Amblyopia Research: 2002-2006
  
Graefes Arch Clin Exp Ophthalmol. 2006 Oct 18; [Epub ahead of print]
Factors affecting the stability of visual function following cessation of occlusion therapy for amblyopia.
Tacagni DJ, Stewart CE, Moseley MJ, Fielder AR.
Faculty of Medicine, Imperial College London, London, UK.

AIM: To identify factors that predict which children with amblyopia are at greatest risk of regression of visual acuity (VA) following the cessation of occlusion therapy. METHOD: A retrospective analysis was performed of 182 children (mean age at cessation of treatment; 5.9+/-1.6 years) who had undergone occlusion therapy for unilateral amblyopia, and had been followed up at least once within 15 months of cessation. Statistical analysis was used to identify whether change in VA following treatment cessation had any association with various factors, including the child's age, type of amblyopia, degree of anisometropia, initial severity of amblyopia, binocular vision status, length and dose of occlusion therapy, and VA response to treatment. RESULTS: At 1 year, follow-up from treatment cessation, children with "mixed" amblyopia (both anisometropia and strabismus) demonstrated significantly (p=0.03) greater deterioration in VA (0.11+/-0.11 log units) than children with only anisometropia (0.02+/-0.08 log units) or only strabismus (0.05+/-0.10 log units). However, none of the other factors investigated were found to be significant predictors. CONCLUSION: This study supports previous research that it is possible to identify those children most at risk of deterioration in VA following cessation of occlusion therapy. The presence of mixed amblyopia was the only risk factor identified in this study. Management of amblyopia should take this into account, with a more intensive follow-up recommended for those with both anisometropia and strabismus (mixed) amblyopia.

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J Pediatr Ophthalmol Strabismus. 2006 Jul-Aug;43(4):207-11; quiz 231-2.
Treatment options for anisohyperopia.
Granet DB, Christian W, Gomi CE, Banuelos L, Castro E.
Department of Ophthalmology, UCSD/Ratner Children's Eye Center, University of California, San Diego, California 92093-0946, USA.

PURPOSE: To investigate the success of conventional methods in the treatment of anisohyperopic amblyopia. METHODS: A retrospective chart review of all patients with anisohyperopic amblyopia seen at the UCSD/ Ratner Children's Eye Center during a 42-month period was performed. The charts of 35 patients aged 3 to 14 years (mean age, 6.8 years) with 1.5 to 6.5 diopters of anisohyperopia were reviewed. Main outcome measures were the difference in refractive error and the pre- and post-treatment Snellen equivalent distance acuities. Treatment consisted of one or a combination of the following: spectacles, contact lenses, patching, and atropine. Binocularity was determined using the Titmus test. Compliance to treatment also was rated. RESULTS: Thirteen (37.1%) patients were treated with spectacles alone, 11 (31.5%) were treated with a combination of atropine and patching, 8 (22.8%) were treated with patching alone, 2 (5.7%) received blurring contact lenses, and 1 (2.9%) patient was treated with atropine alone. The average pretreatment visual acuity was 20/108, with an improvement to an average of 20/27 at the termination of treatment. Ninety-four percent of the patients obtained a visual acuity of 20/40 or better. CONCLUSIONS: Conventional methods of treatment are effective in improving vision and binocular status in anisohyperopia. Depending on the patient, only spectacles may be required.

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Am J Ophthalmol. 2006 Jul;142(1):132-140.
Relationship between anisometropia, patient age, and the development of amblyopia.
Donahue SP.
Departments of Ophthalmology, Pediatrics, and Neurology, Vanderbilt University School of Medicine, Nashville, Tennessee 37232, USA. sean.donahue@vanderbilt.edu

PURPOSE: Previous studies evaluating the effect of anisometropia on amblyopia development have been biased because subject selection occurred as a result of decreased acuity. Photoscreening identifies anisometropic children in a manner that is not biased by acuity, and allows an opportunity to evaluate how patient age influences the prevalence and depth of amblyopia. DESIGN: Retrospective observational study of preschool children with anisometropia. METHODS: A statewide preschool photoscreening program screened 119,311 children and identified 792 with anisometropia >1.0 diopters. We correlated age with visual acuity and amblyopia depth. Results were compared with 562 strabismic children similarly identified. RESULTS: Only 14% (six of 44) of anisometropic children aged 1 year or younger had amblyopia. Amblyopia was detected in 40% (32 of 80) of 2-year-olds, 65% (119 of 182) of 3-year-olds, and 76% of 5-year-olds. Amblyopia depth also increased with age. Moderate amblyopia prevalence was 2% (ages 0 to 1), 17% (age 2), and rose steadily to 45% (ages 6 to 7). Severe amblyopia was rare for children aged 0 to 3, 9% at age 4, and 14% at age 5. Children with strabismus had a relatively stable prevalence (30% ages 0 to 2; 42% ages 3 to 4; and 44% ages 5 to 7) and depth of amblyopia. CONCLUSIONS: Younger children with anisometropia have a lower prevalence and depth of amblyopia than older children. By age 3, when most children undergo traditional screening, amblyopia has usually already developed. New vision screening technologies that allow early detection of anisometropia provide ophthalmologists an opportunity to intervene early, perhaps retarding or even preventing the development of amblyopia.

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Cochrane Database Syst Rev. 2006 Jul 19;3:CD005136.
Interventions for stimulus deprivation amblyopia.
Hatt S, Antonio-Santos A, Powell C, Vedula SS.
International Centre for Eye Health, c/o Cochrane Eyes and Vision Group, London School of Hygiene & Tropical Medicine, Keppel Street, London, UK WC1E 7HT. sarahrhatt@gmail.com

BACKGROUND: Stimulus deprivation amblyopia (SDA) develops due to an obstruction to the clear passage of light, preventing clear formation of an image on the retina for example, cataract, ptosis (droopy eyelid). It is particularly severe and can be resistant to treatment and the visual prognosis is often poor. Stimulus deprivation amblyopia is rare and precise estimates of prevalence difficult to come by; it probably constitutes less than 3% of all cases of amblyopia. In developed countries most patients present under the age of one; in less developed parts of the world presentation is likely to be significantly later than this.The mainstay of treatment is patching of the better-seeing eye but regimes vary, treatment is difficult to execute and results are often disappointing. OBJECTIVES: The objectives of this review were to evaluate the effectiveness of occlusion treatment for SDA, determine the optimum treatment regime and factors that may affect outcome. SEARCH STRATEGY: We searched the Cochrane Central Register of Controlled Trials - CENTRAL (which contains the Cochrane Eyes and Vision Group Trials Register) on The Cochrane Library (2006, Issue 1), MEDLINE (1996 to April 2006), EMBASE (1980 to April 2006) and LILACS (Latin American and Caribbean Literature on Health Sciences) (to November 2004). There were no date or language restrictions. SELECTION CRITERIA: We aimed to include randomised and quasi-randomised controlled trials of subjects with unilateral SDA defined as worse than 0.2 LogMAR or equivalent. There were no restrictions with respect to age, gender, ethnicity, co-morbidities, medication use, and the number of participants. DATA COLLECTION AND ANALYSIS: Two authors independently assessed study abstracts identified by the electronic searches. MAIN RESULTS: No trials were identified that met the inclusion criteria. AUTHORS' CONCLUSIONS: It is not possible to conclude how effective treatment for SDA is or which treatment regime produces the best results. There is a need for further study in this area.

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Strabismus. 2006 Jun;14(2):71-3.
Medical treatment of amblyopia: present state and perspectives.
Campos EC, Fresina M.
Ophthalmology Service, University of Bologna, Bologna, Italy. campos@alma.unibo.it

A brief review is provided on the role of experimental modulation of the visual system during its plastic period. The importance of several substances has been demonstrated. Potential clinical applications of available studies on the treatment of amblyopia are summarized. The role of the dopaminergic system and particularly of dopamine in amblyopia are also discussed. The results of the use of cytidine-5'-diphosphocholine (citicoline) in amblyopia are evaluated in detail. The advantages of and indications for an association of citicoline with part-time occlusion are also discussed. Finally, new administration modalities of citicoline, more detailed evaluation of its efficacy, and the use of new substances are briefly analyzed.

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J AAPOS. 2006 Jun;10(3):193-7.
Strabismus and amblyopia in bilateral Peters anomaly.
Najjar DM, Christiansen SP, Bothun ED, Summers CG.
Department of Ophthalmology, University of Minnesota, Minneapolis, Minnesota 55455, USA.

BACKGROUND: Peters anomaly is a rare form of anterior segment dysgenesis in which abnormal cleavage of the anterior chamber occurs at the end of the third week of gestation. We examined the prevalence of strabismus and amblyopia and analyzed predictive factors for their development, as well as the visual outcome and associated anomalies in patients with bilateral Peters anomaly. METHODS: Using a retrospective review, we identified 25 consecutive patients with bilateral Peters anomaly who were observed between August 1995 and February 2005. Ocular structural and systemic anomalies, amblyopia therapy, visual acuity, and binocular alignment at last visit were recorded. Fisher's exact test was used to identify any association between defined predictive factors and the development of strabismus. RESULTS: Mean follow-up time was 5.1 year (range, 0.5-21 years). Median age at presentation was 2.5 months (range, 1 day to 13 years). Penetrating keratoplasties were performed on 34 eyes in 20 patients. Final best-corrected visual acuity ranged from 20/25 to no light perception. Thirteen of 18 patients with recorded motility (72%) developed strabismus: esotropia (n = 7), exotropia (n = 5), and variable (n = 1); one also had dissociated vertical deviation. Patients with equal vision were either orthophoric (n = 4) or had intermittent esotropia (n = 1), whereas strabismus occurred in 100% of patients whose vision was asymmetric by more than 1.5 octaves. Asymmetric vision was the only statistically significant predictive factor for the development of strabismus (P = 0.002). Amblyopia treatment resulted in improved vision in 3 of 5 patients. CONCLUSION: Strabismus occurs frequently in bilateral Peters anomaly. Asymmetric vision, (because of ocular structural anomalies) postoperative complications, and amblyopia may predispose to strabismus. Despite ocular structural limitations, amblyopia therapy is recommended in the aggressive rehabilitation of these eyes.

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J AAPOS. 2006 Jun;10(3):193-7.
Strabismus and amblyopia in bilateral peters anomaly.
Najjar DM, Christiansen SP, Bothun ED, Summers CG.
Department of Ophthalmology, University of Minnesota, Minneapolis, Minnesota.

Background: Peters anomaly is a rare form of anterior segment dysgenesis in which abnormal cleavage of the anterior chamber occurs at the end of the third week of gestation. We examined the prevalence of strabismus and amblyopia and analyzed predictive factors for their development, as well as the visual outcome and associated anomalies in patients with bilateral Peters anomaly. Methods: Using a retrospective review, we identified 25 consecutive patients with bilateral Peters anomaly who were observed between August 1995 and February 2005. Ocular structural and systemic anomalies, amblyopia therapy, visual acuity, and binocular alignment at last visit were recorded. Fisher's exact test was used to identify any association between defined predictive factors and the development of strabismus. Results: Mean follow-up time was 5.1 year (range, 0.5-21 years). Median age at presentation was 2.5 months (range, 1 day to 13 years). Penetrating keratoplasties were performed on 34 eyes in 20 patients. Final best-corrected visual acuity ranged from 20/25 to no light perception. Thirteen of 18 patients with recorded motility (72%) developed strabismus: esotropia (n = 7), exotropia (n = 5), and variable (n = 1); one also had dissociated vertical deviation. Patients with equal vision were either orthophoric (n = 4) or had intermittent esotropia (n = 1), whereas strabismus occurred in 100% of patients whose vision was asymmetric by more than 1.5 octaves. Asymmetric vision was the only statistically significant predictive factor for the development of strabismus (P = 0.002). Amblyopia treatment resulted in improved vision in 3 of 5 patients. Conclusion: Strabismus occurs frequently in bilateral Peters anomaly. Asymmetric vision, (because of ocular structural anomalies) postoperative complications, and amblyopia may predispose to strabismus. Despite ocular structural limitations, amblyopia therapy is recommended in the aggressive rehabilitation of these eyes.

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Ophthalmology. 2006 Jun;113(6):904-12. Comment in: Ophthalmology. 2006 Jun;113(6):893.
A randomized trial to evaluate 2 hours of daily patching for strabismic and anisometropic amblyopia in children.
Wallace DK; Pediatric Eye Disease Investigator Group; Edwards AR, Cotter SA, Beck RW, Arnold RW, Astle WF, Barnhardt CN, Birch EE, Donahue SP, Everett DF, Felius J, Holmes JM, Kraker RT, Melia M, Repka MX, Sala NA, Silbert DI, Weise KK.
Jaeb Center for Health Research, 15310 Amberly Drive, Suite 350, Tampa, FL 33647, USA. pedig@jaeb.org

OBJECTIVE: To compare 2 hours of daily patching (combined with 1 hour of concurrent near visual activities) with a control group of spectacle wear alone (if needed) for treatment of moderate to severe amblyopia in children 3 to 7 years old. DESIGN: Prospective randomized multicenter clinical trial (46 sites). PARTICIPANTS: One hundred eighty children 3 to 7 years old with best-corrected amblyopic-eye visual acuity (VA) of 20/40 to 20/400 associated with strabismus, anisometropia, or both who had worn optimal refractive correction (if needed) for at least 16 weeks or for 2 consecutive visits without improvement. INTERVENTION: Randomization either to 2 hours of daily patching with 1 hour of near visual activities or to spectacles alone (if needed). Patients were continued on the randomized treatment (or no treatment) until no further improvement was noted. MAIN OUTCOME MEASURE: Best-corrected VA in the amblyopic eye after 5 weeks. RESULTS: Improvement in VA of the amblyopic eye from baseline to 5 weeks averaged 1.1 lines in the patching group and 0.5 lines in the control group (P = 0.006), and improvement from baseline to best measured VA at any visit averaged 2.2 lines in the patching group and 1.3 lines in the control group (P<0.001). CONCLUSION: After a period of treatment with spectacles, 2 hours of daily patching combined with 1 hour of near visual activities modestly improves moderate to severe amblyopia in children 3 to 7 years old.

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Ophthalmology. 2006 Jun;113(6):895-903. Comment in: Ophthalmology. 2006 Jun;113(6):893.
Treatment of anisometropic amblyopia in children with refractive correction.
Cotter SA; Pediatric Eye Disease Investigator Group; Edwards AR, Wallace DK, Beck RW, Arnold RW, Astle WF, Barnhardt CN, Birch EE, Donahue SP, Everett DF, Felius J, Holmes JM, Kraker RT, Melia M, Repka MX, Sala NA, Silbert DI, Weise KK.
Jaeb Center for Health Research, 15310 Amberly Drive, Suite 350, Tampa, FL 33647, USA. pedig@jaeb.org

OBJECTIVE: To evaluate the effectiveness of refractive correction alone for the treatment of untreated anisometropic amblyopia in children 3 to <7 years old. DESIGN: Prospective, multicenter, noncomparative intervention. PARTICIPANTS: Eighty-four children 3 to <7 years old with untreated anisometropic amblyopia ranging from 20/40 to 20/250. METHODS: Optimal refractive correction was provided, and visual acuity (VA) was measured with the new spectacle correction at baseline and at 5-week intervals until VA stabilized or amblyopia resolved. MAIN OUTCOME MEASURES: Maximum improvement in best-corrected VA in the amblyopic eye and proportion of children whose amblyopia resolved (interocular difference of < or =1 line) with refractive correction alone. RESULTS: Amblyopia improved with optical correction by > or =2 lines in 77% of the patients and resolved in 27%. Improvement took up to 30 weeks for stabilization criteria to be met. After stabilization, additional improvement occurred with spectacles alone in 21 of 34 patients observed in a control group of a subsequent randomized trial, with amblyopia resolving in 6. Treatment outcome was not related to age, but was related to better baseline VA and lesser amounts of anisometropia. CONCLUSION: Refractive correction alone improves VA in many cases and results in resolution of amblyopia in at least one third of 3- to <7-year-old children with untreated anisometropic amblyopia. Although most cases of resolution occur with moderate (20/40-20/100) amblyopia, the average 3-line improvement in VA resulting from treatment with spectacles may lessen the burden of subsequent amblyopia therapy for those with denser levels of amblyopia.

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Cont Lens Anterior Eye. 2006 May 16; [Epub ahead of print]
Orthoptic indications for contact lens wear.
Evans BJ.
Institute of Optometry, 56-62 Newington Causeway, London SE1 6DS, UK; Department of Optometry and Visual Science, City University, Northampton Square, London EC1V 0HB, UK.

Orthoptic anomalies are prevalent: they are encountered in at least 5% of patients seen in a typical primary eyecare practice. Several cases are reviewed that highlight the role of contact lenses in treating orthoptic anomalies. In particular, contact lenses are the preferred optical approach to the correction of anisometropia, and it is often argued that anisometropia should be corrected as young as possible. However, fitting contact lenses to patients, particularly children, with anisometropic amblyopia has been problematic because there is no immediate binocular acuity improvement when the contact lenses are inserted which reduces patient motivation. Continuous wear with silicone hydrogels represents a breakthrough for these cases and some illustrative case studies are given. The visual deficit in amblyopia can be reduced in some cases solely by fitting contact lenses, without the need for occlusion therapy. Other orthoptic uses of contact lenses are reviewed including: correcting motor deviations, occlusion, and infantile onset nystagmus. It is concluded that there are orthoptic anomalies where contact lenses are the preferred mode of correction. It is in patients' best interest for practitioners to discuss contact lenses in these cases.

