Can perceptual learning be used to treat amblyopia beyond the critical period of visual development?

Harnessing brain plasticity to improve binocular vision in amblyopia: An evidence-based update

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.

Measurement of visual function in infantile nystagmus: a systematic review

BACKGROUND/AIMS

Recent work has called into question the ability of visual acuity (VA) to accurately represent changes in visual function in infantile nystagmus (IN). This systematic review investigated factors affecting visual performance in IN, to guide development of suitable alternatives to VA.

METHODS

Included studies used an experimental manipulation to assess changes in visual function in people with IN. Interventional studies, case series and case studies were excluded. Six databases were searched in August 2023. Selection, detection, attrition and measurement bias were assessed. Due to heterogeneous methodologies, narrative synthesis was undertaken.

RESULTS

Eighteen relevant papers were identified, 11 of which complied with the review criteria. Articles were grouped according to the factor manipulated to evoke within-participant changes in performance (motion blur, psychological state, gaze angle or visual crowding). Optotype, image, grating and moving stimuli have been employed under varying lighting conditions and exposure duration.

CONCLUSION

Several factors affecting visual performance should be considered when assessing visual function in IN. While maximum VA is a useful metric, its measurement deliberately minimises nystagmus-specific factors such as changes in visual performance with gaze angle and the 'slow to see' phenomenon. Maximum VA can be measured using the null zone, providing unlimited viewing time, reducing stress/mental load and minimising visual crowding. Gaze-dependent functional vision space is a promising measure which quantifies the impact of the null zone but does not consider temporal vision. Although no complete measurement technique has yet been proven, this review provides insights to guide future work towards development of appropriate methods.

Effects of Perceptual Learning on Deprivation Amblyopia in Children with Limbal Dermoid: A Randomized Controlled Trial

Limbal dermoid (LD) is a congenital ocular tumor that causes amblyopia and damages visual acuity (VA) and visual function. This study evaluated the therapeutic efficacy of perceptual learning (PL) toward improving contrast sensitivity function (CSF) and VA. A total of 25 children with LD and 25 normal children were compared in terms of CSF and VA. The LD group was further randomly allocated into two arms: nine underwent PL combined with patching and eight underwent patching only; eight patients quit the amblyopia treatment. The primary outcome was the area under log CSF (AULCSF), and the secondary outcome was the best corrected VA (BCVA). The CSF was obviously reduced in the LD group compared with that in the normal group. Moreover, the difference in the changes in the AULCSF between the PL and patching groups after 6 months of training was 0.59 (95% CI: 0.32, 0.86, p < 0.001), and the between-group difference in VA at 6 months was −0.30 (95% CI: −0.46, −0.14, p < 0.001). Children suffering from LD with amblyopia exhibited CSF deficits and VA loss simultaneously. PL could improve CSF and VA in the amblyopic eye better than patching.

Exogenous attention generalizes location transfer of perceptual learning in adults with amblyopia

Visual perceptual learning (VPL) is a behavioral manifestation of brain neuroplasticity. However, its practical effectiveness is limited because improvements are often specific to the trained conditions and require significant time and effort. It is critical to understand the conditions that promote learning and transfer. Covert endogenous (voluntary) and exogenous (involuntary) spatial attention help overcome VPL location specificity in neurotypical adults, but whether they also do so for people with atypical visual development is unknown. This study investigates the role of exogenous attention during VPL in adults with amblyopia, an ideal population given their asymmetrically developed, but highly plastic, visual cortex. Here we show that training on a discrimination task leads to improvements in foveal contrast sensitivity, acuity, and stereoacuity. Notably, exogenous attention helps generalize learning beyond trained spatial locations. Future large-scale studies can verify the extent to which attention enhances the effectiveness of perceptual learning during rehabilitation of visual disorders.

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Contrast sensitivity (CS)-based VPL in amblyopes improves CS, acuity and stereoacuity

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Similar improvement in trained amblyopic eye and untrained fellow eye

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Exogenous spatial attention facilitates location transfer of VPL in amblyopic adults

Efficacy of vision therapy for unilateral refractive amblyopia in children aged 7-10 years

Background

There is a critical period for visual development, conventionally considered to be the first 6 years of life. Children aged 7 years and older are significantly less responsive to amblyopia treatment. This study investigated the efficacy of binocular vision therapy in amblyopic children aged 7–10 years.

Methods

This retrospective study enrolled 36 children with unilateral amblyopia who were divided into a case group (receiving vision therapy, optical correction, and part-time patching of the weaker eye) and a control group (receiving optical correction and part-time patching of the weaker eye). Visual acuity (VA) was measured at baseline, at the 3-month, 6-month, and 9-month visits, and 3 months after cessation of treatment.

Results

There were 19 subjects in the case group and 17 subjects in the control group. Mean VA in the case group improved from 0.39 ± 0.24 logMAR at baseline to 0.10 ± 0.23 logMAR at the endpoint of treatment (p < 0.001, paired t-test). Mean VA in the control group improved from 0.64 ± 0.30 logMAR at baseline to 0.52 ± 0.27 logMAR at the endpoint of treatment (p = 0.015, paired t-test). The improvement was significantly greater in the case group than in the control group (p = 0.006, two-samples independent t-test). All subjects underwent follow-up examinations within 6 to 12 months. There was no regression of VA in the case group 3 months after cessation of vision therapy. The patients in the case group who received visual therapy were with better VA improvement then patients with only optic correction and patching.

Conclusions

Vision therapy combined with conventional treatment (optical correction and part-time patching) is more effective than conventional treatment alone in children aged 7–10 years with unilateral refractive amblyopia. The treatment results not only in greater vision gain, but also in shorter duration of treatment.

