Eye to Eye

Treatment of a Manifest Strabismus With

Amblyopia
Panelists: Daniel T. Weaver, MD, Miles J. Burke, MD, Jane C. Edmond, MD

Miles J. Burke, MD, is in private practice, Cincinnati, Ohio. for 6 months because they’re not
Jane C. Edmond, MD, is from the Department of Pediatric Ophthalmology, complying with anything, and that
Texas Children’s Hospital, Houston, Texas. makes me nervous about surgery.
Daniel T. Weaver, MD, is from Billings Clinic, Billings, Montana. And of course families are always
more concerned about the crossed
Moderator: Leonard B. Nelson, MD, MBA, Editor
eye and I’m more concerned about
the vision. So I think getting the
Nelson: The topic for today is would like to get the amblyopia family on board is important.
treatment of a manifest strabismus down as far as possible before you Nelson: Do you find that the
with amblyopia and I am going operate? amblyopia can be successfully treat-
start with some general treatment Burke: I would like at least ed in a patient who has a manifest
plans. Dr. Burke, how do you gen- that level, too. A worse level of strabismus? Because when you have
erally treat patients who have stra- amblyopia, I wouldn’t. the patch off the eye is deviated.
bismus and amblyopia? And what Nelson: You would continue Weaver: So you’re wondering
level of amblyopia improvement patching. if the strabismus improves with
would you need to have prior to Burke: I would continue patching?
surgery? patching after the surgery. Nelson: I’d like to know at
Burke: The criterion that I Nelson: Before you did the what stage you would operate on
would use for amblyopia would surgery? a patient who has a manifest stra-
probably be 20/80 or worse. I Burke: Yes. bismus and amblyopia.
would always try to maximize the Nelson: Dr. Weaver? Weaver: 20/60.
visual acuity before I operate. I find Weaver: I would probably Nelson: Dr. Edmond?
that the sensory adaptations of bin- patch a bit more than that. Assum- Edmond: Vision is the most
ocularity improve the visual func- ing the other eye is in the 20/20 to important part of what we do and
tions because then you’re actually 20/30 range, I might try to get the I think alignment comes second.
getting some stimulus while you’re eye to at least 20/50 or 20/60. But So I’m fairly aggressive about am-
doing your amblyopic therapy. If I I agree with Dr. Burke. I think it’s blyopia treatment prior to stra-
saw 20/40 or 20/60, I would start important that you get a much bet- bismus surgery. I would complete
the therapy but I would also tell ter result if you can get a patient amblyopia treatment right before I
the family that at their next visit within three or four lines of the intervene with strabismus surgery.
I’m probably going to recommend presumably intact eye when you I don’t want to do a lot of amblyo-
the additionally necessary surgi- actually operate. I’d discuss surgery pia treatment after my surgery is
cal therapy. I don’t always have to at the first visit, but I think compli- done because it may interrupt the
reach my end limit before I add ance with patching is important. process of establishing fusion.
surgical therapy. It’s also helpful to know how Remember in the ATS study,
Nelson: If you had a patient hooked in the family is to the whole some orthotropic patients treated
who had visual acuity of 20/80 treatment plan. Some of my patients with atropine were esotropic after
when you first examined him, you come in and I won’t see them again the atropine therapy was com-

Journal of Pediatric Ophthalmology & Strabismus • Vol. 47, No. 1, 2010 5

Eye to Eye
pleted and their target vision was
reached.
Nelson: How long would you
continue patching with a patient
who has a manifest strabismus be-
fore you would assume that the vi-
sion is not going to improve?
Edmond: If after three rounds
of good compliance with patching
there is no improvement in vision,
it is considered refractory amblyopia.
At that point you can intervene with
a recess–resect procedure for align-
ment.
Nelson: Now that we have
an idea of the general treatment
of how we approach patients with
manifest strabismus and amblyo-
pia, let’s discuss a couple of specific
cases. The first case is a 3-year-old
child whose visual acuity with pic-
tures was 20/30 in the right eye and
20/200 in the left eye and who had
a comitant esotropia of 35 prism
diopters and a refraction of +2 in
the right eye and +5 in the left eye.
