On Monday I examined 2 children, both of whom are amblyopic. Amblyopia (also called lazy eye) is a condition where one eye sees poorly, even with eyeglasses or contact lenses. Amblyopia can develop in childhood due to:
- An obstruction of vision within one eye due to injury or disease; (deprivation amblyopia)
- Significant differences between the clearness of the images seen by each eye due to farsightedness, nearsightedness or astigmatism; (refractive amblyopia)
- Misaligned eyes or crossed eyes (Strabismus) (strabismic amblyopia).
Both children have refractive amblyopia. M is a 12 year old boy who had been diagnosed with amblyopia many years ago. Treatment consisted of the prescription of glasses for full-time wear and a patching regimen. Patching the better seeing eye for 2 hours per day would force him to use the amblyopic eye while performing visually-guided activities. M’s amblyopia is not too severe. Wearing the patch and performing activities with only the amblyopic eye is probably a little uncomfortable and inconvenient (the cost), but improvements in vision and visual function are likely to be achieved. As the vision in his amblyopic eye improves, so will his binocular skills and depth perception (the benefits).
M was reluctant to wear his glasses, and even more reluctant to comply with the patching regimen. As a result, the vision in his amblyopic eye has improved very little. When I questioned his mother about why he was not wearing the glasses or complying with the patching therapy, she simply said, “he doesn’t like to do it.”
C is a 4 year old boy who failed the vision screening at the pediatrician’s office. As soon as I attempted to cover his better seeing eye to measure his visual acuity, his behaviors and demeanor changed. He tried “peeking” under the patch and when that didn’t work, he tried to take the patch off, and when that didn’t work, he tried to leave the exam room! This child is very myopic in one eye only, and as a result, has severe amblyopia. Even with lenses, he had to be 3 feet away from the Biggest E to see it. The treatment plan for C is the same–the prescription of glasses for full-time wear and patching. However, when he is patched and forced to use only his amblyopic eye, C is very impaired. He will have great difficulty accomplishing any visual tasks when he wears the patch. Using the same analysis, the cost of treatment from the perspective of this 4 year old boy is very high. The severe amblyopia is much more difficult to treat and the prognosis is poor. So while the cost of treatment is high, the expected benefits are low. When I explained this to C’s mother, she began to cry. She understood that although the expected outcomes of treatment are more limited, there are no alternatives. If C’s vision is going to improve at all, he must wear the glasses full-time and wear the patch for several hours every day.
Patching therapy can be very difficult for a family. Young children may not understand why they need to wear the patch and will be reluctant to comply with treatment. They take off the patch as soon as mom or dad turns around. They tilt their heads to try to peek under the patch and use the better eye. They whine. They cry. Patching therapy becomes an ordeal and the parent backs down. As a result, vision does not improve and the amblyopia lingers.
Poor compliance with medical treatment is not unique to the treatment of amblyopia. Patching is a form of medical treatment no different than taking medication or receiving immunizations. I do my best to educate my patients and their parents. I try to be honest about the cost/benefit ratio. But it is up to the parents to make sure the patching therapy is done. Patching requires tough love.
For more information about the treatment of amblyopia, read the Clinical Practice Guidelines published by the American Optometric Association.
Mindsight 
Hi! I recently came across this blog and have been reading along. I thought I would leave my first comment. I don’t know what to say except that I have enjoyed reading. Nice blog. I will keep visiting this blog very often. Thank you for all the very information you have shared.
One of the uses of contact lenses is for cases of significant anisometropia in children. Level of binocular ability should be determined. If the child cannot achieve binocular ability, then any improvement in sight for the amblyopic eye will regress due to suppression.
To assess the optimum powers of the contact lenses, I used pattern evoked visual potential as a measurement for many successful years in practice.
Dear Dr. Kaplan….you mentioned your research…can you email me a copy so I can read more about this interesting topic? Thanks.
Dominick
Dominick, here is a summary.
Thanks for your request.
1. Between the years of 1974 and 1977, through the help of a Federal Grant investigators from the Departments of Education, Speech Pathology and Audiology, Psychology and myself from Optometry, at the University of Houston, demonstrated the value of an interdisciplinary approach in working with reading handicapped and learning disabled children, that included amblyopia and strabismus.
