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Study Review

Interested in recently published scientific information about amblyopia (lazy eye) and about associated conditions like misaligned eyes (strabismus) or refractive error (need for glasses)? 

Every month or so we will review a recently published study from a peer reviewed journal about amblyopia and associated conditions.  We'll translate the scientific jargon into an easy to understand review of the science article so you'll know what is important for you and your child with amblyopia. 

Study 11    Preschoolers Suffer a Loss of Visual Motor Function if They have Untreated Refractive Error

Study 10    Lazy Eye and Misaligned Eyes Lead to Poor Motor Skills in Children

Study 9:     Cataract and Amblyopia

Study 8:     Factors Associated with Recurrence of Amblyopia on Cessation of Patching

Study 7:     Vision Screening Program Important for Early Detection of Amblyopia

Study 6:     Vision Recovery in the Amblyopic Eye Following Loss of Vision in the Good Eye

Study 5:     Amblyopia Cured by Glasses Alone

Study 4:     Amblyopia in Both Eyes

Study 3:     The Return of Amblyopia Following Termination of Therapy

Study 2:     Compliance with Patching Therapy

Study 1:     The Psychological Impact of Amblyopia and Strabismus

Study 11:        Preschoolers Suffer a Loss of Visual Motor Function if They have Untreated Refractive Error

Roch-Levecq and colleagues, "Ametropia, preschoolers' cognitive abilities, and effects of spectacle correction".  Archives of Ophthalmology, 2008, p252-258.

 Roch-Levecq and colleagues looked at the effects of wearing glasses on visual-motor function in preschool children.  The average age of the children was 4.6 years and most were female (60%) and most were Latino (86%).  The investigators wanted to know if preschoolers with significant refractive errors (4 diopters of hyperopia or/and 2 diopters of astigmatism); that is, children who really needed glasses to see things clearly, suffered from losses in eye-hand coordination and other visual-motor problems compared to similar aged matched children who didn't need glasses.

The investigators had 35 children who needed glasses (the experimental group) and 35 children who did not need glasses (the normal control group) perform two standard tests of visual motor function (Beery-Buktenica developmental test of visual-motor integration, and the Wechsler Preschool and Primary scale of intelligence-Revised scores).  These tests were competed at the start of the study and 6 weeks after the children in the experimental group were given their glasses.

At the start of the study, the investigators found that those children who needed glasses performed much worse than the children who did not need glasses; in other words, children with uncorrected refractive error performed worse on both tests than children with normal vision.  Further, 6 weeks after the children were given their glasses they improved in visual motor performance at least on the Beery-Buktenica developmental test of visual-motor function.  Therefore, preschool children with uncorrected refractive error can't see as well as normal children and their visual-motor function suffers because of it.  However, providing these young children with corrective glasses allowed the children to improve their performance equal to normally sighted children.

This is one of the first studies to show that children really need proper eyesight to perform well in preschool. An undiagnosed refractive error can negatively affect their school performance and perhaps even their performance on the playground where visual motor function is really needed.  Thankfully, the study also shows that when preschools are provided their proper eyeglasses that they can quickly recover in their visual-motor performance.

The current study highlights the need for preschool children to have their eyes checked before starting school.  Luckily, in Ohio, school vision screenings are mandated in Kindergarten and in first grade to catch many of the children who have an undiagnosed eye problem.  If your child fails a school vision screening test, the study also shows the importance of getting your child into the eye doctor's office where he or she can be properly examined, diagnosed and treated, if necessary.

Study 10:

Lazy Eye and Misaligned Eyes Lead to Poor Motor skills in Children

 Does your child have problems with fine motor skills, like cutting-out a circle or drawing through a straight path or copying a circle, diamond or triangle?  If so, it may be important to have him or her checked for a lazy eye or for an eye misalignment.

 Webber and colleagues (2008, Invest. Ophthal. Vis. Science) recently reported that children (average age of 8 years) with amblyopia and particularly children with misaligned eyes (strabismus) had poor fine motor skills compared to age matched normal children.  They had children perform fine motor tasks including those listed in Table 1 (below).  The investigators also assessed upper limb (arm and hand) sped and dexterity tasks as listed in Table 2 (below).

 Table 1.  List of fine motor skills

 Table 2.  List of Upper Limb Speed and Dexterity

 The investigators found that children with lazy eye, and particularly those children with misaligned eyes (strabismus) performed much worse on the fine motor skill tasks than normal sighted children.  These deficits in fine motor skills became very apparent when the children were given a restricted time (15 seconds) to perform their motor task.  Also, when accuracy was assessed, those children with strabismus performed worse than normal children.

 Bottom line:  It is very important to diagnose and treat children with lazy eye and with misaligned eyes.  If left untreated, not only will these eye problems affect vision, they may also affect eye-hand coordination and fine motor skills, in particular.  If you have a child who performs poorly on fine motor skill tasks as listed in Table 1, have his or eyes checked by an eye doctor.

Study 9:

Cataracts and Amblyopia

By

L. E. Leguire Ph.D., MBA

Executive Director

Ohio Amblyope Registry

The most common reasons for an infant or child to develop amblyopia, commonly known as "lazy eye", include misaligned eyes (strabismus), a difference in refractive error between the eyes (anisometropia) and refractive error, usually hyperopia.  Another important reason for an infant or young child to develop amblyopia is because of the presence of a cataract in one or both eyes.  Usually, people think of cataracts as only occurring in older adults.  Indeed, if you live long enough, most people will develop cataracts in their lifetime.  However, infants can be born with cataracts and older children can develop cataracts for numerous reasons.

A cataract is a clouding or opacity of the lens of the eye such that light is not refracted (bent) properly to focus on the back of the eye, known as the retina.  The main purpose of the lens, which is changeable and flexible (at least until a person is 45 years old or so), is to focus light onto the retina.  If light is focused properly by the lens, a sharp image is projected onto the retina and the person will experience clear and sharp vision.  If, however, the light is focused in front of the retina, as in myopia, or if the light is focused behind the retina, as in hyperopia, the person will experience blurred vision - a sign that the person needs glasses.  With a cataract, light is scattered and cannot be focused onto the retina to create a clear and sharp image.  Scattered light caused by a cataract can be very unpleasant and can cause light sensitivity and can even be painful.  Patients with a cataract in one eye may intentionally or unintentionally close the affected eye to reduce the light sensitivity and blurred vision.  Patients with cataracts may see halos around lights and/or may experience "star-burst" when looking at on-coming car headlights, for example.  As cataracts get worse, my mother-in-law would say "as the cataract ripens", visual acuity will start to decrease.

