Amblyopia Preferred Practice Pattern®

A comparative study of stereopsis in term and preterm children with and without retinopathy of prematurity

PURPOSE

To evaluate stereopsis in term-born, preterm, and preterm children with and without retinopathy of prematurity (ROP) and its treatment.

METHODS

The cross-sectional study included 322 children between 3 and 11 years of age born term or preterm, with or without ROP, and with or without treatment for ROP. The ROP treatments were laser therapy, intravitreal injection (IVI) of anti-vascular endothelial growth factor, or their combination. Stereoacuity was measured using the Titmus Stereo Test, and the results among various age groups were analyzed.

RESULTS

Stereopsis was found to improve with increasing age at testing (P < 0.001) across the entire study population. The term group exhibited significantly better stereoacuity than the preterm group (P < 0.001). At 3-5 years and 6-8 years, the preterm children without ROP exhibited significantly better stereoacuity than did those with ROP (P < 0.001 and P = 0.02, respectively); however, at 9-11 years, both groups exhibited similar stereoacuity (P = 0.34). The stereoacuity in the children with untreated ROP was similar to that of the children with treated ROP in all age groups (P > 0.05). No significant differences in stereopsis were identified between children with ROP treated with laser versus with IVI (P > 0.05). From multivariate analysis, younger age at testing (P = 0.001) and younger gestational age (P < 0.001) were associated with poorer stereopsis.

CONCLUSIONS

Stereopsis development gradually improved with age in all groups. The children born preterm exhibited poorer stereoacuity than those born term. Children with ROP treated with laser photocoagulation versus IVI may exhibit similar levels of stereoacuity. Younger age at testing and gestational age were independent risk factors for poorer stereoacuity.

Analyses of eye movement parameters in children with anisometropic amblyopia

OBJECTIVE

To investigate the characteristics of eye movement in children with anisometropic amblyopia, and to compare those characteristics with eye movement in a control group.

METHODS

31 children in the anisometropic amblyopia group (31 amblyopic eyes in group A, 31 contralateral eyes in group B) and 24 children in the control group (48 eyes in group C). Group A was subdivided into groups Aa (severe amblyopia) and Ab (mild-moderate amblyopia). The overall age range was 6-12 years (mean, 7.83 ± 1.79 years). All children underwent ophthalmic examinations; eye movement parameters including saccade latency and amplitude were evaluated using an Eyelink1000 eye tracker. Data Viewer and MATLAB software were used for data analysis.

RESULTS

Mean and maximum saccade latencies, as well as mean and maximum saccade amplitudes, were significantly greater in group A than in groups B and C before and after treatment (P < 0.05). Mean and maximum saccade latencies were significantly different among groups Aa, Ab, and C (P < 0.05). Pupil trajectories in two detection modes suggested that binocular fixation was better than monocular fixation.

CONCLUSIONS

Eye movement parameters significantly differed between contralateral normal eyes and control eyes. Clinical evaluation of children with anisometropic amblyopia should not focus only on static visual acuity, but also on the assessment of eye movement.

Deficits of the "Good" Eye in Amblyopia: Processing Geometric Properties

Purpose

Although fellow eyes of amblyopia are typically considered normal, recent studies have revealed impairments in certain aspects of vision. However, it remains unclear at which level of object processing these impairments occur. This study aims to investigate the functional level of visual perception impairment in the fellow eye of children and adults with amblyopia using the geometric functional hierarchy discrimination task based on Klein Mathematics methodology.

Methods

Seventy-six patients with amblyopia (40 children and 36 adults) and 77 age-matched healthy controls (40 children and 37 adults) were recruited for this study. The participants completed four sets of geometric hierarchies (in ascending order of stability: Euclidean, affine, projective, and topology) and one set of color discrimination tasks. They were instructed to rapidly and accurately select a distinct shape from the four quadrants.

Results

The participants' performance was evaluated using the inverse efficiency (IE) score (IE = response time (RT)/accuracy). The results of IEs show that the fellow eye of children with amblyopia exhibits normal topological processing, yet displays higher IEs in other geometric properties and color processing, suggesting impairments in these specific discrimination abilities. However, adults with amblyopia did not show deficits on any discrimination types compared with adult controls.

Conclusions

The lack of compromised topological processing suggests that amblyopia may not have inflicted any damage to the subcortical visual pathways. Furthermore, these deficits observed in the fellow eye tend to diminish significantly during adulthood, implying that amblyopia may potentially hinder the maturation process of the fellow eye.

Best Vitelliform Macular Dystrophy Natural History Study Report 1: Clinical Features and Genetic Findings

PURPOSE

To analyze the genetic findings, clinical spectrum, and natural history of Best vitelliform macular dystrophy (BVMD) in a cohort of 222 children and adults.

DESIGN

Single-center retrospective, consecutive, observational study.

PARTICIPANTS

Patients with a clinical diagnosis of BVMD from pedigrees with a likely disease-causing monoallelic sequence variant in the BEST1 gene.

METHODS

Data were extracted from electronic and physical case notes. Electrophysiologic assessment and molecular genetic testing were analyzed.

MAIN OUTCOME MEASURES

Molecular genetic test findings and clinical findings including best-corrected visual acuity (BCVA), choroidal neovascularization (CNV) rates, and electrophysiologic parameters.

RESULTS

Two hundred twenty-two patients from 141 families were identified harboring 69 BEST1 variants. Mean age at presentation was 26.8 years (range, 1.3-84.8 years) and most patients (61.5%) demonstrated deterioration of central vision. Major funduscopic findings included 128 eyes (30.6%) with yellow vitelliform lesions, 78 eyes (18.7%) with atrophic changes, 49 eyes (11.7%) with fibrotic changes, 48 eyes (11.5%) with mild pigmentary changes, and 43 eyes (10.3%) showing a vitelliruptive appearance. Mean BCVA was 0.37 logarithm of the minimum angle of resolution (logMAR; Snellen equivalent, 20/47) for the right eye and 0.33 logMAR (Snellen equivalent, 20/43) for the left eye at presentation, with a mean annual loss rate of 0.013 logMAR and 0.009 logMAR, respectively, over a mean follow-up of 9.7 years. Thirty-seven patients (17.3%) received a diagnosis of CNV over a mean follow-up of 8.0 years. Eyes with CNV that received treatment with an anti-vascular endothelial growth factor (VEGF) agent showed better mean BCVA compared with eyes that were not treated with an anti-VEGF agent (0.28 logMAR [Snellen equivalent, 20/38] vs. 0.62 logMAR [Snellen equivalent, 20/83]). Most eyes exhibited a hyperopic refractive error (78.7%), and 13 patients (6.1%) received a diagnosis of amblyopia. Among the 3 most common variants, p.(Ala243Val) was associated with a later age of onset, better age-adjusted BCVA, and less advanced Gass stages compared with p.(Arg218Cys) and p.(Arg218His).

CONCLUSIONS

BVMD shows a wide spectrum of phenotypic variability. The disease is very slowly progressive, and the observed phenotype-genotype correlations allow for more accurate prognostication and counselling.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Comparing paediatric optometric vision care in Canada over a 14-year period

PURPOSE

In Canada, teaching in paediatric eye care has increased in the past decade both within the optometry curriculum and as continuing education to optometrists. Paediatric vision care guidelines have also been established by North American optometric associations. This study examined whether this exposure was associated with changes in paediatric eye care in Canada over a 14-year period.

METHODS

Canadian optometrists were invited to participate in an anonymous 35-item survey in 2007 and 2021. The surveys sought to investigate optometrist's recommendations for first eye examinations, the number of paediatric patients seen in a typical week and preparedness to provide eye examinations to children. Response frequencies were determined for each survey item.

RESULTS

Across Canada, 133/1000 (13.3%) and 261/~6419 (~4.1%) optometrists responded to the survey in 2007 and 2021, respectively. No significant difference was found in the number of years practicing, days per week in practice and total number of patients seen per week. The modal age optometrists recommended children be seen for their first eye examination changed from 3-4 years in 2007 (53%) to 6-12 months in 2021 (61%). In 2007, 87% of respondents provided eye examinations to children <2 years, increasing to 94% in 2021 (p = 0.02). Despite a reduction in the recommended age between the two survey years, the most frequent age children were seen for their first eye examination was 3-4 years (30% in both surveys) and the most common age seen in a typical week remained unchanged (4-6 years-56% 2007; 66% 2021).

CONCLUSION

Although optometrists' willingness to provide paediatric eye care increased over the past 14 years, the number of children seen in a typical week did not change. Barriers to determine why more children are not being seen at an earlier age need to be investigated.

The Performance of Chatbots and the AAPOS Website as a Tool for Amblyopia Education

PURPOSE

To evaluate the understandability, actionability, and readability of responses provided by the website of the American Association for Pediatric Ophthalmology and Strabismus (AAPOS), ChatGPT-3.5, Bard, and Bing Chat about amblyopia and the appropriateness of the responses generated by the chatbots.

METHOD

Twenty-five questions provided by the AAPOS website were directed three times to fresh ChatGPT-3.5, Bard, and Bing Chat interfaces. Two experienced pediatric ophthalmologists categorized the responses of the chatbots in terms of their appropriateness. Flesch Reading Ease (FRE), Flesch Kincaid Grade Level (FKGL), and Coleman-Liau Index (CLI) were used to evaluate the readability of the responses of the AAPOS website and chatbots. Furthermore, the understandability scores were evaluated using the Patient Education Materials Assessment Tool (PEMAT).

RESULTS

The appropriateness of the chatbots' responses was 84.0% for ChatGPT-3.5 and Bard and 80% for Bing Chat (P > .05). For understandability (mean PEMAT-U score AAPOS website: 81.5%, Bard: 77.6%, ChatGPT-3.5: 76.1%, and Bing Chat: 71.5%, P < .05) and actionability (mean PEMAT-A score AAPOS website: 74.6%, Bard: 69.2%, ChatGPT-3.5: 67.8%, and Bing Chat: 64.8%, P < .05), the AAPOs website scored better than the chat-bots. Three readability analyses showed that Bard had the highest mean score, followed by the AAPOS website, Bing Chat, and ChatGPT-3.5, and these scores were more challenging than the recommended level.

CONCLUSIONS

Chatbots have the potential to provide detailed and appropriate responses at acceptable levels. The AAPOS website has the advantage of providing information that is more understandable and actionable. The AAPOS website and chatbots, especially Chat-GPT, provided difficult-to-read data for patient education regarding amblyopia. [J Pediatr Ophthalmol Strabismus. 20XX;X(X):XXX-XXX.].

