Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ONGOING

without form-deprivation amblyopia

1st line – optical correction of any refractive error

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ONGOING
|
without form-deprivation amblyopia
|
mild to moderate strabismic and/or mild to moderate anisometropic amblyopia
1st line – 

optical correction of any refractive error

For mild to moderate strabismic and/or anisometropic amblyopia, first-line treatment is with optical correction alone.[51][52]

Guidelines for prescribing spectacles to treat amblyopia in young children depend on patient age and other risk factors.[1]​ The recommended period to achieve maximum refractive adaptation in the amblyopic eye is 18-22 weeks, but most improvement is seen by 4-12 weeks.[51][54]

Factors associated with successful optical correction include better baseline visual acuity of the amblyopic eye, interocular difference in visual acuity, stereoacuity, and amblyopic eye spherical-equivalence refractive error.[56]

Extended optical correction before patching may be associated with lower treatment success. The EuPatch multicenter, randomized controlled trial found that early patching (wearing spectacles for only 3 weeks before patching) was more effective than extended optical treatment (18 weeks of optical correction before patching) for children with anisometropic, strabismic, or combined-mechanism amblyopia.[57]​ Early patching was more beneficial for severe amblyopia, older children, and larger differences in refractive errors between eyes; extended optical treatment was more beneficial in younger children and mild amblyopia.[57]

Children and parents or caregivers should be made aware of the importance of good adherence to spectacles wearing, which is often suboptimal and highly variable.[58]

Treatment for amblyopia is regarded as being less effective in children age ≥7 years.[85][86]​ There is, however, evidence to suggest that older children (ages 7-12 years) respond partially to amblyopia treatment with spectacles, atropine, and patching, and that the resultant visual benefits may be maintained for between at least 6 and 12 months.[87][88][89]

Following randomization to treatment with full-time patching or with daily atropine therapy, similar improvements in visual acuity (2.3 to 2.4 lines) have been reported at 6 months in patients ages 8-20 years with anisometropic amblyopia (visual acuity of 20/40 to 20/200).[91]

The treatments do not differ for older children (at least to age 15 years), although the exact regimens may vary.[1]

Consider – patching or atropine

Back
ONGOING
|
without form-deprivation amblyopia
|
mild to moderate strabismic and/or mild to moderate anisometropic amblyopia
Consider – 

patching or atropine

Treatment recommended for SOME patients in selected patient group

If amblyopia does not resolve with spectacles alone, patching or atropine penalization are usually added after a period of refractive adaptation, during which improvements in visual acuity are allowed to plateau.[51][52][53][54][55]​​ The recommended period to achieve maximum refractive adaptation in the amblyopic eye is 18-22 weeks, but most improvement is seen by 4-12 weeks.[51][54]

Patching and atropine penalization are equally effective, and visual benefits of treatment are maintained in the long term.[68][69]​​ Atropine has been associated with better adherence and quality of life compared with patching, but with increased risk for adverse events.[70]​ Patching occludes vision in the better eye, whereas atropine eye drops blur vision in the better eye.

Treatment for amblyopia is regarded as being less effective in children age ≥7 years.[85][86]​​ There is, however, evidence to suggest that older children (ages 7-12 years) respond partially to amblyopia treatment with spectacles, atropine, and patching, and that the resultant visual benefits may be maintained for between at least 6 and 12 months.[87][88][89]

Following randomization to treatment with full-time patching or with daily atropine therapy, similar improvements in visual acuity (2.3 to 2.4 lines) have been reported at 6 months in patients ages 8-20 years with anisometropic amblyopia (visual acuity of 20/40 to 20/200).[90]

The treatments do not differ for older children (at least to age 15 years), although the exact regimens may vary.[1]

Patching should be applied directly to the periorbital skin for full occlusive therapy, as opposed to being applied to the spectacle lens (the latter allows children to look around the patch).[1]​ Over-spectacle patching may be a useful alternative for children experiencing skin irritation with adhesive patching.[59]​ A dose-response relationship probably exists between patching duration and amblyopia treatment response.[60][61][62][63]

