Ann L. Webber

The Effect of Amblyopia on Fine Motor Skills in Children

PURPOSE In an investigation of the functional impact of amblyopia in children, the fine motor skills of amblyopes and age-matched control subjects were compared. The influence of visual factors that might predict any decrement in fine motor skills was also explored. METHODS Vision and fine motor skills were tested in a group of children (n = 82; mean age, 8.2 +/- 1.7 [SD] years) with amblyopia of different causes (infantile esotropia, n = 17; acquired strabismus, n = 28; anisometropia, n = 15; mixed, n = 13; and deprivation n = 9), and age-matched control children (n = 37; age 8.3 +/- 1.3 years). Visual motor control (VMC) and upper limb speed and dexterity (ULSD) items of the Bruininks-Oseretsky Test of Motor Proficiency were assessed, and logMAR visual acuity (VA) and Randot stereopsis were measured. Multiple regression models were used to identify the visual determinants of fine motor skills performance. RESULTS Amblyopes performed significantly poorer than control subjects on 9 of 16 fine motor skills subitems and for the overall age-standardized scores for both VMC and ULSD items (P < 0.05). The effects were most evident on timed tasks. The etiology of amblyopia and level of binocular function significantly affected fine motor skill performance on both items; however, when examined in a multiple regression model that took into account the intercorrelation between visual characteristics, poorer fine motor skills performance was associated with strabismus (F(1,75) = 5.428; P = 0.022), but not with the level of binocular function, refractive error, or visual acuity in either eye. CONCLUSIONS Fine motor skills were reduced in children with amblyopia, particularly those with strabismus, compared with control subjects. The deficits in motor performance were greatest on manual dexterity tasks requiring speed and accuracy.

Effect of amblyopia on self-esteem in children.

Purpose. In an investigation of the psychosocial impact of amblyopia on children, the perceived self-esteem of children who had been treated for amblyopia was compared with that of age-matched controls. The influence of amblyopia condition or treatment factors that may impact self-perception scores was also explored. Methods. Children with a history of treatment for amblyopia (n = 47; age 9.2 ± 1.3 years) and age-matched controls (n = 52; age 9.4 ± 0.5 years) completed a standardized age-appropriate questionnaire based evaluation of perceived self-esteem (Harter Self Perception Profile for Children). Their vision characteristics and treatment regimen were also recorded. Bivariate correlation analysis was used to investigate the amblyopic characteristics and treatment factors that may have influenced self-perception scores in the amblyopic group. Results. Children treated for amblyopia had significantly lower social acceptance scores than age-matched control children. In other areas related to self-esteem, including scholastic competence, physical appearance, athletic competence, behavioral conduct and global self worth, amblyopic children gave scores similar to those of control children. Within the amblyopic group, a lower social acceptance score was significantly correlated with a history of treatment with patching but not with a history of strabismus or wearing of glasses. Conclusions. Self-perception of social acceptance was lower in children treated for amblyopia compared with age-matched controls. A reduction in these scores was associated with a history of patching treatment but not with a history of strabismus or spectacle wear.

Effect of simulated astigmatic refractive error on reading performance in the young.

Purpose. Few studies have specifically investigated the functional effects of uncorrected astigmatism on measures of reading fluency. This information is important to provide evidence for the development of clinical guidelines for the correction of astigmatism. Methods. Participants included 30 visually normal, young adults (mean age, 21.7 ± 3.4 years). Distance and near visual acuity and reading fluency were assessed with optimal spectacle correction (baseline) and for two levels of astigmatism, 1.00 diopter cylinder (DC) and 2.00 DC, at two axes (90 and 180°) to induce both against-the-rule (ATR) and with-the-rule (WTR) astigmatism. Reading and eye movement fluency were assessed using standardized clinical measures including the test of Discrete Reading Rate (DRR), the Developmental Eye Movement test (DEM), and by recording eye movement patterns with the Visagraph (III) during reading for comprehension. Results. Both distance and near acuity were significantly decreased compared with baseline for all the astigmatic lens conditions (p < 0.001). Reading speed with the DRR for N16 print size was significantly reduced for the 2.00 DC ATR condition (a reduction of 10%), whereas for smaller text sizes, reading speed was reduced by up to 24% for the 1.00 DC ATR and 2.00 DC condition in both axis directions (p < 0.05). For the DEM, subtest completion speeds were significantly impaired, with the 2.00 DC condition affecting both vertical and horizontal times and the 1.00 DC ATR condition affecting only horizontal times (p < 0.05). Visagraph reading eye movements were not significantly affected by the induced astigmatism. Conclusions. Induced astigmatism impaired performance on selected tests of reading fluency, with ATR astigmatism having significantly greater effects on performance than did WTR, even for relatively small amounts of astigmatic blur of 1.00 DC. These findings have implications for the minimal prescribing criteria for astigmatic refractive errors.

