[ECONOMIC INEQUALITY AND AMBLYOPIA TREATMENT SUCCESS RATES - EXPERIENCE OF A TERTIARY CENTER IN ISRAEL].

INTRODUCTION: Amblyopia is a common cause of visual impairment in children. There is circumstantial evidence for the correlation between living in impoverished areas and treatment failure. However, no large study directly assessed this correlation. AIMS: To check the correlation between socioeconomic status and amblyopia treatment success rates, in children 3-18 years old. METHODS: A retrospective cohort study, review of the electronic medical records of patients treated for amblyopia in a tertiary center during a period of 24 years. RESULTS: A total of 102 participants were enrolled in the study, of whom 50 came from impoverished areas and were the study group. The study and control group participants had similar distribution of age, sex and baseline clinical data. Study group participants had significantly lower baseline visual acuity. The mean follow-up time was 34 months. Both groups had a significant improvement in visual acuity and a significant decline in severe amblyopia proportion. Final visual acuity, visual improvement and amblyopia severity were similar in both groups. The proportion of successful treatments was similar in both groups. DISCUSSION: Although participants from impoverished areas began follow-up with significantly lower visual acuity, their vision has improved during follow-up and was similar to final visual acuity of the control group. Amblyopia treatment has eliminated the gap in visual acuity between amblyopic patients from impoverished areas and amblyopic patients in the general population. Conclusion: Given good treatment compliance, social disparities were not significant determinants of amblyopia treatment success.

Assessment of amblyopic children undergoing occlusion therapy by pattern visual evoked potentials and contrast sensitivity tests.

Background: Amblyopia is a case where one or less commonly, both eyes have impaired visual performance, even with the best optical correction and no visible disease of the visual system. Objectives: To assess contrast sensitivity tests (CST) and pattern visual evoked potentials (PVEP) results in amblyopic children who have already started occlusion therapy for durations ranging from 6 to 12 months. Methods: This cross-sectional study was conducted on 200 eyes of 50 patients with monocular amblyopia and 50 age and sex matched controls. Both patients and controls underwent ophthalmological assessment, PVEP, and CST. Results: There was no statistically significant difference in the results of P100 latencies of qualitative PVEP in amblyopic eyes compared to non-amblyopic eyes and control eyes, while the qualitative CST showed a highly statistically significant difference, being affected in 98% of amblyopic eyes compared to unaffected eyes (4%) and control eyes (4%). The maximum contrast level and minimal contrast level of quantitative CST were significantly lower in amblyopic eyes compared to non-amblyopic and control eyes. The cutoff value of maximal contrast level at mean frequencies of 2.5 ± 0.9 Hz, and a range of (1.1-4.1) for amblyopic eyes is ≤21 dB, while the cutoff value of minimal contrast level at mean frequencies of 13.4 ± 2.6 Hz, and a range of (6.7-18) for amblyopic eyes is ≤12 dB. Conclusion: Detection of amblyopia by CST is a noninvasive and easy procedure, which represents a promising tool to support the diagnosis of amblyopia.

Assessment of the Responses of the Artificial Intelligence-based Chatbot ChatGPT-4 to Frequently Asked Questions About Amblyopia and Childhood Myopia.

PURPOSE: To assess the responses of the ChatGPT-4, the forerunner artificial intelligence-based chatbot, to frequently asked questions regarding two common pediatric ophthalmologic disorders, amblyopia and childhood myopia. METHODS: Twenty-seven questions about amblyopia and 28 questions about childhood myopia were asked of the ChatGPT twice (totally 110 questions). The responses were evaluated by two pediatric ophthalmologists as acceptable, incomplete, or unacceptable. RESULTS: There was remarkable agreement (96.4%) between the two pediatric ophthalmologists on their assessment of the responses. Acceptable responses were provided by the ChatGPT to 93 of 110 (84.6%) questions in total (44 of 54 [81.5%] for amblyopia and 49 of 56 [87.5%] questions for childhood myopia). Seven of 54 (12.9%) responses to questions on amblyopia were graded as incomplete compared to 4 of 56 (7.1%) of questions on childhood myopia. The ChatGPT gave inappropriate responses to three questions about amblyopia (5.6%) and childhood myopia (5.4%). The most noticeable inappropriate responses were related to the definition of reverse amblyopia and the threshold of refractive error for prescription of spectacles to children with myopia. CONCLUSIONS: The ChatGPT has the potential to serve as an adjunct informational tool for pediatric ophthalmology patients and their caregivers by demonstrating a relatively good performance in answering 84.6% of the most frequently asked questions about amblyopia and childhood myopia. [J Pediatr Ophthalmol Strabismus. 2024;61(2):86-89.].