Daily treatment duration: improvement of visual acuity of the amblyopic eye (from baseline to 4 months) did not differ between children (age <7 years; with moderate amblyopia) randomized to 2 hours or to 6 hours of daily patching.[64]​ In another randomized study, 2 hours of daily patching was significantly superior to optical treatment alone in children with mild to severe strabismic and/or anisometropic amblyopia.[65]

Dose intensity and overall treatment duration: one multicenter, randomized controlled trial reported that early intense patching (10 hours/day for 6 days/week) was more effective than extended optical treatment for shortening the treatment period, reducing the number of patching hours over time, and improving compliance.[57]​ A faster treatment response may be seen in strabismic and/or severe amblyopia, in younger children, and during the first month of occlusive therapy.[63]

Compliance: patients are often noncompliant with patching due to adverse effects such as irritation, forced use of an eye with degraded vision, poor cosmesis, and lengthy treatment periods. Interventional materials may improve compliance in poorly adherent children and in children of non-native parents who speak the host country language poorly.[66][67]​​ Poor visual acuity at baseline has been associated with poor compliance.[60]

Atropine eye drops to blur the vision in the better eye (atropine or optical penalization therapy) are sometimes used as an alternative to patching. Patching and atropine penalization are equally effective, and visual benefits of treatment are maintained in the long term.[68][69]​​ Atropine has been associated with better adherence and quality of life compared with patching, but with increased risk for adverse events.[70]

Children ages 3 to <7 years old with moderate amblyopia who were randomized to weekend atropine demonstrated an equivalent treatment response (improvement in visual acuity of the amblyopic eye from baseline to 4 months of 2.3 lines) to that of children receiving daily atropine.[71]

Primary options

atropine ophthalmic: (1%) children ≥3 months of age: 1 drop into the nonamblyopic eye once daily; children ≥3 years of age: 1 drop into the nonamblyopic eye once daily, may repeat dose up to twice daily

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Consider – plano lens in atropinized eye

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ONGOING
|
without form-deprivation amblyopia
|
mild to moderate strabismic and/or mild to moderate anisometropic amblyopia
Consider – 

plano lens in atropinized eye

Treatment recommended for SOME patients in selected patient group

A plano lens for the amblyopic eye can be added to atropine treatment. There may be a very small additional benefit of a plano lens in patients undergoing weekend atropine penalization.[72]

Consider – management of strabismus

Back
ONGOING
|
without form-deprivation amblyopia
|
mild to moderate strabismic and/or mild to moderate anisometropic amblyopia
Consider – 

management of strabismus

Treatment recommended for SOME patients in selected patient group

After the amblyopia has been treated, children with residual strabismus typically undergo strabismus surgery. See Strabismus.

1st line – optical correction of any refractive error

Back
ONGOING
|
without form-deprivation amblyopia
|
severe strabismic and/or severe anisometropic amblyopia
1st line – 

optical correction of any refractive error

The correction of any refractive errors with spectacles is key in amblyopia treatment.[51][52]

Guidelines for prescribing spectacles to treat amblyopia in young children depend on patient age and other risk factors.[1]​ The recommended period to achieve maximum refractive adaptation in the amblyopic eye is 18-22 weeks, but most improvement is seen by 4-12 weeks.[51][54]

Factors associated with successful optical correction include better baseline visual acuity of the amblyopic eye, interocular difference in visual acuity, stereoacuity, and amblyopic eye spherical-equivalence refractive error.[56]

Extended optical correction before patching may be associated with lower treatment success. The EuPatch multicenter, randomized controlled trial found that early patching (wearing spectacles for only 3 weeks before patching) was more effective than extended optical treatment (18 weeks of optical correction before patching) for children with anisometropic, strabismic, or combined-mechanism amblyopia.[57]​ Early patching was more beneficial for severe amblyopia, older children, and larger differences in refractive errors between eyes; extended optical treatment was more beneficial in younger children and mild amblyopia.[57]

Children and parents or caregivers should be made aware of the importance of good adherence to spectacles wearing, which is often suboptimal and highly variable.[58]

