The impact of anisometropic amblyopia on children’s quality of life and mental health: a case-control study

Abstract

AimWe aimed to compare children with anisometropic amblyopia with their healthy peers in terms of quality of life and mental disorders and to identify possible psychosocial difficulties in children with amblyopia.MethodsThis prospective case-control study included 95 children aged 5-12 years with unilateral anisometropic amblyopia between December 2023 and December 2024. Sociodemographic data form, Pediatric Quality of Life Inventory (PedsQL), and Strengths and Difficulties Questionnaire (SDQ) were applied to participants.ResultsMean age was 8.31 years in the patient group and 8.55 years in controls (p=0.058). The amblyopia group showed significantly lower scores in PedsQL total score, physical health, and psychosocial health subscales, as well as higher scores in the SDQ peer problems subscale compared to controls.ConclusionChildren with amblyopia demonstrated impaired quality of life in both physical and psychosocial domains and experienced greater peer relationship difficulties. Ophthalmologists should be aware of these psychosocial impacts for early detection and intervention.

Keywords

Introduction

Amblyopia affects approximately 1-4% of children and represents the leading monocular cause of visual impairment in individuals under 40 years.¹ This unilateral or bilateral visual impairment that does not improve with correction can be effectively prevented or corrected with timely interventions.² Vision encompasses multiple parameters, including shape recognition, motion perception, stereopsis, and contrast sensitivity.³ Even the fellow eye in amblyopes shows inferior performance compared to normal subjects on psychophysical tests.⁴ Normal binocular development requires healthy competition between eyes, and in amblyopia, the better eye’s development is delayed due to a lack of competition.⁵
Research demonstrates that children with amblyopia have lower self-perception and social acceptance compared to healthy peers. Birch et al. reported that amblyopic children feel less competent academically, socially, and athletically, leading to inadequacy and isolation.⁶ Studies show that untreated amblyopia leads to poorer health-related quality of life, with children experiencing emotional and behavioral difficulties.⁷ Treatment-related psychological effects can contribute to increased stress for children and parents.⁸
We aimed to compare children with anisometropic amblyopia with healthy peers regarding quality of life and mental health, identifying possible psychosocial difficulties in this population.

Materials and Methods

This prospective case-control study was conducted at Recep Tayyip Erdogan University Training and Research Hospital following institutional ethics board approval and in accordance with the Declaration of Helsinki. Written informed consent was obtained from all participants. The study population consisted of children aged 5-12 years diagnosed with unilateral anisometropic amblyopia between December 2023 and December 2024. Anisometropic amblyopia was defined as: (1) ≥2 lines difference in best-corrected visual acuity between eyes, (2) anisometropia ≥1.0 D spherical or cylindrical difference, (3) absence of strabismus, and (4) no significant macular pathology or media opacity. Visual acuities were recorded using Snellen charts. Amblyopia severity was classified as mild (6/9 to 6/12), moderate (6/18 to 6/36), or severe (<6/60). Anterior segments were evaluated by slit lamp (Topcon SL-3C), and intraocular pressure measured by pneumotonometry (Topcon Computerized Tonometer). Cover-uncover and alternate prism cover tests excluded strabismus. Cyclopentolate hydrochloride 1% was instilled, and after 45 minutes, skiascopy and autorefractometry (Topcon Auto Keratorefractometer) determined refractive errors. Fundoscopic examination was performed with direct ophthalmoscopy and a +90 D contact lens. Exclusion criteria included: other amblyopia types, visual acuity <0.1 in the amblyopic eye, high refractive errors, organic eye diseases, systemic diseases, psychiatric diagnosis, intraocular pressure >21 mmHg, nystagmus, previous amblyopia treatment, and strabismus. Controls were children aged 5-12 years with perfect uncorrected vision, no refractive error, and no chronic diseases. Assessment Tools Pediatric Quality of Life Inventory (PedsQL): A standardized 23-item instrument evaluating health-related quality of life in pediatric populations, validated in Turkish.^9-10 It covers physical health (8 items), emotional well-being (5 items), social interactions (5 items), and academic functioning (5 items), using a five-point Likert scale. Higher scores indicate better quality of life. Strengths and Difficulties Questionnaire (SDQ): A 25-item behavioral screening tool assessing conduct problems, hyperactivity/inattention, emotional symptoms, peer relationship problems, and prosocial behavior. The Turkish adaptation demonstrates acceptable validity and reliability.¹¹ Ethical Approval This study was approved by the Ethics Committee of Recep Tayyip Erdogan University School of Medicine (Date: 23.11.2023, Decision No: 261). Statistical Analysis Data analysis was conducted using IBM SPSS Statistics Version 26.0. Normality was assessed using Kolmogorov-Smirnov and Shapiro-Wilk tests. An independent samples t-test was used for parametric comparisons, Mann-Whitney U test for non-parametric comparisons. Categorical variables were analyzed using the Pearson chi-square test, with Fisher’s exact test when appropriate. Post-hoc comparisons used Bonferroni correction. p<0.05 was considered significant. Reporting Guidelines This study was reported according to the STROBE guidelines.

