Part-time Patching Research Articles

Effect of a Binocular iPad Game vs Part-time Patching in Children Aged 5 to 12 Years With Amblyopia

A binocular approach to treating anisometropic and strabismic amblyopia has recently been advocated. Initial studies have yielded promising results, suggesting that a larger randomized clinical trial is warranted. To compare visual acuity (VA) improvement in children with amblyopia treated with a binocular iPad game vs part-time patching. A multicenter, noninferiority randomized clinical trial was conducted in community and institutional practices from September 16, 2014, to August 28, 2015. Participants included 385 children aged 5 years to younger than 13 years with amblyopia (20/40 to 20/200, mean 20/63) resulting from strabismus, anisometropia, or both. Participants were randomly assigned to either 16 weeks of a binocular iPad game prescribed for 1 hour a day (190 participants; binocular group) or patching of the fellow eye prescribed for 2 hours a day (195 participants; patching group). Study follow-up visits were scheduled at 4, 8, 12, and 16 weeks. A modified intent-to-treat analysis was performed on participants who completed the 16-week trial. Binocular iPad game or patching of the fellow eye. Change in amblyopic-eye VA from baseline to 16 weeks. Of the 385 participants, 187 were female (48.6%); mean (SD) age was 8.5 (1.9) years. At 16 weeks, mean amblyopic-eye VA improved 1.05 lines (2-sided 95% CI, 0.85-1.24 lines) in the binocular group and 1.35 lines (2-sided 95% CI, 1.17-1.54 lines) in the patching group, with an adjusted treatment group difference of 0.31 lines favoring patching (upper limit of the 1-sided 95% CI, 0.53 lines). This upper limit exceeded the prespecified noninferiority limit of 0.5 lines. Only 39 of the 176 participants (22.2%) randomized to the binocular game and with log file data available performed more than 75% of the prescribed treatment (median, 46%; interquartile range, 20%-72%). In younger participants (aged 5 to <7 years) without prior amblyopia treatment, amblyopic-eye VA improved by a mean (SD) of 2.5 (1.5) lines in the binocular group and 2.8 (0.8) lines in the patching group. Adverse effects (including diplopia) were uncommon and of similar frequency between groups. In children aged 5 to younger than 13 years, amblyopic-eye VA improved with binocular game play and with patching, particularly in younger children (age 5 to <7 years) without prior amblyopia treatment. Although the primary noninferiority analysis was indeterminate, a post hoc analysis suggested that VA improvement with this particular binocular iPad treatment was not as good as with 2 hours of prescribed daily patching. http://www.clinicaltrials.gov Identifier: NCT02200211.

Current Nonsurgical Management of Intermittent Exotropia

Three common nonsurgical management strategies for childhood intermittent exotropia are observation alone, part-time patching, and over-minus spectacles. Each of these approaches has support from recent large observational studies and recent randomized clinical trials. The deterioration rate with observation alone is particularly low, over both a 6-month and 2-year period, suggesting that observation alone is a very reasonable option. Future studies on the natural history of childhood intermittent exotropia are forthcoming and a larger randomized clinical trial of over-minus spectacles versus non-over-minus spectacles is planned.

"Combined occlusion and atropine therapy" versus "Augmented part-time patching" in children with refractory/residual amblyopia: A pilot study

