What is Amblyopia?
A common vision problem in children is amblyopia, or "lazy eye." This condition is so common that it’s frequently identified as the reason for vision loss in children more often than all other causes put together. Amblyopia is a decrease in the child’s vision that can happen even when there is no problem with the structure of the eye. The decrease in vision results when one or both eyes send a blurry image to the brain. The brain then “learns” to only see blurry with that eye, even when glasses are used. Only children can get amblyopia. If it is not treated, it can cause permanent loss of vision.
What kinds of Amblyopia are there?
The different types of amblyopia are strabismic amblyopia, deprivation amblyopia, and refractive amblyopia. The end result of all forms of amblyopia is reduced vision in the affected eye(s).
What is Strabismic Amblyopia?
Strabismic amblyopia develops when the eyes are not straight. One eye may turn in, out, up, or down. When this happens, the brain “turns off” the eye that is not straight and the vision subsequently drops in that eye.
What is Deprivation Amblyopia?
Deprivation amblyopia develops when cataracts or similar conditions deprive young children’s eyes of visual experience. If not treated early, these children can have very poor vision. Sometimes, this kind of amblyopia can affect both eyes.
What is Refractive Amblyopia?
Refractive amblyopia happens when there is a large or unequal amount of refractive error (glasses strength) in a child's eyes. Usually, the brain will "turn off" the eye that has more farsightedness or more astigmatism. Parents and pediatricians may not think there is a problem because the child’s eyes may stay straight. Also, the good eye has normal vision. For these reasons, this kind of amblyopia in children may not be found until the child has a vision test. This kind of amblyopia can affect one or both eyes and can be helped if the problem is found early.
Will glasses help a child with Amblyopia to see better?
Maybe, but they may not correct it all the way to 20/20. With amblyopia, the brain is used to seeing a blurry image, and it cannot interpret the clear image that the glasses produce. With time, the brain may relearn how to see and the vision may increase. Remember, glasses alone do not increase the vision all the way to 20/20, as the brain is used to seeing blurry with that eye. For that reason, the normal eye is treated (with patching or eyedrops) to make the amblyopic (weak) eye stronger.
What can be done if my child has equal high amounts of farsightedness and/or astigmatism and is diagnosed with Bilateral Amblyopia?
Bilateral amblyopia is usually treated with consistent, early glasses, and/or contact lenses with follow-ups over a long period of time. If asymmetric amblyopia (when one eye is better than the other) occurs, then patching or eye drops may be added.
When should Amblyopia be treated?
Early treatment is always best. If necessary, children with refractive errors (like nearsightedness, farsightedness, or astigmatism) can wear glasses or contact lenses when they are as young as one week old. Children with cataracts or other “amblyogenic” conditions are usually treated promptly in order to minimize the development of amblyopia.
How old is TOO old for Amblyopia treatment?
A recent NIH study confirmed that SOME improvement in vision can be attained with amblyopia therapy initiated in younger teenagers of up to 14 years. However, better treatment success is achieved when treatment starts early.
How is amblyopia treated?
One of the most important treatments of amblyopia is correcting the refractive error with consistent use of glasses and/or contact lenses. Other mainstays of amblyopia treatment are to enable as clear an image as possible (for example, by removing a cataract) and forcing the child to use the nondominant eye via patching or eyedrops to blur the better-seeing eye.
When should patching be used for amblyopia treatment?
Patching should only be done if an ophthalmologist recommends it. An ophthalmologist should regularly check how the patch is affecting the child’s vision. Although it can be hard to do, patching usually works very well if started early enough and if the parents and child follow the patching instructions carefully. It is important to patch the dominant eye to allow the weak eye to get stronger.
Are there different types of patches?
The classic patch is an adhesive band-aid-like material, which is applied directly to the skin around the eye. These may be available in different sizes for younger and older children. For children wearing glasses, both cloth and semi-transparent stickers (Bangerter foils) may be placed over or onto the spectacles. "Pirate" patches on elastic bands are especially prone to "peeking" and are therefore only occasionally appropriate.
Is there an alternative to patching to treat amblyopia?
