Further validation of the Amblyopia Treatment Index parental questionnaire

Fine visuomotor skills in amblyopia: a systematic review and meta-analysis

BACKGROUND

Amblyopia is characterised by reduced visual acuity, poor binocular sensory fusion, and impaired or absent stereoacuity. Understanding the extent to which amblyopia affects everyday task performance is important to quantifying the disease burden of amblyopia and can assist clinicians to understand patients' likely functional capability.

METHODS

A systematic literature search identified published studies comparing fine visuomotor performance in either children or adults with amblyopia and those with normal binocular vision. The included studies (22 studies involving 835 amblyopes and 561 controls) reported results of self-perception patient reported outcome measures, tests of motor proficiency and video recorded reaching and grasping. The outcomes of 17 studies were grouped into four meta-analyses, with pooled results reported as standardised mean difference (SMD) with corresponding 95% CI.

RESULTS

Regardless of the cause of amblyopia (anisometropia, strabismus, mixed, deprivation), significant reduction in self-perception of physical competence and athletic competence (SMD=-0.74, 95% CI -1.23 to -0.25, p=0.003); fine motor skills scores (SMD=-0.86, 95% CI -1.27 to -0.45, p<0.0001); speed of visually guided reaching and grasping movements (SMD=0.86, 95% CI 0.65 to 1.08, p<0.00001); and precision of temporal eye-hand coordination (SMD=0.75, 95% CI 0.26 to 1.25, p=0.003) occurred in amblyopes compared with those with normal visual development.

CONCLUSION

Reports of the impact of amblyopia on fine motor skills performance find poorer outcomes in participants with amblyopia compared with those with normal vision development. Consistency in the outcome measure used to assess the functional impact of amblyopia would be valuable for future studies.

Myopia outcome study of atropine in children: Two-year result of daily 0.01% atropine in a European population

PURPOSE

The Myopia Outcome Study of Atropine in Children (MOSAIC) is an investigator-led, double-masked, randomized controlled trial investigating the efficacy and safety of 0.01% atropine eye drops for managing myopia progression in a predominantly White, European population.

METHODS

Children aged 6-16 years with myopia were randomly allocated 2:1 to nightly 0.01% atropine or placebo eye drops in both eyes for 2 years. The primary outcome was cycloplegic spherical equivalent (SE) progression at 24 months. Secondary outcomes included axial length (AL) change, safety and acceptability. Linear mixed models with random intercepts were used for statistical analyses.

RESULTS

Of 250 participants enrolled, 204 (81.6%) completed the 24-month visit (136 (81.4%) treatment, 68 (81.9%) placebo). Baseline characteristics, drop-out and adverse event rates were similar between treatment and control groups. At 24 months, SE change was not significantly different between 0.01% atropine and placebo groups (effect = 0.10 D, p = 0.07), but AL growth was lower in the 0.01% atropine group, compared to the placebo group (-0.07 mm, p = 0.007). Significant treatment effects on SE (0.14 D, p = 0.049) and AL (-0.11 mm, p = 0.002) were observed in children of White, but not non-White (SE = 0.05 D, p = 0.89; AL = 0.008 mm, p = 0.93), ethnicity at 24 months. A larger treatment effect was observed in subjects least affected by COVID-19 restrictions (SE difference = 0.37 D, p = 0.005; AL difference = -0.17 mm, p = 0.001).

CONCLUSIONS

Atropine 0.01% was safe, well-tolerated and effective in slowing axial elongation in this European population. Treatment efficacy varied by ethnicity and eye colour, and potentially by degree of COVID-19 public health restriction exposure during trial participation.

Effects of virtual reality on the treatment of amblyopia in children: A systematic review and meta-analysis

PROBLEM

Virtual reality technology has been used to treat amblyopia in children. However, it is unclear how virtual reality technology differs from conventional patching therapy in terms of effectiveness.

ELIGIBILITY CRITERIA

Eligible randomized controlled studies were retrieved from PubMed, Embase, Scopus, the Cochrane Library, and Web of Science through February 2023.

SAMPLE

Eight studies included 10 trials with 459 participants were included in the current meta-analysis. Two studies (Herbison et al., 2016; Huang et al., 2022) included two trials each. Thus, a total of ten trials were included in the current meta-analysis.

RESULTS

Overall, virtual reality technology treatment significantly improved visual acuity by 0.07 log MAR (95% confidence interval [CI], -0.11 to -0.02; P < 0.001; I2 = 94.4%) compared with traditional patching therapy. In addition, subgroup analyses also revealed that treatment with virtual reality technology was more effective when the child was younger than seven years old, or when the duration of the intervention was no more than twenty hours.

CONCLUSIONS

Virtual reality technology treatment showed significant effects in improving visual acuity in children who were seven years of age or younger with amblyopia.

IMPLICATIONS

Virtual reality technology treatment is effective in treating amblyopia in children. Virtual reality therapy is also entertaining and popular among children and can be applied to the treatment of amblyopia in children in the future.

Amblyopia and the whole child

Amblyopia is a disorder of neurodevelopment that occurs when there is discordant binocular visual experience during the first years of life. While treatments are effective in improving visual acuity, there are significant individual differences in response to treatment that cannot be attributed solely to difference in adherence. In this considerable variability in response to treatment, we argue that treatment outcomes might be optimized by utilizing deep phenotyping of amblyopic deficits to guide alternative treatment choices. In addition, an understanding of the broader knock-on effects of amblyopia on developing visually-guided skills, self-perception, and quality of life will facilitate a whole person healthcare approach to amblyopia.

Low‐concentration atropine eyedrops for myopia control in a multi‐racial cohort of Australian children: A randomised clinical trial

BACKGROUND

To test the hypothesis that 0.01% atropine eyedrops are a safe and effective myopia-control approach in Australian children.

METHODS

Children (6-16 years; 49% Europeans, 18% East Asian, 22% South Asian, and 12% other/mixed ancestry) with documented myopia progression were enrolled into this single-centre randomised, parallel, double-masked, placebo-controlled trial and randomised to receive 0.01% atropine (n = 104) or placebo (n = 49) eyedrops (2:1 ratio) instilled nightly over 24 months (mean index age = 12.2 ± 2.5 and 11.2 ± 2.8 years, respectively). Outcome measures were the changes in spherical equivalent (SE) and axial length (AL) from baseline.

