Highlights & Basics
- Amblyopia is a visual impairment resulting from abnormal visual stimulation during early childhood, the prevalence of which ranges from 1% to 4%.
- Can result from strabismus, form deprivation (e.g., due to congenital cataracts or corneal opacities), and various types of refractive errors. These errors include anisometropia (unequal refractive error between the two eyes), isoametropia (high but similar refractive error in the two eyes), and high astigmatism in one or both eyes.
- Amblyopia due to strabismus with or without refractive error is commonly treated with initial optical correction, and subsequent patching or atropine penalization of the better-seeing eye. Amblyopia due to refractive error alone frequently responds to optical correction alone.
- Amblyopia due to form deprivation is treated initially with early surgery, to remove the visual obstruction. In unilateral or asymmetric cases, patching of the better-seeing eye is necessary after surgery.
- Treatment is highly successful when instituted during the infantile and preschool years, although some children as old as 13-17 years respond to treatment, particularly if there has been no prior therapy.
Quick Reference
History & Exam
Key Factors
infant not tracking parent's face
abnormal red reflex
Other Factors
asymptomatic
subnormal visual acuity for age in one or both eyes
asymmetric corneal light reflex
unequal behavioral response to alternate eye occlusion
abnormal cover/uncover testing
blurred vision
eye strain
congenital nystagmus
abnormal pupil exam
abnormal external eye exam
Diagnostics Tests
1st Tests to Order
visual acuity tests (by specialist)
stereopsis (perception of depth or 3-dimensionality) and binocular vision testing
assessment of fixation, ocular alignment and ocular motility
anterior segment exam using a slit lamp
dilated fundoscopy
cycloplegic retinoscopy
binocular red reflex test (Brückner test)
Emerging Tests
visual evoked potentials
Treatment Options
ongoing
without form-deprivation amblyopia
mild to moderate strabismic and/or mild to moderate anisometropic amblyopia
severe strabismic and/or severe anisometropic amblyopia
bilateral ametropic amblyopia
form-deprivation amblyopia
form-deprivation amblyopia
concurrent nonform-deprivation amblyopia
Definition
Classifications
Types according to etiology
- Strabismus (misalignment of the eyes) results in amblyopia if the child prefers to fixate with one eye instead of freely alternating fixation between two eyes.
- The nonfixating eye (or deviated eye) is suppressed as an adaptive mechanism to avoid double vision.
- Prolonged suppression during early childhood leads to amblyopia.
- Refractive errors defocus the retinal image and, if marked, can cause amblyopia.
- May occur with strabismus.
- Greater anisometropia or astigmatism increase the risk and severity.
- Subtypes include:
- Anisometropic amblyopia: caused by unequal refractive error between the two eyes. Most often develops in hyperopic (long-sighted) children who focus with the less hyperopic eye, leading to persistent blurring of the more hyperopic eye.
- Ametropic (isoametropic) amblyopia: caused by high and similar refractive errors in the two eyes. Both high hyperopia and high myopia (nearsightedness) can cause sufficient retinal image blur to induce amblyopia, but amblyopia occurs more commonly with high hyperopia.
- Meridional amblyopia: high astigmatism in one or both eyes causes blur of a retinal image in a particular meridian.
- Bilateral refractive (isoametropic) amblyopia: uncommon and results from the effect of bilateral blurred retinal images.
- This results from blurring of the retinal image caused by opacities in the cornea, anterior chamber, lens, vitreous, or retinal surface (e.g., macular hemorrhage).
- Deprivation can also occur due to severe ptosis or prolonged occlusion of one or both eyes.
- It is the least common cause, but is often the most severe and difficult to treat.
- This is a form of deprivation amblyopia that develops after therapeutic patching or pharmacologic cycloplegia of the nonamblyopic eye.
- Visual acuity usually returns to baseline without treatment.
- Different subtypes of amblyopia can coexist in the same patient (e.g., strabismic and hyperopic anisometropic amblyopia frequently co-occur).
- Some children with moderate to high hyperopia develop accommodative esotropia (inward turning of the eye). This is a type of strabismus resulting from the yoking of convergence and accommodation (which is necessary to focus the image in the hyperopic eye). If the hyperopia differs between the two eyes, it is generally the more highly hyperopic eye that turns in and develops amblyopia.
