Amblyopia

Abdul Fahma Firmana

I11109026

Amblyopia
The Physician sees nothing
and the Patient very little

Amblyopia
Amblyopia, by definition, refers to a partial loss
of vision in one or both eyes, in the absence of
any organic disease of ocular media, retina and
visual pathway.
Most Common Know as the Lazy-Eye.
Can exist bilaterally but is usually unilateral.

Amblyopia
Most common cause of monocular vision loss in
children.
Prevalence is between 0.2 and 5.5%
Approximately 5% in Newfoundland.

Pathogenesis
Amblyopia is produced by certain amblyogeneic
factors operating during the critical period of
visual development (birth to 6 years of age). The
most sensitive period for development of
amblyopia is first six months of life and it usually
does not develop after the age of 6 years.

Amblyogenic factors include :

Visual (form sense) deprivation as occurs in
anisometropia,
Light deprivation e.g., due to congenital cataract,
Abnormal binocular interaction e.g., in
strabismus.

Types of Amblyopia
Caused by vision disorders that disrupt
normal visual experiences during the critical
period.
There are four types of amblyopia.
Classified by the cause of amblyopia

Types of Amblyopia
1. Strabismic
Amblyopia: caused by
strabismus.
The most common form
of amblyopia.
A misalignment of the
eyes.
Esotropia: One or both
eyes are misaligned in
the inward position.
Exotropia: One or both
eye are misaligned in the
outward direction.

2. Stimulus deprivation amblyopia

Develops when one eye is totally excluded from
seeing early in life as, in congenital or traumatic
cataract, complete ptosis and dense central
corneal opacity.

Types of Amblyopia
Image Deprivation Amblyopia:
caused by an optical
obstruction that prevents the
formation of a sharp, clear
image in one eye.
Cataracts and Ptosis

3. Anisometropic amblyopia
occurs in an eye having higher degree of refractive
error than the fellow eye. It is more common in
anisohypermetropic than the anisomyopic
children. Even 1-2D hypermetropic
anisometropia may cause amblyopia while upto
3D myopic anisometropia usually does not cause
amblyopia.

Anisometropic Amblyopia
The misaligned eye receives a completely
different image.
Can lead to diplopia.
Anisometropic Amblyopia: Caused by
anisometropia.
Anisometropia: Unequal refractive error
between the eyes.
Have a strong eye and a weak eye.
Usually refers to a difference of 1.0 to 1.5 D.

4. Isometropic amblyopia
The kind of bilateral amblyopia occurring in
children with bilateral uncorrected high refractive
error.

Types of Amblyopia
In each case, the image from the affected eye
(weaker or misaligned) eye is suppressed.
Cortical connections from the affected eye
regress.
The suppression becomes permanent.
There is a reduction in the number of binocular
cortical cells.
Leads to a lack of stereopsis or poor stereoacuity.
Also leads to reduced visual acuity and contrast
sensitivity.

Amblyopia
Amblyopia is caused by the existence and
persistence of a monocular visual problem
during the period of plasticity.
This affected eye is placed at a disadvantage in
the formation and preservation of neural
connections to the visual cortex.
The anatomical/physiological result is that few
cells in the visual cortex will be driven by the
amblyopic eye.

 Furthermore, few cells will be binocular.

The visual effects are reduced visual acuity,
contrast sensitivity, vernier acuity, and
stereopsis/stereoacuity.
Because the effects are cortical in nature,
these problems will persist even when the
amblyogenic factor is treated.

Vision for Someone with Amblyopia

Examination for Amblyopia

Acuity testing- age appropriate (Crowding
Phenomena test)
Tests of stereopsis and binocular function (ex.
Worth 4 dot testing)
External examination (looking for ptosis, lid
hemangioma or other lesion which could affect
visual development)
Anterior segment examination (looking for any
media opacity, or irregularity)

Treatment of Amblyopia
The first step of treatment is to correct the
amblyogenic factors.
Treatment of amblyopia should be started as
early as possible (younger the child, better the
prognosis).

Treatment of Amblyopia
Strabismic amblyopia
The strabismus is treated first.
This can be treated by eye muscle surgery.
Some patients have accommodative esotropia
due to high hyperopia.

Treatment of Amblyopia
They are so severely hyperopic that their lenses
must accommodate to see relatively distant
objects.
There is a relationship between how much we
accommodate and how much the eyes converge.
Patients with accommodative esotropia
accommodate so much that their eyes overconverge.

Treatment of Amblyopia
The patient attempts to fixate
the x.
Because he/she is excessively
hyperopic, each lens must
accommodate to see the object.
Because of the relationship
between accommodation and
convergence, the eyes will
converge.
Based on the amount of
accommodation, the eyes will
over-converge.

Treatment of Amblyopia
Accommodative esotropia is treated with glasses

Treatment of Amblyopia
Anisometropic amblyopia
Corrected with glasses.
Image Degradation amblyopia
Cataracts are removed by removing the lens.
An intraocular lens (IOL) can be implanted.

Treatment of Amblyopia
Severe ptosis can be treated surgically.

Treatment of Amblyopia

In some cases the amblyopia will resolve in

response to spectacle correction alone.
In more severe cases however, subjects must
undergo occlusion therapy.
The unaffected eye is patched to force the use of
the previously deprived eye.

Treatment of Amblyopia
This should allow cortical connections to be reestablished leading to improvements in spatial
vision.
Young children are averse to patching.
Thus, children and parents are often not compliant.
This makes it difficult for children to show visual
improvement and for researchers to determine how
effective patching is.

Treatment of Amblyopia
Full-time occlusion does not allow the formation
of binocular cells.
Patient is patched during most of the waking hours.
As a result, good stereoacuity is unlikely.

A better option may be part-time occlusion.

Eg. The patient is patched two hours per day.
This may allow for stereopsis.
Patching can be done at home.

Patching for the treatment of Amblyopia

Patching: training the brain
to use the eye that has
weaker vision. This allows
vision to develop normally
in that eye.

Treatment of Amblyopia
Another type of treatment is penalization.
The unaffected eye is treated with a
pharmacologic agent such as atropine.
Prevents accommodation.
A sharp image can not be formed on the retina.

However, administration of eye drops in young

children is very difficult.

Treatment of Amblyopia
A relatively new treatment is to provide the
patient with levadopa.
Levodopa (L-dopa) is the metabolic precursor of
dopamine.
L-dopa may re-establish a period of plasticity in
the visual cortex.
Allow cortical cells to be open for the formation
of new connections.

Treatment of Amblyopia
There is evidence that L-dopa leads to visual
improvements even in adults.
It is not known whether these improvements are
long-lasting.
Also, L-Dopa may produce improvements in
both eyes.
There may be a persistent difference between the
eyes.

When is Treatment Effective?

The success of treatment depends on three
factors.
The depth of amblyopia
Patients with more severe amblyopia tend to
show poorer outcomes.
Rarely reach 20/20 or 20/25 in the amblyopic
eye.

When is Treatment Effective?

Age of Onset
Cases that exist early tend to show poorer
outcomes.
Duration of Deprivation
The longer the deprivation, the poorer the
outcome.

When is Treatment Effective?

The last two factors are closely linked.
It appears that the duration of deprivation is the
more important of the two.
These last two factors indicate that the prompt,
early detection of amblyopia is critical as early
treatment leads to better outcomes.

Danke