Associations between the cause of amblyopia and pre-treatment contrast sensitivity, stereoacuity, fixation, and nystagmus

Purpose

To explore the association between the cause of amblyopia and pre-treatment contrast sensitivity, stereoacuity, fixation and nystagmus.

Design

Retrospective cohort study.

Methods

A retrospective review was conducted for 3408 patients with amblyopia who had not yet started amblyopia treatment utilizing a large amblyopia patient database maintained at Zhongshan Ophthalmic Centre. Six amblyogenic factor subtypes were identified: anisometropia, isoametropia, strabismus, anisometropia and strabismus, monocular visual deprivation, and binocular visual deprivation amblyopia. Monocular best corrected visual acuity (BCVA), the contrast sensitivity function (CSF), fixation, and stereopsis were compared between the subtypes before and after propensity score matching (PSM) for age and sex.

Results

The two deprivation groups had poorer BCVA and CSF than the other groups. There were no systematic differences in CSF between the non-deprivation groups. Nystagmus was more common in the bilateral amblyopia groups compared to the monocular amblyopia groups. Eccentric fixation was uncommon with the exception of the anisometropia and strabismus group which had an eccentric fixation rate of 20%. Distance stereoacuity measured without monocular cues was absent for almost all patients. The results were consistent when analyzed using PSM.

Conclusion

Visual deprivation causes more severe amblyopia than other amblyogenic factors. For non-deprivation amblyopia subtypes, individual differences such as variation in the severity of the amblyogenic factor might be more important in determining pre-treatment vision than whether amblyopia was caused by refractive error, strabismus or both.

Resting-State Functional Connectivity of the Primary Visual Cortex in Children with Anisometropia Amblyopia

INTRODUCTION

This study aimed to explore the functional connectivity of the primary visual cortex (V1) in children with anisometropic amblyopia by using the resting-state functional connectivity analysis method and determine whether anisometropic amblyopia is associated with changes in brain function.

METHODS

Functional magnetic resonance imaging (fMRI) data were obtained from 16 children with anisometropia amblyopia (CAA group) and 12 healthy children (HC group) during the resting state. The Brodmann area 17 (BA17) was used as the region of interest, and the functional connection (FC) of V1 was analyzed in both groups. A two-sample t test was used to analyze the FC value between the two groups. Pearson's correlation was used to analyze the correlation between the mean FC value in the brain function change area of the CAA group and the best corrected visual acuity (BCVA) of amblyopia. p < 0.05 was considered statistically significant.

RESULTS

There were no significant differences in age and sex between the CAA and HC groups (p > 0.05). Compared to the HC group, the CAA group showed lower FC values in BA17 and the left medial frontal gyrus, as well as BA17 and the left triangle inferior frontal gyrus. Conversely, the CAA group showed higher FC values in BA17 and the left central posterior gyrus. Notably, BCVA in amblyopia did not correlate with the area of change in mean FC in the brain function of the CAA group.

CONCLUSION

Resting-state fMRI-based functional connectivity analysis indicates a significant alteration in V1 of children with anisometropic amblyopia. These findings contribute additional insights into the neuropathological mechanisms underlying visual impairment in anisometropic amblyopia.

Perceptual Learning Based on the Lateral Masking Paradigm in Anisometropic Amblyopia With or Without a Patching History

Purpose

Perceptual learning (PL) has shown promising performance in restoring visual function in adolescent amblyopes. We retrospectively compared the effect of a well-accepted PL paradigm on patients with anisometropic amblyopia with or without a patching therapy history (patching therapy [PT] group versus no patching therapy [NPT] group).

Methods

Eighteen PT and 13 NPT patients with anisometropic amblyopia underwent monocular PL for 3 months. During training, patients practiced a Gabor detection task following the lateral masking paradigm by applying a temporal two-alternative forced choice procedure with the amblyopic eye. Monocular contrast sensitivity functions (CSF), visual acuity, interocular differences in visual function metrics, and stereoacuity were compared before and after training.

Results

PL improved the visual acuity of the amblyopia eyes by 0.5 lines on average in the PT group and 1.5 lines in the NPT group. A significant reduction in the interocular difference in visual acuity was observed in the NPT group (P < 0.01) but not in the PT group (P = 0.05). Regarding CSF metrics, the area under the log CSF and cutoff in the amblyopic eyes of the NPT groups increased after training (P < 0.05). In addition, the interocular differences of the CSF metrics (P < 0.05) in the NPT group were significantly reduced. However, in the PT group, all the CSF metrics were unchanged after training. A total of 27 of 31 patients in both groups had no measurable stereopsis pretraining, and recovery after training was not significant.

Conclusions

PL based on a lateral masking training paradigm improved visual function in anisometropic amblyopia. Patients without a patching history achieved greater benefits.

Translational Relevance

PL based on a lateral masking training paradigm could be a new treatment for amblyopia.

Effectiveness of a Novel Video Game Platform in the Treatment of Pediatric Amblyopia

PURPOSE

To test the non-inferiority of a novel game platform for the treatment of pediatric amblyopia compared to standard eye patching.

METHODS

Forty participants (ages 4 to 18 years) across seven optometric clinics in the United States diagnosed as having amblyopia associated with anisometropia were randomly assigned to either 12 weeks of eye patching therapy (n = 19) or Barron Vision (Barron Associates, Inc) video game treatment (n = 21). Participants in the eye patching group with best corrected visual acuity (BCVA) worse than 20/200 in their amblyopic eye were prescribed 6 hours of patching daily, whereas those whose BCVA was 20/200 (1.00 logarithm of the minimum angle of resolution [logMAR]) or better were instructed to patch for 2 hours daily. Participants in the video game group, irrespective of the severity of their amblyopia, were instructed to play four different 5-minute mini-games five times a week for a total of 20 minutes a day.

RESULTS

A mixed linear modeling analysis of before and after BCVA differences after 12 weeks showed the non-inferiority of video game treatment to eye patching using a 0.10 logMAR threshold while adjusting for the participant's age, sex, and baseline BCVA.

CONCLUSIONS

The results of the study suggest that a 12-week home-based video game vision therapy intervention can provide equivalent treatment outcomes to eye patching for amblyopia in children ages 5 to 18 years. Video game-based vision therapy may be a more acceptable and time-efficient alternative to existing approaches. By incorporating elements of perceptual learning, approaches such as Barron Vision video game treatment may have additional long-term therapeutic benefits and may improve treatment compliance. [J Pediatr Ophthalmol Strabismus. 2024;61(1):20-29.].

[Wavefront characteristics in amblyopia of different etiologies in children]

Purpose. The study investigates corneal and higher-order internal aberrations in patients with amblyopia of different etiologies and their relationship with visual acuity, refraction, axial length, and fixation parameters.

MATERIAL AND METHODS

Forty-five patients (90 eyes) were examined. All patients were divided into five groups: 1 - with dysbinocular amblyopia; 2 - with refractive amblyopia; 3 - with anisometropic amblyopia; 4 - with relative amblyopia due to congenital myopia; 5 (control) - fellow eyes without amblyopia. Aberrometry was performed using the OPD-Scan III device (Nidek, Japan). Fixation parameters were studied on the MP-3 microperimeter (Nidek, Japan). Correlation analysis was performed using Pearson's linear correlation coefficient (r).

RESULTS

In amblyopia associated with congenital myopia, a significant increase in corneal and internal aberrations RMS, Total HOA, astigmatism (V) (0.65±0.26; 1.01±0.31; 4.22±1.17; -2.17±0.72; 0.86±0.3, respectively; control group - 0.44±0.19; 0.58±0.27; 1.0±0.75; -0.94±0.89; 0.47±0.65) and internal spherical aberration (0.06±0.02; control group - 0.04±0.03) was found. In dysbinocular amblyopia, a significant increase in internal aberrations Trefoil (V) and Coma (H) (0.75±0.52 and 0.17±0.35, respectively; control group - 0.05±0.28 and -0.07±0.21) was found, which correlated with a decrease in fixation density in the 2° ring (r= -0.40, r= -0.41).

CONCLUSIONS

The increased level of higher-order aberrations in amblyopia associated with congenital myopia is due to the anatomical and optical features of the eyes. The increase in internal aberrations Trefoil (V) and Coma (H) in dysbinocular amblyopia is associated with a mismatch of the optical elements of the eye due to impaired fixation, i.e., it is not the cause, but the consequence of amblyopia.

Multifocal intraocular lens implantation in children with unilateral congenital cataracts

PURPOSE

To evaluate the vision recovery, reconstruction of binocular visual function, and influencing factors after multifocal intraocular lens implantation in children with unilateral congenital cataracts.

SETTING

University hospital.

DESIGN

Prospective clinical study.

METHODS

In the prospective clinical study, 55 children aged 3 to 14 with unilateral congenital cataracts received multifocal intraocular lenses (TECNIS ZMB00) posterior optic capture from 2019 to 2022. Corrected distance visual acuity (CDVA; 5 m), distance-corrected intermediate visual acuity (DCIVA; 66 cm), distance-corrected near visual acuity (DCNVA; 33 cm), stereoscopic vision, visual quality (objective scatter index [OSI] and modulation transfer function [MTF]), axial length (AL), keratometry (K), and contrast sensitivity (CS), as well as postoperative occlusion compliance were evaluated before and after surgery.

RESULTS

At the final follow-up, 90.91% (50/55) patients showed significant improvement in visual acuity (VA) after surgery. CDVA, DCIVA and DCNVA were 0.23 ± 0.17, 0.39 ± 0.15, and 0.44 ± 0.15 logMAR, respectively. 69.09% (38/55) patients achieved good VA (better than 0.3 logMAR).52.76% (25/48) patients had a positive Titmus test. OSI and MTF were 1.24 ± 0.91 and 42.45 ± 12.30, respectively. 73.68% (28/38) of the patients (better than 0.3 logMAR) underwent strict occlusion therapy. Postoperative VA is correlated with preoperative CDVA ( r = -0.829, P < .001), corneal astigmatism ( r = 0.384, P = .036), △AL (difference between the cataract eyes and contralateral eyes, r = -0.490, P = .006), and occlusion compliance ( r = -0.806, P < .001).

