 I'm chairing the Department of Ophthalmology and try to keep this happy gang moving in the right direction and moving in tune. And it's an absolute honor to be able to present one of our outstanding faculty to talk about a fascinating and important subject. Dr. Payne and I go way back. I'm trying to think exactly how long we go back, but it's a good long ways. I don't want to say it's too long because that would imply that she's older than she's still very young. But she started at Yale, came to our medical school here as a superstar, and I was lucky enough to be her advisor. And she and I worked on some really interesting studies, some of the seminal work that was done in that field. And then clearly she wanted me an ophthalmologist. She took some extra time in research. And I was sad she didn't match with us. I tried hard to convince her. But she went to UCSF. I was a superstar there. And they went back to Children's Hospital in Boston to do her training in Pediatric Ophthalmology. Has been with us. This is a lady who knows and understands this field incredibly well. She's one of our extremely bright young faculty members. And on top of everything else, and I remember this part, I missed it a little bit, but she's a harpist. And it was good enough in her yard to harp. She had a chance to perform in many different venues in many areas. She's a proud mother. And we're proud to have her. With that, we'll let you tell everything that you ever wanted to know about Blasio. It's all yours. Thank you. Thank you very much. This is my daughter that's over here crying. But I am a Utah girl. Like Dr. Olson said, I actually grew up across the street in Federal Heights. And I'm so happy to be back here. I was lucky enough when I was in college to... When I was in college, I didn't know what I was going to do with my life and was trying to figure that out. I had done a lot of music and was actually a history major. And trying to figure out how I wanted to use my life and what I wanted to do. And my older sister had a little girl who was born with a congenital cataract halfway through I was in college. And she had to have surgery when she was three days of old. And after that, she was treated with a contact lens and treated with many, many hours of patching. And that experience was really profound upon me. I just thought this was an amazing visual system that we have that is so sensitive to stimulus that we have to do surgery within the first couple of weeks of life or this child will never develop vision. And my sister thinks Dr. Hoffman is a hero because that is who did the surgery at the time. And I kind of started getting interested in medicine that way and decided to go to medical school. And this is a picture of that niece. As you can see, she's got a little bit of eye crossing because of that cataract. Her ride I was the one with the cataract. And then for many years, she was treated with patching and glasses to strengthen the vision in this eye. And so for many years, this was an ongoing battle for her and her mother to argue about that. But she has actually had a very good outcome and I'm going to talk a little bit more about that. So I was lucky enough to be able to come back here to medical school. And like Dr. Olson said, I did some research with him. But I also really got into doing some genetic research and I worked with Dr. Zang when I was in medical school because I thought I wanted to do ophthalmology. And he was helpful in helping me match an ophthalmology in San Francisco where I really decided that I did want to do pediatrics because it was a great mix of cataracts and a lot of other pathology including amblyopia. And so I went on to do fellowship in Boston where I learned about the hardest part of my job which is adult strabismus because they have double vision and it's very tough to treat. And then I've been back here five years now and working here I was very lucky to be recruited back and I'm very happy to be here and have many great colleagues here. But these past five years I've really thought a lot more about this developing visual system as I see so many kids with amblyopia in my clinic every day. And then also my daughter has some strabismus as well. So it's caused me to really think about it even harder how to treat it, how to make these treatments better for families and that's what I'm going to talk about today. The developing visual system is very complicated. Your eyes are at the front of your brain. That message is carried all the way back to the back of your brain and that's interpreted back there. So so much of your brain has optic radiations running through it that you can imagine that many neurologic diseases affect our visual perception and our tracking. Some of the neurophysiologists who did early work in this were Hubel and Wiesel and they won the 1981 Nobel Prize for this. They took kittens and they sewed one eye shut in the kittens. They took some of the kittens and showed both eyes shut and then they left some of the kittens and then they looked at that back part of the brain and compared it between those three different groups. And what they found was that in these kittens who had one eye sutured shut for the first six months of life, all of the neurons in the back of their brain were driven by that one eye and nothing was driven by the eye that had been closed. And when they opened both eyes up for the next 14 months and left them that way, they were all still stayed that way. These were different than the kittens who had both eyes shut. They had a third of their neurons were driven by both eyes, a third were driven by one eye and a third were just unresponsive and didn't develop. And this was in contrast to those normal kittens who had both eyes open. So we know that there is what we call this critical period of time and it's the time in which you have to have stimulation to your brain to learn how to use your vision and if you don't do that in this first few months of life and for the kitten, you know, it's sometime in these first six months of life, you will never develop vision in that eye. It's permanent brain damage that we cannot reverse. And that is what amblyopia is. It's a similar thing in adults, in humans. So it's a reduction of best corrected visual acuity, meaning that these are people who don't see 2020 out of one eye, but everything else in their eye is normal. There's no other reason why they don't see well except for the fact that there was no visual stimuli that was given to that eye in the, you know, sentinel first months of life or first few years of life in humans. It affects one to three percent of the population. It develops in childhood, but if it's untreated, you know, the effects last a lifetime. And this is something that is preventable. There are three different things that commonly cause amblyopia in my patients. The first is strabismus or any eye misalignment. In children, this is commonly eye crossing, but in, you know, it