Full time patching?

I saw a 4 year old today who was referred from a vision screening for
his first eye exam.

Unaided VA was R 20/30 L 20/70

I 'scoped him at R +.25 -.75 x 80 and L +1.00 - 2.25 x 150, which
didn't produce any significant acuity improvement for the left eye.

My initial treatment will be to Rx the above for full time wear and to
patch the O.D. and see how he does. Would you o.d.'s out there go for
full time, part time, or what for the patching, and would you just black
out the R lens, or go for a total occluder like an elastoplast (do they
still make that?).

thanks for your input

w.stacy, o.d.

 

I'd Rx the full power for full time wear and NOT patch at first. Wait
two months and see if the acuity improves. If the LE comes up to, say
20/40, then continue, If not, check for dominance and if the R is so,
then over-plus the RE for a good distance blur in a second pair of specs
to be worn part time. If I went to full or most-time full-occlusion, I'd
hope for better acuity to start with and might consider contact lenses
with the occluder being a blacked-out OZ. But he's 4, so perhaps the
more traditional method would be fine.

This, of course, assumes that you've ruled out pathology.

Interestingly, I just had a similar case, except the child is a bit
older (6) and with slightly less correction in the more astigmatic eye,
but similar acuity in both. (20/40--20/60). Two months later he was
20/30 and 20/40- .......still not appropriate for his age or optical
error, but on the right track. Patience. He's only 4. A good catch.

Good luck!

LB, O.D.

 

What were the results of the cycloplegic exam, and was there any
improvement in the right eye with the Rx?

One can debate the merits of waiting or not waiting before patching.
However, the evidence seems to weigh in favor of amblyopia in the more
hyperopic astigmatic eye. At four years, full time patching is
indicated by most authorities.

DrG

 

Well, as my usual for a 4 year old, I didn't cycloplege him (hey, I'm
just getting to know him!) I did take fundus photos (no pathology, as
expected) and glad to hear that the more hyperopic eye is "favored" for
the amblyopia! (I mean this seems pretty simple to me) It's just that
I'm not up on the fine details of amblyopia management since nowadays I
mostly see young myopes who use the computer too much!

w.stacy, o.d.

w.stacy, o.d.

 

Hmmm. You may run into disagreement on that issue. I use 0.5%
tropicamide.

Alternate patching could still be done, 4 days on the good eye and 1
day on the amblyopic eye to be on the safe side, or just monitor visual
acuity every few weeks.

DrG

 

Hmm, I always cycloplege suspected amblyopes. You well may find that there
is significant hyperopia in that left eye.

My usual practice would be to Rx the cycloplegic refraction (less
about -0.50) and reassess in 6-8 weeks. Often just wearing the glasses
solves the amblyopia, if not, I start patching after that, with a four year
old, it would be full time, checking progress every two weeks.

Dr Judy

 

sounds like there is considerable variation in Tx for such a patient
among the eye docs here. FWIW, this is my approach:

cycloplegic refraction initially using cyclogel. I usually prescribe
the manifest Rx plus a little extra plus if more hyperopia shows up on
cycloplegic refraction but not too much so I can minimize distance blur
and facilitate patient acceptance of the Rx. I would also be inclined
to give some more plus if there is significant esophoria. personally
I wouldn't patch right off-- I would wait 6-8 weeks to see what kind of
improvement I might get with just the spectacle Rx alone. If I
determine that patching should be initiated, I use part time patching
of 4-6 hours. For patching I use an eye bandage (purchased at local
pharmacy) or frosted tape on the spectacle lens. I generally ask the
parents to spend a little one-on-one time with their child during the
patching time doing a task requiring some visual-motor skills: eg
drawing, puzzles, computer games, etc.

i suppose I should consider using atropine patching but I have not yet
done so. what are other practitioners experiences with it?

PS-- I appreciate this type of posting here. why not get the eye docs
talking to one another about these types of issues rather than just
answering questions and dealing with kooks

 

Welcome back to the old s.m.v.

 

This sounds like a pretty good place to interject a question: I have
this friend who....

- Infantile esotrope

- Current wavefront Rx:
OD 8.44 -1.71 89
OS 7.95 -1.92 69

- Tenacious accommodative spasm, formerly treated with continuous use
of cycloplegics (last was Atropine). All use of cycloplegics now
stopped (can eat endothelial cells for breakfast, side effects nearly
unmanageable)

- 3x strabismus surgery for esotropia

- Now ~4d exo at distance, ~10d exo at near. I know: being exo-
drives accommodation....

- Wearing manifest Rx, full prism in specs (separate distance and
near); wear full cyclo Rx scl's on daily basis (leaving me a tad bit
myopic). I find the cl's less taxing, but could not adapt to full
cycloplegic Rx specs (??)

- Severe dry eye (all 4 puncta cauterized)

- ~2.50d/3.00d tonic accommodation, causes symptoms, greatly
exacerbated with any near work

Latest proposal by my ophth: use of phospholine iodide TID.

My understanding of PI: increases the *amount* of accommodation
achieved with a *given* amount of ennervation to the ciliaries. His
theory: if my level of tonic accommodation is pretty static, perhaps
we can reduce the *effort* behind that level of accommodation and
ameliorate symptoms.

Thoughts? Side effects look, predictably, ugly...

Might this exacerbate exotropia? IIRC, I haven't had my alignment
checked under Atropine in quite some time. I presume I could be more
exo absent the tonic accommodation.

TIA,

Neil