Amblyopia Defined

What is amblyopia?
The brain and the eyes work together to produce vision. The eye focuses light on the back part of the
eye known as the retina. Cells of the retina then trigger nerve signals that travel along the optic
nerves to the brain. Amblyopia is the medical term used when the vision of one eye is reduced
because it fails to work properly with the brain. The eye itself looks normal, but for various reasons
the brain favors the other eye. This condition is also sometimes called lazy eye.
How common is amblyopia?
Amblyopia is the most common cause of visual impairment among children, affecting approximately 2
to 3 out of every 100 children. Unless it is successfully treated in early childhood, amblyopia usually
persists into adulthood. It is also the most common cause of monocular (one eye) visual impairment
among young and middle-aged adults.
Cause
What causes amblyopia?
Amblyopia can result from any condition that prevents the eye from focusing clearly. Amblyopia can
be caused by the misalignment of the two eyesa condition called strabismus. With strabismus, the
eyes can cross in (esotropia) or turn out (exotropia). Occasionally, amblyopia is caused by a clouding
of the front part of the eye, a condition called cataract.
A common cause of amblyopia is the inability of one eye to focus as well as the other one. Amblyopia
can occur when one eye is more nearsighted, more farsighted, or has more astigmatism. These terms
refer to the ability of the eye to focus light on the retina. Farsightedness, or hyperopia, occurs when
the distance from the front to the back of the eye is too short. Eyes that are farsighted tend to focus
better at a distance but have more difficulty focusing on near objects. Nearsightedness, or myopia,
occurs when the eye is too long from front to back. Eyes with nearsightedness tend to focus better on
near objects. Eyes with astigmatism have difficulty focusing on far and near objects because of their
irregular shape.
Treatment
How is amblyopia treated in children?
Treating amblyopia involves forcing the child to use the eye with weaker vision. There are two
common ways to treat amblyopia:
Patching
An adhesive patch is worn over the stronger eye for weeks to months. This therapy forces the child to
use the eye with amblyopia. Patching stimulates vision in the weaker eye and helps parts of the brain
involved in vision develop more completely.
An NEI-funded study1 showed that patching the unaffected eye of children with moderate amblyopia for
two hours daily works as well as patching for six hours daily. Shorter patching time can lead to better
compliance with treatment and improved quality of life for children with amblyopia. However, a
recent study2 showed that children whose amblyopia persists despite two hours of daily patching may
improve if daily patching is extended to 6 hours.
Previously, eye care professionals thought that treating amblyopia would be of little benefit to older
children. However, results from a nationwide clinical trial3 showed that many children from ages seven to
17 years old benefited from treatment for amblyopia. This study shows that age alone should not be
used as a factor to decide whether or not to treat a child for amblyopia.
Atropine
A drop of a drug called atropine is placed in the stronger eye to temporarily blur vision so that the
child will use the eye with amblyopia, especially when focusing on near objects. NEI-supported
research4 has shown that atropine eye drops, when placed in the unaffected eye once a day, work as
well as eye patching. Atropine eye drops are sometimes easier for parents and children to use.
Can amblyopia be treated in adults?
Studies are very limited at this time, and scientists dont know the success rate for treating amblyopia
in adults. During the first seven to ten years of life, the visual system develops rapidly. Important
connections between the eye and the brain are created during this period of growth and development.
Scientists are exploring whether treatment for amblyopia in adults can improve vision.
http://www.nei.nih.gov/health/amblyopia/amblyopia_guide.asp#1, diakses pada 20 Agustus 2014,
pukul 6.05 WIB.
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 childs 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. [See figure 1]
What kinds of amblyopia are there?
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).
What is strabismic amblyopia?
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.
What is deprivation amblyopia?
Deprivation amblyopia develops when cataracts or similar conditions deprive young childrens eyes of visual
experience. If not treated very early, these children can have verypoor vision. Sometimes this kind of amblyopia can
affect both eyes.
What is refractive amblyopia?
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 childs 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.
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 re-learn 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 lenseswith 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 amblyogenicconditions 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 (Brckner 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.
How is amblyopia treated?
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).
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 childs 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. [See figure 2]
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]. They
are 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 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 to moderate degrees of amblyopia, studies have shown that patching
or eyedrops may be similarly effective. Your pediatric ophthalmologist will help you select what 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) do not work
as 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
during 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
Amblyopia. http://www.aapos.org/terms/conditions/21, diakses pada 20 Agustus 2014, pukul 6.04 WIB.