Dr. Weaver, what would be your
initial treatment of this patient?
Weaver: The same distance
and near?
Nelson: The same distance and
near, comitant in all fields of gaze.
Weaver: I would prescribe the
full cycloplegic refraction, which
should be tolerated in a 3-year-
old child. With a visual acuity of
20/200, the vision may actually
be better than that with a +5 in
place. However, practically speak-
ing, I can’t always obtain that in
a 3-year-old child. What I would
probably do in this case is to give
the full cycloplegic refraction and
see the child again in 4 weeks.
I would tell the parents at the
first visit that they would almost
certainly have to go with patch-
ing. Some parents want to start
patching right away and I would
be okay with that. But I think the
6 Copyright ©SLACK Incorporated
most important thing is to prepare
them for the fact that the child
may need surgery and will also
need patching prior to surgery.
Nelson: Dr. Edmond, how
would you handle this initially?
Edmond: I would give the
full cycloplegic refraction. I would
expect the vision to improve in-
stantly, first because of giving the
proper refractive error and then
over the next few months with
spectacle wear alone. A PEDIG
study revealed that months of
wearing the proper spectacle cor-
rection can improve vision with-
out patching.
I would see the child in 3
months and begin either weekend
atropine or 2 hours of patching
a day to the right eye. I’m pretty
sure the left eye is still going to be
amblyopic. Another option would
be to wait another 2 months,
based on the results of the men-
tioned study.
Nelson: Dr. Burke, same ques-
tion.
Burke: The glasses would be
the full cycloplegic refraction. I
would tell the parents that the first
step is to get full-time glasses wear.
Once that starts to be a non-is-
sue, I would begin patching that
eye before I see the child again in
2 months. At that point, I would
know the non-accommodative
component to the esotropia. As Dr.
Weaver said, I would also tell the
parents from the start that I don’t
know whether surgical treatment
will be necessary, but it is possible.
So my first visit with that family
is a detailed discussion about the
multiple tracks that this child may
go through.
Nelson: Let’s assume that the
patient came back in 1 or 2 months
and the visual acuity is still 20/30
in the right eye but has improved
1 line to 20/100 in the left eye and
his esotropia is still comitant to 25
prism diopters. What’s your next
step in treating this patient?
Burke: Usually a child will tol-
erate monocular occlusion in the of-
fice and watch an animal or a movie
for a moment, so I would try to see
if there’s any more hyperopia on the
amblyopic side. I would ask the par-
ents whether their compliance with
patching has been good enough be-
cause in 2 months I would expect
more improvement, perhaps to
20/60 or 20/80. But I would keep
patching and then see him again.
Nelson: Dr. Edmond?
Edmond: Remember that I
would have just given glasses and
I would not have patched. If at 3
months later there were an under-
whelming improvement in vision
in the left eye, I would consider
intervening with amblyopia treat-
ment. Because of the esotropia, I’m
more inclined to treat this child and
not just leave him in the spectacles
for 2 more months to see if his vi-
sion improves in the left eye. He is
a good candidate for atropine. He’s
already esotropic and it doesn’t
matter if the atropine makes him
more esotropic. However, 20/100
is the outer limit of visual acuity
for atropine.
Nelson: So now you’ve given
him the glasses and the atropine
and he comes back 2 months later
with visual acuity in the left eye
that’s still in that 20/100 range
and he still has a manifest esotro-
pia of 25 prism diopters. What
would be your next treatment?
Edmond: This visual acuity
is on the cusp of dense amblyo-
pia versus moderate amblyopia. I
would try patching 3 to 4 hours a
day instead, then see him again in
2 months.
Nelson: Dr. Weaver?

Weaver: The first question I
have is whether the child is wearing
the spectacles. Assuming he is and
his visual acuity is in fact 20/100, I
would check it myself to make sure
that it’s accurate, just in case my
nurse missed it. But if it is 20/100,
I would not go to atropine. I would
aggressively start amblyopia man-
agement with full-time patching
for 3 weeks and at that point pre-
pare the parents for surgery.
