Abstract Objective To investigate the clinical characteristics and effects of comprehensive therapy for the treatment of amblyopia in children. Methods 265 cases (503 eyes) of children were diagnosed according to the national unified amblyopia diagnostic criteria and were treated with comprehensive therapy. The type of amblyopia, the degree of amblyopia, the nature of gaze in the amblyopic eye, the relationship between the patient’s age and the efficacy, and the time to cure amblyopia were also analyzed. Results The total effective rate of amblyopia treatment was 92.9%, of which 72.6% were cured, 20.3% were improved, and 7.1% were invalid; the average duration of cure was 6.5 months. The highest cure rate was found in the refractive amblyopia, 3-6 years old group. Conclusion The efficacy of amblyopia is closely related to the type of amblyopia, the degree of amblyopia, the nature of gaze and the age of the patient, and comprehensive therapy can improve the cure rate of amblyopia and shorten the treatment time. Li Xiaodong, Ophthalmology Department, Baicheng Central Hospital
Keywords amblyopia, treatment
Amblyopia is a relatively common eye disease in children, with a prevalence of 2% to 3% of children. Patients with amblyopia not only have low vision in one or both eyes, but also lose monocular function in both eyes, which seriously affects the quality of life; therefore, amblyopia treatment should be highly valued by ophthalmologists, parents and the society, who should cooperate with the treatment.
1 Information and methods
1.1 General data Among the 265 cases of 503-eyed amblyopic children, there were 257 eyes in 134 cases of males and 246 eyes in 131 cases of females. Age ranged from 3 to 14a, with an average of 7.6a. 391 eyes (77.7%) had refractive amblyopia, 37 eyes (7.4%) had refractive amblyopia, and 75 eyes (14.9%) had strabismic amblyopia. There were 451 eyes with central gaze and 52 eyes with paracentral gaze. There were 55 eyes with severe amblyopia (visual acuity ≤0.1), 277 eyes with moderate amblyopia (visual acuity 0.5-0.2), and 171 eyes with mild amblyopia (0.8-0.6). The external eyes and fundus were normal, and there were no organic eye diseases. The diagnostic criteria and classification methods of amblyopia followed the criteria specified by the National Amblyopia Control Group in April 1996.
1.2 Treatment methods
1.2.1 Routine examination, dilated optometry and prescription: All children were examined for distance and near visual acuity, eye position examination for distance and near vision, external eye and refractive interstitial and fundus examination, gaze nature examination, and tertiary visual function examination by the same vision machine. Routine 1% atropine ophthalmic ointment three times a day for four consecutive days followed by refractive state examination (including retinoscopy optometry and fully automated computerized optometry). For those with dilated pupils, a review will be conducted after 3wk to determine the prescription for glasses, which will be prescribed. For those with combined internal strabismus, complete correction of hyperopic refractive error; for those with orthokeratology combined with moderate or high hyperopia, full correction of spectacles will be worn according to the results of photometry, and after the visual acuity is improved, the prescription of spectacles will be reduced appropriately. Complete correction of astigmatism. For amblyopic patients with medium or high myopia, glasses should be lowered by 1/3 to 1/2 according to the results of the examination and shadowing.
1.2.2 Traditional masking. The number of days of covering is decided according to the age of the patient and the visual acuity of the amblyopic eye. The ratio of coverage is roughly 2:1 for 2-year-olds, 3:l for 3-year-olds, 4:1 for 4-year-olds, 5:l for 5-year-olds, 6:l for 6-year-olds, and continuous coverage for 7-year-olds and older. For monocular amblyopia, the healthy eye is covered for the entire day. For binocular amblyopia, if the visual acuity of both eyes is the same or similar, no masking; if the visual acuity of the two eyes differs by 2 lines or more at the beginning or during the treatment, the better one will be masked for the whole day.
1.2.3 Vision enhancement training. The training content includes: CAM visual stimulation, red light flicker, fine visual acuity training, fusion function training, stereopsis function training, etc. It was performed once a day for a total of 30-40 minutes each time. Light brush therapy and posterior image therapy were selected for those with paracentral gaze.
