Results of Amblyopla Therapy in Eyes with Unilateral Structural Abnormalities

doi:10.1016/S0161-6420(92)31758-0

Ophthalmology

Volume 99, Issue 10, October 1992, Pages 1616-1621

https://doi.org/10.1016/S0161-6420(92)31758-0 Get rights and content

Purpose: The purpose of this study is to analyze the visual results of full-time occlusion therapy in pediatric patients with monocular structural abnormalities and amblyopia.

Methods: The authors reviewed the charts of visually immature patients with unilateral structural abnormalities and decreased visual acuity, who presented to the University of Iowa Hospitals and Clinics over a 20-year period, and underwent amblyopia therapy. The results were categorized according to the type of structural abnormality (i.e., partial media opacity, macula lesion, or optic nerve abnormality). Associated factors, including anisometropia, strabismus, age of presentation, and pupillary responses, were analyzed.

Results: Fifty-one percent of the 51 patients in the study achieved a visual acuity of at least 20/80, including 72% of the patients with media opacities, 42% with macular lesions, and 21 % with optic nerve anomalies. Strabismus and anisometropia occurred frequently and were not prognostically significant. Relative afferent pupillary defects did not contraindicate good results. Amblyopia recurred in 31 % of patients and was successfully treated with resumption of full-time occlusion. Occlusion amblyopia occurred in only one patient and was easily reversed.

Conclusion: The authors recommend a trial of full-time occlusion for patients with all three types of unilateral structural abnormalities. The patients with partial media opacities have a high success rate. Despite lower success rates for the other two groups, good results are possible; no better treatment option exists.

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There are more references available in the full text version of this article.

