Controversy in Amblyopia Management

Leah A. Walsh, M.Sc., O.C.(C.), C.O.M.T. Erik K. Hahn, M.Sc., O.C.(C.), C.O.M.T. G. Robert LaRoche, M.D.

ABSTRACT Background and Purpose: Much has been written about amblyopia treatment. However, there is no consensus on the most efcacious therapeutic modality for amblyopia. The intensity of therapy needed to maximize visual acuity is also widely debated. The diversity of opinions emphasizes that the optimum treatment for amblyopia is unknown. Part of the uncertainty stems from the lack of standardization in the management of amblyopia. The objective of this paper is to conduct an in-depth review of the literature in an attempt to clarify the amblyopia treatment conundrum. Conclusions: The treatment of amblyopia in children is frequently discussed in the literature. It is obvious from the literature that there is the need for prospective studies with consistent controls, clear denitions of what constitutes successful therapy endpoints, and standardization of testing procedures. INTRODUCTION With a prevalence rate between 1% and 4% of the general population,12 amblyopia is the most common cause of vision loss in the rst four decades of life. Amblyopia can be dened as decreased visual acuity in
From the IWK Health Centre, Halifax, Nova Scotia, Canada. Requests for reprints should be addressed to: Leah A. Walsh, M.Sc., O.C.(C.), C.O.M.T., Eye Care Team, IWK Health Centre, 5850/5980 University Ave., PO Box 9700, Halifax, Nova Scotia, Canada, B3K 6R8. e-mail: leah.walsh@iwk.nshealth.ca Presented in part at the Pediatric Session of the Canadian Ophthalmology Society, June 23, 2005, Edmonton, Alberta, Canada.
2006 Board of Regents of the University of Wisconsin System, American Orthoptic Journal, Volume 56, 2006, ISSN 0065-955X, E-ISSN 1553-4448

one or both eyes due to abnormal interocular interaction during the critical period of visual development. Amblyopia may be the result of high uncorrected refractive error (ametropia), ocular misalignment (strabismus), a difference in refractive error between the two eyes (anisometropia),

116

WALSH

or a combination of strabismus and anisometropia, also referred to as mixed type. Amblyopia may also be secondary to iatrogenic treatment (i.e., conventional occlusion, pharmacologic or optical penalization, etc.), commonly referred to as occlusion amblyopia. Studies on the natural history of untreated amblyopia indicate that the vision of the amblyopic eye does not improve3 and can continue to deteriorate throughout childhood4 and adolescence.5 One percent of persons with amblyopia lose vision in their sound eye, below the level of the amblyopic eye, through disease or injury.6 Thus it can be argued that treating amblyopia allows an individual to have two eyes with useful vision should they suffer vision loss in one eye. In addition, better oculomotor stability and improved binocularity correlates with good vision in both eyes.2 These are two powerful arguments in support of the treatment of amblyopia. Amblyopia and its management has come under closer scrutiny since a 1997 meta-analysis on Preschool Vision Screening by Showdon and StewartBrown.7 This report questioned the benet of preschool screening and uncovered signicant problems with amblyopia research. One of the major problems, revealed in the area of amblyopia research, is the lack of evidence that treatment for amblyopia is effective in providing the patient with long-term benets. Despite an apparent lack of solid scientic evidence supporting the long-term efcacy of amblyopia treatment, much has been written to support the concept that amblyopia responds well to treatment.819 There is, however, no consensus on the most efcacious therapeutic modality for amblyopia.811 The amount of occlusion needed to maximize visual acuity in the amblyopic eye has also been debated.1618, 21 The diversity of opinions emphasizes that the optimum treatment for amblyopia is unknown.

