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Amblyopia and strabismus: Trends in prevalence and risk factors among young
adults in Israel
Article in British Journal of Ophthalmology · August 2017
DOI: 10.1136/bjophthalmol-2017-310364

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1
Department of Ophthalmology,
Rambam Health Care Campus,
Haifa, Israel
2 1971 and 1994. Across the birth years, the following trends
Israel Defense Forces, Medical
Corps, Tel Hashomer, Israel
3Bruce and Ruth Rappaport
Faculty of Medicine, Israel
Institute of Technology, Haifa,
Israel
Correspondence to
Dr Yinon Shapira, Department of
Ophthalmology, Rambam Health
Care Campus, Haifa, Israel;
yinonshapira@gmail.com
Received 20 February
2017 Revised 3 July 2017
Accepted 28 July 2017
To cite: Shapira Y, Machluf
Y, Mimouni M, et al.
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science
Amblyopia and strabismus: trends in prevalence
and risk factors among young adults in Israel
Yinon Shapira,1 Yossy Machluf,2 Michael Mimouni,1 Yoram Chaiter,2 Eedy Mezer1,3
Abstract
Aims To estimate the prevalence of amblyopia,
present strabismus and amblyopia risk factors
(ARFs) among young adults in Israel and to
analyse trends over time of prevalence rates.
Methods We conducted a cross-sectional study including
107 608 pre-enlistees aged 17.4±0.6 years born between
of prevalence rates among young adults were analysed:
prevalence of amblyopia, prevalence of strabismus,
severity of amblyopia and prevalence of ARFs
(strabismsus, anisometropia and isoametropia). Unilateral
amblyopia was defined as best corrected visual acuity
(BCVA) of <0.67 (6/9) in either eye or as an interocular
difference of two lines or more. Bilateral amblyopia was
defined as BCVA of <0.67 (6/9) in both eyes. The severity
of amblyopia was classified as mild (BCVA ≥0.5 [6/12]),
moderate (BCVA <0.5 [6/12] and ≥0.25 [6/24]) or severe
(BCVA <0.25 [6/24]).
Results The prevalence of young adulthood amblyopia
declined by 33%, from 1.2% to 0.8% (R2=0.87, p<0.001)
across 24 birth years. This decline may be due to a drop in
unilateral amblyopia from 1% to 0.6% (R2=0.93, p<0.001),
while the prevalence of bilateral amblyopia remained stable
(0.2%, p=0.12). The decline in amblyopia was apparent in
mild and moderate amblyopia, but not in severe amblyopia.
Strabismus and anisometropia were detected in 6–
12% and 11–20% of subjects with unilateral amblyopia,
respectively, without significant trends. Strabismic
amblyopia remained constant in the entire population
across years. Isoametropia was detected in 46–59% of
subjects with bilateral amblyopia without a significant trend
across birth years. Prevalence of strabismus in the study
population decreased by 50%, from 1.2%
to 0.6% (R2=0.75, p<0.001). In subjects with present
strabismus, the prevalence of mild unilateral
amblyopia increased, while moderate or severe
unilateral amblyopia remained relatively stable.
Conclusion Among young adults, the prevalence of
unilateral amblyopia, as well as the prevalence of present
strabismus, decreased significantly over a period of a
generation. The prevalence of strabismic, bilateral or
severe (both unilateral and bilateral) amblyopia remained
stable. The establishment of the national screening
programme for children and the improved utility of
treatment for amblyopia and strabismus coincide with
these trends. Thus, it is possible that these early
interventions resulted in modification of the ‘natural history’
of these conditions and their prevalence in adolescence.
Introduction
Amblyopia, when not treated at the appropriate time,
is the most common cause of uncorrectable visual
impairment in children and in adults up to
Shapira Y, et al. Br J Ophthalmol 2017;0:1–8. doi:10.1136/bjophthalmol-2017-310364
1
60 years old. Strabismus is a common cause of
amblyopia, with repercussions for both social inte-
2
gration and mental health. Identifying and treating
strabismus at an earlier age improves the chance of
restoring binocularity and may prevent permanent
3
strabismus-associated amblyopia.
Previous studies have indicated that treatment of
4
amblyopia in young children is highly successful.
Targeted approaches to screen for amblyopia and treat
156
it have thus been implemented. Indeed, correction
of avoidable causes of amblyopia, for example, by
providing optometric services for chil-dren with