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Lancet. 2006 Apr 22;367(9519):1343-51.
Amblyopia.
Holmes JM, Clarke MP.
Department of Ophthalmology, Mayo Clinic College of Medicine, Rochester, MN 55905, USA. holmes.jonathan@mayo.edu

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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Eur J Ophthalmol. 2006 Mar-Apr;16(2):214-8.
Visual outcome after excimer laser refractive surgery in adult patients with amblyopia.
Roszkowska AM, Biondi S, Chisari G, Messina A, Ferreri FM, Meduri A.
Ophthalmology Clinic, Department of Surgical Specialities, Univ. of Messina, Messina, Italy. anrosz@tiscali.it

PURPOSE: To evaluate the visual and refractive outcome in adult patients wi th refractive and anisometropic amblyopia treated with photorefractive keratectomy. METHODS: An interventional non-comparative study was performed on 50 consecutive patients with amblyopia treated with photorefractive keratectomy. Sixty-eight eyes of 18 participants with bilateral refractive amblyopia and 32 participants with unilateral anisometropic amblyopia were studied. The photorefractive keratectomy was performed with MEL 70 G-Scan excimer laser. Follow-up was 1, 3, 6, and 12 months after the treatment. The mean outcome measures were uncorrected visual acuity (UCVA), best spectacle corrected visual acuity (BCVA), refraction, and corneal transparency. RESULTS: In 64.7% of eyes, the UCVA at 12 months after the treatment was better than or equal to their preoperative BCVA. A total of 82.4% of eyes improved their BCVA one or more lines. No eye lost lines of BCVA, 17.6% remained unvaried, 50% gained one line, 20.6 % gained two lines, and 11.8% gained three lines of BCVA. The number of lines gained correlated strongly with diopters of anisometropia between eyes (p<0.01). The mean sphere changed from -5.62+/-3.37 D to -0.47+/-1 D, mean cylinder varied from -2.36+/-1.57 to -0.18+/-0.41 D, and the spherical equivalent varied from -6.82+/-3.1 to -0.45+/-1.08 D. No clinically significant haze was observed. CONCLUSIONS: Excimer laser refractive surgery appears to be a safe and efficient procedure in the treatment of ametropic and anisometropic amblyopia in adults. Adult patients with anisometropic and refractive amblyopia could benefit from the refractive treatment with significant improvement of the visual acuity.

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Strabismus. 2006 Mar;14(1):43-50.
Amblyopia: contemporary clinical issues.
Williams C, Harrad R.
Bristol Eye Hospital, Bristol, UK.

Research into the clinical management of amblyopia has, most recently, focussed on the effectiveness of amblyopia treatment. Given the mounting evidence that the condition is treatable, an important priority is the detection of individuals with the condition. Here, we review critically the means by which this can be achieved. We conclude that intensive early screening can produce improved outcomes but that the effectiveness of real-life screening programmes is very dependent on the coverage they obtain. An almost entirely neglected subfield of amblyopia treatment research is the identification of reasons why parents and children often fail to comply with occlusion therapy. Here, we examine a psychological approach to this problem and find it to be informative in predicting compliance. Lastly, we consider the disability arising from strabismus, again from a psychological perspective, and find that on a range of psychosocial well-being indicators, strabismus surgery results in significant gains.

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Strabismus. 2006 Mar;14(1):37-42.
The treatment of amblyopia.
Holmes JM, Repka MX, Kraker RT, Clarke MP.
Department of Ophthalmology, Mayo Clinic College of Medicine, Rochester, MN.

Recent studies suggest that children with amblyopia associated with anisometropia, strabismus, or both should be treated initially with best refractive correction until visual acuity is stable. This may take several months, and a proportion of children will achieve equal visual acuity with glasses alone. For residual anisometropic and strabismic amblyopia, the initial choice of patching or atropine should involve the parent and the child. The dose of prescribed patching or atropine may initially be quite modest, such as 2 hours of patching a day or twice weekly atropine. Treatment should be offered to children until at least 12 years of age and possibly to teenagers. Ongoing studies are addressing the role of undertaking near activities while patched and the role of atropine for severe amblyopia and for older amblyopic children. Future studies are needed to investigate the best treatment strategies for residual amblyopia, whether weaning treatment is needed at the end of a course, and how compliance can be enhanced.

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J AAPOS. 2006 Feb;10(1):37-43.
Successful treatment of anisometropic amblyopia with spectacles alone.
Steele AL, Bradfield YS, Kushner BJ, France TD, Struck MC, Gangnon RE.
Department of Ophthalmology, University of Wisconsin, Madison, WI.

Background: The efficacy of treating anisometropic amblyopia with occlusion therapy is well known. However, this form of treatment can be associated with risks. Spectacle correction alone may be a successful and underutilized form of treatment. Methods The records of 28 patients treated successfully for anisometropic amblyopia with glasses alone were reviewed. Age, initial visual acuity and stereoacuity, and nature of anisometropia were analyzed to assess associations with time required for resolution, final visual acuity, and stereoacuity. Incidence of amblyopia recurrence and results of subsequent treatment, including patching, were also studied. Results: Mean time to amblyopia resolution (interocular acuity difference </=1 line) was 5.8 months (range 2 to 15 months). Worse best corrected initial visual acuity was associated with longer time to resolution (Spearman's rho = 0.37, P = 0.05), while age, initial stereoacuity, amount, and type of anisometropia were not (P = 0.43, 0.68, 0.26, 0.47, respectively). None of the astigmatic or myopic patients achieved visual acuity of 20/20 in the amblyopic eye, while seven (39%) of the hyperopic patients did. This difference was significant (P = 0.03). Better initial stereoacuity predicted good final stereoacuity (P = 0.01). Only four (14%) patients developed amblyopia recurrence over an average follow-up period of 1.7 years. All were successfully treated with updated spectacles or patching. Conclusions: Treatment of anisometropic amblyopia with spectacles alone can be a successful option. Patients treated with spectacles alone may experience a lower amblyopia recurrence rate than those treated with occlusion therapy.

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Ophthalmology. 2006 Feb;113(2):169-76. Epub 2005 Dec 19. Comment in: Ophthalmology. 2006 Feb;113(2):167-8.
Long-term outcomes of photorefractive keratectomy for anisometropic amblyopia in children.
Paysse EA, Coats DK, Hussein MA, Hamill MB, Koch DD.
Baylor College of Medicine, Texas Children's Hospital, Houston, Texas 77030, USA. epaysse@bcm.tmc.edu

PURPOSE: To evaluate the long-term visual acuity (VA) and refractive error responses to excimer laser photorefractive keratectomy (PRK) for treatment of anisometropic amblyopia in children. DESIGN: Prospective interventional case-control study. PARTICIPANTS: Eleven children, 2 to 11 years old, with anisometropic amblyopia who were noncompliant with conventional therapy with glasses or contact lenses and occlusion therapy were treated with PRK. A cohort derived retrospectively of 13 compliant and 10 noncompliant children with refractive errors similar to those of the PRK group who were treated with traditional anisometropic amblyopia therapy served as control groups. INTERVENTION: Photorefractive keratectomy for the eye with the higher refractive error. MAIN OUTCOME MEASURES: (1) Refractive error reduction and stability in the treated eye, (2) cycloplegic refraction, (3) VA, (4) stereoacuity, and (5) corneal haze up to 3 years after PRK. Compliant and noncompliant children with anisometropia amblyopia were analyzed as controls for refractive error and VA. RESULTS: Preoperative refractive errors were -13.70 diopters (D) (+/-3.77) for the myopic group and +4.75 D (+/-0.50) for the hyperopic group. Mean postoperative refractive errors at last follow-up (mean, 31 months) were -3.55 D (+/-2.2.5) and +1.41 D (+/-1.07) for the myopic and hyperopic groups, respectively. At last follow-up, cycloplegic refractions in 4 (50%) of 8 myopes and all hyperopes (100%) were within 3 D of that of the fellow eye. Five (63%) of 8 myopic children achieved a refraction within 2 D of the target refraction. Two (67%) of 3 hyperopic patients maintained their refractions within 2 D of the target. Refractive regressions (from 1 year after surgery to last follow-up) were 0.50+/-1.41 D (myopes) and 0.60+/-0.57 D (hyperopes). Seven children (77%) were able to perform psychophysical VA testing preoperatively and postoperatively. Five (71%) of the 7 children had uncorrected VA improvement of at least 2 lines, and 4 (57%) of 7 had best spectacle-corrected VA improvement of at least 2 lines, with 1 improving 7 lines. Five (55%) of 9 children had improvement of their stereoacuity at last follow-up. Subepithelial corneal haze remained negligible. The mean final VA of the PRK group was significantly better than that of the noncompliant control group (P = 0.003). The mean final refractive error for both myopic and hyperopic groups was also significantly better that that of the control groups (P = 0.007 and P<0.0001, respectively). CONCLUSIONS: Photorefractive keratectomy for severe anisometropic amblyopia in children resulted in long-term stable reduction in refractive error and improvement in VA and stereopsis, with negligible persistent corneal haze.

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J Cataract Refract Surg. 2006 Jan;32(1):103-8.
Refractive laser surgery in children with coexisting medical and ocular pathology.
Astle WF, Papp A, Huang PT, Ingram A.
>From the Alberta Children's Hospital, University of Calgary, Division of Ophthalmology, Calgary, Alberta, Canada.

PURPOSE: To report the visual, refractive, and functional outcomes of photorefractive keratectomy (PRK) and of laser-assisted subepithelial keratectomy in a group of children with significant refractive error and underlying medical conditions or ocular pathology who were noncompliant with traditional management. SETTING: Nonhospital surgical facility and a hospital clinic. METHODS: This case series comprised 5 individual cases of anisometropic amblyopia and/or high myopia. Underlying medical and ocular conditions were as follows: upper eyelid hemangioma with oblique myopic astigmatism, Pelizaeus-Merzbacher leukodystrophy with nystagmus, Klippel-Trenaunay-Weber syndrome with glaucoma, incontinentia pigmenti with unilateral optic nerve atrophy, and Goldenhar syndrome with unilateral optic nerve hypoplasia. Photorefractive keratectomy or LASEK was performed in 6 eyes of 5 patients. Age range at the time of surgery was 1.0 to 7.0 years. All procedures were performed under general anesthesia. RESULTS: Best corrected visual acuity improved by 2 lines in 2 patients and 1 line in 2 patients by 6 months after surgery. Stereopsis and/or fusional status improved in 3 patients. Amblyopia treatment compliance improved in 1 patient. Alignment improved without strabismus surgery in 2 cases. A functional vision survey demonstrated a positive effect on the ability of all 5 children to function in their environment. CONCLUSION: During the period of visual cortical plasticity, refractive surgery, by eliminating the refractive component of amblyopia and by promoting fusional ability, provides considerable improvement in children, even those with underlying medical conditions associated with ocular pathology.

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Am J Ophthalmol. 2006 Jan;141(1):175-184.
Amblyopia: diagnostic and therapeutic options.
Wu C, Hunter DG.
Department of Ophthalmology, Children's Hospital Boston, Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115, USA. carolyn.wu@childrens.harvard.edu

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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Indian J Med Res. 2005 Dec;122:497-505.
Factors influencing visual rehabilitation after occlusion therapy in unilateral amblyopia in children.
Menon V, Chaudhuri Z, Saxena R, Gill K, Sachdeva MM.
Dr R.P. Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India.

BACKGROUND & OBJECTIVE: Amblyopia is one of the most common causes of visual impairment in adults and children, and visual loss may be permanent if not treated in time. Though many studies have been done on occlusion therapy which is the mainstay in the treatment of unilateral amblyopia, discrepancies exist in literature about quantification of treatment and follow up measures. The present study was undertaken to evaluate the factors responsible for the successful outcome of treatment and the optimum time required for the same in children with unilateral amblyopia. METHODS: Baseline characteristics of 63 verbal patients with unilateral amblyopia (strabismic, anisometropic, mixed) referred to the Strabismus and Amblyopia Clinic at the Dr Rajendra Prasad Centre for Ophthalmic Sciences, New Delhi between September 2001 to December 2002 who improved to the desired level of visual acuity after treatment for amblyopia in the mentioned time period, were analyzed to assess for factors that directly or indirectly influenced the optimum visual rehabilitation and the average duration of therapy required for the same. The evaluation included assessment of the baseline best-corrected visual acuity (BCVA) and refractive status in both eyes, the age at presentation, the type of amblyopia present, fixation pattern in the amblyopic eye, inter-eye visual acuity difference, and evaluation of compliance through a parental diary system. RESULTS: Baseline BCVA in the amblyopic eye was similar in all the three groups. Patients with anisometropic amblyopia showed a quicker response to therapy. Compliance to treatment was the major factor affecting the overall time required for a successful outcome in most cases. The overall time required for the treatment to be successful (including the period of maintenance) was about 1089 h. INTERPRETATION & CONCLUSION: This hospital-based study showed that the average duration of occlusion therapy to achieve stable isoacuity was 7.2 months with an average occlusion of 6-7 h/day. Compliance to therapy was the most important factor affecting the duration of therapy. With increasing emphasis on paediatric eye diseases, amblyopia is at last getting its due importance as a cause of treatable correctable paediatric visual impairment which can have lifelong repercussions, both in terms of individual disability and financial burden to the society if not treated in time. As the therapy is simple and effective if started early, mass awareness, visual screening, and counselling would go a long way in treating the patients, thus decreasing the prevalence of amblyopia in the country.

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Clin Exp Optom. 2005 Nov;88(6):365-75.
Amblyopia: prevalence, natural history, functional effects and treatment.
Webber AL, Wood J.
School of Optometry, Queensland University of Technology, Brisbane, Australia. webbopt@ozemail.com.au

Amblyopia, defined as poor vision due to abnormal visual experience early in life, affects approximately three per cent of the population and carries a projected lifetime risk of visual loss of at least 1.2 per cent. The presence of amblyopia or its risk factors, mainly strabismus or refractive error, have been primary conditions targeted in childhood vision screenings. Continued support for such screenings requires evidence-based understanding of the prevalence and natural history of amblyopia and its predisposing conditions, and proof that treatment is effective in the long term with minimal negative impact on the patient and family. This review summarises recent research relevant to the clinical understanding of amblyopia, including prevalence data, risk factors, the functional impact of amblyopia and optimum treatment regimes and their justification from a vision and life skills perspective. Collectively, these studies indicate that treatment for amblyopia is effective in reducing the overall prevalence and severity of visual loss from amblyopia. Correction of refractive error alone has been shown to significantly reduce amblyopia and less frequent occlusion can be just as effective as more extensive occlusion. Occlusion or penalisation in amblyopia treatment can create negative changes in behaviour in children and impact on family life, and these factors should be considered in prescribing treatment, particularly because of their influence on compliance. Ongoing treatment trials are being undertaken to determine both the maximum age at which treatment of amblyopia can still be effective and the importance of near activities during occlusion. This review highlights the expansion of current knowledge regarding amblyopia and its treatment to help clinicians provide the best level of care for their amblyopic patients that current knowledge allows.

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Optometry. 2005 Oct;76(10):570-8.
Contemporary issues in amblyopia treatment.
Rutstein RP.
School of Optometry, University of Alabama at Birmingham, 1716 University Boulevard, Birmingham, AL 35294, USA. rrutstein@icare.opt.uab.edu

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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J AAPOS. 2005 Oct;9(5):449-54.
Visual outcome and success of amblyopia treatment in unilateral small posterior lens opacities and lenticonus initially treated nonsurgically.
Travi GM, Schnall BM, Lehman SS, Kelly CJ, Hug D, Hirakata VN, Calhoun JH.
Wills Eye Hospital, Philadelphia, PA, USA. gmtravi@uol.com.br

PURPOSE: We sought to assess the success of amblyopia treatment in patients with small posterior lens opacities as well as the factors associated with a good visual outcome. METHODS: This was a retrospective study of patients with posterior lens opacities that initially were thought to be too small in size to warrant cataract surgery. The following variables were examined: cataract type, location, diameter, persistent hyaloid vessel, anisometropia, strabismus, and age of detection. Success of treatment of amblyopia was defined as improvement by at least 0.3 logMAR units. Good visual outcome was defined as 20/40 or better. Amblyopia was treated by glasses, patching, and/or atropine. Patients who failed with conservative treatment or had an increase in cataract size underwent surgery. RESULTS: Forty-eight (91%) of 53 eyes were amblyopic. Thirty amblyopic eyes had pre- and post-treatment Snellen acuities. Twenty (67%) had their visual acuity (VA) improved by 0.3 logMAR units or greater. None of the measured variables were associated with successful amblyopia treatment. Twenty-five (49%) of 51 patients had a final VA of 20/40 or better. The only variable associated with good visual outcome was cataract type: 18 of 25 (72%) posterior subcapsular cataract and 6 of 23 (32%) posterior lenticonus eyes achieved VA of 20/40 or better (P = 0.008). Six patients who went on to have cataract surgery experienced a larger improvement in BCVA (4.50 logMar units +/- 2.52 lines) compared with patients treated without cataract surgery (2.36 logMar units +/- 3.11 lines). DISCUSSION: Amblyopia treatment was successful in most cases. A small group of patients who underwent cataract surgery experienced a greater VA improvement; however, it was not statistically significant. Further studies are needed to determine which patients would benefit from cataract surgery.

