amblyopia treatment and results
DESCRIPTION
William E. Scott, MD and The Iowa Amblyopia Treatment Study GroupTRANSCRIPT
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Amblyopia Treatment Outcomes at the University of Iowa
Amblyopia Treatment Outcomes at the University of Iowa
William E. Scott, MDand
The Iowa Amblyopia Treatment Study Group
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William E. Scott, MDPamela J. Kutschke, CORonald V. Keech, MDWanda L. Pfeifer, OC(C), COMTLinna Zhang, MDBrian Nichols, MD, PhD
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Flynn Study - 1998Flynn Study - 1998
• From 1965 to 1994, there were 23 studies reporting outcomes of amblyopia occlusion treatment in a total of 961 patients.
• Success (vision > 20/40) in 74.3 % with strabismic and anisometropic amblyopia
• Success related to age, type of amblyopia, and severity of visual loss before treatment
• Variety of occlusion methods used
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ATS1 Study - 2002ATS1 Study - 2002
• Enrolled patients 3 to <7 yrs.• VA 20/40 to 20/100 in amblyopic eye• Randomized
– Occlusion: 6 hrs to full-time; most part-time– Atropine
• Concluded both treatments equally effective although patching produced more rapid improvement.
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PurposePurpose
• To determine the effectiveness and side effects of full time occlusion
• Not a study of compliance
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Charts Reviewed (n=1541) Exclusion Criteria
Charts Reviewed (n=1541) Exclusion Criteria
• No amblyopia (93)• No patching (98)• Too old (176)• Lost to follow-up (289)• Part-time patching only (133)• Not strabismic, anisometropic or
combination (124) • Records unavailable (26)
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Inclusion CriteriaInclusion Criteria
• Strabismic, anisometropic or combination amblyopia
• 24 hr/day or all waking hours occlusion• Follow-up to endpoint • All degrees of amblyopia
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Questions Asked of DatabaseQuestions Asked of Database• What was the outcome of full-time
occlusion?• Did age, type, duration of occlusion or
initial VA of amblyopic eye affect outcome?
• Incidence of occlusion amblyopia?• Stability of endpoint?
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Full-time Occlusion TreatmentFull-time Occlusion Treatment
• 24 hours per day or all waking hours• Follow-up: 1 week per year of age, not to
exceed 4 weeks• Endpoint: equal VA or 3 episodes with no
improvement and good compliance
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Full-time occlusion to GAIN vision.
Part-time occlusion to MAINTAINvision.
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Disadvantages to Full-time Occlusion Treatment
Disadvantages to Full-time Occlusion Treatment
• Social pressure• Skin irritation• Potential of occlusion amblyopia• Shorter interval between visits
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Advantages to Full-time Occlusion Treatment
Advantages to Full-time Occlusion Treatment
• Consistency• Defined endpoint• Faster improvement• Better compliance
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Study Populationn=600
Study Populationn=600
• Strabismic (n=439)– >8horizontal, >5 vertical
• Anisometropia (n=56)– >1.00D difference sphere or cylinder between
the two eyes• Combination (n=105)
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Initial Visual Acuity TestInitial Visual Acuity Test
Fixation 260Line Pictures 109Line E 73HOTV 8Line Numbers 4Line Letters 90Unknown Optotype 56
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Age First PatchedAge First Patched
Range Mean
Strabismic 4 mo to 8.07 yrs 3.12 yrs
Combination 4 mo to 9.92 yrs 4.07 yrs
Anisometropic 1.15 – 8.83 yrs 5.34 yrs
ALL 4 mo to 9.92 yrs 3.49 yrs
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0102030405060708090
100
0 1 2 3 4 5 6 7 8 9
Age at Initial Treatment (yrs)
Num
ber
of P
atie
nts
StrabismusCombinationAnisometropia
Initial Treatment Age by Amblyopia TypeInitial Treatment Age by Amblyopia Type
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Follow-UpFollow-Up
Range (yrs) Mean (yrs)
Strabismus 0 – 26.3 7.4
Combination 0 – 18.7 6.1
Anisometropia 0 – 22.0 5.2
ALL 0 – 26.3 7.2
89% greater than 1 year follow-up.
