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Round Table: Cost-effective vision screening, early amblyopia detection essential
In this final excerpt from a round table held during AAPOS, members of the OSN Pediatrics/Strabismus Section discuss vision screening and trends in the treatment of amblyopia.
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Robert S. Gold, MD: The first topic that we are going to discuss is one that was featured earlier this year in a three-part series, “OSN Special Report: Issues in Vision Screening.” Readers who want to review those articles can find them in the February 1, February 15 and March 1 issues of Ocular Surgery News, or on the OSN Web site, www.OSNSuperSite.com.
First I’d like to introduce a guest participant in our round table, Dr. Robert Arnold, who is the head of the Vision Screening Committee for the American Association for Pediatric Ophthalmology and Strabismus. He contributed to those OSN articles earlier this year, and he is now joining the rest of the Pediatrics/Strabismus Section for our discussion.
Bob, what is your committee in AAPOS doing, and what is their role and your function?
Robert W. Arnold, MD: The Vision Screening Committee has existed for the past decade, and it tries to address policy. It addresses new, emergent technology and education issues as they relate to screening treatable pediatric eye disease within the auspices of AAPOS.
AAPOS has “American” as its first name, but really it is reaching out worldwide to the question of vision screening, not just as an issue in the United States, but in Canada, Mexico and the rest of the world. So we look at a lot of advancing technology and try to determine whether it’s cost-effective and valid, and then see how it should be applied.
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The Vision Screening Committee of AAPOS tries to work closely with the American Academy of Ophthalmology and the American Academy of Pediatrics in the implementation of vision screening.
Vision screening
Dr. Gold: Let’s discuss what the role of the pediatrician is in vision screening. What should we demand our pediatricians do to identify children that should be seen by us?
Dr. Arnold: I think from our medical training the pediatrician in the pediatric office is really the pediatric home base. They truly have a better understanding about cost-effective and valid treatment of kids. Children’s eyes are a part of that.
I see them as the overseers and our allies working with children. The team of pediatricians that I work with is interested in the overall health of children and in their vision.
Pediatricians see children at 4 months of age when it is useful to pick up strabismus. They see them when they are coming in for well-child checks, when they are 18 months, when they are 3 years, 4 years, and then through the school years.
A sequence of appropriate age-related tests over time is the best method for detecting amblyopia. As we know, we can have a child with high amounts of hyperopic anisometropia who would have normal fixation behavior when he is 4 months old, but he may develop amblyopia later. So passing one single test, a screening cover test at 4 months, is not sufficient to determine whether or not that child will have amblyopia later.
A 3-year-old might pass an acuity level of 20/40 or have less than two lines of difference of acuity between eyes at age 3, but she might have fairly dense amblyopia by the time she is entering first grade. So we want to have an ongoing process of screening, and that is where the pediatrician comes in.
Dr. Gold: What should we be telling the pediatricians to look for that they may be missing? Who should we tell them to be sending to us very early on? What type of patients are we looking for that they may let go by?
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Anthony P. Johnson, MD: In our area, the pediatricians do a great job of screening. They already refer patients quickly who have syndromes, who have a family history of amblyopia and strabismus, and, particularly, they are sensitive to Mom’s history, when Mom says, “I think I’m seeing…” whatever, including most frequently strabismus.
The children that are most at risk, because most caregivers are not comfortable assessing them, are the ones that have severe cerebral palsy or severe developmental delays, and are otherwise difficult to assess by anybody, including their caregivers. In our community the school district uses the MTI PhotoScreener effectively in a situation where the school nurses previously would spend an incredible amount of time with only a small number of children that were special-needs kids. They were constantly worried that they were going to miss something, that they were not going to find a real problem, but on the other hand they didn’t want to refer every single child for examination.
Because they’ve been using the PhotoScreener for the past 7 or 8 years, their incidence of missing patients or students has been incredibly low, and the specificity of those being referred is very good. I don’t have actual numbers, but my anecdotal feel is that it is good.
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Roberto Warman, MD: It all depends on the area where you are. We see the exact opposite situation in Miami with the incredible amount of movement of people in and out, the amount of immigration, legal and illegal, of all types of people, Creole, Latin American, Central American, from all over, in addition to bad reimbursement levels for pediatricians by insurance companies. They do not have the ability to spend enough time with their patients in the office. We are seeing levels of amblyopia and missed patients at the level of Third World countries, and this is in the United States.
