Residual Amblyopia Research Articles

Can viewing a 3D movie improve visual function in children with a history of amblyopia and neurotypical children?: A pilot study.

The aim of this pilot study was to determine whether viewing an immersive 3D movie with large disparities in a cinema resulted in improved visual acuity (VA), stereoscopic depth perception (ST), and improved eye alignment in residual amblyopic children and children without amblyopia. A total of 24 children aged between 5 and 12 years with a history of anisometropic and/or strabismic amblyopia, that had been previously treated and who currently have residual amblyopia (N = 14), and in children with typical development without amblyopia (N = 10) viewed the movie in 3D Sing 2 in a cinema for 110 minutes. Visual acuity, stereoacuity and ocular deviation were assessed before viewing the movie, and three months later. Stereoacuity and ocular deviation were also measured immediately after viewing the movie. We observed an improvement in visual acuity in the non-dominant (amblyopic) eye 3 months after viewing the movie in the amblyopic group (P<0.001). Stereopsis improved immediately after viewing the movie (P = 0.02), and after 3 months by ≈ 40% (P = 0.01). Moreover, improvements in stereopsis were also observed in children without amblyopia (P = 0.04). No significant changes in ocular deviation were observed in either group. These pilot results suggest that brief exposure to large disparities by viewing a 3D movie in a cinema can help to improve stereopsis and visual acuity in children aged 5‒12 years with previously treated amblyopia, and provide a rationale for a randomized clinical trial.

Subnormal visual acuity after compliant amblyopia therapy: residual/refractory amblyopia or co-existing pathology? - a retrospective analysis

ABSTRACT Purpose: To assess the prevalence of alternate etiology/co-existing pathology among patients with amblyopia, and to characterize factors contributing to over-diagnosis of amblyopia. Methods: We retrospectively reviewed records of children (from 1 January 2016 to 31 December 2019) who were initially diagnosed as “amblyopia” but later an alternate diagnosis for subnormal vision was established. Patients who had a best corrected visual acuity (BCVA) of ≤20/32 (0.2 logMAR) after compliant amblyopia therapy were divided into 2 groups: those with refractory amblyopia (BCVA improvement from baseline <1 logMAR line) and residual amblyopia (BCVA improvement from baseline >1 logMAR line). Data was collected for presence/absence of amblyogenic risk factors, history, ocular examination, and investigations leading to the final alternate diagnosis. We analyzed the factors that contributed to the initial over-diagnosis of amblyopia using the diagnostic error evaluation and research (DEER) taxonomy tool. Results: During the study period, 508 children with an initial diagnosis of amblyopia met the study criteria. Among these 508 children, 466 were diagnosed to have amblyopia alone, while 26 children (5.1%, median age: 7 years, 17 boys: 9 girls) were revised to have an alternate diagnosis/co-existing pathology. These 26 patients comprised of 2 groups: children referred to us as amblyopia but rediagnosed to have an alternate diagnosis; and a second subset, initially diagnosed by us to have amblyopia, but later found to have alternate diagnosis/co-existing pathology. Subclinical optic neuritis (50%, 13 children), and occult macular dystrophy (OMD) (38.4%, 10 children) were the most frequent alternative diagnoses. Children with ametropic amblyopia (8/26, 30.7%) were most frequently misdiagnosed. Risk factors that led to an initial diagnosis of amblyopia were: high refractive error and heterotropia in 7 patients each (26.9%), anisometropia in 12 (46.1%), and prior pediatric cataract surgery in 4(15.3%). No improvement in BCVA in 21/26 (80.7%) children led to suspicion of co-existing etiology. Other clues were optic disc pallor (11), subnormal color vision (7), history of parental consanguinity in 7, and preceding febrile illness/rhinitis in 1 child. The DEER taxonomy tool suggested that the most common reasons for diagnostic errors were over-emphasis on amblyopia. Conclusion: Our study suggests that 5% of children diagnosed with amblyopia might have co-existing/alternate etiology. Most common co-existing etiologies were subclinical optic neuropathy, and OMD. No improvement in BCVA, subtle history and examination findings prompted further workup. Not considering co-existing etiologies was the most common reason for an initial overdiagnosis of amblyopia.

