Understanding and preventing amblyopia
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Understanding and Preventing Amblyopia. When the doctor sees nothing and the patient sees nothing, the diagnosis is ambluwpia .  Hippocrates, 450 BCE. Understanding Amblyopia. Abnormal visual development Decreased best-corrected visual acuity Unilateral or bilateral

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When the doctor sees nothing and the patient sees nothing, the diagnosis isambluwpia. Hippocrates, 450 BCE

Understanding Amblyopia


Amblyopia definition

Abnormal visual development

Decreased best-corrected visual acuity

Unilateral or bilateral

Apparently normal physical exam, but may also result from recognizable structural abnormalities

Understanding Amblyopia

AMBLYOPIA: DEFINITION


Amblyopia significance

2%–4% of U.S. population affected

Commonly unilateral

Bilateral amblyopia (rare) may mean permanently decreased visual acuity

Understanding Amblyopia

AMBLYOPIA: SIGNIFICANCE


Screening importance

Amblyopia is usually preventable or treatable

Early detection is key to effective treatment

Life-threatening disorders may present as amblyopia

Screening responsibility rests with primary care physician

Understanding Amblyopia

SCREENING: IMPORTANCE


Understanding Amblyopia

In most circumstances, amplyopia can be prevented or treated.


Early detection importance

Visual function develops early in life

Treatment depends on plasticity of visual system

Treatment less likely to be effective as children age

Understanding Amblyopia

EARLY DETECTION: IMPORTANCE


Understanding Amblyopia

Decreased vision  retinoblastoma?


The ophthalmologist treats amblyopia but the primary care physician detects amblyopia

Understanding Amblyopia

The ophthalmologist treats amblyopia, but the primary care physician detects amblyopia.


Preventing amblyopia considerations

Predisposing factors

Presenting features

Detection methods

Treatment rationale

Preventing Amblyopia

PREVENTING AMBLYOPIA:CONSIDERATIONS


Amblyopia predisposing factors

Poor clarity (media opacities) or blockage of light pathway (ptosis)

Poor focus (refractive error)

Poor aim (strabismus)

Preventing Amblyopia

AMBLYOPIA: PREDISPOSING FACTORS


Preventing Amblyopia (ptosis)

Poor clarity


Preventing Amblyopia (ptosis)

Poor focus one eye


Preventing Amblyopia (ptosis)

Poor focus both eyes


Preventing Amblyopia (ptosis)

Poor aim: strabismus


Unilateral amblyopia presentation

Failed vision test (ptosis)

Strabismus

Parental concern

Family history of amblyopia or strabismus

Preventing Amblyopia

UNILATERAL AMBLYOPIA: PRESENTATION


Vision screening ages 3 5
VISION SCREENING AGES 3-5 (ptosis)

May peek around occluder

Adhesive patch works best

Preventing Amblyopia


Preventing Amblyopia (ptosis)

Strabismus is the most common underlying cause of amblyopia.


Diplopia in children

Not a feature of strabismus (ptosis)

May indicate a serious condition

Evaluate promptly and refer

Preventing Amblyopia

DIPLOPIA IN CHILDREN


Parental concerns
PARENTAL CONCERNS (ptosis)

Leukocoria

Enlarged cornea

Preventing Amblyopia


Preventing Amblyopia (ptosis)

A positive family history is often present in children with amblyopia.


Preventing Amblyopia (ptosis)

Bilateral amblyopia


Amblyopia early detection

Assess red reflex (ptosis)

Determine visual acuity

Evaluate ocular alignment

Preventing Amblyopia

AMBLYOPIA: EARLY DETECTION


Preventing Amblyopia (ptosis)

Normal red reflex


Preventing Amblyopia (ptosis)

Assymetric red reflex


Preventing Amblyopia (ptosis)

Direct ophthalmoscope


Preventing Amblyopia (ptosis)

Direct ophthalmoscope: assessing red reflex


Preventing Amblyopia (ptosis)

Direct ophthalmoscope: examining retina


Preventing Amblyopia (ptosis)

Can your child see?


Normal infant vision

Good visual function (ptosis)

Fixate and follow with each eye

Steady fixation

Preventing Amblyopia

NORMAL INFANT VISION


Preventing Amblyopia (ptosis)

Testing infant vision: Can your child see?


