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Medical Forum / General / Vision / July 2006Hyperopia plus amblyopia
Finally, yesterday I took my daughter to the pediatric ophtalmologic clinic. Very nice doctor, she took at least 30 minutes to explain everything to me and my wife. I even did the tests myself to understand completely. The amblyopic eye (right eye) has corrected vision accuracy of 20/200. The good one has 20/20. The OD performed Worth test and my daughter could only see three dots. She happily counted them. She should have seen 4. I could see 4 with both eyes, 3 with left eye and 2 with right eye. She prescribed us +5 on amblyopic eye and +1 on the good eye. Doctor did not do another cycloplegic autorefractor, but I had previous test results with me. She said if hyperopia is 8,5+ we need to have a bit over half that value for diopter on that eye. So we ended up with D5+. We also will have to occlude completely for 40 days and after that 30 more only 5-6 hours a day. Then we'll go for another consult. I am seeking now easy (for daughter) ways to accept the occluder. How all this sounds for you? OD said we can expect anything from no CVA improvement to 20/30 probably in amblyopic eye. Then we need to struggle to excercise fusion. Then if everything goes well, we'll think about CL, glasses, operations and everything else. On 6/18/06 1:12 AM, in article 1150618328.003777.279320@r2g2000cwb.googlegroups.com, > Finally, yesterday I took my daughter to the pediatric ophtalmologic > clinic. Very nice doctor, she took at least 30 minutes to explain [quoted text clipped - 22 lines] > struggle to excercise fusion. Then if everything goes well, we'll think > about CL, glasses, operations and everything else. I would tend to disagree with this treatment. At 20/200, there is little stimulus for accommodation. Leaving the amblyopic eye 3.5 D underplussed is leaving it still very blurry, not sharp on the retina. Why leave it blurry, when the eye wants a sharp image to use, and likely won't accommodate the additional 3.5 D ? I would use the full cycloplegic for each, eye, cutting both the same, perhaps 0.5 to 0.75 D less than the full plus. Only then is the eye-to-eye difference fully accounted for, and close enough to "sharp" focus to get the best from the patching. I don't understand the rational for going slightly more than half of the total - I have never done that. I also would not back off the patching until I saw the results I was looking for. If there is no change while full-time patching, reducing it to 5-6 hrs. just wastes additional time, in my opinion. I've been treating amblyopia for over 25 years, so I speak from experience. David Robins, MD Board certified Ophthalmologist Pediatric ophthalmology and adult strabismus subspecialty > I would tend to disagree with this treatment. At 20/200, there is little > stimulus for accommodation. Leaving the amblyopic eye 3.5 D underplussed is [quoted text clipped - 13 lines] > > I've been treating amblyopia for over 25 years, so I speak from experience. I have no ideea. I highly apreciate your reply, I am just trying to understand everything. Anyway, I have three separate opinions of doctors seeing and testing her. Two said D5+ and one said D3.5+. Why would they all three do that? We started occluding today, and she seems very comfortable with her vision. Would it be the same if the vision would be blurred? Also, as I remember from non-cycloplegic tests her value was D5-5.5+. Wouldn't this mean that she can accomodate the difference? What should I do? Should I ignore last advice and make some glasses with D8+? >> I would tend to disagree with this treatment. At 20/200, there is little >> stimulus for accommodation. Leaving the amblyopic eye 3.5 D underplussed is [quoted text clipped - 26 lines] >What should I do? Should I ignore last advice and make some glasses >with D8+? I've introduced myself before. I'm a patient, NOT a doctor, but I'm a pretty well-versed patient, especially in this kind of issue. I've watched Dr. Robins post here for quite some time. I have the sneaking feeling he's awfully good (I've been seen by the best--some of whom I wouldn't go back to). I was amblyopic and highly hyperopic as an infant. It looks *abundantly* clear to me that I was given insufficient plus early on in life. It seems abundantly clear that this caused significant problems with my accommodative AND vergence amplitudes--placing much too much reliance on MY eyes to focus at near--something they were NOT built to do. All of this caused serious instability in my eye alignment, too, leading to three strabismus surgeries over my lifetime. ================================= If I were starting life again today, I would want: ================================= - maximum plus prescription based on a 4 day Atropine cycloplegic refraction - Dr. Robins' recommendation for occlusion - Careful, and frequent monitoring for eye alignment and binocular function issues - to be placed in contact lenses (again, using the full plus distance prescription) as soon as everybody thought I was ready--likely with (over-the-contacts) reading glasses prescribed for near work (all actual prescriptions would have to be written with significant regard to any effect on eye alignment); - Vision therapy -- as early as it was practical, and for as long as everybody agreed it was beneficial (or harmless). I would want EVERY advantage in terms of accommodative and vergence amplitudes--a place where I (or, quite likely, your daughter) would be inherently weak, and inherently over-taxed. Lastly, I would want to have parents like you--people who are taking a very aggressive stance at making sure that everything that should be done to