1. Amblyopia New knowledge and practical approaches ESA 2007 Early morning course May 21, 2007 Daisy Godts CO, Ilse De Veuster MD University Hospital Antwerp

2. UZ Antwerp ESA 2007 Daisy Godts Amblyopia Pubmed: –5829 amblyopia –3051 amblyopia treatment –2860 amblyopia therapy –490 amblyopia occlusion –149 amblyopia patching –122 amblyopia atropine –70 amblyopia penalization –5 amblyopia inverse occlusion

3. UZ Antwerp ESA 2007 Daisy Godts Definition of amblyopia Amblyopia is a diagnosis of exclusion Because the basis is defective central visual processing, careful assessment of the retina and optic nerve is essential The diagnosis is established by a unilateral or bilateral reduction of BCVA not entirely attributable to structural abnormalities of the visual pathways PPP AAO 2002: Amblyopia

4. UZ Antwerp ESA 2007 Daisy Godts Definition of amblyopia VA  2 / 3 lines ( < 20/50 3 years of age / < 20/40 5 years of age) / fixation behaviour No differences with corrective lenses Amblyopia inducing factor present Onset : immature visual system Prevalence : 2-4% general population PPP AAO 2002: Amblyopia

5. UZ Antwerp ESA 2007 Daisy Godts Definition of amblyopia Pattern deprivation Strabismus : –Synchronous stimulus of visual cortex of non corresponding images of two foveas –Binocular rivalry => suppression Optical defocus –Refractive error removes fine details from the retinal image –Anisometropia : 100% amblyopia risk : +4D/-6D vs 50% +2,5D/-4D

6. UZ Antwerp ESA 2007 Daisy Godts Pathofysiological mechanisms Type of amblyopiaAbnormal binocular interaction Visual image distortion Strabismic+ Refractive: Ametropia Anisometropia+ ++++ Deprivation: Unilateral Bilateral +++++ Organic: Unilateral Bilateral +++++ Focal Points AAO volume XVIII nr 2, March 2000 : Practical management of amblyopia

7. UZ Antwerp ESA 2007 Daisy Godts Management Two principles Optimise clarity of retinal image in the amblyopic eye: clear visual axis + correction of refractive errors Increase cortical processing of visual input of amblyopic eye = enhance the neural stimulus to the visual cortex

8. UZ Antwerp ESA 2007 Daisy Godts Management Parent’s explanation !!!! Surgery if necessary Optical correction : spectacles, contact lenses Patching/occlusion Atropine/penalization/optical penalisation/defocus

9. UZ Antwerp ESA 2007 Daisy Godts Management Response is related to: Type of amblyopia Initial VA Age Duration of amblyopia Method of treatment Compliance

10. UZ Antwerp ESA 2007 Daisy Godts Robbe 8 years During screening low VA RE, consulted ophthalmologist: too late, no treatment anymore. Second opinion VA RE: 0.1 sc0.25 +4.25 Logmar VA LE: 1.0 sc Cycloplegic refraction RE: +6.75 –0.75 x 150 LE: +4.00 -0.75 x 130 Straight eyes with fusion and moderate stereopsis Central fixation BE Anterior and posterior segment: normal Therapy: +4.75/ +2.00

11. UZ Antwerp ESA 2007 Daisy Godts Robbe 8 years 2 months control VA RE: 0.3 cc Logmar VA LE: 1.0 cc BV: normal 8 hours occlusion LE 2 months control: good compliance VA RE: 0.5 cc Logmar VA LE: 1.0 cc BV: normal 6 hours occlusion LE

12. UZ Antwerp ESA 2007 Daisy Godts Robbe 8 years 2 months control: good compliance VA RE: 0.7 cc Logmar VA LE: 1.0 cc BV: normal 4 hours occlusion LE 2 months control: good compliance VA RE: 0.8- cc Logmar VA LE: 1.0 cc BV: normal 2 hours occlusion LE

13. UZ Antwerp ESA 2007 Daisy Godts Steele A L, Bradfield Y S, Kushner B J, France T D, Struck M C, Gangnon R G. Successful Treatment of Anisometropic Amblyopia with Spectacles Alone. J AAPOS 2006;10:37-43 The mean time to resolution in this study was 5.8 + - 3.9 months with a range of 2 to 15 months Age at presentation ranged from 0.8 to 7.9 years (mean 4.8, SD 1.7) We analyzed age, best corrected initial visual acuity in the amblyopic eye, initial stereoacuity, type, and amount of anisometropia to assess which of these presenting characteristics are significantly associated with time to cure. Worse initial visual acuity was significantly associated with longer time to resolution (P 0.05) Anisometropia amblyopia : Glasses

