m An intermittent or constant misalignment of an eye

so that its line of vision is not pointed at the same

object as the other eye
m Can cause amblyopia (a decrease in vision) and
permanent loss of vision
m 2trabismus is caused by an imbalance in the
muscles that control the positioning of the eye.
m 2ymptoms include misalignment of the eyes,
double vision, and eye muscle paralysis.
m The diagnosis is based on an eye examination.
m 2trabismus sometimes resolves on its own, but in
most cases, eyeglasses, eye drops, or surgery is
needed.
m 2ome types are characterized by inward turning of
the eye (esotropia) and some by outward turning
of the eye (exotropia).
m Others are characterized by upward turning of the
eye (hypertropia) or downward turning of the eye
(hypotropia)
m 2trabismus may cause double vision (diplopia) in
an older child or amblyopia in a younger child.
m To examine an infant, a doctor shines a light into
the eyes to see whether the light reflects back
from the same location on each pupil.
m Treatment depends on the characteristics of the
strabismus
m Onfantile Esotropia: Onfantile esotropia is a constant
inward turning of the eyes that develops before 6
months of age
„ it often runs in families and tends to be severe.
„ The eyes often begin to turn inward by 3 months of age.
„ The degree of turning is large and easily noticeable.
m 2urgery, which is accomplished by altering the pull of
the eye muscles, is usually needed to realign the
eyes.
„ ²epeated operations may be necessary.
„ With the best possible treatment, strabismus may not be fully
corrected.
„ Occasionally, amblyopia develops but usually responds to
treatment.
m Accommodative Esotropia
„ Accommodative esotropia is inward turning of the eyes that develops between the
ages of 6 months and 7 years, most often in children aged 2 to 3 years and is
related to optical focusing (accommodation) of the eyes.
„ The misalignment is the result of how the eyes move when focusing on nearby or
distant objects.
„ Children with accommodative esotropia are farsighted.
„ Although everyone's eyes turn inward when focusing on very close objects, eyes
that are farsighted also turn inward when looking at distant objects.
„ On mild cases, the eyes may turn too far inward only when looking at nearby
objects. On more severe cases, the eyes turn too far inward all the time.
„ With treatment, accommodative esotropia can usually be corrected. Eyeglasses
can help the child focus on objects, reducing the tendency for the eyes to turn
inward when viewing those objects. Many children outgrow farsightedness and
eventually do not need eyeglasses.
m Occasionally, drugs (echothiophate) are used to help the eyes to focus
on nearby objects.
m Of eyeglasses and eye drops fail to properly align the eyes, surgery may
help.
m Ontermittent Exotropia
„ Ontermittent exotropia is outward turning of the eyes that
occurs intermittently, usually when the child is looking at
distant objects or when the child is tired or ill.
„ Ontermittent exotropia that is of small magnitude, occurs
infrequently, and does not cause symptoms may not require
treatment because amblyopia does not usually develop.
„ Of symptoms of eye strain from an uncorrected refractive error
become troublesome or if attempting to bring the eyes into
alignment becomes troublesome, eyeglasses may be used
„ On severe cases, surgery may be needed.
m aralytic 2trabismus
„ On paralytic strabismus, one or more of the eye muscles that move the eye in different
directions become paralyzed.
„ As a result, the muscles no longer work in balance.
„ The eye muscle paralysis is usually caused by a disorder that affects the nerves to the eye
muscles, such as certain viral illnesses, brain injuries, or brain tumors that increase pressure
within the skull and compress these nerves.
m On children with paralytic strabismus, movement of the affected eye is impaired
only when the eye tries to move in a specific direction, not in all directions.
m Amblyopia or double vision may develop. The double vision is made worse by
looking in directions normally controlled by the paralyzed eye muscles.
m aralytic strabismus may resolve by itself over time. However, it may need to be
corrected with eyeglasses and covering of the unaffected eye. 2ometimes
eyeglasses with prisms are used. Alternatively, surgery may be needed. Of
paralytic strabismus results from another condition affecting the nerves, such as
a brain tumor, the other condition also needs to be treated.
m Amblyopia refers to a decrease of vision, either
unilaterally or bilaterally, for which no cause can
be found by physical examination of the eye.
m The term functional amblyopia often is used to
describe amblyopia, which is potentially reversible
by occlusion therapy.
m Organic amblyopia refers to irreversible amblyopia
m Most vision loss from amblyopia is preventable or
reversible with the right kind of intervention.
m The recovery of vision depends on how mature
the visual connections are, the length of
deprivation, and at what age the therapy is begun.
m On general, amblyopia is believed to result from
disuse from inadequate foveal or peripheral retinal
stimulation and/or abnormal binocular interaction
that causes different visual input from the foveae
m There are Three critical periods of human visual
acuity development
„ uring these time periods, vision can be affected by the
various mechanisms to cause or reverse amblyopia.
m The development of visual acuity from the 20/200
range to 20/20, which occurs from birth to age 3-5
years.
m The period of the highest risk of deprivation
amblyopia, from a few months to 7 or 8 years.
m The period during which recovery from amblyopia
can be obtained, from the time of deprivation up to
the teenage years or even sometimes the adult
years.
m Ý

