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wandering eye

Definition of wandering eye

Examples of wandering eye in a sentence.

These examples are programmatically compiled from various online sources to illustrate current usage of the word 'wandering eye.' Any opinions expressed in the examples do not represent those of Merriam-Webster or its editors. Send us feedback about these examples.

Dictionary Entries Near wandering eye

wandering dune

wandering jenny

Cite this Entry

“Wandering eye.” Merriam-Webster.com Dictionary , Merriam-Webster, https://www.merriam-webster.com/dictionary/wandering%20eye. Accessed 10 Sep. 2024.

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How to Recognize a ‘Wandering Eye’ in Relationships — and What to Do Next

If you’re in a relationship, looking at others in a sexual or romantic light is known as having a “wandering eye.”

Whether this is OK depends on your individual relationship’s boundaries.

What exactly do we mean by ‘wandering eye’?

Having a wandering eye could include blatantly checking out someone other than your partner(s) or flirting with them.

It could also include admiring someone’s physical beauty, commenting on them, or touching them.

Some people also use the term “wandering eye” to mean you simply find others attractive.

Is having a wandering eye the same thing as cheating?

Some people might define having a wandering eye as cheating.

It depends on your definition of having a wandering eye and your definition of cheating — some people believe flirting is cheating , while others don’t.

You might consider having a wandering eye to be the same as micro-cheating .

However, a wandering eye is usually about someone checking someone else out and flirting with them, but not necessarily engaging in a sexual or romantic relationship with them.

With that said, many people believe that these behaviors could lead to cheating later down the line.

What counts as ‘wandering’?

This depends on your personal definition.

For example, “wandering” might look like:

• flirting with someone other than your partner(s)
• telling someone that they’re sexy, attractive, or beautiful
• attempting to make plans to date or cheat with someone else
• blatantly checking out someone else
• talking about your sexual desires or fantasies with someone else
• fantasizing about someone or masturbating to the thought of them

Sometimes the issue is comparison-based. In a social setting, someone might give more attention to a friend instead of their partner(s). This might make their partner(s) feel like they’re second best.

Again, the above scenarios might be perfectly fine for some couples. For example, many people are totally fine with their partners fantasizing about another person.

In general, having a wandering eye refers more to words and thoughts than actions. Actions like having sex with someone else or dating them would usually be considered cheating , not just having a wandering eye.

Where does social media come into play?

In terms of social media, having a wandering eye might look like following someone for the purpose of checking them out, flirting with them (either openly in the comments or privately in the inbox), or “liking” their photos.

This might feel worse if it seems that the partner is paying more attention to their phone and social media than to them.

Some research shows that, although many people feel that technology has had a positive impact on their relationship, 25 percent of people in a marriage or partnership felt that their partner was distracted by their cell phone when they were together.

However, the boundaries really depend on your relationship. For example, many people might not mind their partner “liking” someone’s photos, but would mind them flirting with another person on social media.

In another example, some people don’t mind their partners flirting with or interacting with others on social media, as long as it’s not done in person.

How do you know if you’ve crossed a line?

Sometimes it’s difficult to know whether you’ve crossed a line.

Finding other people attractive is normal and not necessarily meant as a sign of disrespect. But where do you draw the line between finding people attractive and blatantly checking them out?

Ask yourself:

• Have my partner(s) and I talked about this boundary before? What did we conclude?
• If my partner(s) knew exactly what happened, how would they feel? Would they be OK with it?
• If I was in my partner’s situation and they were the one with the wandering eye, how would I feel?

In general, if you feel guilty about it and you think you’ve crossed a line, it’s probably a good idea to sit with that feeling and think about it. Consider talking to your partner(s) about it.

What should you do if you’ve crossed the line?

Moving forward after you’ve crossed a line can be difficult. It’s not always easy to figure out the next step to remedy the relationship .

Should you tell your partner? That depends on your relationship. Ask yourself the following:

• Have we discussed this before? Where do they stand?
• Am I telling them because they’d appreciate the honesty, or to soothe my own guilt?
• Will the lack of honesty have a negative effect on our relationship? What about my own mental health ?

Remember that no two couples are the same. There’s no answer that will work for every couple, because the way you move forward will depend on yourself, your partner(s), and your relationship.

What if you didn’t know there was a line to begin with?

It might be that you didn’t know that your actions were out of line. Without clearly defined boundaries and expectations, it can be difficult to know what’s OK and what isn’t.

It’s important to apologize, even if you didn’t mean to make your partner(s) feel bad. Emphasize that you’d like to set clearer boundaries so that you’re on the same page when it comes to interacting with others.

What if isn’t you, but your partner?

If a partner has a wandering eye, it’s important to remember that this isn’t a reflection of your value or attractiveness. With that said, it’s perfectly understandable if you do feel hurt or disrespected by their actions.

Talk with your partner. It’s ideal to do this when you’re both feeling OK (and not angry or annoyed).

Explain the issue clearly, detailing:

• exactly what they did or said that felt upsetting to you
• how it made you feel
• what boundary you feel they crossed

To broach the topic, you might want to use a line like, “When you flirt with other people, it makes me feel unloved/disrespected/hurt” or “I want you to know that I’m not OK with you checking out other people in public.”

From here, it’s important to set clear boundaries that you both agree on. You should both feel comfortable with those boundaries so that neither one of you feels disrespected or controlled by the other.

Is it possible to move past it?

If you feel disrespected by your partner’s wandering eye, or if they feel disrespected by yours, it can be difficult to move past it, especially if it’s a constant issue.

Agreeing on boundaries is a good start. Talk about what you’re not comfortable with as well as what you’re comfortable with. Discuss what you consider cheating. The definition varies from person to person!

For example, is it OK to give a friend a forehead kiss? Is it OK to “like” suggestive photos on Instagram? Is fantasizing about others OK?

It could also be helpful to take time to connect with one another. A wandering eye could point to deeper issues in a relationship.

For example, you might seek attention outside of the relationship if you’re not getting much from your partner. You could try scheduling sex , dates, or even a quick getaway for the two of you. Try a new hobby together, or embark on a new exercise routine as a couple.

It’s a good idea to revisit the conversation on boundaries from time to time.

If something changes your relationship — for example, if you become friends with an ex-partner — try re-evaluating your boundaries and checking in with one another.

If you’d like, you can try couples counseling . Here, the counselor will help you and your partner(s) work on the relationship together. Through counseling, you can work on improving communication, setting boundaries, building trust, and more.

The bottom line

Having a wandering eye might be considered cheating by some people. However, in order to have a healthy and happy relationship with your partner(s), it’s best to define your boundaries clearly.

This helps you each understand your expectations and navigate the relationship better.

Sian Ferguson is a freelance health and cannabis writer based in Cape Town, South Africa. She’s passionate about empowering readers to take care of their mental and physical health through science-based, empathetically delivered information.

How we reviewed this article:

• About marriage and family therapists. (n.d.). https://www.aamft.org/About_AAMFT/About_Marriage_and_Family_Therapists.aspx
• Couples, the internet, and social media. (2014). https://www.pewresearch.org/internet/2014/02/20/couples-the-internet-and-social-media-2/

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How to Deal With a Partner Who Has Wandering Eyes

Signs of a wandering eye, differing viewpoints.

• Impact of Social Media
• Have You Crossed a Line?

How to Respond

When a person has a 'wandering eye,' it means looking and having sexual thoughts about people other than their current romantic partner. It may include behaviors such as overtly evaluating and appreciating someone's physical attractiveness or even outright flirting with people who are not their romantic partners.

When the issue of a partner's eyes wandering is discussed, there seem to be two general responses: Either the behavior is brushed off as nothing to be concerned about or feelings of hurt and disrespect ensue, which may harm the relationship .

Some even believe checking out people other than a committed partner is a sure sign of infidelity, or at least a form of micro-cheating . The true answer to whether or not this is OK lies with you, your needs, and your personal boundaries .

It is important to recognize that each person has differing definitions depending on their beliefs and boundaries. Some examples of behaviors that characterize a wandering eye include:

• Blatantly checking out another person
• Flirting with other people
• Having sexual fantasies about others
• Talking about sexual fantasies about other people
• Telling other people they are attractive
• Planning romantic or sexual encounters with people other than their partner
• Texting or DMing people other than their partner

The behaviors that characterize a wandering eye involve how a person thinks about or communicates with people other than their partner. If these thoughts or actions lead to romantic or sexual encounters, it would be defined as cheating .

According to  Gail Saltz, M.D ., a psychiatrist and expert on relationship matters, blatantly checking out, commenting on, repeatedly admiring, and flirting or touching someone else usually feels quite undermining to a partner.

For partners that are bothered by the behavior, having wandering eyes is often described as:

• A sign of disrespect
• Damaging to a relationship
• Insensitive behavior that shows a lack of caring
• One of the first signs of cheating and that a person is looking for another relationship

Dr. Saltz acknowledges that all humans have some measure of voyeurism and exhibitionism: we like to look and we like to show.

But unless both parties are confident of the others' affection and fidelity, an obvious and frequent wandering eye will generally stir up envy and hurt, making one feel unappreciated and even threatened in the relationship.

On the other hand, some people believe that having a wandering eye is perfectly normal behavior. People in this camp often don't worry about a quick glance, and some may not even be bothered by something more.

Those who feel this way often cite the following points:

• Looking at an attractive person is thought to be a natural physiological reaction.
• A person with wandering eyes just appreciates beauty.

Again, it's important to remember that you define what is normal and acceptable for yourself and your relationship. That said, a study published in the  Journal of Personality and Social Psychology found that a consistent wandering eye probably signals a more significant issue in a relationship, which is worth considering.

Some evidence suggests that people prone to having a wandering eye are also more likely to engage in infidelity. One study found that people who found attractive people more attention-grabbing were more likely to eventually cheat on their partners.

Impact of Social Media and Technology

People don't just engage in 'wandering' behaviors in real-world encounters. They can also make their way into online interactions. In such settings, 'wandering' might involve:

• Flirting with another person, either in the comments section on their social media post or via direct message
• "Liking" another person's photos to communicate interest
• Flirtatious, romantic, or sexual texting with people who are not the person's partner
• Intentionally joining social sites in order to engage in flirtatious communication with others

Such behaviors can affect trust, communication, and intimacy in a relationship. According to one survey, around a quarter of people in relationships feel that technology has had a negative impact on their relationships.

Have You or Your Partner Crossed the Line

It isn't always easy to determine if you or your partner have crossed a boundary in your relationship. This is because it is normal to think that other people are attractive and doing so doesn't necessarily mean that you've broken trust with your partner.

In order to recognize whether you or your partner have a wandering eye, consider the following:

• How would your partner feel if they knew about your behaviors?
• How would it make you feel if your partner was doing the same thing?
• Have you ever discussed boundaries with your partner?
• Does your current behavior violate your partner's trust?
• Are you hiding your behavior from your partner?

If you feel like your partner would be hurt or upset and need to hide your actions from them, it is a good sign that your actions are crossing the line. 

If you are bothered by your partner's eyes wandering, Dr. Saltz suggests that you make it clear that although you don't expect them to wear blinders, you don't want them to ogle someone else.

If your partner really won't make any effort to change and doesn't appear to care how it makes you feel, it's likely that other issues may be affecting your relationship that couple's therapy could help examine.

Indeed, it seems that research agrees with this advice. The aforementioned study goes on to say that nagging your partner to stop looking likely won't address any underlying problems, either. Your relationship will require communication and a strategy to boost satisfaction and commitment.

Leading with jealousy and sweeping requests for your partner to change his or her behavior may lead them to tune you out. Instead, Dr. Saltz suggests the following:

• Accept that your partner's wandering eye is not a reflection of your own attractiveness.
• Don't try to "police" your partner's wandering eyes.
• If your partner's wandering eye creates a problem in your relationship, discuss the issue with them. Start with your own feelings, not with an accusation or criticism. 
• Suggest couple's therapy or attend therapy on your own if your requests are continually ignored.
• Try to casually acknowledge it first when a beautiful person comes into view.

A Word From Verywell

A wandering eye could very well be a natural, simple acknowledgment of attractive people—nothing more. Of course, that may not be the case all the time. Regardless, your feelings should be valid to your partner. If it bothers you and you have calmly expressed as such to your partner, he or she should be receptive to your concerns.

DeWall, CN, Maner, JK, Deckman, T, Rouby, DA. Forbidden fruit: inattention to attractive alternatives provokes implicit relationship reactance . J Pers Soc Psychol . 2011;100(4), 621–629. doi:10.1037/a0021749

McNulty JK, Meltzer AL, Makhanova A, Maner JK. Attentional and evaluative biases help people maintain relationships by avoiding infidelity .  J Pers Soc Psychol . 2018;115(1):76-95. doi:10.1037/pspi0000127

Pew Research Center. Couples, the internet, and social media .

American Association for Marriage and Family Therapy. About marriage and family therapists .

Dewall CN, Maner JK, Deckman T, Rouby DA. Forbidden fruit: Inattention to attractive alternatives provokes implicit relationship reactance .  Journal of Personality and Social Psychology . 2011;100(4):621-629. doi:10.1037/a0021749

By Sheri Stritof Sheri Stritof has written about marriage and relationships for 20+ years. She's the co-author of The Everything Great Marriage Book. 

Amblyopia (Lazy Eye)

At a glance: Amblyopia

Poor vision in 1 eye

Eye drops or wearing an eye patch

What is amblyopia?

