Michael X. Repka, M.D., Presents the 2020 Jackson Memorial Lecture

Michael Repka, the David L. Guyton, M.D., and Feduniak Family Professor of Ophthalmology at Wilmer Eye Institute, will present the 77th Jackson Memorial Lecture during this year’s annual meeting of the American Academy of Ophthalmology.

The Jackson Memorial Lecture honors the memory of L. Edward Jackson, whose many contributions to the field include the development and assessment of formal postgraduate medical education. Jackson led the group that formed the American Board for Ophthalmic Examinations, which became the American Board of Ophthalmology, the first medical specialty board in the U.S. He also is credited with promoting retinoscopy, a clinical skill crucial to management of amblyopia.

With this year’s lecture, Repka joins an impressive list of Wilmer alumni who have presented during the lecture’s 76-year history, including Stuart Fine, Jonas Friedenwald, Morton Goldberg, Douglas Jabs, A. Edward Maumenee, Neil Miller, Arnall Patz, Harry Quigley, Al Sommer and Alan Woods. Repka is internationally recognized for his contributions in the fields of pediatric ophthalmology, strabismus, retinopathy of prematurity and pediatric neuro-ophthalmology. His talk is titled “Amblyopia Outcomes Through Clinical Trials and Practice Measurement: Room for Improvement.”

We spoke with Repka about the problem of amblyopia and the ongoing struggle to provide effective screening for this highly treatable condition.

What is amblyopia?

Amblyopia, or lazy eye, is a problem that stems from dysfunction of visual processing in the brain. For a child, or an adult who grows up with amblyopia, the most common deficit is in high-contrast visual acuity. In the affected eye or eyes, they don’t see as well as we’d like them to. In children, amblyopia affects about 2.5% of the population.

People with amblyopia also have other more subtle visual problems. Research suggests, for example, that they seem to have a reduction in how fast they read and how well they detect motion, as well as impaired depth perception. Reduced self-perception of ability has been reported. For some people, amblyopia probably has a minimal effect on their life, whereas in others, it has a major effect.

The impact on quality of life also depends on whether or not the child has eye muscle issues, a condition known as strabismus. Often referred to as crossed eyes, strabismus is actually a misalignment of the eyes in which one eye deviates inward toward the nose or outward, while the other eye remains focused. Uncorrected, strabismus can compound the problem of amblyopia.

How is amblyopia detected?

Detection usually requires medical screening in the home, preschool or school. Ideally, we’d like to identify an affected child while of preschool age, because that’s when treatment is most effective. Vision screening measures include assessment of visual acuity, assessment for strabismus, and assessments or screenings by machine for the presence of risk factors. The most important risk factor is unusual refractive error.

What does treatment involve?

The most important treatment is to get the patient into eyeglasses to correct any refractive error deficits they have, which may also help children who have eye alignment issues. If they don’t get better — although many improve significantly with glasses alone — then you would use either eye drops with atropine or patching to make the child use the less preferred eye. Atropine basically makes it hard for the child to focus with the good eye at near, which stimulates the brain to use the poorer-seeing eye for near vision.

What impediments are there to treatment?

The first challenge is diagnosis or detection. We need to have preschools and pediatricians effectively screening children to make sure they don’t have the risk factors. At school age, that means testing visual acuity to make sure the vision is satisfactory, which has a secondary gain of ensuring they have glasses to see the boards in school. Another possible impediment involves whether they’re able to get glasses, and then, can we put the glasses on the child and keep them there. Of course, it’s also important to keep the glasses updated going forward.

Have we learned anything new about amblyopia or the treatment of it?

The new data I’m presenting in the lecture are from the IRIS Registry, a large clinical database that includes 1.7 million individuals with amblyopia. We can look at their outcomes and see that with regular clinical care, there is improvement in the children’s visual acuity from the time they come into the registry data set to when they’ve done follow-up for at least a couple years.

I also took a clinical data registry outcome measure based on a conceptual outcome measure, created by ophthalmologists and approved by the Centers for Medicare and Medicaid Services, to assess quality of care. It shows that amblyopia treatment in general was successful — by the measure definition — 77% of the time. We were able to see that the outcome for boys and girls was identical. However, the success rate was much lower in African American and Hispanic children compared with white children. An analysis of that discrepancy is underway.

Another thing we’ve learned over the last 20 years, which our IRIS data affirmed, is that there’s a good chance of successfully treating children who are 8–12 years of age. When I was a resident, there was the tendency to say if the condition was detected after age 8, there was no chance of success. In fact, we can get success rates of 50% or 55% in children 8–12 years old, so we know there’s something more that we can do for this group.

What can be done to further improve outcomes?

Some of the novel treatments with binocular therapy under study today, or more long-term pharmacological work with reopening the critical period for vision development, might be game-changers. In addition, more attention to racial and possible socioeconomic disparities could help. This may require dealing with access-to-care issues, or it may be about how we as a society pay for children’s glasses, because often there’s no insurance coverage until a problem is detected. It could be about how we do screening and early detection.

I think commercial and governmental insurance support of preschool screenings would be a great addition — and of course, support for pediatricians and pediatric health clinics, which do the lion’s share of these screenings today.

These are all areas in which we can possibly have some impact on closing the gaps. I should say, however, that I don’t know if the gap is closable. It’s possible that once you’ve had the insult to the brain for any period of time, you can’t ever recover completely from this damage. A future focus, then, might be on determining how to turn the brain back on to be receptive to improvement at an age when we’re not finding complete improvement with conventional therapy.

Michael X. Repka, M.D., is the David L. Guyton, M.D., and Feduniak Family Professor of Ophthalmology and the Vice Chair for Clinical Practice at Wilmer Eye Institute. He is also the American Academy of Ophthalmology's medical director for governmental affairs and the ophthalmology advisor, CPT Advisory Committee for the American Medical Association. “Amblyopia Outcomes Through Clinical Trials and Practice Measurement: Room for Improvement: The LXXVII Edward Jackson Memorial Lecture” was published in the American Journal of Ophthalmology. https://www.sciencedirect.com/science/article/pii/S0002939420304190