Amblyopia treatment dr mirzajani

Amblyopia TreatmentAmblyopia Treatment

Dr. Ali Mirzajani Dr. Ali Mirzajani (BSc, MSc, PhD)(BSc, MSc, PhD)

Department of OptometryDepartment of Optometry Tehran University of Medical Science Tehran University of Medical Science

Classification Classification ofof

Functional AmblyopiaFunctional Amblyopia

Deprivation Amblyopia Refractive Amblyopia A. Anisometropic Amb B. Isometropic Amb (Ametropic Amb) Strabismic Amblyopia

Amblyopia

Other Problems

Management of Management of AmblyopiaAmblyopia

The clinician must first The clinician must first rule out rule out an an organic cause organic cause and treat any and treat any obstacle to vision (eg, cataract, obstacle to vision (eg, cataract, occlusion of the eye from other occlusion of the eye from other etiologies). etiologies).

Remove cataracts Remove cataracts in the first 2 in the first 2 months of life, and aphakic months of life, and aphakic correction must occur quickly.correction must occur quickly.

Management of Amblyopia

The first attempt for treatment of amblyopia is to prescribe optimum optical correction

Not meaning to give the full correction

Management of Management of AmblyopiaAmblyopia

Full cycloplegic refraction should be Full cycloplegic refraction should be given to patients with given to patients with accommodative esotropiaaccommodative esotropia and and amblyopia.amblyopia.

In other patients, a prescription In other patients, a prescription less less than the fullthan the full plus measurement that plus measurement that was refracted may be prescribed was refracted may be prescribed given that the decrease in plus is given that the decrease in plus is symmetric between the two eyes. symmetric between the two eyes.

Management of Management of AmblyopiaAmblyopia

Because Because accommodative amplitude accommodative amplitude is believed to be is believed to be decreaseddecreased in in amblyopic eyes, one needs to be amblyopic eyes, one needs to be cautious about cutting back too cautious about cutting back too much on the amount of plus.much on the amount of plus.

Refractive correction alone has Refractive correction alone has been shown to improve amblyopia been shown to improve amblyopia in up to 77% of patients.in up to 77% of patients.

Management of Management of AmblyopiaAmblyopia

Patients with Patients with bilateral refractive bilateral refractive amblyopia amblyopia do well with spectacle do well with spectacle correction alone.correction alone.

with most children aged 3-10 with most children aged 3-10 years achieving years achieving 20/30 or better 20/30 or better within a year.within a year.

Management of Amblyopia

The The next step next step is forcing the use of the is forcing the use of the amblyopic eye by one of the following amblyopic eye by one of the following methodsmethods..

a. Occlusion b. Optical Penalization c. Medical penalization d. Active Vision Therapy e. Medical Methods f . Complementary methods

Occlusion

occlusion occlusion therapy: therapy: Occlusion Occlusion therapy has been therapy has been the mainstay of the mainstay of treatment since treatment since the 18th century. the 18th century.

Furthermore,Furthermore,

AvicennaAvicenna (980-1037) (980-1037) has suggested has suggested “occlusion” for “occlusion” for treatment of treatment of strabismic amblyopia strabismic amblyopia in his book of “in his book of “The The Canon of MedicineCanon of Medicine”.”.

Occlusion

The following are general The following are general guidelines for occlusion therapy:guidelines for occlusion therapy:

Occlusion

PatchingPatching may be full-time or part- may be full-time or part-time.time.

f/u at intervals of f/u at intervals of 1 week per year 1 week per year of age, if undergoing full-time of age, if undergoing full-time occlusion occlusion to avoid to avoid occlusion occlusion amblyopia in the sound eye.amblyopia in the sound eye.

Occlusion

The Amblyopia Treatment Studies The Amblyopia Treatment Studies (ATS) have helped to provide new (ATS) have helped to provide new informationinformation on the effect of on the effect of various amounts of various amounts of patching.patching.

OcclusionOcclusion

Always consider lack of Always consider lack of compliancecompliance in a child where visual in a child where visual acuity is not improving. acuity is not improving. Compliance is difficult to measure Compliance is difficult to measure but is an important factor in but is an important factor in determining the success of this determining the success of this therapy. therapy.

OcclusionOcclusion

In addition to adhesive patches, In addition to adhesive patches, opaque contact lensesopaque contact lenses, occluders , occluders mounted on spectacles, and mounted on spectacles, and adhesive tape on glasses have adhesive tape on glasses have been used. been used.

OcclusionOcclusion The studies have demonstrated The studies have demonstrated

that, in patients that, in patients aged 3-7 years aged 3-7 years with with deepdeep amblyopia (visual amblyopia (visual acuity between 20/100 and acuity between 20/100 and 20/400), 20/400), full-timefull-time patching patching produced a similar effect to that produced a similar effect to that of 6 hours of of 6 hours of patching per day.patching per day.