Treatment for amblyopia is regarded as being less effective in children age ≥7 years.[85][86]​ There is, however, evidence to suggest that older children (ages 7-12 years) respond partially to amblyopia treatment with spectacles, atropine, and patching, and that the resultant visual benefits may be maintained for between at least 6 and 12 months.[87][88][89]

Following randomization to treatment with full-time patching or with daily atropine therapy, similar improvements in visual acuity (2.3 to 2.4 lines) have been reported at 6 months in patients ages 8-20 years with anisometropic amblyopia (visual acuity of 20/40 to 20/200).[90]

The treatments do not differ for older children (at least to age 15 years), although the exact regimens may vary.[1]

Plus – patching or consideration of atropine

Back
ONGOING
|
without form-deprivation amblyopia
|
severe strabismic and/or severe anisometropic amblyopia
Plus – 

patching or consideration of atropine

Treatment recommended for ALL patients in selected patient group

Children with severe strabismic and/or anisometropic amblyopia require optical correction of refractive errors and additional treatment with patching or optical penalization.[51][52]​​ Patching is the standard addition, although evidence suggests that atropine is also effective.[74]

Adding patching to spectacles, after visual acuity has stabilized with spectacles alone, is beneficial in this group.[65]​ Patching for 6 hours daily has been found to be equally effective to patching full time.[75]

Compliance with patching needs to be taken into consideration. Patching for 2 hours daily improves visual acuity in severe amblyopia, although the magnitude of improvement may be less than with more robust patching regimens.[76]​ The EuPatch study found that early patching with an intensive starting dose of 10 hours per day (for 6 days a week) was beneficial in most children with severe amblyopia.[57]​ With improved visual acuity, the prescribed number of patching hours decreased significantly over the course of the trial.

Some clinicians may intensify treatment by adding topical atropine to the daily patching regiment, but the literature suggests minimal to no added benefit with this approach.[77][78]​​

Treatment for amblyopia is regarded as being less effective in children age ≥7 years.[85][86]​​ There is, however, evidence to suggest that older children (ages 7-12 years) respond partially to amblyopia treatment with spectacles, atropine, and patching, and that the resultant visual benefits may be maintained for between at least 6 and 12 months.[87][88][89]

Following randomization to treatment with full-time patching or with daily atropine therapy, similar improvements in visual acuity (2.3 to 2.4 lines) have been reported at 6 months in patients ages 8-20 years with anisometropic amblyopia (visual acuity of 20/40 to 20/200).[90]

The treatments do not differ for older children (at least to age 15 years), although the exact regimens may vary.[1]

Patching should be applied directly to the periorbital skin for full occlusive therapy, as opposed to being applied to the spectacle lens (the latter allows children to look around the patch).[1]​ However, over-spectacle patching may be a useful alternative for children experiencing skin irritation with adhesive patching.[59]​ A dose-response relationship probably exists between patching duration and amblyopia treatment response.[60][61][62][63]

Daily treatment duration: 2 hours of daily patching was significantly superior to optical treatment alone in children with mild to severe strabismic and/or anisometropic amblyopia.[65]

Dose intensity and overall treatment duration: one multicenter, randomized controlled trial reported that early intense patching (10 hours/day for 6 days/week) was more effective than extended optical treatment for shortening the treatment period, reducing the number of patching hours over time, and improving compliance.[57]​ A faster treatment response may be seen in strabismic and/or severe amblyopia, in younger children, and during the first month of occlusive therapy.[63]

Compliance: patients are often noncompliant with patching due to adverse effects such as irritation, forced use of an eye with degraded vision, poor cosmesis, and lengthy treatment periods. Interventional materials may improve compliance in poorly adherent children and in children of non-native parents who speak the host country language poorly.[66][67]​​ Poor visual acuity at baseline has been associated with poor compliance.[60]

Atropine eye drops to blur the vision in the better eye (atropine or optical penalization therapy) are sometimes used as an alternative to patching. Patching and atropine penalization are equally effective, and visual benefits of treatment are maintained in the long term.[68][69]​​ Atropine has been associated with better adherence and quality of life compared with patching, but with increased risk for adverse events.[70]