That’s why it still is imperative that we find some type of standard that is relatively inexpensive, that will be able to go beyond these economic issues and still screen mobile populations. We cannot depend on the school system, at least not in South Florida.
Rudolph S. Wagner, MD: I agree with Roberto. We have a similar experience in our area where we have a great variation in the socioeconomic level of our patients, and access to health care is a problem. We do not get the screening that we want to have. It is great that children are screened for school, but by that time for many it is too late. We would rather get them in preschool if we can, as opposed to regular school age, because they are still young enough for us to treat some of these conditions more satisfactorily.
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I have read statistics indicating that the percentage of pediatricians throughout the country who actually do visual acuity testing is not high. It is not as good as it should be. I believe it is in the range of 50%, and I’m not even sure it’s that high. I frequently ask patients in my office when they are referred if they were screened or how they were screened, and I would say 50% of the pediatricians of my patients actually do visual acuity testing at appropriate ages. So this is an issue that needs to be addressed, and they need to be taught how to do it.
Dr. Gold: Another factor is that many parents feel that the school screening is an eye examination. The screening substitutes for an eye exam in their minds, and if there is a problem that’s not identified, this child has already had their first eye exam. As we know, that’s not true. So there’s a false sense of security. Also a child may cheat on an eye screening and then be missed.
Kenneth P. Cheng, MD: The concept of the pediatrician being the spot where children have to go at an early age makes the pediatrician’s office the primary focus for where screening has to be done. Obviously, when you wait until school age it is too little, too late, for many of these kids when they are 5 or 6 years old.
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With a mobile population it is difficult, but nevertheless, even in a mobile population kids get sick. When they get sick, that’s the opportunity to make the contact for screening. Hopefully, even the indigent population gets picked up by the public-assistance-type HMOs. The HMOs now have mandates that their providers have to do vision screenings. I think that’s key for better compliance.
Tony, you were saying that pediatricians in your area do a good job, and I have a similar experience in Pittsburgh. I think my population is probably more affluent than the mobile population of Miami, but usually when parents complain, “I think the eyes might be crossed,” there is such a fear of litigious action now. It is easier to just go ahead and refer the patient. I think that pediatricians have gotten the message well that amblyopia has to be treated early.
What do we need to focus on? What gets missed? It’s obviously the anisometropic amblyope, where there is no obvious physical sign of the problem. There is not necessarily as much of a family history as with esotropes, and those are the kids that get missed. Those are the kids for whom currently there is no good way of testing them in the pediatrician’s office when they are young. So that is where photoscreening devices have potential future application.
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Scott E. Olitsky, MD: I want to second the comments made by several people. My experience is that pediatricians are doing a good job once the patient gets in to see them. What we need to concentrate on is not just how to help the pediatricians be most effective. It’s how to get the patients into the system in an organized way so that they can do that good job on more patients.
Naval Sondhi, MD: There are primary care colleagues who do an excellent job, and the point has been made that not all patients or all children get to their offices either in time or at all. In Indiana, we have other agencies that provide this screening function in the form of the school system; in the form of Prevent Blindness Indiana, an organization affiliated with Prevent Blindness America; in the form of churches and other organizations. A combination of all of these probably should be put to use. If we place the onus primarily or solely on the pediatrician’s office we are liable to miss, at least for a long time yet, a lot of children. They may not get their screening.
Comprehensive eye exams
Dr. Gold: There has been a lot of controversy between the ophthalmic community and the optometric community as to whether to mandate a complete eye examination by about the age of 5. Is that mode the better mode, or are other screening modalities better?
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Dr. Arnold: I believe Kentucky is the first state that has experimented in mandating comprehensive eye exams.
In each of our own experiences, or in an academic optometrist’s practice, if we know that a referral has a problem, we look closely for it, and if the child may not get dilated well, you redilate them, and you continue to examine them even if they are having a bad day.
What has never been validated is routine comprehensive eye exams for children who are otherwise low risk, with only about 4% or 5% risk of problems. When your office is running late, when the child is vomiting, you are unlikely to do nearly as comprehensive an eye exam on that child as you do when he or she is already coming in with some of the risk factors that come with a screening referral. So the content of mandated comprehensive eye exams is not yet validated.
Sean Donahue, MD, has some data from in and around Kentucky on the number of children who have unneeded glasses prescriptions or who on subsequent examinations appear not to have been done comprehensively in terms use of cycloplegic drugs, etc. So an experiment with doing mandatory comprehensive eye exams is currently being done in Kentucky. Whether or not that’s a useful way of detecting what we want to find is the question.
