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AmblyopiaUpdateforthePrimaryCareOD2018
1|P a g e w w w . E y e C o d e B l o g . c o m
ChristopherWolfe,OD,FAAO,Dipl.ABO
AmblyopiaAmblyopiaisaunilateralorbilateralconditionthatcausestheinwhichthebestcorrectedvisualacuity(VA)isworsethan20/20inthepresenceofanormalhealthyeye(nostructuralabnormalitiesoroculardisease)[1].Amblyopiadevelopsduringthecriticalperiod,typicallyinpatients<6-8yearsold(criticalperiod)[2].DependingonthelevelofVAreductiontheprevalencechanges:
• UsingVAof20/40orworse–prevalenceis1.4%ofthepopulation[3]
• UsingVAof20/30orworse–prevalenceis3.5%ofthepopulation[3]
InadditiontoareductioninBCVA,patientswithamblyopiacanalsohave:crowdingeffect,unsteadyfixation,poortracking,reducedcontrastsensitivityandinaccurateaccommodativeresponses[4].
BelowwewillclassifyamblyopiabasedontheconditionthatleadstothereductioninbestcorrectedVA.
FormDeprivationAmblyopiaFormdeprivationamblyopiaoccurswhenthereisanobstructioninthevisualaxisthatprecludesaclearimageontheretina.Commonconditionsthatcanleadtoformdeprivationamblyopiainclude[5][6][7][8]:
• Congenitalcataract(mostcommon)• Traumaticcataract• Cornealopacities• Congenitalptosis
• Vitreousopacification• Prolongeduncontrolledpatching• Prolongedunilateralblepharospasm• Prolongedunilateralatropinization
RefractiveAmblyopiaRefractiveamblyopiaresultsfromablurredimageontheretinainoneorbotheyesthatpreventsthenormaldevelopmentofthevisualpathwayresultinginareductioninVAatthelevelofthevisualcortex[1].
Refractiveamblyopiacanbeclassifiedaseitherisoametropicoranisometropic.
IsoametropicIsoametropicrefractiveamblyopiaoccurswhenthereisanequalbuthighuncorrectedrefractiveerrorinbotheyesthatleadstosignificantretinalblurandreducedVA.
AnisometropicAnisometropicrefractiveamblyopiaoccurswhenthereisanunequaluncorrectedrefractiveerrorbetweenthetwoeyesthatleadstosignificantretinalblurandreducedVA.
CROWDING
Patientsimpactedbythecrowdingeffectwillperformbetterwithlinesoflettersthanblocksoflettersandbetterwithsinglelettersthanlinesofletters.
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Typicallyamblyopiaislarger(deeperwithworseVA)forlargerdifferencesinrefractiveerror[9].
AmblyogenicRefractiveErrors[9][10][11][12] Myopia Hyperopia AstigmatismIsoametropic >8.00D >5.00D >2.50D
Anisometropic >3.00D >1.00D >1.50D
TABLE1:COMMONREFRACTIVEAMBLYOGENICRISKFACTORS
HyperopicAnisometropiaSincepatientswithhyperopiawillaccommodatetheleastamountnecessaryatdistanceandneartoseeclearly,lessanisometropiaisrequiredtocauseamblyopiasincethelesshyperopiceyewillbeusedforbothdistanceandnear.MyopicAnisometropiaSincepatientswithmyopiawillusethelessmyopiceyefordistanceandthemoremyopiceyefornearamblyopiawilltendnottooccuruntilthereismorethana3diopterdifferencebetweentheeyes.
StrabismicAmblyopiaStrabismicamblyopiamostcommonlyoccurswhenthereisconstant,unilateralstrabismusduringthecriticalperiod.Sincethereisnobifoveation,eacheyeseesdifferentimages,whichcanleadtoconfusion(centralretina)anddiplopia(peripheralretina).Ifconfusionand/ordiplopialastsforlongenough,thepatientwillactivelysuppressthenon-correspondingretinalimageswhichwillleadtoamblyopia[13].Additionalsensoryadaptationscanoccurtoeliminateconfusionanddiplopia.Theseinclude:
• Eccentricfixation–occurswhenapatientusesanon-fovealpoint(typicallyofthestrabismiceye)whenfixatingmonocularly)[14]
• AnomalousCorrespondence–isabinocularconditionthatlinksanon-fovealpointofthestrabismiceyewiththefoveaofthefixatingeye.
