Attention, parents of children with a lazy eye and patching!

“What do you mean I don’t have to wear an eyepatch anymore?”

What you will learn…

• The Truth About Lazy Eye: your child isn’t lazy so why do we encourage a passive solution…
• Why Patching Isn’t the Answer: you have two eyes, stop reinforcing just one…
• Vision Therapy Can Help: through best effort, growth mindset and safety, patients have found success by working on and developing their visual skills and abilities…
  
  

If you and your child have struggled with patching for a lazy eye and have tried every way possible—bribing, begging, bargaining, rationalizing—and still haven’t been able to find that consistency and visual improvements, then you’re about to read something that you’ve been waiting for…

A few days ago, I met a 6-year-old patient who came in with her mom. Let’s call her Suzy. Suzy was referred to our office as she was recently diagnosed with amblyopia, or a “lazy eye,” and mom just wasn’t completely on board with their treatment options. They were told to wear a patch over her “good” eye for 2-4 hours every day but also warned that the outcome may not be great as she was getting “too old” to get much benefit.

• Patching is hard
  
  

When I asked them how the patching was coming along, mom looked a little flushed and admitted that Suzy just didn’t want to wear the patch. She paused, looking like she wanted to add more, but she didn’t, so I asked her, “what do you do when she refuses?”

“I…I don’t… It’s hard,” she looked defeated. I felt there might be a better question that I could ask.

“How do you feel about patching?”

“I don’t like it,” she tearfully blurted out, “I know I am supposed to do the best, I just don’t think it is right. We’ll try harder. I know we only have a short time to fix this. I wish we would have found out about her eyes earlier. I feel like I am a horrible mom!”

Whoa… that was a lot.

Suzy’s mom would explain that they were told that once a child reaches 7-8 years old, there wouldn’t be any further improvement, so time was critical. They had heard about vision therapy and were hopeful that it wasn’t too late to help Suzy’s eyes.

Although the words were paraphrased to the best of my memory, unfortunately, this event actually happened. Even worse, this happens on a regular, if not weekly basis.

Why won’t you be a good boy? Why won’t you just wear the patch when I ask?

The reality that I hear is the fight between the child and parent become louder and more frustrating and eventually, parents will give up and either settle for any amount of time for patching, or stop patching altogether, and hopefully won’t have to endure the reminder of their “poor” parenting ability when they go to their next eye exam appointment. When they realize again that their child’s eyes just aren’t improving, they set off with the new intention of patching “for real” this time. Cue up the frustration and emotions as the battle resurfaces and each evening is a feeling of failing, mixed with a good amount of “why are you being bad/not listening?” If they ultimately stop patching, any future struggle, whether academically or personally may bring back the thought of “what if this is related to her eyes?”

Let’s also be clear, children know when they don’t do something that mom or dad has asked, then a feeling of trouble, I’m not a good boy/girl will most likely surface. To be reminded of this daily may take its toll.

• We fight about patching every night
  

Although there may be different and more specific definitions, for simplicity, amblyopia, colloquially referred to as “lazy eye,” is when an eye sees poorer than 20/20, even with glasses. Traditionally, treatment just consisted of wearing an eyepatch over the better eye. There are studies that have adjusted the length of patching, so what used to be an all-day event, patching can vary from 2-6 hours. In one of the articles that I reference at the bottom, they refer to a 6-8-hour everyday patching regime!

Treating amblyopia is important

“I can see clearly with both eyes open and only noticed my one eye was blurry when I closed my good eye.”

I’m not an avid cyclist, but I do enjoy a nice bike ride with my family. On one ride, my daughter hit a curb and she scuffed her right knee. Fighting off the tears she eventually picked up her bike. We did a quick check and found that other than a few chips in the paint, it was still safe to ride. After a few blocks, she slowed to a stop and for the rest of the way home, she preferred to walk beside her bike. For the last 2 kilometers, we all walked our bikes along with her and other than the strange sight of the four of us walking on our bike ride, my daughter walked well enough that most probably wouldn’t have noticed her cautious gait, even though her one leg wasn’t as “good” as the other. Although she could keep up with the rest of us, I am sure that if I asked her, she would have preferred both of her legs working the same as each other.

