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April - June 2006

Original Article

99

Evaluation of relationship of ocular parameters and depth of

anisometropic amblyopia with the degree of anisometropia

Simi Zaka-ur-Rab, MS
Purpose: (1) To find out the relationship of the depth of amblyopia with the degree of anisometropia, in
untreated cases of anisometropic amblyopia without strabismus, for both myopic and hypermetropic
individuals. (2) To find out the relationship between various ocular parameters, such as axial length and
corneal curvature, with the degree of anisometropia between the two eyes.
Materials and Methods: This prospective study was conducted between January 2001 and March 2003, in
85 cases of untreated anisometropic amblyopia, who attended the authors out patient department. All
these patients were subjected to a meticulous ocular examination, with special emphasis on (1) refraction
under cycloplegia (2) best corrected visual acuity (3) measurement of axial length by A Scan (4) keratometry.
The depth of amblyopia was calculated in two ways: (1) By finding out decimal visual acuity for each eye
and subsequently calculating their difference. (2) By converting the Snellen acuity into Log MAR units, which
was calculated by finding the Logarithm of the reciprocal of the decimal visual acuity for the two eyes,
followed by calculating the difference between the two. The difference in refraction between the two eyes as
a measure of anisometropia, was determined by the difference in spherical equivalent between the refraction
for each eye.
Results: On comparing hypermetropic and myopic cases, a significant correlation was found between depth
of amblyopia and the degree of anisometropia, in both myopic and hypermetropic patients. The correlation
coefficients were however, found to be greater for hypermetropic than myopic individuals. It was observed
that the difference between the axial length of the two eyes contributed to a major part of anisometropia,
more so in myopic cases.
Conclusions: The depth of amblyopia correlates with the degree of anisometropia in previously untreated
anisometropic amblyopia patients.
Key words: Anisometropia, amblyopia, axial length, keratometry.
Indian J Ophthalmol 2006;54:99-103

Amblyopia is defined as a unilateral or bilateral decrease in

visual acuity, caused by deprivation of form vision or abnormal
binocular interaction, or both, for which no organic causes
can be detected.1 It is associated with strabismus, refractive
errors (anisometropia and severe ametropia) and form
deprivation. It is well recognized, that anisometropia can lead
to amblyopia, but the exact mechanism is not clear, although
according to von Noorden,2 there may be active inhibition of
the fovea to eliminate sensory interference, caused by an
attempt to superimpose a focused image in one eye and a
defocused image in the other. There is now evidence that
factors causing amblyopia may also, in themselves, cause
anisometropia.3
Whether the depth of amblyopia is associated with the
degree of anisometropia, has long been debated. Conflicting
results have been obtained in various studies on the
Institute of Ophthalmology, J.N. Medical College, Aligarh Muslim
University, Aligarh, India
Correspondence to Simi Zaka-ur-Rab, 2 - Wazir Manzil, Luxmibai
Marg, Aligarh - 202 001, UP, India. E-mail: <s_zrab@yahoo.co.in>
Manuscript received: 14.6.04; Revision accepted: 3.2.06

relationship between the degree of anisometropia and depth

of amblyopia.4-8 Moreover, to the best of my knowledge, no
such study has been conducted so as to delineate the
relationship between axial length and corneal curvature of
the eyes, in cases of anisometropia.
This prospective study was therefore conducted: (1) to find
out relationship of the depth of amblyopia with the degree of
anisometropia in untreated cases of anisometropic amblyopia
(without strabismus), for both myopic and hypermetropic
individuals. (2) To find out the relationship between various
ocular parameters such as axial length and corneal curvature
with the degree of anisometropia between the two eyes.

Materials and Methods

The study was conducted between January 2001 and March
2003, in 85 cases of untreated anisometropic amblyopia, who
attended the authors out patient department. Patients with
strabismus, eccentric fixation, microtropia, cataracts, history
of trauma or previous eye surgery or use of spectacles before
the age of 7 years, observable pathology of media or fundi
and age more than 50 years were excluded from the study.
In the present study, anisometropia is reckoned as the

