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.