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.
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
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.
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.
19. CHARACTERISTICS OF
AMBLYOPIC PATIENT
Spatial uncertainty (hand and
eye coordination not good).
Crowding phenomena-
May have unsteady fixation.
May be associated with squint.
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
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…..
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
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