Esotropia(ET)Esotropiaoccurswhentheeyesaretooconvergentfortheobjectofregard.
Congenital/InfantileEsotropia
Congenital(Infantile)esotropiaisaconstantlargeangleesotropiathatoccurspriorto6monthsofage.Additionalclinicalfeaturesthatcanbeseeninclude:
1. Inferiorobliqueoveraction(70%)–thisclinicallysimilarlytoasuperiorobliquepalsy(hyperdeviationduringADduction)
2. Disassociatedverticaldeviation(75%)–elevationofthestrabismiceyewhencovered
INTERMITTENTStrabismuscanbeintermittentoralternatingbutthistypeofstrabismusleadstoamblyopialessfrequentlythanconstantstrabismus.
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3. Latentnystagmus(50%)–typicallyahorizontaljerknystagmusthatmanifestswheneithereyeiscovered,thefastphasewillbeAWAYfromthesideoftheoccludedeye[15]
Thelargeangleofthetropiaprecludesbinocularvisionatanydistancesosurgeryisthemostcommoninitialtreatment.
AccommodativeEsotropiaAccommodativeesotropiaoccurswhenthereiseitherahighAC/Aratioorasignificantamountofhyperopia(>+2.00).Theinitialtreatmenttypicallyincludesspectacleprescriptionwithpossiblebifocalwithaddtoneutralizetheneartropia/phoria.
MechanicalEsotropiaMechanicalEsotropiaoccurswhenthereisarestrictionorobstructionofanextraocularmuscle.Causesinclude:
• Extraocularmusclefibrosisinthyroidorbitopathy• Blowoutfracture• Duanesyndrome-iscongenitalandnon-progressiveand
duetoanabsenceofCNVIandaberrantinnervationofabranchofCNIIIintothelateralrectus[16].Additionally,globeretractionoccurswhenboththelateralandmedialrectusarestimulatedatthesametime[17].Thethreetypesinclude[18]:
o Type1(75-80%)-esotropiainprimarygazewithacompensatoryheadturntotheinvolvedside
o Type2(5-10%)-exotropiainprimarygazewithacompensatoryheadturntotheuninvolvedside
o Type3(10-20%)-eitheranesotropiaorexotropiainprimarygaze,andwillhaveacompensatoryheadturntowardstheinvolvedside.Additionally,thereisnoabilitytoadducttheeye
MicroesotropiaMicroesotropiahasanonsetinchildrenunder3yearsandistypicallyaconstant,unilateralesotropiawithanangleoflessthan10∆.Sincetheangleofthetropiaissmall,itcanbechallengingtodiagnosewithacovertest.Patientswithmicroesotropiacanhaveasmallcentralsuppressionscotomathatleadstonorandotstereopsis,additionally,a4baseout(BO)testcanbeutilizedtoaiddiagnosis.
• Inapatientwithnormalfixationandnomicrotropia,wewillseetwodistinctmovementsona4BOtest.Thesemovementsinclude:
1. Versionalmovementofbotheyestowardtheapexoftheprism2. Convergencere-fixationoftheeyethatisnotcoveredbytheprism
• Inapatientwitharightmicroesotropiaandasmallcentralsuppressionscotoma,wewouldexpecttoseethefollowingona4BOtest:
1. Prismplacedoverrighteye–NOmovement2. Prismplacedoverthelefteye–versionalmovementofbotheyestowardtheright,NO
convergencere-fixation
BLOWOUTWetypicallythinkofinferiorrectusentrapmentassociatedwithblowoutfracturesbutwecanalsoseelateralormedialrectusentrapmentsthatleadtoesotropia[29][30].