Results

The study included 95 participants (55 female, 40 male) in the patient group and 93 participants (50 female, 43 male) in the control group (p=0.568). The mean age was 8.31 years in patients and 8.55 years in controls (p=0.058).
Significant differences existed in maternal (p=0.021) and paternal (p=0.009) education levels between groups, with lower education levels in the amblyopia group. No other demographic differences were observed (Table 1).
Scale score comparisons revealed significant differences in the physical health domain (p=0.002), with markedly lower scores in the patient group. Psychosocial health scores were also significantly lower in the amblyopia group (p<0.001). SDQ peer relationship scores were significantly higher in the patient group (median=3) compared to controls (median=2) (p<0.001), indicating greater peer difficulties. No significant differences were found in other SDQ subscales (Table 2).

Discussion

This study represents one of the few investigations focusing specifically on amblyopia diagnosis impact on children’s quality of life and psychological well-being, distinct from treatment-related effects.
Our results demonstrated that amblyopic children exhibited significantly diminished health-related quality of life in physical health, psychosocial functioning, and overall scores compared to healthy controls. Additionally, peer relationship problems were significantly more pronounced, suggesting amblyopia specifically impairs social integration while not uniformly affecting all emotional and behavioral domains.
The physical health deficits likely reflect the motor-visual integration difficulties inherent in amblyopia. Reduced depth perception and impaired binocular vision affect hand-eye coordination and spatial navigation, impacting daily activities and sports participation.⁹ The psychosocial impairments encompassing emotional, social, and academic functioning suggest broader developmental consequences beyond visual deficits.
Our findings align with previous research showing quality of life impacts in amblyopic children.^12-13 However, unlike studies examining treatment-related psychosocial effects, our research isolated the diagnosis-specific impacts by excluding children undergoing treatment. This approach eliminates confounding factors such as patching stigma or treatment burden.^14-15
The peer relationship difficulties observed merit particular attention. Unlike strabismus, which has visible cosmetic effects potentially affecting social interactions,¹⁶ anisometropic amblyopia lacks obvious external signs. The peer problems likely stem from functional visual deficits affecting social activities, sports participation, and academic performance rather than appearance-related stigma.⁶
The lower parental education levels in the amblyopia group highlight socioeconomic disparities affecting amblyopia prevalence and management. Lower socioeconomic status is associated with delayed diagnosis, reduced treatment access, and poorer adherence.^17-18-19 This finding suggests amblyopia disproportionately affects disadvantaged populations, potentially exacerbating existing health inequalities.
Our study’s strength lies in focusing exclusively on anisometropic amblyopia, creating a homogeneous population and eliminating the confounding effects of strabismus or treatment-related factors. The exclusion of children with mental disorders and chronic illnesses from both groups enhanced comparability and reduced confounding variables.

Limitations

Several limitations should be acknowledged. First, this single-center study with a limited sample size may restrict generalizability. Multi-center studies with larger populations would enhance applicability. Second, focusing specifically on anisometropic amblyopia, while creating homogeneity, limits generalizability to other amblyopia subtypes. Third, we used a general health-related quality of life scale rather than vision-specific instruments, as validated Turkish versions of pediatric vision-specific quality of life questionnaires were unavailable.
Finally, the cross-sectional design prevents causal inferences about the relationship between amblyopia and quality of life outcomes.

Conclusion

Children with anisometropic amblyopia demonstrate significantly impaired quality of life in physical and psychosocial domains and experience greater peer relationship difficulties compared to healthy peers. These findings highlight the importance of ophthalmologists recognizing potential psychosocial impacts alongside visual deficits. Early identification and appropriate interventions addressing both visual and psychosocial aspects may be protective against negative developmental outcomes. Given amblyopia’s positive response to early treatment, comprehensive management should consider quality of life impacts to optimize outcomes and prevent long-term psychosocial consequences.

