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Birch EE, Duffy KR. Leveraging neural plasticity for the treatment of amblyopia. Surv Ophthalmol 2024; 69:818-832. [PMID: 38763223 PMCID: PMC11380599 DOI: 10.1016/j.survophthal.2024.04.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2023] [Revised: 04/27/2024] [Accepted: 04/29/2024] [Indexed: 05/21/2024]
Abstract
Amblyopia is a form of visual cortical impairment that arises from abnormal visual experience early in life. Most often, amblyopia is a unilateral visual impairment that can develop as a result of strabismus, anisometropia, or a combination of these conditions that result in discordant binocular experience. Characterized by reduced visual acuity and impaired binocular function, amblyopia places a substantial burden on the developing child. Although frontline treatment with glasses and patching can improve visual acuity, residual amblyopia remains for most children. Newer binocular-based therapies can elicit rapid recovery of visual acuity and may also improve stereoacuity in some children. Nevertheless, for both treatment modalities full recovery is elusive, recurrence of amblyopia is common, and improvements are negligible when treatment is administered at older ages. Insights derived from animal models about the factors that govern neural plasticity have been leveraged to develop innovative treatments for amblyopia. These novel therapies exhibit efficacy to promote recovery, and some are effective even at ages when conventional treatments fail to yield benefit. Approaches for enhancing visual system plasticity and promoting recovery from amblyopia include altering the balance between excitatory and inhibitory mechanisms, reversing the accumulation of proteins that inhibit plasticity, and harnessing the principles of metaplasticity. Although these therapies have exhibited promising results in animal models, their safety and ability to remediate amblyopia need to be evaluated in humans.
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Affiliation(s)
- Eileen E Birch
- Crystal Charity Ball Pediatric Vision Laboratory, Retina Foundation, Dallas, TX, USA; University of Texas Southwestern Medical Center, Dallas, TX, USA.
| | - Kevin R Duffy
- Department of Psychology and Neuroscience, Dalhousie University, Halifax, NS, Canada
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Wygnanski-Jaffe T, Kushner BJ, Moshkovitz A, Belkin M, Yehezkel O. High-adherence dichoptic treatment versus patching in anisometropic and small angle strabismus amblyopia: a randomized controlled trial. Am J Ophthalmol 2024:S0002-9394(24)00374-X. [PMID: 39179129 DOI: 10.1016/j.ajo.2024.08.011] [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: 02/19/2024] [Revised: 08/11/2024] [Accepted: 08/11/2024] [Indexed: 08/26/2024]
Abstract
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.
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Affiliation(s)
- Tamara Wygnanski-Jaffe
- Goldschleger Eye Institute, Sheba Medical Center, Tel Hashomer, Israel; Sackler Faculty of Medicine, Tel- Aviv University, Tel-Aviv, Israel
| | - Burton J Kushner
- Department of Ophthalmology and Visual Sciences, University of Wisconsin, Madison, USA
| | | | - Michael Belkin
- Sackler Faculty of Medicine, Tel- Aviv University, Tel-Aviv, Israel; Goldschleger Eye Research Institute, Sheba Medical Center, Tel Hashomer, Israel
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Piñero DP, Gil-Casas A, Hurtado-Ceña FJ, Molina-Martin A. Visual Performance of Children with Amblyopia after 6 Weeks of Home-Based Dichoptic Visual Training. CHILDREN (BASEL, SWITZERLAND) 2024; 11:1007. [PMID: 39201941 PMCID: PMC11352600 DOI: 10.3390/children11081007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/09/2024] [Revised: 08/02/2024] [Accepted: 08/15/2024] [Indexed: 09/03/2024]
Abstract
OBJECTIVES This study was aimed at analyzing the efficacy on the improvement of the visual function of a dichoptic online cloud-based platform for the treatment of amblyopia in anisometropic children. METHODS A quasi-experimental (pretest-post-test) study was conducted in 23 subjects with ages from 5 to 15 years old with anisometropic amblyopia combined with additional presence (2 subjects) or not (21 subjects) of microtropia. A total of 30 home-based training sessions of 30 min per session with Bynocs® platform were prescribed for 6 weeks. RESULTS Amblyopic eye logMAR visual acuity (VA) significantly improved from 0.28 ± 0.24 to 0.13 ± 0.20 after the 6-week treatment (p < 0.001). At baseline, 60.9% of participants had VA in amblyopic eye of 0.20 logMAR or worse, whereas this percentage decreased to 21.7% after treatment. Binocular function (BF) significantly improved from 2.82 ± 1.11 to 2.32 ± 0.94 (p < 0.001). Mean compliance was 92%, 87% and 93% at 2, 4 and 6 weeks of treatment, respectively. CONCLUSIONS In conclusion, home-based dichoptic training with the digital platform evaluated is an effective method to improve amblyopic VA and stereoacuity in children with anisometropic amblyopia combined or not with microtropia.