Linking Multi-Modal MRI to Clinical Measures of Visual Field Loss After Stroke

Loss of vision across large parts of the visual field is a common and devastating complication of cerebral strokes. In the clinic, this loss is quantified by measuring the sensitivity threshold across the field of vision using static perimetry. These methods rely on the ability of the patient to report the presence of lights in particular locations. While perimetry provides important information about the intactness of the visual field, the approach has some shortcomings. For example, it cannot distinguish where in the visual pathway the key processing deficit is located. In contrast, brain imaging can provide important information about anatomy, connectivity, and function of the visual pathway following stroke. In particular, functional magnetic resonance imaging (fMRI) and analysis of population receptive fields (pRF) can reveal mismatches between clinical perimetry and maps of cortical areas that still respond to visual stimuli after stroke. Here, we demonstrate how information from different brain imaging modalities-visual field maps derived from fMRI, lesion definitions from anatomical scans, and white matter tracts from diffusion weighted MRI data-provides a more complete picture of vision loss. For any given location in the visual field, the combination of anatomical and functional information can help identify whether vision loss is due to absence of gray matter tissue or likely due to white matter disconnection from other cortical areas. We present a combined imaging acquisition and visual stimulus protocol, together with a description of the analysis methodology, and apply it to datasets from four stroke survivors with homonymous field loss (two with hemianopia, two with quadrantanopia). For researchers trying to understand recovery of vision after stroke and clinicians seeking to stratify patients into different treatment pathways, this approach combines multiple, convergent sources of data to characterize the extent of the stroke damage. We show that such an approach gives a more comprehensive measure of residual visual capacity-in two particular respects: which locations in the visual field should be targeted and what kind of visual attributes are most suited for rehabilitation.

Video game treatment of amblyopia

Amblyopia is visual impairment characterized by a structurally normal eye showing significantly lower visual acuity than the fellow eye. Traditional treatment of amblyopia includes patching the good eye to force the amblyopic eye to work during normal daily activities; however, this approach is are limited by low compliance. Recently, researchers proposed a new treatment for amblyopia: video game playing. In the current review, we discuss whether video game playing can treat amblyopia, whether video game playing could better treat amblyopia than traditional treatments, and how the video game treats amblyopia and its possible mechanism. Based on results from our literature review and meta-analysis, we suggest there is strong evidence for the effectiveness of video game treatments. Moreover, multiple factors within and outside of video games could influence the treatment effect.

Neuroplasticity in older adults revealed by temporary occlusion of one eye

Occluding one eye for several hours alters visual experience. Specifically, occluding one eye shifts the balance of ocular dominance to favour the recently deprived eye, which can be measured using binocular rivalry. This ocular dominance shift demonstrates homeostatic neuroplasticity within the visual system and has been explored in detail in younger adults. Here we measure whether the strength and general features of neuroplasticity revealed by monocular patching are maintained in older adults. Thirty younger (18-35 years) and 30 older adults (60-81 years) participated. Binocular rivalry features were measured before and after 2 h of occlusion. Post-patching, perceptual dominance of the non-patched eye decreased (p < .001) in both age groups. The effect of occlusion on all features of binocular rivalry did not significantly differ between groups. The older visual system maintains the ability to rapidly adjust to changes in perceptual experience induced by eye occlusion. This preservation of neuroplasticity suggests that visual training methods designed to improve visual performance based on eye occlusion should maintain effectiveness into older age.

Alternative Flicker Glass: a New Anti-suppression Approach to the Treatment of Anisometropic Amblyopia

INTRODUCTION

Amlyopia always presents with monocular and binocular dysfunction. In this study, we aim to investage the efficacy of alternative occlusion using liquid crystal glasses versus continuous occlusion therapy using traditional patches for treating amblyopia.

METHODS

Eligible subjects with anisometropic amblyopia were randomized into two groups: alternative flicker glass (AFG) or patching group. In the AFG group, subjects were instructed to wear the flicker glasses for 1 hour a day. The AFG is a lightweight spectacle frame with liquid crystal lenses that provide direct square-wave alternating occlusion, which were pre-programmed at temporal frequency of 7Hz. In the patching group, the patients were prescribed to wear traditional patches for 2 hours a day. The best corrected visual acuity (BCVA), contrast sensitivity function (CSF) and stereoacuity were measured at the baseline, 3 and 12 weeks.

RESULTS

In this pilot study, a total of forty children were recruited, with twenty in the AFG group. Mean BCVA improved by 0.17±0.14logMAR (95% CI=0.10 to 0.23) in the AFG group, while 0.18±0.18logMAR (95% CI=0.09 to 0.26) in the patching group from baseline to 12 weeks. The improvement of BCVA in both groups were significant (both P＜0.01), while no significant difference between the groups (P=0.82). The CSF of both low and high spatial frequencies exhibited significant improvement at 12 weeks in the AFG group (P＜0.01, respectively), while just have a significant improvement at low spatial frequency in the patching group (P＜0.01). The stereoacuity significantly improved by 504.00±848.00 (95% CI= -900.88 to -107.12) arc seconds in the AFG group (P＜0.05), while 263.50± 639.55 (95% CI=-562.82 to 35.82) arc seconds in the patching group (P＞0.05).

CONCLUSION

Alternative flicker glass was effective in improving both monocular and binocular function, which was most likely achieved by reducing the suppression and promoting binocular fusion. This therapy exhibited promise as an alternative method for amblyopia treatment.

Fundamental Differences in Visual Perceptual Learning between Children and Adults

It has remained uncertain whether the mechanisms of visual perceptual learning (VPL)^1-4 remain stable across the lifespan or undergo developmental changes. This uncertainty largely originates from missing results about the mechanisms of VPL in healthy children. We here investigated the mechanisms of task-irrelevant VPL in healthy elementary school age children (7-10 years old) and compared their results to healthy young adults (18-31 years old). Subjects performed a rapid-serial-visual-presentation (RSVP) task at central fixation over the course of several daily sessions while coherent motion was merely exposed as a task-irrelevant feature in the visual periphery either at threshold or suprathreshold levels for coherent motion detection. As a result of this repeated exposure, children and adults both showed enhanced discrimination performance for the threshold task-irrelevant feature as in previous studies with adults.^5-8 However, adults demonstrated a decreased performance for the suprathreshold task-irrelevant feature whereas children increased performance. One possible explanation for this difference is that children cannot effectively suppress salient task-irrelevant features because of weaker selective attention ability compared to that of adults.^9-11 However, our results revealed to the contrary that children with stronger selective attention ability, as measured by the useful field of view (UFOV) test, showed greater increases in performance for the suprathreshold task-irrelevant feature. Together, these results suggest that the mechanisms of VPL change dramatically from childhood to adulthood due to a change in the way learners handle salient task-irrelevant features.

