Treat Amblyopia in Earnest, Vern!

If you click on the “Facts and Fallacies About Vision Therapy” category cloud on the blog you’ll note many instances where Optometry and Ophthalmology are seemingly at odds regarding vision therapy.  Today I’d like to share with you an example of a case in which the two professions ultimately offer what they do best to help a young boy develop improved visual abilities.  Here’s Anthony’s mom, seated in a back corridor of our office, her feet up against the door of one of our vision therapy rooms.  Our staff sometimes refers to this area as our “quiet room”. but when Anthony’s in there it’s usually far from quiet, and mom was making sure that he wouldn’t bolt from the room!  A three and a half year old boy, Anthony got off to a rough start.  He was a big little guy at birth, 10 lbs. 3 ozs.  His right leg was tucked in an awkward position in utero for much of mom’s pregnancy, and she was told when he was born that he might need a brace in order to walk normally.  Maria is a massage therapist, and she refused to accept the dire news, so she worked on Anthony and he was able to develop better bilateral symmetry.

At 32 months of age his mother felt his right eye had been turning inward and took Anthony to a pediatric ophthalmologist for examination upon referral from her pediatrician.  The doctor noted a difference in hyperopia (farsightedness) between the two eyes, and prescribed glasses.  In his report to Anthony’s pediatrician he wrote: “Anthony has a pseudostrabismus, but no true turn.  Of more concern is the anisometropia, which puts him at very high risk for refractive amblyopia.  I gave Anthony a prescription, to be used at all times, and I plan to check his motility and vision again, in about 3 months.”

The doctor’s follow up report three months later notes that he had no strabismus, but a small angle esophoria which is not of concern.  This time he was able to obtain visual acuities through the glasses, which were 20/200 right eye (legally blind), and 20/30 left eye.  He recommended patching the left eye at least 3 hours daily, with atropine in the right eye if patching isn’t successful.

Two months later Anthony returned, and the doctor’s report notes that visual acuity “was not measurable with the right eye” .  Mother was told to continue with the glasses, patching and atropine and to return in 2-3 months.  The doctor wrote: “If the right vision does not improve by that time with both the atropine and patching, then it may be already too late to treat the amblyopia.” 

Amazing, isn’t it?  Here the little guy just turned three, and the pediatric ophthalmologist is telling mom that it may be already too late to treat amblyopia?  I know the U.S. Postal Service is slipping up on the job, but can’t this doc subscribe to Archives of Ophthalmology electronically?  I don’t attend ophthalmology CE meetings, and they don’t attend ours, but it would seem highly unusual for the news of the PEDIG research showing that amblyopia can be successfully treated well beyond age 7 not to have filtered through to this gentleman.  Sure enough, he re-examined Anthony 3 months later, and acuity vision was measured at 20/400 equivalent with the right eye.  The report again states: “I discussed this with mother, and told her that there may be no way to improve the right acuity any further.”  Oh well ….

Anthony’s mom was growing increasingly concerned about his behavior.  She took him to a neuro-developmental pediatrician.  His report states that the family has tried disciplining techniques, which have not been very effective.  (He is very active, restless, doesn’t sit still, prefers to do things his own way, and hence mother’s feet on the door to make sure he knows there’s a barrier he is not to cross.)  MRIs and EEGs were conducted, and proved negative.  The pediatrician recommended that the Child Study Team evaluate him, and that he has early signs of ADHD and ODD.  He recommended a speech and language evaluation, and an OT evalaution to put him on a sensory diet once he’s in a special preschool program.  He also advised counseling with a clinical psychologist for behavior modification strategies.  Notice anything missing?  Yup.  Not a word about vision, other than he’s being managed by the pediatric ophthalmologist.

