Amblyopia Treatment Evidenced-Based Treatment Strategies

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1 Disclosures Amblyopia Treatment Evidenced-Based Treatment Strategies No financial interests in materials or methods Salary support NIH/NEI (EY011751, EY018810) Atropine is not FDA approved for amblyopia treatment Susan A. Cotter Professor Southern California College of Optometry Marshall B Ketchum University ObjecNves Recent clinical trials & prospecnve studies Main results Share clinical perspecnves New treatments on horizon Amblyopia Treatment Dogma Mainstay of amblyopia treatment = occlusion Rx glasses and occlusion simultaneously Patch full- Nme, especially if severe amblyopia Never patch < 4 hours Patching is beher than atropine penalizanon Atropine only for moderate amblyopia Atropine only in younger children Amblyopia cannot be treated beyond 6-9 years Near acnvines should always be done when patched ATS Methods ProspecNve randomized clinical trials or observanonal studies PEDIG invesngators Pediatric optometrists and ophthalmologists USA & Canada University based and private pracnces ATS Methods Primary outcome: Standardized masked assessment of best- corrected visual acuity 1

2 Is There a Treatment Effect Over Time from Wearing a RefracNve CorrecNon Alone? RefracNve CorrecNon Guidelines Based on 1% cyclopentolate refracnon Full anisometropia, asngmansm, myopia Hyperopia Fully correct (primarily for ET) OR Under- correct symmetrically* *no more than 1.50 D for most PEDIG studies RefracNve CorrecNon Alone in Anisometropic Amblyopia Spectacles Alone for Aniso Amblyopia Mean VA of Amblyopic Eye Previously untreated 3 to <7 years old (n=84) VA amblyopic eye = 20/40 to 20/250 3 logmar lines IOD Enroll Rx Specs Baseline (Amblyopia confirmed) Mean VA 20/80 5 w 10 w 15 w 20 w 25 w 30 w Mean Visual Acuity Score 20/32 20/40 20/50 20/63 20/80 20/100 20/80 Baseline 20/40 Best VA ATS- 5: Previously Untreated 3- <7 yr olds with Anisometropic Amblyopia Visual Acuity Improvement Mean lines 2.9 ± lines 3 lines 20/40 20/100 20/125 20/250 PEDIG. Ophthalmology 2006;113: % 60% 2.9 lines 2.8 lines ATS- 5: Previously Untreated 3- <7 yr olds with Anisometropic Amblyopia Visual Acuity Improvement Mean lines 2.9 ± lines 3 lines 20/40 20/100 20/125 20/250 Resolu?on (VA = or ± 1 line) PEDIG. Ophthalmology 2006;113: % 60% 2.9 lines 2.8 lines Overall 27% 20/40-20/100 33% 20/125 20/150 6% 2

3 RefracNve CorrecNon for Amblyopia Associated with Strabismus? 3- <7 yrs amblyopia assoc w/ strabismus No prior refracnve correcnon or amblyopia tx Amblyopia 20/40 20/400; 3- line IOD Ametropia at least 1 of the following: 1.00 D asngmansm in amblyopic eye 1.00 D SE anisometropia D SE hyperopia in either eye Treatment with Spectacles Only Follow- Up at 9 weeks 18- week Outcome Exam Post- outcome 9- week FU s if VA snll improves 1 line N=146 Change in Amblyopic VA (logmar lines) 4" 3" 2" 1" 0" Change in Visual Acuity Between Baseline & 18 Weeks 2.3 Lines Combined" Ophthalmology 2012;119: Lines Strabismus" Total % Improved 2 lines 69% 88% 75% % Improved 3 lines 50% 63% 53% % Resolved 28% 40% 32% Specs Only: Amblyopic Eye VA Mean Lines of Improvement Was VA Improvement Related to Eye Alignment? Aniso Strab Comb No relanonship! Ophthalmology 2012;119: Frequency Time Course to Achieve Best VA Combined- Mechanism Strabismus- Only Baseline 9 Weeks 18 Weeks 27 Weeks 36 Weeks 45 Weeks Weeks Most (>90%) achieved best VA by 18 weeks Follow- Up Schedule for OpNcal Treatment of Amblyopia? 6-10 week intervals May have no improvement between 2 visits yet improve at next visit 3

