I would be very grateful to anyone who has time to explain the pros and cons of the different options for managing early presbyopia in someone with anisometropic amblyopia? I have looked through previous posts but haven't been able to identify a discussion of this.
I hope this question is of a sufficiently general nature for consumer questions! My first attempt at a question has been locked as too specifically related to my situation - my apologies for this,
Isabella (London, UK)
Only one option for amblyopia, if the patient is young take him to a good pediatric ophthalmologist now. Follow his instructions to the letter. If the patient is not pre-teen, forget the amblyopia part it's too late to help. Of course there are some of the younger O.D.'s who have a theory that it can be helped later and you can see one of them.
As to presbyopia it ain't goin away, just get a pair of bifocals. If the patient also has amblyopia and is old enough to have presbyopia, make sure they are lined bifocals. People with amblyopia or any retinal disfuntion have enough trouble seeing without the disortion of progressive lenses not matter how high priced/high~tech and improved over last year's model.
Anisometropia creates "doubling" when looking down through the reading portion of a multifocal, so multifocal designs that minimize downgaze are better.
Amblyopia, or any other "one-eyed" condition, usually results in high attention to detail in the better eye, therefore lens design, progressives specifically, has to be carefully chosen.
Sometimes, the amblyopia will be of sufficient compensatory depth as to render the doubling a non-issue, but that varies by case.
The refractive error is a factor in all of this, as well.
Last edited by drk; 02-23-2006 at 12:47 PM.
Chip, for you: (cut and paste from another forum)
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Sight Can Recover Quickly In Amblyopia
New research findings led by Thomas Krahe and Ary S. Ramoa of Virginia Commonwealth University School of Medicine offer two pieces of good news for treating children with amblyopia. First, the researchers have found evidence that the neural wiring in the brain's visual system is not dismantled by visual deprivation--for example, due to a cataract--during what is known as the "critical period" of vision development. Rather, the wiring is merely deactivated, capable of being rapidly reactivated when vision is restored. And secondly, the researchers wrote in an article published in the October 20, 2005, issue of Neuron, their findings suggest that allowing children with amblyopia to use both eyes--rather than patching the stronger eye to encourage use of the weaker one--enables better recovery.
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New Ways Identified To Treat 'Lazy Eye' In Children: Beyond Eye Patches And Daily Drops
ST. LOUIS -- New research suggests a way to treat "lazy eye" that may be easier on children--and their parents--than current treatments.
Researchers at Saint Louis University and other institutions have found that atropine eye drops administered two days a week are as effective at treating amblyopia, or "lazy eye," as daily drops or an eye patch. The research was published today in the journal Ophthalmology.
"As anyone who has given eye drops to a child knows, this is good news," said Oscar Cruz, M.D., chairman of the department of ophthalmology at Saint Louis University and a researcher in the study. "It makes it much less of a hassle to administer the medicine, which is crucial for young patients to develop healthy vision."
Amblyopia occurs when the brain favors one eye over the other. The condition can be corrected by temporarily impairing vision in the "strong" eye, forcing the weak eye to work harder to compensate. This traditionally has been accomplished when a child wears an eye patch over the strong eye.
An earlier study by the same research group, known as the Pediatric Eye Disease Investigator Group (PEDIG), found that daily doses of atropine drops, which dilate the eye and blur vision, were as effective as an eye patch. Another study by the group found that eye patches could be effective when worn for only two hours a day, rather than six hours.
Adults With Lazy Eye Can Improve: New Treatment Offers Promise For Previously Incurable Condition
Young adults with amblyopia, or lazy eye, can improve substantially and retain their gains under a new treatment developed by researchers at USC and three Chinese universities.
A lazy eye in children appears normal but does not see properly, even with corrective lenses. If untreated, the eye will not develop fully, resulting in permanent loss of vision.
Amblyopia has been considered incurable in children older than eight. The new study, published online by Vision Research, documented a 70 percent improvement in eye chart performance in 19-year-old subjects. The average one-year retention rate was 90 percent.
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Isabella, this can get really deep but I will point out a few general things that a professional will consider.
In the case of Amblyopia, it is less likely that double vision will be a problem than with other sources of anisometropia (such as cataract surgery). Because of this, often the first attempt with bifocals is to do everything normally and be sure to pick a lens that will give the "good eye" maximum clarity. Hopefully this works!
If double vision does occur in down gaze then many options must be considered.
Progressives: Upside - attractive, intermediate distance correction
Downside - longest distance from optical center to reading
which is likely to induce double vision.
Lined Bifocals: Upside - shorter distance from optical center to reading area which makes it less likely to cause double vision
Downside - Not as attractive, no intermediate
Near Only: Upside - very unlikely to cause double vision, large reading area
Downside - always have to carry around an extra pair of glasses
Slab Off: Upside - can be applied to any of the above and
gets rid of double vision
Downside - doesn't look attractive, can be difficult to make
which is why it is usually a specialty order
This stuff is too advanced for a consumer to make the decisions. Consumers should seek care with a competant professional and exert patience while the best method of correction is being determined. Don't try to decide for yourself!
Thanks very much for this!
You are right that it is hard to make decisions about this as a consumer, but in a busy optician's shop with no great evidence of awareness of issues around amblyopia, decisions by the consumer are expected, so it's really very helpful to have some further food for thought. It makes me think that maybe it's a good idea to seek out some sort of more specialist advice - I've now seen on the net that one of the local universities runs a binocular vision public clinic, maybe that's the sort of place to go for good advice? It would be interesting to discuss with them also whether they think there is any prospect of improving amblyopia.
