Angela M. Tjiam

Rotterdam AMblyopia screening effectiveness study: detection and causes of amblyopia in a large birth cohort.

PURPOSE. The Dutch population-based child health monitoring program includes regular preverbal (age range, 1-24 months) and preschool (age range, 36-72 months) vision screening. This study is on the contribution of an organized vision screening program to the detection of amblyopia. METHODS. A 7-year birth cohort study of 4624 children was started in 1996/1997 in Rotterdam. Vision screening data were obtained from the child screening centers. Treating orthoptists working at the regional ophthalmology departments provided information about diagnosis and treatment. The diagnosis was reviewed by two experts. The parents provided additional information on their childs eye history through written questionnaires and telephone interviews. At age 7 years, the children underwent a final examination by the study orthoptists. RESULTS. Of the 3897 children still living in Rotterdam by 2004, 2964 (76.1%) underwent the final examination. Amblyopia was diagnosed in 100 (3.4%) of these (95% CI, 2.7-4.0). At age 7, 23% had visual acuity >0.3 logMAR. Amblyopia was caused by refractive error (n = 42), strabismus (n = 19), combined-mechanism (n = 30), deprivation (n = 7), or unknown (n = 2). Eighty-three amblyopia cases had been detected before age 7. Amblyopia detection followed positive results in vision screening in 56 children, either preverbal (n = 15) or preschool (n = 41). Twenty-six other amblyopes were self-referred (n = 12, before a first positive screening test), especially strabismic or combined-mechanism amblyopia; data were uncertain for one other positively screened amblyopic child. Amblyopia remained undetected until age 7 due to unsuccessful referral (n = 4, three with visual acuity >0.3 logMAR at age 7) or false-negative screening (n = 13). CONCLUSIONS. Most cases of amblyopia were detected by vision screening with visual acuity measurement. Preverbal screening contributed little to the detection of refractive amblyopia.

An Educational Cartoon Accelerates Amblyopia Therapy and Improves Compliance, Especially among Children of Immigrants

PURPOSE We showed previously that an educational cartoon that explains without words why amblyopic children should wear their eye patch improves compliance, especially in children of immigrant parents who speak Dutch poorly. We now implemented this cartoon in clinics in low socioeconomic status (SES) areas with a large proportion of immigrants and clinics elsewhere in the Netherlands. DESIGN Clinical, prospective, nonrandomized, preimplementation, and postimplementation study. PARTICIPANTS Amblyopic children aged 3 to 6 years who started occlusion therapy. METHODS Preimplementation, children received standard orthoptic care. Postimplementation, children starting occlusion therapy received the cartoon in addition. At implementation, treating orthoptists followed a course on compliance. In low SES areas, compliance was measured electronically during 1 week. MAIN OUTCOME MEASURES The clinical effects of the cartoon-electronically measured compliance, outpatient attendance rate, and speed of reduction in interocular-acuity difference (SRIAD)-averaged over 15 months of observation. RESULTS In low SES areas, 114 children were included preimplementation versus 65 children postimplementation; elsewhere in the Netherlands, 335 versus 249 children were included. In low SES areas, mean electronically measured compliance was 52.0% preimplementation versus 62.3% postimplementation (P=0.146); 41.8% versus 21.6% (P=0.043) of children occluded less than 30% of prescribed occlusion time. Attendance rates in low SES areas were 60.3% preimplementation versus 76.0% postimplementation (P=0.141), and 82.7% versus 84.5%, respectively, elsewhere in the Netherlands. In low SES areas, the SRIAD was 0.215 log/year preimplementation versus 0.316 log/year postimplementation (P=0.025), whereas elsewhere in the Netherlands, these were 0.244 versus 0.292 log/year, respectively (P=0.005; the SRIADs improvement was significantly better in low SES areas than elsewhere, P=0.0203). This advantage remained after adjustment for confounding factors. Overall, 25.1% versus 30.1% (P=0.038) had completed occlusion therapy after 15 months. CONCLUSIONS After implementation of the cartoon, electronically measured compliance improved, attendance improved, acuity increased more rapidly, and treatment was shorter. This may be due, in part, to additional measures such as the course on compliance. However, that these advantages were especially pronounced in children in low SES areas with a large proportion of immigrants who spoke Dutch poorly supports its use in such areas.