4 Clinical ImplicaNons What About Isoametropic Amblyopia? Mean VA ~ 3 lines; amblyopia resolved 25% Some not need occlusion When occlusion needed BeHer VA when start Lessen burden of subsequent tx parncularly for denser amblyopia One new treatment at a Nme Example: X 180 (20/50) X 175 (20/50) Am J Ophthalmol 2007; 114: ATS- 7: Bilateral RefracNve Amblyopia in Children 3 to <10 Years Goal: Determine amount & Nme course of VA improvement Major eligibility criteria: +4.00D SE +/or 2.00D cyl OD & OS 20/40 to 20/400 OD/OS Primary outcome = Binocular VA at 1 year Am J Ophthalmol 2007;144: logmar Results: Mean VA Over Time yr: 3.9 lines (95% CI = 3.5 to 4.2) 20/40 20/25 Baseline 5 weeks 1 year Baseline VA: Hyperopes only (35%) = 20/80; asngmats only (42%) = 20/50 ATS- 7: Probability of Binocular VA 20/25 is 74% at 1 Year ATS- 7: Baseline Factors PredicNve of Binocular Visual Acuity Improvement? Am J Ophthalmol 2007;144: N=113 Baseline factor P value Worse binocular acuity* <0.001 Cause of amblyopia.18 Age.17 Strabismus.84 Hyperopia amount.94 AsNgmaNsm amount.46 Anisometropia amount.39 Interocular VA difference.05 Stereoacuity.52 *20/40-20/80: mean= 3.4 lines; 20/100-20/320: mean = 6.3 lines 4

5 Conclusion OpNcal Treatment of Amblyopia Patching or Atropine? If So, How Much? OpNcal correcnon of refracnve error alone has a true treatment effect on amblyopia beyond the immediate VA gains from simply eliminanng opncal blur But refracnve correcnon alone does not eliminate all amblyopia. ATS: Randomized Randomized Clinical Trials Trials Patients Randomized Study RCT s: Amblyopia Treatment Studies 3 to <7 years Prescribed Treatments Depth of Amblyopia Mean Lines VA Mean VA Post- tx ATS- 1 6 hrs patching vs. daily atropine Moderate /30 20/30-2 Treatment 1 Treatment 2 Completed OUTCOME EXAM Completed * 1 hr of near acnvines while patched also prescribed for both groups Arch Ophthalmol 2002;120: What Have We Learned About Patching Dosage? Patching Dosage Studies Severe Amblyopia Trial (20/100-20/400) Moderate Amblyopia Trial (20/40-20/80) Randomize Randomize Full-time All (-1) hr / day* patching Part-time 6 hrs / day* patching Part-time 6 hrs / day* patching Minimal-time 2 hrs / day* patching 5-week FU Visit 17-week Outcome Visit * 1 hour of near activities Arch Ophthalmol 2003;121:503-11; Ophthalmology 2003;110:

6 Severe Amblyopia Trial (20/100-20/400) Full-time All (-1) hr / day* patching Patching Dosage Studies Randomize Part-time 6 hrs / day* patching 5-week FU Visit Moderate Amblyopia Trial (20/40-20/80) Part-time 6 hrs / day* patching 17-week Outcome Visit Randomize Arch Ophthalmol 2003;121:503-11; Ophthalmology 2003;110: Minimal-time 2 hrs / day* patching * 1 hour of near activities Study ATS- 1 ATS- 2B ATS- 2A RCT s: Amblyopia Treatment Studies 3 to <7 years Prescribed Treatments 6 hrs patching vs. daily atropine 2 hrs patching vs. 6 hrs patching* 6 hrs patching vs. full- Nme patching* Depth of Amblyopia Moderate Moderate Severe Mean Lines VA * 1 hr of near acnvines while patched also prescribed for both groups Mean VA Post- tx 20/30 20/ /32 20/ /50 20/50-2 Less patching (vs. convention) is effective Ophthalmology 2002;120: & 2003;121:503-11; Ophthalmology 2003;110: & 2004;111: Patching Treatment for 3 to < 7 yrs Lesser amount prescribed; compliance? Prescribed completed If inadequate response: can increase patching intensity OR prescribe atropine Patching Treatment for 3 to < 7 yrs Consider glasses only first Patching vs. atropine 6 hrs of patching is faster than daily atropine Choice for child / family Moderate amblyopia - start with 2 hrs/day Severe amblyopia - start with 6 hrs/day * *ATS- 6: 2 hrs for some with severe - effecnve RCT of Occlusion Dose Monitors Actual Patching Dose 52 8yr- olds w/ strabismic or combined amblyopia OpNmal spectacles & randomized to: No patching Rx 3 hours patching Rx 6 hours patching 12- wk outcome: compliance Mean patching Nme Rx 3 hrs = 1.75 hrs Rx 6 hrs = 2.5 hrs Copyright 2002 BMJ Publishing Group x=4.2 hrs x=6.2 hrs Awan et al. Invest Ophthalmol Vis Sci 2005 Stewart, C. E et al. BMJ 2007;335:707 n = 80 x = 5.5 yrs 6

