Compliance with the prescribed occlusion treatment for amblyopia

High-adherence dichoptic treatment versus patching in anisometropic and small angle strabismus amblyopia: a randomized controlled trial

PURPOSE

To compare the effectiveness and safety of a novel binocular eye-tracking-based-home-treatment (CureSight) to patching for the treatment of amblyopia.

DESIGN

Prospective, masked, randomized controlled noninferiority trial.

SETTING

Multicenter, multinational, home treatment.

PARTICIPANTS

One hundred forty-nine children 4 to < 9 years with anisometropic, small-angle strabismic, or mixed-mechanism amblyopia were randomized to either binocular treatment (n=75) or patching (n=74).

INTERVENTIONS

The binocular treatment group used the CureSight system for 90 min/day, 5 days/week for 16 weeks (120 hours). The patching group received 2-hour patching 7 days/week (224 hours).

MAIN OUTCOME MEASURES

The primary outcome was the mean improvement from baseline in amblyopic eye visual acuity (VA) to week 16 in both study groups (non-inferiority of ≤0.10 logarithm of the minimum angle of resolution [logMAR]). Other outcomes included changes in stereoacuity and binocular VA from baseline to week 16.

RESULTS

The mean improvement from baseline at week 16 in the binocular treatment group was noninferior to patching group improvement in the modified intent-to-treat (mITT) dataset (LS mean difference between groups in improvement from baseline: 0.034 logMAR (95% CI -0.009 to 0.076)). In the per-protocol (PP) dataset, the mean improvement from baseline at week 16 in the binocular treatment group was superior to patching group improvement (LS mean difference between groups in improvement from baseline: 0.05 logMAR ([95% CI; 0.007 to 0.097]). At week 16, both groups showed significant median improvement in stereoacuity, with no significant between-group difference in the magnitude of improvement in both the mITT and the PP datasets. Binocular VA was also improved in both groups (p<0.0001). Median adherence in the mITT binocular treatment group (94.0%) was also significantly higher than in the patching group (83.9%; p=0.0038).

CONCLUSIONS

Binocular, eye-tracking-based amblyopia home treatment is at least as effective as patching.

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.].

Stereoptic serious games as a visual rehabilitation tool for individuals with a residual amblyopia (AMBER trial): a protocol for a crossover randomized controlled trial

BACKGROUND

Amblyopia is the most common developmental vision disorder in children. The initial treatment consists of refractive correction. When insufficient, occlusion therapy may further improve visual acuity. However, the challenges and compliance issues associated with occlusion therapy may result in treatment failure and residual amblyopia. Virtual reality (VR) games developed to improve visual function have shown positive preliminary results. The aim of this study is to determine the efficacy of these games to improve vision, attention, and motor skills in patients with residual amblyopia and identify brain-related changes. We hypothesize that a VR-based training with the suggested ingredients (3D cues and rich feedback), combined with increasing the difficulty level and the use of various games in a home-based environment is crucial for treatment efficacy of vision recovery, and may be particularly effective in children.

METHODS

The AMBER study is a randomized, cross-over, controlled trial designed to assess the effect of binocular stimulation (VR-based stereoptic serious games) in individuals with residual amblyopia (n = 30, 6-35 years of age), compared to refractive correction on vision, selective attention and motor control skills. Additionally, they will be compared to a control group of age-matched healthy individuals (n = 30) to account for the unique benefit of VR-based serious games. All participants will play serious games 30 min per day, 5 days per week, for 8 weeks. The games are delivered with the Vivid Vision Home software. The amblyopic cohort will receive both treatments in a randomized order according to the type of amblyopia, while the control group will only receive the VR-based stereoscopic serious games. The primary outcome is visual acuity in the amblyopic eye. Secondary outcomes include stereoacuity, functional vision, cortical visual responses, selective attention, and motor control. The outcomes will be measured before and after each treatment with 8-week follow-up.

DISCUSSION

The VR-based games used in this study have been conceived to deliver binocular visual stimulation tailored to the individual visual needs of the patient, which will potentially result in improved basic and functional vision skills as well as visual attention and motor control skills.

TRIAL REGISTRATION

This protocol is registered on ClinicalTrials.gov (identifier: NCT05114252) and in the Swiss National Clinical Trials Portal (identifier: SNCTP000005024).

PECARE: Parental Feedback to Improve Congenital Cataract Care in Sweden

PURPOSE

To analyze non-directed parental feedback to health care providers responsible for pediatric cataract care in Sweden.

METHODS

A directed content analysis was used to analyze data consisting of text representing free comments provided by 40 parents. A deductive approach was employed by applying the model of balancing the child's inability and ability, which includes the categories mastering, collaborating, facilitating, and adapting.

RESULTS

Parents lacked piloting and self-management support. They experienced an absence of partnership with the health care team and not being taken seriously. They also felt abandoned by health care, resulting in emotional distress. Parents highlighted the impact of their social network and the challenges involved in accepting and adapting to the changes in everyday life.

