1. Brendan

2. Amblyopia: New Treatments
Pamela F. Gallin, M.D.
Director, Pediatric Ophthalmology
Children’s Hospital of New York
Edward S. Harkness Eye Institute

3. IF Vision Screens were done as children THEN 2% - 5% of adults would NOT be legally blind!

4. Army Induction Studies

5. your brain (occiput) does not see
What is Amblyopia?
One eye is IN focus
&
One eye is NOT in focus
your brain (occiput) does not see

6. Amblyopia

7. Normal Retina

8. Duke Elder Classification
Amblyopia ex Anopsia
Congenital (Organic) Amblyopia
Strabismic Amblyopia
Anisometropic Amblyopia

9. Amblyopia ex Anopsia (Anterior Segment)
Stimulation deprivation amblyopia from lack of formation of retinal images
Congenital Ptosis (lids)
Corneal Opacification
Congenital Cataract

13. 2. Congenital (Organic) Amblyopia (Posterior)
Seemingly undetectable lesion ...but during treatment… no visual improvement…
because of retinal or visual pathway dysfunction

14. 3. Strabismic Amblyopia
Active inhibition or suppression of one retinal image by the cerebral cortex to eliminate the diplopia (double) by the deviating eye

15. 4. Anisometropic Amblyopia
Optically unmatched eyes so that one eye is in focus, and the other is not
Silent Disease
as least 1.5 to 2.0 diopters difference or more between the 2 eyes

16. Nobel Prize 1981
David Hubel
Torsten Wiesel

17. Hubel and Wiesel 80% of occiput is binocular
suture lids of one eye at birth…
… small % cells binocular
... small % normal
occlude one eye at birth & open at 3 months
… occlude 2nd eye…..BLIND transiently
some vision returns, but permanently suppressed
No light to both eyes from birth…
less damage

18. Visual Cortex
Occiput

19. LGN involved??
1941
Le Gros Clark
Journal of Anatomy
75, 419

20. LGN involved

21. Cerebral cortical inhibition (suppression) is: an active process at the level of LGN and calcarine cortex

22. Amblyopia is a Silent Disease

23. Brendan

24. American Academy of Ophthalmology
recommend vision screen at 3.5 years of age

25. Vision Screen Allen Cards E game # Slide Letters New Techniques
desktop VEP

26. Snellen Chart

27. Diopsys: desktop VEP

28. Patient views grating and yields VEP

29. Diopsys Results
Norm
Abnl

30. Dilated Cycloplegic Retinoscopy
Mydriacyl 1%
Cyclogel 0.5%, 1%, (2%)

31. An unmatched set optically
Right eye IN focus
Then
RIght eye vision
Normal
Left eye Not in focus
Then
Left eye Vision
Decreased
(unless intervention)

32. Brain shuts off image from out of focus eye
Suppression
Brain shuts off image from out of focus eye

33. So, give glasses to one eye and it will see?
Yes, image will be focused on retina
But, image will NOT be developed in brain
Because, cortical cells are scrambled (H&W)
BUT
They can become functional up to years

34. Exceptions: Small differences… glasses (with Rx in 1 eye) can work
Large differences…
need contact lens for one eye

35. Maintain until 9 years of age
The goal is 20/25
Maintain until 9 years of age

36. Treatment Patching OcclusionTherapy Penalization -optical
-pharmacologic
Bangerter Films
New Techniques

37. Patching (Occlusion Therapy)
On face
adhesives vary
1 week/year life
…5 y.o. = 5 wks
…1 y.o. = 1 wk

38. Occlusion Amblyopia

39. Brendan
11 months /
Patch and glasses

40. Optical Penalization Pharmacologic atropine Optical
blur good eye with out of focus lens
Bangerter Film

41. Brendan wouldn’t wear patch and glasses
So, we added Atropine under the patch

42. Brendan wouldn’t wear patch at all,
So, in addition to the Atropine,
we added Bangerter film

43. Bangerter Films Clear pieces of plastic (colorforms)
Adjust level of blur (e.g. net vision you have)
Can see large targets with both eyes
Peripheral Vision INTACT
Socially acceptable in elementary school!!
INVISIBLE
Imported from Switzerland ($2.00)

44. Bangerter Films

45. We added a contact lens with atropine in the other eye
And because the difference between the 2 eye prescriptions was so high (and that is why he didn’t like the glasses)
We added a contact lens
with atropine in the other eye

46. Contact Lenses used when the differences very high
after 9 years of age, when don’t want to wear glasses for one eye

47. After contact lenses AND 21
Consider refractive surgery
e.g. Lasik and others

48. Brendan had High Anisometropia (8.75)
glasses & patch
glasses & patch & atropine
glasses & patch & atropine & Bangerter film
THEN
contact lens & patch & atropine

49. We knew that:
Brendan had vision 20/70…from Diopsys
And that:
He would be Blind in that eye
IF Nothing was done

50. Youngest child in world
October, 2002
Lasik
Youngest child in world
Vision 20/40!!!!!
Dr. Jonathan Davidorf
UCLA

52. Brendan began to have slight myopia and astigmatism
Vision began to slip
Treated like regular small anisometropia
Glasses/BG film/Atropine (prn)
August, 2004 Vision 20/20 right..20/50 left
Age 4.5 (much room to maneuver)

53. October, 2004 Left Eye 20/60 January, 2005 Left Eye 20/80

54. Brendan

55. Amblyopia is a SILENT disease
2% to 5% of adult population
PREVENTABLE
If diagnosed EARLY by vision screens!!!

56. Vision Screens mandatory at 3.5 years all annual visits ? Diopsys

57. Treatment Glasses (if anisometropia) Occlusion = Patching Atropine
Bangerter Films

58. contact lens (one eye) Refractive Surgery (lasik)
Desperation:
contact lens (one eye)
Refractive Surgery (lasik)

59. Treatment must be continued until 9 years of age
Treatment must be continued until 9 years of age! Hubel and Wiesel but, it works!!

60. 2% - 5% of children should NOT be blind in one eye
YOU CAN
prevent this with a vision screen