Neuroplasticity of the visual cortex: in sickness and in health

Brain plasticity refers to the ability of synaptic connections to adapt their function and structure in response to experience, including environmental changes, sensory deprivation and injuries. Plasticity is a distinctive, but not exclusive, property of the developing nervous system. This review introduces the concept of neuroplasticity and describes classic paradigms to illustrate cellular and molecular mechanisms underlying synapse modifiability. Then, we summarize a growing number of studies showing that the adult cerebral cortex retains a significant degree of plasticity highlighting how the identification of strategies to enhance the plastic potential of the adult brain could pave the way for the development of novel therapeutic approaches aimed at treating amblyopia and other neurodevelopmental disorders. Finally, we analyze how the visual system adjusts to neurodegenerative conditions leading to blindness and we discuss the crucial role of spared plasticity in the visual system for sight recovery.

The Effect of Perceptual Learning on Face Recognition in Individuals with Central Vision Loss

Purpose

To examine whether perceptual learning can improve face discrimination and recognition in older adults with central vision loss.

Methods

Ten participants with age-related macular degeneration (ARMD) received 5 days of training on a face discrimination task (mean age, 78 ± 10 years). We measured the magnitude of improvements (i.e., a reduction in threshold size at which faces were able to be discriminated) and whether they generalized to an untrained face recognition task. Measurements of visual acuity, fixation stability, and preferred retinal locus were taken before and after training to contextualize learning-related effects. The performance of the ARMD training group was compared to nine untrained age-matched controls (8 = ARMD, 1 = juvenile macular degeneration; mean age, 77 ± 10 years).

Results

Perceptual learning on the face discrimination task reduced the threshold size for face discrimination performance in the trained group, with a mean change (SD) of –32.7% (+15.9%). The threshold for performance on the face recognition task was also reduced, with a mean change (SD) of –22.4% (+2.31%). These changes were independent of changes in visual acuity, fixation stability, or preferred retinal locus. Untrained participants showed no statistically significant reduction in threshold size for face discrimination, with a mean change (SD) of –8.3% (+10.1%), or face recognition, with a mean change (SD) of +2.36% (–5.12%).

Conclusions

This study shows that face discrimination and recognition can be reliably improved in ARMD using perceptual learning. The benefits point to considerable perceptual plasticity in higher-level cortical areas involved in face-processing. This novel finding highlights that a key visual difficulty in those suffering from ARMD is readily amenable to rehabilitation.

Vision training with VEP biofeedback in amblyopia after the critical period

PURPOSE

The purpose of this study was to investigate the benefits of vision training with visual evoked potentials (VEP) biofeedback in amblyopia after the critical period in 8 to 17-year (11.5 ± 3.1) old children.

METHODS

Ten participants with monocular amblyopia after the critical period underwent a 10-week, 20-session vision training program with the Retimax Vision Trainer device. During each session, the participants were instructed to be as focused as possible onto the fixation point in the middle of the screen. The size of the fixation point and the pitch of the background sound were changing according to VEP parameters and thus provided the participants real-time feedback of their visual performance.

RESULTS

The mean BCVA improvement across our group was 0.12 LogMAR (p < 0.01). There was also a significant increase in contrast sensitivity to the FACT chart across all spatial frequencies (all p < 0.05). Electrophysiologic data revealed higher steady-state visual evoked potentials (SS-VEP) amplitudes and correspondingly lower fixation point values in the last 2 weeks of training compared to the first 2 weeks (both p < 0.01). Due to unexplainably low VEP amplitude levels in later trainings compared to those in the beginning in two participants, we have not found a significant correlation between the increase in BCVA and the increase in SS-VEP amplitude (p = 0.88). At the follow-up at 2 and 12 months following the end of training, both BCVA and contrast sensitivity remained within the levels achieved at the end of training. In some participants, however, no improvement of BCVA was observed.

CONCLUSIONS

The tested vision training approach demonstrates modest but stable improvement of psychophysical parameters as well as objective characteristics in amblyopia after the critical period. Real-time SS-VEP can be used as an objective parameter to monitor participants' attention during vision training stimulation.

The Potential of Virtual Reality for Inducing Neuroplasticity in Children with Amblyopia

In recent years, virtual reality (VR) has emerged as a new safe and effective tool for neurorehabilitation of different childhood and adulthood conditions. VR-based therapies can induce cortical reorganization and promote the activation of different neuronal connections over a wide range of ages, leading to contrasted improvements in motor and functional skills. The use of VR for the visual rehabilitation in amblyopia has been investigated in the last years, with the potential of using serious games combining perceptual learning and dichoptic stimulation. This combination of technologies allows the clinician to measure, treat, and control changes in interocular suppression, which is one of the factors leading to cortical alterations in amblyopia. Several clinical researches on this issue have been conducted, showing the potential of promoting visual acuity, contrast sensitivity, and stereopsis improvement. Indeed, several systems have been evaluated for amblyopia treatment including the use of different commercially available types of head mounted displays (HMDs). These HMDs are mostly well tolerated by patients during short exposures and do not cause significant long-term side effects, although their use has been occasionally associated with some visual discomfort and other complications in certain types of subjects. More studies are needed to confirm these promising therapies in controlled randomized clinical trials, with special emphasis on the definition of the most adequate planning for obtaining an effective recovery of the visual and binocular function.

Selective serotonin reuptake inhibitors may lead to improved cataract surgery outcomes in patients with amblyopia

Purpose

To evaluate the effects of selective serotonin reuptake inhibitor (SSRI)/serotonin norepinephrine reuptake inhibitor (SNRI) medications in combination with cataract surgery in treating amblyopia in adult patients.

