Original Article

Philippine Journal of

OPHTHALMOLOGY

Visual Outcomes of Amblyopia Therapy

Melissa Anne M. Santos, MD, Marissa N. Valbuena, MD, MHPEd, and Andrea Kristina F.
Monzon-Pajarillo, MD
Department of Ophthalmology and Visual Sciences
Philippine General Hospital
University of the Philippines Manila
Ermita, Manila
Correspondence: Melissa Anne M. Santos, MD
Email: melissasantosmd@yahoo.com
Disclosure: No financial assistance was received for this study. The authors have no proprietary or financial interest in any products used or
cited in this study.

ABSTRACT
Objective: To determine the visual outcome of amblyopia treatment and describe the relationship between age of
onset and consult, compliance as measured by a patch diary, amblyopia subtype, and severity with the final visual
outcome.
Methods: Thirty-two consecutive, newly-diagnosed cases of amblyopia, aged 3-8 years on initial consult, with no
history of prior amblyopia treatment, were included. Patching was done based on current AAO recommendations
and patients were followed up monthly for 6 months. Treatment success was defined as best corrected visual acuity
(BCVA) better than 20/30 (0.17LogMAR), or a 3-line improvement from baseline, or stable isoacuity for at least
3 months. Treatment failure was defined as no improvement of BCVA after 3 months of occlusion therapy or a
regression of 2 lines. Descriptive and correlation statistics were performed comparing age of onset and consult,
amblyopia subtype, severity, and compliance with the main outcome measure of BCVA at 6 months.
Results: Sixteen (50%) attained treatment success. Patients seen earlier (age 2-5 years) had higher rates of success
(75%) than those seen later (age 6-8 years) (35%). A moderately strong negative correlation (r=-0.48, p=0.01)
existed between severity of amblyopia and final BCVA at 6 months. overall compliance to patching was 8818%,
with good compliance in the success group (92%) compared to fair compliance in the failure group (84%) and a
moderate correlation between compliance and BCVA (r=0.37, p=0.05).
Conclusion: Treatment success was related to severity, compliance, and younger age of treatment. In the presence
of good compliance, severity was a strong prognostic variable.
Keywords: Amblyopia, Patching, Compliance, Sensory Deprivation, Anisometropia, Occlusion therapy
Philipp J Ophthalmol 2012; 37:33-38

January - June 2012

33

Amblyopia is defined as a unilateral or bilateral

reduction of best corrected visual acuity (BCVA) that
cannot be attributed to the effect of any structural
abnormality of the eye1. It is objectively measured as a
BCVA poorer than 20/40 (0.30 LogMAR) bilaterally or
a difference in BCVA of 2 or more lines (0.2 LogMAR)
using a Snellen chart or its equivalent. Common
causes of amblyopia are strabismus, anisometropia, or
high bilateral refractive error and visual deprivation.2,3
The incidence of amblyopia is reportedly at 3.5%
worldwide, 1.6% - 3.5% in the United Kingdom and
2.0% - 2.5% in the United States.1.4 Its prevalence
varies in different ethnic groups. Amblyopia was
detected in 2.6% of Hispanic/Latino children and
1.5% of African-American children.5 The overall
prevalence in Singapore was 0.35% with no racial
difference among Chinese (0.34%), Malays (0.37%),
and Indians. The anisometropic form was most
commonly seen in several studies.6,7,8 The outcomes
of amblyopia showed varied results, with some
indicating that visual acuity deteriorated more in
patients with strabismic amblyopia, and others with
anisometropic amblyopia compared to patients with
the other types of amblyopia.5,6,7,9
The Amblyopic Treatment Study (ATS) divided
amblyopic patients into two groups based on severity.
Mild to moderate amblyopia is characterized by a
visual acuity of 20/40 - 20/80 (0.3 -0.6 LogMAR)
while severely amblyopic patients have a visual acuity
of 20/100 (0.7 LogMAR) to 20/400 (1.3 LogMAR). 2,3
The aim of amblyopia treatment is to improve visual
acuity and to prevent or reverse vision impairment.1,2
With timely intervention, the reduction in visual
acuity caused by amblyopia can be completely or
partially reversed.10,11 The ATS showed that more
than 75% of amblyopic children less than 7 years of
age had significant improvement in their BCVA to
20/30 [0.176 LogMAR] or better after treatment.12 All
patients with amblyopia should, therefore, be treated
and the caregiver educated.
The principles of amblyopia treatment are as
follows: eliminate any obstacle to vision, correct
refractive error, force the patient to use the poorer
eye by penalization with atropine or by patching of
the better eye,12 and lastly, surgery to treat the cause
of the amblyopia, if applicable. These options may
be used alone or in combination depending on the
nature of amblyopia.13
The ATS 2A showed that patients with severe
amblyopia had an improvement of 4.7 lines in those
34

