Round table: Glasses vs. patching in anisometropic amblyopia

In the second excerpt from a round table held during the AAPOS meeting, members of the OSN Pediatrics/Strabismus Section discuss treatments for amblyopia.

Robert S. Gold

Robert S. Gold, MD: Our second subject is patients with anisometropic amblyopia without strabismus and certain treatments of it.

Let’s say you see a first-time patient who is 9 years old, has never been treated before, has peaked on all his vision screen tests with the pediatrician and comes in with 20/200 vision in the right eye and 20/20 vision in the left eye with a +5 D refractive error in the right eye and a +0.5 D error in the left. How would you initially treat this patient?

Rudolph S. Wagner

Rudolph S. Wagner, MD: The patient is 9 years old, so that makes it a little more difficult because treatment may be less effective at this age. In a case like this, I would give him a pair of glasses with plano in one eye and +4.5 D in the other. If he has any binocularity, I would just try the glasses and see if he will wear them for 4 to 6 weeks, and then check his vision.

Of course, you could start patching right away, but if he is 9 years old, we are not going to miss much by waiting a few more weeks, so I would start with the glasses and see what kind of improvement I get. Even if I couldn’t demonstrate improvement immediately in the office with refraction, I would check him in about 6 weeks and see what is going on, and then make a decision at that point, treating the amblyopia with occlusion or atropine or whatever may be necessary.

Scott E. Olitsky

Scott E. Olitsky, MD: I think the question is whether to start patching or atropine or have him start by only wearing his glasses. I would discuss this with the parents and let them know what the chances are that the glasses alone may improve him. Even if you don’t think that you are going to hit the maximum improvement with the glasses, let’s say he improves to 20/60 and stops, patching him or using atropine at that point will be a little less onerous for him and for the family.

On the other hand, part of it might depend on the time of year as to what the family is going to be doing. If summer is coming up and the family does not want to have to deal with patching or drops over the summer, I might prescribe the glasses and see him in a few months. I think a lot of this is communication with the parents, and I guess there is no right or wrong answer as long as you are following this patient and treating him if he does not get better with glasses.

Kenneth P. Cheng

Kenneth P. Cheng, MD: I guess I am a little different. It would be almost inconceivable to me that the patient would improve entirely with just glasses. It is still worth doing some penalization treatment if he is 20/200. He might come back to 20/80 or 20/50 with just glasses, but he would still have amblyopia that I think I would want to treat. So I pretty much always provide the glasses as you have, and I always start off with penalization treatment.

Dr. Gold: Is that with patching or with atropine?

Dr. Cheng: I am more of a patcher than an atropine person, especially when you are already late out of the gate and we have a relatively dense amblyopia. At the 20/200 level, I am still not sure that the patient isn’t going to fixate with the good eye even under atropine duress. So one of the things that I will do, if the parents says to me, “There is just no way he is going to wear this patch,” and he seems like the kind of kid who just in no way is going to cooperate with it, while they are there on that first visit and they are cyclopleged, I will cover up the bad eye and pull out the near card and see how well he can see. And if he is truly blurred enough in that eye with the cycloplegia to the 20/200 level, then I think that the atropine would be a reasonable alternative for the patient. But if he is under the effects of 1% or 2% Cyclogyl in my office at 20/80 or worse with a near card, then I am not so sure that the atropine is going to work for that patient, and then I tell the parent that I strongly suggest the patching.

Dr. Olitsky: I used to start the same way because I felt just like you. I used to think that this child probably will not get completely better without something, but my thinking has changed that it might be a lot easier to penalize him or patch him at 20/60 than it will be at 20/200 initially, and that is why I have switched my treatment plan in some of these cases.

Dr. Gold: One of the other things that Rudy said before is that this is a 9-year-old boy that over 9 years this has happened, and so is another 4 to 6 weeks going to be such a critical time factor to not see what happens first with the glasses. I have a tendency to agree with that initially and then see where we are, and plant the seed that we may have to do something different in a 6-week period of time.

Dr. Cheng: I have no problem with that. I think I just developed a style in which I try to minimize the number of visits. But I can see your rationale if he is starting off not quite so bad. I have no idea whether I am right or wrong on this, but my gut instinct would be that if the patient is going to improve with glasses alone in 4 to 6 weeks, he would probably improve with the patch after just a couple of days or a week and then not mind the patch as terribly much.

Dr. Wagner: You may be able to improve his vision with a post-cycloplegic refraction. An improvement of a few lines would make you feel better. But you are right. If this is a pure 20/200 and no potential improvement you can see or demonstrate, he is probably not going to get better.

Dr. Gold: Let’s do two scenarios. The patient comes back 6 weeks later, still 20/200 in the amblyopic eye. Where do you go from here?

