11

22

Unilateral or less commonly, bilateral Unilateral or less commonly, bilateral reduction of best corrected visual acuity that reduction of best corrected visual acuity that can not be attributed directly to the effect of can not be attributed directly to the effect of any structural abnormality of the eye or the any structural abnormality of the eye or the posterior visual pathway. posterior visual pathway.

Unilateral or less commonly, bilateral Unilateral or less commonly, bilateral reduction of best corrected visual acuity that reduction of best corrected visual acuity that can not be attributed directly to the effect of can not be attributed directly to the effect of any structural abnormality of the eye or the any structural abnormality of the eye or the posterior visual pathway. posterior visual pathway.

33

Resulting from one of following: Resulting from one of following: Resulting from one of following: Resulting from one of following:

A.A. Strabismus Strabismus - - DDEVIATIONEVIATION

B.B. Anisometropia or high bilateral refractive Anisometropia or high bilateral refractive error (Isoametropia) - error (Isoametropia) - DDEFOCUSEFOCUS

C.C. Visual deprivation - Visual deprivation - DDEPRIVATIONEPRIVATION

A.A. Strabismus Strabismus - - DDEVIATIONEVIATION

B.B. Anisometropia or high bilateral refractive Anisometropia or high bilateral refractive error (Isoametropia) - error (Isoametropia) - DDEFOCUSEFOCUS

C.C. Visual deprivation - Visual deprivation - DDEPRIVATIONEPRIVATION

44

Prevalence: 2%-4% Prevalence: 2%-4% Commonly unilateral Commonly unilateral Nearly all amblyopic visual loss is Nearly all amblyopic visual loss is

preventable or reversible with timely preventable or reversible with timely detection and appropriate intervention.detection and appropriate intervention.

Children with amblyopia or at risk for Children with amblyopia or at risk for amblyopia should be identified at a young amblyopia should be identified at a young age when the prognosis for successful age when the prognosis for successful treatment is best. treatment is best.

Role of screening is important Role of screening is important

Prevalence: 2%-4% Prevalence: 2%-4% Commonly unilateral Commonly unilateral Nearly all amblyopic visual loss is Nearly all amblyopic visual loss is

preventable or reversible with timely preventable or reversible with timely detection and appropriate intervention.detection and appropriate intervention.

Children with amblyopia or at risk for Children with amblyopia or at risk for amblyopia should be identified at a young amblyopia should be identified at a young age when the prognosis for successful age when the prognosis for successful treatment is best. treatment is best.

Role of screening is important Role of screening is important

55

Amblyopia is primarily a defect of central Amblyopia is primarily a defect of central vision. vision.

There is a critical period for sensitivity in There is a critical period for sensitivity in developing amblyopia.developing amblyopia.

The time necessary for amblyopia to occur The time necessary for amblyopia to occur during critical period is shorter for stimulus during critical period is shorter for stimulus deprivation than for strabismus or deprivation than for strabismus or anisometropia.anisometropia.

Amblyopia is primarily a defect of central Amblyopia is primarily a defect of central vision. vision.

There is a critical period for sensitivity in There is a critical period for sensitivity in developing amblyopia.developing amblyopia.

The time necessary for amblyopia to occur The time necessary for amblyopia to occur during critical period is shorter for stimulus during critical period is shorter for stimulus deprivation than for strabismus or deprivation than for strabismus or anisometropia.anisometropia.

66

Neurophysiology:Neurophysiology:Neurophysiology:Neurophysiology:

Cells of the primary visual cortex can completely Cells of the primary visual cortex can completely lose their innate ability or show significant lose their innate ability or show significant functional functional deficiencies deficiencies

Abnormalities also occur in neurons in the lateral Abnormalities also occur in neurons in the lateral geniculate body geniculate body

Evidence concerning involvement at the retinal level Evidence concerning involvement at the retinal level remains inconclusive remains inconclusive

Cells of the primary visual cortex can completely Cells of the primary visual cortex can completely lose their innate ability or show significant lose their innate ability or show significant functional functional deficiencies deficiencies

Abnormalities also occur in neurons in the lateral Abnormalities also occur in neurons in the lateral geniculate body geniculate body

Evidence concerning involvement at the retinal level Evidence concerning involvement at the retinal level remains inconclusive remains inconclusive

77

88

99

1010

Classification:Classification:Classification:Classification:

1.1. Strabismus Amblyopia :Strabismus Amblyopia :DDeviationeviation

2.2. Anisometropia Amblyopia : Anisometropia Amblyopia : DDefocussefocuss

3.3. Amblyopia Due to bilateral high refractive Amblyopia Due to bilateral high refractive error (isometropic) :error (isometropic) :DDefocussefocuss

