Management of Amblyopia

MANAGEMENT OF
AMBLYOPIA
DEFINITION
 Greek : amblyos ; blunt and opia ;
vision.
 Amblyopia is decreased of best
corrected visual acuity in one of
both eyes, without organic
abnormalities signs in visual
media and structure of the
globe.
 Prevalence about 2 % of the
general population.
CAUSES OF AMBLYOPIA
(By K.Wright)
1. Strabismic amblyopia:
a. Congenital esotropia
b. Congenital eksotropia
c. Accomodative esotropia
d. Intermitten exotropia
2. Monocular pattern distortion:
a. Anisometropia
 Hyperopia > +1.50 D
 Myopia > -3.00 D
 Meridional > +1.50 D
b. Media Opacity
 Unilateral cataract
 Unilateral corneal opacity
 Unilateral vitreous haemorrhage or

opacity
3. Bilateral pattern distortion:
a. Ametropia
o Bilateral high hipermetropia >
+5.00 D
o Bilateral meridional > 2.50 D
b. Media opacity
o Bilateral congenital cataract
o Bilateral corneal opacity
o Bilateral vitreous opacity
CLASSIFICATION
 Strabismic Amblyopia
Most common forms
Misalignment of axial visual abnormal
binocular interaction different image
between two eyes visual confusion or
diplopia suppressi long term
suppression amblyopia
 Anisometropic Amblyopia
Develops when unequal refractive
error in two eyes causes the image on
one retina to be chronically
defocused.
This condition is thought to result
partly from the direct effect of
image blur on the development of
visual acuity in the involved eye and
partly from interocular competition
or inhibition similar to that
responsible for strabismic amblyopia
Anisometropia hyperopic or
astigmatism: 1 – 2 D
Anisometropia myopia: -3 D mild
amblyopia
Unilateral high myopia: -6 D severe
amblyopia
 Isometropia Amblyopia
• Result from large approximately
equal, uncorrected refractive error in
both eyes of a young child.
• It mechanism involves the effect of
blurred retinal images alone
• Hypermetropia: > +5D
• Myopia: > -10 D
• Astigmatism: > 2 D
 Deprivitation Amblyopia
Amblyopia ex anopsia or disuse
amblyopia
Caused by congenital or early
acquired media opacities.
Congenital cataract (< 6 y.o), central,
± 3 mm or more severe
amblyopia
Occlusion amblyopia caused
by excessive therapeutic patching
EXAMINATION OF THE
PATIENT WITH AMBLYOPIA
Visual acuity testing protocols used to

diagnose amblyopia depend upon age
and abilities of each individual child.
1. Assesment of visual behavior/acuity.
 Is the key critical element in
diagnosis of amblyopia in preverbal
children.
 Child’s ability to fixate and follow an
accommodative visual target, such
examiner’s face or a small toy.
2. Fixation behavior testing
 Involves moving a visual target through
the child’s visual space.
 Each eye testing separately by occluding
the fellow eye during testing.
 The ability to follow past midline develops
at approximately 2 m.o
 vertical eye movements typically develop
around 3 m.o
3. The differential occlusion objection
test
 Is a classic visual behavior test for
moderate to severe amblyopia.
 Measuring the child’s reasons to
sequential occlusion of the eyes.
 Children with unequal vision typically
become fussy or agitated when the
better eye is covered.
4. Fixation preference testing
 This test is performed for patient
with strabismus
 The demonstrate to absence or
presence of equability to maintain
fixation with either eye by first
occluding one eye and determining
if the child can maintain fixation
with currently fixing eye upon
removal of the occluder and then
repeating the process for the
contralateral eye.
5. Visual acuity testing
 Visual acuity test depend on age or
ability of the child.
 A difference in best corrected visual
acuity of two lines between fellow eye
is clinically indicative of amblyopia.
 HOTV, Tumbling E, Landolt C, Allen
Figure
TREATMENT OF AMBLYOPIA
 The goal of amblyopia treatment is the

achievement of the maximum visual
acuity for an individual patient.
 The basic strategy treating amblyopia:
Clear retinal image
Correct ocular dominance
Amblyopia treatment goals
 Monocular goals:
 eliminate eccentric fixation
 establish foveal fixation
 improve visual acuity
 Binocular goals:
 eliminate sensory anomalies
 stabilize binocular vision