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Visual Function in Children With Posterior Lens Opacities Before and After Surgery
2022, American Journal of Ophthalmology
To evaluate the visual function before and after cataract surgery in children with congenital posterior lens opacities as well as the factors associated with a good visual outcome.
Perspective case-series study.
Pediatric patients with posterior lens opacities who underwent cataract surgery were recruited in this study. The cataract type, location, area of opacities, and strabismus were examined perioperatively. Moreover, visual acuity, modulation transfer function (MTF), ocular aberrations, and stereopsis were measured before and after cataract surgery.
Sixty-nine eyes of 63 patients were studied. The mean age of patients at surgery was 6.5 ± 2.9 years. Visual function including corrected distance visual acuity (CDVA), MTF cutoff frequency, and ocular aberrations were significantly affected in eyes with posterior lens opacities. Postoperatively, CDVA was significantly improved from 0.81 ± 0.53 logMAR to 0.40 ± 0.40 logarithm of the minimum angle of resolution (logMAR) (P < .001). Thirty-nine patients (56.5%) achieved a final VA of 20/40 or better. Moreover, MTF cutoff values were significantly improved, and total ocular aberrations were decreased after cataract removal (both P < .001). The stereopsis was also improved postoperatively (P < .001). The multivariate analysis of the risk factors for postoperative CDVA showed that worse preoperative CDVA, larger size of lens opacities, and mean keratometry were the risk factors (all P < .05).
Visual function can be significantly decreased in children with posterior lens opacities, and surgery was effective in improving visual function. Patients with a CDVA of 0.52 logMAR or better, a size of lens opacity <6.5 mm² and smaller mean keratometry had a greater CDVA postoperatively.
Diagnosis of amblyopia
2021, Journal de Pediatrie et de Puericulture
L’amblyopie est un trouble du développement qui intéresse l’ensemble du système visuel et du cortex visuel au-delà du cortex extra-strié. Le principal retentissement fonctionnel est une altération de l’acuité visuelle de l’œil dominé. Mais, tous les paramètres de la fonction visuelle sont perturbés puisqu’il peut être mis en évidence un déficit de la sensibilité aux contrastes ou de la vision stéréoscopique et une hyperacuité visuelle Vernier au niveau de l’œil « sain ». Ce trouble du développement ne peut s’installer qu’au cours de la période critique du développement cérébral, période de maturation et de plus grande plasticité cérébrale, et plus volontiers lors du pic de celle-ci, avant l’âge de 3 ans. Cette période est également celle au cours de laquelle la rééducation est la plus efficace. L’amblyopie est due soit à une privation visuelle, soit à un strabisme soit enfin à une anisométropie. Elle peut également s’associer à des troubles organiques lors de formes dites « mixtes ». L’amblyopie est définie par une différence d’acuité visuelle d’au moins une ligne d’acuité visuelle LogMAR. Hormis lorsqu’il existe un strabisme franc, ce déficit visuel reste souvent méconnu chez un enfant qui ne se plaint pas et voit bien d’un œil. C’est dire l’importance du dépistage, cherchant toutes les situations à risques telles qu’une différence de réfraction entre les deux yeux ou des facteurs héréditaires. Dans tous les cas, la confirmation de sa présence est indispensable avant la mise en route de la rééducation. Cette mise en évidence repose sur la mesure de la réfraction sous cycloplégie, le bilan ophtalmologique et orthoptique. L’acuité visuelle ou l’acuité de résolution peuvent être mesurées, avec des contraintes liées à l’âge. La rééducation nécessite pour être efficace la coopération active des parents. Elle repose ensuite sur la prescription de la correction optique totale déterminée sous cycloplégie qui peut parfois suffire à corriger cette amblyopie. La rééducation en elle-même est basée sur l’occlusion ou la pénalisation de l’œil sain permettant à l’œil dominé de développer sa vision et doit être complétée par un traitement d’entretien jusqu’à la fin de la période critique. En son absence, il existe un risque de récidive.
Amblyopia is a developmental disorder that affects the entire visual system and the visual cortex beyond the extra-striated cortex. The main functional manifestation is an impairment of visual acuity in one eye called “the dominated eye”. However, all the parameters of visual function are disturbed since it can be demonstrated a deficit in contrast sensitivity or stereoscopic vision. In addition, a Vernier visual hyperacuity is frequently observed in the “healthy” eye. This developmental disorder can only occur during the critical period of brain development, a period of maturation and greater brain plasticity, and more readily at its peak, before the age of 3. Rehabilitation is also most effective during this period. Amblyopia is due either to visual deprivation, or to strabismus or finally to anisometropia. It can also be associated with organic disorders in so-called “mixed” forms. Amblyopia is defined as a difference in visual acuity of at least one LogMAR visual acuity line. Except when there is a manifest strabismus, this visual deficit is often unrecognised in a child who does not complain and sees well with one eye. This shows the importance of screening, looking for all risky situations, such as a difference in refraction between the two eyes or hereditary factors. In all cases, confirmation of its presence is essential before starting rehabilitation. This demonstration is based on the measurement of refraction under cycloplegia, the ophthalmological and orthoptic assessment. Visual acuity or grating acuity can be measured by specific method according to the age of the child, with age-related difficulties. In order to be effective, rehabilitation requires the active cooperation of parents. It is then based on the prescription of total optical correction determined under cycloplegia which may sometimes be sufficient to correct this amblyopia. The rehabilitation itself is based on the occlusion or penalisation of the healthy eye allowing the dominated eye to develop its vision and must be supplemented by maintenance treatment until the end of the critical period. In its absence, there is a risk of recurrence.
Pickwell’s Binocular Vision Anomalies
2021, Pickwell's Binocular Vision Anomalies
Visual Outcomes in Presumed Congenital Foveal Toxoplasmosis
2020, American Journal of Ophthalmology
Citation Excerpt :
Kushner similarly found that amblyopia therapy improved vision in 7 patients with optic nerve abnormalities.4 Bradford and associates reviewed 51 patients with structural ocular lesions who underwent amblyopia therapy and noted that half achieved a visual acuity of 20/80, including 40% of patients with macular pathology.11 On review of the literature, we did not find reports of amblyopia treatment for macular-involving toxoplasmosis specifically.
Congenital macular lesions attributed to toxoplasmosis may limit potential visual acuity. The appearance and location of these scars may cause physicians to overlook associated amblyopia. This study reviews the visual outcomes and benefits of amblyopia therapy in children with foveal toxoplasmosis scars.
