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Atropine vs Patching for Treatment of Amblyopia in Children

Atropine vs Patching for Treatment of Amblyopia in Children Abstract Objective To compare patching and atropine as treatments for moderate amblyopia in children younger than 7 years. Methods In a randomized clinical trial, 419 children younger than 7 years with amblyopia and visual acuity in the range of 20/40 to 20/100 were assigned to receive either patching or atropine at 47 clinical sites. Main Outcome Measure Visual acuity in the amblyopic eye and sound eye after 6 months. Results Visual acuity in the amblyopic eye improved in both groups (improvement from baseline to 6 months was 3.16 lines in the patching group and 2.84 lines in the atropine group). Improvement was initially faster in thepatching group, but after 6 months, the difference in visual acuity between treatment groups was small and clinically inconsequential (mean difference at 6 months, 0.034 logMAR units; 95% confidence interval, 0.005-0.064 logMAR units). The 6-month acuity was 20/30 or better in the amblyopic eye and/or improved from baseline by 3 or more lines in 79% of the patching group and 74% of the atropine group. Both treatments were well tolerated, although atropine had a slightly higher degree of acceptability on a parental questionnaire. More patients in the atropine group than in the patching group had reduced acuity in the sound eye at 6 months, but this did not persist with further follow-up. Conclusion Atropine and patching produce improvement of similar magnitude, and both are appropriate modalities for the initial treatment of moderate amblyopia in children aged 3 to less than 7 years. Commentary Amblyopia remains one of the leading causes of monocular blindness.1-3 The standard treatment of amblyopia is to occlude the unaffected eye. This effective treatment has remained essentially unchanged since it was described approximately 250 years ago.1 An alternative treatment for amblyopia known as "pharmacologic penalization" has been recommended by some ophthalmologists as an acceptable alternative to standard patching for treating amblyopia.4-6 This treatment consists of the daily use of atropine sulfate drops in the unaffected eye to cause sufficient blur that the child will spontaneously prefer to use the amblyopic eye. Some advantages of this treatment modality seem readily apparent. The most common problem with standard patching is compliance, as the child can easily remove the occlusive patch. In addition, wearing a noticeable eye patch may have some social stigma and may even be embarrassing for some children. Pharmacologic penalization avoids both of these problems. On the other hand, there are several concerns about the use of pharmacologic penalization. In fact, in a recent survey, 97% of pediatric ophthalmologists reported still using standard occlusion as their treatment of choice for an amblyopic child.7 One of the main concerns is that pharmacologic penalization may be less effective and take longer to work than traditional occlusion. For pharmacologic penalization to be effective, atropine must blur the vision in the unaffected eye to such a degree that its visual acuity is poorer than that in the amblyopic eye. Hence this approach might not be effective for treating patients with severe amblyopia. Also, depending on the nature of the child's refractive error, pharmacologic penalization may only result in use of the amblyopic eye for viewing at near range (eg, one third of a meter). If the child has a negligible refractive error in his/her unaffected (but atropine-treated) eye, he/she will continue to use that eye when looking into the distance. In theory, this can result in a slower or less effective treatment response. In addition, many ophthalmologists are concerned that keeping one eye continuously out of focus optically may cause deterioration in the patient's ocular alignment. Moreover, children undergoing pharmacologic penalization are typically more light sensitive because of the dilated pupil. This may necessitate the use of sunglasses, hats with visors, or avoidance of engaging in activities in bright sunlight. The study by the Pediatric Eye Disease Investigator Group7 published in the March 2002 issue of Archives of Ophthalmology compared the effectiveness of pharmacologic penalization with standard occlusion therapy for the treatment of mild-to-moderate amblyopia, defined as visual acuity of less than 20/40 to equal to or better than 20/100. In a randomized clinical trial involving 419 children aged 3 to 7 years, the authors found that the 2 treatments had similar rates of success at 6 months. Although neither treatment appeared distinctly better, the conclusion was that the physician and patient can make the initial treatment choice for managing amblyopia of this degree, after carefully weighing individual preferences and trade-offs. Several questions remain unanswered by this study. It is known that pharmacologic penalization is not effective for patients with dense amblyopia.7 Therefore, subdividing patients in this study by the density of their amblyopia might provide some interesting information. For example, perhaps penalization is less effective than patching for patients with denser levels of amblyopia (eg, 20/80 to 20/100), and perhaps more effective than patching for milder degrees of amblyopia. Also, the study design does not clearly address the issue as to whether patching or pharmacologic penalization results in more rapid resolution of amblyopia, even though there was initially an earlier response with patching. If patching results in more rapid improvement in vision, this knowledge might influence physician and parental choice when weighing the respective trade-offs of these 2 treatment modalities. Similarly, if either treatment resulted in substantially fewer office visits to complete treatment, the economic benefits of one treatment over the other could be significant. However, the total cost for treating amblyopia, either with patching or pharmacologic penalization, is relatively small compared with the costs of most other interventions for restoring vision for monocularly blind eyes, and the financial impact on the overall health care delivery system is quite modest. The study by the Pediatric Eye Disease Investigator Group7 suggests that standard occlusion therapy and pharmacologic penalization result in visual improvement of similar magnitude when used for treating children with mild-to-moderate amblyopia. Having approximately equally effective treatment alternatives from which to choose certainly should be beneficial for physicians as well as for pediatric patients and their families. References 1. Flynn JT. 17th annual Frank Costenbader lecture: amblyopia revisited. J Pediatr Ophthalmol Strabismus.1991;28:183-201.Google Scholar 2. National Eye Institute Office of Biometry and Epidemiology. Report on the National Eye Institute's Visual Acuity Impairment Survey Pilot Study. Washington, DC: US Dept of Health and Human Services; 1984. 3. Attebo K, Mitchell P, Cumming R, Smith W, Jolly N, Sparkes R. Prevalence and causes of amblyopia in an adult population. Ophthalmology.1998;105:154-159.Google Scholar 4. Swann AP, Hunter CD. A survey of amblyopia treated by atropine occlusion. Br Orthopt J.1974;31:65-69.Google Scholar 5. Foley-Nolan A, McCann A, O'Keefe M. Atropine penalisation vs occlusion as the primary treatment for amblyopia. Br J Ophthalmol.1997;81:54-57.Google Scholar 6. Simons K, Stein L, Sener EC, Vitale S, Guyton DL. Full-time atropine, intermittent atropine and optical penalization and binocular outcome in treatment of strabismic amblyopia. Ophthalmology.1997;104:2143-2155.Google Scholar 7. Pediatric Eye Disease Investigator Group. A randomized trial of atropine vs patching for treatment of moderate amblyopia in children. Arch Ophthalmol.2002;120:268-278.Google Scholar http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png JAMA American Medical Association