• You would want to be at your best potential, wouldn’t you?
  

I am not sure if that example is appropriate, but even if one eye is weaker, with both eyes open, the world is generally still clear. Many of us probably don’t go through life with one eye closed. But I am also sure that if I asked, most of the patients with amblyopia would prefer to have both of their eyes working the same as each other.

Does patching even work?

Well, that depends on the study and the definition of success. Some studies qualify success as simply just seeing better than they did before they started patching. So, if a patient was, say 20/50 before they started patching and then 20/40 after they patched, then that could be considered success. Full disclosure, before my current appreciation of my model of vision, I would recommend patching. This is what I was taught. And I actually did see improvements. I can recall a few patients that, after a year of patching, improved from 20/60 or so, to 20/20 in their weaker eye. Awesome, as I am patting myself on the back. I can also recall patients that showed no improvement after a year or more of patching, so maybe I’ll pat myself on the back with a little less enthusiasm.

• Wearing an eye patch is the only way to improve a lazy eye, right? Wrong!
  

There is another study that even if the patient improves all the way to 20/20, the risk of losing that gain, or regression is real. In fact, they found that about 25% of patients were expected to regress.

I hate wearing the patch!

I hope you can also imagine the difficulty of trying to have your child wear an eye patch every day for that duration. I realize that when I ask that, it puts the task of being empathetic to the parents’ dilemma. So, along with what the parents face, what about the child? Can you appreciate what it must feel like wearing a patch over your good eye, so that when you see your world, watch television, play on a tablet, interact with others, eat dinner, play, everything is blurry? Remember, we’re only wearing the patch because the eye isn’t seeing clearly to begin with.

• A good way stop your child from taking off the patch is to stop his arms from moving! Please don’t do this. Seriously. Don’t.

The difficulty from the parent and the child’s perspective is so real, that there was a study published in 2017, that proudly proclaimed that they had the answer to this dilemma of non-compliance—elbow splinting! Elbow splinting is basically wearing a device that prevented the arm from being able to reach the face or head. If you think about it, this solution kind of makes sense. If your child that needs to wear a patch, but constantly rips it off as soon as you turn your back, what better way to stop him than to prevent his arm from bending so they are physically unable to move their arm to do so! In that study, patients were less than 6 years old, and parents were given the choice to splint one or both arms. What’s better, 1 or 2? (Please forgive me, optometry jokes and dad jokes come naturally to me!) Fortunately, or unfortunately, the study concluded that an elbow splint was a “viable” choice when compliance was poor. Sigh.

You don’t have to wear a patch to improve vision!

Some of you reading this from your devices may be wondering why I am sighing. Well, first, I think we can appreciate that if wearing a patch over your “better” eye, you are then forced to only see through your “worse” eye, so essentially your world is blurry is already difficult, then wearing something that prevents and restricts your arm from moving in a full range of motion must seem like a million times worse. Oh…and I suppose we should remember that you need to do this for at least 2-6 hours a day. One other thing to consider, how many 5-year-old children have six hours after school before bedtime? So, in their case, please do this at school too. With the teacher. In front of their classmates. On the playground.

• Vision therapy can help improve without the hours of patching every day

Secondly, guess what? You don’t have to patch! Patching isn’t necessary! For years, especially in vision therapy circles, we have known there is a better way. We know that by teaching the brain to use both eyes together in an easy and effortless manner, then not only would there be improvements, but those improvements would have a better chance to be more permanent. By the way, what we also observed was that the improvements were more than just in visual acuity; often, our patients would show a change in self-confidence and behaviour. Yes, this isn’t necessarily measurable, but subjectively, parents would share their excitement as their child displayed growth in other areas of their lives.