„ revalence of amblyopia is difficult to assess and varies in the
literature, ranging from 1-3.5% in healthy children to 4-5.3% in
children with ophthalmic problems. Most data show that about 2%
of the general population has amblyopia.
„ Amblyopia was shown in the Visual Acuity Ompairment 2urvey
sponsored by the National Eye Onstitute (NEO) to be the leading
cause of monocular vision loss in adults aged 20-70 years or
older. revalence of amblyopia has not changed much over the
years.
m 







„ Amblyopia is an important socioeconomic problem. 2tudies have

shown that it is the number one cause of monocular vision loss in
adults. Furthermore, persons with amblyopia have a higher risk of
becoming blind because of potential loss to the sound eye from
other causes.
m ²
„ No racial preference is known.
m 
„ No gender preference is known.
m 6 
„ Amblyopia occurs during the critical periods of visual
development. An increased risk exists in those children
who are developmentally delayed, were premature,
and/or have a positive family history
m Ocular history
„ Elicit any previous history of patching or eye drops as
well as past compliance with these therapies.
„ ocument previous ocular surgery or disease.
m On addition to the routine information, obtaining a
family history of strabismus or other ocular
problems is important because the presence of
these ocular problems may predispose a child to
amblyopia.
m Visual acuity
„ iagnosis of amblyopia usually requires a 2-line
difference of visual acuity between the eyes
„ Crowding phenomenon: A common characteristic of
amblyopic eyes is difficulty in distinguishing optotypes
that are close together. Visual acuity often is better when
the patient is presented with single letters rather than a
line of letters.
„ iagnosis is not an issue in children old enough to read
or with use of the tumbling E.
m Testing in preverbal children
„ Of the child protests with covering of the sound eye, amblyopia
can be diagnosed if it is dense.
„ Fixation preference may be assessed, especially when
strabismus is present.
„ Onduced tropia test may be performed by holding a 10-prism
diopter before one eye in cases of an orthophoria or a
microtropia.
„ On infants who cross-fixate, pay attention to when the fixation
switch occurs; if it occurs near primary position, then visual
acuity is equal in both eyes.
„ Caution should be used when obtaining Teller acuity in
children, as grating acuity may be less reduced than 2nellen
acuity, especially in strabismic amblyopia.
m Contrast sensitivity: 2trabismic and anisometropic
amblyopic eyes have marked losses of threshold
contrast sensitivity, especially at higher spatial
frequencies; this loss increases with the severity of
amblyopia.
m Neutral density filters: atients with strabismic
amblyopia may have better visual acuity or less of a
decline of visual acuity when tested with neutral
density filters compared to the normal eye. This was
not found to be true in patients with anisometropic
amblyopia or organic disease.
m Binocular function: Amblyopia usually is associated
with changes in binocular function or stereopsis.
m Eccentric fixation: 2ome patients with amblyopia may
consistently fixate with a nonfoveal area of the retina under
monocular use of the amblyopic eye, the mechanism of which is
unknown. This can be diagnosed by holding a fixation light in the
midline in front of the patient and asking them to fixate on it while
the normal eye is covered. The reflection of the light will not be
centered.
m ²efraction: Cycloplegic refraction must be performed on all
patients, using retinoscopy to obtain an objective refraction. On
most cases, the more hyperopic eye or the eye with more
astigmatism will be the amblyopic eye. Of this is not true, one
needs to investigate further for ocular pathology.
m ²est of examination: erform a full eye examination to rule out
ocular pathology
m Anisometropia
„ Onhibition of the fovea occurs to eliminate the abnormal
binocular interaction caused by one defocused image
and one focused image.
„ This type of amblyopia is more common in patients with
anisohypermetropia than anisomyopia. 2mall amounts of
hyperopic anisometropia, such as 1-2 diopters, can
induce amblyopia. On myopia, mild myopic anisometropia
up to -3.00 diopters usually does not cause amblyopia.
„ Hypermetropic anisometropia of 1.50 diopters or greater
is a long-term risk factor for deterioration of visual acuity
after occlusion therapy.
m 2trabismus
„ The patient favors fixation strongly with one eye and
does not alternate fixation. This leads to inhibition of
visual input to the retinocortical pathways.
„ Oncidence of amblyopia is greater in esotropic patients
than in exotropic patients.
m 2trabismic anisometropia: These patients have
strabismus associated with anisometropia.
m Visual deprivation: Amblyopia results from disuse or
understimulation of the retina. This condition may be
unilateral or bilateral. Examples include cataract,
corneal opacities, ptosis, and surgical lid closure.
m Organic: 2tructural abnormalities of the retina or the
optic nerve may be present. Functional amblyopia
may be superimposed on the organic visual loss.
m O 


