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AmblyopiaAmblyopiaDiagnosis and PreventionDiagnosis and Prevention
Stephen W. Groves, M.D.Stephen W. Groves, M.D.
His Vision for ChildrenHis Vision for Children
Pediatric OphthalmologyPediatric Ophthalmology
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Amblyopia: HistoryAmblyopia: History
• “When the doctor sees nothing and the
patient sees nothing, the diagnosis is
amblyopia.”• Hippocrates, 450 B.C.
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Amblyopia: DefinitionAmblyopia: Definition
• Uncorrectable, decreased vision in an
otherwise structurally normal eye – definition includes an operated eye made
“structurally normal” by surgery (e.g. post
cataract surgery)
• May be unilateral (most common) or
bilateral
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Amblyopia: Three Main TypesAmblyopia: Three Main Types
• Strabismus (misaligned eyes) – one eye used, one eye suppressed
• Media opacity – particularly when unilateral and early
• High refractive errors –
especially when asymmetric
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Strabismus: Misaligned EyesStrabismus: Misaligned Eyes
• Adult onset strabismus: horrible diplopia – e.g. traumatic 6th nerve palsy with esotropia
• Childhood onset strabismus: suppressionand amblyopia – child notices no visual disturbance
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Strabismus: EsotropiaStrabismus: Esotropia
• Infantile esotropia – poor ability to develop binocular fusion
• stereopsis develops very early in life
– more common with CNS abnormalities
– presents at birth or in first few months
– large angle of crossing - obvious
– amblyopia or alternating fixation
– surgical correction
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Strabismus: EsotropiaStrabismus: Esotropia
• Accomodative esotropia – presents later, age 18mo - 3yrs common
– small angle of deviation - not obvious
– usually normal neurologically
– starts insidiously (only when tired, ill)
– etiology: hyperopia• accomodative (focusing) reflex tied to convergence
(crossing)
• family hx
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Strabismus: EsotropiaStrabismus: Esotropia
• Accomodative esotropia cont’d – amblyopia common
• more hyperopic eye tends to cross and become
amblyopic
– esotropia treatment: hyperopic (magnifying)
spectacles•
surgery usually not needed (only 30%) unlesscontrol inadequate with glasses
– amblyopia treatment: patch the better eye
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Strabismus: EsotropiaStrabismus: Esotropia
• Accomodative esotropia cont’d – critical to have the proper spectacle correction
to maintain straight eyes• if eyes straight with glasses:
– binocular fusion/stereopsis regained (remember child
was straight and fusing for first 1-2 yrs)
– amblyopia partly “self-treats” since both eyes are being
used simultaneously• if eyes remain crossed with glasses:
– fusion lost
– amblyopia worsens
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Strabismus: ExotropiaStrabismus: Exotropia
• Often have good fusional ability
• Amblyopia less common than with
esotropia
• Treatment options: – alternate patching
– over-minused spectacles (stimulate
convergence)
– surgery
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Strabismus: TreatmentStrabismus: Treatment
• Straighten the eyes – glasses, surgery, both
•Patch the better eye
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Amblyopia: Three Main TypesAmblyopia: Three Main Types
• Strabismus (misaligned eyes)
• Media opacity
• High refractive errors
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Media OpacityMedia Opacity
• Best example: monocular congenital
cataract
• Total deprivation of sensory input to cortex
in one eye with normal sensory input in
fellow eye leads to rapid dense amblyopia
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Media Opacity: CataractMedia Opacity: Cataract
• Treatment: – urgent cataract surgery (clearing of media
opacity)
– may patch both eyes prior to surgery to
prevent amblyopia
– contact lens to restore focus
– diligent patching of unoperated eye after surgery
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Media Opacity: OthersMedia Opacity: Others
• Any opacity preventing light from reaching
the retina – Ptotic (drooping) upper eyelid
– Corneal scar/opacity• forceps injury at birth
• hereditary abnormalities
– Cataract – Vitreous opacity, hemorrhage
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Media Opacity: TreatmentMedia Opacity: Treatment
• Clear the media – surgically lift ptotic eyelid
– corneal transplant
– cataract removal
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Amblyopia: Three Main TypesAmblyopia: Three Main Types
• Strabismus (misaligned eyes)
• Media opacity
• High refractive errors
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High Refractive ErrorsHigh Refractive Errors
• Clear input to the visual cortex is required
to develop good vision
• Myopia (nearsighted) – eye too long
• Hyperopia (farsighted) – eye too short
• Astigmatism (distortion) – eye football shaped
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High Refractive ErrorsHigh Refractive Errors
• If retinal image in each eye is severely
unfocused, bilateral amblyopia may result
(uncommon) – high myopia
– high hyperopia
– high astigmatism
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Refractive Amblyopia:Refractive Amblyopia:
TreatmentTreatment
• Glasses - clears retinal image
• Patch the better eye - forces brain to use
image from “weaker” eye
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Amblyopia: Prevention/EarlyAmblyopia: Prevention/Early
TreatmentTreatment
• Awareness of problem – Overall affects 2-5% of population
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Amblyopia: Prevention/EarlyAmblyopia: Prevention/Early
Treatment - BirthTreatment - Birth
• First examination by primary care doctor
before newborn leaves hospital
• Look for clear, equal red reflex – congenital cataract
– hereditary corneal dystrophies
• Ocular alignment unreliable in first week of
life
