What is amblyopia?
A common vision problem in children is amblyopia, or "lazy eye." It is so
common that it is the reason for more vision loss in children than all other
causes put together. Amblyopia is a decrease in the child’s vision that can
happen even when there is no problem with the structure of the eye. The
decrease in vision results when one or both eyes send a blurry image to the
brain. The brain then “learns” to only see blurry with that eye, even when
glasses are used. Only children can get amblyopia. If it is not treated, it
can cause permanent loss of vision.
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Types of amblyopia
There are several different types and causes of amblyopia: Strabismic
amblyopia, deprivation amblyopia, and refractive amblyopia. The end result
of all forms of amblyopia is reduced vision in the affected eye(s).
Strabismic amblyopia develops when the eyes are not
straight. One eye may turn in, out, up or down. When this happens, the brain
“turns off” the eye that is not straight and the vision subsequently drops
in that eye.
Deprivation amblyopia develops when cataracts or similar
conditions “deprive” young children’s eyes of visual experience. If not
treated very early, these children can have very poor vision. Sometimes this
kind of amblyopia can affect both eyes.
Refractive amblyopia happens when there is a large or
unequal amount of refractive error (glasses strength) in a child's eyes.
Usually the brain will "turn off" the eye that has more farsightedness or
more astigmatism. Parents and pediatricians may not think there is a problem
because the child’s eyes may stay straight. Also, the “good” eye has normal
vision. For these reasons, this kind of amblyopia in children may not be
found until the child has a vision test. This kind of amblyopia can affect
one or both eyes and can be helped if the problem is found early.
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Causes & Symptoms
Amblyopia occurs when the brain and eyes do not work together properly.
In persons with amblyopia, the brain favors one eye. The preferred eye
has normal vision, but because the brain ignores the other eye, a person's
vision ability does not develop normally. Between ages 5 and 10, the brain
stops growing and the condition becomes permanent.
Strabismus is the most common cause of amblyopia, and there is often a
family history of this condition. Other causes include:
- Astigmatism in both eyes
- Childhood cataracts
- Farsightedness
- Nearsightedness
Symptoms include:
- Eyes that turn in or out
- Eyes that do not appear to work together
- Inability to judge depth correctly
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Treatment & Prognosis
Amblyopia is usually easily diagnosed with a complete examination of the
eyes. Special tests are usually not required.
Treatment
One of the most important treatments of amblyopia is correcting the
refractive error with consistent use of glasses and/or contact lenses. Other
mainstays of amblyopia treatment are to enable as clear an image as possible
(for example, by removing a cataract), and forcing the child to use the
nondominant eye (via patching or eyedrops to blur the better-seeing eye).
Sometimes, drops are used to blur the vision of the normal eye instead of
putting a patch on it.
The underlying condition will also require treatment. For treatment of
crossed eyes, see: Strabismus
Children whose vision cannot be expected to fully recover should wear
glasses with protective lenses of polycarbonate, as should all children with
only one good eye caused by any disorder. Polycarbonate glasses are shatter
and scratch resistant.
Prognosis
Children who receive treatment before age 5 usually have a near complete
recovery of normal vision. Delaying treatment can result in permanent
vision problems. After age 10, only a partial recovery of vision can
be expected.
Possible complications include eye muscle problems that may require several
surgeries and permanent vision loss in the affected eye.
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FAQ's
Will glasses help a child with amblyopia to see better?
Maybe, but they may not correct it all the way to 20/20. With amblyopia, the
brain is “used to” seeing a blurry image and it cannot interpret the clear
image that the glasses produce. With time, however, the brain may “relearn”
how to see and the vision may increase. Remember, glasses alone do not
increase the vision all the way to 20/20, as the brain is used to seeing
blurry with that eye. For that reason, the normal eye is treated (with
patching or eyedrops) to make the amblyopic (weak) eye stronger.
What can be done if my child has equal high amounts of
farsightedness and/or astigmatism and is diagnosed with bilateral amblyopia?
Bilateral amblyopia is usually treated with consistent, early glasses, and
or contact lenses with follow-up over a long period of time. If asymmetric
amblyopia (one eye better than the other) occurs, then patching or eye drops
may be added.
When should amblyopia be treated?
Early treatment is always best. If necessary, children with refractive
errors (nearsightedness, farsightedness or astigmatism) can wear glasses or
contact lenses when they are as young as one week old. Children with
cataracts or other “amblyogenic” conditions are usually treated promptly in
order to minimize the development of amblyopia.
How old is TOO old for amblyopia treatment?
A recent National Institutes of Health (NIH) study confirmed that SOME
improvement in vision can be attained with amblyopia therapy initiated in
younger teenagers (through age 14 years). Better treatment success is
achieved when treatment starts early, however.
How can I get early treatment for amblyopia?
Some forms of amblyopia, such as that associated with large-deviation
strabismus, may be easily detected by parents. Other types of amblyopia
(from high refractive error) might cause a child to move very close to
objects or squint his or her eyes. Still other forms of amblyopia may NOT be
obvious to parents and therefore must be detected by Vision Screening.
What is Vision Screening?
