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Wu G, Lee DA, Zhao W, Wong A, Jhangiani R, Kurniawan S. ChatGPT and Google Assistant as a Source of Patient Education for Patients With Amblyopia: Content Analysis. J Med Internet Res 2024; 26:e52401. [PMID: 39146013 PMCID: PMC11362700 DOI: 10.2196/52401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Revised: 04/24/2024] [Accepted: 04/30/2024] [Indexed: 08/16/2024] Open
Abstract
BACKGROUND We queried ChatGPT (OpenAI) and Google Assistant about amblyopia and compared their answers with the keywords found on the American Association for Pediatric Ophthalmology and Strabismus (AAPOS) website, specifically the section on amblyopia. Out of the 26 keywords chosen from the website, ChatGPT included 11 (42%) in its responses, while Google included 8 (31%). OBJECTIVE Our study investigated the adherence of ChatGPT-3.5 and Google Assistant to the guidelines of the AAPOS for patient education on amblyopia. METHODS ChatGPT-3.5 was used. The four questions taken from the AAPOS website, specifically its glossary section for amblyopia, are as follows: (1) What is amblyopia? (2) What causes amblyopia? (3) How is amblyopia treated? (4) What happens if amblyopia is untreated? Approved and selected by ophthalmologists (GW and DL), the keywords from AAPOS were words or phrases that deemed significant for the education of patients with amblyopia. The "Flesch-Kincaid Grade Level" formula, approved by the US Department of Education, was used to evaluate the reading comprehension level for the responses from ChatGPT, Google Assistant, and AAPOS. RESULTS In their responses, ChatGPT did not mention the term "ophthalmologist," whereas Google Assistant and AAPOS both mentioned the term once and twice, respectively. ChatGPT did, however, use the term "eye doctors" once. According to the Flesch-Kincaid test, the average reading level of AAPOS was 11.4 (SD 2.1; the lowest level) while that of Google was 13.1 (SD 4.8; the highest required reading level), also showing the greatest variation in grade level in its responses. ChatGPT's answers, on average, scored 12.4 (SD 1.1) grade level. They were all similar in terms of difficulty level in reading. For the keywords, out of the 4 responses, ChatGPT used 42% (11/26) of the keywords, whereas Google Assistant used 31% (8/26). CONCLUSIONS ChatGPT trains on texts and phrases and generates new sentences, while Google Assistant automatically copies website links. As ophthalmologists, we should consider including "see an ophthalmologist" on our websites and journals. While ChatGPT is here to stay, we, as physicians, need to monitor its answers.
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Affiliation(s)
- Gloria Wu
- University of California, San Francisco School of Medicine, San Francisco, CA, United States
| | - David A Lee
- McGovern Medical School, University of Texas Health Science Center at Houston, Houston, CA, United States
| | - Weichen Zhao
- College of Biological Sciences, University of California, Davis, Davis, CA, United States
| | - Adrial Wong
- College of Biological Sciences, University of California, Davis, Davis, CA, United States
| | - Rohan Jhangiani
- Department of Computational Media, University of California, Santa Cruz, Santa Cruz, CA, United States
| | - Sri Kurniawan
- Department of Computational Media, University of California, Santa Cruz, Santa Cruz, CA, United States
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Kaur S, Sharda S, Aggarwal H, Dadeya S. Comprehensive review of amblyopia: Types and management. Indian J Ophthalmol 2023; 71:2677-2686. [PMID: 37417105 PMCID: PMC10491072 DOI: 10.4103/ijo.ijo_338_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Revised: 03/23/2023] [Accepted: 03/28/2023] [Indexed: 07/08/2023] Open
Abstract
The optimal method of treatment for a child depends on the patient's age at the time of diagnosis, the onset and type of amblyopia, and the degree of compliance attainable. In deprivation amblyopia, the cause of visual impairment (e.g., cataract, ptosis) needs to be treated first, and then the disorder can be treated such as other types of amblyopia. Anisometropic amblyopia needs glasses first. In strabismic amblyopia, conventionally amblyopia should be treated first, and then strabismus corrected. Correction of strabismus will have little if any effect on the amblyopia, although the timing of surgery is controversial. Best outcomes are achieved if amblyopia is treated before the age of 7 years. The earlier the treatment, the more efficacious it is. In selected cases of bilateral amblyopia, the more defective eye must be given a competitive advantage over the comparatively good eye. Glasses alone can work when a refractive component is present, but occlusion might make the glasses work faster. The gold standard therapy for amblyopia remains occlusion of the better eye although penalization is also evidenced to achieve equal results. Pharmacotherapy has been shown to achieve suboptimal outcomes. Newer monocular and binocular therapies based on neural tasks and games are adjuncts to patching and can also be used in adults.
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Affiliation(s)
- Savleen Kaur
- Advanced Eye Centre, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Shipra Sharda
- Guru Nanak Eye Centre, Maulana Azad Medical College, New Delhi, India
| | | | - Subhash Dadeya
- Guru Nanak Eye Centre, Maulana Azad Medical College, New Delhi, India
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Wang S, Wen W, Zhu W, Liu Y, Zou L, Tian T, Lin J, Liu R, Liu H. Effect of Combined Atropine and Patching vs Patching Alone for Treatment of Severe Amblyopia in Children Aged 3 to 12 Years: A Randomized Clinical Trial. JAMA Ophthalmol 2021; 139:990-996. [PMID: 34264296 DOI: 10.1001/jamaophthalmol.2021.2413] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Importance Patching is often less effective for severe amblyopia because of poor adherence. For the treatment of severe amblyopia, although combined atropine and patching therapy (CAPT) has been found to be efficacious, it is currently unknown whether CAPT is more efficacious than patching alone. Objective To compare the efficacy of CAPT vs patching alone in children aged 3 to 12 years with severe amblyopia. Design, Setting, and Participants This single-center randomized clinical trial was conducted from November 2018 to May 2020. The visual acuity (VA) examiner was masked to the treatment groups. The follow-up visits were at 3 months and 6 months. Participants aged 3 to 12 years with severe amblyopia (20/100 to 20/500) resulting from strabismus, anisometropia, or both were randomly assigned to CAPT or patching therapy. Interventions CAPT or patching alone for 6 months. Main Outcomes and Measures Change of the amblyopic eye VA from baseline to 6 months. Results Among 108 participants, the mean (SD) age was 5.2 (1.8) years, and 54 (50%) were female. Overall, 53 participants (49%) were randomized to CAPT and 55 (51%) were randomized to patching therapy. At baseline, the mean (SD) amblyopic eye VA was 0.95 (0.22) logMAR (approximately 20/200 [2.2 lines]). At 6 months, the CAPT group's mean improvement in amblyopic eye VA was 0.72 logMAR (7.2 lines) compared with 0.58 logMAR (5.8 lines) in the patching alone group (difference, 0.14 logMAR [1.4 lines] greater in the CAPT group; 95% CI, 0.05-0.22 logMAR [0.5-2.2 lines]; P = .002). The amblyopic eye VA improvement in the CAPT group also was greater than that in the patching alone group at 3 months (difference in the means, 0.13 logMAR [1.3 lines]; 95% CI, 0.04-0.22 logMAR [0.4-2.2 lines]; P = .004). No participants were withdrawn because of adverse effects. Conclusions and Relevance CAPT resulted in more mean improvement of amblyopic eye VA than patching alone among participants enrolled in this trial, although the clinical relevance of this relatively small VA difference cannot be determined from this trial. Trial Registration Chinese Clinical Trial Registry Identifier: ChiCTR1800018663.
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Affiliation(s)
- Shu Wang
- Eye Institute, Department of Ophthalmology, Eye & ENT Hospital, Fudan University, Shanghai, China.,NHC Key Laboratory of Myopia (Fudan University), Shanghai, China.,Shanghai Key Laboratory of Visual Impairment and Restoration, Shanghai, China
| | - Wen Wen
- Eye Institute, Department of Ophthalmology, Eye & ENT Hospital, Fudan University, Shanghai, China.,NHC Key Laboratory of Myopia (Fudan University), Shanghai, China.,Shanghai Key Laboratory of Visual Impairment and Restoration, Shanghai, China
| | - Wenqing Zhu
- Eye Institute, Department of Ophthalmology, Eye & ENT Hospital, Fudan University, Shanghai, China.,NHC Key Laboratory of Myopia (Fudan University), Shanghai, China.,Shanghai Key Laboratory of Visual Impairment and Restoration, Shanghai, China
| | - Yan Liu
- Eye Institute, Department of Ophthalmology, Eye & ENT Hospital, Fudan University, Shanghai, China.,NHC Key Laboratory of Myopia (Fudan University), Shanghai, China.,Shanghai Key Laboratory of Visual Impairment and Restoration, Shanghai, China
| | - Leilei Zou
- Eye Institute, Department of Ophthalmology, Eye & ENT Hospital, Fudan University, Shanghai, China.,NHC Key Laboratory of Myopia (Fudan University), Shanghai, China.,Shanghai Key Laboratory of Visual Impairment and Restoration, Shanghai, China
| | - Tian Tian
- Eye Institute, Department of Ophthalmology, Eye & ENT Hospital, Fudan University, Shanghai, China.,NHC Key Laboratory of Myopia (Fudan University), Shanghai, China.,Shanghai Key Laboratory of Visual Impairment and Restoration, Shanghai, China
| | - Jing Lin
- Eye Institute, Department of Ophthalmology, Eye & ENT Hospital, Fudan University, Shanghai, China.,NHC Key Laboratory of Myopia (Fudan University), Shanghai, China.,Shanghai Key Laboratory of Visual Impairment and Restoration, Shanghai, China
| | - Rui Liu
- Eye Institute, Department of Ophthalmology, Eye & ENT Hospital, Fudan University, Shanghai, China.,NHC Key Laboratory of Myopia (Fudan University), Shanghai, China.,Shanghai Key Laboratory of Visual Impairment and Restoration, Shanghai, China
| | - Hong Liu
- Eye Institute, Department of Ophthalmology, Eye & ENT Hospital, Fudan University, Shanghai, China.,Department of Ophthalmology, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
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Amblyopia Outcomes Through Clinical Trials and Practice Measurement: Room for Improvement: The LXXVII Edward Jackson Memorial Lecture. Am J Ophthalmol 2020; 219:A1-A26. [PMID: 32777377 DOI: 10.1016/j.ajo.2020.07.053] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Accepted: 07/27/2020] [Indexed: 11/21/2022]
Abstract
PURPOSE To describe amblyopia prevalence and outcomes using results from randomized studies and a clinical registry. DESIGN Review of published studies, analysis of data in Intelligent Research in Sight (IRIS) Registry from 2013 to 2019, personal perspective. METHODS Literature review, analysis of IRIS Registry data and IRIS-50, a visual acuity quality measure. RESULTS Clinical trials have reduced the treatment burden of amblyopia by reducing hours of patching and frequency of atropine eye drops with clinical success of about 83%. There is no appreciable age effect if treatment is started before 5 years of age, outcomes are stable to at least 15 years of age, and treatment can be somewhat effective until 12 years of age. The IRIS Registry identified 1,760,066 individuals with amblyopia for a prevalence of 2.47%. Refractive error alone accounted for 68.9% of childhood cases. Mean amblyopic eye visual acuity improved 1.8 lines for children 3-6 years of age and 0.8 lines for 7-12 years, but mean residual amblyopia was more than 2 lines. Among 18,841 children aged 3-7 years eligible for IRIS-50, 77.3% were successful. The odds ratios for success were significantly lower for African-American (0.67; 95% confidence interval [CI] = 0.58 to 0.78) and Hispanic or Latino (0.84; 95% CI = 0.75 to 0.94) children compared with white children. CONCLUSIONS Clinical trials provided evidence of a beneficial effect from several treatments, with substantially reduced doses than previously recommended. Registry data from clinical practice found residual visual acuity impairment among all ages and races, especially among minorities.