I don’t find that a +2 eye with
atropine in a 3-year-old child would
give me a good enough endpoint
to be comfortable. I think we may
have to go to surgery before I would
be finished with my own atropine
protocol. So I would aggressively
patch and start to discuss surgery
and hopefully get the child down in
the 20/50 range.
Nelson: So you’re continuing
patching, whatever patching pro-
tocol you use. How long are you
going to wait before you address
the strabismus?
Weaver: Two cycles of patch-
ing. In this case, you could go 2 or
3 weeks of patching, 1 week per
year of age. If the parents didn’t
want to do full-time patching,
then perhaps less for a longer pe-
riod of time. But I think if there’s
this much esotropia, I would not
go more than two cycles.
In an older child, I would
probably continue patching lon-
ger to make sure the visual acuity
was not going to improve before
we sort of give up on the eye. In
this case, as Dr. Edmond has men-
tioned, we’re working toward an
endpoint. I’m getting concerned
about the esodeviation that’s still
evident and so I’m going to step
it up a little bit and probably fast
forward.
Nelson: Dr. Burke, at what
point would you do surgery? It’s
Journal of Pediatric Ophthalmology & Strabismus • Vol. 47, No. 1, 2010
apparent that the vision in that
amblyopic eye is not improving.
Burke: I would also say two
cycles of patching. I would try to
make sure that the child is fully
relaxed in his hyperopic prescrip-
tion and would do the cycloplegic
refraction again the day that I de-
cide. If it’s the same number, I op-
erate. If it’s not the same number,
he would get one more interval of
patching because I want to make
sure that I don’t overtreat the eso-
tropia surgically.
Nelson: Dr. Edmond, same
question. It appears that perhaps
the manifest strabismus is in some
way impairing the ability to im-
prove the vision regardless of how
much you’re patching or using at-
ropine.
Edmond: We still get results
with atropine or patching even
with patients who have strabis-
mus. But after three patching cy-
cles, I’m concerned, too. Our best
results from amblyopia treatment
are in the first cycle and if we’re
not seeing any significant change,
perhaps this child’s vision is not
going to improve.
Nelson: Let’s assume that
the patient’s vision does improve.
You’ve patched him, he still has
a manifest strabismus. Do you
find that sometimes the amount
of strabismus is reduced? Because
I’ve already stated that the patient
initially presented with an esotro-
pia of 35 prism diopters, came
back after a month, has worn the
glasses, and now his esotropia is
25. Would you expect, beyond
that first month or so, that the
strabismus will change with im-
provement in the vision?
Edmond: I don’t think so.
Maybe in a few rare cases, but not
in general.
Weaver: I agree with that to a
Eye to Eye
point, but I think it does change. I
think it can improve slowly, perhaps
coming to a certain point and not
go beyond that point. I don’t think
it will go away, but I think the dos-
age of strabismus surgery can be
altered. As the vision improves, the
difference between operating on an
esotropia of 35 versus an esotropia
of 20 is significant. I think that may
lower the risk of a consecutive exo-
deviation postoperatively.
Nelson: So you would agree
with Dr. Edmond that at some
point the strabismus is going to
need to be addressed and those
patients will come back during
the first visit who still have a fairly
significant manifest deviation.
Weaver: Correct.
Nelson: Dr. Burke, same ques-
tion.
Burke: I find that I don’t see
much change. I think the only thing
that I could interpret as a change is
better fixation in the amblyopic eye
so I get a more accurate measure-
ment. With a 3-year-old child with
a visual acuity of 20/200, I’m do-
ing a Krimsky or Hirschberg iden-
tification and hopefully when I get
them to a more improved level and
he is more cooperative after seeing
me several times, he will let me do
an alternate cover test. That may be
the difference, but I don’t think it
changes much.
Edmond: The change is in the
reliability of your examination.
Nelson: Do you find that
when you do correct the strabis-
mus in this particular child that
the vision often improves sub-
stantially as opposed to prior to
it, right before it? And if that’s the
case, doesn’t the strabismus play a
substantial role in preventing the
vision from improving any further
with amblyopia treatment?
Burke: I try to achieve ex-
7
Eye to Eye
tremely good visual acuity before I
operate most times and then I get
hopefully a decent amount of bin-
ocularity or at least a microtropia
postoperatively. I’ve seen those pa-
tients improve over months with
just observation. So I think the
strabismic realignment does help.