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Affiliation(s)
- David P. Piñero
- Department of Optics, Pharmacology and Anatomy, University of Alicante, 03690 Alicante, Spain
- Department of Ophthalmology, Vithas Medimar International Hospital, 03016 Alicante, Spain;
| | - Amparo Gil-Casas
- Optometric Clinic, Lluís Alcanyís Foundation, University of Valencia, 46020 Valencia, Spain;
| | | | - Ainhoa Molina-Martin
- Department of Ophthalmology, Vithas Medimar International Hospital, 03016 Alicante, Spain;
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Thompson B, Concetta Morrone M, Bex P, Lozama A, Sabel BA. Harnessing brain plasticity to improve binocular vision in amblyopia: An evidence-based update. Eur J Ophthalmol 2024; 34:901-912. [PMID: 37431104 PMCID: PMC11295393 DOI: 10.1177/11206721231187426] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Accepted: 06/11/2023] [Indexed: 07/12/2023]
Abstract
Amblyopia is a developmental visual disorder resulting from atypical binocular experience in early childhood that leads to abnormal visual cortex development and vision impairment. Recovery from amblyopia requires significant visual cortex neuroplasticity, i.e. the ability of the central nervous system and its synaptic connections to adapt their structure and function. There is a high level of neuroplasticity in early development and, historically, neuroplastic responses to changes in visual experience were thought to be restricted to a "critical period" in early life. However, as our review now shows, the evidence is growing that plasticity of the adult visual system can also be harnessed to improve vision in amblyopia. Amblyopia treatment involves correcting refractive error to ensure clear and equal retinal image formation in both eyes, then, if necessary, promoting the use of the amblyopic eye by hindering or reducing visual input from the better eye through patching or pharmacologic therapy. Early treatment in children can lead to visual acuity gains and the development of binocular vision in some cases; however, many children do not respond to treatment, and many adults with amblyopia have historically been untreated or undertreated. Here we review the current evidence on how dichoptic training can be used as a novel binocular therapeutic approach to facilitate visual processing of input from the amblyopic eye and can simultaneously engage both eyes in a training task that requires binocular integration. It is a novel and promising treatment for amblyopia in both children and adults.
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Affiliation(s)
- Benjamin Thompson
- Department of Optometry and Vision Science, University of Waterloo, Waterloo, ON, Canada
- Centre for Eye and Vision Science, Hong Kong
| | - Maria Concetta Morrone
- Department of Translational Research on New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Peter Bex
- Department of Psychology, Northeastern University, Boston, MA, USA
| | - Anthony Lozama
- Novartis Pharmaceutical Corporation, East Hanover, NJ, USA
| | - Bernhard A. Sabel
- Institute of Medical Psychology, Faculty of Medicine, Otto-von-Guericke University of Magdeburg, Magdeburg, Germany
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Liu J, Huang C, Cotter SA, Chan LYL, Yu Y, Jia Y, Ye Q, Feng L, Yao Y, Jiang R, Xiao C, Xu Z, Zhuang Y, He Y, Zhou Y, Chen X, Yuan J, Wen Y, Yu W, Pang Y, Lu ZL, Thompson B, Li J. Novel Quantitative Contrast Sensitivity Function Enhances the Prediction of Treatment Outcome and Recurrence in Amblyopia. Invest Ophthalmol Vis Sci 2024; 65:31. [PMID: 38771572 PMCID: PMC11114618 DOI: 10.1167/iovs.65.5.31] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Accepted: 01/20/2024] [Indexed: 05/22/2024] Open
Abstract
Purpose Although effective amblyopia treatments are available, treatment outcome is unpredictable, and the condition recurs in up to 25% of the patients. We aimed to evaluate whether a large-scale quantitative contrast sensitivity function (CSF) data source, coupled with machine learning (ML) algorithms, can predict amblyopia treatment response and recurrence in individuals. Methods Visual function measures from traditional chart vision acuity (VA) and novel CSF assessments were used as the main predictive variables in the models. Information from 58 potential predictors was extracted to predict treatment response and recurrence. Six ML methods were applied to construct models. The SHapley Additive exPlanations was used to explain the predictions. Results A total of 2559 consecutive records of 643 patients with amblyopia were eligible for modeling. Combining variables from VA and CSF assessments gave the highest accuracy for treatment response prediction, with the area under the receiver operating characteristic curve (AUC) of 0.863 and 0.815 for outcome predictions after 3 and 6 months, respectively. Variables from the VA assessment alone predicted the treatment response, with AUC values of 0.723 and 0.675 after 3 and 6 months, respectively. Variables from the CSF assessment gave rise to an AUC of 0.909 for recurrence prediction compared to 0.539 for VA assessment alone, and adding VA variables did not improve predictive performance. The interocular differences in CSF features are significant contributors to recurrence risk. Conclusions Our models showed CSF data could enhance treatment response prediction and accurately predict amblyopia recurrence, which has the potential to guide amblyopia management by enabling patient-tailored decision making.
