Patient selection and follow-up in dichoptic treatment: a practical frame

This article offers a practical frame for positioning dichoptic approaches in clinical practice. It is not a protocol; the decision always rests with the treating clinician and varies by patient.

Cycloplegic refraction and full optical correction are the precondition of any plan. Active treatment started without correction does not allow the outcome to be interpreted properly.

Refractive adaptation is the phase observed with spectacles alone, where meaningful acuity gains are expected. A proportion of cases achieve substantial improvement without further treatment, so skipping this phase is not advised.

Type and depth of amblyopia: anisometropic, strabismic or mixed; the interocular acuity difference.

Binocular status: presence and depth of suppression, fusional capacity, level of stereopsis. This triad defines the target area of a binocular approach.

Alignment: presence and size of manifest deviation; with a significant deviation, the practicability of dichoptic presentation warrants separate consideration.

Age and adherence history: if patching was tried before, how much was actually completed and why treatment lapsed.

Cases with clear adherence problems: if patching cannot in practice be delivered, no outcome follows regardless of the biological rationale. Deliverability here is directly a question of efficacy.

Cases where stereopsis is an explicit goal: monocular treatment does not exercise binocular function directly, so a binocular component is needed if stereo gain is the aim.

Cases plateaued on patching: where acuity gains have stalled while binocular function lags, broadening the target becomes relevant.

Cases where patching cannot be sustained for skin reactions or social reasons.

Visual acuity: each eye separately, under standard conditions.

Suppression: change in its depth, often an early indicator that can respond before acuity does.

Stereopsis: the most direct measure of progress toward the binocular target.

Adherence data: the proportion of sessions actually completed. Self-reported figures can overstate real use, so objective tracking is preferable where available.

If measures have not shifted within the expected window, question adherence first: before changing the method, establish whether the method was actually delivered.

Where adherence is adequate and response is absent, consider adjusting intensity, contrast settings or the method itself; combination approaches are also an option.

Once gains are achieved, tapering with a maintenance plan is preferable to abrupt cessation, and monitoring continues given the risk of regression.