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*infants should have their first eye exam at 6 months of age, then 1 year, then 3 years, and then
start of school

Functional vs. organic amblyopia

● organic amblyopia: results from congenital defects or later insults to the visual pathwyas
○ generally not remediable once damage is done, can be some resolution in
certain cases (nutrritional, toxic)
● functional amblyopia results from aberrant input to the visual system

Does therapy for amblyopia work?

● Amblyopia Treatment Studies (ATS)
● administered through PEDIG (1997)
○ funded by NEI through NIH
○ multicenter (80 sites): 132 MDs at 63 sites, 52 ODs at 17 sites
○ randomized trials
○ large patient pool
● These studies have been helpful in determining what treatments are effective, in what
dosese, and for what age groups

ATS studies: ATS 1

● ATS1: daily use of atropine was as effective as 6 hours daily patching (6 hours to full
time) for moderate amblyopia (to 2 yeras post treatment) ages 3-7
○ both work, patching produced more RAPID chagnes

ATS 2: How much patching?

● patching 2 hours vs. 6 hours for moderate amblyopia (20/40-80)
● patching 6 hours vs. full time for severe amblyopia (20/100-400) in children 3-7
● Results:
○ with near activities, 2 hours=6 hours for moderate
○ with near activities, 6 hours=full time for severe amblyopia

ATS 2B: Weekend or daily atropine

● ATS 2B: daily vs. weekend atropine for moderate amblyopia in children age 3-7
○ weekend appears to be as effectiv as daily
○ increased complaints of sun-sensitivity in weekenders
ATS 2C
● Amblyopia recurrence study: 156 children with successfully treated amblyopia who were
ready to stop treatment
○ overall 24% recurrence within one year
○ roughly equal numbers for patching and atropine

ATS 3: children 7-18 YO

● assigned to various groups
○ optical correction alone (control group)
Page 2 of 18 (Steiner’s Material: Treatment of Amblyopia)

○ patching (2-6 hours)

○ patching with near activities
○ atropine (7-12 YO only)
● results: in about ¼ of amblyopes aged 7-18, vision improved with correction
alone!
● 7-12 YO: improvement occurred whether or not previous interventions had been
attempted
● 13-17 YO: patching made a difference if they had no previous treatment; much less
improvement in previously treated patients

ATS 5: Treatment of anisometropic amblyopia in children with refractive correction alone

● studied previously untreated aniso amblyopic children
● rechecked acuity every 5 weeks as long as acuity was improving
● mean improvement 2.9 lines +/-1.8
● 20/40-100 baseline (N=66): 2.8 lines
● 20/125-250 baseline (N=18): 2.9 lines
● What made for better VA retention?
○ better baseline acuity (P=0.02)
○ lower anisometropia (P=0.03)
● age was NOT a significant factor (P=0.40)
● Giving refractive correction alone resolved amblyopia in roughly ½ of 3-7 YO with aniso
amblyopia
● moderate amblyopes had best resolution. Mean improvement ~3 lines of VA
● clinical pearl: attempt the best care with the least burden on your patients
○ reasonable to begin treatment with spectacle wear alone
○ educate parents that patching might be necessary, especially for deeper
amblyopia
○ better binocular skills can help lock in VA

ATS: treatment of strabismic amblyopia with spectacles alone

● 12 patients, constant strabismus, amblyopia, no prior treatment
● prescribed glasses. VA checked every 5 weeks until no improvement noted
● mean improvement 2.2 (+/- 1.8 lines)
○ 9/12 patients gained 2 or more lines
○ resolution for amblyopia seen in 3 patients
● study was SMALL
● results likely depend on magnitude of strabismus and other adaptations
● takeaway: try spectacles first and educate that there will likely be patching, VT in the
future
● Allowing VA to improve first with spectacles alone will make patching compliance easier

2 hours patching or glasses alone?