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I NDIAN J OURNAL OF OPHTHALMOLOGY

difference in refraction of one diopter or more, in either sphere

or cylinder, between the two eyes and amblyopia was taken
to be the difference in visual acuity of one or more lines on the
standard Snellen chart between the eyes (with no known
disease to account for the same).
All these patients were subjected to a detailed history
taking and meticulous ocular examination with special
emphasis on (1) refraction under cycloplegia (2) best corrected
visual acuity (3) measurement of axial length by A Scan (4)
keratometry (5) slit lamp examination and (7) fundus
examination.
In all the cases, a senior refractionist did the cycloplegic
refraction and post-mydriatic test, manually. Incidentally, there
was no case that could read only a few letters and not the
entire line, so line acuity was measured in all the cases by
using Snellen test types by the same refractionist, which was
counter-checked by the author. The biometry and
keratometry was done in all the cases by a different observer.
The patients were given code numbers and the observer who
had done biometry and keratometry had no information about
the refractive status or the visual acuity of the cases. To increase
the accuracy, an average of three biometry and keratometry
readings were taken by the same person, in all cases. For the
keratometry, a mean of three keratometric readings were
taken for K1 and K2 and then a mean K value was calculated
for both the eyes.
All the cases were referred to squint clinic for a detailed
orthoptic checkup and 4 prism base out test, to rule out
microtropia. The orthoptic findings were counter-checked by
the author and only those cases in which no disparity was
found, were included in the study. All the patients were
subjected to a meticulous slit lamp and fundus examination
by direct and indirect ophthalmoscopy and slit lamp
biomicroscopy by a 90 D lens in the retina clinic by the author
herself, to rule out any other ocular pathology.
The depth of amblyopia is equal to the difference in the
best corrected visual acuity between the two eyes, at post
mydriatic test. This was calculated in two ways: (1) By
converting the Snellen fraction into decimals, i.e, finding out
decimal visual acuity for each eye and then calculating their
difference. (2) By converting the Snellen acuity into Log MAR
units (Logarithm of the minimal angle of resolution). This
was calculated by finding the Logarithm of the reciprocal of
decimal visual acuity for both eyes and then calculating the
difference between the two. The difference in refraction
between the two eyes as a measure of anisometropia, was
determined by finding out the difference in spherical
equivalent between the cycloplegic refraction for each eye.
The study groups were divided into hypermetropic and
myopic individuals for statistical analysis. The amount of
anisometropia was correlated to each of the two measures of
depth of amblyopia by Pearson Rank Correlation Coefficients.
These coefficients were also used to find out the relationship
between various ocular parameters and amount of
anisometropia. Statistical significance was defined as P < 0.05.

Results
Eighty-five patients ranging between 7 to 50 years in age (mean
age, 24.95 years) were identified as having anisometropic

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Vol. 54 No. 2

amblyopia, without strabismus.There were 53 males and 32

females. Age and gender-wise distribution of the cases is
shown in Table 1.
Fifty-five out of 85 patients were anisohypermetropic
(mean age, 25.83 years) and out of 85, 30 were anisomyopic
(mean age, 23.33 years). There were seven cases of
anisometropia, in which one eye was hyperopic and the other
eye was myopic, but only one eye of these cases having higher
amount of refractive error was amblyopic, whereas, the other
eye had normal vision. These cases were grouped under
anisohypermetropic or anisomyopic amblyopia, depending
upon the refractive status of the amblyopic eye. Four of these
cases were of anisohypermetropic amblyopia, whereas the
remaining three cases were of anisomyopic amblyopia.
Depth of amblyopia (depicted by difference in Snellen
Fraction and difference in Log MAR units), amount of
Anisometropia, changes in corneal curvature and axial length
for hypermetropic cases, is shown in Table 2 and for myopic
cases, is shown in Table 3.
Statistical analysis carried out using SPSS data spread sheet,
revealed that there was a significant correlation in
hypermetropic cases, between amount of anisometropia and
the depth of amblyopia, with Pearson Correlation Coefficient
being 0.603 (P<0.001), for difference in Snellen fraction and
0.644 (P < 0.001) for difference in Log MAR units. There was
a negative correlation between amount of anisohypermetropia
and the difference in keratometry reading between the two
eyes. This was statistically insignificant, the Pearson
Correlation Coefficient being -0.147 (P=0.285). A strong
relationship was, however, observed between the amount of
anisohypermetropia and the difference in axial length between
the two eyes, with a Pearson Correlation Coefficient of 0.609,
which was significant at 0.01 level.
In myopic cases, a positive correlation was found between
the amount of anisometropia and the depth of amblyopia,
with Pearson Correlation Coefficient being 0.468 (P=0.009)
for difference in Snellen fraction and 0.463 (P=0.010) for
difference in Log MAR units. There was a negative correlation
between the amount of anisomyopia and the difference in
keratometry reading, between the two eyes. This was
statistically insignificant, with a low Pearson Correlation
Coefficient of - 0.020 (P=0.917). A strong relationship,
nevertheless, was observed between the amount of
anisomyopia and the difference in axial length between the
two eyes, with a Pearson Correlation Coefficient of 0.674,
which was significant at 0.01 level.
On comparing hypermetropic [Table 4] and myopic [Table
5] cases, a significant correlation was found between depth of
Table 1: Age and gender wise distribution of cases
Age range
(Years)