Amblyopia treatment: an evidence-based approach to maximising treatment outcome.

The basis of treatment for amblyopia (poor vision due to abnormal visual experience early in life) for 250 years has been patching of the unaffected eye for extended times to ensure a period of use of the affected eye. Over the last decade randomised controlled treatment trials have provided some evidence on how to tailor amblyopia therapy more precisely to achieve the best visual outcome with the least negative impact on the patient and the family. This review highlights the expansion of knowledge regarding treatment for amblyopia and aims to provide optometrists with a summary of research evidence to enable them to better treat amblyopia.

Effect of amblyopia on the Developmental Eye Movement test in children.

Purpose. To investigate the functional impact of amblyopia in children, the performance of amblyopic and age-matched control children on a clinical test of eye movements was compared. The influence of visual factors on test outcome measures was explored. Methods. Eye movements were assessed with the Developmental Eye Movement (DEM) test, in a group of children with amblyopia (n = 39; age, 9.1 ± 0.9 years) of different causes (infantile esotropia, n = 7; acquired strabismus, n = 10; anisometropia, n = 8; mixed, n = 8; deprivation, n = 6) and in an age-matched control group (n = 42; age, 9.3 ± 0.4 years). LogMAR visual acuity (VA), stereoacuity, and refractive error were also recorded in both groups. Results. No significant difference was found between the amblyopic and age-matched control group for any of the outcome measures of the DEM (vertical time, horizontal time, number of errors and ratio(horizontal time/vertical time)). The DEM measures were not significantly related to VA in either eye, level of binocular function (stereoacuity), history of strabismus, or refractive error. Conclusions. The performance of amblyopic children on the DEM, a commonly used clinical measure of eye movements, has not previously been reported. Under habitual binocular viewing conditions, amblyopia has no effect on DEM outcome scores despite significant impairment of binocular vision and decreased VA in both the better and worse eye.

DEM test, visagraph eye movement recordings, and reading ability in children

Purpose. To determine how Developmental Eye Movement (DEM) test results relate to reading eye movement patterns recorded with the Visagraph in visually normal children, and whether DEM results and recorded eye movement patterns relate to standardized reading achievement scores. Methods. Fifty-nine school-age children (age = 9.7 ± 0.6 years) completed the DEM test and had eye movements recorded with the Visagraph III test while reading for comprehension. Monocular visual acuity in each eye and random dot stereoacuity were measured and standardized scores on independently administered reading comprehension tests [reading progress test (RPT)] were obtained. Results. Children with slower DEM horizontal and vertical adjusted times tended to have slower reading rates with the Visagraph (r = −0.547 and −0.414 respectively). Although a significant correlation was also found between the DEM ratio and Visagraph reading rate (r = −0.368), the strength of the relationship was less than that between DEM horizontal adjusted time and reading rate. DEM outcome scores were not significantly associated with RPT scores. When the relative contribution of reading ability (RPT) and DEM scores was accounted for in multivariate analysis, DEM outcomes were not significantly associated with Visagraph reading rate. RPT scores were associated with Visagraph outcomes of duration of fixations (r = −0.403) and calculated reading rate (r = 0.366) but not with DEM outcomes. Conclusions. DEM outcomes can identify children whose Visagraph recorded eye movement patterns show slow reading rates. However, when reading ability is accounted for, DEM outcomes are a poor predictor of reading rate. Visagraph outcomes of duration of fixation and reading rate relate to standardized reading achievement scores; however, DEM results do not.