refractive errors, is one of the priorities of the World
7
Health Organization Initiative Vision 2020, and
preschool vision screening is receiving increasing
8
attention.
While several population-based studies assessed the
prevalence of amblyopia and strabismus in various
world regions and ethnic populations, to the best of
our knowledge, no population-based studies have
assessed the trends over time in prev-alence of
amblyopia and its associated risk factors.
Furthermore, evaluating the trends of amblyopia
and/or strabismus in an older, non-paediatric popu-
lation may provide valuable feedback for ongoing
efforts to reduce the prevalence of these conditions
and perhaps help further refine the recommenda-tions
for screening and treatment.
In the current study, trends over time in the
prevalence rates of amblyopia and present stra-bismus
among young adults in northern Israel, over
approximately one generation, were assessed.
Methods
This research adhered to the tenets of the Declara-tion
of Helsinki.
Study participants
Military conscription of 18-year-old adolescents in
Israel is mandatory, and they are obliged by law to
appear at the Israel Defense Forces (IDF) recruiting
office at the age of 17 years. At the end of an
extensive medical evaluation process, a medical
profile and appropriate Functional Classi-fications
Codes (FCCs) are assigned to each recruit and stored
in a computerised database. FCCs describe the
medical status and are similar to the International
Classification of Diseases coding. The medical
process and its outcomes were previ-ously described
9 10
in detail.
The computerised database of the northern
recruitment centre of Israel was used for this study,
previously shown to have a stringent, high-quality
10
medical process and reliable medical data.
1
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Clinical science
The study population consisted of consecutive conscripts 16–19
years old, born between 1971 and 1994, who completed the medical
profiling process in the years 1988–2012.
Exclusion criteria
Subjects diagnosed with visual impairment found to have fundus or
anterior segment abnormalities or a history of organic causes that
may decrease best corrected visual acuity (BCVA) were excluded
from this analysis. Exclusion conditions included the presence of
ptosis, lagophthalmus, epiphora, chronic conjunc-
tivitis/blepharoconjuctivitis, keratoconjunctivitis sicca, corneal
disorders/opacities, uveitis, glaucoma, cataract, aphakia, retinal
disorders/degenerative diseases, visual fields impairment, optic
nerve disorders or nystagmus.
Data collection
Throughout the study years, each subject had their uncorrected
distance visual acuity determined using a standard projected Snellen
chart examination. Visual acuity was examined by a selected group
of skilled medical technicians who were trained by experienced
staff ophthalmologists and the physician staff. The training was
based on specific and detailed protocols that were published by the
IDF Medical Corps. Care was taken to adhere to the protocol and
use the same principles and methods over the years . Subjects who
could read all the letters but one of the 1.0 (6/6) line, without optical
correction, were assumed to have 0  dioptres (D) refractive error.
Subjects unable to correctly read more than one letter of the 6/6 line
without optical correction were referred for automated non-
cycloplegic refraction (Speedy K; Nikon Corp., Tokyo, Japan; KR-
8000 and KR7000S, Topcon, Tokyo, Japan, and earlier models)
followed by subjective refraction validation with a standard Snellen
chart for determination of BCVA, determined by either a certified
optometrist or an ophthalmologist. The visual acuity was scored
using line assignment scoring, with the value of the lowest line in
which the majority of letters can be read accurately scored as the
patient’s visual acuity. All recruits unable to correctly read more
than one letter of the 6/6 line with optical correction, and all with
strabismus, were examined by an ophthalmologist. FCCs were
determined according to recommendations of the ophthalmologist
and rechecked before final determination by the medical
committee’s chairmen. Strabismus was determined based on routine
orthoptic cover–uncover test and alternate cover test.
The computerised medical database of all eligible recruits was