CONCLUSIONS

Multifocal intraocular lens implantation could obtain relatively satisfactory VA (CDVA, DCIVA and DCNVA) and the binocular visual function of children with unilateral congenital cataracts. Postoperative VA is related to preoperative VA, corneal astigmatism, △AL, and occlusion compliance.

Reduced perception-action dissociation in children with amblyopia

The functional distinction between vision-for-perception and vision-for-action is a key aspect of understanding the primate visual system. While this dissociation has been well-established in adulthood, its development and dependence on typical visual experience remain unclear. To address these questions, we examined two groups of children: typically developed children and those with amblyopia, who presumably have a sub-optimal visual experience. The Ponzo illusion, known to impact perception but not visuomotor behaviors across age groups, was employed to assess the extent of dissociation. Participants engaged in two tasks involving the Ponzo illusion: a grasping task (vision-for-action) and a manual estimation task (vision-for-perception), with objects placed on the "close" and "far" surfaces of the illusion. Typically developed children displayed grasping movements that were unaffected by the illusion, as their grasping apertures were scaled based on object size, independent of its location. In contrast, children with amblyopia exhibited a clear susceptibility to the illusion, showing larger apertures for objects placed on the 'far' surface of the illusion, and smaller apertures for objects placed on the 'close' surface. Interestingly, both groups of children demonstrated similar susceptibility to the illusion during the perceptual task, with objects placed on the far surface being perceived as longer compared to objects placed on the close surface. These findings shed light on the impact of atypical visual development on the emergence of the dissociation between perception and action, highlighting the crucial role of typical visual experience in establishing this distinction.

Evaluation of Publications from the American Academy of Ophthalmology: A 5-Year Analysis of Ophthalmology Literature

Objective

To analyze recent publications in Ophthalmology, the journal of the American Academy of Ophthalmology.

Design

Retrospective review of published articles.

Participants

No human participants were involved in the study.

Methods

Articles published in Ophthalmology from January 2018 to December 2022 were reviewed and analyzed.

Main Outcome Measures

Research and review articles were included and analyzed per the following: total number of published articles based on related subspecialty area, level of evidence using the modified Oxford level of evidence, number of citations, number of listed authors, gender of the corresponding author, country of affiliation of the corresponding and contributing author(s), and involvement of consortium(s), group(s), or committee(s).

Results

A total of 965 articles were included. The mean (standard deviation) number of authors per article was 8.6 (5.7) and the majority of corresponding authors were male (665, 70.7%). The greatest number of published articles were related to retina (296, 30.7%) followed by glaucoma (172, 17.8%). The greatest number of Preferred Practice Pattern guidelines were also related to retina (7/24, 29.1%), followed by cornea/dry eye syndrome/external disease (6/24, 25%). Retina (77) had the most level 1 evidence, glaucoma (30) for level 2 evidence, and retina for levels 3 (69) and 4 (65). There were 223 articles contributed by consortia/groups/committees, with most from retina (73, 32.7%) followed by glaucoma (40, 17.9%). The mean number of citations per subspecialty article was highest in retina (45.8/article), followed by uveitis (31.7/article). The United States had the greatest number of affiliated corresponding authors (544, 56.4%), followed by the United Kingdom (68, 7.0%). There were 357 (37.0%) articles with coauthors affiliated outside the corresponding author's country of affiliation, although with a downward trend over the most recent 5-year period. There has been an increasing trend in the number of authors and consortia/group/committee involvement in publications.

Conclusions

Although team science and collaborations have increased recently, ongoing efforts to diversify individuals, groups, and subspecialties may be needed.

Financial Disclosures

Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Levodopa/Carbidopa to Augment the Treatment of Amblyopia: A Report by the American Academy of Ophthalmology

PURPOSE

To review the published literature on the use of levodopa/carbidopa to augment the treatment of amblyopia.

METHODS

Literature searches for English language studies were last conducted in October 2022 in the PubMed database with no date restrictions. The combined searches yielded 55 articles, of which 23 were reviewed in full text. Twelve of these were considered appropriate for inclusion in this assessment and were assigned a level of evidence rating by the panel methodologist. Nine studies were rated level I, and 3 studies were rated level II; there were no level III studies.

RESULTS

The duration of treatment was limited to 3 to 16 weeks because of concern about long-term adverse effects such as tardive dyskinesia. This complication was not reported in any of the study participants. The dose of levodopa ranged from 1.5 to 8.3 mg/kg/day, generally divided into 3 daily doses. The carbidopa dose was approximately 25% of the levodopa dose in all treatments. Evidence from these studies indicates that augmenting traditional patch occlusion therapy with the oral administration of levodopa/carbidopa can improve the vision of amblyopic children, but the effect was small (0.17-0.3 logarithm of the minimum angle of resolution [logMAR] units) and only statistically significant when compared with patching alone in 2 of the 12 studies cited. Regression of vision was reported in the majority of studies (9 of 12 reported; range, 0-0.17 logMAR unit regression) after discontinuation of therapy. Short-term side effects of the medications were not consistently reported but were most frequently mild and included headache and nausea.

CONCLUSIONS

The best available evidence is currently insufficient to show that augmenting amblyopia therapy using up to 16 weeks of levodopa/carbidopa will result in meaningful improvement in visual acuity. Given the potential for significant side effects such as tardive dyskinesia with long-term therapy, levodopa/carbidopa does not appear to be a viable option for amblyopia therapy FINANCIAL DISCLOSURE(S): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Amblyopia-A novel virtual round table to explore the caregiver perspective

PURPOSE

A survey aimed to capture the caregiver's perspective on the impact of amblyopia and its treatment on the child and family, as well as caregivers' views on the design and feasibility of clinical trials investigating dichoptic binocular therapies for amblyopia.

METHODS

Parents of amblyopic children, patient advocates and healthcare professionals took part in a moderated, structured discussion on a novel virtual advisory-board platform.

RESULTS

Seven parents of children with amblyopia, two patient organisation representatives, one ophthalmologist and one optometrist participated in the survey. A total of 645 posts were entered on the platform over a 14-day period in September 2021. There was widespread agreement that the management of amblyopia poses more of a burden on the child and family than the condition itself, with treatment burden accentuated when treatment is unsuccessful. Parents expressed uncertainty and frustration in relation to the duration of patching, success of patching and alternative treatment options, and felt there was inadequate readily available, easy-to-understand information on the condition. Parents reported that a new treatment for amblyopia, such as dichoptic binocular therapy using video games, should be safe, non-invasive and engaging compared with an eye patch. Treating at home, potentially for a shorter treatment duration, and with an entertaining game were the main reasons parents would join a clinical study with this type of novel therapy. However, due to a limited critical period treatment window, parents would feel more comfortable joining a clinical trial if traditional therapies were offered in conjunction with those under investigation.

CONCLUSION

Patient perspectives and the role of caregivers in the acceptance of any interventional treatments are increasingly recognised. Understanding how amblyopia and its treatment impacts a child and family should be an important premise to guide therapy and evaluate treatment value, both in clinical trials and in routine medical practice.

The Suppressive Basis of Ocular Dominance Changes Induced by Short-Term Monocular Deprivation in Normal and Amblyopic Adults

Purpose

We aimed to study the effect of short-term monocular deprivation on the suppressive interocular interactions in normals and amblyopes by using a dichoptic masking paradigm.

Methods

Nine adults with anisometropic or mixed amblyopia and 10 control adults participated in our study. The contrast sensitivity in discriminating a target Gabor dichoptically masked was measured before and after 2 hours of monocular deprivation. The mask consisted of bandpass-filtered noise. Both the target and the mask were horizontally oriented at the spatial frequency of 1.31 cpd. Deprivation was achieved using an opaque patch on the amblyopic eye of amblyopes and the dominant eye of controls.

Results

Results were similar in both controls and amblyopes. After 2 hours of monocular deprivation, the previously patched eye showed a significant increase in contrast sensitivity under dichoptic masking, which also suggested reduced suppressive effect from the nonpatched eye. Meanwhile, the contrast sensitivity of the nonpatched eye remained almost unchanged under dichoptic masking.

Conclusions

We demonstrate that the ocular dominance changes induced by short-term monocular deprivation-namely, the strengthening of the deprived eye's contribution-are associated with the unilateral and asymmetric changes in suppressive interaction. The suppression from the nondeprived eye is reduced after short-term monocular deprivation. This provides a better understanding of how inverse patching (patching of the amblyopic eye) could, by reducing the suppressive drive from the normally sighted (nondeprived) eye, form the basis of a new treatment for the binocular deficit in amblyopia.

Amblyopia treatment outcomes in patients with neurodevelopmental disorders

PURPOSE

To compare amblyopia treatment outcomes between patients with neurodevelopmental disorders and their typically developing peers.

METHODS

Of 2,311 patients diagnosed with amblyopia between 2010 and 2014 at Boston Children's Hospital, 460 met inclusion criteria (age 2-12 with anisometropic, strabismic, or mixed amblyopia [interocular difference (IOD) ≥2 lines]). Treatment and visual outcomes were analyzed according to neurodevelopmental status: neurodevelopmental delay (DD) versus typical development (TD).

RESULTS

The DD group (n = 54) and TD group (n = 406) were similar in demographics, amblyogenic risk factors, baseline visual measures, prescribed therapy, and adherence (P ≥ 0.10). Between-visit follow-up time was longer for the DD group (0.65 [0.42- 0.97] years) than for the TD group (0.5 [0.36-0.82] years; P = 0.023). IOD improved similarly in each group by the last visit (DD, -0.15 logMAR [-0.31 to -0.02]; TD, -0.2 logMAR [-0.38 to -0.1]; P = 0.09). Each group reached amblyopia resolution by the last visit at similar frequencies (DD, 23/54 [43%]; TD, 211/406 [52%]; P > 0.2). DD diagnosis did not independently influence amblyopia resolution (HR, 0.77; 95% CI, 0.53-1.12; P = 0.17), but each additional month of interval time between follow-up visits reduced the likelihood of resolution by 2.7% (HR, 0.67; 95% CI, 0.51-0.87; P = 0.003).

CONCLUSIONS

Patients with DD and those with TD responded similarly to amblyopia therapy; however, follow-up intervals were longer in patients with DD and correlated with the likelihood of persistent amblyopia, suggesting that greater efforts at assuring follow-up may benefit patients with DD.

Implementation of Rapid Genome Sequencing for Critically Ill Infants With Complex Congenital Heart Disease

BACKGROUND

Rapid genome sequencing (rGS) has been shown to improve care of critically ill infants. Congenital heart disease (CHD) is a leading cause of infant mortality and is often caused by genetic disorders, yet the utility of rGS has not been prospectively studied in this population.

