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Preferences for treating amblyopia pit patching against glasses alone and atropine penalization
Round table participants also share their thoughts on how they use atropine penalization.
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At the annual American Association for Pediatric Ophthalmology and Strabismus meeting in New Orleans, OSN Pediatrics/Strabismus Section Editor Robert S. Gold, MD, led a round table discussion on preferences for treating amblyopia. Panelists revealed their rationale and biases for treating with glasses only, patching and atropine penalization.
Compliance with patching
Robert S. Gold, MD: The question has to do with amblyopia treatment. When do you start amblyopia treatment with glasses only?
Roberto Warman, MD: It has to do with how much time we have. The younger the child, the better it is to start with glasses and then revisit a few months later. You still have time to add your patching or your penalization with drops. But if I get a 5.5-year-old or a 6-year-old and he is already 20/60 in that eye, I feel I do not have the luxury of time, so I do both. I start the glasses and one or another type of penalization. But there is no question that if you have time, glasses alone solve a lot of the cases.
Anthony P. Johnson, MD: I am assuming you are talking about anisometropic amblyopia for high refractive error. As soon as you recognize it, that is the time to address it. I agree with Roberto: The younger they are, certainly you need to correct the anisometropia initially. I have seen some 2- and 3-year-olds respond surprisingly well. But most of the time they do require some sort of penalization to really get it equal. I do not have any problems with just starting them in glasses at first. But if it is obvious that there is a strong fixation preference difference and they are not able to read the chart, then I am always quick to start penalization along with the glasses.
Scott E. Olitsky, MD: This is something I have changed doing. When I trained, I was taught that it was worthless to just give somebody a pair of glasses without starting to patch as well. I know that is not true in many cases, so I discuss both with the parents. For those patients who do not have very dense amblyopia, the majority of them could just start with glasses. At one point, my thinking was that most of these patients were going to require treatment anyway, but I came to the realization that it would be a lot easier to start that penalization or patching if their vision had improved several lines. So I offer that option to parents of children who do not have very dense amblyopia, and virtually all of them choose to start glasses first.
Roundtable Participants
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Moderator
- Robert S. Gold
- Kenneth P. Cheng
- Anthony P. Johnson
- Scott E. Olitsky
- Roberto Warman
- M. Edward Wilson
Gold: After 28 years of practice, I have come full circle also. The No. 1 noncompliant situation in probably every pediatric ophthalmologist’s office is compliance with patching, at least in my population. More often now, similar to what Scott said, depending on how dense the amblyopia is, I start these children in glasses and bring them back in a couple of months to see how they are doing. If the amblyopia is more dense, I will do both. But it seems to me that parents are much more amenable to one treatment vs. two treatments at the same time.
I am adapting to my population, and I will try glasses first for a shorter period of time, 2 or 3 months depending on age, while preparing the parents for the next step, which will probably be to add patching.
Kenneth P. Cheng, MD: I would agree with basically everything that has been said. If it is only a line of difference in vision, then I certainly have no problem with the parent just starting glasses alone, although I typically tell the parent to start patching, too. I tell them that the glasses are the most important thing, and I will have them do a minimum amount of patching if there is only a small difference in vision.
If there is a larger difference in vision or if you cannot measure visual acuity or there is a strong fixation preference, then I tell them the patching is also very important. The glasses are No. 1 most important, but the patching is equally important. You have to do both. At least in my experience, the glasses alone are not going to be enough for the patient who has a significant amblyopia, or at least you are not going to know that the glasses alone will be enough for quite a while. It can save a visit, and it saves time.
What really gets done, though, is self-selected by the parent and child. You can say whatever you want, but if the child is going to be noncompliant, he is going to be noncompliant. Or if the parents hate the idea of patching, they are just not going to try that hard.
M. Edward Wilson, MD: I do think the doctor’s attitude, what we pitch, is important. It does positively affect compliance. What we have learned from the PEDIG trials and our experience is that we should view glasses as an amblyopia treatment.
Cheng: I completely agree.
Wilson: I am not sure we did in the past. I tell the parents that, for anisometropia with straight eyes, the glasses are most important. They level the playing field. Now the images match. And I tell them that if you are a good glasses wearer, perhaps we will not have to go to stage 2 and do patching or atropine. So it motivates them to be a good glasses wearer. As long as they are improving with glasses alone, I stay with glasses alone. When they plateau, I add another treatment. That way I know which treatment to give credit to. If the child has dense amblyopia, I do not mind starting two things at the same time, but I would rather start one treatment at a time and see how far we can go with that treatment and then add to it. That just feels better to me.