14. UZ Antwerp ESA 2007 Daisy Godts Anisometropic amblyopia : Glasses 3 - 7 years Anisometropia :  0,5D SE or  1,5 D astigmatism Prescription: hyperopia > 3D full or max –1,5D hyperopia < 3 D ( investigator ) VA 20/40 – 20/250 VA change : 2,9 lines +- 1,8 77% patients improvement of  2 lines Resolution of amblyopia ( VA  1 line) = 27% Amblyopia resolution ~ base line VA ~ magnitude of anisometropia PEDIG Treatment of anisometropic amblyopia in children with refractive correction. Ophthalmoly 2006; 113:895.

15. UZ Antwerp ESA 2007 Daisy Godts Aaron 4 years 19/09/06 During screening low VA BE, consulted ophthalmologist: no treatment possible. Second opinion VA RE: 0.10 scLEA symbols VA LE: 0.20 sc Cycloplegic refraction RE: +6.50 –1.75 x 0 LE: -1.50 –1.50 x 0 Straight eyes Anterior segment: normal Posterior segment: RE normal, LE myelin vessels Therapy: contact lenses +6.00 –1.75 x 0 -1.50 –1.25 x 0

16. UZ Antwerp ESA 2007 Daisy Godts Aaron 4 years Posterior segment: RE normal, LE myelin vessels

17. UZ Antwerp ESA 2007 Daisy Godts Aaron 4 years 1 month control: VA RE: 0.16 ccl LEA symbols VA LE: 0.40 ccl BV: normal 2 months control: VA RE: 0.25 ccl LEA symbols VA LE: 0.50 ccl Near VA RE: 0.4/1.6 ccl LE: 0.4/ 0.8 ccl 6 hours occlusion LE

18. UZ Antwerp ESA 2007 Daisy Godts Aaron 4 years 1 month control: good compliance to occlusion VA RE: 0.40 ccl LEA symbols VA LE: 0.50 ccl Near VA RE: 0.4/1.0 cclLE: 0.4/ 0.8 ccl BV: normal 6 hours occlusion LE 2 months control: good compliance VA RE: 0.60 ccl LEA symbols VA LE: 0.60 ccl Near VA RE: 0.4/1.0 cclLE: 0.4/ 0.8 ccl 3 hours occlusion LE

19. UZ Antwerp ESA 2007 Daisy Godts Patching regimens 3 - 7 years Moderate amblyopia : 20/40 –20/80 Anisometropic, strabismic and mixed amblyopia 2 hours + 1 hour near activity vs 6 hours + 1hr Age/base line acuity/ cause of amblyopia : no difference Results: –5 weeks: 2 hrs 1,84 lines improvement vs 1,92 line –4 months : 2,4 lines improvement in both groups PEDIG A randomized trial of patching regimens for treatment of moderate amblyopia in children. Arch Ophthalmol 2003; 121: 603

20. UZ Antwerp ESA 2007 Daisy Godts Patching regimens 3 - 7 years Severe amblyopia : 20/100 –20/400 Anisometropic, strabismic and mixed amblyopia Full-time vs 6 hours + 1 hour near activity each Age/base line acuity/ cause of amblyopia : no difference Results: –5 weeks: 6 hrs 3.5 lines improvement vs 3.7 lines in FTO –4 months : 6 hrs 4.8 lines improvement vs 4.7 lines in FTO PEDIG A randomized trial of prescribed patching regimens for treatment of severe amblyopia. Ophthalmology 2003; 110: 2075

21. UZ Antwerp ESA 2007 Daisy Godts Argita 9 years 10/11/06 first ophthalmological examination because poor VA during school examination, Roma gypsies VA RE: 0.2 scLogmar VA LE: 0.1 sc Cycloplegic refraction RE: +9.00 –2.00 x 170 LE: +10.00 –2.75 x 10 Straight eyes Anterior and posterior segment: normal Therapy: +8.00 –2.00 x 170 +9.00 –2.75 x 10

22. UZ Antwerp ESA 2007 Daisy Godts Argita 9 years 09/02/07 3 months of full-time spectacle wear VA RE: 0.6 ccLogmar VA LE: 0.2 cc Micro-esotropia LE central fixation Therapy: 6 hours occlusion RE, control 2 months 17/04/07 good compliance to occlusion VA RE: 0.6 ccLogmar VA LE: 0.25 cc Micro-esotropia LE central fixation Therapy: more/idem occlusion RE ? Stop occlusion?

