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Medical Forum / General / Vision / April 2005Full time patching?
I saw a 4 year old today who was referred from a vision screening for his first eye exam. Unaided VA was R 20/30 L 20/70 I 'scoped him at R +.25 -.75 x 80 and L +1.00 - 2.25 x 150, which didn't produce any significant acuity improvement for the left eye. My initial treatment will be to Rx the above for full time wear and to patch the O.D. and see how he does. Would you o.d.'s out there go for full time, part time, or what for the patching, and would you just black out the R lens, or go for a total occluder like an elastoplast (do they still make that?). thanks for your input w.stacy, o.d. > I saw a 4 year old today who was referred from a vision screening for > his first eye exam. [quoted text clipped - 13 lines] > > w.stacy, o.d. I'd Rx the full power for full time wear and NOT patch at first. Wait two months and see if the acuity improves. If the LE comes up to, say 20/40, then continue, If not, check for dominance and if the R is so, then over-plus the RE for a good distance blur in a second pair of specs to be worn part time. If I went to full or most-time full-occlusion, I'd hope for better acuity to start with and might consider contact lenses with the occluder being a blacked-out OZ. But he's 4, so perhaps the more traditional method would be fine. This, of course, assumes that you've ruled out pathology. Interestingly, I just had a similar case, except the child is a bit older (6) and with slightly less correction in the more astigmatic eye, but similar acuity in both. (20/40--20/60). Two months later he was 20/30 and 20/40- .......still not appropriate for his age or optical error, but on the right track. Patience. He's only 4. A good catch. Good luck! LB, O.D. What were the results of the cycloplegic exam, and was there any improvement in the right eye with the Rx? One can debate the merits of waiting or not waiting before patching. However, the evidence seems to weigh in favor of amblyopia in the more hyperopic astigmatic eye. At four years, full time patching is indicated by most authorities. DrG > What were the results of the cycloplegic exam, and was there any > improvement in the right eye with the Rx? [quoted text clipped - 5 lines] > > DrG Well, as my usual for a 4 year old, I didn't cycloplege him (hey, I'm just getting to know him!) I did take fundus photos (no pathology, as expected) and glad to hear that the more hyperopic eye is "favored" for the amblyopia! (I mean this seems pretty simple to me) It's just that I'm not up on the fine details of amblyopia management since nowadays I mostly see young myopes who use the computer too much! w.stacy, o.d. w.stacy, o.d. Hmmm. You may run into disagreement on that issue. I use 0.5% tropicamide. Alternate patching could still be done, 4 days on the good eye and 1 day on the amblyopic eye to be on the safe side, or just monitor visual acuity every few weeks. DrG >> What were the results of the cycloplegic exam, and was there any >> improvement in the right eye with the Rx? [quoted text clipped - 12 lines] > I'm not up on the fine details of amblyopia management since nowadays I > mostly see young myopes who use the computer too much! Hmm, I always cycloplege suspected amblyopes. You well may find that there is significant hyperopia in that left eye. My usual practice would be to Rx the cycloplegic refraction (less about -0.50) and reassess in 6-8 weeks. Often just wearing the glasses solves the amblyopia, if not, I start patching after that, with a four year old, it would be full time, checking progress every two weeks. Dr Judy > Hmm, I always cycloplege suspected amblyopes. You well may find that there > is significant hyperopia in that left eye. I know that's conventional wisdom, with which I often disagree. Since the eyes are yoked in accommodation, and since he obviously is fixating/focusing with the good (essentially emmetropic) eye during retinoscopy, I fail to see how the astigmatic/amblyopic eye could have significantly more hyperopia than found on said retinoscopy. Can you explain such a scenario? BTW I did not attempt subjective refraction on the amblyopic eye which would only be reliable under cycloplegia, but again, why put him through that when I already know what I'd find? > My usual practice would be to Rx the cycloplegic refraction (less > about -0.50) and reassess in 6-8 weeks. Often just wearing the glasses > solves the amblyopia, if not, I start patching after that, with a four year > old, it would be full time, checking progress every two weeks. OK thanks for that and to all for the