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Milla M, Piñero DP. Characterization, passive and active treatment in strabismic amblyopia: a narrative review. Int J Ophthalmol 2020; 13:1132-1147. [PMID: 32685403 PMCID: PMC7321947 DOI: 10.18240/ijo.2020.07.18] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2019] [Accepted: 03/15/2020] [Indexed: 12/22/2022] Open
Abstract
Strabismic amblyopia is characterized by a distorted spatial perception. In this condition, the neurofunctional disorder occurring during first years of life provoke several monocular and binocular anomalies such as crowding, deficits in the accommodative response, contrast sensitivity, and ocular motility abilities. The inhibition of the binocular function of the brain by the misaligned amblyopic eye induces a binocular imbalance leading to interocular suppression and the reduction or lack of stereoacuity. Passive treatments such as occlusion, optical and/or pharmacological penalization, and Bangerter foils has been demonstrated to be potentially useful treatments for strabismic amblyopia. Recent researches have proved new pharmacological options to improve and maintain visual acuity after occlusion treatment in strabismic amblyopia. Likewise, the active vision therapy, in the last years, is becoming a very relevant therapeutic option in combination with passive treatments, especially during and after monocular therapy, in the attempt of recovering the imbalanced binocular vision.
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Affiliation(s)
- Myriam Milla
- Department of Optometry, OFTALVIST Alicante, Alicante 03016, Spain
- Group of Optics and Visual Perception, Department of Optics, Pharmacology and Anatomy, University of Alicante, San Vicente del Raspeig, Alicante 03690, Spain
| | - David P. Piñero
- Group of Optics and Visual Perception, Department of Optics, Pharmacology and Anatomy, University of Alicante, San Vicente del Raspeig, Alicante 03690, Spain
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Abstract
BACKGROUND Amblyopia is defined as impaired visual acuity in one or both eyes without demonstrable abnormality of the visual pathway, and is not immediately resolved by wearing glasses. OBJECTIVES In performing this systematic review, we aimed to synthesize the best available evidence regarding the effectiveness and safety of conventional occlusion therapy compared to atropine penalization in treating amblyopia. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (which contains the Cochrane Eyes and Vision Trials Register) (2018, Issue 8); Ovid MEDLINE; Ovid Embase; LILACS BIREME; ClinicalTrials.gov; ISRCTN; and the WHO ICTRP on 7 September 2018. SELECTION CRITERIA We included randomized/quasi-randomized controlled trials comparing conventional occlusion to atropine penalization for amblyopia. DATA COLLECTION AND ANALYSIS Two review authors independently screened abstracts and full-text articles, abstracted data, and assessed risk of bias. MAIN RESULTS We included seven trials (five randomized controlled trials and two quasi-randomized controlled trials) conducted in six countries (China, India, Iran, Ireland, Spain, and the United States) with a total of 1177 amblyopic eyes. Three of these seven trials were from the original 2009 version of the review. We assessed two trials as having a low risk of bias across all domains, and the remaining five trials as having unclear or high risk of bias for some domains.As different occlusion modalities, atropine penalization regimens, and populations were used across the included trials, we did not conduct any meta-analysis due to clinical and statistical heterogeneity. Evidence from six trials (two at low risk of bias) suggests that atropine penalization is as effective as conventional occlusion in improving visual acuity. Similar improvement in visual acuity was reported at all time points at which it was assessed, ranging from five weeks (improvement of 1 line) to 10 years (improvement of greater than 3 lines). At six months, although most participants (363/522) come from a trial rated as at low risk of bias with a precise estimate (mean difference (MD) 0.03, 95% confidence interval (CI) 0.00 to 0.06), two other trials rated as at high risk of bias produced inconsistent estimates and wide confidence intervals (MD -0.02, 95% CI -0.11 to 0.07 and MD -0.14, 95% CI -0.23 to -0.05; moderate-certainty evidence). At 24 months, additional improvement was found in both groups, but there continued to be no meaningful difference between those receiving occlusion and those receiving atropine therapies (moderate-certainty evidence).We did not find any difference in ocular alignment, stereo acuity, or sound eye visual acuity between occlusion and atropine penalization groups (moderate-certainty evidence). Both treatments were well tolerated. Atropine was associated with better adherence (moderate-certainty evidence) and quality of life (moderate-certainty evidence), but also a higher reported risk of adverse events in terms of mild reduction in the visual acuity of the sound eye not requiring treatment and light sensitivity (high-certainty evidence). Skin, lid, or conjunctival irritation were more common among participants receiving patching than those receiving atropine (high-certainty evidence). Atropine penalization costs less than conventional occlusion. AUTHORS' CONCLUSIONS Both conventional occlusion and atropine penalization produce visual acuity improvement in the amblyopic eye. Atropine penalization appears to be as effective as conventional occlusion, although the magnitude of improvement differed among the trials we analyzed.
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Affiliation(s)
- Tianjing Li
- Johns Hopkins Bloomberg School of Public HealthDepartment of Epidemiology615 North Wolfe Street, E6011BaltimoreMarylandUSA21205
| | - Riaz Qureshi
- Johns Hopkins Bloomberg School of Public HealthDepartment of Epidemiology615 North Wolfe Street, E6011BaltimoreMarylandUSA21205
| | - Kate Taylor
- Royal Victoria InfirmaryDepartment of OphthalmologyClaremont WingQueen Victoria RoadNewcastle upon TyneUKNE1 4LP
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The treatment of amblyopia: current practice and emerging trends. Graefes Arch Clin Exp Ophthalmol 2019; 257:1061-1078. [DOI: 10.1007/s00417-019-04254-w] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2018] [Revised: 12/22/2018] [Accepted: 01/17/2019] [Indexed: 02/04/2023] Open
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Mezad-Koursh D, Rosenblatt A, Newman H, Stolovitch C. Home use of binocular dichoptic video content device for treatment of amblyopia: a pilot study. J AAPOS 2018; 22:134-138.e4. [PMID: 29555515 DOI: 10.1016/j.jaapos.2017.12.012] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2017] [Revised: 10/09/2017] [Accepted: 12/11/2017] [Indexed: 11/24/2022]
Abstract
PURPOSE To evaluate the efficacy of the BinoVision home system as measured by improvement of visual acuity in the patient's amblyopic eye. METHODS An open-label prospective pilot-trial of the system was conducted with amblyopic children aged 4-8 years at the pediatric ophthalmology unit, Tel-Aviv Medical Center, January 2014 to October 2015. Participants were assigned to the study or sham group for treatment with BinoVision for 8 or 12 weeks. Patients were instructed to watch animated television shows and videos at home using the BinoVision device for 60 minutes, 6 days a week. The BinoVision program incorporates elements at different contrast and brightness levels for both eyes, weak eye tracking training by superimposed screen images, and weak eye flicker stimuli with alerting sound manipulations. Patients were examined at 4, 8, 12, 24, and 36 weeks. RESULTS A total of 27 children were recruited (14 boys), with 19 in the treatment group. Median age was 5 years (range, 4-8 years). Mean visual acuity improved by 0.26 logMAR lines in the treatment group from baseline to 12 weeks. Visual acuity was improved compared to baseline during all study and follow-up appointments (P < 0.01), with stabilization of visual acuity after cessation of treatment. The sham group completed 4 weeks of sham protocol with no change in visual acuity (P = 0.285). The average compliance rate was 88% ± 16% (50% to 100%) in treatment group. CONCLUSIONS This pilot trial of 12 weeks of amblyopia treatment with the BinoVision home system demonstrated significant improvement in patients' visual acuity.