reviewed and the relevant data were extracted , including: birth
year, age at presentation, gender, spherical equivalent (SE),
cylinder, BCVA and strabismus status (based on FCCs).
Definitions
Unilateral amblyopia was defined as BCVA of <0.67 (6/9) in either
eye or as an interocular difference (IOD) of two lines or more.
Bilateral amblyopia was defined as BCVA of <0.67 (6/9) in both
eyes. The severity of amblyopia was classified as mild (BCVA ≥0.5
[6/12]), moderate (BCVA <0.5 [6/12] and ≥0.25 [6/24]) or
5
severe (BCVA <0.25 [6/24]).
Anisometropia criteria included eyes with an IOD (SE) >+1.5D
for anisohyperopia, a cylinder IOD >2D for anisoast-igmatism or
11
an IOD >−|3D| for anisomyopia. Isoametropia criteria included
eyes with bilateral hyperopia >+4D for isohy-peropia, bilateral
myopia >|−5D| for isomyopia or bilateral astigmatism >2D for
11
isoastigmatism.
2 Shapira Y, et al. Br J Ophthalmol 2017;0:1–8. doi:10.1136/bjophthalmol-2017-310364
Statistical analysis
Data were analysed by the StatSoft Statistica software, version 10
(StatSoft, Oklahoma, USA). Analyses of regression over time were
conducted for five equally spaced time periods (1971– 1975; 1976–
1980; 1981–1985; 1986–1990; 1991–1994). A polynomial
regression analysis was performed to assess the significance of non-
linear trends. Graphs are presented with their corresponding
2
regression lines, respective equations, R and p values.
2
A χ test was used for comparison of proportions. Student’s t-test
or analysis of variance was used for comparison of means, as
appropriate. A two-sided p value of<0.05 was considered as
statistically significant.
Results
Of the 107 896 young adults who presented at the recruit-ment
centre, 288 (0.3%) were excluded from this analysis due to potential
organic causes of decreased visual acuity. Thus, the study
population consisted of 107 608 young adults born between 1971
and 1994. The mean age was 17.4±0.6 years (median 17.3, range
16–19) and 58% were men.
Unilateral or bilateral amblyopia was detected in 884 (0.82%;
95% CI–0.77% to 0.88%) and 216 (0.2%; 95% CI–0.18% to 0.23%)
subjects, respectively. The prevalence of amblyopia risk factors
(ARFs) detected in variable severities of unilateral or bilateral
amblyopia is presented in table 1.
Trends in the prevalence of amblyopia
There was a general trend of declining prevalence of amblyopia
2
across 24 birth years (R =0.87, p<0.001) (figure 1A; see online
supplementary figure 1 for corresponding year-by-year data anal-
ysis). The prevalence of amblyopia was 1.2% (95% CI–1.07% to
1.23%)% in the population born between 1971 and 1985, with a
decline to 0.8% (95% CI–0.73% to 0.90%, p<0.001) in the
population born between 1986 and 1994. This decline can be
attributed to a drop in unilateral amblyopia prevalence from 1%
(95% CI–0.86% to 1.01%)% to 0.6% (95% CI–0.58% to 0.73%,
2
R =0.93, p<0.001), while bilateral amblyopia prev-alence remained
relatively stable (~0.2%, 95% CI–0.18% to 0.23%, p=0.12).
Trends in the severity of amblyopia
Amblyopia severity was analysed for all cases of amblyopia
(unilateral as well as bilateral). There was a general decrease in the
2
prevalence of mild cases (R =0.74, p<0.001) of amblyopia, with a
pooled prevalence of 0.70% (95% CI–0.59% to 0.71%) in those
born between 1971 and 1985 compared with 0.40% in those born
between 1986 and 1994 (95% CI–0.32% to 0.44%, p<0.001; figure
1B). Similarly, there was also a decrease in the prevalence of
2
moderate cases (R =0.82, p=0.003), with a pooled prevalence of
0.34% (95% CI–0.30% to 0.39%) and 0.20% (95% CI–0.17% to
0.26%) for those born between 1971 and 1985 and between 1986
and 1994, respectively (p<0.001). The prevalence of severe
amblyopia did not change and was ~0.18% (95% CI–0.16% to
0.21%) across years (p=0.19).
Trends in the presence of strabismus
There was a significant fluctuation in the prevalence of present
strabismus among young adults in the study population over time
2
(R =0.75, p<0.001) (figure 2A; see online supplementary figure 2
for a corresponding year-by-year data analysis). The prevalence of
present strabismus was 1.2% (95% CI–1.11% to 1.28%) in the
population born between 1971 and 1985, with a decline to
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Clinical science
0.6% (95% CI–0.53% to 0.68%, p<0.0001) in the population born