can be eyes that drift out. It can be one eye that's a little bit higher than the other. The other thing that does is refractive differences. So these are differences in the prescription between the two eyes. This can be near-sidedness, far-sidedness, or astigmatism. Or the last, which is the most least common, but the most difficult to treat is visual deprivation. So these are things that block the image from getting to the back of the eye to be interpreted. And this is, you know, caused by things like cataract or corneal disease. Strabismus. This is a huge part of what I do. It is misalignment of the eyes. As you can see in this schematic here, this is somebody with crossed eyes, and their eyes are looking at two different images. So as an adaptation mechanism, the brain will adapt and choose one eye, you know, the children will choose one eye to look at, out of, and one eye to ignore. And then that eye, they will, you know, because otherwise they would get double vision. So they will adapt and just learn to look out of the one eye and completely turn off the other eye. And that eye becomes amblyopic. Fovial disparity. That just means that this back part of the eye, so this eye is lined up to see this moon and this eye is lined up to see the star here. But the children will just choose one eye. And sometimes we don't understand why they choose one or the other, but they will choose this one. They will develop good vision in this eye and they will not develop good vision in this eye. One of the other common reasons why children develop amblyopia is called anisometropia, which is a long word to mean these two eyes are different shapes. So this is a little schematic here showing that these eyes are straight. They, you know, are lined up. They're both looking at this bunny. But this eye is focused here, so this eye would be clear. The image would be clear, whereas this eye would not, because this eye is a little bit shorter. This eye is a little more what we call hyperopic. Most kids are a little hyperopic. And if they're both eyes are hyperopic, it's not a problem because their lens here can change shape. It can become a little bit fatter, a little bit stronger, and it can move that image into focus. So it can take that image that was into focus here and move it up. If that's the case in both eyes, they will focus them both. If that's the case in one eye where this eye has to work a little harder, they just won't do it and they all are this way. They will just use this eye to see and this eye they leave blur and they just never learn to see clearly in this eye. Most people in adulthood are emetropic, meaning they don't need glasses to see clearly. Some people are myopic, meaning their eye is a little bit too long. The image is in focus in front of the eye, in front of the back of the eye where it should be. Children are all hyperopic, meaning their eye is too small. Evolutionarily they have evolved that way because their eye is going to grow. Most children will be hyperopic and then grow into being emetropic. But the problem comes when one eye is more hyperopic than the other because the hyperopic eye, the shorter eye, becomes the amblyopic eye. This is an accommodative hyperopic eye, meaning this child has moved their lens to move that image into focus. Most kids can do that, but they just don't if there's a competition between the two eyes. So we treat them by putting a pair of glasses. So we just put a lens here that's a little stronger to move that focus up to this back of this eye here. Amblyopia is associated with strabismus, associated with eye misalignment in 50% of cases and is more common in premature infants, which we're seeing more and more premature infants as our resuscitation methods are getting better. It's also more common in families who have a history of amblyopia. Sometimes it can be strabismic or anisomatropic or some kind of combination of the two. But amblyopia is more than a difference in visual acuity. When you go into the doctor's office and read the chart, you're just reading a black and white chart on a screen in the dark room. But that is so much less than your whole vision is. It's so much less than you perceiving vision out of doors. Vision also consists of color, movement, contour, contrast and binocular vision in people who have two eyes working together. And these things are all abnormal in people with amblyopia. One quick and dirty way we have to measure to pick up on if kids have amblyopia is if we can get them to cooperate with stereo acuity testing. This is a little bit like a 3D movie. So you have to have good acuity in both eyes and straight eyes to be able to perceive a 3D movie because you have to have your eyes working together. So we have these children see if they can put these glasses on. So these glasses, you know, when they're looking at these circles, one of these circles will pop up and the one that pops up is actually a little bit different out of one eye versus the other eye. It's a little bit to the left on the top one and a little bit to the right here. Your brain integrates that together and you get the sensation that the image is coming up. People with crossed eyes or people with severe amblyopia who don't have two eyes working together do not have stereopsis. And parents are always worried when they come in and they don't have stereopsis and wondering, does that mean they don't have depth perception? And the answer to that is no. They do have depth perception because you don't have to have stereopsis to have depth perception. These are things that play into depth perception such as object overlap, object size, highlights, and shadows perspective. And realistically your stereopsis is only active for the first few feet of your vision and then after that you're really relying on monocular cues. However, it probably does have some professional implications. Certainly you will not become a fighter pilot if you don't have good stereopsis. They do check that. I interviewed for residency. At least one residency had tested my stereocuity, so some surgery programs do that. And you probably won't be a Wimbledon champion. I think there's some amount of having really good stereocuity to be able to tell that spin on that ball. We also are recently finding that there are other things that are abnormal in people with amblyopia, things as simple as reading. So this was a study that was done that compared amblyopic children to normal children with treated eye crossing. And they had them read a passage and then they tested these children and had them answer a series of questions. And only the kids who got 80% of the questions right were included. But they had a monitor and they monitored their eye movement. And what they found was the kids with amblyopia, and this is kids using both eyes. So it's not like they're just using their amblyopic eye, but they have much more forward saccades. So they do not smoothly follow words across the page. What they do is