A complete Guide to study regarding Amblyopia: Definition, Classification, Investigation & Management

1. AMBLYOPIA, CLASSIFICATION &
MANAGEMENT

2. What is amblyopia?
• “Lazy eye”
• A unilateral/bilateral condition
• The best corrected VA is poorer than 6/9 in
absence of the ocular media and fundus
anomalies or ocular disease.
• Prevalence:- occurs about 1 in 25 children develop some
degree of amblyopia.
• High risk of becoming blind.

3. Normal vision Amblyopia ( Loss of vision)

4. How does it happen?
Brain does not full recognize the image
from amblyopic eye
Weakening of that eye over time and a
reduction in its clarity of vision
Brain may block or suppress the images
sent by eye and favor the clearer eye.

5. Definition
• Visual impairment resulting from
abnormal development of the brain
– A consequence of blurred or unequal
inputs to the eyes during the sensitive
period for visual development

6. What causes of amblyopia?
• There are four major causes of amblyopia which are:
Unequal/Poor visual acuity
Unequal refractive error (Anisometropia)
Bilateral equal high refractive errors (isoametropia)
Uncorrected moderate/high astigmatism
Strabismus/Misaligned Eyes
 Blockage or deprivation
 Toxic

7. Unequal/Poor visual acuity due to:
1) Unequal refractive error (Anisometropia)

8. Unequal/Poor visual acuity due to:
Uncorrected high myopia Uncorrected high hyperopia
2) Bilateral equal high refractive errors (isoametropia)
More than -6.00D to -9.00D More than +4.00D
Blurred image form onto the retina
because ray of light focused in front of
the retina.
Blurred image form onto the retina
because ray of light focused at the back
of retina.

9. Unequal/Poor visual acuity due to:
3) Uncorrected moderate/high astigmatism
Meridional amblyopia is a mild condition in which lines are seen less clearly at
some orientations than others after full refractive correction.

10. Unequal/Poor visual acuity due to:
3) Uncorrected moderate/high astigmatism
A Compound myopic
B Simple myopic
C Mixed astigmatism
D Simple hyperopic
E Compound hyperopic
Clinical types of astigmatism which can lead to meridonal astigmatism if it is not
corrected within plastic age.

11. Constant strabismus or an imbalance in the
positioning of the two eyes

12. Strabismic amblyopia

13. Blockage or deprivation
an opacity in the line of vision-e.g: cataract
Due to: -Congenital/traumatic cataract
-Congenital ptosis
-Congenital/traumatic corneal opacities.

14. Toxic • Drugs -
chloramphenicol,
digoxin, ethambutol
• Tobacco- piped
smoker, excessive
smoker
• Alcohol- alcoholic
• Chemicals- Lead,
methanol
• Nutritional
disorders - such as
Strachan's
syndrome, lack of
vitamin A and zinc.
The optic nerve head in acquired optic
neuropathies

15. What are the types of amblyopia?
• The nature of amblyopia differs depending
on the cause:-
Refractive amblyopia
Anisometropic amblyopia
Meridonial amblyopia
Strabismic amblyopia
Visual deprivation amblyopia
Toxic amblyopia

16. Classification of amblyopia
Functional Amblyopia
• Not due to the diseases in
the eye
• unilateral/bilateral of the
eye
• Reversible
• Examples:
– Refractive amblyopia
– Anisometropic amblyopia
– Meridonial amblyopia
– Strabismic amblyopia
Structural/Pathological Amblyopia
• Due to lesion in the eye or
visual pathway
• unilateral/bilateral of the
eye
• Irreversible
• Examples:
– Visual deprivation
amblyopia
– Toxic amblyopia

17. PEDIG Amblyopia Studies
• Amblyopia subtype
– Strabismic
– Anisometropic
– Combination of strabismic & anisometropic
– Ametropic
• Amblyopia severity
– Moderate: Va 20/40-20/80
– Severe: Va 20/100-20/400
• Patient age: 3 to 17