Amblyopia (also called lazy eye) i s a type of poor vision  that usually happens in just 1 eye but less commonly in both eyes. It develops when there’s a breakdown in how the brain and the eye work together, and the brain can’t recognize the sight from 1 eye. Over time, the brain relies more and more on the other, stronger eye — while vision in the weaker eye gets worse.

It’s called “lazy eye” because the stronger eye works better. But people with amblyopia are not lazy, and they can’t control the way their eyes work.

Amblyopia starts in childhood, and it’s the most common cause of vision loss in kids. Up to 3 out of 100 children have it. The good news is that early treatment works well and usually prevents long-term vision problems.

What are the symptoms of amblyopia?

Symptoms of amblyopia can be hard to notice. Kids with amblyopia may have poor depth perception — they have trouble telling how near or far something is. Parents may also notice signs that their child is struggling to see clearly, like:

• Shutting 1 eye
• Tilting their head

In many cases, parents don’t know their child has amblyopia until a doctor diagnoses it during an eye exam. That’s why it’s important for all kids to get a vision screening at least once between ages 3 and 5.

Is my child at risk for amblyopia?

Some kids are born with amblyopia and others develop it later in childhood. The chances of having amblyopia are higher in kids who:

• Were born early (premature)
• Were smaller than average at birth
• Have a family history of amblyopia, childhood cataracts, or other eye conditions
• Have developmental disabilities

What causes amblyopia?

In many cases, doctors don’t know the cause of amblyopia. But sometimes, a different vision problem can lead to amblyopia.

Normally, the brain uses nerve signals from both eyes to see. But if an eye condition makes vision in 1 eye worse, the brain may try to work around it. It starts to “turn off” signals from the weaker eye and rely only on the stronger eye.

Some eye conditions that can lead to amblyopia are:

• Refractive errors. These include common vision problems like nearsightedness (having trouble seeing far away), farsightedness (having trouble seeing things up close), and astigmatism (which can cause blurry vision). Normally, these problems are easy to fix with glasses or contacts. But if they’re not treated, the brain may start to rely more on the eye with stronger vision.
• Strabismus . Usually, the eyes move together as a pair. But in kids with strabismus, the eyes don’t line up. One eye might drift in, out, up, or down.
• Cataract. This causes cloudiness in the lens of the eye, making things look blurry. While most cataracts happen in older people, babies and children can also develop cataracts.

How will my child’s doctor check for amblyopia?

As part of a normal vision screening , your child’s doctor will look for signs of amblyopia. All kids ages 3 to 5 need to have their vision checked at least once.

What’s the treatment for amblyopia?

If there’s a vision problem causing amblyopia, the doctor may treat that first. For example, doctors may recommend glasses or contacts (for kids who are nearsighted or farsighted) or surgery (for kids with cataract).

The next step is to re-train the brain and force it to use the weaker eye. The more the brain uses it, the stronger it gets. Treatments include:

Wearing an eye patch on the stronger eye. By covering up this eye with a stick-on eye patch (similar to a Band-Aid), the brain has to use the weaker eye to see. Some kids only need to wear the patch for 2 hours a day, while others may need to wear it whenever they're awake.

Putting special eye drops in the stronger eye. A once-a-day drop of the drug atropine can temporarily blur near vision, which forces the brain to use the other eye. For some kids, this treatment works as well as an eye patch, and some parents find it easier to use (for example, because young children may try to pull off eye patches).

After your child starts treatment, their vision may start to get better within a few weeks. But it will probably take months to get the best results. After that, your child may still need to use these treatments from time to time to stop amblyopia from coming back.

It’s important to start treating children with amblyopia early — the sooner the better. Kids who grow up without treatment may have lifelong vision problems. Amblyopia treatment is usually less effective in adults than in children.

Last updated: September 22, 2022

Lazy eye (amblyopia)

On this page, preparing for your appointment.

Your doctor will conduct an eye exam, checking for eye health, a wandering eye, a difference in vision between the eyes or poor vision in both eyes. Eyedrops are generally used to dilate the eyes. The eyedrops cause blurred vision that lasts for several hours or a day.

The method used to test vision depends on your child's age and stage of development:

• Preverbal children. A lighted magnifying device can be used to detect cataracts. Other tests can assess an infant's or toddler's ability to fix his or her gaze and to follow a moving object.
• Children age 3 and older. Tests using pictures or letters can assess the child's vision. Each eye is covered in turn to test the other.

It's important to start treatment for lazy eye as soon as possible in childhood, when the complicated connections between the eye and the brain are forming. The best results occur when treatment starts before age 7, although half of children between the ages of 7 and 17 respond to treatment.

Treatment options depend on the cause of lazy eye and on how much the condition is affecting your child's vision. Your doctor might recommend:

• Corrective eyewear. Glasses or contact lenses can correct problems such as nearsightedness, farsightedness or astigmatism that result in lazy eye.
• Eye patches. To stimulate the weaker eye, your child wears an eye patch over the eye with better vision for two to six or more hours a day. In rare cases, wearing an eye patch too long can cause amblyopia to develop in the patched eye. However it's usually reversible.
• Bangerter filter. This special filter is placed on the eyeglass lens of the stronger eye. The filter blurs the stronger eye and, like an eye patch, works to stimulate the weaker eye.
• Eyedrops. An eyedrop of a medication called atropine (Isopto Atropine) can temporarily blur vision in the stronger eye. Usually prescribed for use on weekends or daily, use of the drops encourages your child to use the weaker eye, and offers an alternative to a patch. Side effects include sensitivity to light and eye irritation.
• Surgery. Your child might need surgery if he or she has droopy eyelids or cataracts that cause deprivation amblyopia. If your child's eyes continue to cross or wander apart with the appropriate glasses, your doctor might recommend surgical repair to straighten the eyes, in addition to other lazy eye treatments.

Activity-based treatments — such as drawing, doing puzzles or playing computer games — are available. The effectiveness of adding these activities to other therapies hasn't been proved. Research into new treatments is ongoing.

For most children with lazy eye, proper treatment improves vision within weeks to months. Treatment might last from six months to two years.

It's important for your child to be monitored for recurrence of lazy eye — which can happen in up to 25 percent of children with the condition. If lazy eye recurs, treatment will need to start again.

Clinical trials

Explore Mayo Clinic studies testing new treatments, interventions and tests as a means to prevent, detect, treat or manage this condition.

Your child's doctor might refer you to a doctor who specializes in treating eye disorders in children (pediatric ophthalmologist).

Here's some information to help you get ready.

What you can do

Make a list of the following:

• Symptoms, including any that may seem unrelated to the reason why you scheduled the appointment, and when you noticed them
• All medications, vitamins and supplements your child takes, including doses
• Key medical information, including other conditions or allergies your child has
• Your family history of eye problems, such as lazy eye, cataracts or glaucoma
• Questions to ask your doctor

For lazy eye, questions to ask your doctor include:

• What is the likely cause of my child's lazy eye?
• Is there another possible diagnosis?
• What treatment options are most likely to help my child?
• How much improvement can we expect with treatment?
• Is my child at risk of other complications from this condition?
• Is this condition likely to recur after treatment?
• How often should my child be seen for follow-up visits?

What to expect from your doctor

Your doctor is likely to ask you questions, such as:

• Does your child appear to have problems seeing?
• Do your child's eyes appear to cross or wander?
• Does your child hold things close to see them?
• Does your child squint?
• Have you noticed anything else unusual about your child's vision?
• Have your child's eyes been injured?

Aug 14, 2021

• Coats DK, et al. Amblyopia in children: Classification, screening, and evaluation. https://www.uptodate.com/contents/search. Accessed June 8, 2021.
• AskMayoExpert. Amblyopia. Mayo Clinic; 2021.
• Amblyopia. National Eye Institute. https://www.nei.nih.gov/learn-about-eye-health/eye-conditions-and-diseases/amblyopia-lazy-eye. Accessed June 8, 2021.
• Amblyopia preferred practice pattern. American Academy of Ophthalmology. https://www.aao.org/preferred-practice-pattern/amblyopia-ppp-2017. Accessed June 8, 2021.
• Coats DK, et al. Amblyopia in children: Management and outcome. https://www.uptodate.com/contents/search. Accessed June 8, 2021.
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What is a Wandering Eye?

The term “wandering eye” has two distinctly different meanings that should not be confused. Fortunately, the meaning is usually clear from context, as in one sense, it refers to a medical condition, and in another it refers to a lack of fidelity. Both are usually treatable.

In the sense of a medical condition, wandering eye is a condition that causes the focus of one or both eyes to drift away when a person is looking at something. Essentially, the condition prevents both eyes from focusing together and, depending on the severity of the condition, it can be quite irritating for the patient. It may also be disconcerting for people who might interact with the patient. This condition is not the same as lazy eye, a condition in which visual information from one eye does not reach the brain.

Wandering eye is typically diagnosed during routine eye examinations, if the doctor notices that the patient has trouble focusing both eyes on an object. It can be treated with physical therapy in the form of eye exercises, specially designed glasses, and surgery, in extreme cases. The eye doctor may also explore the root cause behind the problem, as the condition can sometimes be a symptom of brain and nervous system conditions that warrant further investigation.

In the second sense, someone is said to have the “wandering eye” when he or she cannot stay focused on a primary partner. Typically, the this precedes acts of outright infidelity, and it can be a sign that a relationship is troubled, or that someone in a relationship is unhappy with the status quo. People may also be accused of having a wandering eye for perfectly innocent reasons; for example, a jealous partner might be angry about being neglected at a party in favor of someone else, and suggest that the other partner is paying too much attention to other people.

In the case of infidelity, a wandering eye can be tricky to treat. As a general rule, identifying the problem early is a good thing, as is a conversation about the situation and the relationship. A couple may choose to pursue therapy to talk through the issues that may be leading to discontent, or they may opt to deal with the situation on their own. A person who looks at someone other than his or her partner does not necessarily have the intention to stray; some people simply have a natural appreciation for individuals they find beautiful, and they may be unable to contain it.

Ever since she began contributing to the site several years ago, Mary has embraced the exciting challenge of being a WiseGeek researcher and writer. Mary has a liberal arts degree from Goddard College and spends her free time reading, cooking, and exploring the great outdoors.

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Amblyopia: Types, Diagnosis, Treatment, and New Perspectives

• Mark Complete

Introduction

Amblyopia is clinically defined as reduction of visual acuity in one or both eyes, caused by abnormal binocular interaction during the critical period of visual development, that cannot be attributed to any ocular or visual system abnormality or to refractive error. 1 The American Academy of Ophthalmology considers amblyopia an interocular difference of 2 lines or more in a visual acuity table (without specifying any), or visual acuity worse than or equal to 20/30 with the best optical correction. 2

With an incidence of 3% to 6%, amblyopia is the most common cause of low visual acuity in children and adults in developed countries and has great economic and social impact. 3-5 Individuals with amblyopia often have restricted career options and reduced quality of life, including less social contact, cosmetic distress (if associated with strabismus), low self-esteem, visual disorientation, and fear of losing vision in the other eye. 5-8

The adoption of interocular difference of visual acuity as a definition contemplates many of the points that concern the different definitions for amblyopia, such as reduction of visual acuity, functional imbalance between the eyes, and inadequate binocular information input in primary visual cortex. 9-12

P athop hysiology

Though well-known since antiquity, many neural, physiological, and psychological aspects of amblyopia are still not fully understood. 1,13

Classically defined as a decrease in visual acuity (which is clinically easier to assess), reduced contrast sensitivity of high spatial frequencies, and a binocular vision deficit, amblyopia also affects the development of a broad range of neural, sensory, oculomotor, and perceptual functions of vision. 11,14,15 Different visual functions are not fully developed at birth; their full development depends on 3 fundamental conditions during the critical period of visual development in infancy: adequate stimuli received from each eye, ocular parallelism (corresponding images), and integrity of the visual pathways.

Disturbances on input of stimuli received by visual cortex during this plastic and unstable stage of visual development prevent proper use of inputs from the involved eye, culminating in amblyopia. The impact on the visual system is closely related to the time at which the visual disturbance begins, and its intensity, type, and duration.

When the visual stimulus disorder is precocious, severe, unidentified, and not reversed in the first months or years of life, it can lead to profound structural modification of the visual neuronal circuit, causing definitive morphological changes in cortical structures of the lateral geniculate nucleus (LGN) and visual cortex, which lead to definitive alterations in the final visual function of amblyopic eyes. 16

When the visual stimulus disorder comes later and with less intensity, the normal anatomy construction of the system is maintained, but it is still possible to have active inhibition from neurons of the normal eye on neurons of the affected eye, also leading to functional amblyopia. This neurological mechanism inhibits the image of the affected eye in an attempt to not disturb the processing of the normal eye. 17

The pioneering works by Hubel and Wiesel of cortical structures of cats that had one eye sutured at different times during visual development clearly show a difference in anatomy and functioning of cortical visual neurons corresponding to each eye. 18-20 The final behavior of visual function in early-onset and late-onset amblyopia is also significantly different. 16,17,21,22

Since amblyopia is a visual development disorder, early diagnosis of ocular changes associated with amblyopia is crucial for good visual prognosis because it allows treatment to begin at a stage where the visual neurological pathways are still amenable to stimulation, recovery, and reversal of cortical damage.

The main ocular alterations that predispose to amblyopia are deprivation of visual stimuli (pupil occlusion by ptosis, opacities of optical media, nystagmus, and many others), alteration of sharpness of visual stimuli by refractive changes (high ametropia and/or anisometropia), and non-corresponding images received by each eye (strabismus). 