Children ages 3 to <7 years old with moderate amblyopia who were randomized to weekend atropine demonstrated an equivalent treatment response (improvement in visual acuity of the amblyopic eye from baseline to 4 months of 2.3 lines) to that of children receiving daily atropine.[71]​ 

Combined patching plus atropine penalization: some clinicians may intensify treatment by adding topical atropine to the daily patching regiment, but the literature suggests minimal to no added benefit with this approach.[77][78]​​

Primary options

atropine ophthalmic: (1%) children ≥3 months of age: 1 drop into the nonamblyopic eye once daily; children ≥3 years: 1 drop into the nonamblyopic eye once daily, may repeat dose up to twice daily

More

Consider – management of strabismus

Back
ONGOING
|
without form-deprivation amblyopia
|
severe strabismic and/or severe anisometropic amblyopia
Consider – 

management of strabismus

Treatment recommended for SOME patients in selected patient group

After the amblyopia has been treated, children with residual strabismus typically undergo strabismus surgery. See Strabismus.

1st line – optical correction

Back
ONGOING
|
without form-deprivation amblyopia
|
bilateral ametropic amblyopia
1st line – 

optical correction

Often resolves with optical correction alone.[79]​

One prospective study evaluated the response to spectacle treatment for bilateral ametropic amblyopia in children ages 3-9 years.[79]​ Mean binocular visual acuity improved from 20/63 at baseline to 20/25 at 1 year.

form-deprivation amblyopia

1st line – surgery

Back
ONGOING
|
form-deprivation amblyopia
1st line – 

surgery

Early surgery is recommended when the cause of amblyopia is obstruction of the visual axis, such as corneal opacity, cataract, nonclearing vitreous hemorrhage, or severe ptosis.

Surgical intervention is less urgent when the form deprivation occurs bilaterally as opposed to unilaterally. To maximize visual outcomes, surgery for bilateral congenital cataracts should be performed before 14 weeks of age and earlier if possible, and surgery for unilateral congenital cataracts should be performed before 6 weeks of age.[80][81]

Plus – patching

Back
ONGOING
|
form-deprivation amblyopia
Plus – 

patching

Treatment recommended for ALL patients in selected patient group

For patients with unilateral- or asymmetric-deprivation amblyopia, such as children with unilateral congenital cataracts, patching the sound eye is a necessary additional treatment.

Plus – optical correction of any refractive error ± patching or atropine

Back
ONGOING
|
form-deprivation amblyopia
|
concurrent nonform-deprivation amblyopia
Plus – 

optical correction of any refractive error ± patching or atropine

Treatment recommended for ALL patients in selected patient group

Deprivation amblyopia may coexist with other forms of amblyopia, including anisometropic and strabismic. These should be addressed in conjunction with treatment to clear the visual axis.

Ongoing treatment may be with correction of any refractive error with spectacles or contact lenses, with or without patching of the nonamblyopic eye or blurring of the nonamblyopic eye with atropine eye drops.

Primary options

atropine ophthalmic: (1%) children ≥3 months of age: 1 drop into the nonamblyopic eye once daily; children ≥3 years: 1 drop into the nonamblyopic eye once daily, may repeat dose up to twice daily

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refractory amblyopia

1st line – temporary closure of better-seeing eye

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ONGOING
|
refractory amblyopia
1st line – 

temporary closure of better-seeing eye

Refractory amblyopia in a noncompliant patient can be treated by closing the eyelid over the better-seeing eye temporarily, using surgical or medical techniques. These include the use of sutures, injection of botulinum toxin to the levator muscle, and application of cyanoacrylate glue to the eyelid margin.[83][84]​ Parents or caregivers might be hesitant to consent to these treatments given the need for anesthesia, as well as the cosmetic and psychological effects on the child.

Less invasive ways to improve compliance include the use of interventional materials, such as cartoons or information booklets. Randomized controlled trials have shown the benefit of using interventional materials to improve treatment compliance in poorly adherent children and in children of non-native parents who speak their host country language poorly.[66][67]​ It is suggested that attempts should be made first with intervention material.

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Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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