Angie De La Cruz

Binocular iPad treatment for amblyopia in preschool children.

BACKGROUND Recent experimental evidence supports a role for binocular visual experience in the treatment of amblyopia. The purpose of this study was to determine whether repeated binocular visual experience with dichoptic iPad games could effectively treat amblyopia in preschool children. METHODS A total of 50 consecutive amblyopic preschool children 3-6.9 years of age were assigned to play sham iPad games (first 5 children) or binocular iPad games (n = 45) for at least 4 hours per week for 4 weeks. Thirty (67%) children in the binocular iPad group and 4 (80%) in the sham iPad group were also treated with patching at a different time of day. Visual acuity and stereoacuity were assessed at baseline, at 4 weeks, and at 3 months after the cessation of game play. RESULTS The sham iPad group had no significant improvement in visual acuity (t4 = 0.34, P = 0.75). In the binocular iPad group, mean visual acuity (plus or minus standard error) improved from 0.43 ± 0.03 at baseline to 0.34 ± 0.03 logMAR at 4 weeks (n = 45; paired t44 = 4.93; P < 0.0001). Stereoacuity did not significantly improve (t44 = 1.35, P = 0.18). Children who played the binocular iPad games for ≥8 hours (≥50% compliance) had significantly more visual acuity improvement than children who played 0-4 hours (t43 = 4.21, P = 0.0001). CONCLUSIONS Repeated binocular experience, provided by dichoptic iPad game play, was more effective than sham iPad game play as a treatment for amblyopia in preschool children.

Dichoptic movie viewing treats childhood amblyopia

BACKGROUND Contrast-balanced dichoptic experience with perceptual-learning tasks or simple games has been shown to improve visual acuity significantly in amblyopia. However, these tasks are intensive and repetitive, and up to 40% of unsupervised patients are noncompliant. We investigated the efficacy of a potentially more engaging movie method to provide contrast-balanced binocular experience via complementary dichoptic stimulation. METHODS Eight amblyopic children 4-10 years of age were enrolled in a prospective cohort study to watch 3 dichoptic movies per week for 2 weeks on a passive 3D display. Dichoptic versions of 18 popular animated feature films were created. A patterned image mask of irregularly shaped blobs was multiplied with the movie images seen by the amblyopic eye and an inverse mask was multiplied with the images seen by the fellow eye. Fellow-eye contrast was initially set at a reduced level that allowed binocular vision and was then incremented by 10% at each visit. Best-corrected visual acuity, random dot stereoacuity, and interocular suppression were measured at baseline and 2 weeks. RESULTS Mean amblyopic eye visual acuity (with standard error of the mean) improved from a logarithm of minimum angle of resolution of 0.72 ± 0.08 at baseline to 0.52 ± 0.09 (P = 0.003); that is, 2.0 lines of improvement at the 2-week outcome visit. No significant change in interocular suppression or stereoacuity was found. CONCLUSIONS Passive viewing of dichoptic feature films is feasible and could be a promising new treatment for childhood amblyopia. The maximum improvement that may be achieved by watching dichoptic movies remains to be determined. No known side effects are associated with this new treatment.

Amblyopic children read more slowly than controls under natural, binocular reading conditions

BACKGROUND Recent evidence suggests that amblyopia results in fixation instability and atypical saccades. Reading is a vision-reliant ability that requires sequential eye movements, including forward and regressive saccades. This study investigated reading and associated eye movements in school-age amblyopic children. METHODS Amblyopic children with strabismus and/or anisometropia (n = 29) were compared to nonamblyopic children treated for strabismus (n = 23) and normal control children (n = 21). While fitted with the ReadAlyzer, an eye movement recording system, children silently read a grade-level paragraph of text during binocular viewing. Reading rate, number of forward and regressive saccades per 100 words, and fixation duration were determined. Comprehension was evaluated with a 10-item quiz; only data from children with at least 80% correct responses were included. RESULTS Amblyopic children read more slowly and had more saccades compared with nonamblyopic children with treated strabismus and normal controls. Fixation duration did not differ significantly for amblyopic children versus normal controls. Treated strabismic children without amblyopia did not differ significantly from normal controls on any reading measure. Amblyopic eye visual acuity was not correlated with any reading measure. CONCLUSIONS Amblyopia was associated with slower reading speed in school-age children. Treatment for monocular amblyopia visual acuity impairment could improve reading speed and efficiency.

