Dx Amblyopia WE CAN WIPE OUT AMBLYOPIA IN OUR LIFETIMES

OVERVIEW Amblyopia Characteristics/TherapyAmblyopia Characteristics/Therapy Most Clinico-Legal Problems for ODs Infantile Esotropia-A CaseInfantile Esotropia-A Case The Infant Examination SequenceThe Infant Examination Sequence Infantile Esotropia CharacteristicsInfantile Esotropia Characteristics Infantile Esotropia TherapyInfantile Esotropia Therapy The Older EsotropeThe Older Esotrope Exotropia: Congenital & FunctionalExotropia: Congenital & Functional

AMBLYOPIA Caused by Anisometropia and Strabismus and what most eye care practitioners are interested in treating Rule Out Pathology

Ocular and Neurologic Disease Masquerading as Functional Vision Disorders AmblyopiaAmblyopia StrabismusStrabismus Brain Tumors: Bitemporal Field Loss Vascular Accidents Ocular and/or Visual Pathway Diseases

Amblyopia Amblyopia: A Diagnosis of Exclusion. Make sure there is no pathology first.Amblyopia: A Diagnosis of Exclusion. Make sure there is no pathology first. Amblyopia may improve with vision therapy even with pathologyAmblyopia may improve with vision therapy even with pathology Always do visual fields of both eyes of amblyopes (color and neutral density)Always do visual fields of both eyes of amblyopes (color and neutral density) Must have 1. Anisometropia, 2. Constant Unilateral Strabismus, 3. ^ Bilateral RE, 4. Deprivation HxMust have 1. Anisometropia, 2. Constant Unilateral Strabismus, 3. ^ Bilateral RE, 4. Deprivation Hx

Bilateral Amblyopia-Careful Bilateral Retinal Schisis--X-LinkedBilateral Retinal Schisis--X-Linked ElectrodiagnosticsElectrodiagnostics ERG Electroretinogram VEP Visual Evoked Potential Pictures X RaysX Rays CT ScansCT Scans MRIsMRIs OCTOCT

Amblyopia Differential Dx Block-Line-Letter VA s: Better with lettersBlock-Line-Letter VA s: Better with letters Contrast Typically not impacted in Amblyopia Psychometric VA s: Sigmoid CurvePsychometric VA s: Sigmoid Curve Neutral Density Filters: Devastates VANeutral Density Filters: Devastates VA Macular Integrity Tester: No BrushMacular Integrity Tester: No Brush Magnification: 2.5 Telescope really improves VA beyond what is expectedMagnification: 2.5 Telescope really improves VA beyond what is expected Color Vision: NormalColor Vision: Normal Normal Amsler Grid and ElectrodiagnosticsNormal Amsler Grid and Electrodiagnostics

Special Visual Acuity Charts Psychometric ChartPsychometric Chart Flom Chart Cs Wesson-Davidson Chart Es Bailey-Lovie log MARBailey-Lovie log MAR Relative = Separation High and Low Contrast Contrast SensitivityContrast Sensitivity LEALEA B-VATB-VAT

Amblyopia and VA Acuity improves with isolated lettersAcuity improves with isolated letters First and last letter seen more oftenFirst and last letter seen more often Letters read out of orderLetters read out of order Letters change as chart is viewedLetters change as chart is viewed Chart appears gray, dim or poor qualityChart appears gray, dim or poor quality Refraction: Better but I just cannot read itRefraction: Better but I just cannot read it LARGE JNDsLARGE JNDs

Amblyopia 2.5% of population2.5% of population A problem of binocularityA problem of binocularity Fixation--BinocularityFixation--Binocularity Anisometropia Constant Unilateral Strabismus