Vignette
Common Vignette 1
Common Vignette 2
Other Presentations
Epidemiology
Etiology
Pathophysiology
- Strabismus (misalignment of the eyes) is thought to result in amblyopia because of the competitive or inhibitory interaction between the cortical inputs from the two eyes. Cortical vision centers from the fixating eye dominate, and cortical vision centers from the nonfixating eye are chronically suppressed.[1]
- Anisometropia (unequal refractive error in the two eyes) causes the image on one retina to be chronically defocused. Amblyopia results from the direct effect of image blur on visual development. It also partly results from interocular competition (or inhibition) similar to that responsible for strabismic amblyopia.[1]
- Ametropia (both eyes are about equally defocused) causes no cortical competition or inhibition between the two eyes. Amblyopia results from image blur alone.[1]
- Corneal and/or lenticular astigmatism in a particular meridian may result in meridional amblyopia due to optical defocus. Amblyopia is partially due to loss of cells in the primary visual cortex with an orientation similar to the blurred meridian.[1]
- Occlusion of the visual axis or severe image blur caused by opacities in the visual axis may result in form-deprivation amblyopia. Unilateral occlusion is worse than bilateral occlusion of similar magnitude because interocular competition adds to the direct developmental impact of image degradation.[1]
Images
Snellen letters
Allen figures on card
Esotropia: left eye fixating (note decentered light reflection on right cornea)
Slit lamp
Author performing slit lamp exam
Portable slit lamp
Retinoscope with plus and minus spherical lenses for refraction
Indirect ophthalmoscope with 28 diopter lens for performing fundus exam
Author performing indirect ophthalmoscopy
Treatment of amblyopia with spectacles and patching
Diagnostic Approach
History
Primary care provider ocular assessment
- Infants 3 to 6 months of age: these infants may be more interested in fixing and following a face. Parents should confirm that the child can track their face at home when attentive and that the child has a social/responsive smile.
- Infants older than 6 months (preverbal): parents should confirm that the child can track their face at home when he or she is attentive. These children should also be able to fix and follow a small toy. To test, the infant must be cooperative and attentive to achieve a reliable response. Objects that make noise can be used to get the infant's attention, but sound cues should not be present during the assessment of the infant's ability to fix and follow. The fixation and following test, performed under monocular conditions, can be used until the child is verbal. The infant's behavioral response to alternate occlusion of each eye may also be assessed. The infant should object or not object equally in both eyes.
- Verbal children (more than about 3 years of age): most children can cooperate with visual acuity testing using an eye chart. The following eye charts are considered most accurate and acceptable by the World Health Organization: Sloan letters, Lea symbols, "H, O, T, V" letters, and the tumbling E chart.[1] [24] Snellen letters and Allen figures are not considered as accurate.[1][24] Children who do not know the letters can be tested with a number or picture chart, or taught the "H, O, T, V" letter chart. Shy children who do not want to speak aloud can play a matching game instead. Testing can be performed at 10 feet (3 meters) with appropriately sized targets, as children may be distracted performing a test at the recommended testing distance of 20 feet (6 meters). Most 3- or 4-year-old children can cooperate with visual acuity testing to 20/40, and 5-year-old children to 20/30. Patients should be tested under monocular conditions. In other words, each eye must be tested independently because a normal binocular visual acuity could miss complete blindness in one eye. Children frequently peek, so patches or special occlusive glasses are more reliable than hand-held occluders (a child's hand is perhaps the least effective occluder, as the child may peek between the fingers).Indications for referral to an ophthalmologist include:[24]
- Visual acuity in either eye worse than 20/50 in a 3-year-old
- Visual acuity in either eye worse than 20/40 in a 4-year-old to 5-year-old
- More than 2-line difference in visual acuity between the two eyes. (In practice, most pediatric ophthalmologists treat amblyopia as long as vision continues to improve, even if the magnitude of difference between the two eyes decreases to just one line or several letters on the eye chart.)Images
- Detecting a symmetric light reflex centered on the pupil in both eyes: a light is shone on the eyes from an arm's length away while the patient looks at a small toy held adjacent to the light. If the reflection of the light is symmetrically centered on the cornea in each eye, no manifest strabismus is present. If it is decentered in one eye, manifest strabismus is likely.Image
- Cover/uncover testing: a cooperative child can also undergo this test, which is a more reliable assessment of normal ocular alignment. While the child is fixating (staring) at an object, the examiner should cover one eye and look for a refixation movement of the uncovered eye. Then, the cover should be removed and placed over the other eye to again look for a refixation movement of the uncovered eye. A refixation movement in either eye indicates strabismus. Children with strabismus require referral to an ophthalmologist for further assessment. If the child constantly fixates with one eye, and the other eye remains deviated, the child has decreased vision in the deviated eye, which is often due to strabismic amblyopia. Strabismic children who alternate fixation between the two eyes and can maintain fixation through a blink with either eye probably do not have amblyopia.
