An 8-year-old patient who has done a good job with wearing glasses and occlusion therapy should be congratulated. Wearing the glasses is an important part of the prescribed treatment. It does seem that the initial therapy was an acceptable approach for a school age child. We have studied combined therapy with glasses, occlusion, and atropine in this age range and found it better than glasses alone but we do not yet know whether atropine or patching is the best treatment when prescribed alone. I am concerned about the apparent decline in vision after loss to follow-up for a year. A decline in vision from amblyopia at this age is uncommon, although not impossible. I am pleased the fundus is normal, but I would emphasize the need to confirm that there is no afferent pupillary defect and the optic discs appear equally normal with either direct ophthalmoscopy or slit-lamp biomicroscopy. Assuming this is the case I would try to resume glasses as well as some patching, perhaps a minimum of 14 hours per week or atropine at least twice weekly for 3 months. I would also consider one last attempt with combined therapy of patching and atropine for 4 months. Stressing the value of the spectacles is also necessary.
If there is a suggestion of optic nerve disease or an abnormal afferent pupillary light reaction, the child should undergo some form of neuroimaging of the visual pathways.