Correlation between Visual Acuity, Contrast Sensitivity and Depth of Vision before and after Partial Time Occlusion Therapy in Strabismic and Anisometropic Amblyopes

Background Amblyopia is known as the visual developmental disorder that follows selective disruption of the visual input to one eye early in life. It is considered the second most common cause of decreased visual acuity in both children and adults affecting greatly both economic and social life. It affects most of the visual parameters, so great efforts are carried out in developing effective methods controlling different deficits in amblyopia, being a great concern for all the society. However, monocular occlusion therapy remains the easiest and most popular way despite that there are many doubts in its reliability in controlling visual abnormalities other than acuity. Purpose To compare the different performance of anisometropic and strabismic eyes with moderate amblyopia, using partial occlusion therapy regarding visual acuity, contrast sensitivity and depth of vision. Methods Forty-nine children between 7 and 12 years old suffering from moderate amblyopia were classified into two groups: 25 anisometropic amblyopes and 24 strabismic ones. Two hour occlusion regimen with near activity was conducted by patients, assured by parents monitoring. Evaluation of visual acuity, contrast sensitivity and stereoacuity was conducted at each visit throughout the treatment regimen which was continued for 6 months on monthly follow up basis. Results Children in both groups improved significantly in visual acuity. There was a considerable difference among the distribution of improvement within each group where 9% of strabismic amblyopes achieved full visual recovery as compared to 40% in the anisometropic group, and 62.5% had residual amblyopia as compared to 36% in the anisometropic one, in spite of no significant difference of average improvement between groups (&amp;lt;0.0001). Only 42% of the strabismic amblyopes improved in stereoacuity as compared to 88% of the anisometropic ones, however, the difference in mean improvement was not significant between the two groups. Conclusion Children with moderate anisometropic or strabismic amblyopia 7-12 years old, can get considerable benefits from part time occlusion therapy in different visual aspects. The anisometropic amblyopes have better contrast sensitivity improvement and more reliable expectations of recovery being largely dependent on the initial visual acuity.

Retinal microvascular changes in unilateral functional amblyopia detected by oct-angiography and follow-up during treatment.

To evaluate the macular microvascular changes using optical coherence tomographic angiography (OCT-A) in children with unilateral amblyopia and their reversibility during treatment. Patients with unilateral strabismic or anisometropic amblyopia or residual amblyopia from early congenital cataract surgery, examined between October 2019 and March 2021, were included. Vessel density and perfusion density in the superficial capillary plexus and area, perimeter and circularity of the foveal avascular zone (FAZ) were analysed using OCT-A in amblyopic eyes, contralateral eyes and control group healthy eyes. Correlation analyses between the microvascular parameters and the visual acuity were performed. In a pilot study on a few patients from the amblyopic cohort, longitudinal follow-up during treatment was also performed. A total of 128 eyes of 64 patients were included: 32 amblyopic eyes compared with 32 contralateral eyes and 64 control eyes. Vessel density and perfusion density in the superficial capillary plexus were significantly lower in amblyopic eyes compared to control eyes in 6 × 6 mm (p < 0.02) and 3 × 3 mm (p < 0.01) scans. Correlation analyses showed a linear decrease in vessel density and perfusion density with decreasing visual acuity. The microvascular changes observed were reversible with the occlusion treatment of amblyopia (p < 0.001). The study found a decrease in vessel density and perfusion density in the macula of children with unilateral functional amblyopia. These microvascular changes were correlated with visual acuity and appeared to be reversible with treatment of amblyopia. On the whole, OCT-A appears to be a relevant complementary examination when it comes to diagnosing and monitoring functional amblyopia.