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Invest Ophthalmol Vis Sci. 2005 Sep;46(9):3161-8.
Perceptual learning improves visual performance in juvenile amblyopia.
Li RW, Young KG, Hoenig P, Levi DM.

PURPOSE: To determine whether practicing a position-discrimination task improves visual performance in children with amblyopia and to determine the mechanism(s) of improvement. METHODS: Five children (age range, 7-10 years) with amblyopia practiced a positional acuity task in which they had to judge which of three pairs of lines was misaligned. Positional noise was produced by distributing the individual patches of each line segment according to a Gaussian probability function. Observers were trained at three noise levels (including 0), with each observer performing between 3000 and 4000 responses in 7 to 10 sessions. Trial-by-trial feedback was provided. RESULTS: Four of the five observers showed significant improvement in positional acuity. In those four observers, on average, positional acuity with no noise improved by approximately 32% and with high noise by approximately 26%. A position-averaging model was used to parse the improvement into an increase in efficiency or a decrease in equivalent input noise. Two observers showed increased efficiency (51% and 117% improvements) with no significant change in equivalent input noise across sessions. The other two observers showed both a decrease in equivalent input noise (18% and 29%) and an increase in efficiency (17% and 71%). All five observers showed substantial improvement in Snellen acuity (approximately 26%) after practice. CONCLUSIONS: Perceptual learning can improve visual performance in amblyopic children. The improvement can be parsed into two important factors: decreased equivalent input noise and increased efficiency. Perceptual learning techniques may add an effective new method to the armamentarium of amblyopia treatments.

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Invest Ophthalmol Vis Sci. 2005 Sep;46(9):3152-60.
Treatment of unilateral amblyopia: factors influencing visual outcome.
Stewart CE, Fielder AR, Stephens DA, Moseley MJ.
Department of Optometry and Visual Science, City University, London, United Kingdom.

PURPOSE: To identify factors that influence the outcome of treatment for unilateral amblyopia, as a part of the Monitored Occlusion Treatment of Amblyopia Study (MOTAS). METHODS: This was an intervention study consisting of three nonoverlapping phases: "Baseline", "refractive adaptation" (18 weeks of full-time spectacle wear), and "occlusion" (6 hours of patching per day, objectively monitored). Condition factors: type of amblyopia, age of participant, initial severity of amblyopia, fixation, and binocular vision status; treatment factors: refractive adaptation and occlusion (total dose [hours] and dose rate [hours per day]) were assessed for their influence on visual outcome. Visual outcome was expressed in three ways: logMAR (logarithm of the minimum angle of resolution) change, residual amblyopia, and proportion of the deficit corrected. RESULTS: The study included 85 participants (mean age, 5.1 +/- 1.4 years) with amblyopia associated with strabismus (n = 32) or anisometropia (n = 20) or associated with both anisometropia and strabismus (n = 33). Treatment factors: cumulative occlusion dose exceeding 50 hours, and dose rates >/=1 hour per day resulted in (P </= 0.01) lower residual amblyopia and a greater proportion of the deficit corrected. Condition factors associated with poor outcome (high residual amblyopia) were presence of eccentric fixation, severe initial amblyopia, and no binocular vision. CONCLUSIONS: Factors influencing outcome with treatment for amblyopia are occlusion dose (the rate of delivery and cumulative dose worn), the initial severity of the amblyopia, binocular vision status, fixation of the amblyopic eye, and the age of the subject at the start of treatment.

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Eye. 2005 Jun 3; [Epub ahead of print]
Resolution in partially accomodative esotropia during occlusion treatment for amblyopia.
Koc F, Ozal H, Yasar H, Firat E.
1Strabismus, SSK Ankara Eye Disease Hospital, Ulucanlar, Ankara, Turkey.

PURPOSE: To evaluate alignment changes in partially accommodative esotropia during occlusion treatment for amblyopia. METHOD: Changes at the deviation angles of 63 partially accommodative esotropia patients, who had occlusion treatment for amblyopia, were evaluated retrospectively. RESULTS: Mean deviation angle at the start of therapy without glasses was 45 PD (10-90 PD) and became 27 PD (5-70 PD) after at least 2 months with glasses. During 12 (2-36) months of occlusion period, mean manifest deviation angle with glasses decreased to 11 PD (0-50) (P<0.001) and amblyopia resolved in 71.5% of the cases. After termination of amblyopia treatment 24 (38%) cases had surgery for the residual deviation but if we had planned surgery before amblyopia treatment, 81% of the patients would have had surgery. DISCUSSION: Should amblyopia be treated initially or should we operate first in patients with strabismus and amblyopia together? Our research suggests that we should not hurry to operate in high hypermetropic partially accommodative cases, which have amblyopia and a long-term history of strabismus. Initial amblyopia treatment in these cases allows time for resolution of the nonaccomodative component in strabismus and can significantly decrease the necessity for surgery.Eye advance online publication, 3 June 2005; doi:10.1038/sj.eye.6701874.

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Strabismus. 2005 Jun;13(2):63-9.
Efficacy of occlusion treatment in amblyopia and clinical risk factors affecting the results of treatment.
Arikan G, Yaman A, Berk AT.
Department of Ophthalmology, Pediatric Ophthalmology and Strabismus Unit, Dokuz Eylul University, 35320 Narlidere, Izmir, Turkey. gulozden@hotmail.com

PURPOSE: To evaluate the factors influencing visual outcome in strabismic, strabismic-anisometropic and anisometropic amblyopia following occlusion treatment. METHODS: Records of 128 pediatric patients who had been treated for amblyopia by occlusion of the fellow eye between March 1992 and March 2003 were reviewed retrospectively. Age and level of visual acuity at initiation of treatment, occlusion time (full-time, part-time or minimal) and type of amblyopia were analyzed for the effect on visual outcome. RESULTS: The mean age of the patients was 5.69 +/- 2.01 years (3 to 12 years). Mean follow-up time was 3 years 2 months (6 months to 10 years). Mean visual acuity improvements were similar for the subtypes of amblyopia (strabismic amblyopia 0.38 +/- 0.29 logMAR units, strabismic-anisometropic amblyopia 0.46 +/- 0.40 logMAR units, anisometropic amblyopia 0.35 +/- 0.24 logMAR units). Level of initial visual acuity, age at initiation of treatment and type of occlusion correlated with the final visual acuity (p = 0.000, p = 0.035, p = 0.012, respectively). When the analysis was performed according to the subtypes of amblyopia, initial visual acuity was the only factor associated with the final visual acuity in all types of amblyopia (p < 0.05). CONCLUSION: The level of initial visual acuity is the most significant factor determining the success of treatment in amblyopia.

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J AAPOS. 2005 Apr;9(2):129-36.
A randomized pilot study of near activities versus non-near activities during patching therapy for amblyopia.
Holmes JM, Edwards AR, Beck RW, Arnold RW, Johnson DA, Klimek DL, Kraker RT, Lee KA, Lyon DW, Nosel ER, Repka MX, Sala NA, Silbert DI, Tamkins S; Pediatric Eye Disease Investigator Group.
Jaeb Center for Health Research, 15310 Amberly Drive, Tampa, FL 33647, USA. pedig@jaeb.org

BACKGROUND: To plan a future randomized clinical trial, we conducted a pilot study to determine whether children randomized to near or non-near activities would perform prescribed activities. A secondary aim was to obtain a preliminary estimate of the effect of near versus non-near activities on amblyopic eye visual acuity, when combined with 2 hours of daily patching. METHODS: Sixty-four children, 3 to less than 7 years of age, with anisometropic, strabismic, or combined amblyopia (20/40 to 20/400) were randomly assigned to receive either 2 hours of daily patching with near activities or 2 hours of daily patching without near activities. Parents completed daily calendars for 4 weeks recording the activities performed while patched and received a weekly telephone call in which they were asked to describe the activities performed during the previous 2 hours of patching. Visual acuity was assessed at 4 weeks. RESULTS: The children assigned to near visual activities performed more near activities than those assigned to non-near activities (by calendars, mean 1.6 +/- 0.5 hours versus 0.2 +/- 0.2 hours daily, P < 0.001; by telephone interviews, 1.6 +/- 0.4 hours versus 0.4 +/- 0.5 hours daily, P < 0.001). After 4 weeks of treatment, there was a suggestion of greater improvement in amblyopic eye visual acuity in those assigned to near visual activities (mean 2.6 lines versus 1.6 lines, P = 0.07). The treatment group difference in visual acuity was present for patients with severe amblyopia but not moderate amblyopia. CONCLUSIONS: Children patched and instructed to perform near activities for amblyopia spent more time performing those near activities than children who were instructed to perform non-near activities. Our results suggest that performing near activities while patched may be beneficial in treating amblyopia. Based on our data, a formal randomized amblyopia treatment trial of patching with and without near activities is both feasible and desirable.

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J AAPOS. 2005 Apr;9(2):107-11.
Amblyopia treatment outcomes.
Scott WE, Kutschke PJ, Keech RV, Pfeifer WL, Nichols B, Zhang L.
Department of Ophthalmology and Visual Sciences, University of Iowa Health Care, Iowa City, IA 52242, USA.

PURPOSE: To determine the effectiveness and side effects of full-time occlusion for the treatment of amblyopia. METHODS: Patients with unilateral amblyopia secondary to strabismus, anisometropia, or a combination of the two were retrospective reviewed. All patients had full-time occlusion encompassing 24 hours per day or all waking hours, followed to a defined endpoint. Success was defined as 20/30 or better or equal visual acuity by fixation pattern between the two eyes. The ultimate goal was equal visual acuity. RESULTS: Six hundred patients fit the inclusion criteria. Mean follow-up after the cessation of full-time patching was 7.2 years. Eighty-nine percent were followed for more than 1 year. Mean age at last follow-up visit was 10.82 years. Ninety-six percent of patients attained a successful visual result. Sixty percent attained equal visual acuity. Younger patients required less occlusion time to endpoint and had a better visual outcome ( P < 0.0001). Initial visual acuity was significantly related to best visual acuity attained ( P < 0.0001). The incidence of occlusion amblyopia was 25.8%. CONCLUSIONS: Full-time occlusion produces excellent visual acuity results. It was shown to be effective with no long-term complications if patients proceed as directed.

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Eye. 2005 Apr 15; [Epub ahead of print]
Preliminary results from the use of the novel Interactive Binocular Treatment (I-BiTtrade mark) system, in the treatment of strabismic and anisometropic amblyopia.
Waddingham PE, Butler TK, Cobb SV, Moody AD, Comaish IF, Haworth SM, Gregson RM, Ash IM, Brown SM, Eastgate RM, Griffiths GD.
[1] 1Directorate of Ophthalmology, 'A' Floor, Eye, Ear, Nose and Throat Centre, Queen's Medical Centre, Nottingham, UK [2] 2Virtual Reality Applications Research Team (VIRART), University of Nottingham, School of 4 M, University Park, Nottingham, UK.

BACKGROUND: We have developed a novel application of adapted virtual reality (VR) technology, for the binocular treatment of amblyopia. We describe the use of the system in six children. METHODS: Subjects consisted of three conventional treatment 'failures' and three conventional treatment 'refusers', with a mean age of 6.25 years (5.42-7.75 years). Treatment consisted of watching video clips and playing interactive games with specifically designed software to allow streamed binocular image presentation. RESULTS: Initial vision in the amblyopic eye ranged from 6/12 to 6/120 and post-treatment 6/7.5 to 6/24-1. Total treatment time was a mean of 4.4 h. Five out of six children have shown an improvement in their vision (average increase of 10 letters), including those who had previously failed to comply with conventional occlusion. CONCLUSIONS: Improvements in vision were demonstrable within a short period of time, in some children after 1 h of treatment. This system is an exciting and promising application of VR technology as a new treatment for amblyopia.Eye advance online publication, 15 April 2005; doi:10.1038/sj.eye.6701883.

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Arch Ophthalmol. 2005 Apr;123(4):437-47.
Randomized trial of treatment of amblyopia in children aged 7 to 17 years.
Scheiman MM, Hertle RW, Beck RW, Edwards AR, Birch E, Cotter SA, Crouch ER Jr, Cruz OA, Davitt BV, Donahue S, Holmes JM, Lyon DW, Repka MX, Sala NA, Silbert DI, Suh DW, Tamkins SM; Pediatric Eye Disease Investigator Group.
Jaeb Center for Health Research, Tampa, FL 33647, USA. pedig@jaeb.org

OBJECTIVE: To evaluate the effectiveness of treatment of amblyopia in children aged 7 to 17 years. METHODS: At 49 clinical sites, 507 patients with amblyopic eye visual acuity ranging from 20/40 to 20/400 were provided with optimal optical correction and then randomized to a treatment group (2-6 hours per day of prescribed patching combined with near visual activities for all patients plus atropine sulfate for children aged 7 to 12 years) or an optical correction group (optical correction alone). Patients whose amblyopic eye acuity improved 10 or more letters (> or =2 lines) by 24 weeks were considered responders. RESULTS: In the 7- to 12-year-olds (n = 404), 53% of the treatment group were responders compared with 25% of the optical correction group (P<.001). In the 13- to 17-year-olds (n = 103), the responder rates were 25% and 23%, respectively, overall (adjusted P = .22) but 47% and 20%, respectively, among patients not previously treated with patching and/or atropine for amblyopia (adjusted P = .03). Most patients, including responders, were left with a residual visual acuity deficit. CONCLUSIONS: Amblyopia improves with optical correction alone in about one fourth of patients aged 7 to 17 years, although most patients who are initially treated with optical correction alone will require additional treatment for amblyopia. For patients aged 7 to 12 years, prescribing 2 to 6 hours per day of patching with near visual activities and atropine can improve visual acuity even if the amblyopia has been previously treated. For patients 13 to 17 years, prescribing patching 2 to 6 hours per day with near visual activities may improve visual acuity when amblyopia has not been previously treated but appears to be of little benefit if amblyopia was previously treated with patching. We do not yet know whether visual acuity improvement will be sustained once treatment is discontinued; therefore, conclusions regarding the long-term benefit of treatment and the development of treatment recommendations for amblyopia in children 7 years and older await the results of a follow-up study we are conducting on the patients who responded to treatment.

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J Pediatr Ophthalmol Strabismus. 2005 Mar-Apr;42(2):82-8.
A systematic review of the applicability and efficacy of eye exercises.
Rawstron JA, Burley CD, Elder MJ.
Ophthalmology Department, Christchurch Hospital, Christchurch, New Zealand.

PURPOSE: To examine the current scientific evidence base regarding the efficacy of eye exercises as used in optometric vision therapy. METHODS: A search was performed of the following databases: Allied and Complementary Medicine Database, Cochrane Database of Systematic Reviews, Cochrane Register of Controlled Trials, EMBASE, and MEDLINE. Relevant articles were reviewed and analyzed for strengths and weaknesses. Pertinent sections of classic texts were studied to provide a historical basis and to serve as a source for additional early references. RESULTS: Forty-three refereed studies were obtained. Of these, 14 were clinical trials (10 controlled studies), 18 review articles, 2 historical articles, 1 case report, 6 editorials or letters, and 2 position statements from professional colleges. Many of the references listed by the larger reviews were unpublished or published in obscure or nonrefereed sources and therefore were not accessible. CONCLUSIONS: Eye exercises have been purported to improve a wide range of conditions including vergence problems, ocular motility disorders, accommodative dysfunction, amblyopia, learning disabilities, dyslexia, asthenopia, myopia, motion sickness, sports performance, stereopsis, visual field defects, visual acuity, and general well-being. Small controlled trials and a large number of cases support the treatment of convergence insufficiency. Less robust, but believable, evidence indicates visual training may be useful in developing fine stereoscopic skills and improving visual field remnants after brain damage. As yet there is no clear scientific evidence published in the mainstream literature supporting the use of eye exercises in the remainder of the areas reviewed, and their use therefore remains controversial.

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Surv Ophthalmol. 2005 Mar-Apr;50(2):123-66.
Amblyopia characterization, treatment, and prophylaxis.
Simons K.
Pediatric Vision Laboratory, Krieger Children's Eye Center, Wilmer Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland 21287-9028, USA.

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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Arch Ophthalmol. 2005 Feb;123(2):149-57.
Two-year follow-up of a 6-month randomized trial of atropine vs patching for treatment of moderate amblyopia in children.
Repka MX, Wallace DK, Beck RW, Kraker RT, Birch EE, Cotter SA, Donahue S, Everett DF, Hertle RW, Holmes JM, Quinn GE, Scheiman MM, Weakley DR; Pediatric Eye Disease Investigator Group.
Jaeb Center for Health Research, Tampa, FL 33647, USA. pedig@jaeb.org

OBJECTIVE: To compare patching and atropine sulfate as treatments for moderate amblyopia in children 18 months after completion of a 6-month randomized trial. METHODS: In a randomized, multicenter (47 sites) clinical trial, 419 children younger than 7 years with amblyopia (20/40 to 20/100 in the affected eye) were assigned to receive either patching or atropine eye drops for 6 months. Between 6 months and 2 years, treatment was at the discretion of the investigator.Main Outcome Measure Visual acuity in the amblyopic eye and sound eye after 2 years. RESULTS: At 2 years, visual acuity in the amblyopic eye improved from baseline a mean of 3.7 lines in the patching group and 3.6 lines in the atropine group. The difference in visual acuity between treatment groups was small: 0.01 logMAR (95% confidence interval, -0.02 to 0.04). In both treatment groups, the mean amblyopic eye acuity was approximately 20/32, 1.8 lines worse than the mean sound eye acuity, which was approximately 20/20. CONCLUSIONS: Atropine or patching for 6 months followed by best clinical care until 2 years produced similar improvement of moderate amblyopia in children between 3 and 7 years of age at enrollment. However, on average the amblyopic eye acuity was still approximately 2 lines worse than the sound eye.

