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Proudlock FA, Hisaund M, Maconachie G, Papageorgiou E, Manouchehrinia A, Dahlmann-Noor A, Khandelwal P, Self J, Beisse C, Gottlob I. Extended optical treatment versus early patching with an intensive patching regimen in children with amblyopia in Europe (EuPatch): a multicentre, randomised controlled trial. Lancet 2024; 403:1766-1778. [PMID: 38704172 DOI: 10.1016/s0140-6736(23)02893-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Revised: 12/21/2023] [Accepted: 12/22/2023] [Indexed: 05/06/2024]
Abstract
BACKGROUND Amblyopia, the most common visual impairment of childhood, is a public health concern. An extended period of optical treatment before patching is recommended by the clinical guidelines of several countries. The aim of this study was to compare an intensive patching regimen, with and without extended optical treatment (EOT), in a randomised controlled trial. METHODS EuPatch was a randomised controlled trial conducted in 30 hospitals in the UK, Greece, Austria, Germany, and Switzerland. Children aged 3-8 years with newly detected, untreated amblyopia (defined as an interocular difference ≥0·30 logarithm of the minimum angle of resolution [logMAR] best corrected visual acuity [BCVA]) due to anisometropia, strabismus, or both were eligible. Participants were randomly assigned (1:1) via a computer-generated sequence to either the EOT group (18 weeks of glasses use before patching) or to the early patching group (3 weeks of glasses use before patching), stratified for type and severity of amblyopia. All participants were initially prescribed an intensive patching regimen (10 h/day, 6 days per week), supplemented with motivational materials. The patching period was up to 24 weeks. Participants, parents or guardians, assessors, and the trial statistician were not masked to treatment allocation. The primary outcome was successful treatment (ie, ≤0·20 logMAR interocular difference in BCVA) after 12 weeks of patching. Two primary analyses were conducted: the main analysis included all participants, including those who dropped out, but excluded those who did not provide outcome data at week 12 and remained on the study; the other analysis imputed this missing data. All eligible and randomly assigned participants were assessed for adverse events. This study is registered with the International Standard Randomised Controlled Trial Number registry (ISRCTN51712593) and is no longer recruiting. FINDINGS Between June 20, 2013, and March 12, 2020, after exclusion of eight participants found ineligible after detailed screening, we randomly assigned 334 participants (170 to the EOT group and 164 to the early patching group), including 188 (56%) boys, 146 (44%) girls, and two (1%) participants whose sex was not recorded. 317 participants (158 in the EOT group and 159 in the early patching group) were analysed for the primary outcome without imputation of missing data (median follow-up time 42 weeks [IQR 42] in the EOT group vs 27 weeks [27] in the early patching group). 24 (14%) of 170 participants in the EOT group and ten (6%) of 164 in the early patching group were excluded or dropped out of the study, mostly due to loss to follow-up and withdrawal of consent; ten (6%) in the EOT group and three (2%) in the early patching group missed the 12 week visit but remained on the study. A higher proportion of participants in the early patching group had successful treatment (107 [67%] of 159) than those in the EOT group (86 [54%] of 158; 13% difference; p=0·019) after 12 weeks of patching. No serious adverse events related to the interventions occurred. INTERPRETATION The results from this trial indicate that early patching is more effective than EOT for the treatment of most children with amblyopia. Our findings also provide data for the personalisation of amblyopia treatments. FUNDING Action Medical Research, NIHR Clinical Research Network, and Ulverscroft Foundation.
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Affiliation(s)
- Frank A Proudlock
- Ulverscroft Eye Unit, Department of Psychology and Vision Sciences, University of Leicester, Leicester, UK
| | - Michael Hisaund
- Ulverscroft Eye Unit, Department of Psychology and Vision Sciences, University of Leicester, Leicester, UK
| | - Gail Maconachie
- School of Allied Health Professions, Nursing and Midwifery, Faculty of Health, University of Sheffield, Sheffield, UK
| | | | - Ali Manouchehrinia
- Karolinska Neuroimmunology and Multiple Sclerosis Centre, Department of Clinical Neurosciences, Karolinska University Hospital, Stockholm, Sweden
| | - Annegret Dahlmann-Noor
- NIHR Moorfields Biomedical Research Centre, London, UK; Moorfields Eye Hospital NHS Foundation Trust, London, UK; Institute of Ophthalmology, University College London, London, UK
| | - Payal Khandelwal
- Children's Community Eye Service, Cambridgeshire Community Services NHS Trust, Bedford, UK
| | - Jay Self
- Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Christina Beisse
- Department of Ophthalmology, University of Heidelberg, Heidelberg, Germany
| | - Irene Gottlob
- Ulverscroft Eye Unit, Department of Psychology and Vision Sciences, University of Leicester, Leicester, UK; Department of Neurology, Cooper University Health Care, Cooper Medical School of Rowan University, Camden, NJ, USA.