Types of Amblyopia

Deprivation amblyopia.

Deprivation happens when eye diseases prevent the light stimulus from reaching the retina, thus forestalling the normal visual process. It also may occur due to anatomic deficits of the retina or optic nerve, or abnormal movement disorders of the eye (nystagmus). When it occurs during the critical period of visual development, it can cause amblyopia. The main diseases that cause this are congenital cataract, blepharoptosis, nystagmus disorders, optic nerve coloboma and hypoplasia, retinal disorders, persistent fetal vasculature; other disease processes can also result in amblyopia.

Amblyopia caused by deprivation was the first type studied in works of Hubel and Wiesel in the 1950s. The authors demonstrated that suturing the eyelids of cats deprived their eyes from receiving visual stimuli, which led to innumerable anatomical and functional changes in the cortical visual pathways. The authors found that these changes were more drastic the earlier, the more intense, and the more prolonged the deprivation. 18,23-27

Studies with cats 18 and monkeys 10,25-27 have shown that the primary alteration of monocular visual deprivation is a change to the cortical ocular dominance columns. In cats, during the most sensitive phase of the critical period, a day of deprivation leads to a slight reduction in vision. Two to 3 days lead to a proportionally much more severe visual reduction, whereas deprivations of more than 6 to 10 days lead to full shift of the cells from the ocular dominance column to the side of the opposing eye, with severe reduction of vision. 19,28

In addition to changes in V1, amblyopia is associated with morphological changes in CGL. 25,27,29-32

The effect of late eye closure has also been studied. Thus, the effect of deprivation on the size of the bands of the cortical ocular dominance columns was greatly reduced when closure occurred after 10 weeks of age. 19,32

Therefore, 3 months would be the end of the critical period of cortical changes in a monkey, which would correspond to approximately 18 months of life in a human. 33 At this age, the critical development period has not ended but is susceptible to different changes in the visual system. 32 Despite the importance of data from animal models, several authors caution that comparisons between these models and human models should be carefully analyzed. Not only is brain structure different among species, but deprivation studied in animal models is known and controlled, whereas in most cases involving children, there will be varied clinical pictures and multiple associated factors to amblyopia. 34

Having taken this into account, many authors proved that deprivation causes different impacts on children’s vision, and that the period and severity of deprivation will bring different deficits to the final visual function. 35,36

The ideal period to treat the causes of deprivation in humans is within the first six months of life; after that, the chance to ensure the effectiveness of treatment and achieve normal results decreases rapidly. 37 The severity of deprivation makes a difference in these first 6 months. For instance, dense bilateral cataracts not treated by 3 months of age will almost assuredly lead to the development of nystagmus, which will severely limit visual acuity permanently. 38

Deprivation amblyopia causes profound anatomical changes in visual circuitry and has the greatest impact on visual acuity and all other visual functions. Its treatment is challenging, and results are generally less successful than in  other forms of amblyopia. 4,37,39

Anisometropic amblyopia

Anisometropia is a difference in the state of refraction of at least 1 diopter between 2 eyes. 40 The prevalence of anisometropic amblyopia is about 4.7% in children and may be myopic, astigmatic, or hypermetropic. The most common type of anisometropia seems to vary with the age, ethnicity, and ocular pathologies of the analyzed sample. 41-44

Hypermetropic anisometropia is the most likely type to cause amblyopia, since the retina of the more ametropic eye never receives a clear and defined image: The fovea of the good eye is focused and there will be no stimulus of accommodative effort to adjust the focus of the more hyperopic eye. In myopic anisometropia, the more ametropic eye can be used for near vision, preventing the same levels of amblyopia as seen with hyperopia. 1,45,46

Anisometropia may be considered a moderate form of deprivation of visual stimulus, since the more ametropic eye is deprived of receiving a good-quality stimulus in retina. Anatomical and functional changes similar to deprivation are therefore expected in amblyopia caused by anisometropia. 47,48

In cases of anisometropia as well as in deprivation, there is a partial "disconnection" of the affected eye in the primary visual cortex, leading to abnormal neuronal competition. While in normal animals most cortical neurons respond to stimulation of 2 eyes, in animals that were subjected to occlusion or blurring of the image of one eye, the proportion of cortical neurons responding to stimuli of the affected eye is much smaller. There is also clear evidence of neural acuity deficit in anisometropia and deprivation. That is, cortical neurons that still respond to stimuli of the affected eye tend to have diffuse and insensitive receptive fields and, therefore, generate worse spatial resolution and contrast sensitivity. 30,49,50

The severity of amblyopia is not directly related to the magnitude of the refractive degree itself but to the amount of anisometropia between the 2 eyes. Levi and colleagues demonstrated that VA falls rapidly with increasing magnitude of anisometropia, but that only occurs in high isoametropias with very high refractive levels (> 15D), suggesting that mechanisms other than optical blur, especially abnormal binocular interactions, are involved in the risk of amblyopia. 48,51

Despite differences in the inputs received from each eye, in anisometropia both eyes receive congruent images; that is, unlike strabismus there is no stimulation of non-corresponding retinal areas. The suppression is mainly foveal, but the periphery continues to fuse images. 52,53 Therefore, pure anisometropic amblyopia classically leads to significant visual acuity deficits compatible with loss of contrast sensitivity of all spatial frequencies, but with relative sparing of binocular vision. 11,54,55

Anisometropic amblyopia is often associated with microtropia, leading to a mixed mechanism of visual disturbance. 1

Amblyopia by pure anisometropia is the one with the best prognosis, with sometimes surprising recovery of VA with the use of adequate correction alone, and even in later treatments. 56 Studies have shown that the presence of preserved or subnormal binocular function is an important factor for the recovery of the system, although the same research has shown that in addition to classic monocular occlusive treatment, other forms of balanced binocular (dichoptic) treatment are ideal for restoring normal visual function. 57-59

Strabismic amblyopia

Strabismus is a deviation of one eye with loss of eye parallelism. As a result, the eyes do not receive equal images, leading the visual system to adapt to this change. 1

When the visual system is completely formed (when the person reaches adulthood), the perception of non-corresponding images by 2 eyes leads to double vision, but when the visual system is in its critical period of development (in childhood), the brain is still capable of using mechanisms to avoid diplopia or rivalry by inhibiting the activation of the retinocortical pathways originating from the fovea of ​the deviating eye. This adaptive mechanism avoids diplopia, but it causes a restructuring of the visual cortical circuits in the visual cortex that in turn causes amblyopia.

In strabismic amblyopia, the cortical ocular dominance columns remain structured, even in cases of moderate amblyopia. Only in cases of deep amblyopia are there reports of alteration of dominance columns. 25,26,60-65

Although the cortical cellular apparatus is relatively preserved, many functional changes occur in the visual system. There is active and deep suppression of the dominant eye over the deviating eye, retinal correspondence is completely lost, and cellular interactions are altered.

Tychesen and colleagues have shown many visual function alterations in monkeys with strabismus, as well as loss of V1 binocular connections. 25-27,65 The severity of motor ocular changes and the loss of V1 binocular connections increased as a function of the duration of decorrelation. The animals exposed to only 3 weeks of decorrelation recovered these functions. Other studies have shown that excitatory interactions for the deviating eye remain deactivated, but inhibitory ones do not, even after correction of the position of the deviating eye, indicating active cortical suppression and an imbalance between the cortical cellular columns. 66-68

Strabismus causes change in or loss of connectivity to the cortical spatial information pathways, altering the spatial summation and side inhibitions of received stimuli and, consequently, preventing the integration of contours and shapes. A distortion of the spatial vision occurs that interferes with numerous discriminatory visual tasks including visual acuity, Vernier visual acuity (alignment accuracy), and crowding. 69-74

In strabismus there is no binocular facilitation for any type of stimulus; the suppression is constant and strong and is probably a modified form of suppression of binocular rivalry. 53 Suppression is also found in the fovea of the normal eye when the amblyopic eye is fixing, showing that lost visual acuity is not related solely to suppression. Thus, it is suppression that leads to amblyopia in an individual who has strabismus and not vice versa, because the inactivity of the system may interfere with the process of synaptic development. 67

In strabismus, the different stimuli received by the eyes prevent normal image fusion, compromising binocular vision and summation and the ability to discriminate disparity and depth of vision with altered stereoscopic visual acuity (stereopsis) and even postural stability. 6,60,75-81

Contrast sensitivity in strabismic amblyopia is less affected than in amblyopia due to deprivation or anisometropia, with change mainly to high spatial frequencies. 82

Amblyopia caused by strabismus therefore has a major impact on visual acuity and binocular vision, and contrast sensitivity is relatively sparing. 11

Mixed amblyopia

Amblyopia is considered mixed when caused by 2 amblyogenic factors. Combination of anisometropic and strabismic amblyopia is common, especially in partially accommodative esotropia, microtropia, and monofixation syndrome. 1,55

Clinically, mixed amblyopia is more severe with similar deficits of visual functions, there is an exacerbation of visual acuity loss and contrast sensitivity and typically an extinction of stereopsia. The magnitude of the impact on each visual function will depend on the concomitant onset or at different times of each ocular change. 6

A study comparing visual acuity, Vernier acuity, grating acuity, contrast sensitivity, and binocular function of adults with amblyopia of different etiologies (11 categories) with normal subjects revealed 2 main dimensions of variation of visual performance on subjects with amblyopia: one related to visual acuity measures (optotypes, Vernier, and grids) and the other related to contrast sensitivity measurements (Pelli-Robson and edge contrast sensitivity). 47 The authors have demonstrated different distributions of visual loss for different amblyopia categories and have suggested that 2 consequences of associated conditions—resolution reduction and loss of binocularity—determine the visual deficit pattern. 47

Figure 1 . Amblyopia Map: The figure shows the mean locations of the 11 clinically defined subject categories in the two-factor space. The diagonal bars show one standard error of the mean measured along the principal axes of the elliptical distributions. (Reprinted with permission from McKee et al. [2003]) . 

Other Cortical Areas and Complex Functions Affected by Amblyopia

Amblyopia is, therefore, a neural disorder resulting from abnormal brain stimulation during the critical period of visual development. As shown by several studies, the striate cortex (V1) is the main cortical area affected by amblyopia. Amblyopes have decreased binocular neurons and decreased neurons responsible for the amblyopic eye in V1 in addition to active binocular suppression. 23,30,61,65,83-87

Despite the well-known visual processing deficits, recent work has shown that amblyopic patients present alterations in visual processing of high-order cortical functions 88 such as deficiency in movement integration, 89 perception and processing of shape and global contour, 13,90-92 altered perception of alignment (Vernier acuity), and symmetry. 93,94 Deficits in tasks involving high-order attention components have also been described 72,95-102 as enumeration of objects, prolonged attentional blinking, the "crowding" phenomenon, the reading process, and visual decision-making. Recent evidence shows that the perceptual impact of amblyopia extends even beyond vision to multisensory processing. 103 Abnormalities are evident in audiovisual speech perception, 104-106 spatial audiovisual localization, 107 and temporal judgment tasks. 108

These high-order deficits are also found in the fellow eye 72,109-113 and during binocular vision. 98,103,114,115

The element common to all of these affected sensory-motor tasks is they are not limited to acuity, and that they require both local and global cortical processing 91,116 and involve extraction and segregation of a background noise signal, 117-119   clearly implicating high-order visual processes.

To confirm these deficits found by electrophysiological and psychophysical research, new technologies such as positron emission tomography, 120,121 magnetoencephalography, 122 anatomic and functional magnetic resonance imaging (MRI), and functional magnetic resonance imaging (fMRI) 54,123-128 are being used to investigate the sites and extent of cortical deficits in humans with amblyopia. 103

These studies show alterations of activation in both V1 and extra-striate areas of the visual pathways of the amblyopic patient (ventral: V2, V4, V8, and dorsal: mean temporal area [MT] / V5), and show that activity transmission of the amblyopic eye is progressively affected the higher the processing level. 54,124,126,129

Studies with fMRI are also confirming different impacts on visual cortex related to different types of amblyopia. Recent findings suggest a more profound disorganization of the cortical arrangement in patients with strabismic amblyopia, in which the interhemispheric asymmetry for parvo- and magnocellular input processing was lost, whereas normal cortical asymmetry was present in those with anisometropic amblyopia. 130-132

Although these studies focus on the location of visual changes, it should be noted that cortical activity depends on constant interaction between different brain areas, and it is imperative to determine if high-processing areas inherit abnormalities from lower levels of processing or if there are developmental abnormalities in extra-striate that may have direct consequences on visual processing. 89 Therefore, a better understanding of amblyopia requires investigation of how amblyopia is associated with abnormal interactions between various brain areas and how these feedback and feedforward interactions are affected. 6,114,133

Recent research has shown that amblyopia leads to abnormality of multisensory brain processing that persists even in a binocular condition. Richards and colleagues demonstrated in their experiments alterations in the temporal, spatial, and speech audiovisual perception in amblyopic subjects, indicating that amblyopia causes multisensorial brain alteration and not only a uni-sensorial visual impairment. 103,107,108

Despite the varied deficits in visual function, the diagnosis of amblyopia is still done by measuring visual acuity on an eye chart, using optotype-based recognition.