Effectiveness of screening for amblyopia and other eye disorders in a prospective birth cohort study

Objective To establish whether the current vision screening practice in the Netherlands is effective in preventing permanent visual loss and to estimate the sensitivity of the programme. Settings In the Netherlands, all children are invited for preverbal (1, 3, 6–9 and 14–24 months) and preschool (36, 45, and 60–72 months) vision screening. Screening attendance is high, but the effectiveness in reducing amblyopia is unknown. Methods In a 7-year cohort study, 4624 children born in the city of Rotterdam between 16 September 1996 and 15 May 1997 were followed through all routine vision screening examinations. At age seven, visual acuity (VA) of children still living in Rotterdam was assessed by study orthoptists. In case of VA > 0.1 logMAR in one or both eyes, two or more logMAR lines of interocular difference or eye disorders like strabismus, children underwent a more intensive eye examination. Results Attendance at the 9-month screening was 89%, decreasing to about 75% at later examinations. Of preverbal tests, 2.5% were positive, and of preschool tests, 10%. In total, 19% of children had a positive vision screening test at least once. Amblyopia prevalence was 3.4%. Sensitivity of the vision screening programme was 73% and specificity 83%. At age seven, 0.7–1.2% (confirmed vs final exam) of the children had a VA > 0.3 logMAR in the worse eye compared with 2–3.9% (in literature) reported prevalence in non-screening situations. Children who were less frequently screened had a higher chance of poor vision (>0.3 logMAR) at age seven. Conclusion The Dutch child vision screening programme may reduce the risk of persistent amblyopia (VA > 0.3 logMAR) at age seven by more than half.

Sociocultural and psychological determinants in migrants for noncompliance with occlusion therapy for amblyopia

BackgroundCompliance with occlusion therapy for amblyopia in children is low when their parents have a low level of education, speak Dutch poorly, or originate from another country. We determined how sociocultural and psychological determinants affect compliance.MethodsIncluded were amblyopic children between the ages of 3 and 6, living in low socio-economic status (SES) areas. Compliance with occlusion therapy was measured electronically. Their parents completed an oral questionnaire, based on the “Social Position & Use of Social Services by Migrants and Natives” questionnaire that included demographics and questions on issues like education, employment, religion and social contacts. Parental fluency in Dutch was rated on a five-point scale. Regression analysis was used to describe the relationship between the level of compliance and sociocultural and psychological determinants.ResultsData from 45 children and their parents were analyzed. Mean electronically measured compliance was 56 ± 44 percent. Children whose parents had close contact with their neighbors or who were highly dependent on their family demonstrated low levels of compliance. Children of parents who were members of a club and who had positive conceptualizations of Dutch society showed high levels of compliance. Poor compliance was also associated with low income, depression, and when patching interfered with the child’s outdoor activity. Religion was not associated with compliance.ConclusionsPoor compliance with occlusion therapy seems correlated with indicators of social cohesion. High social cohesion at micro level, i.e., family, neighbors and friends, and low social cohesion on macro level, i.e., Dutch society, are associated with noncompliance. However, such parents tend to speak Dutch poorly, so it is difficult to determine its actual cause.

How Dutch orthoptists deal with noncompliance with occlusion therapy for amblyopia.

