Perspective
Amblyopia: Diagnostic and Therapeutic Options

https://doi.org/10.1016/j.ajo.2005.07.060Get rights and content

Purpose

To provide an overview of the current state of knowledge of amblyopia and highlight recent advances in diagnosis and treatment.

Design

Review of literature and perspective.

Methods

MEDLINE search for amblyopia, with a review of all recent literature adding authors’ personal perspectives on the findings.

Results

Increased awareness of amblyopia and better screening techniques are required to identify children who are at risk for amblyopia at a younger age. Randomized, controlled trials have established atropine penalization as a viable alternative to occlusion therapy, have suggested that less treatment may be better tolerated and as effective as more traditionally used dosages, and have found no compelling evidence that treatment is beneficial clinically for older (over age 10) children with amblyopia.

Conclusion

Early detection and treatment of amblyopia can improve the chances for a successful visual outcome. Considering that the conditions that place a patient at risk for amblyopia can be identified, that amblyopia responds to treatment, and that well-tolerated treatments for the condition are now recognized, it is not unreasonable to imagine that, in the near future, severe amblyopia could be eliminated as a public health problem.

Section snippets

Types of amblyopia

Amblyopia may result from strabismus, refractive error, or deprivation. Binocularity and stereopsis are most likely to be preserved when retinal blur causes amblyopia and binocular alignment remains intact.

Screening for amblyopia

Amblyopia is remarkably responsive to treatment if therapy is initiated early in life; however, delayed treatment can result in severe visual impairment.26, 27 Many of the common conditions that can lead to amblyopia can be difficult to detect in children, with half of all amblyopia cases undetected until age 5 years.28 The American Academy of Pediatrics29 states that vision screening should begin at birth and continue as part of a child’s regular medical checkups. All newborn infants should be

Treatment of amblyopia

The first step in amblyopia treatment is to provide a clear retinal image for the amblyopic eye if deprivation exists; however, merely removing the initial deprivation condition is usually insufficient to reverse the amblyopia. The second step consists of occluding or penalizing the dominant eye.

Occlusion therapy with patching of the dominant eye has been the cornerstone of amblyopia treatment, despite the lack of data that demonstrate its superiority over other options.44 Practitioners

Discussion

Amblyopia is the most common treatable cause of decreased vision in children and remains as one of the most common causes of decreased vision in adults. Aside from the visual deficits, amblyopia may also have a negative psychosocial impact. Patients with an amblyopic eye have an increased risk for vision loss in the fellow eye and considerably greater disability when this does occur. As a result, cost-utility analysis indicates that amblyopia therapy is highly cost-effective when compared with

Carolyn Wu, MD, received a BA from the University of Pennsylvania and a MD from Albert Einstein College of Medicine. Her residency was at the New York University School of Medicine and Manhattan Eye, Ear, and Throat Hospital. She completed a fellowship in pediatric ophthalmology at Children’s Hospital Boston, where she joined the faculty and is an Instructor in Ophthalmology at Harvard Medical School.

References (111)

  • S. Hrisos et al.

    The emotional impact of amblyopia treatment in preschool childrenrandomized controlled trial

    Ophthalmology

    (2004)
  • R.A. Kennedy et al.

    Evaluation of the iScreen digital screening system for amblyogenic factors

    Can J Ophthalmol

    (2000)
  • J.W. Simon et al.

    A new visual evoked potential system for vision screening in infants and young children

    J AAPOS

    (2004)
  • S.P. Donahue

    How often are spectacles prescribed to “normal” preschool children?

    J AAPOS

    (2004)
  • M.W. Preslan et al.

    Baltimore vision screening projectphase 2

    Ophthalmology

    (1998)
  • M. Oliver et al.

    Compliance and results of treatment for amblyopia in children more than 8 years old

    Am J Ophthalmol

    (1986)
  • K. Simons et al.

    Full-time atropine, intermittent atropine, and optical penalization and binocular outcome in treatment of strabismic amblyopia

    Ophthalmology

    (1997)
  • R.W. Beck

    The Pediatric Eye Disease Investigator group

    J AAPOS

    (1998)
  • K. Simons et al.

    Penalization vs part-time occlusion and binocular outcome in treatment of strabismic amblyopia

    Ophthalmology

    (1997)
  • E. Campos

    Amblyopia

    Surv Ophthalmol

    (1995)
  • M. Epelbaum et al.

    The sensitive period for strabismic amblyopia in humans

    Ophthalmology

    (1993)
  • E.A. Packwood et al.

    The psychosocial effects of amblyopia study

    J AAPOS

    (1999)
  • J. Rahi et al.

    Risk, causes, and outcomes of visual impairment after loss of vision in the non-amblyopic eyea population-based study

    Lancet

    (2002)
  • N.S. Levy et al.

    Stereoscopic perception and Snellen visual acuity

    Am J Ophthalmol

    (1974)
  • S.Y. Lee et al.

    The relationship between stereopsis and visual acuity after occlusion therapy for amblyopia

    Ophthalmology

    (2003)
  • E.E. Birch et al.

    Stereopsis and long-term stability of alignment in esotropia

    J AAPOS

    (2004)
  • E.E. Birch et al.

    Why does early surgical alignment improve stereoacuity outcomes in infantile esotropia?

    J AAPOS

    (2000)
  • R. Autrata et al.

    Laser-assisted subepithelial keratectomy and photorefractive keratectomy vs conventional treatment of myopic anisometropic amblyopia in children

    J Cataract Refract Surg

    (2004)
  • C.B. Phillips et al.

    Laser in situ keratomileusis for treated anisometropic amblyopia in awake, autofixating pediatric and adolescent patients

    J Cataract Refract Surg

    (2004)
  • W.F. Astle et al.

