Binocular iPad treatment for amblyopia in preschool children

Birch, Eileen E.; Li, Simone L.; Jost, Reed M.; Morale, Sarah E.; Cruz, Angie De La; Dao, Lori; Stager, David R.

doi:10.1016/j.jaapos.2014.09.009

Cited by 133 publications

(126 citation statements)

References 28 publications

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“…Indeed, 85% (23 of 27) of children played at least 75% of prescribed treatment compared with 44% (20 of 45) in the Tetris game study. 15 Furthermore, some children at the 4-week visit in our study had already completed all game levels or had reached 100% fellow eye contrast.…”

Section: Discussionmentioning

confidence: 87%

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Binocular iPad Game vs Patching for Treatment of Amblyopia in Children

Kelly

Jost

Dao³

et al. 2016

JAMA Ophthalmol

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174

209

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IMPORTANCE Fellow eye patching has long been the standard treatment for amblyopia, but it does not always restore 20/20 vision or teach the eyes to work together. Amblyopia can be treated with binocular games that rebalance contrast between the eyes so that a child may overcome suppression. However, it is unclear whether binocular treatment is comparable to patching in treating amblyopia.OBJECTIVES To assess the effectiveness of a binocular iPad (Apple Inc) adventure game as amblyopia treatment and compare this binocular treatment with patching, the current standard of care. DESIGN, SETTING, AND PARTICIPANTSThis investigation was a randomized clinical trial with a crossover design at a nonprofit eye research institute. Between February 20, 2015, and January 4, 2016, a total of 28 patients were enrolled in the study, with 14 randomized to binocular game treatment and 14 to patching treatment.INTERVENTIONS Binocular game and patching as amblyopia treatments. MAIN OUTCOMES AND MEASURESThe primary outcome was change in amblyopic eye best-corrected visual acuity (BCVA) at the 2-week visit. Secondary outcomes were change in stereoacuity and suppression at the 2-week visit and change in BCVA at the 4-week visit. RESULTS Among 28 children, the mean (SD) age at baseline was 6.7 (1.4) years (age range, 4.6-9.5 years), and 7 (25%) were female. At baseline, the mean (SD) amblyopic eye BCVA was 0.48 (0.14) logMAR (approximately 20/63; range, 0.3-0.8 logMAR [20/40 to 20/125]), with 14 children randomized to the binocular game and 14 to patching for 2 weeks. At the 2-week visit, improvement in amblyopic eye BCVA was greater with the binocular game compared with patching, with a mean (SD) improvement of 0.15 (0.08) logMAR (mean [SD], 1.5 [0.8] lines) vs 0.07 (0.08) logMAR (mean [SD], 0.7 [0.8] line; P = .02) after 2 weeks of treatment. These improvements from baseline were significant for the binocular game (mean [SD] improvement, 1.5 [0.8] lines; P < .001) and for patching (mean [SD] improvement, 0.7 [0.8] line; P = .006). Depth of suppression improved from baseline at the 2-week visit for the binocular game (mean [SD], 4.82 [2.82] vs 3.24 [2.87]; P = .03) and for patching (mean [SD], 4.77 [3.10] vs 2.57 [1.67]; P = .004). Patching children crossed over to binocular game treatment, and all 28 children played the game for another 2 weeks. At the 4-week visit, no group difference was found in BCVA change, with children who crossed over to the binocular games catching up with children treated with binocular games, for a mean (SD) improvement of 0.17 (0.10) logMAR (mean [SD], 1.7 [1.0] lines) for the binocular game vs a mean (SD) improvement of 0.16 (0.12) logMAR (mean [SD], 1.6 [1.2] lines) for the patching crossover (P = .73). CONCLUSIONS AND RELEVANCEA binocular iPad game was effective in treating childhood amblyopia and was more efficacious than patching at the 2-week visit. Binocular games that rebalance contrast to overcome suppression are a promising additional option for treating amblyopia.TRIAL REGISTRATION clinicaltrials....