Binocular vision is important

By learning how to use both eyes together, or binocular vision, it helps to reinforce what I think is a more efficient and more beneficial gathering of information, or perception and being able to do so in a more accurate manner, might help each of us to feel more comfortable in our daily journey and interactions. We might take for granted that just being able to see clearly is important regardless of both eyes, or which eye is doing the clear seeing. This is true, seeing clearly is important. I will also admit that I continue to be excitedly surprised when patients reveal that colours look more vibrant when they achieve binocular vision. Their world looks richer! Imagine being in a more colourful world, how does that change our appreciation of the one that we are in?

Also, recall my story of my daughter and when she fell off her bike and how it might apply to using both eyes. Even though we can see well enough with one good eye, would it not be so much better to be able to use both eyes together in an easy and effortless manner?

You have two eyes. Patching keeps you only using one!

I think of amblyopia as, for whatever reason, the brain has difficulty using both eyes together in an easy and effortless manner, so instead of fighting through the stress of using both eyes, the brain creates a blur in one eye, so the conflict between the eyes is manageable enough to allow the person to work through their daily activities.

• What you should know about patching. (You might actually be making it harder.)
  

If the issue is then a difficulty between using both eyes, wearing a patch to stop the “good” eye and subsequently allow the “poorer” eye to work harder, does that teach how to use both eyes together, or does it reinforce only using one eye? It continues only using one eye!

Studies are showing us that binocular vision training may have a better effect on visual acuity compared to patching. And in our experience, there really isn’t an age limit to improvements. The limits that we have found is hard-work and determination.

One of the stories that remind of the struggle that parents have with patching is with Billy (we changed his name due to patient privacy).

“Billy” came to our office after being referred by his regular optometrist. He had been patching his right eye for 2 hours a day for a two-and-a-half years, and felt it was helping, however, dad admitted that it was getting harder to continue and they were not as diligent in the past few months. At their most recent exam, they were given the bad news that the progress made had gone back to the initial level of vision prior to patching. Dad blamed himself for not pushing as hard as he could and also admitted the daily battle with Billy to patch was difficult to navigate.

When they first started vision therapy, they were very skeptical of the lack of patching needed and the unique nature of the program; dad was anxious as he desperately wanted the best for his son.

Shortly after beginning, they began to see progress and at their first assessment, they were both relieved to see that the vision had improved. Perhaps more importantly, they found there were even more interesting improvements in school achievement and behaviour.

By the end of therapy, they were very excited that not only was Billy seeing better, he was also achieving better grades at school and was doing better at soccer. All of this, I believe was due to his ability to better use both eyes as a team, easily and effortlessly and not in conflict.

After he graduated, I got to see his performance at a soccer practice. (My one daughter plays soccer as well, so it was a nice coincidence in a shared facility). He did great!

Another patient of ours that came to us had a history of a “lazy” right eye. They were initially referred to our office from their family optometrist because they were worried about the poor vision. So much so that they had met with an ophthalmologist who had given a strict regimen of daily patching for 2 hours a day since he was one-years-old. He was 7-years-old when he came to our office. SIX YEARS OF PATCHING! Not only were they patching everyday, they were no longer seeing the improvements that they were hoping to find. Their optometrist recognized that vision therapy might be an option so he referred them to meet with me. After the initial exam and testing, they enrolled our vision therapy program. The results were tremendous. Not only did his vision improve, there were also changes in his own confidence. We recognized his confidence in his own self had improved and his ability to successfully complete tasks in an easier manner was so important for his growth.

“[AS] has always been good in school however with the help of vision therapy it has become easier for him to succeed. He no longer experiences double vision and is able to see the board more clearly. We have also noticed that his hand eye coordination has greatly imporved. This has allowed hime to have more fun when playing catch, and has lowered his grustration level. Thank so much to Dr. Huang and the staff at Eye Care First!”

What happened with Suzy?

After discussion and alleviating some of her mom’s concerns, they decided to start vision therapy right away. Both Suzy and her mom were smiling and looked relieved when I told them that they could stop patching. In the process of our conversation, her mom revealed that Suzy was really smart, and school was, in general, really easy. We talked some more, and we found out that easy things were actually boring to Suzy and that she enjoyed things that challenged her; she loved to learn! What is even more exciting for me was that because Suzy enjoyed challenges and loved to learn, I really think she will be very successful in vision therapy!