4.4. Deprivation Amblyopia :Deprivation Amblyopia :DDeviationeviation

1.1. Strabismus Amblyopia :Strabismus Amblyopia :DDeviationeviation

2.2. Anisometropia Amblyopia : Anisometropia Amblyopia : DDefocussefocuss

3.3. Amblyopia Due to bilateral high refractive Amblyopia Due to bilateral high refractive error (isometropic) :error (isometropic) :DDefocussefocuss

4.4. Deprivation Amblyopia :Deprivation Amblyopia :DDeviationeviation

1111

Strabismus AmblyopiaStrabismus AmblyopiaStrabismus AmblyopiaStrabismus Amblyopia

The most common form of amblyopiaThe most common form of amblyopia Strabismic amblyopia is thought to result Strabismic amblyopia is thought to result

from competitive or inhibitory interaction from competitive or inhibitory interaction between neurons carrying the nonfusible between neurons carrying the nonfusible inputs from the two eyes.inputs from the two eyes.

Which leads to domination of cortical vision Which leads to domination of cortical vision centers by the fixating eye and chronically centers by the fixating eye and chronically reduced responsiveness to the nonfixating reduced responsiveness to the nonfixating eye input. eye input.

The most common form of amblyopiaThe most common form of amblyopia Strabismic amblyopia is thought to result Strabismic amblyopia is thought to result

from competitive or inhibitory interaction from competitive or inhibitory interaction between neurons carrying the nonfusible between neurons carrying the nonfusible inputs from the two eyes.inputs from the two eyes.

Which leads to domination of cortical vision Which leads to domination of cortical vision centers by the fixating eye and chronically centers by the fixating eye and chronically reduced responsiveness to the nonfixating reduced responsiveness to the nonfixating eye input. eye input.

1212

Anisometropia AmblyopiaAnisometropia AmblyopiaAnisometropia AmblyopiaAnisometropia Amblyopia

Second in frequency Second in frequency It develops when unequal refractive error in the two It develops when unequal refractive error in the two

eyes causes the image on the one retina to be eyes causes the image on the one retina to be chronically defocused.chronically defocused.

This condition is thought to result:This condition is thought to result: Partly from the direct effect of image blur in the Partly from the direct effect of image blur in the

development of visual acuity.development of visual acuity. Partly from intraocular competition or inhibitionPartly from intraocular competition or inhibition

Second in frequency Second in frequency It develops when unequal refractive error in the two It develops when unequal refractive error in the two

eyes causes the image on the one retina to be eyes causes the image on the one retina to be chronically defocused.chronically defocused.

This condition is thought to result:This condition is thought to result: Partly from the direct effect of image blur in the Partly from the direct effect of image blur in the

development of visual acuity.development of visual acuity. Partly from intraocular competition or inhibitionPartly from intraocular competition or inhibition

1313

1414

Mild hyperopic or astigmatic anisometropia Mild hyperopic or astigmatic anisometropia (1.5D) (1.5D) mild amblyopia mild amblyopia

Mild myopia anisometropia (less than -2.5D) Mild myopia anisometropia (less than -2.5D) usually doesn't cause amblyopiausually doesn't cause amblyopia

unilateral high myopia (-6D) unilateral high myopia (-6D) sever sever amblyopia visual loss.amblyopia visual loss.

Mild hyperopic or astigmatic anisometropia Mild hyperopic or astigmatic anisometropia (1.5D) (1.5D) mild amblyopia mild amblyopia

Mild myopia anisometropia (less than -2.5D) Mild myopia anisometropia (less than -2.5D) usually doesn't cause amblyopiausually doesn't cause amblyopia

unilateral high myopia (-6D) unilateral high myopia (-6D) sever sever amblyopia visual loss.amblyopia visual loss.

1515

Amblyopia Due to bilateral high Amblyopia Due to bilateral high refractive error (isometropia)refractive error (isometropia)

Amblyopia Due to bilateral high Amblyopia Due to bilateral high refractive error (isometropia)refractive error (isometropia)

isometropic amblyopia result from large, isometropic amblyopia result from large, approximately equal, uncorrected refractive approximately equal, uncorrected refractive error in both eyes of a young child.error in both eyes of a young child.

Hyperopia exceeding 5D & myopia excess of Hyperopia exceeding 5D & myopia excess of 10 D 10 D risk risk bilateral amblyopia bilateral amblyopia

isometropic amblyopia result from large, isometropic amblyopia result from large, approximately equal, uncorrected refractive approximately equal, uncorrected refractive error in both eyes of a young child.error in both eyes of a young child.

Hyperopia exceeding 5D & myopia excess of Hyperopia exceeding 5D & myopia excess of 10 D 10 D risk risk bilateral amblyopia bilateral amblyopia

1616

Meridonial amblyopia:Meridonial amblyopia: Uncorrected bilateral astigmatism in early Uncorrected bilateral astigmatism in early

childhood may result in loss of resolving childhood may result in loss of resolving ability limited to chronically blurred ability limited to chronically blurred meridians.meridians.