23. UZ Antwerp ESA 2007 Daisy Godts Treatment of amblyopia > 7 years 7 - 10,3 years (36 patients) Anisometropic, strabismic and mixed amblyopia Spectacles + full time occlusion/ total penalisation Follow up : 1 year after no further improvement in VA VA 20/50- 20/400 start ~ end 20/20 –20/30 for all patients Duration : 0,6 yrs aniso / 1,0 yrs strab / 0,8 yrs mix BV improved or maintained in 61% of cases Mintz-Hittner H et al.Succesfull amblyopia therapy initiated after age 7 years. Arch Ophthalmology 2000;118: 1535

24. UZ Antwerp ESA 2007 Daisy Godts Nikki 10 years Foster child since 1 year, abandoned by her parents because of drug problems. Had glassed and occlusion long ago VA RE: 1.0 scLogmar VA LE: 0.05 sc0.1 +5.OO –4.00 x 0° Cycloplegic refraction RE: +2.50 LE: +6.25 –4.00 x 0° CT: 12^esotropia LE Central fixation BE Anterior and posterior segment: normal Therapy: Glasses? Occlusion?

25. UZ Antwerp ESA 2007 Daisy Godts Nikki 10 years Glasses RE + 1.25 LE + 5.00 –4.00 x 0° Full time occlusion RE 1.5 months:VA RE: 1.0 ccLogmar VA LE: 0.5 cc 12^ET Full time occlusion RE 3 months:VA RE: 1.0 ccLogmar VA LE: 0.6 cc 12^ET Full time occlusion RE

26. UZ Antwerp ESA 2007 Daisy Godts Nikki 10 years 5 months:Occlusion done  7- 8 hours VA RE: 1.0 ccLogmar VA LE: 0.6 cc 12^ET 4 hours occlusion RE 7 months:VA RE: 1.0 ccLogmar VA LE: 0.7 cc 10^ET Titmus: 4/9 2 hours occlusion RE

27. UZ Antwerp ESA 2007 Daisy Godts Nikki 11 years 9 months:VA RE: 1.0 ccLogmar VA LE: 0.7 cc 10^ET’ Titmus 5/9, Lang I: positive 1 hour occlusion RE 12 months:VA RE: 1.0 ccLogmar VA LE: 0.7 cc 10^ET’ Titmus: 5/9, Lang I & II: positive 1 hour occlusion RE once a week

28. UZ Antwerp ESA 2007 Daisy Godts Nikki 12 years 18 months:VA RE: 1.0 ccLogmar VA LE: 0.7 cc 8^ET Titmus 6/9, Lang I & II: positive Stop occlusion RE 24 months:VA RE: 1.0 ccLogmar VA LE: 0.7 cc 8^ET Titmus: 5/9, Lang I & II: positive, TNO 240”

29. UZ Antwerp ESA 2007 Daisy Godts Treatment of amblyopia > 10 years 10 - 18 years, 66 patients VA 20/40 –20/160 Optimal optical correction > 4 wks Anisometropic, strabismic and mixed amblyopia Daily patching  2 hrs/day ( 1 hour of near visual activity) 2 month follow up 18/66 (27%) VA improvement with 2 or more lines 10-14 years vs 14–18 years: no difference PEDIG A prospective, pilot study of treatment of amblyopia in children 10 to < 18 years old. Am J Ophthalmol 2004;137: 581-583.

30. UZ Antwerp ESA 2007 Daisy Godts Treatment of amblyopia > 7 years 7 - 17 years, 507 patients 2 groups: younger group 7-12 years, older group 13-17 years VA 20/40 – 20/400 Anisometropic, strabismic and mixed amblyopia Optimal optical correction alone or + 2-6h patching+atropine 24 weeks follow-up (6 weeks controls) Younger group: 53% improvement (patching+atropine) 25% improvement (optical correction) Older group: 25% improvement (patching) 23% improvement (optical correction) No diplopia PEDIG Randomized trial of treatment of amblyopia in children aged 7 to 17 years. Arch Ophthalmol 2005; 123: 437-447