Using the above comprehensive treatment, generally 1 to 2mo review once, according to the recovery of visual acuity, adjust the masking method, 0.5a check shadow optometry once, according to the refractive state, change the lens degree. After the improvement of strabismic amblyopia, the residual strabismus will be surgically corrected to consolidate the treatment effect. After cure, follow-up observation was performed for 1.5 to 2 years.
1.3 The efficacy criteria were evaluated according to the criteria established by the National Amblyopic Strabismus Prevention and Control Group in April 1996.
1.4 Statistical treatment: X2 test was performed for statistical analysis of the count data.
2 Results
In 503 amblyopic eyes, the total effective rate of treatment was 92.9%, of which 72.6% were cured, 20.3% were improved and 7.1% were invalid, and the average duration of basic cure was 6.5 months.
2.1 Relationship between age and efficacy (Table 1): the younger the age, the better the treatment effect, and the difference between groups was statistically significant (P
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Age (years) Number of eyes Cured Progress Ineffective
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3 to 6 298 238(79.93) 49(16.4) 11(3.7)
6～12 172 109(63.4) 45(26.7) 17(9.9)
12 to 14 33 18(54.5) 7(21.2) 8(24.2)
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Total 503 365 102 36
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X2=31.64 P<0.01
2.2 Relationship between amblyopia type and efficacy (Table 2): the basic cure rate of refractive amblyopia was the highest, reaching 77.0%, and the difference between groups was statistically significant (P<0.01).
Table 2 Type of amblyopia and curative effect Eye (%)
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Amblyopia type Number of eyes Basic cure Progress Ineffective
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Refractive error 391 301(77.0) 63(16.1) 27(6.9)
Refractive aberrations 37 18(48.7) 16(43.2) 3(8.1)
Strabismus 75 46(61.3) 23(30.7) 6(8.0)
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Total 503 365 102 36
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X2=20.39 P<0.01
2.3 The relationship between the degree of amblyopia and the curative effect (Table 3): the deeper the degree of amblyopia, the worse the curative effect. The basic cure rate of mild amblyopia was the highest, 96.5%, and the basic cure rate of severe amblyopia was 23.3%, with a statistically significant difference between groups (P
Table 3 Degree of amblyopia and curative effect Eye (%)
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Degree of amblyopia Number of eyes Basic cure Progress Ineffective
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Mild 171 165(96.5) 2(1.2) 4(2.3)
Moderate 277 187(67.5) 67(24.2) 23(8.3)
Severe 55 13(23.3) 33(30.0) 9(16.4)
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Total 503 365 102 36
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X2=175.93 P<0.01
2.4 The relationship between the nature of gaze and efficacy (Table 4): the efficacy of central gaze was better than that of paracentral gaze, and the difference between the two groups was statistically significant (P
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Nature of gaze Number of eyes Basic cure Progress Ineffective
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Central gaze 451 248(77.2) 74(16.4) 29(6.4)
Paracentral gaze 52 17(32.7) 28(53.8) 7(13.5)
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Total 503 365 102 36
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X2=49.01 P<0.01
3 Discussion
Amblyopia is a developmental disorder that can cause visual developmental disorders leading to amblyopia if a normal visual developmental environment is not available during the sensitive period of visual development. von Noorden classified amblyopia into five types of amblyopia: refractive error amblyopia, refractive aberration amblyopia, strabismic amblyopia, form deprivation amblyopia, and congenital amblyopia according to the pathogenesis of amblyopia. the latter two types of amblyopia are less common and have a poorer prognosis. The first three types of reversible functional amblyopia, i.e., amblyopia treated by this group of comprehensive therapies, are mostly seen in clinical practice. There are many treatment options for amblyopia, depending on the type of amblyopia, the degree of amblyopia, and the age of treatment. These include surgical removal of form deprivation factors, timely and correct refractive correction, and masking or suppression of the healthy eye to remove the inhibition of the dominant eye over the inferior eye in abnormal binocular interaction. On top of this, appropriate stimulation training is provided to the amblyopic eye to increase the efficacy.
