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2 Unilateral or less commonly, bilateral reduction of best corrected visual acuity that can not be attributed directly to the effect of any structural abnormality of the eye or the posterior visual pathway. Unilateral or less commonly, bilateral reduction of best corrected visual acuity that can not be attributed directly to the effect of any structural abnormality of the eye or the posterior visual pathway.

3 Resulting from one of following: A. Strabismus - DEVIATION B. Anisometropia or high bilateral refractive error (Isoametropia) - DEFOCUS C. Visual deprivation - DEPRIVATION A. Strabismus - DEVIATION B. Anisometropia or high bilateral refractive error (Isoametropia) - DEFOCUS C. Visual deprivation - DEPRIVATION

4 Prevalence: 2%-4% Prevalence: 2%-4% Commonly unilateral Commonly unilateral Nearly all amblyopic visual loss is preventable or reversible with timely detection and appropriate intervention. Nearly all amblyopic visual loss is preventable or reversible with timely detection and appropriate intervention. Children with amblyopia or at risk for amblyopia should be identified at a young age when the prognosis for successful treatment is best. Children with amblyopia or at risk for amblyopia should be identified at a young age when the prognosis for successful treatment is best. Role of screening is important Role of screening is important Prevalence: 2%-4% Prevalence: 2%-4% Commonly unilateral Commonly unilateral Nearly all amblyopic visual loss is preventable or reversible with timely detection and appropriate intervention. Nearly all amblyopic visual loss is preventable or reversible with timely detection and appropriate intervention. Children with amblyopia or at risk for amblyopia should be identified at a young age when the prognosis for successful treatment is best. Children with amblyopia or at risk for amblyopia should be identified at a young age when the prognosis for successful treatment is best. Role of screening is important Role of screening is important

5 Amblyopia is primarily a defect of central vision. Amblyopia is primarily a defect of central vision. There is a critical period for sensitivity in developing amblyopia. There is a critical period for sensitivity in developing amblyopia. The time necessary for amblyopia to occur during critical period is shorter for stimulus deprivation than for strabismus or anisometropia. The time necessary for amblyopia to occur during critical period is shorter for stimulus deprivation than for strabismus or anisometropia. Amblyopia is primarily a defect of central vision. Amblyopia is primarily a defect of central vision. There is a critical period for sensitivity in developing amblyopia. There is a critical period for sensitivity in developing amblyopia. The time necessary for amblyopia to occur during critical period is shorter for stimulus deprivation than for strabismus or anisometropia. The time necessary for amblyopia to occur during critical period is shorter for stimulus deprivation than for strabismus or anisometropia.

6 Neurophysiology:Neurophysiology: Cells of the primary visual cortex can completely lose their innate ability or show significant functional deficiencies Cells of the primary visual cortex can completely lose their innate ability or show significant functional deficiencies Abnormalities also occur in neurons in the lateral geniculate body Abnormalities also occur in neurons in the lateral geniculate body Evidence concerning involvement at the retinal level remains inconclusive Evidence concerning involvement at the retinal level remains inconclusive Cells of the primary visual cortex can completely lose their innate ability or show significant functional deficiencies Cells of the primary visual cortex can completely lose their innate ability or show significant functional deficiencies Abnormalities also occur in neurons in the lateral geniculate body Abnormalities also occur in neurons in the lateral geniculate body Evidence concerning involvement at the retinal level remains inconclusive Evidence concerning involvement at the retinal level remains inconclusive

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10 Classification:Classification: 1. Strabismus Amblyopia :Deviation 2. Anisometropia Amblyopia : Defocuss 3. Amblyopia Due to bilateral high refractive error (isometropic) :Defocuss 4. Deprivation Amblyopia :Deviation 1. Strabismus Amblyopia :Deviation 2. Anisometropia Amblyopia : Defocuss 3. Amblyopia Due to bilateral high refractive error (isometropic) :Defocuss 4. Deprivation Amblyopia :Deviation