Patients and methods

A retrospective chart review study was conducted on patients who had undergone cataract surgery at the Johns Hopkins Hospital Wilmer Eye Institute. Six inclusion criteria were used to assess patient eligibility: 1) >18 years of age, 2) diagnosis of amblyopia, 3) diagnosis of cataract and treatment with surgery, 4) electronic medical record contains pre-surgery and post-surgery visual acuity (VA) measurements, 5) electronic medical record contains information on whether the patient was ever prescribed a SSRI/SNRI and the treatment duration, and 6) interocular VA difference of two lines or more on Snellen chart prior to cataract surgery. From each record, preoperative VA, postoperative VA, date of surgery, date at which postoperative VA was measured, and age at surgery were collected.

Results

A total of 237 patients were included, with 38 of them being on SSRI/SNRI. The mean improvement in VA after surgery was not significantly greater in patients on SSRI/SNRI (SSRI/SNRI: −0.276 logMAR, control: −0.192 logMAR, p=0.15). Multivariable regression was subsequently performed and while holding all other variables constant, demonstrated a statistically significant improvement in VA in patients on SSRI/SNRI (95% CI: −0.194, −0.0116, p=0.03). The regression analysis further demonstrated that advanced age has an adverse effect on the change in post-op VA (CI: 3.34×10⁻³ logMAR, 9.77×10⁻³ logMAR, p<0.005). Worse baseline VA is associated with a greater improvement in post-op VA (95% CI: −0.659 logMAR, −0.463 logMAR, p<0.005) but adverse effect on the absolute post-op VA (95% CI: 0.341 logMAR, 0.544 logMAR, p<0.005).

Conclusion

This study suggests that patients with amblyopia undergoing cataract surgery may potentially have a greater visual improvement when treated with SSRI/SNRIs.

Analysis of Macular Vessel Density and Foveal Avascular Zone in Adults with Amblyopia

Purpose: To quantify and compare the foveal avascular zone (FAZ) and the whole, parafoveal and foveal vessel density of superficial (SCP) and deep capillary plexus (DCP) in amblyopic eyes of adults and age-matched controls.Methods: This cross-sectional study involved 52 eyes from 34 subjects aged 18 to 45 years. Optical coherence tomography angiography (OCTA) was performed to all participants and SCP, DCP and FAZ were evaluated. SPSS (Statistical Package for the Social Sciences) 23 was used for data analysis.Results: Eighteen of 34 subjects (52,9%) were amblyopic and 16 (47,1%) of them controlled. Mean subject age was 31.2 years in the amblyopia group and 28.3 years in the control group. The mean FAZ measurements were 0.28 ± 0.08 in amblyopic eyes, 0.29 ± 0.08 in fellow eyes and 0.3 ± 0.11 in control eyes. The whole, foveal and parafoveal vessel density of SCP in both 3x3-mm and 6x6-mm scans were not statistically different in amblyopic eyes, fellow eyes and control eyes. In 6x6-mm scans, the whole, and parafoveal vessel density of DCP were significantly lower in amblyopic eyes than controls. There was no statistically significant difference in 3x3-mm scans about DCP.Conclusion: OCTA revealed lower vessel density in DCP of amblyopic eyes than fellow eyes and controls in adults.

'It's too late'. Is it really? Considerations for amblyopia treatment in older children

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.

Contrast and spatial frequency modulation for diagnosis of amblyopia: An electrophysiological approach

Purpose

To evaluate the diagnostic value of visual evoked potentials (VEPs) and to find out which test setting has the most sensitivity and specificity for amblyopia diagnosis.

Methods

Thirty-three adult anisometropic amblyopes were intended in this study and were tested for visual evoked potentials with different stimulus conditions including three spatial frequencies [1, 2, and 4-cycles-per-degree (cpd)] at four contrast levels (100, 50, 25, and 5%). We also tested psychophysical contrast sensitivity and compared the results with electrophysiological ones. We plotted Receiver Operating Characteristic (ROC) curve for each VEP recording and psychophysical contrast sensitivity to evaluate the area under the curve, sensitivity, specificity, and cut-point value of each test stimulus for detecting amblyopic eyes.

Results

Thirty-three amblyopic and 33 non-amblyopic eyes were examined for psychophysical contrast sensitivity and VEPs. Area under the ROC curve (AURC) findings showed that VEP with different stimulus settings can significantly detect amblyopic eyes, as well as psychophysical contrast sensitivity test. We found that P100 amplitudes had the largest AURC in response to stimuli of 2-cpd spatial frequency at 50 (P < 0.001) and 25% (P < 0.001) contrast levels, respectively. Cut-off amplitudes for these stimuli were 8.65 and 4.50 μV, which had a sensitivity of 0.758 and 0.697 and a specificity of 0.788 and 0.848, respectively. The sensitivity and specificity of VEP P100 amplitude in response to the stimuli with 2 cpd spatial frequency and 50 and 25% contrast were greater than the findings obtained from psychophysical contrast sensitivity test.

Conclusion

According to our findings, assessment of VEP amplitudes in response to stimuli of 2-cpd spatial frequency at 50 and 25% contrast levels can best detect amblyopia with highest sensitivity and specificity and thus, are the protocols of choice for detection of amblyopic eyes.

A new counterintuitive training for adult amblyopia

Objectives

The aim of this study was to investigate whether short-term inverse occlusion, combined with moderate physical exercise, could promote the recovery of visual acuity and stereopsis in a group of adult anisometropic amblyopes.

Methods

Ten adult anisometropic patients underwent six brief (2 h) training sessions over a period of 4 weeks. Each training session consisted in the occlusion of the amblyopic eye combined with physical exercise (intermittent cycling on a stationary bike). Visual acuity (measured with ETDRS charts), stereoacuity (measured with the TNO test), and sensory eye dominance (measured with binocular rivalry) were tested before and after each training session, as well as in follow-up visits performed 1 month, 3 months, and 1 year after the end of the training.

Results

After six brief (2 h) training sessions, visual acuity improved in all 10 patients (0.15 ± 0.02 LogMar), and six of them also recovered stereopsis. The improvement was preserved for up to 1 year after training. A pilot experiment suggested that physical activity might play an important role for the recovery of visual acuity and stereopsis.

Conclusions

Our results suggest a noninvasive training strategy for adult human amblyopia based on an inverse-occlusion procedure combined with physical exercise.