DISCUSSION Success Caution needs to be taken when attempting to compare and contrast the reported success rates of the various therapeutic modalities. There is not one clear and all-encompassing denition of success: individual studies adopt a vastly different denition of what constitutes a successful response to treatment. The problem also arises when success rates are recorded and reported without providing the criteria for success. Interpretations of outcomes can be misleading due to the omission of endpoint guidelines. In some studies, success has been correlated with achieving a specic level of visual acuity (e.g., 20/30 or 20/40)12, 1416, 19, 22, 43 whereas other investigators have dened success based as 20/30 or better or a three line improvement from the initial visual acuity of the amblyopic eye.9, 17 It is possible that at the completion of amblyopia therapy visual acuity in the amblyopic eye can be signicantly below that of the nonamblyopic eye yet considered to be successfully treated. For example, the visual acuity of a patient could have improved three lines from 20/200 to 20/100 and would still be considered a success using the above criterion. There are other areas that may require consideration in the discussion on whether or not therapy has been successful. Occupational and personal expectations, meeting driving standards, functional implications, and the long-term stability of acuity represent some of the areas deserving of consideration. Occlusion of the nonamblyopic eye, to stimulate use of the amblyopic eye, has been the mainstay of treatment for centuries.20 However, the success rate of occlusion therapy varies in the reported literature, ranging from 3090%.1216 As previously alluded to, the discrepancy of the reported success rates can be second-

American Orthoptic Journal

117

AMBLYOPIA CONTROVERSY

ary to inconsistent denitions of success as well as variations in methodology. The inclusion/exclusion of noncompliant subjects also skews the success rates, making the rates falsely low if noncompliant subjects are used during data analysis. Flynn and colleagues recently conducted a large review of the literature that revealed vision of 20/40 or better was achieved in 74% of the patients, when all of the data from 23 studies was pooled.15 Some of the studies that were evaluated included subjects who had previously failed therapy, and the majority of the studies utilized part-time occlusion. In this multistudy review, data were not analyzed separately despite the variability in the intensity of the prescribed occlusion. Scott and coworkers published a series of articles on the effectiveness of full-time occlusion and found this treatment to be highly effective, with the success rates ranging from 83 to 96%.12, 22, 23 This high intensity occlusion regimen is not without its risks, as the most recent article by Scott reported that their prevalence of occlusion amblyopia was 25.8%.23 Intensity of Therapy The amount of occlusion needed to maximize vision is also debatable. Reported occlusion rates have varied from as low as 15 minutes per day56 to twenty-four hours per day, seven days per week.12, 22, 23 Minimal occlusion has produced some improvement in the past; however, some of these previous studies had shortcomings relating to control group, refractive correction, visual acuity assessment, or they merely failed to report on these variables.46, 47 The Pediatric Eye Disease Investigator Group (PEDIG) investigated various occlusion regimens with some interesting results. In their rst published study, two hours of occlusion was compared to six hours in subjects with moderate amblyopia (20/4020/80).17 The

authors found that similar acuity gains were achieved in both of the groups. A later PEDIG study investigated the response of six hours versus full-time occlusion in severe amblyopia (20/10020/ 400).24 Again the acuity gains were similar in both groups. Compliance was subpar in both of these studies, thus making it difcult, if not impossible, to interpret the results of these articles. On average the compliance rate was around 50%, which, to say the least, is disappointing. However, the conclusion that two hours of occlusion was as effective as six hours, and six hours was as effective as full-time, could lead to the erroneous assumption that two hours therefore must be as effective as full-time occlusion, when this was never directly investigated. Denition, Risk, and Duration of Full-Time Occlusion The denition of what constitutes fulltime occlusion (FTO) is another gray area. Some authors have clearly dened FTO as wearing occlusion twenty-four hours per day, seven days per week12, 2225 whereas frequently all waking hours minus one is considered full-time occlusion.58 High percentage occlusion has been recognized as occlusion of the nonamblyopic eye for 75% or more of the childs waking hours.25 The amount of occlusion actually being conducted, in the various denitions of FTO/ high percentage occlusions, is currently not being debated for its potential role in the success of amblyopia therapy. However, the amount of occlusion can have an impact on the potential development of occlusion amblyopia, as evidenced by Scott23 with this complication being reported in 25.8% of the subjects prescribed occlusion of the nonamblyopic eye, twenty-four hours per day, seven days per week. In the Scott study, only one of the patients with occlusion amblyopia had a nal outcome of better vision