When an infant is born with a cataract in one or both eyes, the condition is called "congenital cataract".    Congenital cataracts are often "nuclear cataracts", a reference to the location of the cataract in the lens of the eye.  A congenital cataract may be large or small and may or may not affect vision depending on its location in the lens.  If the congenital cataract is small and not in the center light pathway (visual axis) of the lens, it might not affect vision and there may be no reason to remove the cataract and lens of the eye.  Congenital cataracts often do not change in size as the child grows.  Often, however, congenital cataracts require immediate medical treatment and surgery.  Delaying cataract surgery, even for a few weeks, in a young infant can lead to a permanent loss of vision due to the rapid development of deep amblyopia that may not respond to treatment.

If the cataract develops later in childhood the cataract is called a "developmental cataract".  Developmental cataracts are sometimes "lamellar cataracts", specifying the location of the cataract within the lens.   Developmental cataracts are not present at birth and form later in childhood.  Developmental cataracts do grow in size over time and, depending on size and location, may require surgery to remove the cataract and lens of the eye. 

If a cataract forms after trauma to the eye, often a penetrating injury to the eye, it is called a "traumatic cataract".  A traumatic cataract may form soon after trauma to the eye and require removal of the lens.  Traumatic cataracts can grow very large and encompass the whole or nearly the whole lens requiring immediate surgery particularly in a young child; otherwise, amblyopia may develop.

Cataract surgery is serious surgery and requires general (whole body) anesthesia.  As a consequence, the ophthalmologist, an eye doctor that performs surgery, will not want to perform cataract surgery on an infant or child until the cataract interferes with vision; that is, until the cataract threatens vision.  At the same time, however, amblyopia can develop rapidly and become very deep and cause blindness in a very young infant with congenital cataracts.  As a consequence, surgery is often performed in the first few months of life if there is a congenital cataract.  Indeed, studies have shown that visual outcome is much better in infants with congenital cataracts when cataract surgery is performed before the first 6 - 12 weeks of life than when it is performed later.

Children with cataracts pose numerous challenges for the eye doctor.  On the one hand, the doctor doesn't want to undertake surgery and general anesthesia on a young infant for fear of serious complications and to avoid the unique challenges posed by such little patients with small eyes.  On the other hand, the eye doctor doesn't want to wait too long and have deep amblyopia develop in the infant and thus complicate management of the patient.  This is where professional judgment comes to play and the eye doctor knows when surgery is required, particularly if the cataract is large or interferes with light entering the eye.

Amblyopia and strabismus (misaligned eyes) are two signs that a cataract is serious enough to have it surgically removed.  Also, nystagmus (repetitive back-and-forth movement of the eyes) development in an infant with congenital cataracts is a serious sign of a significant and permanent loss of vision.  Children with congenital cataracts who develop nystagmus have, in general, a poor visual outcome even if the cataracts are subsequently removed and proper optical correction provided.  Infants with congenital cataracts who develop nystagmus often have a visual acuity of 20/200 - legal blindness.

In the last 30 years, much research has been undertaken as to the timing of surgery for congenital cataracts.  To prevent the development of amblyopia or strabismus, congenital cataracts are removed as early as possible, often in the first 6 weeks of life.  In general, infants who have had cataract surgery performed in the first 6-8 weeks of life do much better, in terms of visual acuity, than infants who had cataract surgery performs after 12 weeks of life.  A real problem after cataract surgery is determination of the best way to correct the high refractive error that is present once the natural lens of the eye is removed.  Unless good optical correction is provided following cataract surgery, the patient is essentially blind and can see very little after the natural lens of the eye removed.  Without the natural lens, and without proper optical correction, a child may have light perception only, and not be able to see object details.

Basically, there are 3 choices for correcting the high refractive error caused by removal of the natural lens of the eye: glasses, contact lens and intraocular lens.  Unfortunately, all choices leave a lot to be desired and none are ideal for all patients.  Glasses for patients who have had cataract surgery are very thick and heavy.  Trying to get an infant to wear thick, heavy glasses poses numerous challenges for the parents.  These challenges are amplified if only one eye was operated on and when only one eye needs a thick lens.

Contact lenses also pose numerous challenges to the patient and parent.  Daily insertion of the contact, cleaning of the contact and trying to avoid the patient from simply rubbing out the contact are just some of the challenges.  Also, because the contacts are very high power, they're expensive and a young patient may "go through" numerous contacts over a year period.  Also, infants seem to have a knack for swallowing the contact with an anxious parent checking the diapers on a regular basis to retrieve the contact lens.  Often, the contact lens simply disappears never to be seen again.  In the mean time, when the patient doesn't have the contact on the eye properly, he or she will experience blurred vision and the chance of amblyopia increases dramatically.

If you're elderly and require cataract surgery, optical correction simply involves replacing the old cataract lens with an intraocular lens - sort of a contact lens that fits inside the eye.  An intraocular lens is very small and lightweight and is inserted inside the eye in the same location or nearly so as the natural lens.  Unfortunately, intraocular lenses in infants and young children pose a host of problems.  First, because the eye is still growing in childhood, numerous complications can result with cataract surgery and intraocular lens implantation.  The cataract surgery in children is much more complicated than in adults, because of the small size of the eyes and other surgical considerations.  A common complication in children with an intraocular lens is opacification of the visual axis; that is, cells within the eye adhering to the intraocular lens and preventing light from being focused on the retina - equivalent to another "cataract" forming but this time on the intraocular lens.  This is referred to as an "after cataract".  If needed, the intraocular lens can be replaced.  Probably the most serious complication of an intraocular lens in a child is the development of secondary glaucoma that can lead to blindness in the affected eye(s).

Whichever optical correction is undertaken following cataract surgery, regular follow-up and rapid treatment of amblyopia are essential for minimizing the development of amblyopia and other complications.  Ideally, an infant or child who has had cataract surgery is given proper optical correction and is closely managed with regular eye doctor appointments to prevent or treat the development of amblyopia and misaligned eyes.

Causes of Cataracts

Regarding congenital cataracts, most of the time the reason for the cataract(s) is unknown.  However, congenital cataracts can run in families, so there is a clear genetic component in some cases.  Congenital cataracts are sometimes associated with infections, steroid use and exposure to radiation during pregnancy.  Alcohol and drug use during pregnancy is also associated with congenital cataracts.  Numerous syndromes or diseases are also associated with congenital cataracts, including Down's syndrome, Trisomy 13 and Rubella syndrome among others.  Metabolic abnormalities can also lead to cataract formation.