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Affiliation(s)
- Jing Liu
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-Sen University, Guangzhou, China
| | - Chencui Huang
- AI Lab, Beijing Deepwise & League of PHD Technology Co., Ltd, Beijing, China
| | - Susan A. Cotter
- Southern California College of Optometry, Marshall B. Ketchum University, Fullerton, California, United States
| | - Lily Y. L. Chan
- School of Optometry, The Hong Kong Polytechnic University, Hong Kong, China
| | - Yizhou Yu
- AI Lab, Beijing Deepwise & League of PHD Technology Co., Ltd, Beijing, China
- Department of Computer Science, The University of Hong Kong, Hong Kong, China
| | - Yu Jia
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-Sen University, Guangzhou, China
- Centre for Eye and Vision Research, 17W Science Park, Hong Kong, China
| | - Qingqing Ye
- 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
| | - 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
| | - Chutong Xiao
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-Sen University, Guangzhou, China
- Donald Bren School of Information and Computer Sciences, University of California Irvine, California, United States
| | - 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
| | - Junpeng Yuan
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-Sen University, Guangzhou, China
| | - Yun Wen
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-Sen University, Guangzhou, China
| | - Wentong Yu
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-Sen University, Guangzhou, China
| | - Yangfei Pang
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-Sen University, Guangzhou, China
| | - Zhong-Lin Lu
- Division of Arts and Sciences, New York University Shanghai, Shanghai, China
- Department of Neural Science and Psychology, New York University, New York, New York, United States
- Institute of Brain and Cognitive Science, New York University-East China Normal University, Shanghai, China
| | - Benjamin Thompson
- Centre for Eye and Vision Research, 17W Science Park, Hong Kong, China
- School of Optometry and Vision Science, University of Waterloo, Waterloo, Ontario, Canada
- Liggins Institute, The University of Auckland, Auckland, New Zealand
| | - Jinrong Li
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-Sen University, Guangzhou, China
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Schmucker C, Thörel E, Flatscher-Thöni M, Sow D, Göhner A, Stühlinger V, Mühlberger N, Lagrèze WA, Meerpohl J. Computer-Assisted Visual Training in Children and Adolescents with Developmental Visual Disorders. DEUTSCHES ARZTEBLATT INTERNATIONAL 2023; 120:747-753. [PMID: 37656479 PMCID: PMC10722492 DOI: 10.3238/arztebl.m2023.0191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Revised: 08/09/2023] [Accepted: 08/09/2023] [Indexed: 09/02/2023]
Abstract
BACKGROUND In this systematic review, we address the question whether children and adolescents with developmental visual disorders benefit from computer-assisted visual training. METHODS Systematic literature searches were carried out in three bibliographic databases (initial search in October 2021) and trial registries. Included were randomized controlled trials that evaluated the efficacy of computer-assisted visual training in children and adolescents with developmental visual disorders in comparison to no training, sham training, or conservative treatment. RESULTS The inclusion criteria were met by 17 trials (with a total of 1323 children and adolescents) focusing on binocular or monocular computer-assisted visual training for the treatment of amblyopia. In these trials, visual training was carried out for 2 to 24 weeks, either as "stand alone" therapy or in addition to occlusion therapy. Six trials showed a statistically significant difference in favor of the visual training for the outcome "best corrected visual acuity of the amblyopic eye." However, this difference was small and mostly below the threshold of clinical relevance of -0.05 logMAR (equivalent to an improvement of 0.5 lines on the eye chart, or 2.5 letters per line). Only few data were available for the outcomes "binocular vision" and "adverse events"; the differences between the groups were similarly small. CONCLUSION The currently available data do not permit any firm conclusions regarding the efficacy of visual training in children and adolescents with amblyopia. Moreover, treatment adherence was often insufficient and the treatment durations in the trials was relatively short. No results from randomized trials have yet been published with respect to other developmental visual disorders (refractive errors, strabismus).
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Affiliation(s)
- Christine Schmucker
- Institute for Evidence in Medicine, Medical Center – University of Freiburg, Faculty of Medicine, Albert Ludwig University of Freiburg
| | - Eberhard Thörel
- Institute for Evidence in Medicine, Medical Center – University of Freiburg, Faculty of Medicine, Albert Ludwig University of Freiburg
| | - Magdalena Flatscher-Thöni
- Institute for Public Health, Medical Decision Making and Health Technology Assessment, UMIT TIROL – Private University for Health Sciences and Technology
| | - Dorothea Sow
- Department of Information Management, Quality and Economic Efficiency in Health Care (IQWiG), Cologne
| | - Anne Göhner
- Center for Geriatric Medicine and Gerontology, Freiburg University Hospital, Faculty of Medicine, Albert Ludwigs University Freiburg
| | - Verena Stühlinger
- Institute for Public Health, Medical Decision Making and Health Technology Assessment, UMIT TIROL – Private University for Health Sciences and Technology
| | - Nikolai Mühlberger
- Institute for Public Health, Medical Decision Making and Health Technology Assessment, UMIT TIROL – Private University for Health Sciences and Technology
| | - Wolf A. Lagrèze
- Department of Ophthalmology, Freiburg University Hospital, Faculty of Medicine, Albert Ludwigs University Freiburg
- *The authors contributed equally to this paper
| | - Jörg Meerpohl
- Institute for Evidence in Medicine, Medical Center – University of Freiburg, Faculty of Medicine, Albert Ludwig University of Freiburg
- Cochrane Germany, Cochrane Germany Foundation, Freiburg
- *The authors contributed equally to this paper
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Nowik M, Perna F, Dahlmann-Noor A, Stern J, Malkowski JP, Weisberger A, Webber A. Amblyopia-A novel virtual round table to explore the caregiver perspective. Ophthalmic Physiol Opt 2023; 43:1571-1580. [PMID: 37515472 DOI: 10.1111/opo.13209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Revised: 06/08/2023] [Accepted: 07/17/2023] [Indexed: 07/30/2023]
Abstract
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.
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Affiliation(s)
| | | | | | - Jude Stern
- c/o International Agency for the Prevention of Blindness (IAPB), Sydney, New South Wales, Australia
| | | | | | - Ann Webber
- School of Optometry and Vision Science, Queensland University of Technology, Brisbane, Queensland, Australia
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Jost RM, Kelly KR, Birch EE. Risk of recurrence after cessation of dichoptic, binocular treatment of amblyopia. J AAPOS 2023; 27:298-300. [PMID: 37619861 PMCID: PMC10592044 DOI: 10.1016/j.jaapos.2023.06.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Revised: 06/09/2023] [Accepted: 06/16/2023] [Indexed: 08/26/2023]
Abstract
Contrast-rebalanced dichoptic games and videos have been shown to be an effective treatment for childhood amblyopia. Whether the visual acuity gains achieved with these binocular treatments are long-lasting has not been determined. In this prospective cohort study of 100 consecutive amblyopic children who improved by ≥0.2 logMAR or obtained ≤0.2 logMAR amblyopic eye visual acuity during a binocular treatment clinical trial, risk of recurrence was 24% (95% CI, 16%-35%) at up to 3 years' follow-up according to Kaplan-Meier survival analysis, which accounts for censored, truncated, and missing data. Risk of recurrence was similar among children who required additional treatment for residual amblyopia after 4-8 weeks of dichoptic treatment (n = 62 [19%]; 95% CI, 10%-34%) and those who did not (n = 38 [32%]; 95% CI, 18%-52%; P = 0.12). There was no association between recurrence and age, visual acuity at the end of binocular treatment, stereoacuity, or ocular alignment. In a secondary analysis to compare rates of recurrence with published data, risk of recurrence in the subset of children who had no additional treatment for residual amblyopia (28%) was similar to the reported recurrence after cessation of successful patching and atropine (24%) at 12 months. Children with successful binocular treatment of amblyopia require monitoring for recurrence of amblyopia.