Males
no. (%)

Females
no. (%)

Total cases
no. (%)

10 yrs
10 - 20
20 - 30
30 - 40
40 - 50
Total cases

3 (5.66)
21 (39.62)
11 (20.75)
14 (26.42)
4 (7.55)
53 (100)

4 (12.5)
9 (28.12)
11 (34.37)
5 (15.63)
3 (9.38)
32 (100)

7 (8.24)
30 (35.29)
22 (25.88)
19 (22.35)
7 (8.24)
85 (100)

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Zaka-ur-Rab: Ocular parameters and amblyopia in anisometropia
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101

Table 2: Variables for hypermetropic cases

Case
no.
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55

Difference in
snellen fraction

Difference in
log MAR units

Difference in
refraction

Difference in
keratometry

Difference in
axial length

0.83
0.42
0.83
0.50
0.67
0.50
0.67
0.93
0.83
0.93
0.50
0.97
0.75
0.50
0.50
0.90
0.90
0.67
0.90
0.17
0.75
0.83
0.50
0.83
0.33
0.95
0.83
0.83
0.42
0.33
0.33
0.90
0.33
0.50
0.93
0.90
0.67
0.90
0.67
0.90
0.08
0.33
0.33
0.75
0-33
0.95
0.83
0.90
0.90
0.75
0.57
0.67
0.67
0.83
0.33

0.78
0.42
0.78
0.30
0.48
0.30
0.48
1.18
0.78
1.18
0.30
1.48
0.60
0.30
0.30
1.00
1.00
0.48
1.00
0.18
0.60
0.78
0.30
0.78
0.18
1.30
0.78
0.78
0.42
0.18
0.18
1.00
0.18
0.30
1.18
1.00
0.48
1.00
0.48
1.00
0.12
0.30
0.30
0.60
0.18
1.30
0.78
1.00
1.00
0.60
0.82
0.48
0.48
0.78
0.18

3.25
3.50
4.50
4.87
2.00
2.25
2.75
5.25
5.75
4.14
2.25
4.75
4.00
4.75
3.50
3.00
4.75
3.00
4.50
1.00
3.50
5.25
6.63
5.45
2.50
5.75
3.00
5.75
2.50
2.50
4.00
6.50
0.25
2.75
5.00
4.75
3.50
4.25
0.86
5.00
3.00
2.50
2.00
4.25
0.25
7.00
3.75
4.25
6.25
3.00
7.00
4.50
2.00
4.25
1.00

0.13
0.00
0.75
0.25
0.12
0.00
1.00
1.63
0.75
0.50
0.37
2.12
0.63
0.25
0.25
0.50
0.00
0.25
1.62
0.00
0.38
0.25
0.86
0.00
0.87
0.63
0.88
0.13
2.00
0.38
0.00
0.00
1.50
0.75
0.63
0.88
0.50
0.13
1.75
0.50
0.38
0.50
0.50
0.50
0.25
0.13
1.25
0.38
0.25
0.38
0.38
1.00
2.25
1.25
0.12

1.82
0.87
1.93
1.85
1.18
2.08
0.37
3.42
2.05
2.16
0.84
2.65
2.18
0.56
1.83
1.91
1.40
2.04
1.66
0.39
1.62
2.64
2.07
2.23
1.62
1.89
1.78
2.67
1.24
0.16
1.60
2.49
0.54
1.02
1.10
2.39
5.52
2.10
0.50
2.31
0.14
2.03
0.46
1.39
0.03
2.89
1.79
1.82
2.50
1.36
2.81
2.41
1.20
1.91
0.38

amblyopia and the degree of anisometropia, in both myopic

and hypermetropic patients. The correlation coefficients were
however, greater for hypermetropic, than myopic individuals.
Further, it was observed that the difference between the axial
length of the two eyes contributed to a major part of
anisometropia, more so in myopic cases.