Regarding developmental cataracts, much like congenital cataracts, the reason for the cataract(s) is often unknown.  Developmental cataracts may be associated with nutritional or metabolic abnormalities, certain diseases and certain syndromes.  Exposure to radiation, extended use of steroids or other drugs are sometimes related to cataract development.  Sometimes, the type and location of the cataract provides clues as to the cause of the cataract. 

Brief Literature Review

Zetterstrom and colleagues (Cataract Refract. Surg. 2005 p824-840) review the literature on the management of cataract in children and offer this advice:

Weisberg and colleagues (Ophthalmology, 2005, p1625-1628) undertook a retrospective study in which they reviewed the medical charts of 94 patients who had cataract surgery.  They found the following:

Travi and colleagues (J AAPOS 2005, p449-454) undertook a review of the charts of 53 patients who had cataracts initially thought to be too small to justify cataract surgery.  Patients were first treated for the amblyopia, which included glasses, patching and atropine (dilating eye drop in the better eye).  The patients who failed to improve underwent cataract surgery.  Of those who had cataract surgery, 67% showed a 3 line improvement on the eye chart.  Also, 25 of 51 patients (49%) had a final visual acuity of 20/40 or better, considered a success.  Overall, patients who had undergone cataract surgery had a final visual acuity better than those patients who did not have cataract surgery, although the differences between the surgery and non-surgery groups was not statistically significant.

Forbes and Guo (Pediatric Ophthalmol. & Strabismus, 2006, p143-151) reviewed the recent literature on the surgical management of cataracts in children.  They report that the success of surgery and long-term management of infants and children with cataracts has improved.  They cite progress in getting infants in earlier for cataract surgery, better forms of optical correction including more use of the intraocular lens, and the employment of many surgical techniques in children which were developed for older people with cataracts.  One major topic of discussion was the need for early surgery, at or before 6 weeks of age, before the development of binocular vision; that is, before the two eyes start to work together for single vision and depth perception.

Ruth and Lambert (J AAPOS 2006, p587-588) presented a case report of an infant with a congenital cataract in one eye.  The patient underwent cataract extraction and intraocular lens implantation at 8 weeks of age.   The patient ended up with better vision in the eye that had a cataract than in the other "normal" eye. 

As it turns out, sometimes when young infants are occluded for amblyopia; that is, when a patch is placed on the normal eye to force use of the lazy eye, so-called "reverse amblyopia" can occur.   Reverse amblyopia is a form of deprivational amblyopia in which amblyopia is caused by patching the normal eye too long.  Such reversal of amblyopia is fairly common in infants, particularly if parents get too aggressive and patch the patient much longer than the doctor's recommendation of patching time.  Reverse amblyopia can also develop when a parent misses an eye doctor appointment and continues to patch the child beyond the recommended time between appointments.

Ledoux and colleagues (J AAPOS, 2007, p218-224) undertook a chart review of 510 pediatric patients who had undergone cataract surgery and primarily received an intraocular lens.  After looking over the data the authors reported on the findings from 139 patients.  The average age of the patients was about 5 years, so most of the patients had developmental cataracts.  Vision was assessed about 4 years later, when the patients were about 9 years old.  The results showed that 50% of the patients had a visual acuity of better than 20/30 and 50% had a visual acuity of worse than 20/30.  When a child had a cataract in only one eye, the median visual acuity was 20/40 and when the child had a cataract in both eyes the median visual acuity was 20/25.  In general, older children had better visual acuity than younger children due mainly to the presence or absence of amblyopia.  About 14% of the patients ended up with a visual acuity of 20/200 or worse (legal blindness).  Of the 139 children, 18 (13%) required muscle surgery for an eye misalignment and 22 (16%) needed additional intraocular (within the eye) surgery due to problems related to the intraocular lens or related to the cataract extraction.

Terms to Remember

Phakic eye (Phakia)   An eye with a natural lens in place.  A normal eye.

Aphakic eye (Aphakia)  An eye without the natural lens.

Pseudophakic eye (Pseudophakia)   An eye that has had the natural lens removed and an intraocular lens implanted in the eye.

Study Story 8:

Article Review by L. E. Leguire Ph.D., MBA

Article: Factors Associated with Recurrence of Amblyopia on Cessation of Patching

Holmes et al, Ophthalmology, 2007; 114: p1427 - 1432

As part of the PEDIG (Pediatric Eye Disease Investigator Group) study group, Holmes and colleagues undertook a study of 69 amblyopic children under the age of 8 years who had previously been "successfully" treated for amblyopia with glasses and patching of the good eye.  Some of the children may also have had eye muscle surgery to correct the strabismus (eye misalignment).  The children in the study had amblyopia due to an eye misalignment (strabismus) or due to a difference in refractive error between the eyes (anisometropia).  The investigators were interested in how patching was stopped; suddenly or gradually, and the effect on later visual acuity.  For example, the suddenly stopped patching group of children had their patching stopped suddenly after wearing the patch for 6 - 8 hours per day.  The gradually stopped group of children had their patching first reduced from 6 - 8 hours per day to 2 hours per day followed by the termination of all patching.  There was also a group of children who were patched just for 2 hours per day and than also completely stopped.

The children in each group were followed for one year after the termination of patching to see how much visual acuity, if any, the children lost after patching was stopped.  Those children who lost two or more lines on the visual acuity chart were considered to have lost a significant amount of vision (visual acuity); that is, they "regressed" or had a recurrence of amblyopia.

The authors found that those children who had the best visual acuity after the termination of patching had the greatest chance of losing visual acuity.  This was a very surprising finding.  On the other hand, those children who had the worse visual acuity after stopping patching had the least amount of regression of visual acuity.  Also, the authors found that those children who had excellent depth perception (stereopsis) and had excellent eye alignment (i.e., no or minimal strabismus) were just as likely to lose visual acuity after the termination of patching as those children who had eye misalignments or poor depth perception - another unexpected finding.  The authors also found that those children with a history of regression of visual acuity also had an increased chance of regression following the termination of patching - no surprise here.

Another surprising finding of the study was that the risk of regression (i.e., loss of visual acuity) was the same regardless of the age of the child at the time patching was stopped.  Children about 7 years of age were just as likely to regress in visual acuity as children three years of age.  Traditionally, doctors believed that the older the child at the time patching is stopped the less likely the child would regress in visual acuity.

