Clinical profile of amblyopia and outcome of occlusion therapy in pediatric populations attending a referral hospital

AIM: To study clinical profile of amblyopia and also the outcomes of occlusion therapy among the amblyopes. METHODS: This was a hospital-based longitudinal study by design. Data were collected from April 2015 to April 2016 in Ophthalmology Department of Dhulikhel Hospital. Presenting visual acuity, chief complaint at presentation, age at presentation, refractive status, binocularity and fixation patterns were assessed in all the children with amblyopia. Improvement in visual acuity was also noted in all the subjects after occlusion therapy, which is a most commonly used modality of treatment for amblyopia. RESULTS: Among 1092 children examined during the study period, 60 (5.49%) were amblyopic. Among them, 35 (58.30%) were females and 25 (41.70%) were males. The mean age at presentation was 8.87±3.29y. Meridional amblyopia was the most prevalent subtype seen in 43.3% (n=26) of children followed by anisohypermetropic amblyopia (20%, n=12). The most common refractive error was astigmatism accounting for 58.30% of the total cases followed by hypermetropia (22.5%) and myopia (7.5%). Compliance with spectacle wear combined with occlusion therapy and active vision therapy was 73.3% (n=44). There was a statistically significant improvement in visual acuity of the amblyopic eyes after the different treatment strategies after 3mo (P=0.002). CONCLUSION: Prevalence of amblyopia and associated visual impairment is still a public health issue in developing countries like Nepal. Lack of awareness and lack of community or preschool vision screening for children lead to late presentation and significant visual impairment associated with the condition. The burden can easily be reduced with screening camps, timely referrals and proper interventions.

Evaluation of a novel dichoptic training method using polarising film for treatment of amblyopia

We have developed a new, low-cost, easily administered method that uses a polarising film to enable dichoptic training for amblyopia. In this study, we compared its effects with occlusion therapy using an eye patch. Fifty-eight patients (4.7 ± 0.1 years old) diagnosed with anisometric amblyopia were included and instructed to wear complete refractive correction glasses with either occlusion therapy using an eye patch (eye patch group) or dichoptic training using polarising film (polarising film group) for two hours per day. We examined the improvement in the visual acuity and adherence rate of the patients two months after treatment initiation. After training, the polarising film group showed significant improvement in visual acuity compared with the eye patch group. The adherence rate was also significantly better in the polarising film group than in the eye patch group. In both groups, there was a significant correlation between the improvement in visual acuity and adherence rate. This new dichoptic training using a polarising film was shown to be effective for anisometropic amblyopia.

Evaluation of the efficacy, safety, and stability of posterior chamber phakic intraocular lenses for correcting intractable myopic anisometropic amblyopia in a pediatric cohort

Background Myopic anisometropic amblyopia in pediatrics is one of the most challenging clinical situations that can face an ophthalmologist. Conventional correction modalities for myopic anisometropia, using spectacles, contact lenses, and/or occlusion therapy, may not be suitable for some pediatric patients or for some ocular conditions. This may lead to the development of anisometropic amblyopia. The aim of the present study was to evaluate the visual and the refractive efficacy, safety, and stability of Posterior Chamber Phakic Intraocular Lenses (PC-pIOLs) for correcting myopic anisometropic amblyopia in a pediatric cohort. Methods This case series, prospective, interventional study was conducted at Watany Eye Hospital, Cairo, Egypt. It comprised children and teenagers with myopic anisometropic amblyopia and unsuccessful conventional therapy. After implantation of Intraocular Collamer Lenses “ICLs” (Visian ICL, Model V4c, STAAR Surgical, Monrovia, California, USA), postoperative follow-up visits were scheduled, with automated refraction and Pentacam imaging performed. Results The study enrolled 42 eyes of 42 patients. The age range was 3 to 18 years (mean ± SD = 10.74 years ±4.16). The mean preoperative spherical equivalent (SE) was − 12.85 D ± 2.74. The results declared a significant improvement in the postoperative Corrected Distance Visual Acuity “CDVA” (P value < 0.01) and SE (P value < 0.01). The efficacy index had a value of 1.18 ± 0.3 and the safety index was 1.09 ± 0.24. The follow-up visits had a mean ± SD of 14.67 months ±16.56 (range of 1 to 54 months). The results showed a refractive stability, with statistically insignificant improvements in the patients’ visual acuity and refractive status on evaluating the enrolled pediatrics during the follow-up visits compared to the first postoperative visits. No postoperative complications were encountered. Worthy of mention is that there was a significant (80%) non-compliance with the prescribed postoperative occlusion therapy. Conclusions The present study, with the longest reported follow-up range, declared the long-term efficacy, safety, and stability of Visian ICLs for correcting myopic anisometropic amblyopia in pediatrics. The reported non-compliance with occlusion therapy validates the early implantation of Visian ICLs in cases with failed conventional therapy to guard against anisometropic amblyopia.