Durable recovery from amblyopia with donepezil

An elevated threshold for neuroplasticity limits visual gains with treatment of residual amblyopia in older children and adults. Acetylcholinesterase inhibitors (AChEI) can enable visual neuroplasticity and promote recovery from amblyopia in adult mice. Motivated by these promising findings, we sought to determine whether donepezil, a commercially available AChEI, can enable recovery in older children and adults with residual amblyopia. In this open-label pilot efficacy study, 16 participants (mean age 16 years; range 9–37 years) with residual anisometropic and/or strabismic amblyopia were treated with daily oral donepezil for 12 weeks. Donepezil dosage was started at 2.5 or 5.0 mg based on age and increased by 2.5 mg if the amblyopic eye visual acuity did not improve by 1 line from the visit 4 weeks prior for a maximum dosage of 7.5 or 10 mg. Participants < 18 years of age further patched the dominant eye. The primary outcome was visual acuity in the amblyopic eye at 22 weeks, 10 weeks after treatment was discontinued. Mean amblyopic eye visual acuity improved 1.2 lines (range 0.0–3.0), and 4/16 (25%) improved by ≥ 2 lines after 12 weeks of treatment. Gains were maintained 10 weeks after cessation of donepezil and were similar for children and adults. Adverse events were mild and self-limited. Residual amblyopia improves in older children and adults treated with donepezil, supporting the concept that the critical window of visual cortical plasticity can be pharmacologically manipulated to treat amblyopia. Placebo-controlled studies are needed.

Race, Ethnicity, Insurance, and Population Density Associations with Pediatric Strabismus and Strabismic Amblyopia in the IRIS® Registry

To evaluate the associations of sociodemographic factors with pediatric strabismus diagnosis and outcomes. Retrospective cohort study. American Academy of Ophthalmology IRIS® Registry (Intelligent Research in Sight) patients with strabismus diagnosed before the age of 10 years. Multivariable regression models evaluated the associations of race and ethnicity, insurance, population density, and ophthalmologist ratio with age at strabismus diagnosis, diagnosis of amblyopia, residual amblyopia, and strabismus surgery. Survival analysis evaluated the same predictors of interest with the outcome of time to strabismus surgery. Age at strabismus diagnosis, rate of amblyopia and residual amblyopia, and rate of and time to strabismus surgery. The median age at diagnosis was 5 years (interquartile range, 3-7) for 106 723 children with esotropia (ET) and 54 454 children with exotropia (XT). Amblyopia diagnosis was more likely with Medicaid insurance than commercial insurance (odds ratio [OR], 1.05 for ET; 1.25 for XT; P < 0.01), as was residual amblyopia (OR, 1.70 for ET; 1.53 for XT; P < 0.01). For XT, Black children were more likely to develop residual amblyopia than White children (OR, 1.34; P < 0.01). Children with Medicaid were more likely to undergo surgery and did so sooner after diagnosis (hazard ratio [HR], 1.23 for ET; 1.21 for XT; P < 0.01) than those with commercial insurance. Compared with White children, Black, Hispanic, and Asian children were less likely to undergo ET surgery and received surgery later (all HRs < 0.87; P < 0.01), and Hispanic and Asian children were less likely to undergo XT surgery and received surgery later (all HRs < 0.85; P < 0.01). Increasing population density and clinician ratio were associated with lower HR for ET surgery (P < 0.01). Children with strabismus covered by Medicaid insurance had increased odds of amblyopia and underwent strabismus surgery sooner after diagnosis compared with children covered by commercial insurance. After adjusting for insurance status, Black, Hispanic, and Asian children were less likely to receive strabismus surgery with a longer delay between diagnosis and surgery compared with White children. Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Stereoptic serious games as a visual rehabilitation tool for individuals with a residual amblyopia (AMBER trial): a protocol for a crossover randomized controlled trial

BackgroundAmblyopia is the most common developmental vision disorder in children. The initial treatment consists of refractive correction. When insufficient, occlusion therapy may further improve visual acuity. However, the challenges and compliance issues associated with occlusion therapy may result in treatment failure and residual amblyopia. Virtual reality (VR) games developed to improve visual function have shown positive preliminary results. The aim of this study is to determine the efficacy of these games to improve vision, attention, and motor skills in patients with residual amblyopia and identify brain-related changes. We hypothesize that a VR-based training with the suggested ingredients (3D cues and rich feedback), combined with increasing the difficulty level and the use of various games in a home-based environment is crucial for treatment efficacy of vision recovery, and may be particularly effective in children.MethodsThe AMBER study is a randomized, cross-over, controlled trial designed to assess the effect of binocular stimulation (VR-based stereoptic serious games) in individuals with residual amblyopia (n = 30, 6–35 years of age), compared to refractive correction on vision, selective attention and motor control skills. Additionally, they will be compared to a control group of age-matched healthy individuals (n = 30) to account for the unique benefit of VR-based serious games. All participants will play serious games 30 min per day, 5 days per week, for 8 weeks. The games are delivered with the Vivid Vision Home software. The amblyopic cohort will receive both treatments in a randomized order according to the type of amblyopia, while the control group will only receive the VR-based stereoscopic serious games. The primary outcome is visual acuity in the amblyopic eye. Secondary outcomes include stereoacuity, functional vision, cortical visual responses, selective attention, and motor control. The outcomes will be measured before and after each treatment with 8-week follow-up.DiscussionThe VR-based games used in this study have been conceived to deliver binocular visual stimulation tailored to the individual visual needs of the patient, which will potentially result in improved basic and functional vision skills as well as visual attention and motor control skills.Trial registrationThis protocol is registered on ClinicalTrials.gov (identifier: NCT05114252) and in the Swiss National Clinical Trials Portal (identifier: SNCTP000005024).