Purpose:To compare the efficacy of combined occlusion and atropine therapy (COAT) and augmented part-time patching for the treatment of unilateral refractory/residual amblyopia.Methodology:This retrospective study evaluated children between 4 and 11 years with refractory/residual amblyopia who were treated with either additional atropine (COAT group) or increased hours of patching (augmented group). Data were collected on improvement in best-corrected visual acuity (BCVA; logarithm of the minimum angle of resolution [logMAR] units) at each follow-up visit.Results:There were 19 children in the COAT group and 17 children in the augmented group. The baseline BCVA of the amblyopic eye was 0.79 ± 0.36 logMAR in the COAT group and 0.72 ± 0.26 logMAR in augmented group. Children were statistically significantly younger in the COAT group (6.4 ± 2.2 years) compared to the augmented group (8.6 ± 3.3 years, P = 0.02). The mean duration of follow-up was statistically significantly longer in the augmented group (20.2 COAT group; 13.9 months augmented group) (P = 0.03). Compliance was similar in both groups. LogMAR BCVA (adjusted for difference in age and baseline BCVA) was statistically significantly better in the COAT group (0.56 ± 0.04) compared to the augmented group (0.80 ± 0.04) at 3 months (P = 0.000); 6 months (COAT group, 0.50 ± 0.04 vs. augmented group, 0.74 ± 0.04; P = 0.04) and at 1 year (COAT group, 0.42 ± 0.04 vs. augmented group, 0.67 ± 0.04, P = 0.000). There was statistically significantly greater improvement in logMAR BCVA at 6 months in COAT group (0.26 ± 0.15) compared to the augmented group (0.02 ± 0.14), (P = 0.0002). Age, gender, pretreatment BCVA, duration of follow-up, or compliance to patching did not affect improvement in BCVA.Conclusions:COAT may result in greater improvement in BCVA than augmented part-time patching in children with unilateral residual/refractory amblyopia.

A Randomized Trial Comparing Part-time Patching with Observation for Intermittent Exotropia in Children 12 to 35 Months of Age

To determine the effectiveness of part-time patching for treating intermittent exotropia (IXT) in young children. Multicenter, randomized clinical trial. Two hundred one children 12 to 35 months of age with untreated IXT meeting the following criteria: (1) IXT at distance OR constant exotropia at distance and either IXT or exophoria at near, and (2) 15-prism diopter (Δ) or more exodeviation at distance or near by prism and alternate cover test (PACT) but at least 10 Δ exodeviation at distance by PACT. Participants were assigned randomly to either observation (no treatment for 6 months) or patching prescribed for 3 hours daily for 5 months, followed by 1 month of no patching. The primary outcome was deterioration, defined as constant exotropia measuring at least 10 Δ at distance and near or receipt of nonprotocol treatment for IXT. Of the 177 participants (88%) completing the 6-month primary outcome examination, deterioration occurred in 4.6% (4 of 87) of the participants in the observation group and in 2.2% (2 of 90) of the participants in the patching group (difference, 2.4%; P = 0.27; 95% confidence interval, -3.8% to +9.4%). Motor deterioration occurred in 2.3% (2 of 87) of the observation group and in 2.2% (2 of 90) of the patching group (difference, 0.08%; P = 0.55; 95% confidence interval, -5.8% to +6.1%). For the observation and patching groups, respectively, 6-month mean PACT measurements were 27.9 Δ versus 24.9 Δ at distance (P = 0.02) and 19.3 Δ versus 17.0 Δ at near (P = 0.10); 6-month mean exotropia control scores were 2.8 versus 2.3 points at distance (P = 0.02) and 1.4 versus 1.1 points at near (P = 0.26). Among children 12 to 35 months of age with previously untreated IXT, deterioration over 6 months was uncommon, with or without patching treatment. There was insufficient evidence to recommend part-time patching for the treatment of IXT in children in this age group.

Atropine vs Patching-Reply.

