Amblyopia (lazy eye)

A lazy eye is one in which the vision has failed to develop fully, where the eye appears to be normal. Up to 5% of the population are affected by this condition. It is treatable in the majority of cases if diagnosed early enough and the treatment regime strictly adhered to. It is worth treating because the individual affected is at a disadvantage from the point of view of employment. For example commercial flying, commercial trucking, employment with the armed or police forces may not be open to those with an amblyopic eye. The remaining eye is at risk of injury during life, particularly in the building and farming industries. The visual system develops during the first decade of life, mostly before seven or eight years of age. The eyes and brain learn to see and to work together during this developmental phase.

Causes of Amblyopia. Refractive Errors

The eyes are designed to bring images into focus on the most sensitive part of the retina which is responsible for detailed vision. The remainder of the retina is responsible for navigation. The majority of children are long-sighted. Under normal circumstances the eye is able to compensate for long-sight by accommodation, a compensating mechanism which also comes into play when focusing near at hand. In a small percentage of children the degree of long sight is so great, or the difference in power between the eyes is so great that it interferes with normal development of vision. Astigmatism is due to irregular curvature of the cornea which projects the image onto the retina at different points of focus resulting in a blurred image. The corneal surface is often described in this case as rugby ball in shape though this is not visible to the naked eye. In short sight the image is brought to focus behind the retina. Short sight is less common in early childhood, the majority developing in and progressing through the teens, stabilising in the late teens or early twenties. The eye is unable to compensate for this error. Appropriate correction in the form of spectacle , contact lens (or more recently, refractive surgery) are required. Refractive errors which predispose to amblyopia fall into recognised groups. Iso-ametropia indicates an equal degree of long-sight, astigmatism or even short-sight which are of sufficient degree to impair normal development of vision in both eyes An-isometropia indicates a difference in the refractive power of the eyes. This may be due to an unequal degree of long-sight, astigmatism or short -sight, which are of sufficient degree to impair normal development of vision in one or other eye. The function of spectacle correction is to level the playing field from the point of view of the development of vision in both eyes. The vision may improve spontaneously or the stronger eye may require a patch so the weaker eye can learn to see. The earlier treatment is commenced , the better the improvement in vision. Constant monitoring is required during the first decade of life to ensure that improvement takes place and is maintained. At the end of the first decade the system matures. If the vision has not recovered by then it is unlikely that further treatment would be of value.

Strabismus (Squint)

Strabismus and refractive error are closely inter-related. Your ophthalmologist will be concerned not only with the cosmetic appearance of the strabismus but also with the development of normal vision and the potential for binocular function. The onset of strabismus is due to the failure of the fusion mechanism which couples the eyes together to achieve binocular vision. The mechanism is related to loss of fusion rather than paralysis. Fusion appears to be the human equivalent of a software programme which can fail either because of inherent weakness or when stressed by other abnormalities outside its normal tolerances e.g. moderate to high anisometropia. There are a number of recognised patterns of strabismus. Some present in infancy while the majority present in the first few years of life. Occasionally youngsters will present at about 7 years of age with sudden onset of a convergent strabismus. The majority of cases are convergent (turned in). Less than 15% are divergent. The conditions described here relate to convergent strabismus.

Infantile Strabismus.
Strabismus onset in the first six months of life is termed infantile and is associated with a number of characteristics which usually appear within the early years. Strabismus is always abnormal and the infant should first be examined by the General Practitioner for confirmation and referral to an Ophthalmologist if confirmed. The angle of strabismus is usually cosmetically obvious. The child can look with either eye indicating normal vision. ( If a child has a preference for one eye then the vision of the fellow eye is probably weaker). Often these children will use the right eye when looking toward the left side and the left eye when looking to the right side. This may suggest that the child is unable to rotate the eyes fully and the question of a nerve palsy must be ruled out. These children are normally slightly long-sighted, similar to the average infant population. Surgical intervention is the treatment of choice as soon as the diagnosis is firmly established. Surgery offers the potential benefit of re-establishing binocular function. Where binocular function reactivates the eyes normally remain straight. Where binocular function does not reactivate the angle of strabismus may not remain stable and may turn inwards or outwards in time. Further surgical intervention may then be indicated to improve the cosmetic appearance. Before proceeding to surgery the ophthalmologist will rule out the question of extreme long sight which may control with spectacle correction alone. Bilateral nerve palsy, and Duanes syndrome will also be ruled out. The infantile strabismus pattern has a number of associated features including vertical overshoot of eyes on extreme left or right gaze. A latent wobble of the eyes may be detected when the eye is covered. The significance is not known but it does not interfere with vision. Finally either eye may exhibit an intermittent up-drift, particularly when daydreaming. All children with this condition require careful follow up during the first decade of life.