11 Strabismus Amblyopia The most common form of amblyopia The most common form of amblyopia Strabismic amblyopia is thought to result from competitive or inhibitory interaction between neurons carrying the nonfusible inputs from the two eyes. Strabismic amblyopia is thought to result from competitive or inhibitory interaction between neurons carrying the nonfusible inputs from the two eyes. Which leads to domination of cortical vision centers by the fixating eye and chronically reduced responsiveness to the nonfixating eye input. Which leads to domination of cortical vision centers by the fixating eye and chronically reduced responsiveness to the nonfixating eye input. The most common form of amblyopia The most common form of amblyopia Strabismic amblyopia is thought to result from competitive or inhibitory interaction between neurons carrying the nonfusible inputs from the two eyes. Strabismic amblyopia is thought to result from competitive or inhibitory interaction between neurons carrying the nonfusible inputs from the two eyes. Which leads to domination of cortical vision centers by the fixating eye and chronically reduced responsiveness to the nonfixating eye input. Which leads to domination of cortical vision centers by the fixating eye and chronically reduced responsiveness to the nonfixating eye input.

12 Anisometropia Amblyopia Second in frequency Second in frequency It develops when unequal refractive error in the two eyes causes the image on the one retina to be chronically defocused. It develops when unequal refractive error in the two eyes causes the image on the one retina to be chronically defocused. This condition is thought to result: This condition is thought to result: Partly from the direct effect of image blur in the development of visual acuity. Partly from the direct effect of image blur in the development of visual acuity. Partly from intraocular competition or inhibition Partly from intraocular competition or inhibition Second in frequency Second in frequency It develops when unequal refractive error in the two eyes causes the image on the one retina to be chronically defocused. It develops when unequal refractive error in the two eyes causes the image on the one retina to be chronically defocused. This condition is thought to result: This condition is thought to result: Partly from the direct effect of image blur in the development of visual acuity. Partly from the direct effect of image blur in the development of visual acuity. Partly from intraocular competition or inhibition Partly from intraocular competition or inhibition

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14 Mild hyperopic or astigmatic anisometropia (1.5D)  mild amblyopia Mild hyperopic or astigmatic anisometropia (1.5D)  mild amblyopia Mild myopia anisometropia (less than -2.5D) usually doesn't cause amblyopia Mild myopia anisometropia (less than -2.5D) usually doesn't cause amblyopia unilateral high myopia (-6D)  sever amblyopia visual loss. unilateral high myopia (-6D)  sever amblyopia visual loss. Mild hyperopic or astigmatic anisometropia (1.5D)  mild amblyopia Mild hyperopic or astigmatic anisometropia (1.5D)  mild amblyopia Mild myopia anisometropia (less than -2.5D) usually doesn't cause amblyopia Mild myopia anisometropia (less than -2.5D) usually doesn't cause amblyopia unilateral high myopia (-6D)  sever amblyopia visual loss. unilateral high myopia (-6D)  sever amblyopia visual loss.

15 Amblyopia Due to bilateral high refractive error (isometropia) isometropic amblyopia result from large, approximately equal, uncorrected refractive error in both eyes of a young child. isometropic amblyopia result from large, approximately equal, uncorrected refractive error in both eyes of a young child. Hyperopia exceeding 5D & myopia excess of 10 D  risk  bilateral amblyopia Hyperopia exceeding 5D & myopia excess of 10 D  risk  bilateral amblyopia isometropic amblyopia result from large, approximately equal, uncorrected refractive error in both eyes of a young child. isometropic amblyopia result from large, approximately equal, uncorrected refractive error in both eyes of a young child. Hyperopia exceeding 5D & myopia excess of 10 D  risk  bilateral amblyopia Hyperopia exceeding 5D & myopia excess of 10 D  risk  bilateral amblyopia

16 Meridonial amblyopia: Meridonial amblyopia: Uncorrected bilateral astigmatism in early childhood may result in loss of resolving ability limited to chronically blurred meridians. Uncorrected bilateral astigmatism in early childhood may result in loss of resolving ability limited to chronically blurred meridians. Meridonial amblyopia: Meridonial amblyopia: Uncorrected bilateral astigmatism in early childhood may result in loss of resolving ability limited to chronically blurred meridians. Uncorrected bilateral astigmatism in early childhood may result in loss of resolving ability limited to chronically blurred meridians.

