AMBLYOPIA

DANANG MUSTOFA
Amblyopia represents diminished vision occurring during the years
of visual development secondary to abnormal visual stimulation. It is
usually unilateral but it can be bilateral. The diminished vision is
beyond the level expected from the ocular pathology present.
Etiology
 Unilateral
causes of amblyopia also include the same
types of media opacities seen in bilateral cases.
However, the most common causes of unilateral
amblyopia are strabismus and anisometropia, or a
combination of the two.
 Examples of etiologies for bilateral amblyopia include
bilateral media opacities (ex. corneal opacities,
infantile or childhood cataracts, or vitreous
hemorrhages), or ametropia (bilateral high
astigmatism or high hypermetropia).
Risk Factor
 A positive family history of strabismus, amblyopia, or media
opacities would increase the risk of amblyopia in the child.
Children who have conditions that increase the risk of strabismus,
anisometropia, or media opacities (ex. Down syndrome) would
also be at increased risk for the development of amblyopia.
Pathophysiology
 Abnormal visual stimulation during the critical period of visual
development results in brain damage. Structural and functional
damage occurs in the lateral geniculate nucleus and the striate
cortex of the visual center in the occipital lobe in the form of
atrophy of connections, loss of cross-linking between connections
and loss of laterality of connections.
Primary prevention
 The key to prevention is detection. There are numerous
techniques to detect amblyopia, all with varying degrees of
specificity, sensitivity, complexity and cost. These include a
complete ophthalmic examination, photoscreening, visual
evoked potentials, acuity charts, and tests of stereopsis and
binocular function. Children who are at higher risk for amblyopia
should be watched closely for early signs of this condition. In
general, the quicker amblyopia is detected and addressed, the
less negative effect it has on the visual system.
Classification
 Strabismic amblyopia results from abnormal binocular interaction
where there is continued monocular suppression of the deviating
eye.
 Anisometropic amblyopia is caused by a difference in refractive
error between the eyes and may result from a difference of as
little as 1 dioptre. The more ametropic eye receives a blurred
image, in a mild form of visual deprivation. It is frequently
associated with microstrabismus and may coexist with strabismic
amblyopia.
 Stimulus deprivation amblyopia results from vision deprivation. It
may be unilateral or bilateral and is typically caused by opacities
in the media (e.g. cataract) or ptosis that covers the pupil.
 Bilateral ametropic amblyopia results from high symmetrical
refractive errors, usually hypermetropia .
 Meridional amblyopia results from image blur in one meridian. It
can be unilateral or bilateral and is caused by uncorrected
astigmatism (usually >1 D) persisting beyond the period of
emmetropization in early childhood.
Signs
 The presence or absence of signs of amblyopia would depend
on what the underlying etiology for the amblyopia is.
 Deprivational amblyopia could manifest with ptosis, an eyelid
hemangioma, or a cataract for example.
 Strabismic amblyopia may show a constant or intermittent ocular
deviation.
 Anisometropic amblyopia often shows no obvious signs when
observing the patient, but cycloplegic retinoscopy will reveal the
anisometropia.
 On clinical examination, unilateral amblyopia will show
asymmetric visual behavior or acuity testing results (although not
all patients with asymmetric acuity have amblyopia).
 Severe cases may have a mild afferent pupillary defect.
 The crowding phenomenon is important to be aware of when
testing visual acuity in an amblyope.
Symptoms
 Patients with unilateral amblyopia are often asymptomatic.
Occasionally, patients will complain that one eye is blurry, or
younger children may report discomfort in the affected eye.
Torticollis occurs infrequently. Poor depth perception or
clumsiness may be noted.
Diagnosis
 In the absence of an organic lesion, a difference in best
corrected VA of two Snellen lines or more (or >1 log unit) is
indicative of amblyopia. Visual acuity in amblyopia is usually
better when reading single letters than letters in a row. This
‘crowding’ phenomenon occurs to a certain extent in normal
individuals but is more marked in amblyopes and must be taken
into account when testing preverbal children.
Treatment
 Occlusion of the normal eye, to encourage use of the amblyopic
eye, is the most effective treatment. The regimen, full-time or part-
time, depends on the age of the patient and the density of
amblyopia.
 Penalization, in which vision in the normal eye is blurred with
atropine, is an alternative method. It may work best in the treatment
of moderate amblyopia (6/24 or better). Patch occlusion is likely to
produce a quicker response than atropine, which has
conventionally been reserved for use when compliance with patch
occlusion is poor. Weekend instillation may be adequate.
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