In preverbal children who cannot complete this task, the diagnosis can be made using behavioral methods such as the fixation preference by observing the vigor with which the child objects to occlusion of one eye relative to the other. Grading schemes can be used to quantitatively measure fixation preference, 134 and grating acuity can be determined using the Teller acuity cards. 135 Recognition visual acuity testing based on optotypes (letters, numbers, or symbols) must be done as soon as the child can perform this task reliably. 136

As amblyopia is a common and preventable visual deficit, there is a great concern regarding early diagnosis and in determining more effective treatments for the condition. The American Academy of Pediatrics recommends screening for amblyopia as part of the regular well-child visit made by a pediatrician or family care practitioner, including the use of instrument-based vision screening techniques for preverbal children. 137

Randomized longitudinal studies have shown that screening improves vision outcomes, decreasing the prevalence of amblyopia by as much as 60%. 138 Moreover, novel technologies, such as instrument-based devices (vision screeners) help primary care providers diagnose amblyopia in the early stages and refer children for specialized ophthalmologic care. 139,140 Earlier detection can allow for earlier treatment and will result in better outcomes for those children whose amblyopia is detected early. 141

The gold standard treatment for amblyopia is patching the better eye to force the brain to use the weaker eye. Depriving the fellow/fixating eye of vision forces the amblyopic eye to strike suppression and to use the visual cortex corresponding to the eye to recover connections for better vision. Alternatives to patching are optical penalization with atropine eye drops, filters to blur the better eye, optical defocus using glasses or contact lenses, and dichoptic video games.

In the last 20 years, PEDIG (Pediatric Eye Disease Investigator Group), 142-143  as well as MOTAS (Monitored Occlusion Treatment of Amblyopia Study), 144   have conducted randomized clinical trials to address the main issues of occlusive treatment and to define optimal treatment protocols.

The PEDIG studies have published 17 Amblyopia Treatment Studies (ATS) that are evaluating amblyopic treatment for children 3 to 17 years old, and the major results to date are:

• Optical correction alone is successful in improving the amblyopia in nearly 1/3 of patients (anisometropic, strabismic, or mixed) 56,145
• Patching is an effective treatment for amblyopia. 146
• The ideal number of hours of patching was evaluated. Children 3 to 7 years old with moderate amblyopia were randomized to 2 hours of patching per day compared with 6 hours of patching daily. Although the 6-hours occlusion group had had a faster improvement, at the end of 4 months of treatment both groups achieved similar visual acuity (20/30 visual acuity or at least 3 lines of improvement from baseline), with no statistically significant difference between the groups. 147 Another ATS evaluated severe amblyopia (20/100 to 20/400), comparing groups using 6 hours of patching with full-time patching. At the end of the treatment period, both groups had good outcomes with an average improvement in visual acuity of 4.8 lines (6 hours) and 4.7 lines (full time) and no statistically significant difference between the groups. 148 Higher hours of patching were associated with worse compliance: Only 6% of patients with higher hours of patching complied for the prescribed time. 149 These studies provide useful information about the effect on visual acuity of the number of hours that are prescribed, and can be used as a guide to customize patching treatment for each individual patient. 3
• Atropine for penalization proved to be as effective as occlusion. Although the occlusion group had a quicker visual acuity improvement, at the end of 6 months of treatment there was an equal improvement of visual acuity for the 2 groups, and it was maintained in long-term follow-up (up to 15 years). In addition to those who used daily atropine, patients who used atropine once a week showed improvement in visual acuity and had better compliance. 150
• Treatment of amblyopia is most effective with children under 7 years of age. Children up to 13 years of age showed significant improvement in vision with patching, although the rate of response to treatment may be slower, require a higher dose of patching, and the extent of recovery may be less complete. 151
• There is a high rate of recurrence after the end of amblyopia treatment with similar rates for occlusion and atropine (approximately 25%). This rate was 4 times higher in children who did not have a gradual taper of their treatment for at least 5 weeks following the resolution of amblyopia. Factors also linked with greater recurrence rates included better visual acuity at the end of treatment, greater number of lines of improvement, and previous history of recurrence. 152,153
• Children patching with near work for part of the patching time had more improvement than children who patched with no near work as part of the patching regimen. 154,155

 Table 1 . Gunton, K. B. (2013) Advances in amblyopia: What have we learned from PEDIG trials? Pediatrics, 131 , 540-547.   

New Perspectives in Amblyopia

The study of amblyopia over the years has allowed better understanding of brain function. The anatomical and functional structure of the visual system has been studied in further detail, through new models and with more advanced technology, attempting to correlate findings with electrophysiological data, psychophysical data, and now neuroimaging data.

Since Hubel and Wiesel demonstrated anatomical and functional alterations in the primary visual cortex due to amblyopia in animal models, much has been discovered about the impact of amblyopia on the visual system and the importance of a critical period of cerebral plasticity on the effective treatment period. Two major shifts in paradigm regarding amblyopia that these bodies of work brought were the belief that successful treatment of amblyopia outside the critical period is possible, and the concept that amblyopia is more of a binocular, rather than a monocular, disease. 156

Treatment of amblyopia outside the critical period

 We know that the young brain is more plastic than an adult brain, but we also know that the adult brain is still capable of learning and recovering after injury, so it is clear that there is plasticity at a synaptic level, a cellular level, and at the level of cortical representation. One interpretation in this context is that the critical period ends with an increased threshold for plasticity rather than complete closure, so it is necessary to find stimuli and ways to stimulate the specific plasticity of the adult brain. 15,156 Intracortical inhibitory circuitry was discovered as a key factor for defining the limits of cortical plasticity. It has been shown that a brief reduction of  gamma-aminobutyric acid-ergic (GABAergic) inhibition in the brains of rats is able to reopen a window of plasticity in the visual system well after the normal closure of the critical periods, 157 so several intrinsic and extrinsic modes of augmentation of plasticity have been employed to facilitate amblyopia therapy beyond the critical period of development.

Intrinsic augmentation can be achieved by manipulating the neurotransmitter systems that regulate synaptic plasticity in an environmental and/or behavioral way. This effect is achieved by action of cholinergic pathways and also action of norepinephrine and serotonin to disinhibit cortical visual neurons. One can stimulate this system through environmental enrichment (exercise and visual enrichment), prolonged dark exposure, caloric restriction, and with new or challenging visual tasks (perceptual learning). 15,158-162

Extrinsic augmentation uses exogenous manipulation of this endogenous neuromodulatory system. One of these methods is pharmacological and the most commonly used drug for this purpose is levodopa. Non-randomized studies have suggested that the use of levodopa along with occlusive treatment led to improvement in visual acuity, mainly in those amblyopic patients for whom traditional treatment had failed. However, a randomized, placebo-controlled clinical trial conducted by PEDIG showed that the improvement in visual acuity with levodopa did not have a statistically significant difference compared to a placebo, and the improvement in vision in the levodopa group was not sustained during follow-up after stopping the medication. 163

Another possibility would be the use of medications that alter the expression of genes to remove the molecular “brakes” on cortical plasticity. Animal models support the use of histone deacetylase inhibitors (valproate) to treat amblyopia. 164-167

The neuromodulatory systems can also be accessed via direct and non-invasive activation by subthreshold electric current or transmagnetic stimulation. Transcranial direct current stimulation (TDCS) and transcranial magnetic stimulation (TMS) have been employed in an effort to facilitate plasticity in stroke patients as well as patients with amblyopia. Although both techniques have shown improved contrast sensitivity in amblyopic patients and facilitated stereopsis, the effects were not clinically significant. Further studies are needed to evaluate the efficacy and safety of these technologies. 168

Amblyopia as a binocular disease

Amblyopia typically affects visual acuity in one eye, and was always considered a monocular disease. For this reason, the main treatment has been occlusion of the fellow eye to improve the monocular function of the amblyopic eye. However, there are now a large number of studies showing that the deficit in amblyopia extends beyond monocular visual acuity impairment and into higher-order function such as binocular vision, fixation instability, and visuomotor activities due to abnormal interocular interactions. 11,169,170 The common factors in those additional deficits in amblyopia are that they are not acuity-limited tasks; they require integration of information over relatively large regions of space and/or time, and they involve extracting a signal from noise. 86 These deficits are not corrected by monocular treatment and remain even when visual acuity is recovered after patching.

Based on these findings, it has been argued that amblyopia is intrinsically a binocular problem and that suppression should be addressed first in treatment of amblyopia, as opposed to hoping that binocular vision will return after monocular acuity improvement as result of occlusion therapy. Based on this suggestion, new binocular treatments have been proposed. Hess, Mansouri, and Thompson proposed a treatment based on strengthening binocular combination through a gradual reduction in suppression. 57,171,172 Using this binocular approach, they demonstrated that individuals with strabismic amblyopia could combine information normally between their eyes when suppression was reduced by presenting stimuli of different contrasts to each eye via dichoptic viewing. By gradually increasing the contrast presented to the fellow eye, they showed that this approach led to improvement in binocular vision. Eventually, binocular combination occurred when the eyes viewed objects of the same physical contrast. In addition, concomitant improvement in stereopsis and monocular acuity of the amblyopic eye also occurred. 6

Based on these findings, these authors proposed a new type of treatment for amblyopia, commonly called dichoptic treatment. It is a strategy that aims to stimulate the 2 eyes simultaneously, thus promoting the possibility of improvement of monocular visual acuity of the amblyopic eye, but also combatting suppression and working to normalize binocular interactions for recovery of binocular vision. To achieve this, the contrast or luminance of visual input to the fellow eye is reduced to match the performance of the amblyopic eye.

This concept has been applied to passive and active forms of training for amblyopia. Passive training modalities include watching movies under dichoptic viewing conditions, allowing each image to be manipulated and simultaneously presented to the 2 eyes independently. 58 Active training applies perceptual learning using hand-held tablets which, when combined with red-green glasses, present video games that require binocular function to complete the game’s objective. 59,173-175 Both active and passive strategies of dichoptic treatment had good results, with improvement of visual acuity and many cases of normalization or recovery of binocular vision, including in adult individuals.

Given these promising results, PEDIG conducted a large, randomized, controlled trial to compare 1 hour of daily falling-blocks game play with 2 hours of daily patching over 16 weeks between patients from 5 to 13 years old. The study showed a poor adherence to the game regimen prescribed (only 22% of children completing at least 75% of the prescribed play) and found that, for this particular game, the VA improvement was not as good as with 2 hours of prescribed daily patching. 176 Similar results were found in another well-designed multi-center randomized clinical trial (BRAVO study). 177

Even with these disappointing results, the study authors encourage new research using more engaging gameplay to reduce noncompliance due to the nature of the game itself: The falling-blocks-style game is not appealing to children. New protocols with different and more engaging games such as action-oriented adventure games, first-person shooter games, virtual reality, and 3-dimensional gaming platforms are being analyzed for this purpose. 178-180

Although dichoptic treatment did not show substantial improvement in visual acuity and stereopsis, all protocols showed improved contrast processing during the games, which suggests better binocular interaction and decreased suppression. In order to assess the subjective perception of individuals about changes in their vision, it is necessary to evaluate how other visual functions that depend directly on the normal binocular interaction, such as Vernier acuity, contrast sensitivity of different levels of complexity, global movement tasks, fixation stability, and even quality of life (as determined through questionnaires), are improved by dichoptic treatment.

More careful and global study of amblyopic subjects can give us explanations about the great variability of response to treatment of these individuals. It can also help us better define, understand, and categorize amblyopia and thus prepare a more customized treatment for each patient. 181

Recent research in amblyopia brings new concepts and a better understanding about this common vision-threatening clinical condition. Now we know that the primary dysfunction within the amblyopic visual system first occurs in area V1, and that the effect caused by amblyopia can be amplified in higher areas of processing. We know that there are significant clinical and functional differences in the patterns of visual loss among the clinically defined categories of amblyopia. Finally, we understand that there appears to be substantial neural plasticity in the amblyopic brain beyond the “critical period,” potentially opening the door to treatment of amblyopia in the teens and into adulthood. 

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• Li SL, Jost RM, Morale SE, Stager DR, Dao L, Stager D, et al. A binocular iPad treatment for amblyopic children. Eye (Lond) . 2014;28(10):1246-1253.
• Holmes JM, Manh VM, Lazar EL, Beck RW, Birch EE, Kraker RT, et al. Effect of a binocular iPad game vs part-time patching in children aged 5 to 12 years with amblyopia: a randomized clinical trial. JAMA Ophthalmol . 2016;134(12):1391-1400.
• Gao TY, Guo CX, Babu RJ, Black JM, Bobier WR, Chakraborty A, et al; BRAVO Study Team. Effectiveness of a binocular video game vs placebo video game for improving visual functions in older children, teenagers, and adults with amblyopia: a randomized clinical trial. JAMA Ophthalmol . 2018;136(2):172-181.
• Kelly KR, Jost RM, Dao L, Beauchamp CL, Leffler JN, Birch EE. Binocular iPad game vs patching for treatment of amblyopia in children: a randomized clinical trial. JAMA Ophthalmol . 2016;134(12):1402-1408.
• Vedamurthy I, Knill DC, Huang SJ, Yung A, Ding J, Kwon OS, et al. Recovering stereo vision by squashing virtual bugs in a virtual reality environment. Philos Trans R Soc Lond B Biol Sci . 2016;371(1697).
• Žiak P, Holm A, Halička J, Mojžiš P, Piñero DP. Amblyopia treatment of adults with dichoptic training using the virtual reality oculus rift head mounted display: preliminary results. BMC Ophthalmol . 2017;17(1):105.
• Holmes JM. Lessons from recent randomized clinical trials of binocular treatment for amblyopia. JAMA Ophthalmol . 2018;136(2):181-183.