Fluoxetine does not enhance the effect of perceptual learning on visual function in adults with amblyopia

Amblyopia is a common visual disorder that is treatable in childhood. However, therapies have limited efficacy in adult patients with amblyopia. Fluoxetine can reinstate early-life critical period-like neuronal plasticity and has been used to recover functional vision in adult rats with amblyopia. We conducted a Phase 2, randomized (fluoxetine vs. placebo), double-blind, multicenter clinical trial examined whether or not fluoxetine can improve visual acuity in amblyopic adults. This interventional trial included 42 participants diagnosed with moderate to severe amblyopia. Subjects were randomized to receive either 20 mg fluoxetine (n = 22) or placebo (n = 20). During the 10-week treatment period, all subjects performed daily computerized perceptual training and eye patching. At the primary endpoint, the mean treatment group difference in visual acuity improvement was only 0.027 logMAR units (95% CI: −0.057 to 0.110; p = 0.524). However, visual acuity had significantly improved from baseline to 10 weeks in both fluoxetine (−0.167 logMAR; 95% CI: −0.226 to −0.108; p < 0.001) and placebo (−0.194 logMAR; 95% CI: −0.254 to −0.133; p < 0.001) groups. While this study failed to provide evidence that fluoxetine enhances neuroplasticity, our data support other recent clinical studies suggesting that improvement of vision can be accomplished in adults with amblyopia.

Optical treatment of amblyopia in older children and adults is essential prior to enrolment in a clinical trial

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.

Part-time versus full-time occlusion therapy for treatment of amblyopia: A meta-analysis

PURPOSE

To compare full-time occlusion (FTO) and part-time occlusion (PTO) therapy in the treatment of amblyopia, with the secondary aim of evaluating the minimum number of hours of part-time patching required for maximal effect from occlusion.

METHODS

A literature search was performed in PubMed, Scopus, Science Direct, Ovid, Web of Science and Cochrane library. Methodological quality of the literature was evaluated according to the Oxford Center for Evidence Based Medicine and modified Newcastle-Ottawa scale. Statistical analyses were performed using Comprehensive Meta-Analysis (version 2, Biostat Inc., USA).

RESULTS

The present meta-analysis included six studies [three randomized controlled trials (RCTs) and three non-RCTs]. Pooled standardized difference in the mean changes in the visual acuity was 0.337 [lower and upper limits: -0.009, 0.683] higher in the FTO as compared to the PTO group; however, this difference was not statistically significant (P = 0.056, Cochrane Q value = 20.4 (P = 0.001), I2 = 75.49%). Egger's regression intercept was 5.46 (P = 0.04). The pooled standardized difference in means of visual acuity changes was 1.097 [lower and upper limits: 0.68, 1.513] higher in the FTO arm (P < 0.001), and 0.7 [lower and upper limits: 0.315, 1.085] higher in the PTO arm (P < 0.001) compared to PTO less than two hours.

CONCLUSIONS

This meta-analysis shows no statistically significant difference between PTO and FTO in treatment of amblyopia. However, our results suggest that the minimum effective PTO duration, to observe maximal improvement in visual acuity is six hours per day.

Enhanced neural function in highly aberrated eyes following perceptual learning with adaptive optics

Highly aberrated keratoconic (KC) eyes do not elicit the expected visual advantage from customized optical corrections. This is attributed to the neural insensitivity arising from chronic visual experience with poor retinal image quality, dominated by low spatial frequencies. The goal of this study was to investigate if targeted perceptual learning with adaptive optics (AO) can stimulate neural plasticity in these highly aberrated eyes. The worse eye of 2 KC subjects was trained in a contrast threshold test under AO correction. Prior to training, tumbling 'E' visual acuity and contrast sensitivity at 4, 8, 12, 16, 20, 24 and 28 c/deg were measured in both the trained and untrained eyes of each subject with their routine prescription and with AO correction for a 6mm pupil. The high spatial frequency requiring 50% contrast for detection with AO correction was picked as the training frequency. Subjects were required to train on a contrast detection test with AO correction for 1h for 5 consecutive days. During each training session, threshold contrast measurement at the training frequency with AO was conducted. Pre-training measures were repeated after the 5 training sessions in both eyes (i.e., post-training). After training, contrast sensitivity under AO correction improved on average across spatial frequency by a factor of 1.91 (range: 1.77-2.04) and 1.75 (1.22-2.34) for the two subjects. This improvement in contrast sensitivity transferred to visual acuity with the two subjects improving by 1.5 and 1.3 lines respectively with AO following training. One of the two subjects denoted an interocular transfer of training and an improvement in performance with their routine prescription post-training. This training-induced visual benefit demonstrates the potential of AO as a tool for neural rehabilitation in patients with abnormal corneas. Moreover, it reveals a sufficient degree of neural plasticity in normally developed adults who have a long history of abnormal visual experience due to optical imperfections.

Training to improve contrast sensitivity in amblyopia: correction of high-order aberrations

Perceptual learning is considered a potential treatment for amblyopia even in adult patients who have progressed beyond the critical period of visual development because adult amblyopes retain sufficient visual plasticity. When perceptual learning is performed with the correction of high-order aberrations (HOAs), a greater degree of neural plasticity is present in normal adults and those with highly aberrated keratoconic eyes. Because amblyopic eyes show more severe HOAs than normal eyes, it is interesting to study the effects of HOA-corrected visual perceptual learning in amblyopia. In the present study, we trained twenty-six older child and adult anisometropic amblyopes while their HOAs were corrected using a real-time closed-loop adaptive optics perceptual learning system (AOPL). We found that adaptive optics (AO) correction improved the modulation transfer functions (MTFs) and contrast sensitivity functions (CSFs) of older children and adults with anisometropic amblyopia. When perceptual learning was performed with AO correction of the ocular HOAs, the improvements in visual function were not only demonstrated in the condition with AO correction but were also maintained in the condition without AO correction. Additionally, the learning effect with AO correction was transferred to the untrained visual acuity and fellow eyes in the condition without AO correction.

