Help for 5 year old with Amblyopia

Discussion in 'Optometry Archives' started by Guest, Sep 30, 2003.

  1. Guest

    Guest Guest

    I have a 5 year, 7 month old son who was recently diagnosed iwth Amblyopia.
    His right eye is +8.0 and his left is +4.25. However, the optometrist wrote
    a prescription for +4.0 and +2.13, saying the full strength prescription
    would be too much at this time, perhaps suggesting he would eventually get
    the right prescription (?). Also, she suggested we come back three weeks
    after getting the glasses to learn eye exercises, which I believe are about
    wearing a patch. I've researched this online to some extent, but could use
    some help from those more experienced with this problem. He follows objects
    with both eyes, so he doesn't appear to have the "lazy eye" problem.
    However, I was pretty upset when I was told his brain is not using his +8.0
    eye, and it would have been better if this were caught earlier, because
    there is less opportunity to correct the problem. Some research suggests
    age 6 is the limit for "eye patch" therapy, and after that you have to live
    with the deficiency. I put a patch on him tonight (should we delay 3 weeks
    as the optometrist suggested), and he could interpret 1" letters at about
    24" way. He could walk around with the patch. Also, he was able to
    preceive depth of objects in comparison tests. So, is his neuronal wiring
    really in jeopardy? Also, is it reasonable to start him at half dose on his
    prescription? From what I find, +8.0 is pretty severe. Yet, he can write
    his name and hasn't had any problems at school. Apparently they can use a
    light instrument to measure the error, so is that accurate enough to say for
    sure it is +8.0? I'm just trying to understand the diagnosis and what to

    Brandons' Dad
    Guest, Sep 30, 2003
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  2. Guest

    Mark A Guest

    I am not a doc, but have had Amblyopia all my life. I wore a patch when I
    was about 8 years old, and my bad eye improved with the patch on the good
    eye, but then reverted back when the patch was removed because the two eyes
    did not work well together. It's not the end of the world if it cannot be
    fixed, but you should keep trying with the patch and exercises. After the
    lazy eye comes up to full vision and the patch is off for a few days, I
    would consider putting it back on again and off again on a regular cycle.

    The fact that both eyes follow objects does not mean much, because both my
    eyes follow objects (including my lazy eye), at least up to a point. No one
    can tell I have a lazy eye by looking at me, even though my bad eye is about

    I think that the lower Rx may be a good idea, especially for farsighted. I
    was over prescribed so much when I was a teenager, that I could never wear
    the glasses. This is especially true if the test is a theoretical
    measurement and not based on a eye chart reading. Young people have strong
    muscles in the eyes that can correct their vision. Bottom line is whether he
    can read and see clearly at a distance with the new lenses.
    Mark A, Sep 30, 2003
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  3. Guest

    Dr. Leukoma Guest

    Your son's optometrist has offered a reasonable diagnosis and treatment
    plan. Amblyopia is far more common in the more farsighted eye of
    farsighted children. The older the child, the more resistant is the visual
    system to treatment. The age of 5 years is considered to be rather late
    for treatment, although most of the children I have treated were that age
    or above at the time of diagnosis. Many of them have responded well to
    treatment which includes prescribing lenses to correct the refractive error
    and occluding the dominant or "good" eye. You will find that doctors vary
    widely in their opinions about the magnitude of the prescription or the
    amount of time spent in patching. I have even recommended contact lenses
    for young children if a significant amount of anisometropia is present.
    Otherwise, we start with eyeglasses. I often wait a couple of weeks to
    allow the child to get comfortable with wearing the prescription first,
    unless I am dealing with an infant or young toddler, for whom a few weeks
    of non-treatment might be significant.

    Dr. Leukoma, Sep 30, 2003
  4. Guest

    Dr Judy Guest

    This is a reasonable start, it corrects the difference between the eyes and
    allows the child to adapt to glasses. Using the full Rx may lead to
    resistance by your son to wearing them.

    Also, she suggested we come back three weeks
    Lazy eye is the lay term for amblyopia, it does not involve eye muscles at
    all, so eye movement will be normal. Eye muscle disorders are called
    strabismus, lay turn would be turned eye or wall eye. The patch will
    force his brain to attend to the lazy eye instead of ignoring it and will
    help stimulate growth and connection of neurons in the brain that serve that
    A one inch letter at 24 inches is very big. A normal eye would be able to
    see that letter at 10 to 15 feet. Walking around does not require good
    acuity, only peripheral awareness which an amblyopic eye will have. Depth
    perception, as opposed to stereoacuity relies upon many cues that exist with
    only one eye such as relative size of objects, overlap, haze.
    If the best corrected acuity in the amblyopic eye is less than the best
    corrected acuity in the non amblyopic eye, his neurons are not doing the

    Also, is it reasonable to start him at half dose on his
    He would do those tasks with the good eye; in fact, he could do those if the
    amblyopic eye was glass.