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9 Signs your Partner has a Wandering Eye & How to Deal

Jenni Jacobsen is a licensed social worker with a master's degree in social work from The Ohio State University, and she is in the process of completing her dissertation... Read more

In This Article

Has your partner been acting a bit different lately?

Maybe you’ve caught them glancing a little too long at someone else?

Or perhaps they seem more interested in their phone than in your conversations?

It can be confusing and a bit heartbreaking, right?

No one wants to feel like they’re competing for their partner’s attention .

But how do you know if it’s just a phase or something more serious?

Could they have a wandering eye?

Relationships come with their ups and downs, but noticing certain behaviors can make you wonder what’s really going on. Spotting the signs early can make a huge difference in how you handle the situation.

So, what should you be on the lookout for? Let’s break it down!

What does it mean to have a wandering eye?

Having a wandering eye means your partner’s attention seems to drift towards others, even when you’re right there! 

Ever noticed them giving a flirty smile to the barista or checking out someone at the gym? 

It can be pretty frustrating, right? 

It’s like, “Hey, I’m standing right here!” 

So, what’s up with that? 

Does it mean they’re unhappy, or are they just naturally a bit more… observant? 

Sometimes, it’s harmless, but other times, it could hint at deeper issues. It doesn’t always mean they’re looking to stray, but it’s definitely worth paying attention to.

And hey, everyone appreciates a little extra admiration now and then, but when it’s your partner, you’d prefer they save those looks for you!

5 potential causes of wandering eyes in a relationship

When it comes to relationships, a wandering eye can stir up all sorts of emotions and questions. 

Is a wandering eye a red flag? 

What causes a wandering eye, and is it more common in men or women with wandering eyes? 

Let’s dig into some potential causes behind those lingering glances.

1. Lack of attention in the relationship

Sometimes, when one partner feels neglected, their eyes start to wander. It’s like, “Hey, remember me?” This can happen when life gets busy, and you’re not spending enough quality time together . Without that emotional connection, it’s easy to get distracted by others.

Maybe they’re just craving a bit of validation or a spark that seems to be missing. Reconnecting with your partner can often help refocus those wandering eyes back to where they belong.

Research indicates that couples who spend more time arguing daily are less satisfied and perceive more negative qualities in their relationships. Conversely, those who talk more report greater satisfaction, positive qualities, and closeness.

2. Low self-esteem

Ever heard the phrase, “Looking for love in all the wrong places”? Low self-esteem can lead to a wandering eye as individuals seek external validation . They might be checking out others to feel better about themselves. 

It’s not about finding someone better but rather a quick confidence boost. Addressing self-esteem issues within the relationship can make a big difference and bring back that sense of security and worth.

3. Thrill of the chase

Some people just love the excitement of flirting and the thrill of the chase. It’s like they can’t help themselves when they see someone attractive . This doesn’t always mean they want to cheat; sometimes, they just enjoy the game. 

But, of course, this can be confusing and hurtful. If your partner thrives on this kind of attention, it might be time to discuss boundaries and how it makes you feel.

4. Unresolved relationship issues

Is your relationship experiencing some turbulence? Unresolved issues can lead to a wandering eye as one partner looks for an escape or distraction . It’s like sticking their head in the sand, hoping the problems will go away. 

Instead of addressing the issues head-on, they might find it easier to focus on someone else. Open communication and working through problems together can help keep both sets of eyes on each other.

5. Natural curiosity

Sometimes, it’s just plain curiosity! Humans are naturally curious beings, and noticing an attractive person doesn’t always mean trouble. Men or women with wandering eyes might simply be appreciating beauty without any intention of straying . 

However, if it starts to affect your relationship, it’s important to talk about it. Setting clear expectations and understanding each other’s feelings can help manage this natural tendency.

Does having a wandering eye mean your partner is cheating?

Roaming eyes can be a source of concern in some relationships, and whether it signals cheating depends on the situation. It can be a natural reaction for people to glance in the direction of an attractive person.

You may even find that you tend to look in the direction of members of the same sex who happen to be beautiful. You are simply noticing and appreciating beauty, which is human nature.

When it is a quick glance and nothing more, it is probably nothing to worry about and likely does not mean your significant other is cheating. We cannot expect our partners to wear blinders and avoid acknowledging other people.

If your partner notices people of the opposite sex but quickly turns their attention back to you, this behavior is usually totally acceptable.

On the other hand, there are cases where it can indicate a larger problem. In fact, people who view others as attractive are more likely to stray in their relationships. That being said, having a wandering eye is not the only indication that someone is at risk of cheating .

Other factors are linked to cheating, including being dissatisfied with the relationship. Furthermore, the link between cheating and a roaming eye is seen among people who have difficulty looking away from attractive people.

What all of this means is that quick glances that occur in reaction to an attractive person do not typically mean your partner is cheating.

However, when a roaming eye becomes excessive, and it seems like your partner cannot help himself but continue to gawk, something more may be going on here, especially if he openly flirts with or talks about how hot other people are.

9 signs your partner has a wandering eye

Wondering if your partner has wandering eyes? It’s not always easy to tell, but there are some signs that can clue you in. 

So, what is a wandering eye, and how do you spot it? 

Let’s dive into some telltale behaviors that might indicate your partner’s attention is drifting.

1. Constantly checking out others

Your partner seems to have a habit of checking out other people, even when you’re together. It’s like their eyes are on a mission! Sure, glancing is normal, but if they’re doing double-takes or staring, it might be a sign . 

They might even be commenting on others’ appearances in a way that makes you feel uncomfortable or overlooked.

When you should be concerned: If it makes you feel uncomfortable or disrespected, it’s time to have a chat about how this behavior affects you and the relationship.

2. Excessive use of social media for attention

Is your partner always on social media, liking, commenting, or sliding into DMs? This might be more than just being social. They could be looking for attention and validation from others . 

If their online interactions seem to be getting more frequent or more personal, it might be a sign of seeking external validation.

When you should be concerned: If their social media interactions are more engaging than their conversations with you, it’s a red flag that needs addressing.

3. Flirty behavior

Does your partner have a flirty personality? 

While some people are naturally charismatic, constant flirting can be a sign of a wandering eye. It’s fun until it crosses boundaries. They might enjoy the thrill and attention they get from others, even if it makes you feel uneasy .

When you should be concerned: If their flirting makes you feel sidelined, or if it’s more than just playful banter, it’s time to set some clear boundaries.

4. Comparing you to others

Ever feel like you’re being compared to that cute coworker or the gym instructor? If your partner keeps bringing up other people’s looks or qualities, it might be a sign . This can undermine your confidence and make you feel like you’re not enough.

When you should be concerned: If these comparisons make you feel inadequate or hurt, it’s important to discuss why they feel the need to do this and how it impacts you.

Studies show intrinsic expressive suppression leads to lower relationship satisfaction over time, whereas intrinsic cognitive reappraisal relates to higher relationship quality. Similarly, downward comparison in romantic relationships tends to result in lower positive feelings.

5. Secretive behavior

Notice your partner being extra secretive with their phone or computer? They might be hiding something. 

Suspicious? If they quickly change screens when you walk by or get defensive when you ask about their online activity, it’s worth noting .

When you should be concerned: If they’re constantly hiding their screen or getting defensive about their online activity, it’s worth digging deeper to understand what’s going on.

6. Lack of attention toward you

Feeling like you’re no longer the center of their world? 

If your partner’s attention has noticeably shifted away from you, it could be a wandering eye issue . They might seem distracted or uninterested in spending time with you, making you feel neglected.

When you should be concerned: If they’re more interested in everyone else but you, it’s crucial to address the lack of attention and find out what’s causing the distance.

7. Increased interest in their appearance

Suddenly, they’re spending more time getting ready or hitting the gym? 

While self-improvement is great, doing it for the wrong reasons isn’t. If they start dressing up more often or paying extra attention to their looks when they go out without you, it could be a sign .

When you should be concerned: If their increased focus on appearance is paired with other signs of a wandering eye, it’s time to discuss their motivations and what’s driving these changes.

8. Emotional distance

Do you feel a growing emotional gap between you two? If your partner seems emotionally distant, it might be because their attention is elsewhere . They might be less communicative, more withdrawn, or just not as engaged in your relationship as they used to be.

When you should be concerned: Emotional distance can be a sign of deeper issues. If they’re not willing to open up or reconnect, it’s a serious concern that needs to be addressed.

9. Denying or downplaying obvious behavior

You’ve caught them in the act, but they deny it or brush it off? Classic move! 

If they’re downplaying their wandering eye behavior, it’s a sign . They might try to convince you that you’re overreacting or that it’s all in your head, which can be frustrating and confusing.

When you should be concerned: If they refuse to acknowledge your feelings or make excuses for their actions, it’s important to have an honest conversation about trust and respect in your relationship.

How to deal with a partner who has wandering eyes: 7 ways

It’s frustrating when your partner’s eyes seem to wander, especially when you’re right there with them. This issue can shake your confidence and raise questions about your relationship’s future. 

But don’t panic—there are practical ways to address it! From open communication to setting boundaries, let’s dive into how to stop wandering eyes and maintain a happy, secure relationship.

1. Have an honest conversation

Talking openly is essential. Ask your partner about their wandering eyes without being accusatory . Use “I feel” statements to express how their behavior affects you. 

It could be something they’re unaware of or an issue they’re willing to work on. Transparency helps build trust and understanding.

Talk this way: “I feel hurt when you look at others that way. Can we talk about it?”

2. Establish boundaries

Setting boundaries can help prevent misunderstandings . Discuss what behaviors make you uncomfortable and agree on limits that respect both partners . This might include avoiding certain situations or being mindful of eye contact with others.

Talk this way: “Let’s set some boundaries that we both agree on so we can avoid any hurt feelings.”

3. Boost your self-confidence

Sometimes, your partner’s wandering eyes can make you doubt yourself. Work on boosting your self-esteem through activities that make you feel good and confident . Remember, you are enough!

Talk this way: “I’m working on my confidence, and it would mean a lot if you could support me by being more mindful of where you look.”

4. Seek professional help

If the problem persists, consider seeking help from a relationship counselor. They can provide tools and strategies to address deeper issues and improve your connection.

Talk this way: “I think it might help us to talk to a counselor about this. What do you think?”

5. Spend quality time together

Strengthening your bond can reduce wandering eyes. Engage in activities that you both enjoy and make time for each other . A strong connection often means less temptation to look elsewhere.

Talk this way: “Let’s plan more activities together that we both enjoy. I love spending time with you!”

6. Address underlying issues

Sometimes, wandering eyes are a symptom of deeper problems in the relationship. Address any underlying issues such as dissatisfaction or unmet needs . This can help resolve the behavior.

Talk this way: “Is there something missing in our relationship that we should talk about?”

In the video below, Andrea Crump talks about how the roaming eyes of a person can cause insecurities in their partner. She provides tips to handle it. Take a look:

7. Practice empathy

Understanding why your partner’s eyes wander can help you address the issue with compassion . They might not realize how their actions affect you . Empathy can lead to a more constructive conversation.

Talk this way: “I understand that sometimes habits are hard to break, but it hurts me. Can we work on this together?”

Dealing with a partner who has wandering eyes can be tricky, but it’s all about perspective and communication. Recognize that a quick glance doesn’t necessarily mean disinterest or disrespect. 

By having open conversations, setting boundaries, and focusing on the positives in your relationship, you can handle this issue together. 

Remember, every relationship has its quirks, and addressing them with understanding can strengthen your bond . 

If concerns persist, don’t hesitate to seek professional guidance to ensure both of you feel valued and secure. Love and trust are built on communication, so keep talking and listening to each other!

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Jenni Jacobsen is a licensed social worker with a master's degree in social work from The Ohio State University, and she is in the process of completing her dissertation for a Doctorate of Philosophy in Psychology. She has worked in the social work field for 8 years and is currently a professor at Mount Read more Vernon Nazarene University. She writes website content about mental health, addiction, and fitness.   Licensed as both a social worker through Ohio Board of Counselors, Social Workers, and Marriage/Family Therapists and school social worker through Ohio Department of Education as well as a personal trainer through American Council on Exercise. Read less

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What is the difference between Amblyopia and Strabismus?

• June 26, 2019

Amblyopia vs Strabismus

Very simply, Strabismus , the medical term for "crossed-eye",  is a problem with eye alignment, in which both eyes do not look at the same place at the same time.  Amblyopia,  the medical term for "lazy-eye",  is a problem with visual acuity, or eyesight. Many people make the mistake of saying that a person who has a crossed or turned eye (strabismus) has a "lazy-eye," but lazy-eye (amblyopia) and strabismus are not the same condition. 

Both strabismus and amblyopia are treatable conditions by a vision therapy specialist .

Strabismus is the most common cause of amblyopia and amblyopia often occurs along with strabismus. However, amblyopia can occur without strabismus.  But, there's more to it than this.  Let's take a look at these vision disorders side-by-side.

References:

You may also be interested in these blog posts:.

• What is lazy eye?
• Lazy eye: 12 Things You Didn't Know
• How to fix a lazy eye
• Vision Therapy Success Stories: Jillian
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A lazy eye (amblyopia) is when the vision in 1 eye does not develop properly. Rarely, both eyes can be affected.

Check if you have a lazy eye

A lazy eye does not always cause symptoms and is often first diagnosed during an eye test.