others who answered. I'm going to push for full time patching/SRx wear, with my usual allowance for time off for good behavior. I will recheck in 2 mos and if there's not major improvement at that point, will cycloplege him then. w.stacy, o.d. sounds like there is considerable variation in Tx for such a patient among the eye docs here. FWIW, this is my approach: cycloplegic refraction initially using cyclogel. I usually prescribe the manifest Rx plus a little extra plus if more hyperopia shows up on cycloplegic refraction but not too much so I can minimize distance blur and facilitate patient acceptance of the Rx. I would also be inclined to give some more plus if there is significant esophoria. personally I wouldn't patch right off-- I would wait 6-8 weeks to see what kind of improvement I might get with just the spectacle Rx alone. If I determine that patching should be initiated, I use part time patching of 4-6 hours. For patching I use an eye bandage (purchased at local pharmacy) or frosted tape on the spectacle lens. I generally ask the parents to spend a little one-on-one time with their child during the patching time doing a task requiring some visual-motor skills: eg drawing, puzzles, computer games, etc. i suppose I should consider using atropine patching but I have not yet done so. what are other practitioners experiences with it? PS-- I appreciate this type of posting here. why not get the eye docs talking to one another about these types of issues rather than just answering questions and dealing with kooks >PS-- I appreciate this type of posting here. why not get the eye docs >talking to one another about these types of issues rather than just >answering questions and dealing with kooks Welcome back to the old s.m.v. :-) It sounds like you're using a recipe for possible latent hyperopia and maybe an associated eso problem. I would go along with it if that were the case, although I've not had an occasion to try atropine Tx. However, the present case was not particularly hyperopic, and there was no hint of strabismus or even esophoria. The 4 year old had anisometropic astigmatism with mild amblyopia in the astigmatic eye. While I'm always on the lookout for latent hyperopia, when I scope one eye at essentially plano, I tend to trust my retinoscope on the fellow eye. Again, I would not attempt to subjectively refract the astigmatic eye without cycloplegia, but then I'm not ready to try a subjective on this little guy yet. But thanks for the post and I also like this kind of exchange better than the hothead pseudoscience stuff. w.stacy, o.d. > sounds like there is considerable variation in Tx for such a patient > among the eye docs here. FWIW, this is my approach: [quoted text clipped - 19 lines] > talking to one another about these types of issues rather than just > answering questions and dealing with kooks >It sounds like you're using a recipe for possible latent hyperopia and >maybe an associated eso problem. I would go along with it if that were [quoted text clipped - 12 lines] >But thanks for the post and I also like this kind of exchange better >than the hothead pseudoscience stuff. This sounds like a pretty good place to interject a question: I have this friend who.... - Infantile esotrope - Current wavefront Rx: OD 8.44 -1.71 89 OS 7.95 -1.92 69 - Tenacious accommodative spasm, formerly treated with continuous use of cycloplegics (last was Atropine). All use of cycloplegics now stopped (can eat endothelial cells for breakfast, side effects nearly unmanageable) - 3x strabismus surgery for esotropia - Now ~4d exo at distance, ~10d exo at near. I know: being exo- drives accommodation.... - Wearing manifest Rx, full prism in specs (separate distance and near); wear full cyclo Rx scl's on daily basis (leaving me a tad bit myopic). I find the cl's less taxing, but could not adapt to full cycloplegic Rx specs (??) - Severe dry eye (all 4 puncta cauterized) - ~2.50d/3.00d tonic accommodation, causes symptoms, greatly exacerbated with any near work Latest proposal by my ophth: use of phospholine iodide TID. My understanding of PI: increases the *amount* of accommodation achieved with a *given* amount of ennervation to the ciliaries. His theory: if my level of tonic accommodation is pretty static, perhaps we can reduce the *effort* behind that level of accommodation and ameliorate symptoms. Thoughts? Side effects look, predictably, ugly... Might this exacerbate exotropia? IIRC, I haven't had my alignment checked under Atropine in quite some time. I presume I could be more exo absent the tonic accommodation. TIA, Neil |
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