kind of overshoot lots and have lots more saccades. So you can imagine that reading is much more difficult for these kids. And what they found also was that the depth of amblyopia, meaning the kids who had worse visual acuity in that amblyopic eye, were not necessarily the ones who had worse reading speeds or slower reading speeds. Treatment for amblyopia is most effective in the young children, like we said, because that developing visual system is most sensitive in the early days. But it's very difficult to assess vision in these young children. How do we assess vision? When kids are born, we want to make sure they react to light by six weeks of age. We want to make sure they have maintained eye contact. Three months of age, we want to make sure that they can fix and follow an object around. But you can imagine that kids with amblyopia still are going to be able to fix and follow with both eyes. So it's not always a great way of testing vision. And by two years old, we can start to test their vision using these pictures across a room and later we use the standard eye chart. In young children, we try to look at their fixation preference. What does that mean? In kids who are crossed, they're looking at you with one eye and one eye is crossed. And usually that one eye that's crossed is always crossed. And then we will cover the eye. They're looking out of enforcement to look out of the eye. They're non-preferred eye. And then watching how quickly they go back to their preferred eye can tell us something about their vision. If they come right back, we know they have pretty severe amblyopia. If they kind of wait for a minute and then kind of go back, usually they don't have as severe of amblyopia. And some kids, especially the kids that are really, really crossed, sometimes won't have amblyopia because they use this eye to look that way and this one to look this way and then they just don't move their eyes around. So we can look at their fixation preference. And in kids who aren't crossed, we can kind of simulate crossing by putting a prism in front of their eyes. So this young child, you know, we have a prism that was put here in front of this eye. And if both eyes are strong, that eye will move this way to follow that where the image is displaced and then move back. And that's another way we can simulate strabismus or simulate my eye misalignment to see if they bring their eyes back into being straight. This is tough in the clinic, though, because the second you get that prism up there, they start looking at the prism and stop looking at you and it can be quite tricky, but you know, it's quite important when we're looking at kids and trying to figure out before we dilate them in things what their fixation preference is, do they have a stronger eye? One other way we can test vision is by having children look at these cards. And infants have a tendency to look at the pattern. So these cards have a pattern on one side and the patterns get progressively, the stripes get progressively thinner. And the kids with better acuity will be able to follow these cards now further and further. The problem is that we're often trying to tell the difference between one eye and the other so you have to put a patch on. And you will lose the cooperation often of the kid when you put that patch on or if not when you put the patch on the first time when you take it off and put it on the second eye. So it can be quite tough, but it can tell you a lot. And it can be very useful too in kids who are young and have a brain tumor and it's not responding, you know, it's responding somewhat to chemotherapy but we're not really sure, it hasn't really shown growth on MRI or things as we'll be trying to follow vision with things like this. So this kind can be useful in situations like that. This is the visual acuity chart that most of us are familiar with. If we've ever had an eye exam, you know, kids usually have to be five or older. It just really depends on the kid to be able to cooperate. We need to test each eye and kids with amblyopia are quite tricky and peeking around a patch or peeking around a paddle which is why we often have to patch them. Something else interesting about amblyopia is what we call this crowding phenomenon. This is a brain disease. This is brain damage. So if you ask an amblyopic kid to read this line with their amblyopic eye they're going to tell you EPF and then add a few more letters in there. They will be much better at telling you what the letters on the first and the last are because their brain cannot organize that information and oftentimes they can see the letters but they can't tell you what they are. They'll read a lot more in between them. The second you let them read with their good eye they'll say, oh yeah, and they'll read them all for you. But it's what we call this crowding phenomenon. So they will often read the chart great if you give them one letter if you give them one letter and make it smaller, smaller, smaller. But the second you add these bars around it or crowd the letter they get confused and can't tell you. So to be able to detect amblyopia we will often, even in kids who can't read a whole line, just put one letter and put what we call these crowding bars around them. The AAP which is the Academy of Pediatrics, the Academy of Ophthalmology and the Academy of Pediatric Ophthalmology these are what they recommend for screening for all kids. When they're born the pediatricians should check their red reflex. When they're six months the pediatricians should again check their red reflex and then between six months and three years they don't need to do anything until they can read the chart. But this is a long period of time if some child has amblyopia that we are not picking up on and treating. Red reflex testing, some pediatricians are really great at this and some are not so much, most are not so much. In fact my niece who was diagnosed with a cataract it was actually her father who picked up on that cataract and was staring at her and noticed that it was not the pediatrician and that's often the case, moms are often better at this than pediatricians. So it's kind of a skill that is being lost. I love to have pediatric residents in the clinic and this is the biggest skill I try to teach them, it's just in every kid. Do you see that there's a difference in the reflex between these two eyes? Because I think it's a tough skill to pick up on and most kids are normal so it's hard sometimes for pediatricians to or pediatrics residents to learn that skill. So you can see here that this seems pretty dramatic that this reflex is much brighter than this one. This child is much more near-sided and has more stigmatism in this eye so this eye is duller than this one. This kid is very near-sided in both but this eye is more near-sided than this one. So you can see just by looking at a red reflex you can tell that there are differences here that these red reflexes are not equal but it's