Deprivation Amblyopia
I just diagnosed a dense cataract OD on a 3yr 8month old boy. He/family had no prior exam or knowledge of the cataract. He had no meausrable VA or ability to "count fingers". His fixation and tracking with OD alone was extremely low. He had a variable exotropic posture. He has high myopia OD -11.50 while OD was +3.00 which did not improve acuity. Retinal health appeared ok for what could be viewed. He was seen by a pediatric OMD who advised surgery with implant followed by 10 hours of patching daily for an undetermined amount of time. Since the surgeon is out of the area all treatment of the amblyopia would be left to me with periodic visits to him. I called him to discuss the plan, informing him I was concerned with his recommended patching protocol and that I would reduce the patching in favor of supplementing with vision therapy. I asked him if he was familiar with VT as an option. He stated he was not opposed to the vision therapy as long as the patching was 8-10 hours. I am unsure that I want to continue care on the case as I am not in agreement with the treatment plan.
Question: 1. Who has treated a deprivation amblyopia case like this and what can I expect a VT program to do for him. I informed mother that the ability to achieve localization, movement detection, visual motor etc would be a benefit but did not want to promise more than that.
2.. How do you handle a surgeon like this? He seemed unconcerned when I expressed my concern on such an agressive patching protocol and the likelyhood that it would interfere with development in many other ways..... I have another case where after 2 years of patching the good eye and poor results in the aphakic eye... now we have very poor visual development, poor processing and visual motor etc.. We bagged the aphakic eye to do VT on the sighted eye to get some improvement in visual skill and processing.
3. If we do decide to proceed with surgery and VT-- what advice to you have in treating a case like this. Child coop is rather low at this age.
Thanks for any help!
Question: 1. Who has treated a deprivation amblyopia case like this and what can I expect a VT program to do for him. I informed mother that the ability to achieve localization, movement detection, visual motor etc would be a benefit but did not want to promise more than that.
2.. How do you handle a surgeon like this? He seemed unconcerned when I expressed my concern on such an agressive patching protocol and the likelyhood that it would interfere with development in many other ways..... I have another case where after 2 years of patching the good eye and poor results in the aphakic eye... now we have very poor visual development, poor processing and visual motor etc.. We bagged the aphakic eye to do VT on the sighted eye to get some improvement in visual skill and processing.
3. If we do decide to proceed with surgery and VT-- what advice to you have in treating a case like this. Child coop is rather low at this age.
Thanks for any help!
Views: 41
Replies to This Discussion
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Permalink Reply by Dr. Dan L. Fortenbacher on -
Heidi,
Here are some thoughts. This case requires agressive treatment. I concur with the course of action as stated above. While I can not say I have had a case exactly like the one you present, I have had many other amblyopes with complicating factors. So to answer your question in #1...you won't know until you try. The patient's response to your VT treatment plan will also give you a better way to provide a long term prognosis.
In response to #2, present your case to the family not the surgeon. They make the decision for the course of treatment. In my experience most parents understand that patching alone is no substitute for active vision therapy which address' binocular vision. Amblyopia is a binocular vision problem. Advise the parents that patching alone teaches the child to be a "one-eyed" person.
In response to #3, as far as VT activities I've found the best thing is for the VT staff and doctors to spend "team time" brain storming techniques. You will be able to create your own ideas through your group of experienced therapists and you the experienced doctor. Good luck I know working with toddlers can be very challenging.
Dan
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Permalink Reply by Dominick M. Maino, OD, MEd, FAAO on
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As far as the treatment goes....you explain to the parents what you want to do and why and let them choose...most often they will choose patching less in favor of vision therapy.....Also you might want to consider atropine...any child this age will not like being patched...but if you use atropine and if you can blur the better seeing eye at near enough ....you can still achieve a therapeutic affect.
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Permalink Reply by Kenneth on -
Heidi,
I would very much want to see what kind of VA you get after the surgery with the implant before taking on this kind of case. I wold also advise the parents of a less than optimistic ptrognosis. If some sort of reasom]nable improvement is achieved surgically then I would consider the extreme patching but with very close monitoring and switching to active patching for less hours as soon as possible.
Ken koslowe OD MS FCOVD-A
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