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Hamidi A, Jalalifar S, Atigh SBQ, Darvishi A, Sharif NM, Lashkardoost H, Sangsefidi N, Shandiz JH. The prevalence of functional amblyopia and its related risk factors in preschool children in North-Eastern Iran. Oman J Ophthalmol 2024; 17:59-64. [PMID: 38524325 PMCID: PMC10957057 DOI: 10.4103/ojo.ojo_295_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2022] [Revised: 07/01/2023] [Accepted: 07/03/2023] [Indexed: 03/26/2024] Open
Abstract
BACKGROUND Purpose was to determine the prevalence of amblyopia and its related risk factors in children aged 3-6 years in Bojnurd, north-eastern Iran. MATERIALS AND METHODS In this cross-sectional study, from 12,331 children aged 3-6 in Bojnurd, 6600 children participated in annual amblyopic screening program and among them, around 1100 suspected cases were referred for full ophthalmic examinations. Measurement of visual acuity, cycloplegic refraction, subjective refraction, and cover test were performed for all participants. Amblyopia was defined as CDVA of 0.2 LogMar or less in each eye or 2-line difference or more in best-corrected visual acuity between two eyes. RESULTS The prevalence of amblyopia was estimated 0.95% (95% confidence interval [CI]: 0.73%-1.2%). There was no relationship between amblyopia with age and genders. Most amblyopic children were hyperopic (61.9%; 95% CI: 48.7-73.8). Strabismus was found in 17.4% of amblyopic patients (95% CI: 9.05%-29.09%). Approximately half of the amblyopic children were anisometropic (55.5%; 95% CI: 42.40%-68.08%). The most common type of amblyopia was anisohyperopic (55.56%; 95% CI: 42.5%-67.5%). The prevalence of bilateral amblyopia was more than unilateral amblyopia. The assessment of data showed that hyperopia, astigmatism, and anisometropia were the most common causes of amblyopia in this study. CONCLUSIONS The prevalence of amblyopia was estimated about 1% in north-eastern Iran. Our study indicated a valuable information around the effect of refractive error and anisometropia on amblyopia which could be helpful in designing a comprehensive vision screening program for preschool children.
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Affiliation(s)
- Aghdas Hamidi
- Department of Optometry, School of Paramedical Science, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Samira Jalalifar
- Department of Surgery, School of Medicine, North Khorasan University of Medical Sciences, Bojnurd, Iran
| | - Somayyeh Boomi Quchan Atigh
- Department of Optometry, School of Paramedical Science, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Azam Darvishi
- Department of Optometry, School of Paramedical Science, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Nasrin Moghadas Sharif
- Department of Optometry, School of Paramedical Science, Mashhad University of Medical Sciences, Mashhad, Iran
- Refractive Errors Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Hossein Lashkardoost
- Department of Public Health, School of Public Health, North Khorasan University of Medical Sciences, Bojnurd, Iran
| | - Negar Sangsefidi
- Department of Biostatistics, School of Health, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Javad Heravian Shandiz
- Department of Optometry, School of Paramedical Science, Mashhad University of Medical Sciences, Mashhad, Iran
- Refractive Errors Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
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Bui Quoc E, Kulp MT, Burns JG, Thompson B. Amblyopia: A review of unmet needs, current treatment options, and emerging therapies. Surv Ophthalmol 2023; 68:507-525. [PMID: 36681277 DOI: 10.1016/j.survophthal.2023.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Revised: 01/03/2023] [Accepted: 01/13/2023] [Indexed: 01/20/2023]
Abstract
Amblyopia is a global public health issue with extensive, multifaceted impacts on vision and quality of life (QoL) for both patients and families. Geographical variation exists in the management of amblyopia, with traditional mainstay treatments, optical correction, and fellow eye occlusion most successful when implemented at an early age. In recent years, however, studies demonstrating meaningful improvements in older children and adults have challenged the concept of a complete loss of visual processing plasticity beyond the critical period of visual development, with growing evidence supporting the potential efficacy of emerging, more engaging, binocular therapies in both adults and children. Binocular approaches aim to restore deficits in amblyopia that extend beyond monocular visual acuity impairment, including binocular fusion and visuomotor skills. In view of this, incorporating outcome measures that evaluate the visual performance and functional ability of individuals with amblyopia will provide a clearer understanding of the effect of amblyopia on QoL and a more comprehensive evaluation of amblyopia therapies.