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Exotropia(XT)Exotropiaoccurswhentheeyesaretoodivergentfortheobjectofregard.
CongenitalExotropiaCongenitalexotropiaistypicallyconstantandoccurspriorto6monthsofage.Patientswithcongenitalexotropiahaveanincreasedincidenceof[19]:
• cerebralpalsy• neurologicdisorders• craniofacialdisorders• ocularalbinism
SensoryExotropiaSensoryexotropiaoccursinpatientswithseverelyreducedVAorablindeye.Inpatientswhoaretypicallyolderthan2-4yearsoldiftheybecomeblindorseverelylowvisioncanalsobecomeexotropicduetoaninabilitytodisparateimages[20].
IntermittentExotropiaIntermittentexotropiatypicallyoccurswhenviewingdistanceobjectswhenpatientsaretired,sickorinsomewayataloweredmentalstate(eg.intoxicated)andunderbrightlyilluminatedsituations.The3subtypesofintermittentexotropiaare:
1. BasicIntermittentXT–distanceandnearphoria/tropiameasurementsarewithin10∆ofeachotherandconvergenceisnotimpacted.
2. Pseudo-divergenceexcess–characterizedbyanexotropiathatislargeratdistancebutresolvesafteraperiod(30-60minutes)ofocclusionofthenon-fixatingeye.Thesepatientstypicallycompensatebyincreasingtonicfusionalconvergence.
3. Divergenceexcess–characterizedbyanexotropiathatislargeratdistancethannearbutdoesnotresolveafterocclusionofthenon-fixatingeyeandtypicallyahighAC/Aratio.
DifferentialDiagnosisofAmblyopiaIntheassessmentofpatientswithamblyopiaitisimportanttoconsiderotherconditionsthatcanmasqueradeasrefractiveorstrabismicamblyopia.Someconditionshaveobviousclinicalfindingsandothersaremoresubtle.Theseconditionsinclude[21]:
• Duane’ssyndrome(XT/ET)• CNIIIpalsy(XT)• CNVIpalsy(ET)• Internuclearophthalmoplegia(XT)–affectedeyehaslimitedAdductionand“normaleye”
appearstoexotropicandexhibitsnystagmusonABduction• Orbitalfibrosis/thyroideyedisease(XT/ET)–exotropiceyewillnotmoveinonADductionand
therewillberesistancetoADductiononforcedductiontesting• Moebiussyndrome(XT/ET)–anonprogressivecraniofacialandneurologicaldisorderthat
manifestsasprimarilyasfacialparalysiswithlackoflateraleyemovements• Myastheniagravis(XT/ET)• Achromatopsia
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• Coloboma• Myelinatednervefibers• Retinopathyofprematurity• Degenerativemyopia• Hypoplasticopticnerve• Keratoconus• Mediaopacities• Macular,perimacularchorioretinalscar• Macularpathology(e.g.,Stargardt'sdisease)• Opticatrophy• Retrobulbarneuritis• Nystagmus(congenital,latent,manifestlatent)• Craniopharyngioma
TraditionalTreatmentandManagementAsdiscussedabove,therearemanysubsequentsequelaeforthevisualsystemthatcanoccurinpatientswithamblyopia.Traditionaltreatmentoptionsinclude:
1. Refractive error correction 2. Patching 3. Penalization 4. Vision therapy 5. Surgery UpdateontheLiterature–AmblyopiaTreatmentStudies(ATS)Becauseoftheabovevariables,itcanmakedesigningalargestudychallengingtotractimprovementineachoftheareassinceimprovementcouldbemonitoredbasedonVA,binocularvision,accommodativeaccuracy,andevencosmesis.TheadvantageoftheAmblyopiaTreatmentStudiesisthattheyarelargemulti-centerprospectivestudiesthatcanhelpguideusonhowtoimproveVAwithdifferenttreatmentoptionsinpatientswithamblyopia.ThedownsidewiththestudiesisthattheydealalmostexclusivelywithimprovementsinVAandtheyhavehadadifficulttime,duetomanypotentialfactors,evaluatingtheimpactofvisiontherapyandsurgery. ATS-1:Inpatientswithmoderateamblyopiaispatchingorpenalizationmoreeffectiveinpatientsaged3-7yearsold?[22]
• 419childrenwithamblyopia(20/40to20/100)wererandomizedto:o 215patching(6hourstofulltime)o 204atropine(1%QD)
• BaselinemeanVAintheamblyopiceye:20/63• Baselinemeandifferenceinacuitybetweeneyes:4.4lines• VAImprovement:
o SixMonthsMeanVA:§ Patching:20/32§ Atropine:20/32-2
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§ Improvementinitiallywasfasterinthepatchinggroup,butaftersixmonths,thedifferenceinacuitybetweentreatmentgroupswassmall
o TwoYearMeanVA:§ Patching:+3.7lines§ Atropine:+3.6lines
ATS-2A:Inpatientswithsevereamblyopiais6hoursofpatchingaseffectiveasfull-timepatchinginpatientsaged3-7yearsold?[23]
• 175childrenwithsevereamblyopia(20/100to20/400)wererandomizedtoeither6hoursperdayorfull-timedailypatching.