Gold: I agree. You do not know which treatment is going to work. If you do both, is it the glasses that are working? Is it the patching that is working. Or is it both? That is why I tell the parents I am staging the treatment, and it has worked for me. I have only started doing this in the last couple of years; I used to be a much more aggressive patcher. It is amazing to me, whether it is the child or the parent, how many do not comply with patching. By staging, they are prepared for patching to start if the child does not see well at visit 2.
Olitsky: Two things come to mind. One is that we are recognizing that this is not necessarily about switching fixation; this is about binocularity. By putting them in the glasses, we may not need to force them to use that other eye. The other is the point about the two treatments becomes a bigger deal at the end. What is the chance that you need some maintenance patching? You know that it is zero if you never had to use any patching, so it answers that question for me by not throwing two things in at the same time.
Gold: We have known for a long time that glasses are treating the amblyopia, and it was thought probably years and years ago that we had to do more than one thing. We had to patch. We had to do glasses. But the PEDIG studies have shown us this, and it has been proven to us.
Cheng: The good thing is that you are reassured now that less patching is just as effective or almost as effective as patching for large percentages of the day. By patching for just a short hour or two, you will see a good effect from that.
Johnson: Bob, you mentioned that some of your practice pattern has changed just over the last few years. What I now spend more time doing is cheerleading for the mom. I try to be her cheerleader because we cannot lose the mom on this. When I see on the chart, “Not successful with patching,” I have finally realized that I need to spend most of my time encouraging her and telling her, “I know it’s hard. I know that your child is not going to thank you until he or she is 25 years old and they have their own child with amblyopia.” At least the visit, instead of it seeming like I am fussing at the mom, which I probably did for 10 or 15 years, I feel that encouraging her actually bears more fruit.
Atropine penalization
Gold: We talked about atropine a little bit. What are your thought processes on atropine penalization? I have always felt atropine lasts too long. I am a little hesitant still, to this day, to use it, except in noncompliant patients. What are the concerns, problems and successes you have had with atropine in your practices?
Warman: I have always been a strong advocate of atropine penalization way before PEDIG, and I still use it a lot. I think when you are really worried and you are running out of time, it is more important to start with the patching in severe amblyopia. But in general, if you are dealing with mostly reasonable people, atropine is safe even if it is long-lasting.
Wilson: I use atropine a lot. Probably most often I use it as a reward for good patching. So if they patch and make progress and the vision is better, but they are fatigued, I say, “You’ve done a great job. Let’s graduate you to a different treatment,” and maybe I will use weekend atropine or something like that. I am not so concerned about how long it lasts. I have to explain to the mom that while the dilation lasts a long time, the cycloplegia only lasts 24 hours or so, and so we need to apply it at the frequency that we have recommended.
It is also nice in educated parents to explain the differences and let them choose. There are pros and cons to each treatment. You can patch 2 hours a day maybe with a video game or you can use atropine, which does not have skin problems and does not require a daily watch of the clock. Sometimes the parent has a strong choice of one or the other. Sometimes the child helps make the choice. But I tell them, “One of the two has to be done, and it has to be done well.” And if one is not working, I switch to the other. It is nice to have the two options. They are very different.
Johnson: I know I am an outlier among all pediatric ophthalmologists. I still have not accepted that it is equivalent. I know the PEDIG study says that it is not shown to be statistically inferior, but statistics are tricky. I have never, ever started anybody on atropine. I have had people move into the community, and if they are doing well and they are happy with it, I have not stopped them. But I will tell the mom, if she asks me about it, that there are potential side effects, although they are more theoretical unless you just poison someone with atropine. And I will say that it appears that nothing is better than patching, and if patching is a total disaster, then there is no doubt that atropine is better than nothing at all.
The other thing that I think about is that we are trying to promote binocularity. If it is daily atropine and there is a 24-hour lasting effect of the cycloplegia, especially in a child who is learning to read — say 5, 6 or 7 years old — and they are not able to see what they are trying to do with their better eye, it seems like that would be a very detrimental thing, although I have never heard anybody who is a strong atropine user say they have ever had that experience. With a patch, you either have it on or you have it off. It is all or nothing.