Meridonial amblyopia:Meridonial amblyopia: Uncorrected bilateral astigmatism in early Uncorrected bilateral astigmatism in early

childhood may result in loss of resolving childhood may result in loss of resolving ability limited to chronically blurred ability limited to chronically blurred meridians.meridians.

1717

Deprivation AmblyopiaDeprivation AmblyopiaDeprivation AmblyopiaDeprivation Amblyopia

It is usually caused by congenital or early It is usually caused by congenital or early acquired media opacity.acquired media opacity.

This form of amblyopia is the least common This form of amblyopia is the least common but most damaging and difficult to treat. but most damaging and difficult to treat.

In bilateral cases acuity can be 20/200 or In bilateral cases acuity can be 20/200 or worse.worse.

It is usually caused by congenital or early It is usually caused by congenital or early acquired media opacity.acquired media opacity.

This form of amblyopia is the least common This form of amblyopia is the least common but most damaging and difficult to treat. but most damaging and difficult to treat.

In bilateral cases acuity can be 20/200 or In bilateral cases acuity can be 20/200 or worse.worse.

1818

1919

In children younger than 6 years, dense In children younger than 6 years, dense congenital cataract that occupy the central 3 congenital cataract that occupy the central 3 mm. or more of the lens must be considered mm. or more of the lens must be considered capable of causing sever amblyopiacapable of causing sever amblyopia..

Similar lens opacities acquired after 6 years Similar lens opacities acquired after 6 years are generally less harmful.are generally less harmful.

In children younger than 6 years, dense In children younger than 6 years, dense congenital cataract that occupy the central 3 congenital cataract that occupy the central 3 mm. or more of the lens must be considered mm. or more of the lens must be considered capable of causing sever amblyopiacapable of causing sever amblyopia..

Similar lens opacities acquired after 6 years Similar lens opacities acquired after 6 years are generally less harmful.are generally less harmful.

2020

Small polar cataracts & lamellar cataracts Small polar cataracts & lamellar cataracts may cause mild to moderate amblyopia or may cause mild to moderate amblyopia or may have no effect on visual development.may have no effect on visual development.

Occlusion amblyopia is a form of deprivation Occlusion amblyopia is a form of deprivation caused by excessive therapeutic patching. caused by excessive therapeutic patching.

Small polar cataracts & lamellar cataracts Small polar cataracts & lamellar cataracts may cause mild to moderate amblyopia or may cause mild to moderate amblyopia or may have no effect on visual development.may have no effect on visual development.

Occlusion amblyopia is a form of deprivation Occlusion amblyopia is a form of deprivation caused by excessive therapeutic patching. caused by excessive therapeutic patching.

2121

Diagnosis Diagnosis Diagnosis Diagnosis

Characteristics of vision alone cannot be Characteristics of vision alone cannot be used to reliably differentiate amblyopia from used to reliably differentiate amblyopia from other form of visual loss. other form of visual loss.

The crowding phenomenon is typical for The crowding phenomenon is typical for amblyopia but not uniformly demonstrable.amblyopia but not uniformly demonstrable.

Afferent pupillary defect are Characteristic of Afferent pupillary defect are Characteristic of optic nerve disease but occasiinally appear to optic nerve disease but occasiinally appear to be present with amblyopia be present with amblyopia

Characteristics of vision alone cannot be Characteristics of vision alone cannot be used to reliably differentiate amblyopia from used to reliably differentiate amblyopia from other form of visual loss. other form of visual loss.

The crowding phenomenon is typical for The crowding phenomenon is typical for amblyopia but not uniformly demonstrable.amblyopia but not uniformly demonstrable.

Afferent pupillary defect are Characteristic of Afferent pupillary defect are Characteristic of optic nerve disease but occasiinally appear to optic nerve disease but occasiinally appear to be present with amblyopia be present with amblyopia

2222

Multiple assessment using a variety of tests or Multiple assessment using a variety of tests or performed on different occasions are performed on different occasions are sometime required to make a final judgment sometime required to make a final judgment concerning the presence and severity of concerning the presence and severity of amblyopia.amblyopia.

Multiple assessment using a variety of tests or Multiple assessment using a variety of tests or performed on different occasions are performed on different occasions are sometime required to make a final judgment sometime required to make a final judgment concerning the presence and severity of concerning the presence and severity of amblyopia.amblyopia.

2323

Binocular fixation pattern:Binocular fixation pattern: It is a test for estimating the relative level of It is a test for estimating the relative level of

vision in the two eyes for children with vision in the two eyes for children with strabismus who are under the age of about 3.strabismus who are under the age of about 3.

This test is quite sensitive for detecting This test is quite sensitive for detecting amblyopia but results can be falsely positive.amblyopia but results can be falsely positive.