Background: We previously found that compliance with occlusion therapy for amblyopia is poor, especially among children of non-native parents who spoke Dutch poorly and who were low educated. We investigated conception, awareness, attitude, and actions to deal with noncompliance among Dutch orthoptists. Methods: Orthoptists working in non-native, low socioeconomic status (SES) areas and a selection of orthoptists working elsewhere in the Netherlands were studied. They were observed in their practice, received a structured questionnaire, and underwent a semi-structured interview. Finally, a short survey was sent to all working orthoptists in the Netherlands. Results: Nine orthoptists working in non-native, low-SES areas and 23 working elsewhere in the Netherlands participated. One hundred and fifty-one orthoptists returned the short survey. Major discrepancies existed in conception, awareness, and attitude. Opinions differed on what should be defined as noncompliance and on what causes noncompliance. Some orthoptists found noncompliance annoying, unpleasant, and hard to imagine, others were more understanding. Many pitied the noncompliant child. Almost all thought that the success of occlusion therapy lies both with the parents and the orthoptist, but one third thought that noncompliance was not solely their responsibility. Patients’ compliance was estimated at 69.3% in non-native, low-SES areas (electronically, 52% had been measured), at 74.1% by the other 23 orthoptists, and at 73.8% in the short survey. Actions to improve compliance were diverse; some increased occlusion hours whereas others decreased them. In non-native, low-SES areas, 22% spoke Dutch moderately to none; the allotted time for a patient’s first visit was 21′; the time spent on explaining to the parents was 2’30” and to the child 10”. In practices of the other 23 orthoptists, 6% spoke Dutch moderately to none (P<0.0001), the time for a patient’s first visit was 27’24” (P=0.47), and the periods spent explaining were 2’51” (P=0.59) and 26” (P=0.17), respectively. Conclusion: Conception, awareness, attitude, and actions to deal with noncompliance varied among orthoptists. In non-native, low-SES areas, time spent on explanation was shorter, despite a lower fluency in Dutch among the parents.

Comfort of Wear and Material Properties of Eye Patches for Amblyopia Treatment and the Influence on Compliance

Background: Occlusion therapy for amblyopia has been the mainstay of treatment for centuries, however, acceptance of the patch is often lacking. This study evaluated comfort of wear of the eye patch and assessed the mechanical properties in order to achieve a more individualized prescription. Methods: For 8 consecutive days, parents used each of the four main brands of patches for 2 consecutive days in a randomized fashion. After 2 days a 21-item questionnaire was completed to evaluate comfort of wear for each patch. Compliance was measured electronically using the Occlusion Dose Monitor (ODM). In addition, breathing capacity at 23°C and 33°C, resistance to water penetration, opacity, and strength of adhesion to the skin were measured. Results: Twenty-four children participated. Overall, satisfaction was moderate: large differences in discomfort when removing the patch, skin reaction, and cosmetic appearance were found. In the material measurements large differences were found in opacity and strength of adhesion to the skin. In all brands breathing capability was minimal. Answers given by the parents matched the physical properties of the eye patch. There was no difference in electronically measured compliance between patches. Conclusions: We found large differences in comfort of wear and mechanical properties. Therefore, when prescribing a certain brand of patch, the wide variety needs to be taken into account. Further study into these properties seems warranted; especially breathing capability requires improvement since children often wear the patch for a longer period of time. This could contribute to increasing satisfaction and consequently may improve compliance.

Implementation of an Educational Cartoon (“the Patchbook”) and Other Compliance-Enhancing Measures by Orthoptists in Occlusion Treatment of Amblyopia

ABSTRACT Purpose: This implementation study evaluated orthoptists’ use of an educational cartoon (“the Patchbook”) and other measures to improve compliance with occlusion therapy for amblyopia. Methods: Participating orthoptists provided standard orthoptic care for one year, adding the Patchbook in the second year. They attended courses on compliance and intercultural communication by communication skills training. Many other compliance-enhancing measures were initiated. Orthoptists’ awareness, attitude, and activities regarding noncompliance were assessed through interviews, questionnaires, and observations. Their use of the Patchbook was measured. The study was performed in low socio-economic status (SES) areas and in other areas in the Netherlands. It was attempted to integrate education on compliance into basic and continuing orthoptic training. Results: The Patchbook was used by all 9 orthoptists who participated in low-SES areas and 17 of 23 orthoptists in other areas. Courses changed awareness and attitude about compliance, but this was not sustained. Although orthoptists estimated compliance during patching at 70%, three-quarters never suspected noncompliance during a full day of observation in any of their patients. Explanations to parents who spoke Dutch poorly were short. In the second year, explanations to children were longer. Implementation of all 7 additional compliance-enhancing measures failed. Education on compliance was not integrated into orthoptists’ training. Conclusion: Almost all orthoptists used the Patchbook and, as another study demonstrated, it proved to be very effective, especially in low-SES areas. Duration of explanation was inversely proportional to parents’ fluency in Dutch. Noncompliance was rarely suspected by orthoptists. Although 7 additional compliance-enhancing measures had been conceived and planned with the best intentions, they were not realized. These required extra, unpaid time from the orthoptists, which is especially scarce in hospitals in low-SES areas where the educational cartoon is most needed.