• Doing the same thing, expect similar results

The truth about vision therapy is that it is going to take work. It’s going to take effort. It’s going to take time. It’s going to be an investment. Now think about what you are putting that work, effort, time and investment towards. Typically, the journey begins with an initial eye exam including a visual skills assessment. We need to find out what are some of the reasons that may have contributed to something like amblyopia. Additional tests may be determined from that meeting. How important is it if you can help improve your child’s vision? By enrolling in our vision therapy program, you have a chance to start that journey.

Now, here you are, the point of making that change. You can either continue the path that you already know, try harder with patching, give up on patching and give up on improving your child’s vision or you can try something new.

The path that you already know will probably give you similar results that you already experience, but if you really want a different outcome, then you’re going to have to do something different. Try something different and get that change.

Click here to book your appointment and we will contact you as soon as we can and help you get started on that that change.

If you are struggling with patching, well, great news, you don’t have to patch! Vision therapy can help you improve your vision! Click here to book your appointment to find out how to get started and to get more information.

If you found this article helpful or informative, click to join our email list to get more information like this.

P.S. If your child absolutely hates patching and still is struggling with one eye seeing better than the other, then imagine his or her relief that they can do something about their eyes AND not have to patch! Click here to book your appointment to start making that change.

Hansel M Huang, OD, FCOVD

Neuro-Behavioural Optometrist
Board Certified Developmental Optometrist
Master Practitioner of Neuro Linguistic Programming
Master Practitioner of Mental and Emotional Release
Master Practitioner of Hypnotherapy

References

1. Chen CW, Zhu Q, Duan YB, Yao JY. “Comparison between binocular therapy and patching for treatment of amblyopia: a meta-analysis of randomised controlled trials.” BMJ Open Ophthalmol. 2021 Feb 24;6(1):e000625. doi: 10.1136/bmjophth-2020-000625. PMID: 33718612; PMCID: PMC7908277.
2. Holmes JM, Melia M, Bradfield YS, Cruz OA, Forbes B; Pediatric Eye Disease Investigator Group. “Factors associated with recurrence of amblyopia on cessation of patching.” Ophthalmology. 2007 Aug;114(8):1427-32. doi: 10.1016/j.ophtha.2006.11.023. Epub 2007 Mar 23. PMID: 17363058; PMCID: PMC2384230.
3. Levi DM. “Rethinking amblyopia 2020.” Vision Res. 2020 Nov;176:118-129. doi: 10.1016/j.visres.2020.07.014. Epub 2020 Aug 28. PMID: 32866759; PMCID: PMC7487000.
4. Levi DM, Knill DC, Bavelier D. “Stereopsis and amblyopia: A mini-review.” Vision Res. 2015 Sep;114:17-30. doi: 10.1016/j.visres.2015.01.002. Epub 2015 Jan 29. PMID: 25637854; PMCID: PMC4519435.
5. Liu XY, Zhang YW, Gao F, Chen F, Zhang JY. “Dichoptic Perceptual Training in Children With Amblyopia With or Without Patching History.” Invest Ophthalmol Vis Sci. 2021 May 3;62(6):4. doi: 10.1167/iovs.62.6.4. PMID: 33944893; PMCID: PMC8107508.
6. Sabri K, Easterbrook B, Wakeman B, Mehta V, Riyaz R. “Elbow splinting as a method to increase patching compliance in amblyopia therapy.” Eye (Lond). 2017 Mar;31(3):406-410. doi: 10.1038/eye.2016.222. Epub 2016 Nov 4. PMID: 27813515; PMCID: PMC5350358.
7. Wong AM. “New concepts concerning the neural mechanisms of amblyopia and their clinical implications.” Can J Ophthalmol. 2012 Oct;47(5):399-409. doi: 10.1016/j.jcjo.2012.05.002. Epub 2012 Jun 29. PMID: 23036539