18. Type Causes
Refractive amblyopia • Uncorrected isometropia
• Result :- A blurred image in both eyes.
Anisometropic amblyopia
(Second in frequency)
• Uncorrected anisometropia
• Result :- A blurred image in more ametropic
eye.
Meridonial amblyopia • uncorrected high astigmatism
• Result :- A blurred and distorted image in
unilateral or bilateral eyes.
Strabismic amblyopia
(most common)
• Constant strabismus
• Suppression in deviated eye
Functional Amblyopia

19. Structural/Pathological Amblyopia
Types Causes
Visual deprivation amblyopia • Opacities in ocular media or
structures
• Examples:- cataracts, cornea
opacities and cloudy vitreous in
infants.
Toxic amblyopia • Drugs, tobacco, alcohol, chemicals,
nutritional disorders.

20. What are the sign and symptoms of amblyopia?
Symptoms
• No symptoms
• Blurred vision
• Reduced vision
• Reduced contrast
sensitivity
Signs
• No obvious sign, unless
severe abnormality is
present.
• Rubbing or squinting of
eyes
• Misaligning eyes
• Reduced VA
• Droopy eyelid

21. ASSESMENT

22. Assessment of deviation
– Compare magnitude at distance versus near
• Laterality
• Concomitancy
• frequency
– The test is
• Cover test
• Hirchberg test
– Uses pen torch
– Corneal reflexes
• Bruchner test
– Uses ophthalmoscope
– Observe the color and brightness of fundus reflexes and
compared

23. Hirschberg test Bruckner test

24. Strategies in assessment of amblyopia
1. Visual Acuity (VA)
• Degree of amblyopia
• Crowding phenomena
– Normal Snellen Chart
• Line Acuity
– Single Letter Chart
• Single Letter Acuity
2. Neutral Density (ND) Filter
• Depth of amblyopia
• Differentiate between
organic amblyopia or
functional amblyopia

25. 1. Visual Acuity (VA)
– Amblyopes perform better when isolated letters
are used instead of full chart.
– Crowding effect
• Single letter acuity
– Infant
• Teller acuity chart
– Preschool-aged children
• Lea symbols, HOTV or broken wheel cards
– School-aged children
• Snellen chart or Log MAR chart

26. Visual Acuity Chart
Snellen Chart Single letter chart

27. Single Letter Acuity
Advantage
• Directly measures acuity
especially in children 3-6
years old.
Disadvantage
• Isolated letters can be
used, which may lead to
under estimated
amblyopia visual loss.
Solutions:
 Crowding bar may help alleviate this problem

28. Crowding effect
• Crowding bar, or contour interaction bars, allow the examiner to
test the crowding phenomenon with isolated optotype.
• Bar surrounding the optotype mimic the full of optotype to the
amblyopia child.
E O

29. • In strabismic eye, mostly
it use other part of area
instead of fovea area
which consist rod.
• Image that form will
reduce in contrast.
• Hence, it also reduce the
visual acuity of the eye.

30. 2. Neutral Density (ND) Filter
• Strabismic amblyopia
– Better VA with ND filter
compared to the normal
eye
– The use of a neutral-
density (ND) filter in
front of the fixing eye
enhanced motion-in-
depth performance.
– exhibit residual
performance for motion
in depth, and it is
disparity based
• Anisometropic amblyopia
– Cannot be diagnosed with
neutral density filter
ND bar

31. Neutral Density (ND) Filter
Strabismic amblyopia Anisometropic amblyopia
VA increased with ND filter VA cannot be diagnosed with ND
filter

32. Contrast sensitivity test
– Detect functional differences between
strabismic and anisometropic amblyopes
– Strabismic amblyopes showed abnormalities
only in the high spatial frequency range
– Anisometropic amblyopes showed an abnormal
function both in the low and high spatial
frequency range