METHODS

We conducted a prospective evaluation of rGS to improve the care of infants with complex CHD in our cardiac neonatal intensive care unit.

RESULTS

In a cohort of 48 infants with complex CHD, rGS diagnosed 14 genetic disorders in 13 (27%) individuals and led to changes in clinical management in 8 (62%) cases with diagnostic results. These included 2 cases in whom genetic diagnoses helped avert intensive, futile interventions before cardiac neonatal intensive care unit discharge, and 3 cases in whom eye disease was diagnosed and treated in early childhood.

CONCLUSIONS

Our study provides the first prospective evaluation of rGS for infants with complex CHD to our knowledge. We found that rGS diagnosed genetic disorders in 27% of cases and led to changes in management in 62% of cases with diagnostic results. Our model of care depended on coordination between neonatologists, cardiologists, surgeons, geneticists, and genetic counselors. These findings highlight the important role of rGS in CHD and demonstrate the need for expanded study of how to implement this resource to a broader population of infants with CHD.

Human deprivation amblyopia: treatment insights from animal models

Amblyopia is a common visual impairment that develops during the early years of postnatal life. It emerges as a sequela to eye misalignment, an imbalanced refractive state, or obstruction to form vision. All of these conditions prevent normal vision and derail the typical development of neural connections within the visual system. Among the subtypes of amblyopia, the most debilitating and recalcitrant to treatment is deprivation amblyopia. Nevertheless, human studies focused on advancing the standard of care for amblyopia have largely avoided recruitment of patients with this rare but severe impairment subtype. In this review, we delineate characteristics of deprivation amblyopia and underscore the critical need for new and more effective therapy. Animal models offer a unique opportunity to address this unmet need by enabling the development of unconventional and potent amblyopia therapies that cannot be pioneered in humans. Insights derived from studies using animal models are discussed as potential therapeutic innovations for the remediation of deprivation amblyopia. Retinal inactivation is highlighted as an emerging therapy that exhibits efficacy against the effects of monocular deprivation at ages when conventional therapy is ineffective, and recovery occurs without apparent detriment to the treated eye.

Gene Therapy in Hereditary Retinal Dystrophies: The Usefulness of Diagnostic Tools in Candidate Patient Selections

PURPOSE

Gene therapy actually seems to have promising results in the treatment of Leber Congenital Amaurosis and some different inherited retinal diseases (IRDs); the primary goal of this strategy is to change gene defects with a wild-type gene without defects in a DNA sequence to achieve partial recovery of the photoreceptor function and, consequently, partially restore lost retinal functions. This approach led to the introduction of a new drug (voretigene neparvovec-rzyl) for replacement of the RPE65 gene in patients affected by Leber Congenital Amaurosis (LCA); however, the treatment results are inconstant and with variable long-lasting effects due to a lack of correctly evaluating the anatomical and functional conditions of residual photoreceptors. These variabilities may also be related to host immunoreactive reactions towards the Adenovirus-associated vector. A broad spectrum of retinal dystrophies frequently generates doubt as to whether the disease or the patient is a good candidate for a successful gene treatment, because, very often, different diseases share similar genetic characteristics, causing an inconstant genotype/phenotype correlation between clinical characteristics also within the same family. For example, mutations on the RPE65 gene cause Leber Congenital Amaurosis (LCA) but also some forms of Retinitis Pigmentosa (RP), Bardet Biedl Syndrome (BBS), Congenital Stationary Night Blindness (CSNB) and Usher syndrome (USH), with a very wide spectrum of clinical manifestations. These confusing elements are due to the different pathways in which the product protein (retinoid isomer-hydrolase) is involved and, consequently, the overlapping metabolism in retinal function. Considering this point and the cost of the drug (over USD one hundred thousand), it would be mandatory to follow guidelines or algorithms to assess the best-fitting disease and candidate patients to maximize the output. Unfortunately, at the moment, there are no suggestions regarding who to treat with gene therapy. Moreover, gene therapy might be helpful in other forms of inherited retinal dystrophies, with more frequent incidence of the disease and better functional conditions (actually, gene therapy is proposed only for patients with poor vision, considering possible side effects due to the treatment procedures), in which this approach leads to better function and, hopefully, visual restoration. But, in this view, who might be a disease candidate or patient to undergo gene therapy, in relationship to the onset of clinical trials for several different forms of IRD? Further, what is the gold standard for tests able to correctly select the patient? Our work aims to evaluate clinical considerations on instrumental morphofunctional tests to assess candidate subjects for treatment and correlate them with clinical and genetic defect analysis that, often, is not correspondent. We try to define which parameters are an essential and indispensable part of the clinical rationale to select patients with IRDs for gene therapy. This review will describe a series of models used to characterize retinal morphology and function from tests, such as optical coherence tomography (OCT) and electrophysiological evaluation (ERG), and its evaluation as a primary outcome in clinical trials. A secondary aim is to propose an ancillary clinical classification of IRDs and their accessibility based on gene therapy's current state of the art.

MATERIAL AND METHODS

OCT, ERG, and visual field examinations were performed in different forms of IRDs, classified based on clinical and retinal conditions; compared to the gene defect classification, we utilized a diagnostic algorithm for the clinical classification based on morphofunctional information of the retina of patients, which could significantly improve diagnostic accuracy and, consequently, help the ophthalmologist to make a correct diagnosis to achieve optimal clinical results. These considerations are very helpful in selecting IRD patients who might respond to gene therapy with possible therapeutic success and filter out those in which treatment has a lower chance or no chance of positive results due to bad retinal conditions, avoiding time-consuming patient management with unsatisfactory results.

Dichoptic Game Training in Strabismic Amblyopia Improves the Visual Evoked Response

Dichoptic video gaming offers an alternative approach in amblyopia treatment by allowing different information to be presented in the two eyes, resulting to reduced suppression and/or enhanced fusion. The aim of this case report series is to evaluate the outcome of supervised dichoptic training, with the use of video games in a virtual reality (VR) system, on far and near visual acuity (VA), stereoacuity, and the visual evoked response of an adult and two children with strabismic amblyopia. Results suggest that despite the absence of improvement in VA following supervised dichoptic training, a remarkable increase in stereoacuity was evident with a concurrent decrease in phorias. Moreover, an improvement in the P100 latency of the pattern visual evoked potentials (VEPs) in the amblyopic eye was observed in all participants. Finally, at least two sessions per week were completed for each patient under continuous supervision, implying sufficient compliance and treatment efficiency with dichoptic video gaming. Supervised dichoptic training, consisting of at least 20 hours of video gaming using a VR system, improves stereoacuity and the latency of the visual evoked response in the amblyopic eye. This probably occurs by overcoming its suppression, indicating that the speed of visual processing, as evaluated by pattern VEPs, may precede improvements in VA.

Assessment of macular microvascular changes in children following treatment of anisometropic myopic amblyopia using optical coherence tomography angiography

PURPOSE

To evaluate macular microvascular changes in the form of foveal avascular zone (FAZ) area and vessel density in the superficial, deep capillary plexuses, and choriocapillaris using optical coherence tomography angiography (OCTA) in children with anisometropic myopic amblyopia before and after treatment.

METHODS

This prospective observational study included 32 patients younger than 12 years old with anisomyopic amblyopia. OCTA was done before patients' treatment with optical correction with or without patching and was repeated after successful amblyopia treatment. Outcomes included superficial, deep, and choriocapillaris vessel density (VD) and superficial and deep FAZ areas.

RESULTS

The study included 13 males (40.6%) and 19 females (59.4%), and the mean age was 9.52 ± 1.33 years. Fifty-three percent (53%) of patients needed only optical correction, and the remaining 47% needed additional patching therapy. After successful treatment, there was a significant improvement in amblyopic eyes in best-corrected visual acuity (p < 0.001), with higher VD values in superficial capillary plexuses (p < 0.001), deep capillary plexuses (p < 0.001), and foveal choriocapillaris (p = 0.030). In the glasses with patching subgroup, the difference between pre-treatment and post-treatment parameters revealed a significant improvement in vessel density in superficial retinal plexuses (foveal and parafoveal; p values 0.023 and < 0.001, respectively) and deep retinal plexuses (whole image, foveal, and parafoveal; p values 0.003, < 0.001, and 0.002, respectively). While amblyopic eyes treated with glasses alone had a significantly greater difference in choriocapillaris foveal VD (p value = 0.022).

CONCLUSION

After effective amblyopia treatment, amblyopic eyes exhibited improved best-corrected visual acuity and better macular perfusion along the superficial, deep vascular density, and choriocapillaris foveal VD.

CLINICAL TRIAL REGISTRATION

CinicalTrials.gov Identifier: NCT05223153.

Validation of the Waterloo Differential Visual Acuity Test (WatDAT) and Comparison With Existing Pediatric Tests of Visual Acuity

Purpose

The new Waterloo Differential Acuity Test (WatDAT) is designed to allow recognition visual acuity (VA) measurement in children before they can typically undertake matching tests. The study purpose was to validate WatDAT in adults with normal and reduced VA.

Methods

Eighty adults (18 to <40 years of age) participated (32 normal VA, 12 reduced VA, and 36 simulated reduced VA). Monocular VA was measured on two occasions in random order for WatDAT (versions with 3 and 5 distractors for Faces and Patti Pics house among circles), Lea Symbols, Kay Pictures and Patti Pics matching tests, Teller Acuity Cards, Cardiff Acuity Test, and Early Treatment Diabetic Retinopathy Study (ETDRS) letter chart. Pediatric tests were validated against ETDRS using limits of agreement (LoA), sensitivity, and specificity. The LoA for repeatability were also determined.

Results

WatDAT showed minimal bias compared with ETDRS, and LoAs, which were similar to pediatric matching tests (0.241-0.250). Both preferential looking tests showed higher bias and LoAs than ETDRS. Matching tests showed good agreement with ETDRS, except for Kay Pictures and Lea Uncrowded test, which overestimated VA. WatDAT showed high sensitivity (>0.96) and specificity (>0.79), which improved with criterion adjustment and were significantly higher than for the preferential looking tests. LoA for repeatability for WatDAT 3 Faces and WatDAT 5 Faces were comparable with the ETDRS.

Conclusions

WatDAT demonstrates good agreement and repeatability compared with the gold-standard ETDRS letter chart, and performed better than preferential looking tests, the alternative until a child can undertake a matching VA test.

