Justin Williams, 6, is a healthy, energetic boy who likes to watch cartoons, ride his bike, play on the computer and horse around with his two brothers, ages 8 and 15 months. But the treatment he receives for an eye condition keeps him from enjoying these activities – or much of anything – up to eight hours a day.

In fact, he recently was in the car with his folks when his dad suddenly hit the brake, apparently – to Justin, anyway – for no reason. His mom, Jessica Williams, of Kalispell, Mt., recalls Justin shouting from the back seat, "What are you waiting for, Dad? Go!" "When I told him there were tons of cars in front of us, he shrugged his shoulders and said, 'I don't see any cars,'" says Williams.

Justin was diagnosed with amblyopia, or "lazy eye," the most common cause of visual impairment in childhood, according to the National Eye Institute, an arm of the U.S. Department of Health and Human Services' National Institutes of Health.

Up to 5 percent – five out of 100 – of American babies and young children develop lazy eye. "[It] is a condition of poor vision in an otherwise healthy eye because the brain has learned to favor the other eye" due to crossed or wandering eyes or those with severe nearsightedness or farsightedness, the NEI reports. If left untreated, amblyopia can result in vision loss in the "lazy" eye. But it can be treated, often very successfully. The key lies in early detection and consistent treatment.

Diagnosing Lazy Eye
There was no indication prior to his first, yet routine, eye exam that Justin had any vision problems. His mother says he performed just fine in school, as well as on the playground.

At his exam, the doctor covered his right eye and asked Justin to recite lines of letters off an eye chart with his left eye. "We were all amazed at what happened [next]," says Williams. "Justin got a little shy and kept repeating, 'I don't know,' over and over." He couldn't even make out the largest letter on the chart.

Initially, Williams thought her middle son was kidding around, but soon realized there was a problem. "When we asked Justin about his eye, he said, 'Oh yeah – that's my fuzzy eye,'" she says. Apparently, her son never thought to question its lack of clarity.

The doctor diagnosed Justin with amblyopia (pronounced am-BLEE-opia) and farsightedness in his left eye. At 20/400, his left eye is legally blind. He now wears glasses to help correct the astigmatism that caused the amblyopia, but until the eye strengthens, he still only sees about 20/200 with the corrective lenses.

In infants and young kids with lazy eye, the eyeball and the optic nerve are completely normal, says Dr. Janet Neigel, F.A.C.S., a clinical associate professor of ophthalmology at the University of Medicine and Dentistry of New Jersey in Newark, N.J., and an orbitalfacial surgeon at the Neigel Center for Cosmetic and Laser Surgery in West Orange, N.J. The problem lies in the pathways between the nerve and the eye, affecting a person's ability to see images clearly, explains Dr. Neigel.

Treatment Options: Patching
Justin's doctor called for the most common first step in treating amblyopia: patching the good eye for many hours a day to force the brain to adjust to using – and, hopefully, improving – the fuzzy eye's ability to see.

Neigel says most ophthalmologists will recommend patching the good eye for about a third of the day. This treatment cannot be done, say, 24 hours a day, because "that would induce amblyopia in the other eye." In fact, shortly after the patch is removed from the good eye, it often registers the outside world blurry; the brain has to readjust to using both eyes.

Though patching is a very successful way to treat lazy eye, children are loathe to comply with doctors' orders, especially if they're in school. The kids risk being teased and dealing with peers who want to take off the patch. Not to mention active kids have to completely curb their busy lifestyle while wearing a patch. "While patched, he is not allowed to ride a bike, play on a playground or do anything that could be dangerous for a blind person," says Williams. That's a tall order for a first-grade boy.

But patching candidates can take heart: A study in the May 2003 Archives of Ophthalmology reports that patching kids for two hours a day seems to be as effective, if not more so, as patching them for six hours a day. "Now, children can look forward to attending school without the patch," says Dr. Paul A. Sieving, M.D., Ph.D., director of the NEI, in a press release following the study's publication. The NEI is one of the agencies that sponsored the study. He adds, "This will make them feel better about themselves" and, by extension, more willing to wear the patch and improve their vision.

One factor complicating Justin's situation is his age. The older a child gets, the more permanent his visual pathways become. Though debate remains on this subject, it's generally believed that after 7 years of age, one sees little to no improvement. And age 9 is considered the "outside" of treatable children, according to Neigel.