Papers were presented at the American Academy of Optometry in the years 1976 and 1977.
Publications:
“An Interdisciplinary Team Approach – A Case Study.” Journal of the American Optometric Association, Vol. 47(9), pp. 1153-1166, September, 1976.
“A Comparison of left and Right Eye Speed of Recognition Values in Average and Below Readers.” Optometric Extension Program Papers, Vol. 30(2), November, 1977.
“The Interdisciplinary Modified Motor Evaluation.” Academic Therapy Journal, Vol. 14:1, pp. 67-72, September, 1977.
“Interdisciplinary Care of the Learning Disabled” 1978, Co-author with Diana Phelps. Published by Public Health Service, 1200 Main Tower, Dallas, Texas, 75202, U.S.A.
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2. While at Pacific University’s College of Optometry, I headed up two investigations in collaboration with a clinical social worker, B.J. Seymore.
The first was to investigate other mitigating causes to findings in Myopic Patients. These results were presented at the American Academy of Optometry meeting in 1983 as well as to the Optometric Meeting – North Central States Congress in 1983.
The actual study is published in my book:
“Seeing Without Glasses” – Improving Your Vision Naturally, 1994. 3rd Printing, June, 1990. Beyond Words Publishing, 20827 N.W. Cornell Road, Suite 500, Hillsboro, Oregon, 97124.-9808, U.S.A.
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3. The second study investigated other parameters like reduced visual fields, reactions to stress and home related family factors in reading disabled children. Clinical cases included subjects with amblyopia and strabismus.
Publication:
“Changes in Form Visual Fields in Reading Disabled Children, Produced by Syntonic (colored light) Stimulation.” The International Journal of Biosocial Research, Vol. 5(1), pp. 20-33, 1983.
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4. In the 90’s I continued investigating these clinical phenomena in more depth and my clinical cases and experiences were recorded in my books:
“The Power Behind Your Eyes” – Improving Your Eyesight Through Integrated Vision Therapy – Inner Traditions, Rochester, Vermont. 1995.
“Conscious Seeing” – Transforming Your Life Through Your Eyes – Beyond Words Publishing, 20827 N.W. Cornell Road, Suite 500, Hillsboro, Oregon, 97124-9808, U.S.A. 2001
Dr. Kaplan,
I appreciate your sensitivities on this topic, but from a medical-legal perspective, your suggestion that patching a child who has amblyopia is a violation of this child’s human rights is not applicable. Time and again the courts have ruled that if a medical treatment is necessary, to not do so, is neglect. It is my responsibility to provide the patient with access to the best treatment available. The AOA has provided evidenced-based clinical practice guidelines that support patching as the cornerstone of amblyopia therapy. Of course patient care is not always black and white, and I would consider the ethical question you have raised. I listen very closely to both my patients and their parents and if there are circumstances that make patching or any other treatment unreasonable at that point in time, then I will alter my therapeutic approach as appropriate. Ultimately it is the parent’s decision, but I would provide them with as much information as possible for them to make an informed decision.
Dr. Mozlin, I am happy to see that you offer the parents the broad range of information. In addition, my research points out that the child’s ‘not seeing’ through one eye, from a deeper integrated point of view, can be related to the parents and family life situation. That is, the child’s ‘blindness’ can be a family problem as well. I documented this in my investigations at the University of Houston and Pacific University, Colleges of Optometry. My point in bringing this up is that in providing treatment options for amblyopia, and maximising the success possibilities, we need to take an interdisciplinary approach in identifying the real cause of the amblyopia. I personally find that the optometric vision therapy for amblyopia, and the child’s successful co-operation, is helped when the real source cause of the problem is included. This deeper integrated approach certainly fits your medical responsibility model. What I am still not convinced of though is the analogy to the tough love model!
After 40 years of helping myself with vision therapy and my patients, I have realised that when a patient, a child in this case, says they don’t like to wear their glasses, or cover their one eye, I listen to them. I know about ‘tough love’, having three children myself, however, forcing a child with a ‘medical treatment’ that does not ask the question, what is the background reason for the patient not wanting to see is a violation of a human right.