or anisometropia Total (%) ARFs

between 1986 and 1994. Strabismic amblyopia was detected in
0.067–0.095% of the entire population in the different birth years,
without a significant trend (p=0.82). Unilateral amblyopia was

39%

64%

64%

72%
44%

40%
present in 4–14% of strabismic subjects (figure 2B), with a
significantly higher prevalence among subjects born between 1986
2
and 1994 (R =0.91, p=0.004). This peak can be attributed to a
Total (%)strabismus and/

significant rise in the occurrence of mild unilateral amblyopia

2
among strabismic subjects (R =0.75, p=0.003). The proportion of

25%

10%

11%

24%
20%

23% moderate or severe unilateral amblyopia did not change signifi-

cantly over time (p=0.52 and p=0.22, respectively; figure 2B)
among strabismic subjects.
isoametropia

Strabismus was diagnosed in 6–12% of cases with unilateral

2
amblyopia, without a significant trend (R =0.52, p=0.48; see online
112/468

24/174

64/121
42/242

37/70

12/25
supplementary figure 3A).
(24%)

(17%)

(14%)

(54%)

(53%)

(48%)
Any
Isoastigmatism

Prevalence of anisometropia and isoametropia

Anisometropia was diagnosed in 11–20% of unilateral ambly-opia
2
in the different birth years, without a significant trend (R =0.67,
19/121
37/468

17/242

6/174

16/70
(16%)

(23%)

(12%)
3/25

p=0.21; see online supplementary figure 3B). The prevalence of

(8%)

(7%)

(3%)

anisometropic amblyopia was 0.1–0.17% of the entire population in

the different birth years, without a signifi-cant trend (p=0.10).
Isomyopia

A comparison of anisometropia proportion, mean IOD and mean

12/174

41/121
64/468

15/242

BCVA between unilateral amblyopes and non-amblyopes is

21/70
(14%)

(34%)

(30%)

(24%)
6/25
(6%)

(7%)

presented in table 2. There was a 30-fold to 100-fold greater chance

of clinically significant anisohyperopia, anisomyopia or anisoastig-
matism among unilateral amblyopes compared with non-ambly-
Isoametropia

Isohyperopia

opes. On the other hand, among amblyopes versus non-amblyopes

amblyopia

passing the clinically significant thresholds of anisometropia, there

11/468

10/242

6/174

4/121

(12%)
0/70

3/25

were no significant differences in the mean IODs. Also, there was

(2%)

(4%)

(3%)

(3%)

(0%)

no difference in the BCVA of anisohyperopic, anisomyopic or

anisoastigmatic amblyopic subjects (p=0.09).
and strabismus

Bilateral ametropia (ie, iso - hyperopic, myopic or astigmatic)

occurred in 46–59% of bilateral amblyopes in the different birth
2/2428%)(9%)(0.
severities of unilateral or

2
years, without a significant trend (R =0.31, p=0.88; see online
supplementary figure 3B), and 20% of all cases with unilateral
4/174
5/468

0/121
(0%)
(2%)

(0%)
0/70

0/24

amblyopia had isoametropia (table 1).

(1%)

(0%)

The prevalence of isoametropia, mean isoametropia magni-tude

Anisometropia
Anisometropia Strabismus

and mean BCVA were compared between bilateral ambly-opes and

bilateral

21/242

non-amblyopes (table 3). There was a 20-fold to 50-fold greater

18/174
32/468

5%)(2.
3/121
(10%)

(20%)
3/70

5/25
(7%)

(4%)

chance of clinically significant iso - hyperopia, myopia or

astigmatism among bilateral amblyopes when compared with non-
amblyopes. Among bilateral amblyopes versus non-amblyopes
passing the clinically significant thresholds of isomyopia, the mean
(ARFs) in

magnitude of isomyopia was significantly larger among bilateral

30/174

10/121
66/468

36/242
different

(14%)

(15%)

(17%)