118

Volume 56, 2006

WALSH

in the previously amblyopic eye, which remained after measures were taken to reverse the occlusion amblyopia. The duration of full-time occlusion (FTO) necessary to maximize visual acuity was investigated by Keech and colleagues, who noted that minimal improvement, if any, was noted beyond three cycles of FTO.25 Full-time occlusion in this study was all waking hours, but patients were accepted if they complied with 75% or more of FTO. One cycle consisted of FTO for all waking hours for a duration of one week for every year of age of the patient, with a maximum of four consecutive weeks. The question then arises: does different degrees of fulltime occlusion require an adaptation of the amount of consecutive cycles? Clinically, three cycles of occlusion without improvement in visual acuity is generally the endpoint of therapy.25 After this some form of tapering or maintenance occlusion is frequently employed. Therapy Duration The effect of treatment duration on the results has been debated throughout the amblyopia literature, with conicting views. Past publications have varied from no correlation between the hours of treatment and the visual acuity gained,24 to a highly signicant relationship,3, 18, 26 with even an inverse correlation being reported.19 Hiscox and colleagues found that better visual acuity outcome was directly related to the lower amounts of prescribed occlusion; however, these subjects also had higher levels of initial acuity at the commencement of treatment.19 The authors looked at the nal acuity level rather than total acuity gained at treatment cessation. Clearly reported that the majority of improvement was noted within the rst six months of therapy, with poor prognosis if visual acuity was not normalized within this time interval.18 She also concluded

that the optimal duration of occlusion was 400 hours, and that full-time occlusion was more effective than part-time occlusion. A more recent study, by Stewart and associates, utilized electronic dose monitored occlusion, and found that on average there was an improvement of 0.1 logMAR (one line of vision) per 120 hours of occlusion.27 The majority of the acuity gain was noted within the rst six weeks of therapy with further improvement noted up to 12 weeks. They also found that occlusion rates of two hours per day to six hours per day generated equal outcomes although higher doses attained their outcome more rapidly. Their general conclusions indicate that 200 or more hours of occlusion resulted in residual amblyopia of less than two lines of visual acuity (0.2 log units). Role of Visual Attentiveness Whether or not visual concentration plays a role in the efcacy of amblyopia therapy is also debatable. This area of uncertainty originated in the late 1970s when CAM therapy was popular.47 Although the purpose of this older study was not specifically designed to investigate whether or not the addition of visual attentive activities could enhance the efcacy of therapy, it may have sparked what is currently an ongoing discussion on the potential association between near activities and the visual outcome. The PEDIG recently conducted a prospective, randomized trial, directly comparing minimal amounts of occlusion (2 hours per day) with, and without, near visual activities.28 The study found that there was a suggestion of greater acuity gains (on average one logMAR line) in the group that were prescribed near visual activities. Not surprisingly, they concluded that children who were instructed to perform near activities while occluded actually performed more near activities while occluded than the group that was instructed to perform

American Orthoptic Journal

119

AMBLYOPIA CONTROVERSY

non-near activities while occluded. The question is whether or not one line difference in acuity is clinically signicant or merely secondary to common variations that may occur during clinical visual acuity assessments. One also has to wonder if subjects who are asked to perform specic tasks are more compliant with therapy, thus resulting in more substantial acuity gains, although both groups reported similar compliance. The study could have beneted by including some type of electronic dose monitoring system evaluating compliance, thus allowing the visual attentiveness to be the main inuencing factor, eliminating potential bias in parental reporting of compliance. Obviously, this is an area that requires further exploration and the authors indicate that a future randomized trial may be pending. Penalization In the past, penalization has often been viewed as a modality utilized when occlusion has been unsuccessful. Previous studies have demonstrated that both optical and pharmacological penalization, either in isolation or combined, can be effective therapy in amblyopia management.810, 29, 30 France reported an impressive response in which 93% of subjects undergoing optical penalization demonstrated acuity improvement with no reported visual regression.29 With reported better tolerance, and increased compliance, penalization is now being promoted as one of the primary therapeutic modalities in the battle against amblyopia.30 However, there are issues that need to be addressed when pharmacological penalization is being considered such as: the concentration of atropine, the optimal time for instillation (a.m. vs. p.m.), the duration of the cycloplegic effect, the refractive error, and the level of vision in the penalized eye versus that of the amblyopia eye. When attempting to make direct comparisons between the efcacy of