Showing a strong preference when vision is Showing a strong preference when vision is equal or nearly equal in the two eyes, equal or nearly equal in the two eyes, particularly with small angle strabismic particularly with small angle strabismic deviations.deviations.

Binocular fixation pattern:Binocular fixation pattern: It is a test for estimating the relative level of It is a test for estimating the relative level of

vision in the two eyes for children with vision in the two eyes for children with strabismus who are under the age of about 3.strabismus who are under the age of about 3.

This test is quite sensitive for detecting This test is quite sensitive for detecting amblyopia but results can be falsely positive.amblyopia but results can be falsely positive.

Showing a strong preference when vision is Showing a strong preference when vision is equal or nearly equal in the two eyes, equal or nearly equal in the two eyes, particularly with small angle strabismic particularly with small angle strabismic deviations.deviations.

2424

The modified Snellen technique directly The modified Snellen technique directly measures acuity in children 3-6 years old.measures acuity in children 3-6 years old.

Often, however, only isolated letters can be Often, however, only isolated letters can be used, which may lead to under estimated used, which may lead to under estimated amblyopia visual loss.amblyopia visual loss.

Croding bar may help alleviate this problem.Croding bar may help alleviate this problem.

The modified Snellen technique directly The modified Snellen technique directly measures acuity in children 3-6 years old.measures acuity in children 3-6 years old.

Often, however, only isolated letters can be Often, however, only isolated letters can be used, which may lead to under estimated used, which may lead to under estimated amblyopia visual loss.amblyopia visual loss.

Croding bar may help alleviate this problem.Croding bar may help alleviate this problem.

2525

Crowding bar, or contour interaction bars, allow the Crowding bar, or contour interaction bars, allow the examinator to test the crowing phenomenon with examinator to test the crowing phenomenon with isolated optotype. Bar surrounding the optotype isolated optotype. Bar surrounding the optotype mimic the full of optotype to the amblyopia child.mimic the full of optotype to the amblyopia child.

Crowding bar, or contour interaction bars, allow the Crowding bar, or contour interaction bars, allow the examinator to test the crowing phenomenon with examinator to test the crowing phenomenon with isolated optotype. Bar surrounding the optotype isolated optotype. Bar surrounding the optotype mimic the full of optotype to the amblyopia child.mimic the full of optotype to the amblyopia child.

E O

2626

Treatment Treatment Treatment Treatment

Treatment of amblyopiaTreatment of amblyopia involves the involves the following steps: following steps:

Eliminating (if possible) any obstacle to Eliminating (if possible) any obstacle to vision such as a cataract vision such as a cataract

Correcting refractive error Correcting refractive error Forcing use of the poorer eye by limiting use Forcing use of the poorer eye by limiting use

of the better eye.of the better eye.

Treatment of amblyopiaTreatment of amblyopia involves the involves the following steps: following steps:

Eliminating (if possible) any obstacle to Eliminating (if possible) any obstacle to vision such as a cataract vision such as a cataract

Correcting refractive error Correcting refractive error Forcing use of the poorer eye by limiting use Forcing use of the poorer eye by limiting use

of the better eye.of the better eye.

2727

Cataract removal Cataract removal Cataract removal Cataract removal

Cataracts capable of producing amblyopia require Cataracts capable of producing amblyopia require surgery without unnecessary delay.surgery without unnecessary delay.

Removal of significant congenital lens opacities Removal of significant congenital lens opacities during the first 2-3 months of life is necessary for during the first 2-3 months of life is necessary for optimal recovery of vision.optimal recovery of vision.

In symmetrical bilateral cases, the interval between In symmetrical bilateral cases, the interval between operations on the first and second eyes should be no operations on the first and second eyes should be no more than 1 week.more than 1 week.

Acutely developing severe traumatic cataracts in Acutely developing severe traumatic cataracts in children younger than 6 years should be removed children younger than 6 years should be removed within a few weeks of injury, if possible.within a few weeks of injury, if possible.

Cataracts capable of producing amblyopia require Cataracts capable of producing amblyopia require surgery without unnecessary delay.surgery without unnecessary delay.

Removal of significant congenital lens opacities Removal of significant congenital lens opacities during the first 2-3 months of life is necessary for during the first 2-3 months of life is necessary for optimal recovery of vision.optimal recovery of vision.

In symmetrical bilateral cases, the interval between In symmetrical bilateral cases, the interval between operations on the first and second eyes should be no operations on the first and second eyes should be no more than 1 week.more than 1 week.

Acutely developing severe traumatic cataracts in Acutely developing severe traumatic cataracts in children younger than 6 years should be removed children younger than 6 years should be removed within a few weeks of injury, if possible.within a few weeks of injury, if possible.