A population-level post-screening treatment cost framework to help inform vision screening choices for children under the age of seven.

PURPOSE/BACKGROUND: Visual acuity (VA) screening in children primarily detects low VA and amblyopia between 3 and 6 years of age. Photoscreening is a low-cost, lower-expertise alternative which can be carried out on younger children and looks instead for refractive amblyopia risk factors so that early glasses may prevent or mitigate the conditions. The long-term benefits and costs of providing many children with glasses in an attempt to avoid development of amblyopia for some of them needs clarification. This paper presents a framework for modeling potential post-referral costs of different screening models once referred children reach specialist services. METHODS: The EUSCREEN Screening Cost-Effectiveness Model was used together with published literature to estimate referral rates and case mix of referrals from different screening modalities (photoscreening and VA screening at 2, 3-4 years and 4-5 years). UK 2019-20 published National Health Service (NHS) costings were used across all scenarios to model the comparative post-referral costs to the point of discharge from specialist services. Potential costs were compared between a) orthoptist, b) state funded ophthalmologist and c) private ophthalmologist care. RESULTS: Earlier VA screening and photoscreening yield higher numbers of referrals because of lower sensitivity and specificity for disease, and a different case mix, compared to later VA screening. Photoscreening referrals are a mixture of reduced VA caused by amblyopia and refractive error, and children with amblyopia risk factors, most of which are treated with glasses. Costs relate mainly to the secondary care providers and the number of visits per child. Treatment by an ophthalmologist of a referral at 2 years of age can be more than x10 more expensive than an orthoptist service receiving referrals at 5 years, but outcomes can still be good from referrals aged 5. CONCLUSIONS: All children should be screened for amblyopia and low vision before the age of 6. Very early detection of amblyopia refractive risk factors may prevent or mitigate amblyopia for some affected children, but population-level outcomes from a single high-quality VA screening at 4-5 years can also be very good. Total patient-journey costs incurred by earlier detection and treatment are much higher than if screening is carried out later because younger children need more professional input before discharge, so early screening is less cost-effective in the long term. Population coverage, local healthcare models, local case-mix, public health awareness, training, data monitoring and audit are critical factors to consider when planning, evaluating, or changing any screening programme.

Assessment of macular microvascular changes in children following treatment of anisometropic myopic amblyopia using optical coherence tomography angiography.

PURPOSE: To evaluate macular microvascular changes in the form of foveal avascular zone (FAZ) area and vessel density in the superficial, deep capillary plexuses, and choriocapillaris using optical coherence tomography angiography (OCTA) in children with anisometropic myopic amblyopia before and after treatment. METHODS: This prospective observational study included 32 patients younger than 12 years old with anisomyopic amblyopia. OCTA was done before patients' treatment with optical correction with or without patching and was repeated after successful amblyopia treatment. Outcomes included superficial, deep, and choriocapillaris vessel density (VD) and superficial and deep FAZ areas. RESULTS: The study included 13 males (40.6%) and 19 females (59.4%), and the mean age was 9.52 ± 1.33 years. Fifty-three percent (53%) of patients needed only optical correction, and the remaining 47% needed additional patching therapy. After successful treatment, there was a significant improvement in amblyopic eyes in best-corrected visual acuity (p < 0.001), with higher VD values in superficial capillary plexuses (p < 0.001), deep capillary plexuses (p < 0.001), and foveal choriocapillaris (p = 0.030). In the glasses with patching subgroup, the difference between pre-treatment and post-treatment parameters revealed a significant improvement in vessel density in superficial retinal plexuses (foveal and parafoveal; p values 0.023 and < 0.001, respectively) and deep retinal plexuses (whole image, foveal, and parafoveal; p values 0.003, < 0.001, and 0.002, respectively). While amblyopic eyes treated with glasses alone had a significantly greater difference in choriocapillaris foveal VD (p value = 0.022). CONCLUSION: After effective amblyopia treatment, amblyopic eyes exhibited improved best-corrected visual acuity and better macular perfusion along the superficial, deep vascular density, and choriocapillaris foveal VD. CLINICAL TRIAL REGISTRATION: CinicalTrials.gov Identifier: NCT05223153.

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

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.

The Assessment of YouTube Videos as a Source of Information for Amblyopia Treatment.

