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HOT TOPICS IN AMBLYOPIA SRC 2008

HOT TOPICS IN AMBLYOPIA SRC 2008 . LIONEL KOWAL. When to worry [and when not to worry] about strabismus and amblyopia. NOT TO WORRY…. When it all ‘fits’ Right age / anisohyperopia / glasses help vision and alignment…. 4 year old ET L D: 25∆, N: 35 ∆ R 6/8, L 6/24 R +3, L +4 Glasses

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HOT TOPICS IN AMBLYOPIA SRC 2008

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  1. HOT TOPICS IN AMBLYOPIASRC 2008 LIONEL KOWAL

  2. When to worry [and when not to worry] about strabismus and amblyopia

  3. NOT TO WORRY… When it all ‘fits’ Right age / anisohyperopia / glasses help vision and alignment…. • 4 year old ET L D: 25∆, N: 35 ∆ • R 6/8, L 6/24 R +3, L +4 Glasses • L 6/24  6/18  6/12 • Patching  6/10  6/9 • ET 25/35  phoria 12 / ET’ 25 • Bifocals  orthotropia

  4. WHEN TO WORRY…. Lateral incomitance ET or XT greater to L or R gaze ET greater on lateral gaze 6th XT …. Brainstem / INO

  5. WHEN TO WORRY…. Resistant amblyopia Check the pupil for afferent defect Re-examine the disc and retina

  6. WHEN TO WORRY…. ET Distance > Near Raised intra cranial pressure 6th nerve palsy

  7. WHEN TO WORRY…. Abnormal morphology Is the disc / macula normal? ..size …shape ...pigmentation If you find it difficult to be sure it’s OK or not, others probably will too Best test for a suspicious disc: show to someone else

  8. Abnormal morphology 2008: Hi- tech imaging helps BUT Sub - expert HRT OFTEN misleading

  9. When to operate in strabismus and when not to operate in strabismus.…& ‘why wasn’t this done years ago?’

  10. When to operate in strabismus…WHY DO I OPERATE? • TO MAKE THIS PATIENT’S LIFE BETTER Better visual system • Stabilise/ improve amblyopia • Better peripheral field [ET] • Better binocularity AND… • Normal appearance and improved psychosocial development • Better motor co-ordination

  11. When to operate in strabismus… Better outcome if • Constantly misaligned < 4 mo [child] or < 12 mo [adult] • Angle ≤ 50 ∆ ET, ≤ 35 ∆ XT

  12. When NOT to operate in strabismus… • Very variable strabismus • Patient expectations ≠ mine +4DS, ET 30∆. Straight forever sc not realistic

  13. When NOT to operate … • Despite adequate education, parents remain opposed. Anti - surgery websites - death rates & complications exaggerated DON GETZ “The best "cure" rate is 11%” • USA >20 deaths per year for strabismus surgery

  14. When NOT to operate … ?Under- trained surgeon. • Clearly a factor in other surgical areas • ~20 ophthalmologists are Fellowship trained in peds or strabismus • >20% of private strabismus surgeries in Australia [billed through Medicare] are done by 2 ophthalmologists • ?reason for declining numbers [fewer repeat surgeries because so many are done by experts]

  15. ‘Why wasn’t this done years ago?’ • 20 yo with 30∆ ET or XT dating back to childhood more likely to have PERMANENT paradoxical diplopia after alignment surgery than the same surgery in a 5 yo • Childhood visual system more flexible - ARC less likely to be profound / persistent in a child than an adult

  16. Delaying surgery ‘till s/he’s old enough to decide for him/her- self’ can mean deferring it to a time when a good cosmetic and functional result is no longer possible

  17. Is full time occlusion dead? Factors that influence outcome of amblyopia treatment fall into two categories: • those that relate to the underlying conditions (condition factors)and • those that relate to its treatment (treatment factors).

  18. Treatment factors • Optimal refraction - regularly re-checked • Occlusion method & dose • Accuracy of alignment

  19. Occlusion method / dose • PEDIG: 75+% get better with 2h/d [<6/24] or 6h/d [<6/120] CAN MORE OCCLUSION GET EVEN BETTER RESULTS?

  20. Is full time occlusion dead? MOTAS <50% of the amblyopic deficit corrected in 23%

  21. IS MORE EVEN BETTER?

  22. THE IOWA STUDIES

  23. Amblyopia Treatment Outcomes.WE. Scott.. JAAPOS April 2005 • Retrospective review of patients who had full-time occlusion [24 h/d or all waking hours]. • 600 pts followed for av. 7 y after the cessation of full-time patching. 90% ≥ 1 year. • Success : ≥ 20/30 or better or equal VA by fixation pattern - seen in 96% • 60% attained equal visual acuity.

  24. Amblyopia Treatment Outcomes.WE. Scott.. • Younger patients required less occlusion time to endpoint and had a better visual outcome (P < 0.0001). • Initial VA related to best VA attained (P < 0.0001). • Incidence of occlusion amblyopia 25.8%.

  25. Amblyopia Treatment Outcomes.WE. Scott.. Looks like more = better BUT > 2ce risk of occlusion amblyopia Assume equal fixation = equal acuity < 100% followup

  26. PEDIG - RECRUITING…. • Treatment of residual amblyopia 6/9 to 6/15. • Compare intensive treatment [8 h/d of patching + daily atropine] with glasses alone

  27. IS MORE EVEN BETTER? • For most children with amblyopia - probably not • For some - maybe …….stay tuned!

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