Definition:
Unilateral or, less commonly bilateral
Decrease in BCVA
Caused by form vision deprivation and/or abnormal
binocular interaction
There is no identifiable pathology in the eye or visual
pathway
Classification:
Strabismic amblyopia
Refractive amblyopia
Stimulus deprivation amblyopia
Refractive amblyopia:
Occurs due to consistent defocus of the retinal
image in one or both eyes
3 types: I. Anisometropic
II. Isometropic
III. Meridional
Refractive amblyopia:
Occurs due to consistent defocus of the retinal
image in one or both eyes
3 types: I. Anisometropic
II. Isometropic
III. Meridional
Strabismic Amblyopia:
Develops in the deviating eye of a child.
Caused by inhibitory interaction between
neurons carrying non-fusible input from the two
eyes.
Results in reduced responsiveness to input
from the non-fixating eye.
Stimulus Deprivation Amblyopia:
Least common but most severe
Occurs because of an abnormality that obstructs
the visual axis or otherwise interferes with central
vision
Stimulus Deprivation Amblyopia:
Caused by
1. Congenital or early-acquired cataract
2. Blepharoptosis
3. Corneal opacities
4. Vitreous haemorrhage
Treatment of Amblyopia:
Principles of treatment:
Eliminate any obstruction of the visual axis.
Correct any significant refractive error.
Correction of Strabismus.
Force use of amblyopic eye by limiting use of the
better eye.
Refractive Correction:
Must be done with cycloplegic agent.
Anisometropic, isometropic and even strabismic
amblyopia may improve to some extent with refraction
alone.
Aphakic refraction after cataract surgery must be
done promptly.
Pathophysiology:
Any form visual deprivation during childhood
↓
Abnormal input due to visual interruption
↓
Brain neglects the abnormal input through suppression
↓
Amblyopia develops
Anisometropic Amblyopia:
Caused by difference in refractive errors in 2 eyes
Hypermetropia : ˃1.50 D
Myopia : ˃ 3.00 D
Astigmatism : ˃ 2.00 D
Bilateral Ametropic Amblyopia:
Bilateral decrease in VA that results from large,
almost equal, uncorrected refractive errors in 2 eyes
Results in deleterious effect of blurred retinal image
Bilateral Ametropic Amblyopia:
Hypermetropia: > +4.00 to +5.00D
Myopia : > -5.00 to -6.00D
Astigmatism : > +/-2.00 to +/-3.00D
OCCLUSION THERAPY
Occlusion of the sound eye is most effective.
When fixation is central, simple & effective.
When fixation is eccentric & the child is <7yrs,
central fixation may be recovered.
Older the child, harder to regain central fixation.
OCCLUSION THERAPY
Types of occluders
Adhesive patches
Spectacle mounted occluders
Opaque contact lenses
OCCLUSION THERAPY
Part-time occlusion
≤ 6/60 : 6 waking hours/day
˂ 6/18 - 6/36 : 4 waking hours/day
6/12 - 6/18 : 2 waking hours/day
Maintenance patching of 1-2 hours/day is often given
to prevent recurrence after successful patching
OCCLUSION THERAPY
Full-time occlusion
Occlusion during all waking hours.
With aggressive patching strabismus may occur due
to lack of binocular viewing and tenuous fusion.
HOW TO GO ABOUT OCCLUSION
Motivation of child and parents.
Active vision exercises by amblyopic eye like reading
comics and story books.
In case of vision improvement, occlusion is continued
till amblyopic eye has not only developed equal vision
but also equal preference of fixation.
May take 3-6 months or more.
OCCLUSION THERAPY
Full-time occlusion
Occlusion during all waking hours.
With aggressive patching strabismus may occur due
to lack of binocular viewing and tenuous fusion.
Follow up:
First one or two visit –monthly interval
Subsequent follow up- three to six months
If no improvement after 3 months, review refraction,
do fundoscopy, carry out optic nerve function test
If everything ok, verify about occlusion.
After achieving equal vision, small maintenance
occlusion to be continued up to 12-13 years.
Penalization:
Penalization of the better eye by means of
cycloplegics to force for greater use of the amblyopic
eye
Methods:
1.Atropine penalization
2.Optical penalization(plus lens)
Newer treatment modalities:
Perceptual learning
Dichoptic training
Pharmacologic therapy
Video games
Smart glasses
Soft ware based occlusion e.g. ocutab, amblyopia I
Video gaming:
Video gaming have been shown to produce
improvement on the visual functions in a normal visual
system
Drug therapy:
LEVODOPA has been studied as an adjunct to
patching.
Citicholine is now more acceptable for pharmacologic
manipulation.
Drug therapy:
Advantages:
Augments conventional occlusion.
Speeds up recovery of visual functions.
Improves compliance.
Reduces cost and duration of treatment.
PLEOPTICS:
Involves active stimulation of fovea to overcome
eccentric fixation & improves VA.
First, the peripheral retina including the eccentrically
fixing area around the fovea is dazzled.
Only indication is cooperative and intelligent child
older than 6yrs having eccentric fixation.
Complications of Therapy:
Overtreatment may cause reverse amblyopia in
sound eye.
May develop strabismus.
Lack of adherence can prolong treatment along
with failure.
May show recurrence after discontinuation of
treatment even after successful correction.
Prevention and Screening:
For the early detection of the amblyopia
Regular screening of child’s vision
Routine check-up in pre-school children
School sight testing program.
CONCLUSION:
Amblyopia though critical, but preventable condition.
Proper evaluation, timed intervention and meticulous
followup should be done to prevent and treat
amblyopia.