33. Contrast sensitivity test
Pelli-Robson contrast sensitivity chart Functional Acuity Contrast Test (FACT)

34. Eccentric fixation
– Fixate away from fovea
• In strabismic amblyopic eye
– Visuscopy
• Detect and assess eccentric fixation
• Explain decreased vision and lead to a more accurate
measurement of strabismus
• Grid center is temporal to foveal reflex(temporal EF)
• Grid center is nasal to foveal reflex(nasal EF)
• Grid center is superior to foveal reflex(superior EF)
• Grid center is inferior to foveal reflex(inferior EF)

35. Eccentric Fixation

37. Binocularity/stereoacuity test
– Ambyopia reduced VA, it also has reduced stereopsis
– Stereo smile for infant
– Preschool random-dot stereogram or random-dot test for
preschool children
TNO test

38. Refraction
– commonly can determine anisometropia
– Cycloplegic refraction
• Spasm the ciliary muscle to inactive the
accommodation by using drug
– Uses 1% cyclopentolate hydrochoride
– Usually more hyperopic or more astigmatic eye
for the amblyopic eye

39. External and internal ocular
examination of the eye
– Determine either it is visual deprivation
amblyopia or afferent pupillary defect are
characteristic of optic nerve disease but
occasionally appear to be present with
amblyopia
– To rule out ocular pathology
– These examination consist of assessment
• Physiological function
• Anatomical status

40. MANAGEMENT
Goal of treatment
Passive therapy
•Optical correction
•Occlusion
•Penalization
Active therapy
•CAM visual stimulator
•Intermittent photic stimulation (IPS)
•Pleoptics

41. GOAL OF TREATMENT:
to restore and improves visual acuity by two
strategies:
1. present CLEAR retinal image to the amblyopic eye
• eliminate causes of visual deprivation
• correcting visually important refractive errors
2. make the child use the amblyopic eye
• Recommended treatment should be based on
– patient’s age, visual acuity, compliance with previous
treatment & physical, social and psychological status

42.  CHOICES OF TREATMENT
the choices of treatment of amblyopia are used alone or in
combination to achieve goal of treatment
1. Passive therapy:
The patient experiences a change in visual stimulation without any
conscious effort
i. Proper refractive correction
ii. Occlusion
iii. Penalization

43. Passive therapy:
i. Proper refractive correction
• PURPOSE:
– to provide sharp images and providing
OPTIMAL environment for amblyopia
therapy
• Give pt proper optical correction
alone
– Short period of time (6-8 weeks)
before initiation of other therapy

44. Passive therapy:
ii. Occlusion
• PURPOSE:
cover good eye to stimulate amblyopic eye
• Enable the amblyopic eye to enhance neural input to the visual cortex
• Decreasing inhibition better eye

45. TOTAL VS PARTIAL OCCLUSION
total partial
•All light is prevented from
entering eye.
•Employed in amblyopic eyes
with acuity less than 6/24
•Occlusion using elastoplast,
gauze pad, tape, doynes rubber
occluder.
•Does not cut off the total light
entering eye
•Degrades the vision of normal
eye such that amblyopic eye gets
better vision and preference
•Occlusion using cellophane,
transparent nail polish, or a
higher plus lens.

46. CONVENTIONAL VS INVERSE OCCLUSION
Conventional Inverse
•Occlusion of sound eye •Occlusion of amblyopic
eye so that eccentric
fixation becomes less fixed

47. FULL TIME VS PART TIME
Full time Part time
Removed only while going to
bed at night
Short time each day during close
work or watching television.
Choice of initial Rx In relapses after Rx and also for
maintanence

48. • Patches • Micropore tape with soft tissue paper
• Spectacle patch / frost glass • Doyne’s occluder

49. • Ways of patching
– There are several ways of patching
– Excluding light and form:
• Adhesive patching
• Spectacle occlude
• Opaque contact lens
– Excluding form (ie: frosted glass)

50. - Partial patching form
• allow appreciation of form but diminish
acuity
– ie. Translucent materials (Bangerter foil)
– foil is cut to size and positioned on inner lens
surface
• or occlusion covering part of spectacles
– ie. Lower half of spectacles
– to promote use of the amblyopic eye for near
work