Anthony’s mother was determined to look further.  The pediatric ophthalmologist had become “very aggressive” toward Anthony on his last visit, at which time he told Maria that there was nothing further to be done, and to wear polycarbonate lenses to protect the vision in Anthony’s left eye. They felt unwelcomed in his office.  They went to another pediaric ophthalmologist who was kinder and more patient with Anthony, and told Maria not to give up, but to get a pair or Rec Specs so Anthony doesn’t look over his glasses, and to patch his left eye 24/7.  Anthony’s strabismus was constant now.  She asked about vision therapy and again was told there was nothing to  be done other than patching.  Frustrated, Maria went surfing.  And when she found Jillian’s Story on facebook she was overjoyed.  She found a link to us through that page and immediately knew by going on our facebook page that we were the right office for Anthony.  His grandmother is a retired special education teacher, and she had a good vibe that going the developmental optometry route made a lot of sense – and that the neuro-developmental pediatrician should have thought of a consult with us.

Maria brought Anthony to us a month after she had seen Ped Ophthalmol #2.  Despite patching full time over his glasses his best corrected acuity of the right eye at that time was still only 20/200 equivalent (legally blind).  We conducted a VEP  and determined that although his two eyes were out of phase due to his strabismus (constant 15^ ET R eye with glasses), his potential for visual acuity was equal in both eyes.  We not only continued aggressive patching and full time wear of the Rx; we implemented vision therapy in earnest.  No — I didn’t say we approached vision therapy like Ernest, Vern.  I said we did it in earnest, with regular office visits and assigned home therapy.

We did low tech stuff, high tech stuff, all while Anthony was patched, and one month after we began Anthony’s visual acuity had already improved from 20/200 to 20/50!  Our whole therapy staff was magnificent in working with him,  and man did it take a village to visually raise this child.  But we did it, and within 4 months Anthony was holding between 20/30 and 20/20 with the right eye. At that point his right esotropia was steady at between 15^- 20^ and Ped. Ophthalmol #2, who’s a real mensch  wanted to do strab surgery on the R eye.  We’ve worked together on cases before, so I figured fine – let him operate and we’ll pick up with Anthony a week after surgery to safeguard his amblyopia and work on extending the quality of his binocular vision.

So that’s where we are, Vern.  Just saw Anthony yesterday for a progress evaluation (he’s such a pleasure to examine after a good night’s sleep!).  He has no random  dot stereopsis, cover test is at 8^ esotropia of the right eye, and he suppresses that eye at distance.  The good news is that he does show Worth 4 Dot fusion briefy at 4 feet and then goes into a diplopia pattern within that distance.  So there’s a centration region we can continue to build on.  More importantly, there’s a lesson to be learned here about treating amblyopia in earnest.

– Leonard J. Press, O.D. , FCOVD, FAAO, with a big assist from Dr. Daniel Press, Dr. Michelle Brennan, Danielle Delaney, Jennifer Ehrentraut, the Billson Family, and our front desk team of Judy and Jodi who make sure that Anthony flies in and out of the office through his own private entrance and exit!







4 thoughts on “Treat Amblyopia in Earnest, Vern!

  1. Thanks for this story, Dr. Press. VTODs are most often labeled with less than complimentary epithets by OMDs, but they are often the first to drop the ball on these cases. Imagine, prescribing ADHD meds for a child whose behavioural issues stem from amblyopia? Somethings is most definitely missing from pedagogical and pediatric curriculae.

  2. You’re welcome, Dr. Boulet, and I fully agree regarding the narrow focus in pediatric curriculae, particularly when it comes to deferring to omniscient ophthalmology – even on matters of optometric expertise – hence travesties such as the Joint AAP/AAO Policy Mis-Statement regarding VT. I do, however, have to qualify your remark about ADHD meds/behavioral issues and amblyopia. This child’s behavioral issues, including extreme hyperactivity, are not related to his amblyopia. While much of behavior can be linked to visual issues, let’s not over-extrapolate.

  3. Yes we have all seen the ignorance of MD vision care.
    I am curios as to the need for surgery PRIOR to VT since you were successful with a very similar patient that I referred to you

    • Good observation, Dr. Sherman. Two points: 1) the surgery wasn’t done prior to VT. It took place 4 months into VT once improvement in the amblyopia was well under way. 2). The surgery wasn’t my idea in this case, but I was willing to work with it because I was able to continue VT with minimal disruption in continuity. All too often the surgeon tells the patient to d/c VT post-surgically, but this wasn’t the case here because I had a good working relationship with this particular surgeon.

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