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Affiliation(s)
- Daphna Mezad-Koursh
- Department of Ophthalmology, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - Amir Rosenblatt
- Department of Ophthalmology, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Hadas Newman
- Department of Ophthalmology, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Chaim Stolovitch
- Department of Ophthalmology, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Abstract
BACKGROUND Pediatric ophthalmologists are increasingly expected to promote, preserve, and restore binocular vision. METHODS Clinical studies on restoring alignment and stereopsis in the management of amblyopia, esotropia, exotropia, and complex strabismus are reviewed from the perspective of the author's published work and personal experiences. RESULTS Treatment of amblyopia by means of optical rehabilitation, occlusion, or penalization has been reinforced by medical treatment and perceptual training with monocular or binocular video games. Studies indicate that early management of esotropia and alignment within 8Δ is required for regaining stereopsis. In the surgical management of intermittent exotropia, distance stereopsis by Frisby Davis Distance stereotest can predict better stereopsis, with patients having preoperative distance stereopsis of <70 arcsec less likely to improve after surgery. The surgeon's armamentarium for correcting alignment and restoring binocular vision include procedures such as adjustable, partial vertical rectus muscle transposition in cases of exotropic Duane syndrome and lateral rectus palsy, periosteal fixation of the globe or of the lateral rectus muscle, and medial transposition of the split lateral rectus muscle. CONCLUSIONS The goal for present-day strabismologists is not merely to correct strabismus but also to achieve alignment of eyes in time to ensure normal development of stereopsis in children and to restore alignment and stereopsis in adults.
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Affiliation(s)
- Pradeep Sharma
- Pediatric Ophthalmology and Strabismus Services, Dr R P Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi.
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Seol BR, Yu YS, Kim SJ. Effect of 4-Month Intermittent Atropine Penalization in Amblyopic Children for Whom Patch Therapy Had Failed. J Pediatr Ophthalmol Strabismus 2017; 54:375-380. [PMID: 28678304 DOI: 10.3928/01913913-20170329-02] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2017] [Accepted: 03/23/2017] [Indexed: 11/20/2022]
Abstract
PURPOSE To evaluate the effect of 4-month intermittent atropine penalization in children with amblyopia for whom patch therapy had failed and to analyze the factors associated with treatment success. METHODS This retrospective observational study included participants who visited the hospital between January 1, 2011, and December 31, 2015. Forty-one children with amblyopia for whom patch therapy had failed were included and their medical records were analyzed retrospectively. They were treated with 1% atropine eye drops in the sound eye twice per week for 4 months. Treatment success was defined as a best corrected visual acuity (BCVA) improvement of two lines in the amblyopic eye. Age, cause of amblyopia, pretreatment BCVA at the start of atropine penalization in the amblyopic eye, age at the start of eyeglass prescription, age at the start of patch therapy, duration, compliance with and total amount of patch therapy, type of refraction, type of strabismus, and cause of failure of patch therapy were analyzed and compared between two groups: the failure and success groups. RESULTS Twenty of 41 patients (48.8%) showed treatment success. The mean age was 5.59 ± 1.52 years and the mean BCVA of the amblyopic eye was 0.40 ± 0.20 logarithm of the minimum angle of resolution (logMAR). Younger age and poor pretreatment BCVA at the start of atropine penalization in the amblyopic eye were the factors associated with treatment success. CONCLUSIONS Intermittent atropine penalization for 4 months can improve BCVA in children with amblyopia for whom patch therapy has failed. Atropine penalization can be especially effective in younger children and those with poor BCVA at the start of atropine penalization in the amblyopic eye. [J Pediatr Ophthalmol Strabismus. 2017;54(6):375-380.].
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Singh A, Nagpal R, Mittal SK, Bahuguna C, Kumar P. Pharmacological therapy for amblyopia. Taiwan J Ophthalmol 2017; 7:62-69. [PMID: 29018759 PMCID: PMC5602150 DOI: 10.4103/tjo.tjo_8_17] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Amblyopia is the most common cause of preventable blindness in children and young adults. Most of the amblyopic visual loss is reversible if detected and treated at appropriate time. It affects 1.0 to 5.0% of the general population. Various treatment modalities have been tried like refractive correction, patching (both full time and part time), penalization and pharmacological therapy. Refractive correction alone improves visual acuity in one third of patients with anisometropic amblyopia. Various drugs have also been tried of which carbidopa & levodopa have been popular. Most of these agents are still in experimental stage, though levodopa-carbidopa combination therapy has been widely studied in human amblyopes with good outcomes. Levodopa therapy may be considered in cases with residual amblyopia, although occlusion therapy remains the initial treatment choice. Regression of effect after stoppage of therapy remains a concern. Further studies are therefore needed to evaluate the full efficacy and side effect profile of these agents.
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Affiliation(s)
- Anupam Singh
- Department of Ophthalmology, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
| | - Ritu Nagpal
- Department of Ophthalmology, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
| | - Sanjeev Kumar Mittal
- Department of Ophthalmology, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
| | - Chirag Bahuguna
- Department of Ophthalmology, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
| | - Prashant Kumar
- Department of Ophthalmology, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
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Sale A, Berardi N. Active training for amblyopia in adult rodents. Front Behav Neurosci 2015; 9:281. [PMID: 26578911 PMCID: PMC4621305 DOI: 10.3389/fnbeh.2015.00281] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2015] [Accepted: 10/06/2015] [Indexed: 11/13/2022] Open
Abstract
Amblyopia is the most diffused form of visual function impairment affecting one eye, with a prevalence of 1–5% in the total world population. Amblyopia is usually caused by an early functional imbalance between the two eyes, deriving from anisometropia, strabismus, or congenital cataract, leading to severe deficits in visual acuity, contrast sensitivity and stereopsis. While amblyopia can be efficiently treated in children, it becomes irreversible in adults, as a result of a dramatic decline in visual cortex plasticity which occurs at the end of the critical period (CP) in the primary visual cortex. Notwithstanding this widely accepted dogma, recent evidence in animal models and in human patients have started to challenge this view, revealing a previously unsuspected possibility to enhance plasticity in the adult visual system and to achieve substantial visual function recovery. Among the new proposed intervention strategies, non invasive procedures based on environmental enrichment, physical exercise or visual perceptual learning (vPL) appear particularly promising in terms of future applicability in the clinical setting. In this survey, we will review recent literature concerning the application of these behavioral intervention strategies to the treatment of amblyopia, with a focus on possible underlying molecular and cellular mechanisms.
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Affiliation(s)
- Alessandro Sale
- Neuroscience Institute, National Research Council Pisa, Italy
| | - Nicoletta Berardi
- Neuroscience Institute, National Research Council Pisa, Italy ; Department of Neuroscience, Psychology, Drug Research and Child Health NEUROFARBA, University of Florence Florence, Italy
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Wallace DK, Lazar EL, Repka MX, Holmes JM, Kraker RT, Hoover DL, Weise KK, Waters AL, Rice ML, Peters RJ. A randomized trial of adding a plano lens to atropine for amblyopia. J AAPOS 2015; 19:42-8. [PMID: 25727586 PMCID: PMC4354879 DOI: 10.1016/j.jaapos.2014.10.022] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2014] [Revised: 10/10/2014] [Accepted: 10/14/2014] [Indexed: 11/30/2022]
Abstract
BACKGROUND Some children have residual amblyopia after treatment with atropine eyedrops for amblyopia due to strabismus and/or anisometropia. We conducted a randomized clinical trial to evaluate the effectiveness of augmenting the effect of atropine by changing the lens over the fellow eye to plano in children with residual amblyopia. METHODS A total of 73 children 3 to <8 years of age (mean, 5.8 years) with stable residual amblyopia (range, 20/32 to 20/160, mean 20/63(+1)) were enrolled after at least 12 weeks of atropine treatment of the fellow eye. Participants were randomly assigned to continuing weekend atropine alone or wearing a plano lens over the fellow eye (while continuing atropine). The primary outcome was assessed at 10 weeks, and participants were followed until improvement ceased. RESULTS At the 10-week primary outcome visit, amblyopic-eye visual acuity had improved an average of 1.1 lines with the plano lens and 0.6 lines with atropine only (difference adjusted for baseline visual acuity = + 0.5 line; 95% CI, -0.1 to +1.2). At the primary outcome or later visit when the best-measured visual acuity was observed, the mean amblyopic-eye improvement from baseline was 1.9 lines with the plano lens and 0.8 lines with atropine only. CONCLUSIONS When amblyopic-eye visual acuity stops improving with atropine treatment, there may be a small benefit to augmenting atropine therapy with a plano lens over the fellow eye. However, the effect was not statistically significant, and the large confidence interval raises the possibility of no benefit or a benefit larger than we observed. A larger study would be necessary to get a more precise estimate of the treatment effect.