51. • Type
• Direct occlusion
• Patch the good eye
• stimulate amblyopic eye
• Indication for
• deprivation amblyopia
• anisometropic amblyopia

52. • Inverse occlusion
• For amblyopia associated with EF --> strabismic
amblyopia
• Patching the amblyopic eye
• To weaken eccentric fixation of amblyopic eye
• If children under 5 year old age
• direct full time occlusion may risk reverse amblyopia
• Do direct occlusion alternate with inverse occlusion
• Ie: for 3 years old children, may need 3 days direct and 1
day indirect occlusion consider 1 cycle and repeated
period of time

53. • Duration
– Based on binocular vision status, age,
performance need
• Full time occlusion
• 24 hours a day/waking hours
• For children over 7 years over plastic age
• When there is no binocular vision
• strabismic amblyopia
– Alternate strabismus
– Constant strabismus
• Also anisometropic amblyopia with poor binocular vision
• Shows more rapid development

54. • Part time occlusion
• For specific periods / prescribed activities
• When binocularity is present
• anisometropic amblyopia
• To help preserve fusion
• Prevent occluded eye become amblyopic if doing full time
occlusion
• Children under 4 years
• 2 hours per day
• Prevent deprivation amblyopia in good eye

55. How much patching??
The amblyopia treatment study have helped to
define the role of full time patching vs part time
patching
• In patients aged 3-7 years with severe amblyopia
(VA B/W 6/30 to 6/120) full time patching
produced similar effect to that of six hours
patching per day
• In patients aged 3-7 years with moderate
amblyopia (VA better than 6/30) 2 hours
patching produced similar effect to that of six
hours patching per day

56. Treatment of amblyopia in 7-17 yrs
• For 7-13 yrs age group 2-6 hours of
patching can improve VA only if
previously treated
• For 13-17 yrs age group 2-6 hous of
patching improved VA even if not treated
previously

57. HOW TO GO ABOUT OCCLUSION
• Motivation of child and parents.
• Active vision exercises by amblyopic eye like dotting
O’s and encircling E’s in a newspaper, joining dots,
reading comics and story books.
• In case of vision improvement, occlusion is
continued till amblyopic eye has not only developed
equal vision but also equal preference of fixation.
• May take 3-6 months.
• If there is no improvement. Then treatment is
stopped. Also other causes to be ruled out.
• Maintainence treatment is continued atleast upto 9
yrs of age with part time occlusion and exercises

58. Rx schedule for initial occlusion
Age in yrs Period of occlusion(days)
Direct : inverse
Follow up after every
Upto 2 2 :1 15 days
3 3 : 1 15 days
4 4 : 1 1 month
5 5 : 1 1 month
6 & older 6 : 1 1 month

59. • Follow up-depending on age, severity of
amblyopia and compliance
• To look for-VA, fixation pattern and occlusion
amblyopia
• When to stop occlusion
VA equals in both eyes
alternation of fixation
• When VA is stable patching may be decreased
slowly
• Because amblyopia recurres in large no. of
patients maintanence therapy or tapering of
therapy should be strongly considered.

60. Disadvantages of occlusion
• Occlusion amblyopia
• Non compliance
• Psychological distress
• Appearance of constant deviation
• Allergic skin rash
• Diplopia
• Cosmetically inacceptable

61. Prognostic considerations
• Younger the age better the prognosis
• Type of amblyopia myopic anisometropia> hyperopic
anisometropia> strabismic amblyopia> stimulus
deprivation
• Pretreatment VA
• Type of occlusion
• Type of fixation
• Near exercises
• Patient compliance and parent
education
• Presence of astigmatism
• Method of treatment termination
• Previous treatment
• Refractive correction

62. • Occlusion is maintained until there has
been no further improvement for the last 5-
6 weeks
• Frequent check are necessary to monitor
ocular health, binocular status and each
eye’s acuity