„ Of suspicion exists of an organic cause for decreased
vision and the ocular examination is normal, then further
investigations into retinal or optic nerve causes should be
initiated. 2tudies to perform include imaging of the visual
system through CT scan, M²O, and fluorescein
angiography to assess the retina.
m


„ Although differences in the electrophysiologic responses
of normal eyes versus amblyopic eyes have been
reported, these techniques remain investigational and the
differences are controversial
m S

 



„ Histologic studies of the lateral geniculate nucleus in

kittens with deprivation amblyopia have shown that cells
receiving input from the deprived eye were shrunken and
atrophied, while cells receiving input from the
nondeprived eye were expanded.
m 
 

m The clinician must first rule out an organic cause
and treat any obstacle to vision (eg, cataract,
occlusion of the eye from other etiologies).
m ²emove cataracts in the first 2 months of life, and
aphakic correction must occur quickly.
m Treatment of anisometropia and refractive errors must occur
next.
„ The amblyopic eye must have the most accurate optical correction
possible. This should occur prior to any occlusion therapy because vision
may improve with spectacles alone.
„ Full cycloplegic refraction should be given to patients with
accommodative esotropia and amblyopia. On other patients, a prescription
less than the full plus measurement that was refracted may be prescribed
given that the decrease in plus is symmetric between the two eyes.
Because accommodative amplitude is believed to be decreased in
amblyopic eyes, one needs to be cautious about cutting back too much
on the amount of plus. ²efractive correction alone has been shown to
improve amblyopia in up to 77% of patients in a nationwide trial.
„ atients with bilateral refractive amblyopia do well with spectacle
correction alone, with most children aged 3-10 years achieving 20/25 or
better within a year.
m The next step is forcing the use of the amblyopic eye by
occlusion therapy. Occlusion therapy has been the mainstay of
treatment since the 18th century. The following are general
guidelines for occlusion therapy:
„ atching may be full-time or part-time. 2tandard teaching has been that
children need to be observed at intervals of 1 week per year of age, if
undergoing full-time occlusion to avoid occlusion amblyopia in the sound
eye. The Amblyopia Treatment 2tudies (AT2) have helped to provide new
information on the effect of various amounts of patching.
„ Always consider lack of compliance in a child where visual acuity is not
improving. Compliance is difficult to measure but is an important factor in
determining the success of this therapy.
„ On addition to adhesive patches, opaque contact lenses, occluders
mounted on spectacles, and adhesive tape on glasses have been used.
„ Establishing the fact that the vision of the better eye has been degraded
sufficiently with the chosen therapy is important.
m The Amblyopia Treatment 2tudies have helped to define the role of full-time
patching versus part-time patching in patients with amblyopia. The studies have
demonstrated that, in patients aged 3-7 years with severe amblyopia (visual
acuity between 20/100 and 20/400), full-time patching produced a similar effect
to that of 6 hours of patching per day. On a separate study, 2 hours of daily
patching produced an improvement in visual acuity similar to that of 6 hours of
daily patching when treating moderate amblyopia (visual acuity better than
20/100) in children aged 3-7 years. On this study, patching was prescribed in
combination with 1 hour of near visual activities.
m ata from the Amblyopia Treatment 2tudies are also available for older patients.
For patients aged from 7 years to younger than 13 years, the Amblyopia
Treatment 2tudies have suggested that prescribing 2-6 hours a day of patching
can improve visual acuity even if the amblyopia has been previously treated.
For patients aged from 13 years to younger than 18 years, prescribing 2-6 hours
a day of patching might improve visual acuity when amblyopia has not been
previously treated; however, this is likely to be of little benefit if amblyopia was
previously treated with patching. Long-term results from these studies are still
pending.
m The Amblyopia Treatment 2tudies have also found
that about one fourth of children with amblyopia who
were successfully treated experience a recurrence
within the first year after discontinuation of treatment.
ata from these studies suggest that patients treated
with 6 or more hours a day of patching have a greater
risk of recurrence when patching is stopped abruptly
rather than when it is reduced to 2 hours a day prior to
cessation of patching. ²andomized studies have still
yet to be performed.
m enalization therapy
„ On the past, penalization therapy was reserved for
children who would not wear a patch or in whom
compliance was an issue. The Amblyopia Treatment
2tudies, however, have demonstrated that atropine
penalization in patients with moderate amblyopia (defined
by the study as visual acuity better than 20/100) is as
effective as patching. The Amblyopia Treatment 2tudies
were performed in children aged 3-7 years
m The Amblyopia Treatment 2tudies have also
demonstrated that weekend use of atropine provided
an improvement in visual acuity similar to that of daily
use of atropine when treating moderate amblyopia in
children aged 3-7 years.
m Atropine drops or ointment is instilled in the
nonamblyopic eye. This therapy is sometimes used in
conjunction with patching or occlusion of the glasses
(eg, adhesive tape, nail polish) by individual
practitioners. On the Amblyopia Treatment 2tudies that
evaluated patching versus atropine penalization,
atropine penalization and patching were used in
conjunction with 1 hour of near visual activities.
m This technique may also be used for maintenance
therapy, which is useful, especially in patients with
mild amblyopia.
m Other options include optical blurring through contact
lenses or elevated bifocal segments.
m The endpoint of therapy is spontaneous alternation of
fixation or equal visual acuity in both eyes.
„ When visual acuity is stable, patching may be decreased
slowly, depending on the child's tendency for the amblyopia to
recur.
„ Because amblyopia recurs in a large number of patients (see
rognosis), maintenance therapy or tapering of therapy should
be strongly considered. This tapering is controversial, so
individual physicians vary in their approaches
m Treatment of strabismus generally occurs last. The
endpoint of strabismic amblyopia is freely
alternating fixation with equal vision. 2urgery
generally is performed after this endpoint has
been reached.
m 2urgical therapy for strabismus generally should
occur after amblyopia is reversed. isadvantages
to surgical therapy prior to correction of amblyopia
include difficulty in telling if amblyopia is present
because there is no longer a strabismus to assess
fixation preference and higher potential to being
lost to follow-up, as the child cosmetically looks
better. The improved cosmesis gives the parents a
false sense of security about the vision improving.
m harmacologic treatment with levodopa has been
investigated and has showed transient improvement of
vision in amblyopic eyes. However, the exact role of such
pharmacologic agents has not been determined. Levodopa
currently is not being used clinically.
m Atropine penalization (with either ointment or drops) is an
alternative method of blurring vision in the sound eye of
patients who refuse patching. Ot may be applied once a day
to patients in the preferred eye only.
m 
  

