An Evaluation of Treatment of Amblyopia in Children 7 to 18 Years Old (ATS3)

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Study Results. Archives of Ophthalmology 2005 article

Although it is well established that amblyopia can be treated effectively in young children, the general belief amongst eye care professionals is that treatment beyond a certain age is ineffective. Some eye care professionals believe that a treatment response is unlikely after the age of 6 or 7 years, while others consider age 9 or 10 years to be the upper age limit for successful treatment. The American Academy of Ophthalmology Preferred Practice Pattern for amblyopia recommends treatment up to age 10 years. The opinion that amblyopia treatment is ineffective in older children may have arisen because the age of 6 to 7 years is thought to be the end of the "critical period" for visual development in humans (Scheiman MM Arch Ophthalmol 2005;123:437-47)

NEI supported Pediatric Eye Disease Investigator Group has carried out a multicenter randomized controlled trial to address the question, "Will older children respond to amblyopia treatment?" To answer the question, 507 patients with amblyopic eye visual acuity ranging from 20/40 to 20/400 were provided with optimal optical correction and then randomized to a treatment group (2-6 hours per day of prescribed patching combined with near visual activities for all patients plus atropine sulfate for children aged 7 to 12 years) or an optical correction group (optical correction alone). ; they were then observed to determine whether visual acuity improved by at least 2 lines (10 letters) over 6 months.

The study found that throughout the age range of 7 to 17 years, optical correction alone improved visual acuity by 10 or more letters (which equates to 2 or more lines) in about one fourth of patients.

In the patients aged 7 to 12 years, augmenting the optical correction with patching (combined with near activities during the patching) and atropine doubled the responder rate.

In the patients 13-17 years, the primary analysis did not demonstrate a benefit to prescribing patching (with near activities) over optical correction alone. There was a strong suggestion of improvement with this treatment among patients who had not been previously treated for amblyopia with patching and/or atropine (responder rate was 47% in patients not previously treated compared with 16% in those previously treated).

"It is important to emphasize what this study is not. It is not a study of whether near tasks such as playing Game Boy or doing homework can improve or hinder the effectiveness of amblyopia therapy, nor is it a study of how many hours of patching should be prescribed. It is not a study of the relative efficacy of patching vs atropine for older children with amblyopia, nor is it a study of whether the "belt and suspenders" approach of combining atropine and patching is more effective than treatment with either alone. Without follow-up data, it is not even a study of whether we should treat older children newly diagnosed with amblyopia. Until we know the regression rate in these age groups (which may be very high) and the functional benefits of a 2-line (10-letter) improvement in visual acuity at this age (which may be minimal), we will not know whether there is reason to treat older amblyopia patients.

In this study, some older patients with amblyopia responded to treatment, but most did not. Those who did respond were left with a residual visual acuity deficit. The take-home lesson is that considering how difficult it is to treat older children for amblyopia, it is vitally important to identify and treat amblyopia early in life, well before age 7 years." (Hunter DG. Arch Ophthalmol. 2005;123:557-8)

Study Conclusion: Although the results indicate that visual acuity can be improved by treating amblyopia in older children, it is not known whether the improvement will be sustained after treatment is discontinued. Therefore, a conclusion regarding the long-term benefit of treatment and the development of treatment recommendations for amblyopia in children 7 years and older will need to await the results of a follow-up study we are conducting on the patients who responded to treatment.

Email to contact the study group: pedig@jaeb.org

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