the Tide
I can honestly say I had not given enough thought to procedural anxiety and – more importantly – what I could do to mitigate it, until an encounter with a research participant some years ago. I happened to interview an adult, third-generation retinoblastoma survivor about their lived experience. My opening question: “Tell me about your experience with having retinoblastoma” was answered with them telling me about their recollection of having eye drops.
“Sometimes they had to restrain me, because I wouldn’t open my eyes… they placed me on a bed… four adults or something holding on to a limb each, and then one to the head, and then another one putting in the drops.”
I tearfully listened as I realised I, too, had been guilty (with parental permission) of a similar method because we just needed to get the dilating drops in to complete the required ophthalmic examination.
Although they went on to describe reaching adulthood and understanding the need for eye drops, the impact of their experience was deep and long lasting.
“From my perspective I hold no grudge against the nurses and doctors who helped treat me,” they reported. “I now know and understand that they did what they did to help me. They didn’t mean any harm, but at the time I didn’t understand that.”
The interviewee continued, “Though the bad experiences will stay with me, I’m also grateful for their work and dedication. If they hadn’t done what they did, I might not have survived or I might have been blind.”
While I took comfort from this patient’s understanding, their experience made me sit up and think more deeply about procedural anxiety and consider what I could do to improve processes, increase awareness, and ‘do better’.
What’s important for me, is that there’s a continuous learning, improvement, and development in the devices, techniques, and medication used to examine and treat children, so their experiences will be as comfortable and safe as possible.
Learning A New Way
I have learned much from child life therapists/specialists in Australia as well as overseas. The literature also makes it clear that preparation, explanation, and peer modelling can make all the difference when it comes to reducing anxiety around procedures and interventions.1
Armed with these learnings to ‘do better’, I have actively changed my technique to:
- Provide the child with a full explanation without the eye drops in my hand.
This can sometimes be derailed when the caregiver interjects and falsely reassures the child the drops don’t sting – they do, and you cannot lie as this does not promote their trust.
I recommend changing the words used to reframe the procedure and the sensations. Replace any reference to the word “sting” to “warm” or “tingle”. This can make all the difference. It’s also useful to give the sensation a purpose: “that’s how I know I got them in”.
- I show a video of me putting eye drops in a child with their eyes closed.
This is peer modelling and is very helpful in demonstrating to a child that their “peer” can do the task/receive the intervention, and they can too.
- Validate their feelings and fears.
Reassure the child that it is ok to be scared, but they are safe as there is a parent with them. I explain I don’t like putting drops in any more than they like having them. I also declare “I am the best eye dropper in the whole world”. This statement serves to improve confidence in myself as much as getting a smile from the child.
- Give the child some choice: they can be seated on their parent’s lap; in the chair with their head back; or lying down on a bed, across their parent’s lap, or in a comforting cuddle (comfort position).
Often children feel powerless and have no choices, but we can restore that power by letting them make the choices that they can make. The one choice they don’t have though is not having the drops.
- Give the child something to do:
– Hold a tissue or toy for comfort,
–Count the number of blinks they take,
– Sing a song with them, or
– Listen to their favourite song.
- Practise putting the eye drops in a toy they have brought with them; they can provide the comfort to their toy.
- Have the child keep their eyes gently closed, and place the drop in the corner of their eye.
No one wants their eyes to be prised open. If the child can relax in their preferred position, placing the drops in the corner of their eyes and blinking them in works very well.
Prepare the Child in Advance
Parents sometimes ask how they might be able to prepare their child for an eye examination. Peer modelling has been shown to support children to prepare for invasive interventions.
At the Royal Children’s Hospital in Victoria, together with the team from the Be Positive program, a short video was made following a child through an eye examination, including eye drop instillation. This short video is an excellent resource to prepare a child, and their caregiver in advance of their appointment. This video has now been viewed almost one million times.
A New Way Forward
Finally, to reduce procedural anxiety, it is important to promote awareness:
- Talk about procedural anxiety in our patients with colleagues,
- Celebrate the wins, acknowledge the losses, and
- Realise that some children do better with practising at home with ocular lubricants – this can be a very successful approach to desensitise eye drop instillation.
Following the 2024 World Congress for Paediatric Ophthalmology and Strabismus Symposium in Kuala Lumpur, a small but enthusiastic group of eye health care professionals – orthoptists, optometrists and ophthalmologists – established a working group to develop resources and explore strategies to improve procedural anxiety in children.
The first task was to change the name to Procedural Comfort in Ophthalmology. Irrespective of which craft group one belongs to, we need to be collaborative if we are to acknowledge and mitigate procedural anxiety. As a group, we must consider how we can actively pursue and promote Procedural Comfort in Ophthalmology. If you are interested in joining the group, please contact Dr Sandra Staffieri at: sandra.staffieri@unimelb.edu.au.
Dr Sandra Staffieri AO is a Research Fellow at the Centre for Eye Research Australia (CERA) and the Retinoblastoma Care Co-ordinator/Senior Clinical Orthoptist at the Royal Children’s Hospital, Victoria.
Dr Staffieri completed her PhD at CERA, University of Melbourne. With the aim of reducing delayed diagnosis of retinoblastoma, her study included the development and evaluation of an information pamphlet for new parents describing important early signs of eye problems in children.
References
- Flowers SR, Birnie KA. Procedural preparation and support as a standard of care in pediatric oncology. Pediatr Blood Cancer. 2015;62 Suppl 5:S694-723.
- Sujuan JL, Handa S, Perera C, Chia A. The psychological impact of eyedrops administration in children. J AAPOS. 2015;19(4):338-43.
- Law GC, Bulbul A, Jones CJ, Smith H. ‘The mean mummy way’ – experiences of parents instilling eye drops to their young children as described in online forums and blogs. BMC Pediatr. 2020;20(1):514.
