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Amblyopia treatment dr mirzajani


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Amblyopia treatment dr mirzajani

  1. 1. Amblyopia TreatmentAmblyopia Treatment Dr. Ali MirzajaniDr. Ali Mirzajani (BSc, MSc, PhD)(BSc, MSc, PhD) Department of OptometryDepartment of Optometry Tehran University of Medical ScienceTehran University of Medical Science
  2. 2. ClassificationClassification ofof Functional AmblyopiaFunctional Amblyopia Deprivation Amblyopia  Refractive Amblyopia A. Anisometropic Amb B. Isometropic Amb (Ametropic Amb)  Strabismic Amblyopia
  3. 3. Amblyopia Other Problems
  4. 4. Management of AmblyopiaManagement of Amblyopia  The clinician must firstThe clinician must first rule outrule out anan organic causeorganic cause and treat any obstacleand treat any obstacle to vision (eg, cataract, occlusion of theto vision (eg, cataract, occlusion of the eye from other etiologies).eye from other etiologies).  Remove cataractsRemove cataracts in the first 2in the first 2 monthsmonths of life, and aphakic correction mustof life, and aphakic correction must occur quickly.occur quickly.
  5. 5. Management of Amblyopia  The first attempt for treatment of amblyopia is to prescribe optimum optical correction  Not meaning to give the full correction
  6. 6. Management of AmblyopiaManagement of Amblyopia  Full cycloplegic refraction should beFull cycloplegic refraction should be given to patients withgiven to patients with accommodativeaccommodative esotropiaesotropia and amblyopia.and amblyopia.  In other patients, a prescriptionIn other patients, a prescription lessless than the fullthan the full plus measurement thatplus measurement that was refracted may be prescribed givenwas refracted may be prescribed given that the decrease in plus is symmetricthat the decrease in plus is symmetric between the two eyes.between the two eyes.
  7. 7. Management of AmblyopiaManagement of Amblyopia  BecauseBecause accommodative amplitudeaccommodative amplitude isis believed to bebelieved to be decreaseddecreased in amblyopicin amblyopic eyes, one needs to be cautious abouteyes, one needs to be cautious about cutting back too much on the amountcutting back too much on the amount of plus.of plus.  Refractive correction alone has beenRefractive correction alone has been shown to improve amblyopia in up toshown to improve amblyopia in up to 77% of patients.77% of patients.
  8. 8. Management of AmblyopiaManagement of Amblyopia  Patients withPatients with bilateral refractivebilateral refractive amblyopiaamblyopia do well with spectacledo well with spectacle correction alone.correction alone.  with most children aged 3-10 yearswith most children aged 3-10 years achievingachieving 20/30 or better20/30 or better within a year.within a year.
  9. 9. Management of Amblyopia  TheThe next stepnext step is forcing the use of theis forcing the use of the amblyopic eye by one of the followingamblyopic 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
  10. 10. Occlusion  occlusion therapy:occlusion therapy: Occlusion therapyOcclusion therapy has been thehas been the mainstay ofmainstay of treatment since thetreatment since the 18th century.18th century.
  11. 11. Furthermore,Furthermore, AvicennaAvicenna (980-1037) has(980-1037) has suggested “occlusion” forsuggested “occlusion” for treatment of strabismictreatment of strabismic amblyopia in his book ofamblyopia in his book of ““The Canon ofThe Canon of MedicineMedicine”.”.
  12. 12. Occlusion  The following are general guidelinesThe following are general guidelines for occlusion therapy:for occlusion therapy:
  13. 13. Occlusion  PatchingPatching may be full-time or part-time.may be full-time or part-time.  f/u at intervals off/u at intervals of 1 week per year1 week per year ofof age, if undergoing full-time occlusionage, if undergoing full-time occlusion to avoidto avoid occlusion amblyopia in theocclusion amblyopia in the sound eye.sound eye.
  14. 14. Occlusion  The Amblyopia Treatment StudiesThe Amblyopia Treatment Studies (ATS) have helped to provide new(ATS) have helped to provide new informationinformation on the effect of variouson the effect of various amounts ofamounts of patching.patching.