Translational Relevance

Good validity of the Waterloo Differential Acuity Test was demonstrated in adults as a first step to showing its potential for detecting childhood visual disorders.

Comparison of Retinal and Choroidal Microvasculature Changes in Monocular Amblyopic and Non-amblyopic Eyes following Short-term Patch Occlusion Treatment

PURPOSE

Our objective was to investigate whether there were differences in the short-term changes of retinal and choroidal microvasculature between amblyopic and non-amblyopic eyes after patch occlusion treatment in patients with monocular amblyopia. Additionally, we aimed to determine if these changes were associated with improvements in clinical parameters.

METHODS

We conducted a retrospective, longitudinal paired-eye case-control study by analyzing the medical records of patients under the age of 12 who had monocular amblyopia and underwent patch occlusion treatment for a duration of 2 to 12 months. Using optical coherence tomography angiography images, we compared the foveal avascular zone width, retinal blood vessel density (VD), choroidal thickness (CT), and choroidal vascularity index (CVI) in amblyopic and non-amblyopic eyes before and after patch occlusion treatment. We analyzed the correlations between the aforementioned parameters and changes in best-corrected visual acuity (BCVA) and stereopsis.

RESULTS

Overall, 114 eyes from 57 patients were enrolled. At baseline, parafoveal superficial plexus VD, foveal and parafoveal deep capillary plexus VD (DCPD) were lower by 0.994 ± 3.312% (p = .026), 2.403 ± 8.273% (p = .033), and 2.469 ± 4.095% (p < .001), respectively; CT was thicker by 30.6 ± 90.7 μm (p = .014); and CVI was higher by 1.920 ± 3.432% (p < 001) in the amblyopic eyes than in the non-amblyopic eyes. Following short-term patch occlusion treatment, foveal and parafoveal DCPD increased by 1.264 ± 3.829% (p = .017) and 1.028 ± 3.662% (p = .036), respectively, CT thinned by 15.5 ± 51.5 μm (p = .019), and CVI decreased by 1.296 ± 3.997% (p = .018) in the amblyopic eyes. Following patch occlusion treatment, as the foveal DCPD decreased and CVI increased, the BCVA improved (p = .017 and .035, respectively).

CONCLUSION

Following patch occlusion treatment, increased foveal DCPD and decreased CVI were associated with improved BCVA.

Short-term effects of occlusion therapy and optical correction on microvasculature in monocular amblyopia: a retrospective case-control study

This retrospective longitudinal case-control study investigated the short-term effects of patch occlusion treatment compared with optical correction on the microvasculature in monocular amblyopia. We included patients with monocular amblyopia treated for 2-12 months; they were classified into two groups according to the treatment regimen: patch occlusion or optical correction. Children aged < 12 years who presented to our clinic for examination without amblyopia diagnosis were enrolled as the control group. Changes in retinal and choroid microvasculature according to treatment were examined, and the correlation between changes in microvasculature and improvement in best-corrected visual acuity (BCVA) was evaluated. There were 57, 35, and 41 patients in the patch occlusion, optical correction, and control groups, respectively (mean age, 6.4 ± 2.0 years). Both amblyopic groups showed changes in the foveal and parafoveal deep capillary plexus vessel density (DCPD), choroidal thickness, and choroidal vascularity index (CVI) following short-term treatment (mean, 4.5 months). In the patch occlusion group, BCVA improved as the foveal DCPD increased (P = 0.013) and the CVI decreased (P = 0.037). In the optical correction group, BCVA improved as the foveal and parafoveal DCPD increased (P = 0.009). Increased foveal DCPD following amblyopia treatment and decreased CVI by patch occlusion were associated with improved BCVA.

Characteristics and predictive factors of visual function improvements after monocular perceptual learning in amblyopia

Monocular perceptual learning has shown promising performance in restoring visual function in amblyopes beyond the critical period in the laboratory. However, the treatment outcome is variable and indeterminate in actual clinical and neuroscientific practice. We aimed to explore the efficacy of monocular perceptual learning in the clinical setting. By combining continuous monitoring of perceptual learning and clinical measurements, we evaluated the efficacy and characteristics of visual acuity and contrast sensitivity function improvement and further explored the individualized effect after perceptual learning. Amblyopes (average age:17 ± 7 years old) were trained in a monocular two-alternative forced choice identification task at the 50% contrast threshold of the amblyopic eye for 10-15 days. We found that monocular perceptual learning improves both visual acuity and contrast sensitivity function in amblyopia. The broader activation of spatial contrast sensitivity, with a significant improvement in lower spatial frequencies, contributed to improving visual acuity. Visual acuity changes in the early stage can predict the endpoint treatment outcomes. Our results confirm the efficacy of monocular perceptual learning and suggest potential predictors of training outcomes to assist in the future management of clinical intervention and vision neuroscience research in amblyopia beyond the critical period of visual plasticity.

Translating and evaluating the Chinese version of Pediatric Eye Questionnaire (PedEyeQ-CN) for children

OBJECTIVES

To investigate the reliability and validity of Chinese version of the Pediatric Eye Questionnaire (PedEyeQ-CN) by testing ophthalmic patients in China.

METHODS

The PedEyeQ (standard English version) was translated by local researchers. Children were asked to complete the Child section, and their parents the Proxy and Parent sections. 160 children (32 normal controls, 77 with refractive error, 48 with strabismus/amblyopia, 3 with other eye conditions) aged 5-11 years old, and one parent of each child were recruited. Cronbach's α and intraclass correlation coefficient were calculated to examine the reliability and test-retest reliability; the score differences between controls and patients were compared to examine the validity.

RESULTS

The internal consistency (Cronbach's α ≥ 0.76) and test-retest reliability (r > 0.80) of PedEyeQ-CN were robust. Children with eye conditions had lower scores compared with children with normal vision (refractive error: 10 out of 13 domains, P ≤ 0.021; strabismus/amblyopia: all domains, P ≤ 0.015). Children with strabismus/amblyopia had lower scores compared with children with refractive error (two domains, P = 0.048, P = 0.001). Visual acuity was significantly correlated with functional vision (P = 0.005), but not significantly correlated with the eye-related quality of life (ER-QOL).

CONCLUSIONS

The PedEyeQ-CN is a valuable tool for assessing the functional vision and ER-QOL of Chinese children and help us increase our understanding about the impact of eye conditions on children and their families.

Clinical analysis of eye movement-based data in the medical diagnosis of amblyopia

Amblyopia is an abnormal visual processing-induced developmental disorder of the central nervous system that affects static and dynamic vision, as well as binocular visual function. Currently, changes in static vision in one eye are the gold standard for amblyopia diagnosis. However, there have been few comprehensive analyses of changes in dynamic vision, especially eye movement, among children with amblyopia. Here, we proposed an optimization scheme involving a video eye tracker combined with an "artificial eye" for comprehensive examination of eye movement in children with amblyopia; we sought to improve the diagnostic criteria for amblyopia and provide theoretical support for practical treatment. The resulting eye movement data were used to construct a deep learning approach for diagnostic and predictive applications. Through efforts to manage the uncooperativeness of children with strabismus who could not complete the eye movement assessment, this study quantitatively and objectively assessed the clinical implications of eye movement characteristics in children with amblyopia. Our results indicated that an amblyopic eye is always in a state of adjustment, and thus is not "lazy." Additionally, we found that the eye movement parameters of amblyopic eyes and eyes with normal vision are significantly different. Finally, we identified eye movement parameters that can be used to supplement and optimize the diagnostic criteria for amblyopia, providing a diagnostic basis for evaluation of binocular visual function.

Evaluation of retinal microcirculation alterations using optical coherence tomography angiography in patients with hyperopia ametropic amblyopia: A case-control study

Given that there are controversial findings regarding vessel density in amblyopia, we quantified retinal microcirculation using optical coherence tomography angiography and compared it between hyperopic ametropic amblyopia eyes and age-matched control eyes. This case-control study was conducted from March 2021 to March 2022 at the Affiliated Eye Hospital of Nanchang University, Nanchang, China. Both groups included 72 eyes. Foveal avascular zone area, circularity and perimeter, perfusion density and vessel density of macular superficial retinal capillary plexus, macular thickness, macular volume, peripapillary retinal nerve fiber layer thickness, and ganglion cell-inner plexiform layer thickness were compared between hyperopia ametropic amblyopia eyes and age-matched control eyes. Additionally, best-corrected visual acuity, maximum corneal curvature, minimum corneal curvature, and anterior chamber depth were measured. In the hyperopia ametropic amblyopia eyes and control eyes, vessel density was 7.51 ± 2.13 and 9.91 ± 2.71 mm-1 in the central, 17.20 ± 1.38 and 18.25 ± 1.37 mm-1 in the inner, and 17.90 ± 0.88 and 18.43 ± 0.97 mm-1 in the full regions, respectively. The perfusion densities were 0.17 ± 0.06 and 0.23 ± 0.07 in the central, 0.41 ± 0.05 and 0.44 ± 0.03 in the inner, and 0.44 ± 0.03 and 0.46 ± 0.02 in the full regions, respectively. The central macular thicknesses of hyperopia ametropic amblyopia and control eyes were 240.04 ± 20.11 and 235.08 ± 24.41 µm, respectively. Foveal avascular zone perimeter and circularity (P < .043 and P = .001) significantly differed between the 2 groups. Hyperopia ametropic amblyopia eyes showed lower appreciably in vessel and perfusion densities, which could be one of the major pathophysiological mechanisms of hyperopia ametropic amblyopia and provide a new direction for the diagnosis and treatment of amblyopia.

Temporal synchrony discrimination is abnormal in dichoptic but not monocular visual processing in treated anisometropic amblyopes

PURPOSE

To evaluate whether temporal synchrony processing deficits remain when normal visual acuity is restored in adults with unilateral anisometropic amblyopia.

METHODS

We recruited 14 clinically treated anisometropic amblyopes (mean age 23.17 ± 2.53 years) with best-corrected visual acuity ≤ 0.1 logMAR and 15 age-matched emmetropes (mean age 24.40 ± 1.92 years) with normal vision to participate in our experiment. We presented two pairs of flicking Gaussian dots (1 Hz) as visual stimuli: one pair of dots was synchronous (reference), and the other pair of dots was asynchronous (signal). Subjects were asked to determine the position of the asynchronous pair. We applied the constant stimuli method to measure the temporal synchrony threshold under monocular and dichoptic viewing conditions. There were eight temporal phase lags in the asynchronous pair. The minimum degree of the temporal phase at which a participant can discriminate a signal pair is defined as the temporal synchrony threshold.