Based on the study findings, the investigators suggested that regardless of how well a child does in terms of amblyopia therapy and regardless of the child's visual acuity at the end of patching therapy, there is a need for "careful and prolonged follow-up" of children who are treated for amblyopia.

This article has generated a lot of discussion in the eye doctor community, primarily because of all the unexpected findings.  Indeed, the authors of the study go to great lengths, in the Discussion section of the article, to point-out that their results are contrary to previous study results, unexpected and counterintuitive.  In the Discussion section of the article, the authors point-out numerous possibilities as to what might have gone wrong with the study and what might have lead to the unexpected study results.

What should we take away for the study?  Perhaps that there needs to be more study on this topic before the current results are taken seriously.  There are so many questions raised by the study that one has to ask if the study is valid or even worth publishing in the first place.   However, the PEDIG investigators are some of the best of the best in clinical research.  In addition, it is difficult to question the statistics behind the results of the study as these are straight forward and transparent. 

A host of issues can be raised regarding the subjects in the study, a very heterogeneous group with different histories of treatment and experience.  Further, a major drawback in many PEDIG studies is the lack of documentation regarding compliance of patching therapy.  The PEDIG investigators rely on the parents undertaking the prescribed hours of patching therapy without actually objectively documenting that the hours of patching reported by the parents is really the number of hours that the child was patched.  For example, in one study by this reviewer (Dr. Leguire), we found that parents typically patch for two hours less than prescribed by their child's eye doctor.  If children are not patched the hours that the investigators think that the child is patched, this would complicate interpretation of the study findings.  In addition, children are notorious at not wearing their patch as prescribed.  For example, one celebrated case documented in the Eye Clinic at Columbus Children's hospital:  An amblyopic child was being patch full time (about 8 hours per day); yet, after several months the child was not responding to therapy.  An investigation revealed the cause of the lack of improvement - once the child was on the school bus he removed his patch from the good eye and placed it on the amblyopic eye so he could see.  The teacher reported that the child was compliant in wearing his patch all day long.  On the return bus trip the child would remove the patch from his amblyopic eye and place it back on the good eye.  At home, the mother saw that the child was also compliant in wearing the patch all day long.

One thing is certain; children with amblyopia must be followed closely by their eye doctor and not only during treatment but also after successful treatment to ensure that if the amblyopia does return that it can be dealt with in a timely manner.

Study Story 7:

Vision Screening Programs Important in Early Detection of Amblyopia

By Dr. Paulette Schmidt

 Vision disorders are the most frequently occurring handicapping conditions in childhood in the United States.  How is this possible?  First, children do not know how they should see, so they do not tell us that they cannot see. Second, vision problems usually do not hurt.  Third, it is not possible to identify vision problems simply by looking at a child. 

 Amblyopia is an important cause of visual impairment; it  originates in childhood and, if undetected and untreated, prevents a child’s full visual development.  Amblyopia can result in permanent vision loss.  Further, before amblyopia treatment can begin, children with or at risk for amblyopia must be detected. 

 Amblyopia occurs in as many as one in 20 children. An estimated 75,000 to 200,000 three-year-old children in the United States have amblyopia.  Children with amblyopia are at 16 times the risk for blindness in their good eye in comparison to children with normal vision. Amblyopia poses a significant public health problem in the United States.  The Healthy People 2010 Program, a federal program designed to improve health care of children, targets an increased participation of preschool-age children in vision screening programs to detect amblyopia early when treatment is most effective.  In Scandinavia, as the result of vision screening programs in which all preschool-age children have their vision tested, the occurrence of amblyopia has been reduced by 90 percent.

 Vision screening tests are not diagnostic and are not a substitute for comprehensive eye examinations.  However, with accepted treatment for amblyopia established, amblyopia meets the inclusion criteria for detection in public health screening programs.  In the absence of comprehensive eye examinations for all children, amblyopia is targeted for early detection through vision screening programs.   

Vision screening is a quick, simple public health strategy to detect children with or at risk for eye disorders.  Vision screening does not provide a diagnosis or treatment; vision screening identifies those with or at risk for a vision disorder.  Vision screening is typically conducted by a nurse or trained layperson.

 With an increased emphasis on screening for amblyopia among preschool-age children, use of effective vision screening tests is essential.  Uncorrected farsightedness (hyperopia) and/or astigmatism are both a type of refractive error. Uncorrected farsightedness (hyperopia) and/or astigmatism and eye misalignment (strabismus) are the most frequent causes of amblyopia.  Further, eye misalignment is frequently caused by uncorrected farsightedness (hyperopia).  Therefore, screening for amblyopia must use tests known to be effective in detecting refractive error. 

The effectiveness of screening tests used to detect amblyopia was scientifically established by the VIP Study, funded by the National Eye Institute of the National Institutes of Health and conducted in five U.S. cities. 

 Results reported by VIP included the best tests for use in preschool vision screening and which tests perform poorly; vision screenings conducted by trained lay people were found to be similar to those conducted by trained nurses and eye doctors when standardized training and testing procedures were used. 

Eleven vision screening tests were evaluated in the VIP Study: three tests of refractive error, three tests of visual acuity, three tests of eye alignment, and two photoscreeners (tests of refractive error plus eye alignment).

 Over 4,500 preschool-age children had their vision screened.  Results varied tremendously in terms of the effectiveness of the tests for detecting amblyopia and risk factors for amblyopia (refractive error and eye misalignment). Further, vision screening tests that targeted detection of refractive error were found to be particularly effective in amblyopia detection among preschool-age children.  Regardless of who performed the test, effective tests include the Retinomax Autorefractor and SureSight Vision Screener.  Photoscreeners were found less accurate than the autorefractors in screening for refractive error. Amblyopia detection was especially effective when lay screeners used the Single crowded LEA Symbols Visual Acuity Screening Test at five feet.         

 In summary, amblyopia is an important cause of visual impairment in childhood with continued impact in later life.  Vision loss due to amblyopia is preventable. Detection of amblyopia is targeted through vision screening programs.  As the result of the VIP Study, the most effective vision screening tests for use in detecting amblyopia in preschoolers have been scientifically established.  Parents should ask whether amblyopia screening programs are available in their local communities.  Parents should also check to see whether the most effective vision screening tests for amblyopia detections are being utilized.

 Further information about the VIP Study is available at http://optometry.osu.edu/research/vip or www.nei.nih.gov.

