Part-time vs.

Full-time
Occlusion for Amblyopia:
Evidence for Part-time Patching
Noëlle S. Matta, CO., C.R.C., C.O.T.
David I. Silbert, M.D., F.A.A.R

ABSTRACT
Amblyopia is characterized by a decreased uncorrectable
visual acuity in a structurally normal eye. Occlusion ther-
apy has been used for years to improve acuity, and, tradi-
tionally, practitioners have utilized full-time patching. This
article will explore more recent research looking at using
part-time patching in the treatment of amblyopia.

WHAT IS AMBLYOPIA? racts or visually significant ptosis.^ For

Amblyopia occurs when visual acuity is
reduced and is not immediately correct-
able with glasses in a structurally normal
eye. Amblyopia is most commonly caused
by strabismus due to suppression and
from significant refractive error in one or
both eyes. Deprivation amblyopia can be
caused by structural anomalies that block
the visual axis, such as congenital cata-
the purposes of this review article, we will
only discuss refractive and strabismic am-
blyopia. Amblyopia is found in 1.6-3.6%
of the population,^ more frequently in the
medically underserved.^ When treated at a
young age, this condition is completely re-
versible making pédiatrie vision screening
essential to avoid preventable vision loss.'*
AMBLYOPIA RISK FACTORS

In 2003, The American Association for

From the Family Eye Group, Lancaster, Pennsylvania.
Pédiatrie Ophthalmology and Strabismus
(AAPOS) defined criteria to determine
Reprint requests should be addressed to: Noëlle S. Matta when a child is at risk for developing am-
CO., C.R.C., C.O.T., Family Eye Group, 2110 Harrisburg
Pike, Ste. 215, Lancaster, PA 17601; e-mail: NoelleMatta®
blyopia^:
gmail.com
• Anisometropia (spherical or cylindri-
Presented as part of a Symposium of the Joint Meeting of the
American Orthoptic Council, the American Association of
cal) >1.5D
Certified Orthoptists, and the American Academy of Oph- • Any manifest strabismus
thalmology, Chicago, Illinois, November 11, 2012. • Hyperopia >3.5 D in any meridian
© 2013 Board of Regents of the University of Wisconsin System, American Orthoptic Journal, Volume 63,2013, ISSN 0065-955X. E-ISSN 1553-4448

14
 MATTA

TABLE 1
PART-TIME VS. FULL-TIME OCCLUSION FOR AMBLYOPIA:
EVIDENCE FOR PART-TIME PATCHING

Refractive risk factor targets

Age (months) Astigmatism Hyperopia Anisometropia Myopia

12-30 > 2.0 D >4.5D >2.5D > -3.5 D

31-48 >2.0D >4.0D >2.0D > -3.0 D
> 48 > 1.5 D >3.5D >1.5D >-1.5D

Nonrefractive amblyopia risk factor targets for all ages

• Manifest strabismus > 8"* in'. primary position
• Media opacity

• Myopia magnitude >3 D in any me- ing cycloplegic refraction, if amblyopia is

ridian
• Any media opacity >1 mm in size
• Astigmatism >1.5 D at 90° or 180°;
>1.0 D in oblique axis (>10° eccentric
to 90° or 180°)
• Ptosis < 1 mm margin reflex distance
These criteria have recently been revised
to the following^ (Table 1).
WHY DO WE TREAT AMBLYOPIA?
Amblyopia is one of the leading causes
of vision loss in adults under the age of
40.' Treatment of amblyopia is very cost
effective at $100 for a 6-month supply of
patches.® Children treated for amblyopia
may have an improvement in their stra-
bismus or a reduction in the deviation of
the strabismus, changing the surgical
plan.^ Treatment of amblyopia is protec-
tive for the patient. It is important for a
patient to have two functioning eyes in
case visual acuity should be compromised
in the sound eye from trauma, diabetes,
glaucoma, etc.^°
TREATMENT OPTIONS FOR
AMBLYOPIA
After receiving a comprehensive pédi-
atrie ophthalmology examination includ-
present a determination must be made if
the child has significant refractive error. If
so, full-time glasses should be prescribed
based on the cycloplegic refraction. ^^ Full-
strength should be prescribed, or the
spherical power can be symmetrically re-
duced. Some children will have resolution
of their amblyopia with glasses use alone,^^
but if amblyopia persists occlusion therapy
can be started. Common options of occlu-
sion therapy include patching (using a
stick on or cloth eye patch) or pharmaceu-
tical penalization (atropine).^^ Less com-
mon options can include optical penaliza-
tion,^* Bangerterfilter,^^occlusive contact
lens,^^ translucent tape,^^ plastic occlusive
shield,^* or botulinum toxin to induce pto-
sis and thus occlusion of the sound eye.^^
PATCHING
Patching therapy is commonly used to
treat amblyopia, but there is much de-
bate over the length of time that patching
should be prescribed. Occlusion therapy
has been used since at least 1949.^° Most
older studies prescribe patching full time,
or full time except 1 hour. There have been
two clinical trials comparing full-time to
part-time patching. Holmes et al. reported
for the Pédiatrie Eye Disease Investigator
Group (PEDIG) that young children patch-