Philippine Academy of Ophthalmology

patched full time and for at least 6 hours.14 ATS 2B

showed a 2.4 line improvement in those with mild to
moderate amblyopia when patched for 2-6 hours.15 A
similar improvement was obtained with penalization
with atropine. Both studies were conducted in the 3-7
year age group. 1,2,11
The American Academy of Ophthalmology
(AAO) preferred practice pattern2-recommended
schedule of treatment and follow-up was age-specific,
with the longer follow-up periods for older patients.
For the 2- to 8-year-old, follow-up ranged from 3-16
weeks when on high percentage occlusion (>6 hours
a day) and 2 to 6 months when on low percentage
occlusion (<6 hours). An average duration of
treatment of 6 to 9 weeks was sufficient to result in
improvement of vision.15
Reported rates of compliance for patching
vary widely from 49 to 87%.12 Low compliance to
the patching regimen was identified as a major
hindrance to the success of treatment.16 Compliance
was found to be the most important factor affecting
visual outcome7. The use of a patch diary was found
to correspond well with an electronic Occlusion Dose
Monitor (ODM).17 This allowed researchers to use
the patching diary as an objective means to measure
compliance. Though useful for recording purposes,
diaries filled out by the patients were not enough to
increase the overall concordance and compliance.18
Parental supervision and implementation increased
the compliance to patching and recording on the
diaries.19-21.
Despite its worldwide prevalence, there is no
published Filipino data on the visual outcomes
following treatment. This data can guide practitioners
in the treatment and follow-up of Filipino amblyopic
patients.
Thus, this study determined the visual outcomes
of amblyopia treatment with patching measured as
best corrected visual acuity (BCVA). It also correlated
the following factors with improvement in vision: age
of onset, age of initial consult, amblyopia subtype
or diagnosis, severity of amblyopia, and compliance
using a patch diary.

METHODOLOGY
This was a descriptive study of newly diagnosed
cases of amblyopia seen at the Pediatric Ophthalmo
logy and Strabismus Clinic of the Philippine General

Philippine Journal of

OPHTHALMOLOGY

Hospital from May 2010 to December 2010. Included

were all patients diagnosed with amblyopia between
3 to 8 years on initial consult, without previous
amblyopia treatment, and whose parents gave consent
to participate in the study. Patients diagnosed with
delayed visual maturity (DVM) or global develop
mental delay (GDD) were excluded.16

patched and the patching hours logged in the patching

diary by the parents to be brought back at the next
follow-up visit. Washable hand-sticked patches were
given and new sets of patches were provided on
follow-up. Treatment given was based on the AAO
preferred practice pattern.2

This study was approved by the hospital ethics

r eview board. Parental consent forms were written in
both English and Filipino and were signed by parents
of the participants. Study procedures conformed to
the tenets of the Declaration of Helsinki. Patient
data was kept confidential and identity was kept
anonymous.

Monthly follow-up visits were conducted for 6

months. To enhance follow-up and prevent patient
drop out, follow-up dates were agreed upon both by
the examiner and the caregiver or on the same day as
the patients scheduled visit at the subspecialty clinic. At
each visit, BCVA was measured first in the amblyopic
eye, then in the fellow eye. Ocular alignment and short
acting cycloplegic refraction were measured. Patching
diaries were submitted and compliance to patching
regimen was recorded with caregiver feedback. On
follow-up dates when the patching diaries were not
brought in by the caregiver, compliance was based on
caregiver recall and recorded. Reasons for the absent
diaries were noted.

