Help for 5 year old with Amblyopia

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
do.

Thanks,
Brandons' Dad

 

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
20/200.

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.

 

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.

DrG

 

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
eye.

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
job.

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.

 

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
vision.

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,
IMNSHO.

 

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?

Thanks
Jeff

 

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.

Jeff

 

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?

 

Jeff,

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.

DrG

 

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.

DrG

 

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
country.

Thanks,
Jeff

 

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).

 

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
experience.

DrG

 

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.

 

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.

DrG

 

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

DrG

 

You are absolutely correct, Mark.

DrG

 

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.

DrG

 

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

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.

DrG

 

DrG:

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 .

Jeff