Elbow splinting increases amblyopia patching compliance…Really!!?

“Cutting edge” amblyopia research just announced, April 18, 2017, in Ophthalmology Times on ModernMedicine.com: Elbow splinting increases amblyopia patching compliance.

Yes, this story is true! It is not an attempt to fabricate the news or make a joke. It is a valid research article just published in the Eye Journal, Eye (2017) 31, 406–410. A quote from  the online article states, “…Elbow splints can increase children’s compliance with a patching regimen for amblyopia, researchers say.” A second quote further states, “…Adding elbow splints to the occlusion therapy regimen is an effective and parentally acceptable treatment method to ensure that all is done in order to try and improve vision in amblyopic eyes…”

The article further quotes previous research that says, “…people with uncorrected amblyopia have triple the risk of depression, double the risk of mortality and greater difficulties with day-to-day living…” This statement shows the seriousness of amblyopia. It is not just poor sight in one eye. It affects the entire quality of life of the person.

This statement confirms that the consequences of amblyopia extends much beyond reduced eye sight. But, does splinting a child’s arms to prevent them from removing an eye patch seem like a reasonable approach for treating amblyopia? Doesn’t this seem more like something right out of medieval times?

Indeed, amblyopia, often referred to as lazy eye, is a serious neuro-developmental vision problem that affects about 3% of people worldwide. The result of amblyopia is a loss of visual acuity in the affected eye due to a binocular vision dysfunction. In addition to loss of visual acuity in the amblyopic eye, the patient will have poor depth perception, poor eye hand coordination, poor visual processing and typically poor reading fluency. Historically the only treatment considered for amblyopia was occlusion therapy typically with an eye patch worn over the fellow eye. The problem with patching is that occlusion therapy has been found to be only moderately effective and riddled with negative consequences involving:

  • Eye sight improves with patching, but even with good compliance will often regress when discontinued
  • Patching does not treat the underlying cause of amblyopia which is due to a binocular vision problem
  • Occlusion as an overall treatment can have poor or marginal results
  • The child wearing an eye patch often experiences bullying, teasing, emotional upset, frustration, anger and general unhappiness
  • With patching there is a need of more parent attention associated with the child’s treatment

What do we now know? There is a much better way to treat amblyopia with superior outcomes, provides the patient with the opportunity to gain binocular vision and stereopsis (3-D) and does not require a daily eye patch (or Atropine) as a part of the treatment. This treatment protocol, including supporting research, is outlined for ophthalmologists, optometrists and the public on The VisionHelp Amblyopia Project.

Indeed the use of patching in the treatment for amblyopia has been around for over 100 years and considered to be the standard of care based on multiple amblyopia research projects in the past. But now there is a much better and modern “no patch” method  that does not require physical manipulation of the child to comply. Therefore, hasn’t the time come for health care of the 21st century to recognize occlusion therapy for what it is…a “dated approach”, not a modern medicine approach to a complex visual problem?

Come on!! Children with amblyopia deserve better care than elbow splints and an eye patch!

To learn more, here is a video that summarizes the modern approach to Amblyopia.

Dan L. Fortenbacher, O.D., FCOVD

15 thoughts on “Elbow splinting increases amblyopia patching compliance…Really!!?

  1. Thank you for posting Dr. Dan!

    “The article further quotes previous research that says, “ people with uncorrected amblyopia have triple the risk of depression, double the risk of mortality and greater difficulties with day-to-day living…”

    I wonder how the elbow splints help with depression and difficulties with day-to-day living 🙂

    This is just sad.

  2. This is nothing new, we’ve seen this in our area over 15 years ago. If you are inept at working with children and providing activities that promote recovery and function, then use a splint….wrong! Refer to someone that can- see http://www.covd.org ! We had a child in our area who was much smarter than the OMD who had the patient ‘splinted’ by his parents. The child still got the patch off by using his eye against the couch. Unfortunately this led to a severe corneal abrasion which developed into a keratitis. Thus we also have bad side effects with this line of thinking.

  3. We have seen a dramatic increase in our rate of success and speed of improvement since following a more modern approach to amblyopia treatment. Thank you Dr. Dan Fortenbacher for making a point to inform both eye doctors and the public that there are better approaches to treatment than hours of passive patching. I have had toddlers enter my clinic with inflatable “swimming arm floats” and I wonder how they can even eat or develop fine motor skills with this approach. I am happy to give my patients a much better alternative.

  4. Hard to believe that this was published as a real research paper by an ophthalmology journal. This sounds like something from the 19th century – antiquated and barbaric by modern standards. Or maybe it was originally written for The Onion.

  5. When I first saw this article I thought “Ha ha bad joke”. But it is not a joke and was published in an actual Ophthalmological publication called “Ophthalmology Times”. Welcome back to the Dark Ages.

  6. In the video in the link, he only discusses strabismic and refractive amblyopia but negates deprivational amblyopia which is many times where this form of restraint is employed in treatment. For most mild/moderate amblyope’s this would should never be attempted but in some severe cases, when all other options have been exhausted, extreme measures must be taken or the visual potential of the eye may be lost forever. Unfortunately, sometimes the “archaic” approach is the only effective form of treatment available. As optometrists, we should be open minded about any and all options (therapeutic, pharmaceutical or surgical) of potentially improving our patients vision.

    • Thank you Dr. Carlson for your thoughtful comment. Your point about the video not including deprivation amblyopia, such as congenital cataracts, is correct. However, the video was developed and utilized in this blog to provide a parent a broader understanding for the most common cause of amblyopia, that being strabismus or anisometropia. But, even for those with deprivation amblyopia, the models of treatment that include binocular vision therapy and perceptual learning as outlined in the treatment protocols in the VisionHelp Amblyopia Project are evidence-based and more effective and without the undo negative side effects associated with patching. Furthermore, this “elbow splint” study had an N of 41. 59% were strabismic (esotropic) amblyopes, 37% were anisometropic amblyopes and only 2 (4%) were deprivation amblyopes (congenital cataracts). Regarding the notion of an eye being “lost forever” due to amblyopia is also perpetuating the myth that there is a critical period for treatment of amblyopia. Research in multiple research studies have show even adults can respond to vision therapy when done in a binocular model and other important elements. You are correct however, the ATS research does imply that patching is not effective for those beyond about age 10. On that note, I agree with your premise. I also agree with your point that optometrists should be open to all options especially when they are notably better for the patient! The notion of surgery, pharmacological or in this case elbow splinting, when compared to the alternative is “arcane” and has more risks than benefits. So my question is, in what other scenario in patient care would the optometrist recommend medical management that has poorer outcomes and greater negative side-effects? Let’s bring amblyopia management up to the same level that we hold to be in the best interest of the patient.

      • Dr. F., thanks for the additional notes. Let me add that while we all need to remain open to treatment options, and research these to know what’s in the toolbox, we need to also remain open to the possibility that a lesser outcome, or no movement, might be a better alternative to child abuse. We all have to define for ourselves where that line is drawn, and what we are willing to do ‘for the benefit of the child’. Kids as a rule detest patching, and this is a whole other level of invasion – not quite as bad as suturing (shades of Clockwork Orange…).

    • lol, good point. I’m sure that trial will be posted shortly, then we might expect the OFATT – Opiods for Amblyopia Treatment Trials, where we will investigate the relationship between dosing and patching compliance. Thanks for the dark giggle, Tuan Tran.

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