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Home \ Vision Therapy \ Lazy Eye, Strabismus & Amblyopia \ What is Refractive Amblyopia?

What is Refractive Amblyopia?

Amblyopia, also known as "lazy eye," is the lack of normal visual development despite the eye being healthy. If left untreated, it can cause legal blindness in the affected eye. About 2% to 3% of the population is amblyopic. 

Amblyopia Signs and Symptoms

Amblyopia generally starts at birth or during early childhood. It is often not obvious and has no symptoms.  Parents and even health care professional therefore are not aware that there is a problem.  Afterwards, parents feel guilty for not having realized that there is a problem.  At times they feel as though their pediatirican might have let them down.

What causes Amblyopia?

The two common types of amblyopia are Strabismic Amblyopia and Refractive Amblyopia.

Strabismus

Strabismus is the condition in which the two eyes are not pointing in the same direction and are not well aligned.  Often, this mis-alignement is not obvious, and this is why it is easliy missed by parents or even doctors.  The eye may be healthy and not have disease, but because the two eyes are not well aligned, a clear image is not developed in the brain.  Strabismus may be constant or intermittent.  It is much more common for amblyopia to develop if the eye turns in rather than if the eye turns out.

Refractive Amlyopia

Unilateral Amblyopia occurs when the brain does not recieve a clear image from one eye because of a large difference in the prescription (nearsightedness, farsightedness and/or astigmatism) of the two eyes.  Here too, the brain does not develop the information from that eye (channel).  

Bilateral Amblyopia (amblyopia in both channels/eyes) occurs when the power (prescription) in both eyes is very high, and therefore clear vision does not develop in either eye.

It's important to correct amblyopia as early as possible, before the brain ignores vision in the affected eye.

Amblyopia leads to poor visual acuity, but more importantly, it leads to poor eye coordination and poor depth perception.  It can lead to clumsiness, tripping or knocking into things, and difficulty with catching a ball acurately.  It may lead to difficutlies with reading and learning.  

Treatment of Amblyopia

Amblyopia is often best treated by Vision Therapy.

First, the source of the amblyopia must be identified.  When indicated, eyeglasses are prescribed.  Many eye doctors, particularly Pediatric Ophthalmologists, begin treatment by patching the "bad" eye.  Patching typically doesn't work, and when it doesn't, some doctors recommend atropine eye drops.

Please understand that there is not really a "good" eye and a "bad" eye. 

It is important to understand that there are different approaches to treatment of amblyopia;

  • The medical approach treats the problem as a problem in that one eye.  Treating one eye may improve the acuity (being able to see letters on a chart) for a while, but often reverts and regresses.
  • The developmental or therapuetic approach realizes that amblyopia is really not a problem in an eye, but rather a problem of not being able to use the two eyes together as a team. This approach is therefore often much more successful. 

In the same way that it was difficult for a parent to identify if someone had the problem to begin with, it is often difficult for them to know if a doctor's  recommendation to patch the eye is really working.  They therefore may be losing time with an ineffective outdated treatment plan.  

Is surgery the answer?  

Clearly, when the problem is Refractive Amblyopia, the two eye are pointing straight, so there is no indication for surgery whatsoever.

When the two eyes are not pointing straight, then some doctors recommend surgery.  Most often, however, surgery does not address the underlying problem.  Surgery has the advantage of making the eyes appear cosmetically  "normal" or straight to others, but it almost never addresses the underlying problem of not being able to use the two eyes together as a team. 

Does Patching Work ?

When the problem is Refractive Amblyopia, many doctors prescribe patching the "bad" eye.   Patching often does not yield the results of long-term improvement.   Jillian's Story, is a very good book to read about this.  The book is authored by Renee Benoit, Jillian’s mother, who tells her daughter's story of frustration and unsuccessful outcome of patching.  It is written as one parent to another.  

Amblyopia is often best treated by Vision Therapy.  Vision Therapy is a specific treatment plan to address the underlying problem so ultimatley the individual can then use their two eyes to work as a team, thus restoring vision.

The rationale is that the 'stronger eye' is patched in order to force the weaker eye to work harder. Patching is often prescribed for several hours each day or even all day long.  It may continue for weeks or months. Most children do not like wearing the patch because

  1. they then lose the information from the whole side of the body that the patch is on.
  2. they become disoriented because they now see blurry since the can no longer use their 'good eye'.
  3. other children make fun of them.

Is there any wonder then as to why a child would not want to wear a patch?  

Often, if eyeglasses are prescibed, the child will remove the eyeglasses or look over them.  When a patch is prescribed, children often remove the patch when  their parents are not present.  They dislike the feel of the patch when being worn and removing the patch is also uncomfortable.  Think of the feeling of removing a band aid. 

Contact Lenses for Amblyopia Treatment

At times, contact lenses offer the best treatment because they allow for an equal sized picture on the retina, the back of the eye.  Eyeglasses can't do that.  Eyeglasses give a magnified view on the side with the higher power lens.   The images then cannot be combined in the brain.  Contact lenses have the benefit of eliminating that size difference.

Rarely, an occluding contact lens is used.  This has the advantage of patching, but without using a patch.  The advantages are that the child cannot look over the contact lens as they would with eyeglasses, and a second advantage is that there is no “pirate” look. 

At times, a contact lens is worn to blur the image of the "good" eye in order to enable the patients to continue receiving information from that channel, but  without blocking it off totally.  Remember,  the idea behind therapy is to enable the individual to ultimately use the two eyes together as a team.  The closer the therapy is to real life, the more likely the success.

Rarely, treatment of amblyopia with atropine is used.  One drop is placed in the  child's "good" eye, blurrying the vision in that eye.  This enables the brain to begin to use the eye that had not being seeing.  The advantage is that the parent no longer has to make sure that the child wears the eye patch.

What If Surgery Had Already Been Done?

Surgery rarely corrects the muscle problem that causes strabismus, even if the eyes look straight.  In most cases, the eyes never focus together and see properly.  Surgery tries to address the way someone looks to others.  It does not address how the person with strabismus sees, even after surgery.  Vision Therapy, although now more complicated and more involved after surgical 'correction", can address and often correct the amblyopia.  

Dr. Susan Barry, a neurobiologist (not an eye doctor) describes her ordeal in her book, Fixing My Gaze.  She describes how she had 3 strabismus surgeries at a young age, and never gained the ability to use her two eyes together as a team.  As an adult, near 50 years old, she had Vision Therapy and obtained that ability.  This attest to the brain's ability to change, a concept called neuropalsticity

Amblyopia does not go away on its own.  Untreated amblyopia can lead to permanent visual problems and poor depth perception. To prevent this and to give your child the best vision possible, amblyopia should be treated early by vision therapy.

An old axiom that is still held by many doctors is that amblyopia must be detected and aggressively treated before the age of 8 or 9.  In reality, amblyopia can be treated at any age, although clearly, if treated earlier, it is often simpler and quicker to address.  Not only is 20/20 acuity usually attainable, but more significantly, the individual will then be able to use the two eyes together as a team.  

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