Dr. Olitsky: I would start full-time occlusion. I like full-time occlusion, especially in a child like this.

Dr. Gold: In a 9-year-old who has to go to school every day?

Dr. Olitsky: One option is to patch after school and on weekends. Although studies show that prescribing less patching has about the same endpoint, we do not really know how much the patients in these studies patched. I do think the studies have shown that patients who patched more each day got better faster.

Dr. Wagner: You would ideally like to patch as much as possible. You might be lucky if it is the time of year when school is out and you can get more hours of occlusion therapy. I would tell them to start with 4 hours after school, and then try to step it up on weekends to 8 hours daily.

Dr. Cheng: I would agree. I do after school and on weekends because I agree with Scott entirely. If you can get them to wear it at school all day long, they are going to maximize their chances for an improvement. But the flip side of the coin is that there is just going to be such a tremendous resistance that you may lose the after school hours, too.

Dr. Gold: Which brings me to my next question — would anyone in this scenario use atropine at this point?

Dr. Olitsky: Not as my primary treatment.

Dr. Wagner: No.

Dr. Cheng: No.

Dr. Gold: When would you, or would you at all? Ken, I will ask you first. In this scenario, the patient came back after 6 weeks 20/200. He went home, he said he patched, he came back another 6 weeks later and it is the same.

Dr. Cheng: Again, unless I can determine that he is going to switch fixation and fixate with the good eye, I don’t think it is going to work. And if he has patched, I don’t think the atropine is going to do any more.

Dr. Gold: Rudy?

Dr. Wagner: Yes, I agree. I think if he did wear the patch, I don’t think the atropine is going to work.

Dr. Gold: Scott?

Dr. Olitsky: I also agree. I think you have to find out if he has been patching. Sometimes when you ask the parents in a way that they don’t have to be defensive, you find out maybe they were not patching quite as much as they initially said.

Dr. Gold: In the next scenario, the patient comes back 6 weeks later after wearing glasses and is now 20/70 in that amblyopic eye, so definitely better. What is your next step?

Dr. Cheng: I would say, “I’d really like you to wear a patch.”

Dr. Gold: So you would patch. And how much would you patch?

Dr. Cheng: I would patch the patient 3 or 4 hours a day after school.

Dr. Gold: Rudy?

Dr. Wagner: Same for me.

Dr. Gold: Scott?

Dr. Olitsky: I would give the parents the option of full-time occlusion or atropine.

Dr. Gold: The point of me asking this is, in a talk at the AAPOS meeting today, they talked a lot about atropine, and I think that at least the four of us who are sitting around this table reserve atropine for times of what we would consider to be either failed or noncompliant patching patients in the proper situation.

Dr. Olitsky: I would say, my change in this case was because of the vision. In the appropriate group of vision range, I offer parents both options. If they ask me which I would prefer, I would probably say I like patching. I think it works faster, but both should hopefully get to the same endpoint.

Dr. Gold: Rudy?

Dr. Wagner: Yes, I agree. I think one of the things that I saw in the study presented today is that the atropine therapy worked much better in the 3- to 6-year-old age group vs. the 7- to 12-year-old group.

Dr. Cheng: Let me ask a question. Again, I do not have much experience with this because I don’t use that much atropine, but of your patients using atropine, have you had anyone note that the children just don’t do well with reading at school, or have any parents complained to you that it seems like the children are having more trouble?

Dr. Gold: I can answer that question. Because I live in Florida, if there is one scenario with atropine, it is light sensitivity. We have them wear UV protection. I have to give notes sometimes when kids are going to school saying they are allowed to wear sunglasses at recess outside. So if there is anything that I have found, that has been the biggest side effect. Rudy?

Dr. Wagner: I see the same problem – glare. Children complain about light sensitivity. I don’t know that I have many kids that I have used it on that have been older than 5 or in the kindergarten age group, where they would be symptomatic from the blur and glare that atropine produces.

Dr. Gold: Scott?

Dr. Olitsky: I have heard some complaints, but then again, I also patch during school hours, so I hear complaints about that. I am not sure that there is any significant difference.

• Kenneth P. Cheng, MD, can be reached at 1000 Stonewood Drive, Suite 310, Wexford, PA 15090; 724-934-3333; e-mail: kpc123@verizon.net.
• 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.
• Scott E. Olitsky, MD, can be reached at Children’s Mercy Hospital, 2401 Gillham Road, Kansas City, MO 64108; 816-234-3000; fax; 816-346-1375; e-mail: seolitsky@cmh.edu.
• Rudolph S. Wagner, MD, can be reached at Children’s Eye Care Center, 1 Clara Maass Drive, Belleville, NJ 07109; 973-751-1702; fax: 908-665-8482; e-mail: wagdoc@comcast.net.