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Kim MS, Kim WJ, Kim MM. A Case of Reverse Amblyopia of the Dominant Eye that was Refractory to Treatment. JOURNAL OF THE KOREAN OPHTHALMOLOGICAL SOCIETY 2015. [DOI: 10.3341/jkos.2015.56.2.304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- Min Seok Kim
- Department of Ophthalmology, Yeungnam University College of Medicine, Daegu, Korea
| | - Won Jae Kim
- Department of Ophthalmology, Yeungnam University College of Medicine, Daegu, Korea
| | - Myung Mi Kim
- Department of Ophthalmology, Yeungnam University College of Medicine, Daegu, Korea
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Piano M, O'Connor AR, Newsham D. Use of atropine penalization to treat amblyopia in UK orthoptic practice. J Pediatr Ophthalmol Strabismus 2014; 51:363-9. [PMID: 25427306 DOI: 10.3928/01913913-20141021-08] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2014] [Accepted: 09/03/2014] [Indexed: 11/20/2022]
Abstract
PURPOSE To compare clinical practice patterns regarding atropine penalization use by UK orthoptists to the current evidence base and identify any existing barriers against use of AP as first-line treatment. METHODS An online survey was designed to assess current practice patterns of UK orthoptists using atropine penalization. They were asked to identify issues limiting their use of atropine penalization and give opinions on its effectiveness compared to occlusion. Descriptive statistics and content analysis were applied to the results. RESULTS Responses were obtained from 151 orthoptists throughout the United Kingdom. The main perceived barriers to use of atropine penalization were inability to prescribe atropine and supply difficulties. However, respondents also did not consider atropine penalization as effective as occlusion in treating amblyopia, contrary to recent research findings. Patient selection criteria and treatment administration largely follow current evidence. More orthoptists use atropine penalization as first-line treatment than previously reported. CONCLUSIONS Practitioners tend to closely follow the current evidence base when using atropine penalization, but reluctance in offering it as first-line treatment or providing a choice for parents between occlusion and atropine still remains. This may result from concerns regarding atropine's general efficacy, side effects, and risk of reverse amblyopia. Alternatively, as demonstrated in other areas of medicine, it may reflect the inherent delay of research findings translating to clinical practice changes.
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Repka MX, Kraker RT, Holmes JM, Summers AI, Glaser SR, Barnhardt CN, Tien DR. Atropine vs patching for treatment of moderate amblyopia: follow-up at 15 years of age of a randomized clinical trial. JAMA Ophthalmol 2014; 132:799-805. [PMID: 24789375 DOI: 10.1001/jamaophthalmol.2014.392] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Initial treatment for amblyopia of the fellow eye with patching and atropine sulfate eyedrops improves visual acuity. Long-term data on the durability of treatment benefit are needed. OBJECTIVE To report visual acuity at 15 years of age among patients who were younger than 7 years when enrolled in a treatment trial for moderate amblyopia. DESIGN, SETTING, AND PARTICIPANTS In a multicenter clinical trial, 419 children with amblyopia (visual acuity, 20/40 to 20/100) were randomly assigned to patching (minimum of 6 h/d) or atropine sulfate eyedrops, 1% (1 drop daily), for 6 months. Treatment after 6 months was at the discretion of the investigator. Two years after enrollment, an unselected subgroup of 188 children were enrolled into long-term follow-up. INTERVENTION Initial treatment with patching or atropine with subsequent treatment at investigator discretion. MAIN OUTCOMES AND MEASURES Visual acuity at 15 years of age with the electronic Early Treatment Diabetic Retinopathy Study test in amblyopic and fellow eyes. RESULTS Mean visual acuity in the amblyopic eye measured in 147 participants at 15 years of age was 0.14 logMAR (approximately 20/25); 59.9% of amblyopic eyes had visual acuity of 20/25 or better and 33.3%, 20/20 or better. Mean interocular acuity difference (IOD) at 15 years of age was 0.21 logMAR (2.1 lines); 48.3% had an IOD of 2 or more lines and 71.4%, 1 or more lines. Treatment (other than spectacles) was prescribed for 9 participants (6.1%) aged 10 to 15 years. Mean IOD was similar at examinations at 10 and 15 years of age (2.0 and 2.1 logMAR lines, respectively; P = .39). Better visual acuity at the 15-year examination was achieved in those who were younger than 5 years at the time of entry into the randomized clinical trial (mean logMAR, 0.09) compared with those aged 5 to 6 years (mean logMAR, 0.18; P < .001). When we compared subgroups based on original treatment with atropine or patching, no significant differences were observed in visual acuity of amblyopic and fellow eyes at 15 years of age (P = .44 and P = .43, respectively). CONCLUSIONS AND RELEVANCE At 15 years of age, most children treated for moderate amblyopia when younger than 7 years have good visual acuity, although mild residual amblyopia is common. The outcome is similar regardless of initial treatment with atropine or patching. The results indicate that improvement occurring with amblyopia treatment is maintained until at least 15 years of age. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00000170.
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Affiliation(s)
- Michael X Repka
- Wilmer Ophthalmological Institute, The John Hopkins University, Baltimore, Maryland
| | - Raymond T Kraker
- Pediatric Eye Disease Investigator Group Coordinating Center, Jaeb Center for Health Research, Tampa, Florida
| | | | | | | | | | - David R Tien
- Pediatric Ophthalmology and Strabismus Associates, Providence, Rhode Island
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Bonaccorsi J, Berardi N, Sale A. Treatment of amblyopia in the adult: insights from a new rodent model of visual perceptual learning. Front Neural Circuits 2014; 8:82. [PMID: 25076874 PMCID: PMC4100600 DOI: 10.3389/fncir.2014.00082] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2014] [Accepted: 06/27/2014] [Indexed: 11/19/2022] Open
Abstract
Amblyopia is the most common form of impairment of visual function affecting one eye, with a prevalence of about 1–5% of the total world population. Amblyopia usually derives from conditions of early functional imbalance between the two eyes, owing to anisometropia, strabismus, or congenital cataract, and results in a pronounced reduction of visual acuity and severe deficits in contrast sensitivity and stereopsis. It is widely accepted that, due to a lack of sufficient plasticity in the adult brain, amblyopia becomes untreatable after the closure of the critical period in the primary visual cortex. However, recent results obtained both in animal models and in clinical trials have challenged this view, unmasking a previously unsuspected potential for promoting recovery even in adulthood. In this context, non invasive procedures based on visual perceptual learning, i.e., the improvement in visual performance on a variety of simple visual tasks following practice, emerge as particularly promising to rescue discrimination abilities in adult amblyopic subjects. This review will survey recent work regarding the impact of visual perceptual learning on amblyopia, with a special focus on a new experimental model of perceptual learning in the amblyopic rat.
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Affiliation(s)
- Joyce Bonaccorsi
- Department of Medicine, Institute of Neuroscience CNR, National Research Council (CNR) Pisa, Italy
| | - Nicoletta Berardi
- Department of Medicine, Institute of Neuroscience CNR, National Research Council (CNR) Pisa, Italy ; Department of Psychology, Florence University Florence, Italy
| | - Alessandro Sale
- Department of Medicine, Institute of Neuroscience CNR, National Research Council (CNR) Pisa, Italy
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Abstract
PURPOSE To investigate the safety and efficacy of the treatment of myopic anisometropia with 1% atropine. METHODS Twenty-two children with myopic anisometropia were prescribed 1% solution of atropine sulfate to the more myopic eye, one drop before sleep every 3 days. Children were visited every 3 to 4 months until the degree of anisometropia was no more than 0.5 diopters (D) ("Success") or unchanged after 9 months of treatment ("No effect"). The treatment effect was assessed by comparing the interocular imbalance in refraction and axial length before and after the treatment. A detailed questionnaire about subjective symptoms in each visit and an electroretinogram in the end were administered to evaluate the side effects of this treatment. RESULTS The subjects were followed for 7 to 16 months. Six subjects withdrew participation on their own accord, and three were excluded because of inconstant usage of drug. Of the 13 remaining subjects, the refraction of the treated eyes decreased by 0.63 ± 0.59 D (p = 0.007), whereas that of the untreated eyes increased by -0.72 ± 0.65 D (p < 0.001). A corresponding trend was also found in the change of the axial length. Accordingly, the level of anisometropia was reduced from 1.82 ± 0.73 D to 0.47 ± 0.65 D (p < 0.001) and 10 (76.9%) of the 13 subjects were designated a "Success." One percent atropine was well tolerated by the children, and no electroretinogram abnormality was detected. CONCLUSIONS The results from this pilot study indicate that monocular usage of a solution of 1% atropine sulfate is an effective treatment to reduce anisometropia, although with some tolerable side effects. Nevertheless, an attenuated benefit was observed after cessation of atropine treatment. Thus, participants should be informed of a possible rebound effect before the administration of atropine for myopic anisometropia.
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Interactive binocular treatment (I-BiT) for amblyopia: results of a pilot study of 3D shutter glasses system. Eye (Lond) 2013; 27:1077-83. [PMID: 23807383 DOI: 10.1038/eye.2013.113] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2012] [Accepted: 05/01/2013] [Indexed: 11/08/2022] Open
Abstract
PURPOSE A computer-based interactive binocular treatment system (I-BiT) for amblyopia has been developed, which utilises commercially available 3D 'shutter glasses'. The purpose of this pilot study was to report the effect of treatment on visual acuity (VA) in children with amblyopia. METHODS Thirty minutes of I-BiT treatment was given once weekly for 6 weeks. Treatment sessions consisted of playing a computer game and watching a DVD through the I-BiT system. VA was assessed at baseline, mid-treatment, at the end of treatment, and at 4 weeks post treatment. Standard summary statistics and an exploratory one-way analysis of variance (ANOVA) were performed. RESULTS Ten patients were enrolled with strabismic, anisometropic, or mixed amblyopia. The mean age was 5.4 years. Nine patients (90%) completed the full course of I-BiT treatment with a mean improvement of 0.18 (SD=0.143). Six out of nine patients (67%) who completed the treatment showed a clinically significant improvement of 0.125 LogMAR units or more at follow-up. The exploratory one-way ANOVA showed an overall effect over time (F=7.95, P=0.01). No adverse effects were reported. CONCLUSION This small, uncontrolled study has shown VA gains with 3 hours of I-BiT treatment. Although it is recognised that this pilot study had significant limitations-it was unblinded, uncontrolled, and too small to permit formal statistical analysis-these results suggest that further investigation of I-BiT treatment is worthwhile.