The main symptoms include:

• shutting 1 eye or squinting when looking at things
• eyes pointing in different directions (a squint )
• not being able to follow an object or person with your eyes
• tilting your head when looking at something
• having tired eyes and rubbing your eyes a lot
• difficulty catching or throwing
• tripping or falling over a lot
• blinking a lot

Many children do not notice anything wrong with their vision.

You can check a younger child's eyes by covering each eye with your hand, 1 at a time. They may complain if you cover their good eye.

Older children may say they're not able to see as well with 1 eye and may have problems with reading, writing and drawing.

Non-urgent advice: Go to an opticians if:

• you're worried about your or your child's vision
• you have not had an eye test for 2 years

What happens during an eye test

To check if you or your child have a lazy eye, an eye test specialist called an optometrist will usually do an eye test.

You'll be asked to look at lights or read letters while different lenses are placed in front of your eyes.

To check the health of your eyes, you or your child may be given eye drops so the optometrist can see the back of your eye more clearly.

If you or your child needs glasses, you'll be given a prescription. You can take this to any optician.

Find out more about eye tests for children

NHS eye tests

NHS eye tests are free for some people, including:

• children aged under 18, or under 19 and in full-time education
• people who have diabetes or glaucoma
• people on some benefits, including Universal Credit

Find out more about free NHS eye tests

Treatments for a lazy eye

How lazy eye is treated depends on what's causing it.

Treatment for a lazy eye aims to improve vision in the weaker eye.

This may include:

• wearing glasses to correct your vision
• wearing an eye patch over the stronger eye for a few hours a day for several months – these are usually worn with glasses
• using eye drops to temporarily blur vision in the stronger eye

Treatment should ideally start before the age of 7, when vision is still developing.

If lazy eye is caused by cataracts or a drooping eyelid, you may need surgery.

You may also need to have surgery if you have a squint. This will straighten the eyes and allow them to work together better, but does not improve your vision.

Some people are entitled to a voucher to help towards the cost of glasses or contact lenses, including:

• if you're on some benefits, including Universal Credit

If you do not have a voucher, you'll have to pay for glasses or contact lenses.

Find out more about NHS optical vouchers

Page last reviewed: 04 January 2023 Next review due: 04 January 2026

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Amblyopia (lazy eye)

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• Amblyopia occurs when your eye develops abnormally in early life — the weak, or ‘lazy’, eye often wanders inwards or outwards.
• If left untreated, amblyopia can lead to permanent vision loss in the affected eye.
• Take your child to their doctor if they show any signs of amblyopia, such as eyes that don’t seem to 'work together'.
• There are many treatment options for amblyopia, including glasses, contact lenses, an eye patch or surgery.
• Amblyopia can return after treatment, so it's important to see your doctor and/or optometrist to check your child's condition over time.

What is amblyopia?

Amblyopia is a condition where one eye develops abnormally in early life. The weak, or 'lazy', eye often wanders inwards or outwards. In rare cases, both eyes can be affected. If left untreated, amblyopia can lead to permanent vision loss in the affected eye.

The condition usually occurs in children between birth and age 7 years, and is the leading cause of decreased vision in one eye in children. Amblyopia is more common in small or premature babies, or children with a family history of the condition.

What causes amblyopia?

Amblyopia develops when one eye receives weaker visual signals in early life. Since the brain receives these fewer visual signals, it starts to ignore input from that eye, and the eyes do not work together properly. One eye then appears to be ‘lazy’ as it doesn’t move together with the other eye.

Amblyopia can be caused by anything that blurs a child's vision or causes crossed eyes.

Common causes include:

• an imbalance in the muscles that position the eyes (known as strabismus )
• a difference in the sharpness of vision (visual acuity) between the eyes
• an imperfection on the surface of the eye ( astigmatism )
• any problem with one eye, such as a cloudy area in the lens ( cataract )

What are the symptoms of amblyopia?

A key sign of amblyopia is when one eye appears to be ‘lazy’ as it doesn’t move together with the other eye.

Other signs that you, your baby or child might have amblyopia include:

• an eye that wanders inwards or outwards
• squinting or shutting one eye
• head tilting
• poor depth perception (the ability to see in three dimensions, including an object’s size and how far away they are)

Learn more about eyesight in children .

CHECK YOUR SYMPTOMS — Use the Symptom Checker and find out if you need to seek medical help.

When should I see my doctor?

See your doctor or visit an optometrist if you notice symptoms of amblyopia. See a doctor if you notice one of your baby’s eyes wandering in their alignment at any time following the first few weeks after birth. It is also a good idea to have your child’s eyes tested before they start school .

Take your child to their doctor or visit an optometrist if they are showing symptoms of amblyopia. Treatment is most successful if started early — ideally before the age of 8 years.

How is amblyopia diagnosed?

Amblyopia is diagnosed by a doctor, community nurse, optometrist or ophthalmologist (specialist eye doctor). To diagnose amblyopia, your health professional will ask about your family’s eye health history, examine your (or your child’s) eyes and carry out an eye test .

In around 1 in 4 people, amblyopia recurs after treatment. This is why it is important to have your child's eyes checked by your doctor or optometrist regularly, even after treatment ends.

You don’t need a referral from your doctor to see an optometrist. If your doctor or optometrist thinks you should see an ophthalmologist, they will give you a referral .

ASK YOUR DOCTOR — Preparing for an appointment? Use the Question Builder for general tips on what to ask your GP or specialist.

FIND A HEALTH SERVICE — The Service Finder can help you find doctors, pharmacies, hospitals and other health services.

How is amblyopia treated?

The type of treatment will depend on the cause of amblyopia and whether it is affecting your child's vision.

The earlier treatment for amblyopia starts, the better the outcome. This is because it is important to correct the condition while the connections between the eyes and the brain are forming.

Some treatments are designed to strengthen the weaker eye by forcing the brain to use it instead of the stronger eye. These include covering the stronger eye with a patch or temporarily blurring its vision with special drops. This treatment usually works within several weeks or months, although it can continue for up to 2 years.

If amblyopia is caused by eye conditions such as near-sightedness , far-sightedness or astigmatism , your doctor may prescribe glasses or contact lenses.

If cataracts or droopy eyelids (ptosis) are a problem, your doctor may recommend surgery.

Resources and support

For more information on eye health and for help finding an optometrist visit Optometry Australia .

Queensland Health provides information on amblyopia (lazy eye) in children , including when to seek help, treatment and tips for helping your child.

Do you prefer to read in languages other than English?

Vision Australia offers a guide to their services in a range of community languages .

Looking for information for Aboriginal and/or Torres Strait Islander people?

Read more on eye health for Aboriginal and/or Torres Strait Islander people at HealthInfoNet.

Visit The Fred Hollows Foundation to learn 5 Things You Should Know About Aboriginal Eye Health .

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Last reviewed: March 2024

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• 1.1 Definition
• 1.2 Etiology
• 1.3 Risk Factors
• 1.4 General Pathology
• 1.5 Pathophysiology
• 1.6 Primary prevention
• 2.1 History
• 2.2 Physical examination
• 2.4 Symptoms
• 2.5 Clinical diagnosis
• 2.6 Diagnostic procedures
• 2.7 Laboratory test
• 2.8 Differential diagnosis
• 3.1 General treatment
• 3.2 Medical therapy
• 3.3 Medical follow up
• 3.4 Surgery
• 3.5 Surgical follow-up
• 3.6 Complications
• 3.7 Prognosis
• 4.1.1 Objectives
• 4.1.2 Design
• 4.1.3 Main outcome measures
• 4.1.4 Results
• 4.1.5 Limitations
• 4.1.6 Conclusions
• 4.1.7 Pearls for clinical practice
• 5 Additional Resources
• 6 References

Disease Entity

Amblyopia is a relatively common disorder and a major cause of visual impairment in children. It represents an insult to the visual system during the critical period of development whereby an ocular pathology (ex. strabismus, anisometropia, high refractive error, or deprivation) interferes with normal cortical visual development. Approximately 3-5% of children are affected by amblyopia. [1]

Amblyopia represents diminished vision occurring during the years of visual development secondary to abnormal visual stimulation or abnormal binocular interaction. It is usually unilateral but it can be bilateral. The diminished vision is beyond the level expected from the ocular pathology present.

Bilateral amblyopia is less common than unilateral amblyopia. Bilateral cases are caused by bilateral image blur (anterior visual pathway). Examples of etiologies for bilateral amblyopia include bilateral media opacities (including corneal opacities, infantile or childhood cataracts, or vitreous hemorrhages), or ametropia (bilateral high astigmatism or high hypermetropia). Unilateral causes of amblyopia also include the same types of media opacities seen in bilateral cases. However, the most common causes of unilateral amblyopia are strabismus and anisometropia, or a combination of the two [2] [3]

The etiologies of amblyopia can be easily remembered with the following mnemonic: S.O.S. Spectacles (anisometropia or high myopic or hyperopic refractive error), Occlusion (media opacities, retinal disease, optic nerve pathology, corneal disease, etc.), and Strabismus.

Risk Factors

A positive family history of strabismus, amblyopia, or media opacities would increase the risk of amblyopia in the child. Children who have conditions that increase the risk of strabismus, anisometropia, or media opacities (including Down syndrome) would also be at increased risk for the development of amblyopia. The risk of developing amblyopia, from a condition that is known to cause amblyopia, diminishes as the child approaches 8-10 years of age. As a corollary to this, the depth of amblyopia is typically less severe the older the child is at the time of onset of the amblyogenic factor.

General Pathology

In cases of bilateral amblyopia, the basic pathology is a significant blurred retinal image in each eye causing a disruption of normal visual development. This disruption must occur during the critical period of visual development (the first 8-10 years of life). The depth of damage depends on the severity of the blur, the length of time of the abnormal vision, and the age of onset of the insult. The pathology involved in unilateral amblyopia can be twofold. Retinal image blur in one eye can inhibit cortical activity from one eye, preventing normal visual development. Alternatively, misaligned eyes can prevent the normal process of fusion from taking place. This can result in suppression of the deviating eye, diminishing the acuity of the eye, and loss of binocularity. Sensory amblyopia is more severe than strabismic or anisometropic amblyopia and is tough to treat. Among strabismic amblyopias, esotropia is more prone to develop amblyopia as the fovea of the deviating eye has to compete with the stronger nasal retina (temporal hemifield) of the fellow eye which results in suppression of the deviating eye.

Pathophysiology

Abnormal visual stimulation during the critical period of visual development results in brain damage. Structural and functional damage occurs in the lateral geniculate nucleus and the striate cortex of the visual center in the occipital lobe in the form of atrophy of connections, loss of cross-linking between connections, and loss of laterality of connections.

Primary prevention

The key to prevention is detection. There are numerous techniques to detect amblyopia, all with varying degrees of specificity, sensitivity, complexity, and cost. These include a complete ophthalmic examination, photoscreening, visual evoked potentials, acuity charts, and tests of stereopsis and binocular function. Children who are at higher risk for amblyopia should be watched closely for early signs of this condition. In general, the quicker amblyopia is detected and addressed, the less negative effect it has on the visual system. Vision screening is advocated on the state level to screen as many children as possible for this disease prior to the age of kindergarten. Early intervention results in better overall vision. This is why the American Association for Pediatric Ophthalmology and Strabismus , the American Academy of Pediatrics , and the American Academy of Ophthalmology all support pre-kindergarten vision screening for children .

Amblyopia should be considered as a possible diagnosis in children with asymmetric visual behavior or acuity. It can also complicate the course of children with strabismus, or unilateral ocular or adnexal pathology such as a cataract, eyelid capillary hemangioma, or corneal scar. Bilateral amblyopia can also occur and should be thought of when a bilateral ocular condition occurs and despite treatment, some degree of diminished acuity persists. A careful history, thorough physical examination, and knowledge of possible etiologies of amblyopia can help the clinician to diagnose this condition.

Parents will often bring their child to the Ophthalmologist because of the underlying cause of the amblyopia (ptosis, strabismus, leukocoria, eyelid hemangioma), without realizing that amblyopia is present. In fact, anisometropic amblyopia usually goes undetected until picked up by a vision screening. The overwhelming majority of children with unilateral amblyopia do not complain of decreased acuity because they do not notice it unless one eye is occluded. The history taking process should include any family history of vision problems (specifically amblyopia and strabismus). Parents should be asked if the child was premature, and if they have ever noted any eye misalignment. Any prior testing (including school or Pediatrician vision screening, neuroimaging) should be noted. If any abnormality in the child's visual behavior has been noted, the duration is important. Also, some children may already have received care for amblyopia somewhere else. If this is the case, type of treatment and duration should be determined. Old records can be helpful.