    Apparently they can use a
    The advice given to you by your optometrist is reasonable and meets the
    current standard of care for amblyopia, ie, any other eye doctor would give
    the same advice. The only difference might be in the speed at which you
    move to full prescription.
    Dr Judy, Sep 30, 2003
  5. Guest

    Dan Abel Guest

    I'm not sure what you mean by "follows objects with both eyes". Even with
    a totally blind eye, both eyes will move together unless there is a
    separate problem.

    I don't know much about amblyopia myself. My wife, who is 52, has had
    this all her life. They tried fixing it, but I think they were too late,
    and she did not cooperate besides. She has poor eye/hand coordination,
    and poor depth perception. Despite having a good build, she was poor at
    most sports. She was a good swimmer, since that doesn't require much

    Your son will have to deal with this minor disability for the rest of his
    life if it can't be fixed now. It's definitely worth a major effort,
    Dan Abel, Sep 30, 2003
  6. Guest

    Guest Guest

    What are the eye exercises, and why are we waiting three weeks to adjust to
    glasses when the key issue seems to be the neuronal activity associated with
    that eye? It would seem better to start now with the patch, at least to get
    the brain to see through the bad eye, even before his glasses arrive (which
    is in 1-2 days). Why waste three weeks when we have less than 6 months to
    work with?

    Guest, Sep 30, 2003
  7. Guest

    Guest Guest

    I am trying my son on a patch now, before he receives his prescription, to
    see how he can see. He is able to walk around, but tells me he can see with
    both eyes. Yet, when I cover his both eyes he cannot. Is his brain being
    fooled into thinking it is using his good eye, because it is not used to
    receiving inputs from his bad? Is this a good or bad sign? Also, is this
    best treated by an Optometrist or Pediatric Opthamologist? Do treatments
    vary between the two? I'm eager to do everything to restore sight to his
    weak/unused eye. Also, he had routine visits with a peditrician all his
    life. Early on he had vision tests, and nothing showed a problem. Why
    doesn't the government do something about mandatory testing, since this
    problem seems so prevalent? Honestly, I feel like holding the predrician
    liable for malpractice if this doesn't clear up.

    Guest, Sep 30, 2003
  8. Guest

    Dan Abel Guest

    You've got me curious. I understand that a pediatrician can't test the
    vision of an infant, but then again, an OD would have difficulty getting
    that kid to wear glasses!

    Is it usual for pediatricians to refer patients of say, 3 years old, where
    they should be able to test the vision and determine if they cannot see as
    well in one eye?
    Dan Abel, Oct 1, 2003
  9. Guest

    Dr. Leukoma Guest


    Having worked with many parents of newly diagnosed amblyopes, I can
    understand your impatience and anxiety. The treatment window does not
    automatically shut at 5 years, and I cannot imagine that three more weeks
    will matter. It depends on the level of amblyopia. As I said, most of the
    children I treat are first diagnosed at that age, and some of them have a
    good outcome. Having said that, the proper sequence of events is to begin
    patching with the right prescription. As a "lazy" eye, your son's
    accommodation - or ability to focus at near - is likely impaired as well,
    and will have more difficulty responding to an image that is out-of-focus.
    The very first step is to put a clear image on the retina, or to enable the
    eye to receive a clear image. Would patching without a prescription
    contra-indicated while you are awaiting the eyeglasses? I cannot think of
    any reason why it would be, so long as you discuss this with your son's eye
    doctor. You should call your doctor and discuss your concerns.

    Dr. Leukoma, Oct 1, 2003
  10. Guest

    Dr. Leukoma Guest

    I am not against VT for amblyopia, but is it the patching or is it the
    therapy? I always tell the parents to make sure the child does lots of
    close detailed work along with the occlusion therapy. Again, please point
    out studies in the mainstream literature which support the notion that
    patching along with VT improves the outcome over patching alone.

    Dr. Leukoma, Oct 1, 2003
  11. Guest

    Guest Guest

    Given his right eye is +8.0 and left is +4.25, and he his 5 years, 7 months
    old, and assuming full cooperation with glasses, vision therpy, and patch
    work, what is the expected outcome? I want to understand the real world
    expectations, based on cases similiar to this one. I want to understand how
    best to help him. And I want to understand how I can help prevent this from
    happening to others. Many on this news group have helped me on my way. My
    initial reaction was denial, then anger, then vengence. I have heard that
    our "former" peditrician, despite making it on the "best pediatrician's in
    America book", has left more than one child undiagnosed/misdiagnosed as
    several parents have found with their replacements. He left out of town
    without warning or explanation, to relocate on the other side of the

    Guest, Oct 2, 2003
  12. Guest

    Mark A Guest

    I am not sure, but it sounds like the Rx above is the theoretical Rx based
    on a measurement of the eye and not based on an eye test. Young people have
    strong eye muscles that can adapt the shape of their eyes to accommodate,
    and usually farsighted people only reach the theoretical worst vision when
    one gets quite a bit older. Maybe that makes it a bit harder to diagnose
    vision problems in infants. But I have no idea if pediatricians are supposed
    to detect vision problems, if that is what you are referring to.

