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1. Passive Therapy in
Management of Amblyopia
Maharajgunj Medical
Campus, IOM, Nepal
Bikash Sapkota
B. Optometry
Final Year

2. IMPORTANCE OF TREATMENT
 If left untreated, amblyopia produces a range of
functional deficits
 Binocular function is also compromised
 The presence of amblyopia (or its treatment) impact
on educational attainment, future career
opportunities, self-esteem & quality of life
 The studies reveal the practical and emotional
impact of amblyopia and provide additional evidence
in support of the need to develop effective
treatment

3. Goal of Treatment
To restore and improve visual acuity by two strategies:
I. Present clear retinal image to the amblyopic eye
o Eliminate causes of visual deprivation
o Correcting visually significant refractive errors
II. Make the child use the amblyopic eye
 Recommended treatment should be based on
o Pt.’s age, VA, compliance with previous treatment &
physical, social and psychological status

4. What would be the perfect amblyopia
therapy?
 Effective
 Good compliance
 Acceptable to pts. and parent
 Quick
 Safe
 Easy to administer
 Cost effective
 Well maintained

5. Choices of Treatment
The choices of treatment of amblyopia are
used alone or in combination to achieve goal
of treatment
1. Passive Therapy
The patient experiences a change in visual
stimulation without any conscious effort
i. Proper refractive correction
ii. Occlusion
iii. Penalization

6. 2. Active Therapy
It is designed to improve visual performance by the
patient’s
conscious involvement in a sequence of a specific,
controlled
visual task that provide feedback
i. Pleoptics
ii. Near activities
iii. Active stimulation therapy using CAM vision
stimulator
iv. Syntonic phototherapy
v. Role of perceptual learning
vi. Binocular stimulation
vii. Software-based active treatments
viii. Exposure to dark

7. Passive
Therapy
Refractive
Correction
Occlusion
Penalization

8. Proper Refractive Correction
Purpose
 To provide sharp images and providing optimal
environment for amblyopia therapy
 Give pt. proper optical correction alone
- Short period of time (6-8 weeks) before initiation of
other therapy
- In case of refractive amblyopia, a progressive
improvement in
acuity for up to 16 - 22 weeks has been shown in
some pts.
after refractive correction (Stewart C. et al 2004)

9. When to Prescribe

10. REFRACTIVE ERROR CORRECTION
 Improves VA in 25-33% of patients with anisometropic
amblyopia and also in strabismic amblyopia
 ATS-5 (PEDIG) 2006 concluded that amblyopia
improved with optical correction in 77% and resolved
in 27%
 Chen et al (AJO 2007) concluded that amblyopia
improved with optical correction in 93% and resolved
in 45%
 Penalisation and occlusion is required only if the VA
doesn’t improve with glasses for 4 months

11. Occlusion Therapy
 The most powerful and effective means of treating
amblyopia
 Mainstay of treatment since 18th century to till now
 Highly effective until 8 years of age
 New studies have shown improvements upto 24 yrs of
age
 Cover good eye to stimulate amblyopic eye

12. o When fixation is central: simple & effective
o When fixation is eccentric: <7yrs central fixation
recover
o Older the child harder to regain central fixation
Mode of Action
 Prevent fixating eye taking part in act of vision and
removes inhibitory stimulus that arises from
stimulation from fixating eye (non-amblyopic eye)

13. TYPES OF OCCLUSION
Occlusion
Total or
Partial
Conventional
or Inverse
Full Time or
Part Time

14. Total VS Partial Occlusion
Total Partial
•All light is prevented from
entering eye
•Employed in amblyopic
eyes
with acuity less than
6/24
•Occlusion using
elastoplast, gauze pad,
tape, doynes rubber
occluder
•Does not cut off the total
light
entering eye
•Degrades the vision of
normal
eye such that amblyopic
eye
gets better vision and
preference
•Occlusion using
cellophane,
transparent nail polish, or

15. Conventional VS Inverse
Conventional Inverse
•Occlusion of sound
eye
•Occlusion of
amblyopic
eye so that eccentric
fixation becomes less
fixed
Full Time VS Part Time
Full time Part time
Removed only while going
to bed at night
Short time each day during
close work or watching
television
Choice of initial Rx In relapses after Rx and
also for maintenance

16. Patches
Micropore tape with soft tissue paper
Spectacle patch / frost glass
Doyne’s occluder Opaque Contact Lens

17. How to go about Occlusion?
 Motivation of child and parents
 Active vision exercises by amblyopic while non-
amblyopic eye is occluded
 Occlusion is continued till amblyopic eye has
developed equal vision and equal preference of
fixation
 May take 3-6 months
 If there is no improvement, then treatment is
stopped
 Maintenance treatment is continued at least up to
9 yrs of age with part time occlusion and
exercises

