AMBLIOPIAAMBLIOPIA

Sakinah Ginna R Sakinah Ginna R

Rizkiani Juleshodia WRizkiani Juleshodia W

DEFINISIDEFINISI

Penurunan tajam penglihatan dengan Penurunan tajam penglihatan dengan koreksi terbaik unilateral atau bilateral koreksi terbaik unilateral atau bilateral yang bukan disebabkan secara langsung yang bukan disebabkan secara langsung oleh berbagai kelainan struktur bola mata oleh berbagai kelainan struktur bola mata atau adanya gangguan jalur penglihatan atau adanya gangguan jalur penglihatan posterior.posterior.

33

Prevalence: 2%-4% in the North American Prevalence: 2%-4% in the North American population population

Commonly unilateral Commonly unilateral Nearly all amblyopic visual loss is Nearly all amblyopic visual loss is

preventable or reversible with timely preventable or reversible with timely detection and appropriate intervention.detection and appropriate intervention.

Children with amblyopia or at risk for Children with amblyopia or at risk for amblyopia should be identified at a young amblyopia should be identified at a young age when the prognosis for successful age when the prognosis for successful treatment is best. treatment is best.

Role of screening is important Role of screening is important

Prevalence: 2%-4% in the North American Prevalence: 2%-4% in the North American population population

Commonly unilateral Commonly unilateral Nearly all amblyopic visual loss is Nearly all amblyopic visual loss is

preventable or reversible with timely preventable or reversible with timely detection and appropriate intervention.detection and appropriate intervention.

Children with amblyopia or at risk for Children with amblyopia or at risk for amblyopia should be identified at a young amblyopia should be identified at a young age when the prognosis for successful age when the prognosis for successful treatment is best. treatment is best.

Role of screening is important Role of screening is important

ETIOLOGIETIOLOGI

Kurangnya rangsangan untuk Kurangnya rangsangan untuk meningkatkan perkembangan penglihatan meningkatkan perkembangan penglihatan makula, antara lain akibat :makula, antara lain akibat : StrabismusStrabismus KatarakKatarak Kelainan refraksi unilateral atau bilateral yang Kelainan refraksi unilateral atau bilateral yang

tidak dikoreksitidak dikoreksi

ETIOLOGIETIOLOGI Nirpakai Nirpakai (non use)(non use)

Terjadi akibat tidak dipergunakannya elemen Terjadi akibat tidak dipergunakannya elemen visual retino kortikal pada saat kritis visual retino kortikal pada saat kritis perkembangannya (t.u. sebelum 9 tahun)perkembangannya (t.u. sebelum 9 tahun)

Supresi Supresi

Di bawah penglihatan binokular, bayangan Di bawah penglihatan binokular, bayangan yang terlihat di salah satu mata menjadi yang terlihat di salah satu mata menjadi predominan dan yang terlihat di mata yang predominan dan yang terlihat di mata yang lain tidak dipersepsikan.lain tidak dipersepsikan.

66

77

88

MANIFESTASI KLINIKMANIFESTASI KLINIK

Berkurangnya penglihatan satu mataBerkurangnya penglihatan satu mata Menurunnya tajam penglihatan terutama pada Menurunnya tajam penglihatan terutama pada

fenomena fenomena crowdingcrowding Hilangnya sensitivitas korneaHilangnya sensitivitas kornea Mata mudah mengalami fiksasi eksentrikMata mudah mengalami fiksasi eksentrik Adanya anisokoriaAdanya anisokoria Tidak mempengaruhi penglihatan warnaTidak mempengaruhi penglihatan warna Biasanya daya akomodasi menurunBiasanya daya akomodasi menurun Tidak terdapat kelainan organik pada retina Tidak terdapat kelainan organik pada retina

maupun korteks serebrimaupun korteks serebri

KLASIFIKASIKLASIFIKASI

Ambliopia fungsionalAmbliopia fungsional Ambliopia strabismikAmbliopia strabismik Ambliopia refraktifAmbliopia refraktif Ambliopia anisometropikAmbliopia anisometropik Ambliopia ametropikAmbliopia ametropik Ambliopia eks anopsiaAmbliopia eks anopsia Ambliopia intoksikasiAmbliopia intoksikasi Ambliopia histeriaAmbliopia histeria Ambliopia organikAmbliopia organik

Ambliopia strabismusAmbliopia strabismus

Terjadi akibat juling lama (terjadi supresi Terjadi akibat juling lama (terjadi supresi pada mata u mencegah diplopia)pada mata u mencegah diplopia)

Kedudukan bola mata tidak sejajar Kedudukan bola mata tidak sejajar hanya satu mata yang diarahkan pada hanya satu mata yang diarahkan pada benda yang dilihat.benda yang dilihat.