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Affiliation(s)
- Reed M Jost
- Retina Foundation of the Southwest, Dallas, Texas.
| | | | - Eileen E Birch
- Retina Foundation of the Southwest, Dallas, Texas; Department of Ophthalmology, University of Texas Southwestern Medical Center, Dallas, Texas
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Wygnanski-Jaffe T, Kushner BJ, Moshkovitz A, Belkin M, Yehezkel O. An Eye-Tracking-Based Dichoptic Home Treatment for Amblyopia: A Multicenter Randomized Clinical Trial. Ophthalmology 2023; 130:274-285. [PMID: 36306974 DOI: 10.1016/j.ophtha.2022.10.020] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Revised: 10/18/2022] [Accepted: 10/18/2022] [Indexed: 11/06/2022] Open
Abstract
PURPOSE Comparing visual outcomes after use of a novel binocular eye-tracking-based home treatment (CureSight; NovaSight, Ltd) with patching. DESIGN Prospective, multicenter, randomized, masked, controlled, noninferiority pivotal trial. PARTICIPANTS One hundred three children 4 to < 9 years with anisometropic, small-angle strabismic or mixed-mechanism amblyopia were randomized 1:1 to either CureSight treatment or patching. METHODS The CureSight treatment uses combined anaglyph glasses and an eye tracker to induce real-time blur around the fellow eye fovea in dichoptic streamed video content. Participants used the device for 90 minutes/day, 5 days/week for 16 weeks (120 hours). The patching group received 2 hours of patching 7 days/week (224 hours). The prespecified noninferiority margin was 1 line. MAIN OUTCOME MEASURES The primary outcome was the improvement in the amblyopic eye visual acuity (VA), modeled with a repeated measures analysis of covariance. Secondary outcomes included stereoacuity, binocular VA, and treatment adherence rates, analyzed by a 1-sample Wilcoxon test within each group and a 2-sample Wilcoxon test comparing groups. Safety outcomes included the frequency and severity of study-related adverse events (AEs). RESULTS CureSight group VA improvement was found to be noninferior to patching group improvement (0.28 ± 0.13 logarithm of the minimum angle of resolution [logMAR] [P < 0.0001] and 0.23 ± 0.14 logMAR [P < 0.0001], respectively; 90% confidence interval [CI] of difference, -0.008 to 0.076). Stereoacuity improvement of 0.40 log arcseconds (P < 0.0001) and improved binocular VA (0.13 logMAR; P < 0.0001) were observed in the binocular treatment group, with similar improvements in the patching group in stereoacuity (0.40 log arcseconds; P < 0.0001) and binocular VA (0.09 logMAR; P < 0.0001), with no significant difference between improvements in the 2 groups in either stereoacuity (difference, 0; 95% CI, -0.27 to -0.27; P = 0.76) or binocular VA (difference, 0.041; 95% CI, -0.002 to 0.085; P = 0.07). The binocular treatment group had a significantly higher adherence than the patching group (91% vs. 83%; 95% CI, -4.0% to 21%; P = 0.011). No serious AEs were found. CONCLUSIONS Binocular treatment was well tolerated and noninferior to patching in amblyopic children 4 to < 9 years of age. High adherence may provide an alternative treatment option for amblyopia. FINANCIAL DISCLOSURE(S) Proprietary or commercial disclosure may be found after the references.
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Affiliation(s)
- Tamara Wygnanski-Jaffe
- Goldschleger Eye Institute, Sheba Medical Center, Tel Hashomer, Israel; Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Burton J Kushner
- Department of Ophthalmology and Visual Sciences, University of Wisconsin, Madison, Wisconsin
| | | | - Michael Belkin
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel; Goldschleger Eye Research Institute, Sheba Medical Center, Tel Hashomer, Israel
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Birch EE, Kelly KR. Amblyopia and the whole child. Prog Retin Eye Res 2023; 93:101168. [PMID: 36736071 PMCID: PMC9998377 DOI: 10.1016/j.preteyeres.2023.101168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Revised: 01/04/2023] [Accepted: 01/05/2023] [Indexed: 02/04/2023]
Abstract
Amblyopia is a disorder of neurodevelopment that occurs when there is discordant binocular visual experience during the first years of life. While treatments are effective in improving visual acuity, there are significant individual differences in response to treatment that cannot be attributed solely to difference in adherence. In this considerable variability in response to treatment, we argue that treatment outcomes might be optimized by utilizing deep phenotyping of amblyopic deficits to guide alternative treatment choices. In addition, an understanding of the broader knock-on effects of amblyopia on developing visually-guided skills, self-perception, and quality of life will facilitate a whole person healthcare approach to amblyopia.
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Affiliation(s)
- Eileen E Birch
- Pediatric Vision Laboratory, Retina Foundation of the Southwest, 9600 North Central Expressway #200, Dallas, TX, 75225, USA; Department of Ophthalmology, University of Texas Southwestern Medical Center, 5303 Harry Hines Boulevard, Dallas, TX, 75390, USA.
| | - Krista R Kelly
- Department of Ophthalmology, University of Texas Southwestern Medical Center, 5303 Harry Hines Boulevard, Dallas, TX, 75390, USA; Vision and Neurodevelopment Laboratory, Retina Foundation of the Southwest, 9600 North Central Expressway #200, Dallas, TX, 75225, USA.
