The basis for traditional amblyopia treatment is to deprive the "good" eye while optimizing the visual experience of the amblyopic eye.  This boils down in most cases to patching the good eye.  Many patching schemes and other techniques have been devised to optimize amblyopia treatment.

For the infant and under 1 year of age Patch good eye 3-4 days full time *  Patch amblyopic eye 1 day - Repeat this pattern until alternation

* Patching of the amblyopic eye avoids iatrogenic or patch amblyopia - keeping one eye patched at all times during treatment avoids "undoing" any good that previous patching has accomplished (von Noorden).  This also eliminates the need for ultra-close follow-up in the very young.  This scheme is perfectly safe for several weeks to a month or more in the child less than one year old.

Patching in the older child requires less stringent follow up and can be designed to fit the patient's unique need.  In general full time patching is more effective - patching in the younger, preschooler is more effective.

	Patch observing for alternation		Surgery when alternating		Follow - may need part time patch until 7 or 8 yrs
Strabismic
	Patch good eye 60%		Follow until stable - equal vision rare
Unilateral Aphakia/Psuedo Phakia
	Rx OD Plano + 1.00 x 90 OS +4.00 +1.50 x 110
OD + 1.00 + 1.00 x 90 OS + 5.00 + 1.50 x 110	Glasses only for several months		Equal vision Amblyopia		continue glasses careful part-time patching

The reality is that many cases of patching fail.  Why?

* Poor cooperation

* Underlying organic defect

* Started too late

* Grossly unequal eyes (unilateral high myopia - unilateral aphakia)

* Latent nystagmus - this greatly hinders patching

When is it okay to stop patching?

* 2 to 3 months of compliant patching with no progress

* With improvement (R) relapse (R) improvement (R) relapse, etc.

* Over age +/-8 years - (but every amblyopic patient deserves at least one attempt at patching)

* Severe psychological trauma can result from excessive patching

	Cloth pirate patches do not work! Children peek		On glass occlusion does not work for deep amblyopia, but in some mild cases, special filters which reduce vision have been effective for treatment of mild amblyopia
	A cloth patch with a side shield has been effective in some cases of patch intolerance in young children		Patches with black, light impervious layers have been said to be more effective.

Note!  Heat sensitive patch monitors which work somewhat like radiation exposure badges have shown that patches tend to be worn much less than parents have reported.

Penalization for Treatment of Amblyopia

This technique uses 1% atropine given once each day (one drop with punctal occlusion) to eliminate accommodation in the "good" eye.

Fully accommodating fully corrected amblyopic eye If child has glasses temporarily replace correction in good eye with a plano lens

Penalization works best if the preferred eye is hyperopic +3.00 or more.  This ensures penalization at distance and near.  Near penalization probably won't work with a myope.  Before starting penalization check uncorrected vision in the preferred eye with full cycloplegia.  If vision is less than the amblyopic eye, penalization will be effective at distance and near fixation.

Pharmocologic agents which sensitize and stimulate the sensory system have been used to improve vision in the amblyopic eye.  In some cases, mostly during clinical research, limited success has been achieved.   Pharmocologic treatment of amblyopia is not a viable clinical tool at this time.

Pleoptics Started in '50's, this method is aimed at restoring vitality of the fovea/macula of the amblyopic eye.  Pleoptics was highly equipment/ technician dependent. It did not prove to be a sustainable treatment modality.  Patching remains the most effective when children are also using their eyes such as with TV, puzzles, etc.  Active use of the amblyopic eye may be a valuable legacy of pleoptics.  Eye use should be encouraged for children being treated with patch therapy.

The Amblyopia Naysayers

* Some ophthalmologists disavow patching as not necessary stating that amblyopia is not disabling and the patient has another eye. (This is the position of at least one non-U.S. local strabismus society.)

* Screening for amblyopia has been said to be unproven as a useful activity.

The Reality about Amblyopia

* Caught early - by age 3-4 - amblyopia treatment can be successful and should be encouraged.

* Strabismic amblyopia can be diagnosed and treated early because of the obvious physical sign.

* Mass screening is the best way to detect amblyopia early.  It should be done before school which is the most effective time to patch.

* Children who attain a given level of vision and relapse, can if needed regain and possibly exceed that level.  After a certain age + 4-5 years, once you have vision you can regain it.

* Under binocular conditions an amblyopia of 20/40 or an amblyopia of 20/200 will function about the same (See Strabismus Minute, Vol. 1, No. 4,  "Why Two Eyes",  Mar. 21, 1999)

* We may be overzealous in our patching of some older children given the above.

* Children with amblyopia should wear safety (polycarbonate) lenses and safety frames.

* In spite of the potential seriousness - loss of the good eye in cases of amblyopia is very rare even in the very old who undergo age related macular degeneration, diabetic retinopathy, etc.

Amblyopia has been and will undoubtedly remain a challenge to parents and ophthalmologists alike.