Patch-free streaming contrast-rebalanced dichoptic cartoons versus patching for treatment of amblyopia in children aged 3 to 5 years: a pilot, randomized clinical trial.

BACKGROUND: We developed and tested a dichoptic treatment designed for younger children that can be viewed freely and involves a dichoptic manipulation of a popular animation series that enables contrast-rebalancing without disrupting fusion. Our aim was to assess whether this novel amblyopia treatment is superior to patching in children aged 3-5 years. METHODS: A total of 34 children with amblyopia were randomly assigned to contrast-rebalanced dichoptic cartoons (4 hours/week) or patching (14 hours/week) for 2 weeks. Children in the cartoon group continued watching cartoons for an additional 2 weeks. Designed to target the youngest and most treatable children, the dichoptic cartoons presented the entire scene to the amblyopic eye at 100% contrast, while the fellow eye view was presented at reduced contrast with the main character omitted. Best-corrected visual acuity (BCVA), stereoacuity, suppression, and manual dexterity were measured at each visit. RESULTS: After 2 weeks, improvement in amblyopic eye BCVA was greater for dichoptic treatment than for patching, with a mean improvement of 0.11 ± 0.08 versus 0.06 ± 0.09 logMAR, respectively (P = 0.04). Stereoacuity, suppression, and manual dexterity did not improve significantly more in the dichoptic group than the patching group at 2 weeks. After 4 weeks of dichoptic cartoon treatment, mean visual acuity improvement in the dichoptic group was 0.16 logMAR (95% CI, 0.10-0.21). CONCLUSIONS: In our study cohort, a contrast-rebalanced dichoptic cartoon was more effective than patching in treating childhood amblyopia after 2 weeks. Dichoptic cartoons that rebalance contrast to overcome suppression provide an additional treatment option for amblyopia in young children.

Objective assessment of control compared with clinical triple office control score in children with intermittent exotropia.

Poor control of intermittent exotropia may be used as an indication for surgery. However, control fluctuates during the day and from day to day. The standardized triple office control score (mean of three scores on a 6-point ordinal scale) is representative of repeated assessments throughout the day, but lacks validation against an objective measure of eye movements. We report the agreement between the triple office control score measured by the referring eyecare professional and lab-measured vergence instability using an EyeLink video eye tracker. Near and distance triple office control scores were moderately correlated with vergence instability. Near, but not distance, triple office control score was moderately correlated with the percentage of time intermittent exotropia was manifest during EyeLink recording. Larger triple office control scores for intermittent exotropia provide a meaningful description of larger vergence instability, supporting its use in clinical decisions and as a measure in clinical trials.

Slow Binocular Reading in Amblyopic Children Is a Fellow Eye Deficit.

SIGNIFICANCE: Amblyopic children read 25% slower than their peers during binocular silent reading. PURPOSE: We compared binocular reading to fellow eye reading to determine whether slow reading in amblyopic children is due to binocular inhibition; that is, the amblyopic eye is interfering during binocular reading. METHODS: In a cross-sectional study, 38 children with amblyopia and 36 age-similar control children who completed grades 1 to 6 were enrolled. Children silently read grade-appropriate paragraphs during binocular reading and fellow eye reading while wearing ReadAlyzer eye-tracking goggles (Compevo AB, Stockholm, Sweden). Reading rate, number of forward saccades, number of regressive saccades, and fixation duration were analyzed between groups and between viewing conditions. We also examined whether sensory factors (amblyopia severity, stereoacuity, suppression) were related to slow reading. RESULTS: For amblyopic children, binocular reading versus fellow eye reading did not differ for reading rate (176 ± 60 vs. 173 ± 53 words per minute, P = .69), number of forward saccades (104 ± 35 vs. 97 ± 33 saccades/100 words, P = .18), number of regressive saccades (21 ± 15 vs. 22 ± 13 saccades/100 words, P = .75), or fixation duration (0.31 ± 0.06 vs. 0.32 ± 0.07 seconds, P = .44). As expected, amblyopic children had a slower reading rate and more forward saccades than control children during binocular reading and fellow eye reading. Slow reading was not related to any sensory factors. CONCLUSIONS: Binocular reading did not differ from fellow eye reading in amblyopic children. Thus, binocular inhibition is unlikely to play a role in slow binocular reading and is instead a fellow eye deficit that emerges from a disruption in binocular visual experience during development.

Temporal Eye-Hand Coordination During Visually Guided Reaching in 7- to 12-Year-Old Children With Strabismus.

Purpose: We recently found slow visually guided reaching in strabismic children, especially in the final approach. Here, we expand on those data by reporting saccade kinematics and temporal eye-hand coordination during visually guided reaching in children treated for strabismus compared with controls. Methods: Thirty children diagnosed with esotropia, a form of strabismus, 7 to 12 years of age and 32 age-similar control children were enrolled. Eye movements and index finger movements were recorded. While viewing binocularly, children reached out and touched a small dot that appeared randomly in one of four locations along the horizontal meridian (±5° or ±10°). Saccade kinematic measures (latency, accuracy and precision, peak velocity, and frequency of corrective and reach-related saccades) and temporal eye-hand coordination measures (saccade-to-reach planning interval, saccade-to-reach peak velocity interval) were compared. Factors associated with impaired performance were also evaluated. Results: During visually guided reaching, strabismic children had longer primary saccade latency (strabismic, 195 ± 29 ms vs. control; 175 ± 23 ms; P = 0.004), a 25% decrease in primary saccade precision (0.15 ± 0.06 vs. 0.12 ± 0.03; P = 0.007), a 45% decrease in the final saccade precision (0.16 ± 0.06 vs. 0.11 ± 0.03; P < 0.001), and more reach-related saccades (16 ± 13% of trials vs. 8 ± 6% of trials; P = 0.001) compared with a control group. No measurable stereoacuity was related to poor saccade kinematics. Conclusions: Strabismus impacts saccade kinematics during visually guided reaching in children, with poor binocularity playing a role in performance. Coupled with previous data showing slow reaching in the final approach, the current saccade data suggest that children treated for strabismus have not yet adapted or formed an efficient compensatory strategy during visually guided reaching.

