Amblyopia

Chairman :Dr.Inamur Rahman Choudhury

Associate.Professor.NIO&H

Moderator : Dr. Mujtahid Md Hossain Rubel

Assistant. Professor. NIO&H.
Presenter : Dr. Zakia Yasmin
DO Resident , NIO&H.
What is Amblyopia?
 Amblyipia by definition refers to a partial loss of
sight in one or both eyes, in the absence of
ophthalmoscopic or other marked objective signs.It
results from psychical suppression of the retinal
image.
 It is the unilateral, rarely bilateral, decrease in best
corrected visual acuity caused by form visual
deprivation and/ or abnormal binocular interaction,
for which there is no identifiable pathology of the
eye or visual pathway.
Causes
 Failure of normal neural development
in the immature visual system.
 Abnormal visual experience :-
1. Visual deprivation
2. Strabismus
3. Refractive error (anisometropia,
isoametropia)
Classification
 Visual deprivation amblyopia
 Strabismic amblyopia
 Refractiva amblyopia :-
1. Anisometropic
2. Isoametropic
3. Meridional
Pathophysiology
 Visual deprivation amblyopia :-
Monocular visual deprivation

Two eyes compete for synaptic contacts in the cortex

Deprived eye losses connections already formed at

birth with postsynaptic cortical target

Ocular dominance columns of the visual cortex

shrinkage
Cont…
 Strabismic amblyopia :-
1. Abnormal input –
Strabismus

Preventing the synchronous firing of

correlated images from two eyes

Abnormal input to the striate cortex

Interocular suppression
Cont…
 Strabismic amblyopia :-
1. Optical defocus –
Dominant eye focused on object of regard,
while deviated eye in different direction

Object may be too near or too far to be

focused for deviated eye

Asynchrony or inhibition of 1 set of signals in

the striate cortex
Evaluation
 History taking
 Examination
 Investigation
Clinical features
 Visualacuity :- Reduced (BCVA two
snellen or > 1 log unit)
Cont…
 Colour vision :- usually normal
 Subtle afferent pupillary defect :- rare/
only in severe cases of amblyopia
 Fixation pattern :- centric or eccentric
Cont…
 Crowding phenomenon :- present
 Effect of neutral density filter :- less in
amblyopia
 Grating acuity :-reduce in strabismic
amblyopia
 Fundoscopy :- normal .
Cont…
 Refractive changes :-
 Anisometropia –
Hypermetop >1.50 D
Astigmatism >2.00 D
Myopia >3.00 D
 Ametropia –
Hypermetop >4.00 – 5.00 D
Astigmatism >2.00 – 3.00 D
Myopia >5.00 – 6.00 D
 Astigmatism –
Meridional astigmatism >1.00 D
Screening
 Based on age of child
 Direct measurement of VA
 Testing for risk factors –
a. Corneal light reflex test
b. Cover test
c. Bruckner test
Treatment
 Eliminateany obstruction of the visual
axis (cataract)

 Correct any significant refractive error

 Force use of the amblyopic eye by

limiting use of the better eye
Critical period
 Strabismic amblyopia :-
7-8 years

 Anisometropic amblyopia :-
8-10 years
Cataract removal
 Timing:-
Unilateral cataract - 4-6 wks age

 Aphakia :- Refractive correction

Refractive correction
 Cycloplegic refraction

 Refractivecorrection with occlusion/

penalization

 Refractive surgery
Occlusion therapy
 Occlusoin
of the normal eye to
encourage use of the amblyopic eye.

 Treatment regimen :-
Depending on the age of patient and
density of the amblyopia
1. Full-time
2. Part-time
Occlusion therapy
 Criteria :-
 The younger the patient, the more
rapid the likely improvement but the
greater the risk of inducing
amblyopia in the normal eye.
 The better the VA at the start of
occlusion, the shorter the duration
required.
Cont…
 If there has been no improvement
after 6 months of effective occlusion,
further treatment is unlikely to be
fruitful.
Materials used for occlusion
 Adhesive patches

 Spectacle mounted occluder

 Opaque contact lens

Part-Time occlusion
 Occlusion for 2-6 hours

 Therelative duration of patch-on and

patch-off intervals reflects the degree
of amblyopia.
Cont…
 Regimen :-

Visual acuity Occlusion time

6/12 – 6/24 2 hours
6/24 – 6/60 4 hours
< 6/60 6 hours

 Maintenance therapy :-
1 - 2 hours per day to prevent recurrence
amblyopia
Full-Time occlusion
 Occlusion during all working hours.

 6/60– PL :- Sometime Full time

occlusion.

 Inducedstrabismus due to lack of

binocular viewing and tenuous fusion.
Follow up
 Related to :-
a. Intensity of treatment
b. Age of the child

 2 – 3 months after initiation of

treatment.

 Subsequent visits based on early

response.
Penalization
 Use of amblyopic eyes by degradation
of the better eye’s vision temporarily
inferior to the amblyopic eye’s without
complete occlusion of fellow eye.

 It allows a degree of binocularity.

Pharmacological penalization
 Cycloplegic agent – Atropine 1%
solution
 In better seeing eye to unable
accommodation
 Work best in moderate amblyopia
(≥6/24) and poor compliance
 Instillation – daily / weekend (adequet)
 Monitoring of reverse amblyopia
Optical penalization
 Prescription
of excessive plus lens
(fogging) and diffusing filters for the
sound eye.

 To
avoid potential pharmacological
adverse effect.
Complications of therapy
 Reverse amblyopia

 Induced strabismus
Unresponsiveness
 Complete or partial Unresponsiveness
despite of good compliance.
 Needs a repeat comprehensive eye
examination.
 Neuroimaging
 Termination of therapy If there has
been no improvement after 3 - 6
months despite good treatment
adherence.
Recurrence
 One third of patient shows recurrence

 Incidenceof recurrence decreased by

1 -2 hours regimen or reduced
frequency penalization for few months
before cessation of therapy.

 Periodicmonitoring until age 8 – 10

years at 12 months intervals.
Counseling
 Counselingabout the importance of
therapy and regular monitoring.

 Parents are instructed to watch for a

switch in fixation preference and
prompt report.
THANK
YOU