OcclusionOcclusion . In a separate study, . In a separate study, 2 hours of daily 2 hours of daily

patchingpatching produced an improvement in produced an improvement in visual acuity similar to that of visual acuity similar to that of 6 hours of 6 hours of daily patchingdaily patching when treating moderate when treating moderate amblyopia (visual acuity better than amblyopia (visual acuity better than 20/10020/100) in children aged 3-7 years.) in children aged 3-7 years.

In this study, patching was prescribed in In this study, patching was prescribed in combination with 1 hour of near visual combination with 1 hour of near visual activities.activities.

OcclusionOcclusion

For patients aged from For patients aged from 7 years to 7 years to younger than 13 yearsyounger than 13 years, the , the Amblyopia Treatment Studies Amblyopia Treatment Studies have suggested that prescribing have suggested that prescribing 2-6 hours 2-6 hours a day of patching can a day of patching can improve visual acuity improve visual acuity even if even if the the amblyopia amblyopia has been previously has been previously treated.treated.

OcclusionOcclusion

For patients aged from For patients aged from 13 years to 13 years to younger than 18 yearsyounger than 18 years, prescribing , prescribing 2-6 2-6 hourshours a day of patching might improve a day of patching might improve visual acuity when amblyopia visual acuity when amblyopia has not has not been been previously previously treatedtreated; however, this ; however, this is likely to be of little benefit if is likely to be of little benefit if amblyopia was previously treated with amblyopia was previously treated with patching. Long-term results from patching. Long-term results from these studies are still pending.these studies are still pending.

OcclusionOcclusion

The Amblyopia Treatment Studies The Amblyopia Treatment Studies have also found that about have also found that about one one fourth fourth of children with amblyopia of children with amblyopia who were successfully treated who were successfully treated experience a recurrenceexperience a recurrence within within the first year the first year after discontinuation after discontinuation of treatment. of treatment.

OcclusionOcclusion

Data from these studies suggest that Data from these studies suggest that patients patients treated with 6 or more hours treated with 6 or more hours a day of patching have a greater risk a day of patching have a greater risk of of recurrence recurrence when patching is when patching is stopped abruptly stopped abruptly rather than rather than when it when it is is reduced to 2 hours reduced to 2 hours a day prior to a day prior to cessation of patching. Randomized cessation of patching. Randomized studies have still yet to be studies have still yet to be performed.performed.

occlusion dose monitorocclusion dose monitor

Occlusion dose monitorOcclusion dose monitor (ODM) is a (ODM) is a device to measure compliance with device to measure compliance with patch-wearing during the treatment patch-wearing during the treatment of amblyopia objectively.of amblyopia objectively.

It measures the temperature It measures the temperature difference between the front and difference between the front and back of the ODM every 2-5 minutes back of the ODM every 2-5 minutes by means of by means of two thermistorstwo thermistors..

Optical Penalization

Optical penalizationOptical penalization

Optical penalization isOptical penalization is reserved for reserved for children who would not wear children who would not wear a patch a patch or in whom or in whom compliancecompliance was an issue. was an issue.

Optical penalization involves altering Optical penalization involves altering the spectacle or contact lens the spectacle or contact lens correction of the sound eye to correction of the sound eye to produce image blur, potentially produce image blur, potentially providing the amblyopic eye a providing the amblyopic eye a competitive adventage competitive adventage

Optical penalizationOptical penalization

Distance optical penalizationDistance optical penalization Near optical penalizationNear optical penalization Total optical penalizationTotal optical penalization

Medical penalizationMedical penalization

The Amblyopia Treatment Studies, The Amblyopia Treatment Studies, however, have demonstrated that however, have demonstrated that CycloplegicCycloplegic ( (atropine) penalization atropine) penalization in in patients with patients with moderatemoderate amblyopia amblyopia (defined by the study as visual acuity (defined by the study as visual acuity better than 20/100better than 20/100) is as effective as ) is as effective as patching. The Amblyopia Treatment patching. The Amblyopia Treatment Studies were performed in children Studies were performed in children aged 3-7 years.aged 3-7 years.

Medical penalizationMedical penalization

Atropine drops or ointment is Atropine drops or ointment is instilled in the instilled in the nonamblyopic nonamblyopic eye.eye.

This therapy is sometimes used in This therapy is sometimes used in conjunction with conjunction with patching or patching or occlusion of the glasses (eg, occlusion of the glasses (eg, adhesive tape, nail polish) by adhesive tape, nail polish) by individual practitioners.individual practitioners.

Medical penalizationMedical penalization

In the Amblyopia Treatment In the Amblyopia Treatment Studies that evaluated patching Studies that evaluated patching versus atropine penalization, versus atropine penalization, atropine penalization and atropine penalization and patching patching were used in conjunction were used in conjunction with 1 hour of near visual with 1 hour of near visual activities. activities.

Medical therapyMedical therapy

Pharmacologic Pharmacologic treatment with treatment with levodopalevodopa has been investigated has been investigated and has showed and has showed transient transient improvement improvement of vision in amblyopic of vision in amblyopic eyes. However, the exact role of eyes. However, the exact role of such pharmacologic agents has not such pharmacologic agents has not been determined. Levodopa been determined. Levodopa currently is not currently is not being used being used clinically. clinically.