  15. 15. OcclusionOcclusion  Always consider lack ofAlways consider lack of compliancecompliance inin a child where visual acuity is nota child where visual acuity is not improving. Compliance is difficult toimproving. Compliance is difficult to measure but is an important factor inmeasure but is an important factor in determining the success of thisdetermining the success of this therapy.therapy.
  16. 16. OcclusionOcclusion  In addition to adhesive patches,In addition to adhesive patches, opaque contact lensesopaque contact lenses, occluders, occluders mounted on spectacles, and adhesivemounted on spectacles, and adhesive tape on glasses have been used.tape on glasses have been used.
  17. 17. OcclusionOcclusion  The studies have demonstrated that,The studies have demonstrated that, in patientsin patients aged 3-7 yearsaged 3-7 years withwith deepdeep amblyopia (visual acuity betweenamblyopia (visual acuity between 20/100 and 20/400),20/100 and 20/400), full-timefull-time patchingpatching produced a similar effect to thatproduced a similar effect to that of 6of 6 hours ofhours of patching per day.patching per day.
  18. 18. OcclusionOcclusion  . In a separate study,. In a separate study, 2 hours of daily2 hours of daily patchingpatching produced an improvement inproduced an improvement in visual acuity similar to that ofvisual acuity similar to that of 6 hours6 hours of daily patchingof daily patching when treatingwhen treating moderate amblyopia (visual acuitymoderate amblyopia (visual acuity better thanbetter than 20/10020/100) in children aged 3-) in children aged 3- 7 years.7 years.  In this study, patching was prescribedIn this study, patching was prescribed in combination with 1 hour of nearin combination with 1 hour of near visual activities.visual activities.
  19. 19. OcclusionOcclusion  For patients aged fromFor patients aged from 7 years to7 years to younger than 13 yearsyounger than 13 years, the Amblyopia, the Amblyopia Treatment Studies have suggestedTreatment Studies have suggested that prescribingthat prescribing 2-6 hours2-6 hours a day ofa day of patching can improve visual acuitypatching can improve visual acuity even ifeven if the amblyopiathe amblyopia has beenhas been previously treated.previously treated.
  20. 20. OcclusionOcclusion  For patients aged fromFor patients aged from 13 years to13 years to younger than 18 yearsyounger than 18 years, prescribing, prescribing 2-62-6 hourshours a day of patching might improvea day of patching might improve visual acuity when amblyopiavisual acuity when amblyopia has nothas not beenbeen previouslypreviously treatedtreated; however, this; however, this is likely to be of little benefit ifis likely to be of little benefit if amblyopia was previously treated withamblyopia was previously treated with patching. Long-term results from thesepatching. Long-term results from these studies are still pending.studies are still pending.
  21. 21. OcclusionOcclusion  The Amblyopia Treatment StudiesThe Amblyopia Treatment Studies have also found that abouthave also found that about one fourthone fourth of children with amblyopia who wereof children with amblyopia who were successfully treatedsuccessfully treated experience aexperience a recurrencerecurrence withinwithin the first yearthe first year afterafter discontinuation of treatment.discontinuation of treatment.
  22. 22. OcclusionOcclusion  Data from these studies suggest thatData from these studies suggest that patientspatients treated with 6 or more hourstreated with 6 or more hours aa day of patching have a greater risk ofday of patching have a greater risk of recurrencerecurrence when patching is stoppedwhen patching is stopped abruptlyabruptly rather thanrather than when it iswhen it is reducedreduced to 2 hoursto 2 hours a day prior to cessation ofa day prior to cessation of patching. Randomized studies havepatching. Randomized studies have still yet to be performed.still yet to be performed.
  23. 23. occlusion dose monitorocclusion dose monitor  Occlusion dose monitorOcclusion dose monitor (ODM) is a(ODM) is a device to measure compliance withdevice to measure compliance with patch-wearing during the treatment ofpatch-wearing during the treatment of amblyopia objectively.amblyopia objectively.  It measures the temperature differenceIt measures the temperature difference between the front and back of the ODMbetween the front and back of the ODM every 2-5 minutes by means ofevery 2-5 minutes by means of twotwo thermistorsthermistors..