2828

Refractive correction Refractive correction Refractive correction Refractive correction

In generally, optical prescription for In generally, optical prescription for amblyopic eyes should correct the full amblyopic eyes should correct the full refractive error as determined with refractive error as determined with cyclopagic.cyclopagic.

In generally, optical prescription for In generally, optical prescription for amblyopic eyes should correct the full amblyopic eyes should correct the full refractive error as determined with refractive error as determined with cyclopagic.cyclopagic.

2929

Occlusion and optical degradation Occlusion and optical degradation Occlusion and optical degradation Occlusion and optical degradation

Full time occlusion of the sound eye:Full time occlusion of the sound eye: Defined as occlusion for all or all but one waking Defined as occlusion for all or all but one waking

hour. hour. It is the most powerful means of treating of It is the most powerful means of treating of

amblyopia by enforced use of the defective eye. amblyopia by enforced use of the defective eye. The patch can either be left in place at night or The patch can either be left in place at night or

removed at bedtime.removed at bedtime. Spectacle-mounted occluser or special opaque Spectacle-mounted occluser or special opaque

contact lenses can be used as an alternative to full-contact lenses can be used as an alternative to full-time patching if skin irritation or poor adhesion time patching if skin irritation or poor adhesion proves to be a significant problemproves to be a significant problem

Full time occlusion of the sound eye:Full time occlusion of the sound eye: Defined as occlusion for all or all but one waking Defined as occlusion for all or all but one waking

hour. hour. It is the most powerful means of treating of It is the most powerful means of treating of

amblyopia by enforced use of the defective eye. amblyopia by enforced use of the defective eye. The patch can either be left in place at night or The patch can either be left in place at night or

removed at bedtime.removed at bedtime. Spectacle-mounted occluser or special opaque Spectacle-mounted occluser or special opaque

contact lenses can be used as an alternative to full-contact lenses can be used as an alternative to full-time patching if skin irritation or poor adhesion time patching if skin irritation or poor adhesion proves to be a significant problemproves to be a significant problem

3030

3131

Full time patching should generally be used Full time patching should generally be used only when constant strabismus eliminates only when constant strabismus eliminates any possibility of useful binocular vision any possibility of useful binocular vision because because full time patching runs a small full time patching runs a small risk of perturbing binocularity. risk of perturbing binocularity.

Full time patching should generally be used Full time patching should generally be used only when constant strabismus eliminates only when constant strabismus eliminates any possibility of useful binocular vision any possibility of useful binocular vision because because full time patching runs a small full time patching runs a small risk of perturbing binocularity. risk of perturbing binocularity.

3232

Part-time occlusion:Part-time occlusion: Defined as occlusion for 1-6 hours per day.Defined as occlusion for 1-6 hours per day. The children undergoing part time occlusion The children undergoing part time occlusion

should be kept as visually active as possible should be kept as visually active as possible when the patch is in place.when the patch is in place.

Compliance with occlusion therapy for Compliance with occlusion therapy for amblyopia declines with increasing age.amblyopia declines with increasing age.

Part-time occlusion:Part-time occlusion: Defined as occlusion for 1-6 hours per day.Defined as occlusion for 1-6 hours per day. The children undergoing part time occlusion The children undergoing part time occlusion

should be kept as visually active as possible should be kept as visually active as possible when the patch is in place.when the patch is in place.

Compliance with occlusion therapy for Compliance with occlusion therapy for amblyopia declines with increasing age.amblyopia declines with increasing age.

3333

Penalization: Penalization: A cycloplegic agent (usually atropine 1% or A cycloplegic agent (usually atropine 1% or

homatropine )homatropine ) once daily to the better eye once daily to the better eye This form of treatment has recently been This form of treatment has recently been

demonstrated to be as effective as patching demonstrated to be as effective as patching for mild to moderate amblyopia. for mild to moderate amblyopia.

Penalization: Penalization: A cycloplegic agent (usually atropine 1% or A cycloplegic agent (usually atropine 1% or

homatropine )homatropine ) once daily to the better eye once daily to the better eye This form of treatment has recently been This form of treatment has recently been

demonstrated to be as effective as patching demonstrated to be as effective as patching for mild to moderate amblyopia. for mild to moderate amblyopia.

E.B.M.E.B.M.

