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American Academy of Ophthalmology (section 6) 2002-2003

Design by Shafei Rahimi (Medical Student)

rahimi@doctor.com
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 Unilateral
Unilateral or or less
less commonly,
commonly, bilateral
bilateral
reduction
reduction ofof best
best corrected
corrected visual
visual acuity
acuity that
that
can
can not
not be
be attributed
attributed directly
directly to
to the
the effect
effect of
of
any
any structural
structural abnormality
abnormality of of the
the eye
eye or
or the
the
posterior
posterior visual
visual pathway.
pathway. Defect
Defect of
of central
central
vision
vision

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 Resulting from one of following:

A.
A. Strabismus
Strabismus
B.
B. Anisometropia
Anisometropia or or high
high bilateral
bilateral refractive
refractive
error
error (Isoametropia)
(Isoametropia)
C.
C. Visual
Visual deprivation
deprivation

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 Prevalence:
Prevalence: 2%-4%
2%-4% in in the
the North
North American
American
population
population
 Commonly
Commonly unilateral
unilateral
 Nearly
Nearly allall amblyopic
amblyopic visualvisual loss
loss isis
preventable
preventable or or reversible
reversible withwith timely
timely
detection
detection and
and appropriate
appropriate intervention.
intervention.
 Children
Children with
with amblyopia
amblyopia or or atat risk
risk for
for
amblyopia
amblyopia should
should be be identified
identified at
at aa young
young
age
age when
when the the prognosis
prognosis for for successful
successful
treatment
treatment is
is best.
best.
 Role
Role of
of screening
screening is is important
important
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 Amblyopia
Amblyopia is is primarily
primarily aa defect
defect of
of central
central
vision.
vision.
 There
There isis aa critical
critical period
period for
for sensitivity
sensitivity in
in
developing
developing amblyopia.
amblyopia.
 The
The time
time necessary
necessary for for amblyopia
amblyopia toto occur
occur
during
during critical
critical period
period is
is shorter
shorter for
for stimulus
stimulus
deprivation
deprivation than than for for strabismus
strabismus or or
anisometropia.
anisometropia.

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Neurophysiology:


 Cells
Cells of
of the
the primary
primary visual
visual cortex
cortex can
can completely
completely
lose
lose their
their innate
innate ability
ability or
or show
show significant
significant
functional
functional deficiencies
deficiencies


 Abnormalities
Abnormalities also
also occur
occur in
in neurons
neurons in
in the
the lateral
lateral
geniculate
geniculate body
body


 Evidence
Evidence concerning
concerning involvement
involvement at
at the
the retinal
retinal level
level
remains
remains inconclusive
inconclusive

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Classification:

1.
1. Strabismus
Strabismus Amblyopia
Amblyopia
2.
2. Anisometropia
Anisometropia Amblyopia
Amblyopia
3.
3. Amblyopia
Amblyopia Due
Due to
to bilateral
bilateral high
high refractive
refractive
error
error (isometropia)
(isometropia)
4.
4. Deprivation
Deprivation Amblyopia
Amblyopia

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Strabismus Amblyopia
 The
The most
most common
common formform ofof amblyopia
amblyopia
 Strabismic
Strabismic amblyopia
amblyopia is is thought
thought toto result
result
from
from competitive
competitive or or inhibitory
inhibitory interaction
interaction
between
between neurons
neurons carrying
carrying thethe nonfusible
nonfusible
inputs
inputs from
from the
the tow
tow eye.
eye.
 Which
Which leads
leads to
to domination
domination of of cortical
cortical vision
vision
centers
centers by
by the
the fixating
fixating eye
eye and
and chronically
chronically
reduced
reduced responsiveness
responsiveness to to the
the nonfixating
nonfixating
eye
eye input.
input.

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Anisometropia Amblyopia


 Second
Second inin frequency
frequency

 It
It develops
develops when
when unequal
unequal refractive
refractive error
error in
in the
the tow
tow
eyes
eyes causes
causes the the image
image onon the
the one
one retina
retina to
to be
be
chronically
chronically defocused.
defocused.

 This
This condition
condition isis thought
thought to
to result:
result:

 Partly
Partly from
from the
the direct
direct effect
effect of
of image
image blur
blur in
in the
the
development
development of of visual
visual acuity.
acuity.

 Partly
Partly from
from intraocular
intraocular competition
competition oror inhibition
inhibition

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 Mild
Mild hyperopic
hyperopic oror astigmatic
astigmatic anisometropia
anisometropia
(1-2D) 
(1-2D)  mild
mild amblyopia
amblyopia
 Mild
Mild myopia
myopia anisometropia
anisometropia (less
(less than
than -3D)
-3D)
usually
usually doesn't
doesn't cause
cause amblyopia
amblyopia
 unilateral
unilateral high
high myopia (-6D) 
myopia (-6D)  sever
sever
amblyopia
amblyopia visual
visual loss.
loss.
 The
The eye
eye ss of
of aa child
child with
with anisometropic
anisometropic
amblyopia
amblyopia look
look normaly
normaly toto the
the family
family and
and
primary
primary care
care physician.
physician.

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 Amblyopia Due to bilateral high
refractive error (isometropia)
 isometropia
isometropia amblyopia
amblyopia result
result from
from large,
large,
approximately
approximately equal,
equal, uncorrected
uncorrected refractive
refractive
error
error in
in both
both eyes
eyes of
of aa young
young child.
child.
 Hyperopia
Hyperopia exceeding
exceeding 5D5D && myopia
myopia excess
excess of
of
10 D
10 D risk
 risk  bilateral
bilateral amblyopia
amblyopia

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 Merdional
Merdional amblyopia:
amblyopia:
 Uncorrected
Uncorrected bilateral
bilateral astigmatism
astigmatism in
in early
early
childhood
childhood may
may result
result in
in loss
loss of
of resoling
resoling
ability
ability limited
limited to to chronically
chronically blurred
blurred
meridians.
meridians.

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Deprivation Amblyopia

 It
It is
is usually
usually caused
caused by
by congenital
congenital or or early
early
acquired
acquired media
media opacity.
opacity.
 This
This form
form of
of amblyopia
amblyopia isis the
the least
least common
common
but
but most
most damaging
damaging and
and difficult
difficult to
to treat.
treat.
 In
In bilateral
bilateral cases
cases acuity
acuity can
can bebe 20/200
20/200 oror
worse.
worse.

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 In
In children
children younger
younger than
than 66 years,
years, dons
dons
congenital
congenital cataract
cataract that
that occupy
occupy the
the central
central 33
mm.
mm. or
or more
more ofof the
the lens
lens must
must be
be considered
considered
capable
capable of
of causing
causing sever
sever amblyopia
amblyopia..
 Similar
Similar lens
lens opacities
opacities acquired
acquired after
after 66 years
years
are
are generally
generally less
less harmful.
harmful.

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 Small
Small polar
polar cataracts
cataracts && lamellar
lamellar cataracts
cataracts
may
may cause
cause mild
mild to
to moderate
moderate amblyopia
amblyopia or
or
may
may have
have no
no effect
effect on
on visual
visual development.
development.

 Occlusion
Occlusion amblyopia
amblyopia is
is aa form
form of
of deprivation
deprivation
caused
caused by
by excessive
excessive therapeutic
therapeutic patching.
patching.

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Diagnosis
 Characteristics
Characteristics of of vision
vision alone
alone cannot
cannot be
be
used
used to
to reliably
reliably differentiated
differentiated amblyopia
amblyopia from
from
other
other form
form of
of visual
visual loss.
loss.
 The
The crowding
crowding phenomenon
phenomenon is is typical
typical for
for
amblyopia
amblyopia butbut not
not uniformly
uniformly demonstrable.
demonstrable.
 Afferent
Afferent pupillary
pupillary defect
defect are
are Characteristic
Characteristic ofof
optic
optic nerve
nerve disease
disease but
but occasiinally
occasiinally appear
appear to
to
be
be present
present with
with amblyopia
amblyopia

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 Multiple
Multiple assessment
assessment using
using aa variety
variety of
of tests
tests or
or
performed
performed on on different
different occasions
occasions are are
sometime
sometime required
required to
to make
make aa final
final judgment
judgment
concerning
concerning the
the presence
presence and and severity
severity ofof
amblyopia.
amblyopia.

