Department of Ophthalmology University Mnchen
Head: Prof. Dr. A. Kampik
Early Detection and
Treatment of Amblyopia
Klaus-Peter Boergen
Prague 2015
Amblyopia and Pleoptics
Amblyopia
functional deficit due to disturbed visual
development which is correctable
during the sensitive period
Amblyopia
1. Visual development
2. Early diagnosis
3. Early treatment
Amblyopia
1. Visual development
2. Early diagnosis
3. Early treatment
Visual Development
normal
disturbed amblyopia
Development of the visual pathways
optic nerve
rapid postnatal myelinisation
(Yakolev + Lecours, 1967; Nakayama, 1968)
latency reduction (VEP) during the 4th and 5th month
(Umezaki + Morell, 1970; Sokol, 1979)
corpus geniculatum laterale
rapid cell growth; normal adult size at the end of the
2nd year
(Hickey, 1977)
Normal visual development
postnatal morphological maturation
(e.g. myelinisation of the optic nerve)
redundant synaptogenesis
(differentiation by function i.e.
adequate visual in-put)
Methods for measuring visual acuity in infants
detection tests
(Worth, 1915; Sheridan, 1969)
induction of follow movements
(Schwarting, 1954)
optokinetic nystagmus
(Catford, 1973)
preferential looking (PL)
visual evoked potentials (VEP)
Preferential looking (PL)
grating acuity measured by
pattern preference phenomenon
Perception deficits in amblyopes
(Hess et al., 1978)
1 c/d 4 c/d 10 c/d 15 c/d
1 c/d 4 c/d 10 c/d
Contrast sensitivity and amblyopia
1 4 10 15
300
TG
100
vertikal
horizontal
10
1
0,1 1 10 100
Spatial frequency (Cycles/degree) (Hess et al., 1978)
Visual development
Differentiation of the fovea synaptic development
Myelinisation of the optic nerve dominance columns
Oculomotor development growth of the globe
others
Grating acuity
Visual function
Snellen acuity
H S Contrast vision
Stereopsis
3 Mo 6 Mo 1y 5y 10 y
H S Colour vision
Age
PL and normal visual development
visual acuity (central and peripheral)
contrast sensitivity
colour vision
pattern detection
stereopsis
Stereosehschrfe [min] 0
20
40
60
80
5 10 15 20 25 30 35
Alter [Wochen]
(Birch et al., 1982)
Visual and oculomotor development
1. month: monocular fixation
2. month: binocular fixation
3. month: follow movements
4 month: stereopis
Cave:delayed visual development
Sensitive period:
development and maturation of visual
functions
decreasing sensitivity
Duration of the sensitive period
high decreasing residual sensitivity
sensitivity sensitivity
acuity testing possible
0 1 2 3 4 5 6 7 9 years
maturation
development
Visual Development
normal
disturbed amblyopia
Time course of amblyopia development
the earlier amblyopiogenic factors
appear the faster amblyopia
develops
Amblyopia
1. Visual development
2. Early diagnosis
3. Early treatment
Pathogenic factors for amblyopia
form deprivation e.g.:
bilateral cataract
bilateral ptosis
ametropia
nystagmus
abnormal binocular interaction e.g.:
unilateral squint
combination of both
unilateral cataract
anisometropia
Obvious amblyopiogenic factors
opacities of the optic media
(cornea, lens, vitreous)
ptosis
squint (unilateral)
nystagmus
Uncertain amblyopiogenic factors
decent eye changes
temporary eye changes
'Hidden' amblyopiogenic factors
microstrabism
refractive errors
(ametropia, astigmatism, anisometropia)
Early detection of amblyopiogenic factors
history (family, prematurity)
inspection
Brckner-test
retinoscopy
Early detection of amblyopiogenic factors
history (family, prematurity)
inspection
Brckner-test
retinoscopy
Early detection of amblyopiogenic factors
history (family, prematurity)
inspection
Brckner-test
retinoscopy
PL and amblyopia detection
reduced sensitivity for amblyopia
only deep amblyopia detectable by PL
Konturinteraktion
(Flom et al. 1963)
L
Amblyopia
1. Visual development
2. Early diagnosis
3. Early treatment
Functional chances of treatment
The earlier the better !
Prerequisites for successful amblyopia treatment
early diagnosis (sensitive period)
optimal visual stimulation
adequate occlusion regime
Optimal visual stimulation
surgery (cataract, ptosis)
correction of refractive errors
(spectacles, contact lenses)
Prerequisites for successful amblyopia treatment
early diagnosis (sensitive period)
optimal visual stimulation
adequate occlusion regime
Relative amblyopia (Bangerter, 1955)
functional deficit superimposed to
an organic defect.
Anatomical-functional correlations in the macular area
Right eye
Macular area
Parafovea
5
Perifovea
Foveola
Fovea
Temporal
1 mm = 3,35
1 = 0,57
5
0,6
2,5
4,2 9,2
Visus
1,0 - 20/20
0,7 - 20/30
0,5 - 20/40
2 3 5 7 9 1213,5 0,4 - 20/50
0
Excentricity 0,3 - 20/70
0,2 - 20/100
5 10 15 20 25 30
0,5
0,1 - 20/200
Visual acuity
0,4 0,3 0,2 0,1
(Bishop, 1987)
No active pleoptic!!!!
Summary:
1. Amblyopia develops the faster the younger the
child
2. Early detection is mandatory for good functional
results
3. Relative amblyopia should always be treated when
early detected
4. Occlusion regime must be adapted to the childs
age