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Plast Reconstr Surg. 2005 Jan;115(1):22-30.
Periorbital lymphatic malformation: clinical course and management in 42 patients.
Greene AK, Burrows PE, Smith L, Mulliken JB.
Vascular Anomalies Center, Division of Plastic Surgery, and the Department of Radiology, Children's Hospital, Harvard Medical School, Boston, Mass 02115, USA.

Lymphatic malformation in the orbital cavity and surrounding region often causes disfigurement and visual problems. To better clarify the evolution and treatment of this condition, the authors studied a retrospective cohort of 42 consecutive patients seen between 1971 and 2003 and analyzed anatomic features, complications, and management. The ratio of female to male patients was 1:1. Most periorbital lymphatic malformations were noted at birth (59 percent), presenting as either unilateral swelling (60 percent) or a periorbital mass (24 percent). Sixty-two percent of lesions were on the left side. The ipsilateral cheek, temple, and forehead also were involved in 57 percent of patients. Twenty-two percent of lesions were intraconal, 30 percent were extraconal, and 48 percent were in both spaces. Forty-five percent of children had an associated cerebral developmental venous anomaly. Periorbital lymphatic malformation caused major morbidity; 52 percent of patients had intralesional bleeding and 26 percent of patients had a history of infection. Other common complications included intermittent swelling (76 percent), blepharoptosis (52 percent), proptosis (45 percent), pain (21 percent), amblyopia (33 percent), chemosis (19 percent), astigmatism (17 percent), and strabismus (7 percent). Ultimately, 40 percent of children had diminished vision and 7 percent became blind in the affected eye. Management of periorbital lymphatic malformation involved an interdisciplinary team that included an interventional radiologist, a craniofacial surgeon, and an ophthalmologist. The two therapeutic strategies were sclerotherapy (40 percent) and resection (57 percent); most patients required several interventions. A coronal approach was used for subtotal excision of fronto-temporal-orbital lymphatic malformation in 13 patients, whereas a tarsal incision was used for lesions isolated to the eyelid (n = 14). Ocular proptosis was temporarily managed by tarsorrhaphy (n = 9), but expansion of the bony orbit was needed to correct persistent proptosis (n = 8). Orbital exenteration was necessary in two patients.

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J Cataract Refract Surg. 2004 Dec;30(12):2529-35.
Laser-assisted subepithelial keratectomy in children.
Astle WF, Huang PT, Ingram AD, Farran RP.
Alberta Children's Hospital, University of Calgary Division of Ophthalmology, Calgary, Alberta, Canada.

PURPOSE: To evaluate whether laser-assisted subepithelial keratectomy (LASEK) achieves effective targeted myopic correction with less post-treatment corneal haze than observed with photorefractive keratectomy (PRK) in children who fail traditional forms of treatment for myopic anisometropic amblyopia and high myopia. SETTING: Nonhospital surgical facility with follow-up in a hospital clinic setting. METHODS: This prospective study comprised 36 eyes of 25 patients. The mean patient age at treatment was 8.27 years (range 1.0 to 17.4 years). Patients were divided into 3 groups: those with myopic anisometropic amblyopia (13 patients/13 eyes), those with bilateral high myopia (11 patients/22 eyes), and those with high myopia post-penetrating keratoplasty (1 patient/1 eye). All patients were treated with LASEK under general anesthesia using the Visx 20/20 B excimer laser and a multizone, multipass ablation technique. Although the myopia was as high as -22.00 diopters (D) spherical equivalent (SE) in some eyes, no eye was treated for more than -19.00 D SE. RESULTS: At 1 year, the mean SE decreased from -8.03 D to -1.19 D. Forty-four percent of eyes were within +/-1.0 D of the targeted correction; 78% of eyes had clear corneas with no haze. In the entire group, the mean best corrected visual acuity improved from 20/80 to 20/50. A functional-vision survey demonstrated a positive effect on the patients' ability to function in their environments after LASEK. CONCLUSIONS: Laser-assisted subepithelial keratectomy in children represents another method of providing long-term resolution of bilateral high myopia and myopic anisometropic amblyopia with minimal post-laser haze. The reduction in post-laser haze with LASEK compared to that with the standard PRK technique may represent an advantage in treating these complex patients.

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J Cataract Refract Surg. 2004 Dec;30(12):2517-21.
Improvement in best corrected visual acuity in amblyopic adult eyes after laser in situ keratomileusis.
Sakatani K, Jabbur NS, O'Brien TP.
Refractive Eye Surgery Service, Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland 21093, USA.

PURPOSE: To evaluate improvement in best spectacle-corrected visual acuity (BSCVA) after laser in situ keratomileusis (LASIK) in adult patients with amblyopia. SETTING: Refractive Eye Surgery Center, Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA. METHODS: The charts of consecutive patients with a diagnosis of amblyopia at the time of refractive evaluation who had LASIK were reviewed retrospectively. The preoperative and postoperative uncorrected visual acuity (UCVA) and BSCVA were analyzed. RESULTS: Twenty-one eyes of 19 patients were identified as having amblyopia and LASIK surgery. Eight patients (42.1%) were diagnosed with amblyopia only, 6 patients (31.6%) had anisometropic amblyopia, 4 patients (21.1%) had strabismic amblyopia, and 1 patient (5.2%) had anisometropic and strabismic amblyopia. Eleven eyes (52.4%) had myopic astigmatism, 7 eyes (33.3%) were hyperopic, and 3 eyes (14.3%) had mixed astigmatism. Seven eyes (33.3 %) experienced more than a 1-line improvement in postoperative UCVA compared with the preoperative BSCVA. Nine eyes (42.8%) experienced more than a 1-line improvement in postoperative BSCVA compared with the preoperative BSCVA. The BSCVA was unchanged in 11 eyes (52.4%) and was worse by 2 lines in 1 eye (4.8%). CONCLUSION: After LASIK, the postoperative BSCVA was better than preoperatively in 42.8% of eyes with a history of amblyopia and the postoperative UCVA was better than the preoperative BSCVA in 33.3%.

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J Cataract Refract Surg. 2004 Dec;30(12):2522-8.
Laser in situ keratomileusis for treated anisometropic amblyopia in awake, autofixating pediatric and adolescent patients.
Phillips CB, Prager TC, McClellan G, Mintz-Hittner HA.
Department of Ophthalmology and Visual Science, University of Texas-Houston Medical School, Houston, Texas, USA.

PURPOSE: To establish the safety and efficacy of laser in situ keratomileusis (LASIK) in pediatric and adolescent patients with anisometropic amblyopia who completed amblyopia therapy and had a visual acuity of 20/30 or better bilaterally. SETTING: Department of Ophthalmology and Visual Science, University of Texas-Houston Medical School, Houston, Texas, USA. METHODS: From August 2000 to March 2002, LASIK was performed in 21 eyes of 19 consecutive patients meeting eligibility requirements. The procedure was performed with the Summit Autonomous LADARVision 4000 excimer laser (Alcon Laboratories, Inc.) in the amblyopic eye for the correction of anisometropia or in both eyes. All patients were awake and autofixating during the procedure. RESULTS: The mean patient age was 13.14 years (range 8 to 19 years). Seventeen patients were treated in the amblyopic eye only to correct anisometropia; treatment was performed in both eyes of 2 patients who were older than 18 years. Patients were followed for a mean of 18.0 months (range 8.6 to 26.5 months). Anisometropia was greater than 2.00 diopters (D) in all cases (mean 4.43 D, range 13.25 to 2.25 D). The percentage deviation from the attempted correction in the myopic group was 4.0% +/- 4.0% (SD) (range 2.0% to 10.0%) and 38.0% +/- 13.0% (range 5.0% to 58.0%) in the hyperopic group. Anisometropia decreased uniformly to less than 2.00 D in all patients (mean 1.52 D). The percentage of patients with stereo acuity increased from 63.0% preoperatively to 84.0% postoperatively. CONCLUSIONS: Laser in situ keratomileusis safely and effectively reduced anisometropia in these patients. If stereo acuity is not possible preoperatively, it may be obtained postoperatively.

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Br J Ophthalmol. 2004 Dec;88(12):1552-6.
Refractive adaptation in amblyopia: quantification of effect and implications for practice.
Stewart CE, Moseley MJ, Fielder AR, Stephens DA.
Department of Visual Neuroscience, Imperial College London, Charing Cross Campus, Margravine Road, London W6 8RP, UK. c.stewart@imperial.ac.uk.

AIM: To describe the visual response to spectacle correction ("refractive adaptation") for children with unilateral amblyopia as a function of age, type of amblyopia, and category of refractive error. METHOD: Measurement of corrected amblyopic and fellow eye logMAR visual acuity in newly diagnosed children. Measurements repeated at 6 weekly intervals for a total 18 weeks. RESULTS: Data were collected from 65 children of mean (SD) age 5.1 (1.4) years with previously untreated amblyopia and significant refractive error. Amblyopia was associated with anisometropia in 18 (5.5 (1.4) years), strabismus in 16 (4.2 (0.98) years), and mixed in 31 (5.2 (1.5) years) of the study participants. Mean (SD) corrected visual acuity of amblyopic eyes improved significantly (p<0.001) from 0.67 (0.38) to 0.43 (0.37) logMAR: a mean improvement of 0.24 (0.18), range 0.0-0.6 log units. Change in logMAR visual acuity did not significantly differ as a function of amblyopia type (p = 0.29) (anisometropia 0.22 (0.13); mixed 0.18 (0.14); strabismic 0.30 (0.24)) or for age (p = 0.38) ("under 4 years" 0.23 (0.18); "4-6 years" 0.24 (0.20); "over 6 years" 0.16 (0.23)). CONCLUSION: Refractive adaptation is a distinct component of amblyopia treatment. To appropriately evaluate mainstream therapies such as occlusion and penalisation, the beneficial effects of refractive adaptation need to be fully differentiated. A consequence for clinical practice is that children may start occlusion with improved visual acuity, possibly enhancing compliance, and in some cases unnecessary patching will be avoided.

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Ophthalmology. 2004 Nov;111(11):2076-85.
A randomized trial of atropine regimens for treatment of moderate amblyopia in children.
Repka MX, Cotter SA, Beck RW, Kraker RT, Birch EE, Everett DF, Hertle RW, Holmes JM, Quinn GE, Sala NA, Scheiman MM, Stager DR Sr, Wallace DK; Pediatric Eye Disease Investigator Group.
Jaeb Center for Health Research, 15310 Amberly Drive, Suite 350, Tampa, FL 33647, USA. rbeck@jaeb.org

OBJECTIVE: To compare daily atropine to weekend atropine as prescribed treatments for moderate amblyopia in children younger than 7 years. DESIGN: Prospective, randomized multicenter clinical trial (30 sites). PARTICIPANTS: One hundred sixty-eight children younger than 7 years with amblyopia in the range of 20/40 to 20/80 associated with strabismus, anisometropia, or both. INTERVENTION: Randomization either to daily atropine or to weekend atropine for 4 months. Partial responders were continued on the randomized treatment until no further improvement was noted. MAIN OUTCOME MEASURE: Visual acuity (VA) in the amblyopic eye after 4 months. RESULTS: The improvement in VA of the amblyopic eye from baseline to 4 months averaged 2.3 lines in each group. The VA of the amblyopic eye at study completion was either (1) at least 20/25 or (2) better than or equal to that of the sound eye in 39 children (47%) in the daily group and 45 children (53%) in the weekend group. The VA of the sound eye at the end of follow-up was reduced by 2 lines in one patient in each group. Stereoacuity outcomes were similar in the 2 groups. CONCLUSIONS: Weekend atropine provides an improvement in VA of a magnitude similar to that of the improvement provided by daily atropine in treating moderate amblyopia in children 3 to 7 years old. This article contains additional online-only material available at http://www.ophsource.com/periodicals/ophtha.

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J Fr Ophtalmol. 2004 Nov;27(9 Pt 1):1017-24.
[Importance of occlusion therapy for amblyopia in partial unilateral congenital cataracts that are discovered late.]
[Article in French]
Denion E, Dedes V, Bonne M, Labalette P, Berger C, Guilbert F, Bouckehove S, Rouland JF.
Service d'Ophtalmologie, Hopital Huriez, CHRU de Lille, avenue Michel Polonovski, 59037 Lille cedex.

PURPOSE: The aim of this study is to investigate the importance of occlusion therapy for amblyopia in patients with partial unilateral congenital cataracts that were discovered after 24 months of age. MATERIAL: and methods: A retrospective study was conducted on 11 patients, each of whom underwent a clinical examination including a cycloplegic refraction with atropine. The average age when the cataract was diagnosed was 35 months. The average distance visual acuity was 6/78 and the average near visual acuity was 35/175. Occlusion therapy using adhesive patches was started after refractive error correction. In two cases, observance was mediocre. RESULTS: Ametropia was found in every patient, with anisometropia in nine patients (alpha<0.02). This anisometropia included an astigmatism that was always greater on the side with the cataract (alpha<0.001), averaging 2.7 diopters. After occlusion therapy for amblyopia, the average visual acuity significantly improved to 6/22 in distance vision (alpha<0.02) and 35/45 in near vision (alpha<0.01). The average follow-up period was 28 months (5-60 months). CONCLUSION: Amblyopia is related to lens opacities as well as frequently associated anisometropia. Functional improvement is greater in near vision than in distance vision. With occlusion therapy for amblyopia, accommodation is preserved. This factor is of utmost importance as near vision is preferential in young children. This study provides an opportunity to recall the importance of refraction and occlusion therapy for amblyopia, which must be systematically attempted in cases of partial unilateral congenital cataracts before considering a surgical procedure.

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J AAPOS. 2004 Oct;8(5):420-8.
Risk of amblyopia recurrence after cessation of treatment.
Holmes JM, Beck RW, Kraker RT, Astle WF, Birch EE, Cole SR, Cotter SA, Donahue S, Everett DF, Hertle RW, Keech RV, Paysse E, Quinn GF, Repka MX, Scheiman MM; Pediatric Eye Disease Investigator Group.
Jaeb Center for Health Research, Tampa, FL 33647, USA. holmes.jonathan@mayo.edu

BACKGROUND: Although amblyopia can be successfully treated with patching or atropine, there have been few prospective studies of amblyopia recurrence once treatment is discontinued. METHODS: We enrolled 156 children with successfully treated anisometropic or strabismic amblyopia (145 completed follow-up), who were younger than 8 years of age and who received continuous amblyopia treatment for the previous 3 months (prescribed at least 2 hours of daily patching or prescribed at least one drop of atropine per week) and who had improved at least 3 logMAR levels during the period of continuous treatment. Patients were followed off treatment for 52 weeks to assess recurrence of amblyopia, defined as a 2 or more logMAR level reduction of visual acuity from enrollment, confirmed by a second examination. Recurrence was also considered to have occurred if treatment was restarted because of a nonreplicated 2 or more logMAR level reduction of visual acuity. RESULTS: Recurrence occurred in 35 (24%) of 145 cases (95% confidence interval 17% to 32%) and was similar in patients who stopped patching (25%) and in patients who stopped atropine (21%). In patients treated with moderately intense patching (6 to 8 hours per day), recurrence was more common (11 of 26; 42%) when treatment was not reduced prior to cessation than when treatment was reduced to 2 hours per day prior to cessation (3 of 22; 14%, odds ratio 4.4, 95% confidence interval 1.0 to 18.7). CONCLUSIONS: Approximately one fourth of successfully treated amblyopic children experience a recurrence within the first year off treatment. For patients treated with 6 or more hours of daily patching, our data suggest that the risk of recurrence is greater when patching is stopped abruptly rather than when it is reduced to 2 hours per day prior to cessation. A randomized clinical trial of no weaning versus weaning in successfully-treated amblyopia is warranted to confirm these observational findings.