• Allpatientswereprescribedatleastonehourperdayofnearvisualactivitieswhilepatching
• VAImprovement:o 6hoursperdayofpatching: +4.8lineso Full-timedailypatching: +4.7lines
ClinicalPearlsATS-1
• Bothtreatmentswerewelltolerated,althoughatropinehadaslightlyhigherdegreeofacceptabilityonaparentalquestionnaire
• At6monthsitisslightlymorelikelyforpatientstakingatropinetohavereducedacuityinthesoundeyeatsixmonthsbutthisdidnotpersistwithfurtherfollowup
• Patchingadvantage:morerapidimprovementinVAandpossiblyaslightlybetteracuityoutcome
• Atropineadvantage:easieradministrationandlowercost• Ifonetreatmentdoesn’tworkconsiderswitchingtotheother• Initialchoiceofpatchingoratropinecanbemadebytheproviderandparent
ClinicalPearlsATS-2A
• Forpatientswithsevereamblyopia,startwith6hoursofpatchingdaily•
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ATS-2B:Inpatientswithmoderateamblyopiais2hoursofpatchingaseffectiveas6hoursofpatchinginpatientsaged3-7yearsold?[24]
• 189childrenwithsevereamblyopia(20/40to20/80)wererandomizedtoeither2hoursor6hoursdailypatching.
• Allpatientswereprescribedatleastonehourperdayofnearvisualactivitieswhilepatching
• VAImprovement:o 2hoursperdayofpatching: +2.4lineso 6hoursperdayofpatching: +2.4lines
ATS-2C:Howoftenwillamblyopiaregressaftertreatmentisstopped?[25]• 156children(<8yearsold)withsuccessfullytreated(improvementinVAwithpatchingor
atropine)anisometropicorstrabismicamblyopia8yearsofage,• Followedwithouttreatmentfor52weekstoassessrecurrenceofamblyopia,
o Recurrencedefinedaseither:§ 2ormorelogMARlevelreductionofVAfromenrollment§ Treatmentisrestarted
• Recurrenceo Patientswhowerepenalized: 21%o Patientswhowerepatched: 25%
• Ifpatchingis≥6hoursandNOtaper: 42%• Ifpatchingis≥6hoursandthentaper: 14%
ClinicalPearlsATS-2B
• Forpatientswithmoderateamblyopia,startwith2hoursofpatchingdaily•
ClinicalPearlsATS-2C
• ~1/4ofsuccessfully-treatedamblyopeswillhavearecurrenceinthefirstyearofstoppingtreatment.
• Forpatientstreatedwith6+hoursofdailypatching,theriskofrecurrenceisgreaterwhenpatchingisstoppedabruptlyratherthanwhenitisreducedto2hoursperdaypriortocessation.
