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Dx Amblyopia

Dx Amblyopia. WE CAN WIPE OUT AMBLYOPIA IN OUR LIFETIMES. OVERVIEW. Amblyopia Characteristics/Therapy Most Clinico-Legal Problems for OD’s Infantile Esotropia-A Case The Infant Examination Sequence Infantile Esotropia Characteristics Infantile Esotropia Therapy The Older Esotrope

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Dx Amblyopia

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  1. Dx Amblyopia WE CAN WIPE OUT AMBLYOPIA IN OUR LIFETIMES

  2. OVERVIEW • Amblyopia Characteristics/Therapy • Most Clinico-Legal Problems for OD’s • Infantile Esotropia-A Case • The Infant Examination Sequence • Infantile Esotropia Characteristics • Infantile Esotropia Therapy • The Older Esotrope • Exotropia: “Congenital” & “Functional”

  3. AMBLYOPIA Caused by Anisometropia and Strabismus and what most eye care practitioners are interested in treating Rule Out Pathology

  4. Ocular and Neurologic Disease Masquerading as Functional Vision Disorders • Amblyopia • Strabismus • Brain Tumors: Bitemporal Field Loss • Vascular Accidents • Ocular and/or Visual Pathway Diseases

  5. Amblyopia • Amblyopia: A Diagnosis of Exclusion. Make sure there is no pathology first. • Amblyopia may improve with vision therapy even with pathology • Always do visual fields of both eyes of amblyopes (color and neutral density) • Must have 1. Anisometropia, 2. Constant Unilateral Strabismus, 3. ^ Bilateral RE, 4. Deprivation Hx

  6. Bilateral Amblyopia-Careful • Bilateral Retinal Schisis--X-Linked • Electrodiagnostics • ERG Electroretinogram • VEP Visual Evoked Potential • Pictures • X Rays • CT Scans • MRI’s • OCT

  7. Amblyopia Differential Dx • Block-Line-Letter VA s: Better with letters • Contrast Typically not impacted in Amblyopia • Psychometric VA s: Sigmoid Curve • Neutral Density Filters: Devastates VA • Macular Integrity Tester: No Brush • Magnification: 2.5 Telescope really improves VA beyond what is expected • Color Vision: Normal • Normal Amsler Grid and Electrodiagnostics

  8. Special Visual Acuity Charts • Psychometric Chart • Flom Chart C’s • Wesson-Davidson Chart E’s • Bailey-Lovie log MAR • Relative = Separation • High and Low Contrast • Contrast Sensitivity • LEA • B-VAT

  9. Amblyopia and VA • Acuity improves with isolated letters • First and last letter seen more often • Letters read out of order • Letters change as chart is viewed • Chart appears gray, dim or poor quality • Refraction: Better but I just cannot read it • LARGE JND’s

  10. Amblyopia • 2.5% of population • A problem of binocularity • Fixation--Binocularity • Anisometropia • Constant Unilateral Strabismus

  11. Amblyopia Timelines • Critical Period: Birth to 6 mo…Treat now… Blind-Nystagmus • Treat Pathology…Fixate with each eye • Sensitive Period: 6 mo to 8 yr.… Treat… Visually Impaired • Susceptible Period: 8 to 18 yr.…Treat if compliant…may return • Residual Plasticity Period: 18 yr.> not likely (Lee R. Adult Amblyope: JBO 12/99 pp115-131)

  12. Amblyopia is Developmental& A BINOCULAR Dx • Not just a reduction in VA but in total vision • Poor Eye Movements • Poor Accommodation • Poor Spatio-Temporal Integration…Trouble judging distances and lengths…Crowding • Requires more than just patching

  13. Clinical Classification of Amblyopia • Organic (Organic) • Form Deprivation (Structural) • Strabismus (Spatial Conflict) • Refractive • Isometropic and Anisometropic • Psychogenic • Voluntary (Malingering) • Involuntary: Hysterical and Streff’s Syndrome