17 Deprivation Amblyopia It is usually caused by congenital or early acquired media opacity. It is usually caused by congenital or early acquired media opacity. This form of amblyopia is the least common but most damaging and difficult to treat. This form of amblyopia is the least common but most damaging and difficult to treat. In bilateral cases acuity can be 20/200 or worse. In bilateral cases acuity can be 20/200 or worse. It is usually caused by congenital or early acquired media opacity. It is usually caused by congenital or early acquired media opacity. This form of amblyopia is the least common but most damaging and difficult to treat. This form of amblyopia is the least common but most damaging and difficult to treat. In bilateral cases acuity can be 20/200 or worse. In bilateral cases acuity can be 20/200 or worse.

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19 In children younger than 6 years, dense congenital cataract that occupy the central 3 mm. or more of the lens must be considered capable of causing sever amblyopia. In children younger than 6 years, dense congenital cataract that occupy the central 3 mm. or more of the lens must be considered capable of causing sever amblyopia. Similar lens opacities acquired after 6 years are generally less harmful. Similar lens opacities acquired after 6 years are generally less harmful. In children younger than 6 years, dense congenital cataract that occupy the central 3 mm. or more of the lens must be considered capable of causing sever amblyopia. In children younger than 6 years, dense congenital cataract that occupy the central 3 mm. or more of the lens must be considered capable of causing sever amblyopia. Similar lens opacities acquired after 6 years are generally less harmful. Similar lens opacities acquired after 6 years are generally less harmful.

20 Small polar cataracts & lamellar cataracts may cause mild to moderate amblyopia or may have no effect on visual development. Small polar cataracts & lamellar cataracts may cause mild to moderate amblyopia or may have no effect on visual development. Occlusion amblyopia is a form of deprivation caused by excessive therapeutic patching. Occlusion amblyopia is a form of deprivation caused by excessive therapeutic patching. Small polar cataracts & lamellar cataracts may cause mild to moderate amblyopia or may have no effect on visual development. Small polar cataracts & lamellar cataracts may cause mild to moderate amblyopia or may have no effect on visual development. Occlusion amblyopia is a form of deprivation caused by excessive therapeutic patching. Occlusion amblyopia is a form of deprivation caused by excessive therapeutic patching.

21 DiagnosisDiagnosis Characteristics of vision alone cannot be used to reliably differentiate amblyopia from other form of visual loss. Characteristics of vision alone cannot be used to reliably differentiate amblyopia from other form of visual loss. The crowding phenomenon is typical for amblyopia but not uniformly demonstrable. The crowding phenomenon is typical for amblyopia but not uniformly demonstrable. Afferent pupillary defect are Characteristic of optic nerve disease but occasiinally appear to be present with amblyopia Afferent pupillary defect are Characteristic of optic nerve disease but occasiinally appear to be present with amblyopia Characteristics of vision alone cannot be used to reliably differentiate amblyopia from other form of visual loss. Characteristics of vision alone cannot be used to reliably differentiate amblyopia from other form of visual loss. The crowding phenomenon is typical for amblyopia but not uniformly demonstrable. The crowding phenomenon is typical for amblyopia but not uniformly demonstrable. Afferent pupillary defect are Characteristic of optic nerve disease but occasiinally appear to be present with amblyopia Afferent pupillary defect are Characteristic of optic nerve disease but occasiinally appear to be present with amblyopia

22 Multiple assessment using a variety of tests or performed on different occasions are sometime required to make a final judgment concerning the presence and severity of amblyopia. Multiple assessment using a variety of tests or performed on different occasions are sometime required to make a final judgment concerning the presence and severity of amblyopia.