Комбинированный подход к лечению анизометропической амблиопии у детей (клинический случай)

A clinical case of patient K., 12 years old, with a diagnosis of anisometropia, anisometropic amblyopia, mixed astigmatism of the right eye, mild myopia, complex myopic astigmatism of the left eye is presented. Due to the intolerance of eyeglass and contact correction, the preservation of residual amblyopia against the background of regularly performed pleoptic treatment, the patient underwent laser refractive surgery of the amblyopic eye by Femto LASIK method in order to eliminate aniseikonia, which made it possible to successfully select glasses for permanent wearing with correction of the myopic eye and carry out further treatment in conditions of free haploscopy on a binarimeter with obtaining a high functional result. When observed in dynamics after 1 month and six months, the stability of anatomical and functional indicators was noted, which makes it possible to consider a highly effective combined approach in the treatment of anisometropic form of amblyopia in children. Keywords: amblyopia, children, anisometropia, FemtoLASIK, binarimetry

Prevalence of residual amblyopia in adulthood and its association on educational outcome and quality of life in the Northern Finland Birth Cohort.

The purpose of the current study was to evaluate the prevalence of residual amblyopia in adults in a population screened and treated in childhood. We also wanted to evaluate the association of amblyopia on school success, level of education, and quality of life. This is a follow-up study of 2708 subjects of the Northern Finland Birth Cohort. At the age of 46, the subjects took part in ophthalmic examinations, including the measurement of best-corrected visual acuity (BCVA) and refraction. Residual amblyopia was defined as BCVA 20/30 or less (logMAR ≥0.2) in one or both eyes or a two-line interocular visual acuity difference and absence of any pathological ocular factors. The quality of life was assessed with a 15D questionnaire, and educational outcome, school success, and episodic memory with a CANTAB-PAL (paired associates learning) test were evaluated. The prevalence of amblyopia in the current adult population aged 46 years was 1.3% (n= 36). At 14 years, the amblyopia subjects had had significant differences in mean spherical equivalent between the amblyopic and fellow eye and strabismus more often than controls. No significant differences were observed in the CANTAB-PAL test or in educational outcome. However, amblyopia subjects had significant difficulties in the 15D questionnaire in terms of vision (54% vs. 34%, p= 0.01). Due to screening and treatment in childhood, the number of adults with residual amblyopia was low. Despite minor visual impairment and discomfort, they cope very well in life in terms of educational outcome and quality of life.

Comparison of the outcome of partial time occlusion therapy in strabismic versus anisometropic moderate amblyopes

Background Early in life, selective visual input disruption to one eye compromises most of the visual aspects, resulting in amblyopia, with a great social and economic effect. Despite being the easiest and most popular treatment regimen, monocular occlusion therapy is often questioned for efficacy in controlling visual abnormalities other than acuity in different etiologies of amblyopia. Purpose To find out the difference in response of moderately amblyopic, anisometropic versus strabismic eyes to partial occlusion therapy regarding visual acuity (VA), contrast sensitivity (CS), and depth of vision and find out any correlation of improvement of these parameters. Patients and methods This prospective comparative study included 49 moderately amblyopic children between 7 and 12 years of age divided into two groups: 25 anisometropic and 24 strabismic ones. Patients received 2-h parent-monitored occlusion regimen with near activity for 6 months on a monthly basis of follow-up. VA, CS, and stereoacuity were evaluated at each visit. Results Both groups showed significant improvement in VA, although the difference in the average amount of improvement was not significant (P&lt;0.0001). Intragroup distribution of improvement was considerably different, where 9% of strabismic amblyopes achieved full visual recovery as compared with 40% of the anisometropic, and 62.5% had residual amblyopia versus 36% in the anisometropic group. CS improved significantly more in the anisometropic group (P=0.0493). Only 42% of the strabismic amblyopes improved in stereoacuity as compared with 88% of the anisometropic ones; the mean difference was not significant. In anisometropic amblyopes, initial VA correlated significantly with CS (P=0.019) and stereoacuity improvement (P=0.0133). Conclusion Moderately amblyopic anisometropic or strabismic children 7–12 years old can get benefit in different visual aspects from part-time occlusion therapy. The anisometropic amblyopes show better CS improvement and more reliable expectations of recovery that are largely dependent on the initial visual.