  14. Amblyopic Clinical Pearls • Problems within 1st 6 months most dangerous---Congenital Cataracts-Critical • Early dense cataracts-a true critical intervention • Late onset not as severe-Sensitive-Can be amblyopic up to about 8 years • Treatment at any time but less certain outcomes-Requires a motivated patient

  15. Streff’s Bilateral Juvenile Amblyopia • Refracts: -.5 to +1D…+ may help • VA Far: 20/25 to 20/400…Walk around + • VA Near: Worse than Far…^ c + • Habitual RD: 10 in or less/Peers…+ moves RD out • Dynamic Ret: Dull reflexes and increased lag… + improves reflexes • Fixation: Unstable central… + ^ stability

  16. Streff’s Bilateral Juvenile Amblyopia • Pursuit: Refixations… + improves • Pen in Cap: Misses… + improves • Yoked ^: Base preferred • Ball Catching: + improves timing • VO Star: Poor Centration… + improves • History: High achiever, females, around puberty, at exam time, holidays and spring

  17. Streff’s Syndrome in Animals

  18. Tx Amblyopia

  19. Amblyopia Efficacy of VTx .1 Significance at 16+ for 4 linesBirnbaum et al. JAAO May 77

  20. Congenital esotropia vs. amblyopia: surgery or noneHelveston, EM. Origins of congential esotropia. J Ped Ophthalmol Strab 1993;30:215-232

  21. Treatment of Amblyopia • Isometropic: >-5D eventual full Rx but in steps…. Consider underminus…>+ 2D Temper Rx by age, amount, in steps, keep symmetrical…Think in terms of keeping 2D of hyperopia uncorrected... Cylinder >1.25Temper Rx as with +…symmetrical and low…always trial frame…PROBE LENS TESTING

  22. Amblyopia • Anisometropia: >-2D or +1D consider CL (depending on the age and responses) … • Eventual full Rx may be much more balanced… • MOST ANSIO AMBLYOPIA from + > 1 • Keep symmetrical and spherical equivalents • Keep Rxs Small and Simple

  23. Occlusion • Full Time Direct Occlusion • 1 day for each year of life and no patch the other day for the anisometropic amblyope • For the strabismic amblyope indirectly patch the other eye for one day • Partial Occlusion • Bi-Nasal Occlusion • Patch for hours rather than days

  24. Treatment Modalities for Amblyopia • Patching verses Penalization • Big advantage of Penalization-it can be done • Binocularity is not destroyed • Penalization • Bangerter Foils • Fingernail Polish • Scotch Tape • Extra Plus • Meds

  25. Penalization • Foils • Colored Filters (Mono in Binocular Field) • Wesson Method • Extra Plus • Clear Finger Nail Paint • Cycloplegia • Bi-Nasal Occlusion • Bi-Temporal Occlusion • Atropine

  26. Rxs for the older Amblyope and Esotrope • Always try to balance Rx • Use minimal Rx to plateau VA • Use minimal Rx to plateau Angle of turn • Hold off Rxing lenses until some VT has been attempted (weeks) • Plan to titrate UP + on esotropes and anisometropes

  27. Contact Lenses and Amblyopia • Knapp’s Law: Predicts image size based upon length of the eye--spectacles more appropriate • Think CL even with Knapp’s Law • More likely to wear than “odd” glasses • better image quality • No prismatic or Centration problems

  28. Amblyopia Therapy: Press • Refractive Amblyopia • Normally responds quicker than strabismus • Passive Suppression • Binocular integration present • Less occlusion time needed • Loss of resolution - little spatial distortion • Knows where and how far the target is • Like looking in smoked glass or cellophane

  29. Amblyopia Therapy • Strabismic Amblyopia • Loss of resolution and spatial confusion • Takes more time • Must develop central fixation first • Active suppression • Poor performance

  30. Summarized Early Phases -Tx • Rx • Monocular activities • Patching/Penalization • Accommodation • Ocular Motility • Form Recognition (Modified Updegrave) • Perceptual Discrimination (Size, Shape, Feely Meely, etc)

  31. Later Phases Tx Amblyopia • Monocular Fixation in a Binocular Field • Biocular Therapy • Binocular Therapy • Intersensory Integration

