What is the recommended management for a 27-month-old child with amblyopia (lazy eye)?

Management of Amblyopia in a 27-Month-Old Child

For a 27-month-old child with amblyopia (lazy eye), the recommended initial management is correction of any refractive error with appropriate eyeglasses, followed by patching of the nonamblyopic eye for 2 hours daily if visual acuity does not improve with optical correction alone. 1

Initial Assessment and Management

• A complete eye examination by a pediatric ophthalmologist, including visual acuity testing, cycloplegic refraction, funduscopic examination, and sensorimotor evaluation, is essential to confirm the diagnosis and determine the cause of amblyopia 1
• Correction of any refractive error with appropriate eyeglasses should be the first step in treatment, as this alone may improve visual acuity in approximately one-fourth of children 1, 2
• Allow 8-18 weeks for the child to adapt to the eyeglasses before assessing the need for additional treatment 1

Treatment Options After Refractive Correction

Patching Therapy

• For moderate amblyopia (20/40 to 20/80), prescribe 2 hours of daily patching of the nonamblyopic eye 1
• For severe amblyopia (worse than 20/80), prescribe 6 hours of daily patching, although 2 hours may be effective in some cases 1, 3
• Patching should be combined with at least 1 hour of near-visual activities during the patching period 1
• Direct adhesive patches applied to the skin are preferred over cloth patches mounted on eyeglass frames, as children can look around cloth patches 1

Pharmacological Treatment (Atropine)

• Atropine 1% ophthalmic solution applied to the nonamblyopic eye is an effective alternative to patching for children 3 years and older 1, 4
• Atropine works by temporarily blurring vision in the nonamblyopic eye through cycloplegia 1
• Atropine may be particularly useful when:
  • Patching is not tolerated or compliance is poor 1
  • The child has latent nystagmus 1
  • Maintenance treatment is needed 1

Follow-Up and Monitoring

• Schedule follow-up examination 2-3 months after initiating treatment 1
• Maintain consistent testing environment and visual acuity measurement methods across visits 1
• Adjust treatment based on response:
  • If visual acuity improves and fellow eye is stable, continue the same treatment regimen 1
  • If visual acuity is unchanged despite good adherence, consider increasing patching from 2 to 6 hours daily or switching to atropine 1
  • If visual acuity in the amblyopic eye decreases, retest visual acuity, check refractive status, and confirm adherence 1

Potential Side Effects and Complications

• Patching may cause:

  • Skin irritation (common in 41% of children, moderate/severe in 6%) 1
  • Occlusion amblyopia in the patched eye (rare) 1
  • Psychological distress for child and parents 1
  • Increased risk of accidents due to reduced visual field 1

• Atropine may cause:

  • Photosensitivity and blurred vision 1, 4
  • Transient reduction of visual acuity in the nonamblyopic eye 1
  • Systemic effects (rare): dry mouth, flushed skin, tachycardia 4

Special Considerations for Young Children

• Early intervention is critical as treatment is most effective in children under 7 years of age 2
• Educating parents about the importance of treatment improves compliance 1
• Monitor for development of strabismus during treatment, as it may worsen or improve 1
• Amblyopia recurs in approximately 25% of children, so continued surveillance is important even after successful treatment 2