much easier to tell something that is dramatic like retinoblastoma which is an eye cancer. You can see the retina here is popping up and pushing against the back of that lens there but this is a skill that is kind of being lost and some of it now is being taken over by these photo screeners. So some insurances are reimbursing pediatricians for these so more and more are getting these. It's a device that analyzes the red reflex but it can be useful in these kids who are young but it's not accurate unless the child is fixating and in my experience now there are a few pediatrics offices that are now referring to me who had these. It's not a very accurate test and part of that I think is the parameters in which they're measuring what they're referring for. Some of it is that it doesn't work as well on young kids but it's similar to this in that it's just a machine to try to analyze this red reflex. Should every child have an exam? Should we be seeing every kid to see if we can pick up on amblyopia? No, that's just too many kids especially in this valley. We really don't even have enough pediatric ophthalmologist to deal with the number of kids we have in this valley. The Moran is working hard to try to hire more. We've recently hired Leah who is back there who is an MD-PhD who is much smarter than I am and doing lots of research and we're hiring somebody else but there just are too many children to really see everybody. And the reality is most kids don't need glasses. Most kids are fine and have normal visual acuity in each eye. The other thing is that giving classes to kids who don't need them is potentially harmful not just because the lenses are often flip-flops which I see in my clinic all the time but because in some of these kids we know they're hyper-opic, we know that they're far-sighted and that's how evolutionarily they've been built so maybe if we put the glasses on these kids we're interrupting how their eye grows and we're stopping that. It's also just impractical especially as more and more both parents are working it's going to be an overload on health systems so we really don't want to see every kid. The other thing is that all kids everybody has refractive error. Everybody has glasses can make their vision better but that doesn't mean we should put them all in glasses and for young kids we tolerate a lot of refractive errors so you can see here in a kid that's less than one if they have minus five prescription or more we put them in glasses but that's a pretty high prescription so those kids with just small amounts of myopia we don't need to treat because their vision is going to develop normally. This is a table just saying that we don't need to put glasses on every kid even if they have some prescription we want to look at the things that are going to lead to amblyopia and treat those kids. This was a study done at Vanderbilt by a pediatric ophthalmologist who looked at 102,000 kids who were photoscreened and what he found was that 25% of the kids who failed the screening really did not have ambulogenic risk factors they were false positive screenings but 19% of these kids got glasses and 32% were given glasses for a die-after or less I just saw a kid yesterday that was in the glasses that were plus 0.5 and he was one year old so sometimes I take kids out of glasses all the time because they really don't need them and it's potentially interfering with how their eye is growing we don't want people to grow up to be adults who are farsighted because they're going to be completely glasses dependent whereas people who are a little nearsighted might kind of like that when they get presbiopic so the truth is we don't want to put glasses on kids if we don't have to so this is a study that I've been involved in to try to not only pick up on amblyopia but to learn more about amblyopia to learn more about eye tracking to hopefully help develop better ways of treating this disease in the future so this is a girl at my clinic here this is the EAE which is the entertainment arts and engineering department who I've been working with to try to develop this game so this girl here is patched and playing our game this is the device we are using to try to follow eye tracking and as you can see it picks up at a sampling rate of 120 times a second it's looking at the eyes to see where they are tracking and we just put it at the bottom it's 12 inches so we just put it at the bottom of this computer screen and just hook it up to a regular computer this is from the website this is a commercially available device that creates a reflex off the eye here and then is able to use some algorithms to follow exactly where the eyes are following targets on the screen it's used primarily in product marketing to see where your eyes are pulled when you are looking at a website because most things are driven by money but we are trying to use this to learn more about eye tracking so what in these kids with amblyopia so these are little targets here that the eyes are following and the longer they follow them they start breaking apart and go off the screen and then a new one will appear so this is the eye tracking here it's a quite simplistic game and then this is the target there are different size targets and the targets all take a different path from the periphery to the center although the path is the same when we are comparing the targets have a different path but they are the same when we compare one eye to the other eye so what are we measuring we are measuring how long it takes the kids to find the object what is the distance between the gaze and the center of the target so how well are they following that target and how long do they follow that target each eye we present 15 targets and then we have each kid play it for about 3 to 5 minutes we are looking at kids 2 to 17 those with normal acuity and then their siblings or kids who are referred to as a dynamic with just a normal screening and then comparing how they do between the two the kids play the game with both eyes open and then we patch them and play one guy against the other eye and we are still collecting data on this we are in the very early stages but what we hope to learn is to know more about eye tracking and to know about these increased saccades and how they don't follow images of what's well and hopefully help develop novel treatments in the future the hardest part of amblyopia is treating it and discuss the problems inherent in treating this but if we can get binocular therapies meaning if we can come up with treatments that use both eyes together one we may more adequately treat this disease and get these kids to use their eyes together better in the future and more importantly they will probably be better tolerated and more effective at treating this disease in the future I think eye tracking will help us understand a lot more about diseases so much of the brain has visual pathways running through it and we know these are affected in things