Amblyopia

Prolonged abnormal visual experience in a child under the age of 7 years may lead to amblyopia
(reduced visual acuity in the absence of detectable organic disease in one eye). The three clinical
causes of amblyopia include amblyopia due to visual deprivation (eg, congenital cataract or optic
nerve hypoplasia), amblyopia due to strabismus, and amblyopia due to unequal refractive error
(anisometropia). Often, more than one etiology is present. Although classically thought of as
untreatable after 7 years of age, recent studies show that some forms of amblyopia may be
successfully treated in older children.

In strabismus, the eye used habitually for fixation retains normal acuity and the nonpreferred eye
often develops decreased vision (amblyopia). Amblyopia is common in esotropia and is often severe.
In contrast, amblyopia is uncommon in exotropia and is mild if present. If spontaneous alternation of
fixation is present, amblyopia does not develop. Suppression and amblyopia are different processes.
Amblyopia is present when the affected eye is tested alone. Suppression occurs under binocular
conditions and is a process in which the brain "ignores" a portion of the image received from the
deviating eye so that the patient avoids diplopia. This visual field defect is termed a facultative
scotoma, since no visual deficit can be demonstrated when the suppressing eye is tested alone.

Amblyopia

Amblyopia is decreased visual acuity of one eye (uncorrectable with lenses) in the absence of organic
eye disease. Organic eye disease may be present but insufficient to explain the level of vision.

Normal anatomic development of the retina and visual cortex is determined by postnatal visual
experience. Visual deprivation due to any cause, congenital or acquired, during the critical period of
development (probably lasting up to age 8 in humans) prevents the establishment of normal vision in
the involved eye. Reversal of this effect becomes increasingly difficult with increasing age of the child.
Early suspicion and prompt referral for treatment of the underlying condition are important in
preventing amblyopia.

The most common causes of amblyopia are strabismus, in which the image from the deviated eye is
suppressed to prevent diplopia, and anisometropia, in which an inability to focus the eyes
simultaneously causes suppression of the image of one eye. High degrees of hypermetropia or
astigmatism, in which both eyes may become amblyopic because of failure to form a focused image
in either eye, are less common causes of amblyopia. All of these conditions are treatable if detected
early in life and if the patient is compliant with treatment recommendations. Treatment of amblyopia
involves appropriate correction of refractive error and then, if necessary, initiating occlusion therapy
(patching) of the sound eye several hours a day, or the use of penalization (pharmacologic blurring of
the sound eye) daily for several weeks. No matter what the therapy instituted, visual acuity of both
eyes must be monitored.

Since poor visual function in a young child may go unnoticed, routine screening by the age of 4 years
is advocated to detect decreased visual acuity or the presence of amblyogenic factors (strabismus,
anisometropia).