The gold-standard treatment for childhood amblyopia remains patching or penalizing the fellow eye, resulting in an average of about a one line (0.1 logMAR) improvement in visual acuity following ≈120 h of patching in children 3-8 years old. However, compliance with patching and other treatment options is often poor. In contrast, fast-paced action video games can be highly engaging, and have been shown to yield broad-based improvements in vision and attention in adult amblyopia. Here, we pilot-tested a custom-made action video game to treat children with amblyopia. Twenty-one (n = 21) children (mean age 9.95 ± 3.14 [se]) with unilateral amblyopia (n = 12 anisometropic and n = 9 strabismic) completed 20 h of game play either monocularly, with the fellow eye patched (n = 11), or dichoptically, with reduced contrast to the fellow eye (n = 10). Participants were assessed for visual acuity (VA), stereo acuity and reading speed at baseline, and following 10 and 20 h of play. Additional exploratory analyses examined improvements after 6-10 weeks of completion of training (follow-up). Following 20 h of training, VA improved, on average, by 0.14 logMAR (≈38%) for the dichoptic group and by 0.06 logMAR (≈15%) for the monocular group. Similarly, stereoacuity improved by 0.07 log arcsec (≈17%) following dichoptic training, and by 0.06 log arcsec (≈15%) following monocular training. Across both treatment groups, 7 of the 12 individuals with anisometropic amblyopia showed improvement in stereoacuity, whereas only 1 of the 9 strabismic individuals improved. Most improvements were largely retained at follow-up. Our feasibility study therefore suggests that the action video game approach may be used as an effective adjunct treatment for amblyopia in children, achieving results similar to those of the gold-standard treatment in shorter duration.

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Abnormal early visual development can result in a constellation of neural and visual deficits collectively known as amblyopia. Among the many deficits, a common finding is that both saccadic and manual reaction times to targets presented to the amblyopic eye are substantially delayed when compared to the fellow eye or to normal eyes. Given the well-known deficits in contrast sensitivity in the amblyopic eye, a natural question is whether the prolonged reaction times are simply a consequence of reduced stimulus visibility. To address this question, in Experiment 1 we measure saccadic reaction times (RT) to perifoveal stimuli as a function of effective stimulus contrast (i.e., contrast scaled by the amblyopic eye's contrast threshold). We find that when sensory differences between the eyes are minimized, the asymptotic RTs of our anisometropic amblyopes were similar in the two eyes. However, our results suggest that some strabismic amblyopes have an irreducible delay at the asymptote. That is, even when the sensory differences of the stimulus were accounted for, these observers still had large interocular differences (on average, 77 ms) in saccadic reaction time. In Experiment 2, to assess the role of fixation on saccadic reaction time we compared reaction time with and without a foveal target (the “gap effect”). Our results suggest that, while removing the fixation target does indeed speed up reaction time in the amblyopic eye, the gap effect is similar in the two eyes. Therefore, the gap effect does not eliminate the irreducible delay in the amblyopic eye. Finally, in Experiment 3 we compared the interocular differences in saccadic and manual reaction times in the same observers. This allowed us to determine the relationship between the latencies in the two modalities. We found a strong correlation between the differences in saccadic and manual reaction times; however, the manual RT difference is about half that of saccadic RT, suggesting that there may be two separable effects on saccadic reaction time: (a) a central problem with directing actions to a target, related to disengagement of attention at the fovea, which results in delays in both saccadic and manual reaction times, and (b) a further delay in saccadic reaction times because of the motor refractory period from a previous saccade or microsaccade, made in an attempt to stabilize the amblyopic eye of strabismics.

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