Perceptual learning improves neural processing in myopic vision

Visual performance is jointly determined by the quality of optical transmission of the eye and neural processing in the visual system. An open question is: Can effects of optical defects be compensated by perceptual learning in neural processing? To address this question, we conducted a perceptual learning study on 23 observers with myopic vision, targeting high frequency deficits by training them in a monocular grating detection task in the non-dominant eye near their individual cutoff spatial frequencies. The contrast sensitivity function and visual acuity in both eyes (without optical correction) were assessed for all the observers in the training group before and after training, and for all the observers in the control group twice with a 10-day interval between the tests. In addition, the threshold versus external noise contrast function was measured for five observers in the training group before and after training. We found that (a) training significantly improved contrast sensitivity at the trained spatial frequency, visual acuity, and contrast sensitivity over a wide range of spatial frequencies in both eyes; (b) training did not lead to any significant refractive changes; (c) the mechanism of improvements was a combination of internal additive noise reduction and external noise exclusion; and (d) the improvements in visual acuity and contrast sensitivity were almost fully retained for at least four months in the three observers tested. These results suggest that perceptual learning may provide a potential noninvasive procedure to compensate for optical defects in mild to modest myopia.

Temporal Instabilities in Amblyopic Perception: A Quantitative Approach

The purpose of this study is to quantify the temporal characteristics of spatial misperceptions in human amblyopia. Twenty-two adult participants with strabismus, strabismic, anisometropic, or mixed amblyopia were asked to describe their subjective percept of static geometrical patterns with different spatial frequencies and shapes, as seen with their non-dominant eye. We generated digital reconstructions of their perception (static images or movies) that were subsequently validated by the subjects using consecutive matching sessions. We calculated the Shannon entropy variation in time for each recorded movie, as a measure of temporal instability. Nineteen of the 22 subjects perceived temporal instabilities that can be broadly classified in two categories. We found that the average frequency of the perceived temporal instabilities is ∼1 Hz. The stimuli with higher spatial frequencies yielded more often temporally unstable perceptions with higher frequencies. We suggest that type and amount of temporal instabilities in amblyopic vision are correlated with the etiology and spatial frequency of the stimulus.

Fractality of sensations and the brain health: the theory linking neurodegenerative disorder with distortion of spatial and temporal scale-invariance and fractal complexity of the visible world

The theory that ties normal functioning and pathology of the brain and visual system with the spatial-temporal structure of the visual and other sensory stimuli is described for the first time in the present study. The deficit of fractal complexity of environmental influences can lead to the distortion of fractal complexity in the visual pathways of the brain and abnormalities of development or aging. The use of fractal light stimuli and fractal stimuli of other modalities can help to restore the functions of the brain, particularly in the elderly and in patients with neurodegenerative disorders or amblyopia. Non-linear dynamics of these physiological processes have a strong base of evidence, which is seen in the impaired fractal regulation of rhythmic activity in aged and diseased brains. From birth to old age, we live in a non-linear world, in which objects and processes with the properties of fractality and non-linearity surround us. Against this background, the evolution of man took place and all periods of life unfolded. Works of art created by man may also have fractal properties. The positive influence of music on cognitive functions is well-known. Insufficiency of sensory experience is believed to play a crucial role in the pathogenesis of amblyopia and age-dependent diseases. The brain is very plastic in its early development, and the plasticity decreases throughout life. However, several studies showed the possibility to reactivate the adult's neuroplasticity in a variety of ways. We propose that a non-linear structure of sensory information on many spatial and temporal scales is crucial to the brain health and fractal regulation of physiological rhythms. Theoretical substantiation of the author's theory is presented. Possible applications and the future research that can experimentally confirm or refute the theoretical concept are considered.

A dichoptic custom-made action video game as a treatment for adult amblyopia

Previous studies have employed different experimental approaches to enhance visual function in adults with amblyopia including perceptual learning, videogame play, and dichoptic training. Here, we evaluated the efficacy of a novel dichoptic action videogame combining all three approaches. This experimental intervention was compared to a conventional, yet unstudied method of supervised occlusion while watching movies. Adults with unilateral amblyopia were assigned to either play the dichoptic action game (n=23; 'game' group), or to watch movies monocularly while the fellow eye was patched (n=15; 'movies' group) for a total of 40hours. Following training, visual acuity (VA) improved on average by ≈0.14logMAR (≈28%) in the game group, with improvements noted in both anisometropic and strabismic patients. This improvement is similar to that obtained following perceptual learning, video game play or dichoptic training. Surprisingly, patients with anisometropic amblyopia in the movies group showed similar improvement, revealing a greater impact of supervised occlusion in adults than typically thought. Stereoacuity, reading speed, and contrast sensitivity improved more for game group participants compared with movies group participants. Most improvements were largely retained following a 2-month no-contact period. This novel video game, which combines action gaming, perceptual learning and dichoptic presentation, results in VA improvements equivalent to those previously documented with each of these techniques alone. Our game intervention led to greater improvement than control training in a variety of visual functions, thus suggesting that this approach has promise for the treatment of adult amblyopia.

Dichoptic training improves contrast sensitivity in adults with amblyopia

Dichoptic training is designed to promote binocular vision in patients with amblyopia. Initial studies have found that the training effects transfer to both binocular (stereopsis) and monocular (recognition acuity) visual functions. The aim of this study was to assess whether dichoptic training effects also transfer to contrast sensitivity (CS) in adults with amblyopia. We analyzed CS data from 30 adults who had taken part in one of two previous dichoptic training studies and assessed whether the changes in CS exceeded the 95% confidence intervals for change based on test-retest data from a separate group of observers with amblyopia. CS was measured using Gabor patches (0.5, 3 and 10cpd) before and after 10days of dichoptic training. Training was delivered using a dichoptic video game viewed through video goggles (n=15) or on an iPod touch equipped with a lenticular overlay screen (n=15). In the iPod touch study, training was combined with anodal transcranial direct current stimulation of the visual cortex. We found that dichoptic training significantly improved CS across all spatial frequencies tested for both groups. These results suggest that dichoptic training modifies the sensitivity of the neural systems that underpin monocular CS.

