Dr Mihir Kothari, Dr Renu Singhania. Mahatme Eye Hospital and Jyotirmay Eye Clinic.

1. Oral Triclofos sedation in evaluation of young and
uncooperative children in pediatric ophthalmology
E poster No 106: Dr Mihir Kothari, Dr Renu Singhania
Mahatme Eye Hospital and Jyotirmay Eye Clinic
drmihirkothari@jyotirmay.com
Financial Conflicts - None

2. Introduction
• Evaluation of children under anesthesia is frequently
required in Pediatric Ophthalmology
• Developmental glaucoma, cataract, chronic uveitis,
retinoblastoma, high myopia etc. require repeatedly
• Long-term side-effects of single or repeated
administration of general anesthesia is a concern

3. Growing concerns with general
anesthesia in children
• Good WV. Is anesthesia safe for young children? J AAPOS 2014;18:519-20.
• DiMaggio, C., Sun, L.S., Ing, C., and Li, G. Pediatric anesthesia and neurodevelopmental impairments: a Bayesian
meta-analysis. J Neurosurg Anesthesiol 2012; 24:376–381.
• Flick RP, Katusic SK, Colligan RC, Wilder RT, Voigt RG, Olson MD, et al. Cognitive and behavioral outcomes after
early exposure to anesthesia and surgery. Pediatrics 2011;128: 1053–61.
• Stratmann G, Lee J, Sall JW, Lee BH, Alvi RS, Shih J, et al. Effect of general anesthesia in infancy on long-term
recognition memory in humans and rats. Neuropsychopharmacology 2014;39:2275-87.
• Negative impact on
o Cognition, memory and behavior
• Modestly elevated risk of
o adverse behavioral or developmental outcomes
• 60% increased risk of learning disorders
• Almost all the anethetics have significant effects on neurotransmitters

4. Chloral hydrate
• Liebig first introduced it into pediatric dentistry practice in
1832
• Oldest, safest and the best studied sedative –
hypnotic
• Triclofos is the pharmacologically active metabolite of
chloral hydrate
• Less gastric irritant and is better accepted orally in
children

5. Subjects and methods
• Prospective interventional cohort study
• Inclusion Criteria
o Children < 16 years
o Uncooperative for relevant and necessary ophthalmic exams
• Exclusion Criteria
o Children < 12 months
o Active respiratory/febrile illness
• Statistics
o Paired t test was used as test of significance
o P<0.05 was considered significant

6. Results
• Thirty nine examinations under sedations (EUS)
• On thirty six consecutive children
• 16 were females
• The mean age was 2.9 year (1-9years)
• Examination could be completed in all the patients
• All had IOP, 1 had FDT, 1 Suture removal, 1 excision of
granuloma, 2 had A scan and keratometry

7. Results
N=39 Mean (SD) Mean onset of sedation in
minutes (Pearson r)
Mean duration of sedation in
minutes (Pearson r)
Age 2.9 (1.6) 65 (r=0.15) 64 (r=0)
Weight 11.7 (3)
65( 0.26)
64 (-0.0855)
Gender Boys
(n=20)
Girls
(n=19)
Boys
(n=20)
Girls
(n=19)
59 minutes 71 minutes 72 minutes 56 minutes
P value <0.01 <0.01

8. Discussion
• In 21 patients, application of proparacaine HCl eye drops
caused the child to partially arouse for a moment
• Avoid touching the eye lashes as eye lash reflex was
intact
• We used full therapeutic dose of 75mg/kg
• Does not cause any cardio-respiratory problems
hence used for Echo in Congenital Heart Disease and
Electro Encephalography in Seizure disorders
• Not safe in children with active asthma

9. Discussion
• No significant change in the pulse rate and the spO2
before and after administration of oral triclofos
• Onset of sedation with triclofos was highly variable
ranging from 10 minutes to as long as 270 minutes (boys
were faster to fall asleep)

10. Discussion – informal
data
• Children sleep earlier if they had slept late on the
previous night and they were made to wake up earlier on
the day
• Sedation is rapid if the sedation is given during the
routine sleep hours of the child
• Repeated sedations did not alter the timing of onset
and duration of sedation

11. Conclusion
• Oral triclofos at a dose of 75mg/kg/dose was safe and
effective for the examination of uncooperative children
in pediatric ophthalmology practice
• Further studies are needed to evaluate the effect of oral
triclofos on
o Intraocular pressure measurement in children
o Its long term effect on the cognition and the neurodevelopment of the children