Why do We Patch?

by Dr. Laura Sperazza, Director of Low Vision Services, Lighthouse Guild

As parents it is important that we are aware of the many warning signs associated with vision impairment in children. The earlier a problem can be detected and treated, the less likely it is to have a lasting, developmental effect. Children are typically unaware that they have a vision problem, making it all the more important for parents to be on the lookout for warning signs. Here are some signs that would indicate your child may have a vision impairment:

  • Difficulty reading, such as frequently losing place or skipping words
  • Sitting too close to the TV
  • Constantly rubbing his/her eyes
  • Extreme sensitivity to the light
  • Closing one eye to read or watch TV
  • Frequent headaches

If you notice any of these warning signs of a vision problem, or you notice any other irregularities with your child’s vision, you should schedule a consultation with an eye doctor as soon as possible to have your child examined.

Patching one eye is a common treatment for amblyopia. Amblyopia is the medical term used when the vision in one of the eyes is reduced because the eye and the brain are not working together properly. The eye itself looks normal, but it is not being used normally because the brain is favoring the other eye. This condition is also sometimes called lazy eye. Amblyopia is the most common cause of visual impairment among children, affecting approximately 2 to 3 out of every 100 children. Unless it is successfully treated in early childhood, amblyopia usually persists into adulthood. It is also the most common cause of monocular (one eye) visual impairment among young and middle-aged adults. Amblyopia can occur when one eye is more nearsighted, more farsighted or has more astigmatism than the other or when there is a misalignment of the two eyes, called strabismus. If one eye turns in, it is called esotropia, if one eye turns out it is called exotropia. Sometimes amblyopia can be caused by a clouding of the front of the eye due to cataracts or corneal disease. Treating amblyopia involves forcing the child to use the eye with weaker vision. There are two common ways to treat amblyopia:

Patching

An adhesive patch is worn over the stronger eye for weeks to months. This therapy forces the child to use the eye with amblyopia. Patching stimulates vision in the weaker eye and helps parts of the brain involved in vision develop more completely.
A National Eye Institute study showed that patching the unaffected eye of children with moderate amblyopia for two hours daily works as well as patching for six hours daily. Shorter patching time can lead to better compliance with treatment and improved quality of life for children with amblyopia. However, a recent study showed that children whose amblyopia persists despite two hours of daily patching may improve if daily patching is extended to six hours.

Previously, eye care professionals thought that treating amblyopia would be of little benefit to older children. However, results from a nationwide study showed that many children from ages seven to 17 years old benefited from treatment for amblyopia. This study shows that age alone should not be used as a factor to decide whether or not to treat a child for amblyopia.

Atropine

A drop of a drug called atropine is placed in the stronger eye to temporarily blur vision so that the child will use the eye with amblyopia, especially when focusing on near objects. The National Eye Institute has shown that atropine eye drops, when placed in the unaffected eye once a day, work as well as eye patching. Atropine eye drops are sometimes easier for parents and children to use.

Glasses may be prescribed to treat any focusing problems, but patching may still be required to treat the amblyopia. Surgery cannot correct amblyopia, and even though it may be performed to straighten the eyes, patching may still be required before and/or after surgery.

If amblyopia is not treated, it may result in a permanent and serious visual loss in one eye, it may affect depth perception, or it could result in a lifetime of poor vision if the good eye becomes diseased or injured. This will cause a life-long issue for the child.

Patching is sometimes also prescribed to help children control drifting eyes even when the vision is equal. The amount of patching therapy required is different for every child.  In general, the younger the child and the earlier treatment is started, the less time it will take for the vision to improve. Some forms of amblyopia can be more severe and difficult to treat than others.

Your doctor may prescribe the patch to be worn full-time or for a certain number of hours a day. After vision has improved and stabilized in the lazy eye, patching is often continued and tapered slowly to prevent relapse. Worsening of vision can occur after patching is discontinued, which makes it important to have the vision checked regularly during and after treatment.

Some people recommend detailed or near work while wearing the patch to encourage use of the lazy eye and speed visual recovery. The best exercise, though, is wearing the patch! If the vision in the weak eye is extremely poor, it is important to supervise your child’s activities while being patched. Playing outside near streets or driveways is not recommended.

Unfortunately, not all children’s vision improves after a reasonable period of compliant patching and your doctor may eventually advise to stop treatment. The type of patch I recommend for the best results are adhesive skin patches. A patch should fit firmly and comfortably on the skin around the eye underneath the glasses and should not allow the child to be able to peek around the edges. IMPORTANT!

Although the adhesive types of patches are recommended, some patients who experience skin irritation or compliance problems may benefit from the use of a different type of patch. Fabric patches that cover the lens of the glasses can be useful as long as the child is not able to peek around the patch

Getting children to wear eye patches can be a difficult challenge and a lot of hard work. Successful treatment mostly depends on your commitment, involvement, and ability to gain your child’s cooperation. Don’t give up too soon. There are occasionally times when patching continues to be impossible and you may have to accept that one eye will always be poorer than the other. It is always reassuring to know that you have done everything you possibly can with patching before accepting this.

I would only recommend patching during school if the child is compliant, I feel it is better to patch at home so the parent can monitor that it is being done correctly and so the child does not feel anxious or embarrassed.

TIPS

  • Routine (especially for little ones) is extremely important. Do not let a day go by that you do not make at least one or two patching attempts. Make an attempt, but do not persist to the point that your life or your child’s life becomes miserable. Just try again each day. The child will eventually understand that you’re not giving up. If the daily routine stops, the child has won the battle.
  • It may help to start slowly; high levels of patching early may induce frustration. Ask your doctor if you can gradually add an hour a day or week.
  • Use positive reinforcement and avoid negative reinforcement or power struggles. Allowing patching to become a battle is almost guaranteed to be a fight in which the child wins.
  • Use rewards.
    • Link patching with activities the child enjoys (TV, video games, etc.)
    • Try playing King or Queen for a Day; start on a weekend with adult supervision and fill the day with special privileges and attention to distract from patching.
  • Use a timer to indicate when the patch comes off. This makes the timer the ‘bad guy,’ not the parent.
  • Consider having a rule that only parents or caregivers can touch the patch.
    Try patching at school or daycare where there may be better supervision and distraction.
  • Be creative
    • Have your child help decorate patches with fabric paints, stamps, temporary tattoos, rub-on transfers, stickers, or other craft material.
    • Use the computer to print clip-art pictures directly onto patches.
      Invent patching games.

Resources:

Amblyopia Fact Sheet

Additional Articles about Amblyopia

Patching the Eye to Treat Amblyopia