comes with several important factors to rule out before therapeutic intervention can begin. These factors include varying etiologies, such as restrictive, hemorrhagic, neurological, or refractive, to name a few. Reasons for strabismus that can be solved with better control of systemic health issues or removal of a mass will typically allow for improvement without the need of therapy. Amblyopia, while sometimes presenting alongside strabismus, is defined as reduced vision in the absence of ocular pathology. Commonly associated with refractive error, amblyopia can also be caused by deprivation, or a blockage of the light coming through the eye due to a physical entity. Whatever the steps leading up to a diagnosis of amblyopia or strabismus, when a patient or parent is sitting in my chair asking what to do, it is important I remember my three R’s: “Refract, Reconnect, Red/Green.” Prescribing corrective lenses is often an essential first step in strabismus and amblyopia treatment. This step is one that leaves optometrists contemplating the appropriate prescription to write. After all, many factors must be taken into consideration, meaning that the correct answer is often unclear. Best-corrected visual acuity, lens minification/magnification, improvement of ocular alignment, and the perception of space through such lenses are some of the influences on how one’s visual experience can be affected. During my time at both my externship rotations, it was expected that new patients arriving with TBI or for a binocular evaluation would recheck refraction and complete lensometry on any current spectacles. Assuming that the addition of prism or tinting was unnecessary, patients' spectacle prescriptions weren’t updated unless there was an improvement associated with the change. At first, I didn’t understand the necessity, especially for patients that had been referred by other optometrists for a vision therapy evaluation. Over time, however, I was able to correctly identify those who could benefit from a prescription change, even if it was a minor one. These cases gave me an understanding and appreciation on the impact an accurate refraction can have on the binocular system. Once the patient has the appropriate glasses prescription, additional treatment options include full or partial occlusive patching and/or atropine penalization of the better-seeing eye. Though atropine is one of the oldest techniques used for the treatment of amblyopia, it is not used for patients with strabismus. Instead, patching is commonly the treatment of choice for strabismus. The theories behind blocking or degrading the signal of the non-strabismic or amblyopic eye is to force engagement of the eye showing a deficit. This forced reconnection of the strabismic or amblyopic eye can work to strengthen or jump start the neurological signals sent to the brain to allow for normal visual development. Up until this point in treatment, the brain has been allowed the opportunity to ignore the signals sent by the deficit eye and focus only on the signals sent by the clearer, comfortable-seeing eye. This phenomenon is known as suppression. However, if there is no suppression and the brain is receiving and attending to both eyes, it can cause diplopia and confusion for the patient. Either way, reconnecting and forcing the brain to attend to the eye exhibiting amblyopia and strabismus allows for equal opportunity and better success when the eyes are then asked to work together. Following improvement with refraction and reconnecting the signals from the eye to the brain with monocular techniques, binocular and antisuppression therapies, such as in the utilization of red/green glasses, are appropriate to teach the brain coordination and fusion. Anti-suppression activities are when the patient is tasked with watching or participating in an activity wearing red and green glasses. With opposing colored lenses over each eye, if the brain is not attending to both eyes, the activity cannot be completed. Binocular therapy exercises, in contrast, work to team the eyes together and encourage stereopsis. True stereopsis is seen through bi-foveation and the appropriate perception of space around them. Thus, it is important that the brain is able to equally process the information sent from both eyes without suppression in order to appreciate and understand true binocularity and stereopsis. I had the opportunity to extern at two clinics who took differing methods when it came to working with younger patients presenting with strabismus and/or amblyopia. One of the offices took the approach of skipping monocular occlusion and atropine to focus solely on therapeutic techniques to build up stereopsis, anti-suppression, and binocular vision. Although not widely studied or used for strabismus, these doctors were also incorporating the use of technology, like CureSight and Luminopia, for at-home therapy in lieu of in-office therapy for many of their amblyopic patients. The second office relied heavily on the evidence-based medicine associated with monocular patching and/or atropine use until the age of 7 years old. While they did not dismiss anti-suppression or binocular therapy, their initial approach was to stick with patching and the use of atropine for their younger patients with strabismus and/or amblyopia. While neither office offered an inappropriate initial treatment to their strabismic and amblyopic patients, it can be confusing for new graduates to choose a preferred method. While I see the benefits of both approaches, the dedication of time and resources to Optometry & Visual Performance 297 Volume 13 | Issue 4 | December 2025
RkJQdWJsaXNoZXIy MjEyMDQ0Nw==