Amblyopia

The decision to patch the better eye must be made by the ophthalmologist, with the aim of training the whole visual system and improving the visual acuity of the amblyopic eye, whether or not strabismus is present. Continuous monitoring by a qualified ophthalmologist is essential, both to check how well patching is working and to avoid causing amblyopia in the dominant, normal eye.

Treating amblyopia depends on the adaptability (plasticity) of the visual system. Once the brain “matures,” it no longer responds satisfactorily to treatment. Treatment should ideally be completed by the age of 8–9 years. However, the most recent large study funded by the US National Institutes of Health (NIH) showed that at least some patients up to the age of 17 respond to treatment with patching.

Treatment must be individualized for each case. Modern studies have given ophthalmologists clear guidelines on the duration and frequency of patching according to age and the severity of the amblyopia. Two hours of patching per day have been shown to be sufficient provided the amblyopia is not severe and the patient is between 3 and 7 years old. An absolute requirement is active use of the visual system during these hours (drawing, playing, reading, etc.). Part-time patching on weekends only can be sufficient in cases that have already responded to treatment.

Yes. In selected cases, atropine drops in the better eye (penalization) can be used instead of patching, and digital dichoptic (binocular) therapies are available for suitable patients, as described above. Parents should, however, be careful with another category of offerings.

Beware of “vision training programs” from non-ophthalmic centers. In recent years, a growing ecosystem of non-ophthalmic providers has emerged in Greece and internationally: optometrists specializing in “behavioral optometry,” private “vision training” centers and “visual gymnastics” agencies. They widely promote extensive and expensive programs of visual exercises (known as “vision therapy,” “behavioral vision therapy” or “visual training”), promising to address an extremely broad range of conditions: dyslexia, learning difficulties, ADHD, reading difficulties, poor school performance, attention disorders, athletic performance, and even “syndromes” such as convergence insufficiency offered as a catch-all explanation for any difficulty. In most cases these are commercial packages of dozens of sessions, at considerable cost and without transparent measures of therapeutic outcome.

The position of the leading international pediatric and ophthalmology organizations is clear and unequivocal. It is set out in a joint statement by the American Academy of Pediatrics (AAP), the American Academy of Ophthalmology (AAO), the American Association for Pediatric Ophthalmology and Strabismus (AAPOS) and the American Association of Certified Orthoptists (first issued in 2009 and reaffirmed since). According to this statement, there is no scientific evidence that eye exercises (vision therapy) or special colored lenses are effective in treating learning disabilities such as dyslexia. Dyslexia is a language-based neurodevelopmental disorder, not a visual one. ADHD is a neurodevelopmental disorder, not a visual one. Poor school performance has multiple causes (cognitive, educational, psychosocial) that need to be assessed by the appropriate professionals (pediatrician, child psychologist, speech-language therapist, special educator), not treated with eye exercises.

The scientific community regards behavioral vision therapy, when applied to the above indications, as lacking scientific support (pseudoscience). The best-established condition that benefits from visual exercises is symptomatic convergence insufficiency, and even then only with specific, specialized orthoptic protocols. Furthermore, despite advertising claims, there is no scientific evidence that “visual system training” slows the progression of myopia (the Tracksight method is not yet certified), or that it improves athletic performance in various sports.

At Athens Vision, we apply only therapeutic approaches with an established scientific basis, CE-marked where applicable and accepted by the ophthalmology community. When a patient comes to us with a history of participation in a “vision therapy” program from a non-ophthalmic provider, our recommendation is almost always the same: a systematic reassessment of the real cause of the problem and referral to the appropriate specialists (pediatrician, developmental specialist, speech-language therapist, child psychologist, special educator, or eye-movement assessment with the Greek eyeRADAR method), depending on the actual findings. We advise all parents to be especially cautious when they are offered a “treatment” that promises to correct refractive errors, learning difficulties, ADHD and athletic performance all at once. Such broad promises usually reflect misleading practices or, at best, approaches with no scientific foundation (pseudoscience).

Correcting strabismus (if present) is not a direct treatment for amblyopia. On the other hand, aligning the eyes is a basic prerequisite for improving binocular cooperation and binocular vision, which are always affected in amblyopia. For this reason, when strabismus and amblyopia coexist, surgical correction of the strabismus may be needed, along with continuous follow-up.

Restoring vision to 20/20 (10/10) is not always possible in amblyopia treatment. In general, treatment should continue for as long as it is effective. This usually means patching for several months and sustained effort on the part of the parents. When a young child cooperates poorly, we recommend a temporary pause in treatment, which often allows the child to cooperate much better later. If treatment proves ineffective despite all this, usually because of age, discontinuing it is recommended.