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Amblyopia
Classification and external resources
ICD-10 H53.0
ICD-9 368.0
DiseasesDB 503
MedlinePlus 001014
eMedicine oph/316
MeSH D000550

Amblyopia, otherwise known as lazy eye,[1] is a disorder of the visual system that is characterized by poor or indistinct vision in an eye that is otherwise physically normal, or out of proportion to associated structural abnormalities. It has been estimated to affect 1–5% of the population.[2]

The problem is caused by either no transmission or poor transmission of the visual image to the brain for a sustained period of dysfunction or during early childhood. Amblyopia normally only affects one eye, but it is possible to be amblyopic in both eyes if both are similarly deprived of a good, clear visual image. Detecting the condition in early childhood increases the chance of successful treatment.

While the colloquialism "lazy eye" is frequently used to refer to amblyopia, the term is inaccurate because there is no "laziness" of either the eye or the amblyope involved in the condition. "Lazy brain" is a more accurate term to describe amblyopia. The term "lazy eye" is imprecise because it is also a layman's term for strabismus, particularly exotropia.

Contents

Physiology

Amblyopia is a developmental problem in the brain, not an organic problem in the eye (although organic problems can induce amblyopia which persist after the organic problem has resolved).[3] The part of the brain corresponding to the visual system from the affected eye is not stimulated properly, and develops abnormally. This has been confirmed via direct brain examination. David H. Hubel and Torsten Wiesel won the Nobel Prize in Physiology or Medicine in 1981 for their work demonstrating the irreversible 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.[4]

Symptoms

Many people with amblyopia, especially those who are only mildly so, 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 associated 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.[5] 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.[6] However perception of depth from monocular cues such as size, perspective, and motion parallax is normal.

Types

Amblyopia can be caused by deprivation of vision early in life by vision-obstructing disorders such as congenital cataracts, by strabismus (misaligned eyes), or by anisometropia (different degrees of myopia or hypermetropia in each eye). Ambylopia can also occur physiologically after tobacco or alcohol consumption.

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Strabismic amblyopia

A child wearing an adhesive eyepatch to correct amblyopia

Strabismus, sometimes erroneously also 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, but may cause abnormal vision in the deviating or strabismic eye due to the discrepancy between the images projecting to the brain from the two eyes.[7] Adult-onset strabismus usually causes double vision (diplopia), since the two eyes are not fixated 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. Strabismic amblyopia is treated by clarifying the visual image with glasses, and/or encouraging use of the amblyopic eye with an eyepatch over the dominant eye or pharmacologic penalization of it. 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 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.[8]

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 refraction between the two eyes. The eye which provides the brain with a clearer image (closer to 20/20) 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.[9] Frequently, amblyopia is associated with a combination of anisometropia and strabismus.

Pure refractive amblyopia is treated by correcting the refractive error early with prescription lenses and patching or penalizing the good eye.

Meridional amblyopia is a mild condition in which lines are seen less clearly at some orientations than others after full refractive correction. An individual who had an astigmatism at a young age that was not corrected by glasses will later have astigmatism that cannot be optically corrected.

Form-deprivation and occlusion amblyopia

Form-deprivation amblyopia (Amblyopia ex anopsia) results when the ocular media become opaque, such as is the case with cataracts or corneal scarring from forceps injuries during birth.[10] 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

Treatments

Treatment of strabismic or anisometropic amblyopia consists of correcting the optical deficit and forcing use of the amblyopic eye, either by patching the good eye, or by instilling topical atropine in the eye with better vision. 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" in the other eye.[8][11]

Form 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.[8]

Clinical trials and experiments

Although the best outcome is achieved if treatment is started before age 5, research has shown that children older than age 10 and some adults can show improvement in the affected eye. Children from 7 to 12 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.[8][12]

Vision therapy programs are occasionally partially effective on motivated adults, at least in the short term.[13]

A recent study,[14] widely reported in the popular press,[15] has suggested that repetitive transcranial magnetic stimulation may temporarily improve contrast sensitivity and spatial resolution in the affected eye of amblyopic adults. These results await verification by other researchers.

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.[16]

In another recent clinical trial conducted in a hospital in China and coordinated with a research program at University of Southern California, 28 of 30 patients being treated for amblyopia showed dramatic gains with some developing 20/20 vision. The treatment involved only the use of basic computer desktop software and vision training exercises.[17]

See also

References

  1. ^ 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.  
  2. ^ Weber, JL; Wood, Joanne (2005). "Amblyopia: Prevalence, Natural History, Functional Effects and Treatment" ( – Scholar search). Clinical and Experimental Optometry 88 (6): 365–375. doi:10.1111/j.1444-0938.2005.tb05102.x. PMID 16329744. http://www.optometrists.asn.au/gui/files/ceo886365.pdf.  
  3. ^ 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. http://journalofvision.org/3/5/5/McKee-2003-jov-3-5-5.pdf.  
  4. ^ Jeffrey Cooper & Rachel Cooper. "All About Strabismus". Optometrists Network. http://www.strabismus.org/detection_diagnosis.html. Retrieved 2008-03-09.  
  5. ^ 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 Opt Image Sci Vis 23 (5): 986–992. doi:10.1364/JOSAA.23.000986. PMID 16642175.  
  6. ^ 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.  
  7. ^ Levi, D.M. (2006). "Visual processing in amblyopia: human studies". Strabismus 14 (1): 11–19. doi:10.1080/09273970500536243. PMID 16513566.  
  8. ^ a b c d Holmes, Repka, Kraker & Clarke (2006). "The treatment of amblyopia". Strabismus 15 (1): 37–42. doi:10.1080/09273970500536227.  
  9. ^ "Commonly Missed Diagnoses in the Childhood Eye Examination". American Family Physician. August 15, 2001. http://www.aafp.org/afp/20010815/623.html.  
  10. ^ 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. doi:10.1001/archopht.99.12.2137 (inactive 2010-01-05). PMID 7305711. http://archopht.ama-assn.org/cgi/content/abstract/99/12/2137.  
  11. ^ Amblyopia NEI Health Information
  12. ^ 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.  
  13. ^ Treatment of Amblyopia (Lazy Eye)
  14. ^ 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. http://www.current-biology.com/content/article/abstract?uid=PIIS0960982208008087.  
  15. ^ National Public Radio. "Magnetic Pulses To Brain Help 'Lazy Eye'". http://www.npr.org/templates/story/story.php?storyId=92965339.  
  16. ^ BBC News: Video games tackle 'lazy eye'
  17. ^ USC News

5. Polat U, Ma-Naim T, Belkin M, Sagi D. Improving vision in adult amblyopia by perceptual learning. PNAS. 2004 Apr 27;101(17):6692-7. Epub 2004 Apr 19.

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