ensure excellent vision ... is being done. Nice job! I'm just another data point, and *even I* wouldn't suggest that you should give it equal weight. Just some more thoughts from somebody who's been there ... AND has fought their way out of it a few times. [As always, Docs: If I bunged anything up, please jump in] All the best, Neil > >> I would tend to disagree with this treatment. At 20/200, there is little > >> stimulus for accommodation. Leaving the amblyopic eye 3.5 D underplussed is [quoted text clipped - 79 lines] > All the best, > Neil I am desperate. Why would I receive such advice then from such respectable pediatric ODs here? Can it be some information I do not know but they know from consultation? >> >> I would tend to disagree with this treatment. At 20/200, there is little >> >> stimulus for accommodation. Leaving the amblyopic eye 3.5 D underplussed is [quoted text clipped - 83 lines] >respectable pediatric ODs here? Can it be some information I do not >know but they know from consultation? Again, there may be better people to respond to this than I, but... So much of this is *NOT* absolute right/wrong, better/worse ... yet. Much of what you're looking at, or that I lived, is a matter of art and some *thoroughly* educated judgments by caring, skilled practitioners. There may simply NOT BE 100,000 cases like your daughter and me that allow for large-scale testing to know *with certainty* what's best. To your credit, you do not come across--at least to me--as "desperate" I think that's a very good thing. Better to make the right decision than a fast one here. Since (in my belief) you are "out at the fringes" where NOT a great deal of "hard science" exists, if I were you, I'd be trying to reason this through myself: - What makes sense based on all that *I* have learned? - What do *I* perceive as the potential risks and rewards of each doctor's recommended course of action?? In this case, *I* (Neil) see fairly material risks in UNDER-correcting your daughter. The mechanism is simple: (ANALOGY): she was born with a weak leg. UNDERcorrecting her asks her to put all of her weight on that leg ... every day ... all day. This seems likely (to me) to cause that leg to buckle under the pressure (accommodation) and that knee to turn inward as she walks (vergence). Hey ... not a bad analogy :-) The risks of *FULL* correction for the hyperopia?? To my thinking, the ONLY significant risks are IF giving her a full plus Atropinised prescription causes her eyes to turn (strabismus), but ... again ... I mentioned this before ... and it's an easy one for the doctor to compensate for when evaluating the best prescription. *I* would think that the goal is to get your daughter's focusing (accommodative) and turning (convergence) systems to be as "relaxed" as possible at all times ... and THEN to "exercise" and "build" them in a controlled setting (vision therapy) where a good practitioner can decide at what point it's time to stop for the day and to measure progress all along the way. As I've said before: I'm 42. I've been dealing with this for my entire life. The only one who's probably had a harder time with this than me is ... my mother ... watching ... unable to help. You're doing a GREAT job. Just try to relax ... as much as possible ... keep learning ... and weigh all of this information yourself. Ask each doctor about the other doctor's advice: "Doc B says to do this. Why do you think that's good or bad advice?" They won't always LOVE you for that but ... tough. It's your kid :-) On 6/19/06 8:47 AM, in article 1150732034.681335.27080@i40g2000cwc.googlegroups.com, >> I would tend to disagree with this treatment. At 20/200, there is little >> stimulus for accommodation. Leaving the amblyopic eye 3.5 D underplussed is [quoted text clipped - 26 lines] > What should I do? Should I ignore last advice and make some glasses > with D8+? The vision is amblyopic, so it is used to being blurry and wouldn't care. The non-cycloplegic value does indicate the eye is capable of some accommodation, but doesn't mean it will STAY in focus as it needs to. I can only tell you what I would do, but she is not my patient, and it would be unethical for this is be more than an educational discussion with me at this point. I cannot make medical recommendations over the internet. > The vision is amblyopic, so it is used to being blurry and wouldn't care. > The non-cycloplegic value does indicate the eye is capable of some [quoted text clipped - 3 lines] > be unethical for this is be more than an educational discussion with me at > this point. I cannot make medical recommendations over the internet. Of course David, I would not expect anything else. On the other hand I appreciate very much you have the time and mood to reply to my posts. I will go through with what current OD prescribed for another 38 days (2 already passed) and then go to another check. I will discuss with OD the improvement if it is the case and tell her that I heard other opinions, then kindly ask to try to explain to me the future course of action. Would this hurt? My daughter will have 4 years on 1st of July. Is it too late? On 6/22/06 11:43 AM, in article 1151001805.760874.63050@g10g2000cwb.googlegroups.com, >> The vision is amblyopic, so it is used to being blurry and wouldn't care. >> The non-cycloplegic value does indicate the eye is capable of some [quoted text clipped - 15 lines] > Would this hurt? My daughter will have 4 years on 1st of July. Is it > too late? No, not too late. You can afford to do this. Even if there is SOME improvement, it still doesn't validate the entire treatment design. But, once again, there is no single "right" way. My way is just what I and many of my colegues would do