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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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12
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Lu ZL, Dosher BA. Current directions in visual perceptual learning. NATURE REVIEWS PSYCHOLOGY 2022; 1:654-668. [PMID: 37274562 PMCID: PMC10237053 DOI: 10.1038/s44159-022-00107-2] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 08/16/2022] [Indexed: 06/06/2023]
Abstract
The visual expertise of adult humans is jointly determined by evolution, visual development, and visual perceptual learning. Perceptual learning refers to performance improvements in perceptual tasks after practice or training in the task. It occurs in almost all visual tasks, ranging from simple feature detection to complex scene analysis. In this Review, we focus on key behavioral aspects of visual perceptual learning. We begin by describing visual perceptual learning tasks and manipulations that influence the magnitude of learning, and then discuss specificity of learning. Next, we present theories and computational models of learning and specificity. We then review applications of visual perceptual learning in visual rehabilitation. Finally, we summarize the general principles of visual perceptual learning, discuss the tension between plasticity and stability, and conclude with new research directions.
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Affiliation(s)
- Zhong-Lin Lu
- Division of Arts and Sciences, New York University Shanghai, Shanghai, China
- Center for Neural Science, New York University, New York, NY, USA
- Department of Psychology, New York University, New York, NY, USA
- Institute of Brain and Cognitive Science, New York University - East China Normal University, Shanghai, China
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13
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Fixation instability, astigmatism, and lack of stereopsis as factors impeding recovery of binocular balance in amblyopia following binocular therapy. Sci Rep 2022; 12:10311. [PMID: 35725590 PMCID: PMC9209502 DOI: 10.1038/s41598-022-13947-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Accepted: 05/31/2022] [Indexed: 11/22/2022] Open
Abstract
Dichoptic therapy is a promising method for improving vision in pediatric and adult patients with amblyopia. However, a systematic understanding about changes in specific visual functions and substantial variation of effect among patients is lacking. Utilizing a novel stereoscopic augmented-reality based training program, 24 pediatric and 18 adult patients were trained for 20 h along a three-month time course with a one-month post-training follow-up for pediatric patients. Changes in stereopsis, distance and near visual acuity, and contrast sensitivity for amblyopic and fellow eyes were measured, and interocular differences were analyzed. To reveal what contributes to successful dichoptic therapy, ANCOVA models were used to analyze progress, considering clinical baseline parameters as covariates that are potential requirements for amblyopic recovery. Significant and lasting improvements have been achieved in stereoacuity, interocular near visual acuity, and interocular contrast sensitivity. Importantly, astigmatism, fixation instability, and lack of stereopsis were major limiting factors for visual acuity, stereoacuity, and contrast sensitivity recovery, respectively. The results demonstrate the feasibility of treatment-efficacy prediction in certain aspects of dichoptic amblyopia therapy. Furthermore, our findings may aid in developing personalized therapeutic protocols, capable of considering individual clinical status, to help clinicians in tailoring therapy to patient profiles for better outcome.
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Hess RF. Reasons why we might want to question the use of patching to treat amblyopia as well as the reliance on visual acuity as the primary outcome measure. BMJ Open Ophthalmol 2022; 7:bmjophth-2021-000914. [PMID: 36161844 PMCID: PMC9121476 DOI: 10.1136/bmjophth-2021-000914] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Accepted: 12/17/2021] [Indexed: 12/18/2022] Open
Abstract
Recent evidence suggests that the primary deficit in amblyopia is loss of binocular vision and that the loss of monocular acuity is a secondary consequence. This new understanding derived from recent laboratory studies questions the present therapy and its primary acuity-based endpoint, which have been the gold standard in the treatment of this condition for the past 200 years.
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Affiliation(s)
- Robert F Hess
- Department Ophthalmology and Vision Sciences, McGill University, Montreal, Québec, Canada
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15
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Randomized clinical trial of streaming dichoptic movies versus patching for treatment of amblyopia in children aged 3 to 7 years. Sci Rep 2022; 12:4157. [PMID: 35264692 PMCID: PMC8905014 DOI: 10.1038/s41598-022-08010-9] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Accepted: 03/01/2022] [Indexed: 11/14/2022] Open
Abstract
Contrast-rebalanced dichoptic movies have been shown to be an effective binocular treatment for amblyopia in the laboratory. Yet, at-home therapy is a more practical approach. In a randomized clinical trial, we compared dichoptic movies, streamed at-home on a handheld 3D-enabled game console, versus patching as amblyopia treatment. Sixty-five amblyopic children (3–7 years; 20/32–125) were randomly assigned to one of two parallel arms, binocular treatment (3 movies/week) or patching (14 h/week). The primary outcome, change in best corrected visual acuity (BCVA) at the 2-week visit was completed by 28 and 30, respectively. After the primary outcome, both groups of children had the option to complete up to 6 weeks of binocular treatment. At the 2-week primary outcome visit, BCVA had improved in the movie (0.07 ± 0.02 logMAR; p < .001) and patching (0.06 ± 0.01 logMAR; p < 0.001) groups. There was no significant difference between groups (CI95%: − 0.02 to 0.04; p = .48). Visual acuity improved in both groups with binocular treatment up to 6 weeks (0.15 and 0.18 logMAR improvement, respectively). This novel, at-home, binocular movie treatment improved amblyopic eye BCVA after 2 weeks (similar to patching), with additional improvement up to 6 weeks. Repeated binocular visual experience with contrast-rebalanced binocular movies provides an additional treatment option for amblyopia. Clincaltrials.gov identifier: NCT03825107 (31/01/2019).
