Amblyopia

1
Brendan
2
AmblyopiaNew Treatments

• Pamela F. Gallin, M.D.
• Director, Pediatric Ophthalmology
• Childrens Hospital of New York
• Edward S. Harkness Eye Institute

3
IFVision Screens were done as children
THEN2 - 5 of adults would NOT be legally
blind!
4
Army Induction Studies
5
What is Amblyopia?

• One eye is IN focus
• One eye is NOT in focus
• your brain (occiput) does not see

6
Amblyopia
7
Normal Retina
8
Duke Elder Classification

1. Amblyopia ex Anopsia
2. Congenital (Organic) Amblyopia
3. Strabismic Amblyopia
4. Anisometropic Amblyopia

9
Amblyopia ex Anopsia (Anterior Segment)

• Stimulation deprivation amblyopia from lack
  of formation of retinal images
• Congenital Ptosis (lids)
• Corneal Opacification
• Congenital Cataract

10
(No Transcript)
11
(No Transcript)
12
(No Transcript)
13
2. Congenital (Organic) Amblyopia (Posterior)

• Seemingly undetectable lesion ...but during
  treatment no visual improvement
• because of retinal or visual pathway
  dysfunction

14
3. Strabismic Amblyopia

• Active inhibition or suppression of one retinal
  image by the cerebral cortex to eliminate the
  diplopia (double) by the deviating eye

15
4. Anisometropic Amblyopia

• Optically unmatched eyes so that one eye is in
  focus, and the other is not
• Silent Disease
• as least 1.5 to 2.0 diopters difference or more
  between the 2 eyes

16
Nobel Prize 1981
David Hubel
Torsten Wiesel
17
Hubel and Wiesel

• 80 of occiput is binocular
• suture lids of one eye at birth
• small cells binocular
• ... small normal
• occlude one eye at birth open at 3 months
• occlude 2nd eye..BLIND transiently
• some vision returns, but permanently
  suppressed
• No light to both eyes from birth
• less damage

18
Visual Cortex
Occiput
19
LGN involved??

• 1941
• Le Gros Clark
• Journal of Anatomy
  
• 75, 419

20
LGN involved
21
Cerebral cortical inhibition (suppression) is
an active process at the level of LGN and
calcarine cortex
22
Amblyopia is a Silent Disease
23
Brendan
24
American Academy of Ophthalmology

• recommend vision screen at 3.5 years of age

25
Vision Screen

• Allen Cards
• E game
• Slide
• Letters
• New Techniques
• desktop VEP

26
Snellen Chart
27
Diopsys desktop VEP
28
Patient views grating and yields VEP
29
Diopsys Results
Norm
Abnl
30
Dilated Cycloplegic Retinoscopy

• Mydriacyl 1
• Cyclogel 0.5, 1, (2)

31
An unmatched set optically
Right eye IN focus Then RIght
eye vision Normal
Left eye Not in focus Then Left
eye Vision Decreased (unless
intervention)
32
Suppression

• Brain shuts off image from out of focus eye

33
So, give glasses to one eye and it will see?

• Yes, image will be focused on retina
• But, image will NOT be developed in brain
• Because, cortical cells are scrambled (HW)
• BUT
• They can become functional up to 7.5 - 9 years
  

34
Exceptions

• Small differences
• glasses (with Rx in 1 eye) can work
• Large differences
• need contact lens for one eye

35
The goal is 20/25

• Maintain until 9 years of age

36
Treatment

• Patching OcclusionTherapy
• Penalization
• -optical
• -pharmacologic
• Bangerter Films
• New Techniques

37
Patching (Occlusion Therapy)

• On face
• adhesives vary
• 1 week/year life
• 5 y.o. 5 wks
• 1 y.o. 1 wk

38
Occlusion Amblyopia
39
Brendan

• 11 months
• 1.75 / - 7.00
• Patch and glasses

40
Optical Penalization

• Pharmacologic
• atropine
• Optical
• blur good eye with out of focus lens
• Bangerter Film

41
Brendan wouldnt wear patch and glasses

• So, we added Atropine under the patch

42
Brendan wouldnt wear patch at all,

• So, in addition to the Atropine,
• we added Bangerter film

43
Bangerter Films

• Clear pieces of plastic (colorforms)
• Adjust level of blur (e.g. net vision you have)
• Can see large targets with both eyes
• Peripheral Vision INTACT
• Socially acceptable in elementary school!!
• INVISIBLE
• Imported from Switzerland (2.00)

44
Bangerter Films
45
And because the difference between the 2 eye
prescriptions was so high (and that is why he
didnt like the glasses)

• We added a contact lens
• with atropine in the other eye

46
Contact Lenses

• used when the differences very high
• after 9 years of age, when dont want to
  wear glasses for one eye

47
After contact lenses AND 21

• Consider refractive surgery
• e.g. Lasik and others

48
Brendan had High Anisometropia(8.75)

• glasses patch
• glasses patch atropine
• glasses patch atropine Bangerter film
• THEN
• contact lens patch atropine

49

• We knew that
• Brendan had vision 20/70from Diopsys
• And that
• He would be Blind in that eye
• IF Nothing was done

50
October, 2002 Lasik Youngest child in
world Vision 20/40!!!!!
Dr. Jonathan Davidorf UCLA
51
(No Transcript)
52
Brendan began to have slight myopia and
astigmatism Vision began to slip Treated like
regular small anisometropia Glasses/BG
film/Atropine (prn) August, 2004 Vision 20/20
right..20/50 left Age 4.5 (much room to maneuver)
53
October, 2004 Left Eye 20/60January, 2005
Left Eye 20/80
54
Brendan
55

• Amblyopia is a SILENT disease
• 2 to 5 of adult population
• PREVENTABLE
• If diagnosed EARLY by vision screens!!!

56
Vision Screensmandatory at 3.5 yearsall
annual visits? Diopsys
57
Treatment

• Glasses (if anisometropia)
• Occlusion Patching
• Atropine
• Bangerter Films

58
Desperation

• contact lens (one eye)
• Refractive Surgery (lasik)

59
Treatment must be continued until 9 years of
age!Hubel and Wieselbut, it works!!
60
2 - 5 of children should NOT be blind in one
eye

• YOU CAN
• prevent this with a vision screen

61
(No Transcript)