5/70

1/25
(8%)

(7%)

(4%)

amblyopes. Similarly, the mean magnitude of clinically significant

isohyperopia was marginally larger in cases of bilateral amblyopia,
while isoastigmatism was comparable between the groups (table 3).
There was no difference in the BCVA of iso - hyperopic, myopic or
astigmatic subjects with bilateral amblyopia (p=0.15).
Proportion of amblyopia risk

Of total
468/884

121/216

Discussion
(53%)

(56%)

To the best of our knowledge, this study is the first to describe the
change in prevalence of amblyopia and strabismus over a
Affected side Severity

considerable period and in a large population-based sample. The

242/884

174/884

70/216

25/216

fact that our subjects were sampled over a span of a generation of

Mild

Mild

birth years within the same age group, using the same eval-uation
techniques, criteria and classification codes and metic-ulous
documentation, provided an opportunity to estimate trends over the
Amblyopia

Moderate
Unilateral

Moderate
Table 1

Bilateral
factors

Severe
Severe
(n=884)

(n=216)

years. We revealed a decline in the prevalence of young adulthood

(27%)

(20%)

(32%)

(12%)

amblyopia by 33% (from 1.2% to 0.8%). We also identified a

decline in the prevalence of young adulthood
Shapira Y, et al. Br J Ophthalmol 2017;0:1–8. doi:10.1136/bjophthalmol-2017-310364 3
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Clinical science

Figure 1 (A) Prevalence of unilateral and bilateral amblyopia by birth year among young adults. (B) Pooled prevalence of
unilateral and bilateral amblyopia, stratified according to severity, by birth year among young adults.

strabismus. Of note, the strabismus trend is not as consistent as the
one observed in the case of young adulthood amblyopia, with a
relatively fluctuating pattern in the birth years preceding 1985.
Nevertheless, after 1985 indeed the declining regression trend is
emphasised. Furthermore, the pooled prevalence of strabismus was
1.2% in the population born between 1971 and 1985, with a 50%
decline to 0.6% in the population born between 1986 and 1994. This
pooled discrimination is similar and congruent to the corresponding
amblyopia prevalence analysis.
12
A recent study by Rosman et al in Singaporean men aged 18–
19 years, all pre-enlistees to obligatory military service, reported
0.35% amblyopia prevalence. This rate is lower than previous
13–15
estimates in adult populations (>30 years) and is in agreement
with the figures in our young adult population.
4 Shapira Y, et al. Br J Ophthalmol 2017;0:1–8. doi:10.1136/bjophthalmol-2017-310364
Indeed, the population’s age group and characteristics (ie,
conscripts) are comparable with our sample, with a notable
12
difference that only men were assessed by Rosman et al.
Since the early 1990s, Israeli children have undergone
compulsory vision screening before age 6. The implementa-tion of
this screening, together with the universal healthcare provided to all
Israeli citizens by legislation (passed in 1994), may explain the
overall relatively low rates of amblyopia and strabismus in our
12
Israeli young adults. Rosman et al propose that the low
prevalence in their study may partly be explained by a national
screening programme, started in 1991, to detect and treat amblyopia
among Singaporean school children. They do, however, disclose
that no data were available to verify that this programme is
12
effective in reducing amblyopia. Unlike Rosman
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Clinical science

Figure 2 (A) Prevalence of young adulthood strabismus by birth year. (B) Prevalence of unilateral amblyopia, stratified by
severity, by birth year among strabismic young adults.

