Comparative Efficacy of Penalization Methods in Moderate to Mild Amblyopia

doi:10.1016/j.ajo.2007.10.029

American Journal of Ophthalmology

Volume 145, Issue 3, March 2008, Pages 562-569

https://doi.org/10.1016/j.ajo.2007.10.029 Get rights and content

Purpose

To compare the efficacy and sensory outcome of pharmacologic and optical penalization in the treatment of moderate to mild amblyopia.

Design

Randomized clinical trial.

Methods

In an institutional setting, two- to 10-year-old children with strabismic or anisometropic amblyopia (visual acuity in the amblyopic eye at least 20/60) who were cooperative to measure visual acuity using the logarithm of the minimum angle of resolution (logMAR) crowded Glasgow acuity cards were randomized into two groups of therapy (n = 35 in each group), 1% atropine, and optical penalization with positive lenses, after stratification by cause of amblyopia. Visual acuity was tested by the logMAR crowded Glasgow acuity cards, after retinoscopic refraction, and deviation angle were measured by the simultaneous prism and cover or Krimsky test. Stereoacuity was determined using the Titmus fly test and Randot preschool or Randot circles stereoacuity test. Change in visual acuity of the amblyopic eye and in interocular difference of visual acuity after six months of amblyopia therapy was the main outcome measure; stereoacuity at six months of therapy was a secondary outcome measure.

Results

Thirty-one and 32 children completed the outcome examination in the atropine and optical penalization group, respectively. Average improvement in visual acuity of the amblyopic eye was larger in the atropine than in the optical penalization group (3.4 and 1.8 logMAR lines, respectively), as well as average improvement in interocular difference of visual acuity (2.8 and 1.3 logMAR lines, respectively). Better stereoacuity, but nonsignificantly different, was detected in the atropine group.

Conclusions

Atropine penalization may be considered more effective than optical penalization with positive lenses.

Section snippets

Patient Selection and Sample Size

Subjects included were selected from among children treated for amblyopia between January 2004 and December 2005 in Hospital Ramón y Cajal. The upper age limit for inclusion in the study was 10 years. The lower age limit was determined by the ability to cooperate with visual acuity testing using the logMAR crowded Glasgow acuity cards. For inclusion, interocular difference in visual acuity was at least two logMAR lines (0.2 logMAR units), and visual acuity in the amblyopic eye was at least 0.5

Results

The characteristics of children included in the study are summarized in Table 1. The outcome examination was completed by 32 children (91.4%) in the optical penalization group and by 31 children in the atropine group (88.5%). In the optical penalization group, three children were lost to follow-up. In the atropine group, two patients discontinued treatment because of intolerance, one was withdrawn because the amblyopic eye was treated mistakenly with atropine (subsequently treated with

Discussion

Pharmacologic penalization with atropine may be considered more effective than optical penalization by wearing a plus defocus lens in the treatment of moderate or mild amblyopia. Although using optical penalization is helpful in treating amblyopia, the effect of this treatment after six months (1.8 lines) is only slightly larger than half the effect of atropine penalization (3.4 lines). The stronger effect of atropine may be explained in part by the better compliance in comparison with optical

References (23)

M.X. Repka et al.
The efficacy of optical and pharmacological penalization
Ophthalmology
(1993)
M.X. Repka et al.
Determination of optical penalization by vectographic fixation reversal
Ophthalmology
(1985)
N.S. Levy et al.
Stereoscopic perception and Snellen visual acuity
Am J Ophthalmol
(1974)
G.K. von Noorden
Binocular vision and ocular motility: theory and management of strabismus
A randomized trial of atropine vs patching for treatment of moderate amblyopia in children
Arch Ophthalmol
(2002)
Two-year follow-up of a 6-month randomized trial of atropine vs patching for treatment of moderate amblyopia in children
Arch Ophthalmol
(2005)
T.N. Wiesel et al.
Single-cell responses in striate cortex of kittens deprived of vision in one eye
J Neurophysiol
(1963)
D.H. Hubel et al.
The period of susceptibility to the physiological effects of unilateral eye closure in kittens
J Physiol
(1970)
L. Altmann et al.
Functional and neuronal binocularity in kittens raised with rapidly alternating monocular occlusion
J Neurophysiol
(1987)
B. Timney
Effects of brief monocular deprivation on binocular depth perception in the cat: a sensitive period for loss of stereopsis
Vis Neurosci
(1990)

K. Simons et al.

Full-time atropine, intermittent atropine, and optical penalization, and binocular outcome in treatment of strabismic amblyopia

Ophthalmology

(1997)

Cited by (25)