23 Binocular fixation pattern: Binocular fixation pattern: It is a test for estimating the relative level of vision in the two eyes for children with strabismus who are under the age of about 3. It is a test for estimating the relative level of vision in the two eyes for children with strabismus who are under the age of about 3. This test is quite sensitive for detecting amblyopia but results can be falsely positive. This test is quite sensitive for detecting amblyopia but results can be falsely positive. Showing a strong preference when vision is equal or nearly equal in the two eyes, particularly with small angle strabismic deviations. Showing a strong preference when vision is equal or nearly equal in the two eyes, particularly with small angle strabismic deviations. Binocular fixation pattern: Binocular fixation pattern: It is a test for estimating the relative level of vision in the two eyes for children with strabismus who are under the age of about 3. It is a test for estimating the relative level of vision in the two eyes for children with strabismus who are under the age of about 3. This test is quite sensitive for detecting amblyopia but results can be falsely positive. This test is quite sensitive for detecting amblyopia but results can be falsely positive. Showing a strong preference when vision is equal or nearly equal in the two eyes, particularly with small angle strabismic deviations. Showing a strong preference when vision is equal or nearly equal in the two eyes, particularly with small angle strabismic deviations.

24 The modified Snellen technique directly measures acuity in children 3-6 years old. The modified Snellen technique directly measures acuity in children 3-6 years old. Often, however, only isolated letters can be used, which may lead to under estimated amblyopia visual loss. Often, however, only isolated letters can be used, which may lead to under estimated amblyopia visual loss. Croding bar may help alleviate this problem. Croding bar may help alleviate this problem. The modified Snellen technique directly measures acuity in children 3-6 years old. The modified Snellen technique directly measures acuity in children 3-6 years old. Often, however, only isolated letters can be used, which may lead to under estimated amblyopia visual loss. Often, however, only isolated letters can be used, which may lead to under estimated amblyopia visual loss. Croding bar may help alleviate this problem. Croding bar may help alleviate this problem.

25 Crowding bar, or contour interaction bars, allow the examinator to test the crowing phenomenon with isolated optotype. Bar surrounding the optotype mimic the full of optotype to the amblyopia child. Crowding bar, or contour interaction bars, allow the examinator to test the crowing phenomenon with isolated optotype. Bar surrounding the optotype mimic the full of optotype to the amblyopia child. E O

26 TreatmentTreatment Treatment of amblyopia involves the following steps: Treatment of amblyopia involves the following steps: Eliminating (if possible) any obstacle to vision such as a cataract Eliminating (if possible) any obstacle to vision such as a cataract Correcting refractive error Correcting refractive error Forcing use of the poorer eye by limiting use of the better eye. Forcing use of the poorer eye by limiting use of the better eye. Treatment of amblyopia involves the following steps: Treatment of amblyopia involves the following steps: Eliminating (if possible) any obstacle to vision such as a cataract Eliminating (if possible) any obstacle to vision such as a cataract Correcting refractive error Correcting refractive error Forcing use of the poorer eye by limiting use of the better eye. Forcing use of the poorer eye by limiting use of the better eye.

27 Cataract removal Cataracts capable of producing amblyopia require surgery without unnecessary delay. Cataracts capable of producing amblyopia require surgery without unnecessary delay. Removal of significant congenital lens opacities during the first 2-3 months of life is necessary for optimal recovery of vision. Removal of significant congenital lens opacities during the first 2-3 months of life is necessary for optimal recovery of vision. In symmetrical bilateral cases, the interval between operations on the first and second eyes should be no more than 1 week. In symmetrical bilateral cases, the interval between operations on the first and second eyes should be no more than 1 week. Acutely developing severe traumatic cataracts in children younger than 6 years should be removed within a few weeks of injury, if possible. Acutely developing severe traumatic cataracts in children younger than 6 years should be removed within a few weeks of injury, if possible. Cataracts capable of producing amblyopia require surgery without unnecessary delay. Cataracts capable of producing amblyopia require surgery without unnecessary delay. Removal of significant congenital lens opacities during the first 2-3 months of life is necessary for optimal recovery of vision. Removal of significant congenital lens opacities during the first 2-3 months of life is necessary for optimal recovery of vision. In symmetrical bilateral cases, the interval between operations on the first and second eyes should be no more than 1 week. In symmetrical bilateral cases, the interval between operations on the first and second eyes should be no more than 1 week. Acutely developing severe traumatic cataracts in children younger than 6 years should be removed within a few weeks of injury, if possible. Acutely developing severe traumatic cataracts in children younger than 6 years should be removed within a few weeks of injury, if possible.

