Amblyopia

Amblyopia, commonly called lazy eye, is a condition in children when vision does not develop properly in one eye. If its left untreated, a child's vision will never develop correctly in that eye. Vision impairment becomes permanent because as the childs brain matures, it will "ignore" the image coming from the poorly seeing eye . Thats why its essential to have a child with amblyopia regularly tested by an eye doctor. Amblyopia is an eye disorder characterized by an impaired vision in an eye that otherwise appears normal, or out of proportion to associated structural abnormalities of the eye. It has been estimated to affect 1-5% of the population In amblyopia, visual stimulation either fails to transmit or is poorly transmitted through the optic nerve to the brain for a continuous period of time. It can also occur when the brain "turns off" the visual processing of one eye to prevent double-vision, for example in strabismus (crossed-eyes). It often occurs during early childhood, resulting in poor or blurry vision. Amblyopia normally affects only one eye in most patients. However, it is possible, though rare, to be amblyopic in both eyes, if both fail to receive clear visual images. Detecting the condition in early childhood increases the chance of successful treatment, especially if detected before the age of five. The earlier it is detected, and the underlying cause corrected with glasses or surgery, the more successful the treatment in equalizing vision between the two eyes What Causes Amblyopia? Amblyopia usually starts when one eye has much better focus than the other eye. For example, one eye might be very farsighted or have a lot of astigmatism, while the other does not. When a child's brain is confronted with both a blurry image and a clear one, it begins to ignore the blurry image. If this goes on for months or years in a young child, the vision in the eye that sees the blurry image will deteriorate. Physiology Amblyopia is a developmental problem in the brain, not any intrinsic, organic neurological problem in the eyeball (although organic problems can lead to amblyopia which can continue to exist after the organic problem has resolved by medical intervention). The part of the brain receiving images from the affected eye is not stimulated properly and does not develop to its full visual potential. This has been confirmed by direct brain examination. David H. Hubel and Torsten Wiesel won the Nobel Prize in Physiology or Medicine in 1981 for their work in showing the extent of the damage to ocular dominance columns produced in kittens by sufficient visual deprivation during the so-called "critical period." The maximum "critical period" in humans is from birth to two years old.

Another cause of amblyopia is strabismus, which is an ocular misalignment, meaning that one eye turns inward or outward. This prevents the eyes from focusing together on an image and may cause double vision. To combat this, the child's brain generally chooses to ignore the image from the deviated eye, causing the vision in that eye to deteriorate. Its this misalignment of the eyes that leads some people to call amblyopia "lazy eye." Symptoms Many people with amblyopia, especially those who only have a mild form, are not even aware they have the condition until tested at older ages, since the vision in their stronger eye is normal. However, people who have severe amblyopia may experience related visual disorders, most notably poor depth perception. Amblyopes may suffer from poor spatial acuity, low sensitivity to contrast and some "higher-level" deficits to vision such as reduced sensitivity to motion. These deficits are usually specific to the amblyopic eye. Amblyopes also suffer from problems of binocular vision such as limited stereoscopic depth perception and usually have difficulty seeing the three-dimensional images in hidden stereoscopic displays such as autostereograms. However, perception of depth from monocular cues such as size, perspective, and motion parallax remains normal. Types Amblyopia has three main causes:

Strabismic: by strabismus (misaligned eyes) Refractive: by anisometropia (high degrees of nearsightedness, farsightedness, or astigmatism in one or both eyes) Deprivational: by deprivation of vision early in life by vision-obstructing disorders such as congenital cataract

Strabismus amblyopia Strabismus, sometimes also called lazy eye, is a condition in which the eyes are misaligned. Strabismus usually results in normal vision in the preferred sighting (or "fellow") eye (the eye that the person prefers to use), but may cause abnormal vision in the deviating or strabismus eye due to the difference between the images projecting to the brain from the two eyes. Adult-onset strabismus usually causes double vision (diplopia), since the two eyes are not fixed on the same object. Children's brains, however, are more neuroplastic, and therefore can more easily adapt by suppressing images from one of the eyes, eliminating the double vision. This plastic response of the brain, however, interrupts the brain's normal development, resulting in the amblyopia. Recent evidence points to a cause of infantile strabism lying with the input to the visual cortex. Strabismus amblyopia is treated by clarifying the visual image with glasses, or encouraging use of the amblyopic eye with an eyepatch over the dominant eye or pharmacologic penalization of the better eye. Penalization usually consists of applying atropine drops to temporarily dilate the pupil, which leads to blurring of vision in the good eye. This helps to prevent the bullying and teasing associated with wearing a patch, although sometimes

