Amblyopia is a hot topic in pediatric ophthalmology

In this report, OSN's Pediatrics/Strabismus Section Editor looks at amblyopia and retinopathy of prematurity.

Issue: September 1, 2004

ByRobert S. Gold, MD

“These studies have shown that atrophine is a reasonable alternative to patching for the non-compliant child.”
— Robert S. Gold, MD

The hottest topics in most pediatric ophthalmology practices today are amblyopia, amblyopia, amblyopia and amblyopia. In my osn specific practice, retinopathy of prematurity is a close second.

I would like to briefly review several recent major studies regarding the treatment of amblyopia. The first of these was published in March 2002, stating that atropine could be equal to patching therapy for amblyopia. The initial reaction and the media frenzy that were caused by the authors’ statement filled our offices with phone calls. It was an absolutely unbelievable situation in most pediatric ophthalmology offices.

Several months later, another study was published comparing 2 hours of patching to 6 hours of patching in children. That caused another media frenzy.

Here we were, recommending the age-old practices of full-time patching or half-time patching, and we had parents coming in and saying, “Why are you patching my child all day when an article came out saying that 2 hours of patching would be just as good?”

The repercussions for our practices have been significant, but as a result we have learned a lot about how to talk to parents about compliance. So perhaps the initial disruption was worthwhile because of what we learned from it.

Patching confusion

One of the most startling statements in the series of articles by the Pediatric Eye Disease Investigator Group (PEDIG), which caused all kinds of controversy, was the suggestion that the parent or the child’s preference may be the overriding factor in deciding which treatment to prescribe.

Burton Kushner, MD, commented on one of the PEDIG studies in an accompanying article in Ophthalmology. Dr. Kushner noted that atropine did work perhaps better than many of us anticipated, and he said that he believed these studies have shown that atropine is a reasonable alternative to patching for the noncompliant child.

There is a very important word in that statement – alternative. Atropine is not necessarily the No. 1 choice. It is an alternative.

To recap the most controversial studies: The PEDIG study published in 2002 found that atropine drops were a comparable method of therapy to eye patching for the treatment of moderate amblyopia in children. In 2003, the same group published data showing that patching the unaffected eye of a patient with moderate amblyopia for 2 hours daily was as effective as patching the eye for 6 hours. Later that year, the group published data in Ophthalmology showing that penalization took significantly longer to achieve target visual acuity than atropine.

How to handle

So there are many signals being sent. What does OSN’s Pediatrics/Strabismus Section Editor conclude, and how should we be treating these patients?

Well, these studies certainly opened all of our eyes — not only those of our parents, but also the pediatric ophthalmologists’ eyes. What I tell parents is that we have to make the decision based on our considerable experience, and that it has to be definitive. It can’t be wishy-washy.

We need to listen to what the parents are saying to us about compliance, but they have to understand that we have been doing this for years, and we know where the treatment needs to go.

It is a two-way street. You are not only treating the child, you’re treating the parent, and you have to have the parent buy into your treatment. I often have the parents keep a log, especially with regard to patching, and bring it into the office so we can go over whether things are working or not. If something is not working, you have to do something different.

The PEDIG authors are now studying whether patching into the teenage years, even up to age 17, will be effective. Data from that study will be reported in the near future.

ROP issues

In late 2003 the authors of the Early Treatment for Retinopathy of Prematurity (ETROP) study published new indications for treatment of retinopathy of prematurity (ROP). It is obvious that one of our greatest fears is vision loss in an infant, especially in a premature infant.

This study found that more aggressive treatment, earlier treatment at different stages, is beneficial. The initial study by the ETROP group basically recommended treatment at stage 3 in certain ramifications.

This current study was more aggressive. The authors did peripheral ablation much earlier, with treatment in stage 2, even in stage 1, even in zone 2.

The lesson was that we should treat these children much earlier and much more aggressively to try to prevent vision loss.

We have seen an increased number of zone 1 cases. We are now much more attentive to the zone 1 cases. Posterior zone 2 cases are becoming much more quickly treated. Even with the addition of early treatment for selected eyes with prethreshold ROP, some of the eyes will still progress to unfavorable visual or structural outcomes.

ROP is one of the most prominent medicolegal issues in pediatric ophthalmology today. We have instituted tracking systems in order to try to follow the patients. When they miss appointments it has become the ophthalmologist’s fault, not the parents’ fault. So this is the new way, the new business, of doing ophthalmology. We have to find and follow these patients. We can’t let them go.

Future considerations

A number of large-scale studies are either in the planning stages or under way in pediatric ophthalmology.

There are plans for a multicenter study of infant cataract surgery with IOLs. We are going to be looking into and talking a lot about adult strabismus. We will be looking at diplopic symptoms before and after strabismus surgery in adults. We are also going to be discussing the visual benefits following pediatric refractive surgery.

A note from the editors

Dr. Gold points out that he made these remarks at the OSN Section Editor Summit in March, and “a lot has happened since then.” Read the Pediatrics/Strabismus section of OSN for continuing updates on the hot topics in pediatric ophthalmology and strabismus.

Pinto on Practice Management

The October 1 issue will feature John B. Pinto, OSN’s Practice Management Section Editor, who will discuss tactics to guide your practice into the future.

For Your Information:

Robert S. Gold, MD, can be reached at 225 W. State Road 434, Suite 111, Longwood, FL 32750; 407-767-6411; fax: 407-767-8160; e-mail: rsgeye@aol.com.

References:

The Pediatric Eye Disease Investigator Group. A randomized trial of atropine vs. patching for treatment of moderate amblyopia in children. Arch Ophthalmol. 2002;120(3):268-278.

The Pediatric Eye Disease Investigator Group. A randomized trial of patching regimens for treatment of moderate amblyopia in children. Arch Ophthalmol. 2003;121:603-611.

The Pediatric Eye Disease Investigator Group. A comparison of atropine and patching treatments for moderate amblyopia by patient age, cause of amblyopia, depth of amblyopia, and other factors. Ophthalmology. 2003;110:1632-1638.

Kushner BJ. Discussion. Ophthalmology. 2003;110:1
637-1638.

Early Treatment For Retinopathy Of Prematurity Cooperative Group. Revised indications for the treatment of retinopathy of prematurity: Results of the early treatment for retinopathy of prematurity randomized trial. Arch Ophthalmol. 2003;121(12):1684-1694.