Physical examination

Examination should consist of the following:

• Acuity testing (age appropriate): Single optotypes (without crowding bar) are not recommended as a good acuity testing technique in amblyopes because this test will tend to underestimate the degree of amblyopia (crowding phenomenon).
• Record the power of any current spectacles
• Subjective refraction if age appropriate
• Tests of stereopsis and binocular function (including Worth 4 dot testing, TNO stereo test)
• External examination (looking for ptosis, lid hemangioma or other lesion which could affect visual development)
• Presence or absence of an afferent pupil defect [4]
• Anterior segment examination (looking for any media opacity, or irregularity)
• Motility and ocular alignment
• Funduscopic examination
• Cycloplegic retinoscopy

The presence or absence of signs of amblyopia would depend on what the underlying etiology for the amblyopia is. Deprivational amblyopia could manifest with ptosis, an eyelid hemangioma, or a cataract for example. Strabismic amblyopia may show a constant or intermittent ocular deviation. Esotropia causes more amblyopia as compared to exotropia since esotropia is constant and exotropia is usually intermittent in nature. Anisometropic amblyopia often shows no obvious signs when observing the patient, but cycloplegic retinoscopy will reveal the anisometropia. On clinical examination, unilateral amblyopia will show asymmetric visual behavior or acuity testing results (although not all patients with asymmetric acuity have amblyopia). Severe cases may have a mild afferent pupillary defect. The crowding phenomenon is important to be aware of when testing visual acuity in an amblyope. The amblyopic eye of these patients will visualize individual letters better than a whole line of letters. Therefore, if the visual acuity tester uses individual letters (without crowding bar), then they may underestimate the degree of amblyopia that is present or miss it entirely. A neutral density filter significantly reduces vision in organic disease, but generally does not in pure amblyopia.

Patients with unilateral amblyopia are often asymptomatic. Occasionally, patients will complain that one eye is blurry, or younger children may report discomfort in the affected eye. Torticollis occurs infrequently. Poor depth perception or clumsiness may be noted.

Clinical diagnosis

In cases of unilateral amblyopia, the diagnosis requires two components. First, the patient must have a condition that can cause unilateral amblyopia. Examples would include strabismus, anisometropia, or a deprivational cause (ptosis, cataract, etc.). Second, the patient must have residual asymmetric acuity beyond the level expected from the underlying condition or that persists after treatment of the underlying condition. For example, a child with anisometropic hyperopia receives proper spectacle correction. Acuity in the more hyperopic eye improves but is still below that of the less hyperopic eye. This asymmetry of acuity represents amblyopia. In cases of bilateral amblyopia, a condition must be present during the critical years of visual development which produces constant, significant visual blur. Examples of such conditions would include bilateral vitreous hemorrhages, bilateral cataracts, bilateral corneal pathology, bilateral high hypermetropia, or bilateral high astigmatism.

Diagnostic procedures

A normal, comprehensive ophthalmic examination is usually all that is necessary to diagnose amblyopia. Components of this examination include (but are not limited to): acuity testing, cycloplegic refraction and retinoscopy, tests of stereopsis and binocular vision, evaluation of pupillary responses, anterior segment examination, cover-uncover and alternate-cover testing, and dilated funduscopic examination. See the Physical Examination section above.

Laboratory test

Laboratory testing is not a typical feature of amblyopia diagnosis. Certainly if the etiology of the amblyopia was unclear, or if vision was deteriorating despite treatment, neuroimaging would be considered. Fundus dystrophies (specifically Stargardt disease) may have normal appearing fundus in early stages with unexplained vision loss. Such patients may need fundus photo, fluorescein angiogram, optical coherence tomography of macula, and electrophysiological tests. Patients with high astigmatism may need corneal topography to rule out keratoconus.

Differential diagnosis

There are cases of decreased acuity in children in which amblyopia is not present. Ocular pathology or refractive error (or even improper spectacle correction) may cause decreased acuity without any superimposed amblyopia. Prechiasmal lesions or optic nerve insult can also produce unilateral decreased acuity.

Although there is much practitioner variability in the treatment of amblyopia, the general idea is to first treat the underlying cause for the amblyopia. Examples of this treatment would include prescribing glasses for anisometropia, strabismus surgery or spectacles to eliminate strabismus, or removal of a unilateral cataract to eliminate the media opacity. In unilateral or asymmetric cases of amblyopia, if there is a residual visual deficit after the underlying etiology is treated then amblyopia is said to exist. This can be addressed with occlusion therapy, pharmacologic therapy, or some other less commonly used modalities. Much of the data on the success of various treatment modalities for amblyopia through the years has come from retrospective, single site chart-review type studies. Over the last decade, there has been an explosion of amblyopia research. The need for prospective randomized trials in the treatment of amblyopia has begun to be met by the Pediatric Eye Disease Investigator Group (PEDIG) . This is an NEI-funded network including both University-based and community-based clinicians. The power of such a group lies in its ability to conduct multiple trials in a cost-effective fashion, with simple protocols implemented as part of routine practice [5] . Patients are enrolled at multiple clinical sites in a prospective randomized fashion, with standardized visual testing protocols [6] .Important data derived from these studies is present throughout this section on amblyopia.

General treatment

The key to optimal treatment of amblyopia is early detection and intervention. In symmetric bilateral cases, treatment consists of addressing the etiology of the diminished vision. Often there is residual bilateral amblyopia which may improve over time [7] . In asymmetric cases or unilateral cases, active treatment with patching, pharmacologic agents, or some less commonly used modalities can often improve the residual visual deficit.

Medical therapy

In anisometropic patients, some improvement in amblyopia can occur with glasses alone. Starting treatment in this manner may lessen the burden of subsequent amblyopia therapy for those with denser levels of amblyopia and in some cases may obviate the need for patching or pharmacologic penalization. Patching of the sound eye to improve the acuity of the amblyopic eye is the most commonly used technique to treat amblyopia. Patching compliance is a major concern, with high rates of poor compliance or noncompliance in some studies. Compliance with therapy can be bolstered by parental education and improving parental attitudes towards patching therapy. The number of prescribed patching hours per day varies widely between practitioners. In general most doctors recommend heavier patching regimens for worse degrees of amblyopia. The thought behind this is that heavier patching would improve results and the rapidity of obtaining them. However this practice has been called into question by recent PEDIG studies.

A study of severe amblyopes randomized the patching regimen to 6 hours of prescribed patching per day versus 12 hours per day. At the 4-month outcome visit, acuity improvements and rapidity of improvement were essentially identical between the groups [8] . A similar study of moderate amblyopes comparing 2 hours of prescribed patching per day to 6 hours per day, also found no difference in results [9] . Some clinicians also prescribe 'near activities' in conjunction with patching but this was not found to be beneficial in a recent study [10] .

Pharmacologic penalization of the sound eye is another commonly used modality to treat amblyopia. Atropine is the most commonly used pharmacologic agent. Dosing can be a drop in the sound eye daily, or on weekends only. A recent study showed results with weekend-only dosing to be similar to daily dosing for moderate amblyopes [11] . In children who wear hyperopic spectacles, atropine usage is sometimes combined with replacing the hyperopic lens over the sound eye with a plano lens. This was felt to 'enhance' treatment,  but a recent study showed only a minimal benefit of this additional step in therapy [12] .A common assumption is that atropine use in the amblyopic patient can only be effective if it induces a fixation switch. This assumption has been called into question by a recent study. Often the decision whether to treat the amblyopic child with patching or pharmacologic agents, is based on the practitioner's practice patterns and parental wishes.

A head-to-head study showed that 6 hours a day of patching therapy produced a slightly more rapid and beneficial effect than daily instillation of Atropine 1%, in moderate amblyopes younger than 7 years of age. However, the final difference at 6 months was not statistically significant and a parental questionnaire showed families preferred pharmacologic therapy over patching [13] .

Other modalities of medical amblyopia management include optical penalization with an occlusive Bangerter filter placed on the glasses lens or the use of a high plus lens to blur the sound eye, as well as contact lenses used as occlusion or for blurring.

Dichoptic video games and dichoptic movies are being studied as potential novel therapies for amblyopia. PEDIG studies showed that patching was superior to the use of an earlier, less engaging, dichoptic falling blocks video game for amblyopia treatment [14] [15] . More recently, PEDIG showed that in children aged 7 to 12 years who received previous treatment for amblyopia other than spectacles, the dichoptic adventure video game Dig Rush showed no benefit to vision or stereoacuity after 4-8 weeks of treatment over spectacle use alone. [16]

A novel digital therapeutic using virtual reality (VR) headsets, Luminopia One, delivers dichoptic amblyopia therapy while providing an engaging patient experience. Therapeutic visual stimuli are presented using real-time modification of patient-selected, cloud-based video content (e.g., television shows or movies) within a head-mounted display. In a randomized clinical trial of 105 children aged 4-7 years across 21 sites with anisometropic or strabismic amblyopia, amblyopic eye visual acuity improved by 1.8 lines in the Luminopia One treatment group compared to 0.8 lines in the spectacles-alone control group. [17] On 2021 October, the FDA approved Luminopia One for "improvement in visual acuity in children with amblyopia, aged 4-7, associated with anisometropia and/or with mild strabismus,"

CureSight is a promising dichoptic treatment for amblyopia that uses eye-tracking to induce real-time blur around the fellow eye fovea in dichoptic streamed video content. CureSight (90 min/day, 5 days/week) was found to be non-inferior to patching (2 hours/day, 7 days/week) in a 16 week multicenter trial of 103 children 4 to < 9 years with anisometropic, small-angle strabismic or mixed-mechanism amblyopia. [18]

Medical follow up

Follow up during treatment is typically somewhere between every 1-3 months. When treatment is discontinued, follow-up is necessary to ensure there is no regression of effect [19] .

Amblyopia itself is not a surgical condition, but there are times when surgery may treat the underlying cause of the amblyopia. Refractive surgery may be used to correct anisometropia. However, refractive surgeries are not approved by the Food and Drug Administration (FDA, USA) below 18 years of age. Eye muscle surgery can correct strabismus. Cataract, ptosis, vitrectomy, or corneal surgery may alleviate causes of deprivation.

Surgical follow-up

Even though surgery may be performed to alleviate some of the etiologies of amblyopia, most cases will still require follow-up to treat the amblyopia that is present. For example, in a child with strabismic amblyopia, eliminating the ocular misalignment does not automatically fully correct the amblyopia which resulted from the strabismus.

Complications

Overly aggressive amblyopia therapy (especially in younger patients) can produce reverse amblyopia of the sound eye. A new strabismus or a decompensation of an existing strabismus can also occur. Patches can be irritating to the skin, and the skin underlying the patch can become hypopigmented relative to the rest of the facial skin. There is also a potential social stigma associated with wearing the patch to school in some cases. Atropine use can cause side effects related to the use of this medication: flushing, rapid heart rate, mood changes (uncommon) and photophobia (common) would be examples of side effects occurring with the use of this medication. Reverse amblyopia can also occur with Atropine use as can decompensation of existing strabismus or development of a new strabismus. Cases of reverse amblyopia are infrequent and usually mild. Most cases resolve with discontinuation of treatment.

The keys to treatment success are younger age at detection/treatment, short course until intervention, and compliance with treatment. The effectiveness of intensive screening protocols to detect amblyopia at a young age has been shown to result in a better acuity of the amblyopic eye at age 7.5 years. Most patients do improve with treatment, but often residual amblyopia remains. With cessation of amblyopia treatment there is a risk of recurrence. In one study, the risk of recurrence was higher with better visual acuity at the time of cessation of treatment, a greater number of lines improved during the previous treatment, and a prior history of recurrence. Orthotropia or excellent stereoacuity at the time of patching cessation did not appear to have a protective effect on the risk of recurrence. In a prospective study of cessation of treatment in children aged 3 to <8 years with successfully treated amblyopia due to anisometropia, strabismus or both, the risk of amblyopia recurrence was found to be 24%. Patients treated with 6 to 8 hours of daily patching had a 4-fold greater odds of recurrence if patching was stopped abruptly rather than when it was reduced to 2 hours per day prior to cessation. Careful and prolonged follow-up during the amblyogenic years, is needed for all children who have been previously treated for amblyopia to prevent a recurrence. In general, the younger amblyopes are treated, the better the likelihood of improvement.

Most textbooks do not recommend trying amblyopia therapy in the second decade of life but some improvement can be obtained in few cases. A study of amblyopia therapy in children aged 7-17 years found that amblyopia improves to some degree with optical correction alone in about one fourth of patients. However most required additional treatment for amblyopia [20] . For patients aged 7 to 12 years, 2 to 6 hours per day of patching with near visual activities and atropine improved visual acuity even if the amblyopia had been previously treated. For patients 13 to 17 years, improvement was only noted in those children who had not been previously treated. The degree of improvement in these older children was much more modest than results from other studies of younger children, so the importance of early detection and treatment remains.

Studies have demonstrated that amblyopic children read significantly more slowly than controls, even when the vision in the amblyopic eye is only reduced to 20/30 vision. [21] [22] Amblyopia can also impact academic related fine-motor outcomes, such as multiple-choice answer completion time. [23]

Pertinent clinical trials

Pediatric eye disease investigators group study (pedig) –or– amblyopia treatment study.

Arch Ophthalmol 2002;120:268 | Arch Ophthalmol 2003;121:603 | Ophthalmol 2003;110:2075 | J AAPOS 2004;8:420 | Arch Ophthalmol 2005;123:437 | Ophthalmol 2006;113:895 | Ophthalmol 2006;113:904.

The goal was to determine if correcting the refractive error alone can treat amblyopia, the benefits of patching, and the risks of recurrence after suspension of treatment. In addition, it wanted to know until what age can amblyopia be treated and the management with atropine and occlusion.

This trial tried to facilitate an evidence-based approach to the treatment of amblyopia.

Clinical trials involving

• Observational study of spectacles alone for anisometropic amblyopia.
• Amblyopia treatment randomized to daily atropine to the fellow eye or at least 6 hours of patching per day.
• 2 concurrent randomized trials of patching, prescribed 2 hours/day versus 6 hours/day for moderate amblyopia and prescribed 6 hours/day versus full-time for severe amblyopia.
• Patching in older children: children randomised to receive optical correction ± patching for near activities.
• Recurrence of amblyopia: children treated with patching or atropine for at least three months with at least three lines of improvement were brought off therapy, and followed up for one year.