RESULTS

Under monocular viewing conditions where both the reference and signal pairs were presented to one eye, the temporal synchrony thresholds of previous amblyopic eyes and fellow eyes were not significantly different (p = 0.15). Under dichoptic viewing conditions where both the reference and signal pairs were dichoptically presented to both eyes, the temporal synchrony threshold in the treated anisometropic amblyopes was significantly higher than that of the controls (119.34 ± 20.43 vs. 99.78 ± 16.60 ms, p = 0.009). There was no significant correlation between the monocular and dichoptic viewing conditions in the treated amblyopes (r = -0.22, p = 0.94).

CONCLUSIONS

Temporal synchrony discrimination is abnormal under dichoptic but not under monocular visual stimulation in treated anisometropic amblyopes with normalised visual acuity.

Binocular amblyopia treatment improves manual dexterity

PURPOSE

To determine whether deficits in manual dexterity in children with amblyopia improve after binocular amblyopia treatment and whether improvements are related to age at treatment, baseline sensory status, or amount of improvement in sensory status with treatment.

METHODS

Manual dexterity (Movement Assessment Battery for Children-2), visual acuity, fusion, suppression, and stereoacuity were measured at baseline and after 4-8 weeks of binocular amblyopia in 134 children with amblyopia, including 75 children in the "younger group" (aged 3 to <7 years) and 59 in the "older group" (aged 7-10 years), and in 40 age-similar control children.

RESULTS

Baseline manual dexterity standard scores of amblyopic children were significantly below those of controls in both the younger (8.81 ± 0.33 vs 11.80 ± 0.60 [P < 0.0001]) and older groups (7.19 ± 0.34 vs 9.75 ± 0.57 [P = 0.00013]). After 4-8 weeks of binocular amblyopia treatment, the younger group standard score improved to 9.85 ± 0.35 and the older group improved to 8.08 ± 0.39, but both groups remained significantly lower than controls (P = 0.03 and P = 0.01, resp.). Improvement in manual dexterity standard score was not associated with any baseline factors but was weakly correlated with the amount of visual acuity improvement (rs = 0.26; 95% CI, 0.09-0.41) CONCLUSIONS: Manual dexterity impairments are common among children with amblyopia. In our study cohort, binocular amblyopia treatment improved visual acuity and manual dexterity.

Retrobulbar Blood Flow Parameters in Patients With Anisometropic Amblyopia

Introduction We aim to compare retrobulbar blood flow parameters between the amblyopic eye and the fellow eye in patients with anisometropic amblyopia. Methods Peak systolic velocity (PSV) and end-diastolic velocity (EDV) of the ophthalmic artery (OA), central retinal artery (CRA), and posterior ciliary artery (PCA) were measured by color Doppler imaging (CDI), and the resistivity index (RI) and pulsatility index (PI) were calculated in 62 patients aged 12-40 years with anisometropic amblyopia. Results The mean PSV values of OA, CRA, and PCA in amblyopic and fellow eyes were 30.38 ± 10.34, 8.45 ± 2.27, and 8.03 ± 2.77, and 33.73 ± 14.46, 8.35 ± 2.05, and 8.81 ± 2.77, respectively. The mean EDV values of OA, CRA, and PCA in amblyopic and fellow eyes were 6.86 ± 2.64, 1.47 ± 1.59, and 1.94 ± 2.03, and 8.57 ± 4.30, 1.80 ± 1.73, and 2.32 ± 1.20, respectively. The mean RI values of OA, CRA, and PCA in amblyopic and fellow eyes were 0.77 ± 0.10, 0.85 ± 0.14, and 0.78 ± 0.15, and 0.75 ± 0.07, 0.79 ± 0.20, and 0.74 ± 0.13, respectively. OA-PSV and OA-EDV values were significantly lower in the amblyopic eye than in the healthy eye (p < 0.05). OA-RI values were significantly higher (p < 0.05) in the amblyopic eye than in the healthy eye. Conclusions Considering the decrease in PSV and EDV and the increase in RI, which are the blood flow parameters of the amblyopic eye, our study may provide guidance to focus on increasing blood flow in the treatment of amblyopia.

Refractive errors and ocular findings in children and adolescents with mental disorders: a retrospective study

BACKGROUND

An increasing prevalence of mental disorders (MDs) has been reported among children and adolescents. However, only few studies have conducted ocular examinations, including those on refractive status, in these groups of patients. Thus, the purpose of this study was to evaluate the refractive status and ocular findings in children and adolescents with MDs compared with matched controls with similar socioeconomic backgrounds.

METHODS

A total of 178 participants with MDs and 200 controls were recruited between April 2021 and May 2022. All the children and adolescents underwent cycloplegic or noncycloplegic autorefraction and retinoscopy, slit-lamp biomicroscopy, and dilated fundus examinations. Ocular alignment was assessed using Hirschberg, Krimsky, or prism cover tests. The prevalence of refractive errors and ocular findings was the main outcome.

RESULTS

Twenty-seven percent of patients with MDs and 8% of controls had ocular findings, the most common of which were conjunctivitis, keratitis, and trichiasis. For refractive status, 70% (124/178) of patients with MDs had myopia ≤-1.00 DS, and 2% (4/178) had hyperopia ≥+2.00 DS. In the control group, 70% (140/200) of patients had myopia ≤-1.00 DS, and 1% (2/200) had hyperopia ≥+2.00 DS. No differences were observed between the MD and control groups. However, the patients in the MD group (14.25±2.69 years) were significantly more susceptible to strabismus (P<0.05) and amblyopia (P<0.01) than those in the control group (13.65±3.04 years). There was a substantial difference between the two groups in the time spent on screen-based devices (P<0.001). Furthermore, mental retardation (OR=3.286, P<0.01), emotional disorders (OR=2.003, P<0.01), and adjustment disorders (OR=2.629, P<0.01) were associated with an increased risk of amblyopia. Depression (OR =1.362, P<0.01) and emotional disorders (OR=2.205, P<0.01) were associated with a higher prevalence of strabismus.

CONCLUSION

Ophthalmological examinations should be performed in children and adolescents with MDs because MDs are associated with a high prevalence of refractive errors and ocular diseases. Detection and intervention of ocular and refractive findings in children and adolescents with MDs are necessary and effective in alleviating the economic burden in healthcare and improving individuals' quality of life.

Cost-effectiveness of Universal School- and Community-Based Vision Testing Strategies to Detect Amblyopia in Children in Ontario, Canada

IMPORTANCE

Screening for amblyopia in primary care visits is recommended for young children, yet screening rates are poor. Although the prevalence of amblyopia is low (3%-5%) among young children, universal screening in schools and mandatory optometric examinations may improve vision care, but the cost-effectiveness of these vision testing strategies compared with the standard in primary care is unknown.

OBJECTIVE

To evaluate the relative cost-effectiveness of universal school screening and mandated optometric examinations compared with standard care vision screening in primary care visits in Toronto, Canada, with the aim of detecting and facilitating treatment of amblyopia and amblyopia risk factors from the Ontario government's perspective.

DESIGN, SETTING, AND PARTICIPANTS

An economic evaluation was conducted from July 2019 to May 2021 using a Markov model to compare 15-year costs and quality-adjusted life-years (QALYs) between school screening and optometric examination compared with primary care screening in Toronto, Canada. Parameters were derived from published literature, the Ontario Schedule of Benefits and Fees, and the Kindergarten Vision Testing Program. A hypothetical cohort of 25 000 children aged 3 to 5 years was simulated. It was assumed that children in the cohort had irreversible vision impairment if not diagnosed by an optometrist. In addition, incremental costs and outcomes of 0 were adjusted to favor the reference strategy. Vision testing programs were designed to detect amblyopia and amblyopia risk factors.

MAIN OUTCOMES AND MEASURES

For each strategy, the mean costs per child included the costs of screening, optometric examinations, and treatment. The mean health benefits (QALYs) gained were informed by the presence of vision impairment and the benefits of treatment. Incremental cost-effectiveness ratios were calculated for each alternative strategy relative to the standard primary care screening strategy as the additional cost required to achieve an additional QALY at a willingness-to-pay threshold of $50 000 Canadian dollars (CAD) ($37 690) per QALY gained.

RESULTS

School screening relative to primary care screening yielded cost savings of CAD $84.09 (95% CI, CAD $82.22-$85.95) (US $63.38 [95% CI, US $61.97-$64.78]) per child and an incremental gain of 0.0004 (95% CI, -0.0047 to 0.0055) QALYs per child. Optometric examinations relative to primary care screening yielded cost savings of CAD $74.47 (95% CI, CAD $72.90-$76.03) (US $56.13 [95% CI, $54.95-$57.30]) per child and an incremental gain of 0.0508 (95% CI, 0.0455-0.0561) QALYs per child. At a willingness-to-pay threshold of CAD $50 000 (US $37 690) per QALY gained, school screening and optometric examinations were cost-effective relative to primary care screening in only 20% and 29% of iterations, respectively.

CONCLUSIONS AND RELEVANCE

In this study, because amblyopia prevalence is low among young children and most children in the hypothetical cohort had healthy vision, universal school screening and optometric examinations were not cost-effective relative to primary care screening for detecting amblyopia in young children in Toronto, Canada. The mean added health benefits of school screening and optometric examinations compared with primary care screening did not warrant the resources used.

Design and assessment of amblyopia, strabismus, and myopia treatment and vision training using virtual reality

Background

Virtual reality is a relatively new intervention that has the potential to be used in the treatment of eye and vision problems. This article reviews the use of virtual reality-related interventions in amblyopia, strabismus, and myopia research.

Methods

Sources covered in the review included 48 peer-reviewed research published between January 2000 and January 2023 from five electronic databases (ACM Digital Library, IEEE Xplore, PubMed, ScienceDirect and Web of Science). To prevent any missing relevant articles, the keywords, and terms used in the search included "VR", "virtual reality", "amblyopia", "strabismus," and "myopia". Quality assessment and data extraction were performed independently by two authors to form a narrative synthesis to summarize findings from the included research.