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Abstract
PURPOSE Virtual reality (VR)-based treatment has been introduced as a potential option for amblyopia management, presumably without involving the problems of occlusion and penalization, including variable and unsatisfactory outcomes, long duration of treatment, poor compliance, psychological impact, and complications. However, VR-based treatment is costly and not accessible for most children. This paper introduces a method that encompasses the advantages of VR-based treatment at a lower cost. METHODS The presented system consists of a pair of glasses with two color filters and software for use on a personal computer. The software is designed such that some active graphic components can only be seen by the amblyopic eye and are filtered out for the other eye. Some components would be seen by both to encourage fusion. The result is that the patient must use both eyes, and specifically the amblyopic eye, to play the games. RESULTS A prototype of the system, the ABG InSight, was found capable of successfully filtering out elements of a certain color and therefore, could prove to be a viable alternative to VR-based treatment for amblyopia. CONCLUSION The anaglyphic system maintains most of the advantages of VR-based systems, but is less costly and highly accessible. It fulfills the means that VR-based systems are designed to achieve, and warrants further investigation.
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Affiliation(s)
- Ali Rastegarpour
- Ophthalmic Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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Characterization of Bangerter filter effect in mild and moderate anisometropic amblyopia: predictive factors for the visual outcome. Graefes Arch Clin Exp Ophthalmol 2010; 249:759-66. [DOI: 10.1007/s00417-010-1564-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2010] [Revised: 10/27/2010] [Accepted: 10/29/2010] [Indexed: 10/18/2022] Open
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Kim SJ, Park YJ, Yoo JM. The Effects of Occlusion Therapy in Patients With Anisometropic Amblyopia Aged 8 Years and Older. JOURNAL OF THE KOREAN OPHTHALMOLOGICAL SOCIETY 2010. [DOI: 10.3341/jkos.2010.51.1.70] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- Seong Jae Kim
- Department of Ophthalmology, Gyeongsang National University, College of Medicine, Chinju, Korea
| | - Yeon Jeong Park
- Department of Ophthalmology, Gyeongsang National University, College of Medicine, Chinju, Korea
| | - Ji Myoung Yoo
- Department of Ophthalmology, Gyeongsang National University, College of Medicine, Chinju, Korea
- Gyeongsang Institute of Health Science, Gyeongsang National University, Chinju, Korea
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Abstract
BACKGROUND Amblyopia is defined as defective visual acuity in one or both eyes without demonstrable abnormality of the visual pathway, and is not immediately resolved by wearing glasses. OBJECTIVES To assess the effectiveness and safety of conventional occlusion versus atropine penalization for amblyopia. SEARCH STRATEGY We searched CENTRAL, MEDLINE, EMBASE, LILACS, the WHO International Clinical Trials Registry Platform, preference lists, science citation index and ongoing trials up to June 2009. SELECTION CRITERIA We included randomized/quasi-randomized controlled trials comparing conventional occlusion to atropine penalization for amblyopia. DATA COLLECTION AND ANALYSIS Two authors independently screened abstracts and full text articles, abstracted data, and assessed the risk of bias. MAIN RESULTS Three trials with a total of 525 amblyopic eyes were included. One trial was assessed as having a low risk of bias among these three trials, and one was assessed as having a high risk of bias.Evidence from three trials suggests atropine penalization is as effective as conventional occlusion. One trial found similar improvement in vision at six and 24 months. At six months, visual acuity in the amblyopic eye improved from baseline 3.16 lines in the occlusion and 2.84 lines in the atropine group (mean difference 0.034 logMAR; 95% confidence interval (CI) 0.005 to 0.064 logMAR). At 24 months, additional improvement was seen in both groups; but there continued to be no meaningful difference (mean difference 0.01 logMAR; 95% CI -0.02 to 0.04 logMAR). The second trial reported atropine to be more effective than occlusion. At six months, visual acuity improved 1.8 lines in the patching group and 3.4 lines in the atropine penalization group, and was in favor of atropine (mean difference -0.16 logMAR; 95% CI -0.23 to -0.09 logMAR). Different occlusion modalities were used in these two trials. The third trial had inherent methodological flaws and limited inference could be drawn.No difference in ocular alignment, stereo acuity and sound eye visual acuity between occlusion and atropine penalization was found. Although both treatments were well tolerated, compliance was better in atropine. Atropine penalization costs less than conventional occlusion. The results indicate that atropine penalization is as effective as conventional occlusion. AUTHORS' CONCLUSIONS Both conventional occlusion and atropine penalization produce visual acuity improvement in the amblyopic eye. Atropine penalization appears to be as effective as conventional occlusion, although the magnitude of improvement differed among the three trials. Atropine penalization can be used as first line treatment for amblyopia.
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Affiliation(s)
- Tianjing Li
- Cochrane Eyes and Vision Group US Project, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
| | - Kate Shotton
- Department of Ophthalmology, Royal Victoria Infirmary, Newcastle upon Tyne, UK
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Polat U, Ma-Naim T, Spierer A. Treatment of children with amblyopia by perceptual learning. Vision Res 2009; 49:2599-603. [PMID: 19622368 DOI: 10.1016/j.visres.2009.07.008] [Citation(s) in RCA: 67] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2009] [Revised: 07/14/2009] [Accepted: 07/15/2009] [Indexed: 11/30/2022]
Abstract
Recent studies have shown that perceptual learning has the potential to treat amblyopia. In this study we tested whether a recent perceptual learning technique that improved visual functions in adults can be applied to improve the vision of children after the conventional treatment of patching has failed. A prospective clinical pilot study was carried out in children who were non-compliant with patching or in whom patching had failed despite good compliance. Each child underwent a complete eye examination before and after treatment. The treatment was based on a perceptual learning technique that was similar to the adult study [Polat, U., Ma-Naim, T., Belkin, M., & Sagi, D. (2004). Improving vision in adult amblyopia by perceptual learning. Proceedings of the National Academy of Sciences of the United States of America, 101(17), 6692-6697]. Between blocks, children played a computer game to engage and maintain their attention in order to increase compliance. Each child received two treatment sessions a week, with a total of not more than 40 sessions. Each session lasted for about 1h and included a total practice time of about 30min. The age of the children (n=5) was between 7 and 8years (mean 7.3years). For the whole group, the average improvement in visual acuity was 1.5 Snellen lines or 2.12 ETDRS lines. The training improved the contrast sensitivity, which reached the normal range after treatment. Thus, the perceptual learning technique can be successfully used to treat children with amblyopia even after the conventional treatment of patching fails.
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Affiliation(s)
- Uri Polat
- Goldschleger Eye Research Institute, Tel-Aviv University, Sheba Medical Center, 52621 Tel Hashomer, Israel.
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Repka MX, Kraker RT, Beck RW, Birch E, Cotter SA, Holmes JM, Hertle RW, Hoover DL, Klimek DL, Marsh-Tootle W, Scheiman MM, Suh DW, Weakley DR. Treatment of severe amblyopia with weekend atropine: results from 2 randomized clinical trials. J AAPOS 2009; 13:258-63. [PMID: 19541265 PMCID: PMC2713117 DOI: 10.1016/j.jaapos.2009.03.002] [Citation(s) in RCA: 71] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2008] [Revised: 02/18/2009] [Accepted: 03/03/2009] [Indexed: 11/15/2022]
Abstract
PURPOSE To determine the effectiveness of weekend atropine for severe amblyopia from strabismus, anisometropia, or both combined among children 3 to 12 years of age. METHODS We enrolled children into 2 prospective, randomized multicenter clinical trials of amblyopia therapy. Herein we report the results for severe amblyopia, 20/125 to 20/400. In Trial 1, 60 children 3 to 6 years of age (mean, 4.4 years) were randomized to weekend atropine plus a plano lens or weekend atropine plus full spectacle correction for the sound eye. In Trial 2, 40 children 7 to 12 years of age (mean, 9.3 years) were randomized to weekend atropine or 2 hours of daily patching. The visual acuity outcome was assessed at 18 weeks in Trial 1 and 17 weeks in Trial 2. RESULTS In Trial 1, visual acuity improved by an average of 4.5 lines in the atropine plus correction group (95% CI, 3.2-5.8 lines) and 5.1 lines in the atropine plus plano lens group (95% CI, 3.7-6.4 lines). In Trial 2, visual acuity improved by an average of 1.5 lines in the atropine group (95% CI, 0.5-2.5 lines) and 1.8 lines in the patching group (95% CI, 1.1-2.6 lines). CONCLUSIONS Weekend atropine can improve visual acuity in children 3 to 12 years of age with severe amblyopia. Improvement may be greater in younger children.
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Affiliation(s)
- Michael X Repka
- Wilmer Ophthalmological Institute, Johns Hopkins University, Baltimore, Maryland, USA.
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Repka MX, Kraker RT, Beck RW, Holmes JM, Cotter SA, Birch EE, Astle WF, Chandler DL, Felius J, Arnold RW, Tien DR, Glaser SR. A randomized trial of atropine vs patching for treatment of moderate amblyopia: follow-up at age 10 years. ACTA ACUST UNITED AC 2008; 126:1039-44. [PMID: 18695096 PMCID: PMC2614351 DOI: 10.1001/archopht.126.8.1039] [Citation(s) in RCA: 76] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
OBJECTIVE To determine the visual acuity outcome at age 10 years for children younger than 7 years when enrolled in a treatment trial for moderate amblyopia. METHODS In a multicenter clinical trial, 419 children with amblyopia (visual acuity, 20/40-20/100) were randomized to patching or atropine eyedrops for 6 months. Two years after enrollment, a subgroup of 188 children entered long-term follow-up. Treatment after 6 months was at the discretion of the investigator; 89% of children were treated. MAIN OUTCOME MEASURE Visual acuity at age 10 years with the electronic Early Treatment Diabetic Retinopathy Study test. APPLICATION TO CLINICAL PRACTICE Patching and atropine eyedrops produce comparable improvement in visual acuity that is maintained through age 10 years. RESULTS The mean amblyopic eye acuity, measured in 169 patients, at age 10 years was 0.17 logMAR (logarithm of the minimum angle of resolution) (approximately 20/32), and 46% of amblyopic eyes had an acuity of 20/25 or better. Age younger than 5 years at entry into the randomized trial was associated with a better visual acuity outcome (P < .001). Mean amblyopic and sound eye visual acuities at age 10 years were similar in the original treatment groups (P = .56 and P = .80, respectively). CONCLUSIONS At age 10 years, the improvement of the amblyopic eye is maintained, although residual amblyopia is common after treatment initiated at age 3 years to younger than 7 years. The outcome is similar regardless of initial treatment with atropine or patching.