Study Story 6:

Vision Recovery in the Amblyopic Eye Following Loss of Vision in the Good Eye

By L. E. Leguire Ph.D., MBA

 In older children as well an in adults with permanent amblyopia, it is strongly recommended that the amblyopic patient wear glasses to protect the remaining good eye because amblyopic patients are at an increased risk of injury to that eye. For example, Tierney (1989) notes that amblyopic patients have a probability of injury to the remaining good eye of between 0.1 and 0.2 percent (about 1-2 per 1,000 patients). Therefore, if your child has completed therapy and still has significant amblyopia, protective glasses are in order. In addition, the glasses should be made with polycarbonate lenses - a very high impact plastic (i.e., glasses have less of a chance of shattering when hit by a high velocity object).

 The implicit assumption of requiring amblyopic patients to wear glasses to protect the remaining good eye is that if the patient lost vision in their good eye that they would have to rely on the poor vision in the amblyopic eye to live. Many patients with permanent amblyopia are legally blind in their amblyopic eye, so if they lost vision in their good eye they would be, to say the least, worse off. However, as with most things, there are exceptions to the rule and this applies to amblyopia.

 Over the past 20 years or so, there have been numerous "case reports" of an amblyopic patient losing vision in their good eye through disease or accident and, surprisingly, vision in the amblyopic eye actually improved! While this is an exception to the general rule, the phenomenon has occurred enough times to warrant study.  Perhaps knowledge gained from these unusual cases might provide avenues for future research.

 Hoffmann and Lippert (1982) performed animal studies in which the animals were made amblyopic (by blocking vision to one eye during early life and thus creating amblyopia) and then the good eye was either  closed (eyelids closed) or the good eye was surgically removed. They found that vision in the amblyopic eye was about 33 percent better when the good eye was removed compared to when the eyelids were just closed. As a follow-up to this study, Rabin (1984) first reported about an amblyopic patient who lost central vision in the good eye and there was subsequent improved vision in the amblyopic eye.

 Tierney (1989) reported a case study of a 65-year-old man who had a hemorrhage in his good eye and vision recovered in his amblyopic eye. Lengyel and Valmaggia (2006) also reported a patient who lost vision in the good eye via a stroke. Following the loss of vision in the good eye due to the stroke (retinal arterial occlusion), the patient went from about 20/200 visual acuity (legal blindness) to 20/63 (good enough to drive a car during the day) over a three-month period.

 The million-dollar question is why? Why is vision in the amblyopic eye able to recover following loss of vision in the good eye? No one really knows. Animal studies of amblyopia show that structural changes take place in the brain due to amblyopia, like smaller cells and less number of cells responsible for vision in the amblyopic eye. The old adage “Use it or lose it,” comes to mind. However, there are also strong interactions, at the cellular level, between the good eye and amblyopic eye, even in adults.

 The good eye is known to suppress or "turn-off" some of the vision in the amblyopic eye. Such a suppression process helps to create single vision, particularly when the eyes are not pointing in the same direction, such as in the case of amblyopic patients with an eye misalignment (i.e., strabismus). In addition, many cells in the visual parts of the brain are binocular; that is, the cells respond to visual information coming from either eye, with the good eye providing more or better input than the amblyopic eye. It is possible that when a patient loses vision in the good eye, the amblyopic eye is released from suppression and thus "sees better." On the other hand, perhaps the binocular cells of the brain are able to respond better to input from the amblyopic eye once visual input from the good eye is of a poor quality or, in the worse case, no longer available (as in the case of the good eye being removed).

 Whatever the reason for vision recovery in the amblyopic eye following loss of vision in the good eye, it is hoped that no one will ever have to face such a situation—better to protect the remaining good eye from injury in the first place.

References

 Tierney, DW. Vision recovery in amblyopia after contralateral subretinal hemorrhage. J. American Optometric Assoc. 1989; 60 (4), p281 - 283.

 Hoffmann, KP and Lippert, P. Recovery of vision with the deprived eye after loss of the non-deprived eye in cats. Hum Neurobiology. 1982; 1 (1), p45 - 48.

 Rabin, J. Visual improvement in amblyopia after visual loss in the dominant eye. Am. J. Optometry and Physiological Optics. 1984, 61 (5), p334 - 337.

 Lengyel, D and Valmaggia, C. Visual improvement of an amblyopic eye in an adult patient after vision loss in the non-amblyopic eye (German)  Klin Monatsbl Augrnheilkd. 2006, 223 (5), p462 - 464.

Study Story 5:

Amblyopia Cured by Glasses alone

by L. E. Leguire Ph.D. MBA

 Article Reviewed:  Chen, P L., Chen, JT., Tai, M C., Chang, C C., and Lu, D W. “Anisometropic Amblyopia Treated With Spectacle Correction Alone: Possible Factors Predicting Success and Time to Start Patching,” Am. J. Ophthalmology, 2007 Jan, 143 (1): p54-60.

 The authors of this study examined 60 children between the ages of three and seven years (average age of 5.3 yrs) who were newly diagnosed with anisometropic amblyopia. Anisometropic amblyopia is amblyopia due to a difference in refractive error between the eyes and, in their case, the children had an average difference in refractive error between the eyes of about three diopters. A difference of three diopters would be like having one eye focused on an object one meter from your face and the other eye focused at an object at 1/4 meters from your face. Because the eyes cannot focus at the same time on an object, the eye that cannot focus on the object becomes amblyopic. The authors wanted to know how often glasses alone (without patching therapy, at least at first) might improve or even "cure" the amblyopia.

 The authors gave the children glasses and followed the children every month to chart their progress in visual acuity in the amblyopic eye. The results showed that a vast majority of the children (93 percent) showed at least a two-line improvement in visual acuity in the amblyopic eye because of wearing the glasses alone (a two-line improvement on the eye chart the investigators used is equal to about a 37 percent improvement). Forty-five percent of the children had their amblyopia cured or resolved with glasses alone. The average improvement in these children was 3.8 lines on the visual acuity chart.

 When looking at the improvement in visual acuity over time (every month), the investigators found that most of the improvement in visual acuity occurred in the first three months, after that visual acuity improved very slowly. For those children in which the amblyopia was cured, the duration of wearing glasses alone ranged from one to about 10 months.

 For those children whose amblyopia was cured by glasses alone, these children initially had better visual acuity to begin with; their visual acuity ranged from about 20/32 (two lines below 20/20) to about 20/80 (six lines below 20/20). In addition, the children who were cured by glasses alone had, on average, less of a difference in refractive error between the eyes (i.e., less anisometropia): less than four diopters.