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Age at Last Follow-UpAge at Last Follow-Up
Range Mean
All Types 0.92 – 30.35 yrs 10.82 yrs
349 patients >9 yrs at last visit.
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SuccessSuccess
• Visual acuity 20/30 or better or equal between the two eyes
• Ultimate goal is equal visual acuity between the two eyes.
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Best VA AchievedBest VA AchievedStrabismic
(n=439)Combination
(n=105)Anisometropic
(n=56)ALL
(n=600)20/15 – 20/30
or = VA429
(97.7%)96 (91.4%) 53 (94.6%) 578
(96.3%)20/40 0 2 (93.3%) 3 (100%) 5 (97.2%)
20/50 – 20/80 7 3 0 10
< 20/100 3 4 0 7
Equal VA 288(65.6%)
54 (51.4%) 16 (28.6%) 358(59.7%)
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Duration vs. Age for All TypesDuration vs. Age for All Types
0
1
2
3
4
0 1 2 3 4 5 6 7 8+
Age at Initial Treatment (yrs)
Dur
atio
n of
Occ
lusi
on (m
os)
p <.0001
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Duration of OcclusionDuration of Occlusion
• Related to initial VA– worse initial VA longer duration (p< .0001)
• Related to type of amblyopia– strabismic amblyopes had a shorter duration of
occlusion to reach endpoint than anisometropes or combination.
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Initial VA vs. Best VA(n=317)
Initial VA vs. Best VA(n=317)
15
20
25
30
35
4025 30 40 50 60 80 10
0
125
200
300
400
500
800
CF
Initial Snellen VA (20/)
Mea
n B
est S
nelle
n V
A (2
0/)
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Worse initial VA Worse VA outcomep< .0001
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Age vs OutcomeAge vs Outcome
20
25
30
35
40
0 1 2 3 4 5 6 7 8
Age (yrs)
Snel
len
VA
(20/
)
ALL
p< .0001
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Age Treatment StartedAge Treatment Started
• Related to best VA – Younger children had better outcome (p< .0001)
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Type of Amblyopia Related to Outcome
Type of Amblyopia Related to Outcome
Best LogMAR(mean)
Best Snellen
Strabismic 0.07 20/20-20/25
Combination 0.12 20/25-20/30
Anisometropic 0.07 20/20-20/25
Not statistically significant.
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Anisometropia and Combination (n=161)
Anisometropia and Combination (n=161)
• Degree of anisometropia related to both initial and best VA (p< .0001)
• Myopes had a worse visual outcome than those with hyperopia or astigmatism. (p<.0001)
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Age 2-3yrs vs Age 4-5yrsAge 2-3yrs vs Age 4-5yrs
• Best VA not significantly different between the two groups.
• Number of patients with equal VA significantly greater in 2-3yr olds. (p< .0001)
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Age 2-3yrs vs Age 4-5yrsAge 2-3yrs vs Age 4-5yrs
20/30 or better = VA2-3 yrs
(n=100)100 (100%) 71 (71%)
4-5 yrs(n=92)
88 (96%) 41 (44%)
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Occlusion Amblyopia (n=155)Occlusion Amblyopia (n=155)
• Incidence of Occlusion Amblyopia = 25.8%
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SummarySummary
Flynn Study(FTO/PTO) • 74% had 20/40 or
better • 50% 20/30 or better• 16% 20/20 or better
Iowa Study• 97% had 20/40 or
better or = VA• 96% 20/30 or better• 50% 20/20 or better• 38 pts. CSM OU
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SummarySummary
ATS1 Study (33% FTO)• 79% had 20/30 or
better or > 3 lines improvement.
• 64% 20/30 or better• 16% 20/20 or better
(6 month outcome data)
Iowa Study• 98% had 20/30 or
better or > 3 lines improvement.
• 95% 20/30 or better• 50% 20/20 or better
(average 7 yr. follow-up)
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• In ATS1 study, full-time occlusion not considered for all patients because it was not the standard of care.
• Why not full-time occlude?
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ConclusionConclusion
• Full-time occlusion should be the practice standard.
• Effective• No long-term complications