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Tejedor J, Ogallar C. Comparative efficacy of penalization methods in moderate to mild amblyopia. Am J Ophthalmol 2008; 145:562-9. [PMID: 18207121 DOI: 10.1016/j.ajo.2007.10.029] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2007] [Revised: 10/23/2007] [Accepted: 10/30/2007] [Indexed: 11/18/2022]
Abstract
PURPOSE To compare the efficacy and sensory outcome of pharmacologic and optical penalization in the treatment of moderate to mild amblyopia. DESIGN Randomized clinical trial. METHODS In an institutional setting, two- to 10-year-old children with strabismic or anisometropic amblyopia (visual acuity in the amblyopic eye at least 20/60) who were cooperative to measure visual acuity using the logarithm of the minimum angle of resolution (logMAR) crowded Glasgow acuity cards were randomized into two groups of therapy (n=35 in each group), 1% atropine, and optical penalization with positive lenses, after stratification by cause of amblyopia. Visual acuity was tested by the logMAR crowded Glasgow acuity cards, after retinoscopic refraction, and deviation angle were measured by the simultaneous prism and cover or Krimsky test. Stereoacuity was determined using the Titmus fly test and Randot preschool or Randot circles stereoacuity test. Change in visual acuity of the amblyopic eye and in interocular difference of visual acuity after six months of amblyopia therapy was the main outcome measure; stereoacuity at six months of therapy was a secondary outcome measure. RESULTS Thirty-one and 32 children completed the outcome examination in the atropine and optical penalization group, respectively. Average improvement in visual acuity of the amblyopic eye was larger in the atropine than in the optical penalization group (3.4 and 1.8 logMAR lines, respectively), as well as average improvement in interocular difference of visual acuity (2.8 and 1.3 logMAR lines, respectively). Better stereoacuity, but nonsignificantly different, was detected in the atropine group. CONCLUSIONS Atropine penalization may be considered more effective than optical penalization with positive lenses.
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Affiliation(s)
- Jaime Tejedor
- Department of Ophthalmology, Hospital Ramón y Cajal, Madrid, Spain.
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A review of 58 patients with periorbital haemangiomas to determine appropriate cases for intervention. J Plast Reconstr Aesthet Surg 2008; 61:138-49. [DOI: 10.1016/j.bjps.2007.08.014] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2007] [Accepted: 08/28/2007] [Indexed: 11/20/2022]
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Kim YH, Choi MY. The Prospective Comparison of the Efficacy of Intermittent Atropine Penalization and Part-time Occlusion Therapy. JOURNAL OF THE KOREAN OPHTHALMOLOGICAL SOCIETY 2008. [DOI: 10.3341/jkos.2008.49.6.958] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- Youn Hui Kim
- Department of Ophthalmology, Chungbuk National University College of Medicine, Chungbuk National University Medical Research Institute, Cheongju, Korea
| | - Mi Young Choi
- Department of Ophthalmology, Chungbuk National University College of Medicine, Chungbuk National University Medical Research Institute, Cheongju, Korea
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Stanković B, Milenković S. Continuous full-time occlusion of the sound eye vs full-time occlusion of the sound eye periodically alternating with occlusion of the amblyopic eye in treatment of amblyopia: a prospective randomized study. Eur J Ophthalmol 2007; 17:11-9. [PMID: 17294378 DOI: 10.1177/112067210701700103] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
PURPOSE To compare continuous full-time (24 hours per day) occlusion of the sound eye with full-time occlusion (24 hours per day) of the sound eye 1 day more than the years of age periodically alternating with occlusion of the amblyopic eye for 1 day, as treatments for profound strabismic amblyopia in children older than 5 years. METHODS A total of 53 patients with visual acuity (VA) of 0.4 and less in the amblyopic eye (tested by crowded Landolt Cs) after previously being provided optimal optical correction were randomly assigned to receive either of the two patching regimens. VA and pattern reversal visual evoked potentials (PVEP) were recorded prospectively at 1-month intervals. Improvement in VA and the reduction in crowding difficulties (CD) were the main outcome measures of the treatment efficiency. RESULTS Both treatment modalities were equally effective. Of the 51 subjects who completed the study, 21 (41.2%) were cured whereas 32 (62.7%) attained satisfactory improvement. Recovery of VA was related to age, with cure being obtained in 23.5% (4/17) and satisfactory improvement in 52.9% (9/17) of patients older than 9 years. Larger gain in VA influenced the stability of the vision over time. CONCLUSIONS It can be concluded that in clinically monitored parameters both treatment modalities were equally effective without any statistical or clinical significance in the observed groups of patients. However, events like the ""trade-off"" effect, occurrence of occlusion amblyopia, or prolongation of PVEP latency of the sound eye indicate that full-time continuous occlusion possibly presents a more effective form of treatment.
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Affiliation(s)
- B Stanković
- Institute of Ophthalmology, Clinical Centre of Serbia, Belgrade, Serbia.
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Abstract
Results from recent randomised clinical trials in amblyopia should change our approach to screening for and treatment of amblyopia. Based on the current evidence, if one screening session is used, screening at school entry could be the most reasonable time. Clinicians should preferably use age-appropriate LogMAR acuity tests, and treatment should only be considered for children who are clearly not in the typical range for their age. Any substantial refractive error should be corrected before further treatment is considered and the child should be followed in spectacles until no further improvement is recorded, which can take up to 6 months. Parents and carers should then be offered an informed choice between patching and atropine drops. Successful patching regimens can last as little as 1 h or 2 h a day, and successful atropine regimens as little as one drop twice a week. Intense and extended regimens might not be needed in initial therapy.
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Affiliation(s)
- Jonathan M Holmes
- Department of Ophthalmology, Mayo Clinic College of Medicine, Rochester, MN 55905, USA.
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Walsh LA, Hahn EK, Laroche GR. Controversy in amblyopia management. THE AMERICAN ORTHOPTIC JOURNAL 2006; 56:116-125. [PMID: 21149138 DOI: 10.3368/aoj.56.1.116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
BACKGROUND AND PURPOSE Much has been written about amblyopia treatment. However, there is no consensus on the most efficacious therapeutic modality for amblyopia. The intensity of therapy needed to maximize visual acuity is also widely debated. The diversity of opinions emphasizes that the optimum treatment for amblyopia is unknown. Part of the uncertainty stems from the lack of standardization in the management of amblyopia. The objective of this paper is to conduct an in-depth review of the literature in an attempt to clarify the amblyopia treatment conundrum. CONCLUSIONS The treatment of amblyopia in children is frequently discussed in the literature. It is obvious from the literature that there is the need for prospective studies with consistent controls, clear definitions of what constitutes successful therapy endpoints, and standardization of testing procedures.
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Wu C, Hunter DG. Amblyopia: diagnostic and therapeutic options. Am J Ophthalmol 2006; 141:175-184. [PMID: 16386994 DOI: 10.1016/j.ajo.2005.07.060] [Citation(s) in RCA: 91] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2005] [Revised: 07/26/2005] [Accepted: 07/26/2005] [Indexed: 11/25/2022]
Abstract
PURPOSE To provide an overview of the current state of knowledge of amblyopia and highlight recent advances in diagnosis and treatment. DESIGN Review of literature and perspective. METHODS MEDLINE search for amblyopia, with a review of all recent literature adding authors' personal perspectives on the findings. RESULTS Increased awareness of amblyopia and better screening techniques are required to identify children who are at risk for amblyopia at a younger age. Randomized, controlled trials have established atropine penalization as a viable alternative to occlusion therapy, have suggested that less treatment may be better tolerated and as effective as more traditionally used dosages, and have found no compelling evidence that treatment is beneficial clinically for older (over age 10) children with amblyopia. CONCLUSION Early detection and treatment of amblyopia can improve the chances for a successful visual outcome. Considering that the conditions that place a patient at risk for amblyopia can be identified, that amblyopia responds to treatment, and that well-tolerated treatments for the condition are now recognized, it is not unreasonable to imagine that, in the near future, severe amblyopia could be eliminated as a public health problem.
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Affiliation(s)
- Carolyn Wu
- Department of Ophthalmology, Children's Hospital Boston, Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115, USA.
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Abstract
PURPOSE The aim of this report is to review the contemporary research in amblyopia treatment and how it will affect clinical practice patterns. METHODS Topics addressed include prescribing the optimal refractive correction, the most effective treatment, duration and intensity of treatment, regression after treatment, the upper age for treatment, and the chance of the amblyope losing his or her sound eye. RESULTS AND CONCLUSIONS The optimal refractive correction is best determined with cycloplegic retinoscopy; pharmacologic penalization can be as effective as patching in children with moderate amblyopia; less-intense treatment regimens have been found to be as effective as more-intense treatment regimens; regression can occur in as many as 25% of all treated patients; some older amblyopes can be treated successfully; and the amblyope has a higher chance of becoming blind than the nonamblyope.
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Affiliation(s)
- Robert P Rutstein
- School of Optometry, University of Alabama at Birmingham, 1716 University Boulevard, Birmingham, AL 35294, USA.