Recovery from amblyopia with cholinesterase inhibition

An elevated threshold for neuroplasticity limits visual gains with treatment of residual amblyopia in late childhood and adulthood. Donepezil, an acetylcholinesterase inhibitor, can enable visual neuroplasticity and promote recovery from amblyopia in adult mice. Motivated by these promising findings, we sought to determine whether donepezil can enable recovery in older children and adults with residual amblyopia.

Costs and effectiveness of two models of school-entry visual acuity screening in the UK

ABSTRACT Cost effectiveness of different visual screening modalities cannot be calculated without long-term outcome data. This paper reports detailed outcomes from a gold-standard UK recommended orthoptist-delivered screening (ODS) at 4–5 years in school, compared to a neighboring school-nurse delivered screening (SNDS), both feeding into the same treatment pathway. The target condition was reduced visual acuity (VA) of worse than logMAR 0.2 in either eye. Available records from screening databases and hospital records were analyzed, comparing the two services wherever possible. More screening data was available from the ODS. ODS: 5706 screened, 3.5% referred. False positives 6.5%, PPV 91.4%, sensitivity 97.9%, and specificity 99.8% for reduced VA. Cost per child with reduced vision detected £195.22, and per amblyope detected £683.28. The mean treatment cost per child with reduced VA was £331.68 and for amblyopia treatment was £458.65. SNDS: 5630 screened and 3.8% referred (plus some referrals to local optometrists lost to follow up). False positives 34%, PPV 53.2%, sensitivity and specificity estimated as 89.3% and 98.67%. Costs to secondary services of false positives were seven times greater. The cost per child with confirmed reduced vision seen at the hospital was 46% more; and per amblyope detected was 39% more. Outcomes for treatment post referral in both groups were similar and excellent. 86% of genuine referrals improved to within normal limits with glasses alone. Of 221 genuine referrals with final outcome data, all now have better than 0.2logMAR acuity in the better eye and only two (0.9%) have residual amblyopia in one eye worse than 0.4logMAR. About 14–18% of children with reduced VA would have passed AAPOS photoscreening referral criteria. An orthoptist-delivered single VA screen at 4–5 years is highly cost effective with good outcomes. The main contributing factors to success appear to be training and experience in accurate VA testing, the opportunity to rescreen equivocal results, and monitoring, audit, and feedback of outcomes.

Outcomes of using Bangerter foils for the treatment of residual amblyopia following patching therapy.

To evaluate the effectiveness of additional treatment using Bangerter foil (BF) for children with residual amblyopia. Patients with residual amblyopia who were treated with BF between 2015 and 2020 were reviewed. Residual amblyopia was defined as no further improvement in vision following patching therapy for at least 6months. BF that corresponds to the VA of the amblyopic eye was applied to the spectacle lens of the fellow eye. Patients were divided into two groups: group A, which included patients treated with BF alone, and group B, which included patients treated with BF and a head-mounted display. After at least 2months of treatment, baseline and final VA and stereoacuity were compared. Seventy-four patients with a mean age of 8.0 ± 1.6years at the time of BF treatment were included. The mean duration of the BF treatment was 10.4 ± 5.6months. After a mean follow-up period of 24.9 ± 11.9months after BF treatment, the median (IQR) VA of the amblyopic eye changed from 0.20 (0.15-0.40) LogMAR to 0.10 (0.04-0.20) LogMAR (P = 0.001). The median (IQR) stereoacuity changed from 3.19 (2.53-3.75) log arcsec to 2.60 (2.15-3.48) log arcsec (P = 0.001). The number of patients improved vision by 0.2 LogMAR or more lines was 18 patients (30%) for group A and 3 patients (23%) for group B. The VA of the amblyopic eye before BF treatment was significantly associated with vision improvement. BF can be considered an alternative treatment plan to provide further benefit for children with residual amblyopia.