Amblyopia Timelines Critical Period: Birth to 6 moTreat now Blind-NystagmusCritical Period: Birth to 6 moTreat now Blind-Nystagmus Treat PathologyFixate with each eye Sensitive Period: 6 mo to 8 yr. Treat Visually ImpairedSensitive Period: 6 mo to 8 yr. Treat Visually Impaired Susceptible Period: 8 to 18 yr.Treat if compliantmay returnSusceptible Period: 8 to 18 yr.Treat if compliantmay return Residual Plasticity Period: 18 yr.> not likely (Lee R. Adult Amblyope: JBO 12/99 pp115- 131)Residual Plasticity Period: 18 yr.> not likely (Lee R. Adult Amblyope: JBO 12/99 pp115- 131)

Amblyopia is Developmental & A BINOCULAR Dx Not just a reduction in VA but in total visionNot just a reduction in VA but in total vision Poor Eye MovementsPoor Eye Movements Poor AccommodationPoor Accommodation Poor Spatio-Temporal IntegrationTrouble judging distances and lengthsCrowdingPoor Spatio-Temporal IntegrationTrouble judging distances and lengthsCrowding Requires more than just patching

Clinical Classification of Amblyopia Organic (Organic)Organic (Organic) Form Deprivation (Structural)Form Deprivation (Structural) Strabismus (Spatial Conflict)Strabismus (Spatial Conflict) RefractiveRefractive Isometropic and Anisometropic PsychogenicPsychogenic Voluntary (Malingering) Involuntary: Hysterical and Streffs Syndrome

Amblyopic Clinical Pearls Problems within 1st 6 months most dangerous---Congenital Cataracts-CriticalProblems within 1st 6 months most dangerous---Congenital Cataracts-Critical Early dense cataracts-a true critical intervention Late onset not as severe-Sensitive-Can be amblyopic up to about 8 yearsLate onset not as severe-Sensitive-Can be amblyopic up to about 8 years Treatment at any time but less certain outcomes-Requires a motivated patientTreatment at any time but less certain outcomes-Requires a motivated patient

Streffs Bilateral Juvenile Amblyopia Refracts: -.5 to +1D+ may helpRefracts: -.5 to +1D+ may help VA Far: 20/25 to 20/400Walk around +VA Far: 20/25 to 20/400Walk around + VA Near: Worse than Far^ c +VA Near: Worse than Far^ c + Habitual RD: 10 in or less/Peers+ moves RD outHabitual RD: 10 in or less/Peers+ moves RD out Dynamic Ret: Dull reflexes and increased lag + improves reflexesDynamic Ret: Dull reflexes and increased lag + improves reflexes Fixation: Unstable central + ^ stabilityFixation: Unstable central + ^ stability

Streffs Bilateral Juvenile Amblyopia Pursuit: Refixations + improvesPursuit: Refixations + improves Pen in Cap: Misses + improvesPen in Cap: Misses + improves Yoked ^: Base preferredYoked ^: Base preferred Ball Catching: + improves timingBall Catching: + improves timing VO Star: Poor Centration + improvesVO Star: Poor Centration + improves History: High achiever, females, around puberty, at exam time, holidays and springHistory: High achiever, females, around puberty, at exam time, holidays and spring

Streffs Syndrome in Animals

Tx Amblyopia

Amblyopia Efficacy of VTx.1 S ignificance at 16+ for 4 lines Birnbaum et al. JAAO May 77

Congenital esotropia vs. amblyopia: surgery or none Helveston, EM. Origins of congential esotropia. J Ped Ophthalmol Strab 1993;30:215-232

Treatment of Amblyopia Isometropic: >-5D eventual full Rx but in steps. Consider underminus>+ 2D Temper Rx by age, amount, in steps, keep symmetricalThink in terms of keeping 2D of hyperopia uncorrected... Cylinder >1.25 Temper Rx as with +symmetrical and lowalways trial framePROBE LENS TESTINGIsometropic: >-5D eventual full Rx but in steps. Consider underminus>+ 2D Temper Rx by age, amount, in steps, keep symmetricalThink in terms of keeping 2D of hyperopia uncorrected... Cylinder >1.25 Temper Rx as with +symmetrical and lowalways trial framePROBE LENS TESTING