Results

Total number of 48 references were reviewed. There were 31 studies published on amblyopia, 18 on strabismus, and 6 on myopia, with 7 studies overlapping amblyopia and strabismus. In terms of technology, smartphone-based virtual reality headset viewers were utilized more often in amblyopia research, but commercial standalone virtual reality headsets were used more frequently in myopia and strabismus-related research. The software and virtual environment were mostly developed based on vision therapy and dichoptic training paradigms.

Conclusion

It has been suggested that virtual reality technology offers a potentially effective tool for amblyopia, strabismus, and myopia studies. Nonetheless, a variety of factors, especially the virtual environment and systems employed in the data presented, must be explored before determining whether virtual reality can be effectively applied in clinical settings. This review is significant as the technology in virtual reality software and application design features have been investigated and considered for future reference.

National survey of amblyopia treatment in Japan: comparison with amblyopia treatment study results of the pediatric eye disease investigator group

PURPOSE

To investigate the treatment policy for amblyopia in Japan as of 2017 through a survey of multiple facilities and to compare the findings with those obtained by the Amblyopia Treatment Study (ATS) of the Pediatric Eye Disease Investigator Group.

STUDY DESIGN

Questionnaire survey study.

SUBJECTS AND METHODS

A questionnaire was sent to 181 facilities where patients with amblyopia are being treated. The outcomes of the present survey were compared with the results of the ATS study, and the coincidence rates were evaluated.

RESULTS

The questionnaire response rate was 68.0%. The treatment plan that showed the highest agreement between the outcomes of the ATS study and the present study was whether or not treatment was to be given to patients aged 10-15 years who had received no previous treatment; 90% of the facilities answered that they would provide treatment to such patients as well. The next highest agreement was the future treatment of amblyopia with stable visual acuity in the affected eye; 82.6% of the facilities responded that they would reduce the occlusion time. On the other hand, the lowest agreement rate was the follow-up period of the refractive correction for moderate anisometropic amblyopia. The ATS showed "4 months," whereas most of the facilities in the present survey replied "3 months." The agreement rate was 10.8%.

CONCLUSION

The amblyopia treatment in Japan survey did not always agree with the research results of the ATS. Japanese ophthalmologists tend to make treatment plans for amblyopia according to their clinical experience.

Children With Amblyopia Make More Saccadic Fixations When Doing the Visual Search Task

Purpose

Individuals with amblyopia are known to have functional vision deficits (e.g., reduced reading speed) in spite of good visual acuity in the nonamblyopic eye. We studied and compared eye movements in children with and without amblyopia to examine how a visual scene is explored during visual search.

Methods

Children (six to 16 years of age) in the control group (n = 14) and cases group with anisometropic amblyopia (n = 23) participated in a visual search study, in which they looked for targets in real-world images displayed on a computer monitor. Eyelink 1000 Plus was used to track the eye movements. Three viewing conditions were randomized: dominant/fellow eye, nondominant/amblyopic eye, and binocular viewing. Visual search performance was measured by combining search time and accuracy.

Results

As expected, poorer visual search performance was observed in the amblyopic eye when compared to the controls and fellow eye (P < 0.005). However, the reaction time was longer even in binocular and fellow eye viewing conditions than the controls (P < 0.028). Children with amblyopia made more saccades (17 vs. 12, P = 0.007), without the need to fixate longer (P = 0.312), but with more fixations in the target interest area (4.65 vs. 3.14, P = 0.002) when compared to controls. These eye movement patterns were observed in both the fellow eye and binocular viewing conditions.

Conclusions

In spite of good visual acuity in the fellow eye, children with amblyopia needed to sample the scene with more fixations. Even upon gazing at the target location, they made more fixations before confirming a hit. These search patterns suggest a possible narrower spatial visual span to process the visual information in children with amblyopia.

Automated screening devices for vision screening in preschool children: A comparison of the PlusoptiX S12C photoscreener and retinomax K+3 autorefractor

Introduction

Automated vision screening devices such as photoscreeners and autorefractors have been used to accurately identify amblyopia, refractive amblyopia risk factors (ARFs), and refractive error in young children; however, there is conflicting data about the effectiveness of different screening devices. We compared the performance of two commercially available screening devices in preschool children.

Methods

Children aged 3 to 5 years attending 5 preschools in Anaheim Elementary School District were screened with the PlusoptiX S12C photoscreener using ROC 3 referral criteria and Retinomax K+3 autorefractor in March 2022. Screened children were offered free cycloplegic eye examinations performed by optometrists on the UCI EyeMobile for Children mobile clinic. Children were evaluated for the presence of refractive ARFs using 2021 American Association for Pediatric Ophthalmology and Strabismus age-based referral criteria guidelines for instrument-based screening.

Results

A total of 158 children were screened and 79 children received cycloplegic examinations. At least one refractive ARF was found in 20% of examined children, corresponding to a sensitivity/specificity/positive predictive value (PPV)/negative predictive value (NPV) of 94%/89%/68%/98% for the PlusoptiX and 100%/65%/42%/100% for the Retinomax.

Discussion

In detecting refractive ARFs, the PlusoptiX was found to have a higher specificity and PPV while the Retinomax had a higher sensitivity and NPV. While both devices demonstrated a high sensitivity and NPV, we found that the PlusoptiX performed better overall as a screening device for our program as the Retinomax referred too many children.

Awareness and Knowledge of Amblyopia: A Cross-Sectional Study Among the Population of Hail City, Saudi Arabia

Introduction Amblyopia, also known as the lazy eye, is the reduction of the best-corrected visual acuity of one or both eyes that cannot be attributed exclusively to a structural abnormality of the eye. This study investigated the Hail population's awareness of amblyopia. Methods A cross-sectional study was conducted in Hail, Kingdom of Saudi Arabia (KSA), from May to October 2022. Data entry and analysis were done using RStudio (R version 4.1.1). Results This study included 496 of the general population (23.8% males and 76.2% females), and the majority of them had a university degree (65.7%). Of the population, 52.4% knew the definition of amblyopia, 43.4% knew the treatment of amblyopia, and 85.1% knew the importance of checking the child's vision before school to ensure normal development. In 35.7% of the population, the main source of information was the internet and social media. The median knowledge score of participants was 4 (interquartile range (IQR): 3-5) with a minimum of 0 and a maximum of 9. Based on the univariate analysis, participants aged 41 years or older had significantly lower knowledge scores (β = -0.40, 95% confidence interval (CI): -0.81 to -0.99, p = 0.049), whereas respondents with a positive family history of amblyopia had a significantly higher knowledge score (β = 0.32, 95%CI: 0.02 to 0.61, p = 0.034). Conclusions This study assessed the awareness and knowledge of amblyopia among the population in Hail city. According to our data, we found a significantly poor awareness and knowledge compared to other big cities in the same country such as Riyadh and Jeddah. This indicates that knowledge in smaller cities is deficient in enough and accurate sources of knowledge of eye conditions.

Congenital Stationary Night Blindness: Clinical and Genetic Features

Congenital stationary night blindness (CSNB) is an inherited retinal disease (IRD) that causes night blindness in childhood with heterogeneous genetic, electrophysical, and clinical characteristics. The development of sequencing technologies and gene therapy have increased the ease and urgency of diagnosing IRDs. This study describes seven Taiwanese patients from six unrelated families examined at a tertiary referral center, diagnosed with CSNB, and confirmed by genetic testing. Complete ophthalmic exams included best corrected visual acuity, retinal imaging, and an electroretinogram. The effects of identified novel variants were predicted using clinical details, protein prediction tools, and conservation scores. One patient had an autosomal dominant CSNB with a RHO variant; five patients had complete CSNB with variants in GRM6, TRPM1, and NYX; and one patient had incomplete CSNB with variants in CACNA1F. The patients had Riggs and Schubert-Bornschein types of CSNB with autosomal dominant, autosomal recessive, and X-linked inheritance patterns. This is the first report of CSNB patients in Taiwan with confirmed genetic testing, providing novel perspectives on molecular etiology and genotype-phenotype correlation of CSNB. Particularly, variants in TRPM1, NYX, and CACNA1F in our patient cohort have not previously been described, although their clinical significance needs further study. Additional study is needed for the genotype-phenotype correlation of different mutations causing CSNB. In addition to genetic etiology, the future of gene therapy for CSNB patients is reviewed and discussed.

Effectiveness of Laser Refractive Surgery to Address Anisometropic Amblyogenic Refractive Error in Children: A Report by the American Academy of Ophthalmology

PURPOSE

To review the published literature assessing the safety and effectiveness of laser refractive surgery to treat anisometropic amblyogenic refractive error in children aged ≤ 18 years.

METHODS

A literature search of the PubMed database was conducted in October 2021 with no date limitations and restricted to publications in English. The search yielded 137 articles, 69 of which were reviewed in full text. Eleven articles met the criteria for inclusion and were assigned a level of evidence rating.

RESULTS

The 11 included articles were all level III evidence and consisted of 1 case-control study and 10 case series. Six studies used laser-assisted in situ keratomileusis (LASIK), 1 used photorefractive keratectomy (PRK), 1 used refractive lenticule extraction/small incision lenticule extraction, and the rest used a combination of LASIK, PRK, laser epithelial keratomileusis (LASEK), or refractive lenticule extraction/small incision lenticule extraction. Five studies enrolled patients with anisometropic myopia, 2 studies enrolled patients with anisometropic hyperopia, and the remainder were mixed. Although all studies demonstrated an improvement in best-corrected visual acuity (BCVA), the magnitude of improvement varied widely. As study parameters varied, a successful outcome was defined as residual refractive error of 1 diopter (D) or less of the target refraction because this was the most commonly used metric. Successful outcomes ranged between 38% and 87%, with a mean follow-up ranging from 4 months to 7 years. Despite this wide range, all studies demonstrated an improvement in the magnitude of anisometropia. Regression in refractive error occurred more frequently and to a greater degree in myopic eyes and eyes with longer follow-up, and in younger patients. Although one study reported 2 free flaps, most studies reported no serious adverse events. The most common complications were corneal haze and striae.

CONCLUSIONS

Findings from included studies suggest that laser refractive surgery may address amblyogenic refractive error in children and that it appears to decrease anisometropia. However, the evidence for improvement in amblyopia is unclear and long-term safety data are lacking. Long-term data and well-designed clinical studies that use newer refractive technologies in standardized patient populations would help address the role of refractive surgery in children and its potential impact on amblyopia.

Factors predicting regression of visual acuity following successful treatment of anisometropic amblyopia

Objective

To identify factors associated with visual acuity regression following successful treatment of anisometropic amblyopia.