Acquired Strabismus
Onset after six months of age is usually associated with a different group of features. The onset may be intermittent initially, usually when the child is tired or ill. Illness is not usually the cause of strabismus but is the final stress on a system which is about to fail. The predisposing factors include extended family history, all the factors already covered in the section on Amblyopia and any other cause of failure of visual development e.g. abnormal eyes. The GP should be consulted and the child referred for ophthalmologists opinion.

Steps in Evaluation Strabismus is suggested by the cosmetic appearance, in particular by asymmetry of the nasal aspect of white of eye. It may be confirmed by asymmetry of light reflected on the cornea. The cover test confirms whether or not the eyes were aligned or were fixed on different points. The degree of misalignment is measured for both near and distance by prism dioptres. There are a number of means of measuring vision in the preverbal and pre school child. More accurate assessment can be achieved from about three and a half onwards. Where one eye is constantly turned, the vision is likely to be much weaker in that eye. The next step requires instillation of drops to paralyse the mechanism of accommodation so that an accurate measurement of the optical power of the eye can be made. The vision may be blurred for up to 36 hours after instillation of the drop. The strongest possible spectacle correction is then prescribed. The aim is to (1) eliminate the need to use the accommodation mechanism and (2) make up any imbalance in the optical power of the eyes. The child must wear the spectacle correction constantly every day. When the child returns for examination within six or ten weeks the eyes are once again examined for alignment. Fully Accommodative Strabismus On average at least one third will be perfectly aligned and may display early signs of stereopsis in addition to fusion. Stereopsis is an additional quality of vision, which allows assessment of distance, depth and speed. This group usually develop strong binocular function. Part time occlusion therapy may be required to improve vision in the weaker eye. When the glasses are removed the eye usually reappears. The glasses therefore help control the eye position but do not cure the condition. Surgical intervention is not normally indicated for this group. A number of children will be found to be straight in the distance but still display an angle of strabismus for near. These children are usually helped by use of bifocal lens. They usually develop good binocular function and the majority can manage without bifocals by eleven or twelve years of age. Partly Accommodative strabismus This is really part of the same group. The angle of strabismus is greatly reduced however binocular function does not become re-established. It is thought that there is an additional mechanical element in addition to the accommodation element. The vision must be monitored carefully as this group are more at risk of vision development failure than the previous group. The potential for re-activation of binocular function can be explored by application of prisms to the spectacles. If the child displays evidence of binocular function the early surgical intervention may produce a stable eye position. Once again regular monitoring of the progress of visual development is required and appropriate occlusion therapy maintained until maturity. Non-accommodative Strabismus The remaining one-third fall into this group. The spectacles do not influence the position of the eyes. The vision is monitored closely and appropriate occlusion therapy maintained until maturity. Surgical intervention is offered where the angle of strabismus is cosmetically obvious.

Failure of Visual Development in Abnormal Eyes

Technically this is not amblyopia as it does not fit the definition however as the symptoms are similar eye abnormality must often be considered as a causative factor in strabismus and where vision fails to improve in spite of treatment.

Common abnormalities which affect normal development of vision.

Cataract. Opacities in the lens interfere with development of vision. Infants are screened for cataract soon after delivery. Bilateral cataract will be treated urgently with some success although these infants are also predisposed to glaucoma. Unilateral cataract has proved less amenable to treatment than initially hoped. Glaucoma. Congenital glaucoma may present on delivery or during the first year or two of life. The more severe forms do not do well. Less severe forms have a better chance if the pressure controls easily and appropriate spectacle and patching regimes are instituted. Ptosis. Where the pupil is covered for most of the day the vision will fail to develop in the affected eye. The eye may be covered by a weak upper eyelid which fails to lift adequately or by an eyelid that is abnormally swollen e.g. Haemangioma. Urgent intervention may be indicated for the more severe forms. Tumour. Retinoblastoma is a life threatening eye tumour which occurs in 1:10,000 live births. Diagnosis is often made by examination of children in photographs. If one pupil appears white while the other is a normal red, find out why, immediately. Contact your general practitioner. Other Congenital Eye Abnormalities Usually associated with nystagmus Albinism Corneal opacities Optic nerve hypoplasia Cone dysfunction Other eye abnormalities