Refractive adaptation and efficacy of occlusion therapy in untreated amblyopic patients aged 12 to 40 years

Standard Amblyopia Therapy in Adults with Longstanding Amblyopia Improves Visual Acuity and Contrast Sensitivity

Purpose

Perceptual learning or dichoptic training may result in improved acuity in adult amblyopes. However, for amblyopic children (<18 years), most clinicians recommend standard part-time patching. The purpose of this study was to determine if standard amblyopia therapy results in an enhancement in vision in the amblyopic eye of adults.

Patients and Methods

Fifteen amblyopes (20/30 or worse) were recruited and nine (age (SD) 32.9 (16.31)) with anisometropia or anisometropia and strabismus (ie, combined mechanism amblyopia) completed the study. Previous therapy did not exclude subjects. The subjects received a comprehensive eye exam and wore their best correction for at least four weeks prior to baseline testing. The non-amblyopic eye was patched for 2 hours per day (Amblyopia iNET training for 30 minutes and near/distance activities for 1.5 hours). The subjects had a baseline amblyopia evaluation followed by one visit per week for 12 weeks. At 12 weeks, the treatment was tapered off over one month and the subjects had a final amblyopia evaluation at 24 weeks. Contrast sensitivity was measured at baseline and 12 weeks with the Quick CSF system.

Results

The subjects had a significant improvement in visual acuity across the weeks (p < 0.001). At baseline, weeks 12 and 24, the average logMAR acuities (SE) were 0.55 (0.09), 0.41 (0.08), and 0.38 (0.09), respectively. Weeks 4 to 24 were significantly different (p < 0.001) from baseline. The average acuity improvement over the 24 weeks was 1.7 logMAR lines. There was a significant increase in the area under the log contrast sensitivity function (p = 0.002) and its estimated acuity (p = 0.036) from baseline to 12 weeks.

Conclusion

Standard amblyopia treatment can result in an improvement in visual acuity and contrast sensitivity in adults with longstanding anisometropic or combined mechanism amblyopia even if they had prior therapy.

Three-year results of phase I retinal gene therapy trial for CNGA3-mutated achromatopsia: results of a non randomised controlled trial

AIMS

To determine long-term safety and efficacy outcomes of a subretinal gene therapy for CNGA3-associated achromatopsia. We present data from an open-label, nonrandomised controlled trial (NCT02610582).

METHODS

Details of the study design have been previously described. Briefly, nine patients were treated in three escalating dose groups with subretinal AAV8.CNGA3 gene therapy between November 2015 and October 2016. After the first year, patients were seen on a yearly basis. Safety assessment constituted the primary endpoint. On a secondary level, multiple functional tests were carried out to determine efficacy of the therapy.

RESULTS

No adverse or serious adverse events deemed related to the study drug occurred after year 1. Safety of the therapy, as the primary endpoint of this trial, can, therefore, be confirmed. The functional benefits that were noted in the treated eye at year 1 were persistent throughout the following visits at years 2 and 3. While functional improvement in the treated eye reached statistical significance for some secondary endpoints, for most endpoints, this was not the case when the treated eye was compared with the untreated fellow eye.

CONCLUSION

The results demonstrate a very good safety profile of the therapy even at the highest dose administered. The small sample size limits the statistical power of efficacy analyses. However, trial results inform on the most promising design and endpoints for future clinical trials. Such trials have to determine whether treatment of younger patients results in greater functional gains by avoiding amblyopia as a potential limiting factor.

Recent Treatment Advances in Amblyopia

Occlusion therapy has a long history as the gold standard treatment for amblyopia. Over the past two decades, large multicenter randomized controlled trials and objective dose-monitoring studies have characterized the effects of refractive correction, patching, and atropine penalization, providing insights into the impact of factors such as age and treatment dose. More recent approaches, whose development has been accelerated by advances in technology, are designed to provide different stimulation to the amblyopic eye and the fellow eye. This review explores a variety of such dichoptic approaches, categorized according to whether they primarily feature requisite use of the amblyopic eye in the face of fellow-eye masking, integration of visual information from both eyes, or reduction of stimulus salience in the fellow eye. It is still unclear whether dichoptic treatments are superior to traditional, low-cost treatment methods or whether their therapeutic mechanisms are fundamentally different from those of established treatments. Expected final online publication date for the Annual Review of Vision Science, Volume 8 is September 2022. Please see http://www.annualreviews.org/page/journal/pubdates for revised estimates.

Neuroplasticity in older adults revealed by temporary occlusion of one eye

Occluding one eye for several hours alters visual experience. Specifically, occluding one eye shifts the balance of ocular dominance to favour the recently deprived eye, which can be measured using binocular rivalry. This ocular dominance shift demonstrates homeostatic neuroplasticity within the visual system and has been explored in detail in younger adults. Here we measure whether the strength and general features of neuroplasticity revealed by monocular patching are maintained in older adults. Thirty younger (18-35 years) and 30 older adults (60-81 years) participated. Binocular rivalry features were measured before and after 2 h of occlusion. Post-patching, perceptual dominance of the non-patched eye decreased (p < .001) in both age groups. The effect of occlusion on all features of binocular rivalry did not significantly differ between groups. The older visual system maintains the ability to rapidly adjust to changes in perceptual experience induced by eye occlusion. This preservation of neuroplasticity suggests that visual training methods designed to improve visual performance based on eye occlusion should maintain effectiveness into older age.