Williams feels harried and frustrated, having found out Justin's condition as a 6-year-old on the verge of turning 7. So Justin's lazy eye is being aggressively treated. Other, more drastic, options do exist for kids with amblyopia, but they may prove unnecessary and too extreme for children like Justin.

Dr. Michael Repka, professor of ophthalmology and pediatrics at the Wilmer Eye Institute of Johns Hopkins University School of Medicine in Baltimore and chair of the NEI study, encourages Justin to continue to wear the patch and to avoid further measures at this point. "We have no data to suggest he cannot get better at this age, and I would urge them to try to treat (with the patch)," Dr. Repka says of Justin's family.

Dr. Neigel points out that amblyopia is strictly a childhood problem. Adults who must be patched for medical reasons, including a disease of the thyroid that causes double vision, will not develop lazy eye.

More Treatment Options: Atropine Drops, Vision Therapy, LASIK
But Williams and her husband, Brian, aren't so sure that patching is their only option. They're confused about viable treatments and concerned for Justin's long-term ability to see clearly out of both eyes. "We feel so lost," she says. They sought a second opinion, but it jibed with the first.

Williams has been looking into a practice called Vision Therapy whose practitioners believe a child of any age can beat amblyopia (and other vision problems, including those not solely seen in children). As defined by the American Optometric Association (AOA), vision therapy is individualized to each patient and uses equipment, such as lenses, prisms and filters, ultimately to improve a patient's sight and quality of life.

Though in use for a number of years now, vision therapy is a somewhat controversial practice, according to experts like Dr. Jonathan Song, director of Children's Hospital Los Angeles' Cornea and Refractive Surgery Center and assistant professor of ophthalmology at the University of Southern California. "There is no good study that proves that it works, just anecdotal evidence," he says. "In addition, it is quite expensive. For these reasons I do not recommend it to my patients." But, Dr. Song adds, "If the patient seeks it out I do not discourage (him); I usually tell them it might not help, but will not hurt."

Another treatment sometimes prescribed is atropine drops. These are put into a child's good eye. They dilate the pupil, causing blurred vision. The idea is to relegate the brain to using only the "lazy" eye and trying to focus it. But this method, too, is controversial, as the drops can last up to three days, and it's uncertain the long-term effects on the good eye, says Dr. Neigel.

And surgical procedures, such as LASIK and others performed to treat a crossed or wandering eye, are considered either a tad experimental or only for use in extreme cases. (Dr. Neigel notes that surgery is not used to correct ambloypia; it's used to correct problems that could be occurring in conjunction with lazy eye.)

Meanwhile, the prospect for the vast majority of children with amblyopia is quite good. Roughly only five of 10,000 kids who stick to "conventional treatment" suffer lifelong visual impairment, according to a recent report by Dr. Jonathan M. Davidorf, medical director of Davidorf Eye Group and assistant clinical professor at UCLA's Jules Stein Eye Institute.

What You Can Do
As with so many things in kids' lives, early intervention is paramount. And if there is a problem, frequent and consistent follow up is a must. Dr. Neigel recommends children with no family history of childhood eye problems and with no obvious visual impairment (such as eyes that don't align properly) get their first exam by a pediatric ophthalmologist prior to school age.

Though screening tests are done before entrance into kindergarten or the first grade, it may be a good idea to have your child examined even as young as 3 years of age. The AOA goes a step further, recommending comprehensive eye exams in 6-month-old infants. It says only 14 percent of kids under age 5 have received such exams.

The organization also lists behaviors parents should watch for that could indicate a vision problem. Chief among them, in infants to preschool-age kids, are:

• Avoidance of detailed activities like coloring or doing puzzles;
• Bumping into objects and being unable to judge distances;
• And tilting the head or closing an eye.

"If you think anything doesn't look right, take them in to make sure," says Dr. Neigel. "You don't want to miss anything. The earlier it's caught, the easier it is to treat."

Want to see more?

• Do You See What I See? Diagnosing Vision Problems in Toddlers
• Four Eyes Can Be Fabulous
• Could Your Child Need Glasses?
• Seeing Clearly: Kids and LASIK
• Talk about it!