To evaluate the retinal nerve fiber layer thickness in different types of glaucoma

Objective: Glaucoma is a multifaceted eye disease which is classified as physical damage of retinal ganglion cells which may effect in loss of vision and permanent blindness. While physical damage of glaucoma can be clinically evaluated the optic nerve head and peripapillary retinal nerve fiber layer (RNFL). Our objective is to evaluate the mean RNFL thickness in all types of glaucoma. Methodology: This prospective and cross sectional study was conducted in Glaucoma Clinic of Al Ibrahim Eye Hospital (AIEH), Karachi, for the period from May 2019 to October 2019, after ethical approval from Institutional Research Committee. A total of 64 glaucoma patients were chosen by using non-probability purposive sampling technique. The participant comprised, no known eye disease, no visual impairment, IOP below 22 mmHg, and no obvious retinal disease or defect were included while individuals having a history of ocular diseases or pathology with residual visual impairment, retinal diseases, amblyopia, and history of intraocular surgery or laser therapy were excluded from the study. The collected data were analyzed using Statistical Package for Social Sciences (SPSS) version 20. Results: 64 patients of both genders with mean age of 55.54±15.58 years. The mean intraocular pressure of right eye and left eye was 16.46±8.06 and 16.75±7.82 mmHg, respectively. The mean RNFL thickness in superior, inferior, temporal and nasal quadrant of the right eye was measured 68.23±25.44, 66.79±27.50, 51.75±12.58 and 47.73±18.82 microns, respectively while the mean RNFL thickness in superior, inferior, temporal and nasal quadrant of the left eye was measured 76.01±22.72, 67.42±21.25, 54.37±13.0 and 49.62±11.57 microns, respectively. Conclusion: Our study showed that analysis of retinal nerve fiber layer thickness with optical coherence tomography is the best tool for the diagnosis of glaucoma. It has also been observed in our study that frequency of changes in retinal nerve fiber layer thickness was mostly found in primary open angle glaucoma patients

Fixational eye movements abnormalities and rate of visual acuity and stereoacuity improvement with part time patching

Residual amblyopia is seen in 40% of amblyopic patients treated with part-time patching. Amblyopic patients with infantile onset strabismus or anisometropia can develop fusion maldevelopment nystagmus syndrome (FMNS). The purpose of this study was to understand the effects of presence of FMNS and clinical subtype of amblyopia on visual acuity and stereo-acuity improvement in children treated with part-time patching. Forty amblyopic children who had fixation eye movement recordings and at least 12 months of follow-up after initiating part-time patching were included. We classified amblyopic subjects per the fixational eye movements characteristics into those without any nystagmus, those with FMNS and patients with nystagmus without any structural anomalies that do not meet the criteria of FMNS or idiopathic infantile nystagmus. We also classified the patients per the clinical type of amblyopia. Patching was continued until amblyopia was resolved or no visual acuity improvement was noted at two consecutive visits. Children with anisometropic amblyopia and without FMNS have a faster improvement and plateaued sooner. Regression was only seen in patients with strabismic/mixed amblyopia particularly those with FMNS. Patients with FMNS had improvement in visual acuity but poor stereopsis with part-time patching and required longer duration of treatment.

Using OCT Fixation Shift to Assess Eccentric Fixation in Children With Residual Amblyopia

