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Atropine Treatment of Amblyopia: Is a Swap in Fixation Necessary?

Josephine Leone, BOrth&OphthSc(Hons); Zoran Georgievski, BAppSc(Orth)(Hons); Konstandina Koklanis, PhD

educational objectives
1. To demonstrate the significance of promoting the amblyopic eye and its fovea to restore visual acuity when treating amblyopia. 2. To describe the impact of fixation behavior on visual acuity outcomes during atropine treatment. 3. To recognize the role of the cyclo-swap test as an effective tool in predicting atropine efficacy.

(NFS group). By the end of the 10-week treatment period, both groups demonstrated a mean visual acuity improvement of between 2 and 3 lines (FS = 0.22 log units; NFS = 0.27 log units). Six of the 8 children in the NFS group demonstrated improvement in vision, all of whom also demonstrated a fixation swap at some stage. conclusion: Vision improvement in patients using atropine is likely to be attributable to a fixation swap that occurs during the treatment phase. The CST performed at 1/3 and 6 m has little value in predicting improvements in vision; however, when performed at distances of less than 1/3 m, it may provide valuable clinical information about atropine efficacy. [J Pediatr Ophthalmol Strabismus 2010;47:270-276.]

abstRact
Purpose: To investigate the impact of fixation on vision outcomes in patients with amblyopia undergoing atropine treatment and the validity of the cyclo-swap test (CST) as a method of predicting atropine efficacy. Method: Sixteen children with amblyopia were included. The initial examination included a vision assessment and CST, in which fixation was assessed at 1/3 m, 6 m, and at distances less than 1/3 m. Children were treated for 10 weeks and reviewed at 5-week intervals with cessation of atropine 4 days prior. Vision and fixation were assessed at the follow-up visits. Children demonstrating no fixation swap initially were additionally observed after 1 week of atropine treatment under maximum cycloplegia. Results: Eight children demonstrated a fixation swap (FS group) to the amblyopic eye during the CST at either 1/3 or 6 m, and 8 demonstrated no fixation swap

intRoduction Occlusion and atropine are the most commonly prescribed amblyopia treatments, the goal of treatment being to promote the use of the amblyopic eye and its fovea to restore visual acuity.1 With occlusion, this is achieved by patching the non-amblyopic eye, eliminating its visual input, and forcing fixation with the amblyopic eye. Atropine treatment causes temporary blurred vision in the non-amblyopic eye sufficient to compel the amblyopic eye to take up fixation.1 However, whether this fixation swap occurs depends not

From the Department of Clinical Vision Sciences (JL, ZG, KK), La Trobe University; the Department of Ophthalmology (KK), Royal Childrens Hospital; and the Department & Clinical School of Orthoptics (ZG), Royal Victorian Eye & Ear Hospital, Melbourne, Australia. Originally submitted April 25, 2009. Accepted for publication June 17, 2009. Posted online November 23, 2009. The authors have no financial or proprietary interest in the materials presented herein. Address correspondence to Zoran Georgievski, BAppSc(Orth)(Hons), Department of Clinical Vision Sciences, La Trobe University, Melbourne, Australia. doi: 10.3928/01913913-20091118-05

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only on the vision of the amblyopic eye but also on the hypermetropic refractive error of the non-amblyopic eye.2,3 Selecting patients most appropriate for atropine treatment is therefore not necessarily straightforward for the clinician. Wright and Guyton4 were perhaps the first to report a pretreatment diagnostic test simulating the likely fixation behavior during atropine treatment. The test involves the in-office assessment of fixation following administration of cyclopentolate to the non-amblyopic eye. Wright and Guyton reported that only patients demonstrating a fixation swap to the amblyopic eye with this test showed a subsequent improvement in vision following atropine treatment. We refer to this as a cyclo-swap test. However, it has recently been questioned whether a fixation swap (to the amblyopic eye) is actually necessary for atropine treatment to be successful. Although a recent retrospective review reported that patients swapping fixation during atropine treatment had significantly greater improvement in visual acuity compared with those who did not swap,5 studies by Holmes and Clarke,6 the Pediatric Eye Disease Investigator Group (PEDIG),7,8 and McNamara and Rice9 have asserted that visual acuity improvement can be demonstrated in patients treated with atropine regardless of their fixation behavior. The implication is that a fixation swap is not essential for atropine to be successful. This questions our basic understanding of how atropine works and its indications in amblyopia treatment. Our study aimed to investigate the impact of fixation behavior on visual acuity outcomes following atropine treatment. We also aimed to investigate the validity of the cyclo-swap test as a method of predicting treatment efficacy. Patients and MetHods
Subjects