EvidenceEvidence Based Medicine Based MedicineProspective, randomisedProspective, randomised PEDIG, MOTAS & COCHRANEPEDIG, MOTAS & COCHRANE

EminenceEminence Based Medicine Based Medicine Hopkins: weekend atropineHopkins: weekend atropine Scott [Iowa]: only Scott [Iowa]: only full full timetime

PEDIGPEDIG

PP EE DDiatric ophthalmology iatric ophthalmology IInvestigatornvestigator GGrouproupNorth American Community North American Community

based Ophthalmology and based Ophthalmology and optometryoptometry

MOTASMOTAS

MMonitored onitored OOcclusioncclusion TTreatment of reatment of AAmblyopiamblyopia SStudytudy

England Alistair FielderEngland Alistair Fielder

PEDIG:PEDIG: Amblyopia 6/30 - 6/120Amblyopia 6/30 - 6/120

6 h/d vs. all 6 h/d vs. all [or all -1][or all -1] waking hours waking hours Ages 3-7Ages 3-7 Can do reliable HOTVCan do reliable HOTV 1h/d near activity1h/d near activity

4mo: 4+ line improvement both groups4mo: 4+ line improvement both groupsAge / severity of amblyopia NOT relevant to Age / severity of amblyopia NOT relevant to

outcome!outcome!

PEDIG:PEDIG:

Amblyopia 6/12- 6/24Amblyopia 6/12- 6/242h vs. 6h/d opaque 2h vs. 6h/d opaque occluderoccluder

Ages 3-7Ages 3-7 Can do reliable HOTVCan do reliable HOTV 1h/d near activity1h/d near activity

4mo: same 2.4 line 4mo: same 2.4 line improvementimprovement

Age / severity of amblyopia NOT Age / severity of amblyopia NOT relevant to outcome!relevant to outcome!

PEDIG:PEDIG:

Amblyopia 6/12 - 6/24Amblyopia 6/12 - 6/24

Daily atropine vs. patch 6h/dDaily atropine vs. patch 6h/d 6mo: no difference6mo: no difference Patch: faster responsePatch: faster response 2y: amblyopic eye 1.8 lines 2y: amblyopic eye 1.8 lines

worse in each groupworse in each group Improvement @ 2y: 3.6 vs. 3.7 Improvement @ 2y: 3.6 vs. 3.7

lineslines

PEDIG:PEDIG:

Recurrence of amblyopia after stopping Recurrence of amblyopia after stopping treatmenttreatment

≥ ≥ 3 lines acuity improvement3 lines acuity improvement 25%: ≥ 2 lines loss @ 25%: ≥ 2 lines loss @

12mo12mo 42% after stopping 6h/d42% after stopping 6h/d 14% if 6h/d tapered to 2h/d 14% if 6h/d tapered to 2h/d

before stoppingbefore stopping

MOTAS investigators:MOTAS investigators:

Recurrence of amblyopia after stopping Recurrence of amblyopia after stopping treatmenttreatment

Factors affecting the stability Factors affecting the stability of visual function following of visual function following cessation of occlusion cessation of occlusion therapy for amblyopia.therapy for amblyopia.

Graefe Graefe 6/20076/2007

Tacagni DJTacagni DJ, , …… Fielder ARFielder AR

MOTAS investigators:MOTAS investigators:

Recurrence of amblyopia after stopping treatmentRecurrence of amblyopia after stopping treatment

1 y follow-up from treatment cessation: 1 y follow-up from treatment cessation: children with "mixed" amblyopia children with "mixed" amblyopia (both anisometropia and (both anisometropia and strabismus) had significantly strabismus) had significantly (p=0.03) greater deterioration in VA(p=0.03) greater deterioration in VA (0.11+/-0.11 log units) than children (0.11+/-0.11 log units) than children with only anisometropia (0.02+/-0.08 log with only anisometropia (0.02+/-0.08 log units) or only strabismus (0.05+/-0.10 units) or only strabismus (0.05+/-0.10 log unitslog units). ).

PEDIG:PEDIG:

Amblyopia 6/12 - 6/24Amblyopia 6/12 - 6/24

Daily vs. weekend Daily vs. weekend atropineatropine

Same resultsSame results Daily slightly easier to doDaily slightly easier to do 1/80: occlusion amblyopia1/80: occlusion amblyopia

PEDIG:PEDIG:Amblyopia 6/12 - 6/120 in 7-17yoAmblyopia 6/12 - 6/120 in 7-17yo

Glasses vs. glasses plusGlasses vs. glasses plus 7-127-12: plus = patch 2-6h/d & daily : plus = patch 2-6h/d & daily

atropineatropine Acuity improves by ≥ 2 linesAcuity improves by ≥ 2 lines 13-1713-17: plus = patch 2-6h/d: plus = patch 2-6h/d Some have improved acuitySome have improved acuity 12mo later: 20% have regressed12mo later: 20% have regressed

PEDIG:PEDIG:

Glasses aloneGlasses alone6/12 to 6/756/12 to 6/75 27% cured27% cured Another 50% ≥ 2 lines betterAnother 50% ≥ 2 lines better Took up to 7 moTook up to 7 mo

MOTASMOTASGLASSES ALONEGLASSES ALONE

‘REFRACTIVE ADAPTATION’‘REFRACTIVE ADAPTATION’ VA in 65 newly diagnosed children VA in 65 newly diagnosed children

with difft causes of amblyopia at 6w with difft causes of amblyopia at 6w intervals for 18w intervals for 18w

VA improved significantly VA improved significantly (p,0.001)(p,0.001) from 0.67 to 0.43 logMAR: a mean from 0.67 to 0.43 logMAR: a mean improvement of 0.24 independent of improvement of 0.24 independent of amblyopia type amblyopia type (p = 0.29)(p = 0.29) and age and age (p = (p = 0.38)0.38)

Br J Ophthalmol 2004;88:1552Br J Ophthalmol 2004;88:1552--1556.1556.

