Amblyopia

Diagnosis and Prevention

Stephen W. Groves, M.D.
His Vision for Children
Pediatric Ophthalmology
 Amblyopia: History
• “When the doctor sees nothing and the
patient sees nothing, the diagnosis is
amblyopia.”
• Hippocrates, 450 B.C.
 Amblyopia: Definition
• Uncorrectable, decreased vision in an
otherwise structurally normal eye
– definition includes an operated eye made
“structurally normal” by surgery (e.g. post
cataract surgery)
• May be unilateral (most common) or
bilateral
 Amblyopia: Three Main Types
• Strabismus (misaligned eyes)
– one eye used, one eye suppressed
• Media opacity
– particularly when unilateral and early
• High refractive errors
– especially when asymmetric
 Strabismus: Misaligned Eyes
• Adult onset strabismus: horrible diplopia
– e.g. traumatic 6th nerve palsy with esotropia
• Childhood onset strabismus: suppression
and amblyopia
– child notices no visual disturbance
 Strabismus: Esotropia
• Infantile esotropia
– poor ability to develop binocular fusion
• stereopsis develops very early in life
– more common with CNS abnormalities
– presents at birth or in first few months
– large angle of crossing - obvious
– amblyopia or alternating fixation
– surgical correction
 Strabismus: Esotropia
• Accomodative esotropia
– presents later, age 18mo - 3yrs common
– small angle of deviation - not obvious
– usually normal neurologically
– starts insidiously (only when tired, ill)
– etiology: hyperopia
• accomodative (focusing) reflex tied to convergence
(crossing)
• family hx
 Strabismus: Esotropia
• Accomodative esotropia cont’d
– amblyopia common
• more hyperopic eye tends to cross and become
amblyopic
– esotropia treatment: hyperopic (magnifying)
spectacles
• surgery usually not needed (only 30%) unless
control inadequate with glasses
– amblyopia treatment: patch the better eye
 Strabismus: Esotropia
• Accomodative esotropia cont’d
– critical to have the proper spectacle correction
to maintain straight eyes
• if eyes straight with glasses:
– binocular fusion/stereopsis regained (remember child
was straight and fusing for first 1-2 yrs)
– amblyopia partly “self-treats” since both eyes are being
used simultaneously
• if eyes remain crossed with glasses:
– fusion lost
– amblyopia worsens
 Strabismus: Exotropia
• Often have good fusional ability
• Amblyopia less common than with
esotropia
• Treatment options:
– alternate patching
– over-minused spectacles (stimulate
convergence)
– surgery
 Strabismus: Treatment
• Straighten the eyes
– glasses, surgery, both
• Patch the better eye
 Amblyopia: Three Main Types
• Strabismus (misaligned eyes)
• Media opacity
• High refractive errors
 Media Opacity
• Best example: monocular congenital
cataract
• Total deprivation of sensory input to cortex
in one eye with normal sensory input in
fellow eye leads to rapid dense amblyopia
 Media Opacity: Cataract
• Treatment:
– urgent cataract surgery (clearing of media
opacity)
– may patch both eyes prior to surgery to
prevent amblyopia
– contact lens to restore focus
– diligent patching of unoperated eye after
surgery
 Media Opacity: Others
• Any opacity preventing light from reaching
the retina
– Ptotic (drooping) upper eyelid
– Corneal scar/opacity
• forceps injury at birth
• hereditary abnormalities
– Cataract
– Vitreous opacity, hemorrhage
 Media Opacity: Treatment
• Clear the media
– surgically lift ptotic eyelid
– corneal transplant
– cataract removal
 Amblyopia: Three Main Types
• Strabismus (misaligned eyes)
• Media opacity
• High refractive errors
 High Refractive Errors
• Clear input to the visual cortex is required
to develop good vision
• Myopia (nearsighted)
– eye too long
• Hyperopia (farsighted)
– eye too short
• Astigmatism (distortion)
– eye football shaped
 High Refractive Errors
• If retinal image in each eye is severely
unfocused, bilateral amblyopia may result
(uncommon)
– high myopia
– high hyperopia
– high astigmatism
 High Refractive Errors
• If retinal image in one eye is unfocused,
monocular amblyopia may result (very
common)
– anisometropia (e.g. one eye normal, one eye
moderately farsighted)
– often seen in combination with accomodative
esotropia
 Refractive Amblyopia:
Treatment
• Glasses - clears retinal image
• Patch the better eye - forces brain to use
image from “weaker” eye
 Amblyopia: Prevention/Early
Treatment
• Awareness of problem
– Overall affects 2-5% of population
 Amblyopia: Prevention/Early
Treatment - Birth
• First examination by primary care doctor
before newborn leaves hospital
• Look for clear, equal red reflex
– congenital cataract
– hereditary corneal dystrophies
• Ocular alignment unreliable in first week of
life
 Amblyopia: Prevention/Early
Treatment - Birth to 2 Years
• Examination at each well baby check
• Red reflex
• Ocular alignment should be orthophoric by 3-6
months
– corneal light reflex, alternate cover test
– if alignment not straight by 3 months - refer to
ophthalmologist
• Visual acuity - fix and follow smoothly by 6
months
– check each eye separately
 Amblyopia: Prevention/Early
Treatment - 2 Year Check
• Examinations at each well child check
• Red reflex - Bruckner Test
– direct ophthalmoscope at 0 setting, otoscope without
magnifyer
– distance of 2 feet from patient
– normal - equal red reflex
– unequal refraction - one eye darker reflex
– no/poor reflex - media opacity
– corneal light reflex not symmetric - strabismus
 Amblyopia: Prevention/Early
Treatment - 2 Year Check Cont’d
• Ocular alignment
– corneal light reflex
– alternate cover test
• Visual acuity - fix and follow very smoothly
and consistently
– ask the parent what the child sees - quantitate
“he sits close to TV”
– can the child recognize the parent across the
room
 Amblyopia: Prevention/Early
Treatment - 3, 4, 5 Year Checks
Pediatrics 98(1):153-57,1996 AAP Guidelines