7 Patching Dosage: Variability of Response What About Residual Amblyopia? Stewart et al. BMJ 2007;335:707 A Randomized Trial of Increasing Patching for Amblyopia When amblyopia not resolve with SRx alone, 2 hours patching o en prescribed Treatment successful for many, but some fail to ahain normal VA Once VA stabilizes, but not normal, then what? IF Rx increased patching dosage, will VA improve further? ATS- 15: Increased Patching Run- in Phase VA tesnng every 6 wks with 2 hours daily patching unnl stable ( 12 wks) Mean Age = 5.9 years Patching = 24.4 wks Amblyopic eye VA =20/50-2 Fellow eye VA ~20/20 N=169: 3- <8yrs; 20/32-20/160 Enrollment 2 Hours Daily Patching RandomizaNon 10- Week Primary Outcome Amblyopic Eye VA Improved > 1 line? Improver Exams: Every 10 weeks Study Complete FU unnl amblyopia resolves or no further improvement > 1 line from previous visit YES 6 Hours Daily Patching NO ATS- 15 Results 10- Week Primary Outcome Amblyopic Eye Visual Acuity Mean change in VA from baseline (logmar lines) Difference in mean VA between groups (95% CI), adjusted for baseline VA 2 Hours (N=82) 6 Hours (N=82) (+0.3 to +1.0) ProporNon 2 logmar lines beher 18% 40% Difference in propornons between groups (95% CI) +22% (+8% to +35%) ATS- 15: Mean Change in Amblyopic Eye VA From Baseline Time Point 2 Hours 6 Hours 10- wk Primary Outcome Best Post- randomizanon 0.5 logmar lines 0.9 logmar lines 1.2 logmar lines 1.5 logmar lines Diff B/W Groups +0.6 (+0.3 to +1.0) +0.5 (+0.04 to +1.0) 7

8 ATS- 15: Amblyopic Eye Visual Acuity Improvement ProporNon with 2 logmar line improvement from baseline Percentage of Subjects 60% 50% 40% 30% 20% 10% 0% 18% 40% 2-Hour 10-Week Outcome Visit 6-Hour 39% 51% Best Post-Randomization ATS- 15: Conclusion When amblyopic eye VA stops improving with 2 hrs patching...increasing patching to 6 hrs results in more improvement a er 10 weeks compared with connnuing 2 hrs Ophthalmology 2013;120: If Allergic ReacNon to Patch or Sweaty Kid? Case Examples Other opnons! Atropine Treatment What Have We Learned? Study ATS- 4 Amblyopia Treatment Studies 3 to <7 years Prescribed Treatments Daily atropine vs. weekend atropine Depth of Amblyopia Moderate Mean Lines VA Mean VA Post- tx 20/ /32-2 Ophthalmology 2004;111:

9 Atropine: Side Effects? Atropine Treatment for 3 to <7 yrs red hot dry Time to maximum improvement? 80% by 4 months; all by 10 months 50% reach 20/25 or equal to sound eye Reverse amblyopia? mad Systemic reacnons? Images courtesy of M. Scheiman Tx effect similar to 2- & 6- hrs of prescribed patching First- line treatment & consider for patching failures PEDIG. Ophthalmology 2004;111: ; Arch Ophthalmol. 2009;127:22-30; Arch Ophthalmol. 2008;126: Added Plano Lens for Sound Eye? As ininal tx, added Plano lens for sound eye not augment tx effect significantly (mean lines VA), but.. Amblyopic Eye 20/25 - Atropine only = 29% - Atropine with Plano Lens = 40% Arch Ophthalmol 2009;127(1):22-30 Atropine Instruction Sheet Your child s amblyopia ( lazy eye ) is being treated with atropine eye drops. Atropine blurs the better-seeing eye and dilates its pupil. This encourages use of the eye with poor vision. This treatment often will improve the vision in the amblyopic eye. Treatment: 1 drop of Atropine in the eye in the morning! Every day! Every Saturday and Sunday! Every Wednesday and Saturday X! Every Monday, Wednesday, and Friday Administration of drops Wash your hands before and after giving the drops. Have your child lie down and look at a spot on the ceiling. Gently hold the lower lid open with one hand, hold the dropper bottle at least 1/2 inch from the eye, and gently squeeze the bottle, allowing a single drop to fall either onto the surface of the eye or onto the inside of the lower eyelid. Blot away the excess with a clean tissue. It is normal for the drop to sting for about 10 seconds. If your child is frightened, try administering the drops when the child is asleep. Side effects The drop could cause mild irritation, redness, or swelling around the eye. Rarely, the drop can cause some general problems such as dry mouth, flushed skin, rapid heart rate, or irritability. If this occurs please stop using the drops and contact the office. Storage The drops do not need to be refrigerated, but must be kept out of reach of children. Dilated pupil The pupil may stay dilated for a week or more after a single drop of atropine. This is not something to be alarmed about. Your child should wear a hat and either regular eyeglasses or sunglasses when outside (including recess at school) to make him/her feel more comfortable. Whenever your child sees a doctor or goes to an emergency room, it is important to inform them that your child is using atropine drops so they will know the reason why the pupil is dilated. School Depending on your child s prescription, he/she may continue to use the better eye for distance tasks. However, vision will be blurred for near activities and your child should be allowed to hold things as close as necessary. Questions Please feel free to call us with any questions. Atropine PenalizaNon: Clinical Pearls Sound eye VA tesnng through full plus at FU visits OFF of atropine 2 weeks before diagnose reverse amblyopia Can Atropine Be Used For Severe Amblyopia? 9

10 Atropine for Severe Amblyopia Amblyopic Eye VA Over Time Amblyopic Eye* at 18 Weeks 20/200 20/160 20/125 20/100 20/80 20/63 20/50 20/200 Atropine Only 20/ Atropine + Plano 20/ / / /80 20/63 Severe Amblyopia (20/125 20/400) Atropine Only N=24 Atropine + Plano N=31 Mean VA 20/40 21% 39% Mean VA 20/25 4% 13% 0 wks 5 wks 10 wks 18 wks PEDIG. JAAPOS 2009;13: Small sample size; prospecnve RCT of patching vs atropine for severe amblyopia is needed Bangerter Filters Do They Work as Well as Patching? Other Occlusion OpNons Besides Patching & Atropine? Photo: Courtesy of R. Rutstein PEDIG. Ophthalmology 2010;117: Bangerter Filters for Amblyopia Tx YES! Reasonable opnon for moderate amblyopia Small difference (<0.5 line) vs. patching Lower treatment burden vs. patching What About Recurrence? Consider changing filters at FU visits* *Rutstein et al. J AAPOS April ; 15(2):

11 Amblyopia Recurrence < 8yrs? Recurrence During 1- year FU FU IniNally 20/40 & 3 lines IOD 3 logmar line improvement Tx disconnnued Previous Treatment ConNnuous last 3 mo 2hrs/day patching or 1gt atropine/wk Enrollment 156 children < 8yrs 5w 13w 26w 52w Treatment STOPPED Study period off treatment 2 logmar line in VA from enrollment; VA confirmed by repeat tesnng Tx restarted a er nonreplicated 2 logmar line VA* 2 lines = 21% to 24% Of these, majority by 6 months Recurrence 21% 3% No recurrence AlternaNve DefiniNon Non replicated VA Recurrence Risk Patching Groups Recurrence Low Intensity Non- weaned 14% 1.0 2h stop Moderate Intensity 0.9 ( ) Weaned 14% 6/8h 2h stop 4.4 ( ) Moderate Intensity 42% Non- weaned 6/8h stop Odds rano Can Older Kids with Amblyopia be Successfully Treated? What Have We Learned? Adjusted for age, VA, tropia, stereo, duranon No change in OR ATS- 3: MulN- center RCT sites Older Children: Responder Rate 7- <18 yrs, 20/40 to 20/400 Treatment Groups: Control Group: OpNcal correcnon only AcNve Group: OpNcal correcnon 2-6 hrs patching plus near acnvines Atropine (<13 yrs only) Primary analysis: Compare propornon of treatment responders ( 2 lines VA) between 2 groups PEDIG. Archives of Ophthalmology 2005;123: % Treatment Optical Correction 7 to 12yrs 13 to 17yrs 25% 25% 23% N = 201 N = 203 N = 55 N = 48 P=<0.001 P=0.22 PEDIG. Archives of Ophthalmology 2005;123:

12 Responder Rate yrs Based on Prior Amblyopia Treatment 100 Treatment Optical Correction Maximum Improvement in Amblyopic Eye VA vs. Ageaa Prior Treatment No Prior Treatment 47% % 25% 20% Responder No change 0 N = 38 N = 28 N = 17 N = 20 P=0.72 P=0.03 Marked Individual Variability Amblyopic Children 7- <13 yrs Stability of Acuity 1- year Post Tx? 93% Stable 93% Single Amblyopia Treatment Modality for Older Kids with Moderate Amblyopia? Patching or Atropine? * of 67 panents, 7% 2 line loss PEDIG. Archives of Ophthalmology 2007;125: Hertle et al. Archives of Ophthalmology 2007;125(5): Atropine vs. Patching for Older Kids? *Atropine Weekend (near activities) *12% required readers Moderate Amblyopia (20/40 20/100) 7 - < 13 yrs Follow-up at 5 wks Patching 2 hrs (near activities) Discontinuation of atropine 2 wks prior to 17-week exam Masked assessment of VA at 17 wks (primary outcome visit) Continued FU for Partial Responders until Maximal Improvement 193 panents 39 sites Children 7- <13 Years Amblyopic Eye at 17 Weeks Atropine N=89 Patching N=84 Mean acuity at baseline 20/ /63 +2 Mean acuity at 17 wks 20/ /40 +1 Mean improvement from baseline Mean Difference* 95% CI * Controlling for baseline acuity. Patching Atropine interval shown 1.5 lines 1.7 lines 0.2 lines (- 0.2 to 0.6) 12

13 Children 7- <13 Years Amblyopic Eye Maximal VA Atropine N=95 Patching N=98 Cases of Persistent, Constant Diplopia in Older Children? Mean acuity at baseline 20/ /63 +2 Mean acuity at maximal 20/ /32-2 Mean improvement from baseline Mean Difference (95% CI) 2.2 lines 2.2 lines 0.0 lines (- 0.3 to 0.4) * Controlling for baseline acuity. Patching Atropine interval shown Effect of Age on Response to Amblyopia Treatment in Children What Else Do We Know About Age Effect? Meta- analysis of 4 PEDIG RCT s 996 children; unilateral amblyopia (20/40 to 20/400) RelaNonship bet age (3- <5y, 5- <7y, 7- <13y) and amblyopic eye VA improvement* *adjusnng for baseline amblyopic eye visual acuity, amblyopic eye spherical equivalent, type of amblyopia, prior amblyopia treatment and protocol Arch Ophthalmol 2011 Nov;129(11): /40 to 20/100 Amblyopic Eye Visual Acuity (N=829) Results by Age Group 20/125 to 20/400 Amblyopic Eye Visual Acuity (N=167) Near AcNviNes When Patching?? Mean Improvement (logmar lines) Amblyopic Eye VA Near acnvines: e.g., cra s, reading, wrinng, computer games Distance acnvines: e.g., outdoor play, watching television Near: e.g., cra s, reading, wrinng, computer gam PEDIG. Ophthalmology Distances: 2008;115: e.g., outdoor play, TV 13

14 ATS6: Near vs. Distance AcNviNes * Near vs. Far AcNviNes No advantage to common near acnvines in combinanon with 2 hours of daily patching 20/80 20/40 20/40 Lines Improvement VA <7 yrs; 20/40-20/400; N=425 PEDIG. Ophthalmology 2008;115: Amblyopia Treatment Dogma Mainstay of amblyopia treatment = occlusion Rx glasses and occlusion simultaneously Patch full- Nme, especially if severe amblyopia Never patch < 4 hours Patching is beher than atropine penalizanon Atropine only for moderate amblyopia Atropine only for younger children Amblyopia cannot be treated beyond 6-9 years Near acnvines should always be done when patched Evidence- Based, Step- Wise Management Strategy for Moderate Amblyopia Moderate amblyopia due to anisometropia and/or strabismus Spectacle correcnon; FU every 6-10 weeks unnl no further improvement If persists, ininate addinonal treatment (2 hrs daily patching, weekend atropine, or Bangerter filter); FU every 6-10 wks unnl no further improvement If persists, consider increasing patching from 2 to 6 hours daily* Follow every 6-10 weeks unnl no further improvement When maximum VA, taper or stop treatment & monitor for amblyopia recurrence *AlternaNves: changing to atropine or Bangerter filter What About Vision Therapy? AcNve Amblyopia Therapy Purpose: Enhance effects of occlusion Decrease total tx Nme For whom? Older amblyopes Younger children who plateau with passive tx PaNents with eccentric fixanon Direct toward given panent s deficits 14