Ditemukan pada penderita esotropia, Ditemukan pada penderita esotropia, jarang pada eksotropia.jarang pada eksotropia.

Ambliopia refraktifAmbliopia refraktif

Ametropia yang tidak dikoreksi,Ametropia yang tidak dikoreksi,Anisometropia yang tidak dikoreksi, Anisometropia yang tidak dikoreksi, Isoametropia :Isoametropia :

Hipermetropia dalam, Hipermetropia dalam, Miopia berat Miopia berat AstigmatikAstigmatik

1414

Mild hyperopic or astigmatic anisometropia Mild hyperopic or astigmatic anisometropia (1-2D) (1-2D) mild amblyopia mild amblyopia

Mild myopia anisometropia (less than -3D) Mild myopia anisometropia (less than -3D) usually doesn't cause amblyopiausually doesn't cause amblyopia

unilateral high myopia (-6D) unilateral high myopia (-6D) sever sever amblyopia visual loss.amblyopia visual loss.

The eye s of a child with anisometropic The eye s of a child with anisometropic amblyopia look normaly to the family and amblyopia look normaly to the family and primary care physician. primary care physician.

Mild hyperopic or astigmatic anisometropia Mild hyperopic or astigmatic anisometropia (1-2D) (1-2D) mild amblyopia mild amblyopia

Mild myopia anisometropia (less than -3D) Mild myopia anisometropia (less than -3D) usually doesn't cause amblyopiausually doesn't cause amblyopia

unilateral high myopia (-6D) unilateral high myopia (-6D) sever sever amblyopia visual loss.amblyopia visual loss.

The eye s of a child with anisometropic The eye s of a child with anisometropic amblyopia look normaly to the family and amblyopia look normaly to the family and primary care physician. primary care physician.

1515

Ambliopia anisometrikAmbliopia anisometrik

Anisometropia Anisometropia bayangan benda bayangan benda pada kedua mata tidak sama besar pada kedua mata tidak sama besar mata memfokuskan melihat dengan mata memfokuskan melihat dengan satu mata.satu mata.

Bayangan yang lebih suram akan Bayangan yang lebih suram akan disupresi (mata yang lebih ametropik)disupresi (mata yang lebih ametropik)

Ambliopia ametropiaAmbliopia ametropia

Menurunnya tajam penglihatan mata Menurunnya tajam penglihatan mata dengan kelainan refraksi berat yang tidak dengan kelainan refraksi berat yang tidak dikoreksi :dikoreksi : Hipermetropia tinggi (+ 7,0 D)Hipermetropia tinggi (+ 7,0 D) Astigmat (3,0 D)Astigmat (3,0 D)

Ambliopia eks anopsiaAmbliopia eks anopsia

Akibat penglihatan terganggu pada saat Akibat penglihatan terganggu pada saat perkembangan penglihatan bayi.perkembangan penglihatan bayi.

Dapat terjadi pada katarak kongenital, Dapat terjadi pada katarak kongenital, ptosis, atau kekeruhan kornea sejak lahir ptosis, atau kekeruhan kornea sejak lahir yang terlambat diatasi.yang terlambat diatasi.

1919

In children younger than 6 years, dons In children younger than 6 years, dons congenital cataract that occupy the central 3 congenital cataract that occupy the central 3 mm. or more of the lens must be considered mm. or more of the lens must be considered capable of causing sever amblyopiacapable of causing sever amblyopia..

Similar lens opacities acquired after 6 years Similar lens opacities acquired after 6 years are generally less harmful.are generally less harmful.

In children younger than 6 years, dons In children younger than 6 years, dons congenital cataract that occupy the central 3 congenital cataract that occupy the central 3 mm. or more of the lens must be considered mm. or more of the lens must be considered capable of causing sever amblyopiacapable of causing sever amblyopia..

Similar lens opacities acquired after 6 years Similar lens opacities acquired after 6 years are generally less harmful.are generally less harmful.