American Orthoptic Journal 15

SYMPOSIUM: CONTROVERSIES
ing full time with severe amblyopia had an
impovement of 4.7 lines in their amblyopic
eye, which was similar to children patch-
ing 6 hours per day who had a 4.8 line
improvement.^^ A second study compared
full-time vs. 6 vs. 4 vs. 2 hours per day of
patching in older children with mild-severe
amblyopia, and these patients had an im-
provement of 3.6, 3, 2.6, and 1.7 lines, re-
spectively.^^ The group only patching for 2
hours per day did have less improvement
over the course of the study, but when only
looking at children with mild-moderate
amblyopia there was no significant dif-
ferance. Another study by Stewart et al.
compared 12 to 6 hours of daily patching.^^
Both groups improved similarly (2.4 and
2.6 lines, respectively), and they also re-
ported that parents patched substantially
less than what was prescribed. Another
study by Lee et al. compared 6 vs. 4-5 vs.
3 or less hours of patching and found the
groups improved 5.3, 4.6, and one line, re-
spectively; however, it should be noted that
there were only seventeen children in the 6
hour group, seven children in the 4-5 hour
group, and two children in the 3 hours or
less group, and this must be considered
when weighing the impact of the results.^''
A very large study done by PEDIG com-
pared 10 or more hours of daily patching
to 8 and 6 hours.^^ Children were under
the age of 7 years, had initial amblyopia vi-
sual acuity of 20/40-20/100, and all groups
improved by 3.1 lines. These results were
similar to another PEDIG study looking at
children in the same age group with the
same visual acuity, comparing 2 to 6 hours
of daily patching where both groups im-
proved by 2.4 lines (Table 2 and Figure). ^^
DISCUSSION
After many years of research, it is now
known that children found to have ambly-
opia who are treated at a young age can
achieve normal visual acuity with proper
treatment. If occlusion therapy is required.
16
the choice of which treatment to initiate
should be based on the clinician's, par-
ents', and patient's opinions. If patching
is prescribed, the amount of time should
be based on the clinician's clinical judge-
ment, but part-time occlusion is a reason-
able approach. If part-time occlusion is
initiated and the patient does not make
adequate improvement in their visual acu-
ity, increasing the patching time may be
beneficial. When discontinuing patching, it
has been shown that fewer hours patched
may have less of a risk of recurrence in am-
blyopia.^^ There may be a place for wean-
ing when full-time or more than 2 hours
a day is prescribed, and there is currently
a PEDIG study underway looking to an-
swer this question. Two studies have even
shown that the risk of reverse amblyopia
was significant in children who patched
full time (19-21%).28.29 Another study even
reports on sudden onsent of large-angle
esotropia associated with full-time patch-
ing.^° There have also been studies showing
a trend in members of AAPOS prescribing
fewer hours of patching.^! In 2003, 79% of
members were patching for 8 hours or less
a day, with 29% patching for 4 or less hours
a day. These percentages had increased by
2006 with 92% of members patching 8 or
less hours per day and 53% of members
patching 4 or fewer hours per day.
Whether you prescribe full time, 8
hours, or 2 hours of patching, evidence-
based medicine proves that patching ther-
apy works. Screening programs need to be
improved in the United States to ensure
patients with amblyopia risk factors are
identified and referred to a pédiatrie oph-
thalmology practices so patching can be
initiated in a timely fashion.
REFERENCES
1. Wright KW, Spiegel PH. The Requisites: Pédiat-
rie Ophthalmology and Strabismus. St. Louis:
Mosby Co.; 1999, pp. 200-202.
Volume 63, 2013
 MATTA

