binocular vision question (amblyopia)

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Permalink Reply by Dr. Dan L. Fortenbacher on November 24, 2009 at 1:56am

This will challenge your thinking. The notion of prescribing "full cyclopegic refraction" and then patching. Does the patient who recieves full cycloplegic refraction become automatically bincular and visually comfortable? What will a 6 year old child who has reduced acuity experience when they go to school if they are given atropine therapy? What will this do to there spatial orientation to wear high plus (fog at distance) plus occluding their "good eye"? Have you ever put on a patch and tried to go about your day to day activities even when you have normal 20/20 acuity? Does it affect your mobility and motor skills? What does this do to a child's sense of space and self? Does it build confidence or fear?

I uploaded an excellent article written by Dr. Israel Greenwald and one written by Dr David Cook.

My experience after 30 years of providing office-based vision therapy is that you should prescribe judicsious use of plus, meaning only the most plus that provides most gain. Prescriptions will change over time in treatment Use occlusion therapy only with activities that involve eye-hand coordination and emphasize monocular fixatioins in a binocular field (MFBF). Bi-nasal patching is essential for estopropes. Read these articles to gain key insights!

Best of luck. I would also invite you to join us at the Michigan Vision Therapy Study Group Meeting on January 22-23, 2010 in Grand Rapids, Michigan. Feel free to contact me regarding more information.

Dan L. Fortenbacher, O.D.,FCOVD

Attachments:

• Brock - A Binoc Approach to Ambly Tx - Greenwald.pdf, 15 MB
• Alternatives to Occlusion - Cook.pdf, 14 MB

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Permalink Reply by Clark Hyde on November 24, 2009 at 11:24am

Thanks for your insight. I guess I don't have a good perception of what normal BV is since I am an anisometropic amblyope myself with +5.00/-1.25x035 OS, Plano OD with 20/70 OS and 20/20 OD. I HAVE walked around with a patch on my good eye for hours on end as a child and I'll be honest...I just looked over the patch as a 5 year old...after all, it's no fun to walk around with poor VA all day. This is why I don't agree with my classmates about the long term patching or atropine therapy for the amblyopia.

The patient in our case has a dry refraction of +1.50DS OS, +3.00DS OD. The wet refraction reveals an additional 2 dioptres of latent hyperopia in each eye. Thanks for the insight about not prescribing the full cycloplegic rx. I now agree with you there.

Any thoughts as to whether spectacle wear is sufficient to reduce the amblyopia in this patient?

Thank you so much for your help.

PS, I plan to attend the MVTSG meeting in January.

-Clark

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Permalink Reply by Dr. Leonard J. Press on November 27, 2009 at 12:26pm

Am enjoying the discussion. Your patient will benefit from spectacle Rx alone. This was shown in one of the PEDIG studies on Refractive Amblyopia (Ophthalmology 2006;113:895-903). Additional improvement will usually occur by adding active VT procedures, though in our practice I prefer not to wait until the patient has plateaued with Rx alone, and be more aggressive at the outset if possible. The articles that Dr. Fortenbacher provided from Drs. Greenwald and Cook are excellent in this regard.

You may wish to glance at a couple of chapters on amblyopia that I included in Applied Concepts in Vision Therapy (Mosby 1997 or OEPF 2008), in which I elaborate on MFBF (monocular fixation in a binocular field). I believe that atropine penalization works as well as it does (when it does) because it is an elegant pharmacologic form of MFBF.

Best wishes for your patient's success.

Leonard J. Press, O.D., FCOVD, FAAO

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Permalink Reply by Robert S. Fox on December 2, 2009 at 8:53pm

This has been a very interesting thread to read. I appreciates Clark's desire to question conventional wisdom. As for full correction and patching - it's not based on evidence - it's "just the way it's always been done." I'd like to thank Dan for the great articles - I recall Sherman lecturing and he had many successful outcomes using a reduced Rx and using almost exclusively MFBF activities. I recently had a young girl with amblyopia with severe occlusion nystagmus. Sherman's approach worked very well for her.
This should remind us that most of our non-VT colleagues treat amblyopia themselves using full correction and lots of occlusion - usually with poor results.

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