Journal of Pediatric Ophthalmology and Strabismus

Short Subjects 

Combined Optical and Atropine Treatment of Children With Residual Amblyopia After Atropine Penalization

John W. Simon, MD; Arjun B. Sood, BS; Joshua O. Mali, MD

Abstract

The authors studied 5 cases in which combined optical and atropine treatment (COAT) was instituted in children with residual amblyopia after atropine penalization. All 5 amblyopic eyes improved without lasting decrease in the visual acuity of the dominant eyes. Appropriately administered, COAT may rescue atropine failures.

From the Department of Ophthalmology/Lions Eye Institute, Albany Medical College, Albany, New York.

The authors have no financial or proprietary interest in the materials presented herein.

Address correspondence to John W. Simon, MD, 1220 New Scotland Avenue, Slingerlands, NY 12159. E-mail: SimonJ@mail.amc.edu

Received: December 10, 2012
Accepted: January 11, 2013
Posted Online: February 26, 2013

Abstract

The authors studied 5 cases in which combined optical and atropine treatment (COAT) was instituted in children with residual amblyopia after atropine penalization. All 5 amblyopic eyes improved without lasting decrease in the visual acuity of the dominant eyes. Appropriately administered, COAT may rescue atropine failures.

From the Department of Ophthalmology/Lions Eye Institute, Albany Medical College, Albany, New York.

The authors have no financial or proprietary interest in the materials presented herein.

Address correspondence to John W. Simon, MD, 1220 New Scotland Avenue, Slingerlands, NY 12159. E-mail: SimonJ@mail.amc.edu

Received: December 10, 2012
Accepted: January 11, 2013
Posted Online: February 26, 2013

Introduction

Atropine penalization works by paralyzing accommodation in the dominant eye, thus favoring the amblyopic eye.1 However, replacing the missing accommodation with a plus spectacle lens may undermine the effectiveness of atropine. Some authors have therefore combined atropine with “optical” penalization using a plano lens over the dominant eye, especially in children who are hyperopic.2,3 In one study of 42 children who had failed occlusion, this combined optical and atropine penalization treatment (COAT) was successful in doubling the visual acuity in 76% of amblyopic eyes without damaging dominant eyes.2

A prospective study of children randomly assigned to receive either atropine or COAT found only marginally better results in the latter group.3 To date, no report has considered the effectiveness of adding optical penalization in children who had already failed atropine alone. We identified 5 such children whose amblyopia improved with COAT. Institutional review board approval was obtained for this study.

Case Reports

Case 1

A 3-year-old girl who failed vision screening was found to have an intermittent left esotropia and visual acuities of 20/25 in the right eye and 20/200 in the left eye. She was given 2.0 diopters (D) less than her cycloplegic refraction (+4.50 in the right eye and +6.50 in the left eye), with daily atropine penalization of the right eye. After 1 year, the visual acuities measured 20/25 in the right eye and 20/80 in the left eye. COAT was instituted in the right eye. After 7 months, the visual acuities measured 20/25 in the right eye and 20/40 in the left eye. The hyperopic correction was restored in the right eye.

Case 2

A 15-month-old boy was given 1 D less than the full cyclopegic correction (+5.50 +0.50 × 90 in the right eye and +6.00 + 1.00 × 90 in the left eye), with daily atropine penalization of the right eye for an intermittent left esotropia. After 3 months, the fixation preference remained and COAT was instituted in the right eye. After 5 months, the child alternated fixation and the hyperopic correction was restored in the right eye.

Case 3

A 4-year-old boy with an intermittent right esotropia and visual acuities of 20/50 in the right eye and 20/25 in the left eye was given his full cycloplegic refraction (+2.50 in both eyes). After 2 months, his visual acuities measured 20/40 in the right eye and 20/25 in the left eye. COAT was instituted in the left eye. After 6 weeks, the visual acuities improved to 20/30 in the right eye and 20/25 in the left eye. Hyperopic correction was restored in the left eye.