RESULTS

At 12 months, the mean SE and AL change from baseline were -0.31D (95% confidence interval [CI] = -0.39 to -0.22) and 0.16 mm (95%CI = 0.13-0.20) in the atropine group and -0.53D (95%CI = -0.66 to -0.40) and 0.25 mm (95%CI = 0.20-0.30) in the placebo group (group difference p ≤ 0.01). At 24 months, the mean SE and AL change from baseline was -0.64D (95%CI = -0.73 to -0.56) and 0.34 mm (95%CI = 0.30-0.37) in the atropine group, and -0.78D (95%CI = -0.91 to -0.65) and 0.38 mm (95%CI = 0.33-0.43) in the placebo group. Group difference at 24 months was not statistically significant (p = 0.10). At 24 months, the atropine group had reduced accommodative amplitude and pupillary light response compared to the placebo group.

CONCLUSIONS

In Australian children, 0.01% atropine eyedrops were safe, well-tolerated, and had a modest myopia-control effect, although there was an apparent decrease in efficacy between 18 and 24 months, which is likely driven by a higher dropout rate in the placebo group.

Treatment compliance in amblyopia: A mini-review and description of a novel online platform for compliance tracking

Patient compliance with amblyopia therapies, including eye patching and atropine drops, is crucial for optimal visual acuity outcomes. Studies utilizing objective measures of compliance measurement have consistently shown that a majority of patients receive significantly less treatment than prescribed. We review the subjective and objective compliance rates reported in the literature, assess possible explanations for poor compliance and describe studies of interventions to improve compliance. Additionally, we report our experience implementing Inside Out Care, a novel online platform designed to improve monitoring of amblyopia patient compliance, in our clinics. We have found that this platform, which is accessible via both computer and smartphone, has improved monitoring of amblyopia patient patching compliance, as well as allowed for enhanced doctor-patient communication.

Binocular versus standard occlusion or blurring treatment for unilateral amblyopia in children aged three to eight years

BACKGROUND

Current treatments for amblyopia, typically patching or pharmacological blurring, have limited success. Less than two-thirds of children achieve good acuity of 0.20 logMAR in the amblyopic eye, with limited improvement of stereopsis, and poor adherence to treatment. A new approach, based on presentation of movies or computer games separately to each eye, may yield better results and improve adherence. These treatments aim to balance the input of visual information from each eye to the brain.  OBJECTIVES: To determine whether binocular treatments in children, aged three to eight years, with unilateral amblyopia result in better visual outcomes than conventional patching or pharmacological blurring treatment.

SEARCH METHODS

We searched CENTRAL (which contains the Cochrane Eyes and Vision Trials Register), MEDLINE, Embase, ISRCTN, ClinicalTrials.gov, and the WHO ICTRP to 19 November 2020, with no language restrictions.

SELECTION CRITERIA

Two review authors independently screened the results of the search for relevant studies. We included randomised controlled trials (RCTs) that enrolled children between the ages of three and eight years old with unilateral amblyopia. Amblyopia was classed as present when the best-corrected visual acuity (BCVA) was worse than 0.200 logMAR in the amblyopic eye, with BCVA 0.200 logMAR or better in the fellow eye, in the presence of an amblyogenic risk factor, such as anisometropia, strabismus, or both. To be eligible, children needed to have undergone cycloplegic refraction and  ophthalmic examination, including fundal examination and optical treatment, if indicated, with stable BCVA in the amblyopic eye despite good adherence with wearing glasses. We included any type of binocular viewing intervention, on any device (e.g. computer monitors viewed with liquid-crystal display shutter glasses; hand-held screens, including mobile phones with lenticular prism overlay; or virtual reality displays). Control groups received standard amblyopia treatment, which could include patching or pharmacological blurring of the better-seeing eye. We included full-time (all waking hours) and part-time (between 1 and 12 hours a day) patching regimens. We excluded children who had received any treatment other than optical treatment; and studies with less than 8-week follow-up.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. The primary outcome of the review was the change from baseline of distance BCVA in the amblyopic eye after 16 (± 2) weeks of treatment, measured in logMAR units on an age-appropriate acuity test.

MAIN RESULTS

We identified one eligible RCT of conventional patching treatment versus novel binocular treatment, and analysed a subset of 68 children who fulfilled the age criterion of this review. We obtained data for the mean change in amblyopic eye visual acuity, adverse events (diplopia), and adherence to prescribed treatment at 8- and 16-week follow-up intervals, though no data were available for change in BCVA after 52 weeks. Risk of bias for the included study was considered to be low. The certainty of evidence for the visual acuity outcomes at 8 and 16 weeks of treatment and adherence to the study intervention was rated moderate using the GRADE criteria, downgrading by one level due to imprecision. The certainty of evidence was downgraded by two levels and rated low for the proportion of participants reporting adverse events due to the sample size.  Acuity improved in the amblyopic eye in both the binocular and patching groups following 16 weeks of treatment (improvement of -0.21 logMAR in the binocular group and -0.24 logMAR in the patching group, mean difference (MD) 0.03 logMAR (95% confidence interval (CI) -0.10 to 0.04; 63 children). This difference was non-significant and the improvements in both the binocular and patching groups are also considered clinically similar. Following 8 weeks of treatment, acuity improved in both the binocular and patching groups (improvement of -0.18 logMAR in the patching group compared to -0.16 logMAR improvement in the binocular-treatment group) (MD 0.02, 95% CI -0.04 to 0.08). Again this difference was statistically non-significant, and the differences observed between the patching and binocular groups are also clinically non-significant. No adverse event of permanent diplopia was reported. Adherence was higher in the patching group (47% of participants in the iPad group achieved over 75% compliance compared with 90% of the patching group).  Data were not available for changes in stereopsis nor for contrast sensitivity following treatment.

AUTHORS' CONCLUSIONS

Currently, there is only one RCT that offers evidence of the safety and effectiveness of binocular treatment. The authors are moderately confident that after 16 weeks of treatment, the gain in amblyopic eye acuity with binocular treatment is likely comparable to that of conventional patching treatment. However, due to the limited sample size and lack of long term (52 week) follow-up data, it is not yet possible to draw robust conclusions regarding the overall safety and sustained effectiveness of binocular treatment. Further research, using acknowledged methods of visual acuity and stereoacuity assessment with known reproducibility, is required to inform decisions about the implementation of binocular treatments for amblyopia in clinical practice, and should incorporate longer term follow-up to establish the effectiveness of binocular treatment. Randomised controlled trials should also include outcomes reported by users, adherence to prescribed treatment, and recurrence of amblyopia after cessation of treatment.