● 180 children with strab or aniso amblyopia, VAs from 20/40-400
● Had worn Rx for at least 16 weeks or 2 study visits without improvement
Page 3 of 18 (Steiner’s Material: Treatment of Amblyopia)

● assigned to either:
○ 2 hours patching with near activities
○ eyeglasses alone
● modest gain shown after 5 weeks with patching
● Older children can be helped thorugh amblyopia treatment but prognosis is more
guarded (ages 12+)
● 2 hours of patching works well for moderate amblyopia; more is better for more severe
● parents, patients are accepting of atropine treatment
● most gains are seen within 3 months but additional gains do occur with time
● stopping treatment abruptly is associated with higher risk of recurrence, so a TAPER of
treatment is a good idea
● Further studies will yield more information about treatment in older amblyopes and how
in-office training aids acuity gain/retention

So now you want to treat

● you must determine a prognosis
○ consider previous interventions, patient age
○ consider depth of amblyopia, adaptations, co-morbid conditions
○ consider testing:
■ 2.2 telescope, ND filter, laser interferometry, OCT, contrast sensitivity,
various acuity parameters
● i.e. for -15.00 OD and pl OS, do VEP and OCT
○ Consider patient motivation and ability to comply with tx plan.

You want to treat, but do they want your tx?

● tell patients/parents clearly and tactfully the details of your results and what they mean in
terms of function
● demonstrate whenever possible
● what is likely outcome of doing nothing?
● talk about time, energy, financial commitment
● talk about likely length of process

So after treatment, my eyes will be normal?

● acuity should improve
● basic visual skills should improve
● perceptual skills should improve
● microperimetric deficits can be demonstrated in the amblyopic eye before and after
successful therapy (also in the dominant eye)
● contrast sensitivity can remain unequal

*amblyopic eyes have different saccadic latencies. An increased latency=longer to start making
saccades.
*Determining JND: if VA is 20/150, their JND is +/-1.50!
Page 4 of 18 (Steiner’s Material: Treatment of Amblyopia)

Mono-in-a-bino field (MFBF)

● both eyes are open but only one sees the target
● achieved through color cancellation, polarized images, LCD programs

●
○ pt. wears R/G glasses.
■ example on left:
● red eye will see letters
● green eye: background will look green. It’ll blend into the
background
● good setup for OD (red eye) amblyopia
■ example on right:
● red eye will see background and see it as red. font will blend into
background
● green eye will see background as green and make letters olive
color
● good set up for OS (green eye) amblyopia
● MFBF work starts to introduce to the visual system the idea that the input from the
amblyopia need NOT be suppressed
● Which is more of a challenge?

○
■ left side: with R/G glasses, this set up is for OD amblyope! For OS, the
green will wash print out and blend in with black background.
● Things that are harder to suppress are…
○ larger
○ moving
○ bright/brightly colored
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● As tendency to suppress fades, one can introduce either targets seen only by the
dominant eye or targets visible to both eyes. How do you make things harder for
patients?

○
■ introduce things both eyes can see! On left, you only have black square.
On right, you see white surround (seen by both eyes).
■ make half of letters red and half that are some shade of green to make it
harder

Binocular training
● Can generally begin when acuity improves to about 20/50**
● Includes use of:
○ vectograms
○ stereo cards (keystone cards, i.e.)
○ Brock string
○ lifesaver, eccentric circle
○ computer programs

Binocularity is a lock to acuity

● building the most normal binocular system possible is important to prevent future
suppression of non-dominant eye
● In cases of eccentric fixation, advanced binocular training might not be possible
● What about EF?
○ we’ll discuss this in next lecture

Sequencing of therapy (basic plan):

● improve acuity through refractive means
● improve acuity via patching
● begin work on basic eye movement skills
● begin work on accommodative skills
● work bi-ocular and then binocular skills

Home treatment activities

● filling in circular letters
● coloring
Page 6 of 18 (Steiner’s Material: Treatment of Amblyopia)