Atropine vs Patching for Treatment of Amblyopia in Children

JAMA , Volume 287 (16) – Apr 24, 2002

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References (7)

Publisher
American Medical Association
Copyright
Copyright © 2002 American Medical Association. All Rights Reserved.
ISSN
0098-7484
eISSN
1538-3598
DOI
10.1001/jama.287.16.2145
Publisher site
See Article on Publisher Site

Abstract

Abstract Objective To compare patching and atropine as treatments for moderate amblyopia in children younger than 7 years. Methods In a randomized clinical trial, 419 children younger than 7 years with amblyopia and visual acuity in the range of 20/40 to 20/100 were assigned to receive either patching or atropine at 47 clinical sites. Main Outcome Measure Visual acuity in the amblyopic eye and sound eye after 6 months. Results Visual acuity in the amblyopic eye improved in both groups (improvement from baseline to 6 months was 3.16 lines in the patching group and 2.84 lines in the atropine group). Improvement was initially faster in thepatching group, but after 6 months, the difference in visual acuity between treatment groups was small and clinically inconsequential (mean difference at 6 months, 0.034 logMAR units; 95% confidence interval, 0.005-0.064 logMAR units). The 6-month acuity was 20/30 or better in the amblyopic eye and/or improved from baseline by 3 or more lines in 79% of the patching group and 74% of the atropine group. Both treatments were well tolerated, although atropine had a slightly higher degree of acceptability on a parental questionnaire. More patients in the atropine group than in the patching group had reduced acuity in the sound eye at 6 months, but this did not persist with further follow-up. Conclusion Atropine and patching produce improvement of similar magnitude, and both are appropriate modalities for the initial treatment of moderate amblyopia in children aged 3 to less than 7 years. Commentary Amblyopia remains one of the leading causes of monocular blindness.1-3 The standard treatment of amblyopia is to occlude the unaffected eye. This effective treatment has remained essentially unchanged since it was described approximately 250 years ago.1 An alternative treatment for amblyopia known as "pharmacologic penalization" has been recommended by some ophthalmologists as an acceptable alternative to standard patching for treating amblyopia.4-6 This treatment consists of the daily use of atropine sulfate drops in the unaffected eye to cause sufficient blur that the child will spontaneously prefer to use the amblyopic eye. Some advantages of this treatment modality seem readily apparent. The most common problem with standard patching is compliance, as the child can easily remove the occlusive patch. In addition, wearing a noticeable eye patch may have some social stigma and may even be embarrassing for some children. Pharmacologic penalization avoids both of these problems. On the other hand, there are several concerns about the use of pharmacologic penalization. In fact, in a recent survey, 97% of pediatric ophthalmologists reported still using standard occlusion as their treatment of choice for an amblyopic child.7 One of the main concerns is that pharmacologic penalization may be less effective and take longer to work than traditional occlusion. For pharmacologic penalization to be effective, atropine must blur the vision in the unaffected eye to such a degree that its visual acuity is poorer than that in the amblyopic eye. Hence this approach might not be effective for treating patients with severe amblyopia. Also, depending on the nature of the child's refractive error, pharmacologic penalization may only result in use of the amblyopic eye for viewing at near range (eg, one third of a meter). If the child has a negligible refractive error in his/her unaffected (but atropine-treated) eye, he/she will continue to use that eye when looking into the distance. In theory, this can result in a slower or less effective treatment response. In addition, many ophthalmologists are concerned that keeping one eye continuously out of focus optically may cause deterioration