A NEW LOOK AT PLEOPTICS MARIA JABLONSKI, CO PORT JEFFERSON, NEW YORK
and EVELYN TOMLINSON, CO CHARLESTON, SOUTH CAROLINA
IN recent years the popular consensus regarding pleoptic therapy is that it offers no advantage over conventional occlusion therapy. However, when patients do not respond to direct patching or respond only partially, we have found pleoptics to be a worthwhile mode of treatment.
centrally fixating patient is not as critical as dilating that of one with eccentric fixation, most of the patients' pupils were dilated for greater accuracy and ease of handling.
Fixation was determined by visuscope prior to pleoptophore stimulation. An average of two to four stimulations were given on the In a previous study of 86 patients pleoptophore during each treatment with eccentric fixation treated with session. The after-image was then pleoptic therapy, we reported that projected around Snellen letters, 25% achieved and maintained vis- illiterate E's, or kindergarten picual acuity of 20/40 or better.l In tures of the size the patient could this study we are reporting the barely distinguish, and the patient results of pleoptic therapy in a encouraged to identify them. Part group of 64 patients with central of each session was spent working and unsteady central fixation, aged with the coordinator and corrector, 4 to 17 years, who did not respond and doing fine close work using adequately to dominant eye oc- Sedan's Re-educative Treatment of clusion. Suppression Amblyopia. Home therapy, such as the Weiss exercise PROCEDURE sheets or similar exercises, was preAll patients were seen on a weekly scribed to be done for a minimum schedule of half-hour treatments. of 20 minutes each day. Mter maxiThose with unsteady central fixa- mum visual acuity was achieved, tion were started on inverse occlu- most of the patients received orsion and changed to direct occlusion thoptic therapy if the potential for when fixation became steadier. binocular single vision was present. Those with steady central fixation continued dominant eye occlusion. RESULTS Although dilating the pupil of a Submitted for publication June 11, 1979. Presented at the Southern Regional Meeting of the American Association of Certified Orthoptists, Kiawah Island, South Carolina, April 3()"May 3, 1978. Reprint requests to Eye Treatment Center, St. Charles Hospital, Port Jefferson, NY 11777 (Ms Jablonski).
Sixty-four patients are included in this study. All patients had had unsuccessful direct (conventional) occlusion before being referred for pleoptic therapy. The minimum number of pleoptic treatments given was one; the maximum was three. Original visual acuity varied from
2112
PLEOPTICS
VOLUME 86 DECEMBER 1979
2113
TABLE 1 DISTRIBUTION OF PATIENTS ACCORDING TO ORIGINAL VISUAL ACUITY (TOTAL 64 PATIENTS) ORIGINAL VISUAL ACUITY
No. of
patients
20/30
20/40
20/50
20/60
20/70
20/80
20/100
8
24
20
5
2
3
2
20/30 to 20/100 ~th 20/40-20/50 being the average (Table 1).
Seventeen patients ~th anisometropic amblyopia were fusing prior to beginning pleoptic therapy. The remaining 47 patients had either strabismic amblyopia or mixed anisometropic and strabismic amblyopia; 10 of these were fusing prior to starting therapy. All 64 patients achieved final visual acuity of 20/30 or better (Tables 2 and 2A), as follows: 20/20-19 patients, 20/25-28 patients, and 201 30-17 patients. Twenty-five patients, including the original 17, TABLE 2 FINAL VISUAL ACUITY AFTER TREATMENT FINAL VISUAL ACUITY
20/20 20/25 No. of
patients
19
28
20/30
were fusing at the completion of the pleoptic-orthoptic therapy. All the patients ~th fusion had some degree of stereopsis. Recent follow-up was obtained on 27 patients. The length of follow-up was from one to ten years (Tables 3 and 3A). Of the total 27 patients, five maintained visual acuity of 20/20, nine maintained 20/25, ten maintained 20/30, and the acuity of three patients dropped to 20/50. Twenty-two patients maintained their best visual acuity. All had either normal fusion or a small esotropia ~th ARC fusion. Two patients maintained one line better than their post-treatment acuity; both were fusing. The three patients whose visual acuity dropped to 20/50 had no fusion.