Dr. Lempert raises several issues, which we believe are mistaken or do not affect the interpretation of our results. As described,1 only subjects at sites with >5 enrolled children were eligible for long-term follow-up for logistical reasons, which reduced the proportion of the original cohort that was enrolled in the follow-up study. The 15-year examination was completed by 152 of 188 eligible participants (80.9%). We compared subjects who participated in follow-up with those who did not and noted in the manuscript that those who participated had slightly better visual acuity (VA) at two years than those who did not (20/25 versus 20/32), which could have resulted in a slight overestimate of visual acuity at age 15 years. In addition, 147 participants in Table 1 noted by Dr. Lempert were only those who completed the visit at 15 years of age and had VA tested with the E-ETDRS©.2 Five participants had VA tested with a method other than E-ETDRS and were not included in the primary results. Dr. Lempert also appears to have misread Table 1; 46.9% of fellow eyes had 20/20 or better at baseline (rather than 9.5% he cited, which was the proportion who had 20/16 or better). Nevertheless, we would expect some improvement in the measured VA of the fellow eye over more than 10 years of follow-up due to maturation. We believe that the mean interocular acuity differences (IOD) of 2.1 logMAR lines at 15 years of age and 2.0 logMAR lines at 10 years of age using E-ETDRS testing were greater than the mean IOD of 1.6 logMAR lines at the 2-year exam using the HOTV protocol due to the different methods for testing. In our report at 10 years of age that directly compared the 2 VA testing methods, we found that measured IOD was smaller with HOTV than with E-ETDRS.3 Regarding Dr. Lempert's question regarding the implications of including subjects with fellow eye visual acuity better than 20/20, we did not exclude such children because they are within the spectrum of moderate amblyopia. Their exclusion would have reduced the generalizability of our results and we see no reason why their inclusion would “skew the results.” We chose to include only children with amblyopic-eye visual acuity 20/40 to 20/100 in this trial,4 because when we designed the study, we were uncertain if atropine would be effective with visual acuity less than 20/100.5 (Subsequently atropine has been found to be effective for many cases of severe amblyopia.6) We agree that interpretation of the results should always be viewed in light of eligibility criteria, and we have carefully included that information in each report. Our primary message was that there was little loss of VA improvement after treatment was completed. Our long term follow-up data provide evidence that part-time patching and atropine drops are effective and long lasting treatments for many children, 3 to <7 years of age, who have anisometropic, strabismic or combined amblyopia.

A Randomized Trial Comparing Part-Time Patching with Observation for Children 3 to 10 Years of Age with Intermittent Exotropia

To determine the effectiveness of prescribed part-time patching for treatment of intermittent exotropia (IXT) in children. Multicenter, randomized clinical trial. Three hundred fifty-eight children 3 to <11 years of age with previously untreated (except for refractive correction) IXT and near stereoacuity of 400 seconds of arc or better were enrolled. Intermittent exotropia met the following criteria: (1) IXT at distance OR constant exotropia at distance and either IXT or exophoria at near; (2) exodeviation (tropia or phoria) of at least 15 prism diopters (PD) at distance or near by prism and alternate cover test (PACT); and (3) exodeviation of at least 10 PD at distance by PACT. Participants were assigned randomly either to observation (no treatment for 6 months) or to patching for 3 hours daily for 5 months, with a 1-month washout period of no patching before the 6-month primary outcome examination. The primary outcome was deterioration at either the 3-month or the 6-month follow-up visit, defined as: (1) constant exotropia measuring at least 10 PD at distance and near by simultaneous prism and cover test, and/or (2) near stereoacuity decreased by at least 2 octaves from baseline, both assessed by a masked examiner and confirmed by a retest. Participants who were prescribed any nonrandomized treatment without first meeting either deterioration criteria also were counted as having deteriorated. Of the 324 participants (91%) completing the 6-month primary outcome examination, deterioration occurred in 10 of the 165 participants (6.1%) in the observation group (3 of these 10 started treatment without meeting deterioration criteria) and in 1 of the 159 participants (0.6%) in the part-time patching group (difference, 5.4%; lower limit of 1-sided exact 95% confidence interval, 2.0%; P = 0.004, 1-sided hypothesis test). Deterioration of previously untreated childhood IXT over a 6-month period is uncommon with or without patching treatment. Although there is a slightly lower deterioration rate with patching, both management approaches are reasonable for treating children 3 to 10 years of age with IXT.