CONCLUSIONS

This study emphasizes the consequences of the lack of a caring partnership with health care professionals. Because parents act as mediators of care to the child with congenital cataract, persistence on the part of parents and a family-centered approach are essential for the child's visual development. [J Pediatr Ophthalmol Strabismus. 20XX;XX(X):XX-XX.].

Visual outcomes of photorefractive keratectomy in non-children with anisometropic amblyopia: One-year Follow-up Outcomes

OBJECTIVE

To evaluate the safety, efficiency, short term stability, and sensory results of photorefractive keratectomy (PRK) in anisometropic in non-compliant children with correction.

METHODS

Twelve eyes of 12 children with an age range: 6-17 years and anisometropic amblyopia who underwent PRK under general anesthesia to correct the dioptric difference between the eyes were included in this study. A complete ophthalmic assessment including refractive status, uncorrected and corrected distance visual acuity (UDVA & CDVA), and binocular vision status using the Worth 4-dot test and stereopsis were performed before and 1, 3, 6, and 12 months after PRK.

RESULTS

The mean preoperative CDVA was 0.34 ± 0.24 LogMAR which showed a statistically significant improvement at 12 months (0.20 ± 0.19, p = 0.024) after surgery compared to the preoperative assessment. (p = 0.003) The mean preoperative UDVA was 0.63 ± 0.24 LogMAR that increased to 0.44 ± 0.24, 0.32 ± 0.16, 0.25 ± 0.19, and 0.25 ± 0.19 LogMAR at 1, 3, 6, and 12 months after PRK, respectively. One to three lines improvement in UDVA and CDVA was seen in 10 (83.4%) and 8 eyes (66.7%); while one line UDVA and CDVA loss was seen in one (8.3%) and one (8.3%) eye and unchanged UDVA and CDVA was seen in 1 (8.3%) and 3 eyes (25%), respectively. The mean preoperative stereoacuity was 341.9 ± 245.7 s of arc, which significantly improved to 166.6 ± 87.5 s of arc 12 months after PRK. (p = 0.012).

CONCLUSION

PRK was an effective surgical alternative to improve visual acuity and stereopsis in anisometropic children who did not cooperate with conventional methods of amblyopia therapy.

Efficacy of part-time occlusion in amblyopia in Indian children

Purpose:

To study the effectiveness of part-time occlusion (PTO) in different types of amblyopia in Indian population.

Methods:

Prospective case series of consecutive cases of amblyopia from a tertiary care center were subjected to PTO of the better eye and monitored periodically for 6 months. Those who failed to improve by 6 months were shifted to full-time occlusion of the better eye and followed for a further 3 months.

Results:

175 eyes of 175 patients with amblyopia underwent PTO for 6 months. The mean age of the patients was 10.47 ± 4.69 years (range: 3–26 years). Major subgroups included 94 eyes with strabismic amblyopia and 70 with anisometropic amblyopia. Overall, 168 (96%) children benefited from PTO (improvement being defined as a gain of at least one line of Snellen's visual acuity). The improvement rates for strabismic amblyopes (97.9%) was significantly more than anisometropia (94.3%); P = 0.027. Of the seven patients not responding to PTO, six did not benefit even after full-time patching.

Conclusion:

PTO is a viable and effective modality of management of amblyopia in Indian patients. Strabismic amblyopia was the commonest and responded best to the occlusion therapy in our cohort.

Evaluation of a New Method to Track Changes in Vision at Home for Children Undergoing Amblyopia Treatment

PURPOSE

A new amblyopia tracker app has been designed to provide parents with a method of monitoring a child's vision by presenting a single optotype size that the tester moves to identify the furthest distance the optotypes can be seen. The aim of this study is to evaluate this methodology in adults, comparing the findings to visual acuity (VA) measured with the iSight app and to determine the test retest variability.

METHODS

Adults, aged 18-39 years, with no known eye condition and VA ≤ 0.7 logMAR were recruited. Bangerter filters were used to simulate amblyopia, where VA was reduced below 0.0 with an interocular difference of at least 0.2 logMAR. Testing for both apps was performed monocularly, with the test order being randomised.

RESULTS

Data from 32 subjects were analysed. For the test retest variability analysis, paired t-tests showed no statistically significant difference between the tests for either eye, either app or the interocular acuity difference (p > 0.3 in all cases). Bland Altman plots showed similar limits of agreement between the two apps. When comparing measurements between the apps there was no statistically significant difference on the first or second test, either eye or the interocular acuity difference (p > 0.5 in all cases).

CONCLUSION

The results support the theory that changing distance is a valid method of assessing VA as the measurements agree well with the standard approach of reducing optotype size. Test retest variability is similar between the two apps and there is good agreement between the measurements.

Efficacy of vision-based treatments for children and teens with amblyopia: a systematic review and meta-analysis of randomised controlled trials

Objective

To identify differences in efficacy between vision-based treatments for improving visual acuity (VA) of the amblyopic eye in persons aged 4-17 years old.