Fine motor skills of children with amblyopia improve following binocular treatment

PURPOSE The purpose of this study was to determine whether reduced fine motor skills in children with amblyopia improve after binocular treatment and whether improvements are sustained once treatment has ceased. METHODS Fine motor skills (FMS [Bruininks-Oseretsky Test of Motor Proficiency]), visual acuity (VA [Early Treatment of Diabetic Retinopathy Study chart]) and level of binocular function (BF [Randot preschool stereoacuity and Worth 4 Dot]) were measured in children with amblyopia (n = 20; age: 8.5 ± 1.3 years; 11 anisometropic; 5 strabismic; 4 mixed) and in a group of visually normal children (n = 10; age: 9.63 ± 1.6 years). Eighteen children with amblyopia subsequently completed 5 weeks of binocular treatment provided by home-based dichoptic iPod game play. FMS, VA, and BF were retested at the end of treatment and 12 weeks after treatment cessation. All visually normal children also completed FMS measurements at baseline and 5 weeks later to assess test-retest variability of the FMS scores. RESULTS Prior to treatment, FMS scores in children with amblyopia were poorer than those in children with normal vision (P < 0.05). In the children with amblyopia, binocular treatment significantly improved FMS scores (P < 0.05). Better baseline amblyopic eye VA and BF were associated with greater improvements in FMS score. Improvements were still evident at 12 weeks post treatment. In the visually normal children, FMS scores remained stable across the two test sessions. CONCLUSIONS Binocular treatment provided by dichoptic iPod game play improved FMS performance in children with amblyopia, particularly in those with less severe amblyopia. Improvements were maintained at 3 months following cessation of treatment.

Paediatric hyperopia, accommodative esotropia and refractive amblyopia

Amblyopia is the most common cause of reduced vision in children and young people, affecting approximately two to three per cent of the population. Amblyopia is the consequence of disruption of the normal neurological development of the visual system and can occur with varying levels of severity. Clinically, amblyopia is diagnosed when there is a difference in visual acuity between the eyes of two or more logMAR lines and there is no sign of ocular or visual pathway disease. Careful examination using best practice techniques of the anterior segment and adnexa and of the posterior segment through dilated pupils is required to seek signs of other underlying ocular pathology. Amblyopia is usually classified according to the underlying cause. The most common causes are strabismus (misalignment of the eyes), anisometropia (significant difference in refractive error between eyes) and form deprivation (presence of medial opacity, such as cataract). Unilateral or bilateral amblyopia can arise secondary to a significant bilateral refractive error, while meridional amblyopia can arise from a significant astigmatic refractive error. These conditions create monocular blur or ocular misalignment, which if present during the critical period of visual development (up to about seven years of age) can lead to a loss or rearrangement of neural connections within the visual cortex. The relationship between strabismus and amblyopia is complex in that, as well as being a cause of amblyopia, strabismus and anisometropia can also both arise as a result of amblyopia.

Vision Recovery Despite Retinal Ganglion Cell Loss in Leber’s Hereditary Optic Neuropathy

Purpose To report vision recovery in a single case of Leber’s hereditary optic neuropathy (LHON) (mtDNA14484/ND6 mutation) with longitudinal documentation of retinal ganglion cell layer by ocular coherence tomography (OCT) that includes the pre-onset, acute, and chronic stages of vision loss. Case Report We report LHON in a 16-year-old male patient with Type 1 diabetes and known and documented family history of LHON. The patient presented with best-corrected visual acuities of right eye 20/150 and left eye 20/25−. His retinal nerve fiber layer had thickened compared with baseline measures obtained 19 months before the onset of vision loss. Vision rapidly reduced to “hand movements” vision in each eye over the following 2 months. Despite OCT-documented significant recalcitrant loss of ganglion cell layer, visual acuity remarkably recovered to right eye 20/40+ left eye 20/50+ 16 months after onset of neuropathy. Conclusions A selective loss of ganglion cells and nerve fiber layer can be documented in LHON. Significant recovery of visual acuity can occur without apparent structural recovery.

A pragmatic approach to amblyopia diagnosis: evidence into practice: Pragmatic amblyopia diagnosis Webber and Camuglia

Amblyopia is a common cause of reduced vision in children. The clinical diagnosis is complicated and requires consideration of the severity of vision loss relative to the characteristics of the disrupting amblyogenic factor. Added to the challenge of a thorough examination of very young children, is the weight of consequence if the amblyogenic factor is not identified and treated appropriately within clinically recommended time frames. Further, the poor visual function may be a symptom of more sinister underlying pathology impacting the visual pathway. This review presents an evidence‐based, pragmatic approach to the diagnosis of amblyopia, as a means for guiding best practice for the care of children who present with reduced vision.