Nelson: Dr. Weaver?
Weaver: I think that’s abso-
lutely true. In fact, I patch very little
after surgery. Maybe it’s because I’m
just more aggressive about preopera-
tive patching because that’s the way
we always used to do it. But I don’t
patch a lot after surgery. It may be
because I patched earlier, but it also
may be because with realignment
the motor may help the sensory.
Nelson: Let’s go to another
patient. This is an 8-year-old child
who had congenital esotropia, had
recession of each medial rectus mus-
cle as an infant, and now presents
with visual acuity of 20/30 in the
right eye and 20/20 in the left eye.
He is patching his left eye 3 hours
a day, and has a manifest dissoci-
ated vertical deviation (DVD) of 15
prism diopters in the right eye. You
can also measure some DVD of a
much smaller degree in the left eye.
Otherwise, the eyes appear straight.
He has mild overacting inferior
oblique muscles in each eye. How
would you continue treating this
patient in terms of managing his
amblyopia and what appears to be a
manifest DVD of his right eye with
some DVD in the left eye?
Weaver: I presume the pa-
tient is wearing his best correction
at this point.
Nelson: Yes.
Weaver: The first thing I ask
the parents whenever I see a child
who obviously has congenital stra-
bismus, who’s had surgery, who
has good horizontal alignment,
and who has a DVD, is how of-
8 Copyright ©SLACK Incorporated
ten they see it at home. The DVD
is often larger in the better seeing
eye and it’s not manifest because
that becomes the fixating eye. So
just because you see it in the office
doesn’t mean you have to operate.
In this case, the 15 prism di-
opter DVD is present in the right
eye, which is the weaker of the two.
I would confirm that the left eye is
the preferred fixing eye, which isn’t
always the case but should be in this
situation, and I would ask the par-
ents how often it’s manifest. If the
overaction of the inferior obliques
is mild, I do not do a lot of anteri-
orization of obliques anymore. It’s
just an operation I do not do often.
If this deviation is manifest 40% to
50% of the time, I’d like to know if
the child’s stereopsis is good. If this
is a frequently manifest deviation
that I’m seeing in the office and the
parents are seeing at home, I would
probably discuss strabismus sur-
gery and think about recessing the
right superior rectus muscle.
Nelson: Dr. Edmond?
Edmond: We’re patching him
3 hours a day and he’s 8 years old.
I’m not sure we’re ever going to
get better than 20/30 out of the
right eye. I assume the left eye is
always going to be the preferred
eye and that only the right eye will
manifest the DVD.
The situation is as follows:
per the family, there is an unac-
ceptable right DVD and an ex-
amination reveals a right and
left DVD with 1+ to 2+ inferior
oblique overaction. If we just treat
the right eye, the left eye might
become manifest. Not so much
because he will begin to prefer the
left, better seeing eye, but because
I want to do an inferior oblique
anteropositioning for the DVD
and mild inferior oblique overac-
tion. It is inadvisable to do this
unilaterally, so I will also do infe-
rior oblique anteropositioning in
the left eye. I would put the infe-
rior oblique muscle at the border
of the inferior rectus muscle, not
anterior to it.
Nelson: I would like to com-
ment on one thing you said. If a
patient is 20/30 in the right eye
and 20/20 in the left eye, it’s clear
that he fixates well with his left
eye, and the vision’s probably not
going to change, would you do
surgery on the left eye when you
know that it’s probably not going
to switch?
Edmond: No, but because
I’ve weakened one inferior oblique
muscle I’m afraid we might in-
duce a vertical deviation if I just
operate on one eye because the
opposite eye has inferior oblique
overaction.
Nelson: If there had not been
an inferior oblique overaction
at all, would you still have ap-
proached both eyes?
Edmond: No, I would do a
right superior rectus recession.
Nelson: Dr. Burke, how would
you handle it?
Burke: I find DVD is either
going to be manifest or it’s not.