TABLE 2
OVERVIEW OF STUDIES COMPARING FULL-TIME TO PART-TIME PATCHING,
AND COMPARING VARYING AMOUNTS OF PART-TIME PATCHING

Author (year Age in years Number of Amblyopic visual acuity Hours Lines
published) (average) patients at baseline (average) patched improved

PEDIG (2003)25 < 7 (5.3) 204 20-40 - 20/100 (20/60)

91 20/40 - 20/100 6 3.1
58 20/40 - 20/100 8 3.1
55 20/40 - 20/100 10+ 3.1
Repka (2003)26 <7 (5.2) 189 20/40 - 20/100 (20/63)
(5.1) 95 20/40 - 20/80 (20/63) 2 2.4
(5.4) 94 20/40 - 20/100 (20/63) 6 2.4
Holmes (2003)^1 <7 (4.8) 175 20/100 - 20/400 (20/160)
(4.7) 85 20/100 - 20/400 (20/160) 6 4.8
(5.0) 90 20/100 - 20/400 (20/160) full-time 4.7
Scheiman (2005)^' 13-17 103 20/40 - 20/400 (20/80)
(14.9) 55 20/40 - 20/400 (20/80) 0 6.2
(14.7) 48 20/40 - 20/400 (20/80) 2-6 9.2
Lee (2006)2" 8-12 (8.79) 29 20/25 - 20/80 (20/63)
17 6 5.3
7 4 or 5 4.6
2 3 or less 1
Wallace (2006)^2 3-7 (5.4) 180 20/40 - 20/400 (20/80)
(6.3) 93 20/32 - 20/400 (20/80) 0 0.5
(5.4) 87 20/40 - 20/400 (20/80) 2 1.1
Stewart (2007)2=» 3-8(5.6) 80 (20/63)
(5.4) 40 (20/63) 6 2.6
(5.6) 40 (20/63) 12 2.4
Sigh (2008)22 7-12 (8.9) 100 20/30 or worse
(8.9) 25 20/40 - 20/400 (20/100-20/80) 2 1.7
(9.5) 25 20/30 - 20/400 (20/125) 4 2.6
(10.0) 25 20/30 -20/400 (20/100-20/80) 6 3
(9.3) 25 20/40 - 20/400 (20/125-20/100) full-time 3.6

2. Simons K: Amhlyopia characterization, treat-

FIGURE: Vertical axis shows lines of vision improved
with patching across all studies shown in Table 2.
Horizontal axis shows number of hours patched.
Full-time patching was categorized as 18 hours of
patching.
ment, and prophylaxis. Surv Ophthalmol 2005;
50:123-166.
3. Caca I, et al.: Amblyopia and refractive errors
among school-aged children with low socioeco-
nomic status in southeastern Turkey. J Pediatr
Ophthalmol Strabismus 2012; 11:1-7.
4. Holmes JM, et al.: Effect of age on response to
amblyopia treatment in children. Arch Oph-
thamol 2011; 129:1451-1457.
5. Donahue SP, et al.: Preschool vision screening:
what should we be detecting and how should
we report it? Uniform guidelines for reporting
results of preschool vision screening studies.
JAAPOS 2003; 7:314-316.
6. Donahue SP, et al.: Revised guidelines for re-
porting results from studies of preschool vision
screening. Presentation at the AAPOS annual
meeting, San Antonio Texas, March 27, 2012.