like autism and ADHD where they don't look at faces they track things differently they can't follow, can't stay on task and can't stay on target and you can just tell the second you get a kid in your clinic who comes in they say oh I think there's something wrong with their eyes and they can't follow anything they can't even watch your screen just because their ADHD is so bad I think that a lot of that is a neurologic problem that vision tracking may tell us more about and help us develop more ways of treating it in the future cortical visual impairment is something I see in my clinic a lot and these are kids who have brain damage and as a result don't have normal vision and it can be from anoxic brain injury or hydrocephalus or a lot of these are preemies who have had hemorrhages in their brain but it's something that we're seeing more and more as our medical therapies get better at treating these diseases and helping them live longer we're learning more about the brain through the problems they have in visual perception and tracking the hardest part about amblyopia is treating it and it is much easier to treat in younger children this is my niece here who has got a patch on it only takes weeks to months and infants and toddlers but it takes months to years and older children and it's much tougher to treat than kids like her who you take their natural lens out because as I said that lens that you're born with is amazing because it can change shape and focus things once you put a lens in her you know you're setting it for distance and then have to put a bifocal in here so it's just another reason not to want to use that eye so this is particularly tough to treat in children who have had unilateral cataracts how old is the oldest you can treat kids with amblyopia it's a really good question and we don't fully know the answer to that and that can be frustrating for parents because you say well we don't know but we can try and see if we get a better answer and that uncertainty is always difficult for parents but we know that in kids this is a study done by the pediatric eye disease interest group which is a large organization that has many universities and private practices with doctors in it doing these big studies but they found that there's less than 12 patching there's a 53% improvement rate versus 25% in kids who are older than 13 which is quite amazing because we used to think that anything in the older age groups we wouldn't get any improvement at all but we're finding that even in those older age groups there is some amount of brain plasticity that we are able to harness when we treat these kids so the first thing we do is try to put glasses on these kids like we said the kids who some of them their strabismus gets a lot better when we put glasses on so their eyes are straighter and that's the first thing we do or we put glasses on them to treat their anti-symmetropy or their difference in prescriptions some kids we have to treat with contact lenses when they're really high powers in one eye we usually start with patching atropine is another thing that we can use to treat them and I'll talk about that a little bit it's an eyedrop that penalizes one eye some people use optical penalization meaning that they put a lens in front of the good eye that makes the vision blurry not super helpful sometimes kids just look around that lens a banger filter is kind of the same sort of thing it's just a filter that goes over the good eye there has even been some study done into acupuncture and there have been some favorable results reported from that therapy is something that doesn't have a whole lot of data behind it but some people are still trying it to see if it can help with treating in the amblyopia glasses alone are all you need sometimes and that's mostly in kids who have anti-symmetropic amblyopia meaning they have a difference in their prescriptions between two eyes in young kids just putting the glasses on them for 18 weeks in two thirds of kids 3 to 7 improved by two lines or only a quarter of those kids improved by two lines so that just got less as they got a little bit older patching can improve both their vision and their strabismus often as those kids start seeing better out of one eye we'll start using that eye with the other eye and their strabismus or their eye misalign will get better not always but sometimes it's best performed with adhesive patches because these felt ones are much easier to peek around you have to get the large ones sometimes they are better tolerated just because kids don't like the stickiness being pulled off them this is really the most common treatment but you can imagine it's tough to convince a kid to keep that patch on for a couple of hours a day first they don't want anything on their face second they can't see out of that eye it's blurry so it's really tough and those first few months right after you discover it are really the time when you can get the best treatment out of these it's a tough thing and it can be many months or even years to get any kind of improvement it used to always be thought that more patching was better but PDG just recently has done a big study looking at these kids with moderate amblyopia so this isn't so bad a vision 2040 is the driving cutoff so a little bit worse than driving vision and found that two hours of patching was similar to six hours and whether that's because nobody really gets the six hours in or not we don't really know but two hours a day is usually what we start with patching for these kids atropine is something that we can use it seems a lot easier for some parents because you just put it in twice a week rather than every day and it blurs the vision in their good eye it makes it so they cannot focus in their eye so it makes them like an old person so they can't see up close particularly because they would need a bifocal to do so it is great because it can help them flip fixation but it is tough for kids who are already having trouble in school so when we put this drop in it makes it hard to do their school work and so that can be a hurdle so we can also see somebody who has does not need glasses and we blur the vision in that eye at distance they will still have clear vision it's just up close that the vision starts to get blurry so you can imagine that if we are not blurring it that much maybe we wouldn't have that much improvement but we have seen that there is some improvement in people with severe amblyopia where we are not blurring their vision in their good eye enough that it is even blurrier than their other eye but this is something usually I think most people move to after patching doesn't work because patching is usually just a set amount of time each day and usually tends to be more effective than atropine like I said schoolwork is difficult it makes that pupil large especially over the summer that can be difficult because it lets in more light it can flip the amblyopia which I have done a time or