63. 1. Drug penalization
• 1 gtt of 1% atropine instilled daily
• to good eye
• Provide sufficient blur to force the
child
• use amblyopic eye at near
• good eye at distance
• Has cosmetic advantages and does not
totally disrupt binocular vision
• Effective method of treatment
• for mild to moderate amblyopia in
children
Active therapy:
Penalization

64. Methods of penalisation
a. Near penalization: fixing eye is atropinized &
fully corrected for distance, amblyopic eye is
overcorrected with +2 to +3D .
b. Distance penalization : fixing eye is atropinized
& overcorrected, amblyopic eye is fully
corrected.
c. Total : fixing eye is atropinized &
undercorrected by 4 to 5 D, amblyopic eye is
fully corrected.

65. 2. Optical penalization
• Children who do not tolerate
patching
• Fog the good eye (non-
amblyopic eye) +3.00 D
• Amblyopic eye use for distance
and good eye use for near
• Not practically applicable
– Do near work most of time
compared to distance

66. Patching vs. Atropine for
Moderate Amblyopia
• Age 3-6 years
• Strabismic and/or anisometropic amblyopia
• Either patching or atropine for 6 months
Patching > 6 hrs/day
Success: Taper patching
Resolution: Stop patching
Failure at 4 months:
Increase to 12 hrs/day
Atropine daily
Success: Taper atropine
Resolution: Stop atropine
Failure at 4 months:
Add a Plano lens if the
patient is hyperopic

67. Part-time Vs. Minimal-time Patching For
Moderate Amblyopia
• 3-6 year-olds
• Patching 2 or 6 hrs/day for 4 months
• Practical application
– 2 hours prescribed patching is sufficient for
the initial treatment of moderate amblyopia
– (weekend atropine is sufficient for the initial
treatment of moderate amblyopia)
 Significant improvement of 2.4 lines
improvement seen.

68. Does it help to perform near
activities while patching?
• Age 3-7 years
- Moderate and severe amblyopia
- 2 hours of patching daily with near or distance
activities
- Near: crafts, reading, writing, computer and video
games
- Distance: outdoor play, watching TV
- No difference in visual acuity improvement
after 8 weeks between groups

69. Does it help to add a plano lens
when using atropine?
• 3-6 year-olds
• Moderate amblyopia
• After 4 months of treatment, Va improvement:
 Plano lens group: 2.8 lines.
 Atropine alone group: 2.4 lines
• Amblyopia resolution:
 Plano lens group = 40%
 Atropine alone group = 29%
• Sound eye Va was reduced in more patients in the
atropine + plano lens group than in the atropine alone
group, but the Va reduction did not persist.

70. Part time vs. full time patching
for severe amblyopia
• 3-6 years
• 6 hours vs. full time daily patching for 4
months
• Va improved 4.7 - 4.8 lines in both groups
• Practical application
– 6 hours patching is sufficient for the
initial treatment of severe amblyopia

71. Recurrence of amblyopia after
treatment discontinuation
• 3-7 years of age
• Moderate and severe amblyopia
• Successfully treated for 3 months or longer with patching
or atropine
• Patients were then followed off treatment for 52 weeks
• Amblyopia recurrence defined as >2 line loss in Va
• Amblyopia recurred in 24% (patch) and 21% (atropine) of
patients
• In patients who had been treated with 6-8 hours of daily
patching, amblyopia recurrence was more likely if
patching was abruptly stopped rather than tapered prior
to cessation

72. Treatment of amblyopia in older
children
• 7-12 years, and 13-17 years
• Moderate and severe amblyopia
• All treated with spectacles
• 6 month treatment
 7-12 year-olds randomized to Spectacles Alone or Spectacles
+ Patch + Atropine
• 7-12 year-olds: Spectacles Alone: 53%.
• Spectacles + Patch + Atropine : 25% response
rate (2 lines or more in Va improvement)
 13-17 year-olds randomized to Spectacles Alone or Spectacles
+ Patch
• 13-17 year-olds: Spectacles Alone: 25
• Spectacles + Patch: 23% response rate

73. Medical Treatment
 Levodopa :
• Precursor of dopamine.
• Levodopa is converted into dopamine in the brain.
• Dopamine is a neurotransmitter.
• More effective in case of strabismic and anisometropic
amblyopia.
• Reported a significant improvement in suppression
scotoma and contrast sensitivity.
• Levodopa will cause nausea, vomitting.
• Carbidopa increases the uptake of levodopa into brain.