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Affiliation(s)
- Emmanuel Bui Quoc
- Ophthalmology Department, Robert Debré University Hospital, Assistance Publique Hôpitaux de Paris, Paris, France.
| | | | | | - Benjamin Thompson
- School of Optometry and Vision Science, University of Waterloo, Canada; Centre for Eye and Vision Research, Hong Kong
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Jia Y, Liu J, Ye Q, Zhang S, Feng L, Xu Z, Zhuang Y, He Y, Zhou Y, Chen X, Yao Y, Jiang R, Thompson B, Li J. Factors predicting regression of visual acuity following successful treatment of anisometropic amblyopia. Front Med (Lausanne) 2022; 9:1013136. [PMID: 36388932 PMCID: PMC9659723 DOI: 10.3389/fmed.2022.1013136] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2022] [Accepted: 10/17/2022] [Indexed: 11/28/2022] Open
Abstract
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.
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Affiliation(s)
- Yu Jia
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-Sen University, Guangzhou, China
- Centre for Eye and Vision Research, Hong Kong, Hong Kong SAR, China
| | - Jing Liu
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-Sen University, Guangzhou, China
| | - Qingqing Ye
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-Sen University, Guangzhou, China
| | - Shenglan Zhang
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-Sen University, Guangzhou, China
| | - Lei Feng
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-Sen University, Guangzhou, China
| | - Zixuan Xu
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-Sen University, Guangzhou, China
| | - Yijing Zhuang
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-Sen University, Guangzhou, China
| | - Yunsi He
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-Sen University, Guangzhou, China
| | - Yusong Zhou
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-Sen University, Guangzhou, China
| | - Xiaolan Chen
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-Sen University, Guangzhou, China
| | - Ying Yao
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-Sen University, Guangzhou, China
| | - Rengang Jiang
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-Sen University, Guangzhou, China
| | - Benjamin Thompson
- Centre for Eye and Vision Research, Hong Kong, Hong Kong SAR, China
- School of Optometry and Vision Science, University of Waterloo, Waterloo, ON, Canada
- Liggins Institute, University of Auckland, Auckland, New Zealand
- Benjamin Thompson
| | - Jinrong Li
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-Sen University, Guangzhou, China
- *Correspondence: Jinrong Li
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Li Y, Sun H, Zhu X, Su Y, Yu T, Wu X, Zhou X, Jing L. Efficacy of interventions for amblyopia: a systematic review and network meta-analysis. BMC Ophthalmol 2020; 20:203. [PMID: 32450849 PMCID: PMC7249307 DOI: 10.1186/s12886-020-01442-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2019] [Accepted: 04/22/2020] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Many treatments are currently available for amblyopic patients; although, the comparative efficacy of these therapies is unclear. We conducted a systematic review and network meta-analysis (NMA) to establish the relative efficacy of these treatments for amblyopia. METHODS Electronic databases (MEDLINE, EMBASE, Cochrane Library) were systematically searched from inception to Sep. 2019. Only Randomized clinical trials comparing any two or three of the following treatments were included: refractive correction (spectacles alone), patching of 2 h per day (patch 2H), patch 6H, patch 12H, patch 2H + near activities (N), patch 2H + distant activities (D), atropine (Atr) daily, Atr weekly, Atr weekly + plano lens over the sound eye (Plano), optical penalization and binocular therapy. The reviewers independently extracted the data according to the PRISMA guidelines; assessed study quality by Cochrane risk-of-bias tool for randomized trials. The primary outcome measure was the change in best-corrected visual acuity (BCVA) expressed as log MAR lines. Direct comparisons and a Bayesian meta-analysis were performed to synthesize data. RESULTS Twenty-three studies with 3279 patients were included. In the network meta-analysis, optical penalization was the least effective of all the treatments for the change of visual acuity, spectacles (mean difference [MD], 2.9 Log MAR lines; 95% credibility interval [CrI], 1.8-4.0), patch 2H (MD, 3.3; 95% CrI, 2.3-4.3), patch 6H (MD, 3.6; 95% CrI, 2.6-4.6), patch 12H (MD, 3.4; 95% CrI, 2.3-4.5), patch 2H + N (MD, 3.7; 95% CrI, 2.5-5.0), patch 2H + D (MD, 3.5; 95% CrI, 2.1-5.0), Atr daily (MD, 3.2; 95% CrI, 2.2-4.3), Atr weekly (MD, 3.2; 95% CrI, 2.2-4.3), Atr weekly + Plano (MD, 3.7; 95% CrI, 2.7-4.7), binocular therapy (MD, 3.1; 95% CrI, 2.0-4.2). The patch 6H and patch 2H + N were better than spectacles ([MD, 0.73; 95% Crl, 0.10-1.40]; [MD, 0.84; 95% CrI, 0.19-1.50]). CONCLUSIONS The NMA indicated that the efficacy of the most of the examined treatment modalities for amblyopia were comparable, with no significant difference. Further high quality randomized controlled trials are required to determine their efficacy and acceptability. SYSTEMATIC REVIEW REGISTRATION CRD42019119843.
