Amblyopia Research Supports Treatment Without Patching

New amblyopia research shows that treatment with both eyes is better than patching alone!

eyepatch used in amblyopia researchFor ages, the majority of amblyopia research and treatment has focused on two areas: the use of glasses to provide the clearest vision possible and the use of an eye patch to force the amblyopic (weaker) eye to see.  Patching often worked well. But there are some reasons why patching alone often doesn’t work.

The problem is patching is two fold:

1) Patching is hard!  (It can be like a form of torture for some patients.) Cover up your good eye and see everything blurry for hours on end. You are forced to use an eye that you are not comfortable using, without having any idea how to intentionally move or change focus in that eye. You are just supposed to figure it out. Patients resist patching, avoid visually demanding activities, get frustrated more easily, and often “cheat” or “peek” from behind their patch.

As the American Optometric Association’s Amblyopia Patient Care Guideline says, “Noncompliance with occlusion represents a significant factor in occlusion failures, especially in patients over 8 years of age in whom up to 50 percent noncompliance is common.”

2)  Patching alone does not solve the underlying problem. Amblyopia is not a situation where one eye is normal and the other is lazy. Amblyopia is a situation where one eye is struggling to focus clearly or stay pointed in the right direction, and the other eye is a bully. Yes, literally. The bully eye steals the brain connections from the weaker eye and uses them for itself. So while patching helps the weaker eye reinforce brain connections and see more clearly, it does not teach the bully eye to be nice. It just means the weaker eye can stand up for itself.

For example, it is like taking a right-handed child and putting the right arm in a cast for 8 hours a day for a year or so. Without helping them learn to hold a pencil, button clothes, or eat with their left hand – what will they do? They will avoid activities that need them to use their hands because they are clumsy. And when the cast is off, the right hand still takes over. What about activities that use both hands together, like tying a shoe? They still haven’t really developed equal strength between both hands, fine motor control of the left hand, or any coordination with the right hand.

The same happens with binocular vision (using both eyes). Patients who only use patching, often find the amblyopia returns when the patching stops, because they never learned to use both eyes together. It’s easy for the eyes to slip back into old (bad) habits. More patching? Again? At some point, it would seem easier to just give up and accept less than ideal vision.

But there is good news! I have written about some exciting developments in amblyopia research before, such as the amblyopia Tetris study, which showed that amblyopic treatment not with patching, but by treating both eyes (binocular), improved amblyopia in adults.

amblyopia researchI am happy to report that there has been a recent spate of studies concerning the binocular treatment of amblyopia. Optometrists have felt for years that amblyopia was primarily a binocular phenomenon, and therefore required binocular solutions. We have anecdotally observed 1) faster treatment of amblyopia with binocular vision therapy and 2) greater regression with patching alone versus patching plus some form of binocular therapy. We are very excited to see excellent recent research that supports this view, mostly done by ophthalmologists and neuroscientists.

Be warned, gentle reader, the following are quotes directly from the published scientific papers on amblyopia research. I will summarize below each passage.  Emphasis mine.

Converging evidence points to the pivotal role of decorrelated binocular experience in the genesis of amblyopia and the associated residual deficits. These findings suggest that a new treatment approach designed to treat the binocular dysfunction as the primary deficit in amblyopia may be needed. Prog Retin Eye Res. 2013 Mar; 33: 67–84.

What this means: It turns out that amblyopia might be due to a problem of both eyes, not just the “lazy” one. We should find a way to treat both eyes together.

…dichoptic perceptual learning, designed to strengthen binocular combination by reducing suppression, improves both stereopsis and acuity in adults and children with amblyopia…. As a whole, these results lead us to question the prevalent view that amblyopia is primarily a disorder of monocular vision and should be treated accordingly with monocular occlusion. If we are open to the possibility that binocular interactions lie at the heart of amblyopia, then we could be at the threshold of a new age of therapeutic interventions that don’t involve patching the fellow fixing eye. Ophthalmic and Physiological Optics Volume 34, Issue 2, pages 146–162, March 2014 

What this means: Yep. Amblyopia is a problem of both eyes. And treating both eyes is better. And that means that hours of patching one eye might soon be a thing of the past. And vision therapy is the way of the future for patients of any age.

