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AMBLYOPIA
Mahendra Singh
Assistant Professor and
consultant Optometrist.
CL Gupta Eye Institute.
UP India
DEFINITION
 It is a decrease in visual acuity in one or both
eyes that results from an inability to use the
eye or eyes for central fixation during a
critical period of visual development
 Amblyopia is defined as the condition of
reduced visual acuity, usually unilateral nor
correctable by refractive means and nor
attributable to obvious structural or
pathological ocular anomalies
DEFINITION
Ambloypia in simple means
dullness of vision or diminished
vision.
It arises from a greek word
It can be unilateral or bilateral.
ETIOLOGY
Oclusion, strabismus,
anisometropia, uncorrected high
refractive errors.
Opacities of ocular media.
Depriviation of light or form sense.
CLASSIFICATION
Functional amblyopia- which is
reversible.
Organic amblyopia- which is not
reversible.
FUNCTIONAL AMBLYOPIA
It is sub classified as :-
Stabismus amblyopia.
Refractive amblyopia.
Anisometropic amblyopia.
Ammetrpoic amblyopia.
Meridonial amblyopia.

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Amblyopia.ppt

  • 1. AMBLYOPIA Mahendra Singh Assistant Professor and consultant Optometrist. CL Gupta Eye Institute. UP India
  • 2. DEFINITION  It is a decrease in visual acuity in one or both eyes that results from an inability to use the eye or eyes for central fixation during a critical period of visual development  Amblyopia is defined as the condition of reduced visual acuity, usually unilateral nor correctable by refractive means and nor attributable to obvious structural or pathological ocular anomalies
  • 3. DEFINITION Ambloypia in simple means dullness of vision or diminished vision. It arises from a greek word It can be unilateral or bilateral.
  • 4. ETIOLOGY Oclusion, strabismus, anisometropia, uncorrected high refractive errors. Opacities of ocular media. Depriviation of light or form sense.
  • 5. CLASSIFICATION Functional amblyopia- which is reversible. Organic amblyopia- which is not reversible.
  • 6. FUNCTIONAL AMBLYOPIA It is sub classified as :- Stabismus amblyopia. Refractive amblyopia. Anisometropic amblyopia. Ammetrpoic amblyopia. Meridonial amblyopia.
  • 7. FUNCTIONAL AMBLYOPIA Stimulus depriviation amblyopia Amblyopic examopsia Idiopathic amblyopia Amblyopia secodary to Nystagmus Hysterical amblyiopia
  • 8. STABISMIC AMBLYOPIA Occurs when there is longstanding suppression. When it is constant, unilateral and at all viewing distances. In early childhood. Fovea suppressed to prevent confusion and diplopia.
  • 9. STABISMIC AMBLYOPIA Active cortical inhibition point is zero in deviating eye. Stereopsis is severely decreased or absent. Visual acuity loss is more compared to anisometropic amblyopia. Severity of amblyopia depends on type of deviation. More
  • 10. REFRACTIVE AMBLYOPIA ANISOMETROPIC AMBLYOPIA Most common cause of amblyopia. Difference in the refractive error of both eyes. Dissimilarity of foveal image clarity, size, clarity.
  • 11. REFRACTIVE AMBLYOPIA AMMETROPIC AMBLYOPIA Due to uncorrected high refractive error. Bilateral amblyopia. Isoametropic amblyopia can be classified under this. Occurs in children havin More than +5.00D or More -10.00D.
  • 12. REFRACTIVE AMBLYOPIA MERIDONIAL AMBLYOPIA Occurs due to uncorrected astigmatic refractive error.
  • 13. STIMULUS DEPRIVIATION AMBLYOPIA Result of lack of adequate visual stimulus in early life. Can be unilateral or bilateral. Can be complete (when no light entering) or Partial (when some light enters).
  • 14. AMBLYOPIA EXAMOPSIA Due to disuse of the eyes. E.g. Uniocular, congenital, or traumatic cataract, corneal opacity, complete ptosis occlusion amblyopia.