penalization and occlusion therapy, readers should be cognizant that not all penalization is created equal, for the reasons that have been mentioned above. The cycloplegic effect of atropine penalization needs to be assessed in each patient undergoing this therapy to determine the penalizing effect. Dynamic retinoscopy can provide vital information on the degree of cycloplegia and should be used routinely for patients undergoing atropine penalization. The use of intermittent minimal penalization has also attracted some attention. A large retrospective study conducted by Simons and colleagues found that intermittent pharmacological penalization use (one to three days per week) resulted in a clinically and statistically signicant improvement in visual acuity.10 A more recent study by PEDIG compared daily atropine penalization to weekend only penalization with similar visual acuity gains being achieved in both groups.30 The suggestion that these groups had comparable results, with seven days per week versus two days per week of atropine penalization, raises more questions than answers. The previously mentioned issues with pharmacological penalization may have played a role in the study outcomes and should be examined in future investigations of atropine use for amblyopia therapy. Age and Amblyopia Although there is general consensus that amblyopia responds well to treatment in the younger population,2, 9, 12, 15, 22, 23, 31, 32, 3437 uncertainty exists on whether or not therapy is effective in older populations. This uncertainty is based on the unproven assumption that the critical period for visual development in children ends around the age of 6 to 7 years.48, 49 In a 1995 study, Keech and Kutschke concluded that patients 6 years or older have a low probability of developing amblyopia.49 There have been recent studies to suggest that older

120

Volume 56, 2006

WALSH

patients (even adults) are responsive to amblyopia treatment.12, 22, 43, 5053 The spectrum of successful recovery of visual acuity, at a variety of ages, is encouraging. There are reports that younger patients may achieve a better nal outcome,23, 27, 37, 43, 51 with the age ranges of the subjects in these studies varying from 0 to 17 years. Each study had different age groups, treatment modalities, and follow up criteria, but the overall consensus was that the younger age groups achieved a better visual acuity endpoint. Visually mature individuals (age 1317, 11+) have also been shown to have improvement in their amblyopic eye following therapy,51 or loss of vision in their nonamblyopic eye.50 Age has also been reported to not be an inuencing factor in the overall success, for subjects ranging from 0 to 14 years.12, 14, 19, 22, 34, 43, 5254 Some of these studies reported that the older subjects required a greater period of occlusion to achieve similar results, when compared to younger counterparts.12, 22, 52 Keech noted improvement with fulltime occlusion in subjects aged 2 to 9.5, but did not address the age question. Flynn compiled data from a large pooled sample of subjects (689), but purposefully did not analyze age because of confounding variables.15 Unfortunately, the age variable is often confounded with other inuencing factors such as: initial level of acuity, type of amblyopia, and therapy modalities. Past comparisons have been made without treatment being standardized (e.g., younger patients undergoing fulltime occlusion are being compared to older subjects wearing part-time occlusion). It would appear that the jury is still out on this particular area. Visual Acuity Another factor that has been suggested to inuence treatment outcome is the initial and nal level of visual acuity. Gener-

ally, these studies suggest that subjects with poorer initial visual acuity tend to have poorer nal visual acuity.15, 16, 22, 23 The acuity result in these individuals has also been found to be less stable. Unfortunately, most of these studies either lack long-term follow-up assessments, or are reporting long-term results when in fact they are using repeat or maintenance treatment during the follow-up period.31, 46 Type of Amblyopia The type of amblyopia has been suggested to inuence outcome and stability of visual acuity. Strabismic/anisometropic amblyopia (mixed type) has been reported as having the poorest prognosis for visual acuity success, compared to strabismic amblyopia and anisometropic amblyopia, which have better reported results respectively.14, 15, 18, 19 Strabismic/anisometropic amblyopia (mixed type) has been indicated to be more prone to deterioration than anisometropic amblyopia.31 However, the direct opposite has also been reported with anisometropic amblyopia subjects suffering greater regression following cessation of treatment.36 These ndings are of interest when one would expect that strabismic/anisometropic amblyopia would be discovered and treated at an earlier age than anisometropic amblyopia, yet these results indicate inferior outcomes for the mixed type. Perhaps it is the combination of the amblyopiagenic factors in the mixed group that inuence the therapy outcome. In the anisometropic patients, the spectacle correction eliminates the amblyopiagenic factor, whereas in strabismic patients the amblyopiagenic factor persists until successful surgical correction. This may support those who advocate for earlier surgical realignment prior to, or concurrent with amblyopia therapy. A paper by Lam and colleagues investigated the effect of strabismus surgery prior to the complete resolution of amblyopia, and concluded