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Affiliation(s)
- Yonghong Li
- Department of Evidence-Based Medicine and Clinical Epidemiology, West China Hospital, Sichuan University, No.37 Guoxue Alley, Chengdu, 610041, China
| | - Huan Sun
- Mental Health Center and Psychiatric Laboratory, the State Key Laboratory of Biotherapy, West China Hospital of Sichuan University, No.37 Guoxue Alley, Chengdu, 610041, China
| | - Xiaojuan Zhu
- Department of Ophthalmology, West China Hospital, Sichuan University, No.37 Guoxue Alley, Chengdu, 610041, China
| | - Yana Su
- Department of Evidence-Based Medicine and Clinical Epidemiology, West China Hospital, Sichuan University, No.37 Guoxue Alley, Chengdu, 610041, China
| | - Tianqi Yu
- Department of Evidence-Based Medicine and Clinical Epidemiology, West China Hospital, Sichuan University, No.37 Guoxue Alley, Chengdu, 610041, China
| | - Xinyu Wu
- Department of Evidence-Based Medicine and Clinical Epidemiology, West China Hospital, Sichuan University, No.37 Guoxue Alley, Chengdu, 610041, China
| | - Xiaoqin Zhou
- Department of Clinical Research Management, West China Hospital, Sichuan University, No.37 Guoxue Alley, Chengdu, 610041, China
| | - Li Jing
- Department of Evidence-Based Medicine and Clinical Epidemiology, West China Hospital, Sichuan University, No.37 Guoxue Alley, Chengdu, 610041, China.
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Gao TY, Guo CX, Babu RJ, Black JM, Bobier WR, Chakraborty A, Dai S, Hess RF, Jenkins M, Jiang Y, Kearns LS, Kowal L, Lam CSY, Pang PCK, Parag V, Pieri R, Raveendren RN, South J, Staffieri SE, Wadham A, Walker N, Thompson B. Effectiveness of a Binocular Video Game vs Placebo Video Game for Improving Visual Functions in Older Children, Teenagers, and Adults With Amblyopia: A Randomized Clinical Trial. JAMA Ophthalmol 2019; 136:172-181. [PMID: 29302694 DOI: 10.1001/jamaophthalmol.2017.6090] [Citation(s) in RCA: 80] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Binocular amblyopia treatment using contrast-rebalanced stimuli showed promise in laboratory studies and requires clinical trial investigation in a home-based setting. Objective To compare the effectiveness of a binocular video game with a placebo video game for improving visual functions in older children and adults. Design, Setting, and Participants The Binocular Treatment of Amblyopia Using Videogames clinical trial was a multicenter, double-masked, randomized clinical trial. Between March 2014 and June 2016, 115 participants 7 years and older with unilateral amblyopia (amblyopic eye visual acuity, 0.30-1.00 logMAR; Snellen equivalent, 20/40-20/200) due to anisometropia, strabismus, or both were recruited. Eligible participants were allocated with equal chance to receive either the active or the placebo video game, with minimization stratified by age group (child, age 7 to 12 years; teenager, age 13 to 17 years; and adult, 18 years and older). Interventions Falling-blocks video games played at home on an iPod Touch for 1 hour per day for 6 weeks. The active video game had game elements split between eyes with a dichoptic contrast offset (mean [SD] initial fellow eye contrast, 0.23 [0.14]). The placebo video game presented identical images to both eyes. Main Outcomes and Measures Change in amblyopic eye visual acuity at 6 weeks. Secondary outcomes included compliance, stereoacuity, and interocular suppression. Participants and clinicians who measured outcomes were masked to treatment allocation. Results Of the 115 included participants, 65 (56.5%) were male and 83 (72.2%) were white, and the mean (SD) age at randomization was 21.5 (13.6) years. There were 89 participants (77.4%) who had prior occlusion. The mean (SD) amblyopic eye visual acuity improved 0.06 (0.12) logMAR from baseline in the active group (n = 56) and 0.07 (0.10) logMAR in the placebo group (n = 59). The mean treatment difference between groups, adjusted for baseline visual acuity and age group, was -0.02 logMAR (95% CI, -0.06 to 0.02; P = .25). Compliance with more than 25% of prescribed game play was achieved by 36 participants (64%) in the active group and by 49 (83%) in the placebo group. At 6 weeks, 36 participants (64%) in the active group achieved fellow eye contrast greater than 0.9 in the binocular video game. No group differences were observed for any secondary outcomes. Adverse effects included 3 reports of transient asthenopia. Conclusions and Relevance The specific home-based binocular falling-blocks video game used in this clinical trial did not improve visual outcomes more than the placebo video game despite increases in fellow eye contrast during game play. More engaging video games with considerations for compliance may improve effectiveness. Trial Registration anzctr.org.au Identifier: ACTRN12613001004752.
