Amblyopia - decreased vision in one or both eyes due to abnormal development of vision in

childhood, secondary to abnormal visual stimulation. Estimated to affect between 1-5% of

the population

Cause of disease

Ocular dominance columns (stripes of neurones in visual cortex that respond preferentially
to one eye or the other) established during critical period of neonatal development (1-2
years in humans). Normally, the primary visual cortex develops so it receives input from
both eyes equally.
Ambylopia caused by a problem with the eye which interferes with normal cortical visual
development, cells in primary visual cortex became dominated by input from one eye.
Causes a progressive deterioration of visual acuity in amblyopic eye until the end of the
critical period, at which time visual acuity will stabilise, unless treated.

Caused by underlying ocular pathology, leads to three types:

1. Strabismic condition in which eyes are misaligned
Adult-onset strabismus causes diplopia (double vision) since two eyes are not fixed
on same subject
But Childrens brains are more neuroplastic so more easily adapt by suppressing
images from affected eye, disrupting normal visual development
2. Anisometropic (both eyes have unequal refractive power) caused high degrees of
nearsightedness, farsightedness or astigmastism on one or both eyes (refractive error where
light does not focus evenly on retina)
Eye that provides brain clearer image typically becomes dominant, cortical activity
from eye that provides blurred image is inhibited, disrupting normal visual
3. Deprivation and occlusion (3%) vision-obstructing disorders
Occlusion can be caused by ptsosis (drooping of upper eyelid) which physically
occludes childs vision
Deprivation caused when ocular media (transparent substances of the eye) becomes
opaque (e.g. congenital cataract), prevents adequate visual input from reaching eye,
disrupts normal visual development

Signs and symptoms:

Ambylopia often asymptomatic not aware because vision in stronger eye is normal, so only
aware when stronger eye is occluded. Occasionally patients complain one eye is blurry
Usually parents bring child to ophthalmologist because underlying cause (e.g. strabismus,
ptosis etc.).

Signs: problems with binocular vision (e.g. stereoscopic depth perception). Depth perception
from monocular cues (e.g. perspective and motion parallax) remains normal.
May also have poor pattern recognition and poor acuity, anisometropic amblyopia usually
undetected until picked up by vision screening
Current interventions:

1. Treating underlying cause

Strabismus correct optical deficit with glasses or refractive surgery
Anisometropia correct optical deficit with glasses or eye muscle surgery
Deprivation and occlusion removing the opacity (surgical/non-surgical)
2. After treating underlying cause, if residual visual deficit remains, then amblyopia is present.
Residual unilateral amblyopia is treated by encourage use of weaker eye to strengthen
neural connections so both eyes represented equally
Use of eyepatch, encouraging use of weaker eye. (Concerns: high rates of poor
compliance or noncompliance in some studies, potential social stigma associated
with wearing eyepatch to school)
Pharmacological penalization of stronger eye by applying atropine drops
temporarily paralyses accommodation reflex, leading to blurred vision in the
stronger eye, encouraging use of weaker eye
Managed carefully - overly aggressive therapy can produce reverse amblyopia in
sound eye.

Conclusion

Amblyopia - decreased vision in one or both eyes due to abnormal development of vision
Three main causes strabismus, anisometropia and deprivation/occlusion disrupts normal
visual cortex development, leading to reduced visual acuity in amblyopic eye and
subsequently patient may present with problems with binocular vision
Treatment involves first treating underling cause, then treating amblyopia if present, by
occlusion or pharmacological penalization of stronger eye