Sometimes the stronger eye can be penalized, or blurred, to help the weaker eye get stronger. Blurring the vision in the good eye with drops or with extra power in the glasses will penalize the good eye. This forces the child to use the weaker eye. Ophthalmologists use this treatment instead of patching when the amblyopia is not very bad or when a child is unable to wear the patch as recommended. For mild and moderate degrees of amblyopia, studies have shown that patching or eyedrops may be similarly effective. Your pediatric ophthalmologist will help you select the treatment regimen that is best for your child.
Do drops work for all amblyopic children?
Not all children benefit from eye drop treatment for amblyopia. Penalizing eye drops (such as atropine) work less well when the stronger eye is nearsighted.
How many hours per day patching is enough when treating amblyopia?
The mainstay of treating amblyopia is patching of the dominant (good) eye, either full or part-time during waking hours. Although classic teaching suggests that the more hours per day patching is performed, the greater the result, recent studies suggest that shorter periods may achieve similar results as longer amounts of patching in patients with moderate amounts of amblyopia.
How long does amblyopia patching therapy take to work?
Although vision improvement frequently occurs within weeks of beginning patching treatment, optimal results often take many months. Once vision has been improved, part-time (maintenance) patching or periodic use of atropine eyedrops may be required to keep the vision from slipping or deteriorating. This maintenance treatment may be advisable for several months to years.
During which activities should patching be performed?
The particular activity is not terribly important compared to the need to keep the patch on during the allotted time. As long as the child is conscious and has his or her eyes open, visual input will be processed by the amblyopic eye. On the other hand, the child may be more cooperative, or more open to bargaining, if patching is performed during certain desirable activities, such as watching a preferred television program or video.
Should patching be performed during school hours?
In many instances, school is an excellent time to patch, taking advantage of a nonparental authority figure. Patching in school hours gives the class an opportunity to learn valuable lessons about accepting differences between children. While in most instances children may not need to modify their school activities while patching, sometimes adjustments, such as sitting in the front row of the classroom, will be necessary. If the patient, teacher, and classmates are educated appropriately, school patching need not be a socially stigmatizing experience. On the other hand, a parental or other family figure may be more vigilant in monitoring patching than is possible in the school setting. Parents should be flexible in choosing when to schedule patching.
What if my child refuses to wear the patch?
Many children will resist wearing a patch at first. Successful patching may require persistence and plenty of encouragement from family members, neighbors, and teachers. Children will often throw a temper-tantrum, but they eventually learn not to remove the patch. Another way to help is to provide a reward to the child for keeping the patch on for the prescribed time period.
Can surgery be performed to treat amblyopia?
Surgery on the eye muscles is a treatment for strabismus - it can straighten misaligned eyes. By itself, however, surgery does not usually or completely help the amblyopia. Surgery to make the eyes straight can only help enable the eyes to work together as a team. Children with strabismic amblyopia still need close monitoring and treatment for the amblyopia, and this treatment is usually performed before strabismus surgery is considered.
Children who are born with cataracts may need surgery to take out the cataracts. After surgery, the child will usually need vision correction with glasses or contact lenses and patching.
What are appropriate goals of amblyopia treatment?
In all cases, the goal is the best possible vision in each eye. While not every child can be improved to 20/20, most can obtain a substantial improvement in vision. Although there are exceptions, patching does not usually work as well in children who are older than 9 years of age.
What happens if amblyopia treatment does not work?
In some cases, treatment for amblyopia may not succeed in substantially improving vision. It is hard to decide to stop treatment, but sometimes it is best for both the child and the family. Children who have amblyopia in one eye and good vision only in their other eye can wear safety glasses and sports goggles to protect the normal eye from injury. As long as the good eye stays healthy, these children function normally in most aspects of society.
Special forms of strabismus
Most common special forms of strabismus include:
What is Duane syndrome?
Duane syndrome, also called Duane retraction syndrome (DRS), is a group of eye muscle disorders that cause abnormal eye movements. People with Duane syndrome have difficulty rotating one or both eyes outward (abduction) or inward (adduction).
