Is the natural history of amblopia known?

What is suggested about it though?

-no

-that the VA deteriorates even further without treatment

Does amblyopia greatly affect quality of life?

Does is affect occupational class in later life?

How does treatment in childhood affect lifetime?

- not if the fellow eye maintains good vision

-no, but fewer university degrees among affected vs. unaffected

-more quality life years

What are the 6 factors that influence the response to amblyopia treatment?

Which is the most important?

-type of amblyopia

-depth of amblyopia

-age at initiation of txt

-duration of txt

-type of txt

-compliance with treatment (most important)

What is the percentage range of success rates in amblyopia treatment?

Recent studies show that the percentage of improving by ___ lines of VA or to a VA of ___ (LogMar ___) is ___ - ___ %

What percentrage of amblyopes achieve VA equal to that of the non-affected eye?

- 30%- 92%

-3 lines; 20/32; .2; 60-70%

-50%

What is the treatment for deprivational amblyopia caused by cataract?

When should it be removed?

What is involved in optical rehab?

What does the outcome depend upon?

-surgery at 4-6 weeks of age

-CL or IOL

-whether or not the amblyopia was congenital

Does amblyopia exist in isolation?

What kind of ret/refraction should be done?

What is the first step of treatment?

When should patching or penalization start?

How should these patients be managed lond term?

Can a minfest refraction be done on an amblyopic eye? Why not?

So how is the RE determined?

-no

-cycloplegic

-optimal RE

-when the VA from RE levels off

-period refraction and changes in treatment if necessary

-no- invalid; the amblyopic eye cannot interpret blur relative to the normal eye due to poor accommodation

-cycloplegic retinoscopy

How would you treat an ET?

For __ and __ can cut the Rx by how much? Want to make sure you cut the Rx _____.

For an astigmat?

For and anisometropic amblyope?

For a myope?

What is the most common etiology for an ET?

-full hyperopic correction

-IA and AA; 1.00D- 1.50D; symmetrically

-full cyl correction

-full correction

-full correction

-accommodative

In IA and AA what might happen with full optimal correction?

What is refractive adaptation? This is up to ---- wks?

-may be partially or totally curative

-the period of time in which the VA improves with spectacle correction alone; up to 18 weeks

What are the treatments of choice once the VA has leveld off with correction?

What are the main txts we will go to?

What is the gold standard of amblyopia txt?

-occlusion (main)

-pharmocological penalization (main)

-orthoptics/VT

-other

-occlusion

What is the basis of occlusion txt?

What questions to asses when evaluating treatment regimen?

-deprive the non-amblyopic eye while optimzing the amblyopic eye

-what type, how long, how much, and at what age?

VF occluded can by ___ or ____. 

What are the wearing times that may be prescribed?

Which is not usually the first line of treatment?

Usually start where and go where?

-partial of full/total

-Constant (FTW) - all waking hours

-Part-time wear- 6 hours

-Minimal- 2 hours

-FTW

-start low and Rx more hours as needed

What is the most common light transmissible occlusion method?

Are opaque tie-on patched effective? Why?

What might you have to worry about with skin adhesive patches?

How can you resolve this problem?

-adhesive patch

- no bc the child removes it

-skin sensitivity

-put the patch on the glasses lens

Is it ethical to Rx an occluder CL on the non-amblyopic eye? Why or why not?

What is a bangerter filter?

What acuity will these gradations give?

<0.1

0.1

0.2

0.3

0.4

0.6

0.8

- no; because there are problems that can develop in the good eye with CLs

-small translucent foil that can be placed on the lenses

- (20/300)

- 20/ 200

-20/100

- 20/70

-20/50

- 20/30

-20/25

When is this the treatment of choice?

What are the advantages of these vs other types of occlusion?

What are some disadvantages?

-adults with intractable diplopia

-better compliance, more cosmetically appealing, less disruption of BNV

-can fall off, child looks around the filter

What is "optical blurring" and how is it used?

Is this used commonly?

-monovision

-apply a +3 D fresnel lens to the non-amblyopic eye; the amblyopic eye is used for distance and the non-amblyopic eye used for near

-no, rarely

What is pharmacological blurring?

What is dimming? Is this done today?

What is direct occlusion? Indirect? Alternating and in what frequency?

When is alternating occlusion usually done?

Why is this done?

-atropine in the normal eye

-use of a ND filter or red(chromatic) lens over the non-amblyopic eye; not done today

-occlusion of good eye; occlusion of amblyopic eye; 3 days on good eye and one day on amblyopic eye

-reserved for children in FTW of occlusion (rare)

-to prevent iatrogenic amblyopia

What is the most common type of patching?

What are the 2 goals of occlusion treatment?

Will there be some residual amblyopia with the latter?

-direct, total, opaque occlusion

-maximum improvement and elimination of amblyopia (only in 50%) and establish alternating strabismus pattern in SA

-yes

What is recidivism?