Alan White, PhD, did a study sponsored by the Vision Council of America that determined that the quality adjusted life units for comprehensive pre-kindergarten eye exams was around $13,000. Comparing that value to those of other services, he thought comprehensive eye exams were worth more than, for instance, liver transplants in terms of society’s value of health.
What wasn’t published in that, but what he was able to tell us, was that two vision screenings instead of a comprehensive eye exam had a quality adjusted life year value of about $5,680. So it was less than half the price for a similar value. And we have much better information on validation of vision screening as well.
One of the points raised in this discussion is that the person who is doing the screening, who has a high level of time, and maybe reimbursement or skill, can do a very good job of screening children, and pediatricians respond well to the parents’ concerns. They are by far the best at being able to aim a patient in the right direction given the patient’s symptoms. So a patient who has intermittent strabismus is probably best detected by the comments of the parents to the pediatrician.
Intermittent strabismus is poorly detected by certain tests, even photoscreening. But those are the types of things that are appropriately guided by the pediatrician. Those are not done well by poor-quality lay screening.
Mandated pre-kindergarten screening would allow us to catch the kids who are in pediatricians’ offices and those who are not in pediatricians’ offices. It might cause some of them to check into the pediatrician’s offices to get their screening done, or the screening could be done by other facilities. It is the goal of the Vision Screening Committee of AAPOS to encourage screening that is equal to or better in validity and cost-effectiveness to patch-acuity testing in pre-kindergarten kids.
Dr. Wagner: Bob brings up a good point about validating the comprehensive eye examination. I know as a pediatric ophthalmologist, Bob and everyone in this room is going to do a better, more complete examination than are general ophthalmologists or other people who are not used to taking care of children.
If you start mandating comprehensive exams, you have to consider that you are going to be sending kids to a lot of other physicians. We are not going to be able to handle all of them. The other physicians that will be handling them will not be equipped to take care of children or to make diagnoses in many difficult cases.
Dr. Olitsky: To go back a step, we haven’t even determined what the comprehensive eye examination is. How are we going to analyze how well we’re doing if we don’t know what we’re doing with these children? We have no method to collect data and see how we’re doing over time.
Another thing that has to be taken into consideration is that resources are limited. If we’re going to spend a lot of money doing this, by definition, we’re going to take it away from somewhere else. So it’s imperative for us to find the most cost-effective way of screening these patients.
Dr. Warman: Here’s a slightly different issue related to screening. In the state of Florida, for the third year in a row, we are going to have to fight with the legislature against a mandated screening for retinoblastoma in newborns by pediatricians with a dilated exam. This defies the logic of any screening program. And again we have the problem of resources. We have to know what we are doing and who is going to pay for it. Mandating tests, if we do not have the resources to pay for them, is just going to create a legal nightmare.
Dr. Gold: I want to switch gears and talk about the current technology of photoscreening units – some being developed, and some that will be on the horizon – and their place in today’s vision screening.
Dr. Arnold: I have experience with around 20,000 children in Alaska screened initially with the MTI PhotoScreener, and then when the film became less available for that, we started reaching out to other screeners. We had good experience using David B. Granet, MD’s EyeDx machine. We used the iScreen from Memphis, Jack Bellow, MD’s machine, and then we started using digital cameras like the one that was published in the Journal of Pediatric Ophthalmology & Strabismus by a Russian medical student, Tanya Kovtoun.
Image: Stiglich JM, OSN |
It turns out that from our experience we cannot stop photoscreening right now ethically in Alaska, and yet we’re doing it all charitably, and it’s kind of running us out. The only people we are failing with valid photoscreening are the kids that we don’t get to.
One of the nice things about photoscreening, when you have worked the validation up so that you have a high specificity of screening, is that it feeds into your pediatric eye practice the high hyperopes and high anisometric hyperopes, who are often ones that go straight into the Amblyopia Treatment Study.
So the technology exists, the trouble is interpretation both in time and place. Sean Donahue has interpretation at his center. Other people are working their own interpretation out, but it takes a good deal of feedback to get your interpretation specific enough for it to be constant.