Binocular iPad treatment of amblyopia for lasting improvement of visual acuity.

Repeated experience with dichoptic perceptual learning tasks and dichoptic game play have been shown to be effective in improving the visual acuity of amblyopic children and adults.1–4 However, whether the visual acuity gains achieved with binocular treatment are long lasting has not yet been addressed. We examined the durability of visual acuity improvements obtained as a result of binocular iPad game play in childhood amblyopia.

Assessing Suppression in Amblyopic Children With a Dichoptic Eye Chart

Purpose Suppression 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. Methods We 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 eyes 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. Results Amblyopic 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). Conclusions Severity of suppression can be monitored as part of a routine clinical exam in the management of amblyopia in children.

Modified Test Protocol Improves Sensitivity of the Stereo Fly Test

Background and Purpose Stereoacuity measurement is a common element of pediatric ophthalmic examinations. Although the Stereo Fly Test is routinely used to establish the presence of coarse stereopsis (3000 arcsecs), it often yields a false negative “pass” due to learned responses and non-stereoscopic cues. We developed and evaluated a modified Stereo Fly Test protocol aimed at increasing sensitivity, thus reducing false negatives. Patients and Methods The Stereo Fly Test was administered according to manufacturer instructions to 321 children aged 3–12 years. Children with a “pass” outcome (n = 147) were re-tested wearing glasses fitted with polarizers of matching orientation for both eyes to verify that they were responding to stereoscopic cues (modified protocol). The response to the standard Stereo Fly Test was considered a false negative (pass) if the child still pinched above the plate after disparity cues were eliminated. Randot® Preschool Stereoacuity and Butterfly Tests were used as gold standards. Results and Conclusions Sensitivity was 81% (95% CI: 0.75 – 0.86) for standard administration of the Stereo Fly Test (19% false negative “pass”). The modified protocol increased sensitivity to 90% (95% CI: 0.85 – 0.94). The modified two-step protocol is a simple and convenient way to administer the Stereo Fly Test with increased sensitivity in a clinical setting.

Multiple-Choice Answer Form Completion Time in Children With Amblyopia and Strabismus

Importance Abnormal binocular experience during infancy or childhood from strabismus and/or anisometropia results in visual acuity deficits (eg, amblyopia) and impaired stereoacuity. These pediatric eye conditions have also been linked to slow reading and fine motor impairment. Objective To assess an academic-related fine motor outcome—multiple-choice answer form completion time—in children with amblyopia and strabismus. Design, Setting, and Participants In this cross-sectional study completed between May 2014 and November 2017 at a nonprofit eye research institute, 47 children with amblyopia treated for strabismus, anisometropia, or both, 18 children with nonamblyopic strabismus, and 20 normal controls were enrolled. Exposures Children were asked to transfer the correct answers from a standardized reading achievement test booklet to a multiple-choice answer form as quickly as possible without making mistakes or reading the text. Main Outcomes and Measures The time to complete the task was recorded and analyzed between groups. Results Of the 85 included children, 40 (47%) were female, the mean (SD) age was 10.09 (0.91) years, and the last mean (SD) grade completed was 3.42 (0.92). Compared with children in the control group (mean [SD] time to completion, 230 [63] seconds), children with amblyopia (mean [SD] time to completion, 297 [97] seconds; difference, 63 seconds; 95% CI, 24-102; P = .001) and children with nonamblyopic strabismus (mean [SD] time to completion, 293 [53] seconds; difference, 68 seconds; 95% CI, 21-115; P = .002) required approximately 28% (95% CI, 20-37) more time to fill out a multiple-choice answer form. Completion time was not associated with etiology, visual acuity, or stereoacuity. Conclusions and Relevance Multiple-choice answer forms typically accompany standardized testing in schools in the United States. Longer completion time in children with amblyopia or strabismus may affect a child’s performance on tests using multiple-choice answer forms and may hinder academic success.