Ophthalmology assessment
- Verbal children are best tested with multiple targets or with crowding bars around individual targets.[29] Some young children get distracted or confused when presented with multiple targets, like a series of pictures in a line or grid. An amblyopic eye sees better when an individual target is presented on a blank background than with other targets in the vicinity of the target of interest. Thus, measurements using individual targets overestimate visual acuity in the amblyopic eye. To avoid this overestimate, crowding bars may be used. These consist of stripes that surround an individual target and thereby simulate the presentation of multiple targets.
- This reveals a central or eccentric fixation pattern.
- Patients with a clear visual axis to the fovea and with a normally positioned fovea fixate with the center of the eye, whereas patients with amblyopia, an opacity within the visual axis, or displacement or disease involving the fovea may fixate eccentrically, as if they were looking at an object from the side. Marked eccentric fixation is detected by observing the noncentral position of the corneal reflection in the amblyopic eye while the amblyopic eye fixates on a light. A strabismic patient who can freely alternate fixation between the eyes does not have amblyopia. When either eye is deviated, the fixating other eye should be able to maintain fixation through a blink.
- Stereopsis refers to the perception of 3-dimensionality, or depth. This is typically reduced in children with amblyopia.
- The Titmus, Frisby, and Lang tests are commonly used to measure stereopsis. During the Titmus test, patients wear polarized glasses and are asked to identify 3-dimensional images that appear to pop-up toward them. The degree of stereopsis is reported as the number of arc seconds, with lower numbers (40 arc seconds) indicating better stereopsis than higher numbers (3000 arc seconds). Both the Frisby and Lang stereotests can be performed in free-space without the need for dissociative glasses.
- In strabismic patients, the magnitude of the deviation is measured using prisms.
- The ophthalmologist pays special attention to anomalous head postures, which can indicate peeking, refractive error, strabismus, or nystagmus.
- This is performed to help rule out ocular pathologies that may contribute to decreased vision (e.g., an abnormal pupillary response may be due to optic nerve hypoplasia or a retinal pathology).
- This helps rule out ocular pathologies that may contribute to decreased vision (e.g., an anterior segment exam may reveal cataracts).
- The anterior segment exam is typically performed with a slit lamp.
- A portable slit lamp or magnifier is used for young children.Images
- This is an essential part of the complete ophthalmic exam of a child.
- Eye drops, typically cyclopentolate 0.2%/phenylephrine 1% for infants, and cyclopentolate 1% (occasionally with phenylephrine 2.5%) for toddlers and children, are used to dilate the pupil and relax the ciliary muscle. A relaxed ciliary muscle impairs the strong focusing ability of the child's eye, allowing the ophthalmologist to objectively determine the child's refractive state.
- Many causes of amblyopia can only be assessed with a reliable cycloplegic retinoscopy.
- While performing retinoscopy, the ophthalmologist also assesses the quality of the light reflex to insure nothing in the visual axis interferes with a clear image reaching the retina.Image
- This helps rule out ocular pathologies that may contribute to decreased vision (e.g., macular lesions). Sometimes, these structural ocular defects are solely responsible for vision loss. However, when they occur asymmetrically or monocularly, coexistant amblyopia may explain a portion of the vision loss.
- Dilated fundoscopic exam is typically performed after cycloplegic retinoscopy.