● puzzles
● connect the dots
● bead stringing
○ cheerios on a spaghetti noodle
○ spearing berries with a toothpick
● I-spy books/hidden pictures
● model kits
● video games
● TV is not
● good to provide handouts to give ideas
● rolling a ball back and forth
● line counting (draw parallel lines and pt. counts the lines. As acuity improves, make
lines closer together)
● ball toss/catch
● red acetate activities (eye looking through red lens will have access to information
● amblyopia iNet computer program

Accommodative training
● must be able to see difference between blurry and clear
○ lens sorting (differentiate +/-, power order)
○ near-far rock
○ monocular accommodative rock
○ lens tromboning
○ bi-ocular rock (spirangle, red rock)
○ binocular accommodative rock with suppression check

Fixation is very important!

● Most EF is within 2PD from fovea

○ 3PD is BAD
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● I.e. 2PD of steady EF

○ 2PD+1PD=3. 3x20=60
○ assume 20/60 is from not fixating with fovea
○ So if patient was 20/400, VT is still possible to make it a more functional eye.
**amblyopia seems to involve active suppression of the non-dominant eye
**ATS: about 25% of young children with amblyopia had resolution of amblyopia with spectacle
wear alone

● answer: choice 1--

○ we want green eye (OS) to see the target. When green eye looks at
background, the background will look green and target will look brown.

Choice 3+4: black will be seen by both eyes. OD sees what’s there. green eye interacts with
red print making it look black, blending in with background color.
*choice 3: both eyes will see target as black on both eyes. red eye: print will look reddish (will
show up on dark target). green eye will see black
*choice 4: green eye makes red background look dark, blending with print

EOMs
● unless strabismus exists, should not have a limitation on extent of range of motion
● can have deficits in steady fixation of a still or moving target
○ ???what’s a good way to grade fixation???
● can have difficulty following a moving target smoothly without gain or lag
● will likely have inaccuracies of self-generated pursuits and saccades (sacccdadic
substitution)
● Testing
○ extent of movement
○ steady fixation ability
○ slow pursuits
○ saccades
Page 8 of 18 (Steiner’s Material: Treatment of Amblyopia)

○ reading eye movement testing

■ DEM, King-Devick, Visagraph
○ infrared eye tracking systems
● patients need help initially understanding how their eyes are movinga dn where they are
moving
● good early techniques
○ fixations with verbal feedback
○ monocular prism jumps
■ start with larger powers and work down
○ smooth pursuits with verbal feedback
● four corner saccades
● chalkboard saccades
● stationary pegboard

Binocular skills
● suppression in amblyopia limits development of binocular skills
● generally accepted that binocular training can begin when acuity in amblyopic eye is
~20/50
● work from large, peripheral targets to smaller, central targets
● Level 1: simultaneous awareness
○ dog and pig on Keystone card #1 (if each eye can see target)
○ red/green lustre
● Level 2: flat fusion (common points)
○ red/white/blue dots on Keystone card #3
■ each eye sees white dot. Only one eye sees red dot, and only one
eye sees blue dot. If you have flat fusion, you see straight up and
down line of 3 dots. If eso/exo diplopia, you see four dots
○ worth 4 dot (white dot on bottom should be a fusion of both red and green)
● Level 3: stereopsis
○ randot, stereo fly

Perceptual training
● amblyopic eyes do NOT transmit information to the visual system at the same rate
normal eyes do, causing a mismatch between the eyes
● This can affect development of:
○ vision/binocularity
○ speech development
○ motor skills
○ perceptual skills

Areas of perceptual training

● speed of processing
Page 9 of 18 (Steiner’s Material: Treatment of Amblyopia)