Abbreviations

D: Diopter
PedsQL: Pediatric quality of life inventory
SDQ: Strengths and difficulties questionnaire

References

1. Gong L, Reynaud A, Hess RF. The suppressive basis of ocular dominance changes induced by short-term monocular deprivation in normal and amblyopic adults. Invest Ophthalmol Vis Sci. 2023;64(13):1-12. doi:10.1167/iovs.64.13.2
   Article · PubMed · Google Scholar
2. Hess RF. Reasons why we might want to question the use of patching to treat amblyopia as well as the reliance on visual acuity as the primary outcome measure. BMJ Open Ophthalmol. 2022;7(1). doi:10.1136/bmjophth-2021-000914
   Article · PubMed · Google Scholar
3. Gantz L, Stiebel-Kalish H. Convergence insufficiency: review of clinical diagnostic signs. J Optom. 2022;15(4):256-270. doi:10.1016/j.optom.2021.11.002
   Article · PubMed · Google Scholar
4. Dutta P. Characteristics of binocular vision and oculomotor function among sports-concussed athletes. Indian J Ophthalmol. 2023;71(5):2076-2082. doi:10.4103/ijo.ijo_1932_22
   Article · PubMed · Google Scholar
5. Johansson J, Pansell T, Ygge J. Monocular and binocular reading performance in subjects with normal binocular vision. Clin Exp Optom. 2014;97(4):341-348. doi:10.1111/cxo.12137
   Article · PubMed · Google Scholar
6. Birch EE, Castañeda YS, Cheng-Patel CS, et al. Self-perception of school-aged children with amblyopia and its association with reading speed and motor skills. JAMA Ophthalmol. 2019;137(2):167-174. doi:10.1001/jamaophthalmol.2018.5527
   Article · PubMed · Google Scholar
7. Syntosi A, Felizzi F, Bouchet C. A social media listening study to understand the unmet needs and quality of life in adult and pediatric amblyopia patients. Ophthalmol Ther. 2022;11(6):2183-2196. doi:10.1007/s40123-022-00571-2
   Article · PubMed · Google Scholar
8. Randhawa S, Griffiths N, O’Brien P, et al. Qualitative exploration of the visual function impairments and health-related quality of life impacts of amblyopia in adult and pediatric populations. Ophthalmol Ther. 2023;12(5):2505-2528. doi:10.1007/s40123-023-00751-8
   Article · PubMed · Google Scholar
9. Birch EE, Kelly KR. Amblyopia and the whole child. Prog Retin Eye Res. 2023;93:101117. doi:10.1016/j.preteyeres.2023.101168
   Article · PubMed · Google Scholar
10. Kumar SGP, Ranpise D, Vishwakarma P. Social-emotional issues among children with strabismus higher than among non-strabismus children in Western India. Indian J Ophthalmol. 2023;71(7):2827-2834.
    PubMed · Google Scholar
11. Webber AL, Wood JM, Gole GA. Effect of amblyopia on self-esteem in children. Optom Vis Sci. 2008;85(11):1074-1081. doi:10.1097/opx.0b013e31818b9911
    Article · PubMed · Google Scholar
12. Hatt SR, Leske DA, Castañeda YS, et al. Understanding the impact of residual amblyopia on functional vision and eye-related quality of life using the PedEyeQ. Am J Ophthalmol. 2020;218:173-181. doi:10.1016/j.ajo.2020.05.039
    Article · PubMed · Google Scholar
13. Bogdănici ST, Costin D, Bogdănici CM. Quality of life for amblyopic children and their parents. Rev Med Chir Soc Med Nat Iasi. 2015;119(1):214-220.
    PubMed · Google Scholar
14. Chen Y, Chen X, Chen J. Longitudinal impact on quality of life for school-aged children with amblyopia treatment: perspective from children. Curr Eye Res. 2016;41(2):208-214. doi:10.3109/02713683.2015.1011280
    Article · PubMed · Google Scholar
15. Wen G, McKean-Cowdin R, Varma R, et al. General health-related quality of life in preschool children with strabismus or amblyopia. Ophthalmology. 2011;118(3):574-580. doi:10.1016/j.ophtha.2010.06.039
    Article · PubMed · Google Scholar
16. Webber AL, Wood J. Amblyopia: prevalence, natural history, functional effects, and treatment. Clin Exp Optom. 2005;88(6):365-375. doi:10.1111/j.1444-0938.2005.tb05102.x
    Article · PubMed · Google Scholar
17. Sharma A, Wong AMF, Colpa L. Socioeconomic status and utilization of amblyopia services at a tertiary pediatric hospital in Canada. Can J Ophthalmol. 2016;51(6):452-458. doi:10.1016/j.jcjo.2016.05.001
    Article · PubMed · Google Scholar
18. Zhang XJ, Wong PPY, Wong ES, et al. Delayed diagnosis of amblyopia in children of lower socioeconomic families: the Hong Kong children eye study. Ophthalmic Epidemiol. 2022;29(6):621-628. doi:10.1080/09286586.2021.1986551
    Article · PubMed · Google Scholar
19. Nitzan I, Bez M, Megreli J, et al. Sociodemographic disparities in amblyopia prevalence among 1.5 million adolescents. Eur J Public Health. 2021;31(6):1211-1217. doi:10.1093/eurpub/ckab111
    Article · PubMed · Google Scholar

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