31. UZ Antwerp ESA 2007 Daisy Godts Thomas 4 years Second opinion: glasses +4.00/+5.75 since age 2 year occlusion 4h RE/day poor compliance AV RE: 0.7 cc Snellen E AV LE: 0.2 cc Cycloplegic refraction RE: +4.50 –0.50 x 40 LE: +6.50 –1.00 x 150 Partial accommodative esotropia LE Therapy: LE +6.00 –1.00 x 150 Occlusion RE at school

32. UZ Antwerp ESA 2007 Daisy Godts Thomas 4 years 3 months: Very poor compliance to occlusion AV RE: 0.9 cc Snellen E AV LE: 0.2 cc = partial accommodative ET LE Therapy: Atropine 0.50 % RE, plano glass RE 6 months: AV RE: 0.2 sc/atropine Snellen E AV LE: 0.8 cc Therapy: RE + 4.00 Stop atropine RE, 1 h alternate occlusion

33. UZ Antwerp ESA 2007 Daisy Godts Thomas 5 years 8 months: Good compliance to occlusion AV RE: 0.8 cc Snellen E AV LE: 0.8 cc = partial accommodative ET LE Therapy: 1 h alternate occlusion 14 months: Good compliance to occlusion AV RE: 1.0 cc Snellen E AV LE: 0.8 cc Therapy: 2h occlusion RE

34. UZ Antwerp ESA 2007 Daisy Godts Thomas 6 years 20 months: Good compliance to occlusion AV RE: 1.0 cc Snellen E AV LE: 0.8 cc near VA RE: 1.0 cc LEA VA LE: 0.8 cc = partial accommodative ET LE Therapy: 2 h occlusion RE 26 months: Poor compliance to occlusion AV RE: 1.0 cc Logmar AV LE: 0.6 cc Therapy: Atropine 0.5 % RE 2X week

35. UZ Antwerp ESA 2007 Daisy Godts Thomas 7 years 32 months: No atropine used, occlusion 2 h RE AV RE: 1.0 cc Logmar AV LE: 1.0 = cc near VA RE: 1.0 cc LEA numbers VA LE: 0.8+ cc = partial accommodative ET LE Therapy: 2 h occlusion RE 2-3 times a week

36. UZ Antwerp ESA 2007 Daisy Godts Atropine vs patching 3-7 years, 419 patients VA 20/40 – 20/100 Anisometropic, strabismic and mixed amblyopia Occlusion > 6 hours vs atropine daily Results: –5 wks : 2,22 lines improvement occlusion vs 1,37 atropine –16 wks: 2,94 vs 2,42 –6 months: 3,16 vs 2,84 Patching = more rapid and possible slightly better VA Atropine easier administration and lower cost PEDIG. A randomized trial of atropine vs patching for treatment of moderate amblyopia in children. Arch 2002; 120: 268

37. UZ Antwerp ESA 2007 Daisy Godts Atropine vs patching 3-7 years, 419 children VA 20/40 - 20/100 Anisometropic, strabismic and mixed amblyopia VA 6 months: 0,25 ( 20/30-2) atropine daily vs 0,21 (20/30) occlusion (6h - FTO) Age, depth of amblyopia, cause of amblyopia: no difference  Atropine as effective in VA 20/100 as when 20/40 Occlusion faster improvement especially when VA 20/80- 20/100 and when FTO or nearly FTO PEDIG. A comparison of atropine and patching treatments for moderate amblyopia by patient age, cause of amblyopia, depth of amblyopia and other factors. Ophthalmology 2003; 110: 1632-1638.  

38. UZ Antwerp ESA 2007 Daisy Godts Atropine vs patching : 2 y follow-up Follow-up 18 months after 6-months randomised trial 419 children age < 7 years Initial VA 20/40 to 20/100 After 2 years: VA increased from baseline 3.7 lines (occlusion 6h-FTO) and 3.6 lines (atropine daily) In both groups mean amblyopic VA was  20/32, 1.8 lines worse than the sound eye (20/20) Atropine or patching produced similar improvement of moderate amblyopia in children age 3-7 years PEDIG Two-year follow-up of a 6 month randomized tral of atropine versus patching for treatment of moderate amblyopia in children. Arch Ophthalmol. 2005: 123: 149-157.