17 TABLE 2A
COMPARISON OF ORGINAL AND FINAL VISUAL ACUITY IN 64 PATIENTS NO. OF PATIENTS WITH FINAL VISUAL ACUITY
TOTAL NO. OF PATIENTS
20/20
20/25
20/30
5
7
3 9
8
5
11
4
2
3
Original Visual Acuity
5
20/30 20140 20/50 20/60
2
20170
3
20/80 20/100
8 24 20
2
2
1 1
1 1
1
TABLE
3
AAO
TABLE 3A
VISUAL ACUITY AT FOLLOW-UP AFfER ONE TO TEN YEARS (27 PATIENTS)
COMPARISON DATA ON 27 FOLLOW-UP PATIENTS NO . OF PATIENTS
VISUAL ACUITY
20/20 20/ 25 20/ 30 20/50 No. of patients
OPHTH
JABLONSKI AND TOMLINSON
2114
Pretreatment visual acuity 5
9
10
3
SUMMARY
Sixty-four patients who did not respond adequately to passive conventional occlusion were treated with active pleoptic therapy, and followed with orthoptic therapy when fusion potential was demonstrated_ Patients ranged in age from 4 to 17 years, and ranged in visual acuity from 20/30 to 20/ 100. Seventeen patients had some fusion prior to starting pleoptics. All 64 patients achieved an immediate post-therapy acuity of 20/30 or better; 25 were fusing and demonstrated some stereopsis. Twenty-seven patients were followed for a period of one to ten years, including the 25 patients who were fusing at completion of therapy. Twenty-four (88%) maintained visual acuity of 20/ 30 or better. All fused either normally or with ARC. Three patients, whose visual acuity dropped to 20/50, had no fusion. Only one patient who had fusion at the completion of therapy was unable to maintain it.
20/ 30 20/ 40 20/ 50 20170
3 12 9 1
20/ 80 20/ 100
1 1
Best visual acuity after treatment
20/ 20 20/ 25 20/ 30
7 11 9
Final visual acuity at follow-up
20/ 20 20/ 25 20/30 20/ 50
5 9 10 3
We conclude, therefore, that pleoptics retains value in the treatment of amblyopic patients with steady and unsteady central fixation, in those situations where conventional occlusion is unsuccessful. REFERENCE 1. Jablonski MD, Tomlinson EA: Results of modified pleoptic therapy in eccentric fixation. Am Orthopt J 23:60-64, 1973.
and EVELYN TOMLINSON, CO CHARLESTON, SOUTH CAROLINA
IN recent years the popular consensus regarding pleoptic therapy is that it offers no advantage over conventional occlusion therapy. However, when patients do not respond to direct patching or respond only partially, we have found pleoptics to be a worthwhile mode of treatment.
centrally fixating patient is not as critical as dilating that of one with eccentric fixation, most of the patients' pupils were dilated for greater accuracy and ease of handling.
Fixation was determined by visuscope prior to pleoptophore stimulation. An average of two to four stimulations were given on the In a previous study of 86 patients pleoptophore during each treatment with eccentric fixation treated with session. The after-image was then pleoptic therapy, we reported that projected around Snellen letters, 25% achieved and maintained vis- illiterate E's, or kindergarten picual acuity of 20/40 or better.l In tures of the size the patient could this study we are reporting the barely distinguish, and the patient results of pleoptic therapy in a encouraged to identify them. Part group of 64 patients with central of each session was spent working and unsteady central fixation, aged with the coordinator and corrector, 4 to 17 years, who did not respond and doing fine close work using adequately to dominant eye oc- Sedan's Re-educative Treatment of clusion. Suppression Amblyopia. Home therapy, such as the Weiss exercise PROCEDURE sheets or similar exercises, was preAll patients were seen on a weekly scribed to be done for a minimum schedule of half-hour treatments. of 20 minutes each day. Mter maxiThose with unsteady central fixa- mum visual acuity was achieved, tion were started on inverse occlu- most of the patients received orsion and changed to direct occlusion thoptic therapy if the potential for when fixation became steadier. binocular single vision was present. Those with steady central fixation continued dominant eye occlusion. RESULTS Although dilating the pupil of a Submitted for publication June 11, 1979. Presented at the Southern Regional Meeting of the American Association of Certified Orthoptists, Kiawah Island, South Carolina, April 3()"May 3, 1978. Reprint requests to Eye Treatment Center, St. Charles Hospital, Port Jefferson, NY 11777 (Ms Jablonski).
