A 4-year-old child is diagnosed with dense unilateral amblyopia (6/60 in the amblyopic eye, 6/6 in the fellow eye) caused by a unilateral congenital cataract treated at 6 weeks of age. Current management is spectacle correction with patching of the fellow eye. After 6 months of treatment, the amblyopic eye has improved to 6/24 but progress has plateaued. What should be tried next?

• A Increase patching hours to 6 hours per day
• B Penalisation of the fellow eye with atropine 1% daily ✓
• C Discontinue treatment as visual plasticity is lost by age 4
• D Apply Bangerter foil to the fellow eye spectacle lens as an alternative to patching

Explanation

When compliance with patching is poor or patching is causing psychological distress or has plateaued, atropine penalisation of the fellow eye is an evidence-based alternative. Atropine 1% drops in the fellow (preferred) eye cyclopleges it, preventing near accommodation and forcing use of the amblyopic eye. The PEDIG ATOPO study confirmed atropine is equivalent to patching for moderate amblyopia. For dense amblyopia (6/60 → 6/24), atropine maintains ongoing penalisation without the child removing patches. Visual plasticity extends to at least age 7–8 years (critical period), so treatment should continue. Increasing patching hours beyond current prescription without reason is not the next step. Bangerter foils are weaker than atropine for dense amblyopia.

Reference: Khurana Comprehensive Ophthalmology, 7th ed.

High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP

Written and medically reviewed by the StethoPrep medical team.