  24. 24. Optical Penalization
  25. 25. Optical penalizationOptical penalization  Optical penalization isOptical penalization is reserved forreserved for children who would not wearchildren who would not wear a patcha patch or in whomor in whom compliancecompliance was an issue.was an issue.  Optical penalization involves alteringOptical penalization involves altering the spectacle or contact lensthe spectacle or contact lens correction of the sound eye to producecorrection of the sound eye to produce image blur, potentially providing theimage blur, potentially providing the amblyopic eye a competitiveamblyopic eye a competitive adventageadventage
  26. 26. Optical penalizationOptical penalization  Distance optical penalizationDistance optical penalization  Near optical penalizationNear optical penalization  Total optical penalizationTotal optical penalization
  27. 27. Medical penalizationMedical penalization  The Amblyopia Treatment Studies,The Amblyopia Treatment Studies, however, have demonstrated thathowever, have demonstrated that CycloplegicCycloplegic ((atropine) penalizationatropine) penalization inin patients withpatients with moderatemoderate amblyopiaamblyopia (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 Treatmentpatching. The Amblyopia Treatment Studies were performed in childrenStudies were performed in children aged 3-7 years.aged 3-7 years.
  28. 28. Medical penalizationMedical penalization  Atropine drops or ointment is instilledAtropine drops or ointment is instilled in thein the nonamblyopicnonamblyopic eye.eye.  This therapy is sometimes used inThis therapy is sometimes used in conjunction withconjunction with patching or occlusionpatching or occlusion of the glasses (eg, adhesive tape, nailof the glasses (eg, adhesive tape, nail polish) by individual practitioners.polish) by individual practitioners.
  29. 29. Medical penalizationMedical penalization  In the Amblyopia Treatment StudiesIn the Amblyopia Treatment Studies that evaluated patching versusthat evaluated patching versus atropine penalization,atropine penalization, atropineatropine penalization and patchingpenalization and patching were usedwere used in conjunction with 1 hour of nearin conjunction with 1 hour of near visual activities.visual activities.
  30. 30. Medical therapyMedical therapy  PharmacologicPharmacologic treatment withtreatment with levodopalevodopa has been investigated andhas been investigated and has showedhas showed transient improvementtransient improvement ofof vision in amblyopic eyes. However,vision in amblyopic eyes. However, the exact role of such pharmacologicthe exact role of such pharmacologic agents has not been determined.agents has not been determined. LevodopaLevodopa currently is notcurrently is not being usedbeing used clinically.clinically.
  31. 31. Active TherapyActive Therapy  CAM Therapy (CAM Visual Stimulator)CAM Therapy (CAM Visual Stimulator)  Photic Stimulation byPhotic Stimulation by TBI or Major AmblyoscopeTBI or Major Amblyoscope  Bangerter MethodBangerter Method  Cupper MethodCupper Method
  32. 32. Complementary MethodsComplementary Methods (Alternative Medicine)(Alternative Medicine)  low energy He-Ne laserlow energy He-Ne laser  Magnetic TherapyMagnetic Therapy  AcupunctureAcupuncture  Energy TherapyEnergy Therapy
  33. 33. low energy He-Ne laserlow energy He-Ne laser  Commonly, The low energy He-NeCommonly, The low energy He-Ne laserlaser irradiates the fundusirradiates the fundus directly fordirectly for 3 minutes3 minutes each day.each day.  It is claimed that The low energy He-It is claimed that The low energy He- Ne laser is effective in treatingNe laser is effective in treating amblyopia.amblyopia.
  34. 34. Magnetic Therapy forMagnetic Therapy for AmblyopiaAmblyopia  Canadian researchers found thatCanadian researchers found that beamingbeaming magnetic pulsesmagnetic pulses into theinto the brain improved thebrain improved the sensitivitysensitivity of theof the weaker eyeweaker eye temporarilytemporarily. The study. The study was prompted by reports of newwas prompted by reports of new research that documents theresearch that documents the plasticityplasticity of the adult brain.of the adult brain.