Changes across the psychometric function following perceptual learning of an RSVP reading task

Several recent studies have shown that perceptual learning can result in improvements in reading speed for people with macular disease (e.g., Chung, 2011; Tarita-Nistor et al., 2014). The improvements were reported as an increase in reading speed defined by specific criteria; however, little is known about how other properties of the reading performance or the participants' perceptual responses change as a consequence of learning. In this paper, we performed detailed analyses of data following perceptual learning using an RSVP (rapid serial visual presentation) reading task, looking beyond the change in reading speed defined by the threshold at a given accuracy on a psychometric function relating response accuracy with word exposure duration. Specifically, we explored the statistical characteristics of the response data to address two specific questions: was there a change in the slope of the psychometric function and did the improvements in performance occur consistently across different word exposure durations? Our results show that there is a general steepening of the slope of the psychometric function, leading to non-uniform improvements across stimulus levels.

The effect of normal aging and age-related macular degeneration on perceptual learning

We investigated whether perceptual learning could be used to improve peripheral word identification speed. The relationship between the magnitude of learning and age was established in normal participants to determine whether perceptual learning effects are age invariant. We then investigated whether training could lead to improvements in patients with age-related macular degeneration (AMD). Twenty-eight participants with normal vision and five participants with AMD trained on a word identification task. They were required to identify three-letter words, presented 10° from fixation. To standardize crowding across each of the letters that made up the word, words were flanked laterally by randomly chosen letters. Word identification performance was measured psychophysically using a staircase procedure. Significant improvements in peripheral word identification speed were demonstrated following training (71% ± 18%). Initial task performance was correlated with age, with older participants having poorer performance. However, older adults learned more rapidly such that, following training, they reached the same level of performance as their younger counterparts. As a function of number of trials completed, patients with AMD learned at an equivalent rate as age-matched participants with normal vision. Improvements in word identification speed were maintained at least 6 months after training. We have demonstrated that temporal aspects of word recognition can be improved in peripheral vision with training across a range of ages and these learned improvements are relatively enduring. However, training targeted at other bottlenecks to peripheral reading ability, such as visual crowding, may need to be incorporated to optimize this approach.

Improving visual functions in adult amblyopia with combined perceptual training and transcranial random noise stimulation (tRNS): a pilot study

Amblyopia is a visual disorder due to an abnormal pattern of functional connectivity of the visual cortex and characterized by several visual deficits of spatial vision including impairments of visual acuity (VA) and of the contrast sensitivity function (CSF). Despite being a developmental disorder caused by reduced visual stimulation during early life (critical period), several studies have shown that extensive visual perceptual training can improve VA and CSF in people with amblyopia even in adulthood. With the present study we assessed whether a much shorter perceptual training regime, in association with high-frequency transcranial electrical stimulation (hf-tRNS), was able to improve visual functions in a group of adult participants with amblyopia. Results show that, in comparison with previous studies where a large number sessions with a similar training regime were used (Polat et al., 2004), here just eight sessions of training in contrast detection under lateral masking conditions combined with hf-tRNS, were able to substantially improve VA and CSF in adults with amblyopia.

Improvement of uncorrected visual acuity and contrast sensitivity with perceptual learning and transcranial random noise stimulation in individuals with mild myopia

Perceptual learning has been shown to produce an improvement of visual acuity (VA) and contrast sensitivity (CS) both in subjects with amblyopia and refractive defects such as myopia or presbyopia. Transcranial random noise stimulation (tRNS) has proven to be efficacious in accelerating neural plasticity and boosting perceptual learning in healthy participants. In this study, we investigated whether a short behavioral training regime using a contrast detection task combined with online tRNS was as effective in improving visual functions in participants with mild myopia compared to a 2-month behavioral training regime without tRNS (Camilleri et al., 2014). After 2 weeks of perceptual training in combination with tRNS, participants showed an improvement of 0.15 LogMAR in uncorrected VA (UCVA) that was comparable with that obtained after 8 weeks of training with no tRNS, and an improvement in uncorrected CS (UCCS) at various spatial frequencies (whereas no UCCS improvement was seen after 8 weeks of training with no tRNS). On the other hand, a control group that trained for 2 weeks without stimulation did not show any significant UCVA or UCCS improvement. These results suggest that the combination of behavioral and neuromodulatory techniques can be fast and efficacious in improving sight in individuals with mild myopia.

Neural plasticity underlying visual perceptual learning in aging

Healthy aging is associated with a decline in basic perceptual abilities, as well as higher-level cognitive functions such as working memory. In a recent perceptual training study using moving sweeps of Gabor stimuli, Berry et al. (2010) observed that older adults significantly improved discrimination abilities on the most challenging perceptual tasks that presented paired sweeps at rapid rates of 5 and 10 Hz. Berry et al. further showed that this perceptual training engendered transfer-of-benefit to an untrained working memory task. Here, we investigated the neural underpinnings of the improvements in these perceptual tasks, as assessed by event-related potential (ERP) recordings. Early visual ERP components time-locked to stimulus onset were compared pre- and post-training, as well as relative to a no-contact control group. The visual N1 and N2 components were significantly enhanced after training, and the N1 change correlated with improvements in perceptual discrimination on the task. Further, the change observed for the N1 and N2 was associated with the rapidity of the perceptual challenge; the visual N1 (120-150 ms) was enhanced post-training for 10 Hz sweep pairs, while the N2 (240-280 ms) was enhanced for the 5 Hz sweep pairs. We speculate that these observed post-training neural enhancements reflect improvements by older adults in the allocation of attention that is required to accurately dissociate perceptually overlapping stimuli when presented in rapid sequence. This article is part of a Special Issue entitled SI: Memory Å.

Why don't younger adults in England go to have their eyes examined?

PURPOSE

Most research on attitudes to eye health has focussed on older people, reflecting the higher prevalence of eye diseases in older age groups. Little is known about younger people's attitudes to eye health. This paper explores young adults understanding of eye health and the purpose of eye examinations and the reasons why they do or do not attend for eye examinations. The aim is to provide evidence to inform policy on recommendations relating to eye health for individuals at low risk of visual impairment.