MOTASMOTAS

REFRACTIVE ADAPTATION REFRACTIVE ADAPTATION FOLLOWED BY OCCLUSIONFOLLOWED BY OCCLUSION

Prescribed dose 6h/dPrescribed dose 6h/d Compliance <50% [2.8h].Compliance <50% [2.8h]. Only 10% used it ≥ 5.5 h/dOnly 10% used it ≥ 5.5 h/d 0.1 [1 chart line] VA improvement per 120h 0.1 [1 chart line] VA improvement per 120h

of occlusionof occlusionTotal doses >200h: Total doses >200h: residual amblyopia <0.2 log residual amblyopia <0.2 log >75% of deficit corrected >75% of deficit corrected IOVS 2004IOVS 2004

MOTASMOTASREFRACTIVE ADAPTATION REFRACTIVE ADAPTATION FOLLOWED BY OCCLUSIONFOLLOWED BY OCCLUSION

% of amblyopia deficit corrected% of amblyopia deficit corrected

TypeType Ref. Ref. Adapt.Adapt.

Occl.Occl. Deficit Deficit correctedcorrected

AllAll 3232 4747 7878

AnisoAniso 4444 4242 8686

StrabStrab 3030 5050 8080

MixedMixed 2727 5050 7777

MOTAS:MOTAS:

ELECTRONIC PATCH #1ELECTRONIC PATCH #1

18w of glasses, then patch 18w of glasses, then patch prescribed 6h , 12h/dprescribed 6h , 12h/d

6h/d6h/d: received 4.2 [± 0.5] h/d: received 4.2 [± 0.5] h/d 12h/d12h/d: received 6.2 [± 1.1] h/d: received 6.2 [± 1.1] h/d p=0.06p=0.06 <3h/d: worse outcome<3h/d: worse outcome

MOTAS:MOTAS:

ELECTRONIC PATCH #2ELECTRONIC PATCH #2

6h/d prescribed6h/d prescribed Best acuity after 150 - 250 Best acuity after 150 - 250

hh

2 line gain:2 line gain: 4y: needs 170h4y: needs 170h 6y: needs 236h6y: needs 236h

ELECTRONIC PATCH #3ELECTRONIC PATCH #3 Graefe Graefe 3/2003 3/2003 Simonsz HJSimonsz HJ et al et al..

Compliance : % of electronically Compliance : % of electronically registered time c.f. prescribed time. registered time c.f. prescribed time.

SatisfactorySatisfactory acuity increase acuity increase ratio between acuity of the amblyopic eye ratio between acuity of the amblyopic eye

and acuity of the good eye > 0.75 and acuity of the good eye > 0.75 acuity of the amblyopic eye > 0.5 on E or acuity of the amblyopic eye > 0.5 on E or

Landolt-C, or Landolt-C, or 3 LogMAR lines of increase in acuity. 3 LogMAR lines of increase in acuity.

Results: Results: Graefe Graefe 3/2003 3/2003 Simonsz HJSimonsz HJ et al et al.. Measured compliance Measured compliance ~ 80% in 8/14 children with satisfactory ~ 80% in 8/14 children with satisfactory

acuity increase acuity increase 34% in 6 children with unsatisfactory 34% in 6 children with unsatisfactory

acuity increase. acuity increase. Children with low acuity increase had Children with low acuity increase had

statistically significantly lower compliance statistically significantly lower compliance p=0.038p=0.038

‘‘no pain, no gain’no pain, no gain’

PEDIGPEDIGstudies with completed enrolmentstudies with completed enrolment

Enrollment Completed - Follow Up AEnrollment Completed - Follow Up A Observational study of different types of Observational study of different types of

esotropiaesotropia RCT comparing near vs. distance activities while RCT comparing near vs. distance activities while

patching for amblyopia patching for amblyopia RCT comparing atropine vs atropine with reduced + RCT comparing atropine vs atropine with reduced +

for sound eyefor sound eye Atropine vs occlusion in 7-12 yr oldAtropine vs occlusion in 7-12 yr old NFL in amblyopiaNFL in amblyopia RCT of Progressivelenses vs single vision lenses RCT of Progressivelenses vs single vision lenses

on low myopia with large accommodative lags and on low myopia with large accommodative lags and near esophoria in childrennear esophoria in children

5454

Complication of therapy Complication of therapy Complication of therapy Complication of therapy

Full time occlusion carries the greatest risk of this Full time occlusion carries the greatest risk of this complication and requires close monitoring, especially in the complication and requires close monitoring, especially in the younger child.younger child.

