AMBLYOPIA

Reported by:

Glomarie Hope A. Paquera

Danica Ilah M. Sinco

AMBLYOPIA
Also known as Lazy Eye
Unilateral/bilateral condition
Reduction of best corrected visual acuity due to
cortical suppression of sensory input from an
eye that is receiving blurred or conflicting visual
information, leading to disruption of the normal
development of visual pathways serving that eye

HOW DOES IT HAPPEN?

Brain does not full recognize the image from
amblyopic eye
Weakening of that eye over time and a reduction
in its clarity of vision
Brain may block or suppress the images sent by
eye and favor the clearer eye.

CAUSES OF AMBLYOPIA
Unequal/Poor visual acuity
Unequal refractive error (anisometropia)
Bilateral equal high refractive errors
(isoametropia)
Uncorrected moderate/high astigmatism
Strabismus/Misaligned eyes
Blockage or Deprivation
Toxic

CLASSIFICATION OF AMBLYOPIA
FUNCTIONAL AMBLYOPIA

Not due to the diseases in the

eye
Unilateral/bilateral of the eye
Reversible
Examples:
- refractive amblyopia
- anisometropic amblyopia
- meridional amblyopia
- strabismic amblyopia

ORGANIC AMBLYOPIA

Due to lesion in the eye or

visual pathway
Unilateral/bilateral of the eye
Irreversible
Examples:
- visual deprivation amblyopia
- toxic amblyopia

TYPES OF AMBLYOPIA
Refractive amblyopia
Anisometropic amblyopia
Meridional amblyopia
Strabismic amblyopia
Visual deprivation amblyopia
Toxic amblyopia

FUNCTIONAL AMBLYOPIA
TYPE
Refractive Amblyopia

Anisometropic Amblyopia
(second in frequency)

CAUSES
Uncorrected isometropia
Result: a blurred image in both eyes

Uncorrected anisometropia
Result: a blurred image in more
ametropic eye

Meridional Amblyopia

Uncorrected high astigmatism

Result: a blurred and distorted image
in unilateral or bilateral eyes.

Strabismic Amblyopia
(most common)

Constant strabismus
Suppression in deviated eye

ORGANIC AMBLYOPIA
TYPES
Visual Deprivation Amblyopia

Toxic Amblyopia

CAUSES
Opacities in ocular media or
structures
Examples:
- cataracts
- cornea opacities
- cloudy vitreous in infants

Drugs, tobacco, alcohol, chemicals,

nutritional disorders

SYMPTOMS

SIGNS

Blurred vision
Reduced vision
Reduced contrast sensitivity

No obvious sign, unless severe

abnormality is present
Rubbing or squinting of eyes
Misaligning of eyes
Reduced VA
Droopy eyelid

ASSESSMENT OF DEVIATION
Compare magnitude at distance versus near
Laterality
Concomitancy
Frequency
The test is
Cover test
Hirschberg test
- uses pen torch
- corneal reflexes
Bruckner test
- uses ophthalmoscope
- observe the color and brightness of fundus reflexes and compared

ASSESSMENT OF AMBLYOPIA
1.) Visual Acuity (VA)
Degree of amblyopia
Crowding phenomena
- Normal Snellen Chart
* Line Acuity
- Single Letter Chart
* Single Letter Acuity

2.) Neutral Density (ND)

Depth of amblyopia
Differentiate between organic
amblyopia or functional
amblyopia

VISUAL ACUITY
Amblyopes perform better when isolated letters are
used instead of full chart
Crowding effect
- Single letter acuity

Infant
-Teller acuity chart

Preschool-aged children
-Lea symbols, HOTV or Broken Wheel Cards

School-aged children
- Snellen chart or Log MAR chart

SINGLE LETTER ACUITY

Advantage
Directly measures acuity
especially in children 3-6yrs
old

Disadvantage
Isolated letters can be used,
which may lead to under
estimated amblyopia visual
loss

CROWDING EFFECT
Crowding bar, or contour
interaction bars, allow the
examiner to test the crowding
phenomenon with isolated
optotype.
Bar surrounding the optotype
mimic the full of optotype to
the amblyopia child.

STRABISMIC AMBLYOPIA
In strabismic eye, mostly it use other part of area
instead of fovea area which consist rod
Image that form will reduce in contrast
Hence, it also reduce the visual acuity of the eye

NEUTRAL DENSITY (ND) FILTER

Strabismic Amblyopia
- better VA with ND filter
compared to the normal eye
- the use of neutral density (ND)
filter in front of the fixating
eye enhanced motion in depth
performance
- exhibit residual performance
for motion in depth, and it is
disparity based
Anisometropic Amblyopia
- cannot be diagnosed with
neutral density filter

NEUTRAL DENSITY (ND) FILTER

STRABISMIC AMBLYOPIA

ANISOMETROPIC AMBLYOPIA

CONTRAST SENSITIVITY TEST

Detect functional differences between strabismic
and anisometropic amblyopes
Strabismic amblyopes showed abnormalities
only in the high spatial frequency range
Anisometropic amblyopes showed an abnormal
function both in the low and high spatial
frequency range