application of the eyedrops is more challenging. The ocular alignment itself may be treated with surgical or non-surgical methods, depending on the type and severity of the strabismus. In other cases, a child cannot see well in one eye because something blocks light from getting through, such as a cataract or a small amount of blood or other material in the back of the eye. How Is Amblyopia Diagnosed? All children should be screened before they are school-age. Your child's doctor or the vision program at school will check three aspects of your child's eye health: 1. Your child's eyes let light all the way through. 2. Both eyes see equally well. 3. The eyes move normally. If there's a problem in any area, the doctor or school nurse may recommend a visit to an eye specialist. If you feel that something could be wrong with your child's vision, call your doctor even if your child has been screened at school. Some eye care experts recommend an exam by an eye doctor at 6 months, 3 years, and then every two years in the school years. Ask your doctor or eye doctor which is right for your child. Family history of amblyopia is a risk factor for the condition. Parents cannot tell just by looking at their child if they have amblyopia. Early diagnosis and treatment are the keys to the best visual outcome. Refractive or anisometropic amblyopia Refractive amblyopia may result from anisometropia (unequal refractive error between the two eyes). Anisometropia exists when there is a difference in the power between the two eyes. The eye which provides the brain with a clearer image typically becomes the dominant eye. The image in the other eye is blurred, which results in abnormal development of one half of the visual system. Refractive amblyopia is usually less severe than strabismic amblyopia and is commonly missed by primary care physicians because of its less dramatic appearance and lack of obvious physical manifestation, such as with strabismus. Given that the refractive correction of anisometropia by means of spectacles typically leads to different image magnification for the two eyes, which may in turn prevent binocular vision, a refractive correction using contact lenses is to be considered. Frequently, amblyopia is associated with a combination of anisometropia and strabismus. In some cases, the vision between the eyes can differ to the point where one eye has twice average vision while the other eye is completely blind. Deprivation and occlusion amblyopia Deprivation amblyopia (Amblyopia ex anopsia) results when the ocular media become opaque, such as is the case with congenital cataract or corneal haziness. These opacities prevent adequate visual input from reaching the eye, and therefore disrupt development. If

not treated in a timely fashion, amblyopia may persist even after the cause of the opacity is removed. Sometimes, drooping of the eyelid (ptosis) or some other problem causes the upper eyelid to physically occlude a child's vision, which may cause amblyopia quickly. Occlusion amblyopia may be a complication of a hemangioma that blocks some or all of the eye. How Is Amblyopia Treated? The most common treatment for amblyopia is to force the brain to start using the "bad" eye. This is done by first correcting any underlying problems in that eye and then by putting a patch over the "good" eye. At first, the child will have a hard time seeing with just the weaker eye. However, it is very important that your child wear the patch diligently because this will eventually improve vision. It can take weeks or months for an eye patch to improve vision. Follow your doctor's instructions carefully and follow the schedule to bring your child to the eye doctor to be monitored closely during treatment. Treatment and prognosi Treatments Treatment of strabismic or anisometropic amblyopia consists of correcting the optical deficit (wearing the necessary spectacle prescription) and often forcing use of the amblyopic eye, either by patching the good eye, or by instilling topical atropine in the good eye. There is increasing evidence that refractive therapy (corrective spectacles) should first be used alone, with visual acuity being measured regularly until the improvements to the visual acuity have come to a standstill, and that monocular improvement therapies such as patching should only be considered after this point. The reason is that for some of the patients the improvements that arise due to the corrective spectacles already solve the problem. Concerning patching versus atropine, there is a drawback is using atropine as the drops can have a side-effect of creating nodules in the eye which a correctional ointment can counteract. One should also be wary of over-patching or over-penalizing the good eye when treating for amblyopia, as this can create so-called "reverse amblyopia". Eye patching is usually applied on a part-time schedule, that is about 4-6 hours a day. Treatment is continued as long as vision improves. It is not worthwhile continuing to patch for more than 6 months if there is no improvement. Treatment of individuals age 9 through adult is possible through applied perceptual learning. Deprivation amblyopia is treated by removing the opacity as soon as possible followed by patching or penalizing the good eye to encourage use of the amblyopic eye. The earlier treatment is initiated, the easier and faster the treatment is and the less psychologically damaging. There is also a greater chance of achieving 20/20 vision if treatment is initiated as early as possible. Clinical trials and experiments Although the best outcome is achieved if treatment is started before age 8, research has shown that children older than age 12 and some adults can show improvement in the affected eye. Children from 9 to 11 who wore an eye patch and performed near point activities (vision

therapy) were four times as likely to show a two line improvement on a standard 11 line eye chart than amblyopic children who did not receive treatment. Adolescents aged 13 to 17 showed improvement as well, albeit in smaller amounts than younger children. It is uncertain whether such improvements are only temporary, however, particularly if treatment is discontinued. In an experimental study, older amblyoptic, non-strabismic children were instructed to watch television wearing their usual glasses with a patch over their stronger eye and an additional telescopic lens affixed to the side of the weaker eye to lessen the impact from accommodation, leading to improvements in the eye's visual acuity. For adults, a 2004 study published in PNAS demonstrated that perceptual learning can be used to improve the vision of amblyopic adults. Virtual reality computer games where each eye receives different signals of the virtual world that the player's brain must combine in order to successfully play the game have shown some promise in improving both monocularity in the affected eye as well as binocularity.