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 Binocular
Binocular fixation
fixation pattern:
pattern:
 It
It is
is aa test
test for
for estimating
estimating the
the relative
relative level
level of
of
vision
vision in in the
the tow
tow eyes
eyes for
for children
children with
with
strabismus
strabismus who who are
are under
under the
the age
age of
of about
about 3.3.
 This
This test
test isis quite
quite sensitive
sensitive for
for detecting
detecting
amblyopia
amblyopia but but results
results can
can be
be falsely
falsely positive.
positive.
 Showing
Showing aa strong
strong preference
preference when
when sision
sision is
is
equal
equal or or nearly
nearly equal
equal in in the
the tow
tow eyes,
eyes,
particularly
particularly with with small
small angle
angle strabismic
strabismic
deviations.
deviations.

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 The
The modified
modified Snellen
Snellen technique
technique directly
directly
measures
measures acuity
acuity in
in children
children 3-6
3-6 years
years old.
old.
 Often,
Often, however,
however, only
only isolated
isolated letters
letters can
can be
be
used,
used, which
which may
may lead
lead toto under
under estimated
estimated
amblyopia
amblyopia visual
visual loss.
loss.
 Croding
Croding bar
bar may
may help
help alleviate
alleviate this
this problem.
problem.

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 E O

 Crowding
Crowding bar,
bar, or
or contour
contour interaction
interaction bars,
bars, allow
allow the
the
examinator
examinator toto test
test the
the crowing
crowing phenomenon
phenomenon withwith
isolated
isolated optotype.
optotype. Bar Bar surrounding
surrounding the the optotype
optotype
mimic
mimic the
the full
full of
of optotype
optotype to
to the
the amblyopia
amblyopia child.
child.

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Treatment

 Treatment
Treatment ofof amblyopia
amblyopia involves
involves the
the
following
following steps:
steps:
 Eliminating
Eliminating (if(if possible)
possible) any
any obstacle
obstacle to
to
vision
vision such
such asas aa cataract
cataract
 Correcting
Correcting refractive
refractive error
error
 Forcing
Forcing use
use ofof the
the poorer
poorer eye
eye by
by limiting
limiting use
use
of
of the
the better
better eye.
eye.

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Cataract removal

 Cataracts
Cataracts capable
capable of of producing
producing amblyopia
amblyopia require
require
surgery
surgery without
without unnecessary
unnecessary delay.
delay.

 Removal
Removal of of significant
significant congenital
congenital lens lens opacities
opacities
during
during the
the first
first 2-3
2-3 months
months of of life
life is
is necessary
necessary for
for
optimal
optimal recovery
recovery of of vision.
vision.

 In
In symmetrical
symmetrical bilateral
bilateral cases,
cases, thethe interval
interval between
between
operations
operations on on the
the first
first and
and second
second eyeseyes should
should be
be no
no
more
more than
than 1-21-2 weeks.
weeks.

 Acutely
Acutely developing
developing severe
severe traumatic
traumatic cataracts
cataracts inin
children
children younger
younger thanthan 66 years
years should
should be be removed
removed
within
within aa few
few weeks
weeks of of injury,
injury, ifif possible.
possible.
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Refractive correction

 In
In generally,
generally, optical
optical prescription
prescription for
for
amblyopic
amblyopic eyes
eyes should
should correct
correct the
the full
full
refractive
refractive error
error asas determined
determined withwith
cyclopagic.
cyclopagic.

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Occlusion and optical degradation

 Full
Full time
time occlusion
occlusion of of the
the sound
sound eye:
eye:

 Defined
Defined asas occlusion
occlusion forfor all
all or
or all
all but
but one
one waking
waking
hour.
hour.

 It
It is
is the
the most
most powerful
powerful means
means of of treating
treating ofof
amblyopia
amblyopia byby enforced
enforced use
use of
of the
the defective
defective eye.
eye.

 The
The patch
patch can
can either
either be
be left
left in
in place
place at
at night
night or
or
removed
removed atat bedtime.
bedtime.