Portable rotating grating stimulation for anisometropic amblyopia with 6 months training

Treatment of grating stimulation has been used in amblyopia for decades, but high dropout rate and inconvenience for daily practice occur in previous studies. We developed a home-based portable system with rotating grating stimulation on a tablet. Thirty anisometropic amblyopic children were randomly allocated into the control or Grating group. They drew contour of the picture under patch of a better eye for 6 months. Best-corrected visual acuity (BCVA), grating acuity (GA), and contrast sensitivity (CS) were assessed at the baseline, 1st, 2nd, 3rd, and 6th months of training. All participants completed the 6-month training. Patched eyes of both groups exhibited no difference. Trained eyes of the control group had significantly slight improvement in BCVA and GA. In particular, the Grating group exhibited significantly higher BCVA, GA, and CS compared with those of the control group at the 3rd and 6th months of training. Moreover, percentage of the Grating group with great improvement (BCVA ≥ 0.3 or CS ≥ 0.3) was significantly larger than those of the control group at the 3rd or 6th months of training. The portable grating stimulation system demonstrates its trainability by no dropout and effectiveness by significant improvements in all assessments through a well experimental design.

Trial Registration: ClinicalTrials.gov NCT04213066, registered 30/12/2019, https://clinicaltrials.gov/ct2/show/NCT04213066.

Amblyopia screening effectiveness at 3-4 years old: a cohort study

Objective

To study the effectiveness of amblyopia screening at ages 3-4.

Methods and Analysis

From a population with no previous screening, a cohort of 2300 children with 3-4 years old attending school (91% of children this age attend school in Portugal), were submitted to a complete ophthalmological evaluation. Amblyopia was diagnosed, treated and followed. Amblyopia prevalence, treatment effectiveness, absolute risk reduction (ARR), number needed to screen (NNS) and relative risk reduction (RRR) were estimated.

Results

Past/present history of amblyopia was higher than 3.1%-4.2%, depending on amblyopia definition normatives. Screening at age 3-4, had estimated ARR=2.09% (95% CI 1.50% to 2.68%) with a reduced risk of amblyopia in adulthood of 87% (RRR). NNS was 47.8 (95% CI 37.3 to 66.7). Treatment effectiveness of new diagnosis was 88% (83% if we include children already followed). 91% of new amblyopia diagnoses were refractive (of which 100% surpassed amblyopia Multi-Ethnic Pediatric Eye Disease Study criteria after treatment), while most strabismic amblyopias were already treated or undertreatment. Only 30% of children with refractive amblyopia risk factors that were not followed by an ophthalmologist, ended up having amblyopia at age 3-4. Eye patch was needed equally in new-diagnosis versus treated-earlier refractive amblyopia.

Conclusions

Screening amblyopia in a whole-population setting at age 3-4 is highly effective. For each 48 children screened at age 3-4, one amblyopia is estimated to be prevented in the future (NNS). Screening earlier may lead to overdiagnosis and overtreatments: Treating all new diagnosis before age 3-4 would have a maximal difference in ARR of 0.3%, with the possible burden of as much as 70% children being unnecessary treated before age 3-4.Involving primary care, with policies for timely referral of suspicious/high-risk preverbal children, plus whole screening at age 3-4 seems a rational/effective way of controlling amblyopia.

Self-perception in Children Aged 3 to 7 Years With Amblyopia and Its Association With Deficits in Vision and Fine Motor Skills

Importance

Deficits in fine motor skills and slow reading speed have been reported in school-aged children and adults with amblyopia. These deficits were correlated with lower self-perception of athletic and cognitive competence. Although perceived competence and social acceptance are key determinants of developing self-perception in young children, the association of amblyopia with self-perception and the association of altered self-perception with fine motor skills to date have not been reported for young children aged 3 to 7 years.

Objectives

To investigate whether amblyopia is associated with altered self-perception in young children and to assess whether any differences in self-perception are associated with deficits in vision and fine motor skills.

Design, Setting, and Participants

In this cross-sectional study, conducted at a pediatric vision laboratory from January 10, 2016, to May 4, 2018, healthy children aged 3 to 7 years (preschool to second grade) were enrolled, including 60 children with amblyopia; 30 children who never had amblyopia but had been treated for strabismus, anisometropia, or both; and 20 control children.

Main Outcomes and Measures

Self-perception was assessed using the Pictorial Scale of Perceived Competence and Social Acceptance for Young Children, which includes the following 4 specific domains: cognitive competence, peer acceptance, physical competence, and maternal acceptance (total score range, 1-4; higher scores indicate higher perceived competence or acceptance). Fine motor skills were evaluated with the Manual Dexterity and Aiming and Catching scales of the Movement Assessment Battery for Children, second edition (score range, 1-19; higher scores indicate better skill performance). Visual acuity and stereoacuity also were assessed.

Results

Children with amblyopia (28 girls and 32 boys; mean [SD] age, 6.3 [1.3] years) had significantly lower mean (SD) peer acceptance and physical competence scores compared with the control children (peer acceptance, 2.74 [0.66] vs 3.11 [0.36]; mean difference, 0.37; 95% CI for difference, 0.06-0.68; P = .04; and physical competence, 2.86 [0.60] vs 3.43 [0.52]; mean difference, 0.57; 95% CI for difference, 0.27-0.87; P = .009). Among the children with amblyopia, self-perception of physical competence was significantly correlated with aiming and catching skills (r = 0.43; 95% CI, 0.10-0.67; P = .001) and stereoacuity (r = -0.39; 95% CI, -0.05 to -0.65; P = .02). Children treated for strabismus or anisometropia, but who never had amblyopia, also had significantly lower mean (SD) physical competence scores compared with control children (2.89 [0.54] vs 3.43 [0.52]; 95% CI for difference, 0.23-0.85; P = .03).

Conclusions and Relevance

These findings suggest that lower self-perception of peer acceptance and physical competence identify the broad effects of altered visual development in the everyday life of children with amblyopia.

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

Importance

Binocular amblyopia treatment using contrast-rebalanced stimuli showed promise in laboratory studies and requires clinical trial investigation in a home-based setting.