    Laser-assisted subepithelial keratectomy in children

    J Cataract Refract Surg

    (2004)
  • P. Nucci et al.

    Refractive surgery for unilateral high myopia in children

    J AAPOS

    (2001)
  • E.A. Paysse et al.

    Photorefractive keratectomy for pediatric anisometropiasafety and impact on refractive error, visual acuity, and stereopsis

    Am J Ophthalmol

    (2004)
  • A. Agarwal et al.

    Results of pediatric laser in situ keratomileusis

    J Cataract Refract Surg

    (2000)
  • W.F. Astle et al.

    Photorefractive keratectomy in children

    J Cataract Refract Surg

    (2002)
  • G.K. von Noorden

    Amblyopia: a multidisciplinary approach: proctor lecture

    Invest Ophthalmol Vis Sci

    (1985)
  • R.V. Keech et al.

    Upper age limit for the development of amblyopia

    J Pediatr Ophthalmol Strabismus

    (1995)
  • R. Sireteanu

    The binocular visual system in amblyopia

    Strabismus

    (2000)
  • N.W. Daw

    Critical periods and amblyopia

    Arch Ophthalmol

    (1998)
  • S.E. Navon et al.

    Amblyopia

    Int Ophthalmol Clin

    (1992)
  • G. Lennerstrand et al.

    Screening for ocular dysfunction in childrenapproaching a common program

    Acta Ophthalmol Scand Suppl

    (1995)
  • G. Lennerstrand et al.

    Results of treatment of amblyopia with a screening program for early detection

    Acta Ophthalmol Scand Suppl

    (1996)
  • V. Dobson et al.

    Astigmatism, amblyopia, and visual disability among a Native American population

  • M. Abrahamsson et al.

    Astigmatic axis and amblyopia in childhood

    Acta Ophthalmol Scand

    (2003)
  • A. Jampolsky et al.

    Unequal corrected visual acuity as related to anisometropia

    Arch Ophthalmol

    (1955)
  • H.M. Hittner et al.

    Unilateral peripapillary myelinated nerve fibers with myopia and/or amblyopia

    Arch Ophthalmol

    (1987)
  • J. Sjostrand et al.

    Risk factors in amblyopia

    Eye

    (1990)
  • G. Woodruff et al.

    Factors affecting the outcome of children treated for amblyopia

    Eye

    (1994)
  • G.K. von Noorden et al.

    The lateral geniculate nucleus in human strabismic amblyopia

    Invest Ophthalmol Vis Sci

    (1992)
  • A. Hillis et al.

    The evolving concept of amblyopiaa challenge to epidemiologists

    Am J Epidemiol

    (1983)
  • K. Simons et al.

    Natural history of amblyopia untreated owing to lack of compliance

    Br J Ophthalmol

    (1999)

    • Cited by (129)

    • Evaluating Eye Crossing Using the Corneal Light Reflex

      2023, Journal of Pediatrics

    • Virtual reality prototype for binocular therapy in older children and adults with amblyopia

      2021, Journal of AAPOS

    • Severe reverse amblyopia with atropine penalization

      2020, Journal of AAPOS

    • Effect of Primary Occlusion Therapy in Asymmetric, Bilateral Amblyopia

      2020, American Journal of Ophthalmology
      Citation Excerpt :

      Although this is a relatively rare form of the disease, we have found that many of our patients do fit into this category. Through our retrospective review of amblyopia outcomes over a 5-year period, we found that approximately 7.6% of amblyopic subjects have asymmetric, bilateral amblyopia, resulting in a prevalence of 0.3% in the population (using a total amblyopia frequency of 4%).5 This is slightly higher than the prevalence reported in 1 PEDIG study, where among 113 patients with bilateral amblyopia (frequency of 0.5%), 23 had an IOD of 2 lines or more, giving a prevalence of 0.1%.6

    • Design and assessment of amblyopia, strabismus, and myopia treatment and vision training using virtual reality

      2023, Digital Health

    • Dichoptic Vision Therapy in Adults with Anisometropic Amblyopia: A Systematic Review

      2023, Malaysian Journal of Medicine and Health Sciences
    View all citing articles on Scopus

    Carolyn Wu, MD, received a BA from the University of Pennsylvania and a MD from Albert Einstein College of Medicine. Her residency was at the New York University School of Medicine and Manhattan Eye, Ear, and Throat Hospital. She completed a fellowship in pediatric ophthalmology at Children’s Hospital Boston, where she joined the faculty and is an Instructor in Ophthalmology at Harvard Medical School.

    David G. Hunter, MD, PhD, is Ophthalmologist-in-Chief, Children’s Hospital Boston/Associate Professor of Ophthalmology, Harvard Medical School. He has a BS in electrical engineer from Rice University and a PhD (cell biology) and MD from Baylor College of Medicine. His residency was at the Massachusetts Eye and Ear Infirmary and he was a fellow in pediatric ophthalmology at Johns Hopkins’ Wilmer Eye Institute. After 10 years on faculty at Wilmer, he relocated to Boston in 2002.

    Supported by Research to Prevent Blindness Walt and Lilly Disney Amblyopia Research Award (D.G.H.).

    ⁎

    Conflict of Interest: D.G.H. is a co-inventor on a US Patent: “Guyton DL, Hunter DG, Patel SN, et al. Eye fixation monitor and tracker. US Patent No. 6,027,216, 22 Feb, 2000.” This patent is owned by the Johns Hopkins University and is not licensed by Johns Hopkins to any commercial entity.

    View full text
    Copyright © 2006 Elsevier Inc. All rights reserved.