The ups and downs of sensory eye balance: Monocular deprivation has a biphasic effect on interocular dominance

Classic studies of ocular dominance plasticity in early development showed that monocular deprivation suppresses the neural representation and visual function of the deprived eye. However, recent studies have shown that a short period of monocular deprivation (<3 h) in normal adult humans, shifts sensory eye dominance in favor of the deprived eye. How can these opposing effects be reconciled? Here we argue that there are two systems acting in opposition at different time scales. A fast acting, stabilizing, homeostatic system that rapidly decreases gain in the non-deprived eye or increases gain in the deprived eye, and a relatively sluggish system that shifts balance toward the non-deprived eye, in an effort to reduce input of little utility to active vision. If true, then continuous deprivation should produce a biphasic effect on interocular balance, first shifting balance away from the non-deprived eye, then towards it. Here we investigated the time course of the deprivation effect by monocularly depriving typical adults for 10 h and conducting tests of sensory eye balance at six intervening time points. Consistent with previous short-term deprivation work, we found shifts in sensory eye dominance away from the non-deprived eye up until approximately 5 h. We then observed a turning point, with balance shifting back towards the non-deprived eye, -, a biphasic effect. We argue that this turning point marks where the rapid homeostatic response saturates and is overtaken by the slower system responsible for suppressing monocular input of limited utility.

Visual Training in Virtual Reality in Adult Patients with Anisometric Amblyopia

PURPOSE

Amblyopia is one of the most common childhood disease. The average prevalence of amblyopia in children is estimated at 2-5 %. It arises during the child development until the age of six, if not treated then, it persist throught adulthood. The aim of our work is to retrospectively analyze the results of treatment of anisometropic amblyopia using dichoptical training in virtual reality in adult amblyopic patients.

MATERIALS AND METHODS

Our group consisted of 84 amblyopic patients with anisometropic amblyopia with an average age of 33.8 ± 9.4 years. Patients played a video game twice a week in the Oculus Rift 3D virtual reality. Together they completed 8 visual trainings, with one training lasting 60 minutes. Before and after the training we evaluated the best corrected visual acuity (BCVA).

DISCUSSION

Throughout the group, we observed an improvement of 0.1 BCVA from 0.48 to 0.58 Sloan table (p.

Objective Assessment of the Effect of Optical Treatment on Magnocellular and Parvocellular-biased Visual Response in Anisometropic Amblyopia

Purpose

Optical treatment can improve visual function in anisometropic amblyopia, but there is no electrophysiological evidence, and the underlying change in visual pathway remains unknown. Our aims were to characterize the functional loss in magnocellular and parvocellular visual pathways in anisometropic amblyopia at baseline and to investigate the effect of optical treatment on the 2 visual pathways.

Methods

Using isolated-check visual-evoked potential, we measured the magnocellular- and parvocellular-biased contrast response functions in 15 normal controls (20.13 ± 3.93 years; mean ± standard deviation), 16 patients with anisometropic amblyopia (18.00 ± 6.04 years) who were fully refractive corrected before and 29 (19.41 ± 7.41 years) who had never been corrected. Twelve previously uncorrected amblyopes received optical treatment for more than 2 months and finished the follow-up measurement.

Results

Both the magnocellular- and parvocellular-biased contrast response functions in the amblyopic eye exhibited significantly reduced response and weaker contrast gains. We also found that the uncorrected amblyopes showed a more severe response reduction in magnocellular-biased, but not parvocellular-biased condition when compared with those corrected, with a weaker initial contrast gain and lower maximal response. After optical treatment, 12 uncorrected amblyopes demonstrated improved visual acuity of the amblyopic eye and a significant response gain to magnocellular-biased but not parvocellular-biased stimuli.

Conclusions

We demonstrated deficits to both magnocellular- and parvocellular-biased stimuli in subjects with anisometropic amblyopia. Optical treatment could produce neurophysiological changes in visual pathways even in older children and adults, which may be mediated through the magnocellular pathway.

Dichoptic De-Masking Learning in Adults With Amblyopia and Its Mechanisms

Purpose

Recently, we reported that dichoptic de-masking training can further boost stereoacuity, but not visual acuity, in adults with amblyopia after extensive monocular perceptual training. Here, we investigated whether this dichoptic training targets on interocular suppression directly, or improves vision through high-level brain mechanisms.

Methods

Eleven adults with amblyopia first used amblyopic eyes (AEs) to perform contrast (n = 6) or orientation (n = 5) discrimination training, while resisting dichoptic noise masking from fellow eyes (FEs). Learning was indicated by increased maximal tolerable noise contrast (TNC) for AE contrast/orientation discrimination. After dichoptic training, six observers continued to use AEs to perform monocular training for nine sessions.

Results

(1) Training of dichoptic de-masking doubled maximal TNC, but learning did not transfer much to the same task at an orthogonal orientation or a different task, showing orientation/task specificities. (2) Following a training-plus-exposure (TPE) protocol, AEs then received exposure of the orthogonal orientation by performing the other orientation/contrast discrimination task at the orthogonal orientation. After this TPE training, dichoptic learning with the original discrimination task transferred to the orthogonal orientation. (3) Dichoptic training improved AE's acuity (1.2 lines), stereoacuity (60.2%), and contrast sensitivity (mainly at higher spatial frequencies). (4) Additional monocular training did not produce further acuity and stereoacuity gains.

Conclusions

The initial orientation/task specificities exclude the possibility that dichoptic training reduces physiological interocular suppression. The later transfer of learning to an orthogonal orientation with TPE training suggests improvement in high-level brain processing. Dichoptic training may strengthen top-down attention to AEs to counter the impacts of attentional bias to FEs and/or physiological interocular suppression and improve stereoacuity.