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16
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Tailor V, Ludden S, Bossi M, Bunce C, Greenwood JA, Dahlmann-Noor A. Binocular versus standard occlusion or blurring treatment for unilateral amblyopia in children aged three to eight years. Cochrane Database Syst Rev 2022; 2:CD011347. [PMID: 35129211 PMCID: PMC8819728 DOI: 10.1002/14651858.cd011347.pub3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Current treatments for amblyopia, typically patching or pharmacological blurring, have limited success. Less than two-thirds of children achieve good acuity of 0.20 logMAR in the amblyopic eye, with limited improvement of stereopsis, and poor adherence to treatment. A new approach, based on presentation of movies or computer games separately to each eye, may yield better results and improve adherence. These treatments aim to balance the input of visual information from each eye to the brain. OBJECTIVES: To determine whether binocular treatments in children, aged three to eight years, with unilateral amblyopia result in better visual outcomes than conventional patching or pharmacological blurring treatment. SEARCH METHODS We searched CENTRAL (which contains the Cochrane Eyes and Vision Trials Register), MEDLINE, Embase, ISRCTN, ClinicalTrials.gov, and the WHO ICTRP to 19 November 2020, with no language restrictions. SELECTION CRITERIA Two review authors independently screened the results of the search for relevant studies. We included randomised controlled trials (RCTs) that enrolled children between the ages of three and eight years old with unilateral amblyopia. Amblyopia was classed as present when the best-corrected visual acuity (BCVA) was worse than 0.200 logMAR in the amblyopic eye, with BCVA 0.200 logMAR or better in the fellow eye, in the presence of an amblyogenic risk factor, such as anisometropia, strabismus, or both. To be eligible, children needed to have undergone cycloplegic refraction and ophthalmic examination, including fundal examination and optical treatment, if indicated, with stable BCVA in the amblyopic eye despite good adherence with wearing glasses. We included any type of binocular viewing intervention, on any device (e.g. computer monitors viewed with liquid-crystal display shutter glasses; hand-held screens, including mobile phones with lenticular prism overlay; or virtual reality displays). Control groups received standard amblyopia treatment, which could include patching or pharmacological blurring of the better-seeing eye. We included full-time (all waking hours) and part-time (between 1 and 12 hours a day) patching regimens. We excluded children who had received any treatment other than optical treatment; and studies with less than 8-week follow-up. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane. The primary outcome of the review was the change from baseline of distance BCVA in the amblyopic eye after 16 (± 2) weeks of treatment, measured in logMAR units on an age-appropriate acuity test. MAIN RESULTS We identified one eligible RCT of conventional patching treatment versus novel binocular treatment, and analysed a subset of 68 children who fulfilled the age criterion of this review. We obtained data for the mean change in amblyopic eye visual acuity, adverse events (diplopia), and adherence to prescribed treatment at 8- and 16-week follow-up intervals, though no data were available for change in BCVA after 52 weeks. Risk of bias for the included study was considered to be low. The certainty of evidence for the visual acuity outcomes at 8 and 16 weeks of treatment and adherence to the study intervention was rated moderate using the GRADE criteria, downgrading by one level due to imprecision. The certainty of evidence was downgraded by two levels and rated low for the proportion of participants reporting adverse events due to the sample size. Acuity improved in the amblyopic eye in both the binocular and patching groups following 16 weeks of treatment (improvement of -0.21 logMAR in the binocular group and -0.24 logMAR in the patching group, mean difference (MD) 0.03 logMAR (95% confidence interval (CI) -0.10 to 0.04; 63 children). This difference was non-significant and the improvements in both the binocular and patching groups are also considered clinically similar. Following 8 weeks of treatment, acuity improved in both the binocular and patching groups (improvement of -0.18 logMAR in the patching group compared to -0.16 logMAR improvement in the binocular-treatment group) (MD 0.02, 95% CI -0.04 to 0.08). Again this difference was statistically non-significant, and the differences observed between the patching and binocular groups are also clinically non-significant. No adverse event of permanent diplopia was reported. Adherence was higher in the patching group (47% of participants in the iPad group achieved over 75% compliance compared with 90% of the patching group). Data were not available for changes in stereopsis nor for contrast sensitivity following treatment. AUTHORS' CONCLUSIONS Currently, there is only one RCT that offers evidence of the safety and effectiveness of binocular treatment. The authors are moderately confident that after 16 weeks of treatment, the gain in amblyopic eye acuity with binocular treatment is likely comparable to that of conventional patching treatment. However, due to the limited sample size and lack of long term (52 week) follow-up data, it is not yet possible to draw robust conclusions regarding the overall safety and sustained effectiveness of binocular treatment. Further research, using acknowledged methods of visual acuity and stereoacuity assessment with known reproducibility, is required to inform decisions about the implementation of binocular treatments for amblyopia in clinical practice, and should incorporate longer term follow-up to establish the effectiveness of binocular treatment. Randomised controlled trials should also include outcomes reported by users, adherence to prescribed treatment, and recurrence of amblyopia after cessation of treatment.