  • 15. IDIOPATHIC AMBLYOPIA Unilateral. Occurs in normal patients. -Ve history of strabismus. Clinically V/A and foveal suppression will improve after patching the good eye. But it will recur once the treatment is stopped.
  • 16. ORGANIC AMBLYOPIA Irreversible. Due to undetectable organic lesion in the visual pathway. Classified as Toxic amblyopia. Visual loss results from damage to optic nerve fibers. Due to certain poisons such such as tobacco, ethyl, alcohol, chloroquimine.
  • 17. PATHOPHYSIOLOGY OF AMBLYOPIA. 1. Amblyopic Factor- 1.Visual Depriviation. 2.Light depriviation. 3.Abnormal binocular interaction.
  • 18. CHARACTERISTICS OF AMBLYOPIC PATIENT  Reduced vision.  Decreased contrast sensitivity.  Suppression.  Decreased stereopsis.  Defective accommodation, convergence and fusional vergence affected.
  • 19. CHARACTERISTICS OF AMBLYOPIC PATIENT  Spatial uncertainty (hand and eye coordination not good).  Crowding phenomena-  May have unsteady fixation.  May be associated with squint.
  • 20. INVESTIGATIONS  History.  Visual acuity.  Refraction.  Cover test.  Ocular motility.
  • 21. INVESTIGATIONS  Binocular assesment.  Fixation pattern.  Neutral density filter.
  • 22. FIXATION PATTERN  Can be centric i.e. with fovea.  Can be eccentric i.e. any other point except fovea.
  • 23. CLASSIFICATION OF FIXATION PATTERN  Foveal fixation with 2 degrees of fovea.  Parafoveal fixation with 2-5 degrees of fovea.  Para macular 5-10 degrees.  More than 10 degrees i.e. peripheral fixation.
  • 24. DEFINITION  It is a decrease in visual acuity in one or both eyes that results from an inability to use the eye or eyes for central fixation during a critical period of visual development  Amblyopia is defined as the condition of reduced visual acuity, usually unilateral nor correctable by refractive means and nor attributable to obvious structural or pathological ocular anomalies
  • 25.  The decrease in V/A is due to reduction in form discrimination.  Most pronounced underphotopic visual condition.  Critical period of development  from birth to 6 yrs.  Amblyopia means dullness of vision.  In general V/A < 6/9 is  Amblyopia  In general 20/30 -- 20/70 mild (shallow) 20/80 – 20/120  moderate , worse than 20/120 is marked (deep). Amblyopia
  • 26.  Amblyopia is also defined as by a difference in visual acuity between two eyes. For clinical purpose if the acuity difference is two or more lines in both eye. Then amblyopia is suspected. e.g. Best corrected V/A R 6/9 L 6/5 Other Definition
  • 27. CLASSIFICATION • Different classification under different authors. I :- Classification according to cause  1. Strabismic Amblyopia 2. Anisometropic Amblyopia 3. Isometropic Amblyopia 4. Image degradation Amblyopia 5. Psychogenic Amblyopia
  • 28. STRABISMIC AMBLYOPIA  Occurs in long standing foveal suppression  Constant unilateral strabismus in childhood  Fovea got suppressed to prevent confusion  Suppression is more intense than anisometropic amblyopia .( as acuity loss is more intense )  Highly associated with eccentric fixation
  • 29. ANISOMETROPIC AMBLYOPIA  Most common cause of Amblyopia  Flynn and Cassady reported  microtropia mostly found with anisometropic amblyopia.  He said 20%  solely anisometropia 48%  purely strabismic 32%  both strabismic & anisometropic  It occurs due to decrease in contrast & Aniseikonia.  Severity of Amblyopia is depend upon amount of error.  Meridional Amblyopia
  • 30. ISOMETRIC AMBLYOPIA  2° to high symmetric refractive error ( hyperopia , myopia , astigmatism )  Detected earlier than anisometropic amblyopia.  Little or no suppression.