Sixty-four patients are included in this study. All patients had had unsuccessful direct (conventional) occlusion before being referred for pleoptic therapy. The minimum number of pleoptic treatments given was one; the maximum was three. Original visual acuity varied from
2112
PLEOPTICS
VOLUME 86 DECEMBER 1979
2113
TABLE 1 DISTRIBUTION OF PATIENTS ACCORDING TO ORIGINAL VISUAL ACUITY (TOTAL 64 PATIENTS) ORIGINAL VISUAL ACUITY
No. of
patients
20/30
20/40
20/50
20/60
20/70
20/80
20/100
8
24
20
5
2
3
2
20/30 to 20/100 ~th 20/40-20/50 being the average (Table 1).
Seventeen patients ~th anisometropic amblyopia were fusing prior to beginning pleoptic therapy. The remaining 47 patients had either strabismic amblyopia or mixed anisometropic and strabismic amblyopia; 10 of these were fusing prior to starting therapy. All 64 patients achieved final visual acuity of 20/30 or better (Tables 2 and 2A), as follows: 20/20-19 patients, 20/25-28 patients, and 201 30-17 patients. Twenty-five patients, including the original 17, TABLE 2 FINAL VISUAL ACUITY AFTER TREATMENT FINAL VISUAL ACUITY
20/20 20/25 No. of
patients
19
28
20/30
were fusing at the completion of the pleoptic-orthoptic therapy. All the patients ~th fusion had some degree of stereopsis. Recent follow-up was obtained on 27 patients. The length of follow-up was from one to ten years (Tables 3 and 3A). Of the total 27 patients, five maintained visual acuity of 20/20, nine maintained 20/25, ten maintained 20/30, and the acuity of three patients dropped to 20/50. Twenty-two patients maintained their best visual acuity. All had either normal fusion or a small esotropia ~th ARC fusion. Two patients maintained one line better than their post-treatment acuity; both were fusing. The three patients whose visual acuity dropped to 20/50 had no fusion.
17 TABLE 2A
COMPARISON OF ORGINAL AND FINAL VISUAL ACUITY IN 64 PATIENTS NO. OF PATIENTS WITH FINAL VISUAL ACUITY
TOTAL NO. OF PATIENTS
20/20
20/25
20/30
5
7
3 9
8
5
11
4
2
3
Original Visual Acuity
5
20/30 20140 20/50 20/60
2
20170
3
20/80 20/100
8 24 20
2
2
1 1
1 1
1
TABLE
3
AAO
TABLE 3A
VISUAL ACUITY AT FOLLOW-UP AFfER ONE TO TEN YEARS (27 PATIENTS)
COMPARISON DATA ON 27 FOLLOW-UP PATIENTS NO . OF PATIENTS
VISUAL ACUITY
20/20 20/ 25 20/ 30 20/50 No. of patients
OPHTH
JABLONSKI AND TOMLINSON
2114
Pretreatment visual acuity 5
9
10
3
SUMMARY
Sixty-four patients who did not respond adequately to passive conventional occlusion were treated with active pleoptic therapy, and followed with orthoptic therapy when fusion potential was demonstrated_ Patients ranged in age from 4 to 17 years, and ranged in visual acuity from 20/30 to 20/ 100. Seventeen patients had some fusion prior to starting pleoptics. All 64 patients achieved an immediate post-therapy acuity of 20/30 or better; 25 were fusing and demonstrated some stereopsis. Twenty-seven patients were followed for a period of one to ten years, including the 25 patients who were fusing at completion of therapy. Twenty-four (88%) maintained visual acuity of 20/ 30 or better. All fused either normally or with ARC. Three patients, whose visual acuity dropped to 20/50, had no fusion. Only one patient who had fusion at the completion of therapy was unable to maintain it.
20/ 30 20/ 40 20/ 50 20170
3 12 9 1
20/ 80 20/ 100
1 1
Best visual acuity after treatment
20/ 20 20/ 25 20/ 30
7 11 9
Final visual acuity at follow-up
20/ 20 20/ 25 20/30 20/ 50
5 9 10 3
We conclude, therefore, that pleoptics retains value in the treatment of amblyopic patients with steady and unsteady central fixation, in those situations where conventional occlusion is unsuccessful. REFERENCE 1. Jablonski MD, Tomlinson EA: Results of modified pleoptic therapy in eccentric fixation. Am Orthopt J 23:60-64, 1973.