Dr. Warman: And of course it’s all a matter of where you set your parameters for sensitivity and specificity. For Bob, in Alaska, he has to have patients screened far away, and if they fail they have to be flown in for further work, and that’s very expensive. In the area of Miami where I am, patients have to walk to the next corner store for screening, and we can choose different sensitivities and specificities based on the location of the population we’re studying. It’s not going to be a cookbook of exactly the same parameters everywhere.
Much of this equipment works. It’s just that you are not comparing apples with apples. You have to decide, and that’s what the AAPOS committee will have a tough job with, trying to decide where and how we’re going to set the different parameters and still achieve comparable results.
Dr. Gold: Another thing is that developing new technology takes money, and reimbursement for these tests is controversial. Is there going to be reimbursement for performing screenings?
We have photoscreening units and we have some systems based on visual evoked potential, the Diopsys unit which John Simon, MD’s group reported on last year, and there are wavefront units that are under investigation. There is a lot of technology. The problem is that when you have new technology it has to be paid for.
Dr. Cheng: There is also the question of where the vision screening should be done. It’s not just having the availability of the machines and the manpower, it’s a matter of how do we get access to all of the kids?
If you mandate that children have to be immunized, or at least have a physical waiving immunization before they can enter school or nursery school or be eligible for an assistance program, that’s one way to get the patients to where the work needs to be done. Otherwise, where do you put the screener? If you put it in the school, we’re in the same problem as just having the nurse measure vision. Maybe it is more accurate, but it is late because the kids are 5 years old or more. Ideally, you want to do these screenings when the kids are 3 and 4.
Dr. Arnold: That is a great point. Where is it done? From a legislative standpoint, mandating pre-K screening is one of the few places where the legislature has some impact over parents, because parents want to enroll their kids in school. That actually coincides with the American Academy of Pediatrics guidelines, which call for an acuity test at about 4 years of age.
It may be important to catch a certain number of strabismic and refractive problems quite a bit earlier, as early as 2 years old, to prevent amblyopia. In general, legislation has very little clout over 2-year-olds. Parents pretty much have the care of their own 2-year-olds in mind.
On the other hand, reimbursement for performing screening in conjunction with immunization could be used by HMOs or insurance companies to encourage some form of objective testing in kids younger than 2. I believe one of the last immunization points is 18 months, and then there is another one at age 3. If pediatricians got reimbursed for a vision screening at the 18-month immunization, I think we’d find technology rapidly moving to catch up with that.
It is our goal on the Vision Screening Committee to at least keep up with the standard of patch acuity in pre-K, but to also open the door to any objective technology that’s available now, including VEPs, photoscreening, wavefront, birefringent testing or something new to either equal or exceed what we can do with acuity testing, check for cost-effectiveness and validity, and allow that technology to compete for the same reimbursement for pre-K screening.
Dr. Wagner: There was recent legislation passed in Massachusetts mandating pre-K screening. It will be interesting to see, when this program has been in place for a while, who is doing the screening — whether it will be ophthalmologists, screening organizations or pediatricians. From looking at that data we’ll be able to say.
Dr. Cheng: We haven’t talked about lay screening organizations and volunteer services. In Pittsburgh we’re lucky in that the local blind association has a large task force of volunteer screeners that are trained in an afternoon or a one-day training session. They go out into the preschools and do visual acuity screening on all the kids. Now this misses obviously the kids who aren’t enrolled in preschool; however, they screen thousands of children every year and they do a spectacular job of it very accurately. So it’s a force not to be forgotten about in the overall equation.
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Treatment trends in amblyopia
Dr. Gold: We’re going to segue into one of the reasons vision screening is such a big topic, and that is amblyopia. We have in the past couple of years in this round table talked about patching vs. atropine, the timing of treatment and how much time patching is done. Some of the more recent studies that have come up have to do with weekend atropine and experience with older children.
Image: Stiglich JM, OSN |
I’d like to have the members of the panel discuss current trends. Are you doing things differently than you were 5 years ago? Are you doing things the same? What are you finding in your practice?
Dr. Johnson: In my practice I haven’t done any more with atropine as a primary method of treating amblyopia, but I have had success with treating some older patients, between 10 and 12, that haven’t been treated before, based upon some of the recent pediatric studies. I simply present it to the moms that, “It may be too late to do anything, but this is an opportunity. Even if we don’t see any improvement, at least we’ll know that we’ve done everything we can do.” I’ve seen some fairly surprising results.
I think the question that the study still has to bear out in terms of the future is at what point is it too late to do anything? And as long as you can improve vision, it appears to me at least intuitively that you can also lose vision at the same age.