The investigators conclude by saying that glasses alone might cure about 50 percent of younger children with anisometropic amblyopia. After about four months and assuming there is no further improvement of visual acuity with the glasses alone, patching or penalization (i.e., use of dilating eye drops in the good eye) should be considered.

Additional Information

Glasses alone might even help older children with amblyopia. For example, a multi-center clinical trial of treating older amblyopic children, between the ages of seven and 17 years, found that glasses alone benefited about 25 percent of children between seven and 12 years and 23 percent of children between 13 and 17 years. (For more information about this study, Click Here). Although most of the children had some remaining amblyopia following the termination of treatment, the improvement found with glasses alone could be of real benefit depending on the circumstances, especially later in adult life when visual acuity may be a qualifying factor for certain occupations. For example, to qualify for a commercial motor vehicle (CMV) license and to drive a commercial truck throughout the United States, you have to have at least 20/40 visual acuity in your worst eye. Therefore, if you have amblyopia and one eye is 20/20 and the other eye is 20/60 you would not qualify for a CMV license. However, if you wore your glasses on a regular basis (and assuming that you have anisometropic amblyopia) your vision could improve to say 20/40 and you would qualify for the CMV license.

Finally, it is important to note the importance of wearing glasses, particularly glasses made with polycarbonate lenses, to protect the remaining good eye. Amblyopic individuals are at increased risk of injury to the good eye - so wear the safety glasses made with polycarbonate lenses.

Study Story 4:

Amblyopia in Both Eyes

(A Fictional Story with a Point)

“What do you mean she has lazy eye in both eyes!” exclaimed Judy's mother. Shocked, she sat in disbelief as the eye doctor explained the results of Judy's comprehensive eye exam. “Isn’t lazy eye a problem with one eye and not two?” Judy's mother asked.

Judy has high hyperopia in both eyes, the eye doctor explained; she is a +5 in both eyes. In other words, Judy is very farsighted and will need rather thick glasses in order to see clearly, particularly near objects like books. Right now, Judy can see the 20/40 line on the visual acuity chart with each eye.  Given her age of six years, she should see at least the 20/25 line on the eye chart and ideally the 20/20 line. “What can we do to fix her eye problem?” her mother asked. “We'll place her in the glasses she needs and often glasses alone can fix the problem,” the eye doctor said. “The glasses will also help prevent her eyes from becoming misaligned, a condition called strabismus, which is a common problem in children with high hyperopia like Judy.”

Judy selected the glasses she wanted from the eye doctor's office and her mother scheduled her for a follow-up appointment in four weeks. Judy liked her glasses and became more interested in looking at books. Also, Judy's teacher sent a note home saying that that Judy seemed much more interested in reading and seemed more outgoing in school.

One month later, Judy and her mother returned to the eye doctor's office and Judy's mother was relieved to learn that Judy's vision was improving. “Good news!” the eye doctor told Judy's mother, “Judy's visual acuity has improved to the 20/30 line and her eyes are straight. Let's see her back again in one month to chart her progress.”

Another month went by and Judy's vision continued to improve. At the next eye doctor appointment, Judy's visual acuity was 20/25 in each eye, which is normal for her age. Both Judy's mother and the eye doctor were pleased with Judy's progress and that her “lazy eyes” were normal. Judy continued to do well and at seven years of age her visual acuity was 20/20 in each eye and her eyes remained straight thanks to her glasses.  While this story is fiction, it is meant to convey the facts as listed below:

Further Explanation

Amblyopia in both eyes is called “isoametropic amblyopia,” “bilateral amblyopia,” or sometimes “refractive amblyopia.” Refractive amblyopia refers to the fact that the amblyopia is caused by a refractive error (i.e., need for glasses), but may refer to amblyopia in one or both eyes. Usually, bilateral amblyopia is due to high hyperopia—the child is very farsighted and usually has greater than about +4.5 diopters of refractive error in both eyes (Klimek et al, JAAPOS, 2004, p310-313). In children with such high hyperopia, there is about a nine percent chance that they may have bilateral amblyopia (Klimek et al, 2004) 

Long-term studies have shown that children with bilateral amblyopia usually have a good outcome once they receive glasses (full hyperopic correction) and wear them for one year; there is a good chance that their vision will return to normal. Fern (1989, Optom Vis Sci, p649-658) found that 57 percent of children with bilateral amblyopia had 20/20 vision after one year of wearing glasses and that no child had worse than 20/40 visual acuity, which is good enough for driving a car, for example. It appears that the degree of hyperopic correction relates to whether or not there was a good outcome—the higher the refractive error, the worse the outcome. In some of the children studied, vision continued to improve after one year of wearing the glasses. Further, there is often a real need to wear glasses for high hyperopia to keep the eyes from turning in, a condition called “accommodative esotropia.”

Sometimes, amblyopia may occur in both eyes during the course of occlusion therapy (patching) for amblyopia in younger children and infants. In the very young, if the infant has typical amblyopia, the standard treatment is occlusion of the good eye. Sometimes, occlusion of the good eye can lead to amblyopia in the occluded eye and a return of normal vision in the previous amblyopic eye—the amblyopia seems to have moved from one eye to the other eye. In these rare cases, the eye doctor may balance occlusion between the eyes—a therapy called “alternating occlusion.” For example, the eye doctor may prescribe occlusion of one eye on one day and to alternate the occlusion between the eyes on different days. Therefore, in this latter case, the patient may have had amblyopia in both eyes, but at different times.

Update:  Treating Amblyopia in Both Eyes

 Wallace and colleagues (Am. J. Ophthalmology, 2007) recently published a report on the treatment with glasses alone of children with amblyopia in both eyes.  The children ranged in age between 3 and 10 years.  The children had an average age of about 5 years and wore thick glasses.  In other words, the children had a refractive error of 4 diopters or more of hyperopia (think coke bottle glasses) or had a lot of astigmatism (i.e., irregularly shaped cornea of 2 diopters or more).  The children had a visual acuity with both eyes open of between 20/40 (3 lines worse than 20/20) and 20/400 (legal blindness).  The children were given their best glasses to wear and followed for one year.

 At the end of one year of wearing their best glasses, the children's visual acuity improved greatly.  On average, the children improved by about 4 lines on the acuity chart.  They started with an average visual acuity of 20/63 and improved to an average of 20/25 after one year.  Children who started with a visual acuity between 20/40 and 20/80 showed an average improvement of 3.4 lines on the visual acuity chart.  Children who started with a visual acuity of between 20/100 and 20/320 had an average improvement of visual acuity of 6.3 lines on the visual acuity chart.  Overall, the probability was 74% of vision improving to 20/25 (i.e., normal) after one year of wearing their best glasses.

