3. 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

4. ClassificationClassification
ofof
Functional AmblyopiaFunctional Amblyopia
Deprivation Amblyopia
 Refractive Amblyopia
A. Anisometropic Amb
B. Isometropic Amb
(Ametropic Amb)
 Strabismic Amblyopia

5. Amblyopia
Other Problems

6. 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.

7. Management of
Amblyopia
 The first attempt for treatment of
amblyopia is to prescribe optimum
optical correction
 Not meaning to give the full correction

8. 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.

9. 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.

10. 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.

11. 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

13. 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.

14. 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”.”.

15. Occlusion
 The following are general guidelinesThe following are general guidelines
for occlusion therapy:for occlusion therapy:

16. 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.

18. 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.

19. 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.

20. 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.

21. 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.

22. 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.

23. 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.

25. 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.

26. 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.

27. 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.

28. 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..

29. Optical Penalization

30. 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

31. Optical penalizationOptical penalization
 Distance optical penalizationDistance optical penalization
 Near optical penalizationNear optical penalization
 Total optical penalizationTotal optical penalization

33. 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.

34. 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.

35. 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.

37. 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.

39. 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

41. Complementary MethodsComplementary Methods
(Alternative Medicine)(Alternative Medicine)
 low energy He-Ne laserlow energy He-Ne laser
 Magnetic TherapyMagnetic Therapy
 AcupunctureAcupuncture
 Energy TherapyEnergy Therapy

42. 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.

43. 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.

44. 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

45. 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.

46. Occlusion
Other Methods

47. «‫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

49. 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 eyes.in both eyes.[23][23]
When visual acuity is stable, patchingWhen visual acuity is stable, patching
may be decreasedmay be decreased slowlyslowly..

50. 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.

51. 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.

52. 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.

53. Strabismus ManagementStrabismus Management
 Surgical therapySurgical therapy for strabismusfor strabismus
generally should occur after amblyopiagenerally should occur after amblyopia
is reversed.is reversed.
 Disadvantages to surgical therapyDisadvantages to surgical therapy
prior to correction of amblyopiaprior to correction of amblyopia
include:include:


54. 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 improving.security about the vision improving.

55. 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