Results-An Evaluation of Treatment of Amblyopia in
Children 7 < 18 Years Old (ATS3)
Background
Amblyopia is a condition that occurs when a child's visual system does not develop properly, resulting
in abnormal sight in one or both eyes. The condition is sometimes called "lazy eye." The condition
affects as many as three percent of children in the United States. It is the most common cause of
monocular visual impairment in both children and young and middle-aged adults.
The disorder is caused by any condition that sends the brain abnormal or unequal visual input during
infancy or childhood. These conditions can include an imbalance in the positioning of the eyes, such as
strabismus, in which the eyes are crossed inward (esotropia) or turned outward (exotropia).
Amblyopia also can result from a major difference in refractive error between the two eyes, such as
nearsightedness, farsightedness, orastigmatism. Less common causes of amblyopia are cornea and
lens diseases and injury to the eye of a young child. The results reported in this study do not include
amblyopia from these less common causes.
It has been commonly thought that the best time to try to correct amblyopia was during infancy or
early childhood before the eyes and the entire visual system, including the brain, have fully matured.
Although most eye care professionals agreed that amblyopia could be treated effectively in young
children, many have thought that treatment beyond a certain age is ineffective. Some clinicians
thought that a treatment response was unlikely after the age of six or seven years, while others
considered age nine or ten years to be the upper age limit for successful treatment.
There had been limited data available to eye researchers on treatment of children older than seven.
However, some clinicians reported that treatment did benefit older children. To prepare for a possible
randomized clinical trial on treating amblyopia in older children, the National Eye Institute (NEI)
funded a pilot study that was completed in 2003. The pilot study showed that after treatment, 27
percent of 66 children with amblyopia, ages ten through 17 years, improved their vision in the
affected eye. They gained the ability to read two or more lines of a standard eye chart. The results
justified the NEI-funded, Randomized Trial of Treatment of Amblyopia in Children 7 to < 18 Years Old.
The trial was coordinated by the Pediatric Eye Disease Investigator Group (PEDIG), a network of eye
care professionals at universities and community offices in North America.
The purpose of this trial was to treat two age sets of "older" children, seven through 12 years old and
13 through 17 years old, with conventional amblyopia treatments, both patching and atropine eye
drops. At 49 clinical sites nationwide, 507 children with amblyopic eye vision ranging from 20/40 to
20/400 were recruited into the trial from October 2002 to March 2004. Eye care professionals then
prescribed new eye glasses for all the study children, to obtain the "optimal optical correction." Both
sets of children were then randomly divided into either a "treatment group" or an "optical-correction-
only group," children who received only glasses.
In the treatment group, seven- through 12-year-old children received two to six hours daily patching
of the unaffected eye with near activities, plus daily atropine drops in that eye to temporarily blur their
near vision. The 13 through 17-year-old children in the treatment group received the patching and
near activities but not the eye drops. The near activities included hand-held computer games,
homework, reading, computer work, and the use of workbooks designed for the study with mazes,
and word finds. Vision improvement in the eye with amblyopia occurred over a period of six to 24
weeks.
The results confirm the pilot study results that conventional treatment of amblyopia can be effective in
children even after age seven. As is the case with patients younger than seven, however, most of the
older patients are also left with some remaining visual impairment despite treatment. The
investigators are continuing to study the children for a year after stopping their treatment to
determine whether the benefit reported in this paper will be sustained.
The study authors also reported that patients participating in the clinical trial may differ from
patients in usual clinical practice. The children in the study, with the guidance of their parents, may
have a different level of compliance than may be achieved in clinical practice.
For decades, patching the unaffected eye had been the standard treatment for amblyopia. In March
2002, NEI-supported researchers reported the effectiveness of drug therapy with an eye drop
(atropine) that dilates the pupil and blurs the image seen by the unaffected eye during near viewing.
In May 2003, results of another NEI-funded study, also conducted by the PEDIG at 35 clinical sites,
indicated that patching the unaffected eye of children with moderate amblyopia for two hours daily
works as well as patching the eye for six hours.
http://www.nei.nih.gov/ats3/background.asp, diakses pada 20 Agustus 2014, pukul 6.09 WIB.