Optimising informed patient consent

Irish College of Ophthalmologists, Annual Conference, Knockranny House Hotel, Westport, Co Mayo, 15-17 May 2024.

Obtaining patient consent should be a thorough process allowing time for patients and parents to assimilate information, the Irish College of Ophthalmologists 2024 Annual Conference in Westport was told.

During the dedicated vision and strabismus symposium on the opening day of the conference, Ms Kathryn McCreery, Consultant Ophthalmic Surgeon, Children’s Health Ireland at Crumlin Hospital, Dublin, discussed difficult paediatric consultations, including drop administration in children, evaluation of the child with autism, and delivering bad news.

Other topics covered in her talk included the evaluation of the “uncooperative” child, management of strabismus surgery complications, and the informed consent process in paediatric and adult strabismus surgery.

Ms McCreery emphasised the importance of effective communication with children, parents, and adults undergoing strabismus surgery, with the overall objective of making consultations informative so that there is a complete understanding of the proposed procedure. This includes discussing the indications for surgery, benefits, all major risks, worst case scenarios, alternative options including probable outcomes if surgery is decided against, and providing educational material to take home. Physical consent may be taken at this consultation without duress once the practitioner and patient/guardian are satisfied they are fully informed and can be countersigned on the day of the procedure. “People need time to digest material. So seeing a patient, diagnosing a condition, and operating on them on the same day is not good practice, and is generally not recommended.”

It is also important to talk to children and young adults with capacity and not just address their guardian/parent.

“Indeed, if the child is of an age where they have understanding it should be explained to them as well. So children aged more than seven or eight do have occasional questions, and in Ireland 16 is the official age of consent. I find with the older teens if I have a parent and say a 16-year-old sign the consent form together it is very helpful, as the young adult may not be happy to go it alone,” she told the Medical Independent (MI).

Discussing the diagnosis and management of keratoconus, Ms McCreery noted there is a higher prevalence of this condition in children with Down syndrome. These children are also more likely to have delayed diagnosis and are often unsuitable for corneal grafting. Thus, they may experience poorer visual outcomes. It is therefore very important for all eye care and general clinicians, as well as families/carers of those with Down syndrome, to be aware of keratoconus risk. It is important to assess these children, and ideally examine them with a Pentacam, so keratoconus can be identified earlier and treated appropriately (ie, corneal crosslinking). This early treatment of keratoconus will minimise the risk of corneal scarring and visual loss, she told MI.

Ms McCreery also raised concerns about the rise in myopia in Irish children, which is a global problem linked to modern indoor lifestyles and increased use of screen time. She called for increased awareness and education of both children and parents about the importance of good eye health, limiting screen time, increasing time outdoors in daylight, taking breaks from near visual activities to relax accommodation, which is a driver of myopia progression (20-20-20 rule), and getting eye check-ups.

She also called for the HSE to reimburse dilute atropine drops given to children with identified myopia so as to halt its progression. Low doses of atropine have been proven in Asian populations to slow down progression of myopia by 59 per cent when children use one drop in each eye every night. However, atropine 0.05 per cent eye drops are not licensed with the Health Products Regulatory Authority in Ireland. Only licensed medicines are added to the formal reimbursement list in line with the Health (Pricing and Supply of Medical Goods) Act 2013. Thus the product is not currently reimbursed by the HSE if prescribed for this indication.

The HSE Medicines Management Programme (MMP) reviewed atropine 0.01 per cent eye drops to halt myopia progression, through exceptional arrangements under the community drug schemes on behalf of the Primary Care Reimbursement Service in 2022. However, the MMP declined the request at the time due to what it said was the lack of robust clinical evidence demonstrating the optimal strength, duration of treatment, and efficacy in non-Asian populations.

There are a number of clinical trials currently underway or just completed, including in Ireland, investigating atropine in Caucasian populations (eg, MOSAIC and CHAMP). Atropine eye drops were available to Irish patients who were enrolled in these clinical trials.

There is now evidence that dilute atropine drops are effective in reducing myopia progression in Caucasian children and are safe and well tolerated, said Ms McCreery.

She said she wants the MMP to reconsider and reimburse dilute atropine drops so that they are available to myopic children. “High myopia in adults is associated with an increased risk of macular degeneration, glaucoma, retinal detachment, and cataracts. Reducing the incidence of high myopia in our population will be hugely beneficial to the eye health of future generations in Ireland.”