Full time patching?

Discussion in 'Optometry Archives' started by William Stacy, Apr 7, 2005.

  1. 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.
    William Stacy, Apr 7, 2005
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  2. William Stacy

    LarryDoc Guest

    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.
    LarryDoc, Apr 7, 2005
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  3. William Stacy

    Dr. Leukoma Guest

    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.

    Dr. Leukoma, Apr 7, 2005
  4. William Stacy

    Dr. Stacy Guest

    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.
    Dr. Stacy, Apr 7, 2005
  5. William Stacy

    Dr. Leukoma Guest

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

    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.

    Dr. Leukoma, Apr 7, 2005
  6. William Stacy

    Dr Judy Guest

    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
    Dr Judy, Apr 7, 2005
  7. William Stacy

    retinula Guest

    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
    retinula, Apr 8, 2005
  8. William Stacy

    Neil Brooks Guest

    Welcome back to the old s.m.v.

    Neil Brooks, Apr 8, 2005
  9. William Stacy

    Neil Brooks Guest

    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

    - 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.


    Neil Brooks, Apr 8, 2005
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