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Affiliation(s)
- Vijay Tailor
- NIHR Biomedical Research Centre at Moorfields Eye Hospital NHS Foundation Trust and UCL Institute of Ophthalmology, London, UK
- Experimental Psychology, University College London, London, UK
- Moorfields Eye Hospital NHS Foundation Trust, London, UK
| | - Siobhan Ludden
- NIHR Biomedical Research Centre at Moorfields Eye Hospital NHS Foundation Trust and UCL Institute of Ophthalmology, London, UK
- Moorfields Eye Hospital NHS Foundation Trust, London, UK
- HSE DNCC Grangegorman Eye Clinic, Dublin, Ireland
| | - Manuela Bossi
- Department of Visual Neurosciences, UCL Institute of Ophthalmology, London, UK
| | - Catey Bunce
- The Royal Marsden NHS Foundation Trust, London, UK
| | | | - Annegret Dahlmann-Noor
- NIHR Biomedical Research Centre at Moorfields Eye Hospital NHS Foundation Trust and UCL Institute of Ophthalmology, London, UK
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17
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Rodán A, Candela Marroquín E, Jara García LC. An updated review about perceptual learning as a treatment for amblyopia. JOURNAL OF OPTOMETRY 2022; 15:3-34. [PMID: 33243673 PMCID: PMC8712591 DOI: 10.1016/j.optom.2020.08.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Revised: 08/16/2020] [Accepted: 08/16/2020] [Indexed: 05/31/2023]
Abstract
The purpose of our work is to do an update of recent investigations about amblyopia treatment based on perceptual learning, dichoptic training and videogames. Therefore, we conducted a search of the studies published about this subject in the last six years. The review shows that the investigations during that period have used several kinds of treatments regarding their design (e.g., type of stimulus and context used, duration of the training), and in a wider range of age that also include adults. Most of the studies have found an improvement in some mono and binocular visual functions, such as visual acuity, contrast sensitivity and stereopsis, which for now, it seems advisable that these processes could be used, as an alternative or a complement of the traditional passive therapy. Nevertheless, it would be plausible to conduct additional, controlled and random, clinical trials in order to discover in a more deeply way which perceptive learning method of treatment is more effective for the improvement of visual functions and for how long the effects of the treatment could persist.
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18
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Birch EE, Kelly KR, Wang J. Recent Advances in Screening and Treatment for Amblyopia. Ophthalmol Ther 2021; 10:815-830. [PMID: 34499336 PMCID: PMC8589941 DOI: 10.1007/s40123-021-00394-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Accepted: 08/26/2021] [Indexed: 11/30/2022] Open
Abstract
Amblyopia is the most common cause of monocular visual impairment in children, with a prevalence of 2-3%. Not only is visual acuity reduced in one eye but binocular vision is affected, fellow eye deficits may be present, eye-hand coordination and reading can be affected, and self-perception may be diminished. New technologies for preschool vision screening hold promise for accessible, early, and accurate detection of amblyopia. Together with recent advances in our theoretical understanding of amblyopia and technological advances in amblyopia treatment, we anticipate improved visual outcomes for children affected by this very common eye condition. This article is based on previously conducted studies and does not contain any new studies with human participants or animals performed by any of the authors.
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Affiliation(s)
- Eileen E Birch
- Retina Foundation of the Southwest, 9600 N. Central Expressway, Suite 200, Dallas, TX, 75231, USA.
- Department of Ophthalmology, University of Texas Southwestern Medical Center, Dallas, TX, USA.
| | - Krista R Kelly
- Retina Foundation of the Southwest, 9600 N. Central Expressway, Suite 200, Dallas, TX, 75231, USA
- Department of Ophthalmology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Jingyun Wang
- SUNY College of Optometry, State University of New York, New York, NY, USA
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19
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Toro MD, Bremond-Gignac D, Brézin AP, Cummings AB, Kemer OE, Kermani O, Malyugin BE, Prieto I, Teus MA, Tognetto D, Zweifel S, Rejdak R. COVID-19 outbreak and increased risk of amblyopia and epidemic myopia: Insights from EUROCOVCAT group. Eur J Ophthalmol 2021; 32:17-22. [PMID: 34751045 DOI: 10.1177/11206721211053175] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The most common cause of vision impairment in children is amblyopia. It is defined as impaired visual acuity in one or both eyes that is present with no demonstrable abnormality of the visual pathway and is not immediately resolved by wearing glasses. After the World Health Organization (WHO) recognized COVID-19 as a global pandemic on March 11, 2020, widespread changes and restrictions to social and sanitary practices have presented significant issues in access to eye care during the COVID-19 pandemic. A reduction of more than 80% in pediatric eye care volume up to its total cessation has been observed in different departments. In this scenario, reduced or absent eyesight, due to delay in timely treatment of amblyopic conditions, could create major, long-lasting effects on all aspects of life, including daily personal activities, interacting with the community, school and work opportunities and the ability to access public services. Processes coming out of lockdown should be gradually easing restrictions giving priority to ophthalmology and eye care facilities so that amblyopia does not remain unattended and irreversible as in adults due to lack of timely treatments. If not reversible, this process could lead to a dramatic increase in disability and unsustainable social costs for many governments.
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Affiliation(s)
- Mario Damiano Toro
- Department of General and Pediatric Ophthalmology, 49554Medical University of Lublin, Lublin, Poland.,Department of Ophthalmology, University Hospital of Zurich, Zurich, Switzerland
| | - Dominique Bremond-Gignac
- 246596University Hospital Necker Enfants Malades, APHP, Paris, France.,INSERM 1138, Team 17, Paris Sorbonne University, Cordeliers, Paris, France
| | | | | | | | - Omid Kermani
- Augenklinik am Neumarkt Schildergasse 107 - 109, Köln, Germany
| | - Boris Edvard Malyugin
- 96710Fyodorov Eye Microsurgery Federal State Institution, Moscow, Russian Federation.,A. Yevdokimov Moscow State University of Medicine and Dentistry, Russian Federation
| | | | | | | | - Sandrine Zweifel
- Department of Ophthalmology, University Hospital of Zurich, Zurich, Switzerland
| | - Robert Rejdak
- Department of General and Pediatric Ophthalmology, 49554Medical University of Lublin, Lublin, Poland
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20
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Birch EE, Jost RM, Wang SX, Kelly KR. A pilot randomized trial of contrast-rebalanced binocular treatment for deprivation amblyopia. J AAPOS 2020; 24:344.e1-344.e5. [PMID: 33069871 PMCID: PMC8005476 DOI: 10.1016/j.jaapos.2020.07.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Revised: 06/18/2020] [Accepted: 07/05/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND Binocular neural architecture may be preserved in children with deprivation amblyopia due to unilateral cataract. The purpose of this study was to investigate whether a contrast-rebalanced binocular treatment, recently used with success to treat the interocular suppression and amblyopia in strabismic and anisometropic children, can contribute to rehabilitation of visual acuity in children with deprivation amblyopia secondary to monocular cataract. METHODS In a pilot randomized trial, 15 children (4-13 years of age) were enrolled and randomized to continue with their current treatment only (n = 7) or to continue with their current treatment and add contrast-rebalanced binocular iPad game play 5 hours/week for 4 weeks (n = 8). The primary outcome was change in visual acuity at 4 weeks. RESULTS Although 10 of 15 participants were patching, there was little change in visual acuity during the 3 months prior to enrollment. At the 4-week primary outcome visit, the mean improvement in visual acuity for the binocular game group was significantly greater than that for the current-treatment group (0.08 ± 0.10 logMAR vs -0.03 ± 0.05 logMAR [t10.2 = 2.53, P = 0.03]). None of the children who had dense congenital cataract achieved improved visual acuity with binocular treatment. CONCLUSIONS In this study cohort, visual acuity improved over 8 weeks in children with unilateral deprivation amblyopia who played a binocular contrast-rebalanced binocular iPad game.