  • 31. IMAGE DEGRADATION AMBLYOPIA  Caused by physical obstruction to clear vision in childhood.  Due to light & form stimulus deprivation.  Commonest cause is congenital cataract.
  • 32. PSYCHOGENIC AMBLYOPIA  Due to hysteria & malingering.  Common in children  Can occur in adults those are under stressful situation.
  • 34. FUCTIONAL AMBLYOPIA  Functional means psychological.  It is reversible  Causes like strabismus , anisometropia , isometropia , amblyopia – Ex – anopsia.
  • 35. ORGANIC AMBLYOPIA  It is due to any ocular pathology.  It is of irreversible type  Causes like Corneal lesions, any retinal abnormality, cortical pathology.
  • 36. AMBLYOPIA – EX – ANOPSIA  Now called as Amblyopia of Disuse.  It is due to stimulus deprivation.  Causes like Corneal Opacity , cataract
  • 37. III CLASIFICATION • Chavasse’s divided amblyopia into two types. 1. Amblyopia of Extinction 2. Amblyopia of Arrest
  • 38.  Amblyopia of Extinction :- It is to refer to deteroration of central visual acuity to levels lower than the patient had previously attained.  Amblyopia of Arrest :- It is used to refer to reduced central vision caused by disturbance that prevented visual development.
  • 39. IV CLASSIFICATION a) Organic amblyopia 1. Developmental Amblyopia 2. Toxic Amblyopia 3. Nutritional Amblyopia 4. Other types b) Psychogenic Amblyopia 1. Hysteric Amblyopia 2. Malingering Amblyopia
  • 40.  Developmental  Associated with strabismus, refractive error, visual deprivation.  Toxic  Due to ethambutol, Chloramphenical, quinine etc.  Other Types  Associated with ischemic optic neuropathy, temporal arthritis, retrobulbar neuropathy.  Nutritional Due to vit-B12 deficiency.  Hysterical  2 to an unconscious psychogic disturbance.  Malingering  Conscious faking
  • 41. ELECTROPHYSIOLOGICAL TESTS  VER ( visually evoked response)  It reflects visual input from photoreceptors to the occipital cortex.  Pattern stimulus is used instead of flashing to produce less variability.  In infants it tell that 20/20 V/A reached by age of 6 months  If V/A in two eyes is equal , then difference in amplitude in VER is close to zero & ratio of two eyes is almost one.  So we can find any developmental amblyopia.
  • 42. PATHOPYSIOLOGY  Two fundamental mechanism responsible for developmental amblyopia. a) Visual Deprivation b) Active Cortical Inhibition
  • 43. VISUAL DEPRIVATION  Could be uniocular or binocular  Studies shown that there is a clearly defined period during which deprivation has a profound effect on the development of normal behavior & physiologic responses.  Deprivation during the early part of the critical period is more detorterious than at later times. The period of sensitivity begins as the ocular media clear and continuous through visual maturation.
  • 44. Active cortical inhibition  Both physiological an pharmacological evidence exist for an active inhibitory process in developmental amblyopia  In physiological evidence, normal eye may be responsible for active cortical inhibition  Pharmacological evidence e.g.:-nor epinephrine, GABA (gamma amino butyric acid) {neurotransmitter inhibitors}
  • 45. Retina In amblyopia  Along with the lgb and striate area retina also shows some abnormal changes a) Receptor amblyopia:-some amblyopic eyes have abnormal Stiles-Crawford effect. A defect of the orientation of the retinal receptors results in only a small V/A loss and abnormal Stiles- crawford effect is actually a manifestation of undetected eccentric fixation.
  • 46. b) Pupil light reflex:- usually the pupil light reflex is not abnormal in developmental amblyopia. However with profound developmental amblyopia there can be an afferent pupilary defect. Normally central retina stimulation causes marked constriction then peripheral stimulation and reverse is there in amblyopia.
