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|Classification and external resources|
Amblyopia (also called "lazy eye") is an eye disorder characterized by an impaired vision in an eye that otherwise appears normal, or out of proportion to associated structural abnormalities of the eye. It has been estimated to affect 1-5% of the population.
In amblyopia, visual stimulation either fails to transmit or is poorly transmitted through the optic nerve to the brain for a continuous period of time. It can also occur when the brain "turns off" the visual processing of one eye to prevent double-vision, for example in strabismus (crossed-eyes). It often occurs during early childhood, resulting in poor or blurry vision. Amblyopia normally affects only one eye in most patients. However, it is possible, though rare, to be amblyopic in both eyes, if both fail to receive clear visual images.
Detecting the condition in early childhood increases the chance of successful treatment, especially if detected before the age of five. The earlier it is detected, and the underlying cause corrected with glasses or surgery, the more successful the treatment in equalizing vision between the two eyes.
Amblyopia is a developmental problem in the brain, not any intrinsic, organic neurological problem in the eyeball (although organic problems can lead to amblyopia which can continue to exist after the organic problem has resolved by medical intervention). The part of the brain receiving images from the affected eye is not stimulated properly and does not develop to its full visual potential. This has been confirmed by direct brain examination. David H. Hubel and Torsten Wiesel won the Nobel Prize in Physiology or Medicine in 1981 for their work in showing the extent of the damage to ocular dominance columns produced in kittens by sufficient visual deprivation during the so-called "critical period." The maximum "critical period" in humans is from birth to two years old.
Many people with amblyopia, especially those who only have a mild form, are not even aware they have the condition until tested at older ages, since the vision in their stronger eye is normal. However, people who have severe amblyopia may experience related visual disorders, most notably poor depth perception. Amblyopes may suffer from poor spatial acuity, low sensitivity to contrast and some "higher-level" deficits to vision such as reduced sensitivity to motion. Amblyopia is characterized by several functional abnormalities in spatial vision, including reductions in visual acuity (VA), contrast sensitivity function (CSF), and vernier acuity as well as spatial distortion, abnormal spatial interactions, and impaired contour detection. In addition, amblyopic individuals suffer from binocular abnormalities such as impaired stereoacuity (stereoscopic acuity) and abnormal binocular summation.  Also, a crowding phenomenon is present.  These deficits are usually specific to the amblyopic eye. Amblyopes also suffer from problems of binocular vision such as limited stereoscopic depth perception and usually have difficulty seeing the three-dimensional images in hidden stereoscopic displays such as autostereograms. However, perception of depth from monocular cues such as size, perspective, and motion parallax remains normal.
Amblyopia has three main causes:
- Strabismic: by strabismus (misaligned eyes)
- Refractive: by anisometropia (high degrees of nearsightedness, farsightedness, or astigmatism in one or both eyes)
- Deprivational: by deprivation of vision early in life by vision-obstructing disorders such as congenital cataract
Strabismus, sometimes also erroneusly called lazy eye, is a condition in which the eyes are misaligned. Strabismus usually results in normal vision in the preferred sighting (or "fellow") eye (the eye that the person prefers to use), but may cause abnormal vision in the deviating or strabismus eye due to the difference between the images projecting to the brain from the two eyes. Adult-onset strabismus usually causes double vision (diplopia), since the two eyes are not fixed on the same object. Children's brains, however, are more neuroplastic, and therefore can more easily adapt by suppressing images from one of the eyes, eliminating the double vision. This plastic response of the brain, however, interrupts the brain's normal development, resulting in the amblyopia. Recent evidence points to a cause of infantile strabism lying with the input to the visual cortex.
Strabismic amblyopes tend to show ocular motion deficits when reading, even when they use the nonamblyopic eye. In particular, they tend to make more saccades per line than persons with normal stereo vision, and to have a smaller reading speed, especially when reading a text with small font size.
Strabismus amblyopia is treated by clarifying the visual image with glasses, or encouraging use of the amblyopic eye with an eyepatch over the dominant eye or pharmacologic penalization of the better eye. Penalization usually consists of applying atropine drops to temporarily dilate the pupil, which leads to blurring of vision in the good eye. This helps to prevent the bullying and teasing associated with wearing a patch, although sometimes application of the eyedrops is more challenging. The ocular alignment itself may be treated with surgical or non-surgical methods, depending on the type and severity of the strabismus.