How do normal eye movements occur?
Six muscles, which control the movement of the eye, are attached to the outside of the wall of the eye. In each eye, there are two muscles that move the eye horizontally. The lateral rectus muscle pulls the eye out towards the ear and the medial rectus muscle pulls the eye in towards the nose. There are four other muscles, which move the eye up or down and at an angle. Each eye muscle receives the command for movement from cranial nerves that exit the brain.
What is the cause of Duane Syndrome?
Duane’s syndrome is due to some miswiring of the eye muscles. The “mistake” probably happens around the 6th week of pregnancy and is due to poor development of tiny parts of the brainstem that control the eye muscles.
In Duane syndrome, the sixth cranial nerve that controls the lateral rectus muscle (the muscle that rotates the eye out towards the ear) does not develop properly. Why the nerve does not develop is not yet understood. Thus, the problem is not primarily with the eye muscle itself, but with the nerve that transmits the electrical impulses to the muscle. There is also irregular innervation of a branch from the third cranial nerve, which controls the medial rectus muscle (the muscle that rotates the eye toward the nose). This is why abnormalities may be found in both left gaze and right gaze.
Who gets Duane syndrome?
Duane syndrome affects girls more often than boys. In addition, the left eye is more likely than the right eye to be affected. The reason for this is not known. Around 20% of Duane syndrome patients have both eyes affected. No particular race or ethnic group is more likely to be affected.
What are the other characteristics of Duane syndrome?
- Strabismus: The eyes may be misaligned and point in different directions at all times
- Head position: Patients often maintain a head posture or head turn to keep the eyes straight
- Amblyopia: Reduced vision in the affected eye
- Eyelid narrowing: The affected eye may appear smaller than the other eye
- Upshoot or downshoot: With certain eye movements, the eye may occasionally deviate upward or downward
Is Duane syndrome congenital (present from birth)?
Duane retraction syndrome is present from birth, even if it is not recognized during infancy. An abnormal head posture and strabismus are often visible in old photographs taken in early childhood.
Is Duane syndrome hereditary?
In 90% of cases, the patient has no family history of Duane syndrome. Ten percent of patients will have an affected family member, and these tend to be cases where both eyes are involved. There is currently no test that can determine whether a patient has a hereditary form.
Are there different types of Duane Syndrome?
Duane syndrome is often characterized by whether the primary abnormality is a reduced ability to turn the affected eye(s) outward (type I), inward (type II), or both (type III). Type I is the most common form of Duane syndrome.
Do Duane syndrome patients have other eye problems?
The problem with the 6th cranial nerve is usually an isolated condition, and the child is usually otherwise completely normal. With careful follow-up, the long-term prognosis for good vision is usually excellent.
Occasionally, Duane syndrome may be found in association with other eye problems, including disorders of other cranial nerves, nystagmus (an involuntary back-and-forth movement of the eyeball), cataract, optic nerve abnormalities, microphthalmos (abnormally small eye), and crocodile tears.
Do Duane syndrome patients have non-ocular medical problems?
The problem with the cranial nerve is usually an isolated condition and the child is otherwise completely normal. However, some patients with Duane syndrome often have other problems, such as hearing impairment, Goldenhar syndrome, and spinal/vertebral abnormalities. There is also an increased frequency of Duane syndrome in patients with thalidomide exposure.
When is Duane syndrome treated?
For the majority of patients, Duane syndrome does not require surgical treatment. Surgery for Duane syndrome is indicated for one of three reasons:
- To reduce strabismus
- To eliminate a socially unacceptable head position
- To eliminate a significant upshoot or downshoot
The goal of treatment is to restore satisfactory eye alignment in the straight-ahead position, eliminate an abnormal head posture and to prevent amblyopia. In most cases, eye muscle surgery is required. Because the function of the affected nerve and muscle cannot be restored, the other eye muscles are adjusted to compensate and allow for better eye alignment.
How successful is surgery for Duane syndrome?
