Treatment of Amblyopia in a 20-Month-Old
Initiate optical correction immediately with appropriate spectacles if refractive error is present, as this is the essential first step in treating amblyopia at this age. 1
Initial Management Approach
Step 1: Optical Correction First
- Prescribe spectacles for any significant refractive error and allow a trial period of optical correction alone before adding occlusion or pharmacologic therapy. 1
- In 77% of children aged 3 to <7 years, amblyopia improved by ≥2 lines with optical correction alone, and 27% achieved complete resolution. 1
- This initial optical correction period allows assessment of how much improvement occurs before escalating to more intensive treatments. 1
Step 2: Add Occlusion or Atropine if Optical Correction Plateaus
After optical correction has been maximized (typically after vision stops improving), choose between:
Patching (Occlusion Therapy)
- For moderate amblyopia: prescribe 2 hours of daily patching, which is equally effective as 6 hours daily. 1
- For severe amblyopia: prescribe 6 hours of daily patching, which produces equivalent results to full-time patching. 1
- Combine patching with 1 hour of near visual activities to enhance effectiveness. 1
Atropine 1% Eye Drops (Alternative to Patching)
- Atropine 1% is FDA-approved for penalization of the healthy eye in amblyopia treatment and is as effective as patching. 2
- In children 3 to <7 years, 74% achieved VA ≥20/30 and/or improved by ≥3 lines with atropine over 2 years, compared to 79% with occlusion. 1, 3
- Daily or twice-weekly dosing regimens are both effective. 3
- Atropine works best when the nonamblyopic eye is hyperopic. 3
Critical Age Considerations for This 20-Month-Old
At 20 months of age, this child is younger than the typical study populations (which enrolled children 3 years and older), but treatment should still be initiated because the sensitive period for amblyopia treatment is most effective during early childhood. 1, 4, 5
- The evidence base primarily includes children 3 to <7 years, but earlier intervention is generally recommended when amblyopia is detected. 1, 4
- Children younger than 7 years receive the most benefit from treatment. 5
Safety Precautions for Atropine Use
If choosing atropine 1% for this young patient:
- Screen for narrow iridocorneal angles before initiating treatment, as 1% atropine can precipitate acute angle-closure. 3
- Warn caregivers about photosensitivity and blurred vision lasting up to 2 weeks. 2
- Monitor for systemic absorption effects including tachycardia, flushed skin, drowsiness, or restlessness. 2
- Children with Down syndrome, spastic paralysis, or brain damage are particularly susceptible to CNS and cardiopulmonary toxicity from systemic atropine absorption. 2
Monitoring and Maintenance
- Follow closely for treatment response, as approximately 25% of successfully treated children experience recurrence within the first year after stopping treatment. 4, 5
- Taper patching gradually (reduce to 2 hours daily before complete cessation) rather than stopping abruptly to minimize recurrence risk in children under age 8. 1
- Continue optical correction with spectacles until visual maturity (typically early teens) even after amblyopia resolves. 1
Common Pitfalls to Avoid
- Do not delay treatment waiting for the child to reach age 3—earlier intervention during the sensitive period is preferable. 4, 5, 6
- Do not undercorrect refractive error, as this does not improve outcomes. 7
- If VA fails to improve despite adherence to refractive correction, or especially if VA worsens over time, evaluate for optic neuropathy or maculopathy. 1
- Ensure caregivers understand the diagnosis and treatment rationale, as adherence is critical for success—written instructions improve compliance. 1
Protective Eyewear Consideration
- Once the child is older and if amblyopia results in vision of 20/50 or worse in the affected eye, prescribe impact-resistant eyewear (ANSI Z87.1 frames with ASTM F803 lenses) for full-time wear to protect the better-seeing eye. 1