Procedures

Children between the ages of 3 and 8 years with unilateral strabismic amblyopia, anisometropic amblyopia, or both of at least 2 lines of difference between the eyes were eligible for inclusion. Anisometropia was defined as a difference of 1 diopter of spherical equivalence or greater. Children with a lack of visual acuity improvement with occlusion treatment that could not be attributed to poor adherence were excluded, as were children with other ocular or neurological pathologies.

Prior to commencement, ethics approval to conduct this study was obtained from the relevant institutions. The design of the study in terms of the participants progression is illustrated in Figure 1. Each child initially underwent a preliminary eye examination, including an assessment of distance vision and fixation behavior. A cycloplegic refraction was performed on all children in whom this had not been done within the previous 6 months. New glasses were prescribed if they were found to be undercorrected or overcorrected by 1 diopter of spherical equivalence or greater. Consequently, all wore correction within 1 diopter of the refractive error for both eyes throughout the treatment period. Visual acuity measurements were made using a linear logarithm of the minimum angle of resolution (LogMAR) chart at the standard distance of 3 m with the patients refractive correction. Visual acuity measurements were used to derive an interocular acuity score, a method previously described by our group.10 The assessment of strabismus and fixation preference was made using a cover test performed at both 1/3 and 6 m. In anisometropic children without strabismus, the determination of fixation preference was made using a prism-induced fixation test. This involved placing two loose base-in prisms of approximately 12 to 15 prism diopters simultaneously before each eye. Immediately following this preliminary examination, all children underwent what we refer to as the cyclo-swap test. This involved instilling a drop of cyclopentolate hydrocholoride 1% in the non-amblyopic eye and assessing the childs fixation behavior 45 minutes later. Fixation behavior was assessed on all children at five distances: at the usual 1/3 and 6 m distances and at the nearer distances of 20, 15, and 10 cm. This was performed with optical correction. Based on the results of the cyclo-swap test, children were placed in one of two groups: fixation swap or no fixation swap. The fixation swap group comprised children who swapped fixation at 1/3 m, 6 m, or both. The no fixation swap group comprised children who did not swap fixation at either 1/3 or 6 m or only swapped at distances nearer than 1/3 m. Hence, children swapping fixation at 20, 15, or 10 cm were considered to be in the no fixation swap group because they would normally be considered non-swappers according to their likely clinical performance on the cover test and cyclo-swap test.
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Figure. Flow chart showing progression of children through the study.

Each child was then prescribed one drop of atropine sulfate (1%) to be instilled daily in the nonamblyopic eye. They were observed for 10 weeks and reviewed at 5-week intervals (Fig. 1). The parents were requested to cease atropine 4 days prior to the follow-up appointments so that a visual acuity measurement for the non-amblyopic eye that was as accurate as possible could be made. Follow-up visits included an assessment of visual acuity and fixation. For children in whom the visual acuity difference between the eyes reached less than a 2-line difference during the treatment, the atropine regimen was decreased to every second day. Children in the no fixation swap group had an additional follow-up visit 1 week after the preliminary assessment (Fig. 1). For this visit, they were requested to continue atropine treatment and not stop 4 days prior. The assessment included a cover test at 1/3 and 6 m, as well as at 20, 15, and 10 cm, the purpose being to assess the childs fixation behavior during maximum cycloplegia and under various accommodative demands following a week of atropine use. The analysis of the effect of fixation behavior on the impact of visual acuity outcomes involved a detailed examination of each individual case. This allowed for direct comparison between individual patients and groups and an in-depth investigation of how fixation behavior may relate to visual acuity throughout treatment. This qualitative assessment was considered appropriate given the small case series included.
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Results Sixteen children (9 boys; 7 girls) with ages ranging from 3 to 8 years (mean = 5.6 years) were included. Eleven had strabismic amblyopia, 3 had anisometropic amblyopia, and 2 had mixed amblyopia. One child had Duanes retraction syndrome (type 1) but was included in the study because the affected eye was otherwise healthy. A summary of the childrens clinical characteristics is presented in Table 1. Eight children demonstrated a fixation swap to the amblyopic eye at either 1/3 or 6 m on the cycloswap test and comprised the fixation swap group. The remaining 8 children who did not demonstrate this fixation swap at 1/3 or 6 m comprised the no fixation swap group. The no fixation swap group had a slightly worse mean visual acuity in the amblyopic eye at both study commencement and completion. By the end of the treatment period, however, both groups showed a similar improvement in mean visual acuity. The fixation swap group improved an average of 2.2 lines, whereas the no fixation swap group improved an average of 2.7 lines (Table 2). A summary of each childs fixation behavior and visual acuity during the 10-week treatment period is presented in Table 3.
Fixation Swap Group