If you want to read more about the amblyopia treatment that we offer go here. If you would like to make an appointment to have yourself or child evaluated go here or call 813-792-0637.

Onward and Upward!

Dr. Nate on amblyopia research

An Infographic About Amblyopia

There is a lot of discussion lately about amblyopia (AKA lazy eye), largely due to the recent news reports of adaptations of Tetris and other video games as treatments for amblyopia. As I described in my previous post, these new binocular techniques are definitely better than old-school patching. However, in there essence, these techniques are not new. In fact, optometrists have known for a long time that treating two eyes is better than one. That is the basis of what we do in the vision therapy room to help patients with amblyopia – play games with both eyes at the same time.

I’m very happy to share with you an infographic on amblyopia treatment from the VisionHelp blog.

Amblyopia Infographic

You can read the full story behind the origin of this excellent infographic here. I think it is fantastic!

If you and your child are struggling with patching – you don’t have to be! Not only is binocular therapy more effective than patching – it is way more fun! If you have questions about amblyopia, vision’s therapy, or children’s vision in general, do not hesitate to give us at call at 813-792-0637 or email me at Doc@BrightEyesTampa.com.

And please  – share, pin, tweet or photocopy this infographic!

Dr. Nate

By Nathan Bonilla-Warford, OD
Bright Eyes Family Vision Care
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Tetris therapy for amblyopia? Yes, please.

A new study, about amblyopia, has been published and it is really getting attention. From CBS news to Huffington Post to CNET, everyone is covering it, probably because they get to use the word “Tetris” in the title. Tetris, of course, is the hugely addictive block-stack game that, at least in my memory, was the first hand-held videogame blockbuster.

Amblyopia, known to many people as “lazy eye” is a visual adaptation to conditions that interfere with visual development. On a simple level, it means that even with the best glasses or contact lenses, the eye does not see and function as well as expected. It is not due to disease or injury, but rather a situation where the brain doesn’t communicate well with one eye and can’t use the eyes as a team.
Think of the brain being someone on the internet, and one eye is a friend with 14.4K dial up and the other has a 4G smart phone. Yes, you can communicate with both eyes, but you are going to prefer the 4G because it is faster and can do more things. Trying to use both eyes simultaneously as a team is hard because one is lagging behind and missing information.

I am extremely glad to see this study and I do have some thoughts on it:
First, do not get too excited about the Tetris part. While I really have no doubt that Tetris and similar games stimulate visual planning and cognitive development, I suspect that the main benefit of using Tetris in this study is that it is very engaging, requires attention to visual detail, and requires the  player to make decisions based on visual information. Basically this is true for most video games (and real world games, for that matter). So Tetris is not the magic here.

What IS a big deal about this study is the goggles – they required the eyes to work together to play the game. If you play, you can’t just shut off the amblyopic eye, or you’ll lose because you won’t see the falling blocks. And that isn’t motivating or good therapy.  It isn’t patching or covering the good eye because you won’t see the blocks on the bottom. You still won’t win. This is like conventional patching. You can stimulate the amblyopic eye (upgrading the modem), but that alone only helps somewhat.

What this study shows is that only when both eyes can see and are given the opportunity to work together to achieve a common visual goal is there significant improvement in the amblyopic eye. In my internet analogy, this is not only giving the amblyopic eye a 4G smartphone but making sure it is net savvy. Both eyes are now friends on Facebook and Twitter so they can work together in real time to solve visual-spatial problems efficiently. (Just to be clear: the eyes do not use Facebook, and they do not communicate directly – all that happens in the brain).

So why is this so exciting? Because this is exactly what we do in vision therapy every day. We “upgrade” the eyes to work well individually (4G) but also “network” them to work together (Facebook, Twitter). We don’t use Tetris, but we do use paper & pens, balls, special glasses, computer programs, 3D art, optical illusions and lots of other fun tools to make it fun and productive.

It is great to see more research on this on adults with amblyopia. For too many years, patients have been told that after early childhood there is no hope of improving the vision in the amblyopic eye. It simply is not true. I did a blog post awhile back on the science behind amblyopia. You can see that here. For a great look at binocular treatment of amblyopia, see this recent post on the VisionHelp blog.

Dr. Nate

By Nathan Bonilla-Warford, OD
Bright Eyes Family Vision Care
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