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Invest Ophthalmol Vis Sci. 2004 Sep;45(9):3048-54.
Treatment dose-response in amblyopia therapy: the Monitored Occlusion Treatment of Amblyopia Study (MOTAS).
Stewart CE, Moseley MJ, Stephens DA, Fielder AR.
Department of Visual Neuroscience, Imperial College London, United Kingdom. c.stewart@imperial.ac.uk

PURPOSE: Amblyopia is the commonest visual disorder of childhood. Yet the contributions of the two principal treatments (spectacle wear and occlusion) to outcome are unknown. This study was undertaken to investigate the dose-response relationship of amblyopia therapy. METHODS: The study comprised three distinct phases: baseline, in which repeat measures of visual function were undertaken to confirm the initial visual deficit; refractive adaptation: an 18-week period of spectacle wear with six weekly measurements of logarithm of the minimum angle of resolution (logMAR) visual acuity; occlusion: in which participants were prescribed 6 hours of "patching" per day. In the latter phase, occlusion was objectively monitored and logMAR visual acuity recorded at 2-week intervals until any observed gains had ceased. RESULTS: Data were obtained from 94 participants (mean age, 5.1 +/- 1.4 years) with amblyopia associated with strabismus (n = 34), anisometropia (n = 23), and both anisometropia and strabismus (n = 37). Eighty-six underwent refractive adaptation. Average concordance with patching was 48%. The relationship between logMAR visual acuity gain and total occlusion dose was monotonic and linear. Increasing dose rate beyond 2 h/d hastened the response but did not improve outcome. More than 80% of the improvement during occlusion occurred within 6 weeks. Treatment outcome was significantly better for children younger than 4 years (n = 17) than in those older than 6 years (n = 24; P = 0.0014). CONCLUSIONS: Continuous objective monitoring of the amount of patching therapy received has provided insight into the dose-response relationship of occlusion therapy for amblyopia. Patching is most effective within the first few weeks of treatment, even for those in receipt of a relatively small dose. Further studies are needed to elucidate the neural basis for the dose-response functions. Copyright Association for Research in Vision and Ophthalmology

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Curr Opin Ophthalmol. 2004 Aug;15(4):350-7.
Advances in phakic intraocular lenses: indications, efficacy, safety, and new designs.
Alio JL.
VISSUM/Instituto Oftalmologico de Alicante. Universidad Miguel Hernandez, Alicante, Spain. jlalio@oftalio.com

PURPOSE OF REVIEW: The recent evolution of phakic intraocular lenses (PIOLs) has made this refractive surgical technique safer, very predictable, and effective. Due to these reasons, PIOLs have been expanding the horizon of their indications. The aim of this review is to update the reader in the recent advances reported on the topic during the year 2003. RECENT FINDINGS: The most recent progress has been made towards decreasing the incision size down to 3 mm or less for all PIOLs models to avoid pupil ovalling in angle-supported designs with new biomaterials or exchangeable haptics, and to decrease the incidence of cataract induction in posterior chamber models with modified designs and better sizing. High-order aberrations and the quality of vision are improved with PIOLs. The main limitation for the further development of PIOLs is the lack of adequate diagnostic imaging techniques to perform a precise preoperative study of the anterior segment anatomy. Emerging diagnostic technologies based on the use of very high frequency (100 MHz) ultrasound and optical coherence tomography seem to have a most important role in the future development of PIOLs defining preoperatively the most adequate anatomic conditions for each design. PIOLs offer today an excellent alternative for the correction of high and moderate myopia, hyperopia, and astigmatism. Emerging indications, still under investigation, include presbyopia and pediatric anisometropic amblyopia. SUMMARY: Due to their advantages for quality of vision and the increased knowledge on their safety, as well as the evidence of their predictability, PIOLs are expected to largely increase their clinical use as a refractive surgical technique in the coming years.

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J AAPOS. 2004 Aug;8(4):318-24.
Pediatric transscleral sutured intraocular lenses: Efficacy and safety in 43 eyes followed an average of 3 years.
Bardorf Cm C, Epley Kd K, Lueder Gt G, Tychsen L.

PURPOSE: To report longer term results of transscleral sutured intraocular lens (TSSIOL) implantation in a sizable cohort of aphakic children, who were not suitable for contact lens wear and lacked adequate capsular support for sulcus fixation of an intraocular lens. METHODS: Clinical outcome data were collated by retrospective review after surgery on 43 consecutive eyes in 32 aphakic children (mean age at implantation = 10 years; 33% </= age 7 years). Outcome measures included visual acuity, postoperative refractive error, postoperative complications, and rate of reoperation. Follow-up averaged 37 months. RESULTS: Visual acuity improved after surgery in 70% (30) of operated eyes (in 69% or 22/32 children). Fifty-one percent (22/43 eyes) improved by two lines or more. No patient suffered a loss of acuity or exacerbation of preexisting amblyopia. Postoperative refraction was within +/-2.0 D of the predicted refraction in 93% (40/43) of eyes. Complications, with the exception of one eye (2%), were minor/transient and resolved in the first week after surgery. Complications included small hyphemas (7%, 3/43 eyes), vitreous hemorrhage (5%, 2/43 eyes), and ocular hypertension or hypotony (5%). Two eyes (5%) exhibited episodes of iris capture of the IOL optic, one of which (2%, 1/43) eventually necessitated reoperation for IOL exchange. No retinal detachments or other retinal complications were encountered. CONCLUSION: TSSIOL implantation appears to be a safe and effective method for correcting aphakia in pediatric eyes that lack adequate capsular support. Safety over a follow-up period longer than the average 3 years reported here remains to be determined. The surgery is more difficult to perform than capsular-bag or sulcus implantation and potentially carries greater risks.

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Am J Ophthalmol. 2004 Jul;138(1):70-8.
Photorefractive keratectomy for pediatric anisometropia: safety and impact on refractive error, visual acuity, and stereopsis.
Paysse EA, Hamill MB, Hussein MA, Koch DD.
Cullen Eye Institute, Baylor College of Medicine, Department of Ophthalmology, Texas Children's Hospital, 6621 Fannin Street, CC 640.00, Houston, Texas 77030, USA. epaysse@bcm.tmc.edu

PURPOSE: To establish the safety and possible efficacy of excimer laser photorefractive keratectomy (PRK) for treatment of pediatric anisometropia. DESIGN: Interventional case series METHODS: This is a prospective, noncomparative interventional case series at an individual university practice of photorefractive keratectomy in 11 children aged 2 and 11 years with anisometropic amblyopia who were unable or unwilling to use contact lens, glasses, and occlusion therapy to treat the amblyopia. The eye with the higher refractive error was treated with PRK using a standard adult nomogram. The refractive treatment goal was to decrease the anisometropia to 3 diopters or less. Main outcome measures were cycloplegic refraction, refractive correction, degree of corneal haze, uncorrected and best spectacle-corrected visual acuity, and stereopsis over 12 months. RESULTS: All patients tolerated the procedure well. The mean refractive target reduction was -10.10 +/- 1.39 diopters for myopia and +4.75 +/- 0.50 diopters for hyperopia. The mean achieved refractive error reduction at 12 months for myopia was -10.56 +/- 3.00 diopters and for hyperopia was +4.08 +/- 0.8 diopters. Corneal haze at 12 months was minimal. Uncorrected visual acuity improved by 2 or more lines in 6 (75%) of the eight children able to perform psychophysical acuity tests. Best spectacle-corrected visual acuity improved by 2 lines in 3 (38%) of patients. Stereopsis improved in 3 (33%) of nine patients. CONCLUSIONS: Pediatric PRK can be safely performed for anisometropia. The refractive error response in children appears to be similar to that of adults with comparable refractive errors. Visual acuity and stereopsis improved despite several children being outside the standard age of visual plasticity. Photorefractive keratectomy may play a role in the management of anisometropia in selected pediatric patients.

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Invest Ophthalmol Vis Sci. 2004 Jun;45(6):1817-22.
Binocular visual field changes after surgery in esotropic amblyopia.
Quah SA, Kaye SB.
Royal Liverpool University Hospital and Royal Liverpool Childrens Hospital, Liverpool, United Kingdom.

PURPOSE: To determine binocular visual field (BVF) changes after strabismus surgery in children with large angle esotropia, and whether these changes can be predicted, using a prism to correct the preoperative angle of deviation. METHODS: Monocular visual field (MVF) and BVF were measured by Goldmann perimetry in healthy adults (n = 6) using a range of prisms. Visual fields were then measured in normal children (n = 19) and in children with large angle esotropic amblyopia (n = 28). The visual field was measured preoperatively with and without a prism equal to the angle of esotropia. A further evaluation was made at 2 and 18 months postoperatively. RESULTS: In healthy adults, prisms had no significant effect on the extent of MVF or BVF. There was no significant difference in the MVF in children with and without strabismus. There was a significant reduction in the BVF and in the ratio of the BVF to MVF between normal children (138 degrees, 0.59; P = 0.01) and children with esotropic amblyopia (120 degrees, 0.57; P = 0.02). Postoperatively, there was a significant improvement in the BVF (P = 0.02), which was maintained at 18 months. The increase in BVF was significantly greater than the variation in repeat fields (P = 0.04), with 8 of 13 children showing an increase in the BVF above the 95% CI of the repeatability measurements. There was a good linear correlation between the size of the preoperative BVF in the presence of a prism and the postoperative BVF (r = 0.90 P = 0.001). CONCLUSIONS: Children with esotropic amblyopia demonstrate a significant reduction in their BVF. Prisms correcting the preoperative angle could be used to predict the potential increase in the BVF after surgery. Patients with a BVF/MVF approaching that found in normal children, however, may not show an improvement in the size of their BVF after surgery.

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Klin Monatsbl Augenheilkd. 2004 May;221(5):386-9.
[Does amblyopia therapy make sense in eyes with severe organic defects?]
[Article in German]
Lengyel D, Klainguti G, Mojon DS.
Augenklinik, Kantonsspital St. Gallen, Schweiz.

BACKGROUND: In eyes with severe organic defects the question arises if amblyopia therapy makes sense. PATIENTS AND METHODS: Three children are presented in whom despite severe organic eye diseases amblyopia therapy was tried. The first child had a unilateral large macular scar secondary to retinoblastoma treatment, the second a unilateral severe optic nerve atrophy secondary to an orbital hemangioma, and the third a unilateral large optic nerve coloboma. RESULTS: In the first case a reading visual acuity of 0.9 was achieved by occlusion therapy and in the second a reading visual acuity of 0.5. In the third case occlusion lead to alternation of the divergent strabismus (child too strongly retarded for reliable visual acuity measurements). CONCLUSIONS: During the sensitive phase, amblyopia therapy is also indicated in eyes with severe organic defects since good visual acuities can be achieved.

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Vision Res. 2004;44(14):1623-34.
Treatment of astigmatism-related amblyopia in 3- to 5-year-old children.
Harvey EM, Dobson V, Miller JM, Sherrill DL.
Department of Ophthalmology, The University of Arizona, 655 N. Alvernon, Suite 108, Tucson, AZ 85711, USA. emharvey@u.arizona.edu

Best-corrected acuity was measured for vertical and horizontal gratings and for Lea Symbols recognition acuity in 3- to 5-year-old children with high astigmatism and in non-astigmatic children. There was significant amblyopia among astigmatic children at baseline. There was no evidence that eyeglass correction of astigmatism resulted in a reduction in amblyopia over a 4-month average treatment duration (although vision in astigmatic children was significantly improved immediately upon eyeglass correction, indicating that eyeglass correction did provide a visual benefit). Treatment outcome results are discussed in terms of both methodological issues and theoretical implications.

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Optometry. 2004 Apr;75(4):241-4.
Full-time occlusion compared to part-time occlusion for the treatment of amblyopia.
Hug T.
The Children's Mercy Hospital, Department of Ophthalmology, Kansas City, Missouri 64108, USA. thug@cmh.edu

BACKGROUND: Occlusion of the better-seeing eye as a method of treatment for amblyopia has long been a standard of care. A difference exists between practitioners on using either full-time occlusion or part-time occlusion. METHODS: A retrospective review of pediatric patients (ages 3 to 7 years) with amblyopia was performed. The patients were prescribed either full-time occlusion or part-time occlusion for the primary treatment of their amblyopia. Exclusions were made for patients with an organic or structural component of their amblyopia. Twenty-one patients were included in the full-time occlusion group and 24 patients were included in the part-time occlusion group. RESULTS: Seventy-six percent of patients who completed full-time occlusion achieved 20/40 acuity or better and 67% achieved 20/30 or better, with an average treatment time of six weeks. Fifty-eight percent of patients who completed part-time occlusion achieved 20/40 acuity or better and only 46% achieved 20/30 or better, with an average treatment time of 26 weeks. For patients with 20/80 or worse amblyopia, 82% achieved 20/40 or better with full-time occlusion. Only 40% of part-time occluders with 20/80 or worse achieved 20/40. Occlusion amblyopia did not develop in any patient. CONCLUSION: A higher percentage of amblyopic patients treated with full-time occlusion achieved 20/30 acuity in the amblyopic eye over a shorter duration of treatment.

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Proc Natl Acad Sci U S A. 2004 Apr 27;101(17):6692-7. Epub 2004 Apr 19.
Improving vision in adult amblyopia by perceptual learning.
Polat U, Ma-Naim T, Belkin M, Sagi D.
Goldschleger Eye Research Institute, Tel-Aviv University, Sheba Medical Center, 52621 Tel Hashomer, Israel. upolat@sheba.health.gov.il

Practicing certain visual tasks leads, as a result of a process termed "perceptual learning," to a significant improvement in performance. Learning is specific for basic stimulus features such as local orientation, retinal location, and eye of presentation, suggesting modification of neuronal processes at the primary visual cortex in adults. It is not known, however, whether such low-level learning affects higher-level visual tasks such as recognition. By systematic low-level training of an adult visual system malfunctioning as a result of abnormal development (leading to amblyopia) of the primary visual cortex during the "critical period," we show here that induction of low-level changes might yield significant perceptual benefits that transfer to higher visual tasks. The training procedure resulted in a 2-fold improvement in contrast sensitivity and in letter-recognition tasks. These findings demonstrate that perceptual learning can improve basic representations within an adult visual system that did not develop during the critical period.

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J Pediatr Ophthalmol Strabismus. 2004 Mar-Apr;41(2):89-95.
Successful occlusion therapy for amblyopia in 11- to 15-year-old children.
Mohan K, Saroha V, Sharma A.
Squint Clinic, Grewal Eye Institute, Chandigarh, India.

PURPOSE: To investigate the effectiveness of full-time occlusion therapy in treating amblyopia in 11- to 15-year-old children and to determine its lasting results. PATIENTS AND METHODS: Fifty-five compliant children 11 to 15 years old who had amblyopia were treated with full-time (during all waking hours) occlusion of their good eye until no further improvement in the visual acuity of their amblyopic eye was observed on 3 consecutive monthly follow-up examinations. After this, part-time (4 hours per day) occlusion therapy was used randomly in 24 of 55 patients for 3 to 6 months for maintenance of the final visual acuity. Snellen visual acuity and its logMAR equivalent were recorded before treatment, at the cessation of full-time occlusion therapy, and on the most recent examination. RESULTS: All 55 of the patients had improved visual acuity after treatment. The mean improvement was 0.46 logMAR unit (4.6 Snellen lines). Thirty-two of the patients had a mean follow-up of 17.6 months after the cessation of full-time and maintenance occlusion therapy. Twenty-nine (91%) of the 32 patients maintained improved visual acuity, whereas 3 (9%) exhibited a regression in visual acuity. Maintenance occlusion therapy did not have a significant stabilizing effect on the improved visual acuity. CONCLUSION: Compliant, full-time occlusion effectively improves acuity in children 11 to 15 years old who have amblyopia due to strabismus, anisometropia, or both. Most older patients have lasting improvement with or without maintenance patching.

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Am J Ophthalmol. 2004 Mar;137(3):581-3.
A prospective, pilot study of treatment of amblyopia in children 10 to <18 years old.
Pediatric Eye Disease Investigator Group.

PURPOSE: To determine whether amblyopia can be successfully treated in older children and adolescents. DESIGN: Prospective, single group treatment trial. METHODS: Sixty-six amblyopic patients aged 10 to <18 years with amblyopic eye acuity of 20/40 to 20/160 were treated with daily patching (> or =2 hours a day) combined with at least 1 hour of near activities. Visual acuity was measured before and after 2 months of prescribed treatment. RESULTS: Visual acuity improved 2 or more lines from baseline in 18 (27%) of the 66 patients (95% confidence interval, 17%-40%), and the improvement appeared similar in 10- to <14-year-olds and 14- to <18-year-olds. CONCLUSIONS: Amblyopia treatment can improve visual acuity in older children and adolescents. A randomized controlled trial is needed to determine if there is an upper age limit for which amblyopia treatment is successful.

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J Refract Surg. 2004 Jan-Feb;20(1):25-8.
Laser in situ keratomileusis improves visual acuity in some adult eyes with amblyopia.
Barequet IS, Wygnanski-Jaffe T, Hirsh A.
The Refractive Surgery Center, Herzliya, Israel. barequet@cs.technion.ac.il

PURPOSE: To report the results of laser in situ keratomileusis (LASIK) in a series of adult patients with amblyopia. METHODS: A retrospective noncomparative review was performed on patients with amblyopia who underwent LASIK for correction of ametropia, using the Summit Krumeich Barraquer microkeratome and the Nidek EC-5000 excimer laser. Data were collected on uncorrected visual acuity, best spectacle-corrected visual acuity, manifest refraction, anterior segment evaluation, intraocular pressure, corneal topography, and dilated fundus examination (preoperative and postoperatively on day 1, months 2 and 6). RESULTS: Eight eyes of seven patients were included, with a mean patient age of 30 +/- 10 years (range 21 to 49 yr). Mean preoperative spherical equivalent refraction was -4.70 D (range -12.62 to +4.71 D) and the best spectacle-corrected visual acuity varied from 20/32 to 20/80. At 2 months after LASIK, mean spherical equivalent refraction was -0.37 +/- 0.60 D (range -1.37 to + 0.60 D), uncorrected visual acuity ranged between 20/20 to 20/30, and a mean gain of 3 Snellen lines (range 2 to 4 lines) was observed. All patients reported significant subjective improvement in their perception of vision. The visual acuity and subjective improvement were maintained throughout 6 months postoperatively. CONCLUSIONS: LASIK with the Nidek EC-5000 laser for correction of ametropia in adult amblyopic eyes provided encouraging results for visual acuity improvement beyond correction of the refractive error.