The mean visual acuity of the amblyopic eye in the fixation swap group at study commencement and completion was 0.41 log units (approximately
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TAbLe 1

clinical characteristics of the children

Refractive Error (Spherical Equivalent) Case 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 Sex M M M M F M M F F M F F F M F M Age (Y) 6 8 5 4 3 8 5 4 8 6 8 4 5 4 6 5 Type of Amblyopia Strabismic Strabismic Mixed Strabismic Strabismic Anisometropic Strabismic Strabismic Strabismic (DRS) Mixed Strabismic Strabismic Strabismic Anisometropic Anisometropic Strabismic Ambl +0.75 +0.75 +5.50 +1.75 +0.75 +1.50 +2.75 +1.13 +3.88 -0.36 +2.00 +4.50 +4.86 +3.63 +4.75 +6.50 Non-Ambl +0.50 +0.876 +2.00 +1.50 +0.50 -0.50 +3.00 +1.25 +3.75 +3.25 +2.00 +4.00 +4.00 +1.25 +1.00 +6.50 Initial BCVA Snellen (Log) Ambl 6/38 (0.80) 6/12 (0.34)
-1

Non-Ambl 6/8 (0.10) 6/8+1 (0.08) 6/8 (0.10) 6/10 (0.20) 6/15+1 (0.38) 6/6+1 (0.02) 6/10-1 (0.22) 6/10 (0.20) 6/6 (0.00) 6/12+1 (0.28) 6/5 (-0.10) 6/8 (0.10) 6/8+2 (0.06) 6/8 (0.10) 6/6 (0.00) 6/8+1 (0.08)

6/38+1 (0.78) 6/15 (0.36)

+2

6/24 (0.60) 6/12+2 (0.36) 6/19 (0.48)

+1

6/30+2 (0.66) 6/12 (0.30) 6/19 (0.50) 6/15+2 (0.36) 6/60-2 (0.84) 6/15 (0.36)
+2

6/19 (0.50) 6/24 (0.60) 6/24+1(0.58)

bCVA = best-corrected visual acuity; Ambl = amblyopic eye; Non-Ambl = non-amblyopic eye; DRS = Duanes retraction syndrome.

TAbLe 2

Mean values of the childrens clinical characteristics

Mean Refractive Error (Spherical Equivalent) Mean Age (Y) 6 5 Initial Mean BCVA Snellen (Log) Final Mean BCVA Snellen (Log) Mean IO Difference (Log ) 0.22 0.27

Group FS (n = 8) NFS (n = 8)

Ambl +2.12 +3.47

Non Ambl +1.92 +2.44

Ambl 6/15 (0.41)

-1

Non-Ambl 6/8 (0.11)

-1

Ambl 6/10 (0.20)

-2

Non-Ambl 6/8-1 (0.11)

6/30 (0.65)
+2

6/8 (0.12)
-1

6/15 (0.46) 6/10+2 (0.15)

bCVA = best-corrected visual acuity; Ambl = amblyopic eye; Non-Ambl = non-amblyopic eye; IO = interocular; FS = fixation swap; NFS = no fixation swap.

6/15) and 0.20 log units (approximately 6/10), respectively. The mean interocular score at study commencement and completion was 0.30 log units (3 lines) and 0.08 log units (just < 1 line), respectively, representing a visual acuity improvement of 0.22 log units (just > 2 lines). All children in this group showed improvement of their amblyopia by the end of the 10-week treatment period. The mean refractive error (spherical equivalent) in the non-amblyopic and amblyopic eyes was +1.92 D ( 1.46 D) and +2.11 D ( 1.64 D), respectively.

