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

optical correction of any refractive error

Spectacles alone are a reasonable first-line treatment for mild to moderate strabismic or anisometropic amblyopia (visual acuity of 20/100 or better).[43][44]

Clinicians should be aware of the importance of good adherence to glasses wearing, in addition to other forms of treatment, especially during optical treatment alone, as it has been found that adherence to glasses wearing is highly variable and affects visual outcomes.[45]

Consider – patching or atropine

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

patching or atropine

Treatment recommended for SOME patients in selected patient group

For patients with mild to moderate strabismic or anisometropic amblyopia, randomized trials have found an equal treatment response with either patching or atropine in the 3- to 6-year-old age group.[57][58]

Prescribed patching of 2 hours/day was equivalent to patching 6 hours/day.[50]

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

Daily atropine was equivalent to atropine given only on 2 consecutive days. It has been suggested that the improvement in visual acuity in the amblyopic eye is considerable at 4-12 weeks and then reaches a plateau, after which it only improves slowly.[43] In general, the recommended time length to achieve the maximum outcome of refractive adaptation is 18-22 weeks.[47]

Primary options

atropine ophthalmic: (1%) children >3 years: 1 drop to nonamblyopic eye once daily for 2 days on 2 consecutive days of the week

Consider – plano lens in atropinized eye

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ONGOING
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without form-deprivation amblyopia
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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.[59]

Consider – further management of strabismus

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

further 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.

Consider – more aggressive patching for residual amblyopia

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

more aggressive patching for residual amblyopia

Treatment recommended for SOME patients in selected patient group

After treatment of moderate amblyopia resulting from strabismus or anisometropia with refractive correction and 2 hours of patching, some patients have residual amblyopia. A randomized clinical trial evaluated the effectiveness of increasing prescribed daily patching from 2-6 hours in children with stable residual amblyopia. Increasing patching to 6 hours was more effective than continuing patching at 2 hours daily, with a modest 1.2-line compared with 0.5-line additional visual acuity improvement.[54] This study brings into question whether 2 hours of prescribed daily patching is truly enough or optimal in the treatment of moderate strabismic and anisometropic amblyopia.

1st line – optical correction of any refractive error

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

optical correction of any refractive error

Spectacles alone are a reasonable first-line treatment for strabismic and anisometropic amblyopia in young children, although children with severe amblyopia (visual acuity 20/100 to 20/400) will likely require additional subsequent treatment.[43][44]

Clinicians should be aware of the importance of good adherence to glasses wearing, in addition to other forms of treatment, especially during optical treatment alone, as it has been found that adherence to glasses wearing is highly variable and affects visual outcomes.[45]

Plus – patching or consideration of atropine

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ONGOING
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without form-deprivation amblyopia
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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 amblyopia ages 3-6 years respond equally well to prescribed 6 hours patching and full-time patching.[62]

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

Because shorter-duration patching (e.g., 2 hours) has not been directly compared with 6-hour patching in large randomized trials, it is sensible to prescribe 6 hours of patching for residual severe amblyopia until further studies are performed.[63]

Preliminary studies suggest that atropine may be as effective as patching in treating severe amblyopia, but large randomized trials have not yet been performed.[61]

Primary options

atropine ophthalmic: (1%) children >3 years: 1 drop to nonamblyopic eye once daily

Consider – further management of strabismus

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

further 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.

1st line – optical correction

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

optical correction

Bilateral ametropic amblyopia in 3- to 9-year-old children typically resolves with optical correction alone.[64]​ Treatment does not differ for older children (at least to age 15 years), although the exact regimens may vary.​[1]​

form-deprivation amblyopia

1st line – early surgery

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ONGOING
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form-deprivation amblyopia
1st line – 

early surgery

Recommended to correct visual deprivation due to 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.[65][66]

Occasionally, mild- to moderate-deprivation amblyopia (such as that resulting from a mild unilateral cataract) may initially be treated with patching to see how much visual improvement can be obtained with conservative management before considering surgery.

Plus – patching

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ONGOING
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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 eye drops

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

optical correction of any refractive error ± patching or atropine eye drops

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 years: 1 drop to nonamblyopic eye once daily

refractory amblyopia

1st line – closure of better-seeing eye

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ONGOING
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refractory amblyopia
1st line – 

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.[67][68] However, caregivers might be hesitant to use these techniques for the management of amblyopia in view of the need for anesthesia, as well as the cosmetic and psychological effects on the child. Other 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 subjects and in children of non-native parents who speak their host country language poorly.[55][56] 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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