and have been doing. Good luck. I too am a concerned mum, trying to work out the best course of action for my son. Having shown no problems with his vision it was a complete shock to find ourselves attending hospital after a pre-school routine screening and to be told he was hyperopic (they did the dilation testing thingy with the light being shone into his eyes through various lenses). We were in and out of the door in 10 minutes and feel confused. He has been given a partial prescription (+5D right eye and +6 left eye) and we have been told that he may well develop a squint when the glasses are taken off at night. He currently has no squint.......are we right to be concerned about this course of action? He is to wear these glasses for 6 weeks, when he will be reviewed. When we put the glasses on him he says that everything is blurry (he is just 4) and is refusing to keep them on. We are trying to keep low key, putting him in different situations to see if he will take to wearing them, but all to no avail as he says he can see better without. Are exercises a good option, can they help him improve......it is like a maze for a novice to find their way through conflicting opinions, just want to do the best like the other parent here, sounds as though we are in much the same situation. If you can offer any advice from what you have learnt so far I would be grateful, hope all is going well with your child. > What should I do? Should I ignore last advice and make some glasses > with D8+? The only downside to being over-plussed in this situation is that the far vision will be blurry. The near vision will not. Most of the amblyopia treatment with occlusion will involve doing close work anyway. Besides, giving the full cycloplegic is not really over-plussing, since it measures how much hyperopia is actually there. DrG I agree with Rxing full plus, although I see this kind of "chicken" underprescribing more from o.d.s than from omds, particularly pediatric omds. So it begs the question, maybe they weren't so sure of their original refraction and are "hedging" the bet. Whatever it is, I'd have it checked a third time just to be sure. If it's +8 then +8 she gets... w.stacy, o.d. >>What should I do? Should I ignore last advice and make some glasses >>with D8+? [quoted text clipped - 6 lines] > > DrG >On 6/18/06 1:12 AM, in article >1150618328.003777.279320@r2g2000cwb.googlegroups.com, [quoted text clipped - 41 lines] >for. If there is no change while full-time patching, reducing it to 5-6 hrs. >just wastes additional time, in my opinion. Have you incorporated the results of the completed ATS in your practice? In particular, do you use part-time patching with near-tasks for certain patients who meet the guidelines listed here: <http://public.pedig.jaeb.org/Completed_Studies.htm#ATS2A> or do you use full-time patching exclusively for such patients? >I've been treating amblyopia for over 25 years, so I speak from experience. FWIW, I essentially concur with Dr. Robins assessment. I think cutting that much plus would be a mistake. This would be especially true if she has any strabsimus and/or high AC/A ratio (accommodative convergent strabismus). The only possible difference is that I might, depending on her age and other circumstances, see what happens from mere full-time spectacle correction alone first. I almost always try full-time spectacle correction alone first on purely optical defocus amblyopia, for at least a short period of time, unless time is absolutely critical. I have seen patients, even with relatively deep amblyopia like this, go from 20/200 to 20/60 or 20/80. Additionally, patients and their parents tolerate full-time spectacle correction more than full-time patching. But such patients need to be extremely compliant with their full-time on spectacle wear and follow-ups. If they aren't or can't be, they are then moved directly to full-time patching. If they aren't compliant with that, then they would be referred to Dr. Robins... :) And if you can bring a patient's amblyopic eye's vision up from 20/200 to 20/60 or 20/80, they tolerate patching better than if they were 20/200 in that eye. And I suspect, but know of no studies to back it up, that there is less risk of binocularity problems when spectacles alone are used to improve vision first prior to patching. On 6/19/06 8:58 AM, in article 2ngd9292bdode3haouickg87et3rnghqau@4ax.com, >> On 6/18/06 1:12 AM, in article >> 1150618328.003777.279320@r2g2000cwb.googlegroups.com, [quoted text clipped - 79 lines] > less risk of binocularity problems when spectacles alone are used to > improve vision first prior to patching. I do usually start with just glasses, if the eyes are straight. I was commenting on the patching instructions, starting with full-time and cutting to part-time before seeing the results. I have used some of the PEDIG study findings, but not all. And it doesn't fit every pt. I've seen a number of kids where they weere getting patched 6 hr/day for months and had leveled out at perhaps 20/60, and were told to give up. Increasing patching to near full-time got them almost to 20/20. So, not always is 6 hrs equal to full-time, etc. You need to tailor it to the situation at hand. Therefore, no, I don't use full-time patching exclusively, only when needed. The rest are your statements I essentially agree with also. Except that there appears to be about 7 diopters of anisometropia in this case. DrG > >On 6/18/06 1:12 AM, in article > >1150618328.003777.279320@r2g2000cwb.googlegroups.com, [quoted text clipped - 79 lines] > less risk of binocularity problems when spectacles alone are used to > improve vision first prior to patching. |
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