No Fixation Swap Group

The mean visual acuity of the amblyopic eye in the no fixation swap group at study commencement and completion was 0.65 log units (approximately 6/30) and 0.46 log units (approximately 6/15), respectively. The mean interocular score at study commencement and completion was 0.53 log units (just > 5 lines) and 0.26 log units (just < 3 lines), respectively, representing a visual acuity improvement of 0.27 log units (just < 3 lines). The mean refractive error (spherical equivalent)
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Fixation behavior and visual acuity during atropine treatment

Cyclo-Swap Test Fixation Preference Week 5 Week 10

Preliminary Examination

Case
FS (at all distances) FS (at all distances)
+2

Visual Acuity
N/A N/A N/A N/A N/A N/A N/A N/A Fs (at all distances) NFS (at any distance) ReT/ReT Ret/Ret LeT/ReT ReT/ReT ReT/ReT LeT/LeT ReT/ReT Ret/Ret AeT/AeT ReT/ReT VR 6/10+2, VL 6/6-1 VR 6/10-1, VL 6/10 VR 6/8, VL 6/24 VR 6/38 , VL 6/8
+1

CT
ReT/LeT ReT/ReT AeT/ReT ReT/ReT ReT/LeT LXT/LXT VR 6/4, VL 6/10+1 VR 6/15+2, VL 6/12+1 LeT/LeT LXT/LXT AeT/AeT ReT/AeT Ret/Ret Ret/let VR 6/19, VL 6/12-1 VR 6/8+2, VL 6/10-1 VR 6/6-1, VL 6/10-1 VR 6/60-3, VL 6/10 VR 6/15, VL 6/8-1 VR 6/10+1, VL 6/15 Ret/Ret Ret/Ret LeT/LeT N/A aet/aet LeT/LeT VR 6/24, VL 6/12 ReT/ReT VR 6/6+2, VL 6/10+2 AeT/AeT VR 6/15 , VL 6/10 LeT/LeT VR 6/10, VL 6/6 ReTReT VR 6/10-2, VL 6/6-2 VR 6/15-1, VL 6/15-1 VR 6/6+2, VL 6/8 VR 6/12+1, VL 6/12+1 VR 6/12+2, VL 6/10-1 VR 6/4, VL 6/8+2 VR 6/6-2, VL 6/6-2 VR 6/10-1, VL 6/8 VR 6/10, VL 6/15 VR 6/38 , VL 6/8
+1

Baseline

Week 1

CT

Visual Acuity

CT

Visual Acuity

IO Difference (Log)
0.06 0.16 0.28 0.26 0.18 0.20 0.30 0.28 0.52 0.00

Fixation Swap Group

2 FS (at all distances, except 6 m) FS (at all distances, except 6 m) FS (at all distances, except 6 m) FS (at all distances, except 6 m) FS (at all distances, except 6 m) FS (at all distances) NFS (at any distance) NFS (at any distance) nFs (sF at 10 cm only) Fs (at all distances, except 6 m) NFS (at any distance) nFs (Fs at nearer than Fs (at all distances, 1/3 m only) except 6 m) NFS (at any distance) NFS (at any distance) nFs (Fs at 10 cm only) NFS (at any distance) nFs (Fs at nearer than Pt didnt attend visit 1/3 m only) NFS (at any distance)

VR 6/12-1, VL 6/8+1

ReT/ReT

VR 6/15 , VL 6/10

+2

ReT/ReT

VR 6/6+1, VL 6/12+2 (PFT)

LeT/LeT

7b

VR 6/10-1, VL 6/19+1

LeT/LeT

10

VR 6/19, VL 6/12+1

ReT/ReT

11

VR 6/5, VL 6/15+2

LXT/LXT

13

VR 6/15+2, VL 6/8+2

ReT/ReT

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14

VR 6/19, VL 6/8 (PFT)

ReT/ReT

No Fixation Swap Groupc

VR 6/8, VL 6/38

LeT/LeT

VR 6/38 , VL 6/8

+1

ReT/ReT

VR 6/24, VL 6/15

ReT/ReT

VR 6/15+1, VL 6/15+1 VR 6/6, VL 6/10 VR 6/6, VL 6/10-2 N/A VR 6/8-2, VL 6/8 VR 6/10, VL 6/12

0.22 0.26 0.06 0.08 0.58 0.40

VR 6/10, VL 6/30+2

LeT/LeT

VR 6/6, VL 6/12

LeT/LeT

12

VR 6/60-2, VL 6/8

ReT/ReT

15

VR 6/24, VL 6/6 (PFT)