Amblyopia Anisometropia: >-2D or +1D consider CL (depending on the age and responses) Anisometropia: >-2D or +1D consider CL (depending on the age and responses) Eventual full Rx may be much more balancedEventual full Rx may be much more balanced MOST ANSIO AMBLYOPIA from + > 1MOST ANSIO AMBLYOPIA from + > 1 Keep symmetrical and spherical equivalentsKeep symmetrical and spherical equivalents Keep Rxs Small and SimpleKeep Rxs Small and Simple

Occlusion Full Time Direct OcclusionFull Time Direct Occlusion 1 day for each year of life and no patch the other day for the anisometropic amblyope For the strabismic amblyope indirectly patch the other eye for one day Partial OcclusionPartial Occlusion Bi-Nasal Occlusion Patch for hours rather than days

Treatment Modalities for Amblyopia Patching verses PenalizationPatching verses Penalization Big advantage of Penalization-it can be doneBig advantage of Penalization-it can be done Binocularity is not destroyedBinocularity is not destroyed PenalizationPenalization Bangerter Foils Fingernail Polish Scotch Tape Extra Plus Meds

Penalization FoilsFoils Colored Filters (Mono in Binocular Field)Colored Filters (Mono in Binocular Field) Wesson MethodWesson Method Extra PlusExtra Plus Clear Finger Nail PaintClear Finger Nail Paint CycloplegiaCycloplegia Bi-Nasal OcclusionBi-Nasal Occlusion Bi-Temporal OcclusionBi-Temporal Occlusion AtropineAtropine

Rxs for the older Amblyope and Esotrope Always try to balance RxAlways try to balance Rx Use minimal Rx to plateau VAUse minimal Rx to plateau VA Use minimal Rx to plateau Angle of turnUse minimal Rx to plateau Angle of turn Hold off Rxing lenses until some VT has been attempted (weeks)Hold off Rxing lenses until some VT has been attempted (weeks) Plan to titrate UP + on esotropes and anisometropesPlan to titrate UP + on esotropes and anisometropes

Contact Lenses and Amblyopia Knapps Law: Predicts image size based upon length of the eye--spectacles more appropriateKnapps Law: Predicts image size based upon length of the eye--spectacles more appropriate Think CL even with Knapps LawThink CL even with Knapps Law More likely to wear than odd glasses better image quality No prismatic or Centration problems

Amblyopia Therapy: Press Refractive AmblyopiaRefractive Amblyopia Normally responds quicker than strabismus Passive Suppression Binocular integration present Less occlusion time needed Loss of resolution - little spatial distortion Knows where and how far the target is Like looking in smoked glass or cellophane

Amblyopia Therapy Strabismic AmblyopiaStrabismic Amblyopia Loss of resolution and spatial confusion Takes more time Must develop central fixation first Active suppression Poor performance

Summarized Early Phases -Tx RxRx Monocular activitiesMonocular activities Patching/Penalization Accommodation Ocular Motility Form Recognition (Modified Updegrave) Perceptual Discrimination (Size, Shape, Feely Meely, etc)

Later Phases Tx Amblyopia Monocular Fixation in a Binocular FieldMonocular Fixation in a Binocular Field Biocular TherapyBiocular Therapy Binocular TherapyBinocular Therapy Intersensory IntegrationIntersensory Integration

Monocular Therapy Press Recommends 3 LevelsPress Recommends 3 Levels Gross Motor (Use Sparingly with Patching) Balance BoardBalance Board Walking RailWalking Rail Oculomotor Accommodative

Monocular Therapy OculomotorOculomotor Hart Chart saccades Michigan tracking Pointer in Straw Monocular Prism Jumps Geo Boards, Groffman tracing AN Pointing Line Counting Perceptuomotor Pen MIT

Monocular therapy AccommodativeAccommodative Near Far Hart Charts Free Space Push Up Loose Lens Rock Sequential Minus (JNDs) Minus Lens and Marsden Ball