○ understanding information quickly and being able to use it, make decisions about
it
● spatial skills
○ how do this relate to each other; how do parts form a whole; visual closure skills;
visual figure ground; visualization skills (being able to picture something in your
mind and see how it would be different if you turned it around or added
something to it/put it in a different situation)
○ i.e. tetris, hand grams, geometry. Visual closure skills
○ Figure ground: in a crowded field of view, can you pick out what’s important?
● sequential processing
○ understanding the importance of order; memory skills; important in multi-step
processes

Perceptual skills
● necessary for understanding the world
● necessary for learning
● necessary for vocational/avocational activities
● strabismic amblyopes have demonstrable alterations in their perception of visual space

●
○ i.e. an EXO patient will draw lines FURTHER away

Spectacles
● best option for starting therapy in most cases
● often worry about anisometropia
○ clinically, people adapt to large lens differences fairly readily, especially children
○ trial frame prescriptions, definitely when new, a significant change, or whenever
you have concerns
○ good to let people move, read, etc, before prescribing
● bifocals
○ *lined--better for starting out for kids--they can see the image jump
○ progressives--great for post-cataract patients (these patients are presbyopic!**)
Page 10 of 18 (Steiner’s Material: Treatment of Amblyopia)

● Glass: nice abbe value (higher the better)

● CR-39: nice abbe value as well, can get thick in higher Rx
○ doesn’t scratch as easily
● polycarbonate: impact resistance

Occlusion
● the amblyopic eye picks up fixation when dominant eye is atropined
● Types:
○ direct
○ inverse--cover the amblyopic eye to destabilize EF
○ sectoral--cover one part of the lens (more for strabismus treatment to give people
feedback) and to taper off treatment
○ pharmacologic
● tools: patches, bangerter foils, blur (lenses, tape, nail polish)

**Bruchner reflex: the amblyopic eye will have brighter reflex since the fovea has a lot of
pigment to ABSORB light. So if you’re using another part of the retina (less pigment), you’ll get
more light getting reflected back.

Bangerter foils
● cling to specs
● translucent
○ graded acuity reduction options: 20/800 to 20/25???confirm range
○ cosmesis is very good
Page 11 of 18 (Steiner’s Material: Treatment of Amblyopia)

● good for highly motivated patients

● also good to eliminate diplopia/distortion in patients with macular degeneration, muscle
palsies

Blur
● can be induced by changing dominant eye’s prescription
● can be done by stippling the dominant eye’s lens (tape or nail polish works well)
● pro: full time solution with good cosmesis
● con: full time, can peek around lens

Pharmacologic: Atropine
● typical dose is 1% via drop or ung
● schedule depends on severity of amblyopia and stage of therapy
● start with 2-3x weekly instillation and adjust
● side effects (rare if instilled properly)
○ redness and irritation; enlarged pupil; blur; breathing difficulties; chest/facial
flushing; fevers; convulsions; psychological disturbances
● pros: near full time tx; no need for patching, well accepted by patients/parents
● cons: some children do not like gtts; parent concerns about side effects; possible
iatrogenic amblyopia; sun sensitivity
● **initial results are slower than with patching, but do come
● need to taper treatment

VT
● Modulating stimuli: need to gradually increase level of difficulty
● black=accommodation
● red=oculomotor
Factor Easy Harder

stimulus cues blur and size (near card blur vs. size (loose lens
trombone) rock)

(not crowded) (lots of crowding)

stimulus presentation smooth (ML trombone) step (MAR)

(slow) (fast)

stimulus type large/isolated (L A R G E) small/crowded

(tinylittlefont)

(crowded seriffy type

letters)

cognitive demand none (near far rock) words, sentences ,

equations (...with
Page 12 of 18 (Steiner’s Material: Treatment of Amblyopia)

metronome clapping on
vowels)

(Hart chart coordinates,

Marsden ball with
loading)

environment free space, tactile in instrument, no tactile (on

reinforcement (holding a computer)
near card)
(distracting)
(quiet)