12
et al, we suggest that the decline over time in the proportion of
young adults with amblyopia, as well as in strabismus rates, and the
turning point identified in those born from the mid-1980s and
onwards in our study correspond with both the advent of the
national screening programme and the healthcare legislation.
Additionally, there was an increase in the number of fellow-ship-
trained paediatric ophthalmologists who began practising medicine
in northern Israel from the 1990s, from 1 to 7, over the time span of
this study.
The first birth cohorts in this study, up to approximately the year
1985, are unlikely to have benefitted from the screening programme
and universal healthcare as they would have been beyond the
amblyogenic age, when amblyopia can be most effec-tively treated
at the time those programmes were implemented,
Shapira Y, et al. Br J Ophthalmol 2017;0:1–8. doi:10.1136/bjophthalmol-2017-310364
while the later cohorts might have been expected to show some
benefit. This association also implies that the trend does not denote
a decreasing prevalence of childhood unilateral ambly-opia, but
rather identifies the effect of positive interventions on the natural
history of this condition.
Similarly, while it is plausible that there are some other aspects
related to the decline in strabismus prevalence over time, for
example, due to improved perinatal care in Israel over the last
16 17
decades, our findings do not imply a causality between the
declining strabismus rates (as an ARF) and declining ambly-opia. In
fact, more plausibly they suggest that both conditions declined in
parallel due to a better diagnosis and treatment in the paediatric
population. This effect is expressed as decreased rates of amblyopia
as well as lower rates of strabismus among young
5
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Clinical science
adults. In agreement, we have also shown that the prevalence of
refractive ARFs has not changed over the years and thus could

anisometropia

449/106 508
neither account for the reduction in amblyopia.

Prevalence
Interestingly, while this may explain the noted decline in

132/884

<0.001
42%)(0.
(15%)
amblyopia and the present strabismus rates over the studied years
Any
(and specifically when categorically comparing the rates up to the
year 1985 with the rates after this year), this decline was not noted
in severe amblyopia cases. This can be explained by noting that
(LogMAR) *†
severe cases of amblyopia, due to high hypermetropia, for example,
Mean BCVA

06±0.090.
45±0.210.
are significantly less amenable to treatment compared with cases of

<0.001
18
mild childhood amblyopia, even when detected at an early age.
Furthermore, we observed an increase in the prev-alence of mild
unilateral amblyopia among currently strabismic subjects. Our data
imply that the overall prevalence of strabismic amblyopia remained
Mean IOD (D)*

fairly constant in the (entire) population over the studied decade.

subjects without amblyopia

Accordingly, figures 2A and 2B appear to be mirror images of each

30±0.983.

other, implying that as the prevalence of young adulthood

13±0.94166/1065083.

strabismus decreased in the population, the percentage of strabismic

subjects with mild amblyopia increased. This epidemiological
Anisoastigmatism

finding may imply that cases that were not detected (or successfully
Prevalence

27<0.0010.

treated surgically) included small angle strabismus or stable

19
microtropia, which is associated with a near normal visual acuity.
48/884

16%)(0.
(5.4%)

These cases may have been missed during routine health exams and
thus had less chance of being referred to a paediatric
ophthalmologist, despite the rise in availability of specialists or the
*The analysis was conducted only among amblyopes versus non-amblyopes passing the clinically significant thresholds of these anisometropias†IntheweakereyeBCVA,bestcorrectedvisualacuity;D,dioptres;IOD,interoculardifference;SE,sphericalequivalent
Comparison of anisometropia proportion, mean IOD and mean BCVA between subjects with unilateral amblyopia

implementation of the national screening programme.

Previous studies identified variable rates of ARFs in amblyopic

Mean IOD (SE)* (LogMAR) *†

subjects. The disparity may reflect variability between ethnic

12–
groups, differing population ages or depend on definitions used.
51±0.270.

15 20–22
05±0.08Non-amblyopes36/1065082.0.247/1065085.0.

It has been previously shown that among unilateral

amblyopic children approximately one-third have strabismus, one-
23–25
third have anisometropia and one-third have both.
However, the rates during childhood may be different later in life
during young adulthood. The age range of the study popula-tion
23±3.155.

assessed by Rosman et al was similar to our sample, although they

did not discriminate between unilateral or bilateral cases when
12
reporting ARFs. We found lower rates of anisometropia (up to
<0.001

20%) and anisoastigmatism (5.4%) compared with rates of 38% and

Prevalence

12
14.5%, respectively, as reported by Rosman et al. The prevalence
of strabismic amblyopia in our cohort (8%) was higher than the
57/884

12
5.6% reported in the Singaporean conscripts.
Anisomyopia

53pValue<0.0010.<0.001<0.0010.