American Orthoptic Journal

121

AMBLYOPIA CONTROVERSY

that there was no signicant difference, in both the motor and sensory status, of subjects that had amblyopia partially, or fully corrected, before alignment was attained.60 Interestingly, spontaneous resolution of amblyopia after surgery was also noted in 5 of 21 patients (24%). Compliance When evaluating the efcacy of amblyopia treatment it is imperative that compliance be monitored closely. Unfortunately, the monitoring of compliance varies widely and there is almost a complete lack of objective monitoring. Studies that utilized the electronic dose monitoring system found that compliance is often low with poor correlation between parental recording, and the actual amount of therapy being conducted.56, 57 Previous studies have attempted to use attendance at clinical appointments, as an indicator of compliance with questionable results.37, 38 Whether or not therapy compliance is directly associated with the psychosocial impact of treatment has been the focus of a number of articles.11, 3841 Searle and colleagues reported that only 54% of parents were meeting occlusion expectations and that self-efcacy was positively associated with compliance.38 Parents who believed in their ability to comply with patching increased the likelihood that therapy would be carried out. If parents believed that patching prohibited their childs activities then lower amounts of occlusion were worn. One study investigated the intensity of the occlusion and compliance rates and found that treatment was tolerated well in subjects wearing either six to eight or ten hours of occlusion per day.38 A more recent article compared the psychosocial impact of occlusion versus spectacle wear and concluded that occlusion was no more stressful (for the parents) than spectacles.39 In a series of articles, Newsham examined whether or not knowledge about amblyopia and am-

blyopia therapy played a role in the compliance of occlusion therapy.40, 41 Again the compliance rate was reduced with 54% of subjects failing to occlude 80% of the prescribed time. Seventy-seven percent (75) of the nonconcordant subjects stated a lack of understanding about amblyopia as the reason for noncompliance. Based on what has been reported in the literature on the lack of reliability in the parental record of completed therapy, one could ask if we should automatically prescribe more yet expect less? There are risks with managing our clinical practice with this untrustworthy policy as we will need to ensure that follow up assessments are reective of the increased levels of prescribed treatment. With ongoing concerns regarding limited health care resources, the question of whether or not amblyopia management is cost-effective can be directly impacted by compliance. Less compliance results in a longer treatment timetable and more frequent follow-up assessments (greater costs to the patients and health care system). Stability of Visual Acuity Stability of visual acuity in the amblyopic eye after treatment has also been debated in the literature, although certainly few studies have dealt with this issue. There is a wide discrepancy in the reported recurrence rates of amblyopia, following the cessation of treatment, from as low as 6%42 to as high as 75%.43 Studies have differed with regards to the therapeutic modality, initial and nal visual acuity, patient population, method of visual acuity testing and follow up assessments. The criterion for regression was also variable. The majority of the studies have been retrospective and therefore subject to the limitations that occur with this study design. There was also a generalized lack of standardization of visual acuity measurements in these previous investigations. Finally,