The first follow up visit after initial treatment should occur The first follow up visit after initial treatment should occur within 1 week for an infant and after interval corresponding within 1 week for an infant and after interval corresponding to 1 week per year of age for the older child.to 1 week per year of age for the older child.

Part time occlusion & optical degradation methods allow for Part time occlusion & optical degradation methods allow for less frequent observation but regular follow up is still critical less frequent observation but regular follow up is still critical

Full time occlusion carries the greatest risk of this Full time occlusion carries the greatest risk of this complication and requires close monitoring, especially in the complication and requires close monitoring, especially in the younger child.younger child.

The first follow up visit after initial treatment should occur The first follow up visit after initial treatment should occur within 1 week for an infant and after interval corresponding within 1 week for an infant and after interval corresponding to 1 week per year of age for the older child.to 1 week per year of age for the older child.

Part time occlusion & optical degradation methods allow for Part time occlusion & optical degradation methods allow for less frequent observation but regular follow up is still critical less frequent observation but regular follow up is still critical

5555

The time required for completion of The time required for completion of treatment depends on the following: treatment depends on the following:

1.1. Degree of amblyopia Degree of amblyopia

2.2. Choice of therapeutic approach Choice of therapeutic approach

3.3. Compliance with the prescribed regimen Compliance with the prescribed regimen

4.4. age of the patient age of the patient

The time required for completion of The time required for completion of treatment depends on the following: treatment depends on the following:

1.1. Degree of amblyopia Degree of amblyopia

2.2. Choice of therapeutic approach Choice of therapeutic approach

3.3. Compliance with the prescribed regimen Compliance with the prescribed regimen

4.4. age of the patient age of the patient

5656

Unresponsiveness Unresponsiveness Unresponsiveness Unresponsiveness

Complete or partial Unresponsiveness to treatment Complete or partial Unresponsiveness to treatment occasionally affect younger children but must often occasionally affect younger children but must often occurs in patients older than 5 years.occurs in patients older than 5 years.

Primary therapy should generally be terminated if Primary therapy should generally be terminated if there is a lock of demonstrable progress over 3-6 there is a lock of demonstrable progress over 3-6 months with good compliance.months with good compliance.

Refraction should be carefully rechecked and the Refraction should be carefully rechecked and the macula and optic nerve critically inspected for macula and optic nerve critically inspected for subtle evidence of hypoplasia or other malformation subtle evidence of hypoplasia or other malformation that might have been previously overlooked. that might have been previously overlooked.

Complete or partial Unresponsiveness to treatment Complete or partial Unresponsiveness to treatment occasionally affect younger children but must often occasionally affect younger children but must often occurs in patients older than 5 years.occurs in patients older than 5 years.

Primary therapy should generally be terminated if Primary therapy should generally be terminated if there is a lock of demonstrable progress over 3-6 there is a lock of demonstrable progress over 3-6 months with good compliance.months with good compliance.

Refraction should be carefully rechecked and the Refraction should be carefully rechecked and the macula and optic nerve critically inspected for macula and optic nerve critically inspected for subtle evidence of hypoplasia or other malformation subtle evidence of hypoplasia or other malformation that might have been previously overlooked. that might have been previously overlooked.

5757

Recurrence Recurrence Recurrence Recurrence

When amblyopia treatment is discontinued after fully When amblyopia treatment is discontinued after fully or partially successful completion, approximately half or partially successful completion, approximately half of patients show some dgree of recurrence,of patients show some dgree of recurrence,

Maintenance therapy: Maintenance therapy: Patching for 1-3 hours per day Patching for 1-3 hours per day Optical penalization with spectacles Optical penalization with spectacles Pharmacologic penalization with atropine 1 or 2 day Pharmacologic penalization with atropine 1 or 2 day

per week.per week. This may require periodic monitoring until age 8-10. This may require periodic monitoring until age 8-10.

When amblyopia treatment is discontinued after fully When amblyopia treatment is discontinued after fully or partially successful completion, approximately half or partially successful completion, approximately half of patients show some dgree of recurrence,of patients show some dgree of recurrence,

Maintenance therapy: Maintenance therapy: Patching for 1-3 hours per day Patching for 1-3 hours per day Optical penalization with spectacles Optical penalization with spectacles Pharmacologic penalization with atropine 1 or 2 day Pharmacologic penalization with atropine 1 or 2 day

per week.per week. This may require periodic monitoring until age 8-10. This may require periodic monitoring until age 8-10.