I hesitate to operate for a DVD,
whether it’s superior rectus recession
or inferior oblique anterior transpo-
sition, unless it is really evident. I
have seen some young children who
are patching and their DVD is not
as great as it used to be when they
reach adolescence. If the child is 10
years or older, he can make a serious
comment on whether we should do
it. When the patient is younger and
it’s really manifest, the parents and I
make the decision.
Nelson: Our final case is a 35-
year-old man with a long history of
amblyopia and a non-accommoda-
tive esotropia. His visual acuity is

20/20 in the right eye and 20/100
in the left eye. He has a left eso-
tropia of 30 prism diopters and he
wants surgery. I’d like you to ad-
dress the treatment of this patient
and how you would handle the sit-
uation if the patient asked whether
his vision can improve with the
surgery. Dr. Edmond?
Edmond: Has he ever patched?
Nelson: He’s patched as a
young child and stopped when he
was 8 or 9 years old, but vision has
always been poor.
Edmond: You could offer
patching. It might be successful
to some degree if he had never
patched. But having patched be-
fore, you’re probably not going to
get anything. What was the oral
medication we gave for a while ex-
perimentally?
Nelson: Levodopa.
Edmond: Levodopa. I don’t
think he would go for that and nei-
ther would I. So I would offer him
a recess–resect procedure of the left
eye, and I would not promise him
any change in his vision.
Nelson: Would you approach
the surgery differently in terms of
the fact that he doesn’t see well?
Would you do less surgery?
Edmond: It would be desir-
able for me to leave him slightly
esotropic.
Nelson: Dr. Burke, same ques-
tion.
Burke: For this patient, I
would do both a manifest refrac-
tion pushing plus and a cyclople-
Journal of Pediatric Ophthalmology & Strabismus • Vol. 47, No. 1, 2010
gic refraction. I find that most
35 year olds who aren’t wearing
glasses are hyperopic and it may
change the angle. But let’s assume
for this discussion that it doesn’t.
I would also leave the patient mi-
cro-esotropic. I almost go for the
whole angle. As far as telling him
what to expect, many patients get
gross fusion. They see the depth
of the trees and they come back
ecstatic. So the visual acuity won’t
change, but I think that the bin-
ocularity does.
Nelson: Why would you do
the cycloplegic refraction if you’re
not going to give him his full refrac-
tion?
Burke: I would tell that patient
that in 10 years he’s going to be in
his full cycloplegic refraction. If it
was 0.75 of a diopter higher than
he would accept, I would tell him
that I need to see what the angle
is. I forgot to say that I would put
+3s up in front of him and see how
much his near deviation decreases.
I would be very conservative on
how much the angle is because this
is a patient densely amblyopic for a
long time who is going to go exo-
tropic and so I’d be careful. I’d try
to use all of those modalities to as-
sess the maximum accommodative
relaxation effect.
Nelson: Dr. Weaver?
Weaver: Last question first.
No, they’re not going to improve,
but I’ve had the same experience
Dr. Burke has.
Nelson: In vision?
Eye to Eye
Weaver: In vision. I would
do one additional thing. Having
learned the hard way, I would def-
initely do a red lens test or a Mad-
dox rod to see how much anoma-
lous retinal correspondence there
is. Sometimes you can measure 30
prism diopters of esotropia with
cover testing with vision in this
range, but if you put a red lens
over the right eye, you might have
uncrossed diplopia with 15 or 20
base out prism.
The reason I do that is be-
cause I like to leave the patient
micro-esotropic. I also like to
show him, with the prism in front
of his eye, this is what he’s going
to see after surgery. Someone who
has anomalous retinal correspon-
dence will often be diplopic and
functionally exotropic following
strabismus surgery for esotropia.
They must be made aware of this
risk preoperatively. Postoperative
diplopia is a significant risk in any
adult undergoing repair of long-
standing esotropia.
Nelson: I’d like to thank ev-
erybody for coming.
This Eye to Eye session was con-
ducted on Saturday, April 18, 2009,
during the annual meeting of the
American Association for Pediatric
Ophthalmology & Strabismus.
Drs. Weaver, Edmond, Burke,
and Nelson have no financial or
proprietary interests in the materials
presented herein.
doi: 10.3928/01913913-20100106-01
9