122

Volume 56, 2006

WALSH

these studies have failed to identify one common predictive factor for stability of vision following the cessation of treatment. Cessation of Treatment Another area that lacks clarication is the potential role that therapy tapering plays in the recurrence of amblyopia following the cessation of treatment. A recent study by the PEDIG looked at the recurrence of amblyopia following treatment cessation and found that 42% of patients wearing six or more hours of occlusion were likely to experience some visual acuity regression when therapy was abruptly discontinued.59 Although the main focus of this study was to evaluate the overall risk of amblyopia recurrence following the cessation of treatment, the results did suggest that there is a greater risk of amblyopia recurrence when occlusion is discontinued abruptly rather than when it is weaned. Otherwise, the current literature lacks adequate data on the most appropriate and effective method to end amblyopia treatment. Obviously there is a need for a randomized, prospective, study designed to compare progressive tapering of therapy and abrupt cessation. Research and Clinical Practice Does the existing research in the area of amblyopia alter the way that clinicians manage amblyopia? A recent study focused specically on the recent articles published by the PEDIG, concerning the randomized trial of patching regimens for the treatment of moderate amblyopia, and whether or not the results of this study altered the clinical practice of member ophthalmologists of the American Association for Pediatric Ophthalmology and Strabismus.44 A questionnaire was e-mailed to 380 ophthalmologists with only 90 (23.8%) responding. A nal number of 76 (20%) were used for the data analysis. The conclusion

of this survey revealed that the majority of respondents did not alter their clinical practice despite these recent ndings. Although this study failed to capture the original sample size, with only a 23.8% response rate, the overall aim of this investigation is indeed thought provoking. Another study focused on the role that press coverage can potentially have on parental preferences in amblyopia treatment.45 This article emphasized the impact that positive or negative press can have on parental decision-making, which undoubtedly will affect the choice of, and the compliance with, the prescribed therapy. Initially, after having read press releases regarding amblyopia treatment, parents preferred atropine penalization; however, after being given additional information about the results of previously published studies, there was a shift in opinions with conventional occlusion being the more favorable modality. CONCLUSION Studies in amblyopia treatment are fraught with contradictions. It is not surprising that even the effectiveness of amblyopia treatment has been brought into question. Amblyopia treatment has never been standardized, with few consistent guiding principles that can be utilized in everyday clinical practice. Much of what we have learned about amblyopia has been gained through empirical retrospective studies and anecdotal reports and thus we are limited by the aws associated with this type of data acquisition. There is an obvious need for consistently controlled, prospective, randomized investigations, as well as the need to establish consistent success and regression criterion. Standardization of visual acuity testing procedures is also an essential requirement that is necessary if accurate interpretations and comparisons are to be made. It is time to start looking at amblyopia treatment as a science

American Orthoptic Journal

123

AMBLYOPIA CONTROVERSY

rather than an art and develop standardized goals and objectives to help guide our future endeavors. These studies will aid clinicians in their decision making processes, perhaps even changing their established treatment regimens. REFERENCES
1. Hillis A: Amblyopia: Relevant, curable, neglected. Public Health Rev 1986; 14: 213235. 2. von Noorden GK. Binocular Vision and Ocular Motility: Theory and Management of Strabismus, sixth ed. St. Louis: Mosby; 2000, p. 246. 3. Dorey SE, Adams GW, Lee JP, Sloper JJ: Intensive occlusion therapy for amblyopia. Br J Ophthalmol 2001; 85: 310313. 4. Haase W, Wenzel F: The natural course of untreated functional amblyopia: Does it progress between childhood and adulthood? Binocul Vis Strabismus Q 1996; 12: 1724. 5. Simons K, Preslan M: Natural history of amblyopia untreated owing to lack of compliance. Br J Ophthalmol 1999; 83: 582584. 6. Rahi J, Logan S, Timms C, Eggitt IR, Taylor DSI: Risk, causes, and outcomes of visual impairment after loss of vision in the non-amblyopic eye: A population based study. Lancet 2000; 360: 597602. 7. Snowdon SK, Stewart-Brown SL: Preschool vision screening. Health Technol Assess 1997; 1: 183. 8. Foley-Nolan A, McCann A, OKeefe M: Atropine penalization versus occlusion as the primary treatment for penalization versus part-time occlusion and binocular outcome in treatment of strabismus amblyopia. Ophthalmology 1997; 104: 21562160. 9. Pediatric Eye Disease Investigator Group: A randomized trial of atropine vs. patching for treatment of moderate amblyopia in children. Arch Ophthalmol 2002; 120: 268278. 10. Simons K, Stein L, Sener E, Vitale S, Guyton D: Full-time atropine, intermittent atropine, and optical penalization and binocular outcome in treatment of strabismus amblyopia. Ophthalmology 1997; 104: 21432155. 11. Cole SR et al.: The Amblyopia Treatment Index. J AAPOS 2001; 5: 250254. 12. Scott WE, Stratton VB, Fabre J: Full-time occlusion therapy for amblyopia. Am Orthopt J 1980; 30: 125130. 13. Beardsell R, Clarke S, Hill M: Outcome of occlusion treatment for amblyopia. J Pediatr Ophthalmol Strabismus 1999; 36: 1924. 14. Woodruff G, Hiscox F, Thompson JR, Smith LK:

15.