The effect of part-time patching on near stereoacuity, control, and angle in childhood intermittent exotropia

The effect of part-time patching on near stereoacuity, control, and angle in childhood intermittent exotropia

The case from animal studies for balanced binocular treatment strategies for human amblyopia

Although amblyopia typically manifests itself as a monocular condition, its origin has long been linked to unbalanced neural signals from the two eyes during early postnatal development, a view confirmed by studies conducted on animal models in the last 50 years. Despite recognition of its binocular origin, treatment of amblyopia continues to be dominated by a period of patching of the non-amblyopic eye that necessarily hinders binocular co-operation. This review summarizes evidence from three lines of investigation conducted on an animal model of deprivation amblyopia to support the thesis that treatment of amblyopia should instead focus upon procedures that promote and enhance binocular co-operation. First, experiments with mixed daily visual experience in which episodes of abnormal visual input were pitted against normal binocular exposure revealed that short exposures of the latter offset much longer periods of abnormal input to allow normal development of visual acuity in both eyes. Second, experiments on the use of part-time patching revealed that purposeful introduction of episodes of binocular vision each day could be very beneficial. Periods of binocular exposure that represented 30-50% of the daily visual exposure included with daily occlusion of the non-amblyopic could allow recovery of normal vision in the amblyopic eye. Third, very recent experiments demonstrate that a short 10 day period of total darkness can promote very fast and complete recovery of visual acuity in the amblyopic eye of kittens and may represent an example of a class of artificial environments that have similar beneficial effects. Finally, an approach is described to allow timing of events in kitten and human visual system development to be scaled to optimize the ages for therapeutic interventions.

Occlusion-amblyopia following high dose oral levodopa combined with part time patching

Part time occlusion therapy is not reported to cause occlusion (reverse) amblyopia. However, when combined with high dose oral levodopa, an increase in the plasticity of the visual cortex can lead to occlusion amblyopia. In this case report, we describe a six year old child who developed occlusion amblyopia following part time patching combined with oral levodopa.

Risk Factors Predicting the Need for Additional Surgery in Consecutive Esotropia

To evaluate the risk factors predicting surgical treatment in consecutive esotropia occurring after surgery for intermittent exotropia. The clinical records of 52 patients with consecutive esotropia who underwent exotropia surgery were retrospectively reviewed. All patients demonstrated consecutive esotropia with diplopia or suppression for more than 1 month after surgery for exotropia. Patients were divided into two groups (the surgical group and nonsurgical group) depending on whether surgery was required for consecutive esotropia. Surgery for esotropia was performed only in patients with more than 10 prism diopters (PD) esodeviation that persisted for a minimum of 6 months, those who had suppression in 1 eye or diplopia, and those who could not achieve fine stereopsis. The nonsurgical treatment up to 6 months postoperatively was part-time patching and prism therapy in both groups. Patient characteristics were evaluated in the two groups. The surgical group was composed of 17 patients and the nonsurgical group was composed of 35 patients. Age, gender, refractive error, best-corrected visual acuity, and postoperative overcorrection at 1 day were not significantly different in the two groups (P > .05). However, the distance strabismic angle at 1 month postoperatively was 2.5 ± 3.8 PD esodeviation (range: 14 PD esotropia to 4 PD exotropia) in the nonsurgical group and 5.4 ± 5.1 PD esodeviation (range: 20 PD esotropia to orthotropia) in the surgical group; these values were statistically significant (P < .05). The clinically significant risk factor affecting the surgical decision for consecutive esotropia was a large esotropic angle at 1 month postoperatively in this study.

Efficacy of split hours part-time patching versus continuous hours part-time patching for treatment of anisometropic amblyopia in children: a pilot study

AimTo compare efficacy of ‘split hours part-time patching’ and ‘continuous hours part-time patching’ for the treatment of anisometropic amblyopia.MethodsWe designed a prospective, interventional, non-randomised, comparative pilot study involving children between...