ReT/ReT

16

VR 6/8+1, VL 6/24+1

LeT/LeT

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CT = cover test; IO Difference = interocular difference between baseline and final visit; VR = vision right; VL = vision left; ReT = right esotropia; N/A = not applicable; FS = fixation swap; LeT = left esotropia; AeT = alternating esotropia; PFT = Prism Fixation Test; LXT = left exotropia; NFS = no fixation swap; Pt = patient. a Week 5 visit was shortened to 3 weeks. b Occlusion amblyopia. c bold indicates a swap in fixation at one or more of the five distances assessed in patients in the NFS group.

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in the non-amblyopic and amblyopic eyes was +2.44 D ( 2.13 D) and +3.47 D ( 2.28 D), respectively. Of the 8 children in the no fixation swap group, 6 had improved visual acuity. All of these children demonstrated a swap in fixation to the amblyopic eye at some point in time at one or more of the five distances assessed. Four of the 6 swapped fixation at the baseline visit at distances nearer than 1/3 m, with the other 2 demonstrating a swap in fixation at a later stage, 1 at the 1-week visit and the other at the 5-week visit. Two children in the no fixation swap group showed no improvement in visual acuity. One of these children demonstrated a swap in fixation at week 10, whereas the other child failed to attend the last visit but had not demonstrated a swap in fixation on all previous visits. Table 3 illustrates the eventual fixation swap and visual acuity improvement that occurred in patients in the no fixation swap group. discussion As clinicians, we have believed that the goal in treating amblyopia is to promote the use of the amblyopic eye and its fovea to restore visual acuity.1 An issue central to the use of atropine in the treatment of amblyopia is therefore whether it will blur the vision of the non-amblyopic eye sufficiently to promote and achieve a fixation swap to the amblyopic eye. This was a basis for the aforementioned Wright and Guyton4 study that reported a pretreatment diagnostic test as being effective in predicting patients who would best respond to atropine treatment. There was anticipation in their study that only children showing an immediate in-office fixation swap would subsequently respond to atropine treatment. Despite this, our study shows that even children who would clinically be considered as not having swapped fixation with the cyclo-swap test demonstrate visual acuity improvement. In the past few years, studies by PEDIG7,8 and McNamara and Rice9 have stimulated great interest in this area, and perhaps enough to question the basic and underlying principles of amblyopia management (ie, to promote the use of the amblyopic eye and its fovea to achieve visual acuity improvement). Indeed, these recent studies have suggested that a fixation swap to the amblyopic eye is not necessary for atropine treatment to be successfulpresumably, the blur alone suffices. However, this has not been adequate-