Surgery cannot fix the problem of nerves that go the wrong way and wire up the eye muscles incorrectly. By moving the eye muscles surgery can compensate for the miswiring. Because surgery doesn’t “really” fix the problem, surgery cannot restore normal eye movement, but surgery can (and usually does) substantially improve the situation. The full effect of the surgery may take some weeks to become apparent.
There is a low incidence of unexpected or inadequate results – results that may require further surgery within weeks or even years later.
What is Brown syndrome?
Brown syndrome is also known as Superior Oblique Tendon Sheath syndrome. It is a mechanical problem in which the superior oblique muscle (on the outside of the eyeball) cannot slide freely back and forth. This causes difficulty when the patient tries to look up and in with the affected eye. Brown Syndrome may be present at birth (congenital) or begin later. It also may be present constantly or seem to come and go (intermittent).
What do the eyes of patients with Brown syndrome look like?
The eyes of many patients with Brown syndrome look fairly normal except in side gaze positions. In side gaze (looking toward the affected side), one eye appears higher than the other, particularly when looking to the side and up.
Which eye is affected in Brown syndrome, the higher one or the lower one?
Although the higher eye is often mistakenly presumed to be the abnormal eye, it is actually the lower eye which is affected. Brown syndrome causes the lower eye to have trouble looking up in side gaze. Essentially, the affected eye is being “tethered” or held down by the tight superior oblique tendon.
What is the cause of Brown syndrome?
Although the exact cause of Brown Syndrome is not known, it is clear that there is some abnormality with the tendon that pulls on the superior oblique muscle, or with the bone that the tendon moves through (called a trochlea), or with the combined tendon-trochlea assembly.
Most of the patients with congenital, constant Brown syndrome are believed to have a mechanical abnormality of the superior oblique tendon, the tendon-trochlea complex, or both. These abnormalities may include a reduced elasticity of the superior oblique muscle and tendon, a thickened tendon, a tendon or its covering sheath that is short and/or tight, or fibrous adhesions on the tendon.
Is Brown syndrome hereditary?
Reported cases of Brown syndrome running in families are rare. The condition is more common in girls than boys for reasons that are not clear.
Can Brown syndrome be acquired?
Acquired Brown syndrome is rarer and may be seen following surgery, direct or indirect trauma, or in association with inflammatory diseases, such as adult and juvenile rheumatoid arthritis, systemic lupus erythematosus, and sinusitis. Inflammation of the tendon-trochlea complex is believed to be the common mechanism among these causes, with the inflamed tendon unable to glide smoothly through the trochlea.
Cases of traumatic Brown syndrome have been reported following injury to the eye from various objects including a snowshoe, a bullet, dog bites, windshield glass, and a thumb. Surgical trauma may also lead to Brown syndrome. Cases have occurred following surgery on the eyelid or frontal sinus and after retinal detachment procedures or dental extraction. It may also just develop for no apparent reason at any age.
How is Brown syndrome diagnosed?
The most common finding in Brown Syndrome is the inability to move the affected eye upward when looking in. Most patients have straight eyes when looking directly ahead and when looking down or reading. Their main problem is that when they look up, the affected eye fails to go up properly. Some patients may also have an eye that turns outward (exotropia) when looking up.
People with Brown syndrome often turn or tilt their heads in order to use their eyes together. These positions can include putting the chin up, turning the face or tilting the head. For some patients, the affected eye seems to get “stuck” after looking up or down for long periods of time. When the eye becomes unstuck, they often hear a click and actually feel some pain or discomfort. It is a little like having a trick knee or thumb.
Since little kids look up at adults a lot, Brown syndrome may be more noticeable in them. Parents often don’t notice any problem with the affected eye in a child with Brown syndrome, but visit the ophthalmologist to ask why one eye (the normal eye) rolls up under the upper lid much of the time. The brain puts a lot of energy into the affected eye, trying to get it to move up. The same amount of energy goes into the normal eye, and it goes up higher than usual.
Does Brown syndrome affect one or both eyes?
Ninety percent of patients have only one affected eye, and it is most likely to be the right eye.
Does Brown syndrome cause problems besides abnormal eye movements?
Some children with Brown syndrome also have poor binocular vision, which can result in poor depth perception, amblyopia, or exotropia. A complete eye examination is important for these children.