Refractive or anisometropic amblyopia
Refractive amblyopia may result from anisometropia (unequal refractive error between the two eyes). Anisometropia exists when there is a difference in the power between the two eyes. The eye which provides the brain with a clearer image typically becomes the dominant eye. The image in the other eye is blurred, which results in abnormal development of one half of the visual system. Refractive amblyopia is usually less severe than strabismic amblyopia and is commonly missed by primary care physicians because of its less dramatic appearance and lack of obvious physical manifestation, such as with strabismus. Given that the refractive correction of anisometropia by means of spectacles typically leads to different image magnification for the two eyes, which may in turn prevent binocular vision, a refractive correction using contact lenses is to be considered.
Frequently, amblyopia is associated with a combination of anisometropia and strabismus. In some cases, the vision between the eyes can differ to the point where one eye has twice average vision while the other eye is completely blind.
Deprivation and occlusion amblyopia
Deprivation amblyopia (Amblyopia ex anopsia) results when the ocular media become opaque, such as is the case with congenital cataract or corneal haziness. These opacities prevent adequate visual input from reaching the eye, and therefore disrupt development. If not treated in a timely fashion, amblyopia may persist even after the cause of the opacity is removed. Sometimes, drooping of the eyelid (ptosis) or some other problem causes the upper eyelid to physically occlude a child's vision, which may cause amblyopia quickly. Occlusion amblyopia may be a complication of a hemangioma that blocks some or all of the eye.
Treatment and prognosis
Treatment of strabismic or anisometropic amblyopia consists of correcting the optical deficit (wearing the necessary spectacle prescription) and often forcing use of the amblyopic eye, either by patching the good eye, or by instilling topical atropine in the good eye. There is increasing evidence that refractive therapy (corrective spectacles) should first be used alone, with visual acuity being measured regularly until the improvements to the visual acuity have come to a standstill, and that monocular improvement therapies such as patching should only be considered after this point. The reason is that for some of the patients the improvements that arise due to the corrective spectacles already solve the problem.
Concerning patching versus atropine, there is a drawback is using atropine as the drops can have a side-effect of creating nodules in the eye which a correctional ointment can counteract. One should also be wary of over-patching or over-penalizing the good eye when treating for amblyopia, as this can create so-called "reverse amblyopia". Eye patching is usually applied on a part-time schedule, that is about 4-6 hours a day. Treatment is continued as long as vision improves. It is not worthwhile continuing to patch for more than 6 months if there is no improvement.
Deprivation amblyopia is treated by removing the opacity as soon as possible followed by patching or penalizing the good eye to encourage use of the amblyopic eye. The earlier treatment is initiated, the easier and faster the treatment is and the less psychologically damaging. There is also a greater chance of achieving 20/20 vision if treatment is initiated as early as possible.
Clinical trials and experiments
Although the best outcome is achieved if treatment is started before age 8, research has shown that children older than age 12 and some adults can show improvement in the affected eye. Children from 9 to 11 who wore an eye patch and performed near point activities (vision therapy) were four times as likely to show a two line improvement on a standard 11 line eye chart than amblyopic children who did not receive treatment. Adolescents aged 13 to 17 showed improvement as well, albeit in smaller amounts than younger children. It is uncertain whether such improvements are only temporary, however, particularly if treatment is discontinued.
In an experimental study, older amblyoptic, non-strabismic children were instructed to watch television wearing their usual glasses with a patch over their stronger eye and an additional telescopic lens affixed to the side of the weaker eye to lessen the impact from accommodation, leading to improvements in the eye's visual acuity.
Virtual reality computer games where each eye receives different signals of the virtual world that the player's brain must combine in order to successfully play the game have shown some promise in improving both monocularity in the affected eye as well as binocularity.
A study, widely reported in the popular press, has suggested that repetitive transcranial magnetic stimulation may temporarily improve contrast sensitivity and spatial resolution in the affected eye of amblyopic adults. This approach is still under development, and the results await verification by other researchers.
The most recent study suggests that playing a version of the popular game Tetris that is modified such that each eye sees separate components of the game may also help to treat this condition in adults.
