amblyopia diagnosis and prevention 8-06

8/14/2019 Amblyopia Diagnosis and Prevention 8-06

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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



Amblyopia: HistoryAmblyopia: History

• “When the doctor sees nothing and the

patient sees nothing, the diagnosis is

amblyopia.”• Hippocrates, 450 B.C.



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



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



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



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




• 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




• 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




• 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



Strabismus: ExotropiaStrabismus: Exotropia

• Often have good fusional ability

• Amblyopia less common than with

esotropia

• Treatment options: – alternate patching

– over-minused spectacles (stimulate

convergence)

– surgery



Strabismus: TreatmentStrabismus: Treatment

• Straighten the eyes – glasses, surgery, both

•Patch the better eye




• Strabismus (misaligned eyes)

• Media opacity

• High refractive errors



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



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



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



Media Opacity: TreatmentMedia Opacity: Treatment

• Clear the media – surgically lift ptotic eyelid

– corneal transplant

– cataract removal




• Strabismus (misaligned eyes)

• Media opacity

• High refractive errors



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



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



Refractive Amblyopia:Refractive Amblyopia:

TreatmentTreatment

• Glasses - clears retinal image

• Patch the better eye - forces brain to use

image from “weaker” eye



Amblyopia: Prevention/EarlyAmblyopia: Prevention/Early

TreatmentTreatment

• Awareness of problem – Overall affects 2-5% of population




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




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




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




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




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



Amblyopia: ConclusionAmblyopia: Conclusion

• Straighten the eyes

• Clear the media

• Correct the refractive error



Amblyopia: ConclusionAmblyopia: Conclusion

• Diagnose it early!



Amblyopia Case HistoriesAmblyopia Case Histories



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?




• Ocular motility: barely perceptible

esotropia

• Stereo vision: nil

• Ocular structures: normal




• Cycloplegic Refraction – RE +0.25 D

– LE +4.75 D

• Treatment – glasses

– patch right eye

• Result at one month, 20/60 LE, continue

patching




• Prevention – Bruckner’s test of red reflex

– Acuity screening yearly



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




• Anterior segment exam: bilateral central

cataracts




• 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




• Treatment plan – cataract removal/lens implant

• first eye - exotropia better indicating possible

fusion• second eye surgery also



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




• Acuity: fix and follow (normal for his age)

• Ocular alignment: normal

• Anterior segment exam: normal




• Bruckner’s test - dull but equal reflexes




• Refraction: -10.50 D both eyes

• Treatment: glasses full time

•Expected outcome: excellent vision – caught at young age

– equal refraction




• 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



MTI Photoscreener MTI Photoscreener

• 6 year old white female referred for

evaluation of “possible

amblyopia/strabismus”




• Visual acuity without correction

Right eye 20/25

Left eye 20/400

• Ocular motility

Trace esotropia




• 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



PhotographsPhotographs

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amblyopia diagnosis and prevention 8-06

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