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Affiliation(s)
- Tina Y Gao
- School of Optometry and Vision Science, The University of Auckland, Auckland, New Zealand
| | - Cindy X Guo
- School of Optometry and Vision Science, The University of Auckland, Auckland, New Zealand
| | - Raiju J Babu
- School of Optometry and Vision Science, University of Waterloo, Waterloo, Ontario, Canada
| | - Joanna M Black
- School of Optometry and Vision Science, The University of Auckland, Auckland, New Zealand
| | - William R Bobier
- School of Optometry and Vision Science, University of Waterloo, Waterloo, Ontario, Canada
| | - Arijit Chakraborty
- School of Optometry and Vision Science, University of Waterloo, Waterloo, Ontario, Canada
| | - Shuan Dai
- Department of Ophthalmology, Starship Children's Hospital, Auckland, New Zealand
| | - Robert F Hess
- Department of Ophthalmology, McGill Vision Research, McGill University, Montreal, Quebec, Canada
| | - Michelle Jenkins
- National Institute for Health Innovation, School of Population Health, The University of Auckland, Auckland, New Zealand
| | - Yannan Jiang
- National Institute for Health Innovation, School of Population Health, The University of Auckland, Auckland, New Zealand
| | - Lisa S Kearns
- Centre for Eye Research Australia, Royal Victorian Eye and Ear Hospital, Melbourne, Victoria, Australia.,Ophthalmology, University of Melbourne Department of Surgery, Melbourne, Victoria, Australia
| | - Lionel Kowal
- Centre for Eye Research Australia, Royal Victorian Eye and Ear Hospital, Melbourne, Victoria, Australia.,Ophthalmology, University of Melbourne Department of Surgery, Melbourne, Victoria, Australia
| | - Carly S Y Lam
- School of Optometry, The Hong Kong Polytechnic University, Hong Kong, China
| | - Peter C K Pang
- School of Optometry, The Hong Kong Polytechnic University, Hong Kong, China
| | - Varsha Parag
- National Institute for Health Innovation, School of Population Health, The University of Auckland, Auckland, New Zealand
| | - Roberto Pieri
- Centre for Eye Research Australia, Royal Victorian Eye and Ear Hospital, Melbourne, Victoria, Australia.,Ophthalmology, University of Melbourne Department of Surgery, Melbourne, Victoria, Australia
| | | | - Jayshree South
- School of Optometry and Vision Science, The University of Auckland, Auckland, New Zealand
| | - Sandra Elfride Staffieri
- Centre for Eye Research Australia, Royal Victorian Eye and Ear Hospital, Melbourne, Victoria, Australia.,Ophthalmology, University of Melbourne Department of Surgery, Melbourne, Victoria, Australia
| | - Angela Wadham
- National Institute for Health Innovation, School of Population Health, The University of Auckland, Auckland, New Zealand
| | - Natalie Walker
- National Institute for Health Innovation, School of Population Health, The University of Auckland, Auckland, New Zealand
| | - Benjamin Thompson
- School of Optometry and Vision Science, The University of Auckland, Auckland, New Zealand.,School of Optometry and Vision Science, University of Waterloo, Waterloo, Ontario, Canada.,Department of Ophthalmology, McGill Vision Research, McGill University, Montreal, Quebec, Canada
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The Effect of Combined Patching and Citalopram on Visual Acuity in Adults with Amblyopia: A Randomized, Crossover, Placebo-Controlled Trial. Neural Plast 2019; 2019:5857243. [PMID: 31281343 PMCID: PMC6590556 DOI: 10.1155/2019/5857243] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Accepted: 05/14/2019] [Indexed: 11/17/2022] Open
Abstract
Nonhuman animal models have demonstrated that selective serotonin reuptake inhibitors (SSRIs) can enhance plasticity within the mature visual cortex and enable recovery from amblyopia. The aim of this study was to test the hypothesis that the SSRI citalopram combined with part-time patching of the fellow fixing eye would improve amblyopic eye visual acuity in adult humans. Following a crossover, randomized, double-blind, placebo-controlled design, participants completed two 2-week blocks of fellow fixing eye patching. One block combined patching with citalopram (20 mg/day) and the other with a placebo tablet. The blocks were separated by a 2-week washout period. The primary outcome was change in amblyopic eye visual acuity. Secondary outcomes included stereoacuity and electrophysiological measures of retinal and cortical function. Seven participants were randomized, fewer than our prespecified sample size of 20. There were no statistically significant differences in amblyopic eye visual acuity change between the active (mean ± SD change = 0.08 ± 0.16 logMAR) and the placebo (mean change = −0.01 ± 0.03 logMAR) blocks. No treatment effects were observed for any secondary outcomes. However, 3 of 7 participants experienced a 0.1 logMAR or greater improvement in amblyopic eye visual acuity in the active but not the placebo blocks. These results from a small sample suggest that larger-scale trials of SSRI treatment for adult amblyopia may be warranted. Considerations for future trials include drug dose, treatment duration, and recruitment challenges. This study was preregistered as a clinical trial (ACTRN12611000669998).