28 Refractive correction In generally, optical prescription for amblyopic eyes should correct the full refractive error as determined with cyclopagic. In generally, optical prescription for amblyopic eyes should correct the full refractive error as determined with cyclopagic.

29 Occlusion and optical degradation Full time occlusion of the sound eye: Full time occlusion of the sound eye: Defined as occlusion for all or all but one waking hour. Defined as occlusion for all or all but one waking hour. It is the most powerful means of treating of amblyopia by enforced use of the defective eye. It is the most powerful means of treating of amblyopia by enforced use of the defective eye. The patch can either be left in place at night or removed at bedtime. The patch can either be left in place at night or removed at bedtime. Spectacle-mounted occluser or special opaque contact lenses can be used as an alternative to full- time patching if skin irritation or poor adhesion proves to be a significant problem Spectacle-mounted occluser or special opaque contact lenses can be used as an alternative to full- time patching if skin irritation or poor adhesion proves to be a significant problem Full time occlusion of the sound eye: Full time occlusion of the sound eye: Defined as occlusion for all or all but one waking hour. Defined as occlusion for all or all but one waking hour. It is the most powerful means of treating of amblyopia by enforced use of the defective eye. It is the most powerful means of treating of amblyopia by enforced use of the defective eye. The patch can either be left in place at night or removed at bedtime. The patch can either be left in place at night or removed at bedtime. Spectacle-mounted occluser or special opaque contact lenses can be used as an alternative to full- time patching if skin irritation or poor adhesion proves to be a significant problem Spectacle-mounted occluser or special opaque contact lenses can be used as an alternative to full- time patching if skin irritation or poor adhesion proves to be a significant problem

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31 Full time patching should generally be used only when constant strabismus eliminates any possibility of useful binocular vision because  full time patching runs a small risk of perturbing binocularity. Full time patching should generally be used only when constant strabismus eliminates any possibility of useful binocular vision because  full time patching runs a small risk of perturbing binocularity.

32 Part-time occlusion: Part-time occlusion: Defined as occlusion for 1-6 hours per day. Defined as occlusion for 1-6 hours per day. The children undergoing part time occlusion should be kept as visually active as possible when the patch is in place. The children undergoing part time occlusion should be kept as visually active as possible when the patch is in place. Compliance with occlusion therapy for amblyopia declines with increasing age. Compliance with occlusion therapy for amblyopia declines with increasing age. Part-time occlusion: Part-time occlusion: Defined as occlusion for 1-6 hours per day. Defined as occlusion for 1-6 hours per day. The children undergoing part time occlusion should be kept as visually active as possible when the patch is in place. The children undergoing part time occlusion should be kept as visually active as possible when the patch is in place. Compliance with occlusion therapy for amblyopia declines with increasing age. Compliance with occlusion therapy for amblyopia declines with increasing age.

33 Penalization: Penalization: A cycloplegic agent (usually atropine 1% or homatropine )  once daily to the better eye A cycloplegic agent (usually atropine 1% or homatropine )  once daily to the better eye This form of treatment has recently been demonstrated to be as effective as patching for mild to moderate amblyopia. This form of treatment has recently been demonstrated to be as effective as patching for mild to moderate amblyopia. Penalization: Penalization: A cycloplegic agent (usually atropine 1% or homatropine )  once daily to the better eye A cycloplegic agent (usually atropine 1% or homatropine )  once daily to the better eye This form of treatment has recently been demonstrated to be as effective as patching for mild to moderate amblyopia. This form of treatment has recently been demonstrated to be as effective as patching for mild to moderate amblyopia.