Mono Tx Perceptual Discrim Hidden PicturesHidden Pictures Similarities and DifferencesSimilarities and Differences Monocular Contour Interaction (Back off and read letters/numbers)Monocular Contour Interaction (Back off and read letters/numbers) Random Count All of certain # or letters (Michigan Tracking)Random Count All of certain # or letters (Michigan Tracking) TachistoscopeTachistoscope Form Tracing with Crowding -Kedzia CardForm Tracing with Crowding -Kedzia Card Visual Search Sequential # find correct oneVisual Search Sequential # find correct one Space Matching Distance to ChalkboardSpace Matching Distance to Chalkboard

Monocular Tx in Binocular Field Anaglyphic TV Trainer (Projected Light)Anaglyphic TV Trainer (Projected Light) Sherman VT Playing Cards (1/2 Cards)Sherman VT Playing Cards (1/2 Cards) Lens rock with single Vectogram VA (corresponding to amblyopic eye)Lens rock with single Vectogram VA (corresponding to amblyopic eye) Quoits Clown/Spirangle Wayne Fixator and AnaglyphWayne Fixator and Anaglyph Anaglyphic TracingAnaglyphic Tracing Haidinger Brush/MITHaidinger Brush/MIT Kedzia CardsKedzia Cards

WHY DO VT ON AMBLYOPES: If Patching gives good VA Krumholtz & FitzGerald. Efficacy of treatment modalities in refractive amblyopia. J AOA 1999; 70: 399-404Krumholtz & FitzGerald. Efficacy of treatment modalities in refractive amblyopia. J AOA 1999; 70: 399-404 VAs the same with Patching &full Rx or Patching, full Rx&VT (2 line & 20 ArcSec)VAs the same with Patching &full Rx or Patching, full Rx&VT (2 line & 20 ArcSec) Both Patching and Patching VT group better than Optical Correction aloneBoth Patching and Patching VT group better than Optical Correction alone ONLY VT GROUP HAD BETTER STEREOONLY VT GROUP HAD BETTER STEREO

Efficacy of Tx on Amblyopia Krumholtz I, FitzGerald D. Efficacy of treatment modalities in refractive amblyopia J am Optom Assoc 1999; 70: 399-404 Compare (6 mo) Rx; Rx & Patch; Rx/VT N=78Compare (6 mo) Rx; Rx & Patch; Rx/VT N=78 2 Line and 20 sec increase; the criterion2 Line and 20 sec increase; the criterion Patch and VT have similar VAsPatch and VT have similar VAs VT shows significantly greater stereoVT shows significantly greater stereo Conclusion:Patching aloneimprovement of visual acuity, binocular performance is significantly better when vision therapy is included in the treatment regimen.Conclusion:Patching aloneimprovement of visual acuity, binocular performance is significantly better when vision therapy is included in the treatment regimen.

FitzGerald: Amblyopia Krumholtz I, FitzGerald D. Efficacy of treatment modalities in refractive amblyopia. J Am Optom Assoc 1999;70:399-404 Amblyopia from Refractive (Aniso)Amblyopia from Refractive (Aniso) 2 lines & 20arcsec Improvement2 lines & 20arcsec Improvement TxTx Do Nothing Rx Rx + Patch and Eye Hand Rx + Patch and Eye Hand and VTx RetrospectiveRetrospective 4 to 6 weeks after 2 to 4 months 6 months to 12 months Note in all Tx: Some make dramatic improvement and some never move Patch and VTx are the Same for Amblyopia TxPatch and VTx are the Same for Amblyopia Tx Rx alone was not as effectiveRx alone was not as effective