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Section: Discussionmentioning

confidence: 87%

“…15–17 Contrast rebalancing allows the child to overcome interocular suppression and experience binocular vision while playing the games. 14,18 Poor compliance in 24% to 38% of children indicated that the games developed for our prototype iPad platform (Tetris and Pong) were not engaging.…”

mentioning

confidence: 99%

Binocular iPad Game vs Patching for Treatment of Amblyopia in Children

Kelly

Jost

Dao³

et al. 2016

JAMA Ophthalmol

Self Cite

174

209

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“…These approaches may reactivate latent binocular pathways by reducing inhibitory interactions, boosting attenuated excitatory function, and/or shifting the synaptic modification threshold in favor of potentiation (reviewed in Hess & Thompson, 2015). For example, recent studies have found that both amblyopic preschool children and adults can show enhanced improvements in visual and motor function by playing dichoptic iPad or iPod games (Hess et al, 2011; Birch et al, 2015; Vedamurthy et al, 2015; Webber et al, 2016). Since the lack of binocular function is a key risk factor for persistent amblyopia, the development of new binocular training strategies may have a substantial impact on improving acuity and recovering stereopsis (reviewed in Levi et al, 2015).…”

Section: Environmental and Behavioral Treatmentsmentioning

confidence: 99%

Amblyopia: New molecular/pharmacological and environmental approaches

Stryker

Löwel

2018

Vis Neurosci

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Emerging technologies are now giving us unprecedented access to manipulate brain circuits, shedding new light on treatments for amblyopia. This research is identifying key circuit elements that control brain plasticity and highlight potential therapeutic targets to promote rewiring in the visual system during and beyond early life. Here, we explore how such recent advancements may guide future pharmacological, genetic, and behavioral approaches to treat amblyopia. We will discuss how animal research, which allows us to probe and tap into the underlying circuit and synaptic mechanisms, should best be used to guide therapeutic strategies. Uncovering cellular and molecular pathways that can be safely targeted to promote recovery may pave the way for effective new amblyopia treatments across the lifespan.

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“…10,11 Treatment regimens designed to alleviate suppression via repeated exposure to contrast-balanced binocular stimuli improve visual acuity in amblyopic adults 12 and amblyopic children. 13–16 Thus, severity of suppression may be a useful baseline and outcome measure in clinical amblyopia research.…”

mentioning

confidence: 99%

Assessing Suppression in Amblyopic Children With a Dichoptic Eye Chart

Birch

Morale

Jost

et al. 2016

Invest. Ophthalmol. Vis. Sci.

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PurposeSuppression has a key role in the etiology of amblyopia, and contrast-balanced binocular treatment can overcome suppression and improve visual acuity. Quantitative assessment of suppression could have a role in managing amblyopia. We describe a novel eye chart to assess suppression in children.MethodsWe enrolled 100 children (7–12 years; 63 amblyopic, 25 nonamblyopic with strabismus or anisometropia, 12 controls) in the primary cohort and 22 children (3–6 years; 13 amblyopic, 9 nonamblyopic) in a secondary cohort. Letters were presented on a dichoptic display (5 letters per line). Children wore polarized glasses so that each eye saw a different letter chart. At each position, the identity of the letter and its contrast on each eye's chart differed. Children read 8 lines of letters for each of 3 letter sizes. The contrast balance ratio was the ratio at which 50% of letters seen by the amblyopic eye were reported.ResultsAmblyopic children had significantly higher contrast balance ratios for all letter sizes compared to nonamblyopic children and controls, requiring 4.6 to 5.6 times more contrast in the amblyopic eye compared to the fellow eye (P < 0.0001). Amblyopic eye visual acuity was correlated with contrast balance ratio (r ranged from 0.49–0.57 for the 3 letter sizes). Change in visual acuity with amblyopia treatment was correlated with change in contrast balance ratio (r ranged from 0.43–0.62 for the 3 letter sizes).ConclusionsSeverity of suppression can be monitored as part of a routine clinical exam in the management of amblyopia in children.

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Binocular iPad treatment for amblyopia in preschool children

Cited by 133 publications

References 28 publications

Binocular iPad Game vs Patching for Treatment of Amblyopia in Children

Binocular iPad Game vs Patching for Treatment of Amblyopia in Children

Amblyopia: New molecular/pharmacological and environmental approaches

Assessing Suppression in Amblyopic Children With a Dichoptic Eye Chart

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