E.B.M. Evidence Based Medicine Prospective, randomised PEDIG, MOTAS & COCHRANE PEDIG, MOTAS & COCHRANE Eminence Based Medicine Hopkins: weekend atropine Hopkins: weekend atropine Scott [Iowa]: only full time Scott [Iowa]: only full time

PEDIG P E Diatric ophthalmology Diatric ophthalmology Investigator Investigator Group Group North American Community based Ophthalmology and optometry

MOTAS Monitored Monitored Occlusion Occlusion Treatment of Treatment of Amblyopia Amblyopia Study Study England Alistair Fielder

PEDIG: Amblyopia 6/30 - 6/120 6 h/d vs. all [or all -1] waking hours Ages 3-7 Ages 3-7 Can do reliable HOTV Can do reliable HOTV 1h/d near activity 1h/d near activity 4mo: 4+ line improvement both groups Age / severity of amblyopia NOT relevant to outcome!

PEDIG: Amblyopia 6/12- 6/24 2h vs. 6h/d opaque occluder Ages 3-7 Ages 3-7 Can do reliable HOTV Can do reliable HOTV 1h/d near activity 1h/d near activity 4mo: same 2.4 line improvement Age / severity of amblyopia NOT relevant to outcome!

PEDIG: Amblyopia 6/12 - 6/24 Daily atropine vs. patch 6h/d 6mo: no difference 6mo: no difference Patch: faster response Patch: faster response 2y: amblyopic eye 1.8 lines worse in each group 2y: amblyopic eye 1.8 lines worse in each group 2y: 3.6 vs. 3.7 lines 2y: 3.6 vs. 3.7 lines

PEDIG: Recurrence of amblyopia after stopping treatment ≥ 3 lines acuity improvement 25%: ≥ 2 lines 12mo 25%: ≥ 2 lines 12mo 42% after stopping 6h/d 42% after stopping 6h/d 14% if 6h/d tapered to 2h/d before stopping 14% if 6h/d tapered to 2h/d before stopping

MOTAS investigators: Recurrence of amblyopia after stopping treatment Factors affecting the stability of visual function following cessation of occlusion therapy for amblyopia. Graefe 6/2007 Tacagni DJ Tacagni DJ, … Fielder AR Tacagni DJ, … Fielder AR…Fielder AR Tacagni DJ…Fielder AR

MOTAS investigators: Recurrence of amblyopia after stopping treatment 1 y follow-up from treatment cessation: children with "mixed" amblyopia (both anisometropia and strabismus) had significantly (p=0.03) greater deterioration in VA (0.11+/-0.11 log units) than children with only anisometropia (0.02+/-0.08 log units) or only strabismus (0.05+/ log units ). 1 y follow-up from treatment cessation: children with "mixed" amblyopia (both anisometropia and strabismus) had significantly (p=0.03) greater deterioration in VA (0.11+/-0.11 log units) than children with only anisometropia (0.02+/-0.08 log units) or only strabismus (0.05+/ log units ).

PEDIG: Amblyopia 6/12 - 6/24 Daily vs. weekend atropine Same results Same results Daily slightly easier to do Daily slightly easier to do 1/80: occlusion amblyopia 1/80: occlusion amblyopia

PEDIG: Amblyopia 6/12 - 6/120 in 7-17yo Glasses vs. glasses plus 7-12: plus = patch 2-6h/d & daily atropine 7-12: plus = patch 2-6h/d & daily atropine Acuity improves by ≥ 2 lines Acuity improves by ≥ 2 lines 13-17: plus = patch 2-6h/d 13-17: plus = patch 2-6h/d Some have improved acuity Some have improved acuity 12mo later: 20% have regressed 12mo later: 20% have regressed

PEDIG: Glasses alone 6/12 to 6/75 27% cured 27% cured Another 50% ≥ 2 lines better Another 50% ≥ 2 lines better Took up to 7 mo Took up to 7 mo