American Orthoptic Journal 17

SYMPOSIUM: CONTROVERSIES
7. Attebo K, Mitchell P, Smith W: Visual acuity and
the causes of visual loss in Australia: The Blue
Mountains Eye Study. Ophthalmology 1996;
103:357-364.
8. Angi MR, Pucci V, Forattini F, Formentin PA:
Results of photorefractometric screening for am-
blyogenic defects in children aged 20 months.
Behau Brain Res 1992; 49:91-97.
9. Chun BY, Kwon SJ, Chae SH, Kwon JY: Reduc-
tion of deviation angle during occlusion therapy:
In partially accommodative esotropia with mod-
erate amblyopia. Korean J Ophthalmol 2007;
21:159-162.
10. Rahi J, Logan S, Timms C, Rüssel 1-Eggitt I, Tay-
lor D: Risk, causes and outcomes of visual im-
pairment after loss of vision in the nonamblyo-
pic eye: A population-based study. Lancet 2002;
360:597-602.
11. Donahue SP: Prescribing spectacles in children:
A pédiatrie ophthalmologist's approach. Optom
Vis Set 2007; 84:110-114.
12. Wallace D, et al.: Treatment of bilateral refractive
amblyopia in children 3 to <10 years old. Am J
Ophthalmol 2007; 144:487-496.
13. PEDIG, et al.: A randomized trial of atropine vs.
patching for treatment of moderate amblyopia in
children. Arch Ophthalmol 2002; 120:268-278.
14. Repka MX, Gallin PF, Scholz RT, Guyton DL:
Determination of optical penalization by vecto-
graphic fixation reversal. Opthalmology 1985;
92:1584-1586.
15. PEDIG, et al.: A randomized trial comparing
Bangerter filters and patching for the treatment
of moderate amblyopia in children. Ophthalmol-
ogy 2010; 117:998-1004.
16. Eustis HS, Chamberlain D: Treatment for ambly-
opia: Results using occlusive contact lens. J Pedi-
atr Ophthalmol Strabismus 1996; 33:319-322.
17. Beneish RG, Polomeno RC, Flanders ME,
Koenekoop RK: Optimal compliance for ambly-
opia therapy: Occlusion with a translucent tape
on the lens. Can J Ophthalmol 2009; 44:523-528.
18. Arnold RW, Armitage MD, Limstrom SA: Sutured
protective occluder for severe amblyopia. Arch
Ophthalmol 2008; 126:891-895.
19. Halkiadakis I, Iliaki 0, Kalyvianaki MI, T^ilim-
baris MK: Occlusion therapy of unilateral ambly-
opia with botulinum toxin induced ptosis. Semin
Ophthalmol 2007; 22:55-57.
20. Eakin MK, Eakin RS: The use of occlusion in the
treatment of amblyopia: Five case reports. Am J
Optom Arch Am Acad Optom 1949; 26:400-404.
18
21. Holmes JM, et al.: A randomized trial of pre-
scribed patching regimens for treatment of se-
vere amblyopia in children. Ophthalmology 2003;
110:2075-2087.
22. Singh I, Sachdev N, Brar GS, Kaushik S: Part-
time occlusion therapy for amblyopia in older
children. Indian J Ophthalmol 2008; 56:459-463.
23. Stewart CE, et al.: Objectively monitored patch-
ing regimens for treatment of amblyopia: Ran-
domized trial. BMJ 2007; 335:707.
24. Lee YR, Lee JY: Part-time occlusion therapy for
anisometropic amblyopia detected in children
eight years of age and older. Korean J Ophthal-
mol 2006; 20:171-17 6.
25. PEDIG, et al.: The course of moderate amblyopia
treated with patching in children: Experience of
the amblyopia treatment study. Am J Ophthal-
mol 2003; 136:620-629.
26. Repka MX, et al.: A randomized trial of patching
regimens for treatment of moderate amblyopia in
children. ArcA Ophthalmol 2003; 121:603-611.
27. Holmes JM, et al.: Risk of amblyopia recurrence
after cessation of treatment. J AAPOS 2004;
8:420-428.
28. Varadharajan S, Hussaindeen JR: Visual acuity
deficits in the fellow eyes of children with unilat-
eral amblyopia. JAAPOS 2012; 16:41-45.
29. Longmuir S, et al.: Effect of occlusion amblyopia
after prescribed full-time occlusion on long-term
visual acuity outcomes. J Pediatr Ophthalmol
Strabismus 2012; 4:1-8.
30. Lee H, Kim US: Abruptly developed large eso-
tropia after full time occlusion therapy in ani-
sometropic amblyopia. Int J Ophthalmol 2012;
5:650-651.
31. Wygnanski-Jaffe T, Levin AV: The effect of the
randomized trial of patching regimens for treat-
ment of moderate amblyopia on pédiatrie oph-
thalmologists: Three-year outcome. J AAPOS
2007; 11:569-572.
32. Scheiman MM, et al.: Randomized trial of treat-
ment of amblyopia in children aged 7 to 17 years.
Arch Ophthalmol 2005; 123:437-447.
33. Wallace DK, et al.: Arandomized trial to evaluate
2 hours of daily patching for strabismic and ani-
sometropic amblyopia in children. Ophthalmol-
ogy 2006; 113:904-912.
Key words: amblyopia, occlusion ther-
apy, patching, strabismus
Volume 63, 2013
Copyright of American Orthoptic Journal is the property of University of Wisconsin Press
and its content may not be copied or emailed to multiple sites or posted to a listserv without
the copyright holder's express written permission. However, users may print, download, or
email articles for individual use.