Interestingly, while refractive ARFs were unsurprisingly

Mean BCVA

substantially more prevalent among amblyopes when compared

(LogMAR)*†

23%)(0.

with non-amblyopes, we nonetheless detected a prevalence of close

58±0.280.
(6.4%)

to 0.5% of clinically significant anisometropia and almost 2.5% of

clinically significant isoametropia among indi-viduals without
amblyopia. There are several explanations for this finding. First, it
has been noted that the general prevalence of ARFs is much greater
Mean IOD (SE)*

49±2.80

than previously thought, and that the majority of children with low-
91±1.172.

6
magnitude ARFs do not develop amblyopia. Moreover, changes in
26
refraction continue beyond the amblyogenic age. Another
possible reason that a small percentage of individuals have
Anisohyperopia

significant anisometropia or isoa-metropia and yet do not have

Mean BCVA

associated amblyopia is that they were appropriately treated for

Unilateral amblyopes 27/884
Prevalence

amblyopia as children, including being appropriately prescribed for

03%)(0.

refractive error correc-tion. Supporting this notion is our finding

06±0.09
(3%)

that this group of subjects had similar magnitudes of

anisohyperopia, anisomyopia, anisoastigmatism or isoastigmatism
as corresponding subjects with amblyopia. Unfortunately, we lack
Condition