18.  Follow up-depending on age, severity of amblyopia
and compliance-to look for VA, fixation pattern
and occlusion amblyopia
 When to stop occlusion
- VA equals in both eyes
- Alternation of fixation (Repka 2008)
 When VA is stable patching may be decreased
slowly
 Because amblyopia recurs in large no. of pts.
maintenance therapy or tapering of therapy should
be strongly considered

19. Disadvantages of occlusion
 Prolonged treatment
 Occlusion amblyopia
 Non compliance
 Psychological distress
 Allergic skin rash
 Cosmetically inacceptable

20. Prognostic considerations
 Younger the age better the prognosis
 Type of amblyopia myopic anisometropia>
hyperopic anisometropia> strabismic
amblyopia> stimulus deprivation
 Pre-treatment VA
 Type of occlusion
 Type of fixation
 Near exercises
 Pt. compliance and parent educati
 Presence of astigmatism
 Previous treatment
 Refractive correction

21. Treatment of Anisometropic Amblyopia

22. Treatment of Strabismic Amblyopia

23. Penalization
 Therapeutic technique performed by optically
defocusing the eye with better vision by using
cycloplegia or altering the eye glass lens
Indications
o No compliance for occlusion
o Mild degrees of amblyopia
o Maintainence after occlusion
o Anisometropic amblyopia

24.  Advantages: Cheap, better compliance
 Disadvantages: Side effects of drugs
- Risk of occlusion amblyopia
- Systemic absorption
 Unless penalisation decreases the VA of dominant
eye below the amblyopic eye this form of treatment
is not adviced

25. Methods of penalisation
a. Near penalization: fixing eye is atropinized & fully
corrected for distance, amblyopic eye is
overcorrected with +2.00 to +3.00 D
b. Distance penalization: fixing eye is atropinized &
overcorrected, amblyopic eye is fully corrected
c. Total: fixing eye is atropinized & undercorrected
by 4.00 to 5.00 D, amblyopic eye is fully corrected

26. Summary of the PEDIG studies
Short
title
Ages
(Yrs)
Baselin
e
amblyo
pic eye
acuity
Primary
outcome
measure
Initial
treatment
prescribed
Result
s
(Impro
vemen
t)
Primary conclusion
ATS 1
(35)
3 to
<7
20/40-
20/100
Lines
improvem
ent after
26 weeks
Daily
atropine
At least 6
hrs daily
patching
2.8
lines
3.2
lines
Atropine and patching
are equally effective
as primary treatment
for moderate
amblyopia
ATS
2A
(37)
3 to
<7
20/100
-
20/400
Lines
improvem
ent after
17 weeks
6 hrs daily
patching
Full time
patching
4.8
lines
4.7
lines
6 hrs daily patching
produces
improvement similar
to full time patching
for severe amblyopia
ATS
2B
(36)
3 to
<7
20/40-
20/80
Lines
improvem
ent after
17 weeks
2 hrs daily
patching
6 hrs daily
patching
2.4
lines
2.4
lines
2 or 6 hrs of
prescribed daily
patching produce
similar improvement
for moderate

27. Summary of the PEDIG studies
Short
title
Ages
(Yrs)
Baselin
e
amblyo
pic eye
acuity
Primary
outcome
measure
Initial
treatment
prescribed
Results
(Improvement)
Primary conclusion
ATS3
(39)
7 to
<18
20/40-
20/400
Proportion
of
responders
(improveme
nt >2 lines)
after 24
weeks
2-6 hrs daily
patching (+
atropine if
<12 yrs)
Spectacles
alone if
needed
Response
rates:
Age≤12 yrs:
53%
Age≥13 yrs:
25%
Age≤12yrs:
25%
Age≥13 yrs:
23%
ATS 4
(34)
3 to
<7
20/40-
20/80
Lines
improveme
nt after 17
weeks
Weekend
atropine
Daily atropine
2.3 lines
2.3 lines
Weekend and daily atropine
produce similar
improvement for moderate
amblyopia
ATS 5
(38)
3 to
<8
20/40-
20/400
Lines
improveme
nt after 5
weeks
2 hrs daily
patching
Spectacles
alone if
needed
1.1 lines
0.5 lines
After a period of spectacle
wear, 2 hrs daily patching
is superior to continuing
spectacles alone

28. Practical Implications of the PEDIG studies
 Children < 7 yrs and VA between 6/12 to 6/24
- 2 hrs and 6 hrs patching - same effect
 Children < 7 yrs and VA 6/30 - 6/120
- 6 hrs and full time patching - same effect
 Children < 7 yrs and VA 6/12 - 6/30
- Daily atropine produces similar effect as 6 hrs
patching

29. Practical Implications of the PEDIG studies
 Children 7 to 18 yrs and VA 6/12 to 6/120
- 2 - 6 hrs patching leads to at least 2 lines
improvement
(if no previous treatment) but
- the compliance rate is poor in age >13 yrs
 Children < 8 yrs and VA 6/12 - 6/120
- Patching 2 hrs is better than spectacles alone

30. Amblyopia is still an unsolved problem, the
best modality of treatment is still to be
explored in future
Thankyou