2020

Ambliopia intoksikasiAmbliopia intoksikasi

Penyebab : alkohol, tembakau, timah dan Penyebab : alkohol, tembakau, timah dan bahan toksik lainnyabahan toksik lainnya

Neuritis optikNeuritis optik

Ambliopia histeriaAmbliopia histeria

Terjadi akibat adanya histeria yang dapat Terjadi akibat adanya histeria yang dapat mengenai satu mata, akan tetapi lebih mengenai satu mata, akan tetapi lebih sering mengenai kedua mata.sering mengenai kedua mata.

Pemeriksaan fisik:Pemeriksaan fisik: Lapangan pandang menciut konsentrisLapangan pandang menciut konsentris BlefarospameBlefarospame Memejamkan mataMemejamkan mata LakrimasiLakrimasi

Ambliopia organikAmbliopia organik

ReversibelReversibelMisalnya : ambliopia akibat kerusakan Misalnya : ambliopia akibat kerusakan

fovea kongenital.fovea kongenital.

PEMERIKSAANPEMERIKSAAN

Uji crowding phenomenaUji crowding phenomena

mengetahui adanya ambliopiamengetahui adanya ambliopiaUji densiti filter netralUji densiti filter netral

mengetahui adanya ambliopiamengetahui adanya ambliopiaUji Worth’s Four DotUji Worth’s Four Dot

fusi & penglihatan stereosisfusi & penglihatan stereosisVisuskopVisuskop

Crowding bar, or contour interaction bars, allow the Crowding bar, or contour interaction bars, allow the examinator to test the crowding phenomenon with examinator to test the crowding phenomenon with isolated optotype. Bar surrounding the optotype isolated optotype. Bar surrounding the optotype mimic the full of optotype to the amblyopia child.mimic the full of optotype to the amblyopia child.

Crowding bar, or contour interaction bars, allow the Crowding bar, or contour interaction bars, allow the examinator to test the crowding phenomenon with examinator to test the crowding phenomenon with isolated optotype. Bar surrounding the optotype isolated optotype. Bar surrounding the optotype mimic the full of optotype to the amblyopia child.mimic the full of optotype to the amblyopia child.

2525

E O

2626

Treatment Treatment Treatment Treatment

Treatment of amblyopiaTreatment of amblyopia involves the involves the following steps: following steps:

Eliminating (if possible) any obstacle to Eliminating (if possible) any obstacle to vision such as a cataract vision such as a cataract

Correcting refractive error Correcting refractive error Forcing use of the poorer eye by limiting use Forcing use of the poorer eye by limiting use

of the better eye.of the better eye.

Treatment of amblyopiaTreatment of amblyopia involves the involves the following steps: following steps:

Eliminating (if possible) any obstacle to Eliminating (if possible) any obstacle to vision such as a cataract vision such as a cataract

Correcting refractive error Correcting refractive error Forcing use of the poorer eye by limiting use Forcing use of the poorer eye by limiting use

of the better eye.of the better eye.

2727

Cataract removal Cataract removal Cataract removal Cataract removal

Cataracts capable of producing amblyopia require Cataracts capable of producing amblyopia require surgery without unnecessary delay.surgery without unnecessary delay.

Removal of significant congenital lens opacities Removal of significant congenital lens opacities during the first 2-3 months of life is necessary for during the first 2-3 months of life is necessary for optimal recovery of vision.optimal recovery of vision.

In symmetrical bilateral cases, the interval between In symmetrical bilateral cases, the interval between operations on the first and second eyes should be no operations on the first and second eyes should be no more than 1-2 weeks.more than 1-2 weeks.

Acutely developing severe traumatic cataracts in Acutely developing severe traumatic cataracts in children younger than 6 years should be removed children younger than 6 years should be removed within a few weeks of injury, if possible.within a few weeks of injury, if possible.

Cataracts capable of producing amblyopia require Cataracts capable of producing amblyopia require surgery without unnecessary delay.surgery without unnecessary delay.

Removal of significant congenital lens opacities Removal of significant congenital lens opacities during the first 2-3 months of life is necessary for during the first 2-3 months of life is necessary for optimal recovery of vision.optimal recovery of vision.

In symmetrical bilateral cases, the interval between In symmetrical bilateral cases, the interval between operations on the first and second eyes should be no operations on the first and second eyes should be no more than 1-2 weeks.more than 1-2 weeks.

Acutely developing severe traumatic cataracts in Acutely developing severe traumatic cataracts in children younger than 6 years should be removed children younger than 6 years should be removed within a few weeks of injury, if possible.within a few weeks of injury, if possible.

