Case Example BE 6 year old male

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1 Goals for this lecture Understand how to properly diagnose amblyopia Understand how to utilize patching and atropine in therapy Learn about the role of vision therapy Amblyopia: To See or Not To See Discuss the future in treatment ideas DON W. LYON, OD, MS, FAAO CHIEF OF PEDIATRICS/BINOCULAR VISION SERVICES Case history Mother reports patient failed vision screening No vision complaints from patient School going well, in First grade Case Example BE 6 year old male No headaches, double vision Doing well with reading No medications, no medical conditions 1

2 Clinical Exam Clinical Exam Entrance VA (single surround HOTV) 20/20 OD, 20/200 OS Near VA 20/20 OD, 20/100 OS Cover Test Dist. and Near Ortho Stereo 800 NPA 10D OD, 5D, OS, 10D OU MEM OD, OS Worth Dot 2 red dots all distances (Light and Dark) Pupils, Color Vision, Versions, Visual Fields all normal Dry Retinoscopy OD OS Wet Retinoscopy OD, 20/ OS 20/100 Ocular Health Anterior and Posterior normal OU, no signs of pathology What is our diagnosis? Is it functional amblyopia? Definition of Functional Amblyopia A reduction of visual acuity to 20/30 or less in one eye or a two-line difference between the two eyes, in the absence of pathology Case Report: Best correct acuity 20/20 OD 20/100 OS Visual Function Binocular Vision Vergence Difficulties Contrast Sensitivity Accommodative difficulties Ocular Motor Problems Verneir Acuity Amblyopia is cortical issue not a retinal issue Case Report: Ocular health normal Case Report: Suppression, Unequal Accommodation Leads to decrease in visual function 2

3 What about the cause of functional amblyopia Form Deprivation [issue must develop before child s 8 th birthday] Most often congenital cataract or ptosis Strabismic Most commonly due to esotropia Refractive Hyperopia more common than myopia Mixed cause Strabismus and refractive error Cause of Refractive Functional Amblyopia Bilateral amblyopia Hyperopia 5.00 Diopters Myopia 8.00 Diopters Astigmatism 2.50 Diopters Case Report: Wet Retinoscopy OD OS Anisometropic Amblyopia Hyperopia 1.00 Diopter difference Myopia 3.00 Diopter difference Astigmatism 1.50 Diopter difference Cause of Refractive Functional Amblyopia Bilateral amblyopia Hyperopia 5.00 Diopters Myopia 8.00 Diopters Astigmatism 2.50 Diopters Anisometropic Amblyopia Hyperopia 1.00 Diopter difference Myopia 3.00 Diopter difference Astigmatism 1.50 Diopter difference Patient Case So does our patient have functional amblyopia? Best correct acuity 20/20 OD 20/100 OS Suppression, Unequal Accommodation Wet Retinoscopy OD OS Ocular health normal OU Case Report: Wet Retinoscopy OD OS 3

4 Quick Review of Clinical Elements Quick Review of Clinical Elements Chief Complaint Many times there is no complaint or a complaint of an eye-turn Other complaints can include failing a vision screening Cover Test One of the most important test in the clinical arsenal Ensure that fixation target is large enough for suspected amblyopic eye to see Visual Acuity Birth to 12 months Teller Cards Fix and Follow 1-<3 years Cardiff Cards 3-<7 years Single surround HOTV Single surround Lea symbols 7 years-adult Single surround Snellen Quick Review of Clinical Elements Quick Review of Clinical Elements-Ocular Health Stereo acuity Randot stereo vs. random dot stereo Worth-4-dot Light and dark testing, multiple distances Cycloplegic Retinoscopy and Refraction To find full amount of hyperopia Ocular health evaluation NEVER make a diagnosis of amblyopia without evaluating ocular health! What could mimic functional amblyopia? Retinal disease Coat s disease Stargart s Cone dystrophies Optic nerve head disease Glaucoma Optic nerve head hypoplasia 4