METHODS

Six focus-group meetings were held in Leeds with 43 people aged 18-35 (mean age 22 years). Focus group participants were recruited using a snowballing approach from an initial group of young adults. Focus groups were transcribed and a thematic analysis approach was used.

RESULTS

Children who wore spectacles were often bullied. As people grew up it became more socially acceptable to wear spectacles. Practicalities, aesthetics and fashion were important issues. Knowledge about eye disease and the eye examination were generally poor. Many claimed to value vision, but recognised that young people do not have eye examinations as often as they should. Eye examinations were only perceived to be needed for younger people experiencing problems or to update prescriptions. Eye health was seen as issue for older people. Some had no idea or were shocked about how much spectacles cost. Optometrists were seen differently to other healthcare professionals. The retail aspect of optometry was seen as too dominant. More information was wanted from the NHS on eye health.

CONCLUSION

While young adults are at low risk of sight threatening disease, many do benefit from correction of refractive error. There is an argument for reducing the recommended frequency of eye examinations for low risk individuals from the 2 years currently advised. Nevertheless, young adults need to be made more aware of eye health issues, so that optometrists are seen as more than somewhere that sell spectacles. Increasing awareness of eye health in younger adulthood will also be important to ensure that services are appropriately accessed as they get older.

The Glenn A. Fry Award Lecture 2012: Plasticity of the visual system following central vision loss

Following the onset of central vision loss, most patients develop an eccentric retinal location outside the affected macular region, the preferred retinal locus (PRL), as their new reference for visual tasks. The first goal of this article is to present behavioral evidence showing the presence of experience-dependent plasticity in people with central vision loss. The evidence includes the presence of oculomotor re-referencing of fixational saccades to the PRL; the characteristics of the shape of the crowding zone (spatial region within which the presence of other objects affects the recognition of a target) at the PRL are more "foveal-like" instead of resembling those of the normal periphery; and the change in the shape of the crowding zone at a para-PRL location that includes a component referenced to the PRL. These findings suggest that there is a shift in the referencing locus of the oculomotor and the sensory visual system from the fovea to the PRL for people with central vision loss, implying that the visual system for these individuals is still plastic and can be modified through experiences. The second goal of the article is to demonstrate the feasibility of applying perceptual learning, which capitalizes on the presence of plasticity, as a tool to improve functional vision for people with central vision loss. Our finding that visual function could improve with perceptual learning presents an exciting possibility for the development of an alternative rehabilitative strategy for people with central vision loss.

Environment and Brain Plasticity: Towards an Endogenous Pharmacotherapy

Brain plasticity refers to the remarkable property of cerebral neurons to change their structure and function in response to experience, a fundamental theoretical theme in the field of basic research and a major focus for neural rehabilitation following brain disease. While much of the early work on this topic was based on deprivation approaches relying on sensory experience reduction procedures, major advances have been recently obtained using the conceptually opposite paradigm of environmental enrichment, whereby an enhanced stimulation is provided at multiple cognitive, sensory, social, and motor levels. In this survey, we aim to review past and recent work concerning the influence exerted by the environment on brain plasticity processes, with special emphasis on the underlying cellular and molecular mechanisms and starting from experimental work on animal models to move to highly relevant work performed in humans. We will initiate introducing the concept of brain plasticity and describing classic paradigmatic examples to illustrate how changes at the level of neuronal properties can ultimately affect and direct key perceptual and behavioral outputs. Then, we describe the remarkable effects elicited by early stressful conditions, maternal care, and preweaning enrichment on central nervous system development, with a separate section focusing on neurodevelopmental disorders. A specific section is dedicated to the striking ability of environmental enrichment and physical exercise to empower adult brain plasticity. Finally, we analyze in the last section the ever-increasing available knowledge on the effects elicited by enriched living conditions on physiological and pathological aging brain processes.

Linking assumptions in amblyopia

Over the last 35 years or so, there has been substantial progress in revealing and characterizing the many interesting and sometimes mysterious sensory abnormalities that accompany amblyopia. A goal of many of the studies has been to try to make the link between the sensory losses and the underlying neural losses, resulting in several hypotheses about the site, nature, and cause of amblyopia. This article reviews some of these hypotheses, and the assumptions that link the sensory losses to specific physiological alterations in the brain. Despite intensive study, it turns out to be quite difficult to make a simple linking hypothesis, at least at the level of single neurons, and the locus of the sensory loss remains elusive. It is now clear that the simplest notion-that reduced contrast sensitivity of neurons in cortical area V1 explains the reduction in contrast sensitivity-is too simplistic. Considerations of noise, noise correlations, pooling, and the weighting of information also play a critically important role in making perceptual decisions, and our current models of amblyopia do not adequately take these into account. Indeed, although the reduction of contrast sensitivity is generally considered to reflect "early" neural changes, it seems plausible that it reflects changes at many stages of visual processing.

Perceptual learning treatment in patients with anisometropic amblyopia: a neuroimaging study

AIMS

To investigate the neuromechanisms of perceptual learning treatment in patients with anisometropic amblyopia using functional MRI (fMRI) and diffusion tensor imaging (DTI) techniques.

METHODS

20 patients with monocular anisometropic amblyopia participated in the study. Both fMRI and DTI data were acquired for each patient twice: before and after 30 days' perceptual learning treatment for the amblyopic eye. During fMRI scanning, patients viewed the stimuli with either the sound or amblyopic eye. Changes of cortical activation after treatment were evaluated. In the DTI exams, the fractional anisotropy (FA) values, apparent diffusion coefficient (ADC) values, the voxel numbers of optic radiations (ORs), and the number of tracks were compared between the ipsilateral and the contralateral ORs and also between the previous and posterior scans.

RESULTS

Remarkable increased activation via the amblyopic eyes was found in Brodmann Area (BA) 17-19, bilateral temporal lobes, and right cingulate gyrus after the perceptual learning treatment. No significant changes were found in the FA values, ADC values, voxel numbers, and the number of tracks after the treatment.

CONCLUSIONS

These results indicate that perceptual learning treatment for amblyopia had a positive effect on the visual cortex and temporal lobe visual areas in patients with anisometropic amblyopia.