- Eye drops are used to dilate the pupil and relax the ciliary muscle, typically cyclopentolate 0.2%/phenylephrine 1% for infants, and cyclopentolate 1% (occasionally with phenylephrine 2.5%) for toddlers and children.Images
Investigations
Risk Factors
History & Exam
Tests
Differential Diagnosis
Differentiating Signs/Symptoms
- Many refractive errors, most often myopia and astigmatism, cause unilateral or bilateral decreased vision but do not cause amblyopia. If a child's visual acuity immediately normalizes with the appropriate refractive correction, the cause of decreased vision is refractive error alone, and not refractive amblyopia.
- Children with refractive error may squint to create a pinhole effect and improve vision, and myopic children will see better at near than at distance.
- In amblyopia, vision does not improve with squinting, nor does it improve at a particular testing distance.
Differentiating Tests
- Complete exam by an ophthalmologist (or optometrist).
Functional visual impairment
Differentiating Signs/Symptoms
- Typically presents with bilateral decreased visual acuity at a time when a child experiences stress, such as the birth of a new sibling, divorce, or loss of a loved one.
- A child with functional visual impairment will not show amblyogenic risk factors such as strabismus, significant refractive error, or media opacities, and the child should have an otherwise normal ophthalmologic exam.
Differentiating Tests
- Complete exam by an ophthalmologist (or optometrist).
Differentiating Signs/Symptoms
- Abnormal color vision and visual field defects and abnormal pupillary reflexes.
Differentiating Tests
- Complete exam by an ophthalmologist (or optometrist), brain and orbital MRI with gadolinium enhancement.
Criteria
- Asymmetric objection to occlusion of one eye
- Unequal fixation preference behavior
- Preferential looking difference of two or more octaves (4 card difference on Teller Acuity Cards)
- Best corrected visual acuity difference between the two eyes of two or more lines.
- Best corrected visual acuity less than 20/30 in either eye in a child age 5 or older
- Best corrected visual acuity less than 20/40 in either eye in a child age 4 to less than 5 years
- Best corrected visual acuity less than 20/50 in either eye in a child age 3 and younger.
- Mild to moderate: visual acuity of 20/40 to 20/100
- Severe: visual acuity of 20/100 or worse.
Screening
US screening program
- Any media opacity greater than 1 mm in size
- Manifest strabismus >8 prism diopters (PD) in straight-ahead gaze
- Any of the following refractive errors:[36]
- Children ages 12-30 months: astigmatism >2.0 diopters (D), hyperopia >4.5 D, anisometropia >2.5 D, or myopia >-3.5 D
- Children ages 31-48 months: astigmatism >2.0 D, hyperopia > 4.0 D, anisometropia >2.0 D, or myopia >-3.0 D
- Children >48 months of age: astigmatism >1.5 D, hyperopia >3.5 D, anisometropia >1.5 D, or myopia >-1.5 D.
Childhood screening tests and recommendations by age
- Red reflex test with a direct ophthalmoscope. Refer if absent, white, dull, opacified, or asymmetric.
- External inspection of the eyes to assess for any structural abnormalities (penlight exam is sufficient). Refer structural abnormalities (e.g., ptosis).
- Pupillary exam. Refer if irregular shape, unequal size, and poor or unequal reaction to light.
- In a cooperative infant ≥3 months:
- Fix and follow. Refer if failure to fix and follow.
- Corneal light reflex to check for a symmetrical response in both eyes. Refer if asymmetric or displaced.
- Repeat the tests for the previous age group.
- Consider instrument-based screening for cooperative infants ≥6 months old (e.g., photoscreening and autorefraction), especially for the young and those with developmental delays. This can detect media opacities, strabismus, or concerning refractive errors. However, subjective visual acuity testing is preferred when possible. Refer children with strong myopia, hyperopia, astigmatism, anisometropia, media opacities (>1 mm), and manifest strabismus.
- Repeat the tests for the previous age group.
- Cover/uncover test to assess for refixation movements in the fellow eye. Refer if refixation is present.
- Distance visual acuity testing, independently for each eye. Visual acuity of 20/50 or worse in either eye, or a 2 or greater line difference between the two eyes, should be referred.
