Combined optical and atropine penalization for the treatment of strabismic and anisometropic amblyopia

Introduction: The treatment of amblyopia by occlusion of the fellow eye is beset by problems related to compliance, stigmatization, and regression of visual acuity (VA). Atropine or optical penalization has been used as an alternative treatment for amblyopia and might be synergistic as a combination therapy. Combined optical and atropine penalization treatment (COAT) was therefore assessed in patients with anisometropic and strabismic amblyopia. Methods: Patients with a hypermetropic refractive error in whom occlusion had failed were prescribed daily atropine 1% and a plano spectacle lens to the fellow eye. Outcome measures included VA (LogMAR units), interocular VA difference, adverse events, and adverse reactions. COAT was continued until VA failed to improve after 2 consecutive visits, and then patients were offered occlusion treatment again. Results., Forty-two patients (mean age, 4.73 yrs) were treated with COAT. Patients had attempted occlusion for a mean period of 36 weeks before commencement of COAT. The mean VA of the amblyopic eyes improved after 10 weeks of COAT, from 0.85 (20/113) to 0.28 (20/37) (P<.001), an overall success (doubling of VA) rate of 76%. There was no significant change in the mean VA of the fellow eye as a result of COAT (P=.13). Twenty-two patients recommenced occlusion after COAT for regression (10), lack of further improvement (2), or parental choice (10). The remaining 20 patients maintained their VA without treatment at 93% of post-COAT levels, at a mean follow-up 6.4 months. Overall regression rate was 36%, adverse reaction rate was 2%, adverse event rate was 21%, and presumed compliance rate was 83%. Discussion: COAT is an effective treatment method when occlusion therapy initially fails. COAT is well tolerated and should be considered as an alternative and/or supportive therapy in the management of amblyopia.