1. Am J Ophthalmol 2009;147:357–363 Ap.신선영/R4 권진우
Different Corrections of Hypermetropic Errors in the Successful Treatment of Hypermetropic Amblyopia in Children 3 to 7 Years of Age
Am J Ophthalmol 2009;147:357–363
Ap.신선영/R4 권진우

2. Background Refractive amblyopia Refractive correction
Necessary component
Frequently prescribed before the occlusion or penalization
Hypermetropic amblyopia in children without strabismus
Power of the glasses prescribed for the correction is controversial
Full and partial spectacle correction

3. METHODS Object Diagnostic criteria
3- 7yrs old children diagnosed with hypermetropic amblyopia
retrospectively reviewed.
Diagnostic criteria
A difference of two lines or more on the VA chart
Anisometropic amblyopia
Difference between the refractive errors > 1.00 diopter (D) of hypermetropia
Isometropic amblyopia
bilateral refractive error with hyperopia of ≥4.00 D but without ≥1 D of difference
Exclusion
Prior spectacle correction
Astigmatism of ≥2 D or a difference of ≥1 D, follow-up of less than one year
Ocular disease that could contribute to reduced VA
Learning difficulties
Presence of strabismus

4. METHODS Treatment Appropriate spectacle correction
Assess their VA at follow-up visits approximately one month apart
Patch
Children do not show an improvement in VA at two consecutive visits
VA improvement stabilized before the resolution : excluded
The guidelines for the prescription of glasses
Full correction group
considering the poor accommodation of the amblyopic eye
Partial correction group
Balanced reduction D
Compliance
Good : all day long
Fair : ≥ 50% of the day but less full time
Poor : < 50% of the day

5. RESULTS
182 children
2/3 : anisometropic amblyopia
1/3 : isometropic amblyopia.
102 children
Full hypermetropic correction (full correction group)
mean age at presentation : 5.4 years
The mean VA of the amblyopic eyes at baseline : 0.59 logMAR
The mean time of follow-up : 30.5 months
80 children
a balanced reduction of hypermetropia (partial correction group)
mean age at presentation : 5.15 years
The mean VA of the amblyopic eyes at baseline : 0.57 logMAR
The mean time of follow-up : 27.4 months
There was no statistically significant in the groups for each of these characteristics

6. RESULTS

7. RESULTS Changes of glasses in the first three visits
11 children in the full correction group
10 children in the partial correction group
These changes of glasses in the full correction group mostly resulted from
Complaints about blurred vision
An increase in VA when a minus lens was placed over the glasses
All of these children were older than 5 years
The changes of glasses in the partial correction group
Mostly in children aged 3 to 5 years with underdiagnosed accommodative esotropia.
Transfer 11 children originally in the full correction group to the partial correction group
Transfer 3 children from the partial correction group to the full correction group
Excluded 7 children with accommodative esotropia

8. RESULTS

9. RESULTS Full correction group Partial correction group
Compliance was good in 81 children, fair in 9 children, and poor in 3 children
Amblyopia improved by three or more lines in 90 (97%) children
The mean VA of the amblyopic eyes improved from 0.60 to 0.14 logMAR
Mean follow-up of 34 months
The regression of hypermetropia was 0.44 D/year in the full correction group
Partial correction group
Compliance was good in 72 children, fair in 7 children, and poor in 2 children.
Amblyopia improved by three or more lines in 77 (95%) children
The mean VA of the amblyopic eyes improved from 0.58 to 0.1 logMAR
Mean follow-up of 30 months
The regression of hypermetropia was 0.43 D/year in the full correction group
No difference in the improvement in VA between the 2 groups (P=0.92)
No difference in the reduction of hypermetropia according to age, refractive error, or type of amblyopia.
The higher the initial refractive error, the more regression of hyperopia was noted, although this was not statistically significant

10. RESULTS

11. RESULTS

12. DISCUSSION
In this retrospective study, we analyzed the characteristics of children with hypermetropic amblyopia in terms of the power of spectacle correction
In this study, 96% of patients improved by three and more lines of VA
In previous studies, the percentage of children with an improvement of three or more lines ranged from 21% to 86%.
These differences in outcome are attributable to different inclusion criteria, different periods of follow-up, or different methods of treatment.

13. DISCUSSION
In our study, we used cyclopentolate as the cycloplegic drug.
Rosenbaum
found 0.34 D more hypermetropia with 1% atropine administered over 3 days compared with two drops 0.1 ml (1%) cyclopentolate.
noted 1.0 D or more of hypermetropia was uncovered by atropine in 22% of the children, and almost all this subgroup had an initial cyclopentolate retinoscopy of 2.00 D or more.
Celebi
compared the cycloplegic effects of 1% cyclopentolate and 1% atropine in children aged 5 to 10 years with refractive accommodative esotropia, they found no significant difference in their cycloplegic effects (5.1 D vs 5.2 D, respectively)

14. DISCUSSION
Children who changed the power of their glasses during the first three visits
All our children needed to change their glasses during the first 4 to 8 weeks of follow-up
After 8 weeks, no children needed to change their glasses before 6 months

15. DISCUSSION Emmetropization
Infants are hypermetropic, and that this hypermetropia gradually decreases during infancy and early childhood
The growth of the axial length, a reduction in the dioptric power of the cornea, a reduction in the power of the lens, and the lengthening of the anterior chamber.
However, the mechanisms that regulate these changes are poorly understood.
Studies of animals have suggested that ocular development and refraction are partly regulated by visual feedback related to optic focus.

16. DISCUSSION In a study by Akinson In our study
No difference in the reduction of hyperopia in children with ≥ 3.5 D hyperopia between partial spectacle correction group and no treatment group
Partial spectacle correction for infantile hypermetropia may not interfere in any persistent way with the developmental trend toward emmetropia.
However, they speculated that the emmetropization process is influenced by full spectacle correction
In our study
The reduction in hypermetropia did not differ between the partial and full hypermetropic correction groups.

17. DISCUSSION Some limitations to our study Retrospective
some confounding factors could not be controlled well
We only evaluated cycloplegic refraction with 1% cyclopentolate
The results may have been different if atropine had been used
We did not evaluate the accommodative function regularly.
We used dynamic retinoscopy to evaluate the accommodative response
However, the method we used only roughly assesses the retinoscopic reflex when children fix on a near target.
We did not quantitatively measure the accommodative function

18. DISCUSSION
Summary
Full and partial correction of hyperopic errors improved VA in children aged 3 to 7 years with hyperopic amblyopia.
The reduction of hyperopia was similar with full and partial spectacle correction.
However, for children older than 5 years, full correction should be undertaken with care because the accompanying blur at distance can be a factor that hinders compliance.
In contrast, for younger children, and especially uncooperative children and/or those with high degrees of hyperopia, full correction might be required to avoid strabismus