What can prevent this in SA?

Can VA be regained in recidivism occurs?

More than __% of improvement in VA may occur as early as ___ weeks of treatment?

When should txt be changed or terminated?

What is the most common cause of treatment failure?

When does bulk of improvement happen?

-recurring amblyopia

-establihshing and alternating fixation pattern (ET)

-yes, it can be regained to the improvement level before

-80%; 6

-if pt shows no improvement within 4 months and shows good compliance

-poor compliance

-within first 3-4 months

What are the 3 effects of occlusion on ocular alignment status?

When do these usually happen?

-intermittent strabismus may become constant (rare), anisometropic amblyope may develop a strabismus (can happen), a microtrope may get larger (unlikely)

-with FT occulsion

What are the other forms of occlusion for historical interest?

What is partial occlusion? What does this encourage? Is this efficacious? Is it used?

Is this ever used as an initial treatment?

-partial and inverse occlusion

-binasal occlusion OU; alternating fixation and maintenance of VA gains; unknown; rarely

-no

What is inverse occlusion?

What is the premise behind this?

What type of occlusion is used here?

What is also incorporated into this treatment?

Is it efficacious?

What study looked at direct vs indirect?

When is this used?

-patching the amblyopic eye

-that in young pts, occlusion reinforces EF in amblyopic eye

-total and full-time

-intense vision therapy (pleoptics)

-Wilmer study

- to get the child used to patching treatment and intermittent periods when patching cannot be done (in school)

-occlusion

-prism

-red lens

-optical penalization

-pharmacological penalization

-orthoptics/vision therapy

How is prism used in amblyopia treatment?

What would be used for an ET?

What is this used to treat?

Are there evidence based studies on this? Is it used?

-occlude normal eye and place inverse of correcting prism over the strabismic eye

- Base-In for and ET

-deep amblyopia with EF

-no; no

How is the red filter administered?

What is the premise behind this?

What is the success rate?

-occlusion of normal eye and red lens over amblyopic eye

-encourages the amblyopic eye to fixate with the fovea

Traditionally how were pharmacological agents used?

How is this used today?

What is the purpose?

What is a major advantage to this?

What are the 2 types of pharmacological penalization?

What is this similar to? Is this used often?

-cyclopelgic in the normal eye and miotic in the amblyopic eye

-cycloplegia or the normal eye and can also add over-minus to the normal eye

-forces the amblyopic eye to be used at near and at distance and near with over-minus correction

-you know that the child is being treated

-near and total (discussed above)

-optical penalization in which the non-amblyopic eye is forced to be used at distance- not used

What are the 2 types of optical penalization?

How are these implemented?

Is this efficacious?

-distance- +3.00 over non-amblyopic eye and amblyopic eye given appropriate correction

-alternating- +3.00 in a left lens and +3.00 in right lens of 2 pairs of glasses- use both for distance and near different days

-not established

- moderate amblyopia VA 20/40- 20/80

-where occlusion has been unsuccessful

-prevent recidivism

-patients with NBV potential

-patients with latent nystagmus (presents on occlusion)

What did the PEDIG 2002 study look at?

How was occlusion initially Rxd?

What criteria caused this to increase?

How was atropine initially Rxd?

What criteria caused this to change?

What must all sites have?

-occlusion vs. pharm penalization

-part-time (6hr) wear after 1 month optimal correction

-f after 4 months they had not imporved to 20/30 or >/= 3 lines they were switched to FT occlusion for 2 months

-1 gt daily in normal eye after 1 month optimal Rx

-if improvement not shown by same parameters as above any hyperopic Rx was cut to plano for the next 2 months

-EVAT(HOTV)

What were the results of the PEDIG 2002 study?

What is the conclusion of this study?

If patching doesn't work, should you not try atropine?

-occlusion and atropine were statistically similar, but patching showed greater improvement in the first 5 weeks

-while atropine may be sloer to response, the efficacy of treatment is the same after 6 months for children with moderate amblyopia

-no, just bc one doesn't work doesn't mean you shouldn't try the other

When would orthoptics/vision therapy be used?

How may this affect treatment?

What does this train?

Efficacy?

-in addition to occlusion/pharm penalization

- OM fxn, hand-eye coordination, accommodative fxn

-unknown

When is pleoptics used?

What is this aimed at?

What is this highly dependent on?

How is this done?

What tool is used?

What is pt told to do?

What must also be done when not in training?

***THIS IS A LAST RESORT

- "full-sight"/ deep amblyopia

- restoring vitality of the fovea of the amblyopic eye

-equipement and technician

-with an AI to disrupt the EF and imporve the VA

-Euthyscope

-fixation, pursuits, saccades

-inverse occlusion to inhibit EF

What is pleoptics reserved for?

What are some other orthoptic procedures that can be used?

Are these efficacious?