Patching
Dr. Gold: Please comment on this scenario. A 10-year-old child presents to you for the first time. He has never been examined before, has 20/20 vision in one eye and 20/100 vision in the other eye, has no significant refractive error or anisometropia that needs to be corrected. Let’s say that the patient has a microstrabismus. Otherwise, the eye exam is normal. What do you tell the mother or father? What is your treatment? How long do you treat? When do you see them back?
Dr. Johnson: I would say to that patient’s parents that, based on previously accepted parameters, it may be too late to do anything, but we don’t know that, and recently that’s come into question. I would propose patching 6 hours a day and checking again in 6 weeks. If we’ve made headway, we’ll continue to patch and see how much headway we can make.
Dr. Warman: I would be much more aggressive on an orthophoric kid at age 10 presumably from anisometropia. There’s a much better chance of getting significant improvement with him than with a kid that has a micro-esotropia. The Phoenix Study is showing that it’s worthwhile. But my hopes won’t be that high if the child has not been fixing with that eye. The results will not be as satisfactory.
I would approach it differently than Tony. If I really want to try on an older child who I’m not sure we can help, I would try to convince them to go as many hours of possible, even for 2 weeks. I would probably ask them to wait for a vacation time. If the parents will have vacation for all of the 2 weeks, I tell them, “Let’s partner on this and really work at it. I don’t want you patching for 3 months. I want to know if it’s really worth doing.”
If there is going to be a change, we’ll see a little bit of a change rapidly because the curve is steep at the beginning. But it’s still a small difference.
Dr. Olitsky: This is a patient I would treat today, and I would have treated 5 years ago. I’m not sure when we got into the mindset that you can’t make the older children better. There is at least anecdotal evidence that the plasticity is still there for many years after age 9.
I would have a difficult time telling that family, “If you were here last year I would have treated you had somebody caught this earlier, but since nobody did, now your child is going to be blind.”
So I would always treat that child, and I would say exactly what Roberto said. I’d patch this child very hard. I’d patch them all day, and I would have them back in weeks or a month, mostly to demonstrate to the parents that this is going to get better. Although it’s difficult for the child in fifth or sixth grade, if there is a sign it’s going to get better, that encourages them to keep going.
Dr. Wagner: I agree with Scott and Roberto. In addition to showing them that it can work, we can also show them in a short period of time that maybe it’s not going to work. The parents sometimes need to see that this treatment is not going to work, despite their best efforts. They’ll feel better about having taken that shot. Frequent patching over a short period of time will help make a decision if they can see there is going to be improvement.
Dr. Cheng: There is one pearl that I’ll try on these kids, especially if they have particularly bad vision and the eyes are straight. I’ll have them put a patch on and just go away for an hour. They come back and we measure the vision again, and often the vision is one or two lines better than the earlier vision.
That may save the child a few months of patching later on. If you skip that little step, and they come back in a week or 2 weeks after having worn that patch for 6 hours a day, they may say, “Wow! We improved from 20/200 to 20/80. Let’s keep on going with another 3 months of patching.” But if they had left and come back in 2 hours, they might have gotten that 20/80 right away. I’ve seen that.
We can’t minimize how miserable we make kids by making them wear a patch.
Dr. Sondhi: That’s a point I wanted to make. If the parents are in agreement that a trial patching is required, how do we go about implementing that at the age of 10, where you have such social pressures? I find it difficult to convince a 10-year-old to wear a patch at school. I will try, and I will talk to them, but true compliance is a problem.
I settle for as many hours as possible. I increase it over the weekend, have them use it for all after-school hours and so forth. I bring them back in 6 to 8 weeks. If there is no improvement I discontinue the patching at that time.
Atropine
Dr. Gold: Let’s talk about atropine. One of the recent studies published by the Pediatric Eye Disease Investigator Group found weekend atropine to be as effective as daily administration. Is anyone implementing that technique, or are you continuing to use atropine daily?
Dr. Warman: I used atropine for years before these studies, but I always used it Mondays, Wednesdays and Fridays. I don’t think it makes a big difference. Atropine lasts quite a while. I don’t think you need it daily. Whether you want to put it all into a weekend or spread it out a couple of days a week, that’s just a little reinforcement. The point is, it’s true: You don’t need it daily.
Dr. Sondhi: I use it either on the every-day or the every-other-day regimen. I personally do not use the weekend-only schedule.