5 Disc to Macula Ratio Disc to Macula Ratio Photo courtesy Brad Sutton, OD Photo courtesy Brad Sutton, OD Quick Review of Clinical Elements-Ocular Health What could mimic functional amblyopia? Neurological disease Tumor leading to IV or VI nerve palsy Tumor compressing on nerve head Treatment options for amblyopia Old Standby Therapies Newer/Potential Therapies Spectacles Vision Therapy Patching Binocular Therapy Not all vision loss is due to functional amblyopia! Atropine Drug Therapy 5

6 Designing a Therapy Plan 1. Correct refractive error OPTICAL TREATMENT 2. Initiate additional treatment SECONDARY THERAPY a. Part time occlusion b. Vision therapy c. Atropine What is the Age Effect of Patients on Treatment Response? 3. Modify therapy based upon vision MURKY MIDDLE 4. Stop therapy 5. Monitor for recidivism WEANING MONITORING Meta Analysis of Age Effect 20/40 to 20/100 Amblyopic Eye Visual Acuity (N=829) 20/125 to 20/400 Amblyopic Eye Visual Acuity (N=167) What is the Age Effect of Patients on Treatment Response? Overall there is a decrease between 7-<13 compared to 3-<7 There is a further decrease between 13-<18 compared to 7-<13 What is the age where you would not recommend treatment? 6

7 Designing a Therapy Plan Optical Treatment of Amblyopia 1. Correct refractive error 2. Initiate additional treatment a. Part time occlusion b. Vision therapy c. Atropine Study Ages Type of Amblyopia % Resolution Time Frame ATS <7 yrs. Aniso 33% Up to 30 weeks ATS <7 yrs. Strab & Mixed 32% Up to 18 weeks 3. Modify therapy based upon vision 4. Stop therapy 5. Monitor for recidivism Optical Treatment of Amblyopia What does research tell us about optical therapy? ATS-3 5 First RCT looking at older Cohort Treatment was PTP and/or Atropine for 7- <13 yrs. For 13-<18 was PTP only Percent of Patients Classified as Responder N=85 N=82 N=75 N=75 N=40 N=43 N=52 N=47 7 to <9 9 to <11 11 to <13 13 to <18 Treatment Group Optical Correction Group Can be used initially without other forms of treatment for refractive, strabismic and mixed mechanism amblyopia In some patients can lead to resolution of the visual acuity affects of amblyopia Age at Randomization 7

8 How to prescribe the initial Rx Clinical example Patient BE Typically the presence of strabismus influences the final prescription With esotropia will prescribe full cycloplegic retinoscopy With exotropia or no strabismus typically cut the prescription by up to diopters Entering acuities 20/20 OD, 20/200 OS Cover test Ortho Distance and Near Wet Retinoscopy OD, 20/ OS 20/100 Final prescription OD OS What about the Aniseikonia? Optical correction: Aniseikonia Clinical example Patient BE Need to consider treating of aniseikonia for difference greater than 2.00 diopters Treatment options Contact lenses Aspheric lenses Combination of Contact lenses and Aspheric lenses Equalizing base curve and center thickness Entering acuities 20/20 OD, 20/200 OS Cover test Ortho Distance and Near Wet Retinoscopy OD, 20/ OS 20/100 Final prescription OD OS What about the Aniseikonia? 8

9 Clinical example Patient BE Clinical example GM 7 year old At first follow up visit 8 weeks later VA 20/20 OD, 20/100 OS Cover test Ortho MEM OD, OS Continuation of spectacles no additional treatment needed at this time RTC 6-8 wks First exam, noticed OS turning in for last few years Failed vision screening VA 20/20 OD, 20/70 OS CT 6 LET Dist. 20 LET Near Dry Ret X160 OD, X020 OS Wet Ret X160 OD, X020 OS Prescribed wet ret with a add Clinical example GM 7 year old Designing a Therapy Plan Follow-up visit 6 weeks later acuity stable CT 4 exophoria Distance, 2 LET Near Patient needs additional therapy What can we add to the optical treatment 1. Correct refractive error 2. Initiate additional treatment a. Atropine b. Part time occlusion c. Vision therapy 3. Modify therapy based upon vision 4. Stop therapy 5. Monitor for recidivism 9