2828

Refractive correction Refractive correction Refractive correction Refractive correction

In generally, optical prescription for In generally, optical prescription for amblyopic eyes should correct the full amblyopic eyes should correct the full refractive error as determined with refractive error as determined with cyclopagic.cyclopagic.

In generally, optical prescription for In generally, optical prescription for amblyopic eyes should correct the full amblyopic eyes should correct the full refractive error as determined with refractive error as determined with cyclopagic.cyclopagic.

2929

Occlusion and optical degradation Occlusion and optical degradation Occlusion and optical degradation Occlusion and optical degradation

Full time occlusion of the sound eye:Full time occlusion of the sound eye: Defined as occlusion for all or all but one waking Defined as occlusion for all or all but one waking

hour. hour. It is the most powerful means of treating of It is the most powerful means of treating of

amblyopia by enforced use of the defective eye. amblyopia by enforced use of the defective eye. The patch can either be left in place at night or The patch can either be left in place at night or

removed at bedtime.removed at bedtime. Spectacle-mounted occluser or special opaque Spectacle-mounted occluser or special opaque

contact lenses can be used as an alternative to full-contact lenses can be used as an alternative to full-time patching if skin irritation or poor adhesion time patching if skin irritation or poor adhesion proves to be a significant problemproves to be a significant problem

Full time occlusion of the sound eye:Full time occlusion of the sound eye: Defined as occlusion for all or all but one waking Defined as occlusion for all or all but one waking

hour. hour. It is the most powerful means of treating of It is the most powerful means of treating of

amblyopia by enforced use of the defective eye. amblyopia by enforced use of the defective eye. The patch can either be left in place at night or The patch can either be left in place at night or

removed at bedtime.removed at bedtime. Spectacle-mounted occluser or special opaque Spectacle-mounted occluser or special opaque

contact lenses can be used as an alternative to full-contact lenses can be used as an alternative to full-time patching if skin irritation or poor adhesion time patching if skin irritation or poor adhesion proves to be a significant problemproves to be a significant problem

3030

3131

3232

Full time patching should generally be used Full time patching should generally be used only when constant strabismus eliminates only when constant strabismus eliminates any possibility of useful binocular vision any possibility of useful binocular vision because because full time patching runs a small full time patching runs a small risk of perturbing binocularity. risk of perturbing binocularity.

Full time patching should generally be used Full time patching should generally be used only when constant strabismus eliminates only when constant strabismus eliminates any possibility of useful binocular vision any possibility of useful binocular vision because because full time patching runs a small full time patching runs a small risk of perturbing binocularity. risk of perturbing binocularity.

3333

Part-time occlusion:Part-time occlusion: Defined as occlusion for 1-6 hours per day.Defined as occlusion for 1-6 hours per day. The children undergoing part time occlusion The children undergoing part time occlusion

should be kept as visually active as possible should be kept as visually active as possible when the patch is in place.when the patch is in place.

Compliance with occlusion therapy for Compliance with occlusion therapy for amblyopia declines with increasing age.amblyopia declines with increasing age.

Part-time occlusion:Part-time occlusion: Defined as occlusion for 1-6 hours per day.Defined as occlusion for 1-6 hours per day. The children undergoing part time occlusion The children undergoing part time occlusion

should be kept as visually active as possible should be kept as visually active as possible when the patch is in place.when the patch is in place.

Compliance with occlusion therapy for Compliance with occlusion therapy for amblyopia declines with increasing age.amblyopia declines with increasing age.

3434

Penalization: Penalization: A cyclopagic agent (usually atropine 1% or A cyclopagic agent (usually atropine 1% or

homatropine 5% )homatropine 5% ) once daily to the better once daily to the better eye eye

This form of treatment has recently been This form of treatment has recently been demonstrated to be as effective as patching demonstrated to be as effective as patching for mild to moderate amblyopia. for mild to moderate amblyopia.

Penalization: Penalization: A cyclopagic agent (usually atropine 1% or A cyclopagic agent (usually atropine 1% or

homatropine 5% )homatropine 5% ) once daily to the better once daily to the better eye eye

This form of treatment has recently been This form of treatment has recently been demonstrated to be as effective as patching demonstrated to be as effective as patching for mild to moderate amblyopia. for mild to moderate amblyopia.

3535

Complication of therapy Complication of therapy Complication of therapy Complication of therapy

Full time occlusion carries the greatest risk of this Full time occlusion carries the greatest risk of this complication and requires close monitoring, complication and requires close monitoring, especially in the younger child.especially in the younger child.