16. 17.

18.

19.

20. 21.

22.

23. 24.

25.

26.

27.

28.

29.

30.

31.

Factors affecting the outcome of children treated for amblyopia. Eye 1994; 8: 627631. Flynn JT, Schiffman J, Feuer W, Corona A: The therapy of amblyopia: An analysis of the results of amblyopia therapy utilizing the pooled data of publishes studies. Tr Am. Ophth Soc 1998; XCVI: 432451. Flynn JT, Cassady JC: Current trends in amblyopia therapy. Ophthalmology 1978; 85: 428450. Pediatric Eye Disease Investigator Group: A randomized trial of patching regimens for treatment of moderate amblyopia in children. Arch Ophthalmol 2003; 121: 603611. Cleary M: Efcacy of occlusion for strabismic amblyopia: Can optimal duration be identied? Br J Ophthalmol 2000; 84: 572578. Hiscox F, Strong N, Thompson JR, et al.: Occlusion for amblyopia: A comprehensive survey of outcome. Eye 1992; 6: 300304. von Noorden GK. The History of Strabismology. Oostende, Belgium: J. P. Wayenborgh; 2002. Clarke MP, Wright CM, Hrisos S, Anderson JD: Randomized controlled trial of treatment of unilateral visual impairment detected at preschool vision screening. BMJ 2003; 327: 1251. Scott WE, Dickey C: Stability of visual acuity in amblyopia patients after visual maturity. Graefes Arch Clin Exp Ophthalmol 1988; 226: 154 157. Scott WE et al.: Amblyopia treatment outcomes. J AAPOS 2005; 9: 107111. Pediatric Eye Disease Investigator Group: A randomized trial of prescribed patching regimens for treatment of severe amblyopia in children. Ophthalmology 2003; 110: 20752087. Keech RV et al.: The minimal occlusion trial for the treatment of amblyopia. Ophthalmology 2002; 109: 22612264. Dorey SE, Adams GW, Lee JP, Sloper JJ: Intensive occlusion therapy for amblyopia. Br J Ophthalmol 2001; 85: 310313. Stewart CE et al.: Treatment dose-response in amblyopia therapy: The Monitored Occlusion Treatment of Amblyopia Study (MOTAS). IOVS 2004; 45: 30483054. Pediatric Eye Disease Investigator Group: A randomized pilot study of near activities versus non-near activities during patching therapy for amblyopia. J AAPOS 2005; 9: 129136. France TD, France LW: Optical penalization can improve vision after occlusion treatment. J AAPOS 1999; 3: 341343. Pediatric Eye Disease Investigator Group: A randomized trial of atropine regimens for treatment of moderate amblyopia in children. Ophthalmology 2004; 111: 20762085. Levartovsky S, Gottesman N, Shimshoni M,

124

Volume 56, 2006

WALSH

32.

33.

34.

35.

36.

37.

38.

39. 40.

41.

42.

43.

44.

45.

46.