Moderate amblyopia was defined as 20/40 to 20/80. Severe amblyopi a was defined as 20/100 to 20/400. Successful treatment was defined as the improvement of VA to within one line of the non-amblyopic eye. Recurrence of amblyopia was defined as a reduction in at least two lines after cessation of amblyopia therapy or when treatment was restarted at an investigator’s discretion.

Inclusion criteria were children less than seven years, BCVA in the better eye better than 20/40, and the amblyopic eye less than 20/40. Previous refractive error corrected for at least four weeks before the study.

Main outcome measures

Primary endpoint: BCVA.

More than 4000 subjects have participated in 19 Amblyopia Treatment Studies (ATS). The main ones were:

• Observational study of spectacles alone for anisometropic amblyopia: 84 children, 3 to 6 years of age and VA from 20/40 to 20/250 at enrollment. 77% of the children improved at least 2 lines, and 27% showed resolution within 1 line of the fellow eye. Maximum improvement was achieved by 83% of subjects by 10 weeks, but some children improved for 30 weeks. Improvement was found in children with moderate and severe amblyopia. The key lesson was that spectacles are an effective initial tool in managing amblyopia.
• Amblyopia treatment randomized to daily atropine to the fellow eye or at least 6 hours of patching per day. 419 children, 3 to 6 years of age with amblyopia 20/40 to 20/100. VA improved in both groups at 6 months; during the initial treatment phase, the patching group did improve more quickly, but the atropine group caught up by 6 months. Thus, atropine and patching are effective in the treatment of amblyopia. Parental questionnaires found atropine to be better tolerated in terms of social stigma and compliance. The amblyopia treatment benefit persisted through age 10 years without a mean VA loss, but residual amblyopia remains in a large proportion of children. The mean amblyopic eye VA at 10 years was approximately 20/32, with 46% of amblyopic eyes 20/25 or better. After the initial 6-months, children were treated at the investigator's discretion with occlusion or atropine, and more than 85% of children continued to be prescribed treatment. So, amblyopia treatment is not a short-term task; it represents a long-term effort.
• 2 concurrent randomized trials of patching, prescribed 2 hours/day versus 6 hours/day for moderate amblyopia and prescribed 6 hours/day versus full-time for severe amblyopia in 3 to 6-year-olds children. 175 severe amblyopes were randomised to receive full-time patching vs. six hours/day patching for four months. 189 moderate amblyopes were randomised to receive either two or six hours a day of patching for four months. VA improved with both patching regimens without differences. Therefore, it is reasonable to initiate therapy with a lower dose and increase treatment intensity if the response is not good.
• Patching in older children: 507 children with amblyopia aged 7 to 18 were recruited and randomised to receive optical correction ± patching for near activities. There was a significant improvement in BCVA in those treated with patching in the 7-12 age group but not in the 13 -17 age group. When only the 13-17-year olds with no previous treatment for amblyopia were considered, there was an improvement in the patched group.
• Recurrence of amblyopia: 156 children who had been treated with patching or atropine for at least three months with at least three lines of improvement were brought off therapy at the investigator's discretion and followed up for one year. The average age was 5.9 years, and no child was older than eight. 21% of children experienced amblyopia recurrence, with 40% occurring within the first five weeks.

Limitations

Children younger than three were not included

Conclusions

Refractive correction alone may be effective in the treatment of amblyopia. There is no benefit in patching moderate amblyopes for longer than two hours and severe amblyopes for more than six hours per day. Children need close follow-up after discontinuation of occlusion therapy. There may be a benefit in treating amblyopia until 12 years of age. Teenagers with amblyopia who have never before received treatment may benefit from a trial of patching. There is no clinical difference in using atropine vs. patching in moderate amblyopes.

Pearls for clinical practice

Refraction helps amblyopia.

Moderate amblyopes can be treated using atropine or patching.

Additional Resources

• AAPOS Frequently Asked Questions about Amblyopia
• Prevent Blindness America - Amblyopia
• Boyd K, Puente MA Jr. Amblyopia . American Academy of Ophthalmology. EyeSmart/Eye health. https://www.aao.org/eye-health/diseases/amblyopia-6 . Accessed November 17, 2022.
• Boyd K, Lipsky SN. Depth Perception . American Academy of Ophthalmology. EyeSmart/Eye health. https://www.aao.org/eye-health/anatomy/depth-perception-2 . Accessed November 17, 2022.
• Boyd K, Puente MA Jr. Lazy Eye (Amblyopia) . American Academy of Ophthalmology. EyeSmart/Eye health. https://www.aao.org/eye-health/diseases/lazy-eye-amblyopia . Accessed November 17, 2022.
• Boyd K, Puente MA Jr, Turbert D. Strabismus (Crossed Eyes) . American Academy of Ophthalmology. EyeSmart/Eye health. https://www.aao.org/eye-health/diseases/strabismus-in-children-2 . Accessed November 17, 2022.
• ↑ Backman H. Children at risk of developing amblyopia: When to refer for an eye examination. Paediatr Child Health . 2004;9(9):635-637. doi:10.1093/pch/9.9.635
• ↑ Wright KW and Spiegel PH. Pediatric Ophthalmology and Strabismus. 1st ed. pp 195-229. 1999.
• ↑ Magdalene D, Bhattacharjee H, Choudhury M, Multani PK, Singh A, Deshmukh S, Gupta K. Community outreach: An indicator for assessment of prevalence of amblyopia. Indian J Ophthalmol [serial online] 2018 [cited 2018 Sep 2];66:940-4. Available from:  http://www.ijo.in/text.asp?2018/66/7/940/234966
• ↑ Simakurthy S, Tripathy K. Marcus Gunn Pupil. [Updated 2023 Feb 22]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK557675/
• ↑ Bacal DA. Amblyopia Treatment Studies. Curr Opin Ophthalmol. 15:432-436. 2004.
• ↑ Holmes JM, Beck RW, Repka MX, et al. The amblyopia treatment study visual acuity testing protocol. Arch Ophthalmol 2003, 119:1345-1353.
• ↑ Pediatric Eye Disease Investigator Group. Treatment of bilateral refractive amblyopia in children three to less than 10 years of age. Am J Ophthalmol 2007;144(4):487-96.
• ↑ Pediatric Eye Disease Investigator Group. A randomized trial of prescribed patching regimens for treatment of severe amblyopia in children. Ophthalmology 2003;110:2075-2087.
• ↑ Pediatric Eye Disease Investigator Group. A randomized trial of patching regimens for treatment of moderate amblyopia in children. Ophthalmology 2003;121:603-611.
• ↑ Pediatric Eye Disease Investigator Group. A randomized trial of near versus distance activities while patching for amblyopia in children aged 3 to less than 7 years. Ophthalmology 2008;115(11):2071-8.
• ↑ Pediatric Eye Disease Investigator Group. A randomized trial of atropine regimens for treatment of moderate amblyopia in children. Ophthalmology 2004;111(11):2076-85.
• ↑ Pediatric Eye Disease Investigator Group. Pharmacologic plus optical penalization treatment for amblyopia: results of a randomized trial. Arch Ophthalmol 2009;127(1):22-30.
• ↑ Pediatric Eye Disease Investigator Group. A randomized trial of atropine vs. patching for treatment of moderate amblyopia in children. Arch Ophthalmol 2002;120(3):268-278.
• ↑ PEDIG, Holmes JM, Manh VM, Lazar EL, et al. Effect of a Binocular iPad Game vs Part-time Patching in Children Aged 5 to 12 Years With Amblyopia: A Randomized Clinical Trial. JAMA Ophthalmol. 2016 Dec 1;134(12):1391-1400.
• ↑ PEDIG, Manh VM, Holmes JM, Lazar EL, et al. A Randomized Trial of a Binocular iPad Game Versus Part-Time Patching in Children Aged 13 to 16 Years With Amblyopia. Am J Ophthalmol. 2018 Feb;186:104-115.
• ↑ PEDIG, Holmes JM, Manny RE, Lazar EL, et al. A Randomized Trial of Binocular Dig Rush Game Treatment for Amblyopia in Children Aged 7 to 12 Years. Ophthalmology 2019 Mar;126:456-466.
• ↑ Luminopia Pivotal Trial Group, Xiao S, Angejeli E, Wu HC, et al. Randomized Controlled Trial of a Dichoptic Digital Therapeutic for Amblyopia. Ophthalmology 2022 Jan;129:77-85.
• ↑ Wygnanski-Jaffe T, Kushner BJ, Moshkovitz A, Belkin M et al, on behalf of the CureSight Pivotal Trial Group. An Eye-Tracking–Based Dichoptic Home Treatment for Amblyopia, A Multicenter Randomized Clinical Trial. Ophthalmology 2023;130:274-285.
• ↑ Pediatric Eye Disease Investigator Group. Risk of amblyopia recurrence after cessation of treatment. J AAPOS 2004;8(5):420-8.
• ↑ Pediatric Eye Disease Investigator Group. Randomized trial of treatment of amblyopia in children aged 7 to 17 years. Arch Ophthalmol 2005;123(4):437-47.
• ↑ Kelly KR, Jost RM2 De La Cruz A, Birch EE. Amblyopic children read more slowly than controls under natural, binocular reading conditions. J AAPOS. 2015 Dec;19(6):515-20.
• ↑ Kelly KR, Jost RM, De La Cruz A, et al. Slow reading in children with anisometropic amblyopia is associated with fixation instability and increased saccades. J AAPOS. 2017 Dec;21(6):447-451.
• ↑ Kelly KR, Jost RM, De La Cruz A, Birch EE. Multiple-Choice Answer Form Completion Time in Children With Amblyopia and Strabismus. JAMA Ophthalmol. 2018 Aug 1;136(8):938-941.
• Williams C, Northstone K, Harrad RA, et al. Amblyopia treatment outcomes after screening before or at age 3 years:followup from randomized trial. BMJ 2002; 324:1549-1551.
• Pediatric Eye Disease Investigator Group. Patching vs atropine to treat amblyopia in children aged 7 to 12 years: a randomized trial. Arch Ophthalmol 2008;126(12):1634-1642.
• Pediatric Ophthalmology/Strabismus

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Doctor Verified

What Is Amblyopia (Lazy Eye) In Children: Causes, Symptoms, And Treatment

• Written by : Manali Momaya
• Updated at: Sep 02, 2024 17:56 IST

Amblyopia, commonly known as "lazy eye," occurs when one eye fails to achieve normal visual acuity, even with prescription glasses or contact lenses. This condition typically develops during early childhood and, if left untreated, can lead to permanent vision impairment. To understand more about this condition OnlyMyHealth team interacted with Dr Abhishek Chopra, Consultant Neonatologist and Paediatrician, Cloudnine Group of Hospitals, New Delhi. 

Causes of Amblyopia

Amblyopia develops when the brain and eyes do not work together properly. The condition usually arises from one of three underlying issues:

Strabismus (Misaligned Eyes): The most common cause of amblyopia is strabismus, a condition where the eyes are not properly aligned. Explaining, Dr Chopra said, “One eye may turn in, out, up, or down, leading the brain to rely on the stronger eye while ignoring the weaker one, eventually causing amblyopia.”

Refractive Errors: Amblyopia can also occur due to significant differences in refractive errors between the two eyes, such as nearsightedness, farsightedness, or astigmatism. “The brain receives one clear image and one blurred image, leading to the suppression of the blurred image, which weakens the vision in the affected eye,” Dr Chopra said. 

Deprivation Amblyopia: This type of amblyopia occurs when something obstructs light from entering and being processed by the eye, such as a cataract or droopy eyelid. “Without clear visual input, the brain cannot develop normal vision in that eye,” said Dr Chopra. 

Symptoms of Amblyopia

Amblyopia can be challenging to detect, especially in young children who may not realize they have a vision problem. According to Dr Chopra, parents and caregivers should be aware of the following signs and symptoms:

Squinting or Closing One Eye: A child with amblyopia might squint or close one eye when trying to see clearly, particularly when reading or watching TV.

Poor Depth Perception: Difficulty judging distances or a lack of depth perception can indicate amblyopia.

Head Tilting: Some children may tilt their heads to compensate for vision problems.

Eyes That Don’t Appear to Work Together: If a child's eyes seem to be misaligned or if one eye appears to drift, this could be a sign of amblyopia.

Frequent Eye Rubbing: Children with amblyopia may rub their eyes often due to eye strain.

Regular eye exams are essential for detecting amblyopia early, as children may not be able to articulate their vision problems.

Treatment for Amblyopia

The primary goal of treating amblyopia is to force the brain to use the weaker eye, thereby strengthening its vision. Early diagnosis and treatment are crucial, as the condition is more easily treated in younger children. Treatment options as per Dr Chopra include:

Corrective Eyeglasses or Contact Lenses: If refractive errors are the cause, wearing glasses or contact lenses can help correct the vision discrepancy between the eyes.

Patching: The stronger eye may be covered with an eye patch for several hours a day, compelling the brain to rely on the weaker eye. This method effectively improves vision in the weaker eye over time.

Atropine Drops: Atropine drops can be used in the stronger eye to blur its vision, encouraging the brain to use the weaker eye.

Surgery: In cases where amblyopia is caused by cataracts, strabismus, or other eye conditions, surgery may be required to correct the underlying issue.

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• # Amblyopia
• # Eye sight
• # Eye health
• # Treatment