Discussion
Disagreement exists among workers with regards to the
correlation of depth of amblyopia, with the difference in
refraction between the two eyes. Some authors have found
no relationship between the degree of anisometropia and the

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Vol. 54 No. 2

Table 3: Variables for myopic cases

Case
no.
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30

Difference in
snellen fraction

Difference in
log MAR units

Difference in
refraction

Difference in
keratometry

Difference in
axial length

0.67
0.57
0.50
0.75
0.17
0.67
0.33
0.42
0.33
0.33
0.25
0.90
0.67
0.50
0.50
0.42
0.33
0.33
0.17
0.33
0.57
0.75
0.67
0.67
0.33
0.08
0.75
0.67
0.75
0.33

0.48
0.82
0.30
0.60
0.18
0.48
0.18
0.42
0.30
0.30
0.30
1.00
0.48
0.60
0.30
0.42
0.30
0.18
0.12
0.30
0.82
0.60
0.48
0.48
0.18
0.12
0.60
0.48
0.60
0.18

1.25
3.50
4.00
7.75
2.00
9.00
1.50
8.00
3.50
4.25
5.00
4.86
8.75
4.50
6.25
8.00
11.00
2.00
3.00
2.50
9.75
11.00
1.36
4.00
1.00
0.13
8.00
8.75
6.00
1.50

0.88
1.25
0.00
0.13
0.12
0.25
0.00
1.00
1.50
0.26
0.25
0.25
0.63
0.25
0.75
0.00
0.25
0.00
0.00
0.25
0.38
0.25
0.38
0.50
1.75
0.13
0.50
0.88
3.13
0.63

0.24
2.23
0.67
3.06
2.40
0.46
0.40
2.53
3.72
0.04
1.66
1.20
2.66
1.36
2.18
1.94
2.61
0.58
1.74
0.17
2.99
4.21
0.50
1.83
0.61
0.06
3.55
3.43
1.90
1.40

Table 4: Pearson rank correlation coefficient for

hypermetropic cases
Variables
correlation
Difference in snellen fraction
Difference in log MAR units
Difference in axial length
Difference in keratometry

Amount of
coefficient

Anisometropia
P value

0.603*
0.644*
0.609*
-0.147

< 0.001
< 0.001
< 0.001
0.285

*Correlation significant at the 0.01 level (2-tailed)

Table 5: Pearson rank correlation coefficient for myopic cases

Variables
correlation
Difference in snellen fraction
Difference in log MAR units
Difference in axial length
Difference in keratometry

Amount of
coefficient

Anisometropia
P value

0.468*
0.463*
0.674*
-0.020

0.009
0.010
< 0.001
0.917

*Correlation significant at the 0.01 level (2- tailed)

depth of amblyopia,4-6 whereas others have noted a strong

relationship between them.7,8 While it is well known that
myopia and hypermetropia influence amblyopia differently,
majority of previous studies4,5,7 on the relationship between
anisometropia and amblyopia, did not separate
hypermetropia from myopia, upon statistical analysis. In the

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few studies6,8 where separation was done, the sample size

was quite small to draw any statistical significant correlation.
In the present study, the difference in manifest refraction and
the depth of amblyopia, was found to be strongly correlated
in anisometropic individuals and the difference between the
axial length of the two eyes contributed to a major part of
anisometropia.
Helveston4 defined anisometropia as a difference of 0.50
diopter or more in sphere or cylindrical spherical equivalent.
He studied 57 amblyopic cases with anisometropia and found
no relationship between the degree of anisometropia and
depth of amblyopia in either strabismic or nonstrabismic
individuals.
Malik et al5 examined 212 patients with anisometropia, but
could not find any correlation between the degree of
anisometropia and the depth of amblyopia, in patients with
central fixation. In their study, however, the myopes and
hypermetropes were not examined independently.
Kutschke et al,6 found no relationship between degree of
anisometropia and depth of amblyopia in the myopic,
hypermetropic, or astigmatic groups. The age of patients in
their study ranged between 11 months to 9 years. In such an
age group, the difference in vision could not truthfully reflect
the difference in refraction, because such a population is
visually not mature and might still be somewhere in the
process of developing amblyopia.