in the patient's ocular alignment. Moreover, children undergoing pharmacologic penalization are typically more light sensitive because of the dilated pupil. This may necessitate the use of sunglasses, hats with visors, or avoidance of engaging in activities in bright sunlight. The study by the Pediatric Eye Disease Investigator Group7 published in the March 2002 issue of Archives of Ophthalmology compared the effectiveness of pharmacologic penalization with standard occlusion therapy for the treatment of mild-to-moderate amblyopia, defined as visual acuity of less than 20/40 to equal to or better than 20/100. In a randomized clinical trial involving 419 children aged 3 to 7 years, the authors found that the 2 treatments had similar rates of success at 6 months. Although neither treatment appeared distinctly better, the conclusion was that the physician and patient can make the initial treatment choice for managing amblyopia of this degree, after carefully weighing individual preferences and trade-offs. Several questions remain unanswered by this study. It is known that pharmacologic penalization is not effective for patients with dense amblyopia.7 Therefore, subdividing patients in this study by the density of their amblyopia might provide some interesting information. For example, perhaps penalization is less effective than patching for patients with denser levels of amblyopia (eg, 20/80 to 20/100), and perhaps more effective than patching for milder degrees of amblyopia. Also, the study design does not clearly address the issue as to whether patching or pharmacologic penalization results in more rapid resolution of amblyopia, even though there was initially an earlier response with patching. If patching results in more rapid improvement in vision, this knowledge might influence physician and parental choice when weighing the respective trade-offs of these 2 treatment modalities. Similarly, if either treatment resulted in substantially fewer office visits to complete treatment, the economic benefits of one treatment over the other could be significant. However, the total cost for treating amblyopia, either with patching or pharmacologic penalization, is relatively small compared with the costs of most other interventions for restoring vision for monocularly blind eyes, and the financial impact on the overall health care delivery system is quite modest. The study by the Pediatric Eye Disease Investigator Group7 suggests that standard occlusion therapy and pharmacologic penalization result in visual improvement of similar magnitude when used for treating children with mild-to-moderate amblyopia. Having approximately equally effective treatment alternatives from which to choose certainly should be beneficial for physicians as well as for pediatric patients and their families. References 1. Flynn JT. 17th annual Frank Costenbader lecture: amblyopia revisited. J Pediatr Ophthalmol Strabismus.1991;28:183-201.Google Scholar 2. National Eye Institute Office of Biometry and Epidemiology. Report on the National Eye Institute's Visual Acuity Impairment Survey Pilot Study. Washington, DC: US Dept of Health and Human Services; 1984. 3. Attebo K, Mitchell P, Cumming R, Smith W, Jolly N, Sparkes R. Prevalence and causes of amblyopia in an adult population. Ophthalmology.1998;105:154-159.Google Scholar 4. Swann AP, Hunter CD. A survey of amblyopia treated by atropine occlusion. Br Orthopt J.1974;31:65-69.Google Scholar 5. Foley-Nolan A, McCann A, O'Keefe M. Atropine penalisation vs occlusion as the primary treatment for amblyopia. Br J Ophthalmol.1997;81:54-57.Google Scholar 6. Simons K, Stein L, Sener EC, Vitale S, Guyton DL. Full-time atropine, intermittent atropine and optical penalization and binocular outcome in treatment of strabismic amblyopia. Ophthalmology.1997;104:2143-2155.Google Scholar 7. Pediatric Eye Disease Investigator Group. A randomized trial of atropine vs patching for treatment of moderate amblyopia in children. Arch Ophthalmol.2002;120:268-278.Google Scholar

Journal

JAMAAmerican Medical Association

Published: Apr 24, 2002

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