Preventing Amblyopia (ptosis)

Suspected poor vision: test response to bright light


Preventing Amblyopia (ptosis)

Testing infant vision: Preferential looking test


Preventing Amblyopia (ptosis)

Measuring visual acuity at 18 months to 3 years: picture chart


Preventing Amblyopia (ptosis)

Picture chart Single E chart


Preventing Amblyopia (ptosis)

Snellen acuity chart


Preventing Amblyopia (ptosis)

Depth perception (stereopsis) testing


Preventing Amblyopia (ptosis)

Testing infant vision: Assessing corneal light reflex


Normal (ptosis)

Esotropia

Preventing Amblyopia


Normal (ptosis)

Exotropia

Preventing Amblyopia


Hypertropia (ptosis)

Hypotropia

Preventing Amblyopia


Eyes appear aligned with head tilt and turn. (ptosis)

Misalignment revealed when head is straightened.

Preventing Amblyopia


Referral immediate

Poor red reflex in one or both eyes (ptosis)

Concern about visual function by parent or doctor

Asymmetric or diminishing visual acuity

Constant or acute-onset strabismus

Preventing Amblyopia

REFERRAL: IMMEDIATE


Referral less emergent

Intermittent strabismus on examination (ptosis)

Persistent parental concern

Associated syndromes or systemic disease

Reduced visual acuity in one or both eyes

Preventing Amblyopia

REFERRAL: LESS EMERGENT


Amblyopia treatment rationale

Clearing the media (ptosis)

Focusing the image

Initiating amblyopia therapy

Preventing Amblyopia

AMBLYOPIA:TREATMENT RATIONALE


Preventing Amblyopia (ptosis)

Congenital cataracts


Preventing Amblyopia (ptosis)

Congenital ptosis


Ophthalmologists can quantify refractive error in infants. (ptosis)

Children usually do well with eyeglasses.

Preventing Amblyopia


Preventing Amblyopia (ptosis)

  • Carefully supervise children wearing therapeutic contact lenses.

  • Retain a pair of backup eyeglasses.


Occlusion therapy purpose

Preventing Amblyopia (ptosis)

OCCLUSION THERAPY: PURPOSE

  • Improves visual acuity

  • Does not eliminate strabismus


Occlusion therapy precautions 1

Monitor visual acuity carefully at close intervals (ptosis)

Ensure vision is not being reduced in non-patched eye (“occlusion amblyopia”)

Preventing Amblyopia

OCCLUSION THERAPY: PRECAUTIONS 1


Occlusion therapy precautions 2

Preventing Amblyopia (ptosis)

OCCLUSION THERAPY:PRECAUTIONS 2

  • Part-time occlusion may suffice

  • Ensure parents understand purpose of patching and importance of compliance

  • Follow child’s visual status into the teen years


Preventing Amblyopia (ptosis)

Skin irritation from patching can be avoided.


Atropine penalization therapy

Atropine ointment or drops in non-amblyopic eye at prescribed levels

Atropinized eye cannot accommodate for near vision

Child can still use better-seeing eye for distance

Child switches fixation at near to amblyopic eye

Preventing Amblyopia

ATROPINE PENALIZATION THERAPY


Atropine therapy precautions

Preventing Amblyopia prescribed levels

ATROPINE THERAPY: PRECAUTIONS

  • Monitor VA carefully.

  • Ensure near VA in amblyopic eye can support near tasks

  • Allergic reactions are rare (<1%)

  • Systemic side effects are uncommon and minimal

Warn parents that one eye will

have a “fixed and dilated pupil.”


Preventing Amblyopia prescribed levels

Medieval “occlusion masks” to treat strabismus and amblyopia


Amblyopia predisposing factors1

Poor clarity of ocular media or light blockage prescribed levels

Poor focus

Poor aim

Summary

AMBLYOPIA:PREDISPOSING FACTORS


Amblyopia detection

Assess red reflex prescribed levels

Determine visual acuity

Evaluate ocular alignment

Summary

AMBLYOPIA DETECTION


Amblyopia treatment

Clearing the ocular media prescribed levels

Focusing the image

Amblyopia therapy

Success requires communication among parents, PCP, and ophthalmologist

Summary

AMBLYOPIA TREATMENT


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