evidence whether this category of subjects were indeed treated for

Table 2

41±1.08

amblyopia and/ or prescribed refractive correction at some age prior

and

to their assessment, which could have provided hard data support to

08

6 Shapira Y, et al. Br J Ophthalmol 2017;0:1–8. doi:10.1136/bjophthalmol-2017-310364

 Downloaded from http://bjo.bmj.com/ on August 18, 2017 - Published by group.bmj.com
Table 3 Comparison of isoametropia proportion, mean isoametropia magnitude and mean BCVA between subjects with
bilateral amblyopia and subjects without amblyopia
Isohyperopia Isomyopia
Mean BCVA
Condition Prevalence Mean SE*† (LogMAR)*† Prevalence Mean SE*†
Bilateral 7/216 6.65±2.57 0.50±0.28 68/216 −8.96±3.46
amblyopes (3%) (31.5%)
Non- 64/106 508 5.45±1.43 0.06±0.08 1857/106 508 −6.58±1.47
amblyopes (0.06%) (1.74%)
p Value <0.001 0.06 <0.001 <0.001 <0.001
*Average of means of both eyes per subject
†The analysis was conducted only among amblyopes versus non-amblyopes passing the clinically significant thresholds
of these isoametropias BCVA, best corrected visual acuity; D, dioptres; SE spherical equivalent
this hypothesis. Nevertheless, indirect support to this notion stems
from the fact that Professor Ewy Meyer, who was the first and the
only fellowship trained paediatric ophthalmologist in northern Israel
(before the sharp increase in specialists during the 1990s), has stated
that her standard of care was to prescribe optical correction to these
18
children.
A major limitation of this analysis is that by examining young
adults, we could not assess the refractive error and/or orthoptic
status during the amblyogenic age across childhood. Thus, for
example, a case of 2D hyperopia in childhood that developed into
school-age myopia could pass as an undetected isoametropia case in
this study. Also, the use of cycloplegia for refraction, rather than the
manifest refraction, could have improved the accuracy of diagnosis
of isoametropic and anisometropic refrac-tive errors. Possibly, this
could have resulted in recategorisation of some borderline cases
from isoametropic to anisometropic categories and also from
borderline to significant isoametropia. Furthermore, in terms of
ARFs, accommodation ability differs between two anisohyperopic
eyes, so accuracy in measuring the degree of anisometropia by
cycloplegic refraction is important in assigning risks to these
27
cases.
Furthermore, strabismus that was successfully corrected surgi-
cally during childhood could account for the low rates of stra-bismic
amblyopia among young adults in the present study, as well as for
the decreasing rates of young adulthood strabismus in the later birth
cohorts. Unfortunately, we do not have reliable supportive data
regarding past successful strabismus correction surgery in our
studied population. We can only extrapolate that as the amount of
paediatric ophthalmology surgeons in the north of Israel increased
from a single surgeon to seven surgeons, taken together with the
institutionalisation of screening that this led to an increase in
strabismus correction.
These suggested limitations could partly explain the fact that in
up to 60% of unilateral amblyopia cases and in approximately 30–
35% of bilateral amblyopia cases we could not detect ARFs.
Notably, all subjects with organic causes that could affect normal
vision were excluded from this study and thus could not account for
undetermined cases of visual impairment. Taken together, although
not all ARFs among our young adults could be traced, the reported
trends in amblyopia, as well as present strabismus prevalence across
24 birth years, are valid data that should be considered.
This study has additional limitations. The first is its retro-spective
nature. Second, the fact that the study cohort is from a single
geographical area may mean that data cannot be automat-ically
generalised. Third, the use of non-cycloplegic refraction in subjects
with a visual acuity of 6/6 may have resulted in 0.5D
Shapira Y, et al. Br J Ophthalmol 2017;0:1–8. doi:10.1136/bjophthalmol-2017-310364
Clinical science
Any
Isoastigmatism Isoametropia
Mean BCVA Mean BCVA
(LogMAR)*† Prevalence Mean D*† (LogMAR)*† Prevalence
0.39±0.14 38/216 −1.69±2.25 0.41±0.15 113/216
(17.6%) (52%)
0.04±0.07 574/106 508 −1.98±1.91 0.05±0.08 2495/106 508
(0.54%) (2.34%)
<0.001 <0.001 0.38 <0.001 <0.001
of overestimation of myopia and underestimation of 1–2D of
27
hyperopia. Additionally, while tropicamide 1.0% was routinely
used for fundus examinations, cyclopentolate hydrochloride might
have facilitated a better peripheral examination, perhaps revealing
other explanations for some cases of reduced vision. Lastly, visual
acuity was measured with a projected Snellen chart. This may have
caused under-detection of amblyopia due to visual clues such as
sharp-edged numbers and different numbers of digits per line, in
28 29
contrast to standardised charts such as Sloan. Nonetheless, the
same protocol and examination methods were practised across all
studied years by trained and qualified examiners, with final
diagnosis of amblyopia, and/or strabismus, determined by an
experienced staff ophthalmologist in all cases. Therefore,
inaccuracy in diagnostic methods should not have fluctuated nor
contributed to the identified trends.
In summary, our study provides insights into the trends in young
adulthood amblyopia, attributable to either untreated childhood
amblyopia or amblyopia treatment failure, as well as present
strabismus rates, among young adults in northern Israel over a
generation. It reveals a significant decrease in the prevalence of
unilateral amblyopia. However, the prevalence of severe amblyopia
or bilateral amblyopia did not change. We also witnessed a decrease
in the prevalence of young adulthood strabismus. The
improvements in both the screening and the treatment of amblyopia
and strabismus during childhood may underline these trends
witnessed in young adults, indeed modi-fying the natural history of
these conditions. However, it seems that some forms of amblyopia
remain less amenable to conven-tional treatment and this might be
the focus of future efforts to further decrease its impact. Of final
note, accurate determi-nation of refractive errors is highly important
in the diagnosis and treatment of amblyopia or strabismus. As such,
evaluation of patients should include adequate cycloplegic
refraction with retinoscopy, in addition to subjective refinement. It
may be advisable to adhere to the American Academy of
Ophthalmology Pediatric Ophthalmology/Strabismus Preferred
5
Practice Pattern Guidelines for Pediatric Eye Evaluations.
Contributors YS and EM: analysis and interpretation of data, drafting of
manuscript and critical revision. YM and YC: acquisition of data,
analysis and interpretation of data and critical revision. MM:
analysis and interpretation of data and critical revision.
Competing interests None declared.
Ethics approval Israeli Defense Forces (IDF) Institutional
Review Board (IRB) approval was obtained.
Provenance and peer review Not commissioned; externally peer reviewed.
7
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Clinical science
© Article author(s) (or their employer(s) unless otherwise stated in
the text of the article) 2017. All rights reserved. No commercial use
is permitted unless otherwise expressly granted.
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 Downloaded from http://bjo.bmj.com/ on August 18, 2017 - Published by group.bmj.com

Amblyopia and strabismus: trends in

prevalence and risk factors among young
adults in Israel
Yinon Shapira, Yossy Machluf, Michael Mimouni, Yoram Chaiter
and Eedy Mezer

Br J Ophthalmol published online August 16, 2017

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