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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
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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
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Understanding Amblyopia

Decreased vision  retinoblastoma?

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
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Preventing Amblyopia

Poor focus one eye

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Preventing Amblyopia

Poor focus both eyes

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Preventing Amblyopia

Poor aim: strabismus

unilateral amblyopia presentation

Failed vision test

Strabismus

Parental concern

Family history of amblyopia or strabismus

Preventing Amblyopia

UNILATERAL AMBLYOPIA: PRESENTATION
vision screening ages 3 5
VISION SCREENING AGES 3-5

May peek around occluder

Adhesive patch works best

Preventing Amblyopia

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Preventing Amblyopia

Strabismus is the most common underlying cause of amblyopia.

diplopia in children

Not a feature of strabismus

May indicate a serious condition

Evaluate promptly and refer

Preventing Amblyopia

DIPLOPIA IN CHILDREN
parental concerns
PARENTAL CONCERNS

Leukocoria

Enlarged cornea

Preventing Amblyopia

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Preventing Amblyopia

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

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Preventing Amblyopia

Bilateral amblyopia

amblyopia early detection

Assess red reflex

Determine visual acuity

Evaluate ocular alignment

Preventing Amblyopia

AMBLYOPIA: EARLY DETECTION
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Preventing Amblyopia

Normal red reflex

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Preventing Amblyopia

Assymetric red reflex

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Preventing Amblyopia

Direct ophthalmoscope

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Preventing Amblyopia

Direct ophthalmoscope: assessing red reflex

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Preventing Amblyopia

Direct ophthalmoscope: examining retina

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Preventing Amblyopia

Can your child see?

normal infant vision

Good visual function

Fixate and follow with each eye

Steady fixation

Preventing Amblyopia

NORMAL INFANT VISION
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Preventing Amblyopia

Testing infant vision: Can your child see?

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Preventing Amblyopia

Suspected poor vision: test response to bright light

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Preventing Amblyopia

Testing infant vision: Preferential looking test

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Preventing Amblyopia

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

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Preventing Amblyopia

Picture chart Single E chart

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Preventing Amblyopia

Snellen acuity chart

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Preventing Amblyopia

Depth perception (stereopsis) testing

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Preventing Amblyopia

Testing infant vision: Assessing corneal light reflex

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Normal

Esotropia

Preventing Amblyopia

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Normal

Exotropia

Preventing Amblyopia

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Hypertropia

Hypotropia

Preventing Amblyopia

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Eyes appear aligned with head tilt and turn.

Misalignment revealed when head is straightened.

Preventing Amblyopia

referral immediate

Poor red reflex in one or both eyes

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

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

Focusing the image

Initiating amblyopia therapy

Preventing Amblyopia

AMBLYOPIA:TREATMENT RATIONALE
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Preventing Amblyopia

Congenital cataracts

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Preventing Amblyopia

Congenital ptosis

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Ophthalmologists can quantify refractive error in infants.

Children usually do well with eyeglasses.

Preventing Amblyopia

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Preventing Amblyopia

  • Carefully supervise children wearing therapeutic contact lenses.
  • Retain a pair of backup eyeglasses.
occlusion therapy purpose

Preventing Amblyopia

OCCLUSION THERAPY: PURPOSE
  • Improves visual acuity
  • Does not eliminate strabismus
occlusion therapy precautions 1

Monitor visual acuity carefully at close intervals

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

Preventing Amblyopia

OCCLUSION THERAPY: PRECAUTIONS 1
occlusion therapy precautions 2

Preventing Amblyopia

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
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Preventing Amblyopia

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

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.”

slide56

Preventing Amblyopia

Medieval “occlusion masks” to treat strabismus and amblyopia

amblyopia detection

Assess red reflex

Determine visual acuity

Evaluate ocular alignment

Summary

AMBLYOPIA DETECTION
amblyopia treatment

Clearing the ocular media

Focusing the image

Amblyopia therapy

Success requires communication among parents, PCP, and ophthalmologist

Summary

AMBLYOPIA TREATMENT
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