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ATS-3:Istreatment(patchingorpenalization)effectiveatimprovingVAin7-18yearoldswithamblyopia?[26]
• 507patientswithamblyopia(20/40to20/400)wererandomizedtobetreatedwithspectaclesonlyorspectaclespluspatching/penalization(2-6hours/daydependingonseverity)
• Numberofpatientswhorespondedtoeachtreatmentarmareasfollows:o Patients7to<13yearsold:
§ Spectaclesonly: 25%§ Spectacles+p/p: 53%
o Patients13to<18yearsold:§ Spectaclesonly: 25%§ Spectacles+p/p: 23%
• PatientsPREVIOUSLYtreatedwithp/p: 20%• PatientsNOTPREVIOUSLYtreatedwithp/p: 47%
ATS-4:Isweekendonlyatropineaseffectiveasdailyatropineattreatingpatientswithmoderateamblyopia(20/40to20/80)?[27]
• 168 children (3 to < 7 years old) with moderate amblyopia (strabismus, anisometropia, or mixed) were randomized to be treated with either daily atropine or to weekend atropine
• Improvement in VA of the amblyopic eye from baseline to 4 months averaged 2.3 lines in each group.
• Additionally, VA was either better than 20/25 or better than or equal to the sound eye in: o Daily group: 47% o Weekend group: 53%.
• Stereoacuity outcomes were similar in the two groups. • Patients were more compliant with the daily dosing
ClinicalPearlsATS-3
• Forpatients7to<13yearsold,prescribe2to6hoursperdayofpatching/atropineeveniftheamblyopiahasbeenpreviouslytreated.
• Forpatients13to<18yearsold,prescribe2to6hoursperdayofpatching/atropineifamblyopiahasnotbeenpreviouslytreatedandspectaclesONLYifamblyopiawaspreviouslytreatedwithp/p.
ClinicalPearlsATS-4
• Inpatientswithmoderateamblyipiawhenusingatropine,startwithdailydosingtoimprovecomplianceandthentapertoweekenddosingaftertheinitialfollowup.
•
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ATS-5:HowmucheffectdoesspectaclecorrectionhaveonimprovingVAinpatientswithanisometropicamblyopia?[28]
• 84children(3to<7yearsold)withpreviouslyuntreatedanisometropicamblyopia(20/40to20/250)wereevaluatedforimprovementinBCVAafterspectaclecorrectionoftheirametropia
• Amblyopiaimprovedwithspectaclecorrectionaloneby2ormorelinesin77%ofthepatients• Amblyopiaresolvedwithspectaclecorrectionalonein27%ofpatients• StabilizationofVAtookupto30weeksbutaveragedabout6months• Follow-upoccurredevery5weeksuntilstabilization
ATS-6:Whenpatching,does“distance”or“near”activitieshaveanimpactontheresolutionofamblyopia?[29]
• 425children(3to7years)withamblyopia(20/40–20/400)thatwascausedbyanisometropia,strabismus,orboth,andthatpersistedaftertreatmentwithspectacleswererandomizedto2hoursofpatchingperdaywithEITHERnearordistanceactivities.
• VAimprovementat8weekso Distancegroup: averaged2.6lineso Neargroup: averaged2.5lines
• Childrenwithsevereamblyopia(20/100to20/400)improvedbyameanof3.6lineswith2hoursofdailypatching.
ClinicalPearlsATS-5
• Whenstartingtreatmentforanisometropicrefractiveamblyopia,startwithspectaclecorrectionalonethiscanmakepatchingorpenalizationeasier(ifneeded)sincetheamblyopiceyeVAisbetter.
ClinicalPearlsATS-6
• Whenstartingpatchingtreatmentbothdistanceandnearactivitiesareequallyeffective• Encouragepatientstodoactivitiestheyenjoy(iPad,Wii,etc.)• Patientswithsevereamblyopiawillrespondwith2hoursofpatching
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ATS-7:HowlongeffectiveisspectaclecorrectionaloneatimprovingVAinpatientswithbilateralrefractiveamblyopiaandwhatisthetimeframeforVAimprovement?[30]
• 113children(age3to<10)withuntreatedbilateralrefractiveamblyopia(20/40to20/320)wereprescribedoptimalspectaclecorrection.