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Abstract
Amblyopia has a 1.6-3.6% prevalence, higher in the medically underserved. It is more complex than simply visual acuity loss and the better eye has sub-clinical deficits. Functional limitations appear more extensive and loss of vision in the better eye of amblyopes more prevalent than previously thought. Amblyopia screening and treatment are efficacious, but cost-effectiveness concerns remain. Refractive correction alone may successfully treat anisometropic amblyopia and it, minimal occlusion, and/or catecholamine treatment can provide initial vision improvement that may improve compliance with subsequent long-duration treatment. Atropine penalization appears as effective as occlusion for moderate amblyopia, with limited-day penalization as effective as full-time. Cytidin-5'-diphosphocholine may hold promise as a medical treatment. Interpretation of much of the amblyopia literature is made difficult by: inaccurate visual acuity measurement at initial visit, lack of adequate refractive correction prior to and during treatment, and lack of long-term follow-up results. Successful treatment can be achieved in at most 63-83% of patients. Treatment outcome is a function of initial visual acuity and type of amblyopia, and a reciprocal product of treatment efficacy, duration, and compliance. Age at treatment onset is not predictive of outcome in many studies but detection under versus over 2-3 years of age may be. Multiple screenings prior to that age, and prompt treatment, reduce prevalence. Would a single early cycloplegic photoscreening be as, or more, successful at detection or prediction than the multiple screenings, and more cost-effective? Penalization and occlusion have minimal incidence of reverse amblyopia and/or side-effects, no significant influence on emmetropization, and no consistent effect on sign or size of post-treatment changes in strabismic deviation. There may be a physiologic basis for better age-indifferent outcome than tapped by current treatment methodologies. Infant refractive correction substantially reduces accommodative esotropia and amblyopia incidence without interference with emmetropization. Compensatory prism, alone or post-operatively, and/or minus lens treatment, and/or wide-field fusional amplitude training, may reduce risk of early onset esotropia. Multivariate screening using continuous-scale measurements may be more effective than traditional single-test dichotomous pass/fail measures. Pigmentation may be one parameter because Caucasians are at higher risk for esotropia than non-whites.
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Affiliation(s)
- Kurt Simons
- Pediatric Vision Laboratory, Krieger Children's Eye Center, Wilmer Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland 21287-9028, USA
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Abstract
AIMS/PURPOSE To evaluate the efficacy of occlusion therapy initiated after 9 years of age. METHODS A total of 16 amblyopes of 9 years or older (range, 9.0-14.5 years; mean, 10.5 years) with a difference in visual acuity of over two lines between the eyes alter 4 weeks of first full-time spectacle wear were included. None of the children had undergone a previous ocular examination, had ever worn spectacles, received occlusion therapy, or had strabismus surgery. Initial worst visual acuity after 4 weeks of full-time spectacle wear was 20/100 in three patients, between 20/80 and 20/40 in 11 patients, and 20/30 in two patients. Full-time occlusion was performed in 14 patients and part-time occlusion in two patients. RESULTS The final visual acuity of 15 out of 16 patients (94%) improved at least two lines. The final visual acuities ranged from 20/30 to 20/20 in 14 patients, 20/40 in one patient, and 20/50 in one remaining patient who began amblyopia therapy at 14.5 years of age, with the poorest compliance among the patients. CONCLUSIONS Occlusion therapy for anisometropic and strabismic amblyopia can be successful even if initiated after the age of 9 years.
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Affiliation(s)
- K H Park
- Department of Ophthalmology, Seoul National University, Bundang Hospital, College of Medicine, Seoul National University Sungnam, Korea
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The course of moderate amblyopia treated with atropine in children: experience of the amblyopia treatment study. Am J Ophthalmol 2003; 136:630-9. [PMID: 14516802 DOI: 10.1016/s0002-9394(03)00458-6] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
PURPOSE To assess the course of the response to atropine treatment of moderate amblyopia and to assess factors predictive of the treatment response in children 3 years old to younger than 7 years old. DESIGN Multicenter, randomized clinical trial comparing atropine and patching (one of the amblyopia treatment studies). METHODS A total of 195 children 3 years old to younger than 7 years of age with amblyopia in the range of 20/40 to 20/100 from the atropine treatment arm of this trial were enrolled and included in this analysis. At baseline, daily topical atropine was prescribed for the sound eye. During follow-up, a plano spectacle lens was prescribed for the sound eye for patients whose amblyopia had not been successfully treated with atropine alone. Follow-up examinations were performed at 5 weeks, 16 weeks, and 6 months. The primary outcome measure was visual acuity in the amblyopic eye at 6 months. RESULTS Mean visual acuity improved from baseline by 1.3 lines after 5 weeks of treatment, by 2.4 lines after 16 weeks, and by 2.8 lines at 6 months. Visual acuity of 20/30 or better and/or 3 or more lines of improvement from baseline was achieved by 75% of the patients. Improvement occurred over the entire range of baseline acuities (20/40 to 20/100) and was not related to patient age (P =.36). Among the 134 patients improving 3 or more lines from baseline, 7% achieved their maximum improvement by 5 weeks and 46% by 16 weeks. Among the 55 patients who did not respond adequately to atropine alone and were prescribed a plano lens for the sound eye, the mean improvement before the use of the plano lens was 1.0 lines, compared with 1.6 lines after prescribing the plano lens (P =.11). None of the demographic or clinical factors assessed was predictive of the response to treatment. A shift in fixation preference at/near from the atropinized sound eye to the amblyopic eye was not required for the amblyopic eye to improve; amblyopic eye acuity improved 3 or more lines in 29 (60%) of the 48 patients who were found to be using the atropinized sound eye on fixation preference testing. A 2 or more line decrease in sound eye visual acuity occurred more frequently when a plano lens was prescribed in addition to atropine (7 of 43, 16%) compared with treatment with atropine alone (4 of 123, 3%; P =.01). CONCLUSIONS A beneficial effect of atropine is present throughout the age range of 3 years old to younger than 7 years old, and with an acuity range of 20/40 to 20/100. A shift in near fixation to the amblyopic eye is not essential for atropine to be effective in all cases. Sound eye acuity should be monitored when a plano spectacle lens is prescribed for the sound eye to augment the treatment effect of atropine.
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Tan JHY, Thompson JR, Gottlob I. Differences in the management of amblyopia between European countries. Br J Ophthalmol 2003; 87:291-6. [PMID: 12598440 PMCID: PMC1771562 DOI: 10.1136/bjo.87.3.291] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND Amblyopia treatment is not standardised and differences between centres and countries have not been systematically investigated. This survey compares the different patterns of orthoptic treatment of amblyopia in the United Kingdom (UK) and three German speaking countries (GSC). METHODS Questionnaires were sent to orthoptists in the UK and the GSC asking for their preferred choices of treatment of amblyopia between the ages of 6 months to 10 years. RESULTS The following significant differences in management of amblyopia were found: (1) the number of hours of occlusion per week was higher in the GSC, p<0.0001, (2) orthoptists in the GSC treat amblyopia up to an older age. Orthoptists in the GSC and in the UK predicted similar treatment outcomes. CONCLUSION Orthoptists in the GSC usually treat patients more intensively and for longer, while the prediction of visual outcome does not differ significantly between countries. These results highlight the lack of standardisation in the treatment of the various types of amblyopia.
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Affiliation(s)
- J H Y Tan
- Department of Ophthalmology, University Hospitals of Leicester, Leicester, UK.
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Membreno JH, Brown MM, Brown GC, Sharma S, Beauchamp GR. A cost-utility analysis of therapy for amblyopia. Ophthalmology 2002; 109:2265-71. [PMID: 12466169 DOI: 10.1016/s0161-6420(02)01286-1] [Citation(s) in RCA: 90] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVE Evaluation of the incremental cost-effectiveness of therapy for amblyopia. DESIGN Cost-utility reference-case analysis. METHODS A cost-utility analysis was performed from a third-party insurer perspective by using decision analysis, evidence-based data from the literature, and patient preference-based time trade-off utility values. DATABASE Patient-derived time trade-off ocular utility values and the American Academy of Ophthalmology Preferred Practice Pattern guidelines for the treatment of amblyopia. INTERVENTION Treatment of childhood amblyopia using medical and surgical therapies per the American Academy of Ophthalmology Preferred Practice Pattern. MAIN OUTCOME MEASURE Dollars (year 2001 nominal U.S. dollars) expended per quality-adjusted life-year ($/QALY) gained. RESULTS Treatment for amblyopia resulted in a $/QALY gained of $2281 with a discount rate of 3% for costs and outcomes. Sensitivity analysis, varying costs and utility values by 10%, resulted in a $/QALY gained range from $2053 to $2509. CONCLUSIONS When compared with other interventions in health care, therapy for amblyopia seems to be highly cost-effective. This information is increasingly important for health care policy makers.
