AMBLYOPIA

Dr Rozalina Loebis,SpM
Dept of Ophthalmology-Airlangga
University
2013
 Visual Development
Normal clear stereoscopic vision is
ultimately the product of complex brain
processing.
The cornea and lens focus high-
resolution images onto the retina, and
the retina in turn stimulates visual
areas in the brain where the
information is processed into what we
perceive as sight
 Visual Development cont...

Three-dimensional stereoscopic vision is

derived from the brain receiving retinal
input from each eye and integrating the
images into a single image with depth.
The cortical integration of 2 images into a
single binocular stereoscopic image
is called binocular fusion.
Visual Development cont...

Each eye captures its own

view and the two separate
images are sent on to the
brain for processing. When
the two images arrive
simultaneously in the back
of the brain, they are united
into one picture
 Visual Development cont...

The primary brain processing centers are the lateral

geniculate nucleus (LGN) and striate cortex. These
brain centers process information from more than 1
million retinal axons from each eye.

Excellent high resolution stereoscopic vision

-Accurate eye alignment
-Clear retinal images
-Highly developed visual centers in the brain.
 Visual Development cont...

Curve represents visual acuity development, with age on the horizontal axis and
Snellen acuity on the vertical axis. Note the exponential improvement in visual
acuity during the critical period of visual development (birth to 4 months).
 Visual Development cont...

The critical period of visual development is

the first 2 to 4 months, but visual
development continues up to 7 to 8 years
of age.
This critical period of visual development is
when vision is most rapidly improving
and when the visual system is most
susceptible to the adverse effects of a
blurred image.
 Visual Development cont...

Disruption of normal brain development by

stimulation with a blurred retinal image results in
poor vision and is termed amblyopia.

Requirements for Normal Visual Development

1. Clear retinal image
2. Equal image clarity
3. Proper eye alignment (no strabismus)
 Visual Developmental Milestones

Birth to 2 Months Poor and sporadic fixation

Jerky, fast eye movements
(saccades)
Exotropia 70%, orthotropia 30%
(straight
eyes), esotropia is rare

2 to 6 Months old Accurate fixation (locks on target)

Precise smooth pursuit eye
movements
Orthotropia (straight eyes)

3 to 4 Years old Visual acuity 20/40

5 to 6 Years old Visual acuity 20/30
7 to 9 Years old Visual acuity 20/25 to 20/20
 Amblyopia
Amblyopia occurs in approximately 2% of
the general population and is the most
common cause of decreased vision in
childhood.
The term amblyopia is derived from the
Greek language and means dull vision:
amblys = dull, ops = eye.
 Amblyopia cont

Amblyopia can refer to poor vision from

any cause but in most medical literature,
amblyopia now refers to poor vision
caused by abnormal visual development
secondary to abnormal visual stimulation.
Amblyopia cont
 Amblyopia cont

The pathophysiology of amblyopia was

discovered by Wiesel and Hubel in the late
1960s. Their basic scientific research
showed that in infant animals visual
stimulation with a blurred retinal image
resulted in loss of nuclear cells in the LGN,
the first relay nucleus of the visual system
 Amblyopia cont

Pathology of amblyopia (lateral geniculate nucleus [LGN]). A, Cross section of LGN

from a normal monkey. B and C,Vs amblyopic monkey caused by a unilateral blurred
image. Note that the normal LGN, A has 6 nuclear layers (darkly stained cell layer) and
the amblyopic LGN, B and C only have 3 layers and are thicker than normal. From
Wiesel TN, Hubel DH. Ordered arrangement of orientation columns in monkeys lacking
visual experience. J Comp Neurol. 1974;158:307318.
 Amblyopia cont

Pathology of amblyopia (striate cortex). Histopathology of monkey striate cortex

(visual cortex). A, Well-defined cortex columns are seen in the normal
specimen. B, Cortex columns are underdeveloped in specimen from the
amblyopic monkey. From Horton JC, Hocking DR. Timing of the critical period for plasticity
of ocular dominance columns in macaque striate cortex. J Neurosci. 1997;17:36843709
 Amblyopia cont