• After1yearoftreatmentVAimprovementwas:o Initialbinocularacuityof20/40to20/80was3.4lineso Initialbinocularacuityof20/100to20/320was6.3lines
• Cumulativeprobabilityofbinocularacuityof20/25orbetterwaso 21%at5weekso 46%at13weekso 59%at26weekso 74%at52weeks
ATS-8:Doesweekendatropinewithaplanolensinthesoundeyehelpimproveamblyopiabetterthanweekendatropinealone?[31]
• 180childrenwithmoderateamblyopia(20/40to20/100)wererandomizedtoweekendatropineplusplanolensoverthesoundeyeorweekendatropineusealone.
• Soundeyehadtobehyperopicof+1.50ormore• VAimprovement
o AtropineONLY: 2.4lineso AtropinePLUS: 2.8lines
• AmblyopiceyeVAof20/25orbettero AtropineONLY: 29%o AtropinePLUS: 40%
• PatientsintheatropineplusgroupweremorelikelytohavereducedVAinthesoundeyeat18weeks,however,thiseffectresolvedafterceasingtreatment.
ClinicalPearlsATS-7
• Within1year3/4ofpatientswithbilateralrefractiveamblyopiawithhavebinocularVAimproveto20/25orbetterwithspectaclecorrectionalone.
ClinicalPearlsATS-8
• AugmentingatropinetreatmentwithaplanolensoverthesoundeyedoesnotsignificantlyimproveamblyopiceyeVA
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ATS-9:Ispatchingoratropinemoreeffectiveatimprovingamblyopiainpatientswhoare7to<13?[32]
• 193childrenwithamblyopia(20/40-20/100)wereassignedtoreceiveweekendatropineorpatchingofthesoundeye2hoursperdayandfollowedfor17weeks
• VAimprovement:o Atropine: 7.6letterso Patching: 8.6letters
• VAof20/25orbetter:o Atropine: 17%o Patching: 24%
ATS-10:HoweffectiveareBangerterfiltersoverthesoundeyeatimprovingVAinpatientswithamblyopia?[33]
• 186children(3to<10yearsold)withmoderateamblyopia(20/40-20/80)wererandomizedtoreceive2hoursofdailypatchingoraBangerterfilter(blurtoBVAinamblyopiceye)overthespectaclelensofthesoundeyeandfollowedevery6weeksfor24weeks.
• AverageVAimprovement:o Bangertergroup: 1.9lineso Patchinggroup: 2.3lines
• Percentageofpatientswith3ormorelinesofVAimprovement:o Bangertergroup: 38%o Patchinggroup: 35%
• Percentageofpatientswith20/25VAorbetterinamblyopiceyeacuityo Bangertergroup: 36%o Patchinggroup: 31%,
• TherewasalowertreatmentburdenintheBangertergroup
ClinicalPearlsATS-9
• Treatmentwithatropineorpatchingledtosimilardegreesofimprovementamong7-to<13year-oldswithmoderateamblyopia
• ~20%achievedVAof20/25orbetterintheamblyopiceye
ClinicalPearlsATS-10
• WithasmallaveragedifferenceinVAimprovementbetweenpatchingandBangerterfiltersandlowertreatmentburden,Bangerterfiltertreatmentisareasonabletreatmentoptionforpatientswithmoderateamblyopia.
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ATS-13:HowmucheffectdoesspectaclecorrectionhaveonimprovingVAinpatientswithstrabismicorcombinedmechanismamblyopia?[34]
• 146children(3to<7yearsold)withpreviouslyuntreatedstrabismic(S)amblyopia(n=52)orcombined-mechanism(CM)amblyopia(n=94)weretreatedwithspectaclelensesonly
• AverageVAimprovement: 2.6lineso S: 3.2lineso CM: 2.3lines
• VAimprovementof≥2lines: 75%• VAimprovementof≥3lines: 54%• Resolutionofamblyopia: 32%
ATS-15:InpatientswhoseVAplateauedwhenpatchingasperATS-2BhavefurtherimprovedVAifpatchingtimeisincreased?[35]
• 169children(3to<8years)withstableresidualamblyopia(20/32-20/160)after2hoursofdailypatchingforatleast12weekswererandomizedtoeithercontinue2hoursofdailypatchingorincreasepatchingtimetoanaverageof6hours/day.