Are there different types of Brown syndrome?
Brown syndrome is classified according to its severity. In mild cases, there is a reduced ability to look up and in with the affected eye. In moderate cases, there is also a tendency for the eye to move downward as it is turned in. In severe cases, there is also a tendency for the affected eye to turn downward when the patient looks straight ahead.
When should Brown syndrome be treated?
Treatment recommendations for Brown syndrome vary with the cause and severity of the movement disorder. Close observation alone is usually sufficient in mild cases. Visual acuity and the ability to use both eyes at the same time (binocular vision) should be monitored closely in young children. Nonsurgical treatment is often advised for recently acquired, traumatic, and variable cases. Surgery may be appropriate when the problem is stable and interferes with daily visual interaction. See the section below for when surgery is recommended.
Can Brown syndrome go away (resolve) without treatment?
Spontaneous resolution sometimes occurs in acquired and intermittent cases. In the congenital form of Brown syndrome, the eye movement problem is usually constant and is unlikely to resolve spontaneously. It tends to remain stable or progress only slowly.
Can Brown syndrome be treated without surgery?
Systemic and locally injected corticosteroids have been used to treat inflammation in some cases of acquired Brown syndrome. Nonsteroidal anti-inflammatory agents (like Ibuprofen) have also been used with limited success.
When is surgery appropriate for patients with Brown syndrome?
Surgical treatment is usually limited to cases in which the eye turns down when looking straight ahead, when there is significant double vision in adults, when there is concern over loss of binocular vision in a child, or when there is a very abnormal head position. Occasionally, the initial improvement seen after surgery does not last, so additional surgery is required. Overcorrections, which require a second surgery, are common.
Congenital Nasolacrimal Duct Obstruction
What is a tear duct obstruction?
Tears normally drain from the eye through small openings in the corners of the upper and lower eyelids called puncta. From there, the tears enter the nose through a drainage system known as the nasolacrimal duct. A blocked tear duct occurs when the opening of the duct is obstructed or fails to open properly.
Where is the obstruction in babies with blocked tear ducts?
Infants with nasolacrimal duct obstruction typically have blockage towards the end, or distal, portion of the duct right before it empties into the nose.
What are the causes of nasolacrimal duct obstruction?
The most common cause is the failure of a thin tissue at the end of the tear duct (Valve of Hasner) to open normally at or near the time an infant is born.
Other causes of blocked tear ducts in children that are less common include:
- Absent openings (puncta) at the upper and lower eyelids
- Abnormal growth of the nasal bone that causes the opening of the tear duct entering the nose to be closed off
How common is nasolacrimal duct obstruction?
It is estimated that over 5% of infants are born with symptoms of nasolacrimal duct obstruction affecting one or both eyes. Over ninety percent of these obstructions clear by themselves within the first year of life. Blocked tear ducts in adults are uncommon and are usually the result of injury, recurrent infections, or other disorders. Blocked tear ducts are not believed to run in families or be inherited.
What are the signs of a tear duct obstruction?
Since the tears do not have an open passage to drain into the nose, they well up on the surface of the eye and overflow onto the eyelashes, eyelids, and down the cheek. This can be present within the first days or weeks of a baby’s life.
Sometimes, the drainage system can become infected because tears are not draining through it normally. If this happens, the eyelids can become red and swollen, yellowish-green discharge can be seen, and the eyelids tend to stick together. In severe cases, a serious infection of the tear duct system can occur (dacryocystitis).
Can a blocked tear duct be an intermittent condition?
Some infants who have a narrow tear drainage system may also appear to have signs of a blocked tear duct under certain conditions, such as when the child has a cold (nasal congestion) or when the child goes from going inside to being outside, especially if it is windy or cold.
How is a tear duct obstruction diagnosed?
A history of tearing and discharge at a very early age is strongly suggestive of a blocked tear duct. An ophthalmologist is able to perform certain tests in the office to confirm the diagnosis. It is important that he or she perform a full examination to look for uncommon but important causes of tearing in infants, such as childhood glaucoma.