  • 47. c) Critical flicker Frequency:- The rate at which the flicker of an intermittent light stimulus disappears and become a continuous sensation.CFF change does occur in amblyopia. d) Colour Vision:- It is effected if V / A is below20/100 and also get effected in eccentric fixation. e) Light Perception:- dark perception is almost normal,but form determination is worse at photopic luminance.
  • 48. f) ERG (Electro retino gram):- It shows some abnormal changes.They include a lowered amplitude of “b” wave and diminished potential of “a” wave. g) Saccadic and pursuit movements:- they are also abnormal in amblyopia.3 abnormalities of saccadic system have been reported: i. Increased latency ii. Decrease peak velocity iii. Dysmetria ( inaccuracy )
  • 49. INVESTIGATIONS 1) History:- relevant questions should be asked related to strabismus,refraction and social history. 2) Visual Acuity:- Charts available a) Snellen acuity charts b) Bailey lovie charts c) Tumbling “E” charts d) Picture cards e) OKN,VEP,Preferential looking test.
  • 50. While recording visual acuity examiner should suspect amblyopia if:- a) Letters are missed on several lines using the full chart b) Letters in the middle of a line are more frequently misread than those at the ends of the line. c) Letters are transposed in position. d) Isolated letter acuity is better by one or two lines than single line or full chart acuity.
  • 51. 3) Refractive error 4) Crowding Phenomenon ( Linear acuity and single letter acuity ) 5) Neutral density filter 6) Visual Fields 7) Fixation 8) Cover test 9) Angle of Deviation Continue…..
  • 52. Fixation  Central  Eccentric a) Foveal (2˚) b) Parafoveal (2˚-5˚) c) Paramacular (5˚-10˚) d) Peripheral (beyond 10˚) e) unsteady
  • 53. How to evaluate fixation  Angle kappa  Arc perimeter  Major amblyoscope  Visuscope  Ophthalmoscope  Euthyscope  Co-oridinator  Space co-oridinator  Synaptophore using haidinger brushes  Maxwell spot (round, dark, purplish spot approx 3arc degree in diameter)  Haidinger brushes test
  • 54. Treatment For Centric Fixation  Full refraction under cycloplegics  Direct occlusion  Auto flashing  Red filter  Anti suppression  Haidinger brushes  VTP’s
  • 55.  Full refraction under cycloplegic  Inverse occlusion for at least 1 month  Once fixation become unsteady then continue with inverse occlusion and auto flashing  Haidinger brushes  Direct occlusion when fovea takes its properties and fixation become central  Surgery  Auto flashing  Anti suppression  VTP  Physiological diplopia For Eccentric Fixation
  • 56. Goals of amblyopia treatment Monocular goals  Eliminate eccentric fixation  Eliminate eccentric localization  Establish foveal fixation  Establish foveal localization Binocular goals  Eliminate sensory anomalies  Improve sensory motor skills
  • 57. VTP’s  They improves – 1) Depth perception 2) Visual motor co-ordination 3) Focusing skills 4) Vision 5) Eye tracking 6) Stereopsis 7) Binocular co-ordination
  • 58. VTP’s  Examples:- a) Thread and beat b) Thread and needle c) Drawing pictures d) Games require strong fixation e) Watching Television f) Work require hand eye co-ordination
  • 59. VTP,s
  • 60. VTP,s
  • 61. OTHER TECHNIQUES 1) CAM vision stimulator 2) Pleoptics 3) Penalization Distance penalization Near penalization Total penalization 4) Computer Software's
  • 62. MEDICAL TREATMENT 1) Citicholine 2) Levodopa 3) 6-hydroxydopamine 4) Naloxone 5) Bicuculline
  • 63. TREATMENT PROBLEMS 1) Patching e.g Elastoplasts Opticlude 2) Parental cooperation 3) Occlusion Amblyopia 4) Recurrence