Design and method

This was a retrospective cohort study. Database records for 100 and 61 children with anisometropic amblyopia who met at least one criterion for successful treatment proposed by the Pediatric Eye Disease Investigator Group (PEDIG) and had at least 1 year of follow-up data available after the criterion was met were analyzed. The study sample was split into two groups, those who regressed within 1 year of successful treatment (no longer met any of the PEDIG criteria for successful treatment) and those who did not. A two-step analysis involving a least absolute shrinkage and selection operator (LASSO) regression and a logistic regression were used to identify predictor variables for increased risk of regression. A broad range of clinical, perceptual, and demographic variables were included in the analyses.

Results

Sixty-eight (42.5%) children regressed within 1 year of successful treatment. Among the 27 predictor variables considered within the statistical modeling process, the three most important for predicting treatment regression were the extent of amblyopic eye visual acuity improvement, age at first hospital visit and sex. Specifically, lower risk of regression was associated with larger amblyopic eye visual acuity improvement with treatment, younger age at initiation of treatment and female sex.

Conclusion

Patients who received treatment at a younger age and responded well to treatment had a lower risk of treatment regression. This pattern of results suggests that early detection of amblyopia and strategies that enhance treatment adherence may reduce the risk of treatment regression. The higher risk of regression in boys than girls that we observed may reflect known sex differences in brain development and /or sex differences in environment within our sample of children from South China.

Amblyopia: progress and promise of functional magnetic resonance imaging

Amblyopia is a neurodevelopmental disorder characterized by functional deficits in the visual cortex. Functional magnetic resonance imaging (fMRI) is the most commonly used neuroimaging technique for investigating amblyopia. Herein, we systematically searched a PubMed database from inception to December 2021 to highlight the current progress and promises about fMRI technology in amblyopia; amblyopia's neural mechanism, the comparison of different types of amblyopia, and the evaluation of the therapeutic effect were explored. Relevant articles published in English and appropriate cross-references were considered for inclusion, including basic studies, imaging techniques, clinical diagnostic and therapeutic studies, case series, and reviews.

Refraction development in anisometropic amblyopia with patching therapy

PURPOSE

To investigate the development of refraction in anisometropic amblyopia who had been with patching therapy.

METHODS

We retrospectively reviewed 37,528 medical records of the amblyopes who had been treated with patching therapy between July 2003 and January 2020 at the School of Optometry and Ophthalmology and Eye Hospital of Wenzhou Medical University. We included unilateral anisometropic amblyopia with a follow-up length of not < 2 years. In total, 371 cases were enrolled and followed up for a mean of 4.76 ± 2.11 years. The subjects were then divided into different groups and periods according to their initial spherical equivalent (SE) refractive error and best-corrected visual acuity (BCVA) of the amblyopic eye. Linear mixed-effects models were fitted to calculate the annual change of SE.

RESULTS

The annual changes in SE were -0.32 (-0.35 to -0.30) and -0.16 (-0.19 to -0.14) D/yr for the amblyopic eye and the fellow eye, respectively. The annual changes in SE of amblyopic eyes during the treatment period and the successfully treated period were -0.36 (-0.43 to -0.29; 95% CI) and -0.27 (-0.32 to -0.23; 95% CI) D/yr, respectively; the annual SE changes of the fellow eye during the treatment period and the successfully-treated period were -0.07 (-0.14 to -0.01; 95% CI) and -0.18 (-0.22 to -0.14; 95% CI) D/yr, respectively.

CONCLUSION

The amblyopic eye experienced a significantly greater degree of refractive error changes than the fellow eye and underwent a continuous refractive error reduction before and after 7 years old. After the patching therapy was terminated, emmetropization in the amblyopic eye remained synchronized, whereas the refractive error change was increased in the fellow eye.

Dichoptic and Monocular Visual Acuity in Amblyopia

PURPOSE

Standard-of-care assessment for children with amblyopia includes measuring amblyopic eye best-corrected visual acuity (AE BCVA) with the fellow eye occluded. By definition, this abolishes the interocular suppression fundamental to amblyopia. Thus, measured AE BCVA may not accurately represent that eye's contribution to natural binocular viewing. We compared dichoptic and monocular AE BCVA and examined whether any differences were associated with eye-hand coordination or reading speed.

DESIGN

Cross-sectional study.

METHODS

Dichoptic and monocular AE BCVA of children aged 6-12 years (42 with amblyopia, 24 with recovered normal AE BCVA, 30 control) were measured. Stereoacuity, suppression, eye-hand coordination, and reading speed were also assessed.

RESULTS

Overall, 81% of amblyopic children had worse dichoptic than monocular AE BCVA (mean difference=0.15±0.11 logMAR; P < .0001), and 71% of children with recovered normal AE BCVA had worse dichoptic than monocular AE BCVA (mean difference = 0.20±0.17 logMAR, P < .0001). Controls had no significant difference. The difference between dichoptic and monocular AE BCVA was correlated with performance in standardized aiming/catching (r = -0.48, 95% CI -0.72, -0.14) and manual dexterity tasks (r = -0.37, 95% CI -0.62, -0.06), and with reading speed (r = -0.38, 95% CI -0.65, -0.03).

CONCLUSIONS

Dichoptic AE BCVA deficits were worse than monocular AE BCVA deficits and were associated with reduced stereoacuity and suppression, consistent with the hypothesis that binocular dysfunction plays a role. Further, impaired eye-hand coordination and slow reading were associated with dichoptic, but not monocular, AE BCVA. Some children with amblyopia may benefit from extra time for school tasks requiring eye-hand coordination or reading.

The Study of Short-Term Plastic Visual Perceptual Training Based on Virtual and Augmented Reality Technology in Amblyopia

Backgrounds. The treatment for amblyopia can have a substantial impact on quality of life. Conventional treatments for amblyopia have some limitations, then we try to explore a new and effective method to treat amblyopia. This study aimed to determine the potential effect of short-term plastic visual perceptual training based on VR and AR platforms in amblyopic patients. Methods. All observers were blinded to patient groupings. A total of 145 amblyopic children were randomly assigned into 2 groups: VR group (71 patients) and AR group (74 patients). In the VR group, each subject underwent a 20-min short-term plastic visual perceptual training based on a VR platform, and in the AR group, based on an AR platform. The best-corrected visual acuity (BCVA), fine stereopsis, and contrast sensitivity function (CSF) were measured before and after training. Results. The BCVA (P < 0.001) and fine stereopsis (P < 0.05) were improved significantly both in VR and AR group after training. Moreover, in the AR group, the CSF showed the value of all spatial frequencies had a statistically significant improvement after training (P < 0.05), while in the VR group, only the value of spatial frequency 12 improved significantly (P = 0.008). Conclusions. This study showed that the short-term plastic visual perceptual training based on VR and AR technology can improve BCVA, fine stereopsis and CSF of refractive amblyopia. It was suggested that the visual perceptual training based on the VR and AR platforms may be potentially applied in treatment for amblyopia and provided a high-immersing alternative.

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.

Measuring the impact of suppression on visual acuity in children with amblyopia using a dichoptic visual acuity chart

Purpose

To develop a novel dichoptic visual acuity chart that measures the impact of interocular suppression on the visual acuity of each eye when two eyes are open.

Methods

Fifty-four subjects (19 anisometropic amblyopia, 20 treated amblyopia, and 15 normal children) participated in this study. The visual acuity that was tested under dichoptic-optotypes condition (i.e., presented optotypes to the untested eye) was compared with that under monocular condition (i.e., cover the untested eye with opaque patch). Visual acuity differences between these two conditions were compared among the three groups. The correlations between visual acuity differences and the depth of interocular suppression were then computed. Some participants performed the visual acuity test under dichoptic-luminance condition (i.e., presented mean luminance to the untested eye), and the test-retest reliability was established.

Results

A reduced visual acuity of the non-dominant eye was found in the dichoptic-optotypes condition for the amblyopia group (P &lt; 0.001) and the treated group (P = 0.001); the difference in the treated group was less than that in the amblyopia group (P &lt; 0.001) but more than that in the normal group (P = 0.026). A significant correlation was found between the visual acuity differences and the depth of suppression, which was tested with a binocular phase combination task (P = 0.005). No change was found in the dichoptic-luminance condition.

Conclusion

The amblyopic eye and the previous amblyopic eye seem to suffer from a reduced visual acuity when two eyes are open due to suppression. This was successfully captured by our novel and reliable dichoptic-optotypes visual acuity chart.

Microvascular assessment of macula, choroid, and optic disk in children with unilateral amblyopia using OCT angiography

PURPOSE

To investigate the microvascular changes of macula, choroid, and optic disk in children with unilateral amblyopia.

METHODS

This prospective cross-sectional study involved 39 unilateral amblyopic children and 39 age- and sex-matched heathy participants who served as control. Vessel densities of the superficial and deep capillary plexuses (SCP and DCP), foveal avascular zone (FAZ) area, macular thickness, optic disk vessel density, retinal nerve fiber layer (RNFL) thickness, choriocapillaris vessel density, and subfoveal choroidal thickness were evaluated by OCT angiography (OCTA). Meanwhile, the correlations of microvascular perfusion and structural changes of macula, choroid, and optic disk were analyzed.

RESULTS

The vessel density of SCP and DCP in the whole macula in the amblyopic group was significantly lower than that in the control group after adjusting for age, axial length, and spherical equivalents (all P < 0.05). FAZ area, macular thickness, RNFL thickness, and the optic disk vessel density were not statistically different between the amblyopic group and the control group (all P > 0.05). Subfoveal choroidal thickness of amblyopic eyes was significantly higher than that of control eyes(P = 0.032). Choriocapillaris flow void (FV) in the amblyopic group was greater than that in the control group (P = 0.013). Significant differences were observed between the fellow eyes and the control eyes in choriocapillaris FV and subfoveal choroidal thickness (P = 0.011 and P = 0.042, respectively). Foveal SCP and DCP vessel density in all studied eyes were positively correlated with the whole macular thickness, respectively (r = 0.556 and r = 0.627, respectively, both P < 0.001). Whole SCP and DCP vessel density in the amblyopic eyes were negatively correlated with choriocapillaris FV (r = -0.723, P < 0.001; r = -0.512, P = 0.001, respectively).

CONCLUSION

Children with amblyopic eyes have attenuated macular and choriocapillaris perfusion. There is a need for future studies that will investigate the pathophysiology of amblyopia in children by OCTA.