Clinical Translation of Recommendations from Randomized Clinical Trials on Patching Regimen for Amblyopia

To investigate whether the evidence-based recommendations by the Pediatric Eye Disease Investigator Group (PEDIG) as initial treatment of amblyopia have been implemented into clinical practice and to discuss the necessary steps in translating evidence-based knowledge to inform clinical decision making. Retrospective cohort study. Children with amblyopia seen from 2007 through 2009 by academic and community ophthalmologists in a large urban center in North America that serves a population of more than 8 million. Using PEDIG criteria, moderate amblyopia was defined as visual acuity between 20/40 and 20/80 and severe amblyopia was defined as visual acuity between 20/100 and 20/400. Patching of the sound eye. The number of prescribed patching hours daily and the amblyopic eye visual acuity expressed as logarithm of the minimum angle of resolution (logMAR). For moderate amblyopia, the cohort (n = 71) was prescribed a mean of 3.2 hours of daily patching (95% confidence interval [CI]: 2.8-3.6 hours), which is significantly greater than the recommended 2 hours of daily patching for initial treatment. Only 24% (95% CI, 16%-35%) of them were prescribed the recommended initial patching hours. The amblyopic eye acuity on the 3- to 6-month visit in the cohort (0.23 logMAR) was similar to that of the 4-month visit in the PEDIG cohort (0.24 logMAR; P = 0.74). For severe amblyopia, the cohort (n = 52) was prescribed a mean of 3.9 hours of daily patching (95% CI, 3.5-4.3 hours), which is significantly lower than the recommended 6 hours of daily patching for initial treatment. Only 12% (95% CI, 5%-23%) of them were prescribed the recommended initial patching hours. The amblyopic eye acuity at the 7- to 12-month visit in the cohort (0.44 logMAR) was comparable with that of the 4-month visit in the PEDIG cohort (0.40 logMAR; P = 0.35). The evidence-based recommendations for amblyopia management have not been translated widely into changes in clinical practice in a large urban center in North America, although there is a general move from full-time to part-time patching since the PEDIG results were published. Using a well-established framework for knowledge translation, the Knowledge-to-Action Cycle, the necessary steps required to implement new knowledge into actual clinical practice are discussed.

Part-Time vs. Full-Time Occlusion for Amblyopia: Evidence for Part-Time Patching

Amblyopia is characterized by a decreased uncorrectable visual acuity in a structurally normal eye. Occlusion therapy has been used for years to improve acuity, and, traditionally, practitioners have utilized full-time patching. This article will explore more recent research looking at using part-time patching in the treatment of amblyopia.

Split hours part-time patching versus continous wear part-time patching in moderate to severe anisometropic amblyopia

Split hours part-time patching versus continous wear part-time patching in moderate to severe anisometropic amblyopia

Effect and sustainability of part-time occlusion therapy for patients with anisometropic amblyopia aged ≥8 years

AimsTo study the effect and long-term sustainability of part-time occlusion therapy for anisometropic amblyopia after 8 years of age.MethodsA total of 41 anisometropic amblyopes aged ≥8 years were analysed. In...

Comparison of Results of 2-Hour, 6-Hour and Full-Time Patching Regimens in Treatment of Monocular Amblyopia

Purpose: To compare effects of a 2-hour, 6-hour, and full-time patching regimens in monocular amblyopia patients under 10 years of age. Methods: This study recruited monocular amblyopia patients under 10 years of age. The patients were divided into a 2-hour patching group (group A, n=34), a 6-hour patching group (group B, n=33), and a full time patching group (group C, n=28) according to the patching time. A prospective analysis was then performed. The ages at the start of treatment, differences of corrected visual acuity between the 2 eyes and severity of the 3 groups were compared and analyzed. On the final evaluation, 'success' was defined when the difference of corrected visual acuity between the 2 eyes converted into logMAR was less than 0.1. Results: The ages at the start of treatment in group A, B, C were 5.61, 5.48 and 5.71 years, respectively. The best corrected visual acuity of an amblyopic eye converted into logMAR changed to 0.13 after treatment in group A, to 0.16 in group B and to 0.19 in group C. Although visual acuity after the treatment was increased significantly compared to the beginning of treatment in all 3 groups, the final visual acuity showed no statistically significant difference among the 3 groups. Because the occlusion therapy success rates were 70.6%, 69.7% and 64.3% for groups A, B and C, respectively, there was no statistically significant difference. Conclusions: In the 2-hour, 6-hour, and full-time patching regimens, all patients showed a significant improvement in visual acuity although their success rates were not significantly different. Therefore, the part-time patching therapy favored by patients and parents is effective for the first treatment of amblyopia.

