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Brendan

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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Brendan

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  1. Brendan

  2. Amblyopia:New Treatments Pamela F. Gallin, M.D. Director, Pediatric Ophthalmology Children’s Hospital of New York Edward S. Harkness Eye Institute

  3. IFVision Screens were done as children THEN2% - 5% of adults would NOT be legally blind!

  4. Army Induction Studies

  5. What is Amblyopia? One eye is IN focus & One eye is NOT in focus your brain (occiput) does not see

  6. Amblyopia

  7. Normal Retina

  8. Duke Elder Classification • Amblyopia ex Anopsia • Congenital (Organic) Amblyopia • Strabismic Amblyopia • Anisometropic Amblyopia

  9. Amblyopia ex Anopsia(Anterior Segment) Stimulation deprivation amblyopia from lack of formation of retinal images Congenital Ptosis (lids) Corneal Opacification Congenital Cataract

  10. 2.Congenital (Organic) Amblyopia (Posterior) • Seemingly undetectable lesion ...but during treatment… no visual improvement… because of retinal or visual pathway dysfunction

  11. 3.Strabismic Amblyopia • Active inhibition or suppression of one retinal image by the cerebral cortex to eliminate the diplopia (double) by the deviating eye

  12. 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

  13. Nobel Prize 1981 David Hubel Torsten Wiesel

  14. 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

  15. Visual Cortex Occiput

  16. LGN involved?? 1941 Le Gros Clark Journal of Anatomy 75, 419

  17. LGN involved

  18. Cerebral cortical inhibition (suppression) is:an active process at the level of LGN and calcarine cortex

  19. Amblyopia is a Silent Disease

  20. Brendan

  21. American Academy of Ophthalmology • recommend vision screen at 3.5 years of age

  22. Vision Screen • Allen Cards • E game • # Slide • Letters • New Techniques desktop VEP

  23. Snellen Chart

  24. Diopsys: desktop VEP

  25. Patient views grating and yields VEP

  26. Diopsys Results Norm Abnl

  27. Dilated Cycloplegic Retinoscopy Mydriacyl 1% Cyclogel 0.5%, 1%, (2%)

  28. 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)

  29. Suppression Brain shuts off image from out offocus eye

  30. 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

  31. Exceptions: • Small differences… glasses (with Rx in 1 eye) can work • Large differences… need contact lens for one eye

  32. The goal is 20/25 Maintain until 9 years of age

  33. Treatment • Patching OcclusionTherapy • Penalization -optical -pharmacologic • Bangerter Films • New Techniques

  34. Patching (Occlusion Therapy) • On face • adhesives vary • 1 week/year life …5 y.o. = 5 wks …1 y.o. = 1 wk

  35. Occlusion Amblyopia

  36. Brendan • 11 months • + 1.75 / - 7.00 • Patch and glasses

  37. Optical Penalization • Pharmacologic atropine • Optical blur good eye with out of focus lens • Bangerter Film

  38. Brendan wouldn’t wear patch andglasses So, we addedAtropine under the patch

  39. Brendan wouldn’t wear patch at all, So, in addition to the Atropine, we added Bangerter film

  40. 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)

  41. Bangerter Films

  42. 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

  43. Contact Lenses • used when the differences very high • after 9 years of age, when don’t want to wear glasses for one eye

  44. After contact lenses AND 21 • Consider refractive surgery e.g. Lasik and others

  45. Brendan had High Anisometropia(8.75) • glasses & patch • glasses & patch & atropine • glasses & patch & atropine & Bangerter film THEN • contact lens & patch & atropine

  46. We knew that: Brendan had vision 20/70…from Diopsys And that: He would be Blind in that eye IFNothingwas done

  47. October, 2002 Lasik Youngest child in world Vision 20/40!!!!! Dr. Jonathan Davidorf UCLA

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