- Convergence insufficiency
- Stereopsis recovery
- Vision therapy
- Hess R.F., Thompson B., Baker D.H.: Binocular vision in amblyopia: structure, suppression and plasticity, Ophthalmic Physiol Opt. March 2014, Vol. 34, Nr. 2, pp. 146-162, doi:10.1111/opo.12123.
- Webber, JL; Wood, Joanne (2005). "Amblyopia: Prevalence, Natural History, Functional Effects and Treatment". Clinical and Experimental Optometry 88 (6): 365–375. doi:10.1111/j.1444-0938.2005.tb05102.x. PMID 16329744.
- American Academy of Family Physicians (2007). "Information from your family doctor. Amblyopia ("lazy eye") in your child". American Family Physician 75 (3): 368. PMID 17304868.
- McKee, SP., Levi, DM., Movshon, JA. (2003). "The pattern of visual deficits in amblyopia" (PDF). J Vision 4 (5): 380–405. doi:10.1167/3.5.5. PMID 12875634.
- Jeffrey Cooper & Rachel Cooper. "All About Strabismus". Optometrists Network. Retrieved 9 March 2008.
- Hess, R.F., Mansouri, B., Dakin, S.C., & Allen, H.A. (2006). "Integration of local motion is normal in amblyopia". J. Opt. Soc. Am. A 23 (5): 986–992. doi:10.1364/JOSAA.23.000986. PMID 16642175.
- A study of separation difficulty. Its relationship to visual acuity in normal and amblyopic eyes.
- Tyler, C.W. (2004). Binocular Vision In, Duane's Foundations of Clinical Ophthalmology. Vol. 2, Tasman W., Jaeger E.A. (Eds.), J.B. Lippincott Co.: Philadelphia.
- Wright, Kenneth W.; Spiegel, Peter H.; Thompson, Lisa S. (2006). Handbook of Pediatric Strabismus and Amblyopia. New York, New York: Springer. ISBN 978-0-387-27924-4.
- Levi, D.M. (2006). "Visual processing in amblyopia: human studies". Strabismus 14 (1): 11–19. doi:10.1080/09273970500536243. PMID 16513566.
- Lawrence Tychsen (2012). "The Cause of Infantile Strabismus Lies Upstairs in the Cerebral Cortex, Not Downstairs in the Brainstem". Archives of Ophthalmology 130 (8). pp. 1060–1061. doi:10.1001/archophthalmol.2012.1481.
- Kanonidou E., Gottlob I., Proudlock F.A.: The effect of font size on reading performance in strabismic amblyopia: an eye movement investigation, Invest. Ophthalmol. Vis. Sci. January 2014, Vol. 55, Nr. 1, pp. 451-459, doi:10.1167/iovs.13-13257.
- Kanonidou E, Proudlock FA, Gottlob I.: Reading strategies in mild to moderate strabismic amblyopia: an eye movement investigation., Invest. Ophthalmol. Vis. Sci. 2010, Vol. 51, Nr. 7, pp. 3502-3508, doi:10.1167/iovs.09-4236.
- Holmes, Repka, Kraker & Clarke (2006). "The treatment of amblyopia". Strabismus 15 (1): 37–42. doi:10.1080/09273970500536227. PMID 16513568.
- "Commonly Missed Diagnoses in the Childhood Eye Examination". American Family Physician. August 15, 2001.
- Angell et al.; Robb, RM; Berson, FG (1981). "Visual prognosis in patients with ruptures in Descemet's membrane due to forceps injuries". Arch Ophthalmol 99 (12): 2137–9. doi:10.1001/archopht.1981.03930021013004. PMID 7305711.
- Handbook, p. 127
- Brenda T. Barrett (2009). "Behavioral Optometry Review". Ophthal. Physiol. Opt. 29. pp. 4–25. doi:10.1111/j1475.1313-2008.00607.x.
- Anna L. Steele; Yasmin S. Bradfield; Burton J. Kushner; Thomas D. France; Michael C. Struck; Ronald C. Gangnon (2006). "Successful treatment of anisometric amblyopia with spectacles alone". Journal of AAPOS 10. pp. 37–43.
- C.E. Stewart; M.J. Moseley; A.R. Fielder; D.A. Stephens; and the MOTAS cooperative (2004). "Refractive adaptation in amblyopia: quantification of effect and implications for practice". British Journal of Ophthalmology 88. pp. 1552–1554. doi:10.1136/bjo.2004.044214.