 This study shows the importance of wearing glasses for children with amblyopia in both eyes. 

Study Story 3:

The Return of Amblyopia Following Termination of Therapy

“Connor” was five years old when his mother took him to the eye doctor because she noticed his left eye turning in while he looked at close objects. The eye doctor found that Connor had “accommodative esotropia”—a condition in which an eye turns in toward the nose when the child looks at close objects. Eye glasses corrected the turning in problem, but the eye doctor also found that vision in Connor's left eye was much worse than the vision in his right eye: Connor was diagnosed with amblyopia (“lazy eye”). Although the glasses kept his eyes aligned, in order to treat the amblyopia, Connor also had to wear an eye patch over his good right eye to force his left eye to work harder and recover the lost vision in his left eye.

Connor's parents signed him up with the Ohio Amblyope Registry (OAR), the first statewide registry for children with lazy eye in the United States. Because the eye doctor prescribed “occlusion therapy” to treat Connor's lazy eye, the OAR sent Connor's parents literature about lazy eye, strabismus, eye safety, along with other written materials. In addition, Connor received six free boxes of eye patches, and even a few cloth patches that fit over the glasses (right lens), to help him get started in the occlusion therapy to cure his lazy eye.

Although the glasses kept his eyes aligned, when he wore his glasses, Connor had to wear an eye patch over his good right eye to force his left eye to work harder and to recover the lost visual acuity in his left eye.  Based on the findings of a recent study by eye doctors funded by the National Institutes of Health (for more info on this study click here), Connor's eye doctor prescribed six hours of occlusion therapy and told Connor that he had to play one hour of video games while he wore the patch over his good eye.  “Hey,” Connor said, “maybe this treatment isn’t going to be all bad!”

Occlusion therapy did not go easily since Connor did not like his good eye being covered for six hours per day. The first week was particularly tough, as it seemed that Connor tore off the patch just about as fast as his mother could put it on!  But his parents realized that if the therapy wasn't successful, their son could end up with only one good eye for the rest of his life, so they persevered. The patching therapy got easier when Connor realized that he (and his parents) didn't have a choice—the patching therapy had to be done, period!

As the days turned into weeks, the patching therapy got easier and at the first follow-up eye doctor appointment Conner's visual acuity improved from the top line on the eye chart, 20/200, to the middle of the eye chart, 20/80.  Connor's parents were very happy with his improvement in visual acuity and the eye doctor was very happy as well.  Given Connor's improvement in visual acuity, the eye doctor reduced Connor's patching time to three hours per day.

At Connor's next eye doctor appointment Connor's visual acuity was found to be normal for his age and reached the 20/25 line—the same as his good right eye. “Hooray!” shouted Connor and both of his parents. The eye doctor reduced Connor's patching time to just one hour per day; the eye doctor called it “maintenance therapy” that would make sure that the improved visual acuity in the left eye “stuck.”  When Connor returned to the eye doctor, his visual acuity had stayed at 20/25. The eye doctor stopped the occlusion therapy and Connor's next appointment was scheduled in two months.

Because Connor was doing fine and he wore his glasses well, his parents cancelled his two month follow-up appointment with the eye doctor; it was near the holidays and everyone had just too much to do. The eye doctor saw Connor six months later. Assuming that it would be a “good” appointment, Connor's parents were shocked to learn that Connor's lazy eye had returned. His visual acuity had regressed to 20/40 in the left eye. The eye doctor prescribed two hours of occlusion therapy.

Connor and his parents didn't like the idea of more patching, but realized that occlusion therapy is a long process and that from then on that they would never miss another eye doctor appointment. Connor returned to the eye doctor several times over the next year and the outcome was good: Connor maintained his visual acuity in his left eye and, eventually, he didn't have to wear a patch any more. Connor continues to wear his glasses.

Regression of visual acuity after the termination of occlusion therapy is a common finding occurring in up to 50 percent of amblyopic children undergoing therapy for lazy eye. Tacagni and colleagues (2006) studied 182 children with amblyopia and followed these children for one year after the termination of occlusion therapy. They found that children who had both misaligned eyes (strabismus) and a difference in refractive error between the eyes (anisometropia), the combination of which causes a condition called “anisometropic-strabismic amblyopia” or “mixed amblyopia”, had a greater chance of visual acuity regression following the termination of occlusion therapy than children with only misaligned eyes or children with only a difference in refractive error between the eyes.

Ching and colleagues (1986) found that some children with really poor visual acuity (deep amblyopia due to strabismus) needed maintenance occlusion up to nine years of age. In other words, they needed to be patched for several years once the amblyopia was discovered. In general, children that required maintenance occlusion also had a greater chance of acuity regression following the termination of occlusion after nine years of age. The children in this study were followed up to 12 or 13 years of age. The good thing is that the regression of acuity following the termination of occlusion was, on average, only one line on the visual acuity chart. One take-home message about the Ching et al (1986) study is that it is very important to achieve the best possible visual acuity during the early treatment years so that even if acuity regresses at the end of occlusion therapy, vision will still be fairly good.

Flynn and colleagues (1998) looked at the results of a large group of studies undertaken by different investigators of amblyopia treatment for a total of 961 amblyopic patients. A review of all the studies suggested that success of occlusion therapy depended on several factors: the age at which the amblyopia was discovered (the sooner the better), the type of amblyopia (best outcome for strabismic amblyopes and worse outcome for anisometropic-strabismic amblyopes), and the depth of the amblyopia when first discovered (the worse the visual acuity the poorer the outcome). An important message from the Flynn, et al (1998) study is when it comes to the success of amblyopia treatment, it is very important to have your child examined as young as possible!

L. E. Leguire Ph.D., M.B.A

Executive Director,

Ohio Amblyope Registry

Study 2:

Compliance with Patching Therapy

 By L. E. Leguire Ph.D., MBA

Executive Director of the Ohio Amblyope Registry

A recent article entitled “Why is Compliance with Patching Therapy for Amblyopia so Hard? by Dixon-Woods and Gottlob (Arch Dis Child 2006, p491-494) may be of interest to parents of amblyopic children undergoing patching therapy.  The authors interviewed 25 parents of amblyopic children undergoing patching therapy for amblyopia and provide some insights into how to patch a child for amblyopia.