Data sources

Ovid Embase, PubMed (Medline), the Cochrane Library, Vision Cite and Scopus were systematically searched from 1975 to 17 June 2020.

Methods

Two independent reviewers screened search results for randomised controlled trials of vision-based amblyopia treatments that specified change in amblyopic eye VA (logMAR) as the primary outcome measure. Quality was assessed via risk of bias and GRADE (Grading of Recommendations, Assessment, Development, and Evaluations).

Results

Of the 3346 studies identified, 36 were included in a narrative synthesis. A random effects meta-analysis (five studies) compared the efficacy of binocular treatments versus patching: mean difference -0.03 logMAR; 95% CI 0.01 to 0.04 (p<0.001), favouring patching. An exploratory study-level regression (18 studies) showed no statistically significant differences between vision-based treatments and a reference group of 2-5 hours of patching. Age, sample size and pre-randomisation optical treatment were not statistically significantly associated with changes in amblyopic eye acuity. A network meta-analysis (26 studies) comparing vision-based treatments to patching 2-5 hours found one statistically significant comparison, namely, the favouring of a combination of two treatment arms comparing combination and binocular treatments, against patching 2-5 hours: standard mean difference: 2.63; 95% CI 1.18 to 4.09. However, this result was an indirect comparison calculated from a single study. A linear regression analysis (17 studies) found a significant relationship between adherence and effect size, but the model did not completely fit the data: regression coefficient 0.022; 95% CI 0.004 to 0.040 (p=0.02).

Conclusion

We found no clinically relevant differences in treatment efficacy between the treatments included in this review. Adherence to the prescribed hours of treatment varied considerably and may have had an effect on treatment success.

Current Management of Childhood Amblyopia

Amblyopia is defined as the reduction of best-corrected visual acuity of one or both eyes caused by conditions that affect normal visual development. The basic strategy to treat amblyopia is to obtain a clear retinal image in each eye and correct ocular dominance through forced use of the amblyopic eye. Treatment modalities include correcting any underlying organic disease, prescribing appropriate optical correction, and providing occlusion/penalization therapy for the non-amblyopic eye. Given the success of amblyopia treatment declines with increasing age, the detection and management of amblyopia should begin as early as possible during the sensitive period for visual development. Proper management of amblyopia during childhood can reduce the overall prevalence and severity of visual loss. This study aims to provide an update for the management of childhood amblyopia to provide better visual outcomes.

The effect of different amblyopia treatment protocols on axial length of non-amblyopic eyes in anisohyperopic patients

Purpose

To evaluate the effect of full-time and part-time occlusion therapy on axial length (AL) of non-amblyopic eyes in anisohyperopic patients.

Methods

Sixty-five patients who were treated for anisohyperopic amblyopia were recruited for this prospective cross-sectional study. Treatment was provided as patching of the non-amblyopic for 4 h or less (part-time occlusion therapy, n = 42), patching of the non-amblyopic for 8 h or more (full-time occlusion therapy, n = 13) and refractive correction (spectacles, non-patched group, n = 10). AL measurements were calculated by a Lenstar LS 900 at the last session of amblyopia therapy.

Results

The mean age of patients treated for anisohyperopic amblyopia was 4.90 ± 0.80 years, and the mean follow-up period was 1.50 ± 0.80 years. The mean of spherical equivalent in amblyopic and non-amblyopic eyes were +3.58 ± 2.26 and +1.84 ± 0.97 diopter (D) before treatment, and +3.21 ± 2.28 and +1.49 ± 0.99 D after treatment, respectively. The mean of spherical equivalent in non-amblyopic eyes before (F = 0.452, df = 2, P = 0.639) and after (F = 0.190, df = 2, P = 0.828) treatment did not have any significant difference between the three groups. The mean AL of amblyopic and non-amblyopic eyes were 22.11 ± 93.0 and 22.68 ± 1.07 mm, respectively. The mean AL of the non-amblyopic eye was significantly higher in the full-time occlusion therapy group when compared to the part-time patch and the non-patched groups (P < 0.001). The mean AL of amblyopic eyes showed no difference across the three treatment groups (P = 0.840).

Conclusions

The results show that a longer AL in the non-amblyopic eye, but not the amblyopic eye, can be expected with longer daily hours of patching in anisohyperopic patients. Future studies are needed to evaluate the effect of patching on AL in children with anisohyperopic amblyopia.

[Modern methods of treatment of amblyopia]

Throughout the history of pediatric ophthalmology, pathophysiological state has always played an important role. It's characterized by reduced central vision, often paired with disruption of binocular vision, which is interpreted as amblyopia. Central vision is necessary for social integration, so its disorders cause great quality of life changes in patients limiting their professional activities and complicating everyday life. Despite large number of proposed methods of treatment, amblyopia still remains a pressing problem and its prevalence has not changed significantly over the years.