74. • Levodopa + carbidopa : will reduce the side
effects.
• Lynx 1 is a protein that suppresses
acetylcholine receptor which helps to regulate
plasticity of the mature brain cells.
• Cholinesterase inhibitors will prevent lynx1, it
will be more effective for amblyopic patients.

75. Catecholamine:
• Neurotransmitter.
• Reactivate the visual system sensitive period
of neural plasticity.
• Will not produce reverse amblyopia.
Acupuncture :
• Improve blood flow in visual cortex through
accurate stimulation of nervers present in the
palms and foot using the correct acupoints.

76. 2. Active therapy:
• is designed to improve visual performance by the patient ‘s conscious
involvement in a sequence of a specific, controlled visual task that
provide feedback
i. CAM visual stimulator
ii. Intermittent photic stimulation
iii. Pleoptic

77. PLEOPTICS
• Involves active stimulation of fovea to
overcome eccentric fixation & improves Va.
• The peripheral retina including the eccentrically
fixing area around the fovea is dazzled.
• After lights are turned off, fovea functions better
because the surrounding retinal area is in a state
of hypofunction
• ONLY INDICATION IS coperative and intelligent
child older than 6yrs having eccentric fixation

78. ORE PLEOTOPHORE

79. Active therapy:
i. CAM visual stimulator
• Treat amblyopia
– by intense visual stimulation for
short period of time
• Grating of different spatial frequency
are rotated in front of amblyopic
eye
• The good eye is occluded
• Method based on:
– cortical cell response to specific line
orientation and to certain spatial
frequency.
– Therefore rotation ensured that a large
range of cortical neurons are
stimulated
• Better for anisometropic amblyopia

80. Active therapy:
ii. Intermittent photic stimulation
• Mallet IPS unit
• described as the "heightened
response" to a visual stimulus
• The targets
– consisted of slides containing much
detail of varying type and angular
dimension
– viewed against a red flickering
background.
• Red slight stimulation at 4Hz
• detailed visual task for 20-30
minutes

81. 1. 2.
3. 4.

82. Active therapy:
iii. Pleoptics
• Purposes :
– To disrupt eccentric fixation in strabismic
amblyopia
• Apparatus based on ophthalmoscope
principle
• Euthyscope, projectoscope, pleutophore
• Exposed peripheral retina to a very bright
light while protecting the macular area
• Only suitable for children >7 years old
Euthyscope

83. Surgery
If amblyopia is due to:
• cataract  cataract surgery
• nonclearing vitreous opacities vitrectomy
• corneal opacities  corneal graft
• Blepharoptosis  tarsal tuck

84. Summary
• Patching = atropine
• 2 hours prescribed patching sufficient for treatment of
moderate amblyopia
• Weekend atropine sufficient for treatment of moderate
amblyopia
• Near activities not critical in conjunction with
patching/atropine
• Plano lens not critical
• Active therapy with NLD very effective and improves BSV
as well.
• Taper amblyopia treatment
• Even older children and teenagers may respond to
amblyopia treatment

85. Scenario 1
• A 1 year old child is brought with c/o constant inward deviation
of the left eye noticed since 4 months of age.
• Cycloplegic refraction:
– OD: +2.00DS
– OS: +2.00 DS
• Fixation Assessment – resists occlusion of right eye.
POLL 1:
• Will you correct the refractive error?
a) Yes
b) No
c) Will wait for another 6 months
d) None of the above