39. UZ Antwerp ESA 2007 Daisy Godts Glen 4 years 10/11/04 first ophthalmological examination because poor VA during school examination VA RE: 0.2 scSnellen E VA LE: 1.0 sc Cycloplegic refraction RE: +1.75 LE: +1.75 –0.50 x 100 Esotropia RE, poor fixation possible eccentric Anterior and posterior segment: normal Therapy: orthoptic consult

40. UZ Antwerp ESA 2007 Daisy Godts Glen 4 years 07/06/05 second opinion, low VA RE, no therapy done, consulted ophthalmologist did not know what to do VA RE: 0.01 scSnellen E VA LE: 1.0 sc Cycloplegic refraction RE: +1.75 –0.50 x 105 LE: +1.25 –0.25 x 100 Esotropia RE, no central fixation Anterior and posterior segment: normal Therapy: 4 hours occlusion LE, control 4-5 weeks

41. UZ Antwerp ESA 2007 Daisy Godts Glen 4 years 15/11/05 Poor compliance to occlusion, max 1 hour VA RE: 0.05 scSnellen E VA LE: 1.0 sc Cycloplegic refraction RE: +1.75 –0.50 x 105 LE: +1.21 –0.25 x 100 Esotropia RE, poor fixation Unstable fixation RE Therapy: Atropine 0.5% LE + occlusion LE Control 4 weeks

42. UZ Antwerp ESA 2007 Daisy Godts Glen 5 years 19/10/06 atropine used beginning last year, sometimes occlusion done VA RE: 0.1 scSnellen E VA LE: 1.0 sc Esotropia RE, poor fixation Central unstable fixation RE Therapy: Full time occlusion (day and night) 6 weeks control

43. UZ Antwerp ESA 2007 Daisy Godts Glen 5 years 07/12/06 Good compliance VA RE: 0.5 scSnellen E VA LE: 1.0 sc Therapy: Full time occlusion, 6 weeks control 11/01/07 good compliance VA RE: 0.8 sc Snellen E VA LE: 1.0 sc Therapy: 6 hours occlusion, 8 weeks control 22/03/07 Good compliance VA RE: 0.8 scSnellen E VA LE: 1.0 sc Therapy: 3 hours occlusion, 2 months control

44. UZ Antwerp ESA 2007 Daisy Godts Compliance : occlusion Poor parental fluency in the national language Low level of education Poor acuity at the start of treatment An educational program primarily aimed at the child improved compliance and reduced the number of children who did not comply with occlusion at all SE Loudon, M Fronius, CWN Looman, M Awan, B Simonsz, PJ van der Maas, HJ Simonsz: Predictors and a remedy for noncompliance with amblyopia therapy in children measured with the occlusion dose monitor. Invest Ophthalmol Vis Sci. 2006 Oct;47(10):4393-400.

45. UZ Antwerp ESA 2007 Daisy Godts Dixon Woods M et al. Why is compliance with occlusion therapy for amblyopia so hard? A qualitative study. Arch Dis Child 2006; 91: 491 Compliance : occlusion Semi structured interviews ( n = 28 ) of parents of a child prescribed patching ( 2 to 8 years : mean duration of patching: 3 months to 5 years) Problems with patching –Begin of treatment/ extreme emotional reactions of child/ low VA ~ struggle with everyday life activities –Social impact : risk of teasing –Strain relationship child – parent –Time consuming

46. UZ Antwerp ESA 2007 Daisy Godts Compliance : occlusion Strategies to support patching –Explanation : need for patching –Rewarding the effort with VA increase at follow up/ attention and praise/ game / no big deal –Normalisation strategies : toy with patch /other children with patch –Customising the patch :figures on the patch etc –Establishing routine :structure and routine –Support of others : teachers, day care workers Dixon Woods M et al. Why is compliance with occlusion therapy for amblyopia so hard? A qualitative study. Arch Dis Child 2006; 91: 491

47. UZ Antwerp ESA 2007 Daisy Godts Jef 4.5 years Since 1.5 years glasses + occlusion RE during school hours, no VA improvement, good compliance VA RE: 1.0 sc1.0 cc (+1.00) E linear VA LE: 0.1 sc0.1 cc (+3.00) Cycloplegic refraction RE: +2.50 LE: +4.50 Partial accommodative esotropia LE Parafoveal fixation LE Anterior and posterior segment: normal

48. UZ Antwerp ESA 2007 Daisy Godts Jef 4.5 years Therapy: Inverse occlusion?

49. UZ Antwerp ESA 2007 Daisy Godts Jef 4.5 years 1 month full time inverse occlusion LE VA RE: 0.9 cc Linear E VA LE: <0.05 cc Total fixation loss LE R/ Full time occlusion RE, no bilateral fixation 1 month:VA RE: 0.6 ccLinear E VA LE: 0.2+ cc Central unsteady fixation LE R/ Full time occlusion RE