MOTAS GLASSES ALONE ‘REFRACTIVE ADAPTATION’ VA in 65 newly diagnosed children with difft causes of amblyopia at 6w intervals for 18w VA in 65 newly diagnosed children with difft causes of amblyopia at 6w intervals for 18w VA improved significantly (p,0.001) from 0.67 to 0.43 logMAR: a mean improvement of 0.24 independent of amblyopia type (p = 0.29) and age (p = 0.38) VA improved significantly (p,0.001) from 0.67 to 0.43 logMAR: a mean improvement of 0.24 independent of amblyopia type (p = 0.29) and age (p = 0.38) Br J Ophthalmol 2004;88:

MOTAS REFRACTIVE ADAPTATION FOLLOWED BY OCCLUSION Prescribed dose 6h/d Prescribed dose 6h/d Compliance <50% [2.8h]. Compliance <50% [2.8h]. Only 10% used it ≥ 5.5 h/d Only 10% used it ≥ 5.5 h/d 0.1 [1 chart line] VA improvement per 120h of occlusion 0.1 [1 chart line] VA improvement per 120h of occlusion Total doses >200h: residual amblyopia <0.2 log residual amblyopia <0.2 log >75% of deficit corrected >75% of deficit corrected IOVS 2004

MOTAS REFRACTIVE ADAPTATION FOLLOWED BY OCCLUSION % of amblyopia deficit corrected Type Ref. Adapt. Occl. Deficit corrected All Aniso Strab Mixed275077

MOTAS: ELECTRONIC PATCH #1 18w of glasses, then patch prescribed 6h, 12h/d 18w of glasses, then patch prescribed 6h, 12h/d 6h/d: received 4.2 [± 0.5] h/d 6h/d: received 4.2 [± 0.5] h/d 12h/d: received 6.2 [± 1.1] h/d 12h/d: received 6.2 [± 1.1] h/d p=0.06 p=0.06 <3h/d: worse outcome <3h/d: worse outcome

MOTAS: ELECTRONIC PATCH #2 6h/d prescribed 6h/d prescribed Best acuity after h Best acuity after h 2 line gain: 4y: needs 170h 4y: needs 170h 6y: needs 236h 6y: needs 236h

ELECTRONIC PATCH #3 Graefe 3/2003 Simonsz HJ et al. Simonsz HJSimonsz HJ Compliance : % of electronically registered time c.f. prescribed time. Compliance : % of electronically registered time c.f. prescribed time. Satisfactory acuity increase ratio between acuity of the amblyopic eye and acuity of the good eye > 0.75 ratio between acuity of the amblyopic eye and acuity of the good eye > 0.75 acuity of the amblyopic eye > 0.5 on E or Landolt-C, or acuity of the amblyopic eye > 0.5 on E or Landolt-C, or 3 LogMAR lines of increase in acuity. 3 LogMAR lines of increase in acuity.

Results: Graefe 3/2003 Simonsz HJ et al. Simonsz HJSimonsz HJ Measured compliance ~ 80% in 8/14 children with satisfactory acuity increase ~ 80% in 8/14 children with satisfactory acuity increase 34% in 6 children with unsatisfactory acuity increase. 34% in 6 children with unsatisfactory acuity increase. Children with low acuity increase had statistically significantly lower compliance p=0.038 Children with low acuity increase had statistically significantly lower compliance p=0.038 ‘no pain, no gain’ ‘no pain, no gain’

PEDIG studies with completed enrolment Enrollment Completed - Follow Up A Observational study of different types of esotropia Observational study of different types of esotropia RCT comparing near vs. distance activities while patching for amblyopia RCT comparing near vs. distance activities while patching for amblyopia RCT comparing atropine vs atropine with reduced + for sound eye RCT comparing atropine vs atropine with reduced + for sound eye Atropine vs occlusion in 7-12 yr old Atropine vs occlusion in 7-12 yr old NFL in amblyopia NFL in amblyopia RCT of Progressivelenses vs single vision lenses on low myopia with large accommodative lags and near esophoria in children RCT of Progressivelenses vs single vision lenses on low myopia with large accommodative lags and near esophoria in children

