Administering eye drops to children involves challenges different from adults, such as lack of cooperation, eyelid closure due to fear, and risk of systemic drug absorption. Techniques and adjustments appropriate for the child’s age, along with parental guidance, are essential. Parental adherence (continuation rate of eye drops) greatly influences treatment outcomes.
The main clinical situations requiring pediatric eye drops are as follows:
The volume of one drop of eye drops is 30–50 μL, and the conjunctival sac capacity is about 30 μL at most. Even one drop overflows from the conjunctival sac, but once it enters the sac, it spreads over the ocular surface, so one drop is sufficient.
Cycloplegic agents
Representative drugs: Atropine sulfate hydrate (Nitten Atropine 1%), Cyclopentolate hydrochloride (Cyplegin® 1%), Tropicamide/Phenylephrine (Mydrin P®)
Caution: Highest risk of systemic side effects. The package insert recommends 0.25% for infants and children, but in practice, most facilities use 0.5% and 1% 1).
Uses: Refraction testing (under cycloplegia), Amblyopia treatment (penalization)
Steroid eye drops
Representative drugs: Fluorometholone (Flumetholon® 0.02%/0.1%), Betamethasone (Rinderon®)
Caution: Children have a high proportion of steroid responders. Even 0.1% fluorometholone has been reported to increase intraocular pressure 2). Special caution is needed in infants where intraocular pressure measurement is difficult.
| Drug | Onset of Mydriasis | Resolution of Mydriasis | Duration of Cycloplegia | Resolution of Cycloplegia |
|---|---|---|---|---|
| Atropine sulfate hydrate | 30–40 minutes | Approximately 10 days | 3–5 days | 7–12 days |
| Cyclopentolate hydrochloride | 45 minutes after instillation | 48–72 hours | 45 minutes to 2 hours | Approximately 24 hours |
| Tropicamide (Mydrin M/P) | 15–30 minutes | 5–8 hours | Weak | — |
| Phenylephrine (Neosynesin Kowa) | 40–60 minutes | 5 hours | None | — |
Infants and young children have structural characteristics that make systemic absorption more likely compared to adults.
One drop of eye drops is 30–50 μL, conjunctival sac capacity is up to about 30 μL, and tear volume is about 7 μL. Excess flows into the nasolacrimal duct and enters systemic circulation from the nasal mucosa.
Atropine causes systemic effects via the pathway: nasolacrimal duct → nasal mucosa → systemic circulation → blockade of muscarinic receptors.
Transient neuropsychiatric symptoms: dizziness, ataxia, disorientation, drowsiness, hallucinations. Because of the risk of falls, caregivers must not leave the child unattended.
Steroid responders: approximately 30% in adults2). The proportion of responders is even higher in children. Special caution is needed in infants and young children where intraocular pressure measurement is difficult.
Infants and toddlers (0–2 years)
Fixation method: Swaddling fixation. If two adults are present, one holds the child and secures the child’s legs between their own legs, while the other instills the eye drops. If only one adult is present, use the straddle method (fixation with thighs) or the wrestling method (fixation with legs extended over the arm).
Closed-eye instillation method: Place one drop into the inner canthus (corner of the eye) while the eye is closed. The medication penetrates when the patient blinks.
Instillation at bedtime: Since crying causes the medication to wash away, perform the instillation just as the child falls asleep.
Toddlers (2–5 years)
Position: Place the child’s head on the parent’s lap.
Guidance method: Use verbal instructions such as “Look up” or “Turn your face upward.”
Distraction: Perform while diverting attention with snacks or toys. Use a reward system (stickers, etc.) for motivation.
School-age children (6 years and older)
Self-instillation practice: Practice using a mirror. The goal is gradual transition from dependence on caregivers.
Fist method: Place the hand holding the eye drop bottle on the forehead to stabilize it.
Administering drops to the inner corner of the eye while the child is asleep is effective. Crying causes the medication to be washed away by tears. If fear is the cause, try administering from a position where the child cannot see the bottle or use the closed-eye method.
After instillation, press the inner corner of the eye (lacrimal sac area) for 1–2 minutes. This can reduce systemic absorption by up to 70%4). Atropine instructions state: “Press the inner corner of the eye for 30–40 seconds.”
Close the eyes for several minutes after instillation. This has an effect equivalent to nasolacrimal occlusion 4). Frequent blinking can cause the medication to flow from the punctum to the nose and pharynx.
Gently press with a tissue (do not rub vigorously). Especially for antiglaucoma drugs (PG analogs), washing the face is also effective as they tend to cause side effects around the eyes.
Do not instill atropine during colds, diarrhea, or fever. There is a risk of further worsening thermoregulation disorders.
In children, the nasolacrimal duct is shorter and wider than in adults, making systemic absorption more likely; therefore, lacrimal sac compression is even more important in children. Instruct parents to make it a habit to apply pressure for 30–40 seconds or more after instillation.
Atropine is a potent drug, so it must be explained to parents in the outpatient setting. To allow for consultation if side effects occur, start eye drops on weekday mornings. The effect persists for 2–3 weeks even after discontinuation.
It is recommended to provide written instructions rather than only verbal explanations, and most medical institutions hand out written instructions 1).
Instill one drop daily in the sound eye 5). This is an alternative to patching, reducing vision in the sound eye with atropine while wearing glasses.
Parental explanation items for Ryjusea® Mini Ophthalmic Solution 0.025% (Santen Pharmaceutical, approved December 2024) 3):
Stop the eye drops immediately. If symptoms such as fever, facial flushing, agitation, or hallucinations occur, see an ophthalmologist right away. If you start the eye drops on a weekday morning, you can visit the doctor during the day if side effects occur. If symptoms are mild (only facial flushing), report at the next visit and follow the doctor’s instructions.
If you use a suspension or gel-forming eye drop first, it may interfere with the absorption of subsequent medications, but it is not fatal. As long as you wait at least 5 minutes between drops, there is usually no major problem. It is important to develop a habit of using the correct order.