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Br J Ophthalmol. 2004 Jan;88(1):19-21.
LASIK surgery in children.
O'Keefe M, Nolan L.
Mater Private Hospital and Children's University Hospital, Temple Street, Dublin 1, Ireland. lchopth@indio.ie

AIMS: To report success in the treatment of high myopia in children with LASIK. To report the visual results, complications and postoperative management of children with high myopia. METHODS: Six children (seven eyes) with high myopia were included in this series. Preoperative and postoperative refraction, visual acuity, and pachymetry were compared. RESULTS: Six children with high myopia ranging from -5.00DS to -16DS were treated. There were three males and three females. Five children had improved refraction and visual acuity post-LASIK. Age ranged from 2 to 12 years. Five of the children had unilateral amblyopia preoperatively. One had bilateral high myopia. CONCLUSION: High myopia in children may be treated safely and effectively with LASIK.

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Retina. 2003 Dec;23(6):792-5.
Lens-sparing vitreous surgery for infantile amblyogenic vitreous hemorrhage.
Capone A Jr.
Associated Retinal Consultants, P.C., Royal Oak, Michigan 48073, USA. acaponejr@yahoo.com

PURPOSE: To report on a series of infants with amblyogenic vitreous and/or subinternal limiting membrane hemorrhage managed by lens-sparing vitrectomy. DESIGN: Retrospective case series studying retinal attachment status and visual acuity. RESULTS: Eleven eyes sustained vitreous hemorrhage as a consequence of shaken baby syndrome, 1 due to hyaloidal canal hemorrhage extending into the vitreous, 1 due to Terson syndrome, 1 due to birth trauma, and 2 due to a presumed coagulation disorder. Age of the patients at the time of surgery ranged from 2 to 23 months (age adjusted for prematurity). Follow-up ranged from 7 to 81 months (mean, 28 months). Ten eyes had visual improvement. Two infants with shaken baby syndrome had bilateral nonrecordable flash visual evoked potential before surgery; one eye of one infant had a better than expected visual outcome after surgery. One eye sustained a retinal tear without detachment. One eye in an infant with severe shaken baby syndrome and traumatic retinopathy developed a total rhegmatogenous retinal detachment with proliferative vitreoretinopathy. CONCLUSIONS: Infantile amblyogenic vitreous hemorrhage may be effectively managed by lens-sparing vitreous surgery. Visual outcome of shaken baby syndrome may be limited as a consequence of structural damage to the retina, optic nerve, or posterior visual pathways.

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Arch Ophthalmol. 2003 Nov;121(11):1625-32.
Impact of patching and atropine treatment on the child and family in the amblyopia treatment study.
Holmes JM, Beck RW, Kraker RT, Cole SR, Repka MX, Birch EE, Felius J, Christiansen SP, Coats DK, Kulp MT; Pediatric Eye Disease Investigator Group.

OBJECTIVE: To assess the psychosocial impact on the child and family of patching and atropine as treatments for moderate amblyopia in children younger than 7 years. METHODS: In a randomized, controlled clinical trial, 419 children younger than 7 years with amblyopic eye visual acuity in the range of 20/40 to 20/100 were assigned to receive treatment with either patching or atropine at 47 clinical sites. After 5 weeks of treatment, a parental quality-of-life questionnaire was completed for 364 (87%) of the 419 patients.Main Outcome Measure Overall and subscale scores on the Amblyopia Treatment Index. RESULTS: High internal validity and reliability were demonstrated for the Amblyopia Treatment Index questionnaire. The overall Amblyopia Treatment Index scores and the 3 subscale scores were consistently higher (worse) in the patching group compared with the atropine-treated group (overall mean, 2.52 vs 2.02, P<.001; adverse effects of treatment: mean, 2.35 vs 2.11, P =.002; difficulty with compliance: mean, 2.46 vs 1.99, P<.001; and social stigma: mean, 3.09 vs 1.84, P<.001, respectively). CONCLUSION: Although the Amblyopia Treatment Index questionnaire results indicated that both atropine and patching treatments were well tolerated by the child and family, atropine received more favorable scores overall and on all 3 questionnaire subscales.

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Ophthalmology. 2003 Nov;110(11):2088-92.
The relationship between stereopsis and visual acuity after occlusion therapy for amblyopia.
Lee SY, Isenberg SJ.
Department of Ophthalmology, Jules Stein Eye Institute, University of California Los Angeles School of Medicine, Los Angeles, California 90095, USA.

PURPOSE: To investigate the relationship between visual acuity (VA) and stereoacuity after occlusion therapy in patients with various types of amblyopia. DESIGN: Retrospective noncomparative case series. PARTICIPANTS: Sixty-one children with amblyopia caused by anisometropia with no strabismus (26 children), small angle (</=8 prism diopters) or intermittent strabismus (20), or both (15). METHODS: All were treated with occlusion therapy. Visual acuity and near stereopsis using the Titmus test (Stereo Optical Inc., Chicago, IL) were measured at each clinic visit. MAIN OUTCOME MEASURE: The change in near stereopsis relative to distance VA after occlusion therapy. RESULTS: Mean age at initiation of therapy was 5.1 years (range = 3.5-8) and mean follow-up 52.3 weeks (range = 13-192). Mean duration of occlusion was 36 weeks (range = 12-102). After occlusion treatment, mean VA of all children improved from 0.43 to 0.78 (P<0.0001), whereas mean stereoacuity improved from 1167.4 seconds of arc to 101 (P<0.0001). By the last visit, 85.2% (52 of 61) of patients demonstrated at least 2 lines of improvement in VA. There was a significant linear relationship between VA and stereoacuity (P<0.001). The 26 anisometropic patients without strabismus enjoyed improvement in VA and stereopsis (P<0.0001) similar to that of the 35 with small-angle or intermittent strabismus (P<0.0001). CONCLUSIONS: When employing occlusion therapy for amblyopia (due to anisometropia, small-angle or intermittent strabismus, or a combination), as VA improves, stereopsis generally also improves.

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J Med Assoc Thai. 2003 Aug;86 Suppl 3:S556-62.
Successful amblyopia therapy by using synoptophore.
Subharngkasen I.
Department of Ophthalmology, Queen Sirikit National Institute of Child Health, Bangkok 10400, Thailand.

BACKGROUND: Amblyopia is the most common cause of monocular visual impairment in children. Even though occlusion therapy is the treatment of choice, the success rate has not been well achieved due to poor compliance. Other alternative treatments have been tried for a better outcome. OBJECTIVE: To report successful therapy for amblyopia using synoptophore. METHOD: A retrospective study of 25 amblyopic children enrolled in the amblyopic treatment program, from September 18, 1996 to October 14, 2002. The program included patching of the good eye, stimulating the amblyopic eye with synoptophore, and recording the visual acuity of both eyes each time. All children were regularly examined every 3 months by the same ophthalmologist. The compliance of each individual was reassessed and adjusted. At the end of the training program, visual acuity of the amblyopic and the good eyes were measured, plus the binocularity of both eyes were recorded as the main outcome measurement. RESULT: Final (best) visual acuities were between 20/20 and 20/30 for 19 cases of 21 cases (90%). Final best binocularity was maintained in 15 of 25 patients (60%), including 4 anisometropic patients (100%), 2 ptosis patients (50%), 4 pseudophakic patients (80%), 2 strabismic patients (40%), and 3 combined group patients (100%) CONCLUSION: By using synoptophore to stimulate the amblyopic eye, while occluding the good eye, it improved the level of vision to a certain acceptable degree. Thus, compliance of the treatment can be well achieved. However, the understanding and good cooperation of the parents were also a must for successful amblyopia therapy.

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Ophthalmology. 2003 Nov;110(11):2075-87.
A randomized trial of prescribed patching regimens for treatment of severe amblyopia in children.
Holmes JM, Kraker RT, Beck RW, Birch EE, Cotter SA, Everett DF, Hertle RW, Quinn GE, Repka MX, Scheiman MM, Wallace DK; Pediatric Eye Disease Investigator Group.

OBJECTIVE: To compare full-time patching (all hours or all but 1 hour per day) to 6 hours of patching per day, as prescribed treatments for severe amblyopia in children younger than 7 years. DESIGN: Prospective, randomized multicenter clinical trial (32 sites). PARTICIPANTS: One hundred seventy-five children younger than 7 years with amblyopia in the range of 20/100 to 20/400. INTERVENTION: Randomization either to full-time patching or to 6 hours of patching per day, each combined with at least 1 hour of near-visual activities during patching. MAIN OUTCOME MEASURE: Visual acuity in the amblyopic eye after 4 months. RESULTS: Visual acuity in the amblyopic eye improved a similar amount in both groups. The improvement in the amblyopic eye acuity from baseline to 4 months averaged 4.8 lines in the 6-hour group and 4.7 lines in the full-time group (P = 0.45). CONCLUSION: Six hours of prescribed daily patching produces an improvement in visual acuity that is of similar magnitude to the improvement produced by prescribed full-time patching in treating severe amblyopia in children 3 to less than 7 years of age.

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Am J Ophthalmol. 2003 Oct;136(4):630-9.
The course of moderate amblyopia treated with atropine in children: experience of the amblyopia treatment study.
Pediatric Eye Disease Investigator Group.

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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Am J Ophthalmol. 2003 Oct;136(4):620-9.
The course of moderate amblyopia treated with patching in children: experience of the amblyopia treatment study.
Pediatric Eye Disease Investigator Group.

PURPOSE: To assess the course of the response to patching treatment of moderate amblyopia and to assess factors predictive of the response in children 3 years old to younger than 7 years old. DESIGN: Multicenter, randomized clinical trial comparing patching and atropine (one of the amblyopia treatment studies). METHODS: A total of 209 children 3 years old to younger than 7 years of age with amblyopia in the range of 20/40 to 20/100 from the patching treatment arm of this trial were treated with patching of the sound eye from 6 hours per day up to all waking hours. 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: After 5 weeks of treatment, mean amblyopic eye acuity improved from baseline by 2.2 lines. For patients with baseline acuity of 20/80 or 20/100, a greater number of hours of prescribed patching was associated with greater improvement in the first 5 weeks (P =.05). However, this relationship was not present when baseline acuity was 20/40 to 20/60 (P =.57). At 6 months, visual acuity was improved from baseline by a mean of 3.1 lines, with the amount of improvement no longer related to the number of hours patching prescribed at baseline (P =.93). Among the 157 patients improving at least 3 lines from baseline, 15% achieved their maximum improvement by 5 weeks and 52% by 16 weeks. None of the demographic or clinical factors assessed was predictive of the response to treatment. CONCLUSIONS: In the treatment of moderate amblyopia, a beneficial effect of patching is present throughout the age range of 3 years old to younger than 7 years old and the acuity range of 20/40 to 20/100. At 6 months, the amount of improvement appears to be similar when 6 hours of daily patching are initially prescribed vs a greater number of hours. However, when the baseline acuity is 20/80 to 20/100, a greater number of hours of prescribed patching may improve acuity faster.

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Clin Experiment Ophthalmol. 2003 Oct;31(5):418-23.
Early surgical intervention as definitive treatment for ocular adnexal capillary haemangioma.
Slaughter K, Sullivan T, Boulton J, O'Reagan P, Gole G.
Eyelid, Lacrimal and Orbital Clinic, Royal Children's Hospital, Herston, Queensland, Australia.

Background: Capillary haemangioma is the most common orbital and eyelid tumour of childhood, with a prevalence ranging from 1 to 3%. Periorbital haemangiomas can cause amblyopia secondary to anisometropia, induced astigmatism, strabismus or occlusion of the visual axis. Oral and intralesional steroids are considered to be the most accepted form of primary treatment. The authors have been performing early surgery as definitive treatment in selected lesions and believe it has an important role. Methods: A retrospective chart review of 17 infants (2-20 months old) seen between 1996 and 2002 was carried out. Indications for surgery in the present series were astigmatism, rapid growth, anisometropic amblyopia and obscuration of the visual axis. Thirteen were treated primarily with surgery and the other four were treated with other methods prior to considering surgery. Preoperative computed tomography scans were obtained when indicated. Results: Fourteen lesions were completely excised; residual tissue was deliberately left in order to preserve vital structures in three cases. No major surgical complications were noted. One child with residual tissue after surgery, who had proliferation of the remaining tissue, developed anisometropic amblyopia and ptosis. One child had a mild ptosis postoperatively that resolved after 6 months. Follow up was for an average 11.1 months. Conclusions: Early surgical intervention should be considered in a multidisciplinary team approach as a primary treatment option with selected, isolated haemangiomas, without a significant cutaneous component. Surgery is a safe, effective treatment for selected lesions, provides a definitive early treatment, and prevents astigmatism and occlusion-related amblyopia.

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Ophthalmology. 2003 Aug;110(8):1632-7; discussion 1637-8.
A comparison of atropine and patching treatments for moderate amblyopia by patient age, cause of amblyopia, depth of amblyopia, and other factors.
Pediatric Eye Disease Investigator Group.

OBJECTIVE: To assess whether the relative treatment effect of patching compared with atropine for moderate amblyopia varies according to patient age, cause of amblyopia or depth of amblyopia, and initial number of patching hours prescribed. DESIGN: Multicenter, randomized clinical trial. PARTICIPANTS: Four hundred nineteen children younger than 7 years of age with amblyopia in the range of 20/40 to 20/100. METHODS: Patients were assigned randomly to receive treatment with either patching or atropine and followed up for 6 months. PRIMARY OUTCOME MEASURE: Single-surrounded HOTV optotype visual acuity in the amblyopic eye after 6 months. RESULTS: Improvement in the amblyopic eye visual acuity was slightly greater in the patching group compared with the atropine group in all subgroups based on patient characteristics. The relative treatment effect did not vary with age (P = 0.84), cause of amblyopia (P = 0.68), or baseline amblyopic eye acuity (P = 0.59). Patients with acuity of 20/80 to 20/100 who were prescribed 10 or more hours a day of patching showed a more rapid improvement in acuity than did patients prescribed a lesser amount of patching (P = 0.01) or than did patients in the atropine group (P < 0.001), but by 6 months, the differences were not significant (P = 0.47 and 0.15, respectively). CONCLUSIONS: A beneficial effect of both patching and atropine is present throughout the age range of 3 to younger than 7 years old and the acuity range of 20/40 to 20/100. Patients with acuity of 20/80 to 20/100 improve faster when a greater number of hours of patching is prescribed, but by 6 months, the amount of improvement is not related to the number of hours of patching initially prescribed.

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Acta Ophthalmol Scand. 2003 Jun;81(3):294-8.
Capillary haemangioma of the eyelids and orbit: a clinical review of the safety and efficacy of
intralesional steroid.
O'Keefe M, Lanigan B, Byrne SA.
National Children's Eye Centre, The Children's University Hospital, Dublin, Ireland. tchopth@indigo.ie

PURPOSE: To describe the presenting features, investigations, treatment and outcome of a series of patients with capillary haemangioma of the eyelids and orbit. METHODS: A retrospective analysis of 21 patients, presenting between the years 1985 and 2000. Effectiveness of treatment was determined by final visual acuity and cosmetic result. RESULTS: Lesions were more common in females and the upper eyelid was a definite site of predilection. A total of 87.5% of lesions presented within 6 weeks of birth. Intralesional steroid injections were received by 79% of patients. Amblyopia was a definite complication. No local or systemic complications were associated with intralesional steroid injection. Surgery and laser treatment were reserved for persistent lesions. CONCLUSION: Early recognition and prompt treatment with intralesional steroid prevents early occlusion amblyopia, but follow-up and management of refractive amblyopia with glasses and patching is necessary in the longer term. In this series, intralesional steroid proved to be a safe effective treatment.

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Arch Ophthalmol. 2003 May;121(5):603-11.
A randomized trial of patching regimens for treatment of moderate amblyopia in children.
Repka MX, Beck RW, Holmes JM, Birch EE, Chandler DL, Cotter SA, Hertle RW, Kraker RT, Moke PS, Quinn GE, Scheiman MM; Pediatric Eye Disease Investigator Group.
Jaeb Center for Health Research, Tampa, FL 33613, USA. rbeck@jaeb.org

OBJECTIVE: To compare 2 hours vs 6 hours of daily patching as treatments for moderate amblyopia in children younger than 7 years. METHODS: In a randomized multicenter (35 sites) clinical trial, 189 children younger than 7 years with amblyopia in the range of 20/40 to 20/80 were assigned to receive either 2 hours or 6 hours of daily patching combined with at least 1 hour per day of near visual activities during patching.Main Outcome Measure Visual acuity in the amblyopic eye after 4 months. RESULTS: Visual acuity in the amblyopic eye improved a similar amount in both groups. The improvement in the visual acuity of the amblyopic eye from baseline to 4 months averaged 2.40 lines in each group (P =.98). The 4-month visual acuity was at least 20/32 and/or improved from baseline by 3 or more lines in 62% of patients in each group (P>.99). CONCLUSION: When combined with prescribing 1 hour of near visual activities, 2 hours of daily patching produces an improvement in visual acuity that is of similar magnitude to the improvement produced by 6 hours of daily patching in treating moderate amblyopia in children aged 3 to 7 years.