PurposeEccentric fixation in amblyopia is often estimated grossly without precision. Although the usefulness of optical coherence tomography (OCT) fixation shift in the quantification of eccentric fixation in a small cohort of amblyopic children was recently reported, there is a lack of understanding of characteristics of OCT fixation shift. In a retrospective cohort study, we evaluated eccentric fixation with OCT in a large cohort of children with residual amblyopia.MethodsChildren, age 4 to 17 years, with residual amblyopia (amblyopic, n = 56) and without amblyopia (control, n = 75) were enrolled. Amblyopia was associated with anisometropia alone (anisometropia subtype, n = 28) and strabismus without or with anisometropia (strabismic subtype, n = 28). Spectral domain OCT was used to estimate fixation. The OCT fixation shift, defined as the distance between the fovea and the fixation point, was measured and adjusted with calculated axial length and converted into visual degrees. Fixation shift in amblyopic eyes, fellow nonamblyopic eyes, and right eyes of the control group were compared. Fixation shift between the anisometropic and strabismic amblyopia subtypes was also compared. Its correlation with visual acuity was estimated.ResultsThe mean fixation shift was significantly different: 0.17° ± 0.29° for control right eyes, 0.94° ± 1.24° for amblyopic eyes, and 0.34° ± 0.57° for fellow eyes (χ2 = 23.3; P < 0.001). There was no significant difference between fellow eyes and control eyes (P = 0.11). Fixation shift in amblyopic eyes was significantly correlated with visual acuity (R = 0.44; P < 0.001), and it was significantly smaller in the anisometropic subtype than in the strabismic subtypes (0.34° ± 0.46° vs. 1.54° ± 1.48°, W = 338, P < 0.001).ConclusionsOCT fixation shift can be used both in detection and quantification of eccentric fixation in children with residual amblyopia, especially in those with strabismus.Translational RelevanceOCT fixation shift offers a convenient clinical approach in quantitative evaluation of eccentric fixation in children with strabismic amblyopia.

BYNOCS®1 – A Cloud-Based Indigenous Tele-Health Vision Therapy Software for the Assessment and Management of Binocular Vision Disorders

Background: Binocular vision assessment is an integral part of an eye and vision care practice. With the need for a user friendly, simplified, and comprehensive tool especially in this digital era, we propose a new indigenous cloudbased software, Bynocs.® This manuscript describes the technical details, the functioning of this indigenous software, and a case series demonstrating the application and efficacy of Bynocs® as a tele-health vision therapy tool. All the three cases were handled remotely through the Bynocs tele-health vision therapy platform. Case Reports: Case 1: This is a case of symptomatic convergence insufficiency who had prior compliance issues with a conventional vision therapy approach. With 10 sessions of Bynocs vision therapy focused on improving convergence amplitudes, the patient showed significant improvements in both subjective and objective parameters. Case 2: This case is of a 12 year old child with residual anisometropic amblyopia who had excellent compliance with patching therapy for 3 years but visual acuity had plateaued over the last 6 months. After 20 sessions of Dichoptic amblyopia therapy, best-corrected visual acuity (BCVA) improved by 3 log MAR lines, with improvements in stereoacuity to 100 sec of arc. Case 3: This case of a 10 year old child with residual exophoria after strabismus surgery was referred for managing the residual deviation and associated visual complaints. The child had 20/20 visual acuity in both eyes and 10 prism diopters of residual exophoria at distance and near. After 30 sessions of vision therapy, improvements in fusional vergence amplitudes was achieved along with the deviation restoring to orthophoria at both distance and near, with further improvements in stereoacuity from 400 sec of arc to 120 sec of arc. Conclusions: As tele-health is finding favor across the globe, Bynocs® can be a valuable tele-health vision therapy tool for in the management of binocular vision anomalies and amblyopia with the functionality for remote diagnosis and therapy.

Part time patching treatment outcomes in children with amblyopia with and without fusion maldevelopment nystagmus: An eye movement study.