Baseline Examination

On initial consult, baseline data such as personal

information, age of onset, gender, baseline BCVA
(in LogMAR and Snellen), full cycloplegic refraction,
ocular alignment, physical examination, diagnosis,
underlying cause, amblyopia severity, and laterality
were obtained. Visual acuity test was performed based
on the level of literacy: LEA charts for those unable
to read, and Snellen charts for the literate. Results of
either tests were converted to LogMAR units.20 All
examinations were performed by a single clinician.
The patients were classified according to their
amblyopia subtype:
1. Strabismic amblyopia associated with strabismus
where there was a strong fixation prevalence for
the dominant eye and constant suppression of the
non-dominant eye that was often deviated;
2. Refractive amblyopia anisometropia or amme
tropia of 1D or greater in spherical equivalent
or 1.5D or greater difference in astigmatism and
absence of strabismus or ocular pathology;
3. Sensory deprivation amblyopia - a known or
documented cause of sensory deprivation.18-20
The severity of amblyopia was classified as
mild/moderate with a BCVA between 20/40 and
20/80 (0.3-0.6 LogMAR) and severe with a BCVA of
20/100 20/400 (0.7-1.3 LogMAR).2
Intervention

The patients were prescribed eyeglasses, if

needed. They were provided with monthly patching
diaries where the eye to be patched and the prescribed
number of hours were written. The better eye was

Follow-up Visits

In cases where there was no further improvement

in BCVA of the amblyopic eye after 3 months of good
compliance to occlusion with or without spectacle
correction, or if there was regression in vision not
corrected by a change in spectacles (BCVA), the
patients were re-evaluated. If warranted, change in
prescription lenses were given or surgical intervention
suggested.
Outcome Measures

Treatment success was defined as a BCVA

of the amblyopic eye of 20/30 (0.17 LogMAR)
or better, or a 3-line improvement from baseline
after 6 months, or stable isoacuity maintained for
at least 3 months with ongoing treatment.4
Treatment failure was defined as the BCVA of
20/50 or worse, 0-2 lines of improvement of BCVA
in patients after 3 months of occlusion of greater than
75% of all waking hours or a regression in BCVA of
2 lines.4
Percent compliance to treatment was defined as:
# Hours of actual occlusion per month
_______________________________ x 100%
# Hours prescribed occlusion per month
Compliance was classified as good if >90%,
fair if 70%-90%, and poor if < 70% or if with
irregular entries in the diary.
January - June 2012

35

Table 3. Treatment Outcomes in the 3 Subtypes of Amblyopia

Analysis of Data

Statistical analyses were performed using SPSS

Windows 17.0 (SPSS Inc; Chicago, IL). Descriptive
statistics were performed on the baseline data
and Spearmans correlation was used to analyze
relationships between compliance, age of onset, age
of diagnosis, amblyopia subtype, and severity with the
BCVA at the end of the 6 month treatment period.
Individual progression of BCVA were plotted and
observed for trends.

RESULTS
32 participants were included in the study, 19
females (59.4%) and 13 males (40.6%). Age of consult
ranged from 3 to 8 years with a mean of 6 years and a
mode of 8 years (29%). Recorded age of onset ranged
from 2 to 6 years with a mean of 4.6 years.
All patients followed up for at least 6 months.
No patient dropped out of the study. Patients who
were seen and treated earlier (age 3-5 years) had
higher rates of success (75%) compared to those
treated later (25%) (Table 1). Average compliance
between the 2 groups was similar and not statistically
significant.
All strabismic patients, 67% of sensory, and
25% of refractive had severe amblyopia (Table 2). A
moderate linear correlation (r=0.39, p=0.05) existed
between the subtype and severity of amblyopia.
Table 1. Treatment Outcome Based on Age

