Dear Editor,

We read with great interest the “Bullying and eye patching” commentary by Williams and co-workers in which they report on the psychosocial implications of early versus late treatment of amblyopia.[1] In their birth cohort study, they found that early detection (screening at the age of 3 years and 1 month) and subsequent early treatment of amblyopia resulted in fewer reports of bullying victimisation by age 8 years. On this basis, they appraised pre-school vision screening and suggested that the timing of treatment should be as early as possible, so as to lessen the likelihood of bullying. Whilst the literature suggests that sustained bullying in childhood may have adverse psychosocial consequences in adulthood,[2] and whilst we agree that prevention of bullying is important, there is no evidence indicating that the experiences of children who undergo patching treatment for amblyopia have adverse consequences in terms of children’s longer term well-being.

There is certainly a growing body of evidence suggesting that patching is associated with peer victimisation.[1,3-4] In a study we recently conducted, we found that children not only reported experiences of bullying, but also feelings of stigmatisation regardless of whether they were subjected to victimisation.[5] This resulted in negative psychosocial outcomes for some children. However, whether bullying and or feelings of stigmatisation have longer term psychosocial sequelae remains unanswered. Ideally, prospective longitudinal studies are needed to investigate the long term psychosocial consequences of patching for amblyopia. Although Williams and her colleagues have conducted a prospective study, they have only assessed bullying at one point in time (at 8.5 years of age) and do not appear to have asked children what they perceived as the cause of their victimisation. Without at least the child’s perspective on this, it is impossible to ascertain whether these experiences relate to patching. Furthermore, amblyopia treatment usually always ceases well before the end of the first decade of life. Hence, patching, the source of a child’s differentness within a group of peers, also ceases early in life. It is possible that short-term patching does not necessarily have an adverse effect on an individual’s psychosocial well-being in the long-term. There is also evidence that the removal of a stigmatising feature can have positive implications for an individual. For instance, it has been reported that psychosocial functioning improves with corrective surgery for strabismus.[6-9] More research is needed to investigate whether this similarly relates to patching.

We agree with the authors that bullying and other psychosocial factors should form part of treatment outcome measures; however there is need for future research to also be attentive to the longer term effects of patching treatment for amblyopia. Given the nature of this birth cohort study, the ALSPAC Study team may be able to address this in follow-up studies.

Konstandina Koklanis PhD

Zoran Georgievski BAppSc(Orth)Hons

References

1. Williams C, Horwood J, Northstone K, et al. The timing of patching treatment and a child's wellbeing. British Journal of Ophthalmology 2006;90:670-671.

2. Olweus D. Victimisation by peers: Antecedents and long-term outcomes. In: Rubin KH, Asendorpf J, eds. Social Withdrawal, Inhibition and Shyness in Childhood. Hillsdale, NJ: Lawrence Erlbaum. 1993.

3. Packwood E, Cruz O, Rychwalski P, Keech R. The psychosocial effects of amblyopia study. Journal of the American Association for Pediatric Ophthalmology and Strabismus 1999;3:15-17.

4. Horwood J, Waylen A, Herrick D, et al. Common visual defects and peer victimization in children. Investigative Ophthalmology and Visual Science 2005;46:1177-1181.

5. Koklanis K, Abel L, Aroni R. The psychosocial impact of amblyopia and its treatment: A multidisciplinary study. Clinical and Experimental Ophthalmology in press.

6. Burke J, Leech C, Davis H. Psychosocial implications of strabismus surgery in adults. Journal of Pediatric Ophthalmology and Strabismus 1997;34:159-164.

7. Satterfield D, Keltner J, Morrison T. Psychosocial aspects of strabismus study. Archives of Ophthalmology 1993;111:1100-1105.

8. Jackson S, Harrad R, Morris M, Rumsey N. The psychosocial benefits of corrective surgery for adults with strabismus. British Journal of Ophthalmology 2006;90:883-888.

9. Menon V, Saha J, Tandon R, et al. Study of psychosocial aspects of strabismus. Journal of Pediatric Ophthalmology and Strabismus 2002;39:203- 208.