Vision Screening is strongly recommended by the American Academy of
Pediatrics (AAP) over the course of childhood to detect amblyopia early
enough to allow successful treatment. Pediatricians check newborns for red
reflex to find congenital cataracts. Infants are checked for the ability to
fix and follow and whether they have strabismus. Toddlers can have their
pupillary red reflexes tested with a direct ophthalmoscope (Brückner Test)
or by photoscreening, or by remote autorefraction to identify refractive
errors that can cause amblyopia. When children can consistently identify
objects either by reading, or by matching, the acuity of each eye (with the
non-tested eye patched or covered) is screened to identify amblyopia.
When should patching be used for amblyopia treatment?
Patching should only be done if an ophthalmologist recommends it. An
ophthalmologist should regularly check how the patch is affecting the
child’s vision. Although it can be hard to do, patching usually works very
well if started early enough and if the parents and child follow the
patching instructions carefully. It is important to patch the dominant eye
to allow the weak eye to get stronger.
Are there different types of patches?
The classic patch is an adhesive "Band-Aid" which is applied directly to the
skin around the eye [See figure 3]. These may be available in different
sizes for younger and older children. For children wearing glasses, both
cloth and semi-transparent stickers (Bangerter foils) may be placed over or
onto the spectacles. "Pirate" patches on elastic bands are especially prone
to "peeking" and are therefore only occasionally appropriate.
Is there an alternative to patching to treat amblyopia?
Sometimes the stronger (good) eye can be “penalized” or blurred to help the
weaker eye get stronger. Blurring the vision in the good eye with drops or
with extra power in the glasses will penalize the good eye [See figure 4].
This forces the child to use the weaker eye. Ophthalmologists use this
treatment instead of patching when the amblyopia is not very bad or when a
child is unable to wear the patch as recommended. For mild and moderate
degrees of amblyopia, studies have shown that patching or eyedrops may be
similarly effective. Your pediatric ophthalmologist will help you select
treatment regimen is best for your child.
Do drops work for all amblyopic children?
Not all children benefit from eye drop treatment for amblyopia. Penalizing
eye drops (such as atropine) work less well when the stronger eye is
nearsighted.
How many hours per day patching is enough when treating amblyopia?
The mainstay of treating amblyopia is patching of the dominant (good) eye,
either full or part-time during waking hours. Although classic teaching
suggests that the more hours per day patching is performed, the greater the
result, recent studies suggest that shorter periods may achieve similar
results as longer amounts of patching in patients with moderate amounts of
amblyopia.
How long does amblyopia patching therapy take to work?
Although vision improvement frequently occurs within weeks of beginning
patching treatment, optimal results often take many months. Once vision has
been improved, part-time (maintenance) patching or periodic use of atropine
eyedrops may be required to keep the vision from slipping or deteriorating.
This maintenance treatment may be advisable for several months to years.
During which activities should patching be performed?
The particular activity is not terribly important, compared to the need to
keep the patch on during the allotted time. As long as the child is
conscious and has his or her eyes open, visual input will be processed by
the amblyopic eye. On the other hand, the child may be more cooperative or
more open to bargaining if patching is performed during certain, desirable
activities (such as watching a preferred television program or video). Some
eye doctors believe that the performance of near activities (reading,
coloring, hand-held computer games) during treatment may be more stimulating
to the brain and produce better or more rapid recovery of vision.
Should patching be performed during school hours?
In many instances, school is an excellent time to patch, taking advantage of
a nonparental authority figure. Patching in school hours gives the class an
opportunity to learn valuable lessons about accepting differences between
children. While in most instances, children may not need to modify their
school activities while patching, sometimes adjustments such as sitting in
the front row of the classroom will be necessary. If the patient, teacher,
and classmates are educated appropriately, school patching need not be a
socially stigmatizing experience. On the other hand, frequently a parental
or other family figure may be more vigilant in monitoring patching than is
possible in the school setting. Parents should be flexible in choosing when
to schedule patching.
What if my child refuses to wear the patch?
Many children will resist wearing a patch at first. Successful patching may
require persistence and plenty of encouragement from family members,
neighbors, teachers, etc. Children will often throw a temper-tantrum, but
then they eventually learn not to remove the patch. Another way to help is
to provide a reward to the child for keeping the patch on for the prescribed
time period.
Can surgery be performed to treat amblyopia?
Surgery on the eye muscles is a treatment for
strabismus - it can straighten misaligned eyes. By itself, however,
surgery does not usually or completely help the amblyopia. Surgery to make
the eyes straight can only help enable the eyes to work together as a team.
Children with strabismic amblyopia still need close monitoring and treatment
for the amblyopia, and this treatment is usually performed before strabismus
surgery is considered.
Children who are born with cataracts may need surgery to take out the
cataracts. After surgery, the child will usually need vision correction with
glasses or contact lenses and patching.
What are appropriate goals of amblyopia treatment?
|In all cases, the goal is the best possible vision in each eye. While not
every child can be improved to 20/20, most can obtain a substantial
improvement in vision. Although there are exceptions, patching does not
usually work as well in children who are older than 9 years of age.
What happens if amblyopia treatment does not work?
In some cases, treatment for amblyopia may not succeed in substantially
improving vision. It is hard to decide to stop treatment, but sometimes it
is best for both the child and the family. Children who have amblyopia in
one eye and good vision only in their other eye can wear safety glasses and
sports goggles to protect the normal eye from injury. As long as the good
eye stays healthy, these children function normally in most aspects of
society
Where can I learn more about amblyopia research?
More information about past and ongoing clinical studies regarding amblyopia
can be found at the
National Eye Institute web site.
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