Amblyopia: Detection and Treatment

 

Am Fam Physician. 2019 Dec 15;100(12):745-750.

  Patient information: See related handout on amblyopia.

Author disclosure: No relevant financial affiliations.

Amblyopia is the leading cause of monocular vision loss in children. Early recognition and treatment are important to prevent vision loss. The U.S. Preventive Services Task Force recommends vision screening for all children at least once between three and five years of age to detect the presence of amblyopia or its risk factors. The American Association for Pediatric Ophthalmology and Strabismus and the American Academy of Pediatrics recommend routine, age-appropriate red reflex testing, examination for signs of strabismus, and vision chart testing. Photoscreening may be a useful adjunct to traditional vision screening, but there is limited evidence that it improves visual outcomes. Treatments for amblyopia include patching, atropine eye drops, and optical penalization of the nonamblyopic eye. In children with moderate amblyopia, patching for two hours per day is as effective as six hours, and daily atropine is as effective as daily patching. Children younger than seven years receive the most benefit from treatment, but older children may still benefit. Amblyopia recurs in 25% of children, so continued surveillance is important.

Amblyopia is a decrease in best-corrected visual acuity resulting from abnormal vision development in infancy and early childhood.1,2 The term is derived from a Greek word meaning dullness of vision; it is also called “lazy eye.” Amblyopia is the leading cause of childhood monocular vision loss, with an estimated prevalence of 1% to 6%,3 and it is responsible for permanent vision loss in 2.9% of adults.4 Although amblyopia may be bilateral, it is usually unilateral. The ocular structures are usually normal on physical examination. Associated conditions include unequal refractive error and strabismus (misalignment of the eyes).1 Amblyopia may result from conditions such as cataracts and eyelid ptosis, which disrupt the visual axis and impede a clear image reaching the retina. Children with high refractive error may develop bilateral amblyopia. Once amblyopia is established, corrective lenses usually will not sharpen vision. Early recognition and referral during infancy and childhood are important to prevent vision loss.

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingComment

Children should have vision screening to detect amblyopia or its risk factors at least once between 3 and 5 years of age.9

B

B recommendation from U.S. Preventive Services Task Force: moderate benefit in early detection and treatment weighed against small harm of overdiagnosis

Children 3 to 5 years of age with visual acuity less than 20/40 in either eye, or children 5 years and older with visual acuity less than 20/32 in either eye should be referred to a pediatric ophthalmologist for further examination.14

C

Expert opinion and consensus guideline in the absence of clinical trials

Patching andatropine drops are effective treatments for amblyopia.11,12,2125

A

Consistent evidence from randomized controlled trials and Cochrane reviews showing improved visual acuity

Children younger than 7 years benefit the most from early detection and treatment of amblyopia, although older children may still benefit.8,28

C

Observational study and a meta-analysis showing increased visual acuity in different age groups


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingComment

Children should have vision screening to detect amblyopia or its risk factors at least once between 3 and 5 years of age.9

B

B recommendation from U.S. Preventive Services Task Force: moderate benefit in early detection and treatment weighed against small harm of overdiagnosis

Children 3 to 5 years of age with visual acuity less than 20/40 in either eye, or children 5 years and older with visual acuity less than 20/32 in either eye should be referred to a pediatric ophthalmologist for further examination.14

C

Expert opinion and consensus guideline in the absence of clinical trials

Patching andatropine drops are effective treatments for amblyopia.11,12,2125

A

Consistent evidence from randomized controlled trials and Cochrane reviews showing improved visual acuity

Children younger than 7 years benefit the most from early detection and treatment of amblyopia, although older children may still benefit.8,28

C

Observational study and a meta-analysis showing increased visual acuity in different age groups


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the

The Authors

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JOHN R. MCCONAGHY, MD, is a professor of family medicine, department vice chair, and the associate director of the Family Medicine Residency Program at The Ohio State University Wexner Medical Center, Columbus....

RACHAEL MCGUIRK, MD, is an assistant professor of family medicine at The Ohio State University Wexner Medical Center.

Address correspondence to John R. McConaghy, MD, The Ohio State University Wexner Medical Center, 2231 N. High St., Columbus, OH 43201 (email: john.mcconaghy@osumc.edu). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

References

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10. American Academy of Pediatrics. Policy statement. Visual system assessment in infants, children, and young adults by pediatricians. January 2016. Accessed December 16, 2018. http://pediatrics.aappublications.org/content/137/1/e20153596

11. American Academy of Ophthalmology. Amblyopia PPP - 2017. November 2017. Accessed December 16, 2018. https://www.aao.org/preferred-practice-pattern/amblyopia-ppp-2017

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18. Forcina BD, Peterseim MM, Wilson ME, et al. Performance of spot vision screener in children younger than 3 years of age. Am J Ophthalmol. 2017;178:79–83.

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