Treatment of Strabismic Amblyopia With Refractive Correction (original) (raw)
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A Randomized Trial of Increasing Patching for Amblyopia
Ophthalmology, 2013
Objective-After treatment with refractive correction and patching, some patients have residual amblyopia resulting from strabismus or anisometropia. We conducted a clinical trial to evaluate the effectiveness of increasing prescribed daily patching from 2 to 6 hours in children with stable residual amblyopia. Design-Prospective, randomized, multicenter clinical trial. Participants-A total of 169 children aged 3 to <8 years (mean, 5.9 years) with stable residual amblyopia (20/32-20/160) after 2 hours of daily patching for at least 12 weeks. Intervention-Random assignment to continue 2 hours of daily patching or increase patching time to an average of 6 hours/day. Main Outcome Measures-Best-corrected visual acuity (VA) in the amblyopic eye after 10 weeks. Results-Baseline VA was 0.44 logarithm of the minimum angle of resolution (logMAR) (20/50 −2). Ten weeks after randomization, amblyopic eye VA had improved an average of 1.2 lines in the 6-hour group and 0.5 line in the 2-hour group (difference in mean VA adjusted for acuity at randomization = 0.6 line; 95% confidence interval, 0.3-1.0; P = 0.002). Improvement of 2 or more lines occurred in 40% of participants patched for 6 hours versus 18% of those who continued to patch for 2 hours (P = 0.003).
Outcome study in amblyopia: Treatment and practice pattern variations
Journal of American Association for Pediatric Ophthalmology and Strabismus, 2000
This study retrospectively evaluates the results of amblyopia therapy and suggests hypotheses for future study. We address the various methods of treatment and evaluate the results from the most common therapy techniques. Practice pattern variations were analyzed in addition to the analysis of overall results. For ophthalmologists, there is a need to determine whether actual medical practice approaches the established standard of care, if it exists at all. How often are medical procedures, thought to be appropriate, based on anecdotal observation (case reports) rather than hard data (clinical trials)? The 3 types of vision loss evaluated were strabismic, anisometropic, and deprivation amblyopia. The methods of treatment studied were full-time patching part-time occlusion, penalization, and occlusion of the contact lens. Nine centers, thought to have private as well as indigent patients, were recruited to participate in this study. The centers responded by filling out an extensive questionnaire and sending the information through the World Wide Web for inclusion in a spreadsheet. This information was then collated, and various statistical programs tabulated the results. Although trends, as a consequence of therapy, are suggested from our retrospective analysis, concrete results can only arise from a randomized prospective study. The study included 279 patients. There were a similar number of male and female patients. Only 77% of the patients without fusion before treatment had either single binocular vision or peripheral fusion at the conclusion of therapy. The log improvement of vision was significant in each group. Factors that potentially influenced the results were severity of distance acuity in the amblyopic eye before treatment, duration of treatment, and length of daily patching. The paper suggests that worse vision, not better vision, at the beginning, predicts better outcome in terms of improvement of visual acuity. For example, visual acuity less than 20/70 at the initiation of treatment led to better visual results of geometric log improvement. Surprisingly, among the 9 centers studied, there was a statistically significant difference in many of the areas related to practice patterns. Patient compliance, which directly affects outcome, was highly variable and is a factor that may be readily influenced by the treating physician.
Ophthalmology, 2006
Objective: To compare 2 hours of daily patching (combined with 1 hour of concurrent near visual activities) with a control group of spectacle wear alone (if needed) for treatment of moderate to severe amblyopia in children 3 to 7 years old. Design: Prospective randomized multicenter clinical trial (46 sites). Participants: One hundred eighty children 3 to 7 years old with best-corrected amblyopic-eye visual acuity (VA) of 20/40 to 20/400 associated with strabismus, anisometropia, or both who had worn optimal refractive correction (if needed) for at least 16 weeks or for 2 consecutive visits without improvement. Intervention: Randomization either to 2 hours of daily patching with 1 hour of near visual activities or to spectacles alone (if needed). Patients were continued on the randomized treatment (or no treatment) until no further improvement was noted. Main Outcome Measure: Best-corrected VA in the amblyopic eye after 5 weeks. Results: Improvement in VA of the amblyopic eye from baseline to 5 weeks averaged 1.1 lines in the patching group and 0.5 lines in the control group (P ϭ 0.006), and improvement from baseline to best measured VA at any visit averaged 2.2 lines in the patching group and 1.3 lines in the control group (PϽ0.001). Conclusion: After a period of treatment with spectacles, 2 hours of daily patching combined with 1 hour of near visual activities modestly improves moderate to severe amblyopia in children 3 to 7 years old.