    Even if the problem cannot be corrected, it is not the end of the world. I
    have lived a fairly normal life, and no one can tell I have a amblyopia
    unless I tell them. I played many sports quite well, although I probably
    would have done a bit better hitting a baseball with both eyes. But I did
    play first base in little league, so I couldn't have been that bad.
    Basically my bad eye is like an extended peripheral vision, so it is not
    totally useless. If my good eye is ever permanently damaged, I have been
    assured that my other eye will develop and take over (although I probably
    would bump into a lot of doors for awhile).
    Mark A, Oct 2, 2003
  13. Guest

    Dr. Leukoma Guest

    Dear Jeff,

    Do not lay the blame entirely on your pediatrician. Unless there is some
    visible sign like an eye turning in or out, the pediatrician is not going
    to be able to make the diagnosis. You would be simply amazed at what
    pediatricians do not know about vision. Quite probably the only way this
    could have been discovered is if your child had a professional eye
    examination at an early age. Some of us have been preaching this for years
    to a deaf public. I know that the American Optometric Association has been
    recommending eye examinations on children starting at the age of three
    years. Recently, they have taken the position that children be examined
    even earlier, i.e. neonatal examinations. The medical system relies upon
    the pediatrician as the primary care physician, who then refers to the
    pediatric ophthalmologist if a vision problem is suspected. Optometrists
    have been at the forefront of early detection of amblyopia through early
    and regular professional eye examinations. The fruits of optometrists'
    labors are now starting to be recognized as more states pass laws mandating
    early vision examinations...

    If you want to understand more about the politics of pediatric vision care,
    please email me privately. I guarantee that you will have an eye opening

    Dr. Leukoma, Oct 2, 2003
  14. Guest

    Mark A Guest

    My understanding is that amblyopia has some hereditary correlations, so it
    might be a good idea to verify that in ones family history, and then make
    sure that earlier eye exams are performed for all future children in the
    extended family.
    Mark A, Oct 2, 2003
  15. Guest

    Dr. Leukoma Guest

    Yes, I am sure that Jeff would like all the help he can get. However, I do
    not regard the FOVT group files as being peer-reviewed literature.

    I think that a COVD optometrist would be well-qualified to provide the care
    that Jeff's son needs.

    However, your mention of various occlusion techniques still did nothing to
    prove the efficacy of VT over occlusion alone. All you have stated is that
    various practitioners have various pet treatments. For example, you stated
    that some children respond to two hours of patching while others require
    eight hours or more. The authority on the subject, Van Noorden, in his
    most recent edition, states a clear preference for full-time occlusion.

    Dr. Leukoma, Oct 2, 2003
  16. Guest

    Dr. Leukoma Guest

    It would help if you would state your son's best corrected visual acuity at

    Dr. Leukoma, Oct 2, 2003
  17. Guest

    Dr. Leukoma Guest

    You are absolutely correct, Mark.

    Dr. Leukoma, Oct 2, 2003
  18. Guest

    Dr. Leukoma Guest

    Thanks for the post, Francine. I am quite familiar with those procedures.
    In fact, Step 1 omitted ocular motility and accommodative facility
    training. What I was angling for was a few studies in the peer reviewed
    literature showing the results of vision therapy for amblyopia vs. a
    control involving penalization therapy alone. In my mind, penalization
    therapy - the first step in the process - is practiced universally for the
    treatment of amblyopia, and therefore does not really qualify as a
    treatment practiced only by vision therapists.

    I don't disagree with doing VT if one has the time and money. However,
    patching is the primary and universal treatment. If Jeff's dad needs to
    drive 100 miles to see a VT specialist, he ought to know that the outcome
    will justify the time and money spent. The same holds true for consulting
    a pediatric ophthalmologist vs. the optometrist in his local area.

    You're right. I didn't look at the website.

    Dr. Leukoma, Oct 2, 2003
  19. Guest

    Dr. Leukoma Guest

    Actually, I am still beating around the bush, and so I will get to the

    The term "amblyopia" is very foreign to the general public. I submit that
    optometry has done a very poor job in terms of public education about
    vision problems in the pediatric population. Everybody seems to agree that
    vision is very important, and important for learning, and yet the process
    is by and large delegated to the pediatricians and the school nurses. In
    Texas, where vision screenings are mandated in preschool, they are
    performed by someone who has earned a "certificate" by attending a one day
    course. Jeff's son is a prime reason why this is not acceptable. Beyond
    that, optometrists still offer the most cost effective and convenient
    approach to the detection and treatment of vision disorders in the
    pediatric population. I think that we need to "demystify" the topic of
    amblyopia, and quit mentioning it in the same breath as "pediatric
    ophthalmologists" and "COVD specialists" when the average optometrist is
    well-qualified to do the job.

    Dr. Leukoma, Oct 3, 2003
  20. Guest

    Guest Guest


    Found your web site. I lived in Dallas, Texas for a while myself. I agree
    with your advice. In fact, I have written my congressman and Senator Shelby
    about this issue. Congressman Cramer has approached the FDA for me on my
    hip replacement before, so I'm sure he'll stir the pot, if it's not already
    brewing. Others who have offered advice can help fan the fire. Write your
    congressman and senators. If you can't find their web address, send me an
    email at .

    Guest, Oct 3, 2003
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