- Repeat the tests for the previous age group.
- Distance visual acuity testing, independently for each eye. Visual acuity of 20/40 or worse in either eye, or a ≥2-line difference between the two eyes, should be referred.
Children with developmental delay
Treatment Approach
- To correct any cause of visual deprivation
- To correct refractive errors likely to cause blur
- To promote use of the amblyopic eye to improve visual acuity.
Mild to moderate strabismic and/or mild to moderate anisometropic amblyopia (visual acuity better than 20/100)
Severe strabismic and/or severe anisometropic amblyopia (visual acuity of 20/100 or worse)
Bilateral ametropic amblyopia
Form-deprivation amblyopia
Residual strabismic or anisometropic amblyopia
Refractory amblyopia (noncompliant patient)
Older children (>7 years)
Treatment Options
without form-deprivation amblyopia
mild to moderate strabismic and/or mild to moderate anisometropic amblyopia
optical correction of any refractive error
Comments
- Clinicians should be aware of the importance of good adherence to glasses wearing, in addition to other forms of treatment, especially during optical treatment alone, as it has been found that adherence to glasses wearing is highly variable and affects visual outcomes.[45]
patching or atropine
Primary Options
- atropine ophthalmic
(1%) children >3 years: 1 drop to nonamblyopic eye once daily for 2 days on 2 consecutive days of the week
- atropine ophthalmic
Comments
- Prescribed patching of 2 hours/day was equivalent to patching 6 hours/day.[50]
- Treatment does not differ for older children (at least to age 15 years), although the exact regimens may vary.[1]
- Daily atropine was equivalent to atropine given only on 2 consecutive days. It has been suggested that the improvement in visual acuity in the amblyopic eye is considerable at 4-12 weeks and then reaches a plateau, after which it only improves slowly.[43] In general, the recommended time length to achieve the maximum outcome of refractive adaptation is 18-22 weeks.[47]
plano lens in atropinized eye
Comments
- A plano lens for the amblyopic eye can be added to atropine treatment. There may be a very small additional benefit of a plano lens in patients undergoing weekend atropine penalization.[59]
further management of strabismus
Comments
- After the amblyopia has been treated, children with residual strabismus typically undergo strabismus surgery.
more aggressive patching for residual amblyopia
Comments
- After treatment of moderate amblyopia resulting from strabismus or anisometropia with refractive correction and 2 hours of patching, some patients have residual amblyopia. A randomized clinical trial evaluated the effectiveness of increasing prescribed daily patching from 2-6 hours in children with stable residual amblyopia. Increasing patching to 6 hours was more effective than continuing patching at 2 hours daily, with a modest 1.2-line compared with 0.5-line additional visual acuity improvement.[54] This study brings into question whether 2 hours of prescribed daily patching is truly enough or optimal in the treatment of moderate strabismic and anisometropic amblyopia.
severe strabismic and/or severe anisometropic amblyopia
optical correction of any refractive error
Comments
- Clinicians should be aware of the importance of good adherence to glasses wearing, in addition to other forms of treatment, especially during optical treatment alone, as it has been found that adherence to glasses wearing is highly variable and affects visual outcomes.[45]
patching or consideration of atropine
Primary Options
- atropine ophthalmic
(1%) children >3 years: 1 drop to nonamblyopic eye once daily
- atropine ophthalmic
Comments
- Children with severe amblyopia ages 3-6 years respond equally well to prescribed 6 hours patching and full-time patching.[62]
- Treatment does not differ for older children (at least to age 15 years), although the exact regimens may vary.[1]
- Because shorter-duration patching (e.g., 2 hours) has not been directly compared with 6-hour patching in large randomized trials, it is sensible to prescribe 6 hours of patching for residual severe amblyopia until further studies are performed.[63]
- Preliminary studies suggest that atropine may be as effective as patching in treating severe amblyopia, but large randomized trials have not yet been performed.[61]
further management of strabismus
Comments
- After the amblyopia has been treated, children with residual strabismus typically undergo strabismus surgery.
bilateral ametropic amblyopia
form-deprivation amblyopia
early surgery
Comments
- Recommended to correct visual deprivation due to corneal opacity, cataract, nonclearing vitreous hemorrhage, or severe ptosis.