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J Fr Ophtalmol. 2003 May;26(5):485-8.
[Use of contact lenses for correction of amblyopia in high unilateral myopia in children]
[Article in French]
Gianoli F, Klainguti G.
Unite de Strabologie, Hopital Ophtalmique Universitaire Jules Gonin, 15, avenue de France, CH-1004 Lausanne, Suisse.

Persistent amblyopia in high unilateral myopia (anisometropia higher than or equal to - 3.5 diopters) has different causes: missed early diagnosis or therapeutic strategy error. With the intention of preventing the latter, we investigated the use of contact lenses. With occlusion treatment, we obtained substantial improvement of visual acuity of the amblyopic eye. Exophoric and exotropic patients retained all binocular vision and binocular union, as did most (3/4) of the microesotropic patients. This treatment has the advantages of being permanent, esthetic, and well accepted by parents.

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Ophthalmol Clin North Am. 2003 Mar;16(1):119-25.
New developments in corneal and external disease—LASIK.
Dhaliwal DK, Mather R.
Department of Ophthalmology, University of Pittsburgh School of Medicine, Eye & Ear Institute, 203 Lothrop Street, Room 759, Pittsburgh, PA 15213, USA. dhaliwaldk@msx.upmc.edu

Lamellar refractive surgery has evolved into LASIK, which is a widely performed, versatile procedure with a high patient acceptance. In this chapter, the two main components of LASIK were discussed: flap creation and stromal ablation. In each of these areas, the authors explored current technology and new advances, including the femtosecond laser and wavefront-guided ablations. Expanded indications and therapeutic application of LASIK also have come to the forefront. The treatment of anisomyopic amblyopia in the pediatric population is a prime example and was discussed fully in this chapter. The field of refractive surgery has never been stagnant. Surgeons and scientists continue to explore new modalities to increase safety, to improve results, and to broaden applications that benefit the patient population.

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Neurosci Lett. 2003 Mar 13;339(1):49-52.
Functional MRI of amblyopia before and after levodopa.
Yang CI, Yang ML, Huang JC, Wan YL, Jui-Fang Tsai R, Wai YY, Liu HL.
Department of Ophthalmology, Chang-Gung Memorial Hospital, Taoyuan, Taiwan.

Functional magnetic resonance imaging (fMRI) was applied to five older amblyopes with monocular amblyopia before and after levodopa treatment. During the experiment, images were acquired in two runs with visual stimulation delivered through the sound and the amblyopic eyes, respectively. The experiment was performed on each of the subjects, before and after their oral administration of levodopa/carbidopa (0.5/0.12 mg/kg) three times per day for 7 weeks. Our study demonstrated that there was no effect on the spatial extent of the visual cortical activation during the sound eye stimulation (P=0.17), but some improvement during the amblyopic eye stimulation (P=0.06). The volume ratio between the amblyopic and sound eye stimulation significantly increased after the treatment (P<0.05). This finding supports the previous studies of levodopa effect on amblyopia at the visual cortical level, and suggests that fMRI can be a useful tool in assessing changes of visual cortical activity after the treatment

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Pediatr Clin North Am. 2003 Feb;50(1):189-96.
Amblyopia.
Mittelman D.
Department of Ophthalmology, University of Illinois at Chicago, UIC Eye Center, 1855 W. Taylor, Chicago, IL, USA. mittelmd@yahoo.com

Amblyopia is a serious medical condition affecting tens of millions of individuals around the world. For the most part it is correctable, assuming that it is promptly recognized and vigorously treated. Amblyopia may result from form deprivation, anisometropia, or strabismus in infants and young children. Basic research in animal models has shown that the major pathologic changes in amblyopia occur in the visual cortex of the brain. The mainstay of treatment remains patching, although penalization has a role to play in the management of moderate degrees of amblyopia. Better methods for early identification of patients with amblyopia are being developed, along with newer novel methods of treatment.

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J Pediatr Ophthalmol Strabismus 2002 Nov-Dec;39(6):326-30; quiz 345-6
Long-term follow-up of L-dopa treatment in children with amblyopia.
Leguire LE, Komaromy KL, Nairus TM, Rogers GL.
Department of Ophthalmology, Children's Hospital, Columbus, Ohio 43205-2696, USA.

PURPOSE: To assess regression of visual acuity in children who previously participated in three longitudinal studies of therapy with levodopa-carbidopa (L-dopa) plus occlusion for amblyopia. SUBJECTS AND METHODS: Thirty (91%) of 33 subjects contacted who participated in three similar 7-week, longitudinal dosing studies returned for follow-up. The three previous studies were undertaken approximately 27 (study 1), 21 (study 2), and 9 (study 3) months prior to this follow-up test session. All subjects received L-dopa for 7 weeks combined with part-time occlusion of the dominant eye after the termination of standard, occlusion only, therapy. Some subjects in study 2 received L-dopa without occlusion. Sixteen subjects with amblyopia who received occlusion only served as a control group. RESULTS: Subjects who received L-dopa plus occlusion demonstrated significant, but similar, amounts of regression of visual acuity from the end of their respective L-dopa studies to the follow-up test session. Subjects in study 1 regressed 1.3 lines, subjects in study 2 regressed 1.5 lines, and subjects in study 3 regressed 1.4 lines. The control group regressed, on average, 1.1 lines. This was similar to the overall regression found in the groups receiving L-dopa plus occlusion. Subjects in study 2 who received L-dopa without occlusion regressed 2.1 lines, significantly more than the occlusion only group or the L-dopa plus occlusion group. CONCLUSIONS: Children with amblyopia show similar amounts of regression of visual acuity after therapy with L-dopa plus occlusion and after therapy with occlusion only. Given that therapy with L-dopa plus occlusion initially improved visual acuity by approximately 1.7 lines following the termination of standard therapy, L-dopa plus occlusion may reset baseline visual acuity and lead to long-term improvement in visual acuity after recidivism.

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Ophthalmologica 2002 Nov-Dec;216(6):426-9
Occlusion therapy for the treatment of amblyopia: letting the parents decide.
Tripathi A, O'Donnell NP, Holden R, Kaye L, Kaye SB.
Birmingham and Midland Eye Centre, City Hospital, Birmingham, UK. ajtrip@hotmail.com

BACKGROUND: Compliance with prescribed occlusion therapy is a significant problem in the treatment of amblyopia. Parental preference for a particular type of occlusion treatment has not been previously addressed. Unless parental views are taken into account when planning therapy, compliance may be poor and treatment may fail. SUBJECTS AND METHODS: Parents of children with strabismic and/or anisometropic amblyopia who were due to start or had already had occlusion treatment were included in this study. Group A comprised parents of children who had no previous experience of occlusion, and group B comprised parents of children who had previous experience of occlusion therapy. Parental preferences regarding occlusion therapy were investigated by way of a questionnaire, in which they were asked whether they would prefer part-day/full-week occlusion or all-day/part-week occlusion so that the total number of hours of occlusion per week was the same. RESULTS: One hundred parents completed the questionnaire, 47 from group A and 53 from group B. A significant number of parents in group A (95.3%) who had no previous experience with occlusion preferred part-day/full-week occlusion (p < 0.001), whereas there was no such preference among parents who had experience with occlusion, that is only 54.3% of parents in group B showed a preference for part-day/full-week occlusion (p = 0.1). The reasons given by the parents for their preferences varied but were in keeping with their lifestyles so that the type of occlusion regimen chosen by the parents was in accordance with the reasons given for their choice. CONCLUSION: Parental preferences should be considered when occlusion therapy is planned if compliance is to be improved. For maintenance occlusion, it would be reasonable to prescribe the number of hours of occlusion required per week and allow parents the responsibility to implement the pattern of occlusion according to their circumstances--the implied restriction ensuring that the number of hours of occlusion per week is met. Although parents appeared to have preconceived ideas before the commencement of treatment, their preferences changed once treatment had begun. Copyright 2002 S. Karger AG, Basel

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J AAPOS 2002 Dec;6(6):368-72
Levodopa-carbidopa with occlusion in older children with amblyopia.
Bhartiya P, Sharma P, Biswas NR, Tandon R, Khokhar SK.
All India Institute of Medical Sciences, New Delhi.

PURPOSE: To study the role of levodopa-carbidopa in supplementing occlusion therapy in older children with strabismic or anisometropic amblyopia. Methods: A clinical study was performed on 40 amblyopic children (19 strabismic and 21 anisometropic), 6 to 18 years old (mean age, 10.9 years). They received an average dose of 1.86 mg/kg/day (1.33-2.36 mg/kg/day) of levodopa and carbidopa (4:1 ratio) or a placebo in 3 divided doses over a 4-week period, combined with full-time occlusion. The occlusion was continued for the study duration of 3 months. Early Treatment Diabetic Retinopathy Study visual acuity charts and Cambridge low-contrast gratings for contrast sensitivity (CS) were used to assess visual functions. Tolerance and compliance with occlusion and capsule consumption were assessed. RESULTS: Visual acuity of the nonamblyopic eye did not deteriorate during the study in either group. CS decreased by 22 units in the levodopa group and increased in the placebo group by 53 units at the first month. The CS in the levodopa group recovered later by the third month of follow-up. Both the levodopa and the placebo groups showed significant improvement in visual function in the amblyopic eye (P <.001). Overall changes in logarithm of minimum angle of resolution values and CS in the amblyopic eyes were similar in both groups (P >.05). Strabismic and anisometropic amblyopes did not behave differently. Drug tolerance, occlusion compliance, and capsule ingestion compliance were similar between the groups, with no significant side effects. CONCLUSIONS: Clinically, levodopa supplementation does not offer any advantage over occlusion alone. Moreover, the risk of occlusion amblyopia could increase with the use of drugs like levodopa that might affect the plasticity of the visual cortex.

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Ophthalmology 2002 Dec;109(12):2261-4
The minimum occlusion trial for the treatment of amblyopia.
Keech RV, Ottar W, Zhang L.
Department of Ophthalmology, University of Iowa, Iowa City, Iowa. Shandong Medical University, Shandong, People's Republic of China. ronald-keech@uiowa.edu

OBJECTIVE: To determine whether the traditional regimen of three intervals of full-time occlusion (FTO) for amblyopia without any measurable improvement in visual acuity constitutes an adequate trial. DESIGN: Retrospective, noncomparative, interventional case series. PARTICIPANTS: Sixty-four children younger than 10 years of age with unilateral amblyopia. METHODS: The medical records of patients treated for amblyopia in a university outpatient clinic were reviewed. Patients who underwent one FTO interval without an improvement in visual acuity followed by at least one additional FTO interval were included in the study. MAIN OUTCOME MEASURES: Improvement in visual acuity. RESULTS: Sixty-four patients underwent 81 occlusion trials consisting of one FTO interval without improvement followed by one or more FTO intervals. Visual acuity improved after the second FTO interval in 25 (31%) of the trials. Of the 44 occlusion trials consisting of two FTO intervals without improvement, visual acuity improved after the third FTO interval in 12 (27%) of the trials. Of the 11 occlusion trials consisting of three FTO intervals without improvement followed by one or more additional FTO intervals, acuity did not improve with any of the trials. CONCLUSIONS: A minimum of three intervals of FTO is necessary to determine whether an amblyopia patient will be unresponsive to occlusion therapy. After three FTO intervals without improvement, additional FTO is unlikely to result in an improvement in visual acuity.

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J AAPOS 2002 Oct;6(5):289-93
Combined optical and atropine penalization for the treatment of strabismic and anisometropic amblyopia.
Kaye SB, Chen SI, Price G, Kaye LC, Noonan C, Tripathi A, Ashwin P, Cota N, Clark D, Butcher J.
Royal Liverpool Children's Hospital, United Kingdom.

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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Optometry 2002 Mar;73(3):153-9
Maintenance of improvement gains in refractive amblyopia: a comparison of
treatment modalities.
FitzGerald DE, Krumholtz I.
State University of New York, State College of Optometry, New York 10036, USA. difitzgerald@sunnyopt.edu

BACKGROUND: In June of 1999, an initial study reported on the effect of differing treatment modalities in improving visual acuity and stereoacuity in patients with unilateral refractive amblyopia. This study reports on the patients' visual maintenance of acuity gains for each specified treatment modality. Patients were re-evaluated over a 1- to 2-year period after cessation of treatment. METHODS: Records of patients who participated in the initial study were retrospectively reviewed 1 to 2 years after cessation of therapy to determine whether visual acuity gains were maintained. RESULTS: Patients were divided according to treatment modalities. Results for the three patient groups were as follows: 50% of patients with optical correction alone maintained visual acuity improvement; 60% of patients with optical correction and occlusion maintained visual acuity gains; and 100% of patients with optical correction, occlusion, and vision therapy had maintained visual acuity gains. Of the three age groups--4 years to 6 years, 11 months; 7 years to 9 years, 11 months; and 10 to 14 years--the oldest age group maintained the highest percentage of visual acuity gains. CONCLUSIONS: In our sample, at least 50% of the unilateral anisometropic amblyopic patients, who initially experienced visual acuity gains after treatment (regardless of treatment modality or age) maintained those acuity gains at 1- to 2-year followup. One hundred percent of those patients who received the vision therapy modality of treatment retained the improvement at followup-a statistically significant difference when compared with the other two groups.

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J Refract Surg 2002 Sep-Oct;18(5):519-23
Phakic intraocular lens to correct high myopic amblyopia in children.
Lesueur LC, Arne JL.
Department of Ophthalmology, Purpan Hospital, University of Toulouse, France. lesueur.l@chu-toulouse.fr

PURPOSE: In a clinical investigation, we evaluated anatomical and functional outcomes of posterior phakic chamber lens (ICL) implantation for correction of high myopia with amblyopia in children. METHODS: Twelve eyes of 11 children, age 3 to 16 years, with high myopic amblyopia were operated with implantation of a Staar Surgical ICL. In these patients, conventional therapy with spectacles or contact lenses was unsuccessful. Mean preoperative spherical equivalent refraction was -12.70 D (range -8.00 to -18.00 D) and best spectacle-corrected visual acuity ranged from count fingers to 20/63. Mean follow-up was 20.5 months (range 3 to 48 mo) Preoperative and postoperative anatomical and functional outcomes were compared. RESULTS: We noted good tolerance of ICLs without inflammatory reactions or secondary capsular opacity, stable intraocular pressure, and good ICL position in all eyes. Predictability was +0.71 D (range -0.75 to +2.00 D). Mean postoperative best spectacle-corrected visual acuity was 20/63. Recovery of binocular vision was achieved in six patients and orthotropic position in seven patients. Quality of life was improved in all patients. CONCLUSION: The Staar Surgical phakic ICL appeared to be an effective method to treat high myopia in children with amblyopia. Good results with high satisfaction were noted.

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Strabismus 2002 Jun;10(2):79-82
A preliminary report about the relation between visual acuity increase and compliance in patching therapy for amblyopia.
Loudon SE, Polling JR, Simonsz HJ.
Department of Ophthalmology, Erasmus University, Rotterdam, The Netherlands. seloudon@yahoo.com

PURPOSE: The aim of this study was to establish a relation between visual acuity increase and compliance in children who have been prescribed patching therapy for their amblyopic eye. METHODS AND MATERIALS: In 14 new amblyopic children (mean age 4.3 +/- 1.9 years) compliance was measured electronically during one week, six months after starting patching therapy, with an Occlusion Dose Monitor (ODM), distributed through house visits. The children were diagnosed with anisometropia (5), strabismus (4) and anisometropia and strabismus (5). The degree of amblyopia was expressed as the ratio between the acuity of the amblyopic eye and the acuity of the good eye. Satisfactory increase in acuity was assessed by means of the following three criteria: acuity amblyopic eye / acuity good eye >75%, acuity exceeding 0.5 E-chart, three lines LogMAR acuity increase. RESULTS: Fourteen reliable recordings were obtained, which showed that children who did not patch, or were patched inconsistently, did not reach satisfactory acuity increase. CONCLUSION: There is indeed a statistically significant relation between acuity increase and measured compliance.

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Eye 2002 Sep;16(5):577-9
Contact lenses in the management of high anisometropic amblyopia.
Roberts CJ, Adams GG.
Strabismus Service, Moorfields Eye Hospital, City Road, London, UK. clare_roberts@doctors.org.uk

Poster at College Congress, Birmingham 2001.Oral presentation at European Strabismus Association, Florence 2001. PURPOSE: Anisometropia of more than one dioptre during the sensitive visual period may cause amblyopia. Its management requires refractive correction, and occlusion. Compliance with treatment is critical if visual improvement is to obtained. High anisometropia, poor initial acuity and mixed strabismic/anisometropia amblyopia are predictive factors for a poor outcome. We evaluated contact lens use in the management of high anisometropic amblyopia. METHODS: Retrospective analysis of anisometropic amblyopia managed in a paediatric contact lens clinic (July 1996-July 2000), after standard amblyopia therapy of spectacles and occlusion therapy had been tried. Presenting age, acuity and refraction, duration of lens wear and occlusion, and final visual outcomes were noted. RESULTS: Seven children (four male, three female) presented at age 3.5-6 years (mean 4.5). Six had myopic anisometropia 6.0-18.4 dioptres (mean 10.4 dioptres) and one 6.75 dioptres hypermetropic anisometropia. The initial corrected acuities of the amblyopic eyes were 6/18 to 1/60. Five patients used contact lenses with a range from 5 months to 4 years. Final acuities were 6/12-1/60. Two myopes with 6 dioptres anisometropia improved three to four Snellen lines, one with 8.8 dioptres improved one line. Three with >10 dioptres anisometropia did not improve. The hypermetropic patient improved part of one Snellen line. CONCLUSIONS: High anisometropic amblyopia is challenging to treat. In our study contact lenses improved visual acuity in myopic anisometropia of up to 9 dioptres.