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Piano MEF, Simmers AJ. 'It's too late'. Is it really? Considerations for amblyopia treatment in older children. Ther Adv Ophthalmol 2019; 11:2515841419857379. [PMID: 31259304 PMCID: PMC6585235 DOI: 10.1177/2515841419857379] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Accepted: 05/17/2019] [Indexed: 01/20/2023] Open
Abstract
In recent years, media coverage has demonstrated instances in which families of children aged 7 and older, newly diagnosed with strabismic and/or anisometropic amblyopia through community eyecare services, were told it was 'too late' for their child to effectively respond to conventional amblyopia treatment (occlusion or atropine penalisation). Formal guidance pertaining to binocular vision anomalies from eyecare professional bodies does not specifically make reference to a child's age, beyond stating the importance of early diagnosis and treatment of strabismus/amblyopia. However, there have been many changes in the way we view the recovery period for amblyopia, and it is well demonstrated both within literature and clinical practice that conventional treatment can improve amblyopic eye visual acuity in children beyond the age of 7 years. The occurrence of these media described cases within the community eyecare sphere would suggest it is worthwhile revisiting the literature on the subject of amblyopia treatment in older children (aged 7+ years), to address misconceptions and place in the spotlight current considerations facing clinicians when treating newly diagnosed amblyopia within this age group. This perspective review provides an evidence-based update covering the various considerations associated with treatment of amblyopia in older children, along with recent amblyopia treatment advances that could have an impact on treatment prospects for this patient group. Considerations include the risks, benefits and efficacy of treating newly diagnosed amblyopia in older children, monitoring density of suppression to mitigate intractable diplopia risk, and recent findings regarding binocular treatments for amblyopia.
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Affiliation(s)
| | - Anita J Simmers
- Department of Vision Sciences, School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, UK
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Gao TY, Anstice N, Babu RJ, Black JM, Bobier WR, Dai S, Guo CX, Hess RF, Jenkins M, Jiang Y, Kearns L, Kowal L, Lam CSY, Pang PCK, Parag V, South J, Staffieri SE, Wadham A, Walker N, Thompson B. Optical treatment of amblyopia in older children and adults is essential prior to enrolment in a clinical trial. Ophthalmic Physiol Opt 2018; 38:129-143. [PMID: 29356022 DOI: 10.1111/opo.12437] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2017] [Accepted: 12/03/2017] [Indexed: 11/29/2022]
Abstract
PURPOSE Optical treatment alone can improve visual acuity (VA) in children with amblyopia, thus clinical trials investigating additional amblyopia therapies (such as patching or videogames) for children require a preceding optical treatment phase. Emerging therapies for adult patients are entering clinical trials. It is unknown whether optical treatment is effective for adults with amblyopia and whether an optical correction phase is required for trials involving adults. METHODS We examined participants who underwent optical treatment in the Binocular Treatment for Amblyopia using Videogames (BRAVO) clinical trial (ANZCTR ID: ACTRN12613001004752). Participants were recruited in three age groups (7 to 12, 13 to 17, or ≥18 years), and had unilateral amblyopia due to anisometropia and/or strabismus, with amblyopic eye VA of 0.30-1.00 logMAR (6/12 to 6/60, 20/40 to 20/200). Corrective lenses were prescribed based on cycloplegic refraction to fully correct any anisometropia. VA was assessed using the electronic visual acuity testing algorithm (e-ETDRS) test and near stereoacuity was assessed using the Randot Preschool Test. Participants were assessed every four weeks up to 16 weeks, until either VA was stable or until amblyopic eye VA improved to better than 0.30 logMAR, rendering the participant ineligible for the trial. RESULTS Eighty participants (mean age 24.6 years, range 7.6-55.5 years) completed four to 16 weeks of optical treatment. A small but statistically significant mean improvement in amblyopic eye VA of 0.05 logMAR was observed (S.D. 0.08 logMAR; paired t-test p < 0.0001). Twenty-five participants (31%) improved by ≥1 logMAR line and of these, seven (9%) improved by ≥2 logMAR lines. Stereoacuity improved in 15 participants (19%). Visual improvements were not associated with age, presence of strabismus, or prior occlusion treatment. Two adult participants withdrew due to intolerance to anisometropic correction. Sixteen out of 80 participants (20%) achieved better than 0.30 logMAR VA in the amblyopic eye after optical treatment. Nine of these participants attended additional follow-up and four (44%) showed further VA improvements. CONCLUSIONS Improvements from optical treatment resulted in one-fifth of participants becoming ineligible for the main clinical trial. Studies investigating additional amblyopia therapies must include an appropriate optical treatment only phase and/or parallel treatment group regardless of patient age. Optical treatment of amblyopia in adult patients warrants further investigation.
