Optical treatment of amblyopia: a systematic review and meta-analysis

Background Despite evidence that amblyopia can often be treated by optical treatment alone, many practitioners still do not use an optical-correction-only phase in amblyopia treatment and some investigators omit this important step in their research. This paper aims to systematically review the evidence for the optical treatment of strabismic, refractive and combined-mechanism amblyopia and to quantify the evidence via a meta-analysis. Methods A search of online databases MEDLINE, EMBASE, PsycInfo, the Cochrane Library, and bibliographies of review papers, along with subsequent personal communication, resulted in 29 papers that met our inclusion criteria, with 20 providing sufficient data for the calculation of effect sizes. A meta-analysis was performed to determine effect sizes and the heterogeneity thereof. Meta-regression was used to evaluate the contribution of the possible moderating factors of age, duration of optical correction, and initial visual acuity to the heterogeneity of the studies. In addition, effect sizes were analysed in subgroups based on amblyopia aetiology, that is refractive or strabismic or combined, and also in the fellow eyes. Results No evidence of publication bias in the included studies was found using a Galbraith plot. Optical treatment of amblyopia resulted in a large positive effect size of 1.07 (+/- 0.49, 95-per cent confidence limits) on visual acuity, although the heterogeneity was significant (Q = 597.05, I-2 = 96.65-per cent, p < 0.0001). Meta-regression indicated that effect sizes significantly decreased with age, increased with treatment duration, and that better initial acuity was associated with higher effect sizes. Conclusion Effect sizes were always moderate to large, whether participants were younger or older children, or whether the aetiology was refractive or strabismic. Thus, optical treatment of amblyopia should be considered prior to other treatment in those with refractive error. Improved acuity before initiating other treatment would presumably make occlusion or penalisation less onerous and may improve compliance with further treatment.