PurposeWe investigated how the abnormalities of fixation eye movements (FEMs) of the amblyopic eye were linked with treatment outcomes following part-time patching therapy in children with amblyopia.MethodsWe recruited 53 patients, with at least 12 months of patching, and measured FEMs at the end of treatment. Subjects were classified based on FEM waveforms (those without nystagmus = 21, those with nystagmus without fusion maldevelopment nystagmus (FMN) = 21, and those with FMN = 11) and based on clinical type of amblyopia (anisometropic = 18, strabismic = 6, and mixed = 29). The treatment outcomes such as duration of treatment of receiving part-time patching therapy, visual acuity and stereo-acuity deficits at the end of treatment were determined. Bivariate contour ellipse area (BCEA), fast (fixational saccade/quick phases), and slow (inter-saccadic drifts/slow phases) FEMs of the fellow and amblyopic eye were analyzed.ResultsAnisometropic group had less residual amblyopia (0.23±0.19logMAR acuity) compared to strabismic/mixed (0.36±0.26) groups (p = 0.007). Treatment duration in patients without nystagmus was lower (12.6±9.5months) compared to nystagmus without FMN (25.6±23.2) and FMN (29.5±20.4) groups (p = 0.006). Patients without nystagmus had better stereopsis at the end of treatment (2.3±0.84logarcsecs) compared to nystagmus without FMN (2.6±0.84) group (p = 0.003). The majority of patients with FMN (8/11) had absent stereopsis. BCEA of the amblyopic eye was higher in patients with greater residual visual acuity deficits in patients without nystagmus. No such association was seen in Nystagmus no FMN and FMN groups. Increased amplitude of fast FEMs, increased eye position variance and eye velocity of slow FEMs were seen in patients who had received longer duration of part time patching therapy and in those with greater residual amblyopia, and poor stereopsis at the end of treatment.ConclusionsAssessment of FEM waveforms and fast and slow FEM characteristics are important measures while describing fixation instability in amblyopia. Several FEM abnormalities were associated with stereo-acuity and visual acuity deficits and treatment duration in patients with amblyopia treated with part time patching therapy.

Amblyopia Outcomes Through Clinical Trials and Practice Measurement: Room for Improvement: The LXXVII Edward Jackson Memorial Lecture

To describe amblyopia prevalence and outcomes using results from randomized studies and a clinical registry. Review of published studies, analysis of data in Intelligent Research in Sight (IRIS) Registry from 2013 to 2019, personal perspective. Literature review, analysis of IRIS Registry data and IRIS-50, a visual acuity quality measure. Clinical trials have reduced the treatment burden of amblyopia by reducing hours of patching and frequency of atropine eye drops with clinical success of about 83%. There is no appreciable age effect if treatment is started before 5 years of age, outcomes are stable to at least 15 years of age, and treatment can be somewhat effective until 12 years of age. The IRIS Registry identified 1,760,066 individuals with amblyopia for a prevalence of 2.47%. Refractive error alone accounted for 68.9% of childhood cases. Mean amblyopic eye visual acuity improved 1.8 lines for children 3-6 years of age and 0.8 lines for 7-12 years, but mean residual amblyopia was more than 2 lines. Among 18,841 children aged 3-7 years eligible for IRIS-50, 77.3% were successful. The odds ratios for success were significantly lower for African-American (0.67; 95% confidence interval [CI]= 0.58 to 0.78) and Hispanic or Latino (0.84; 95% CI= 0.75 to 0.94) children compared with white children. Clinical trials provided evidence of a beneficial effect from several treatments, with substantially reduced doses than previously recommended. Registry data from clinical practice found residual visual acuity impairment among all ages and races, especially among minorities.

Understanding the Impact of Residual Amblyopia on Functional Vision and Eye-related Quality of Life Using the PedEyeQ

To evaluate the effect of residual amblyopia on functional vision and eye-related quality of life (ER-QOL) in children and their families using the Pediatric Eye Questionnaire (PedEyeQ). Prospective cross-sectional study. Seventeen children with residual amblyopia (no current treatment except glasses), 48 visually normal controls without glasses, and 19 controls wearing glasses (aged 8-11 years) completed the Child 5-11 year PedEyeQ. One parent for each child completed the Proxy 5-11 PedEyeQ, Parent PedEyeQ. Rasch-calibrated domain scores were calculated for each questionnaire domain and compared between amblyopic children and controls. PedEyeQ scores were significantly lower (worse) for children with residual amblyopia than for controls without glasses across all domains: Child PedEyeQ greatest mean difference 18 points worse on Functional vision domain (95% confidence interval [CI]-29 to-7; P < .001); Proxy PedEyeQ greatest mean difference 31 points worse on Functional vision domain (95% CI-39 to-24; P < .001); Parent PedEyeQ greatest mean difference 34 points worse on the Worry about child's eye condition domain (95% CI-46 to-22; P < .001). Compared with controls wearing glasses, PedEyeQ scores were lower for residual amblyopia on the Child Frustration/worry domain (P= .03), on 4 of 5 Proxy domains (P ≤ .05), and on 3 of 4 Parent domains (P ≤ .05). Residual amblyopia affects functional vision and ER-QOL in children. Parents of amblyopic children also experience lower quality of life. These data help broaden our understanding of the everyday-life impact of childhood residual amblyopia.