The authors found that parents must be the managers of the patching therapy and decide whether or not to follow the prescribed therapy with the associated stress of placing a patch over the child’s good eye for hours at a time.  Parents found patching therapy particularly tough to do in the initial treatment period and things got easier once a routine was established.  At least with older children (4 years or older), explanation, rewards, changing the patch to meet the needs of the child and enlisting the help of others (e.g., school bus drivers, teachers, older sibs, friends of the student) helped with the patching therapy.

With older children, one should never dismiss the value of explanation to the child in language that s/he understands.  Half the battle is won if the child “buys-into” the patching program.  Setting clear objectives with rewards for good patching behavior also seem to help.   This is where routine comes to play:  By patching the same time of day for the same amount of time and with some immediate reward, something the child enjoys, goes a long way in getting the child to wear the patch for the required time.  Also, if the child has TV or Video game play time for, say, 1/2 hour, the parent could lengthen the video play time to one hour if the child plays the video game with the patch on the good eye.

Of course, follow-up visits to the eye doctor are also reinforcing if there is improvement from one visit to the next.  If parents don’t see improvement in the child's vision they’re less likely to follow the doctor’s recommendations.  Also, the parents have to trust the doctor and respect his/her authority on the subject; otherwise, the parents are less likely to follow the doctor’s instructions.  Eye doctors and their staff must convey to the parents the importance of the patching therapy and the need to follow directions.  Further, parents must realize that sometimes patching therapy is very long and may require years of therapy including patching or the use of eye drops to dilate the good eye.  Dilation causes blurred vision in the good eye and forces the child to use the amblyopic eye for seeing more clearly.

It may be important to note that in a study of patching therapy by Leguire and colleagues at Columbus Children’s Hospital, it was found that parents, on average, patched only about 50% of the time suggested by the eye doctor!  Why?  This was answered by another study by Dr. Leguire and colleagues who showed that patching therapy for amblyopia is hard and causes family stress and also causes psychological trauma to the child.  Bottom line, patching therapy is very hard to accomplish and parents have to be committed to the therapy even when faced with a crying child and a long term commitment.

A lot of parents will alter the plain and boring patches used for patching therapy to custom and tailor the patches to the child.  Some children really like stickers (cartoons) on the brown eye patches while other children might want to draw (or have the parent draw) something interesting on the patch.  Some children prefer the patches that fit over glasses while other children might want a more standard “pirate patch” (black patch with string/band around the head.  Other children prefer patches with differing colored images.  Bottom line – children with be more willing to wear a patch they like than wear a patch that they don’t like.  The patch should look "cool" and be something that the child likes.

Family members, friends and fellow students also play a vital role in determining whether or not the child follows patching therapy.   Early-on the parents need to talk with the other family members of the importance of the child wearing the patch.  Under no circumstances should sibs or other family members make fun of the child for wearing the patch.

Teachers also play a vital role in the patching therapy.  While many eye doctors try to avoid having the child wear a patch during school hours, sometimes it is simply necessary to patch the child full time, which would include school hours.  Under these circumstances, the parents need to discuss the patching therapy with the teacher and to have the teacher explain to the rest of the class the reason why the child has to wear the patch.  In this regard, when children with amblyopia sign-up for the Ohio Amblyope Registry and when they’re undergoing patching therapy, the child receives the “Eye Patch Club” packet.  The Eye Patch Club packet, from Prevent Blindness America, includes a lesson plan for teachers to discuss patching for amblyopia as well as stickers and a T-shirt for successfully wearing the patch.  Just one of the many advantages of sign-up with the Ohio Amblyope Registry.

Study 1:

Title:  The VF-14 and Psychological Impact of Amblyopia and Strabismus

By Sabri et al, Invest. Ophthal. and Visual Science, 2006, p4386 - 4392.

Reviewed by

Dr. L. E. Leguire Ph.D., MBA

Executive Director of the Ohio Amblyope Registry

What impact does amblyopia (lazy eye) and strabismus (misaligned eyes) have on a child's psychological well being?  To answer this question, the authors of this study gave two psychological questionnaires to 120 amblyopic teenagers between the ages of 16 - 18 years and to 120 normal children of similar ages. Some of the amblyopic teenagers had misaligned eyes and others did not have noticeable eye misalignments.  The authors assessed the psychological impact of amblyopia (and its treatment) and of strabismus on children's psychological well being. 

The questionnaires covered things like the child becoming frustrated, depressed, getting teased by others, avoiding friends, avoiding going out alone or avoiding sports activities, among others.  The results included the following:

If the child had a noticeable eye misalignment, the results showed:

Bottom line:  Lazy eye or a noticeable eye misalignment can cause significant psychological problems in teenagers!

The authors of the paper go on to cite other studies that found somewhat similar results in teenagers and adults with misaligned eyes:  Satterfield and colleagues (Arch. Ophthalmol. 1993, p1100 - 1105) found that 72% of teenagers and 77% of adults with misaligned eyes had a poor self image.

Packwood and colleagues (J of the AAPOS, 1999, p15-17) found that people with amblyopia, only, (15 - 64 years of age) worried about losing eye sight in their good eye (8%), had poor self image (12%), had problems with work (52%) and that the amblyopia negatively influenced sports (40%).  They also found that amblyopic adults were more likely to be obsessive compulsive, depressed and have more anxiety.

In conclusion, lazy eye and/or having misaligned eyes can cause psychological problems in children and adults.  Although the authors of the article do not address ways to minimize the psychological impact of lazy eye or misaligned eyes, it seems reasonable to expect that detecting amblyopia early when it is very treatable and curable, fixing misaligned eyes by the use of corrective lenses, surgery or by others means and by following your child's eye doctor's instructions in the treatment of amblyopia and strabismus should go a long way in minimizing the psychological impact of such conditions.  The earlier the treatment the better the chances that the lazy eye will be cured and the greater the chances that your child will not experience later in life the psychological problems discussed in the article.

The Ohio Amblyope Registry can help you, as a parent of an amblyopic child, meet these goals and minimize the psychological impact of lazy eye and misaligned eyes on your child's psychological well being.  The Ohio Amblyope Registry provides free patches to treat and cure your child's lazy eye so he/she doesn't have it later in life.  The Ohio Amblyope Registry provides free information about lazy eye and about misaligned eyes to help inform you and your child about these conditions.  The find-an-Eye Doctor page on the web site will help you find an Eye Doctor in Ohio who has an office in your city or in your county and who sees children with lazy eye and misaligned eyes.  By working together, we can help you and your child lead a more normal and psychologically healthy life.

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