FitzGerald: Amblyopia VA &Stereo Krumholtz I, FitzGerald D. Efficacy of treatment modalities in refractive amblyopia. J Am Optom Assoc 1999;70:399-404 & S Optical Correction Alone 41% VA and 18% StereoOptical Correction Alone 41% VA and 18% Stereo Optical Correction and Patch 69% VA and 30% StereoOptical Correction and Patch 69% VA and 30% Stereo Optical Correction; Patch and VTx 67% and 67%Optical Correction; Patch and VTx 67% and 67%

FitzGerald: % Improvement Refractive Amblyopia VA & Stereo Krumholtz I, FitzGerald D. Efficacy of treatment modalities in refractive amblyopia. J Am Optom Assoc 1999;70:399-404

FitzGerald: Refractive Amblyopia FitzGerald DE, Krumholtz I. Maintenance of improvement gains in refractive amblyopia: a comparison of treatment modalities. Optometry 2002; 73: 153-9. Maintenance of Visual Acuity Gains over Time (From 1 to 2 years)Maintenance of Visual Acuity Gains over Time (From 1 to 2 years) Optical Correction 50% Optical Correction & Patching with Eye Hand Activities 60% Optical Correction & Patching with Eye Hand Activities and Vision Therapy 100% 94% of those who maintained their VAs maintained their stereo

FitzGerald: Refractive Amblyopia FitzGerald DE, Krumholtz I. Maintenance of improvement gains in refractive amblyopia: a comparison of treatment modalities. Optometry 2002; 73: 153-9.

Rx, Rx & Patch, Rx & VT Krumholtz, FitzGerald 1999

Maintenance of Gains Amblyopia FitzGerald DE, Krumholtz I. Maintenance of improvement gains in refractive amblyopia:Optometry 2002; 73: 153-9. Records of 6 month study retrospectively at 1 to 2 years to see if gains are holdingRecords of 6 month study retrospectively at 1 to 2 years to see if gains are holding Holding Gains: N=23Holding Gains: N=23 50% with Rx 60% with Rx and Patching 100% with Rx and VT Oldest age held the bestOldest age held the best

VA Gains over Time for Amblyopia (of those improved) FitzGerald & Krumholtz 2002

VA Gains over Time for Amblyopia (of those improved)

Amblyopia Tx and Compliance (N=52) 3 mo Occlusion, previous failure in VA improvement MinsAmblyopia Moo & Ko.Proc 8 Japan-Korea Ophthal 1996

Summary: Amblyopia Tx Consider a modified RxConsider a modified Rx Consider some type of Patching/PenalizationConsider some type of Patching/Penalization Central and Stable FixationCentral and Stable Fixation Central Fixation and Monocular Tx Equality between eyesEquality between eyes Monocular Tx Monocular training in a binocular fieldMonocular training in a binocular field Biocular Tx Suppression TherapySuppression Therapy Biocular Tx Binocular integrationBinocular integration Binocular Therapy

Infantile Esotropia

1st Case: Subjective 19 mo White Female19 mo White Female Esotropia from 6 monthsEsotropia from 6 months Full Term Pregnancy: No problems with pregnancy or birth-First ChildFull Term Pregnancy: No problems with pregnancy or birth-First Child Crawled at 6 monthsCrawled at 6 months Walked at 10 monthsWalked at 10 months Threw tantrums and wanted things her way when tiredThrew tantrums and wanted things her way when tired

1st Case: Subjective Continued O-MD exam at 6 monthsO-MD exam at 6 months Healthy EyesHealthy Eyes Congenital EsotropiaCongenital Esotropia Cycloplegic Rx dispensed (+2.25D sph OU) and told to return in 6 months if not straight surgery would be suggestedCycloplegic Rx dispensed (+2.25D sph OU) and told to return in 6 months if not straight surgery would be suggested

1st Case: Objective Hyperactive ChildHyperactive Child Present RX +2.25Present RX +2.25 Retinoscope at far +1.50Retinoscope at far +1.50 EOMs full--OS less accurateEOMs full--OS less accurate Head MovementHead Movement Uncoordinated Visual Motor Patterns (Body)Uncoordinated Visual Motor Patterns (Body) Eyes HealthyEyes Healthy

