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Amblyopia New knowledge and practical approaches ESA 2007 Early morning course May 21, 2007

Amblyopia New knowledge and practical approaches ESA 2007 Early morning course May 21, 2007. Daisy Godts CO, Ilse De Veuster MD University Hospital Antwerp. Amblyopia. Pubmed: 5829 amblyopia 3051 amblyopia treatment 2860 amblyopia therapy 490 amblyopia occlusion

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Amblyopia New knowledge and practical approaches ESA 2007 Early morning course May 21, 2007

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  1. AmblyopiaNew knowledge and practical approachesESA 2007Early morning courseMay 21, 2007 Daisy Godts CO, Ilse De Veuster MD University Hospital Antwerp

  2. Amblyopia • Pubmed: • 5829 amblyopia • 3051 amblyopia treatment • 2860 amblyopia therapy • 490 amblyopia occlusion • 149 amblyopia patching • 122 amblyopia atropine • 70 amblyopia penalization • 5 amblyopia inverse occlusion UZ Antwerp ESA 2007 Daisy Godts

  3. Definition of amblyopia Amblyopia is a diagnosis of exclusion Because the basis is defective central visual processing, careful assessment of the retina and optic nerve is essential The diagnosis is established by a unilateral or bilateral reduction of BCVA not entirely attributable to structural abnormalities of the visual pathways PPP AAO 2002: Amblyopia UZ Antwerp ESA 2007 Daisy Godts

  4. Definition of amblyopia • VA  2 / 3 lines ( < 20/50 3 years of age / < 20/40 5 years of age)/ fixation behaviour • No differences with corrective lenses • Amblyopia inducing factor present • Onset : immature visual system • Prevalence : 2-4% general population PPP AAO 2002: Amblyopia UZ Antwerp ESA 2007 Daisy Godts

  5. Definition of amblyopia • Pattern deprivation • Strabismus : • Synchronous stimulus of visual cortex of non corresponding images of two foveas • Binocular rivalry => suppression • Optical defocus • Refractive error removes fine details from the retinal image • Anisometropia : 100% amblyopia risk : +4D/-6D vs 50% +2,5D/-4D UZ Antwerp ESA 2007 Daisy Godts

  6. Pathofysiological mechanisms Focal Points AAO volume XVIII nr 2, March 2000 : Practical management of amblyopia UZ Antwerp ESA 2007 Daisy Godts

  7. Management Two principles • Optimise clarity of retinal image in the amblyopic eye: clear visual axis + correction of refractive errors • Increase cortical processing of visual input of amblyopic eye = enhance the neural stimulus to the visual cortex UZ Antwerp ESA 2007 Daisy Godts

  8. Management • Parent’s explanation !!!! • Surgery if necessary • Optical correction : spectacles, contact lenses • Patching/occlusion • Atropine/penalization/optical penalisation/defocus UZ Antwerp ESA 2007 Daisy Godts

  9. Management Response is related to: • Type of amblyopia • Initial VA • Age • Duration of amblyopia • Method of treatment • Compliance UZ Antwerp ESA 2007 Daisy Godts

  10. Robbe 8 years During screening low VA RE, consulted ophthalmologist: too late, no treatment anymore. Second opinion VA RE: 0.1 sc 0.25 +4.25 Logmar VA LE: 1.0 sc Cycloplegic refraction RE: +6.75 –0.75 x 150 LE: +4.00 -0.75 x 130 Straight eyes with fusion and moderate stereopsis Central fixation BE Anterior and posterior segment: normal Therapy: +4.75/ +2.00 UZ Antwerp ESA 2007 Daisy Godts

  11. Robbe 8 years 2 months control VA RE: 0.3 cc Logmar VA LE: 1.0 cc BV: normal 8 hours occlusion LE 2 months control: good compliance VA RE: 0.5 cc Logmar VA LE: 1.0 cc BV: normal 6 hours occlusion LE UZ Antwerp ESA 2007 Daisy Godts

  12. Robbe 8 years 2 months control: good compliance VA RE: 0.7 cc Logmar VA LE: 1.0 cc BV: normal 4 hours occlusion LE 2 months control: good compliance VA RE: 0.8- cc Logmar VA LE: 1.0 cc BV: normal 2 hours occlusion LE UZ Antwerp ESA 2007 Daisy Godts