-older patients who have lost vision in the better eye and whose remaining eye is deeply amblyopic

-macular tag and Hadinger brushes

-unknown

What is the prognosis for amblyopia treatment for:

-very young child

-pre-school to young school age child

-older child/adolescent

-excellent; good chance to improve VA and establish normal fusion

-good

-guarded

-what is the probability of losing non-amblyopic eye later in life

-what is the chance of gaining vision in the amblyopic eye in patients that lose their normal eye

An amblyopic child is __ times more likly to lose vision than a non-amblyopic child.

In which eyes do diseases usually begin that lead to visual loss?

Who reported these findings?

Vision loss is due to __ in younder patients and ___ in older patients. 

-16

-in the eye that is less impaired

-Tomilla and Tarkkanen

-trauma, age-related disease

What are the odds of the VA in the amblyopic eye improving upon loss of the sound eye?

What percent was spontaneous?

What % acheived 20/40 or better?

What does this really depend upon?

When must the sound eye be protected at all times?

What are some diseases affecting the vision in the sound eye?

-34%

-60%

-59%

-if treatment was performed in the amblyopic eye in childhood and if it was successful

-severe, untreatable amblyopia (20/200)

-ARMD, cataracts, choroidal melanoma

-what is the most effective treatment

-what is the needed intesity of treatment

-how many patients suffer recidivism and can it be prevented

-can older patients be treated efficaciously

-is VT affective in treating amblyopia?

What is the most effective treatment for amblyopia? and at what age?

What is another option?

Is there a difference between this and patching?

Why might this option be chosen?

- patching/pharmocological penalization' 3 to <7yoa

-Bangerter filters

-less than 1 line of difference in VA compared to patching

-lower burden of treatment on child/family- more accepting of treatment

What should the initially intensity of treatment be? For moderate amblyopia? For severe?

When should this be increased?

What study looked at this?

What about atropine regimens, daily vs. weekend treatment?

What can be done if there is no improvement?

-2 hrs of daily patching with 1 hour of near activities

-(20/200-20/400)- 6hrs with 1 hr near activities

-should increase if no improvement occurs

-PEDIG 2003

-for moderate amblyopia initially start with weekend atropine and increase frequency as needed

-may also want to make the hyperopic Rx plano in the un-affected cyclopleged eye

What study assessed atropine dosing in severe amblyopia?

What are the recommendations based on this study?

In which patients might improvement be greater?

-PEDIG 2009

-weekend atropine for children with severe amblyopia (20/125-20/400) between 3 and 12

-younger patients

How shoudl amblyopia be managed once it is treated?

What do we know about the recurrence rate of amblyopia? Are there any factors to predict recidivism?

If you have achieved an acuity with treatment, can you get it back after recidivism?

-no accepted standard

-we don't know for either

-yes

What percentage of treated amblyopes had recidivism?

Was there a difference between atropine and patching groups?

Which patients were more likely to experience recidivism?

This leads to what conclusion?

-24%

-not a significant difference

-those with moderately-high levels of patching (6-8hrs/day) that were not weaned off with 2hrs/day (42% vs. 114%)

-that patients should be gradually be worked out of patching/atropine to prevent this

What % will have significant recurrence within one year after txt cessation?

What may lessen this rate of recurrence?

What is a good weaning option?

When is recidivism more likely?

-25%

-weaning them out of treatment

-Bangerter filters to taper treatment

-when the patient is young and less chance when older and visually mature

Can amblyopia be treated in older children?

When did most children improve with treatment?

What was the average time of most improvement?

This proved what?

-from 11-15 full-time occlusion will improve the VA and most older patients have lasting effects

-within first 3-6 mos

-10 mos

-that children older than 9 can acheive improvement with full-time occlusion

What were the findings of the PEDIG 2005 study?

What does this conclude?

-children 7-12 will likely be treatment responders

-children 13-17- will most likely not see benefit with treatment

-sometimes amblyopia treatment can be successful in older patients

Does rxing near point activities improve the VA outcome when treating AA or SA, when combined with 2 hrs of patching?

What else did this study show?

-no

-that children with severe amblyopia responded to 2hrs of daily patching

How often should VAs be monitored in amblyopia?

What bangerter filter should you start with?

What i should you do if there is no improvement or improvemnt stops?

After no further improvement or resolution of amblyopia what should you do?

- every 4-6 weeks

-a 0.3 density filter

-increase intensity, change txt, combine txt

-wean them out of treatment and follow for 1 year after cessation of txt

What is Levodopa?

What do animal amblyopia models show?

What is carbidopa? What does it do?

What role does levadopa play in amblyopia treatment?

-precursor of dopamine (neurotransmitter) that influences visual system on a retinal and cortical level

-deficiency in dopamine

-peripheral decarboxylase that inhibits breakdown of levadopa at peripheral sites and allows more to cross the blood-retinal barrier

-has been shown to imporve VA and maintain improved VA in amblyopic children and adults, especially those less than 8