54 Complication of therapy Full time occlusion carries the greatest risk of this complication and requires close monitoring, especially in the younger child. Full time occlusion carries the greatest risk of this complication and requires close monitoring, especially in the younger child. The first follow up visit after initial treatment should occur within 1 week for an infant and after interval corresponding to 1 week per year of age for the older child. The first follow up visit after initial treatment should occur within 1 week for an infant and after interval corresponding to 1 week per year of age for the older child. Part time occlusion & optical degradation methods allow for less frequent observation but regular follow up is still critical Part time occlusion & optical degradation methods allow for less frequent observation but regular follow up is still critical Full time occlusion carries the greatest risk of this complication and requires close monitoring, especially in the younger child. Full time occlusion carries the greatest risk of this complication and requires close monitoring, especially in the younger child. The first follow up visit after initial treatment should occur within 1 week for an infant and after interval corresponding to 1 week per year of age for the older child. The first follow up visit after initial treatment should occur within 1 week for an infant and after interval corresponding to 1 week per year of age for the older child. Part time occlusion & optical degradation methods allow for less frequent observation but regular follow up is still critical Part time occlusion & optical degradation methods allow for less frequent observation but regular follow up is still critical

55 The time required for completion of treatment depends on the following: The time required for completion of treatment depends on the following: 1. Degree of amblyopia 2. Choice of therapeutic approach 3. Compliance with the prescribed regimen 4. age of the patient The time required for completion of treatment depends on the following: The time required for completion of treatment depends on the following: 1. Degree of amblyopia 2. Choice of therapeutic approach 3. Compliance with the prescribed regimen 4. age of the patient

56 UnresponsivenessUnresponsiveness Complete or partial Unresponsiveness to treatment occasionally affect younger children but must often occurs in patients older than 5 years. Complete or partial Unresponsiveness to treatment occasionally affect younger children but must often occurs in patients older than 5 years. Primary therapy should generally be terminated if there is a lock of demonstrable progress over 3-6 months with good compliance. Primary therapy should generally be terminated if there is a lock of demonstrable progress over 3-6 months with good compliance. Refraction should be carefully rechecked and the macula and optic nerve critically inspected for subtle evidence of hypoplasia or other malformation that might have been previously overlooked. Refraction should be carefully rechecked and the macula and optic nerve critically inspected for subtle evidence of hypoplasia or other malformation that might have been previously overlooked. Complete or partial Unresponsiveness to treatment occasionally affect younger children but must often occurs in patients older than 5 years. Complete or partial Unresponsiveness to treatment occasionally affect younger children but must often occurs in patients older than 5 years. Primary therapy should generally be terminated if there is a lock of demonstrable progress over 3-6 months with good compliance. Primary therapy should generally be terminated if there is a lock of demonstrable progress over 3-6 months with good compliance. Refraction should be carefully rechecked and the macula and optic nerve critically inspected for subtle evidence of hypoplasia or other malformation that might have been previously overlooked. Refraction should be carefully rechecked and the macula and optic nerve critically inspected for subtle evidence of hypoplasia or other malformation that might have been previously overlooked.

57 RecurrenceRecurrence When amblyopia treatment is discontinued after fully or partially successful completion, approximately half of patients show some dgree of recurrence, When amblyopia treatment is discontinued after fully or partially successful completion, approximately half of patients show some dgree of recurrence, Maintenance therapy: Maintenance therapy: Patching for 1-3 hours per day Patching for 1-3 hours per day Optical penalization with spectacles Optical penalization with spectacles Pharmacologic penalization with atropine 1 or 2 day per week. Pharmacologic penalization with atropine 1 or 2 day per week. This may require periodic monitoring until age This may require periodic monitoring until age When amblyopia treatment is discontinued after fully or partially successful completion, approximately half of patients show some dgree of recurrence, When amblyopia treatment is discontinued after fully or partially successful completion, approximately half of patients show some dgree of recurrence, Maintenance therapy: Maintenance therapy: Patching for 1-3 hours per day Patching for 1-3 hours per day Optical penalization with spectacles Optical penalization with spectacles Pharmacologic penalization with atropine 1 or 2 day per week. Pharmacologic penalization with atropine 1 or 2 day per week. This may require periodic monitoring until age This may require periodic monitoring until age 8-10.