Objective

To compare the effectiveness of a binocular video game with a placebo video game for improving visual functions in older children and adults.

Design, Setting, and Participants

The Binocular Treatment of Amblyopia Using Videogames clinical trial was a multicenter, double-masked, randomized clinical trial. Between March 2014 and June 2016, 115 participants 7 years and older with unilateral amblyopia (amblyopic eye visual acuity, 0.30-1.00 logMAR; Snellen equivalent, 20/40-20/200) due to anisometropia, strabismus, or both were recruited. Eligible participants were allocated with equal chance to receive either the active or the placebo video game, with minimization stratified by age group (child, age 7 to 12 years; teenager, age 13 to 17 years; and adult, 18 years and older).

Interventions

Falling-blocks video games played at home on an iPod Touch for 1 hour per day for 6 weeks. The active video game had game elements split between eyes with a dichoptic contrast offset (mean [SD] initial fellow eye contrast, 0.23 [0.14]). The placebo video game presented identical images to both eyes.

Main Outcomes and Measures

Change in amblyopic eye visual acuity at 6 weeks. Secondary outcomes included compliance, stereoacuity, and interocular suppression. Participants and clinicians who measured outcomes were masked to treatment allocation.

Results

Of the 115 included participants, 65 (56.5%) were male and 83 (72.2%) were white, and the mean (SD) age at randomization was 21.5 (13.6) years. There were 89 participants (77.4%) who had prior occlusion. The mean (SD) amblyopic eye visual acuity improved 0.06 (0.12) logMAR from baseline in the active group (n = 56) and 0.07 (0.10) logMAR in the placebo group (n = 59). The mean treatment difference between groups, adjusted for baseline visual acuity and age group, was -0.02 logMAR (95% CI, -0.06 to 0.02; P = .25). Compliance with more than 25% of prescribed game play was achieved by 36 participants (64%) in the active group and by 49 (83%) in the placebo group. At 6 weeks, 36 participants (64%) in the active group achieved fellow eye contrast greater than 0.9 in the binocular video game. No group differences were observed for any secondary outcomes. Adverse effects included 3 reports of transient asthenopia.

Conclusions and Relevance

The specific home-based binocular falling-blocks video game used in this clinical trial did not improve visual outcomes more than the placebo video game despite increases in fellow eye contrast during game play. More engaging video games with considerations for compliance may improve effectiveness.

Trial Registration

anzctr.org.au Identifier: ACTRN12613001004752.

Amblyopia treatment and quality of life: the child's perspective on atropine versus patching

Background: The impact on children of patching versus atropine treatment for amblyopia was assessed using children's perspective Health-Related Quality of Life (HRQoL) scores in 5 to 7-year olds. Methods: Forty-six children on the threshold of commencing either patching or atropine treatment for amblyopia were recruited. Treatment was prescribed for uniocular amblyopia of visual acuity (VA) 0.2 logMAR or worse. After four weeks of their chosen treatment, each child completed the Child Amblyopia Treatment Quality-of-Life Questionnaire (CAT-QoL). The Pediatric Quality of Life Inventory (PedsQL™), Young Child (5-7) Self-Report version, was completed before and after four weeks of treatment. Quality of life scores were compared between the two treatment groups. Results: Sixty-one percent (n = 28) of participants were male and 56.5% (n = 26) were white British. The CAT-QoL has a range of 0-16, with 16 being the worst quality of life. No significant difference was found between the patching group (n = 30, mean age 69.7 months) and the atropine group (n = 16, mean age 69.3 months) for CAT-QoL quality of life scores (Patch median = 6.3, Atropine median = 5.6, U = 199, p = .341, 95% CI of the median difference of -2.3 to 0.9). The Young Child (5-7) Self-Report version of the PedsQL™ has a 'total score' range of 0-100, with 0 being the worst quality of life. There was also no significant difference in PedsQL™ quality of life total scores (Patch median = 80, Atropine median = 83.33, U = 239.5, p = .991, 95% CI of the median difference -13.33 to 10) after four weeks of treatment. Conclusion: Amblyopic children reported that patching and atropine treatments did not have a significant impact on their quality of life. Patching and atropine should continue to be offered as first-line treatments for amblyopia, as children appear to tolerate both well and do not favor one over the other.

Spectacle Wear in Toddlers: Frequency of Wear and Impact of Treatment on the Child and Family

Purpose

We assessed the frequency of spectacle wear and impact of spectacle treatment in toddlers.

Methods

Children 12 to <36 months old with significant refractive error were provided spectacles. After 12 (±6) weeks, parents reported the frequency of spectacle wear and completed the Amblyopia Treatment Index (ATI, modified for spectacle treatment). Factor analysis assessed usefulness of ATI for spectacle treatment. Spectacle wear and ATI results were compared across age (1- vs. 2-year-olds) and sex.

Results

Participants were 91 children (60% male; mean age, 22.98 [SD 6.24] months, 41 1- and 50 2-year-olds) prescribed spectacles for astigmatism (92%), hyperopia (9%), or myopia (1%). Reported frequency of wear was low (<2 hours/day) in 41%, moderate in 23% (2 to <6 hours/day), and high (≥6 hours/day) in 36% and did not differ across age or sex. ATI factor analysis identified three subscales: adverse effects, treatment compliance, and perceived benefit. One-year-olds had poorer scores on adverse effects (P = 0.026) and treatment compliance scales (P = 0.049). Low frequency of spectacle wear was associated with poorer scores on treatment compliance (P < 0.001) and perceived benefit scales (P = 0.004).

Conclusions

Frequency of spectacle wear was not related to age or sex. Younger children may have more difficulty adjusting to treatment. Parents of children with low spectacle wear reported less perceived benefit of treatment.

Translational Relevance

Data on factors associated with frequency of spectacle wear in toddlers is valuable for parents and clinicians and may lead to methods to improve compliance and reduce the negative impact of treatment.