• AverageVAimprovement:o 2-hourgroup: 0.6lineso 6-hourgroup: 1.2lines
• Percentageofpatientswith2ormorelinesofVAimprovement:o 2-hourgroup: 40%o 6-hourgroup: 18%
ClinicalPearlsATS-13
• OpticaltreatmentaloneofSandCMamblyopiaresultsinclinicallysignificantimprovementinamblyopiceyeVA
• Amblyopiawillresolvein~33%ofpatientswithSorCMamblyopiawithspectaclesalone• Spectaclecorrectionaloneshouldbestronglyconsideredastheinitialtreatmentfor
patientswithS/orCMamblyopia
ClinicalPearlsATS-15
• WhenamblyopiceyeVAstopsimprovingwith2hoursofdailypatching,considerincreasingthedailypatchingdosageto6hours
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Bibliography
[1] L.D.S.A.CiuffredaKJ,Amblyopia,Boston:Butterworth-Heinemann,1991.
[2] K.P.KeechRV,"Upperagelimitforthedevelopmentofamblyopia,"JPediatrOphthalmolStrab,vol.32,p.89,1995.
[3] B.H.FlomMC,"Identifyingamblyopiausingassociatedconditions,acuity,andnonacuityfactors,"AmJOptomPhysiolOpt,vol.62,p.153,1985.
[4] ConsensusPanelOnAmblyopia,"CareofthePatientwithAmblyopia,"AmericanOptometricAssociation,2004.[Online].Available:https://www.aoa.org/documents/optometrists/CPG-4.pdf.[Accessed11December2017].
[5] B.S.AndersonRL,"Amblyopiainptosis,"ArchOphthalmol,vol.98,pp.1068-9,1980.
[6] G.C.C.J.HarradRA,"Amblyopiaandstrabismusincongenitalptosis,"Eye,vol.2,pp.625-7,1988.
[7] H.HH,"Occlusionamblyopia:reportofacase,"ArchOphthalmol,vol.62,pp.314-6,1959.
[8] v.N.GK,"Amblyopiacausedbyunilateralatropinization,"Ophthalmology,vol.88,pp.131-3,1981.
[9] F.KD,"Visualacuityoutcomeinisometropichyperopia,"OptomVisSci,Vols.649-58,p.66,1989.
[10]S.M,Amblyopia,Philadelphia:Chilton,1971.
[11]G.D.TanlamaiT,"Prevalenceofmonocularamblyopiaamonganisometropes,"AmJOptomPhysiolOpt,vol.56,pp.704-15,1979.
[12]I.RM,"Refractionasabasisforscreeningchildrenforsquintandamblyopia,"BrJOphthalmol,vol.61,pp.8-15,1977.
[13]F.M.BedellHE,"Monocularspatialdistortioninstrabismicamblyopia,"InvestOphthalmolVisSci,vol.20,pp.263-8,1981.
[14]G.I.BrockFW,"Fixationanomaliesinamblyopia,"ArchOphthalmol,vol.47,pp.775-86,1952.
[15]W.A.B.A.HilesDA,"Characteristicsofinfantileesotropiafollowingearlybimedialrectusrecession,"Archophthalmol,vol.98,pp.697-703,1980.
[16]M.N.C.A.G.W.HotchkissMG,"BilateralDuane'sRetractionSyndromeAClinical-PathologicCaseReport,"ArchOphthalmol,vol.98,pp.870-4,1980.
[17]D.TD,ClinicalOphthalmology.PediatricOphthalmicSurgery.Vol.6,Philadelphia:LippincottWilliams&Wilkins,1994.