„ These agents are used to blur vision in one eye to treat amblyopia
in the contralateral eye
m Outpatient follow-up care needs to continue beyond the
primary completion of amblyopia treatment because visual
deterioration occurs in many children. On a multicenter
study conducted as part of the Amblyopia Treatment
2tudies, one fourth of patients experienced recurrence of
amblyopia within the first year after treatment, with the risk
of recurrence greater if the treatment was stopped abruptly
rather than tapered. One study by Levartovsky et al
showed deterioration in 75% of children with anisometropia
of 1.75 diopters or more after occlusion
therapy. ²ecidivism can occur, even several years after the
initial treatment period, and is as high as 53% after 3 years.
m Vision screening programs: 2tudies have shown these programs
to be technically easy and that they help reduce cost as well as
incidence of amblyopia because of early treatment and detection.
Current programs include use of the photorefractor and school
vision screening programs.
m Amblyopia after trauma
„ Úoung patients who have trauma to their eyes often are at risk for
occlusion amblyopia. ossible reasons include lid edema, hyphema,
occlusive dressing, vitreous hemorrhage, and traumatic cataract.
„ This amblyopia often is superimposed on a visual deficit caused by any
structural abnormality and needs to be taken into account when treating
these children.
„ Vision needs to be monitored closely in children after ocular trauma,
especially in those aged up to 6 years and in nonverbal children.
Occlusive therapy needs to be instituted if there is any suggestion of
decreased vision in the injured eye.
m  


„ The main complication of not treating amblyopia is long-
term irreversible vision loss. Most cases of amblyopia are
reversible if detected and treated early, so this vision loss
is preventable.
m 


„ After 1 year, about 73% of patients show success after their
first trial of occlusion therapy. 2tudies have shown that the
number of patients who retain their level of visual acuity
decreases over time to 53% after 3 years.
„ ²isk factors for failure in amblyopia treatment include the
following:
R Type of amblyopia: atients with high anisometropia and patients
with organic pathology have the worse prognosis. atients with
strabismic amblyopia have the best outcome.
R Age at which therapy began: Úounger patients seem to do better.
R epth of amblyopia at start of therapy: The better the initial visual
acuity in the amblyopic eye, the better the prognosis.