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Amblyopia: Prevention/EarlyAmblyopia: Prevention/Early
Treatment - Birth to 2 YearsTreatment - Birth to 2 Years• Examination at each well baby check
• Red reflex
• Ocular alignment should be orthophoric by 3-6
months – corneal light reflex, alternate cover test
– if alignment not straight by 3 months - refer to
ophthalmologist
• Visual acuity - fix and follow smoothly by 6
months – check each eye separately
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Amblyopia: Prevention/EarlyAmblyopia: Prevention/Early
Treatment - 2 Year CheckTreatment - 2 Year Check• Examinations at each well child check
• Red reflex - Bruckner Test – direct ophthalmoscope at 0 setting, otoscope without
magnifyer – distance of 2 feet from patient
– normal - equal red reflex
– unequal refraction - one eye darker reflex
– no/poor reflex - media opacity
– corneal light reflex not symmetric - strabismus
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Amblyopia: Prevention/EarlyAmblyopia: Prevention/Early
Treatment - 2 Year Check Cont’dTreatment - 2 Year Check Cont’d
• Ocular alignment – corneal light reflex
– alternate cover test
• Visual acuity - fix and follow very smoothly
and consistently – ask the parent what the child sees - quantitate
“he sits close to TV”
– can the child recognize the parent across the
room
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Amblyopia: Prevention/EarlyAmblyopia: Prevention/Early
Treatment - 6+ Year ChecksTreatment - 6+ Year Checks• Red reflex
• Ocular alignment - perfect
• Visual acuity - snellen letters preferable – vision should be 20/30 or better (consider the child)
– refer for vision < 20/30 or 2 line difference (i.e. 20/20
one eye, 20/30 other)
• External, anterior segment
• Ophthalmoscopic exam
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Amblyopia: ConclusionAmblyopia: Conclusion
• Straighten the eyes
• Clear the media
• Correct the refractive error
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Amblyopia: ConclusionAmblyopia: Conclusion
• Diagnose it early!
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Amblyopia Case HistoriesAmblyopia Case Histories
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Amblyopia Case Histories: JHAmblyopia Case Histories: JH
• 7 1/2 year white female failed school
screening exam
• Uncorrected acuity 20/20 RE, 20/200 LE
• Other information?
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Amblyopia Case Histories: JHAmblyopia Case Histories: JH
• Ocular motility: barely perceptible
esotropia
• Stereo vision: nil
• Ocular structures: normal
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Amblyopia Case Histories: JHAmblyopia Case Histories: JH
• Cycloplegic Refraction – RE +0.25 D
– LE +4.75 D
• Treatment – glasses
– patch right eye
• Result at one month, 20/60 LE, continue
patching
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Amblyopia Case Histories: JHAmblyopia Case Histories: JH
• Prevention – Bruckner’s test of red reflex
– Acuity screening yearly
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Amblyopia Case Histories: SPAmblyopia Case Histories: SP
• 2 y.o. black female with exotropia
• Acuity: central, steady, unmaintained RE;
central, steady, maintained LE
• Ocular alignment: marked right exotropia
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Amblyopia Case Histories: SPAmblyopia Case Histories: SP
• Anterior segment exam: bilateral central
cataracts
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Amblyopia Case Histories: SPAmblyopia Case Histories: SP
• Bruckner’s test: dull reflex bilaterally (can
be difficult in black children, reflex not as
bright due to darker pigmentation of retina)
• Ocular alignment: exotropia – corneal light reflex
– alternate cover test
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Amblyopia Case Histories: SPAmblyopia Case Histories: SP
• Treatment plan – cataract removal/lens implant
• first eye - exotropia better indicating possible
fusion• second eye surgery also
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Amblyopia Case Histories: LBAmblyopia Case Histories: LB
• 2 3/4 y.o. black male
• Gets “real close” to TV -
mom demonstrates few
inches
• Mom feels he can see
her across room
• She only thinks there is a
problem when he’s
watching TV or playingwith his cars
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Amblyopia Case Histories: LBAmblyopia Case Histories: LB
• Acuity: fix and follow (normal for his age)
• Ocular alignment: normal
• Anterior segment exam: normal
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Amblyopia Case Histories: LBAmblyopia Case Histories: LB
• Bruckner’s test - dull but equal reflexes
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Amblyopia Case Histories: LBAmblyopia Case Histories: LB
• Refraction: -10.50 D both eyes
• Treatment: glasses full time
•Expected outcome: excellent vision – caught at young age
– equal refraction
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Amblyopia Case Histories: LBAmblyopia Case Histories: LB
• 2 3/4 y.o. black male
• Gets “real close” to TV - mom demonstrates few
inches
• Mom feels he can see her across room• She only thinks there is a problem when he’s
watching TV or playing with his cars
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MTI Photoscreener MTI Photoscreener
• 6 year old white female referred for
evaluation of “possible
amblyopia/strabismus”
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MTI Photoscreener MTI Photoscreener
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MTI Photoscreener MTI Photoscreener
• Visual acuity without correction
Right eye 20/25
Left eye 20/400
• Ocular motility
Trace esotropia
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MTI Photoscreener MTI Photoscreener
• Cycloplegic refraction
Right eye +1.75
Left eye +6.00 (20/200 best acuity)
• Diagnosis
Amblyopia secondary to anisometropia
(unequal focus between the eyes)
• Prognosis: Very good with patch andglasses
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PhotographsPhotographs
For your enjoymentFor your enjoyment
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