10 Patching Patching or Atropine, that is the question? Can be used with any patient of any acuity level Various types of patches to choose from Set amount of therapy time Few cases of allergic response to adhesive Social stigma Atropine Best used when non-amblyopic eye has a hyperopic prescription. Can be used in moderate and severe amblyopia Increased compliance compared to patching One drop in the morning then can forget about it the rest of the day Most common side effect is photophobia Amblyopic Eye Visual Acuity Cumulative Distribution 100% 80% 60% 40% 20% 0% Amblyopic Eye at 4 Months Daily Atropine N=77 6-Hours Patching >20/16 >20/20 >20/25 >20/32 >20/40 >20/50 >20/63 >20/80 >20/100 >20/125 >20/160 4-month Amblyopic Eye Visual Acuity 2-Hours Patching Weekend Atropine N=83 What is an appropriate treatment after spectacles? Tips to improve compliance with treatment Patching 2 hours QD over the non-amblyopic eye in moderate amblyopia 6 hours QD over the non-amblyopic eye in severe amblyopia Give a patching or atropine log to the parents with instructions and contact information Atropine 1 drop Q Saturday & Sunday am in the non-amblyopic eye 10

11 Improving Compliance Tips to improve compliance with treatment Give a patching or atropine log to the parents with instructions and contact information Call the parent to ask about treatment schedule Start with adhesive patches then move to felt if patient compliant or tell patient they can draw on patches One reason for the follow-up visits is to discuss issues with compliance Patient s visual acuity stabilizes now what? Modifying therapy What is stability? Patient having same visual acuity measure, with same optoype, for three consecutive visits Visual acuity can stabilize at 20/20 or stop increasing before 20/20 is reached How do you modify treatment? Switch modalities PTPè A1% or A1%è PTP Is compliance an issue? If currently patching Can increase to 6-8 hrs. [This may result in a further improvement of 1-2 lines acuity in moderate amblyopia] Can add vision therapy If currently using Atropine May attempt daily Atropine Cutting prescription in non-amblyopic eye does not appear to further improve visual acuity 11

12 Modifying therapy Example of Weaning Phase Combine therapies, PTP with A1%? Wean off of therapy With patching decrease the amount of time patching each day by 50% until patching one hour per day, decrease every 4-6 weeks With Atropine decrease days using atropine until using 1Xweekly, decrease every 4-6 weeks Monitor for recidivism quarterly for a year Patient has improved and stabilized to 20/20 after three visits, currently PTP 4 hours qd Decrease PTP to 2 hours qd for 4-6 weeks Follow-up exam to ensure stability remains Stability remains, decrease PTP to 1 hour qd for 4-6 weeks Follow-up exam to ensure stability remains Discontinue PTP and follow-up in 3 months to assess vision Clinical example of weaning Clinical example of weaning Patient stable at 20/80 PTP 4 hours qd compliance has been a growing issue Parent education on options. Parents decided to discontinue PTP Decreased to 2 hours qd, RTC 6 weeks At follow-up visit patient s vision improved to 20/50 with 2 hours qd, compliance has been great What would you do? Keep weaning Remain at 2 hours Increase to 4 hours Patient stable at 20/80 PTP 4 hours qd compliance has been a growing issue Parent education on options. Parents decided to discontinue PTP Decreased to 2 hours qd, RTC 6 weeks At follow-up visit patient s vision improved to 20/50 with 2 hours qd, compliance has been great What would you do? Keep weaning Remain at 2 hours Increase to 4 hours 12

13 Evidence approach to treatment of moderate amblyopia 6 Spectacle correction and follow every 6-10 weeks until no further improvement If amblyopia persists, start 2 hours PTP, weekend A1% or Bangerter filter. Follow every 6-10 weeks until no further improvement If amblyopia persists, consider increasing PTP to 6 hours QD and follow every 6-10 weeks What happens when the Evidence Based Therapy does not work When maximum acuity achieved, taper or stop treatment and monitor for amblyopia recurrence Going beyond research Vision Therapy for amblyopia With the research there is still a large number of children with amblyopia with treatment Is this residual amblyopia? Is this true amblyopia? Are there pathological causes? What else can we do? Many of us either perform VT only with patients and/or combine VT with patching Vision Therapy should include the following, (at a minimum) Monocular activities, including accommodative Vergence activities Anti-suppression activities 13