50. UZ Antwerp ESA 2007 Daisy Godts Jef 4.5 years Central fixation RE Central unsteady fixation LE

51. UZ Antwerp ESA 2007 Daisy Godts Jef 5 years 3 months:Full time occlusion done VA RE: 0.5 ccE linear VA LE: 0.4 cc Central fixation LE ET RE R/ Alternate occlusion 4 months:Alternate occlusion done VA RE: 0.8- ccE linear VA LE: 0.6- cc ET LE Central fixation R/ 6 hours occlusion RE

52. UZ Antwerp ESA 2007 Daisy Godts Jef 5 years 6 months:6 hours occlusion done VA RE: 1.0 ccE linear VA LE: 0.6 cc Central fixation LE ET LE R/ 6 hours occlusion RE 8 months:6 hours occlusion done VA RE: 1.0 ccE linear VA LE: 0.8 cc ET LE Central fixation R/ 4 hours occlusion RE

53. UZ Antwerp ESA 2007 Daisy Godts Inverse occlusion 1.Pigassou-Albouy R. Treatment of eccentric fixation. Inverse prism and occlusion. J Fr Ophtalmol. 1988;11(8-9):597-600. Review. French. No abstract available. 2.Koskela PU, Hyvarinen L. Contrast sensitivity in amblyopia. III. Effect of occlusion. Acta Ophthalmol (Copenh). 1986 Aug;64(4):386-90. 3.Blassmann K, Neuhann T. Treatment of amblyopia with soft occlusion lenses (author's transl). Klin Monatsbl Augenheilkd. 1978 May;172(5):766-70. German. 4.Andree G. The influence of inverse occlusion on fixation and function of amblyopic eyes. Albrecht Von Graefes Arch Klin Exp Ophthalmol. 1966 Aug 15;170(3):257-64. German. No abstract available. 5. Postic G. Influence of inverse and direct occlusion on the amblyopic eye with excentric fixation. Bull Mem Soc Fr Ophtalmol. 1966;79:305-66. French. No abstract available.

54. UZ Antwerp ESA 2007 Daisy Godts Celine 8 years During screening at school 1 year ago low VA LE, glasses (-1.00 –0.50 x 110/-5.00 –3.00 x 145), no occlusion, second opinion VA RE: 0.8 ccLogmar VA LE: 0.3 cc Cycloplegic refraction RE: -1.50 LE: -4.75 –2.75 x 150 Straight eyes with peripheral fusion and central suppression LE, poor stereopsis Central fixation BE Anterior and posterior segment: normal

55. UZ Antwerp ESA 2007 Daisy Godts Celine 8 years 6 weeks 4 hours occlusion RE Good compliance VA RE: 0.8 cc Logmar VA LE: 0.6=/0.7= cc Near VA RE: 1.0 cc LEA numbers LE: 0.8 cc BV: normal 2 hours occlusion RE

56. UZ Antwerp ESA 2007 Daisy Godts Celine 8 years 3 months 1-2 hours occlusion RE VA RE: 0.9 cc Logmar VA LE: 08= cc Near VA RE: 1.0 cc LEA numbers LE: 0.8 cc CT: straight eyes Central and peripheral fusion Good stereopsis Stop occlusion

57. UZ Antwerp ESA 2007 Daisy Godts Celine 9 years Control 1 year VA RE: 0.9 –2.50 Logmar VA LE: 08= –5.50 –2.75 x 150 Near VA RE: 1.0 ccLEA numbers LE: 0.8 cc CT: straight eyes Central and peripheral fusion Good stereopsis

58. UZ Antwerp ESA 2007 Daisy Godts Cessation of treatment Bhola et al. Recurrence of Amblyopia After Occlusion Therapy. Ophthalmology 2006;Vol 113, 11: 2097-2100 < 10 years (retrospective) Anisometropic, strabismic and mixed amblyopia > 8 hours patching daily 27% recurrence of amblyopia after 1 year ( 179 / 653) by  2 logMAR levels Recurrence inversely correlated with patient age Important risk of recurrence when amblyopia therapy is decreased before the age of 10 years