  13. Anisometropia amblyopia : Glasses Age at presentation ranged from 0.8 to 7.9 years (mean 4.8, SD 1.7) The mean time to resolution in this study was 5.8 + -3.9 months with a range of 2 to 15 months We analyzed age, best corrected initial visual acuity in the amblyopic eye, initial stereoacuity, type, and amount of anisometropia to assess which of these presenting characteristics are significantly associated with time to cure. Worse initial visual acuity was significantly associated with longer time to resolution (P 0.05) Steele A L, Bradfield Y S, Kushner B J, France T D, Struck M C, Gangnon R G . Successful Treatment of Anisometropic Amblyopia with Spectacles Alone. J AAPOS 2006;10:37-43 UZ Antwerp ESA 2007 Daisy Godts

  14. Anisometropic amblyopia : Glasses • 3 - 7 years • Anisometropia :  0,5D SE or  1,5 D astigmatism • Prescription: hyperopia > 3D full or max –1,5D • hyperopia < 3 D ( investigator ) • VA 20/40 – 20/250 • VA change : 2,9 lines +- 1,8 • 77% patients improvement of  2 lines • Resolution of amblyopia ( VA  1 line) = 27% • Amblyopia resolution ~ base line VA ~ magnitude of anisometropia PEDIG Treatment of anisometropic amblyopia in children with refractive correction. Ophthalmoly 2006; 113:895. UZ Antwerp ESA 2007 Daisy Godts

  15. Aaron 4 years 19/09/06 During screening low VA BE, consulted ophthalmologist: no treatment possible. Second opinion VA RE: 0.10 sc LEA symbols VA LE: 0.20 sc Cycloplegic refraction RE: +6.50 –1.75 x 0 LE: -1.50 –1.50 x 0 Straight eyes Anterior segment: normal Posterior segment: RE normal, LE myelin vessels Therapy: contact lenses +6.00 –1.75 x 0 -1.50 –1.25 x 0 UZ Antwerp ESA 2007 Daisy Godts

  16. Aaron 4 years Posterior segment: RE normal, LE myelin vessels UZ Antwerp ESA 2007 Daisy Godts

  17. Aaron 4 years 1 month control: VA RE: 0.16 ccl LEA symbols VA LE: 0.40 ccl BV: normal 2 months control: VA RE: 0.25 ccl LEA symbols VA LE: 0.50 ccl Near VA RE: 0.4/1.6 ccl LE: 0.4/ 0.8 ccl 6 hours occlusion LE UZ Antwerp ESA 2007 Daisy Godts

  18. Aaron 4 years 1 month control: good compliance to occlusion VA RE: 0.40 ccl LEA symbols VA LE: 0.50 ccl Near VA RE: 0.4/1.0 ccl LE: 0.4/ 0.8 ccl BV: normal 6 hours occlusion LE 2 months control: good compliance VA RE: 0.60 ccl LEA symbols VA LE: 0.60 ccl Near VA RE: 0.4/1.0 cclLE:0.4/ 0.8 ccl 3 hours occlusion LE UZ Antwerp ESA 2007 Daisy Godts

  19. Patching regimens • 3 - 7 years • Moderate amblyopia : 20/40 –20/80 • Anisometropic, strabismic and mixed amblyopia • 2 hours + 1 hour near activity vs 6 hours + 1hr • Age/base line acuity/ cause of amblyopia : no difference • Results: • 5 weeks: 2 hrs 1,84 lines improvement vs 1,92 line • 4 months : 2,4 lines improvement in both groups PEDIG A randomized trial of patching regimens for treatment of moderate amblyopia in children. Arch Ophthalmol 2003; 121: 603 UZ Antwerp ESA 2007 Daisy Godts

  20. Patching regimens • 3 - 7 years • Severe amblyopia : 20/100 –20/400 • Anisometropic, strabismic and mixed amblyopia • Full-time vs 6 hours + 1 hour near activity each • Age/base line acuity/ cause of amblyopia : no difference • Results: • 5 weeks: 6 hrs 3.5 lines improvement vs 3.7 lines in FTO • 4 months : 6 hrs 4.8 lines improvement vs 4.7 lines in FTO PEDIG A randomized trial of prescribed patching regimens for treatment of severe amblyopia. Ophthalmology 2003; 110: 2075 UZ Antwerp ESA 2007 Daisy Godts

  21. Argita 9 years 10/11/06 firstophthalmological examination because poor VA during school examination, Roma gypsies VA RE: 0.2 sc Logmar VA LE: 0.1 sc Cycloplegic refraction RE: +9.00 –2.00 x 170 LE: +10.00 –2.75 x 10 Straight eyes Anterior and posterior segment: normal Therapy: +8.00 –2.00 x 170 +9.00 –2.75 x 10 UZ Antwerp ESA 2007 Daisy Godts

