Refractive Error and Amblyopia, also Prescription

Refractive Error and Amblyopia

1. Refractive Error in Children & Amblyopia Pediatric Ophthalmology – Strabismus George Raden

2. Refractive State and Vision Assesment 01

3. GOAL 2 Optimal balance between accomodation & convergence 1 Focused retinal image

4. Refractive State Slightly more hyperopic until age 7 Emmetropization Process in the developing eye in which the refractive power of anterior segment & axial length of the eye adjust to reach emmetropia

5. Vision Assessment Subjective refraction  inappropriate Requires paralysis of accomodation Objective refraction be choice Presence of strabismus needs modification of prescribing

6. Vision Assessment

7. Vision Assessment Fixation and Following Behavior

8. Preferential Looking Test Vision Assessment

9. Recognition visual acuity Vision Assessment

10. Optometry Australia’s Paediatric Eye Care Reference Guide, September 2019 Vision Assessment

11. Cycloplegic Refraction Vision Assessment

12. Cycloplegic Refraction Vision Assessment

13. Refractive Error Classification 02

14. Congenital Myopia Developmental Mild : -0.25 - -3.00 D Moderate : -3.25 - -6.00 D Severe : > -6.00 D Focusing power too strong / AXL too long Occur as a results of variety genetic and environmental factors

15. Congenital Myopia Developmental Cycloplegic refraction : until 10 years, very high myopia (>10.0D) & infant with esotropia Corrected full correction include cylinder Undercorrect  controversial Undercorrect in esotropia for decrease deviation  rarely tolerated Overcorrection  additional accommodative stress Parents education Contact lens for high myopia

16. Myopia Prescribing

17. > 5.00 D : more visually impaired Hyperopia Low hyperopia  not necessary to correct Full correction cycloplegic refractive  hyperopia + esotropia Reduce amount of correction in school age child  + short course cycloplegia

18. Hyperopia Prescribing

19. Astigmatism Full correction Moderate or severe astigmatism might be corrected in children <3 years old to give optimal vision

20. Astigmatism Prescribing

21. Amblyopia 03

22. Amblyopia Prevalence 2-4% in North America Most common cause : unilateral vision impairment in adults < 60 yo Prevalence increased with : Born prematurely Developmental delay Family history

23. Amblyopia Unilateral or, less commonly, bilateral reduction of best- corrected visual acuity (also referred to as corrected distance visual acuity) that cannot be attributed directly to the effect of any structural abnormality of the eye or visual pathways Strabismus Refractive error Visual deprivation

24. Vision Assesment Acuity Developed Visual deprivation can cause amblyopia Amblyopia treament still effective Birth to 3-5 years age A few months to 7-8 years age Up to 9 years age

25. Pathophysiology Visual system vulnerable  abnormal input Early postnatal development : critical period cortical development Visual system plasticity  amblyopia revearsal Amblyopic visual deficit  visual cortical changes, lost cells of primary visual cortex

26. Amblyopia Treatment 03

27. Steps 3 Promote use the amblyopic eye 1 Eliminate obstruction visual axis 2 Correct any significant refractive error

28. Steps Refraction correction Occlusion Cataract removal Aphakia : initiated promptly Refractive surgery Unilateral : first 6 weeks of life Bilateral : first 10 weeks of life Unilateral, follow up 2-3 months Full time occlusion  follow up < 1 week per year of age in < 4 years Severe (20/125 – 20/400)  part time (6 h) Moderate (> 20/100) –2 h

29. Pharmacologic / Optical treatment Degradation better eye vision Cycloplegic : atropine sulfate 1% Excessive plus lenses (fogging) Scotch magic tape Bangerter occlusion foil Orthotropia Small angle strabismus Latent nystagmus

30. Binocular treatment Electronic device under dichoptic viewing condition Orthotropia Small angle strabismus Active / passive visual task (require simultaneous perception) High contrast (amblyopic eye) & low contrast (fellow eye)

31. Complication and Challenges in Amblyopia Therapy 03

32. Reverse amblyopia & new strabismus Poor adherence Unresponsiveness Recurrence 01 03 02 04 Full time occlusion Undercorrection hyperopic with cycloplegia Treatment cost adhesive / cloth patches Irritation Children older 5 years old Reexamination anomalies Terminated when lack progress over 3-6 months Reducing treatment before cessation Children 7-12 years age more sustainable Stable : 12-mo exam Complication

33. Thanks!

34. Algoritma Tatalaksana Amblyopia

35. Efek Samping Agen Siklopegik

36. UK - Normal Supply Requirements of Human Medicine Regulations 2012

37. Amblyop Patching Dewasa

38. Myopia Control