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Affiliation(s)
- Eileen E Birch
- Retina Foundation of the Southwest, Dallas, Texas; Department of Ophthalmology, UT Southwestern Medical Center, Dallas, Texas.
| | - Reed M Jost
- Retina Foundation of the Southwest, Dallas, Texas
| | - Serena X Wang
- Department of Ophthalmology, UT Southwestern Medical Center, Dallas, Texas
| | - Krista R Kelly
- Retina Foundation of the Southwest, Dallas, Texas; Department of Ophthalmology, UT Southwestern Medical Center, Dallas, Texas
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21
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Abstract
Recent work has transformed our ideas about the neural mechanisms, behavioral consequences and effective therapies for amblyopia. Since the 1700's, the clinical treatment for amblyopia has consisted of patching or penalizing the strong eye, to force the "lazy" amblyopic eye, to work. This treatment has generally been limited to infants and young children during a sensitive period of development. Over the last 20 years we have learned much about the nature and neural mechanisms underlying the loss of spatial and binocular vision in amblyopia, and that a degree of neural plasticity persists well beyond the sensitive period. Importantly, the last decade has seen a resurgence of research into new approaches to the treatment of amblyopia both in children and adults, which emphasize that monocular therapies may not be the most effective for the fundamentally binocular disorder that is amblyopia. These approaches include perceptual learning, video game play and binocular methods aimed at reducing inhibition of the amblyopic eye by the strong fellow eye, and enhancing binocular fusion and stereopsis. This review focuses on the what we've learned over the past 20 years or so, and will highlight both the successes of these new treatment approaches in labs around the world, and their failures in clinical trials. Reconciling these results raises important new questions that may help to focus future directions.
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Affiliation(s)
- Dennis M Levi
- University of California, Berkeley, School of Optometry & Helen Wills Neuroscience Institute, Berkeley, CA, USA.
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22
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Jost RM, Kelly KR, Hunter JS, Stager DR, Luu B, Leffler JN, Dao L, Beauchamp CL, Birch EE. A randomized clinical trial of contrast increment protocols for binocular amblyopia treatment. J AAPOS 2020; 24:282.e1-282.e7. [PMID: 33045374 PMCID: PMC8328197 DOI: 10.1016/j.jaapos.2020.06.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Revised: 06/16/2020] [Accepted: 06/17/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Most clinical trials of contrast-rebalanced binocular amblyopia treatment used a contrast increment protocol of 10% daily with successful play. Paired with a definition of success requiring only 15-30 min/day of gameplay, this increment protocol could allow children to reach 100% fellow eye contrast in 3-9 hours; however, this may not provide adequate therapeutic time with reduced fellow eye contrast. The purpose of this study was to compare the original protocol against three alternative contrast increment protocols designed to increase the number of treatment hours. METHODS In this prospective study, 63 amblyopic children (4-10 years; amblyopic eye visual acuity, 20/40-125) were randomly assigned one of four daily contrast increment protocols for 4 weeks, all starting with 20% fellow eye contrast: 10%, 5%, 0%, or 10% for first 4 weeks then reset to 20% and repeat 10% increment for the final 4 weeks. Children played contrast-rebalanced games for 1 hour/day, 5 days/week. Best-corrected visual acuity, stereoacuity, and suppression were assessed at baseline and every 2 weeks until the 8-week outcome visit. RESULTS At baseline, mean amblyopic eye best-corrected visual acuity was 0.47 ± 0.14 logMAR (20/60), improving overall 0.14 ± 0.08 logMAR (1.4 lines; P < 0.0001) at 8 weeks. All four protocols resulted in similar improvement in visual acuity (0.13-0.16 logMAR; all Ps < 0.0002). Stereoacuity and suppression also improved (all Ps < 0.05). CONCLUSIONS None of the new protocols resulted in less improvement than the original 10% contrast increment protocol. Contrast-rebalanced binocular games yielded significant improvements in visual acuity, stereoacuity, and suppression with or without daily contrast increments.
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Affiliation(s)
- Reed M Jost
- Retina Foundation of the Southwest, Dallas, Texas.
| | | | | | - David R Stager
- Pediatric Ophthalmology & Adult Strabismus, Plano, Texas
| | - Becky Luu
- Pediatric Ophthalmology & Adult Strabismus, Plano, Texas
| | | | - Lori Dao
- ABC Eyes Pediatric Ophthalmology, Dallas, Texas
| | | | - Eileen E Birch
- Retina Foundation of the Southwest, Dallas, Texas; University of Texas Southwestern Medical Center, Dallas, Texas
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