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Zaka-ur-Rab: Ocular parameters and amblyopia in anisometropia
April - June 2006

Sen7 defined anisometropia as the difference of one or more

diopters in sphere or cylinder. He, in his study, performed
cycloplegic refractions on 172 individuals with anisometropic
amblyopia. He, however, included only 5 cases of
anisometropic amblyopia, who were younger than 7 years
and noted that the higher degree of anisometropia was
associated with a more severe degree of amblyopia.
Townshend et al8 defined anisometropia as the difference
in refraction of 0.75 diopter in either sphere or cylinder
between the two eyes and amblyopia as the difference in visual
acuity between eyes of one or more lines, on the standard
Snellen Chart. They studied 35 cases of untreated
anisometropic amblyopia (older than 7 years) and
demonstrated a positive relationship between the amount of
anisometropia and the depth of amblyopia, for both myopic
and hypermetropic individuals. On statistical analysis, they
observed an unexpected finding, that this correlation was
greater for myopic than hypermetropic individuals.
Cobb et al9 in a retrospective analysis of 112 children with
anisometropic amblyopia, observed that the age of
presentation of a child with anisometropic amblyopia, did not
appear to have significant effect on the final visual acuity, but
the amount of refractive error and degree of anisometropia
at presentation, did correlate strongly with final visual acuity.
In the present study, the correlation between the difference
in manifest refraction and depth of amblyopia, was found to
be greater for hypermetropic cases. This finding was in
accordance with expectation, 2 since retina of the more
ametropic eye of a pair of hypermetropic eyes never receives
a clear image. In anisometropic myopia, however, one eye
can sometimes be used for near work and the less myopic
eye, for distance. In myopic anisometropic cases therefore,
either eye may have a clear image.
It was also observed that the difference between axial
length of the two eyes contributed to a major part of
anisometropia, more so in myopic cases.
have been conducted in
Although several studies
humans to find out the relationship between various types of
refractive errors and ocular parameters such as axial length
and corneal curvature of the eyes, no such work has been
done on cases of anisometropia. In myopia, the corneal
curvature was found to play a minor role in determination of
ocular refraction, specially in mild to moderate cases, 12
whereas, the measurements of axial length paralleled the
degree of myopia, i.e, higher the myopia, longer is the axial
length. 10-12 Stang 13 has reported that hypermetropia, like
myopia, is predominantly axial in nature, although the corneal
radius also plays a role in determining refractive error
magnitude.
10-15

Touzeau et al15 recorded subjective refraction, biometric

103

parameters using orbscan and echography in 190 normal eyes

(including eyes with ametropia), out of 95 patients. They
observed that biometric characteristics of the eye (excluding
cornea characteristics), vary with subjective spherical
equivalent. Axial length presents the strongest correlation with
the subjective spherical equivalent and correlates with the
other ocular biometric parameters, i.e, the axial length plays a
major role in ocular biometry and refraction. As the depth of
amblyopia correlates with the degree of anisometropia,
screening of preschool children for large differences in
refractive errors at an early age, may be important in the
diagnosis, prevention and treatment of anisometropic
amblyopia, which otherwise, may go undetected, being
asymptomatic at an early age.

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1.

von Noorden GK. Mechanism of amblyopia. Doc Ophthalmol

1977;34:93.

2.

von Noorden GK. Binocular Vision and Ocular Motility. 4th

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3.

Fielder AR, Moseley MJ. Anisometropia and amblyopia

chicken or egg? Br J Ophthalmol 1996;80:857-8.

4.

Helveston EM. Relationship between degree of anisometropia

and depth of amblyopia. Am J Ophthalmol 1966;62:757-9.

5.

Malik SR, Gupta AK, Choudhary S. Anisometropia. Its

relation to amblyopia and ccentric fixation. Br J Ophthalmol
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6.

Kutschke PJ, Scott WE, Keech RV. Anisometropic amblyopia.

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7.

Sen DK. Anisometropic amblyopia. J Pediatr Ophthalmol

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8.

Townshend AM, Holmes JM, Evans LS. Depth of

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9.

Cobb CJ, Russell K, Cox A, MacEwen CJ. Factors influencing

visual outcome in anisometropic amblyopes. Br J Ophthalmol
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10. Lo PI, Ho PC, Lau JT, Cheung AY, Goldschmidt E, Tso MO.
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