Objectively monitored patching regimens for treatment of amblyopia: randomised trial
BMJ, 2007
Objectives To compare visual outcome in response to two prescribed rates of occlusion (six hours a day and 12 hours a day). Design Unmasked randomised trial. Setting Research clinics in two London hospitals. Participants 97 children with a confirmed diagnosis of amblyopia associated with strabismus, anisometropia, or both. Interventions: 18 week period of wearing glasses (refractive adaptation) followed by occlusion prescribed ("patching") for six or 12 hours a day. Main outcome measures Visual acuity measured by logMAR letter recognition; objectively monitored rate of occlusion (hours a day). Results The mean age of children at study entry was 5.6 (SD 1.5) years. Ninety were eligible for occlusion but 10 dropped out in this phase, leaving 80 children who were randomised to a prescribed dose rate of six (n=40) or 12 (n=40) hours a day. The mean change in visual acuity of the amblyopic eye was not significantly different (P=0.64) between the two groups (0.26 (95% confidence interval 0.21 to 0.31) log units in six hour group; 0.24 (0.19 to 0.29) log units in 12 hour group). The mean dose rates (hours a day) actually received, however, were also not significantly different (4.2 (3.7 to 4.7) in six hour group v 6.2 (5.1 to 7.3) in 12 hour group; P=0.06). The visual outcome was similar for those children who received three to six hours a day or more than six to 12 hours a day, but significantly better than that in children who received less than three hours a day. Children aged under 4 required significantly less occlusion than older children. Visual outcome was not influenced by type of amblyopia. Conclusions Substantial (six hours a day) and maximal (12 hours a day) prescribed occlusion results in similar visual outcome. On average, the occlusion dose received in the maximal group was only 50% more than in the substantial group and in both groups was much less than that prescribed. Younger children required the least occlusion. Trials registration Clinical Trials NCT00274664.
Current Recommendations for Amblyopia Treatment
American Orthoptic Journal, 2007
Occlusion works. Most clinicians know this to be true from personal experience, and now, thanks to some well-designed clinical research, 1-3 we have scientific proof of its efficacy. For more than two hundred years, occlusion of the sound eye has been used successfully in the treatment of amblyopia. More than 75 articles have been published since 2000, directly or indirectly addressing amblyopia therapy. If occlusion is so effective, why has so much of the recent ABSTRACT Introduction: In spite of convincing scientific studies proving the efficacy of patching therapy, many researchers continue to devise and test alternatives to patching. Patching is unpopular with parents and children, and, as a result, compliance is poor. Poor compliance leads to patching failure. Methods: A review of the literature published since 2000 in peer-reviewed medical journals on the management of amblyopia was done and the results compiled and summarized. Results: Research has suggested that the key to successful amblyopia therapy is not necessarily what treatment method is prescribed, but when it is prescribed, and how strongly the clinician emphasizes compliance at the initial visit. Younger children tend to have a better outcome; however, even older children, teenagers, and prior patching failures can achieve meaningful and lasting improvements in vision, if compliance with therapy is improved. Conclusion: The critical step in the management process may be taking time to convince the parents of the necessity and urgency of the treatment, that the treatment is effective, and that they are capable of carrying out the treatment plan.
American Journal of Ophthalmology, 2005
To determine the effectiveness and side effects of full-time occlusion for the treatment of amblyopia. Methods: Patients with unilateral amblyopia secondary to strabismus, anisometropia, or a combination of the two were retrospective reviewed. All patients had full-time occlusion encompassing 24 hours per day or all waking hours, followed to a defined endpoint. Success was defined as 20/30 or better or equal visual acuity by fixation pattern between the two eyes. The ultimate goal was equal visual acuity. Results: Six hundred patients fit the inclusion criteria. Mean follow-up after the cessation of full-time patching was 7.2 years. Eighty-nine percent were followed for more than 1 year. Mean age at last follow-up visit was 10.82 years. Ninety-six percent of patients attained a successful visual result. Sixty percent attained equal visual acuity. Younger patients required less occlusion time to endpoint and had a better visual outcome (P Ͻ 0.0001). Initial visual acuity was significantly related to best visual acuity attained (P Ͻ 0.0001). The incidence of occlusion amblyopia was 25.8%. Conclusions: Full-time occlusion produces excellent visual acuity results. It was shown to be effective with no long-term complications if patients proceed as directed.