1st Case: Assessment Infantile Esotropia OS with Hyperopia

1st Case: Plan LensesLenses Home Vision TherapyHome Vision Therapy 2/week Later 1/week as a progress examinationLater 1/week as a progress examination

1st Case: Education No GuaranteesNo Guarantees Goal:Goal: Straight Eyes Diminish the Rx if Possible

1st Case: Initial Tx Periodic Patching (short periods of time-more OD than OS)Periodic Patching (short periods of time-more OD than OS) Movement Patterns of Head, Neck and BodyMovement Patterns of Head, Neck and Body Prone Neck Rotations Dry Land Swimming Crawling Bright Objects---Cross Patterning--VT depends on motivation (Time at Task)Bright Objects---Cross Patterning--VT depends on motivation (Time at Task) Sleep Patterns

1st Case: Early Progress Exams 2 Weeks: Change Rx to +1.50 c +0.75 add2 Weeks: Change Rx to +1.50 c +0.75 add Mother reports eyes are straighter 6 Weeks: Change +1.50D with Bi-Nasals6 Weeks: Change +1.50D with Bi-Nasals Mother reports steady improvement of eyes-eyes are straighter longer 9 Weeks: Change Rx to +0.75 c +0.75 Add9 Weeks: Change Rx to +0.75 c +0.75 Add 14 Week: Change Rx to +0.75 and released without bi- nasal occlusion14 Week: Change Rx to +0.75 and released without bi- nasal occlusion

1st Case: Later Progress Exams 1 month post release:1 month post release: Goes without lenses Eye does not turn normally Turns if tired or excitedTurns if tired or excited 3 months post release:3 months post release: Eyes seldom turn Seldom wears Rx

Long Term Follow Up All State BasketballAll State Basketball All State TennisAll State Tennis Full scholarship Southern Miss: TennisFull scholarship Southern Miss: Tennis Real Estate Agent/Broker Gulfport/WigginsReal Estate Agent/Broker Gulfport/Wiggins 34 years of Age34 years of Age Mother of 2Mother of 2

Strabismus Infantile-(within 6 months of age) 1-2% of populationInfantile-(within 6 months of age) 1-2% of population Accommodative esotropia (typically 2 to 3 years) seen in 2-2.5% of populationAccommodative esotropia (typically 2 to 3 years) seen in 2-2.5% of population Most common-Pseudo-esotropia--Most common-Pseudo-esotropia-- Provide ReassuranceProvide Reassurance It is good to photo-document the Pseudo-esotropia (Epicanthal Folds)It is good to photo-document the Pseudo-esotropia (Epicanthal Folds)

Tropia at Birth Hainline etal Chap 15 Simon Early Visual Development Normal and Abnormal Oxford Press 1993

Visual Acuities Follows light and or bright objectFollows light and or bright object Will reach for a candy beadWill reach for a candy bead Optokinetic Nystagmus-Temporal/NasalOptokinetic Nystagmus-Temporal/Nasal Preferential LookingPreferential Looking Cereal CardCereal Card Broken WheelBroken Wheel LeaLea

Pathologies PUPILS and MOTILITIESPUPILS and MOTILITIES Around the eyeAround the eye Anterior SegmentAnterior Segment Posterior SegmentPosterior Segment Ophthalmoscopy should always be last!Ophthalmoscopy should always be last!