Re the options above, is it right that all except the reading glasses one would require full time glasses wear to have a chance of a good outcome? I assume this is the case even if one doesn't find distance correction all that essential and useful at present?
Thank you
Isabella
Require is a strong word, but generally speaking - Yes. There are even more possibilities that could be a factor. For instance, a true amblyope would be recommended to have full time eyewear made of a high impact material such as polycarbonate just for the purposes of protection alone. Also, contact lenses could be an option and are usually recommended in cases of anisometropia.Originally Posted by isabella
Honestly, I could go on for ever talking about what options are out there and why they might work. My goal was just to give you a little general feedback. The school you were talking about seems like a good idea, but is probably not your only option in a place like London. Just find someone that is good with this stuff and ask them.
I feel you, and really understand that this situation can be frustrating. But this is as much as I feel comfortable with explaining.
Our Office participates in the Pedig eye studies.
Here's a link to some of the completed studies:
http://public.pedig.jaeb.org/Completed_Studies.htm
Sorry, Bella, but a bunch of crap has been posted here in response. Anyway, the best way to manage your above patient is to avoid double vision that might be caused by their needing to look through an off center part of the lenses. If you use bifocals or some other type of multifocal, you need to consider slab-off prism. But only if the patient get's double vision. Test for it. If no diplopia, no slab off is needed. If diplopia happens, you can also consider multiple pairs of single vision lenses...
thats a damm good plot, couldnt have put it better myself
Hey, Bill, who do you want a piece of?
I guess I should have toned it down, but couldn't understand why everyone was discussing the amblyopia, which for a pre or presbyope is not an issue at all, unless you want to start treating it at that age (and just why would you?).
;) <----Happy amblyope
I'm sure your advice is very sound. However, if you don't mind a consumer perspective, for me actually my amblyopia has become quite a lot more of an issue now that I'm getting older and have significant presbyopia and increasing farsightedness in my good eye. I was a generally happy amblyope in my 20s and early 30s when I had excellent vision in my good eye and felt no need for glasses. Now that I wear glasses and my vision in my better eye is not so good, for some reason I've become much more aware that I can't see well with my amblyopic eye and don't have good 3D vision without glasses, and the difference between my eyes also seems to cause considerable problems getting glasses prescriptions that work well. So actually, if treatment for amblyopia were feasible, I'd be a lot more interested now as a slightly prematurely (but of course otherwise youthful!) presbyopic 41 year old than I would have been in my 20s. However, I do accept that this is a long shot.
[QUOTE=isabella] don't have good 3D vision without glasses,
That implies you have good 3d vision with glasses, which implies that your amblyopia might not be all that bad. Not sure if you posted them, but what are your best corrected acuities?
I'm afraid I don't know my most recent corrected visual acuity, but it's certainly less than 20/20 and I think it's bad enough to meet the criteria for amblyopia, though a lot better with glasses than without. I definitely do see more 3D with glasses though, though I unfortunately can't know whether it's as 3d as normal people see! But the difference is fairly striking to me, and I've been told in the past that my vision is binocular to some degree. I think one thing that makes getting correction right a bit problematic is that the opticians I've been to seem to assume I don't use my amblyopic eye at all, whereas actually I think the situation is more complicated and maybe troublesome than that.
So does the fact that I am amblyopic explain why I can't do those stupid 3d posters?
Most likely, and you probably wouldn't think they were so stupid if you were able to visualize the affect. They are actually pretty amazing!
Dr. Bill, please don't ask her acuities so you can analyze her case on line. That's poor form.
I think this is a very relevant issue. Sometimes the amblyopic eye can have issues effecting convergance, and also, when the eye is ambliopic (or blury) at distance, is sometimes is starting to be used at near because of the extra magnification from the more plus lens in place. Often these patients can be very tricky and exhibit unusual problems allong the lines of near blur and HA's etc
Last edited by QDO1; 03-04-2006 at 02:42 PM.
ok I didn't know that. seems silly to me as I see nothing wrong with helping people out with answering their questions about vision and eyes, especially when it's about *their* eyes, and especially when they didn't get a decent reply to their original questions by anyone else...
but no worries. it won't happen again on this bored.
Certainly as the patient involved (and incidentally I'm also a physician, so interested in trying to get some reasonable level of general understanding of the problems I have), it's really very useful to read some general discussion of these problems. I think people who have responded have succeeded well in discussing the general issues raised without giving me any really specific advice - seems hard to know why this sort of discussion should really be a problem.
Not saying it's irrelevant, or that you can't be of help, but please answer this:
Professionally, how do you feel about "virtual" medicine? Do you think it will serve Optiboard consumers well? Do you think there is a risk of bad information being promulgated? Do you think this board is sufficiently regulated and by sufficiently qualified personnel who can make the necessary decisions about whether a thread goes into medically risky waters?
Please, be responsible. It's entertainment for you, Dr., but the eye health of the poster that is at stake. Let's don't encourage people to fish online for their medical advice.
Well, then, Dr., please exchange e-mail addresses with the good Dr. Stacy and have at it.
Freudian slip maybe?:)
By the way, the way you were asking for the acuities wasn't all that bad. Really could have gone either way. Dr.K is probably right though.
Last edited by SpecialT; 03-05-2006 at 11:32 AM.
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