AmblyopiaUpdateforthePrimaryCareOD2018
14|P a g e w w w . E y e C o d e B l o g . c o m
[18]H.D.E.E.AndrewsCV,"DuaneSyndrome.GeneReviews,"19March2015.[Online].Available:http://www.ncbi.nlm.nih.gov/books/NBK1190/..[Accessed13December2017].
[19]AmericanAcadomyofOphthalmology,"Exotropia,"[Online].Available:http://eyewiki.aao.org/Exotropia#Congenital_exotropia.[Accessed19December2017].
[20]X.Y.L.Y.LouDH,"Sensoryexotropiasubsequenttosenilecataract,"JZhejiangUnivSciB,vol.6,no.12,pp.1220-2,2005.
[21]AmericanOptometricAssociation,"CPG-4:TheCareofaPatientwithAmblyopia,"[Online].Available:https://www.aoa.org/documents/optometrists/CPG-4.pdf.[Accessed20Decmember2017].
[22]P.E.D.I.Group,"Arandomizedtrialofatropinevspatchingfortreatmentofmoderateamblyopiainchildren,"ArchOphthalmol,vol.120,pp.268-78,2002.
[23]P.E.D.I.Group,"Arandomizedtrialofpatchingregimensfortreatmentofsevereamblyopiainchildren,"Ophthalmology,vol.110,pp.2075-87,2003.
[24]P.E.D.I.Group,"Arandomizedtrialofpatchingregimensfortreatmentofmoderateamblyopiainchildren,"ArchOphthalmol,vol.121,pp.603-11,2003.
[25]P.E.D.I.Group,"Riskofamblyopiarecurrenceaftercessationoftreatment,"JAAPOS,vol.8,pp.420-8,2004.
[26]P.E.D.I.Group,"Randomizedtrialoftreatmentofamblyopiainchildrenaged7to17years,"ArchOphthalmol,vol.123,pp.437-47,2005.
[27]P.E.D.I.Group,"Arandomizedtrialofatropineregimensfortreatmentofmoderateamblyopiainchildren,"Ophthalmology,vol.111,pp.2076-85,2004.
[28]P.E.D.I.Group,"Treatmentofanisometropicamblyopiainchildrenwithrefractivecorrection,"Ophthalmology,vol.113,pp.895-903,2006.
[29]P.E.D.I.Group,"Arandomizedtrialofnearversusdistanceactivitieswhilepatchingforamblyopiainchildrenaged3tolessthan7years,"Ophthalmology,vol.115,pp.2071-8,2008.
[30]P.E.D.I.Group,"Treatmentofbilateralrefractiveamblyopiainchildrenthreetolessthan10yearsofage,"AmJOphthalmol,vol.144,pp.487-96,2007.
[31]P.E.D.I.Group,"Pharmacologicalplusopticalpenalizationtreatmentforamblyopia:resultsofarandomizedtrial,"ArchOphthalmology,vol.127,pp.22-30,2009.
[32]P.E.D.I.Group,"Patchingvsatropinetotreatamblyopiainchildrenaged7to12years:arandomizedtrial,"ArchOphthalmol,vol.126,pp.1634-42,2008.
AmblyopiaUpdateforthePrimaryCareOD2018
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[33]P.E.D.I.Group,"ArandomizedtrialcomparingBangerterfiltersandpatchingforthetreatmentofmoderateamblyopiainchildren,"Ophthalmology,vol.117,no.5,pp.998-1004,2010.
[34]P.E.D.I.Group,"Opticaltreatmentofstrabismicandcombinedstrabismic-anisometropicamblyopia,"Ophthalmology,vol.119,pp.150-8,Jan2012.
[35]P.E.D.I.Group,"Arandomizedtrialofincreasingpatchingforamblyopia,"Ophthalmology,vol.120,no.11,pp.2270-7,2013.
[36]G.M.R.M.MerleH,"Isolatedmedialorbitalblow-out,"ActaOphthalmolScand,vol.76,pp.378-9,1998.
[37]L.V.P.W.O.M.O'TooleL,"Traumaticruptureofthelateralrectus,"Eye,vol.18,pp.221-2,2004.
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