The first follow up visit after initial treatment The first follow up visit after initial treatment should occur within 1 week for an infant and after should occur within 1 week for an infant and after interval corresponding to 1 week per year of age for interval corresponding to 1 week per year of age for the older child.the older child.

Part time occlusion & optical degradation methods Part time occlusion & optical degradation methods allow for less frequent observation but regular allow for less frequent observation but regular follow up is still critical follow up is still critical

Full time occlusion carries the greatest risk of this Full time occlusion carries the greatest risk of this complication and requires close monitoring, complication and requires close monitoring, especially in the younger child.especially in the younger child.

The first follow up visit after initial treatment The first follow up visit after initial treatment should occur within 1 week for an infant and after should occur within 1 week for an infant and after interval corresponding to 1 week per year of age for interval corresponding to 1 week per year of age for the older child.the older child.

Part time occlusion & optical degradation methods Part time occlusion & optical degradation methods allow for less frequent observation but regular allow for less frequent observation but regular follow up is still critical follow up is still critical

3636

The time required for completion of The time required for completion of treatment depends on the following: treatment depends on the following:

1.1. Degree of amblyopia Degree of amblyopia

2.2. Choice of therapeutic approach Choice of therapeutic approach

3.3. Compliance with the prescribed regimen Compliance with the prescribed regimen

4.4. age of the patient age of the patient

The time required for completion of The time required for completion of treatment depends on the following: treatment depends on the following:

1.1. Degree of amblyopia Degree of amblyopia

2.2. Choice of therapeutic approach Choice of therapeutic approach

3.3. Compliance with the prescribed regimen Compliance with the prescribed regimen

4.4. age of the patient age of the patient

3737

Unresponsiveness Unresponsiveness Unresponsiveness Unresponsiveness

Complete or partial Unresponsiveness to treatment Complete or partial Unresponsiveness to treatment occasionally affect younger children but must often occasionally affect younger children but must often occurs in patients older than 5 years.occurs in patients older than 5 years.

Primary therapy should generally be terminated if Primary therapy should generally be terminated if there is a lock of demonstrable progress over 3-6 there is a lock of demonstrable progress over 3-6 months with good compliance.months with good compliance.

Refraction should be carefully rechecked and the Refraction should be carefully rechecked and the macula and optic nerve critically inspected for macula and optic nerve critically inspected for subtle evidence of hypoplasia or other malformation subtle evidence of hypoplasia or other malformation that might have been previously overlooked. that might have been previously overlooked.

Complete or partial Unresponsiveness to treatment Complete or partial Unresponsiveness to treatment occasionally affect younger children but must often occasionally affect younger children but must often occurs in patients older than 5 years.occurs in patients older than 5 years.

Primary therapy should generally be terminated if Primary therapy should generally be terminated if there is a lock of demonstrable progress over 3-6 there is a lock of demonstrable progress over 3-6 months with good compliance.months with good compliance.

Refraction should be carefully rechecked and the Refraction should be carefully rechecked and the macula and optic nerve critically inspected for macula and optic nerve critically inspected for subtle evidence of hypoplasia or other malformation subtle evidence of hypoplasia or other malformation that might have been previously overlooked. that might have been previously overlooked.

3838

Recurrence Recurrence Recurrence Recurrence

When amblyopia treatment is discontinued after fully When amblyopia treatment is discontinued after fully or partially successful completion, approximately half or partially successful completion, approximately half of patients show some dgree of recurrence,of patients show some dgree of recurrence,

Maintenance therapy: Maintenance therapy: Patching for 1-3 hours per day Patching for 1-3 hours per day Optical penalization with spectacles Optical penalization with spectacles Pharmacologic penalization with atropine 1 or 2 day Pharmacologic penalization with atropine 1 or 2 day

per week.per week. This may require periodic monitoring until age 8-10. This may require periodic monitoring until age 8-10.

When amblyopia treatment is discontinued after fully When amblyopia treatment is discontinued after fully or partially successful completion, approximately half or partially successful completion, approximately half of patients show some dgree of recurrence,of patients show some dgree of recurrence,

Maintenance therapy: Maintenance therapy: Patching for 1-3 hours per day Patching for 1-3 hours per day Optical penalization with spectacles Optical penalization with spectacles Pharmacologic penalization with atropine 1 or 2 day Pharmacologic penalization with atropine 1 or 2 day

per week.per week. This may require periodic monitoring until age 8-10. This may require periodic monitoring until age 8-10.