Profile of Amblyopia and Outcome of Occlusion Therapy in Amblyopic Patients Attending Tertiary Care Hospital of Kathmandu

Amblyopia is a common cause of visual impairment in children. The aim of this study was to assess the profile of amblyopia and the outcome of occlusion therapy in amblyopic children attending the eye department of a tertiary care hospital. This was a hospital based prospective interventional study. Sixty-five eyes of 47 patients fulfilling the inclusion criteria were included in the study. Occlusion therapy was started for the diagnosed amblyopic cases after refractive adaptation of 4 weeks. The mean age of presentation was 8.8 ±3.2 years. 29(61.7%) cases had unilateral amblyopia, 18(38.3%) cases had bilateral amblyopia. Ametropic amblyopia (52.3%) was the most common type of amblyopia followed by Anisometropia (23.1%). Refractive error was the most common cause of amblyopia with compound myopic astigmatism seen among 30.8% and hypermetropia among 29.2% of patients. There was no significant association between initial visual acuity with age of presentation and types of amblyopia respectively (P=0.1, P=0.5). The final visual outcome after therapy was better among patients with Ametropic amblyopia than other types (P=0.02). There was significant association between final visual outcome with age, initial visual acuity, type and severity of amblyopia respectively (P<0.001, P<0.001, P=0.02, P=0.02). In conclusion, Ametropia was the most common type of amblyopia. The mean age of presentation was 8.8 years, which was beyond the critical period affecting the outcome of treatment. Uncorrected refractive error was the most common amblyogenic factor. Age of presentation, types and severity of amblyopia are the important contributing factors for the outcome of occlusion therapy. Therefore, early detection and management of amblyopia is important to reduce visual impairment among children.

Does the gamification aspect of an online focal ambient visual acuity stimulation therapeutic game for treating amblyopia in children improve adherence? (Preprint)

BACKGROUND The golden standard treatment for amblyopia is patching the better eye. Visual acuity improvement of the amblyopic eye is significantly impacted by adherence of the patching therapy. It is known that the overall adherence is rather low. OBJECTIVE This retrospective study evaluated whether an updated version of attention binding digital therapeutic games based on the principle of focal ambient visual acuity stimulation (FAVAS) would result in an improved patient adherence in 4- to 16-year-old patients with amblyopia. METHODS We analyzed pseudonymised electronically recorded data from patients treated with occlusion therapy and FAVAS therapeutic games. One group used an older (2015) and the other group the newer version (2020) that provided more attractive therapeutic games with tablet computer functionality. Objective adherence was calculated by comparing the amount of minutes using the therapeutic games as monitored in the automatized logbook versus prescribed minutes of using the games. RESULTS Children in Group 2015 (n=138) spent on average 2009.3±1372.1 (36 to 5472) minutes using FAVAS; children in Group 2020 (n=129) spent on average 2695.5±1526.8 (37.5 to 5672) minutes using the improved therapy. Group 2020 spent on average 686.2 more minutes on FAVAS than Group 2015 (t=3.87, P<.001). Although patient adherence was very variable, compared to the 57%±34% in Group 2015, it significantly improved up to 78%±46% in Group 2020 (t=4.3, P<.001). CONCLUSIONS FAVAS 2020 with an improved gamification aspect as well as tablet computer functionality increased adherence significantly compared to the earlier version FAVAS 2015, indicating that FAVAS 2020 could be an effective approach to support adherence to amblyopia treatment. CLINICALTRIAL DRKS00017633

Value of TCD Foaming Test in Screening Patent Foramen Ovale in Migraine Patients and Efficacy of PFO Occlusion

Objective: To explore the effect of TCD foaming test in screening patent foramen ovale in migraine patients, as well as in the treatment effect. Methods: From September 2019 to August 2020, 236 patients with migraine and 362 patients with normal physical examination were treated in our hospital. According to the random number table method, 60 patients with migraine were selected as the observation group, and 60 patients with normal physical examination were selected as the control group. 48 cases of PFO were confirmed by TCD foaming test Among the patients with migraine, 36 patients received interventional occlusion therapy. The therapeutic effect and VAS score of the two groups were analyzed. Results: Through TCD foaming test, the proportion of PFO in the observation group was 80%, and that in the control group was 13.33%. The proportion of PFO in the observation group was significantly higher than that in the control group, and the difference was statistically significant (X2 = 53.5714, P < 0.01);The symptoms disappeared in 30 patients and improved in 4 patients; Among the 36 patients who received interventional occlusion therapy, the VAS score of patients before and after the operation was significantly changed, and the proportion of patients whose pain disappeared after the operation was 83.33%, which was significantly lower than that before the operation, and the difference was comparable (X2 = 51.4286, P < 0.01). Conclusion: TCD foaming test for PFO screening has strong applicability, not only safe and convenient, will not cause trauma to patients, and through interventional occlusion treatment, can significantly improve the clinical symptoms of migraine patients and cure patients.