15 AcNve Amblyopia Therapy Monocular visual skills Form recogninon/discriminanon AccommodaNon Eye movement Eye- hand coordinanon Eccentric fixanon tx Binocular ann- suppression for anisos Amblyopia Treatments on the Horizon? AnN- suppression Therapy Hess & Thompson et al OVS 2010;l87; Optometry 2012 To et al. IEEE, June 2011 AnN- suppression Tx: Adult Amblyopia Subject Pre- tx VA Post- tx VA Pre- tx stereo Post- tx stereo Hours of tx 1 20/50 20/50 Nil Nil /40 20/ /40 20/25 Nil /63 20/40 Nil /100 20/25 Nil /125 20/ /40 20/40 Nil Nil /50 20/ /80 20/63 Nil Nil Significant improvement in VA (p=0.018) Significant improvement in stereo (p=0.043) To, Thompson, Blum, Maehara, Hess, Coperstock. IEEE, June 2011 Major ObjecNve Amblyopia Treatment Study 18 A randomized trial of binocular treatment versus patching in 5 to <17yr olds To compare change in visual acuity in 5 to <17 year olds with amblyopia treated with ConvenNonal patching (2 hrs/day) Binocular ipad treatment (1 hr/day) 15

16 Major Eligibility Criteria Age 5 to <17 years Unilateral amblyopia: 20/40 to 20/200 No amblyopia treatment for at least 2 weeks prior to enrollment No strabismus at near >10pd Amblyopia Treatment Study 18 Amblyopia Treatment Study 18 Currently RecruiNng Baseline & Randomiza?on Binocular Game Play 1 hr/day, 7 days/week Patching 2 hrs/day, 7 days/week Follow- up Exams 4 Weeks 8 Weeks 12 Weeks 16 Week Primary Outcome Exam What Else is on the Horizon? Adult Subjects with Longstanding Amblyopia AcNon Game No of subjects 10 Treatment dosage Lines (logmar) VA improvement Medal of Honor - Pacific Assault 40 hrs (2 daily) 1.6 % VA improvement 31.2% SimCity Socie?es Non AcNon Game 3 40 hrs % Li et al, PLoS Biol 2011; 89:

17 Control Experiment Watching TV, reading books, kniƒng, surfing Internet, etc Li et al, PLoS Biol 2011; 89: 1-11 Followed by Video Games Treatment Near AcNviNes Video Games No of subjects 7 5 crossed over Treatment dosage 20 hrs 40 hrs Lines (logmar) VA improvement Patching Responsible for Improvement? VA improvement (%) 0.4% 27% Acupuncture vs. Patching 7-12 yrs: aniso amblyopia 20/40-20/125 A er SRx 16 wks Randomized to: 2 hrs/day patching 5 x/wk acupuncture Outcome: VA at 15 wks Zhao et al., Arch Ophthalmol 2010;128(12): Five Acupoints Acupuncture RCT: Results Based on tradinonal Chinese medicine Needles - 15 mins Patching N = 41 Acupuncture N = 42 Mean VA at baseline 20/ /63 Mean VA at 15 wks 20/ /40 Mean improvement from at 15 wks 1.83 lines 2.27 lines Mean VA at 25 wks 20/33 20/38 Adverse effects None 4.9% moderate pain (- ) infecnon Zhao et al., Arch Ophthalmol 2010; 128(12): Conclusions: Acupuncture Treatment Mechanism unclear Increases blood flow to cerebral and ocular vasculatures, simulanng expression of rennal nerve growth factors? Different manipulanon modes exist Amblyopia Treatment No longer have to rely on observations/clinical impressions Evidenced-based treatment strategies A number of treatment options available Still many unanswered questions Presently many ongoing studies 17

18 Thanks for Your Interest 18