ECCENTRIC FIXATION
Fixate away from fovea
- in strabismic amblyopic eye
Visuscopy
- detect and assess eccentric fixation
- explain decreased vision and lead to a more accurate
measurement of strabismus
- grid center is temporal to foveal reflex (temporal EF)
- grid center is nasal to foveal reflex (nasal EF)
- grid center is superior to foveal reflex (superior EF)
- grid center is inferior to foveal reflex (inferior EF)

BINOCULARITY/STEREOACUITY TEST
Amblyopia reduced VA, it also has reduced
stereopsis
Stereo smile for infant
Preschool random-dot stereogram or randomdot test for preschool children

REFRACTION
Commonly can determine anisometropia
Cycloplegic refraction
- spasm the ciliary muscle to inactive the
accommodation by using drug
Uses 1% cyclopentolate hydrochoride
Usually more hyperopic or more astigmatic eye
for the amblyopic eye

EXTERNAL AND INTERNAL OCULAR

EXAMINATION OF THE EYE
Determine either it is visual deprivation
amblyopia or afferent pupillary defect are
characteristic of optic nerve disease but
occasionally appear to be present with
amblyopia
To rule out ocular pathology
These examination consist of assessment
- physiological function
- anatomical status

MANAGEMENT
Goal of Treatment
Passive Therapy
Optical correction
Occlusion
Penalization
Active Therapy
CAM visual stimulator
Intermittent photic stimulation (IPS)
Pleoptics

GOAL OF TREATMENT
To restore and improves visual acuity by two
strategies:
1.)Present CLEAR retinal image to the amblyopic eye
Eliminate causes of visual deprivation
Correcting visually important refractive errors
2.) Make the child use the amblyopic eye
Recommended treatment should be based on
- pxs age, VA, compliance with previous treatment
and physical, social and psychological status

CHOICES OF TREATMENT
The choices of treatment of amblyopia are used
alone or in combination to achieve goal of
treatment
1.)Passive Therapy
- the patient experiences a change in visual
stimulation without any conscious effort
Proper refractive correction
Occlusion
Penalization

PROPER REFRACTIVE CORRECTION

Purpose
- to provide sharp images and providing
OPTIMAL environment for amblyopia therapy
Give the proper optical correction alone
- short period of time (6-8weeks) before
initiation of other therapy

OCCLUSION
Purpose
- cover good eye to stimulate amblyopic
Enable the amblyopic eye to enhance neural
input to the visual cortex
Decreasing inhibition better eye

OCCLUSION CAN BE CLASSIFIED IN SEVERAL

WAYS
Ways of Patching
- adhesive patch
- spectacles occlude
- opaque contact lens
Type
- direct occlusion: to stimualte amblyopic eye
- inverse occlusion: to weaken eccentric fixation
Duration
- full time occlusion: for deprivational amblyopia
- part time occlusion: to help preseve fusion

 Partial patching form

Allow appreciation of form but diminish acuity
- ie. Translucent material (bangerter foil)
- foil is cut to size and positioned on inner lens
surface
Or occlusion covering part of spectacles
- ie. Lower half of spectacles
- to promote use of the amblyopic eye for near work

TYPE
Direct occlusion
- patch the good eye
- stimulate amblyopic eye
Indication for
- deprivation amblyopia
- anisometropic amblyopia

 Inverse occlusion
- for amblyopia associated with EF = strabismic
ambyopia
- patching the amblyopic eye
*to weaken eccentric fixation of amblyopic eye
If children under 5 yrs old
- Direct full time occlusion may risk reverse amblyopia
- Do direct occlusion alternate with inverse occlusion
- ie.: for 3 yrs old children, may need 3 days direct and 1
day indirect occlusion consider 1 cycle and repeated
period of time

 Duration
- based on binocular vision status, age, performance need
Full time occlusion
- 24hrs a day/waking hours
- for children over 7yrs over plastic age
- when there is no binocular vision
- strabismic amblyopia
*alternate strabismus
*constant strabismus
- also anisometropic amblyopia with poor binoculat
vision
- shows more rapid development

 Part time occlusion

- for specific periods/prescribed activities
When binocularity is present
-anisometropic amblyopia
*to help preserve fusion
*prevent occluded eye become amblyopic if
doing full time occlusion
Children under 4 yrs
- 2hrs per day
- prevent deprivation amblyopia in good eye

 Occlusion is maintained until there has been no

further improvement for the last 5-6 weeks
Frequent check are necessary to monitor ocular
health, binocular status and each eyes acuity

PENALIZATION
Drug penalization
- 1gtt of 1% atropine instilled daily to good eye
- provide sufficient blur to force the child
*use amblyopic eye at near
*good eye at distance
Has cosmetic advanteges and does not totally
disrupt binocular vision
Effective method of treatment
- for mild to moderate amblyopia in children

PENALIZATION
Optical penalization
- children who do not tolerate patching
- fog the good eye (non-amblyopic eye) +3.00D
- amblyopic eye use for distance and good eye for
near
- not practically applicable
*do near work most of time compared to
distance

ACTIVE THERAPY
Is designed to improve visual performance by
the patients conscious involvement in a
sequence of a specific, controlled visual task that
provide feedback
CAM visual stimulator
Intermittent photic stimulation
pleoptic

SURGERY
If amblyopia is due to:
Cataract cataract surgery
Nonclearing vitreous opacities vitrectomy
Corneal opacities corneal graft
Blepharoptosis tarsal tuck