Retrospective observational case series.
Setting: Single center. Patient Population: Children with presumed foveal toxoplasmosis scars who underwent amblyopia treatment. Main Outcome Measure: Charts were reviewed for amblyopia treatment, fundus photographs, optical coherence tomography (OCT), and visual acuity.
Median age at presentation was 2.8 years and median follow-up was 6.2 years. Occlusion therapy was undertaken in 9 patients. Median duration of occlusion therapy was 1.7 years. Six patients improved with occlusion therapy (average 4.6 lines gained on optotype acuity). Final visual acuity ranged from 20/25 to 20/250, with 6 of 8 patients better than 20/80. OCT confirmed macular scars in 5 patients, with varying degrees of foveal architecture disruption.
Despite the striking appearance of the lesions in patients with presumed foveal toxoplasmosis, visual potential may be better than expected. The appearance of the lesions is not always predictive of visual outcome. A trial of occlusion therapy to treat amblyopia should be initiated in these patients to ensure that they reach their maximal visual potential.
Rehabilitation on functional amblyopia in Morning Glory Syndrome
2007, Journal Francais d'Ophtalmologie
Le Morning Glory syndrome ou papille en fleur de liseron fait partie du groupe des anomalies congénitales du nerf optique. Ce syndrome est rare, prédominant chez les filles, et en général unilatéral. Il est découvert généralement sur un nystagmus, un strabisme ou une amblyopie.
Nous rapportons l’observation clinique d’une enfant âgée de 2 ans et demi, adressée pour découverte d’un syndrome de Morning Glory gauche associé à une amblyopie sévère (1/10^e Rossano 1/20^e) et à une ésotropie. Le bilan pluridisciplinaire retrouva des anomalies du système nerveux central avec encéphalocèle basale. Une prise en charge rapide de la part fonctionnelle de l’amblyopie permit une récupération d’acuité visuelle de 7/10^e Rossano 1/2 à 1 an.
L’intérêt d’une rééducation de la part fonctionnelle de l’amblyopie dans les anomalies organiques du nerf optique est essentiel. Un enfant présentant un Morning Glory syndrome, dépisté pendant la période de maturation sensorielle, doit bénéficier d’un traitement rapide par occlusion totale, suivi d’un traitement d’entretien. Cet aspect de la prise en charge peut éviter, dans certains cas, une amblyopie profonde. Par ailleurs, un suivi ophtalmologique régulier est nécessaire en raison du risque de décollement de rétine, ainsi qu’un suivi multidisciplinaire, pour dépister une anomalie cytogénétique, un syndrome CHARGE, des anomalies du système nerveux central ou encore des troubles endocriniens.
Le pronostic visuel d’un enfant présentant un Morning Glory syndrome ou une autre anomalie organique, ne peut être qu’amélioré, si un traitement par occlusion n’est pas négligé pendant la période de réversibilité de l’amblyopie. Ce cas en est une illustration.
Morning Glory syndrome, characterized by an enlarged dysplasic optic disc with glial tissue, is one of the congenital anomalies of the optic nerve. This syndrome is rare, prevalent in the girls, and generally unilateral. It can be revealed with nystagmus, strabismus, or amblyopia.
We report the clinical observation of a 2.5-year-old girl, referred for the diagnosis of Morning Glory syndrome in the left eye with severe amblyopia (1/10 Rossano 1/20) and esotropia. This syndrome has associated central nervous system anomalies with a basal encephalocele. Treated with functional amblyopia therapy, visual acuity was 7/10 Rossano 1/2 after 1 year.
Rehabilitation on functional amblyopia in organic optic nerve anomalies is essential. A child with a Morning Glory syndrome, detected during the period of sensory maturation, must be treated with occlusion therapy, followed by maintenance treatment. This part of the treatment can prevent deep amblyopia. Moreover, regular ophthalmologic follow-up to detect complications of retinal detachment and multidisciplinary follow-up to detect a cytogenetic disease, CHARGE syndrome, or association with endocrine and central nervous system anomalies are necessary.
The author recommends occlusion therapy for children with Morning Glory syndrome or other organic asymmetric optic nerve anomalies, during the period of amblyopia reversibility. Most patients’ vision improves after treatment. This case is an illustration.
Refractive laser surgery in children with coexisting medical and ocular pathology
2006, Journal of Cataract and Refractive Surgery
Citation Excerpt :
Additionally, they hypothesize that the enforced iatrogenic visual impairment resulted in significant psychosocial harm and developmental delay in their patient population. Still, despite variable success rates in treating amblyopia associated with structural pathology, Bradford et al.15 recommended full-time occlusion because no better treatment option existed at the time. Amblyopia in the defocused eye caused by anisometropia or bilateral high refractive error, including astigmatism or nystagmus, often responds well to glasses if the amount of anisometropia is 3.00 D or less.20
To report the visual, refractive, and functional outcomes of photorefractive keratectomy (PRK) and of laser-assisted subepithelial keratectomy in a group of children with significant refractive error and underlying medical conditions or ocular pathology who were noncompliant with traditional management.
Nonhospital surgical facility and a hospital clinic.
This case series comprised 5 individual cases of anisometropic amblyopia and/or high myopia. Underlying medical and ocular conditions were as follows: upper eyelid hemangioma with oblique myopic astigmatism, Pelizaeus-Merzbacher leukodystrophy with nystagmus, Klippel-Trenaunay-Weber syndrome with glaucoma, incontinentia pigmenti with unilateral optic nerve atrophy, and Goldenhar syndrome with unilateral optic nerve hypoplasia. Photorefractive keratectomy or LASEK was performed in 6 eyes of 5 patients. Age range at the time of surgery was 1.0 to 7.0 years. All procedures were performed under general anesthesia.
Best corrected visual acuity improved by 2 lines in 2 patients and 1 line in 2 patients by 6 months after surgery. Stereopsis and/or fusional status improved in 3 patients. Amblyopia treatment compliance improved in 1 patient. Alignment improved without strabismus surgery in 2 cases. A functional vision survey demonstrated a positive effect on the ability of all 5 children to function in their environment.
During the period of visual cortical plasticity, refractive surgery, by eliminating the refractive component of amblyopia and by promoting fusional ability, provides considerable improvement in children, even those with underlying medical conditions associated with ocular pathology.

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: Supported in part by an unrestricted grant from Research to Prevent Blindness, Inc, New York, New York.

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Results of Amblyopla Therapy in Eyes with Unilateral Structural Abnormalities

Am J Ophthalmol

Surv Ophthalmol

Ophthalmology

Optic nerve hypoplasia with good visual acuity

Arch Ophthalmol