Amblyopia Management Past, Present and Future. Rachel Clarke Specialist Orthoptist, Manchester Royal Eye Hospital

Transcription

1 Amblyopia Management Past, Present and Future Rachel Clarke Specialist Orthoptist, Manchester Royal Eye Hospital

2 Amblyopia Amblyopia is the most common cause of preventable visual loss in children and results from any aetiology that creates a disparity in the vision from each eye (most common causes being refractive, strabismic, deprivational). The aim of treatment is to allow normal neurological development of the amblyopic eye.

3 Amblyopia Management - Past Treatment for amblyopia dates back to the 1500 s. Ambroise Pare 1564 and Georg Bastill used masks as a form of treatment initially for strabismus.

4 I F Y O U C A N S T I L L R E A D T H I S D R I N K T H R E E M O R E G L A S S E S

5 Amblyopia Management - Past Claude Worth (1903) - refractive correction / use of atropine Bangerter-Pleoptic Therapy (1940 s)

6 Amblyopia Management - Past Cambridge Vision Stimulator (1978) However occlusion remained the main form of amblyopia treatment and arguments concerning the efficacy of occlusion treatment started as early as the 20th century and still continue to this day.

7 Amblyopia Management - Present Estimated that out of 500,000 consultations in UK paediatric eye clinic and orthoptic departments 90% were related to amblyopia (M Clarke 2010) Amblyopia is one of the most common reasons for NHS outpatient treatment The PEDIG (Paediatric Eye Diseases Investigator Group) have played a huge role in the research of amblyopia management

8 Amblyopia Management - Present Refractive Adaptation MOTAS (Stewart et al 2004) and PEDIG Occlusion Debate as to the amount of occlusion. Atropine Often reserved for those not tolerating patching, should it be used as an initial form of treatment? Combined optical penalisation & atropine

9 Occlusion Therapy STUDY METHOD RESULTS ROTAS (Stewart et al 2004) Randomised Occlusion Treatment for Amblyopia Study 6 hours vs. 12 hours occlusion 80 children age 4-7 yrsocclusion dose monitor worn 6 hours results in similar visual outcome as 12 hours Mean dose rates actually given: 4.2hrs (6hr) 6.2 hrs (12hr) MOTAS (Stewart et al 2004) Modelling Dose Response in Amblyopia Toward a child specific treatment plan 6 hours daily occlusion to all, monitored by occlusion dose monitor 72 participants, 38yrsAniso/Strab/Mixed amblyopia Best visual; acuity achieved within hrs Average improvement of 0.1 logmar lines per 120 hours PEDIG 2003 Moderate amblyopia logmar 2 hours vs. 6 hours occlusion 3-7 yrs 2 hours as effective as 6 hours 62% achieved at least 3 lines of improvement with either

10 Occlusion Therapy Contd. PEDIG 2003 Severe amblyopia Logmar 6 hours vs. full time occlusion (all but 1 hour per day). 3-7 yrs 6 hours as effective as full time 4.8 lines vs. 4.7 lines PEDIG 2008 Severe amblyopia hours occlusion, near vs. distance activities 3-7 yrs No statistically significant difference PEDIG 2006 Moderate and severe amblyopia 2 hours occlusion vs. optical correction alone Occluding for 2 hours 0.8 line improvement in VA after 5/52, compared with no improvement in spectacle group

11 Atropine Therapy Study Method Results Repka et al 2004 (moderate amblyopia) Li and Shotton 2009 (moderate amblyopia) Daily vs. weekend atropine 3-7 years old Daily vs. weekend atropine Similar results in both Equal improvements in both Repka et al 2009 Severe amblyopia ( ) Trial 1: Weekend atropine with plano lens vs. weekend atropine with full spectacle correction in 3-6 years Trial 2: Weekend atropine vs. 2 hours daily patching in 7-12 years Atropine combined with plano lens did not effect outcome Weekend atropine was effective Atropine was not significantly more effective than patching

12 Amblyopia Management - Future MREH - Future study into the use of atropine Levodopa - PEDIG pilot study

13 Amblyopia Management - Future Compliance, Age, Weaning, Cessation Factors affecting compliance: involve parent in management decision, visual disability (poor starting VA, eccentric fixation), age (greater neural plasticity in younger). PEDIG atropine vs. occlusion, quality of life questionnaire. Journal of Ophthalmic Practice 2014, survey of orthoptists informed choice between patch and atropine 99% patching first line of treatment 29/340 patch and atropine equally