59. UZ Antwerp ESA 2007 Daisy Godts Cessation of treatment PEDIG. Risk of Amblyopia Recurrence After Cessation of Treatment J AAPOS 2004;8: 420-428. < 8 years Anisometropic, strabismic and mixed amblyopia >2 hours patching daily or > 1 drop atropine weekly VA <20/40 at enrollment, improvement of 3 logMAR levels 24% recurrence of amblyopia after 52 weeks ( 35 / 145) by  2 logMAR levels Occlusion (n = 112) : 25 % recurrence Atropine (n = 33) : 21% recurrence

60. UZ Antwerp ESA 2007 Daisy Godts Cessation of treatment PEDIG. Risk of Amblyopia Recurrence After Cessation of Treatment J AAPOS 2004;8: 420-428. 2 h daily stop: low recurrence risk (14%) 6-8 h patching stop: high recurrence risk (42%) Patching hours should be weaned before treatment is stopped

61. UZ Antwerp ESA 2007 Daisy Godts Cessation of treatment PEDIG. Factors Associated with Recurrence of Amblyopia on Cessation of Patching. Ophthalmology 2007 < 8 years (prospective) Anisometropic, strabismic and mixed amblyopia 6-8 hours patching daily, stopped abruptly/weaned Risk of recurrence higher when: Better VA at the time of cessation More lines of improvement History of recurrence Orthotropia or good stereoacuity no protective effect

62. UZ Antwerp ESA 2007 Daisy Godts 3-7 years Anisometropic, strabismic and mixed amblyopia VA 20/40 – 20/100 Atropine, 6h patching or both Follow-up 2 years 14% new strabismus, 3% > 8  (atropine = occlusion) Microtropia (1-8  ): 36% resolution, 14% increase > 8  Heterotropia > 8  : 20% resolution, 64% increase > 8  Adverse effects of treatment : risk of strabismus PEDIG. The Effect of Amblyopia Therapy on Ocular Alignment. J AAPOS 2005, Vol 9, 6: 542-545.

63. UZ Antwerp ESA 2007 Daisy Godts 3-7 years (419 patients) Anisometropic, strabismic and mixed amblyopia VA 20/40 – 20/100 Atropine daily versus 6h-FTO occlusion 6 months : VA decrease  2 lines 17 patients in atropine group, 3 patients in patching group 2 years: all patients normal VA (20/20) in both groups Adverse effects of treatment : VA sound eye decrease PEDIG. Two-year follow-up of a 6 month randomized tral of atropine versus patching for treatment of moderate amblyopia in children. Arch Ophthalmol. 2005: 123: 149-157.

64. UZ Antwerp ESA 2007 Daisy Godts Mean age : 4 years Follow up : 54 weeks No difference between no treatment / only spectacles/ glasses + occlusion VA 6/9 – 6/36 no strabismus Adverse effects of treatment : stereo acuity. Richardson SR et al. Stereoacuity in Unilateral Visual Impairment Detected at Preschool Screening: Outcomes from a Randomized Controlled Trial Invest Ophthalmol Vis Sci. 2005;46:150–154

65. UZ Antwerp ESA 2007 Daisy Godts Adverse effects of treatment : no success anisometropic amblyopia Hussein M AW et al. Risk Factors for Treatment Failure of Anisometropic Amblyopia. J AAPOS 2004; 8:429-434. 3-8 years 104 children with anisometropic amblyopia VA < 20/50,  3 lines interocular difference Anisometropia  1D Relative failure = failure of VA to improve  3 lines Functional failure = final VA < 20/40

66. UZ Antwerp ESA 2007 Daisy Godts Adverse effects of treatment : no success anisometropic amblyopia Hussein M AW et al. Risk Factors for Treatment Failure of Anisometropic Amblyopia. J AAPOS 2004; 8:429-434. Risk of functional failure Age above 6 years An initial visual acuity of 20/200 or worse Risk of relative failure Poor treatment compliance Astigmatism of  1,5D No risk Degree of anisometropia Type of refractive error Concurrent strabismus

67. UZ Antwerp ESA 2007 Daisy Godts Do we change our habbits Questionaire to 380 pediatric ophthalmologists 39% no modification 33% rare adjustments 12% adapted amount of patching hours Wygnanski-Jaffe T. The Effect on Pediatric Ophthalmologists of the Randomized Trial of Patching Regimens for Treatment of Moderate Amblyopia. J AAPOS 2005;9:208-211.

70. Hope to see you in Antwerp !