  32. Monocular Therapy • Press Recommends 3 Levels • Gross Motor (Use Sparingly with Patching) • Balance Board • Walking Rail • Oculomotor • Accommodative

  33. Monocular Therapy • Oculomotor • Hart Chart saccades • Michigan tracking • Pointer in Straw • Monocular Prism Jumps • Geo Boards, Groffman tracing • AN Pointing • Line Counting • Perceptuomotor Pen • MIT

  34. Monocular therapy • Accommodative • Near Far Hart Charts • Free Space Push Up • Loose Lens Rock • Sequential Minus (JND’s) • Minus Lens and Marsden Ball

  35. Mono Tx Perceptual Discrim • Hidden Pictures • Similarities and Differences • Monocular Contour Interaction (Back off and read letters/numbers) • Random Count All of certain # or letters (Michigan Tracking) • Tachistoscope • Form Tracing with Crowding -Kedzia Card • Visual Search Sequential # find correct one • Space Matching Distance to Chalkboard

  36. Monocular Tx in Binocular Field • Anaglyphic TV Trainer (Projected Light) • Sherman VT Playing Cards (1/2 Cards) • Lens rock with single Vectogram VA (corresponding to amblyopic eye) • Quoits • Clown/Spirangle • Wayne Fixator and Anaglyph • Anaglyphic Tracing • Haidinger Brush/MIT • Kedzia Cards

  37. WHY DO VT ON AMBLYOPES: If Patching gives good VA • Krumholtz & FitzGerald. Efficacy of treatment modalities in refractive amblyopia. J AOA 1999; 70: 399-404 • VA’s the same with Patching &full Rx or Patching, full Rx&VT (2 line & 20 ArcSec) • Both Patching and Patching VT group better than Optical Correction alone • ONLY VT GROUP HAD BETTER STEREO

  38. Efficacy of Tx on AmblyopiaKrumholtz I, FitzGerald D. Efficacy of treatment modalities in refractive amblyopia J am Optom Assoc 1999; 70: 399-404 • Compare (6 mo) Rx; Rx & Patch; Rx/VT N=78 • 2 Line and 20 sec increase; the criterion • Patch and VT have similar VA’s • VT shows significantly greater stereo • Conclusion:“Patching alone…improvement of visual acuity, binocular performance is significantly better when vision therapy is included in the treatment regimen.”

  39. FitzGerald: AmblyopiaKrumholtz I, FitzGerald D. Efficacy of treatment modalities in refractive amblyopia. J Am Optom Assoc 1999;70:399-404 • Amblyopia from Refractive (Aniso) • 2 lines & 20arcsec Improvement • Tx • Do Nothing • Rx • Rx + Patch and Eye Hand • Rx + Patch and Eye Hand and VTx • Retrospective • 4 to 6 weeks after • 2 to 4 months • 6 months to 12 months • Note in all Tx: Some make dramatic improvement and some never move • Patch and VTx are the Same for Amblyopia Tx • Rx alone was not as effective

  40. FitzGerald: Amblyopia VA &StereoKrumholtz I, FitzGerald D. Efficacy of treatment modalities in refractive amblyopia. J Am Optom Assoc 1999;70:399-404 & S • Optical Correction Alone 41% VA and 18% Stereo • Optical Correction and Patch 69% VA and 30% Stereo • Optical Correction; Patch and VTx 67% and 67%

  41. FitzGerald: % Improvement Refractive Amblyopia VA & StereoKrumholtz I, FitzGerald D. Efficacy of treatment modalities in refractive amblyopia. J Am Optom Assoc 1999;70:399-404

  42. FitzGerald: Refractive AmblyopiaFitzGerald DE, Krumholtz I. Maintenance of improvement gains in refractive amblyopia: a comparison of treatment modalities. Optometry 2002; 73: 153-9. • Maintenance of Visual Acuity Gains over Time (From 1 to 2 years) • Optical Correction 50% • Optical Correction & Patching with Eye Hand Activities 60% • Optical Correction & Patching with Eye Hand Activities and Vision Therapy 100% • 94% of those who maintained their VA’s maintained their stereo

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