14 Vision Therapy for amblyopia Core components of the In-Office Vision Therapy Plan One vision therapy plan can be found at (reference 7) This was created based upon insight from members of AOA, AAO, COVD Good starting place for development for Primary Care Optometrists interested in VT Three main areas Accommodation Suppression Vergence Goal is to be able to move in a methodical manner utilizing techniques that are known and endpoints which show improvement Accommodation Suppression Treatment Category Phase 1 Phase 2 Phase 3 Treatment Category Phase 1 Phase 2 Phase 3 Accommodation Letter Chart Accommodative Facility Letter Chart Accommodative Facility Binocular Accommodative Facility with word search ±2.50 Suppression Physiological Diplopia Awareness (Brock String) Red Crayon Activities Red Line Coloring Book Bar Reader Anaglyphic Letter Tracking Vis-à-vis Anaglyphic Letter Tracking Number Find Loose Lens Bi-ocular Facility Accommodative Push-ups Loose Lens Bi-ocular Facility-6.50 Binocular Accommodative Facility with word rock cards ±2.50 Face Form 1 Face Form 2 String Reading Line Tracing 1 Line Tracing 2 14

15 Vergences Where is the research heading? Treatment Category Phase 1 Phase 2 Phase 3 Vergences Barrel Card Brock String with Prism (15 BI and 25 BO) Vectogram SILO/Localization Computer Vergences (15 BI and 25 BO) Vectogram Ranges and Recoveries (L and 30) Computer Jump Ductions (15 BI and 25 BO) Eccentric Circles Vectogram Jumps (L and 30) Aperture Rule (Card 8 BO and Card 4 BI) Dopamine trials 8 Occlusion Monitoring technology Computer games/activities as treatment 9-10 Vision Therapy All of these have at least pilot studies completed. Mini-Tranaglyph Ranges and recoveries (12 BO and 8 BI) Mini-Tranaglyph Ranges and recoveries (25 BO and 15 BI) Biggest question References Will we ever truly be able to treat amblyopia to resolution in all of our patients? Are some destined to have poor eyesight in one eye? Will we find the perfect therapy(s) for every case of amblyopia? For now we should rely on the evidence and know when we need to go beyond it for our patients 1. Friedman DS, Repka MX, Katz J, et al. Prevalence of amblyopia and strabismus in white and African American children aged 6 through 71 months. The Baltimore Pediatric Eye Disease Study. Ophthalmol Nov;116(11): The Multi-ethnic Pediatric Eye Disease Study. Prevalence of amblyopia and strabismus in African American and Hispanic children ages 6 to 72 months. Ophthalmol 2008 Jul; 115(7): PEDIG. Treatment of anisometropic amblyopia in children with refractive correction. Ophthalmol. 2006; 113(6): PEDIG. Optical Treatment of Strabismic and Combined Strabismic-Anisometropic Amblyopia. Ophthalmol 2011;119(1): PEDIG. Randomized trial of treatment of amblyopia in children aged 7 to 17 years. Arch Ophthalmol 2005;123(4):

16 References 6. Pediatric Eye Disease Investigator Group. A randomized trial of increasing patching for amblyopia. Ophthalmology Nov;120(11): Lyon DW, Hopkins K, Chu RH, et al. Feasibility of a clinical trial of vision therapy for treatment of amblyopia. Optom Vis Sci 2013;90(5): Repka MX, Kraker RT, Beck RW, et al. Pilot study of levodopa dose as treatment for residual amblyopia in children aged 8 years to younger than 18 years. Arch Ophthalmol Sep;128(9): Hess RF, Mansouri B, Thompson B. A new binocular approach to the treatment of amblyopia in adults well beyond the critical period of visual development. Restor Neurol Neurosci 2010;28: Hess RF, Thompson B, Black JM, et al. An ipod treatment of amblyopia: an updated binocular approach. Optometry 2012;83: Cohen AH. Monocular fixation in a binocular field. Am Optom Assoc 1981;52: