Amblyopia

[PutiTai]

A cute 6 year old girl came in the other day to get her first eye examination. The refractor read OD 0.00 & OS -4.25, but she actually ended up needing a -6.00 for the left(and I thought -4.25 was bad). I know that there's treatments out there, but with today's technology, could it be that lasik would be a better option?

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[eyestrain]

Was that a +6.00 or -6.00?

 

[PutiTai]

oh wait, it was +6.00

thank you

Her mother was extreme + and her father was an extreme -, so I joked that she must have had her mother's genes

 

[swiftiii]

I'm curious. Was this patient really amblyopic or did she just have a high refractive error? My patient this week was amblyopic, and I am really interested in the topic never having seen one. I guess she was patched as a child (on her good eye) and the muscles would be worked on the bad eye. Following that, because a lot of our patients are very vague on their past history, I am assuming that she had a large tropia when she was little and that was what they were attempting to fix...???

Anyway, she had worn hard contacts about four years prior, but she did NOT like them so she hadn't been wearing anything. Her vision in the bad eye was 20/200 and I ret her at +4.00-3.00X004 to get her to 20/50 (I didn't understand why her previous doctor said she wasn't a good candidate for glasses until we put the lenses in front of her eye!!)

So my point to really telling all this, is that I didn't think sx correction was really an option. Is it? I can't even begin to imagine the specifics of this and I can usually reason anything out. Can anyone explain?

 

[EyeBaller]

First, we need VAs before we decide it's amblyopia. Did the girl also have an eye turn at all?

LASIK isn't really an option, nobody will do LASIK on a 6 yr old.

Depending on the child and parents, a soft CL for the left eye is the best option. Depending on the VAs you would also add part time patching with near activities.

 

[eyestrain]

Okay, +6.00 makes more sense. I agree with the contact idea. Stick a contact on the bad eye and start patching a few hours in conjunction with some demanding near point tasks.

 

[PutiTai]

I'm curious. Was this patient really amblyopic or did she just have a high refractive error?

She was really ablyopic Since it was the first time that anyone knew about her problem, she was given half of her actual prescription and referred to a pediatric optometrist.

 

[IndianaOD]

Wait till you get some more schooling before you get too confused. First check out the Amblyopia Treatment Studies (ATS).

A hyperope should not be under corrected over 2D. My answer would be cut 1.5 D off the cyclo Rx and wear specs until improvement stops. Then begin patching.

 

[KHE]

Wait till you get some more schooling before you get too confused. First check out the Amblyopia Treatment Studies (ATS).

A hyperope should not be under corrected over 2D. My answer would be cut 1.5 D off the cyclo Rx and wear specs until improvement stops. Then begin patching.

Numerous studies have shown a difference of one diopter of hyperopia to be amblyogenic. Why would you undercorrect by 1.5?

 

[IndianaOD]

Numerous studies have shown a difference of one diopter of hyperopia to be amblyogenic. Why would you undercorrect by 1.5?

That would be cut equally. So a +7.00 OD, +2.00 OS would become +5.50 OD and +0.50 OS

 

[KHE]

That would be cut equally. So a +7.00 OD, +2.00 OS would become +5.50 OD and +0.50 OS

But in the case mentioned above, one eye is plano. Therefore, the other eye still ends up uncorrected by a 1.5 diopters with your method.

What would you do for this particular patient?

 

[Karnak]

We are taught to give full cyclo Rx (full plus) in all circumstances for optimal amblyopia treatment outcomes. Even slight over-corrections are advocated (+0.50 overcorrected, even) in younger children (not at school age), because the cyclo might not even get all the plus out. Particularily for treatment of accommodative esotropia (full plus in straight eye)

I'd be interested to know whether this differs from your treatment strategies. (ie I'd give at least the +6.00 assuming it was cyclo rx.)

 

[eyepoker]

very interesting topic. how much can patching the good eye correct the bad eye at this stage? does anyone have any data on it? is it too late for a six year old?

 

[sniklegem]

Studies have shown that it is NEVER too late for some sort of treatment.

 

[hello07]

"Never too late for some sort of treatment" meaning what? You can do occlusion therapy on a 25 or 30 or 40 year old and see VA improvement? Do you know what the term "critical period" in neurophysiology and development means?

 

[swiftiii]

"Never too late for some sort of treatment" meaning what? You can do occlusion therapy on a 25 or 30 or 40 year old and see VA improvement? Do you know what the term "critical period" in neurophysiology and development means?

I Do, I do!! (nice to know something). But before we all go snapping at each other, there are studies that show benefits to VT even when a patient is older. Yes, after about 10 yoa, there is not much improvement in VA alone, but a patient can learn to utilize their bad eye more. For my patient that I mentioned earlier, she was definitely young enough to gain improvement in VA, but that aside, the more important outcome was that she was left with an undetectable eye turn (more important to her; I am not making any statements here.) Sometimes, what we think is important may not be what our patients are thinking, but we shouldn't just dismiss them because they don't follow established studies.

Actually, what I find more interesting is that she started therapy when she was two. So why was she only 20/60 at 18? Not good therapy? Not good following of therapy? Or just not possible to get any better? I mean, I could even see that she had a tropia just by looking at her....

 

[qwopty99]

We are taught to give full cyclo Rx (full plus) in all circumstances for optimal amblyopia treatment outcomes. Even slight over-corrections are advocated (+0.50 overcorrected, even) in younger children (not at school age), because the cyclo might not even get all the plus out. Particularily for treatment of accommodative esotropia (full plus in straight eye)

I'd be interested to know whether this differs from your treatment strategies. (ie I'd give at least the +6.00 assuming it was cyclo rx.)

Why not give full plus in two steps rather than a shotgun approach of just one?

IMO, there's no way a child will relax their eyes sufficiently to appropriately wear their cycloplegic correction. If that's the case, does your school advocate cyclo refractions on ALL patients, and if not, why not?

 

[qwopty99]

"Never too late for some sort of treatment" meaning what? You can do occlusion therapy on a 25 or 30 or 40 year old and see VA improvement? Do you know what the term "critical period" in neurophysiology and development means?

I'm not going to challenge the theory here, but I will say that an OD I worked with who ran a BV clinic, anecdotally told me he patched patients in their 40s and 50s, and had their VAs improve several lines.

I'm not saying it "works", but apparently some people will say they have had patients where it did. Dunno.

 

[IndianaOD]

But in the case mentioned above, one eye is plano. Therefore, the other eye still ends up uncorrected by a 1.5 diopters with your method.

What would you do for this particular patient?

I'd Rx full then.

 

[Graham Lakkis]

"Never too late for some sort of treatment" meaning what? You can do occlusion therapy on a 25 or 30 or 40 year old and see VA improvement? Do you know what the term "critical period" in neurophysiology and development means?

Looks like someone hasn't done any reading of the literature for a while.

Try looking up the ATS (amblyopia treatment studies) conducted by the PEDIG group.

 

[sniklegem]

Not good therapy? Not good following of therapy? Or just not possible to get any better?

I'd go with a combination of the three. #1- were you doing constant occlusion? #2- was she actually wearing her patch at home? #3- relative amblyopia, perhaps?

And if people want me to I will dig out my list of literature references. I'd prefer to not have to do that because I'd rather pack for my trip to Seattle.

 

[sniklegem]

Do you know what the term "critical period" in neurophysiology and development means?

I do. lol.

Here's a question for ya... just because we were talking about it the other day in clinic. Which pharmaceutical agent has been studied as a way to "reopen the critical period" for amblyopic treatment? Did it work? Do you think it is a plausible way to approach those non-treatable amblyopes?

 

[Graham Lakkis]

I do. lol.

Here's a question for ya... just because we were talking about it the other day in clinic. Which pharmaceutical agent has been studied as a way to "reopen the critical period" for amblyopic treatment? Did it work? Do you think it is a plausible way to approach those non-treatable amblyopes?

Prozac.

 

[hello07]

Graham Lakkis,
Keep reading your up to date literature on amblyopia treatment and apply that to your 25 -30 and 40 and 50 year old patients. That will take you far by helping them.
Just because some OD/ Ph.D's publish some 1 -3-5 year studies and happen to get a one line or one letter improvement on the line below the Snellen; they go and publish bogus reports and present them to meeting for people like you to hear them and become impressed.
Wake up dude!

 

[IndianaOD]

Graham Lakkis,
Keep reading your up to date literature on amblyopia treatment and apply that to your 25 -30 and 40 and 50 year old patients. That will take you far by helping them.
Just because some OD/ Ph.D's publish some 1 -3-5 year studies and happen to get a one line or one letter improvement on the line below the Snellen; they go and publish bogus reports and present them to meeting for people like you to hear them and become impressed.
Wake up dude!

I worked with a 43 yo who thought his left eye was blind. I found a ton of cyl that corrected him to 20/80. I patched him down to 20/50. I'm a believer.

 

[hello07]

IndianaOD,
The meeting AOA is coming up. Present your work in Seattle. Generally speaking, patching occlusion for it to be effective has to be done early in one's life and properly. In addition, there are many methods of applying patching therapy with and without correction and exercises on top of that. Again, having good outcomes, MUST be done before the "critical period"- before everything forms and settles -the wiring eyes to brain.
If you are a hero and you helped this person- Good for you.
In the real world, amblyopia whether it be refractive or strabismic is still amblyopia.
i don't buy the arguments. I'm sorry.

 

[sniklegem]

Graham Lakkis,
Keep reading your up to date literature on amblyopia treatment and apply that to your 25 -30 and 40 and 50 year old patients. That will take you far by helping them.
Just because some OD/ Ph.D's publish some 1 -3-5 year studies and happen to get a one line or one letter improvement on the line below the Snellen; they go and publish bogus reports and present them to meeting for people like you to hear them and become impressed.
Wake up dude!

Woah!!!!!! Fight! Fight!

Why are you so cynical, hello? Do you not think that for some patients correcting them 1-2 lines (maybe more?) means the world for their quality of life? Just a question. Thanks in advance for an answer.

 

[sniklegem]

IndianaOD,
The meeting AOA is coming up. Present your work in Seattle. Generally speaking, patching occlusion for it to be effective has to be done early in one's life and properly. In addition, there are many methods of applying patching therapy with and without correction and exercises on top of that. Again, having good outcomes, MUST be done before the "critical period"- before everything forms and settles -the wiring eyes to brain.
If you are a hero and you helped this person- Good for you.
In the real world, amblyopia whether it be refractive or strabismic is still amblyopia.
i don't buy the arguments. I'm sorry.

Dude, are you kidding me? Are you an OMD? I mean, for serious, because that's just old, out-dated thinking. And anyway, Indiana can't present at Seattle; the call for posters for Optometry's Meeting 2009 (DC) is open, though.

 

[qwopty99]

Isn't it the same type of "bogus" research that you condescend here:

Just because some OD/ Ph.D's publish some ... go and publish bogus reports and present them to meeting for people like you to hear them and become impressed.

that leads you to believe this:

having good outcomes, MUST be done before the "critical period"- before everything forms and settles -the wiring eyes to brain.

Why are you so sure about what you believe? What studies have you personally done that proves you are right?

 

[Karnak]

I do. lol.

Here's a question for ya... just because we were talking about it the other day in clinic. Which pharmaceutical agent has been studied as a way to "reopen the critical period" for amblyopic treatment? Did it work? Do you think it is a plausible way to approach those non-treatable amblyopes?

It seems the drug companies were quick to react to the news about Prozac

 

[Karnak]

Why not give full plus in two steps rather than a shotgun approach of just one?

IMO, there's no way a child will relax their eyes sufficiently to appropriately wear their cycloplegic correction. If that's the case, does your school advocate cyclo refractions on ALL patients, and if not, why not?

No, cylcoplegic refractions arent advocated for all patients because all patients dont have similar consequences if theyre undercorrected, and proper control of accommodation is easier to achieve on older patients (ie over 10 even). Retinoscopy is a fair indication of an adult's refractive error... but you want to be sure you have all the plus with a child.

 

[qwopty99]

No, cylcoplegic refractions arent advocated for all patients because all patients dont have similar consequences if theyre undercorrected, and proper control of accommodation is easier to achieve on older patients (ie over 10 even). Retinoscopy is a fair indication of an adult's refractive error... but you want to be sure you have all the plus with a child.

I'm not trying to be devil's advocate here - but why all the dogma?

 

[Karnak]

I'm not trying to be devil's advocate here - but why all the dogma? Do you know whose theoretical dogma you are actually supporting here? If not, why are you dogmatic about it?

#1. What are the "consequences" that you refer to? The epidemiology of the average child's refractive error averages plano at age 6. The average child does not need to wear correction to achieve this target, and they are hyperopic up until this age. Hence, in the average child, a hyperopic refraction leads to emmetropization.


#2. If (as you suggest) a highly-hyperopic child is fully corrected, isn't it possible that will affect his/her emmetropization? What proof do you have that suggests a full cycloplege Rx in a child is most helpful to them? Children that young have and use accommodation.


I'm more likely to leave a child with a bit of plus (say 1 to 1.5 D), in a child who is highly hyperopic, i.e. whatever Rx that allows them to approximate their age-matched norm.

I see your point, and it is a good one.

I quote dogma as I am a student and dont yet have the personal experience or breadth of knowledge that a presumably practicing optometrist such as yourself would have, but I do indeed know whose 'dogma' I quote.

However, would you not agree that the consequences of a hyperopic accommodative esotrope remaining +2.00 undercorrected may be a little more permanent than that of an adult remaining +2.00 undercorrected?
Cylcoplegic refraction is a good idea, I believe, to be sure your refraction is as close to the true patient's ametropia that you can get, at the very least to accurately guide management decisions; even if you dont prescribe the full plus.

 

[qwopty99]

I see your point, and it is a good one.

I quote dogma as I am a student and dont yet have the personal experience or breadth of knowledge that a presumably practicing optometrist such as yourself would have, but I do indeed know whose 'dogma' I quote.

However, would you not agree that the consequences of a hyperopic accommodative esotrope remaining +2.00 undercorrected may be a little more permanent than that of an adult remaining +2.00 undercorrected?
Cylcoplegic refraction is a good idea, I believe, to be sure your refraction is as close to the true patient's ametropia that you can get, at the very least to accurately guide management decisions; even if you dont prescribe the full plus.

I agree the potential neurophysiological consequences of undercorrecting a child hyperope is likely greater than that of an adult.