Sorry, around here I meant the San Francisco bay area; SF, Stanford
University, Silicon valley, or even Berkeley or San Jose if necessary,
even when the lat two are a little further.

Thanks

Javier

On 3/20/06 7:42 AM, in article
1142869366.534360.20150[at]i39g2000cwa.googlegroups.com, "Bogo"
<elbogo[at]sbcglobal.net> wrote:

- quote -



Patching hours really depends on the level of amblyopia, the cause and type
of amblyopia, and whether there is coexsisting strabismus and a possibility
of continued fusion, It is a very individual situation,as far as I'm
concerned.

Thus, it is not how many hours I'd be comfortable with. It ranges from 2 hrs
in a few cases to all day (1 hour off).


Dr. Jampolsky retired from practice a number of years ago.

You might try (all in the CPMC Hospital area on Webster and Clay in SF):
(all excellent people)
Susan Day (in Dr. Jampolsky's old office)
Alan Scott (the other ex-codirector of the Smith-Kettlewell Institute)
Otis Paul
William Good

Where is "around here"?

You don't know how much I value every time you all answer. Thanks

You don't know how much I value every time you all answer. Thanks

I would want to be rechecking his distance script again to make sure it
is strong enough. Also check his near phoria with cover test to see if
he has excessive esophoria at near. This is where bifocals will help if
he has high esophoria.

If he is straight most of the time, then atropine is better than
patching as it will develop 3D vision.

If patching, I find 6hr to full time works better than 2 hr, but with
vision at 20/30, it is at tje stage when I would be looking at
antisuppression treatment with a Bangerter foil (a stick on graded
occluder on the glasses) which is worn full time on the left lens of
the glasses and helps to develop 3D vision as well as improve the RE
vision. The foil drops the LE to around 20/60 to 20/80 on the left eye.
This works if the eyes are nostly straight.

dr grant

Dr. Robins,

Then, instead of two, how many hours of patching per day would you feel
comfortable with?

Regarding Dr. Jampolsky in San Francisco, I'm looking for a Dr. in the
SF bay area, should I try to take my 4 years old kid to see him? Or ask
him for a referral around here?

Thanks again.

Javier

I agree with you on this. Like I say, I don't get too many strabs as
they get filtered pretty quickly away from optometry in most cases, and
the CET's need patching, glasses and surgery in most cases. I don't
even bother with them in most cases (except for the specs) as they need
surgery in most cases and the doc is usually best placed to determine
this as you are well aware.

Occlusion of any sort is what you are comfortable with. Other optons I
know patch, I find I get crappy results and almost invariably allergy
to the opticlude patches. That really sucks!!!

Yes, it is the same Lionel, I am pretty lucky to have one of his ilk in
my town. He works well with optometry, even when we confound him with
6yo girls with Holmes Aide pupil (which Lionel assures me is
impossible). He did add the pearl that Aide comes from Geelong, 1hr
from Melbourne. I didn't know that.

Cheers

grant

I personally don't find some of the PEDIG study results in my own practice;
ie the 2 hr/day patching as being effective in very many cases. I don't
cling to the PEDIG results very much. It is the parents waving the internet
articles in my face, who do.

Regarding then binocular cells- these are kids who probably suffer from lack
of binocular cells anyway, due to the amblyopia they have had all their
life, probably. My feeling is the short time (relative to their life prior)
we are patching, it probably doesn't make any long-term difference. (Not a
study of course, ...)

A lot of amblyopes I get who ARE refractive have such poor vision starting
out that I se no point in using atropine (ie <20/70 or so). My feeling is
atropine really only works if you can switch fixation at near by blurring
more than the amblyopic eye. I check which eye they are using at near, if I
start atropine. If they still use the better eye, how could it be effective?
Yes, I could remove the plus from the atropined eye, or even go minus, to
penalize more, but it is such a hassle. To check vision in that eye, you
then have to put a trial frame with the correct Rx on. And parents complaint
if you then reorder (expensive) new lenses for less penalization, and then
reorder yet again once the amblyopia treatment is over.

David Guyton at Wilmer (who I trained with) has gone almost entirely over to
atropine. He never could explain to my satisfaction how it could work where
the near preference is not switched, and others besides me wonder, too.
However, my other training with Dr. Jampolsky in San Francisco, used a fair
amount of patching. But he was dealing more with strabismic patients, as you
said.

Bottom line, we still don't scientifically really know which treatment is
best. We may THINK we know, based on logic, however, which is what a lot of
our treatments are based on.

BTW, when you say "Lionel", I presume you mean Lionel Kowal, who we all know
of, and have corresponded with myself. As you said, very smart guy.



On 3/18/06 9:49 PM, in article
1142747344.952514.304860[at]e56g...oglegroups.com, "CatmanX"
<drgrant[at]ozemail.com.au> wrote:

- quote -

David,

I have a problem with the PEDIG study, because all the ophthals that
espouse it here are having their kids seen by me after no improvement
in 6 months and going onto atropine and improving in the first month
with me.

My issue is that patching reinforces monocularity, regardless of time,
unless the eyes are straight as you say. Hubel and Wiesel showed that
alternating patching could change cortical cell response from left to
right eye, and when you patch for 2 hours, you force non-preferred
dominance for 2 hours, then preferred eye dominance for the rest of the
day. This results in left eyed cells and right eyed cells, but no
binocular cells.

I used to patch a lot, but my ophthal recommended to refer the kid to
him and get them put on atropine. I did this and we got great results
so I continued to do this. Lionel is a pretty smart guy (I think he has
forgotten more about strabismus than I will ever know) so I listen to
what he has to say. I comanage a lot of my patients with him,
especially if there is the suspicion of surgery needed.

Most of the kids I see are refractive amblyopes so atropine works
brilliantly for them. Strabs are certainly another kettle of fish and
patching is definitely better for many of them (which is probably a
large chunk of your practice).

Cheers,

grant

Bogo, sorry misread the numbers, the left should have the atropine./

dr grant