JND large (>3D) (lens sorting small (0.25D) (lens

2D steps) sorting 0.25D steps)

occlusion monocular (OD/OS only) binocular, biocular (split

spirangle)
● these concepts apply to all areas of therapy:
○ accommodation
○ oculomotor skills
○ binocularity
○ perception: the state of being or process of becoming aware of something
through the senses, a way of regarding, understanding, or interpreting
something; a mental impression.
JND’s
● Examples:
○ 10 PD vs. 4 PD monocular prism jumps
○ small vs. large lens changes
○ ability to judge distances when clown vectos are set at #2 and #10 vs. set at #2
and #4
Anti-suppression
● simplest technique: MFBF (monocular in a binocular field)
○ both eyes are open but only one has access to visual information
○ achieved via:
■ R/G or R/B cancellation
■ polaroid filtration
■ LCD glasses
○ MFBF activities
■ red acetate/green lens over dominant (non-amblyopic) eye
■ red acetate/ red-green glasses on
■ smaller red targets
■ targets that are partially accessible to dominant eye
○ goal: be able to accept input from each eye without suppression

How do I get these activities?

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● Purchase
○ Bernell
○ R/G Toybox
○ Alona King, O.D.
● make them
○ color copying (get a test print!)
■ i.e. have kinkos print in red on white background. if red over right eye,
green over left eye. The green/left eye will see the print!
○ pink/orange highlighter
○ homemade light boards
■ materials:
● R/G acetate sheets (photo supply or Bernell)
● white paper
● sheet protector (optional but handy)
● flashlight, penlight, transilluminator

EF
● a major stumbling point to training
● diagnosed via:
○ visuoscopy
○ MIT/Haidinger brush testing
○ Afterimage transfer testing--make sure patient has NRC! If they have amblyopia,
DO ECCENTRIC FIXATION TESTING!

Pleoptics
● “Equal optics”
● Idea: make using the EF point less desirable than using the fovea. It’s a training
technique for amblyopia!
● How: selectively bleaching the retina with a euthyscope or modified direct o-scope.
Home devices and also be created
● Approaches
○ Bangerter
■ pleoptophore
■ bleached retina with fovea shielded. Stimulated with fovea with flashing
light (up to 100x) repeat several times, do fixation activities.
○ Cuppers
■ euthyscope
■ bleach ring around the fovea. use this ring to provide feedback during
fixation tasks
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■
● Does pleoptics work?
○ successful in cases that did not respond to occlusion alone
○ on average, 52% adult patients achieved 20/40 or better acuity (range 38% to
100%)

Trying to change EF
● inverse patching (patching amblyopic eye)
○ amblyopia is an active process of suppression
○ EF develops as an adaptation to avoid binocular stress
○ removing anomalous input from the system should remove the need for the
adaptation. if you take the anomalous input from amblyopic eye out of the
picture, then in theory it should remove the need to have the adaptation in the
first place. goal: to destabilize the adaptation
○ amblyopic eye should be patched during most waking hours
○ generally patch 1-2 months to see results (monitor for iatrogenic amblyopia)
○ use for patients who have unsteady fixation (using fovea sometimes)
● reverse/inverse prism
○ use enough prism to give them constant diplopia, then fog dominant eye.
○ BI prism will shift light in amblyopic eye to novel place.
○ Fogging dominant eye, amblyopic eye will be searching to take up fixation and
hopefully go back to fovea and stay there
● controlled foveal stimulation
○ giving feedback mechanism so that patient knows when they’re using their fovea
○ if patient doesn’t have ARC ,when you flash fovea of one eye,the after image
should be transferred to fovea of other eye. use that to give patient feedback
about what part of eye they’re using.
Page 15 of 18 (Steiner’s Material: Treatment of Amblyopia)