Treatment compliance in amblyopia: A mini-review and description of a novel online platform for compliance tracking
2022, Survey of Ophthalmology
Citation Excerpt :
In the atropine alone group, 94% were found to have “excellent” compliance, 4% were considered good, 1% was considered fair, and 1% was considered poor.77 These high rates of subjectively reported compliance with atropine treatment are consistent with other studies.28,46,103 Multiple trials examining atropine treatment for childhood myopia also found subjective compliance rates of greater than 90%.14,116
Patient compliance with amblyopia therapies, including eye patching and atropine drops, is crucial for optimal visual acuity outcomes. Studies utilizing objective measures of compliance measurement have consistently shown that a majority of patients receive significantly less treatment than prescribed. We review the subjective and objective compliance rates reported in the literature, assess possible explanations for poor compliance, and describe studies of interventions to improve compliance. Additionally, we report our experience implementing Inside Out Care, a novel online platform designed to improve monitoring of amblyopia patient compliance, in our clinics. We have found that this platform, which is accessible via both computer and smartphone, has improved monitoring of amblyopia patient patching compliance, as well as allowed for enhanced doctor-patient communication.
The pursuit of stereopsis
2018, Journal of AAPOS
Citation Excerpt :
Recent research has focused on newer treatment modalities to address the issue of low compliance.15 Penalization of the sound eye to force fixation with the amblyopic eye has also been shown to be an alternative to patching.16,17 It can be done using optical penalization with glasses and pharmacological penalization using atropine.18
Pediatric ophthalmologists are increasingly expected to promote, preserve, and restore binocular vision.
Clinical studies on restoring alignment and stereopsis in the management of amblyopia, esotropia, exotropia, and complex strabismus are reviewed from the perspective of the author's published work and personal experiences.
Treatment of amblyopia by means of optical rehabilitation, occlusion, or penalization has been reinforced by medical treatment and perceptual training with monocular or binocular video games. Studies indicate that early management of esotropia and alignment within 8^Δ is required for regaining stereopsis. In the surgical management of intermittent exotropia, distance stereopsis by Frisby Davis Distance stereotest can predict better stereopsis, with patients having preoperative distance stereopsis of <70 arcsec less likely to improve after surgery. The surgeon's armamentarium for correcting alignment and restoring binocular vision include procedures such as adjustable, partial vertical rectus muscle transposition in cases of exotropic Duane syndrome and lateral rectus palsy, periosteal fixation of the globe or of the lateral rectus muscle, and medial transposition of the split lateral rectus muscle.
The goal for present-day strabismologists is not merely to correct strabismus but also to achieve alignment of eyes in time to ensure normal development of stereopsis in children and to restore alignment and stereopsis in adults.
Compliance and patching and atropine amblyopia treatments
2015, Vision Research
Citation Excerpt :
Moreover, subjective compliance with atropine treatment is lower, on average, in older children (Scheiman et al., 2008) than in younger amblyopes (Pediatric-Eye-Disease-Investigator-Group, 2002, 2009) (Table 3). To estimate atropine compliance objectively, Tejedor et al. used dynamic retinoscopy to test the patient’s ability to accommodate; they reported 12.9% non-compliance (Tejedor & Ogallar, 2008). Because such an objective method did not track the whole process, it may have under- or over-estimated objective compliance.
In the past 20 years, there has been a great advancement in knowledge pertaining to compliance with amblyopia treatments. The occlusion dose monitor introduced quantitative monitoring methods in patching, which sparked our initial understanding of the dose–response relationship for patching amblyopia treatment. This review focuses on current compliance knowledge and the impact it has on patching and atropine amblyopia treatment.
Whole-population vision screening in children aged 4-5 years to detect amblyopia
2015, The Lancet
Amblyopia is a neurodevelopmental disorder that affects at least 2% of most populations and can lead to permanently reduced vision if not detected and treated within a specific period in childhood. Whole-population screening of children younger than 5 years is applied in many countries. The substantial diversity in existing programmes reflects their heterogeneous implementation in the absence of the complete evidence base that is now a pre-requisite for instituting screening. The functional importance of amblyopia at an individual level is unclear as data are scarce, but in view of the high prevalence the population-level effect might be notable. Screening of all children aged 4–5 years (eg, at school entry) confers most benefit and addresses inequity in access to timely treatment. Screening at younger ages is associated with increased risk of false-positive results, and at older ages with poor outcomes for children with moderate to severe amblyopia. We suggest that the real-life adverse effects of amblyopia should be characterised and screening and diagnosis should be standardised.
Ophthalmological evaluation of normal child. Preventive measures. Signs for alarm
2009, Anales de Pediatria Continuada
Interventions for improving adherence to amblyopia treatments in children
2023, Cochrane Database of Systematic Reviews

View all citing articles on Scopus

View full text

Original articleComparative Efficacy of Penalization Methods in Moderate to Mild Amblyopia

Purpose

Design

Methods

Results

Conclusions

Section snippets

Patient Selection and Sample Size

Results

Discussion

Ophthalmology

Ophthalmology

Am J Ophthalmol

Binocular vision and ocular motility: theory and management of strabismus

A randomized trial of atropine vs patching for treatment of moderate amblyopia in children

Arch Ophthalmol

Two-year follow-up of a 6-month randomized trial of atropine vs patching for treatment of moderate amblyopia in children

Arch Ophthalmol

Single-cell responses in striate cortex of kittens deprived of vision in one eye

J Neurophysiol

The period of susceptibility to the physiological effects of unilateral eye closure in kittens

J Physiol

Functional and neuronal binocularity in kittens raised with rapidly alternating monocular occlusion

J Neurophysiol

Effects of brief monocular deprivation on binocular depth perception in the cat: a sensitive period for loss of stereopsis

Vis Neurosci

Full-time atropine, intermittent atropine, and optical penalization, and binocular outcome in treatment of strabismic amblyopia

Ophthalmology

Original article
Comparative Efficacy of Penalization Methods in Moderate to Mild Amblyopia