A pilot study using electronic reminders for amblyopia treatment

Treatment compliance is the most important factor for predicting a successful outcome in amblyopia treatment. Electronic applications have been successfully employed in other medical conditions in an effort to improve compliance.Aim: To determine whether a smartphone medical adherence application (app) (RxmindMe® Prescription/Medicine Reminder and Pill Tracker) may be successfully incorporated into the treatment plan of patients 3-7 years of age who have not previously been treated for amblyopia.Methods: Children 3-7 years of age were randomized to receive electronic reminders (reminders group) or standard instructions (control group). Visual acuity and compliance with treatment was assessed at the first follow-up visit. The child's adherence with the prescribed treatment was calculated as the reported number of hours of patching performed divided by the number of hours prescribed or compliance percentage. The validated "Amblyopia Treatment Index Parental Questionnaire" was administered to the parent/guardian to assess any differences in the compliance subscale between the two treatment groups. Any difficulties encountered with the use of the reminder app were also recorded at the follow-up visit.Results: Twenty-four participants were enrolled. Twelve participants in the reminder group (eight female, four male; mean age 4.5 ± 1.3) were compared with 12 participants in the control group (five female, seven male; mean 4.8 ± 1.1). No significant differences were found between the two groups in terms of age (p = 0.62), gender (p = 0.22), or degree of amblyopia at the start of treatment (p = 0.99). Eleven of 12 participants in the reminders group were able to incorporate the reminder app into amblyopia treatment. No participant reported malfunction of the alarm portion of the reminder app. There was no significant difference seen in degree of visual acuity improvement, reported percentage compliance or effect on the compliance subscale as assessed by the ATI questionnaire. Several participants reported the app to be "helpful" in initiating treatment.Conclusion: Our findings indicate that use of a smartphone app is feasible in this patient population. Targeting the app to specific patient demographics or when difficulty with compliance is encountered needs to be further investigated.

The Effect of Childhood Eye Disorders on Social Relationships during School Years and Psychological Functioning as Young Adults

Aims:

To determine (1) whether having a visible eye condition and/or treatment with glasses and/or occlusion in childhood has any impact on psychological and/or social outcomes during childhood and young adulthood and (2) whether there is an effect of age at treatment.

Methods:

A cohort of 160 participants was asked to take part in an online study. The cohort had previously taken part in a research study at Royal Preston Hospital from 1999–2006 when they were 3–8 years old (Buckley and Perkins 2010). Participants were divided into treatment and no-defect (control) groups and were invited to take part in the current study when they had reached age 18–21. Thirty-five (35) participants (22.5% of the total cohort) were recruited and completed a series of online questionnaires assessing recalled victimisation at school, current generalised anxiety, current depressive symptoms, current loneliness, current friendship quality, and adjustment to university/work. Questionnaire scores between treated patients and controls were compared.

Results:

Findings showed that young adults who received treatment during their pre-school years, compared to their peers who did not need treatment, reported higher current generalised anxiety and more victimisation when in school.

Those who received treatment in reception class were no different on psycho-social functioning compared to their peers; with both groups reporting higher victimisation than average compared to previous studies, and mild rates of anxiety.

Conclusions:

It appears that having a visible eye condition or treatment with glasses and/or occlusion commencing at pre-school has long term psychological implications, with scores on victimisation and current anxiety levels being higher for the pre-school treatment group compared to the pre-school no defect (control) group. Treatment plans and advice to parents should consider psycho-social outcomes of proposed treatment.

Binocular treatment of amblyopia using videogames (BRAVO): study protocol for a randomised controlled trial

Background

Amblyopia is a common neurodevelopmental disorder of vision that is characterised by visual impairment in one eye and compromised binocular visual function. Existing evidence-based treatments for children include patching the nonamblyopic eye to encourage use of the amblyopic eye. Currently there are no widely accepted treatments available for adults with amblyopia. The aim of this trial is to assess the efficacy of a new binocular, videogame-based treatment for amblyopia in older children and adults. We hypothesise that binocular treatment will significantly improve amblyopic eye visual acuity relative to placebo treatment.

Methods/design

The BRAVO study is a double-blind, randomised, placebo-controlled multicentre trial to assess the effectiveness of a novel videogame-based binocular treatment for amblyopia. One hundred and eight participants aged 7 years or older with anisometropic and/or strabismic amblyopia (defined as ≥0.2 LogMAR interocular visual acuity difference, ≥0.3 LogMAR amblyopic eye visual acuity and no ocular disease) will be recruited via ophthalmologists, optometrists, clinical record searches and public advertisements at five sites in New Zealand, Canada, Hong Kong and Australia. Eligible participants will be randomised by computer in a 1:1 ratio, with stratification by age group: 7–12, 13–17 and 18 years and older. Participants will be randomised to receive 6 weeks of active or placebo home-based binocular treatment. Treatment will be in the form of a modified interactive falling-blocks game, implemented on a 5th generation iPod touch device viewed through red/green anaglyphic glasses. Participants and those assessing outcomes will be blinded to group assignment. The primary outcome is the change in best-corrected distance visual acuity in the amblyopic eye from baseline to 6 weeks post randomisation. Secondary outcomes include distance and near visual acuity, stereopsis, interocular suppression, angle of strabismus (where applicable) measured at baseline, 3, 6, 12 and 24 weeks post randomisation. Treatment compliance and acceptability will also be assessed along with quality of life for adult participants.

Discussion

The BRAVO study is the first randomised controlled trial of a home-based videogame treatment for older children and adults with amblyopia. The results will indicate whether a binocular approach to amblyopia treatment conducted at home is effective for patients aged 7 years or older.

Trial registration

This trial was registered in Australia and New Zealand Clinical Trials Registry (ACTRN12613001004752) on 10 September 2013.

Behaviors of children with unilateral vision impairment in the Infant Aphakia Treatment Study

PURPOSE

To determine whether behavioral functioning of 4.5-year-olds differs between two treatments for unilateral cataract and whether behavioral functioning is predicted by visual acuity in the treated eye.

METHODS

The Infant Aphakia Treatment Study is a multicenter clinical trial in which 114 infants with unilateral congenital cataracts were randomized to undergo cataract extraction with contact lens correction or implantation of an intraocular lens. Patching data were collected during the year preceding a visit at age 4.5 years, when both visual acuity and caregiver-reported behavioral functioning were assessed for 109 participants. Caregiver stress was assessed with the Parenting Stress Index at 4.25 years.

RESULTS

There were no treatment group differences in behavioral functioning as measured by the Child Behavior Checklist. Poorer visual acuity was associated with more externalizing behavior problems (attention problems and aggressive behavior) and total behavior problems in regression models that did not include caregiver stress. Both caregiver stress and dichotomized visual acuity significantly predicted externalizing problems.