86. Scenario 2
• A 4 year old child is referred from school vision screening
programme for further management.
• Visual Acuity: OD: 6/18, N6, OS: 6/9, N6
• Cover Test: Ortho at distance & near
• Cycloplegic refraction:
– OD: +1.50/-4.00X180
– OS:+1.50/-0.50X180
POLL 2:
• Will you correct the refractive error?
a) Yes
b) No
c) Will wait for another 6 months
d) None of the above

87. POLL 3:
• What type of amblyopia is scenario 1 & scenario 2?
a) Anisometric amblyopia
b) Strabismic amblyopia
c) Isometric amblyopia
d) Combined mechanism amblyopia
e) Meridonial amblyopia

88. Poll Question: 4
• Given the following refractive error, what type of amblyopia does
this patient potentially have?
– OD: +5.25 – 2.75 x 180
– OS: +4.00 – 2.50 x 180
a) Amblyopia OD secondary to anisometropic hyperopia
b) Amblyopia OU secondary to high astigmatism OU
c) Amblyopia OD>OS secondary to anisometropic hyperopia and
high astigmatism OU
d) Amblyopia OD>OS secondary to anisometropic hyperopia and
high hyperopia and high astigmatism OU

89. Poll Question: 5
• Which of the following examples will potentially have
amblyopia secondary to strabismus?
a) 12pd Intermittent Left Exotropia at Distance and Near
b) 20pd Constant Alternating Esotropia at Distance and
Near
c) 20pd Intermittent Alternating Exotropia at Dist and 10pd
Exophoria at Near
d) 16pd Constant Right Esotropia at Distance and Near

90. Scenario 3:
This was the Bruckner reflex of three
different boys.
POLL 5:
Identify THE REFRACTIVE ERRORS IN:
A, B, C, and D
A
B
C
D

91. POLL 7
• Predict VA for 3 PD Nasal EF
a) 20/50
b) 20/60
c) 20/80
d) 20/100

92. CASE:
• VISIT 1:
• 5yo female
• CC: Failed school screening; Mom reports occasional squinting
• Birth, developmental, and educational hx – all unremarkable
• Findings:
• DVAsc: OD: 20/60 OS: 20/100 Lea S-line
• PERRLA –APD
• EOMs: SAFE
• CTsc: 2 EP, 4 EP’
• Stereo: RDS: 250” WC: 100”
• SLE: unremarkable

93. CONTD….
• Cyclo Ret:
• •OD: +3.00-3.25x180 (20/40) •OS: +4.50-3.50x180
(20/80)
• Final RX:
• OD: +1.50-3.25x180 •OS: +3.00-3.50x180
• Diagnosis: ????
• Manageent: ????
• Visit 2:
• Patient returns after 3 mos
• VA improves OD: 20/30 OS:20/60
• Stereo WC: 70”
• Advice: ??????
• Visit 3 and 4:
• At subsequent two
appointments
• VA: OD: 20/25 OS: 20/50
• Stereo WC: 60”

94. Poll Question
• A patient came in for their first eye exam and has been diagnosed
with anisometropic refractive amblyopia OS (VA: 20/60). You
prescribed the patient glasses and the patient returns for their 3
month follow up and their vision improves to 20/50.
• What would your next step be?
a) Have the patient continue wearing the glasses full time and have
them return in 3 months
b) Begin patching OD for 2 hours/day, 7 days/week
c) Begin Atropine 1%, 1 gtt OD on the weekends
d) Begin patching OD for 6 hours/day, 7 days/week

95. • Visit 5:
• VA: OD: 20/25+ OS: 20/30
• Stereo WC:30”
• Advice: ??????
• Visit 6:
• VA: OD: 20/20- OS: 20/25+
• Stereo WC:25”
• Advice: ??????

96. Poll Question
• Your amblyopic patient has completed patching therapy.
• They have been patching OS 2 hours/day, 7 days/week
and the vision is OD: 20/20 and OS: 20/20.
• What is your next step?
a) Discontinue patching and have the patient return in 1
year for a comprehensive exam
b) Discontinue patching and have the patient return in 3
months for a follow-up
c) Taper patching to OS 2 hours/day, 4 days/week and
have them return in 3 months