A Long Term Follow Up of Posterior Chamber Phakic Intraocular Lenses for Correcting Intractable Pediatric Myopic Anisometropic Amblyopia

Background Pediatric myopic anisometropic amblyopia is one of the most challenging clinical situations that can face an ophthalmologist. Conventional correction modalities for myopic anisometropic amblyopia, using spectacles, contact lenses, and/or occlusion therapy, may not be suitable for some pediatric patients or for some ocular conditions. This may lead to the development of amblyopia and loss of binocular vision. The aim of the present study was to evaluate the visual and refractive efficacy, safety, and stability of Posterior Chamber Phakic Intraocular Lenses (PC-pIOLs) for correcting pediatric myopic anisometropic amblyopia. Methods This case series, prospective, interventional study was conducted at Watany Eye Hospital, Cairo, Egypt. It comprised 42 eyes of 42 children with myopic anisometropic amblyopia and unsuccessful conventional therapy. After implantation of Intraocular Collamer Lenses “ICLs” (Visian ICL, Model V4c, STAAR Surgical, Monrovia, California, USA), postoperative follow up visits were scheduled, with subjective refraction and Pentacam imaging performed. Results The patients’ age range was 3 to 18 years (mean ± SD = 10.58 years ± 4.23). The mean preoperative SE was − 12.54 D ± 2.93. The results declared a significant improvement in the postoperative CDVA (P value < 0.01) and SE (P value < 0.01). The efficacy index had a value of 1.18 ± 0.3 and the safety index was 1.09 ± 0.24. The follow up visits had a mean ± SD of 14.67 months ± 16.56 (range of 1 to 54 months). The results showed a refractive stability, with slight (statistically insignificant) improvements in the subjective refraction between the first postoperative and the follow up visits. No postoperative complications were encountered. Conclusions The present study, with the longest reported follow up range, declared the long-term efficacy, safety, and stability of Visian ICLs for correcting pediatric myopic anisometropic amblyopia. The reported non-compliance with occlusion therapy validates the early implantation of Visian ICLs in cases of failed conventional therapy to guard against anisometropic amblyopia.

Efficacy of Perceptual Learning-Based Vision Training as an Adjuvant to Occlusion Therapy in the Management of Amblyopia: A Pilot Study

A retrospective study was conducted to evaluate preliminarily the efficacy of perceptual learning (PL) visual training in medium-term follow-up with a specific software (Amblyopia iNET, Home Therapy Systems Inc., Gold Canyon, AZ, USA) for visual acuity (VA) and contrast sensitivity (CS) recovering in a sample of 14 moderate to severe amblyopic subjects with a previously unsuccessful outcome or failure with patching (PL Group). This efficacy was compared with that achieved in a patching control group (13 subjects, Patching 2). At one-month follow-up, a significant VA improvement in the amblyopic eye (AE) was observed in both groups, with no significant differences between them. Additionally, CS was measured in PL Group and exhibited a significant improvement in the AE one month after the beginning of treatment for 3, 6, 12, and 18 cycles/º (p = 0.003). Both groups showed long-lasting retention of visual improvements. A combined therapy of PL-based visual training and patching seems to be effective for improving VA in children with amblyopia who did not recover vision with patching alone or had a poor patching compliance. This preliminary outcome should be confirmed in future clinical trials.

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.

Objective adherence to an online FAVAS therapeutic game for treating amblyopia in children

ABSTRACTAimThis retrospective study was to evaluate whether an updated version of attention binding digital therapeutic games based on the principle of Focal Ambient Visual Acuity Stimulation (FAVAS) would result in an improved patient adherence of patching in 4- to 12-year-old patients with amblyopia.MethodsWe analyzed pseudonymised electronically recorded data from patients treated with two different versions of attention binding digital therapeutic games in 2015 and 2020. Two groups of children treated with occlusion therapy and attention binding digital therapeutic games, divided in treatment version, were compared. Patients in Group 2015 used the old version of therapeutic games without tablet computer functionality, while Group 2020 used more attractive therapeutic games with tablet computer functionality. Objective adherence was calculated by comparing the amount of minutes using the therapeutic games as monitored in the automatized logbook versus prescribed minutes of using the games.ResultsChildren in Group 2015 spent on average 2009.3±1372.1 (36 to 5472) minutes using FAVAS; children in Group 2020 spent on average 2695.5±1526.8 (37.5 to 5672) minutes using the improved therapy. Meaning, Group 2020 spent 686.2 more minutes on FAVAS than Group 2015 (t=3.87, P<0.001). Although patient adherence was very variable, it significantly improved up to 78% ± 46% in Group 2020 compared to the 57% ± 34% in Group 2015 (t=4.3, P<0.001).ConclusionFAVAS 2020 with an improved gamification aspect as well as tablet computer functionality increased adherence significantly compared to the earlier version FAVAS 2015, indicating that FAVAS 2020 could be an effective approach to support patching amblyopia treatment.