- Amblyopia NEI Health Information
- Emmett T. Cunningham, Paul Riordan-Eva. Vaughan & Asbury's general ophthalmology. (18th ed.). McGraw-Hill Medical. ISBN 978-0071634205.
- Zhou, Y,et al. (2005). "Perceptual Learning Improves Contrast Sensitivity and Visual Acuity in Adults with Anisometropic Amblyopia". Vision Research 46 (5): 739–50. doi:10.1016/j.visres.2005.07.031. PMID 16153674.
- Polat, U, et al. (2004). "Improving Vision in Adult Amblyopia by Perceptual Learning". PNAS 101 (17): 6692–7. doi:10.1073/pnas.0401200101. PMC 404107. PMID 15096608.
- Williams, C; Northstone, K; Harrad, K A; Sparrow, J M; Harvey, I; Alspac Study, Team (2002). "Amblyopia treatment outcomes after screening before or at age 3 years: follow up from randomised trial". BMJ 324 (7353): 1549. doi:10.1136/bmj.324.7353.1549. PMC 116606. PMID 12089090.
- Pediatric Eye Disease Investigator Group (2005). "Randomized trial of treatment of amblyopia in children aged 7 to 17 years". Archives of Ophthalmology 123 (April): 437–447. doi:10.1001/archopht.123.4.437. PMID 15824215.
- Fariba Nazem; Samuel N. Markowitz; Stephen Kraft (February 2008). "Treatment of anisometropic amblyopia in older children using macular stimulation with telescopic magnification". Canadian Journal of Ophthalmology / Journal Canadien d'Ophtalmologie 43 (1). pp. 100–104. doi:10.3129/i07-184.
- Pippa Wysong: New advances in amblyopia treatment (downloaded 22 July 2013)
- Polat, U; Polat, Uri; Ma-Naim, Tova; Belkin, Michael; Sagi, Dov (27 April 2004). "Improving vision in adult amblyopia by perceptual learning". PNAS 101 (17): 6692–6697. doi:10.1073/pnas.0401200101. PMC 404107. PMID 15096608.
- BBC News: Video games tackle 'lazy eye'
- Eastgate, RM; Griffiths, GD; Waddingham, PE; Moody, AD; Butler, TKH; Cobb, SV; Comaish, IF; Haworth, SM; Gregson, R; Ash, IM and Brown, SM (2006). "Modified virtual reality technology for treatment of amblyopia". Eye 20 (3): 370–374. doi:10.1038/sj.eye.6701882. PMID 15832182.
- Benjamin Thompson, Behzad Mansouri, Lisa Koski, and Robert F. Hess (2008). "Brain Plasticity in the Adult: Modulation of Function in Amblyopia with rTMS". Current Biology 18 (14): 1067–1071. doi:10.1016/j.cub.2008.06.052. PMID 18635353.
- National Public Radio. "Magnetic Pulses To Brain Help 'Lazy Eye'".
- Robert F. Hess; Benjamin Thompson (February 2013). "New insights into amblyopia: binocular therapy and noninvasive brain stimulation". Journal of AAPOS 17 (1). pp. 89–93. doi:10.1016/j.jaapos.2012.10.018.
- Jinrong Li; Benjamin Thompson; Daming Deng; Lily Y.L. Chan; Minbin Yu; Robert F. Hess (2013). "Dichoptic training enables the adult amblyopic brain to learn". Current Biology 23 (8): R308–9. doi:10.1016/j.cub.2013.01.059. PMID 23618662. Retrieved 28 September 2013.
- Joseph Nordqvist: Tetris Video Game Helps Treat Lazy Eye, Medical News Today (MNT), 23 April 2013.
|Wikimedia Commons has media related to Amblyopia.|
- National Eye Institute (NEI) Resource Guide
- International Orthoptics Association
- Lazy Eye Site from the National Health Service, UK
- Stereo Sue information website by neurologist Susan Barry, healed of strabismus and stereoblindness at the age of 48
- Stereo Sue at TEDx
- Efficacy of full-time occlusion study Visual improvement is possible in almost all patients with severe amblyopia irrespective of their age with full-time occlusion therapy
- News articles
- BBC article on new study that finds lazy eye can be treated in teen years
- U.S. National Institutes of Health - Older Children Can Benefit from Treatment