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Brendan. Amblyopia: New Treatments. Pamela F. Gallin, M.D. Director, Pediatric Ophthalmology Children’s Hospital of New York Edward S. Harkness Eye Institute. IF Vision Screens were done as children THEN 2% - 5% of adults would NOT be legally blind !. Army Induction Studies.
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Amblyopia:New Treatments Pamela F. Gallin, M.D. Director, Pediatric Ophthalmology Children’s Hospital of New York Edward S. Harkness Eye Institute
IFVision Screens were done as children THEN2% - 5% of adults would NOT be legally blind!
What is Amblyopia? One eye is IN focus & One eye is NOT in focus your brain (occiput) does not see
Duke Elder Classification • Amblyopia ex Anopsia • Congenital (Organic) Amblyopia • Strabismic Amblyopia • Anisometropic Amblyopia
Amblyopia ex Anopsia(Anterior Segment) Stimulation deprivation amblyopia from lack of formation of retinal images Congenital Ptosis (lids) Corneal Opacification Congenital Cataract
2.Congenital (Organic) Amblyopia (Posterior) • Seemingly undetectable lesion ...but during treatment… no visual improvement… because of retinal or visual pathway dysfunction
3.Strabismic Amblyopia • Active inhibition or suppression of one retinal image by the cerebral cortex to eliminate the diplopia (double) by the deviating eye
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
Nobel Prize 1981 David Hubel Torsten Wiesel
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
Visual Cortex Occiput
LGN involved?? 1941 Le Gros Clark Journal of Anatomy 75, 419
Cerebral cortical inhibition (suppression) is:an active process at the level of LGN and calcarine cortex
American Academy of Ophthalmology • recommend vision screen at 3.5 years of age
Vision Screen • Allen Cards • E game • # Slide • Letters • New Techniques desktop VEP
Diopsys Results Norm Abnl
Dilated Cycloplegic Retinoscopy Mydriacyl 1% Cyclogel 0.5%, 1%, (2%)
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)
Suppression Brain shuts off image from out offocus eye
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 7.5 - 9 years
Exceptions: • Small differences… glasses (with Rx in 1 eye) can work • Large differences… need contact lens for one eye
The goal is 20/25 Maintain until 9 years of age
Treatment • Patching OcclusionTherapy • Penalization -optical -pharmacologic • Bangerter Films • New Techniques
Patching (Occlusion Therapy) • On face • adhesives vary • 1 week/year life …5 y.o. = 5 wks …1 y.o. = 1 wk
Brendan • 11 months • + 1.75 / - 7.00 • Patch and glasses
Optical Penalization • Pharmacologic atropine • Optical blur good eye with out of focus lens • Bangerter Film
Brendan wouldn’t wear patch andglasses So, we addedAtropine under the patch
Brendan wouldn’t wear patch at all, So, in addition to the Atropine, we added Bangerter film
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)
And because the difference between the 2 eye prescriptions was so high (and that is why he didn’t like the glasses) We added acontact lens with atropine in the other eye
Contact Lenses • used when the differences very high • after 9 years of age, when don’t want to wear glasses for one eye
After contact lenses AND 21 • Consider refractive surgery e.g. Lasik and others
Brendan had High Anisometropia(8.75) • glasses & patch • glasses & patch & atropine • glasses & patch & atropine & Bangerter film THEN • contact lens & patch & atropine
We knew that: Brendan had vision 20/70…from Diopsys And that: He would be Blind in that eye IFNothingwas done
October, 2002 Lasik Youngest child in world Vision 20/40!!!!! Dr. Jonathan Davidorf UCLA