On 5/3/08 3:00 PM, in article 481cdf4b$0$828$58c7af7e@news.kabelfoon.nl,

Actually, they ARE studying the efficacy of patching  older ages than have
traditionally been treated. Textbooks used to say to reason to patch after
age 8. However, the brain is still developing in some past that age, and we
(I, at least) routinely patch kids 9-11 years old and get some effect.
Obviously, it doesn't work well if they are very amblyopic, and won't work
at all if they cannot co the treatment hours necessary. The older kids take
much more patching than the younger kids. Thus, this interferes with school,
homework, and other activities, and they are often failures due to being
unable to patch enough.

I will also say that the results of some of the PEDIG (Pediatric Eye
Diseases Group) studies that are being quoted have to be taken with a grain
of salt. I know the people publishing all this, Dr. Mike Repka from Wilmer
at Hopkins, where I did my training. For example, they say 2 hrs is as
effective as 6 hrs of patch, and 6 hrs is as effective as full-time, but we
all know that is not true for everyone, and has to be tailored to the
individual.

Regarding atropine: amblyopia is not due to the ciliary muscle, etc as
mentioned. It is due to the brain have received a blurry image, or a
conflicting image (as in strabismus), and not learning to see well. Atropine
works by blurring the image for near, at reading distance, and really only
works if the blurred image is blurry enough to switch fixation preference to
the amblyopic eye so it is being used. Therefore, it works only in low to
moderate amblyopes, since it can't blur the image enough in bad amblyopes.
You can help it along by using glasses that are sufficiently "wrong" so as
the blur the eye at near in addition to the atropine. Problem is, one is not
reading all day, so it only is treating part of the time. In addition, some
feel that light getting in the better eye still competes with the amblyopic
eye, and slows treatment. Also, atropine is basically all or none; you can't
really modulate it the way you can with adjusting number of hours of
patching.

I use atropine when I can't use a patch due to poor cooperation, or when I
am patching all out-of-school hours, and need more, but don't want to patch
in school. I also sometimes use it as maintenance after stopping patching.

Regarding the amblyopia treatment in this highly anisometropic myope, he has
not told us what his visual acuity is. He still thinks looking at the
eyeglass power tells you what vision this corresponds to. This kind of
amblyopia is probably severe, and rather resistant to treatment anyway, but
who knows, there still might be some improvement with patching. I think
atropine would be a waste of time if there is any significant amblyopia.

Now, I will also tell you that I have seen some prominent specialists use
full-time patching in full-grown adults (age 40, etc), and get some
improvement. We all joked because he was in Iowa, and we said, sure, you can
tell only an Iowa farmer to patch all day for a year ...  (this was Dr.
William Scott, in Iowa City, very respected, now retired).


David Robins, MD
Board certified Ophthalmologist
Pediatric ophthalmology and adult strabismus subspecialty