- Surgical intervention is less urgent when the form deprivation occurs bilaterally as opposed to unilaterally. To maximize visual outcomes, surgery for bilateral congenital cataracts should be performed before 14 weeks of age and earlier if possible, and surgery for unilateral congenital cataracts should be performed before 6 weeks of age.[65] [66]
- Occasionally, mild- to moderate-deprivation amblyopia (such as that resulting from a mild unilateral cataract) may initially be treated with patching to see how much visual improvement can be obtained with conservative management before considering surgery.
patching
Comments
- For patients with unilateral- or asymmetric-deprivation amblyopia, such as children with unilateral congenital cataracts, patching the sound eye is a necessary additional treatment.
concurrent nonform-deprivation amblyopia
optical correction of any refractive error ± patching or atropine eye drops
Primary Options
- atropine ophthalmic
(1%) children >3 years: 1 drop to nonamblyopic eye once daily
- atropine ophthalmic
Comments
- Deprivation amblyopia may coexist with other forms of amblyopia, including anisometropic and strabismic. These should be addressed in conjunction with treatment to clear the visual axis.
- Ongoing treatment may be with correction of any refractive error with spectacles or contact lenses, with or without patching of the nonamblyopic eye or blurring of the nonamblyopic eye with atropine eye drops.
refractory amblyopia
closure of better-seeing eye
Comments
- Refractory amblyopia in a noncompliant patient can be treated by closing the eyelid over the better-seeing eye temporarily, using surgical or medical techniques. These include the use of sutures, injection of botulinum toxin to the levator muscle, and application of cyanoacrylate glue to the eyelid margin.[67] [68] However, caregivers might be hesitant to use these techniques for the management of amblyopia in view of the need for anesthesia, as well as the cosmetic and psychological effects on the child. Other less invasive ways to improve compliance include the use of interventional materials, such as cartoons or information booklets. Randomized controlled trials have shown the benefit of using interventional materials to improve treatment compliance in poorly adherent subjects and in children of non-native parents who speak their host country language poorly.[55] [56] It is suggested that attempts should be made first with intervention material.
Emerging Tx
Binocular video games
Modulation of the plasticity in the visual system
Levodopa
Liquid crystal glasses
CDP-choline
Transcranial magnetic stimulation
Acupuncture
Refractive surgery for refractive amblyopia and amblyogenic refractive errors
Prevention
Primary Prevention
- Uveitis
- Ptosis
- Gestational age <30 weeks
- Birth weight <1500 g
- Delayed visual or neurologic maturation of unclear etiology
- Cerebral palsy
- Syndromes with ocular involvement (e.g., Down syndrome)
- A family history of amblyopia, strabismus, childhood cataract, or childhood glaucoma.
Secondary Prevention
- Wearing polycarbonate spectacles even if they do not require refractive correction
- Wearing protective goggles and facial protection for contact sports and potentially dangerous activities such as paintball
- Having regular eye exams throughout life.
Follow-Up Overview
Prognosis
Untreated amblyopia
Treated amblyopia
Monitoring
- Consider increasing penalization (patching or atropine) or trying an alternative therapy (including patching or atropine if not tried) if visual acuity remains unchanged after 3 months
- Use an alternative treatment if severe skin irritation occurs with patching or side effects occur with atropine
- Taper or terminate treatment if treatment has been unsuccessful due to underlying pathology
- Temporarily stop treatment and monitor eye alignment and vision if strabismus or diplopia develop
- Temporarily stop treatment, review diagnosis, and monitor if visual acuity decreases in the fellow eye by ≥2 lines (i.e., reverse amblyopia). Consider patching the originally amblyopic eye.