  22. Argita 9 years 09/02/07 3months of full-time spectacle wear VA RE: 0.6 cc Logmar VA LE: 0.2 cc Micro-esotropia LE central fixation Therapy: 6 hours occlusion RE, control 2 months 17/04/07 good compliance to occlusion VA RE: 0.6 cc Logmar VA LE: 0.25 cc Micro-esotropia LE central fixation Therapy: more/idem occlusion RE ? Stop occlusion? UZ Antwerp ESA 2007 Daisy Godts

  23. Treatment of amblyopia > 7 years • 7-10,3 years (36 patients) • Anisometropic, strabismic and mixed amblyopia • Spectacles + full time occlusion/ total penalisation • Follow up : 1 year after no further improvement in VA • VA 20/50- 20/400 start ~ end 20/20 –20/30 for all patients • Duration : 0,6 yrs aniso / 1,0 yrs strab / 0,8 yrs mix • BV improved or maintained in 61% of cases Mintz-Hittner H et al .Succesfull amblyopia therapy initiated after age 7 years. Arch Ophthalmology 2000;118: 1535 UZ Antwerp ESA 2007 Daisy Godts

  24. Nikki 10 years Foster child since 1 year, abandoned by her parents because of drug problems. Had glassed and occlusion long ago VA RE: 1.0 sc Logmar VA LE: 0.05 sc 0.1 +5.OO –4.00 x 0° Cycloplegic refraction RE: +2.50 LE: +6.25 –4.00 x 0° CT: 12^esotropia LE Central fixation BE Anterior and posterior segment: normal Therapy: Glasses? Occlusion? UZ Antwerp ESA 2007 Daisy Godts

  25. Nikki 10 years Glasses RE + 1.25 LE + 5.00 –4.00 x 0° Full time occlusion RE 1.5 months: VA RE: 1.0 cc Logmar VA LE: 0.5 cc 12^ET Full time occlusion RE 3 months: VA RE: 1.0 cc Logmar VA LE: 0.6 cc 12^ET Full time occlusion RE UZ Antwerp ESA 2007 Daisy Godts

  26. Nikki 10 years 5 months: Occlusion done  7- 8 hours VA RE: 1.0 cc Logmar VA LE: 0.6 cc 12^ET 4 hours occlusion RE 7 months: VA RE: 1.0 cc Logmar VA LE: 0.7 cc 10^ET Titmus: 4/9 2 hours occlusion RE UZ Antwerp ESA 2007 Daisy Godts

  27. Nikki 11 years 9 months: VA RE: 1.0 cc Logmar VA LE: 0.7 cc 10^ET’ Titmus 5/9, Lang I: positive 1 hour occlusion RE 12 months: VA RE: 1.0 cc Logmar VA LE: 0.7 cc 10^ET’ Titmus: 5/9, Lang I & II: positive 1 hour occlusion RE once a week UZ Antwerp ESA 2007 Daisy Godts

  28. Nikki 12 years 18 months: VA RE: 1.0 cc Logmar VA LE: 0.7 cc 8^ET Titmus 6/9, Lang I & II: positive Stop occlusion RE 24 months: VA RE: 1.0 cc Logmar VA LE: 0.7 cc 8^ET Titmus: 5/9, Lang I & II: positive, TNO 240” UZ Antwerp ESA 2007 Daisy Godts

  29. Treatment of amblyopia > 10 years • 10 - 18 years, 66 patients • VA 20/40 –20/160 • Optimal optical correction > 4 wks • Anisometropic, strabismic and mixed amblyopia • Daily patching  2 hrs/day ( 1 hour of near visual activity) • 2 month follow up • 18/66 (27%) VA improvement with 2 or more lines • 10-14 years vs 14–18 years: no difference PEDIG A prospective, pilot study of treatment of amblyopia in children 10 to < 18 years old. Am J Ophthalmol 2004;137: 581-583. UZ Antwerp ESA 2007 Daisy Godts

  30. Treatment of amblyopia > 7 years • 7 - 17 years, 507 patients • 2 groups: younger group 7-12 years, older group 13-17 years • VA 20/40 – 20/400 • Anisometropic, strabismic and mixed amblyopia • Optimal optical correction alone or + 2-6h patching+atropine • 24 weeks follow-up (6 weeks controls) • Younger group: 53% improvement (patching+atropine) 25% improvement (optical correction) • Older group: 25% improvement (patching) 23% improvement (optical correction) • No diplopia PEDIG Randomized trial of treatment of amblyopia in children aged 7 to 17 years. Arch Ophthalmol 2005; 123: 437-447 UZ Antwerp ESA 2007 Daisy Godts