ly tested in these studies. The following attempts to explain. The no fixation group in our study comprised eight children who clinically would not be considered to have swapped fixation with the cyclo-swap test at the initial assessment because this was not the case at either 1/3 or 6 m (these being the usual clinical testing distances). However, six of the eight children demonstrated visual acuity improvements. As reported in the results and detailed in the case examples, four of these six children demonstrated a swap in fixation on the initial visit at distances nearer than 1/3 m, where greater accommodation is required to see clearly and therefore cycloplegia produces pronounced blur in the non-amblyopic eye relative to the amblyopic eye. It is conceivable that during treatment these children, on occasion, swapped fixation to the amblyopic eye at distances nearer than what we consider near to be clinically. Further, the two other children who showed visual acuity improvements also actually swapped fixation, but after either 1 or 5 weeks of treatment with atropine. Therefore, all of the children in our study who demonstrated an improvement in visual acuity also demonstrated a swap in fixation on at least one occasion at a distance of 1/3 m, 6 m, or distances less than 1/3 m. Of the two children in the no fixation swap group who did not show improvements in vision, one swapped fixation on the last visit, which may indicate that improvements may have been seen later if the study were to continue and the other demonstrated no change in vision of the amblyopic eye and no swap in fixation. Unlike the PEDIG7,8 and McNamara and Rice9 studies, we tested the fixation behavior of patients at distances nearer than the usual 1/3 m and during maximum cycloplegia. Given our findings, it is possible that the observed visual acuity improvements in their respective studies could be due to patients swapping fixation during atropine treatment that has gone undetected in the clinical setting. It is probable that a swap in fixation may have only occurred at distances nearer than 1/3 m, resulting in intermittent or part-time foveal stimulation of the amblyopic eye. Given that fixation was not assessed at these nearer distances in their studies, visual acuity improvements cannot be determined to have occurred in the absence of a fixation swap to the amblyopic eye.
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So, does the cyclo-swap test (or a similar technique) have any value in predicting atropine efficacy? Our study has shown that this test has limited value when performed at 1/3 or 6 m in predicting improvements in vision. However, an in-office assessment such as the cyclo-swap test may be a useful guide of the frequency of fixation swap akin to the concept of amount of patching. For example, a child who swaps fixation at 1/3 and 6 m will effectively receive a full-time therapeutic effect, whereas a child who does so only at 1/3 m, or even only at nearer distances, will receive a limited part-time therapeutic effect. Newton5 reported that patients who were noted to have swapped fixation during atropine treatment had a significantly greater visual acuity improvement in the amblyopic eye compared with those who were not observed to swap fixation. Similarly in our study, children in the no fixation swap group only demonstrated visual acuity improvements after a fixation swap to the amblyopic eye had been demonstrated. Further research should investigate the relationship between the cyclo-swap test as performed at five distances and the effectiveness of atropine or the rate of visual acuity improvement of atropine treatment. This study has demonstrated that it is likely that patients treated for amblyopia using atropine achieve an improvement of visual acuity via the mechanism of a fixation swap that results during the treatment phase. This seems to be promoted by extended maximum cycloplegia, an increase in accommodative demand, or both. The result of a cyclo-swap testespecially when the assessment of fixation is confined to the usual clinical testing distances of 1/3 and 6 mhas limited value in terms of predicting whether visual acuity improvement is

likely to be achieved. Our study demonstrated that vision can improve, regardless. However, the cycloswap test may be a valuable clinical tool in providing information about prognosis, efficacy, or practicality in relation to the use of atropine in the treatment of amblyopia. We encourage future research to further investigate the efficacy of the cyclo-swap test as performed at various distances, including those nearer than near (1/3 m) and for future amblyopia studies to monitor fixation more closely and again at distances closer than 1/3 m during the atropine treatment phase.
1. Ansons AM, Davis H. Diagnosis and Management of Ocular Motility Disorders, 3rd ed. London: Blackwell; 2001. 2. Arnold RW, Gionet E, Hickel J, Owen M, Armitage MD. Duration and effect of single-dose atropine: paralysis of accommodation in penalization treatment of functional amblyopia. Bin Vision Strabismus Qrtly. 2004;19:81-86. 3. Wallace DK. Visual acuity after cycloplegia in children: implications for atropine penalization. J AAPOS. 1999;3:241-244. 4. Wright KW, Guyton DL. A test for predicting the effectiveness of penalization on amblyopia. In: Henkind P, ed. Acta: XXIV International Congress of Ophthalmology. Philadelphia: J. B. Lippincott; 1983:896-901. 5. Newton JK. Atropine occlusion audit. Br Orthopt J. 2006;3:52. 6. Holmes JM, Clarke MP. Amblyopia. Lancet. 2006;367:13431351. 7. Pediatric Eye Disease Investigator Group. A randomized trial of atropine vs. patching for treatment of moderate amblyopia in children. Arch Ophthalmol. 2002;120:268-278. 8. Pediatric Eye Disease Investigator Group. The course of moderate amblyopia treated with atropine in children: experience of the Amblyopia Treatment Study. Am J Ophthalmol. 2003;136:630639. 9. McNamara R, Rice T. Atropine occlusionHow long does it take for fixation to swap? In: Verlohr D, Georgievski Z, Rydberg A, eds. Global Perspectives Converge Downunder: Transactions of the Xth International Orthoptic Congress, Melbourne, Australia, 14-17 November, 2004. Melbourne, Australia: International Orthoptic Association. 10. Garoufalis P, Georgievski Z, Koklanis K. Long term vision outcomes of conventional treatment of strabismic and anisometropic functional amblyopia. Binoc Vis Strabismus Q. 2007;22:49-56.

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Atropine Treatment of Amblyopia: Is a Swap in Fixation Necessary?