Complications
Citations
Cruz OA, Repka MX, Hercinovic A, et al. Amblyopia preferred practice pattern. Ophthalmology. 2023 Mar;130(3):P136-78.[Abstract][Full Text]
Hutchinson AK, Morse CL, Hercinovic A, et al. Pediatric eye evaluations preferred practice pattern. Ophthalmology. 2023 Mar;130(3):P222-70.[Abstract][Full Text]
US Preventive Services Task Force; Grossman DC, Curry SJ, Owens DK, et al. Vision screening in children ages 6 months to 5 years: US Preventive Services Task Force Recommendation Statement. JAMA. 2017 Sep 5;318(9):836-44.[Abstract][Full Text]
American Academy of Ophthalmology. Pediatric ophthalmology/strabismus summary benchmarks - 2022. December 2022 [internet publication].[Full Text]
Wallace DK, Lazar EL, Holmes JM, et al; Pediatric Eye Disease Investigator Group. A randomized trial of increasing patching for amblyopia. Ophthalmology. 2013 Nov;120(11):2270-7.[Abstract][Full Text]
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Key Articles
Other Online Resources
Referenced Articles
Guidelines
Diagnostic
Summary
Evidence-based recommendations on the diagnosis of amblyopia.Published by
American Academy of Ophthalmology
Published
2022
Summary
Summary benchmarks for the Academy's strabismus pattern. Includes a summary for the diagnosis and management of amblyopia.Published by
American Academy of Ophthalmology
Published
2022
Summary
Evidence-based recommendations on ophthalmic evaluation in children.Published by
American Academy of Ophthalmology
Published
2022
Summary
Summary of guidance on the early detection of treatable eye disease in infancy and childhood.Published by
American Academy of Ophthalmology
Published
2022
Summary
Assesses the effects of screening for impaired visual acuity in primary care settings in preschool children (ages 1-5 years).Published by
US Preventive Services Task Force
Published
2017
Summary
Recommendations regarding when and how frequently to perform eye exams in infants, children, and adults.Published by
American Academy of Ophthalmology
Published
2015
Treatment
Summary
Practice guidelines for the care process of vision rehabilitation, including recommended interventions for reading, daily living activities, safety, community participation, and psychosocial well-being.Published by
American Academy of Ophthalmology
Published
2023
Summary
Evidence-based recommendations on the treatment of amblyopia.Published by
American Academy of Ophthalmology
Published
2022
Summary
Provides expert consensus statements regarding best practice and fundamental standards for children's ophthalmic services.Published by
Royal College of Ophthalmologists
Published
2021
Credits
Patient Instructions
- Understand why amblyopia treatment is needed
- Understand why it must be carried out when the child is young
- Receive encouragement and helpful tips from the physician.
- Education aimed at children, such as providing them with a cartoon about treatment.
- Poor parental fluency in the national language
- Low level of parental education
- A child's poor visual acuity at the start of treatment.
- Many strategies can be employed to improve the likelihood a child will wear spectacles appropriately. The spectacles should be comfortable, the frame should be as indestructible as possible as well as flexible, and the spectacle lens should be large enough to discourage peeking around the edge of the frame. An elastic band that fits behind the head can help keep the spectacles appropriately positioned. A sibling or parent wearing glasses may help. Also compliance may be improved by having some spectacles for the child's doll or stuffed animal to wear. Rarely, temporary use of elbow restraints may be necessary to keep the spectacles on the child's face.
- Similar strategies can be used to adapt a child to wearing a patch. A patch that is sticky enough to not be easily removed should be used, but not one that is so sticky as to irritate the skin. Cloth patches that fit over the spectacles can be used if the child refuses a sticky patch, but this may result in peeking around the edge of the patch. It is best to choose a time to patch when the child is not tired or irritable. Preschool or school teachers may be helpful in enforcing patching compliance, or other caregivers such as grandparents. If methods such as mittens and elbow restraints are deemed appropriate to use, they generally do not need to be used for long. The child adapts to wearing the patch, and vision in the amblyopic eye rapidly improves, making occlusion of the better-seeing eye less disabling.[104]
- Atropine penalization is as successful as patching in the treatment of certain types of amblyopia. Installation of 1 drop of atropine on weekend days or every day is easier than patching for many families to manage. The atropine can be given when the child is asleep.
- The caregiver should stop the atropine drops and call the physician if the child develops adverse effects (e.g., flushing, rash, fever, thirst, agitation, or inappropriate behavior).
- Sunglasses and a hat outdoors are recommended in children receiving atropine eye drops.