Active TherapyActive Therapy

CAM Therapy (CAM Visual CAM Therapy (CAM Visual Stimulator)Stimulator)

Photic Stimulation byPhotic Stimulation by

TBI or Major AmblyoscopeTBI or Major Amblyoscope Bangerter MethodBangerter Method Cupper MethodCupper Method

Complementary Complementary MethodsMethods

(Alternative Medicine)(Alternative Medicine) low energy He-Ne laserlow energy He-Ne laser Magnetic TherapyMagnetic Therapy AcupunctureAcupuncture Energy TherapyEnergy Therapy

low energy He-Ne laserlow energy He-Ne laser

Commonly, The low energy He-Ne Commonly, The low energy He-Ne laser laser irradiates the fundus irradiates the fundus directly for directly for 3 minutes 3 minutes each day.each day.

It is claimed that The low energy It is claimed that The low energy He-Ne laser is effective in treating He-Ne laser is effective in treating amblyopia.amblyopia.

Magnetic Therapy for Magnetic Therapy for AmblyopiaAmblyopia

Canadian researchers found that Canadian researchers found that beaming beaming magnetic pulses magnetic pulses into the into the brain improved the brain improved the sensitivitysensitivity of of the weaker eye the weaker eye temporarilytemporarily. The . The study was prompted by reports of study was prompted by reports of new research that documents the new research that documents the plasticityplasticity of the adult brain. of the adult brain.

Acupuncture for Acupuncture for amblyopia treatmentamblyopia treatment

Acupuncture is a potentially Acupuncture is a potentially useful useful complementary treatment complementary treatment modality that may provide modality that may provide sustainable adjunctive effect to sustainable adjunctive effect to refractive correction for refractive correction for anisometropic amblyopia anisometropic amblyopia in in young childrenyoung children

Energy TherapyEnergy Therapy

There is no scientific evidence There is no scientific evidence that energy healing has effect on that energy healing has effect on amblyopia.amblyopia.

Occlusion

Other Methods

ما » Kرو يغّي Kي حّت بقوم ما VرW Vغّي ي ال الله Kاّندهند «بانفسهم تغّيّير خود آنها آنكه مگر دهد نمي تغّيّير را قومي هّيچ سرنوشت .خداوند

: ی آیه رعد، سوره مجید 11قراّن

Cessation of TherapyCessation of Therapy

The endpoint of therapy is The endpoint of therapy is spontaneous spontaneous alternation of alternation of fixation fixation or or equal visual acuity equal visual acuity in in both eyes.both eyes.[23] [23] When visual acuity is When visual acuity is stable, patching may be stable, patching may be decreased decreased slowlyslowly. .

Cessation of TherapyCessation of Therapy

Because amblyopia recurs in a Because amblyopia recurs in a large number of patients (see large number of patients (see Prognosis), maintenance therapy Prognosis), maintenance therapy or tapering of therapy should be or tapering of therapy should be strongly considered. This strongly considered. This tapering is controversial, so individual is controversial, so individual physicians vary in their physicians vary in their approaches. approaches.

Cessation of TherapyCessation of Therapy

Even though there have been Even though there have been many advances in amblyopia many advances in amblyopia treatment, tailoring the treatment treatment, tailoring the treatment with individual treatment plans is with individual treatment plans is still difficult because the still difficult because the dose/effect response from the dose/effect response from the amount of occlusion is not fully amount of occlusion is not fully understood.understood.

Strabismus Strabismus ManagementManagement

Treatment of strabismus Treatment of strabismus generally occurs last. The generally occurs last. The endpoint of strabismic amblyopia endpoint of strabismic amblyopia is freely alternating fixation with is freely alternating fixation with equal vision. equal vision. Surgery Surgery generally is generally is performed after this endpoint performed after this endpoint has has been reached. been reached.

Strabismus Strabismus ManagementManagement

Surgical therapySurgical therapy for strabismus for strabismus generally should occur after generally should occur after amblyopia is reversed.amblyopia is reversed.

Disadvantages to surgical therapy Disadvantages to surgical therapy prior to correction of amblyopia prior to correction of amblyopia include:include:

Strabismus Strabismus ManagementManagement

1. difficulty in telling if amblyopia is 1. difficulty in telling if amblyopia is present because there is no longer a present because there is no longer a strabismus to assess fixation preferencestrabismus to assess fixation preference

2. and higher potential to being lost to 2. and higher potential to being lost to follow-up, as the child cosmetically follow-up, as the child cosmetically looks better. The improved cosmesis looks better. The improved cosmesis gives the parents a false sense of gives the parents a false sense of security about the vision improving.security about the vision improving.

Strabismus Strabismus ManagementManagement

3. Continuing amblyopia treatment 3. Continuing amblyopia treatment and and patching patching (or penalizations) (or penalizations) may disrupt or may disrupt or preventprevent more more fusion development in binocular fusion development in binocular system.system.

So we're faced with a lack of So we're faced with a lack of success in treating strabismussuccess in treating strabismus