For practical purposes, amblyopia is

defined as at least 2 Snellen lines
difference in visual acuity between the
eyes.
Amblyopia is truly a spectrum of visual
loss, ranging from missing a few letters on
the 20/20 line to hand motion vision.
 Amblyopia cont

Mild image blur (ie, blur associated with a

mild refractive error) causes mild
amblyopia and allows for the development
of some degree of binocular fusion and
stereopsis (ie, peripheral fusion).
A severely blurred image during infancy
(ie, unilateral congenital cataract or corneal
opacity), however, can result in profound
vision loss, no binocular fusion, and
strabismus.
 Amblyopia cont

The visual deficit associated with

amblyopia has certain unique
characteristics, including the crowding
phenomenon and eccentric fixation.
Crowding phenomenon relates to the
fact that patients better visual acuity
reading single optotypes, than reading
multiple optotypes in a row (linear
optotypes)
 Amblyopia cont

The crowding phenomen

A child with amblyopia will test

higher on a visual acuity test
when shown single letters
versus a full line of letters.
 Amblyopia cont

Eccentric fixation is a characteristic of

severe amblyopia.
Patients with mild amblyopia (20/40
20/100) fixate so close to the fovea, they
appear to fixate centrally.
Severe amblyopia, usually 20/200 to count
fingers, is associated with parafoveal
viewing or eccentric fixation.
 Amblyopia cont

When the good eye is occluded and the

amblyopic eye is forced to view, patients
with eccentric fixation demonstrate roaming
eye movements and cannot visually lock on
the target.

The presence of eccentric fixation is a

clinical sign of severe amblyopia and has
a poor visual prognosis
 Amblyopia cont

A foveolar,
B parafoveolar
C peripheral eccentric fixation
 Amblyopia cont

Visual Development and Amblyopia

Critical Period One week to 3 to 4 months
(most susceptible to
amblyopia)

Visual Plasticity Birth to 7 or 8 years

(susceptible to amblyopia)
Extended Plasticity Ten years to adulthood
may retain limited
plasticity (not susceptible
to amblyopia and
amblyopia therapy is
ineffective
 Amblyopia cont

For practical purposes, amblyopia is

defined as at least 2 Snellen lines
difference in visual acuity between the
eyes and cannot be corrected with
glasses.
Amblyopia is truly a spectrum of visual
loss, ranging from missing a few letters on
the 20/20 line to hand motion vision.
 Types of Amblyopia
Types of Amblyopia

1. Strabismic Amblyopia

2. Anisometropic Amblyopia

3. Deprivational Amblyopia
 Treatment of Amblyopia

1. Provide a clear retinal image

correct refractive error : glasses / CL
2. Correct ocular dominance need
ophthalmologist refferal
Occluding the good eye
Occluding the dominant eye stimulates
development of visual areas in the brain that
correlate to the amblyopic eye
 Treatment of Amblyopia Cont

3.- Atropine 1% drops can be used in

patients with amblyopia to blur the vision of
the good eye to force use of the amblyopic
eye; this is called penalization.
-The blurring effect of atropine is greatest
for near vision and eyes that are hyperopic
- Not as effective as Occlusion / Patching
Treatment of Amblyopia Cont

As a general practitioner ,
you are NOT allowed to
COVER an eye or give
ATROPIN 1% eyedrops of
a child under the age of
12 years, whatever was
the cause.
 References
1.Horton JC, Hocking DR. Timing of the critical period for plasticity
of ocular dominance columns in macaque striate cortex. J
Neurosci.1997;17:36843709
2. Sondhi N, Archer SM, Helveston EM. Development of normal
ocular alignment. J Pediatr Ophthalmol Strabismus. 1988;25:210
211
3. von Noorden GK, Crawford ML, Levacy RA. The lateral geniculate
nucleus in human anisometropic amblyopia. Invest Ophthalmol Vis
Sci. 1983;24:788790
4. Wiesel TN, Hubel DH. Ordered arrangement of orientation
columns in monkeys lacking visual experience. J Comp Neurol.
1974;158:307318
5. Wright KW, Matsumoto E, Edelman PM. Binocular fusion and
stereopsis associated with early surgery for monocular congenital
cataracts. Arch Ophthalmol. 1992;110:16071609
Thank you