■ you can do Hart chart activities once you covered up the dominant eye
that had been flashed.
■ once the amblyopic eye sees the afterimage, the patient can put it on
various targets
■ this is also a way to try to elicit better VA during an amblyopia evaluation
■ *****YOU MUST know whether or not your patient has ARC for this to
work!
● ***???review how to make someone have NRC again***
● Haidinger brush
○ the brush is generated ONLY at the fovea via the interaction of polarized light
with the NFL
○ result: if you can appreciate a Haidinger's brush, you can tell where your fovea is
looking
○

???patients can actually move their haidinger brush through a maze? Can
normal ppl do this???
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**We might not be able to improve VA to 20/20 but the therapy we do will help make the visual
system more functional

Midterm coverage:
● Kapoor: 23 questions
● Ciuffreda: 21 T/F questions
● Amblyopia treatment (Steiner): 15 questions
● *know how to interpret DEM and visagraph

*you can start binocular training when VA is about 20/60

Side effects of atropine and cyclopentolate

● Atropine:
○ conjunctival edema, angle closure, increase in IOP, skin flush, thirst, fever,
tachycardia, mental disturbances, sleepiness, convulsions
○ effects last 7-12 days
○ contraindicated in patients with belladonna allergies and in patients with
Down’s syndrome
● Cyclopentolate (1%)
○ eye irritation, keratitis (at doses of over 100 drops per day for several months),
drowsiness, emotional disturbances, IOP elevation, grand mal seizures (rare)
○ contraindicated in patients with spastic paralysis and brain damage
**usually RTC in 1-2 weeks if putting a patient on pharmaologic penalization. Have patient
come in per month to asses VA. You may stop abruptly or taper drops

Jeopardy
1. Amblyogenic factors
a. Isometropia
i. A >2.50
ii. H >5.00
iii. M >8.00
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b. Anisometropia
i. A >1.50
ii. H >1.00
iii. M >3.00
2. **If patient is suppressing an eye on cheiroscopic tracing, the pictures will look
superimposed.
3. **On the keystone, if patient sees only dog or pig but not both, it means they’re
suppressing!
4. S-chart/Flom-chart: Landolt C’s and tumbling E’s
a. useful for assessing amblyopic patients whose fixation status might exacerbate
the crowding effect
b. The S-Chart is a series of 21 slides ranging from VA‘s of 20/9 (Slide #1) to
20/277 (Slide #21).
5. Three descriptive factors important when assessing EF
a. direction
b. stability
c. magnitude
6. Reverse/inverse patching can be used to destabilize EF in a therapy patientw tih
recalcitrant (uncooperative) amblyopia
7. Expected acuity equation for EF: 20/20(EF+1)
8. Overcorrecting prisms are used to eliminate eccentric fixation to amblyopia
9. false: “in anisometropic amblyopia, typical VA might be 20/200, with little if any EF
present”
a. in anisometropic amblyopia, VA is usually better, and usually 80% have EF
10. OD +0.50 to 20/20, OS: +5.50 to 20/80. VIsuoscopy OS: 1.0 PD unsteady nasal. foveal
~5% of the time. VA with AI transfer OS: 20/40
a. bad prognosis. After image (AI) is hopeful.
11. 12 YO, amps 13 OD/OS, acc. facilities 5 OD, 5.5OS, 4 OU (plus is harder), NRA/PRA:
+1.00/-1.75, FCC -0.75H
a. diagnosis: AE, or accommodative spasm
12. executive bifocal benefit: for non comitant strabismus
a. can put different amount of prism in distance and near**
13.
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● error score: age average--not bad

● ratio score: age average--not bad
● H and V score is similar
● rand dysfunction?? getting words out seem to be a problem. poor-automaticity
of saying the numbers!
● expressive language, speed of processing problem...VT will NOT help
● **if automaticity problem and OMD problem, then all scores will be bad.
14. True: amblyopia is the leading cause of legal blindness in those under 40 YO
15. True: the etiology of EF may be related to the phenomenon of monocular spatial
distortion, especially in strabismic amblyopes