 Spectacle-mounted
Spectacle-mounted occluser
occluser or or special
special opaque
opaque
contact
contact lenses
lenses can
can be
be used
used asas an
an alternative
alternative to
to full-
full-
time
time patching
patching ifif skin
skin irritation
irritation or or poor
poor adhesion
adhesion
proves
proves to
to be
be aa significant
significant problem
problem

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 Full
Full time
time patching
patching should
should generally
generally be
be used
used
only
only when
when constant
constant strabismus
strabismus eliminates
eliminates any
any
possibility
possibility of
of useful
useful binocular
binocular vision
vision because
because

 full
full time
time patching
patching runs
runs aa small
small risk
risk of
of
perturbing
perturbing binocularity.
binocularity.

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 Part-time occlusion:
 Defined
Defined as
as occlusion
occlusion for
for 1-6
1-6 hours
hours per
per day.
day.
 The
The children
children undergoing
undergoing partpart time
time occlusion
occlusion
should
should be
be kept
kept as
as visually
visually active
active as
as possible
possible
when
when the
the patch
patch is
is in
in place.
place.
 Compliance
Compliance withwith occlusion
occlusion therapy
therapy forfor
amblyopia
amblyopia declines
declines with
with increasing
increasing age.
age.

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 Penalization:
 A
A cyclopagic
cyclopagic agent
agent (usually
(usually atropine
atropine 1%1% oror
homatropine
homatropine 5%5% )) once
once daily
daily to
to the
the better
better
eye
eye
 This
This form
form ofof treatment
treatment has
has recently
recently been
been
demonstrated
demonstrated toto be
be as
as effective
effective asas patching
patching
for
for mild
mild to
to moderate
moderate amblyopia.
amblyopia.

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Complication of therapy

 Full
Full time
time occlusion
occlusion carries
carries thethe greatest
greatest risk
risk of
of this
this
complication
complication and and requires
requires close close monitoring,
monitoring,
especially
especially inin the
the younger
younger child.
child.

 The
The first
first follow
follow up up visit
visit after
after initial
initial treatment
treatment
should
should occur
occur within
within 11 week
week for for an
an infant
infant and
and after
after
interval
interval corresponding
corresponding to to 11 week
week per
per year
year ofof age
age for
for
the
the older
older child.
child.

 Part
Part time
time occlusion
occlusion & & optical
optical degradation
degradation methods
methods
allow
allow forfor less
less frequent
frequent observation
observation but but regular
regular
follow
follow upup is
is still
still critical
critical

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 The
The time
time required
required for
for completion
completion of
of
treatment
treatment depends
depends on
on the
the following:
following:
1.
1. Degree
Degree of of amblyopia
amblyopia
2.
2. Choice
Choice ofof therapeutic
therapeutic approach
approach
3.
3. Compliance
Compliance withwith the
the prescribed
prescribed regimen
regimen
4.
4. age
age of
of the
the patient
patient

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Unresponsiveness

 Complete
Complete or or partial
partial Unresponsiveness
Unresponsiveness to to treatment
treatment
occasionally
occasionally affect
affect younger
younger children
children but
but must
must often
often
occurs
occurs inin patients
patients older
older than
than 55 years.
years.

 Primary
Primary therapy
therapy should
should generally
generally be
be terminated
terminated ifif
there
there is
is aa lock
lock of
of demonstrable
demonstrable progress
progress over
over 3-6
3-6
months
months with
with good
good compliance.
compliance.

 Refraction
Refraction should
should be
be carefully
carefully rechecked
rechecked and and the
the
macula
macula and and optic
optic nerve
nerve critically
critically inspected
inspected forfor
subtle
subtle evidence
evidence ofof hypoplasia
hypoplasia oror other
other malformation
malformation
that
that might
might have
have been
been previously
previously overlooked.
overlooked.

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 Recurrence

 When
When amblyopia
amblyopia treatment
treatment is
is discontinued
discontinued after
after fully
fully
or
or partially
partially successful
successful completion,
completion, approximately
approximately halfhalf
of
of patients
patients show
show some
some dgree
dgree of
of recurrence,
recurrence,

 Maintenance
Maintenance therapy:
therapy:

 Patching
Patching for
for 1-3
1-3 hours
hours per
per day
day

 Optical
Optical penalization
penalization with
with spectacles
spectacles

 Pharmacologic
Pharmacologic penalization
penalization with
with atropine
atropine 11 or
or 22 day
day
per
per week.
week.

 This
This may
may require
require periodic
periodic monitoring
monitoring until
until age
age 8-10.
8-10.

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