Outcome
Age of Consult n (%) Success Failure Compliance

3-5
12 (37.5%) 75%
25%
87.9%

6-8
20 (62.5%) 35%
65%
88.5%
Table 2. Amblyopia Subtypes, Severity, Outcome, and Compliance
in the Study Population.
Severity
Outcome
Sub-
Com types
Mild-
Severe Success Failure pliance

Moderate
Refractive 15 (75%) 5 (25%) 11 (55%) 9 ( 45%) 92.3%
n=20 (63%) (good)
Sensory
3 (33%) 6 (67%) 2 (22%) 7 (78%) 81%
n=9 ( 28%) (fair)
Strabismic
0 (0%) 3 (100%) 3 (100%) 0 (0%) 8 3.3%
n=3 ( 28%) (fair)
Total
18 (56%) 14 (44%) 16 (50%) 16 ( 50%)

Spearmans correlation between diagnosis and severity: r=0.39,
p=0.05.

36

Philippine Academy of Ophthalmology

Out-
Subtypes
Severity
Com come Sensory Strabis- Refract- Mild-
pliance

mic
ive Moderate Severe
Success 92.2%
(n=16) 2 (12%) 3 (19%) 11 (69%) 11 (69%) 5 (31%) (good)
Failure 84.4%
(n=16) 7 (44%)
0% 9 (56%) 7 (44%) 9 (56%) (fair)
Change
1-2 lines
(n=7 )
(44%) 3 (43%) 4 (57%) 3 (43%) 4 (57%)
No
change
(n=9)
(56%) 4 (44%) 5 (56%) 4 (44%) 5 (56%)

Half of the patients in this study achieved

treatment success. Majority (69%) were diagnosed with
refractive amblyopia and there was a good compliance
to treatment in this group (Table 3). In the treatment
failure group, 56% had refractive amblyopia while
44% had sensory amblyopia with fair compliance to
patching. 44% had improvement of 1-2 lines in BCVA
and 56% had no change. more than half (56%) of the
patients in the treatment failure group were diagnosed
with severe amblyopia (Table 3). There was a mode
rately strong negative correlation (r=-0.48, p=0.01)
between severity of amblyopia and improvement of
BCVA. No patient had a regression in BCVA. Figure
1 shows the change in average BCVA of an amblyopia
eye at 6 months.
Overall compliance to patching in this study
was 88 18%. Patients in the treatment success
group had a 92% compliance compared with 84%
in the treatment failure group. There was a moderate
correlation between compliance and change in BCVA
(r=0.37, p = 0.05). Reasons for poor compliance
to patching were the childs refusal to patch (44%),
inability to patch while the child was in school (31%),
fear of patching the wrong eye (16%), and fear of the
child being teased (9%).

Figure 1. Change in average BCVA of an amblyopic eye at 6 months.

Philippine Journal of
Ten patients had irregular reports on their
patching diary or had follow-ups without their diaries.
Of the 10, 4 participants did not have their diaries in 2
non-consecutive follow-up months. The other 6 had
one follow-up visit without a diary. This resulted in a
total of 18 follow-up visits out of the total 192 visits
(32 participants x 6 follow-ups), or 9.3%, wherein
the patching diaries were absent. The most common
reason for not having the diaries on follow-up was
forgetting to bring the diary (60%). Other reasons
included losing or misplacing the diary and a damaged
diary.
There were no reported allergies or skin
intolerance to the patches.

DISCUSSION
For more than two hundred years, occlusion
of the better eye has been used successfully in the
treatment of amblyopia.1, 2 This study determined
the factors that affected the visual outcomes and
described how they affected BCVA after 6 months of
treatment.
Subtype

Prospective studies in Ethiopia and New

Delhi23-24 showed that strabismic amblyopia was more
common than refractive or sensory amblyopia. Similar
to our results, other studies25-26 demonstrated that
refractive amblyopia was more common than either
strabismic or sensory amblyopia. In a chart review
by Tamayo (Tamayo C & Valbuena MV. Amblyopia
profile at the Philippine General Hospital, 2010,
unpublished data), sensory amblyopia was the
most common in all pediatric age groups. They
included consults seen over 3 years and even those
with visual deprivation type of amblyopia who had
already undergone intervention and given the best
correction.
Age