Treating Amblyopia in Aphakic and Pseudophakic Children

IntroductionAmblyopia is the leading cause of reduced vision in children following cataract surgery. It may develop as a consequence of visual deprivation, anisometropia, or strabismus.MethodsAnimal studies as well as clinical series were reviewed focusing on the pathophysiology and treatment of aphakic and pseudophakic amblyopia.ResultsExcellent visual outcomes have been reported in children with unilateral congenital cataracts following early cataract surgery, optical correction, and part-time patching of their phakic eyes. Progressive patching regimens may help to preserve the binocularity of children following unilateral cataract surgery. Excellent visual outcomes can also be achieved in children with bilateral congenital cataracts if cataract surgery and optical correction are initiated prior to the onset of nystagmus.ConclusionsAmblyopia is the greatest threat to the vision of children following cataract surgery. Constant vigilance is necessary to treat and prevent amblyopia in these children.

Amblyopia Therapy in Imam Khomeini Hospital of Kermanshah

Introduction: Amblyopia is reduced vision in an eye that has not received adequate use during early childhood. The most common cause of unilateral visual loss in children is amblyopia with prevalence rate of 1-4 percent in pre-school children . However, effective treatments may prevent intensive complication. This study was done to assess the treatment effects of amplyopia patients who have referred to Imam Khomeini Hospital of Kermanshah during 1998 to 2000. Materials & Methods: This study was a descriptive interventional before and after assessment. 56 amblyopia-diagnosed patients (86 eyes) with visual acuity less than 9 out of 10 referred to clinic of optometry were selected. In this research tools such as: ophthalmoscope, filter visioscope, dial astigmatic, prism bar, madoxwing, Snellen chart, titmus test and ischihara chart were used for diagnosis. Ophthalmologist performed amblyopia diagnosis and optometrist carried out treatment. Treatments included visual training, bleaching, part time patching, and full time patching and in some cases penalization carried out and descriptive & inferential statistics were used to analyze the data. Results: There were 58.5 percent refractive amblyopia, 10.9 percent strabismic, 7.3 percent deprivative and the rest were involved by mixed problems. The difference rate of steriopsis between after cure and before cure was 329.09 ±253.90 seconds figured by titmus stereo test. The average of visual acuity before and after treatment was 20/60 and 20/30 respectively. Conclusion: The results of this study showed that the considerable improvement was observed in amblyopia eyes with increased vision acuity about 3 lines in Snellen chart after curing the patients. We can conclude that treatment and curing of amblyopia may have good results. The earlier the treatment, the better the opportunity to reverse the vision loss. If not treated early enough, an amblyopic eye may never develop good vision and may even become functionally blind.

The use of part-time occlusion for early onset unilateral exotropia.

Eleven patients (9 months to 5 years of age) with intermittent or constant exotropia of predominantly one eye on distant gaze were studied to investigate the effect of part-time occlusion. No patient had constant exotropia on near fixation. Visual acuity was found to be equal in both eyes. All patients were treated by part-time patching of the non-deviating eye from four to six hours a day and tapered as appropriate. If exotropia recurred after conversion to a heterophoria, part-time occlusion was reinstated. With occlusion, all patients converted to hetero- or orthophoria, at least temporarily. Mean follow-up (to last visit or surgical intervention) was 22 months (range 3 to 37 months). Three patients (27%) later developed constant exotropia (mean 28.3 months after beginning occlusion) and underwent surgery. Three patients (27%) became and remain orthophoric without further patching. Part-time occlusion for preschool patients with exodeviations that are predominantly unilateral can postpone surgical intervention and convert exotropia to orthophoria or exophoria.