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By Sean Henahan

Baltimore - The first systematic study comparing patching and atropine drops indicates that both work well in the treatment of amblyopia in children.
The study randomised 419 moderately amblyopic children less than seven years of age to treatment with either atropine or an eye patch.

A total of 47 clinical sites in the United States, Canada and Mexico participated in the study, which was conducted under the auspices of the Paediatric Eye Disease Investigator Group.

“Amblyopia is the most common cause of visual loss in children and young adults. If there is a good treatment that patients will comply with, more cases of permanent visual loss can be prevented,” said Project Director, Michael X Repka MD of the Wilmer Eye Institute.

The investigators assessed each child's amblyopia and overall visual acuity at baseline and after five, 16 and 26 weeks of treatment. Similar improvements in visual acuity were seen in both treatment groups after six months.

Visual acuity reached 20/30 or better in the amblyopic eye, or had improved from baseline by three or more lines in 79% of the patching group. The same was also true for 74% of those in the atropine group.

“With atropine, you simply put the drop in once in the morning and there is no need to monitor the child for the day. With the patch, children have to be continuously monitored since they often remove it.

“But despite the advantages of atropine, our data suggests ophthalmologists generally prescribe patching 97% of the time,” Dr Repka said.
Some 38% of the amblyopia cases were associated with strabismus and 37% with anisometropia, while 24% of cases had some combination of both. Visual acuity in the nonamblyopic partner eyes tended to be worse with strabismic amblyopia than with anisometropic amblyopia,

Patching time, as prescribed by the patient's ophthalmologist or optometrist, varied widely with 43% of patients wearing the patch for six hours per day and 17% of patients wearing it all the time.

The children in the study tolerated both treatments equally well. Both parents and their children considered the atropine drops to be more acceptable. Compliance, known to be the key factor influencing the success of treatment, was better in the atropine treatment group.

“The initial choice of patching or atropine can be made by the eye care provider or parent. Both patching and atropine are appropriate modalities for the initial treatment of moderate amblyopia in children,” the researchers explained.

“Penalisation — atropine therapy — has the possible advantages of perhaps being more acceptable to patients and their parents, and it can provide for better compliance. The child cannot sabotage treatment by pulling off a patch.

“Patching has the possible advantages of requiring a shorter treatment time — though this is yet to be determined — and providing better flexibility for part-time treatment.
“A child who only needs to patch several hours a day can enjoy many hours daily of normal use of his or her dominant eye. Similarly, as treatment is being tapered off, patching allows for greater flexibility than classic penalisation,” observed Burton J Kushner MD, University of Wisconsin in Madison, in the March issue of the Archives of Ophthalmology.

The study results come at a time of renewed attention to the problem of amblyopia in the US where screening efforts are generally not as comprehensive as those in Europe. Current estimates are that only one in five children is screened.
In an effort to improve the situation, the American Academy of Paediatrics called for photoscreening of all young children. Photoscreening, utilising a camera or video system to image the eye, is becoming more common in the US. It has the advantage of being simple to perform on even very small children.

“Photoscreening offers hope in improving vision screening rates in infants, preverbal children and those with developmental delays who are the most difficult to screen,” the AAP said in a statement.

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