What Are Treatment Options for Amblyopia?

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Patient Presentation
An 8-year-old male came to clinic for his well child visit. He was being treated for strabismus and amblyopia with glasses and patching. His mother said he was mainly compliant with the glasses but wasn’t very much with the patching as he didn’t like looking different than his friends. She had tried multiple methods to try to increase compliance, and reported about 2 hours of patch use/day. “He likely is going to need surgery and I just don’t want to do that,” she said. “I read about some of these vision therapies but he won’t use the patch so I don’t think he’ll do the therapy either. Is there something else?” she asked.

The pertinent physical exam revealed a healthy male with normal vital signs who was growing at the 50%. His physical examination was normal. The diagnosis of a healthy male with vision problems was made. “I’m not the right person to give you all the options; that needs to be his ophthalmologist. But I think there are eye drops that are sometimes used instead of the patching that you can ask them about next week at his appointment. The vision therapies are newer, and again I don’t know much about them. They are certainly not so revolutionary that the studies are being highlighted by the professional organizations and media outlets. I suspect any benefit is probably modest, but again ask the eye doctor next week,” she counseled. “I’ll also give you some ideas how to get him to use the patch.”

Discussion
Amblyopia is a neurodevelopmental visual disorder that is usually monocular but sometimes binocular that has a decrease in visual acuity where there are problems with visual processing but where no organic cause can be identified. Functionally, amblyopia is widely defined based on visual acuity (VA) where there is a “…difference of two or more Snellen’s or logarithm of the minimum angle of resolution (log MAR) lines in BCVA [best-corrected visual acuity] between the normal and amblyopic eye in cases of unilateral amblyopia. For bilateral amblyopia, BCVA should be less than 6/12.” Amblyopia is extremely common with a prevalence between 1-6% in the pediatric age range and 1.43-5.64% in adults. It is classified as mild, moderate or severe based on BCVA, and also classified into refractive, strabismic or stimulus deprivation. Theoretically, the normal and amblyopic eyes have visual images that are mismatched, and the brain suppreses the weaker eye’s image leading to poor acuity in the amblyopic eye. Problems that arise because of amblyopia include “…reduced contrast sensitivity, poor spatial localization, poor stereovision, and foveal crowding.”

Learning Point
The treatment goal is to reduce the acuity differences between the eyes and maintain the improved vision. Most treatments focus on monocular therapy. Treatment at an earlier age has better outcomes than older ages. Patients who are successfully treated still need monitoring.

Potential treatment options include:

  • Refractive correction
    • Considered first line treatment
    • 27-32% overall improvement
    • Initially often done alone for several weeks before using other treatments. Also used as combined treatment
  • Patching
    • Considered second line treatment
    • Can be used alone or often in combined treatment
    • Up to 70% respond to occlusion (including using cycloplegic penalization – see below)
    • Some studies cite continued amblyopia after refractive correction and patching at 50% of patients
    • Number of patching hours depends on the patient. Studies have shown that shorter time periods may be as effective as longer time periods, but compliance was not objectively measured in at least one major study
    • Preferred patch is a direct skin patch
    • Often needs weaning off the patch after clinically improved VA
  • Cycloplegic penalization
    • A cycloplegic drug is instilled in the normal eye to blur its vision and make patient use the amblyopic eye
    • Also considered second line treatment
    • Can be used alone or often in combined treatment
    • Up to 70% respond to occlusion (including using cycloplegic penalization – see below)
    • Can be good in patients with allergies to the patches, non-compliant patients or those with patching failures
  • Bangerter filters
    • A filter is attached to glasses and degrades the visual acuity
    • Used as treatment or maintenance therapy after patching or penalization
  • Surgery
    • Not a direct treatment, but a treatment for strabismus which can cause amblyopia
    • Corrects visual axis obstruction or misalignment
    • Botulinum toxin can also be used for muscle alignment successfully in some populations
  • Other novel therapies
    • These have fewer outcome studies available, potentially high rates of non-compliance with treatment, or limited outcome measures, but do have some data that could be helpful for some patients
    • Liquid crystal glasses
      • Provide intermittent occlusion where crystals in the glasses rapidly alternate between clear and occluded
    • Perception therapy
      • Binocular therapy
      • Idea to improve perception of the visual images
    • Visual display therapy which may include videogame play
      • Binocular therapy
      • Main idea is for visual stimuli to be presented to both eyes and then the eyes have to work together to complete a task
    • Drug treatments
      • Examples include Levo-dopa, Citicoline, Donepezil, and Selective serotonin reuptake inhibitors
      • Main idea is to improve brain plasticity so other treatments may have improved outcomes
      • “…[M]ore randomized trials with larger sample sizes and longer periods of follow-up are required to substantially prove or disprove the benefits of these drugs”

Questions for Further Discussion
1. How good is photoscreening for vision problems in young children? A review can be found here
2. How can you increase compliance for use of glasses? A review can be found here
3. What are potential complications of contact lens use?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for these topics: Amblyopia and Eye Movement Disorders.

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Bui Quoc E, Kulp MT, Burns JG, Thompson B. Amblyopia: A review of unmet needs, current treatment options, and emerging therapies. Survey of Ophthalmology. 2023;68(3):507-525. doi:10.1016/j.survophthal.2023.01.001

Chaturvedi I, Jamil R, Sharma P. Binocular vision therapy for the treatment of Amblyopia – A review. Indian J Ophthalmol. 2023;71(5):1797-1803. doi:10.4103/IJO.IJO_3098_22

Kaur S, Sharda S, Aggarwal H, Dadeya S. Comprehensive review of amblyopia: Types and management. Indian J Ophthalmol. 2023;71(7):2677-2686. doi:10.4103/IJO.IJO_338_23

Chen DML, Han S, Summers A, et. al. Interventions for improving adherence to amblyopia treatments in children. Cochrane Database of Systemic Reviews 2025 (7). Art. No.: CD015820.

Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa

Published