What is the treatment of a blocked tear duct?
Fortunately, most babies born with blocked tear ducts do not need treatment. Over ninety percent of blocked tear ducts clear up spontaneously within the first year of life. In certain circumstances, one or more of the following treatments may be recommended: tear duct massage, topical antibiotics, tear duct probing, balloon tear duct dilation, or tear duct probing with tube placement.
How does tear duct massage work?
Tear duct massage can be performed at home to help the tear duct open on its own. A pediatric ophthalmologist or pediatrician can demonstrate the most effective massage technique.
When should topical antibiotics be used?
Antibiotic eye drops or ointment may be used to treat a secondary infection. However, it is important to realize that the antibiotic drops do not open the blocked tear duct itself. Symptoms of discharge can recur when the eye drops are withdrawn.
When should tear duct probing be performed?
If the tear duct remains blocked, a nasolacrimal duct probing may be performed. This is most commonly advised around age 1 year, but it may be indicated before or after this age for a variety of reasons. Early (6-12 months of age) or very early (under 6 months of age) probings may be useful if the symptoms or infections are particularly bothersome. Early probing may also be appropriate for parents desiring office probing to avoid the need for general anesthesia. Conversely, spontaneous improvement in tear duct obstruction may occasionally occur even after 12 months of age.
How does tear duct probing work?
A smooth probe (resembling a thin, straight wire) is gently passed through the tear duct and into the nose. The probes come in different sizes, so using probes of progressively larger diameters can widen a tear duct system.
What type of anesthesia is necessary for tear duct probing?
Infants up to eight months of age or so can have a tear duct probing done in the office using topical anesthetic drops. Children older than six months of age usually have a tear duct probing with the assistance of brief general anesthesia in a day-surgery setting. A nasolacrimal duct tube can also be placed while a child is asleep in surgery to prevent recurrence of tearing.
How successful is tear duct probing?
Tear duct probing is generally very successful. Over ninety percent of children have resolution of symptoms after the procedure. In some cases, a second probing procedure with additional procedural enhancements may be necessary. In a few cases, a more involved surgery may be needed to open the tear duct system (dacryocystorhinostomy, or DCR).
WHAT IS EXOTROPIA?
Exotropia is a type of ocular misalignment of the eyes (strabismus) when either eye is turned outward (away from the nose). In extreme cases, this produces a "wall-eyed" appearance. Exotropia may be congenital or acquired, intermittent or constant, and associated with normal vision or very poor sight (sensory). At Ticho Eye Associates, our team of ophthalmologists, optometrists, and orthoptists is highly trained in the diagnosis and treatment of all types of exotropia. If you have noticed changes in the alignment of your eyes, reach out to our office in Chicago Ridge, IL, Tinley Park, IL, or Munster, IN.
HOW IS EXOTROPIA TREATED?
Exotropia treatment depends on the type, frequency, and severity of ocular misalignment. Our team will also consider the patient's age and overall eye health. Therapeutic options include prescription glasses, patching, eye exercises, and muscle surgery (strabismus surgery). In general, surgery is only considered when nonsurgical options are unsuccessful or not applicable. Once a thorough eye exam has been completed, our strabismus specialists can discuss which treatments may be best for you or your child.
Exotropia can cause long-term problems with depth perception or even permanent vision loss from strabismic amblyopia. Fortunately, timely intervention is usually successful in restoring satisfactory alignment. Routine eye exams to identify vision concerns should be performed early to preserve the health of your child’s eyes and vision. Contact Ticho Eye Associates today to book an appointment. We conveniently offer locations in Chicago Ridge, IL, Tinley Park, IL, and Munster, IN. We look forward to serving you.
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treat lazy eye
If you suspect amblyopia is the cause of your or your child's vision problems, contact Ticho Eye Associates today. We are conveniently located in Chicago Ridge, IL, Tinley Park, IL, and Munster, IN. With a comprehensive eye exam, our caring team of ophthalmologists can properly diagnose your condition and determine the best course of treatment. To learn more about the different therapies we offer for amblyopia, visit our amblyopia treatment page.