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Strabismus 2002 Mar;10(1):23-30
Non-concordance in amblyopia treatment: the effective use of 'smileys'.
Oto S, Pelit A, Aydin P.
Department of Ophthalmology, Baskent University School of Medicine, Ankara, Turkey. motility2000@hotmail.com

PURPOSE: The success of any specific occlusion regimen is limited by the level of concordance, which is difficult to measure accurately in patching treatment. The aim of this study was to investigate prospectively the concordance rate of a group of children with strabismic and/or anisometropic amblyopia using a schematic diary based on completing 'smiley' images, filled in by the child under parental supervision, and to assess the effect of correlates such as initial visual acuity, age, and total and daily occlusion time on concordance. METHODS: We recruited 51 amblyopic children aged 13 months to 12 years (mean 6.57 +/- 2.82). The median duration of treatment was 16 weeks. Non-concordance was defined as occluding less than 75% of the prescribed time and was analyzed using a concordance index calculated from occlusion time recorded in the diary/prescribed occlusion time. RESULTS: Of the 51 patients followed prospectively, 12 (23.5%) failed to return their diaries (Group 1); 27 (52.9%) complied with occlusion (Group 2); and 12 (23.5%) failed to comply with occlusion completely (Group 3). The total proportion of non-concordance was 47.1% (Group 1 + Group 3). Concordance was not significantly related to initial visual acuity (r = -0.22, p = 0.19), patient age (F = 1.0787, p = 0.349) or total occlusion time (X2 = 2.779, p = 0.249), but the number of daily occlusion hours showed significant difference in Group 1 (X2 = 15.894, p = 0.000). When the three groups were compared for change in visual acuity, a significant difference was found between group 1 and group 2 (X2 = 6.125, p = 0.047). CONCLUSION: The substantial proportion of non-concordance in our study suggests that, although useful for recording purposes, parental diaries may not be stimulating enough to increase the overall level of concordance. Therefore, other forms of monitoring need to be explored.

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Ophthalmic Physiol Opt 2002 Jul;22(4):296-9
Remediation of refractive amblyopia by optical correction alone.
Moseley MJ, Neufeld M, McCarry B, Charnock A, McNamara R, Rice T, Fielder A.
Department of Ophthalmology, Faculty of Medicine, Imperial College of Science, Technology and Medicine, London, UK. m.j.moseley@ic.ac.uk

Amblyopia--the commonest vision abnormality of childhood--is characterized by a loss of visual acuity usually of one eye only. Treatment aims to promote function of the amblyopic eye and does this by restricting, usually through occlusion, the competitive advantage of the fellow eye. Recent experimental evidence demonstrates that the recovery of vision following early deprivation is facilitated by increasing visually evoked activity. An analogous approach in humans is to minimise image blur by correcting refractive error prior to treatment--a practice which may account for the poorly quantified improvements in visual acuity sometimes attributed to 'spectacle adaptation'. Here we describe clinically significant gains in visual acuity obtained over a period of 4-24 weeks in a group of amblyopic children arising solely in response to the correction of refractive error. Consequences for the clinical management of refractive amblyopia are discussed.

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BMJ 2002 Jun 29;324(7353):1549
Amblyopia treatment outcomes after screening before or at age 3 years: follow up from randomised trial.
Williams C, Northstone K, Harrad RA, Sparrow JM, Harvey I; ALSPAC Study Team.
Division of Child Health, University of Bristol, Bristol BS8 1TQ. Cathy.Williams@bristol.ac.uk

OBJECTIVE: To assess the effectiveness of early treatment for amblyopia in children. DESIGN: Follow up of outcomes of treatment for amblyopia in a randomised controlled trial comparing intensive orthoptic screening at 8, 12, 18, 25, 31, and 37 months (intensive group) with orthoptic screening at 37 months only (control group). SETTING: Avon, southwest England. PARTICIPANTS: 3490 children who were part of a birth cohort study. MAIN OUTCOME MEASURES: Prevalence of amblyopia and visual acuity of the worse seeing eye at 7.5 years of age. RESULTS: Amblyopia at 7.5 years was less prevalent in the intensive group than in the control group (0.6% v 1.8%; P=0.02). Mean visual acuities in the worse seeing eye were better for children who had been treated for amblyopia in the intensive group than for similar children in the control group (0.15 v 0.26 LogMAR units; P<0.001). A higher proportion of the children who were treated for amblyopia had been seen in a hospital eye clinic before 3 years of age in the intensive group than in the control group (48% v 13%; P=0.0002). CONCLUSIONS: The intensive screening protocol was associated with better acuity in the amblyopic eye and a lower prevalence of amblyopia at 7.5 years of age, in comparison with screening at 37 months only. These data support the hypothesis that early treatment for amblyopia leads to a better outcome than later treatment and may act as a stimulus for research into feasible screening programmes.

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Optom Vis Sci 2002 Jun;79(6):376-80
The effectiveness of occluder contact lenses in improving occlusion compliance in patients that have failed traditional occlusion therapy.
Joslin CE, McMahon TT, Kaufman LM.
Department of Ophthalmology and Visual Sciences, University of Illinois at Chicago, College of Medicine, 60612, USA. charjosl@uic.edu

PURPOSE: Management of infants and young children with dense amblyopia, including that which results from unilateral congenital cataracts, is challenging because of noncompliance with occlusion therapy. Occluder contact lenses (OCLs) have been described to successfully improve visual acuity in patients with amblyopia. The purpose of this study was to evaluate the effectiveness of OCLs in improving occlusion compliance in infants and young children with dense amblyopia who had failed traditional occlusion therapy. METHODS: Thirteen patients were fit in their nonamblyopic eye with OCLs provided by Wesley Jessen (Des Plaines, IL). All patients had dense amblyopia as diagnosed by a pediatric ophthalmologist. Nine of the 13 patients had deprivational amblyopia associated with unilateral aphakia, 2 patients had strabismic amblyopia, and the other 2 had mixed mechanism amblyopia. All patients had failed traditional occlusion methods. Occlusion was prescribed on a part-time basis to prevent occlusion amblyopia to the better-seeing eye. Compliance with the OCLs was determined by questioning the parents as to whether the prescribed occlusion time was accomplished. RESULTS: Five of the 13 patients (38.4%) did not succeed in the initial 1-mo trial period because of parental difficulties with lens handling. Four patients (30.7%) achieved partial success, as they were able to wear the lens between 4 to 14 mo, at which time they learned to remove the occluder lens. The four remaining patients (30.7%) successfully wore the occluder lenses until the conclusion of the study, a time period ranging from 26 to 60 mo. No complications resulted from OCLs. CONCLUSIONS: OCLs can provide an alternative to achieving occlusion compliance after the failure of traditional occlusion therapy in infants and young children with dense amblyopia.

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J Cataract Refract Surg 2002 Jun;28(6):932-41
Photorefractive keratectomy in children.
Astle WF, Huang PT, Ells AL, Cox RG, Deschenes MC, Vibert HM.
Alberta Children's Hospital, University of Calgary, Division of Ophthalmology, Calgary, Alberta, Canada.

PURPOSE: To evaluate photorefractive keratectomy (PRK) in pediatric patients who fail traditional methods of treatment for myopic anisometropic amblyopia and high myopia. SETTING: Nonhospital surgical facility with follow-up in a hospital clinic setting. METHODS: Photorefractive keratectomy was performed in 40 eyes of 27 patients. The patients were divided into 4 groups based on the type of myopia: myopic anisometropic amblyopia (15 eyes/13 patients), bilateral high myopia (20 eyes/10 patients), high myopia post-penetrating keratoplasty (3 eyes/2 patients), and combined corneal scarring and anisometropic amblyopia (2 eyes/2 patients). All procedures were performed under general anesthesia using the VISX 20/20 B laser and a multizone, multipass ablation technique. Appropriate corneal fixation was achieved with appropriate head positioning (turn and tilt) and an Arrowsmith fixation ring. Myopia was as high as -25.00 diopter (D) spherical equivalent (SE), but no treatment was for more than -17.50 D SE. RESULTS: The mean SE decreased from -10.68 D to -1.37 D at 1 year, a mean change of -9.31 D. At 1 year, the mean best corrected visual acuity improved from 20/70 to 20/40 in the entire group. Forty percent of eyes were within +/-1.0 D of the targeted refraction. There was no haze in 59.5% of eyes. Three eyes initially had 3+ haze; 1 improved to 2+ and 2 required repeat PRK with significant haze reduction. Five eyes (3 patients) with greater than -17.00 D SE myopia before PRK (range -17.50 to -25.00 D) had 3.42 D more effect than predicted (range 0.50 to 5.50 D). A functional vision survey demonstrated a positive effect on the children's ability to function in their environments after the laser treatment. CONCLUSION: Photorefractive keratectomy in children represents another method of providing long-term resolution of bilateral high myopia and myopic anisometropic amblyopia.

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Eye 2002 Mar;16(2):150-5
Psychosocial and clinical determinants of compliance with occlusion therapy for
amblyopic children.
Searle A, Norman P, Harrad R, Vedhara K.
MRC Health Services, Research Collaboration, Department of Social Medicine, University of Bristol, Bristol, UK. A.J.Searle@bristol.ac.uk

AIMS: The objective of this study was to determine the extent that psychosocial and clinical variables influence parental compliance with occlusion therapy (eye patching) in children with amblyopia. METHODS: Children (n = 151) receiving occlusion therapy (eye patching) for the treatment of amblyopia were recruited from five orthoptic clinics in Bristol, UK. Parents completed a questionnaire based on Rogers' (1983) Protection Motivation Theory (PMT). The parents (n = 105) were also followed up 2 months later. Clinical data, including measures of visual acuity, were also recorded. Compliance with eye patching was assessed through self-report accounts of parents. Stepwise regression analyses were used to determine the factors predictive of compliance with eye patching. RESULTS: Self-reported compliance with eye patching at study entry revealed that only 54% of parents were achieving orthoptists' recommendations to patch their child. Perceived self-efficacy was positively associated with compliance and perceived prohibition of the child's activities were negatively associated with compliance. At follow-up, past behaviour accounted for the largest proportion of explained variance in patching behaviour followed by response efficacy, and prohibition of the child's activities. CONCLUSION: The present findings may serve to inform interventions aimed at enhancing current orthoptic practice to improve compliance in amblyopic children. The importance of 'self-efficacy' and past behaviour suggests that consultations with parents exhibiting higher levels of success with patching may elicit strategies that could be shared with parents experiencing difficulties with patching their children. In addition, it is possible that the perceived efficacy of the treatment could be enhanced if orthoptists emphasised evidence of improvements in visual acuity which may, in turn, foster the maintenance of eye patching.

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Neurorehabil Neural Repair 2001;15(3):223-7
Possible role of corticosteroids in nervous system plasticity: improvement in amblyopia after optic neuritis in the fellow eye treated with steroids.
Constantinescu CS, Gottlob I.
Division of Clinical Neurology, University Hospital, Queen's Medical Centre, Nottingham, UK. cris.constantinescu@nottingham.ac.uk

OBJECTIVE: Amblyopia consists of reduced visual function in the absence of organic disease, caused by deficient visual stimulation, most commonly due to squint or refractive error. Amblyopia is thought to be reversible up until the age of approximately 8 years (critical period) and is usually treated with occlusion of the fellow eye. There is recent evidence for visual system plasticity extending beyond the critical period, supported by reports of improvement in visual acuity in the amblyopic eye after loss of vision in the contralateral eye. This suggests that the adult visual system exhibits sufficient plasticity to allow such improvement. We describe here improvement in visual acuity in three amblyopic patients after they received high-dose intravenous glucocorticoids for optic neuritis in the contralateral eye. METHODS: Clinical and neurological evaluation added. RESULTS: In all cases, the improvement was sustained, even after the recovery from the optic neuritis. CONCLUSIONS: Because steroids affect neural plasticity, we hypothesize that they facilitate and enhance visual improvement in amblyopia, a quality that may be tested in future controlled trials.

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J Pediatr Ophthalmol Strabismus 2002 Mar-Apr;39(2):81-9
Effect of levodopa and carbidopa in human amblyopia.
Pandey PK, Chaudhuri Z, Kumar M, Satyabala K, Sharma P.
Department of Ophthalmology, Maulana Azad Medical College, University of Delhi, New Delhi, India.

BACKGROUND: To assess the role of continuous therapy for 3 weeks with levodopa and carbidopa in the management of human amblyopia in children and adults. METHOD: There were 88 amblyopic eyes of 82 subjects included in this double masked randomized prospective clinical trial. Levodopa and carbidopa combination in 2 different dosage schedules were given to both adults and children. The response was monitored of the improvement in visual acuity, contrast sensitivity, and visually evoked potentials. RESULT: Patients receiving higher dosages of levodopa and carbidopa in both adults and children showed a better response to treatment. However, the effect did not last beyond 9 weeks of stopping treatment. CONCLUSION: Though levodopa and carbidopa therapy may not be able to ameliorate amblyopia on its own on a long-term basis, it may be considered nonetheless to be an important adjunct to conventional therapy because it may improve patient compliance for occlusion by improving visual acuity in the amblyopic eye. Thus, it offers promise of improving the functional outcome in these cases. However, longer follow-up trials are needed to substantiate these conclusions.

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Arch Ophthalmol 2002 Mar;120(3):268-78
Comment in: Arch Ophthalmol. 2002 Mar;120(3):387-8.
A randomized trial of atropine vs. patching for treatment of moderate amblyopia in children.
The Pediatric Eye Disease Investigator Group.
Jaeb Center for Health Research, Tampa, Fla. USA.

OBJECTIVE: To compare patching and atropine as treatments for moderate amblyopia in children younger than 7 years. METHODS: In a randomized clinical trial, 419 children younger than 7 years with amblyopia and visual acuity in the range of 20/40 to 20/100 were assigned to receive either patching or atropine at 47 clinical sites. MAIN OUTCOME MEASURE: Visual acuity in the amblyopic eye and sound eye after 6 months. RESULTS: Visual acuity in the amblyopic eye improved in both groups (improvement from baseline to 6 months was 3.16 lines in the patching group and 2.84 lines in the atropine group). Improvement was initially faster in the patching group, but after 6 months, the difference in visual acuity between treatment groups was small and clinically inconsequential (mean difference at 6 months, 0.034 logMAR units; 95% confidence interval, 0.005-0.064 logMAR units). The 6-month acuity was 20/30 or better in the amblyopic eye and/or improved from baseline by 3 or more lines in 79% of the patching group and 74% of the atropine group. Both treatments were well tolerated, although atropine had a slightly higher degree of acceptability on a parental questionnaire. More patients in the atropine group than in the patching group had reduced acuity in the sound eye at 6 months, but this did not persist with further follow-up. CONCLUSION: Atropine and patching produce improvement of similar magnitude, and both are appropriate modalities for the initial treatment of moderate amblyopia in children aged 3 to less than 7 years.

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Ophthalmology 2001 Sep;108(9):1552-5
Comment in: Ophthalmology. 2002 Oct;109(10):1757-8; discussion 1758.
Long-term follow-up of occlusion therapy in amblyopia.
Leiba H, Shimshoni M, Oliver M, Gottesman N, Levartovsky S.
Department of Ophthalmology, Kaplan Medical Center, Rehovot, Israel. leibalLA@tel-aviv.gov.il

OBJECTIVE: To determine whether the results of occlusion therapy for amblyopia are maintained into adulthood. DESIGN: Prospective, observational case series. PARTICIPANTS: Fifty-four patients, who were successfully treated in childhood for unilateral amblyopia by occlusion, were followed up to the age of 9 years, were evaluated in 1984 for long-term results 6.4 years on average after cessation of treatment, and accepted our invitation for reevaluation in 1999. METHODS: All patients were given a complete eye examination. The visual acuity (VA) was measured. RESULTS: The average period of follow-up was 21.5 years (range, 17.2-25.1 years). The mean age at the most recent examination was 29.0 +/- 2.1 years (range, 25.1-34). At this examination, a best-corrected visual acuity (BCVA) of 20/40 or better was achieved by 72.3% of the patients. The mean BCVA was 20/35 (20/25-20/70) at the end of occlusion therapy, 20/45 (20/20-20/300) in 1984, and 20/34 (20/15-20/100) at the present examination. Relative to the results at the end of therapy, BCVA at the present examination was maintained or improved in 66.7% of the patients. Relative to 1984, the BCVA in 1999 was maintained or improved in 87% of the patients. MAIN OUTCOME MEASURE: Visual acuity. CONCLUSION: Comparative evaluation of BCVA at a long-term follow-up examination, performed 21.5 years on average after cessation of occlusion therapy, showed that VA was maintained or improved in two thirds of patients who had been successfully treated by occlusion for unilateral amblyopia in childhood.

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