two so we have to follow these kids closely if we blur the vision in that good eye it can become the bad eye so we have to be careful to watch these kids closely and some kids have a bad reaction here where they become mad as a hatter and hot as a hare so we have to kind of watch these kids too and this is more like it could happen and kids less than three truth about amblyopia is it's an ongoing dynamic process where we have to start with one treatment sometimes move to another treatment really keep encouraging these parents some of the parents just really don't like me because every time they come and see me I just say you got to keep going, you got to keep going and because this is the only time we could do this and this is the the only treatment we have the sad part about our treatment is a quarter of kids are experienced with recurrence within the first year of treatment this is more likely to occur and the kids who are patching longer and we just stop it but even after we stop sometimes it recurs and we have to restart again so we have to keep treating them until we're out of that critical period but we don't know what the end of that critical period is in some kids so we just have to keep following them rechecking their vision and see where what the end of it is and in summary patients with treated amblyopia enjoy better vision as well as improved eye alignment and object tracking our treatments are much better when we pick up on this early but our treatments aren't great right now all we can really do is force them to use the bad eye by decreasing use of the good eye but our hope in the future is that we can do more of these binocular treatments hopefully get things working with computer games or things like that that are a little bit better tolerated a little bit better the truth now is that the biggest burden of treating amblyopias on the parents and this is actually my sister and she spent many years patching this is my niece again and you can see that her eyes have turned out pretty straight and she has 20-25 vision out of that eye which is I very rarely see most of these kids with unilateral cataracts they do not end up with good vision in that eye and that's really a testament to her and her patching over the years but it's a struggle and it's hard and most families just don't make it they just can't get that patching but it's much easier if we can pick up on it earlier and hopefully in the future as we work together I'm a clinician and working on the clinician side of things in an MD and really seeing how these things happen in clinic and hopefully we can work together and try to come up with better treatments in the future that's it I would like to answer any of these questions at what age does amblyopia have to be detected in order for vision loss to be prevented so the answer to that used to be about 7 or 8 years old but recently PDG did a study that showed that even kids up to 13 if they put glasses on them for anisometropic amblyopia and patched them if they hadn't been patched before that they would get some benefit to treatment they've also done some studies where they look at adults who have amblyopia who have a horrible accident happen to their good eye and their vision their amblyopic eye is all that they have and they do find that those people if they're only using that eye in adulthood they can improve a line or two of their vision they've also done some studies patching some adults and found that they can get a little bit of improvement but the second they stop patching they lose that improvement so the answer to this question I think is probably about 13 or 14 years old that we can get some amount of a vision improvement but one of the most frustrating things for parents is it really depends on how deep the amblyopia is and we have to often try to see if we can get it better yes, younger it's usually to get back to 2020 vision you mean in both eyes usually the kids who have just anisometropic amblyopia meaning they just have a difference in the prescription those kids are much easier to treat than the kids who have eye crossing and amblyopia so some kids are can have a difference in their prescription and those kids are harder to treat but if you catch them in the first before 5 years old I think you can still get them back to 2020 but a lot of this a lot of it has to do with how good they are at patching which is really the bottom line what can be done for a 73 year old amblyopian we don't know the answer to that and we are we are working on binocular treatments now to see if playing games that stimulate both eyes we are using a filter or contrast to blur the vision and the good eye and forcing them to use the other one and use them together will that functionally improve any part of their vision and we don't know the answer to that at this point so at this point nothing but we are working on that to see because I think there is a lot about the brain we don't know and retraining the brain in the future we hope to figure that out though I recall you said you are still collecting data have you been informally observing that the game is more effective for children of certain ages than for children of other ages we are really still kind of developing an algorithm to try to follow these tracking but yes it's definitely the kids who are older and more familiar with computer games that are better at tracking and have better data in their good eye their other eye but I think it would be very interesting to compare like my 2 year old who is obscene because she can use YouTube and find things on there if I compared her to kids 20 years ago I bet she would be better at following a thing on a computer screen than these kids before because they are just so used to that now my 8 year old grandson looks through my kaleidoscope by holding the scope off to the side rather than straight ahead probably not I'd have to see how they were holding it but it might be worth getting him checked if he's really looking through the outside but when you're looking through a kaleidoscope there are inner attaining things to look at all over it so I don't know necessarily if they have good vision in both eyes it wouldn't be something to worry about but a kaleidoscope is kind of hard because sometimes you aren't always looking at the central target there but might be worth getting them looked at is amblyopia inherited yes or genetic in nature yes and I am often struck because I will see kids who it's always the right they'll be siblings there and it will be the right eye in every kid and why is that the case I don't know just means that genetically some way there's a reason for them to have smaller eyes on one side certainly eye crossing is very inherited some families have eye crossing and eye drifting out that are in hair that run in those families as a child that had a lazy eyes to business had surgeries see great now with no glasses will I have challenges in the future no likely not you've