CONCLUSIONS

Treatment assignment did not affect caregiver-reported behavior. Poor visual acuity may confer risk for problems with attention and aggressive behavior in preschoolers treated for unilateral cataract.

Binocular versus standard occlusion or blurring treatment for unilateral amblyopia in children aged three to eight years

BACKGROUND

Current treatments for amblyopia in children, occlusion and pharmacological blurring, have had limited success, with less than two-thirds of children achieving good visual acuity of at least 0.20 logMAR in the amblyopic eye, limited improvement of stereopsis, and poor compliance. A new treatment approach, based on the dichoptic presentation of movies or computer games (images presented separately to each eye), may yield better results, as it aims to balance the input of visual information from each eye to the brain. Compliance may also improve with these more child-friendly treatment procedures.

OBJECTIVES

To determine whether binocular treatments in children aged three to eight years with unilateral amblyopia result in better visual outcomes than conventional occlusion or pharmacological blurring treatment.

SEARCH METHODS

We searched the Cochrane Eyes and Vision Group Trials Register (last date of searches: 14 April 2015), the Cochrane Central Register of Controlled Trials (CENTRAL; 2015, Issue 3), Ovid MEDLINE, Ovid MEDLINE In-Process and Other Non-Indexed Citations, Ovid MEDLINE Daily, Ovid OLDMEDLINE (January 1946 to April 2015), EMBASE (January 1980 to April 2015), the ISRCTN registry (www.isrctn.com/editAdvancedSearch), ClinicalTrials.gov (www.clinicaltrials.gov), and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en). We did not use any date or language restrictions in the electronic searches for trials.

SELECTION CRITERIA

Two review authors independently screened the results of the search in order to identify studies that met the inclusion criteria of the review: randomised controlled trials (RCTs) that enrolled participants between the ages of three and eight years old with unilateral amblyopia, defined as best-corrected visual acuity (BCVA) worse than 0.200 logMAR in the amblyopic eye, and BCVA 0.200 logMAR or better in the fellow eye, in the presence of an amblyogenic risk factor such as anisometropia, strabismus, or both. Prior to enrolment, participants were to have undergone a cycloplegic refraction and comprehensive ophthalmic examination including fundal examination. In addition, participants had to have completed a period of optical treatment, if indicated, and BCVA in the amblyopic eye had to remain unchanged on two consecutive assessments despite reportedly good compliance with glasses wearing. Participants were not to have received any treatment other than optical treatment prior to enrolment. We planned to include any type of binocular viewing intervention; these could be delivered on different devices including computer monitors viewed with LCD shutter glasses or hand-held screens including mobile phone screens with lenticular prism overlay. Control groups were to have received standard amblyopia treatment; this could include occlusion or pharmacological blurring of the better-seeing eye. We planned to include full-time (all waking hours) and part-time (between 1 and 12 hours a day) occlusion regimens.

DATA COLLECTION AND ANALYSIS

We planned to use standard methodological procedures expected by The Cochrane Collaboration. We had planned to meta-analyse the primary outcome, that is mean distance BCVA in the amblyopic eye at 12 months after the cessation of treatment.

MAIN RESULTS

We could identify no RCTs in this subject area.

AUTHORS' CONCLUSIONS

Further research is required to allow decisions about implementation of binocular treatments for amblyopia in clinical practice. Currently there are no clinical trials offering standardised evidence of the safety and effectiveness of binocular treatments, but results from non-controlled cohort studies are encouraging. Future research should be conducted in the form of RCTs, using acknowledged methods of visual acuity and stereoacuity assessment with known reproducibility. Other important outcome measures include outcomes reported by users, compliance with treatment, and recurrence of amblyopia after cessation of treatment.

Compliance and patching and atropine amblyopia treatments

In the past 20 years, there has been a great advancement in knowledge pertaining to compliance with amblyopia treatments. The occlusion dose monitor introduced quantitative monitoring methods in patching, which sparked our initial understanding of the dose-response relationship for patching amblyopia treatment. This review focuses on current compliance knowledge and the impact it has on patching and atropine amblyopia treatment.

Identifying potential themes for the Child Amblyopia Treatment Questionnaire

PURPOSE

Patient-reported outcome (PRO) instruments are increasingly common in both clinical practice and research. The data obtained from these instruments can be used to help inform decision making and policy-making decisions. The methodological approaches undertaken in developing PROs is not frequently reported. Literature on the development of the descriptive systems for PROs is sparse in comparison with that on the assessment of the psychometric properties of such instruments. The purpose of this study is to describe the results of qualitative interviews conducted to identify potential themes for the Child Amblyopia Treatment Questionnaire (CAT-QoL), a pediatric disease-specific health-related quality of life instrument for amblyopia designed for children aged 4 to 7 years.

METHODS

Semistructured interviews were undertaken with 59 children (aged 3 years 9 months to 9 years 11 months; average, 6 years 3 months) with amblyopia. The interviews were transcribed verbatim and imported into QSR NVivo 8. Interview transcripts were analyzed to identify potential items to be included in the descriptive system. Thematic content analysis was undertaken using Framework.

RESULTS

Eleven potential themes were identified for inclusion in the CAT-QoL instrument, namely, physical sensation of the treatment, pain, being able to play with other children, how other children have treated them, ability to undertake schoolwork, ability to undertake other tasks, sad or unhappy, cross, worried, frustrated, and feelings toward family members.

CONCLUSIONS

Children are able to identify their thoughts and opinions of their own health and to describe what impact their amblyopia treatment has had on their daily lives. Themes for the draft descriptive system for a pediatric self-reported amblyopia QoL instrument have been identified. A draft version of the CAT-QoL instrument has been developed. Further research is required to refine and assess the psychometric properties of the instrument.

Developing the draft descriptive system for the child amblyopia treatment questionnaire (CAT-Qol): a mixed methods study

BACKGROUND

Amblyopia is a visual condition that occurs in childhood. Screening programmes exist within the United Kingdom (UK) to detect amblyopia, and once detected treatment is given.Existing patient reported outcome (PRO) measures for amblyopia do not meet current recommendations for the methods adopted during their development, or the way in which the instruments are administered. The overall aim of this study was to produce a self-complete PRO instrument for amblyopia for children aged 4-7 years that uses children's responses in the development phase. The study comprised a number of stages. This paper reports on the refinement of the descriptive system for the draft instrument (the Child Amblyopia Treatment Questionnaire, CAT-QoL) using qualitative and quantitative methods.

