Elbow splinting increases amblyopia patching compliance

By Laird Harrison

Elbow splints can increase children’s compliance with a patching regimen for amblyopia, researchers say.

Eighty-three percent of children who had resisted patching kept the patches in place after their elbows were put in splints, K. Sabri and colleagues of McMaster University in Ontario, Canada, reported.

“Adding elbow splints to the occlusion therapy regimen is an effective and parentally acceptable treatment method to ensure that all is done in order to try and improve vision in amblyopic eyes,” they wrote in the journal Eye.

People with uncorrected amblyopia have triple the risk of depression, double the risk of mortality and greater difficulties with day-to-day living, Sabri and colleagues wrote, citing previous research.

Most often, physicians treat the condition by putting a patch over the amblyopic eye. But children find the patches unattractive or irritating. More than half the time, they take the patches off before the therapy is complete.

Methods tried

Parents and physicians have responded with a range of measures to keep patches in place, including suturing the patch to the brow and cheek, using occlusive contact lenses, glueing the fellow eye shut, casting the patient’s arms and injecting purified botulinum A toxin into the levator muscle to induce ptosis.

Such measures can cause pain or infection, and increase the risk of the child developing amblyopia in the fellow eye, Sabri et al. note.

Some parents have rolled magazines and taped them around their children’s elbows to keep them from bending their arms to reach their eyes, and splints of a similar design are also available for sale.

This approach struck the researchers as relatively safe. Parents could remove the splints fairly easily, but children could not.

Sabri et al. wanted to see if the approach really works. So they reviewed the records of 48 children with amblyopia who were fitted for elbow splints at two tertiary paediatric ophthalmology centres between January 2008 and December 2011.

The ophthalmology centres had offered splinting because the children kept their patches in place less than half the recommended time or consistently tried to remove them over the course of three months.

Parents decided whether to splint one or both elbows, and when to remove the patches. But they got instructions to continue splinting until the child was “fully compliant.”

The researchers selected 41 children, 16 female and 25 male, with a median age of 37 months. They excluded four other patients who got their splints at the outset of the patching because of distance from the ophthalmologist, and three for being prescribed splints but not using the intervention.

Twenty-four of the patients presented with esotropia, 15 with anisometropia and two with congenital cataracts as the primary causes of their amblyopia.

The children were “very upset while wearing elbow splints” for a mean of 91 minutes, the researchers wrote. But “parents found the temporary unhappiness was an acceptable side effect in order to aid in the restoration of vision in the amblyopic eye.”

Splints increased compliance

The children wore the splints for a median of seven days, but the time ranged from one to 240 days. Prior to the splinting, the children were prescribed a mean of 4.95 hours of patching per day but actually only kept the patches on for a mean of 1.5 hours.

However, wearing the splints, the children kept the patches in place for a mean of 3.4 hours. The difference between the patching time with splints and without was statistically significant (P ≤ 0.0001).

Visual acuity in the amblyopic eyes increased in 39 of the children following the elbow splinting, but stayed constant in the other two.

After wearing the splints for a while, 34 children were able to keep their patches in place without them. The other seven children figured out how to remove their splints and then take off their patches.

The guardians of 34 of the children said they would recommend elbow splints for other children with amblyopia who were not keeping their patches in place.

The researchers acknowledged some limitations to their study. For example, it is retrospective, so the researchers could not tell how many parents were offered elbow splints and declined them, potentially skewing the sample.

Also, much of the data came from parents’ reports, which could be biased.

However, they remained confident of their findings. “This study provides evidence that splinting as a method of increasing patching compliance for amblyopia therapy is a viable treatment,” they concluded.