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Affiliation(s)
- Jaime H Membreno
- Center for Evidence-Based Health Care Economics, Flourtown, Pennsylvania 19031, USA
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Kaye SB, Chen SI, Price G, Kaye LC, Noonan C, Tripathi A, Ashwin P, Cota N, Clark D, Butcher J. Combined optical and atropine penalization for the treatment of strabismic and anisometropic amblyopia. J AAPOS 2002; 6:289-93. [PMID: 12381987 DOI: 10.1067/mpa.2002.127920] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
INTRODUCTION The treatment of amblyopia by occlusion of the fellow eye is beset by problems related to compliance, stigmatization, and regression of visual acuity (VA). Atropine or optical penalization has been used as an alternative treatment for amblyopia and might be synergistic as a combination therapy. Combined optical and atropine penalization treatment (COAT) was therefore assessed in patients with anisometropic and strabismic amblyopia. METHODS Patients with a hypermetropic refractive error in whom occlusion had failed were prescribed daily atropine 1% and a plano spectacle lens to the fellow eye. Outcome measures included VA (LogMAR units), interocular VA difference, adverse events, and adverse reactions. COAT was continued until VA failed to improve after 2 consecutive visits, and then patients were offered occlusion treatment again. RESULTS Forty-two patients (mean age, 4.73 yrs) were treated with COAT. Patients had attempted occlusion for a mean period of 36 weeks before commencement of COAT. The mean VA of the amblyopic eyes improved after 10 weeks of COAT, from 0.85 (20/113) to 0.28 (20/37) (P <.001), an overall success (doubling of VA) rate of 76%. There was no significant change in the mean VA of the fellow eye as a result of COAT (P =.13). Twenty-two patients recommenced occlusion after COAT for regression (10), lack of further improvement (2), or parental choice (10). The remaining 20 patients maintained their VA without treatment at 93% of post-COAT levels, at a mean follow-up 6.4 months. Overall regression rate was 36%, adverse reaction rate was 2%, adverse event rate was 21%, and presumed compliance rate was 83%. DISCUSSION COAT is an effective treatment method when occlusion therapy initially fails. COAT is well tolerated and should be considered as an alternative and/or supportive therapy in the management of amblyopia.
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Abstract
PURPOSE To assess the overall complication rate of orbitotomies performed in children and to determine the nature of complication to identify possible risk factors. METHODS Thirty children <13 years underwent 33 orbitotomies for space-occupying lesions of the orbit or orbital decompression. A detailed evaluation of the surgical procedures and outcomes was conducted. Follow up averaged 2.5 years (range: 6 months to 5 years). RESULTS The complication rate was 20% (2 of 10 cases) for anterior orbitotomies, 40% (8 of 20 cases) for primary lateral orbitotomies, and 100% (3 of 3 cases) for secondary orbitotomies. Dense amblyopia was noted in 6 of 9 patients. Major complications were frozen eyeball, diplopia, and ptosis. Less serious complications were enophthalmos, internal ophthalmoplegia, dry eye, and eyelid retraction. Six patients underwent extraocular surgery, levator muscle surgery, or both at a later date. CONCLUSION Although the scope of complications is the same in children as in adults, the frequency of cystic benign lesions and small orbits in children can cause more frequent serious complications. Additionally, dense amblyopia of a complicated nature makes visual outcome unpredictable. The most significant risk factors identified were the need for a secondary procedure for recurring pathology and the presence of an intraconal lesion.
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Affiliation(s)
- M Salem
- Faculty of Medicine, Jordan University of Science and Technology, Irbid
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Tong PY, Bassin RE, Enke-Miyazaki E, Macke JP, Tielsch JM, Stager DR, Beauchamp GR, Parks MM. Screening for amblyopia in preverbal children with photoscreening photographs: II. Sensitivity and specificity of the MTI photoscreener. Ophthalmology 2000; 107:1623-9. [PMID: 10964818 DOI: 10.1016/s0161-6420(00)00293-1] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVE To determine the sensitivity and specificity of vision screening using the Medical Technology and Innovations (MTI), Inc., PhotoScreener. DESIGN Cross-sectional study. PARTICIPANTS AND TESTING: Three hundred ninety-two children less than 4 years of age received a complete ophthalmologic examination and were photographed using the MTI PhotoScreener. One hundred three children had normal examinations, and the remaining 284 children had conditions of interest for pediatric screening: ptosis, media opacity, refractive error, or strabismus. Five children were excluded. MAIN OUTCOME MEASURES The grading of the photographs by the manufacturer's representative was compared with the results of the ophthalmologic examinations. Sensitivity and specificity of vision screening were determined. RESULTS The analysis of all informative photographs resulted in a sensitivity of 65% and a specificity of 87%. The sensitivity of detection for children with some forms of strabismus was high, up to 95% for esotropia of 10Delta or more. Sensitivities for the detection of ptosis, media opacity, and refractive error were poor in patients where strabismus was not also present. CONCLUSIONS The MTI PhotoScreener may play a role in preverbal vision screening; identification of two of three children with amblyopiogenic factors before age 4 would be an exciting advance in public health. However, improvement in the ability to identify children with media opacity and refractive error is necessary. Improvements may be possible with modifications of the examination failure and photograph grading criteria.
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Affiliation(s)
- P Y Tong
- Wilmer Ophthalmologic Institute, Johns Hopkins University, Baltimore, Maryland, USA.
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Abstract
Strabismus, or misalignment of the eyes, is a common ophthalmic problem in childhood, affecting 2 to 5% of the preschool population. Amblyopia is an important cause of visual morbidity frequently associated with strabismus, and both conditions should be treated simultaneously. Pharmacological means for treating strabismus and amblyopia can be divided into 3 categories: paralytic agents (botulinum toxin) used directly on the extraocular muscles to affect eye movements; autonomic agents (atropine, miotics) used topically to manipulate the refractive status of the eye and thereby affect alignment, focus and amblyopia; and centrally acting agents, including levodopa and citicoline, which affect the central visual system abnormalities in amblyopia. Botulinum toxin, the paralytic agent that causes the clinical symptoms of botulism poisoning, can be injected in minute quantities to achieve controlled paralysis of the extraocular muscles. Although the role of botulinum toxin is established in adults with paralytic strabismus, its usefulness in the treatment of comitant childhood strabismus (primary esotropia and exotropia) is not universally accepted. Botulinum injections tend to be more effective with smaller degrees of strabismus, in patients with good binocular fusion, and in managing overcorrections or undercorrections after traditional muscle surgery. Inadvertent ptosis and paralysis of adjacent muscles, unpredictable responses and technical constraints of the injections limit its use in children. Miotic therapy, by altering the refractive state of the treated eye, offers an alternative to optical correction with bifocals in treating esotropia due to excessive accommodative convergence. It is also effective in treating residual esotropia following surgery. The ease of use of glasses restricts the wide application of miotics in these common strabismus syndromes. Atropine, an anticholinergic agent, paralyses the ability of the eye to focus or accommodate. In amblyopia therapy, atropine is used to blur vision in the non-amblyopic eye and offers a useful alternative to traditional occlusion therapy with patching, especially in older children who are not compliant with patching. The neurotransmitter precursor levodopa and the related compound citicoline have been demonstrated to improve vision in amblyopic eyes. The therapeutic role of these centrally acting agents in the clinical management of amblyopia remains unproven.
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Affiliation(s)
- K I Chatzistefanou
- Department of Ophthalmology and Visual Sciences, University of Wisconsin-Madison Medical School, 53705, USA
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Abstract
BACKGROUND Atropinization of the sound eye is an alternative to patching in the treatment of amblyopia. Whether atropine treatment can induce a switch in fixation depends on the refractive error of the sound eye, visual acuity of the amblyopic eye, distance from the fixation target, and presence of any optical correction or penalization. General guidelines are needed on the basis of refractive error and visual acuity in the amblyopic eye to predict which patients may potentially benefit from atropine penalization. METHODS Refractive error and visual acuity at distance (6 m) and/or at near (33 cm) were recorded in a normal eye of 126 consecutive children (mean age, 8.2 years), 30 to 60 minutes after receiving cyclopentolate 1%. Visual acuity was plotted versus refractive error at distance and at near, and best-fit curves were calculated. RESULTS There was a consistent, reproducible relationship between refractive error and visual acuity after cycloplegia at both distance and near in healthy children. CONCLUSIONS The results of this study can be used to quickly determine whether atropine penalization has the potential for success on the basis of a patient's visual acuity in the amblyopic eye and refractive error in the sound eye. When adequate hyperopia is present in the sound eye, one should consider testing for fixation preference or initiating a therapeutic trial of atropine. Those children with insufficient hyperopia in the sound eye relative to visual acuity in the amblyopic eye can be spared the time, expense, and potential side effects of atropine penalization.
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Affiliation(s)
- D K Wallace
- Department of Ophthalmology and Pediatrics, University of North Carolina at Chapel Hill, 27599-7040, USA.
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Tong L, Hodgkins PR, Denyer J, Brosnahan D, Harper J, Russell-Eggitt I, Taylor DS, Atherton D. The eye in epidermolysis bullosa. Br J Ophthalmol 1999; 83:323-6. [PMID: 10365041 PMCID: PMC1722980 DOI: 10.1136/bjo.83.3.323] [Citation(s) in RCA: 57] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
AIMS To describe the ophthalmic findings in a large cohort of epidermolysis bullosa (EB) patients managed in one large specialist centre. METHODS A case note review of consecutive patients seen at Great Ormond Street Children's Hospital. Data on the dermatological disease, ophthalmic history, and examination were collected and coded onto a data sheet. RESULTS 181 patients: 50 (28%) simplex EB; 15 (8%) junctional EB; 28 (15%) autosomal dominant dystrophic EB; 72 (40%) autosomal recessive dystrophic EB; nine patients (5%) with dystrophic EB whose inheritance could not be ascertained; and seven cases (4%) of EB that could not be classified. Ocular problems were found in 12% (n = 6) of simplex patients and 40% (n = 6) of those with junctional disease. One patient (of 28) in the autosomal dominant dystrophic group had ocular involvement and 51% (37/72) of patients in the autosomal recessive dystrophic group had ophthalmic complications: corneal (25/72), lid ectropions (3/72), lid blisters (5/72), and symblepharon (3/72). CONCLUSION Ophthalmic complications are common in EB overall but the incidence varies widely with subtype. Ophthalmic complications are the most severe in the dystrophic recessive and junctional subtypes where there is a need for extra vigilance. The major treatment modality was use of ocular lubricants.
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Affiliation(s)
- L Tong
- Department of Ophthalmology, Great Ormond Street Hospital for Children NHS Trust, London
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Sudarshan AP. Alternatives to patching. Ophthalmology 1998; 105:1351. [PMID: 9709736 DOI: 10.1016/s0161-6420(98)98003-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
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