Image: Stiglich JM, OSN |
Dr. Cheng: I’m old-school, and I still patch. I know it works, and my rationale is that the bulk of these kids are in school to learn how to read. They are young, they are 6 years old, and if I’m forcing them to read at school with the eye they can’t see out of, they won’t like reading. To me that makes sense, so I still patch.
I’ve offered atropine to a few, and I’ve got a few patients running around on it. Is anybody else here still from the old school, where you don’t use much atropine?
Dr. Wagner: I prefer to patch, and I think many people do. If you look at the PEDIG data, in a lot of the studies with the atropine, it works best in the range of amblyopia 20/80.
You can treat them a number of ways. Still, for the kids who are 20/100 and 4 years old, it comes down to compliance in most cases, whether it be patching or using atropine. In most cases I’d prefer to start with patching. If they tolerate it, I like the patching better.
Dr. Sondhi: I’m going to play devil’s advocate here. Take the scenario that you just mentioned. If the child is 20/100 and noncompliant to patching, the cause is often poor acuity in the bad eye. I have switched to putting those patients on atropine. I bring them up to a certain level and then put them back to the patch later. They will have to comply as long as the parents get the drop in most days.
Dr. Cheng: Except for the really bad ones who still fixate with their good eye, and the atropine doesn’t do anything.
Dr. Warman: I also try patching first. There’s the whole question of whether the parents understand what needs to be done and are willing to do it, and whether they have control over their child or not. There’s always that kid who’s really impossible with one technique. But when patching doesn’t work — when the months go by and they are up and down — that’s when the atropine is a good adjuvant.
Dr. Gold: In my office, when you have children noncompliant with patching, often the parents come in with articles from the Internet about alternatives to patching, including atropine. So you have to be able to discuss intelligently with the parents the options and your preferences for how to treat their child.
Dr. Olitsky: I totally agree it has to be brought up. I bring it up preemptively. In my practice I discuss atropine and patching. I’m sure that my personal bias comes out in that discussion, but most parents will end up choosing patching.
Many of the kids will say they prefer patching also. That’s 30 minutes after they just received their drop of cycloplegic, so they aren’t thrilled about the thought of getting a drop put in their eye each day.
Dr. Cheng: I have a comment about the PEDIG study that looked at duration of patching. It seemed that wearing the patch for more than 2 hours made no difference. I was shocked by that. In my clinical experience it makes a huge difference.
Dr. Olitsky: The studies looked at how many hours were prescribed. We don’t really know how much they were patching. My experience has been the same: More patching equals faster recovery.
Dr. Cheng: Has that article changed the way any of you practice?
Dr. Gold: It has changed the way I practice. Whether it’s right or wrong, on many patients now I initially prescribe 6 hours of patching a day and see that child back at 4, 6 or 8 weeks. But I tell them that if the vision has not significantly improved, the next step is full-time patching.
I also have done that with 2- to 6-hour patching. If it’s a mild amount of amblyopia, depending on the dynamic of the parents and the dynamic of the child, then sometimes I start them on 2 hours of patching and see them back in a number of weeks. I tell them that if it’s not better we’re going to increase the patching to 6 hours or 8 hours or full-time.
I have changed the way I do that for compliance reasons. But compliance is a tremendous issue. I think children and their parents do not comply a great deal of the time with patching therapy. If we’re prescribing full-time patching we’re probably getting half- or three-quarters-time patching.
Dr. Johnson: I was glad to see the results of that study. Over time I have gone from being an old-school, almost pilgrimish, full-time patcher to relenting somewhat on the aggressiveness of the patching. I have seen that some of these kids and parents will completely fall out of treatment because it is so frustrating. So I have evolved into less aggressive but very consistent patching, emphasizing the need to do some patching every single day. Based on my experience in the past 7 or 8 years, I’ve seen good results with that, and I’m glad to see that the strategy has been validated scientifically.
As for atropine, I’m like Ken. I cannot really embrace it. I present both sides, especially if I sense that the family is going to pursue it, as Scott mentioned earlier. This may be pilgrimish as well, but I feel like this weekend atropine is trying to make it easier, trying make us look like we’re more sensitive. Atropine does have a long duration of action, and as Roberto said alternate days is probably about the same as every day. But I think that’s still not as good as patching, not enough to be the gold standard, except on these moderate amblyopes that the studies have addressed. For severe cases, I think patching is still the way to go.