Randomized clinical trial of streaming dichoptic movies versus patching for treatment of amblyopia in children aged 3 to 7 years.

Contrast-rebalanced dichoptic movies have been shown to be an effective binocular treatment for amblyopia in the laboratory. Yet, at-home therapy is a more practical approach. In a randomized clinical trial, we compared dichoptic movies, streamed at-home on a handheld 3D-enabled game console, versus patching as amblyopia treatment. Sixty-five amblyopic children (3-7 years; 20/32-125) were randomly assigned to one of two parallel arms, binocular treatment (3 movies/week) or patching (14 h/week). The primary outcome, change in best corrected visual acuity (BCVA) at the 2-week visit was completed by 28 and 30, respectively. After the primary outcome, both groups of children had the option to complete up to 6 weeks of binocular treatment. At the 2-week primary outcome visit, BCVA had improved in the movie (0.07 ± 0.02 logMAR; p < .001) and patching (0.06 ± 0.01 logMAR; p < 0.001) groups. There was no significant difference between groups (CI95%: - 0.02 to 0.04; p = .48). Visual acuity improved in both groups with binocular treatment up to 6 weeks (0.15 and 0.18 logMAR improvement, respectively). This novel, at-home, binocular movie treatment improved amblyopic eye BCVA after 2 weeks (similar to patching), with additional improvement up to 6 weeks. Repeated binocular visual experience with contrast-rebalanced binocular movies provides an additional treatment option for amblyopia.Clincaltrials.gov identifier: NCT03825107 (31/01/2019).

Reach Kinematics During Binocular Viewing in 7- to 12-Year-Old Children With Strabismus.

Purpose: Eye-hand coordination is essential for normal development and learning. Discordant binocular experience from childhood strabismus results in sensory and ocular motor impairments that can affect eye-hand coordination. We assessed reach kinematics during visually guided reaching in children treated for strabismus compared with controls. Methods: Thirty-six children aged 7 to 12 years diagnosed with esotropia, a form of strabismus, and a group of 35 age-similar control children were enrolled. Reach movements during visually guided reaching were recorded using the LEAP Motion Controller. While viewing binocularly, children reached out and touched a small dot that appeared randomly in one of four locations (±5° or ±10°). Kinematic measures were reach reaction time, total reach duration, peak velocity, acceleration duration, and deceleration duration. Touch accuracy and factors associated with impaired reach kinematics were evaluated. Results: Strabismic children had longer total reach duration (545 ± 60 ms vs. 504 ± 43 ms; P = 0.002), had longer deceleration duration (343 ± 54 ms vs. 312 ± 45 ms; P = 0.010), and were less accurate (93% ± 6% vs. 96% ± 5%, P = 0.007) than controls. No differences were found for reach reaction time, peak velocity, or acceleration duration (all Ps ≥ 0.197). Binocular dysfunction was more related to slow reaching than amblyopic eye visual acuity. Conclusions: Strabismus affects visually guided reaching in children, with slower reaching in the final approach and reduced endpoint accuracy. Binocular dysfunction was predictive of slow reaching. Unlike strabismic adults who show longer acceleration duration, longer deceleration in the final approach in strabismic children indicates a difference in control that could be due to reduced ability to use visual feedback.

Factors Associated with Impaired Motor Skills in Strabismic and Anisometropic Children.

Purpose: We evaluated motor skills in children diagnosed with strabismus and anisometropia, with or without amblyopia, and explored factors associated with impairments. Methods: A total of 143 strabismic and anisometropic children 3 to 13 years of age (96 amblyopic, 47 nonamblyopic) and a group of age-similar 35 control children completed Manual Dexterity, Aiming and Catching, and Balance tasks from the Movement Assessment Battery for Children, Second Edition. Raw scores were converted to standardized scores, and amblyopic and nonamblyopic children were compared to controls. Clinical and sensory factors associated with motor performance were also evaluated. Results: Overall, amblyopic and nonamblyopic children were three to six times more likely than controls to be at risk for or to have a total motor impairment (≤15th percentile). Although amblyopic children scored lower than controls for the Manual Dexterity, Aiming and Catching, and Balance tasks, nonamblyopic children scored lower on Manual Dexterity only. Factors related to manual dexterity deficits include the presence of amblyopia and binocularity deficits typical of these eye conditions. Aiming, catching, and balance deficits were most pronounced in children with an infantile onset of the eye condition, a history of strabismus, and reduced binocularity. Conclusions: Amblyopia and strabismus disrupt the development of motor ability in children. These findings highlight the widespread effects of discordant binocular input early in life and the visual acuity and binocularity deficits typical of these eye conditions.

Uses of the Inferior Oblique Muscle in Strabismus Surgery.

Inferior oblique muscle weakening is typically performed for overaction of the muscle. In this article, we review inferior oblique muscle anatomy, different weakening procedures, and recent surgical techniques that take advantage of the muscle's unique anatomy for the treatment of additional indications such as excyclotorsion and hypertropia in primary gaze.