likely overcome all that and developed and you're out of that critical period so things should be kind of the same the interesting thing comes often when you sometimes when people get cataract surgery or lasix surgery it changes how their prescription is sometimes extra business can get worse if you've had extra business in the past sometimes when you become presbyopic and start needing bifocals things can change a little bit sometimes people are able to control what we call a latent misalignment so they have a tendency to drift but they don't have a problem but then when you change something by their eyes needing reading glasses that can kind of change things but in general no except if you have cataract surgery it may change things a little bit but I bet you will adapt and be okay how does hypotonia affect vision and what's the best treatment that's a good question your eye muscles are different than most of the muscles in your body because they have so many fast twitch fibers in them your eyes are moving thousands and thousands of times a second as you do micro saccades so they're often affected those muscles are often affected differently than hypotonia and I've had this discussion before with kids also with you know myotonic dystrophy or muscular dystrophy and in general it doesn't affect the eye muscles so much but I think that that is a question we don't fully know the answer to how do you work with nonverbal kids so most kids who or adults who are nonverbal are sent to my clinic and that's what I love about my job is that I don't have to ask a lot of questions sometimes I could just kind of look and figure out is this kid looking with both eyes by covering one eye looking at the other eye how is their visual behavior do they move their eyes all the way around and then dilating their eyes and then looking inside I can figure out what the prescription is and is there any pathology in the back of the eye there so I like that I can at the end of the road I don't have to do a lot of referring out I can kind of answer these questions but in some ways yeah I'm kind of like a veterinary doctor but I work with a lot of nonverbal kids and I don't mind seeing nonverbal kids always because I think that in other clinics they are dismissed because nobody can figure things out but in my job a lot of what I do is just kind of looking at what I see and not having to get a whole lot of information back from them whereas the adults are more difficult patients and I love working with them too because I think that they are my happiest patients but I kind of have a nice balance of that I think that's it but if you does anyone else have any other questions oh I miss yours they were asked oh I have this one oh I did I missed I missed a couple of them yes infantile cataracts what is their ideology and does this condition in any way to cataract development there are kind of two different types of infantile cataracts well there are a couple of different types kids who are born with them in one eye it is usually a fluke and it's usually not inherited and it is usually not associated with anything else and what the cases in those kids is that when your eye is developing you you have a so the front part of your eye this is your lens and your lens needs to be perfectly clear for you to see through it and then your cordia is the clear part of the front of your eye when and then you have your iris here when your eye is developing there is an artery that is from the back of your eye it's really from your nerve over here and it extends forward to the front of your eye to give your eye the nutrients it needs as it's developing that artery should completely disappear before the child is born however in some children it does not so it keeps feeding nutrients and blood and things to the front of the eye and then they develop a cataract at the back of that eye so it is just an abnormal feature of development so those are the unilateral cataracts are usually that that fashion sometimes they are anterior cataracts kids will be born with an anterior cataract on the front of the lens those usually do not cause any problem we do not take those out and they usually do not get worse over time the one thing that they do have is sometimes the eye will grow differently around them and then they will have a stigmatism in that eye the kids with the unilateral cataracts we have to take those cataracts out in the first six weeks of life or they will never have normal vision in that eye the only way they will have normal vision in that eye is that they have a good parent who will patch them vigorously to get vision in that eye because just taking that cataract out isn't going to give them the ability to really have to force them to use it those are the unilateral cataracts some kids are born with bilateral cataracts and we have to sometimes it is inherited as an autosomal dominant trait so there are families where this runs in their family and 50% of the kids have this trait usually they are not related to adult cataracts and they are totally different it is not like they have a tiny tiny cataract that is going to get bigger and bigger and develop when they are older they are going to develop in the first if they are very small they are going to get worse in the first 10 years of life and need to be removed but they are just a totally different entity than adults so everybody if you live long enough you will develop cataracts these children who develop them it is because their lens did not develop normally and there is some amount of impurity in their lens or they got too much nutrients in the beginning the other kinds of cataracts I see a lot in my clinic are kids who are treated with massive doses of steroids for chemotherapy and they develop cataracts as well and those are more like the adult cataracts that you see that are just like the posterior plaques and things so those are more like the adult cataracts that we see these infantile ones are just totally different and they are just an abnormal feature of development what is the relationship between amblyopia and strabismus 50% of kids with amblyopia will have strabismus and 50% of kids with strabismus will have amblyopia so there is a very close tie between those two sometimes we don't know is this eye turning because those eyes were different shapes at the beginning and they started favoring that eye or did the eye start turning and then became amblyopic and then grew differently and the eyes became anisomatropic we don't know the answer to these they are very closely intertwined but the people who have both of those are the toughest like I said the toughest to treat and you have to get on them the earliest can you briefly explain the logic behind your computer game to detect lazy eye in children how does it diagnose lazy eye what feedback is there for the patient so we know that tracking in these kids is abnormal especially in their amblyopic eye and you can tell this just when