Oliver M: Factors affecting long-term results of successfully treated amblyopia. J Pediatr Ophthalmol Strabismus 1992; 29: 219223. Levartovsky S, Oliver M, Gottesman N, Shimshoni M: Factors affecting long-term results of successfully treated amblyopia: Initial visual acuity and type of amblyopia. Br J Ophthalmol 1995; 79: 225228. Gregersen E, Rindziunski OT: Conventional occlusion in the treatment of squint and amblyopia: A 10-year follow-up. Acta Ophthalmol 1965; 434: 6274. Ching FC, Parks MM, Friendly DS: Practical management of amblyopia. J Pediatr Ophthalmol Strabismus 1986; 23: 1216. Oster JG, Simon JW, Jenkins P: When is it safe to stop patching? Br J Ophthalmol 1990; 74: 709711. Ohlsson J, Baumann M, Sjostrand J, Abrahamsson M: Long-term visual outcome in amblyopia treatment. Br J Ophthalmol 2002; 86: 11481151. Oliver M, Neumann R, Chaimovitch Y, Gottesman Y, Shimshoni M: Compliance and results of treatment for amblyopia in children above age 8. Am J Ophthalmol 1986; 102: 340345. Searle A et al.: Psychosocial and clinical determinants of compliance with occlusion therapy for amblyopic children. Eye 2002; 16: 150155. Choong YF et al.: Psychosocial impact of amblyopia treatment. Eye 2004; 18: 369375. Newsham D: A randomized controlled trial of written information: The effect on parental nonconcordance with occlusion therapy. Br J Ophthalmol 2002; 86: 787791. Newsham D: Parental non-concordance with occlusion therapy. Br J Ophthalmol 2000; 84: 957962. Kushner BJ: Functional amblyopia: A purely practical pediatric patching protocol. In: Ophthalmology Annual. New York: Raven Press; 1998. pp. 173198. Rutstein RP, Fuhr PS: Efcacy and stability of amblyopia therapy. Optom Vis Sci 1992; 69: 747754. Wygnanski-Jaffe T: The effect on pediatric ophthalmologists of the randomized trial of patching regimens for treatment of moderate amblyopia. J AAPOS 2005; 3: 208211. Golden RP: The effect of media press coverage on parental preferences in amblyopia treatment. J AAPOS 2005; 3: 212215. Simons K: Amblyopia characteristics, treatment, and prophylaxis. Surv Ophthalmol 2005; 50: 123166.

47. Banks RV et al.: A new treatment for amblyopia. Br Orthopt J 1978; 35: 112. 48. von Noorden GK, Crawford ML: The sensitive period. Trans Ophthalmol Soc UK 1979; 99: 442446. 49. Keech RV, Kutschke PJ: Upper age limit for the development of amblyopia. J Pediatr Ophthalmol Strabismus 1995; 32: 8993. 50. Rahi J, Logan S, Timms C, Eggitt IR, Taylor DSI: Risk, causes, and outcomes of visual impairment after loss of vision in the non-amblyopic eye: A population-based study. Lancet 2000; 360: 597602. 51. Pediatric Eye Disease Investigator Group: Randomized trial of treatment of amblyopia in children aged 7 to 17 years. Arch Ophthalmol 2005; 123: 437447. 52. Mintz-Hittner HA, Fernandez KM: Successful amblyopia therapy initiated after age 7 years. Arch Ophthalmol 2000; 118: 15351541. 53. Park KH et al.: Efcacy of amblyopia therapy initiated after 9 years of age. Eye 2004; 18: 571 574. 54. Sparrow JC, Flynn JT: Amblyopia: A long-term follow-up. J Pediatr Ophthalmol 1979; 14: 6: 333336. 55. Loudon SE et al.: Objective survey of the prescription of occlusion therapy for amblyopia. Graefes Arch Clin Exp Ophthalmol 2004; 242: 736740. 56. Loudon SE et al.: Electronically measured compliance with occlusion therapy for amblyopia is related to visual acuity increase. Graefes Arch Clin Exp Ophthalmol 2003; 241: 176180. 57. Awan M et al.: A randomized controlled trial of unilateral strabismic and mixed amblyopia using occlusion dose monitors to record compliance. IOVS 2004; 46: 14351439. 58. Pediatric Eye Disease Investigator Group: The course of moderate amblyopia treated with patching in children: Experience of the Amblyopia Treatment Study. Am J Ophthalmol 2003; 136: 620628. 59. Pediatric Eye Disease Investigator Group: Risk of amblyopia recurrence after cessation of treatment. J AAPOS 2004; 8: 420428. 60. Lam GC, Repka MX, Guyton, DL: Timing of amblyopia therapy relative to strabismus surgery. Ophthalmology 1993; 100: 17511756.

Key words: amblyopia, controversy, therapy

American Orthoptic Journal

125