METHODS

The study consisted of three components. Children were asked to read, and complete the draft questionnaire as independently as possible. They were then asked about the questionnaire, and its format, in a cognitive debriefing exercise. Observations were made as to the child's ability to read the questionnaire, particular attention was made as to which individual words participants struggled to read. Children were also asked their opinion on the design layout of the questionnaire. Finally, some children were asked to complete a ranking task to help determine the order of the levels of the items as judged by the children. Mid-rank scoring and statistical level of agreement were calculated for the ranking exercise.

RESULTS

Thirty-two (n=32) participants completed a draft questionnaire; each of these underwent a cognitive de-briefing interview. Twenty-two (n=22) children completed the ranking exercise. Ten children did not understand the concept of ranking. The results of the qualitative phase (cognitive de-briefing interview) were used to modify the wording of items and layout of the instrument. Results of the ranking exercise were used to inform the order of the response levels for the items.

CONCLUSION

Responses of young children can be used in the development of PRO instruments. They are able to help inform the content, wording, and format of an instrument, ensuring good content and face validity. The results have been used to further refine the CAT-QoL, however further research is required to assess the psychometric properties of the instrument.

Patient-reported outcome measures (PROMs) in paediatric ophthalmology: a systematic review

AIM

To identify patient-reported outcome measures (PROMs) specifically developed and used to assess the impact of ophthalmic disorders in children and to systematically assess their quality as a basis for recommendations about their use in clinical and research settings.

METHODS

A systematic review of the literature was performed in MEDLINE, EMBASE, PsychINFO, CINAHL and AMED, supplemented by a grey literature search. Papers reporting development and validation of questionnaire instruments for assessing patient-reported outcomes of an ophthalmic disorder in patients aged 2-18 years were included. Quality was assessed by examining the purpose and psychometric properties of the instruments. Strengths and limitations were summarised with recommendations regarding use.

RESULTS

Search identified 17 instruments. Of these, 11 were condition-specific and six were intended for a broader population of children and young people with visual impairment regardless of the ophthalmic condition. Three were developed for use in a specific trial and two are still in development.

CONCLUSIONS

Paediatric ophthalmology PROM development and application is a developing field and new instruments are needed. There is scope for improvement in this area through (a) clarity of definitions of the underlying constructs intended to be measured at the onset of development of new instruments, (b) application of child-centred approaches and (c) adherence to extant guidance and best practice in questionnaire instrument development.

Development and validation of the 21-item children's vision for living scale (CVLS) by Rasch analysis

BACKGROUND

The aim was to develop and validate an instrument called the 'Children's Vision for Living Scale' (CVLS) for the assessment of vision-related quality of life in Saudi Arabian children with and without amblyopia.

METHODS

A 43-item child self-report questionnaire was initially developed based on interviews with children with amblyopia, their parents and eye-care professionals, and a literature review. Following a process that involved the removal of redundant items, 28 items remained and were piloted on children aged five to 12 years with and without amblyopia (n = 48 amblyopic, n = 53 non-amblyopic) living in Saudi Arabia. Rasch analysis was applied to determine whether the 28-item questionnaire fitted the Rasch model. Rasch analysis was used to assess the validity and reliability of the questionnaire. Principal components analysis (PCA) was used to check dimensionality. A 21-item questionnaire resulting from this process was administered in children with (n = 81) and without (n = 82) amblyopia in Saudi Arabia for further validation.

RESULTS

The final 21-item questionnaire had good validity and reliability as demonstrated by person separation of 2.02, person reliability of 0.80 (mean square and standard deviation: infit = 1.01 ± 0.39; outfit = 1.01 ± 0.40) and item reliability of 0.93 (item infit range = 1.33 to 0.78; item outfit range = 0.78 to 1.30). The mean difference between person and item scores of 0.33 ± 0.53 logits (scale range, 2 to -2) indicates that the items are well targeted to the populations. The PCA (dimensionality measures) shows the percentage of variance explained by measures equal to 26.4 per cent (modelled 26.9 per cent) and an eigenvalue of the first contrast of 2.5, which demonstrated good stability.

CONCLUSION

The 21-item CVLS is a valid uni-dimensional child self-report instrument for the assessment of the impact of amblyopia on vision-related quality of life in children with and without amblyopia living in Saudi Arabia.

Parenting stress in the infant aphakia treatment study

OBJECTIVE

To evaluate parenting stress following infants' cataract extraction surgery, and to determine if levels of stress differ between 2 treatments for unilateral congenital cataract in a randomized clinical trial.

METHODS

At surgery, an intraocular lens (IOL) was implanted or children were left aphakic, treated with contact lens (CL). Stress measures were administered 3 months after surgery and at the first visit after the visual acuity (VA) assessment done at 12 months of age.

RESULTS

Caregivers in the IOL group reported higher levels of stress than those in the CL group 3 months after surgery, but there were no group differences in stress scores at the post-VA assessment. Stress scores did not change differentially for participants assigned to IOL versus CL treatments.

CONCLUSIONS

Treatment assignment did not have a significant impact on caregiver stress during infancy or on the change in stress during the child's first 2 years of life.

Advances in amblyopia: what have we learned from PEDIG trials?

Amblyopia is the most common cause of preventable visual loss in children. This article reviews treatment options, durations, and efficacy in randomized multicentered trials conducted by the Pediatric Eye Disease and Investigator Group in the last decade. Parents and patients should be counseled that many forms of treatment are efficacious, allowing the option of choice of best-tolerated treatment method. Compliance is key to successful treatment. The course of treatment is likely at least 6-12 months, with yearly follow-up suggested once amblyopia has been treated to monitor for regression.