The age of onset determined through caregiver

recall, indicated that sensory and strabismic amblyopia
were detected earlier due to noticeable eye findings,
such as ocular misalignment or a dense opacity. Most
patients with anisometropic amblyopia presented as
orthophoria with eyes that appeared normal to the
parent.18 This resulted in a later age of reported onset
that usually occured when the child started school and
reported blurring of vision. Since the determination
of the onset of amblyopia was based on parent recall,

OPHTHALMOLOGY

the correlation between visual outcome with the age

of onset was likely to be unreliable. A more reliable
variable would be the age of the patient at initial
consult which was also the age at initial treatment. Our
study showed higher success rates in those treated at
an earlier age, consistent with other studies.23-26
Compliance and Use of the Patching Diary

Good compliance to the prescribed patching

regimen was seen in the treatment success group as
compared to the fair compliance in the treatment
failure group. A statistically significant linear relation
ship between compliance and change in BCVA
was demonstrated by Loudon who showed that a
low increase in visual acuity had statistically lower
compliance rates.23
In our study, the low incidence of absent patching
diary (9.3%) on follow-up schedules made the recorded
compliance rate a reliable variable. Nevertheless,
reasons for poor compliance were addressed by
longer chair time and more thorough explanation of
the patching regimen. Other studies had suggested
that poor compliance to the patching regimen was
related to poor understanding of amblyopia and the
treatment regimen24-25 and other psychosocial factors.27
Our study had an over-all compliance of 88%
compared to earlier studies with compliance ranging
between 30 - 60%.18, 19 This increased compliance may
have resulted from a combination of factors, such as
more thorough written instructions on the patch diary
utilizing diagrams and cartoons, monthly follow-ups
where instructions were repeated and patient feedback
was encouraged, and the checking and collection
of patching diaries, all these may have incited a
positive effect on compliance. During the monthly
visits, the parents and caregivers were encouraged
to ask questions so that misconceptions could be
corrected.
The use of the diary allowed both the parent or
caregiver and the patient to take an active role in the
treatment by logging the hours on the diary. The diary
was also a means where the caregivers were reminded
of their tasks, and where they were able to write
down their questions that were then answered at the
next follow-up visit. Consistent with earlier studies,
good rapport with the parents and regular advise to
increase awareness on the need for patching enhanced
compliance. The use of a patch diary coupled with
long chair time on each monthly follow-up allowed
the parents and caregivers to have a clearer idea of the
disease and the treatment regimen.
January - June 2012

37

Severity

Patients with mild to moderate amblyopia had a

higher rate of treatment success (61%) as compared
to severe amblyopia (36%). Compliance rates were not
significantly different between the two groups. There
was a strong negative correlation between severity and
change in BCVA as demonstrated in this study. The
severity of amblyopia is an important factor affect
ing the visual outcome in cases where compliance
to patching is good. In spite of this, there can still
be partial response to treatment as seen by a 2 line
improvement in BCVA after 6 months of treatment
in some severe amblyopia.

8.

Outcome and Follow-up Period

Stable isoacuity after 9-10 weeks of treatment (2-3
months) was seen in earlier studies.23-26 Improvement
of BCVA showed no change on months 3 & 4
(Figure 1) and may be misinterpreted as attaining
stable BCVA. However, improvement of at least 1
line in the Snellen chart was seen from months 5-6,
indicating that prolonged patching and follow-up of
these patients are needed beyond 6 months.

13.

Thus, future studies should include a larger

sample size of each subtype of amblyopia with a
longer follow-up period.

38

9.

10.
11.
12.

14.
15.
16.
17.
18.

In summary, amblyopia treatment with occlusion

was most effective in mild to moderate amblyopia.
Early treatment of amblyopia resulted in higher rates
of success. With good compliance, there was some
improvement seen in those with severe amblyopia. A
patching diary can be used to improve compliance and
to increase the understanding of occlusion therapy.

19.

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