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Affiliation(s)
- Tina Y Gao
- School of Optometry and Vision Science, The University of Auckland, Auckland, New Zealand
| | - Nicola Anstice
- School of Optometry and Vision Science, The University of Auckland, Auckland, New Zealand
| | - Raiju J Babu
- School of Optometry and Vision Science, University of Waterloo, Waterloo, Ontario, Canada
| | - Joanna M Black
- School of Optometry and Vision Science, The University of Auckland, Auckland, New Zealand
| | - William R Bobier
- School of Optometry and Vision Science, University of Waterloo, Waterloo, Ontario, Canada
| | - Shuan Dai
- Department of Ophthalmology, Auckland City Hospital and Starship Children's Hospital, Auckland, New Zealand
| | - Cindy X Guo
- School of Optometry and Vision Science, The University of Auckland, Auckland, New Zealand
| | - Robert F Hess
- Department of Ophthalmology, McGill Vision Research, McGill University, Montreal, Quebec, Canada
| | - Michelle Jenkins
- National Institute for Health Innovation, School of Population Health, The University of Auckland, Auckland, New Zealand
| | - Yannan Jiang
- National Institute for Health Innovation, School of Population Health, The University of Auckland, Auckland, New Zealand
| | - Lisa Kearns
- Centre for Eye Research Australia, Royal Victorian Eye and Ear Hospital, Melbourne, Victoria, Australia.,Ophthalmology, Department of Surgery, University of Melbourne, Melbourne, Victoria, Australia
| | - Lionel Kowal
- Centre for Eye Research Australia, Royal Victorian Eye and Ear Hospital, Melbourne, Victoria, Australia.,Ophthalmology, Department of Surgery, University of Melbourne, Melbourne, Victoria, Australia
| | - Carly S Y Lam
- School of Optometry, The Hong Kong Polytechnic University, Hong Kong, China
| | - Peter C K Pang
- School of Optometry, The Hong Kong Polytechnic University, Hong Kong, China
| | - Varsha Parag
- National Institute for Health Innovation, School of Population Health, The University of Auckland, Auckland, New Zealand
| | - Jayshree South
- School of Optometry and Vision Science, The University of Auckland, Auckland, New Zealand
| | - Sandra Elfride Staffieri
- Centre for Eye Research Australia, Royal Victorian Eye and Ear Hospital, Melbourne, Victoria, Australia.,Ophthalmology, Department of Surgery, University of Melbourne, Melbourne, Victoria, Australia
| | - Angela Wadham
- National Institute for Health Innovation, School of Population Health, The University of Auckland, Auckland, New Zealand
| | - Natalie Walker
- National Institute for Health Innovation, School of Population Health, The University of Auckland, Auckland, New Zealand
| | - Benjamin Thompson
- School of Optometry and Vision Science, The University of Auckland, Auckland, New Zealand.,School of Optometry and Vision Science, University of Waterloo, Waterloo, Ontario, Canada
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Guo CX, Babu RJ, Black JM, Bobier WR, Lam CSY, Dai S, Gao TY, Hess RF, Jenkins M, Jiang Y, Kowal L, Parag V, South J, Staffieri SE, Walker N, Wadham A, Thompson B. Binocular treatment of amblyopia using videogames (BRAVO): study protocol for a randomised controlled trial. Trials 2016; 17:504. [PMID: 27756405 PMCID: PMC5069878 DOI: 10.1186/s13063-016-1635-3] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2016] [Accepted: 09/30/2016] [Indexed: 12/02/2022] Open
Abstract
Background Amblyopia is a common neurodevelopmental disorder of vision that is characterised by visual impairment in one eye and compromised binocular visual function. Existing evidence-based treatments for children include patching the nonamblyopic eye to encourage use of the amblyopic eye. Currently there are no widely accepted treatments available for adults with amblyopia. The aim of this trial is to assess the efficacy of a new binocular, videogame-based treatment for amblyopia in older children and adults. We hypothesise that binocular treatment will significantly improve amblyopic eye visual acuity relative to placebo treatment. Methods/design The BRAVO study is a double-blind, randomised, placebo-controlled multicentre trial to assess the effectiveness of a novel videogame-based binocular treatment for amblyopia. One hundred and eight participants aged 7 years or older with anisometropic and/or strabismic amblyopia (defined as ≥0.2 LogMAR interocular visual acuity difference, ≥0.3 LogMAR amblyopic eye visual acuity and no ocular disease) will be recruited via ophthalmologists, optometrists, clinical record searches and public advertisements at five sites in New Zealand, Canada, Hong