Clinicians' perspectives of health related quality of life (HRQoL) implications of amblyopia: a qualitative study

AIMS OR PURPOSE: The health related quality of life (HRQoL) implications of amblyopia and/or its treatment have been reported. However the clinician's perspective has not previously been explored. The purpose of this study was to explore the HRQoL implications of amblyopia and/or its treatment from a clinicians' perspective. METHODS: Three focus group sessions were conducted with practising orthoptists. Thematic content analysis was undertaken, to identify HRQoL themes associated with amblyopia and/or its treatment. RESULTS: Nine HRQoL themes associated with amblyopia and/or its treatment were identified. These included adult quality of life issues; hospital appointments; appearance; glasses-wear; patching treatment; atropine treatment; limited activities; relationships within the family; and treatment compliance. CONCLUSIONS: The HRQoL implications of amblyopia and/or its treatment was similar to those identified in the literature. Participants acknowledged a change in societal attitudes towards glasses and patching; with glasses becoming more socially acceptable. Further research is needed to explore the exact impact of amblyopia and/or its treatment from both the child and the parental perspective.

Amblyopia and quality of life: a systematic review

Amblyopia is a common condition, which can affect up to 5% of the general population. Health-related quality-of-life (HRQoL) implications of amblyopia and/or its treatment have been explored in the literature. A systematic literature search was undertaken during the period of 7-14 May 2010 to identify the HRQoL implications of amblyopia and/or its treatment. A total of 35 papers were included in the literature review. The HRQoL implications of amblyopia related specifically to amblyopia treatment, rather than to the condition itself. These included impact on family life, social interactions, difficulties in undertaking daily activities, as well as feelings and behaviour. The identified studies adopted a number of methodologies. The study populations included children with the condition, parents of children with amblyopia, and adults who had undertaken amblyopia treatment as a child. Some studies developed their own measures of HRQoL, and others determined HRQoL through proxy measures. The reported findings of the HRQoL implications are of importance when considering the management of cases of amblyopia. The issues identified in the literature review are discussed with respect to how HRQoL is measured (treatment compliance vs proxy measures), and whether HRQoL is taken from a child's or a parent's perspective. Changing societal views over glasses and occlusion therapy are also discussed. Further research is required to assess the immediate and long-term effects of amblyopia and/or its treatment on HRQoL using a more standardised approach.

Evaluating the burden of amblyopia treatment from the parent and child's perspective

PURPOSE

To evaluate the psychometric properties of the original Parent and new Child Amblyopia Treatment Index (ATI), questionnaires that assess the burden of amblyopia treatment in children and families, and to compare scores between children treated with atropine or patching.

METHODS

Parent ATI and Child ATI were administered to 233 children 7 to <13 years old and their parents as part of a randomized trial comparing patching and atropine for amblyopia treatment. For each ATI version, construct validity was assessed using factor analysis; internal consistency reliability was assessed using Cronbach's alpha. Data from the Parent ATI and Child ATI were correlated and scores for each version were compared between treatment groups.

RESULTS

We analyzed the 3 subscales found in prior Parent ATI studies in younger children and confirmed subscales for adverse effects and treatment compliance, but not for social stigma, in both parent and child versions. Overall and subscale scores on the Parent ATI and Child ATI were moderately to well correlated except for the social stigma subscale. For both the Parent ATI and the Child ATI, children treated with atropine had better scores than those treated with patching, both overall and on treatment compliance and social stigma subscales (all p values ≤ 0.01).

CONCLUSIONS

When used for children 7 to <13 years old, the Parent ATI and Child ATI have similar factor structures to each other and to the Parent ATI for children 3 to <7 years old. Atropine treatment was found to have less negative impact than patching.

Health-related quality of life measures (HRQoL) in patients with amblyopia and strabismus: a systematic review

BACKGROUND/AIMS

Health-related quality of life (HRQoL) measures are used in healthcare to help inform clinical decision-making and policy-making decisions. A number of disease-specific or condition-specific measures have been developed and applied in ophthalmology; however, their use in the specific fields of amblyopia and strabismus are not as established. The purpose of this study is to identify and discuss specific HRQoL instruments that may be used in the investigation and management of patients with amblyopia and/or strabismus.

METHODS

A systematic literature review was undertaken in November 2009. The electronic databases of AMED (Allied and Complementary Medicine: 1985 to November 2009), the British Nursing Index and Archive (1985 to October 2009), Ovid Medline In-Process and Other Non-Indexed Citations and Ovid Medline (1950 to present) and PsycINFO (1806 to November Week 1 2009) were searched. No language restrictions were applied to the search.

RESULTS

Four instruments were identified: the Amblyopia and Strabismus Questionnaire (A&SQ), the Amblyopia Treatment Index (ATI), the Adult Strabismus Questionnaire (AS-20) and the Intermittent Exotropia Questionnaire (IXTQ).

CONCLUSION

The use of HRQoL measures in patients with amblyopia and/or strabismus is a developing area. Further research is necessary to determine the impact of issues such as diplopia and poor cosmesis upon patient groups, and to determine the influence of ethnicity and parental reporting in these patients.

A randomized trial comparing Bangerter filters and patching for the treatment of moderate amblyopia in children

OBJECTIVE

To determine whether visual acuity improvement with Bangerter filters is similar to improvement with patching as initial therapy for children with moderate amblyopia.

DESIGN

Randomized, clinical trial.

PARTICIPANTS

We enrolled 186 children, 3 to <10 years old, with moderate amblyopia (20/40-20/80).

METHODS

Children were randomly assigned to receive either daily patching or to use a Bangerter filter on the spectacle lens in front of the fellow eye. Study visits were scheduled at 6, 12, 18, and 24 weeks.

MAIN OUTCOME MEASURES

Visual acuity in amblyopic eyes at 24 weeks.

RESULTS

At 24 weeks, amblyopic eye improvement averaged 1.9 lines in the Bangerter group and 2.3 lines in the patching group (difference in mean visual acuities between groups adjusted for baseline acuity = 0.38 line). The upper limit of a 1-sided 95% confidence interval was 0.76 line, which slightly exceeded a prespecified noninferiority limit of <0.75 line. Similar percentages of subjects in each group improved > or =3 lines (Bangerter group 38% vs patching group 35%; P = 0.61) or had > or =20/25 amblyopic eye acuity (36% vs 31%, respectively; P = 0.86). There was a lower treatment burden in the Bangerter group as measured with the Amblyopia Treatment Index. With Bangerter filters, neither a fixation switch to the amblyopic eye nor induced blurring in the fellow eye to worse than that of the amblyopic eye was required for visual acuity improvement.

CONCLUSIONS

Because the average difference in visual acuity improvement between Bangerter filters and patching was less than half a line, and there was lower burden of treatment on the child and family, Bangerter filter treatment is a reasonable option to consider for initial treatment of moderate amblyopia.