• Red reflex
• Ocular alignment - should be perfect
• Visual acuity - allen figures or similar
– each eye tested separately
– vision should be equal and 20/40 or better in each
eye (consider the child)
– refer for vision < 20/40 or 2 line difference, (i.e.
20/25 one eye, 20/40 other)
• External, anterior segment
• Ophthalmoscopic exam
 Amblyopia: Prevention/Early
Treatment - 6+ Year Checks
• Red reflex
• Ocular alignment - perfect
• Visual acuity - snellen letters preferable
– vision should be 20/30 or better (consider the child)
– refer for vision < 20/30 or 2 line difference (i.e. 20/20
one eye, 20/30 other)
• External, anterior segment
• Ophthalmoscopic exam
 Amblyopia: Conclusion
• Straighten the eyes
• Clear the media
• Correct the refractive error
 Amblyopia: Conclusion
• Diagnose it early!
Amblyopia Case Histories
 Amblyopia Case Histories: JH
• 7 1/2 year white female failed school
screening exam
• Uncorrected acuity 20/20 RE, 20/200 LE
• Other information?
 Amblyopia Case Histories: JH
• Ocular motility: barely perceptible
esotropia
• Stereo vision: nil
• Ocular structures: normal
 Amblyopia Case Histories: JH
• Cycloplegic Refraction
– RE +0.25 D
– LE +4.75 D
• Treatment
– glasses
– patch right eye
• Result at one month, 20/60 LE, continue
patching
 Amblyopia Case Histories: JH
• Prevention
– Bruckner’s test of red reflex
– Acuity screening yearly
 Amblyopia Case Histories: SP

• 2 y.o. black female with exotropia

• Acuity: central, steady, unmaintained RE;
central, steady, maintained LE
• Ocular alignment: marked right exotropia
 Amblyopia Case Histories: SP

• Anterior segment exam: bilateral central

cataracts
 Amblyopia Case Histories: SP

• Bruckner’s test: dull reflex bilaterally (can

be difficult in black children, reflex not as
bright due to darker pigmentation of retina)
• Ocular alignment: exotropia
– corneal light reflex
– alternate cover test
 Amblyopia Case Histories: SP

• Treatment plan
– cataract removal/lens implant
• first eye - exotropia better indicating possible
fusion
• second eye surgery also
 Amblyopia Case Histories: LB
• 2 3/4 y.o. black male
• Gets “real close” to TV -
mom demonstrates few
inches
• Mom feels he can see
her across room
• She only thinks there is a
problem when he’s
watching TV or playing
with his cars
 Amblyopia Case Histories: LB
• Acuity: fix and follow (normal for his age)
• Ocular alignment: normal
• Anterior segment exam: normal
 Amblyopia Case Histories: LB
• Bruckner’s test - dull but equal reflexes
 Amblyopia Case Histories: LB
• Refraction: -10.50 D both eyes
• Treatment: glasses full time
• Expected outcome: excellent vision
– caught at young age
– equal refraction
 Bruckner’s Test of Red Reflex
• direct ophthalmoscope at 0 setting, otoscope
without magnifyer
• distance of 2 feet from patient
• normal - equal red reflex
• unequal refraction - one eye darker reflex
• no/poor reflex - media opacity
• corneal light reflex not symmetric - strabismus
 Amblyopia Case Histories: LB
• 2 3/4 y.o. black male
• Gets “real close” to TV - mom demonstrates few
inches
• Mom feels he can see her across room
• She only thinks there is a problem when he’s
watching TV or playing with his cars
 MTI Photoscreener
• 6 year old white female referred for
evaluation of “possible
amblyopia/strabismus”
MTI Photoscreener
 MTI Photoscreener
• Visual acuity without correction
Right eye 20/25
Left eye 20/400
• Ocular motility
Trace esotropia
 MTI Photoscreener
• Cycloplegic refraction
Right eye +1.75
Left eye +6.00 (20/200 best acuity)
• Diagnosis
Amblyopia secondary to anisometropia
(unequal focus between the eyes)
• Prognosis: Very good with patch and
glasses
Photographs
For your enjoyment