Case 4

A 5-year-old boy with a left esotropia and visual acuities of 20/20 in the right eye and 20/50 in the left eye was given his full cycloplegic refraction (+3.75 in the right eye and +5.50 +0.50 × 30 in the left eye) and daily atropine penalization of the right eye. After 1 year, the visual acuities were 20/20 in the right eye and 20/30 in the left eye. COAT was instituted in the right eye. After 5 months, the visual acuities were 20/20 in both eyes. Hyperopic correction was restored in the right eye.

Case 5

A 2-year-old girl with an intermittent left esotropia and visual acuities of 20/30 in the right eye and 20/125 in the left eye was given her full cycloplegic refraction (+3.50 in the right eye and +4.00 in the left eye) with daily atropine penalization of the right eye. After 3 months, the examination was substantially unchanged and COAT was instituted in the right eye. After 3 weeks, the child had a right esotropia with visual acuities of 20/400 in the right eye and 20/70 in the left eye. The hyperopic correction was re-instituted in the right eye. After 2 months, the visual acuities were 20/250 in the right eye and 20/40 in the left eye. COAT was instituted in the left eye. After 6 months, the visual acuities measured 20/30 in the right eye and 20/25 in the left eye. Hyperopic correction was restored in the left eye.

Discussion

Although some authors have compared COAT to atropine penalization alone, others have taken issue with COAT because it eliminates the possibility of binocular cooperation and, depending on age and refractive error, may cause visual symptoms.4,5 We prefer to avoid COAT in cases where it is not necessary. In our experience, atropine penalization alone is both remarkably successful and generally sufficient. The 5 children we describe were exceptions: they all, to some extent, failed atropine alone. We therefore instituted COAT, in each case substituting a plano lens for the hyperopic correction in the dominant eye while continuing the daily atropine. This sequence of treatments, first with atropine and then with atropine and optical penalization if needed, has not been reported.

Fortunately, all 5 amblyopic eyes improved without lasting decrease in the visual acuity of the dominant eyes. We measured visual acuities in all children using age-appropriate tests: HOTV in case 4, Allen pictures in cases 1, 3, and 5, and fixation preference in case 2. The same tests were repeated before and after COAT. In case 5, patching of the left eye was prescribed for 4 months but was difficult for the child. Other children were not patched.

As demonstrated in case 5, the treatment we describe is both potent and potentially hazardous. This 2-year-old child, initially severely amblyopic in her left eye, developed even worse amblyopia in the right eye after only 3 weeks of COAT in the right eye. Fortunately, although prolonged COAT in the left eye was required, visual acuities finally improved to the normal range in both eyes. We recommend monitoring the response of both eyes closely, especially in young children and at the beginning of treatment. Appropriately administered, it may rescue atropine failures.

References

  1. Wu C, Hunter DG. Amblyopia: diagnostic and therapeutic options. Am J Ophthalmol. 2006;141:175–184 doi:10.1016/j.ajo.2005.07.060 [CrossRef] .
  2. Kaye SB, Chen SI, Price G, et al. Combined optical and atropine penalization for the treatment of strabismic and anisometropic amblyopia. J AAPOS. 2002;6:289–293 doi:10.1067/mpa.2002.127920 [CrossRef] .
  3. Pediatric Eye Disease Investigator Group. Pharmacological plus optical penalization treatment for amblyopia: results of a randomized trial. Arch Ophthalmol. 2009;127:22–30.
  4. Morrison DG, Palmer NJ, Sinatra RB, Donahue S. Severe amblyopia of the sound eye resulting from atropine therapy combined with optical penalization. J Pediatr Ophthalmol Strabismus. 2005;42:52–53.
  5. vonNoorden GK. Amblyopia caused by unilateral atropinization. Ophthalmology. 1981;88:131–133.

10.3928/01913913-20130219-01

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