Amblyopia Therapy – How Old is Too Old?

    Traditional ophthalmic teaching has suggested an upper age limit for treating amblyopia, usually in the range of 6 to 7 years. I have always felt that this was somewhat arbitrarily defined and have offered patching and/or penalization therapy to older children. Improvements have been dramatic in some cases, non-existent in others, but the question of compliance has always been an issue. This has recently been verified and quantified in a series of patients reported in the Archives of Ophthalmology by Dr. Helen A. Mintz-Hittner and Kristina M. Fernandez ("Successful Amblyopia Therapy Initiated After Age 7 Years," Arch Ophthalmol. 2000;118:1535-1541).

    Their retrospective study describes treatment results for 36 patients who were initially diagnosed with amblyopia (strabismic, anisometropic, or "mixed") after the age of 7 years. None of these patients had been previously diagnosed with or treated for any ophthalmic problem. Patients with certain types of amblyopia (organic, deprivation) were excluded. All patients were judged to have complied with treatment recommendations, which included optical correction (glasses or contact lenses), full-time occlusion (patch or occlusive contact lens) and/or pharmacologic "penalization" of the better-seeing eye using atropine drops.

    Initial acuities ranged from 20/60 to 20/400 in the amblyopic eye. All patients improved into the 20/20 to 20/30 range – a very gratifying result. Patients were treated for an average 10 months with a range of 3 months to slightly less than 3 years. Methods of "coercion and bribery" were mentioned but not detailed. Many of us would be as interested in these details as the outcome of the study.

    I have had similarly successful results over the years with a somewhat less stringent program of "part-time" patching after school and full-time on weekends with atropine supplementation prescribed on a case-by-case basis. My oldest responder was just over 9 years of age when starting treatment; one of Dr. Hitner’s patients was 10 years, 4 months. Isolated case reports have described treatment successes for milder degrees of amblyopia into the early teen years. These experiences would suggest that the answer to the question in the title should be "We don’t really know – but there is a chance of visual recovery if the child cooperates with treatment recommendations."

    The comparative efficacy of various amblyopia treatment regimens is currently being studied in a multi-center project, the Amblyopia Treatment Study (Vanderbilt is a participating department). Additionally, isolated investigators are exploring the efficacy of drugs which might selectively "unlock" cortical brain cell connections which underlie persistent amblyopia in older individuals. Photoscreening projects such as the Tennessee Lions’ Club/Eye Center outreach are helping to detect anisometropic and strabismic amblyopia at a much younger age when treatment results such as those described in Dr. Hitner’s article can be achieved more quickly and easily.

    One of our major goals in pediatric ophthalmology is to completely eliminate amblyopia. Now more than ever this should be a workable objective for physicians, parents, and children who deal with amblyopia on a day-to-day basis.

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