Amblyopia

Dr. Anisman
17 March 2008
 EBM Recommendations
The USPSTF recommends screening to
detect amblyopia, strabismus, and defects in
visual acutity in children younger than age
5 years
Level B recommendation (at least fair evidence
to support; benefits outweigh harms)
 EBM Recommendations
Examination of the eyes should be
performed beginning in the newborn period
and at all well-child visits. Va measurement
should be performed at the earliest possible
age that is practical (usually approx 3 years
of age)
AAP, SORT C
 Amblyopia: Definition
Poor vision, without an organic cause, that
cannot be corrected with glasses

A failure to develop the neural circuitry

needed to integrate binocular vision
 Amblyopia: Epidemiology
Prevalence = 2-5%
 Amblyopia: Epidemiology
Risk Factors
Anisometropia*
congenital cataract
Strabismus*
TORCH
Prematurity

*two most common causes

 Amblyopia: Epidemiology
Risk Factors
SGA
neurodevelopmental delay
parent with amblyopia
maternal intrapartum smoking
 Amblyopia: Physiology
Only occurs in developmentally immature
eye
B-6m: 20/400-20/80
fully developed by 9 y.o.
nl devel: clear, aligned images OU
conflicting data = suppression
in adult, result is diplopia
Tx = patching good eye or fogging w/meds
 Amblyopia: Natural History
presents as early as 3 months
progression and reversibility both inversely
proportional to childs age
untreated prognosis: very poor
Irreversble by 9 y.o.
 Amblyopia: Natural History
Etiologies
pattern deprivation
optical defocus
Strabismus
 Pattern Deprivation
Congenital cataract
Eyelid hemangioma
Severe congenital ptosis
Corneal Leukomas
Retinoblastoma
To preserve potential for normal vision, must
correct underlying condition/optics by 3-4
months
 Amblyopia: Anisometropia
often has accompanying strabismus
screening tests: early institution of visual
acuity
tx is glasses or contacts, and correction of
any coexisting amblyopia
 Amblyopia: Strabismus
accounts for half of amblyopia
> 50% are esodeviations
tropia = manifest deviation = always
present
phoria = latent deviation = present only
when binocular vision blocked
 Amblyopia: Strabismus
screening tests: corneal light reflex, fix and
follow, cover-uncover.
newborns: intermittent strabismus up to 4
weeks is normal, esp. if exo; eso more
likely to be pathologic.
refer to Ophtho for: any constant deviation (any
age); intermittent exo > 6 months old; intermittent
eso > 2 months old.
 Amblyopia: Strabismus
tx is usually surgery, after correction of any
amblyopia
sometimes only glasses are needed
pseudostrabismus = appearance of
misalignment (usu. eso) due to flat nasal
bridge and large epicanthal folds;
distinguish from true strabismus with proper
testing.
 Evaluation: Birth - 3 years
Ocular Hx
Va
External inspection of eyes & lids
Ocular motility
Pupil exam/ light reflex
Red Reflex
 Evaluation: 3 years and older
previous items plus:
age-appropriate Va
attempt at opthalmoscopy
 History
Does child recognize faces?
Hold objects close to face?
Do eyes appear straight, or do they drift?
Do eyes appear unusual in any way?
Do one or both eyelids droop or tend to
close?
 History
Have eyes ever been injured?
Any tearing? Photophobia?
Nl hand-eye coordination?
Abnl head posturing? Squinting?
 Examination
Va
External exam (lids, orbits, cornea, iris)
Ocular motility & alignment
Pupils (size, reactivity)
Ocular media
 Va
fix and follow starting at 3-6 months
tumbling "E", HOTV, picture charts and
Snellen letters/numbers by 3-4 years*

* See table in Pediatrics 2003; 111; p. 903

 Fix and Follow
A Va test, also tests motility
Present interesting object to child (penlight,
your face, brightly colored toy)
move slowly through fields of gaze and watch
for tracking
do first with both eyes open, then use parent's
hand to occlude each eye separately.
 Fix and Follow
if unable to track, or if becomes fussy when
one eye occluded, refer.
can usually perform in children as young as
3 months
significant unilateral amblyopia unlikely
with nl test
 External exam
lids, orbits, cornea, iris
d/c likely due to infection, allergy, congenital
glaucoma
if abx + NLD massage dont resolve promptly,
refer
Ptosis
unilateral: may cause amblyopia (refer)
bilateral: suspect neurologic disease
 Ocular motility & alignment
Corneal light reflex
Cover-uncover or Cross cover test
Simultaneous red reflex test (Bruckner test)
 Corneal Light Reflex
may be only test one can do on infants and
toddlers
hold penlight at arm's length and note position
of reflection on corneas (nl: midline to just
nasal to center of pupil)
esodeviations: reflection displaced temporally
exodeviations: reflection displaced nasally
 Cover-Uncover
requires reasonably cooperative child; can
be as young as 6 months
two parts to the test, one to detect tropias,
one to detect phorias
child stares at light or other object (both
eyes)
 Cover-Uncover
test for tropia:
may have abnormal corneal light reflex
cover one eye and observe the uncovered eye
if uncovered eye shifts to take up fixation, a tropia
exists in that eye (if eye shifts nasally, an exotropia
exists; if eye shifts temporally, an esotropia exists)
remove cover briefly, and cover other eye and
repeat test
 Cover-Uncover
test for phoria:
corneal light reflex may be nl.
cover one eye and observe the covered eye
if covered eye drifts, a phoria exists in that eye
(if eye drifts nasally, an esophoria exists; if eye
drifts temporally, an exophoria exists)
 Simultaneous red reflex test
(Bruckner test)
View both eyes through direct opthalmoscope
at 2-3 feet (dark room)
Nl: equally bright red reflexes OU
A notable difference in brightness of red
reflexes:
significant refractive errors
congenital cataract
strabismus
 Ocular Media
Red Reflex test
Can detect
opacities in visual axis (cataract or corneal)
retinoblastoma or retinal detachment
Can be done simultaneously with Bruckner
test
 EBM Recommendations
The USPSTF recommends screening to
detect amblyopia, strabismus, and defects in
visual acutity in children younger than age
5 years
Level B recommendation (at least fair evidence
to support; benefits outweigh harms)
 EBM Recommendations
Examination of the eyes should be
performed beginning in the newborn period
and at all well-child visits. Va measurement
should be performed at the earliest possible
age that is practical (usually approx 3 years
of age)
AAP, SORT C
 Amblyopia: Screening
Newborn - 3 months: red reflex
6-36 months: fix and follow,
> 3 year old: formal Va, red reflex &
Bruckner test, corneal reflex, cover-uncover
 Amblyopia: When to Refer
20/50 or worse at 3 y.o.
20/40 or worse at 4 y.o.
20/30 or worse > 5 y.o.
 Amblyopia: When to Refer
2-line difference between eyes at any age
any constant deviation
intermittent exo deviation persisting > 6
months, eso > 2 months
one or more risk factors
 References
Committee on Practice and Ambulatory Medicine
of American Academy of Pediatrics. Eye
Examination in Infants, Children, and Young Adults
by Pediatricians. Pediatrics 2003; 111; 902-907.
Coats D, Paysse E. Refractive Error and
Amblyopia, July 2006. Accessed on-line at
http:www.UpToDate.com on 24 Oct 2007.
Ophthalmology for the Primary Care Physician,
Palay D and Krachmer J (eds). 1997, p. 204-5.