  31. Thomas 4 years Second opinion: glasses +4.00/+5.75 since age 2year occlusion 4h RE/day poor compliance AV RE: 0.7 cc Snellen E AV LE: 0.2 cc Cycloplegic refraction RE: +4.50 –0.50 x 40 LE: +6.50 –1.00 x 150 Partial accommodative esotropia LE Therapy: LE +6.00 –1.00 x 150 Occlusion RE at school UZ Antwerp ESA 2007 Daisy Godts

  32. Thomas 4 years 3 months: Very poor compliance to occlusion AV RE: 0.9 cc Snellen E AV LE: 0.2 cc = partial accommodative ET LE Therapy: Atropine 0.50 % RE, plano glass RE 6 months: AV RE: 0.2 sc/atropine Snellen E AV LE: 0.8 cc Therapy: RE + 4.00 Stop atropine RE, 1 h alternate occlusion UZ Antwerp ESA 2007 Daisy Godts

  33. Thomas 5 years 8 months: Good compliance to occlusion AV RE: 0.8 cc Snellen E AV LE: 0.8 cc = partial accommodative ET LE Therapy: 1 h alternate occlusion 14 months: Good compliance to occlusion AV RE: 1.0 cc Snellen E AV LE: 0.8 cc Therapy: 2h occlusion RE UZ Antwerp ESA 2007 Daisy Godts

  34. Thomas 6 years 20 months: Good compliance to occlusion AV RE: 1.0 cc Snellen E AV LE: 0.8 cc near VA RE: 1.0 cc LEA VA LE: 0.8 cc = partial accommodative ET LE Therapy: 2 h occlusion RE 26 months: Poor compliance to occlusion AV RE: 1.0 cc Logmar AV LE: 0.6 cc Therapy: Atropine 0.5 % RE 2X week UZ Antwerp ESA 2007 Daisy Godts

  35. Thomas 7 years 32 months: No atropine used, occlusion 2 h RE AV RE: 1.0 cc Logmar AV LE: 1.0 = cc near VA RE: 1.0 cc LEA numbers VA LE: 0.8+ cc = partial accommodative ET LE Therapy: 2 h occlusion RE 2-3 times a week UZ Antwerp ESA 2007 Daisy Godts

  36. Atropine vs patching • 3-7 years, 419 patients • VA 20/40 – 20/100 • Anisometropic, strabismic and mixed amblyopia • Occlusion > 6 hours vs atropine daily • Results: • 5 wks : 2,22 lines improvement occlusion vs 1,37 atropine • 16 wks: 2,94 vs 2,42 • 6 months: 3,16 vs 2,84 • Patching = more rapid and possible slightly better VA • Atropine easier administration and lower cost PEDIG. A randomized trial of atropine vs patching for treatment of moderate amblyopia in children. Arch 2002; 120: 268 UZ Antwerp ESA 2007 Daisy Godts

  37. Atropine vs patching • 3-7 years, 419 children • VA 20/40 - 20/100 • Anisometropic, strabismic and mixed amblyopia • VA 6 months: 0,25 ( 20/30-2) atropine daily vs 0,21 (20/30) occlusion (6h - FTO) Age, depth of amblyopia, cause of amblyopia: no difference  Atropine as effective in VA 20/100 as when 20/40 Occlusion faster improvement especially when VA 20/80-20/100 and when FTO or nearly FTO   PEDIG. A comparison of atropine and patching treatments for moderate amblyopia by patient age, cause of amblyopia, depth of amblyopia and other factors. Ophthalmology 2003; 110: 1632-1638. UZ Antwerp ESA 2007 Daisy Godts

  38. Atropine vs patching : 2 y follow-up • Follow-up 18 months after 6-months randomised trial • 419 children age < 7 years • Initial VA 20/40 to 20/100 • After 2 years: VA increased from baseline 3.7 lines (occlusion 6h-FTO) and 3.6 lines (atropine daily) • In both groups mean amblyopic VA was  20/32, 1.8 lines worse than the sound eye (20/20) Atropine or patching produced similar improvement of moderate amblyopia in children age 3-7 years PEDIG Two-year follow-up of a 6 month randomized tral of atropine versus patching for treatment of moderate amblyopia in children. Arch Ophthalmol. 2005: 123: 149-157. UZ Antwerp ESA 2007 Daisy Godts

  39. Glen 4 years 10/11/04 first ophthalmological examination because poor VA during school examination VA RE: 0.2 sc Snellen E VA LE: 1.0 sc Cycloplegic refraction RE: +1.75 LE: +1.75 –0.50 x 100 Esotropia RE, poor fixation possible eccentric Anterior and posterior segment: normal Therapy: orthoptic consult UZ Antwerp ESA 2007 Daisy Godts