1. Recent studies investigating the use of atropine treatment in patients with amblyopia have suggested that: A. All patients with amblyopia can be successfully treated with atropine. B. A fixation swap is essential for atropine treatment to be successful. C. Visual acuity improvement can be demonstrated in patients treated with atropine regardless of fixation behavior. D. Atropine is not an effective treatment in the management of amblyopia. 2. The first authors to report a prediagnostic test simulating likely fixation behavior during atropine treatment were: A. B. C. D. PEDIG. Wright and Guyton. Holmes and Clarke. McNamara and Rice.

3. The cyclo-swap test involves: A. Instilling atropine and assessing the childs fixation behavior. B. Instilling atropine and assessing the childs fixation behavior 45 minutes later. C. Instilling cyclopentolate hydrochloride and assessing the childs fixation behavior. D. Instilling cyclopentolate hydrochloride and assessing the childs fixation behavior 45 minutes later. 4. For best results, the cyclo-swap test should be performed at: A. B. C. D. 10, 15, and 20 cm only. 1/3 m only. 6 m only. 1/3 and 6 m, as well as distances closer than 1/3 m.

5. Children not swapping fixation at either 1/3 or 6 m at the preliminary examination in this study: A. Did not swap fixation at any time during the study. B. Did not show an improvement in visual acuity by the end of the treatment period. C. Showed an improvement in visual acuity by the end of the treatment period. D. Showed an improvement in visual acuity by the end of the treatment period only if also showing a fixation swap at some time during the study.

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6. The improvement in mean visual acuity between the fixation swap and no fixation swap groups at the end of the treatment period: A. B. C. D. Was greater in the fixation swap group. Was greater in the no fixation swap group. Was equal between the two groups. Showed no significant improvement in vision in either group.

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7. Both the fixation swap and no fixation swap groups had an average improvement in visual acuity at the end of the treatment period of: A. B. C. D. 1 line. 2 lines. 4 lines. 5 lines.

SEPTEMBER/oCToBER 2010

Atropine Treatment of Amblyopia: Is a Swap in Fixation Necessary?

Black out the correct answers
1. 2. 3. 4. 5. A A A A A B B B B B C C C C C D D D D D 6. 7. 8. 9. 10. A A A A A B B B B B C C C C C D D D D D

8. Children who demonstrate a fixation swap only at 1/3 m or distances less than 1/3 m during the cycloswap test: A. Will have a greater visual acuity improvement compared to children who also swap at 6 m. B. Will not benefit from atropine treatment. C. Would be more likely to benefit from occlusion treatment. D. Are likely to receive a limited part-time therapeutic effect during atropine treatment. 9. This study demonstrated that: A. The blur alone produced by atropine is suffice to improve vision. B. Children showing an improvement in visual acuity in PEDIG and McNamara and Rice studies regardless of fixation behavior cannot be determined to have occurred in the absence of a fixation swap to the amblyopic eye. C. It changed the goal of amblyopia treatment, that being to promote the use of the amblyopic eye and its fovea. D. All patients with amblyopia can be treated effectively with atropine. 10. The cyclo-swap test: A. Is useful in guiding the clinician and providing information about the prognosis and efficacy of atropine treatment. B. Is useful in predicting improvements in vision. C. Has limited value in a clinical setting. D. Performed at distances less than 1/3 m has no clinical value.

Number of hours you spent on this activity __________________________ (reading article and completing quiz) Forms can be sent by fax to 856-384-6680 This activity is approved for credit from the original date of release, September 1, 2010, through the expiration date of September 15, 2011. Evaluation (must be completed in order for your CME Quiz to be scored) SEPTEMBER/OCTOBER 2010 Check the appropriate box below. Yes No 1. The content of the article was accurately described by the learning objectives. _____ _____ a. To demonstrate the significance of promoting the amblyopic eye and its fovea to restore visual acuity when treating amblyopia. ______ ____ b. To describe the impact of fixation behavior on visual acuity outcomes during atropine treatment. ______ ____ c. To recognize the role of the cyclo-swap test as an effective tool in predicting atropine efficacy. ______ ____ 2. This activity will influence how I practice ophthalmology. ______ ____ a. If you answered yes, list one new thing you learned as a result of this activity ______________________________________________ . 3. The quiz questions were appropriate for assessing my learning. _____ _____ 4. Please rate the degree to which the content presented in this activity was free from commercial bias. No bias Significant bias 5 4 3 2 1 Comments regarding commercial bias _______________________________ ________________________________________________________________ 5. Please list topics you would like to see future CME activities address: _________________________________________________________.

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