Cheng: What do you try if they fail? Despite your cheerleading, what if they fail the patching?
Johnson: I tell them, “I’m not going to quit before you do. We’ve got to do something by whatever method it takes.”
Gold: I rarely have to use atropine. I maybe prescribe atropine a dozen times in a year. Parents do not want to put medicine in their children’s eyes, and the kids do not want to have eye drops put in their eyes. That really is a penalty. In the great majority of patients and parents, that motivates them to succeed. Now, not all of them succeed, and that is when I would go to atropine.
Olitsky: Listening to how different parents react has changed this quite a bit for me from primarily being a patcher. Parents in different communities are not all that much different; it is our bias that comes through, regardless of how we try to explain it to them. With this specific issue, I try to remain bias-free. I look at our job as educating the parent because they all can get on the Internet and read about it. So I try to help them interpret what they read and give them both options so they can choose. I do not tell them one is necessarily better than the other unless it is severe amblyopia. The vast majority pick atropine. Very few — an occasional parent — will say, “I don’t want to put medication in my child’s eye.”
Gold: That is interesting.
Olitsky: Ninety-plus percent choose atropine in that situation. And I like patching.
Wilson: I have a lot of parents who choose it, too. And it is an alternative. I still like patching better, especially if I can get the parent to buy a new video game and only introduce that video game when the patch is on, things where they are on a schedule. But parents often choose the atropine, and not offering atropine would be like saying, “The finish line is a mile away, and you have to run.” Well, you can walk, and you will still get to the finish line. The point is to get to the finish line, and we have several options. Whatever option will get that child to the finish line with the highest percentage, that is what we should do.
Cheng: What Tony said is exactly why I give parents both options, but I display a bias, very much so toward patching, because you have a young child who is just starting to learn to read and you are forcing them to read with their nondominant eye that does not see as well. I don’t know whether that might lead that child to show a little bit less interest in reading. To me that is a big deal that I cannot prove. It is not just that the eye does not see well, but it is the nondominant eye. If you cover your dominant eye to try to read something, it is just not as comfortable. Add on top of that the fact that you have never used that eye before and do not see as well out of that eye — to me, that is a big deal. So I tend to tell them that I like to have them patch after school.
Wilson: Use weekend atropine and see what happens.
Johnson: These are some great points, and I am going to soften my approach. Ed’s analogy of the finish line means we at least have to empower them with something. In my practice, demographically there are different subpopulations. There is the population that is educated and too busy, and it just never happens. And they are the ones who I think would be more likely to do it, unless they say they do not want to put drops in their child’s eye, which sounds like, from Scott’s experience, rarely happens.
The population I really have trouble with are the less educated, less motivated, who are struggling with all different sorts of social situations. The child is spending every other weekend with another parent, or there is undermining going on anyway. That makes me wonder if they could really be consistent with medication that can have some toxic effects. I still have to maybe take that into consideration.
Warman: I think precisely the opposite. I think that the ideal family for using atropine, and I see this a lot, is the divorced parents because usually one of the two believes in the treatment and the other one tends not to. If you can get the drop in once or twice a week, whenever, and the drop is lasting to a certain degree, at least you are getting that. For that family in particular, I think the atropine penalization is a big plus.
- For more information:
- Kenneth P. Cheng, MD, can be reached at 100 Bradford Road, Suite 320, Wexford, PA 15090; email: kpchengmd@me.com.
- Robert S. Gold, MD, can be reached at 790 Concourse Parkway South, Suite 200, Maitland, FL 32751; email: rsgeye@gmail.com.
- Anthony P. Johnson, MD, can be reached at Jervey Eye Group, 601 Halton Road, Greenville, SC 29607; email: apj@jervey.com.
- Scott E. Olitsky, MD, can be reached at Children’s Mercy Hospitals and Clinics, 2401 Gillham Road, Kansas City, MO 64108; email: seolitsky@cmh.edu.
- Roberto Warman, MD, can be reached at Miami Children’s Hospital, 3200 SW 60th Court, Suite 103, Miami, FL 33155; email: rwarman@eyes4kids.com.
- M. Edward Wilson, MD, can be reached at Albert Florens Storm Eye Institute, 167 Ashley Ave., Charleston, SC 29425; email: wilsonme@musc.edu.
Disclosure: The round table participants report no relevant financial disclosures.