Amblyopia discussion Flashcards
Important to
- Diagnose presence of amblyopia
- Determine type of amblyopia
- Know which tests used to investigate amblyopia
- Know expected findings
Types of amblyopia
Meridional
Strabismic
Stimulus deprivational
Anisometropic
Refractive
Ammetropic
Toxic
Aims and stages of management
TO ACHIEVE AND MAINTAIN MAXIMUM VISUAL ACUITY
1) REMOVE ANY CAUSE FOR STIMULUS DEPRIVATION AND CORRECT REFRACTIVE ERROR. ALLOW PERIOD OF TIME (UP TO 18 WEEKS) FOR REFRACTIVE ADAPTATION
- ) CHOOSE APPROPRIATE FORM OF OCCLUSION/PENALISATION THERAPY
3.) TAPER DOWN TREATMENT ONCE MAX VA ACHIEVED AND OBSERVE FOR
STABILISATION OF ACUITY
4.) GO BACK TO (2) IF VA IS NOT MAINTAINED
Evidence suggests..
tapering has more stability in VA
More amblyopia is treated suppression goes down
Stable aniso can be seen by optom
Occlusion amblyopia if
Patch worn for too long
Management if affected by
AGE?
LEVEL OF VA?
FIXATION?
LATENT NYSTAGMUS?
PATIENT / PARENT CHOICE?
Affect of nystagmus on amblyopia
More oscillation in nystagmus reduces VA
PEDIG
2 hours PEDIG mod to mild
4 hours more
Types of contact lenses used for occlusion
HIGH PLUS LENS
OPAQUE CONTACT LENS
Why are CLs used sometimes
Patients with no IOL
What is past pointing
Used for reduced vision children test good eye first and amblyopic eye next- can indicate eccentric fixation
Past pointing method
RELATED TO LOCALISATION
CHECK NON-AMBLYOPIC EYE FIRST
HOLD A PEN APPROX. 25CM IN FRONT OF PATIENT AND ASK TO
TOUCH THE PEN WITH THEIR FINGER
REPEAT WITH AMBLYOPIC EYE
IF FINGER POINTS A FEW CMS TO THE SIDE THEN PAST POINTING HAS BEEN DEMONSTRATED
DON’T REPEAT TOO MANY TIMES AS PATIENTS ADAPT
INDICATES ECCENTRIC FIXATION
Current amblyopia treatment ideas
ATROPINE IS EQUALLY AS GOOD AS PATCHING
REFRACTIVE ADAPTATION CAN RESOLVE AMBLYOPIA WITHOUT THE NEED FOR OCCLUSION SO DON’T COMMENCE OCCLUSION UNTIL ADAPTATION IS COMPLETE
THERE IS LITTLE EVIDENCE THAT THE YOUNGER YOU START OCCLUSION THE BETTER
THE MORE OCCLUSION YOU DO DOES NOT GIVE BETTER OUTCOMES
ATROPINE RESULTS IN BETTER COMPLIANCE AND QOL SCORES SO SHOULD NOT BE SEEN AS A LAST RESORT BUT A FIRST LINE OF TREATMENT
YOU CAN SUCCESSFULLY TREAT AMBLYOPIA BEYOND THE AGE OF 8YRS
Is practice changing
IN THE UK A 2010 ARTICLE REVEALED THAT ONE THIRD OF RESPONDENTS TO A QUESTIONNAIRE HAD NOT CHANGED THEIR PRACTICE FOLLOWING THE ABOVE STUDIES
ATROPINE WAS RARELY OFFERED AS A FIRST LINE OF TREATMENT
60% OF CLINICIANS WOULD PRESCRIBE MORE THAN 6HR OCCLUSION
Compliance study
LESS THAN HALF GAVE WRITTEN INFORMATION TO IMPROVE COMPLIANCE (NEWSHAM 2010) IN 2013 A STUDY FROM NORTH AMERICA REVEALED SIMILAR FINDINGS STATING THAT ‘THE EVIDENCE BASED RECOMMENDATIONS FOR AMBLYOPIA
Reluctance to atropine study
IN 2014 PIANO, O’CONNOR & NEWSHAM REPORTED RELUCTANCE IN FIRST-LINE ATROPINE TREATMENT, POSSIBLY RESULTING FROM CONCERNS REGARDING ATROPINE’S GENERAL EFFICACY, SIDE EFFECTS, AND RISK OF REVERSE AMBLYOPIA
Extreme non- ethical occlusion examples
ARNOLD ET AL (2008) SEWN ON PATCHES – “SEW-ON OCCLUDE SHIELDS ARE AN ALTERNATIVE WHEN ADHERENCE TO THE USE OF OTHER TYPES OF PATCHING IS NOT SATISFACTORY” (PP891)
RUBAB (2008) CYANOACRYLATE GLUE APPLIED TO A PATCH TO INCREASE COMPLIANCE
Carlton 2012 questionnare of amblyopia treatment
PHYSICAL SENSATION OF THE TREATMENT (E.G. FEELING OF THE PATCH/GLASSES ON THE FACE, OR THE FEELING OF THE DROPS BEING INSTILLED)
PAIN OF TREATMENT (E.G. REMOVAL OF PATCH, INSTILLING OF DROPS)
ABILITY TO UNDERTAKE SCHOOL WORK
ABILITY TO UNDERTAKE OTHER TASKS (LIKE PLAYING ON THE COMPUTER, COLOURING, PLAYING GAMES, WATCHING TV)
FEELING SAD OR UNHAPPY
FEELING CROSS
FEELING WORRIED
BEING ABLE TO PLAY WITH OTHER CHILDREN
Are orthoptists exemptions changing things?
POMS
ANTI-MICROBIALS; CHLORAMPHENICOL, FUSIDIC ACID
ANTIMUSCARINICS; ATROPINE, CYCLOPENTOLATE, TROPICAMIDE
LOCAL ANAESTHETICS; LIDOCAINE WITH FLUORESCEIN,
OXYBUPROCAINE, PROXYMETACAINE, TETRACAINE
PHARMACY ONLY MS
PHENYLEPHRINE 2.5%
SODIUM CROMOGLICATE
FLUORESCEIN AND SOME OCULAR LUBRICANTS.