you are checking their vision in the clinic because they will kind of when they read the line with this eye they will just read it straight across if they read it with this eye and it's like they are trying to put together pieces of a puzzle and trying to get those images in there so if you are having them follow a target our hypothesis is that following that target they are not going to follow it as well and they are going to bounce off of it more and just if you compare how they follow targets to one eye to the other eye that is amblyopic we are anticipating that we will see a difference how they track those targets what kind of a difference we see will hopefully help us develop ways to better treat that and to better improve their tracking in the future the big thing we are seeing is reading wise a lot of these parents will just bring their kids in and say because this kid isn't doing well in school do you think it's related to the fact that we are patching I say no I don't think it's related to the reason we are patching but I think it's related to the fact that they have this amblyopia I think it's a little bit tougher for them to learn to read but the truth is the only way we are going to get it better is if you keep working on it but I think that parents knowing that that is a factor and it can also help them so yes the answer to that question is we are detecting it just by how they follow a target because they don't stay on a target as well they are kind of having ballistic saccades they are not smoothly following a target across they are kind of trying to find it as they follow along what is the treatment protocol for an amblyopia starting with infancy so it's tough in infancy you know these kids that we take the cataracts out of I usually do surgery a week later you know put their contact lens on and treat them and then tell the parents to patch their good eye half the time they are awake I have seen one patient who had an infantile cataract that was over patch so their bad eye became their good eye just because they were patching all the one hour a day so it is and then that I developed glaucoma and it was really kind of a nightmare so it is possible to over patch these kids so you have to follow them closely but it depends on the type of amblyopia these kids who are born with cataracts have very severe amblyopia so they need a lot of patching these kids where you pick up on a kid with a year old that has some amblyopia who just needs glasses you probably don't need to patch them at all whereas these kids who come in who are crossing and have need glasses you are going to need to do a lot of patching so if you have glasses see them back if there is still a difference between their vision we start with two hours of patching we do that for several rounds so we do that for six or nine months and then if there is still no improvement after that time we either add atropine or increase the amount of patching so it is really different it is like that last slide said it is a dynamic process and it is different for every kid so it requires a lot of visits I think for parents it can be very frustrating so I think if we we can get better treatments in the future I think it would be better tolerated I think I wrote through all the cards now sorry they gave them to me out of order sure they have done some of those a lot of these ethnic groups have different kinds of refractive errors we know that the Navajo population is very high amounts of with the rule of stigmatism in bullfights and a lot of them have bilateral ambiliopia what does that mean? that means their vision is so blurred without glasses that even when you see this kid at eight years old and put glasses on them you cannot ever get their vision to 2020 because they have never learned to see so we see a lot of that bilateral ambiliopia in the Navajo populations and we have been working actually through division outreach with those kids to get on those reservations and see those a lot of Hispanic kids as well have a lot of with the rule of stigmatism and then we know that a lot of Asian kids are very nearsighted as a population as a world in general we are becoming much more nearsighted and that's just because people are doing more and more computer work and things up close so I think some of this the refractive error in things is changing with times but I think most of those studies have kind of been yeah we've done a lot with the Navajos other underserved populations I don't know the answer to that yes it's it's recessive definitely and I think there's some amount of environmental component as well it's certainly not a straightforward genetic yeah dominant or recessive I think it's even there's some other modifying factors as well definitely yes it is genetic for sure for sure it runs in families and we don't really understand why we don't we don't know why some kids start crossing because usually have a totally otherwise normal brain some of it has to do with refractive correction and things but not all the time some kids are just born with huge isotropia and we don't know why it's kind of interesting I here I see lots of accommodated isotropia meaning that we can fix it with glasses whereas my mentor Dr. Hoffman said that when he worked in Michigan he saw mostly all infantile isotropia so there is definitely population differences yes he's growing a lot and becoming more nearsighted if he is equal vision in both eyes you don't know how you have a clue most kids if they just if they tell you that they're just fine because they're just their eyes growing bigger they're becoming more nearsighted so yes yes and those kids who have high myopia you know have a lot of just kind of tend to and I was one of those kids I'm a minus seven so I you know in those 8, 9, 10, 11, 12 years every year I was growing a diopter or two and that's okay yes those are usually fine the truth is at 13 or 14 we probably can't treat any amblyopia anyway most kids don't tell you about amblyopia that's the problem most kids will not say oh I can't see out of this eye I mean almost no kids do that so when they tell you that their vision is bad it's bad in both eyes so it's not usually an issue and not correcting myopia doesn't create problems visually because myopia is what most people have their eyes too big but everything up close is clear so they will develop normal vision so yeah often times when kids come in with a diopter two or three of myopia I'll just ask the parents are you noticing any problems and if they say no I'll say they don't need glasses would glasses make them better yeah but if they're not having problems it's probably not an issue and it's not going to affect them well thank you so much for coming I really enjoyed sharing with you what I am passionate about and not always the most thrilling topic for others but for those of us who have been affected by it or have family members or things it's something that we're near and dear to us thanks