The effect of amblyopia treatment is closely related to age, type of amblyopia, degree of amblyopia and nature of gaze. From the statistics of this paper, it can be seen that (1) the treatment age of 3-6a group has the best efficacy with a cure rate of 79.9%. It is the same as Simons et al [1] that amblyopia with strabismus, refractive aberration and abnormal retinal correspondence occurs mostly before 6a, and the cure rate of children under 6a is high and the effect can be easily consolidated; (2) the cure rate of mild amblyopia is the highest and the cure rate of severe amblyopia is the lowest. However, comparing with various other reports [2-4], the cure rate of all degrees of amblyopia in this paper was high, which may be related to the comprehensive treatment; (3) the cure rate of those with central gaze was better, with a cure rate of 77.2%, which was higher than the cure rate of 73.34% for central gaze according to Xu Guozhi [2], indicating that this comprehensive treatment is effective in stimulating the central macular sulcus. (4) The basic cure rate of 54.5% in the 12-14 years old group indicates that there is still some plasticity after the critical period of visual development, so the treatment of amblyopia should not be easily abandoned in older children.
The above results show that the younger the age of amblyopia treatment, the better the treatment effect, and early amblyopia screening should be advocated to achieve early detection and early treatment; and the effect of comprehensive treatment is better than single treatment; hospital-based treatment can ensure better efficacy than home treatment. To ensure the effectiveness of treatment, the following points should be noted: 1. Careful examination of eye position and ciliary muscle paralysis before dispensing, accurate optometry, correct prescription of glasses. The starting point of our eyeglasses prescription is to ensure clear imaging of the retina as much as possible, to promote excitatory stimulation of high spatial frequency sensitive cells, to promote eye development, and to complete the process of refractive normalization of visual development. In the case of satisfactory and acceptable visual acuity correction, try to give enough degrees for farsighted internal obliquity and less for external obliquity; give less for myopic internal obliquity and enough for external obliquity; it is more appropriate to correct all astigmatism. 2. insist on wearing glasses, cover treatment should be thorough and well adhered to, cover treatment is an important means of comprehensive therapy. 3. conduct fine visual acuity training for amblyopic eyes to increase the effectiveness of treatment. Through hand, eye and cerebral cortex coordination training, the macular function inhibition of amblyopic eyes can be lifted more quickly and the central vision can be improved. According to the age, intelligence, personality and visual acuity, it is necessary to start with the easy ones and then the difficult ones, first wear beads, buttons and toy inserts with larger holes, and then wear rusty needles, tracing and calligraphy after the visual acuity increases to avoid the boring boredom caused by repeated training.4. The cone cells are sensitive to red light with a wavelength of 640µm [5], so the red light stimulation treatment should ensure that the wavelength of red light used is accurate and effective.5. The amblyopic treatment room should be kept The children’s attention should be focused on the training, and they should not eat or hold toys in their hands. 7. The cooperation between parents and amblyopic children is a very important issue, and it is even related to the success or failure of the treatment. The treatment period of amblyopia is long and the visual acuity changes slowly, so we should explain patiently to the parents of the children to obtain their understanding and cooperation, and prevent the children from stopping halfway. 8. we should understand the personality characteristics of each child to better supervise and guide the treatment.
4 References
［A reconsideation of amblyopia Screening and stereopsis [J].Am J Ophthalmol 1994;78:707-713.
[2] Xu G. C. Preliminary experience of combined therapy in the treatment of amblyopia [J]. Journal of Practical Ophthalmology 1989;7:265-267.
[3] Guo Jingqiu, Liu Jiaqi. Visual physiological stimulation therapy for amblyopia [J]. Chinese Journal of Ophthalmology 1982;18:129-132.
[4] Shen Changli, Zhang Yijing, Su Ruifang, et al. Observation on the efficacy of combined therapy for amblyopia [J]. Journal of Practical Ophthalmology 1989;7:268-269.
[5] Liu Jiaqi, Li Fengming. Practical Ophthalmology (2nd ed.). Beijing: People’s Health Publishing House, 2003,699