Randomized Trial of Treatment of Amblyopia in Children Aged 7 to 17 Years
2005
Objective: To evaluate the effectiveness of treatment of amblyopia in children aged 7 to 17 years. Methods: At 49 clinical sites, 507 patients with amblyopic eye visual acuity ranging from 20/40 to 20/400 were provided with optimal optical correction and then randomized to a treatment group (2-6 hours per day of prescribed patching combined with near visual activities for all patients plus atropine sulfate for children aged 7 to 12 years) or an optical correction group (optical correction alone). Patients whose amblyopic eye acuity improved 10 or more letters (Ն2 lines) by 24 weeks were considered responders.
Background Current treatments for amblyopia in children, occlusion and pharmacological blurring, have had limited success, with less than two- thirds of children achieving good visual acuity of at least 0.20 logMAR in the amblyopic eye, limited improvement of stereopsis, and poor compliance. A new treatment approach, based on the dichoptic presentation of movies or computer games (images presented separately to each eye), may yield better results, as it aims to balance the input of visual information from each eye to the brain. Compliance may also improve with these more child-friendly treatment procedures. Objectives To determine whether binocular treatments in children aged three to eight years with unilateral amblyopia result in better visual outcomes than conventional occlusion or pharmacological blurring treatment. Search methods We searched the Cochrane Eyes and Vision Group Trials Register (last date of searches: 14 April 2015), the Cochrane Central Register of Controlled Trials (CENTRAL; 2015, Issue 3), Ovid MEDLINE, Ovid MEDLINE In-Process and Other Non-Indexed Citations, Ovid MEDLINE Daily, Ovid OLDMEDLINE (January 1946 to April 2015), EMBASE (January 1980 to April 2015), the ISRCTN registry (www.isrctn.com/editAdvancedSearch), ClinicalTrials.gov (www.clinicaltrials.gov), and the World Health Organization (WHO) In- ternational Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en). We did not use any date or language restrictions in the electronic searches for trials. Selection criteria Two review authors independently screened the results of the search in order to identify studies that met the inclusion criteria of the review: randomised controlled trials (RCTs) that enrolled participants between the ages of three and eight years old with unilateral amblyopia, defined as best-corrected visual acuity (BCVA) worse than 0.200 logMAR in the amblyopic eye, and BCVA 0.200 logMAR or better in the fellow eye, in the presence of an amblyogenic risk factor such as anisometropia, strabismus, or both. Prior to enrolment, participants were to have undergone a cycloplegic refraction and comprehensive ophthalmic examination including fundal examination.In addition, participants had to have completed a period of optical treatment, if indicated, and BCVA in the amblyopic eye had to remain unchanged on two consecutive assessments despite reportedly good compliance with glasses wearing. Participants were not to have received any treatment other than optical treatment prior to enrolment. We planned to include any type of binocular viewing intervention; these could be delivered on different devices including computer monitors viewed with LCD shutter glasses or hand- held screens including mobile phone screens with lenticular prism overlay. Control groups were to have received standard amblyopia treatment; this could include occlusion or pharmacological blurring of the better-seeing eye. We planned to include full-time (all waking hours) and part-time (between 1 and 12 hours a day) occlusion regimens. Data collection and analysis We planned to use standard methodological procedures expected by The Cochrane Collaboration. We had planned to meta-analyse the primary outcome, that is mean distance BCVA in the amblyopic eye at 12 months after the cessation of treatment. Main results We could identify no RCTs in this subject area. Authors’ conclusions Further research is required to allow decisions about implementation of binocular treatments for amblyopia in clinical practice. Currently there are no clinical trials offering standardised evidence of the safety and effectiveness of binocular treatments, but results from non- controlled cohort studies are encouraging. Future research should be conducted in the form of RCTs, using acknowledged methods of visual acuity and stereoacuity assessment with known reproducibility. Other important outcome measures include outcomes reported by users, compliance with treatment, and recurrence of amblyopia after cessation of treatment.