  40. Glen 4 years 07/06/05 second opinion, low VA RE, no therapy done, consulted ophthalmologist did not know what to do VA RE: 0.01 sc Snellen E VA LE: 1.0 sc Cycloplegic refraction RE: +1.75 –0.50 x 105 LE: +1.25 –0.25 x 100 Esotropia RE, no central fixation Anterior and posterior segment: normal Therapy: 4 hours occlusion LE, control 4-5 weeks UZ Antwerp ESA 2007 Daisy Godts

  41. Glen 4 years 15/11/05 Poor compliance to occlusion, max 1 hour VA RE: 0.05 sc Snellen E VA LE: 1.0 sc Cycloplegic refraction RE: +1.75 –0.50 x 105 LE: +1.21 –0.25 x 100 Esotropia RE, poor fixation Unstable fixation RE Therapy: Atropine 0.5% LE + occlusion LE Control 4 weeks UZ Antwerp ESA 2007 Daisy Godts

  42. Glen 5 years 19/10/06 atropine used beginning last year, sometimes occlusion done VA RE: 0.1 sc Snellen E VA LE: 1.0 sc Esotropia RE, poor fixation Central unstable fixation RE Therapy: Full time occlusion (day and night) 6 weeks control UZ Antwerp ESA 2007 Daisy Godts

  43. Glen 5 years 07/12/06 Good compliance VA RE: 0.5 sc Snellen E VA LE: 1.0 sc Therapy: Full time occlusion, 6 weeks control 11/01/07 good compliance VA RE: 0.8 sc Snellen E VA LE: 1.0 sc Therapy: 6 hours occlusion, 8 weeks control 22/03/07 Good compliance VA RE: 0.8 sc Snellen E VA LE: 1.0 sc Therapy: 3 hours occlusion, 2 months control UZ Antwerp ESA 2007 Daisy Godts

  44. Compliance : occlusion • Poor parental fluency in the national language • Low level of education • Poor acuity at the start of treatment An educational program primarily aimed at the child improved compliance and reduced the number of children who did not comply with occlusion at all SE Loudon, M Fronius, CWN Looman, M Awan, B Simonsz, PJ van der Maas, HJ Simonsz: Predictors and a remedy for noncompliance with amblyopia therapy in children measured with the occlusion dose monitor.Invest Ophthalmol Vis Sci. 2006 Oct;47(10):4393-400. UZ Antwerp ESA 2007 Daisy Godts

  45. Compliance : occlusion • Semi structured interviews ( n = 28 ) of parents of a child prescribed patching ( 2 to 8 years : mean duration of patching: 3 months to 5 years) • Problems with patching • Begin of treatment/ extreme emotional reactions of child/ low VA ~ struggle with everyday life activities • Social impact : risk of teasing • Strain relationship child – parent • Time consuming Dixon Woods M et al. Why is compliance with occlusion therapy for amblyopia so hard? A qualitative study. Arch Dis Child 2006; 91: 491 UZ Antwerp ESA 2007 Daisy Godts

  46. Compliance : occlusion • Strategies to support patching • Explanation : need for patching • Rewarding the effort with VA increase at follow up/ attention and praise/ game / no big deal • Normalisation strategies : toy with patch /other children with patch • Customising the patch :figures on the patch etc • Establishing routine :structure and routine • Support of others : teachers, day care workers Dixon Woods M et al. Why is compliance with occlusion therapy for amblyopia so hard? A qualitative study. Arch Dis Child 2006; 91: 491 UZ Antwerp ESA 2007 Daisy Godts

  47. Jef 4.5 years Since 1.5 years glasses + occlusion RE during school hours, no VA improvement, good compliance VA RE: 1.0 sc 1.0 cc (+1.00) E linear VA LE: 0.1 sc 0.1 cc (+3.00) Cycloplegic refraction RE: +2.50 LE: +4.50 Partial accommodative esotropia LE Parafoveal fixation LE Anterior and posterior segment: normal UZ Antwerp ESA 2007 Daisy Godts

  48. Jef 4.5 years Therapy: Inverse occlusion? UZ Antwerp ESA 2007 Daisy Godts

  49. Jef 4.5 years 1 month full time inverse occlusion LE VA RE: 0.9 cc Linear E VA LE: <0.05 cc Total fixation loss LE R/ Full time occlusion RE, no bilateral fixation 1 month: VA RE: 0.6 cc Linear E VA LE: 0.2+ cc Central unsteady fixation LE R/Full time occlusion RE UZ Antwerp ESA 2007 Daisy Godts

  50. Jef 4.5 years Central fixation RE Central unsteady fixation LE UZ Antwerp ESA 2007 Daisy Godts

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