Kong and Australia. Eligible participants will be randomised by computer in a 1:1 ratio, with stratification by age group: 7–12, 13–17 and 18 years and older. Participants will be randomised to receive 6 weeks of active or placebo home-based binocular treatment. Treatment will be in the form of a modified interactive falling-blocks game, implemented on a 5th generation iPod touch device viewed through red/green anaglyphic glasses. Participants and those assessing outcomes will be blinded to group assignment. The primary outcome is the change in best-corrected distance visual acuity in the amblyopic eye from baseline to 6 weeks post randomisation. Secondary outcomes include distance and near visual acuity, stereopsis, interocular suppression, angle of strabismus (where applicable) measured at baseline, 3, 6, 12 and 24 weeks post randomisation. Treatment compliance and acceptability will also be assessed along with quality of life for adult participants. Discussion The BRAVO study is the first randomised controlled trial of a home-based videogame treatment for older children and adults with amblyopia. The results will indicate whether a binocular approach to amblyopia treatment conducted at home is effective for patients aged 7 years or older. Trial registration This trial was registered in Australia and New Zealand Clinical Trials Registry (ACTRN12613001004752) on 10 September 2013.
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Affiliation(s)
- Cindy X Guo
- School of Optometry and Vision Science, The University of Auckland, Auckland, New Zealand
| | - Raiju J Babu
- School of Optometry and Vision Science, University of Waterloo, Waterloo, ON, Canada
| | - Joanna M Black
- School of Optometry and Vision Science, The University of Auckland, Auckland, New Zealand
| | - William R Bobier
- School of Optometry and Vision Science, University of Waterloo, Waterloo, ON, Canada
| | - Carly S Y Lam
- School of Optometry, Faculty of Health and Social Sciences, The Hong Kong Polytechnic University, Hong Kong, SAR, China
| | - Shuan Dai
- Department of Ophthalmology, Starship Children's Hospital, Auckland, New Zealand
| | - Tina Y Gao
- School of Optometry and Vision Science, The University of Auckland, Auckland, New Zealand
| | - Robert F Hess
- Department of Ophthalmology, McGill Vision Research, McGill University, Montreal, QC, Canada
| | - Michelle Jenkins
- National Institute for Health Innovation, School of Population Health, The University of Auckland, Auckland, New Zealand
| | - Yannan Jiang
- National Institute for Health Innovation, School of Population Health, The University of Auckland, Auckland, New Zealand
| | - Lionel Kowal
- Department of Surgery, Centre for Eye Research Australia, Royal Victorian Eye and Ear Hospital; Ophthalmology, University of Melbourne, Melbourne, VIC, Australia
| | - Varsha Parag
- National Institute for Health Innovation, School of Population Health, The University of Auckland, Auckland, New Zealand
| | - Jayshree South
- School of Optometry and Vision Science, The University of Auckland, Auckland, New Zealand
| | - Sandra Elfride Staffieri
- Department of Surgery, Centre for Eye Research Australia, Royal Victorian Eye and Ear Hospital; Ophthalmology, University of Melbourne, Melbourne, VIC, Australia
| | - Natalie Walker
- National Institute for Health Innovation, School of Population Health, The University of Auckland, Auckland, New Zealand
| | - Angela Wadham
- National Institute for Health Innovation, School of Population Health, The University of Auckland, Auckland, New Zealand
| | - Benjamin Thompson
- School of Optometry and Vision Science, The University of Auckland, Auckland, New Zealand. .,School of Optometry and Vision Science, University of Waterloo, Waterloo, ON, Canada.
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Thompson B, Chung STL, Kiorpes L, Ledgeway T, McGraw PV. A window into visual cortex development and recovery of vision: Introduction to the Vision Research special issue on Amblyopia. Vision Res 2015; 114:1-3. [PMID: 26095676 DOI: 10.1016/j.visres.2015.06.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Affiliation(s)
- Benjamin Thompson
- School of Optometry and Vision Science, University of Waterloo, Canada; School Optometry and Vision Science, University of Auckland, New Zealand
| | - Susana T L Chung
- School of Optometry, University of California Berkeley, Berkeley, CA 94720-2020, United States
| | - Lynne Kiorpes
- Center for Neural Science, New York University, New York, NY 10003, United States
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