Image Retinal Clear
OPTICAL CORRECTION
 The first step in the management of any
child with amblyopia involves facilitating
projection of a clear image onto the
fovea of each eye.
 Anisometropic amblyopia frequently
respond to refractive correction alone
without the need to occlusion or
penalization therapy
Moseley et al:
Progressive improvement in acuity for
up to 22 weeks in some patients after
refractive correction
Timely started of occlusion therapy
after refraction correction
controversial
Occlusion Therapy
 Lack systemic side effects, is effective
and is not expensive
 Depend on age and severity of amblyopia
 Principal; covering the sound eye to
stimulate the amblyopic eye.
 Part time occlusion and full time
occlusion
 child < 1 y.o:
 1 hr/m.o evaluated every 1-2 weeks
 child >1y.o:
 1 wk/y.o
 Campbel: 20 mnt/dy
VA (83%)
 PEDIG: 2hr = 6hr
 Full time = part time

same outcome
 Anisometropia A (8 PD)
3-4hr/day VA 
Penalization
Blurring the sound eye to force
fixation to the amblyopic eye.
There is 2 type:
Optical penalization positive
lens
Atropine penalization atropine
Optical penalization is useful for mild
ambliopia.
Disadvantage; easy to removed
Atropine penalization: atropine 1%,
homatropine 5%,skopolamine
1 drop/day/week 2 week effective
Side effect: follicullaris conjungtivitis,
conjungtiva edema, eczematous
dermatitis, tachicardia, flush, iatrogenic
amblyopia
useful for mild amblyopia (visus 6/24)
Occlusive Contact Lens
 Eustis and Chamberlain;
 visual acuity  (92 %)
 Complication: conjungtival irritation,
poor contact lens fit
 High recurrence (55%)
Pleoptics
 Treating of eccentric fixation
associated with dense amblyopia
 A bright ring of light is flashed around
the fovea to temporarily “blind” or
saturate the photoreceptors
surrounding the fovea eliminates
vision from the eccentric of fixation
point force fixation to the fovea
 Effective ?
Activity Near Vision
 Coordinate hand and eyes VA 
 PEDIG:
 Occlusion with activity near vision
VA 
Systemic Therapy
 levodopa-cardiopa
 It was a systemic therapy
 contain of catecholamine dopamine
 Effective? Still controversial

 Citicoline
 cystidine-5’-diphosphocoline
 VA (stable for 4 month)
 High relapse
Reccurence
 Amblyopia treatment stop
reccurence 1/2
 Prevented:
 maintenance patching 1-3 hr/day
 optical penalization, optical penalization 1-
2 day/week
 monitoring until age 8-10 interval 6
month
Reverse Amblyopia
 Form of deprivation amblyopia
 assocoated with full time occlusion,
much less than part time, cycloplegic,
optical methods
 Action to taken if reverse is
suspected:
1. each patient who develops such a
reduction in acuity should be reassed
clinically
2. Check the refraction with cycloplegic
3. Retest the vision with new spectacle
4. If the acuity reduction is confirmed,
either stop the active amblyopia therapy
and reexamine the patient in several
weeks or continue or reduce therapy with
careful monitoring of the sound eye
5. If the sound eye is worse than the
amblyopic eye, stop the therapy and
reschedule a visit
6. If the vision in the sound eye si still
down on the subsequent visit, consider
treating the formerly sound eye
Thank You
Thank You

Management of Amblyopia

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Management of Amblyopia

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MANAGEMENT OF

 Myopia > -3.00 D

 Meridional > +1.50 D

 Unilateral corneal opacity

 Unilateral vitreous haemorrhage or

Visual acuity testing protocols used to

 The goal of amblyopia treatment is the

 establish foveal fixation

 improve visual acuity

 stabilize binocular vision

 Full time = part time

 contain of catecholamine dopamine

 Effective? Still controversial

 VA (stable for 4 month)

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