14 Amblyopia Management - Future PEDIG randomised trial comparing bangeter filter and daily patching for treatment of children with moderate amblyopia ( logmar ) Age 3-10 years,180 participants, reviewed at 6,12,18,24 weeks Positives Bangerter Filter Able to change density to modulate degree of deprivation Better compliance/lower burden Negatives Patient may peep around May not uniformly degrade vision (as predicted by manufacturer) Requires the use of glasses for treatment

15 Amblyopia Management - Future Binocular Treatment of Amblyopia I-BiT System Birch et al Binocular ipad Treatment for Amblyopia in preschool children Tailor et al Trial of Balanced Binocular Viewing (BBV) of 3D movies to treat anisometropic amblyopia Simone et al Binocular Treatment of Amblyopia reduces severity of suppression to improve Visual Acuity.

16 Aim: To establish the most effective treatment to benefit patient care, improve and advance practice and service, to ensure the most effective treatment is being delivered

17 Thank you

18 References Ansons A.L. Amblyopia an historical perspective. CE Optometry, 2002; 5(3):79-82 Clarke M.P. Review of amblyopia treatment: Are we overtreating children with amblyopia? BIOJ 2010; 7: 3-7 Stewart C.E, Moseley M.J, Fielder A.R, Stephens DA and the MOTAS cooperative. Refractive adaptation in amblyopia:quantification of effect and implications for practice. Br J Ophthamlomology 2004;88: Stewart C.E, Stephens D.A, Fielder A.R and the MOTAS cooperative. Modeling Dose-Response in Amblyopia:Toward a child specific treatment plan. Investigative Ophthlamology and Visual Science.2007;48: Stewart CE, Stephens DA, Moseley MJ, Fielder AR, ROTAS cooperative. Objectively monitored patching regimes for treatment of amblyopia:randomised trial. British Medical Journal 2007;335: Stewart CE, Moseley MJ, Fielder AR. Amblyopia Therapy: An update. Strabismus 2011;13(3),91-98 Repka M.X, Kraker RT. Paediatric Eye Investigator Group. A randomised trial of atropine vs patching for the treatment of severe amblyopia in children. Ophthalmology 2003;110(11): Li T, Shotton K. Conventional occlusion versus pharmological penalization for amblyopia. Cochrane Data Base Syst Rev 2009;4(4):CD Holmes JM, Kraker RT, Beck RW; Paediatric Eye Disease Investigator Group. A randomised trial of prescribed patching regimes for the treatment of severe amblyopia in children. Arch Ophthalmology2008;126(8): Repka MX, Kraker RT, Beck RW; Paediatric Eye Disease Investigator Group. Treatment of severe amblyopia with weekend atropine:results from 2 randomised clinical trials. JAAPOS 2009;139(3):258-63

19 References Repka MX, Beck RW, Holmes JM et al; Paediatric Eye Investigator Group. A randomised trial of patching regimes for the treatment of moderate amblyopia in children. Arch Ophthalmology 2003;121(5): Repka MX, Cotter SA, Beck RW. A randomised trial of atropine regimes for the treatment of moderate amblyopia in children. Ophthalmology 2004; 111(11): Wallace DK, Paediatric Eye Investigator Group, Edwards AR et al. A randomised trial to evaluate 2 hours of daily patching for amblyopia in children. Ophthalomolgy 2006;113(6): PEDIG (Paediatric Eye Disease Investigator group) Impact of patching and atropine treatment on the child and family in the Amblyopia Treatment study. Arch Ophthalmology 2003;121: Repka MX, Krakre RT, Beck RW et al; Paediatric Eye disease Investigator group. Treatment of severe amblyopia with weekend atropine: results from 2 randomised clinical trials. JAAPOS 2009;13(3): Paediatric Eye Investigator group. Pharmological plus optical penalisation treatment for amblyopia: results of a randomised clinical trial. Arch Ophthalmology 2009;127(1):22-30 Paediatric Eye Investigator Group. A randomised trial comparing bangerter filters and patching fro the treatment of moderate amblyopia in children. Ophthalmology 2011;117(5);