  35. 35. Acupuncture forAcupuncture for amblyopia treatmentamblyopia treatment  Acupuncture is a potentially usefulAcupuncture is a potentially useful complementary treatmentcomplementary treatment modalitymodality that may provide sustainablethat may provide sustainable adjunctive effect to refractiveadjunctive effect to refractive correction forcorrection for anisometropic amblyopiaanisometropic amblyopia in young childrenin young children
  36. 36. Energy TherapyEnergy Therapy  There is no scientific evidence thatThere is no scientific evidence that energy healing has effect onenergy healing has effect on amblyopia.amblyopia.
  37. 37. Occlusion Other Methods
  38. 38. «‫بانفسهم‬ ‫ما‬ ‫يورو‬ّ‫ر‬‫يغ‬ ‫ت ي‬ّ‫ر‬‫ح‬ ‫بقوم‬ ‫ما‬ ‫ور‬ُ ‫ام‬ ‫ي‬ِّ‫يغ‬ُ ‫ام‬ ‫ل‬ ‫ال‬ ‫ن‬ّ‫ر‬ ‫»ا‬ ‫دهند‬ ‫تغييور‬ ‫خود‬ ‫آنها‬ ‫آنكه‬ ‫مگور‬ ‫دهد‬ ‫نم ي‬ ‫تغييور‬ ‫را‬ ‫قوم ي‬ ‫هيچ‬ ‫سورنوشت‬ ‫.خداوند‬ ‫ی‬ ‫آيه‬ ،‫رعد‬ ‫سوره‬ :‫مجيد‬ ‫قوران‬11
  39. 39. Cessation of TherapyCessation of Therapy  The endpoint of therapy isThe endpoint of therapy is spontaneousspontaneous alternation of fixationalternation of fixation oror equal visual acuityequal visual acuity in both both eyes.[23][23] When visual acuity is stable, patchingWhen visual acuity is stable, patching may be decreasedmay be decreased slowlyslowly..
  40. 40. Cessation of TherapyCessation of Therapy  Because amblyopia recurs in a largeBecause amblyopia recurs in a large number of patients (see Prognosis),number of patients (see Prognosis), maintenance therapy or tapering ofmaintenance therapy or tapering of therapy should be strongly considered.therapy should be strongly considered. ThisThis tapering is controversial, sois controversial, so individual physicians vary in theirindividual physicians vary in their approaches.approaches.
  41. 41. Cessation of TherapyCessation of Therapy  Even though there have been manyEven though there have been many advances in amblyopia treatment,advances in amblyopia treatment, tailoring the treatment with individualtailoring the treatment with individual treatment plans is still difficult becausetreatment plans is still difficult because the dose/effect response from thethe dose/effect response from the amount of occlusion is not fullyamount of occlusion is not fully understood.understood.
  42. 42. Strabismus ManagementStrabismus Management  Treatment of strabismus generallyTreatment of strabismus generally occurs last. The endpoint of strabismicoccurs last. The endpoint of strabismic amblyopia is freely alternating fixationamblyopia is freely alternating fixation with equal vision.with equal vision. SurgerySurgery generally isgenerally is performed after this endpointperformed after this endpoint has beenhas been reached.reached.
  43. 43. Strabismus ManagementStrabismus Management  Surgical therapySurgical therapy for strabismusfor strabismus generally should occur after amblyopiagenerally should occur after amblyopia is reversed.  Disadvantages to surgical therapyDisadvantages to surgical therapy prior to correction of amblyopiaprior to correction of amblyopia include:include:    
  44. 44. Strabismus ManagementStrabismus Management 1. difficulty in telling if amblyopia is1. difficulty in telling if amblyopia is present because there is no longer apresent because there is no longer a strabismus to assess fixationstrabismus to assess fixation preferencepreference 2. and higher potential to being lost to2. and higher potential to being lost to follow-up, as the child cosmeticallyfollow-up, as the child cosmetically looks better. The improved cosmesislooks better. The improved cosmesis gives the parents a false sense ofgives the parents a false sense of security about the vision about the vision improving.
  45. 45. Strabismus ManagementStrabismus Management 3. Continuing amblyopia treatment and3. Continuing amblyopia treatment and patchingpatching (or penalizations) may disrupt(or penalizations) may disrupt oror preventprevent more fusion development inmore fusion development in binocular system.binocular system. So we're faced with a lack of success inSo we're faced with a lack of success in treating strabismustreating strabismus