Refractive Error Bruckner (Also Alignment)Bruckner (Also Alignment) PhotorefractionPhotorefraction Mohindras RetinoscopyMohindras Retinoscopy CartoonsCartoons Nearpoint RetinoscopyNearpoint Retinoscopy CycloplegicCycloplegic

Lens Prescription: Very ConservativeVery Conservative Develop Fixation in Each Eye for Anisometropia, Amblyopia and EmmetropizationDevelop Fixation in Each Eye for Anisometropia, Amblyopia and Emmetropization Prescribe Equal Minimal SpheresPrescribe Equal Minimal Spheres Titrate Up or Down the Rx Bi-MonthlyTitrate Up or Down the Rx Bi-Monthly WHEN IN DOUBT, ASK FOR HELP FROM YOUR PEDIATRIC O. D.WHEN IN DOUBT, ASK FOR HELP FROM YOUR PEDIATRIC O. D. Smith et al. UH Refractive Errors

Ocular Motilities Parent Moves BabyParent Moves Baby Horizontal, Down, Up, Rotational Bright ObjectBright Object Black and White Early in Life-Later Colors Noisy Object Noisy Object Bright and Noisy ObjectBright and Noisy Object Broad HBroad H

Binocularity No child is binocular at birthNo child is binocular at birth ???Congenital Esotropia??????Congenital Esotropia??? Convergence indicates both Cortical Fusion and StereopsisConvergence indicates both Cortical Fusion and Stereopsis Critical Periods???Maybe not as Critical???Critical Periods???Maybe not as Critical???

Must Reading Helveston E. 19th Annual Costenbader Lecture on Congenital Esotropia. J Ped Opthtalmol Strab 1993 215-232.Helveston E. 19th Annual Costenbader Lecture on Congenital Esotropia. J Ped Opthtalmol Strab 1993 215-232. Thorn F, et.al. The development of alignment, convergence and sensory binocularity. Invest Ophthalmol Vis Sci 1994 544-553.Thorn F, et.al. The development of alignment, convergence and sensory binocularity. Invest Ophthalmol Vis Sci 1994 544-553.

Developmental Milestones Ocular Motilities Present at 12 weeksOcular Motilities Present at 12 weeks Visual MotorVisual Motor Eye-Hand Coordination Denver Developmental ScreeningDenver Developmental Screening Developmental Clusters Gross MotorGross Motor Fine MotorFine Motor SocialSocial LanguageLanguage

Visual Expecteds At 6 Months VA 20/80 to 20/200VA 20/80 to 20/200 Retinoscopy: Pl to +1.25 Highly VariableRetinoscopy: Pl to +1.25 Highly Variable Pupils Normal and ReactivePupils Normal and Reactive Alignment AlwaysAlignment Always Follows Moving Target in Sitting PositionFollows Moving Target in Sitting Position NPC to the NoseNPC to the Nose No Internal or External PathologiesNo Internal or External Pathologies

Conclusions Assure that Child is Developing CorrectlyAssure that Child is Developing Correctly No PathologyNo Pathology No Amblyopic PredispositionsNo Amblyopic Predispositions No High Refractive SituationsNo High Refractive Situations No Abnormal Binocular DevelopmentsNo Abnormal Binocular Developments No Abnormal Ocular Motor FunctionsNo Abnormal Ocular Motor Functions WHEN IN DOUBT, CALL A FRIEND YOUR PEDIATRIC OPTOMETRISTWHEN IN DOUBT, CALL A FRIEND YOUR PEDIATRIC OPTOMETRIST

Esotropia & Child Development What is normal at birth? AndWhat is normal at birth? And What should one expect as the child grows and matures? AndWhat should one expect as the child grows and matures? And What should be done if one sees that the child is not growing/maturing as it should?What should be done if one sees that the child is not growing/maturing as it should?

Esotropia: Characteristics Esotropia: Characteristics A high incidence in the first yearA high incidence in the first year An increase in incidence in the 2 to 3 year rangeAn increase in incidence in the 2 to 3 year range great majority of esotropia is present by school agegreat majority of esotropia is present by school age Esotropia presenting after school age is very likely to be non-functionalEsotropia presenting after school age is very likely to be non-functional

Incidence of Esotropia: Keiner

Prevalence of Esotropia: Keiner

Prevalence of Esotropia: Scobee

Incidence of Infantile Esotropia by Correlation Wt

Documents

Dx Amblyopia WE CAN WIPE OUT AMBLYOPIA IN OUR LIFETIMES