Concerning manuscript "Compliance and patching and atropine amblyopia treatments" by Jingyun Wang.

http://dx.doi.org/10.1016/j.visres.2015.08.002 0042-6989/ 2015 Elsevier Ltd. All rights reserved. Dear Editor, It is with interest we read the article byWang about compliance with patching and atropine therapy for amblyopia. While we appreciate the attention for the subject, the review draws several unwarranted conclusions from our studies that need correction. First of all, in the second paragraph Wang mentions that ‘‘. . .compliance in their educational cartoon story intervention group decreased less than the reference group after 1 week of the study”. However, it is not only after 1 week of the study: compliance was better throughout the entire treatment period (Loudon et al., 2006). Also, compliance in the intervention group decreased less over time and the number of children who did not patch at all, was 3 against 23 in the control group, who received standard orthoptic treatment. In a subsequent implementation study (Tjiam et al., 2012) the increase in visual acuity in LogMAR lines per unit of time was twice as fast in children who received the cartoon. Further on in the article, the author seems to suggest that the educational program used by us (Loudon et al., 2006) consisted only of reward stickers. However, the children in the intervention group received an educational cartoon story, a calendar with reward stickers and a one-page information sheet for the parents. We later showed in a randomised controlled study that the educational cartoon story was by far the most effective measure in increasing compliance, superior to the reward stickers and to the information sheet for parents (Tjiam et al., 2013). Wang assumes in the third paragraph that the formula we developed for patching duration (Loudon et al., 2006) was meant for general clinical use. However, as stated in our publication, the formula approximated the average occlusion hours that orthoptists in The Hague patched at the time. Hence, we used that to establish a uniform first-time patching prescription in our study. This was done to be able to express compliance as a percentage and to compare values. Wang concludes in paragraph §4.2.4 ‘‘One of the key elements to success in achieving good compliance was the support provided to patients by the healthcare team. Regular, frequent phone contact with patients by healthcare team members promoted compliance (Tjiam et al., 2010)”. Quite the opposite: this was one of the many measures we and the treating orthoptists planned to do, but was never done in the implementation study. That shows why implementation studies can be useful. In paragraph §5.2 ‘‘. . .other successful strategies include rewarding the child with small toys, asking the parent to invent a reward system at home, and letting the child pick the color of his or her eye patch (Tjiam et al., 2010)”. In our studies, children were never rewarded with small toys and parents were never asked to invent a reward system at home but, admittedly, there may have been children who picked the color of their eye patch. Contrary to what is mentioned in paragraph §5.5, we found low levels of compliance in patients with close family bonds and close neighbor contacts (Tjiam et al., 2011). Therefore, it is incorrect to conclude that ‘‘greater support from other society members such as teachers, neighbors, friends and classmates, are associated with better compliance”. Minor issues include that the ODM used in the studies by Simonsz and Fronius does not measure temperature difference ‘‘at the border of the patch”, but at its center. And the referred ‘‘UK study” (Loudon et al., 2009) was not a UK study, but a study in The Hague, The Netherlands. Summarizing, the educational cartoon was the only very effective measure in all of our studies. The cartoon story depicts, without words, the subjective experience of seeing blurred with one eye, the orthoptic examination, the patching therapy and then seeing sharply again, all seen from the perspective of the child.