PURPOSE: To evaluate the efficiency of YouTube videos as a source of information for the treatment of amblyopia. METHODS: The authors searched YouTube (Google) using the keywords "amblyopia treatment" and analyzed the first 200 most relevant videos. Videos were classified as useful or misleading by two independent ophthalmologists. Videos were scored on 5-point scales to evaluate global quality, reliability, and comprehensiveness. General characteristics, viewer interactions, and sources of videos were also recorded. RESULTS: Eighty-seven of 200 videos were appropriate to be included in the current study. Fifty videos (57.5%) were classified as useful and 37 videos (42.5%) were classified as misleading. General characteristics and viewer interactions were not significantly different between useful and misleading videos (P > .05). The mean Global Quality Score, reliability, and comprehensiveness scores were 3.64 ± 1.1, 3.02 ± 1.0, and 2.74 ± 1.2 in useful videos and 2.03 ± 0.9, 2.08 ± 0.8, and 1.62 ± 0.7 in misleading videos, respectively (P < .05). The data suggested that most of the videos uploaded by university channels or non-profit professionals were useful (79.2%), whereas most of the videos uploaded by medical advertisements or for-profit companies were misleading (59.1%). CONCLUSIONS: The results of the current cross-sectional study demonstrated that the number of useful videos for the treatment of amblyopia was higher on YouTube. However, there was still a significant number of misleading videos (42.5%). Therefore, more videos on amblyopia treatment that have sufficient reliability, quality, and comprehensiveness should be uploaded to YouTube. [J Pediatr Ophthalmol Strabismus. 2021;58(5):311-318.].

Objective Assessment of the Effect of Optical Treatment on Magnocellular and Parvocellular-biased Visual Response in Anisometropic Amblyopia.

Purpose: Optical treatment can improve visual function in anisometropic amblyopia, but there is no electrophysiological evidence, and the underlying change in visual pathway remains unknown. Our aims were to characterize the functional loss in magnocellular and parvocellular visual pathways in anisometropic amblyopia at baseline and to investigate the effect of optical treatment on the 2 visual pathways. Methods: Using isolated-check visual-evoked potential, we measured the magnocellular- and parvocellular-biased contrast response functions in 15 normal controls (20.13 ± 3.93 years; mean ± standard deviation), 16 patients with anisometropic amblyopia (18.00 ± 6.04 years) who were fully refractive corrected before and 29 (19.41 ± 7.41 years) who had never been corrected. Twelve previously uncorrected amblyopes received optical treatment for more than 2 months and finished the follow-up measurement. Results: Both the magnocellular- and parvocellular-biased contrast response functions in the amblyopic eye exhibited significantly reduced response and weaker contrast gains. We also found that the uncorrected amblyopes showed a more severe response reduction in magnocellular-biased, but not parvocellular-biased condition when compared with those corrected, with a weaker initial contrast gain and lower maximal response. After optical treatment, 12 uncorrected amblyopes demonstrated improved visual acuity of the amblyopic eye and a significant response gain to magnocellular-biased but not parvocellular-biased stimuli. Conclusions: We demonstrated deficits to both magnocellular- and parvocellular-biased stimuli in subjects with anisometropic amblyopia. Optical treatment could produce neurophysiological changes in visual pathways even in older children and adults, which may be mediated through the magnocellular pathway.

Binocular Treatment of Amblyopia: A Report by the American Academy of Ophthalmology.

PURPOSE: To review the published literature assessing the efficacy of binocular therapy for the treatment of amblyopia compared with standard treatments. METHODS: Literature searches with no date restrictions and limited to the English language were conducted in January 2018 and updated in April 2019 in the PubMed database and the Cochrane Library database with no restrictions. The search yielded 286 citations, and the full text of 50 articles was reviewed. Twenty articles met the inclusion criteria for this assessment and were assigned a level of evidence rating by the panel methodologist. Six studies were rated level I, 1 study was rated level II, and 13 studies were rated level III because of the impact on the development and popularization of this technology. RESULTS: Two of the level I and II studies reviewed described a significant improvement in visual acuity in the binocular group versus standard patching standard treatment (the total number of patients in these 2 studies was 147). However, the 5 studies that failed to show a visual improvement from binocular therapy compared with standard treatments were larger and more rigorously designed (the total number of patients in these 5 studies was 813). Level I and II studies also failed to show a significant improvement over baseline in sensory status, including depth of suppression and stereopsis of those treated with binocular therapy. Several smaller level III case series (total number of patients in these 13 studies was 163) revealed more promising results than the binocular treatments studied in the level I and II studies, especially using treatments that are more engaging and are associated with better compliance. CONCLUSIONS: There is no level I evidence to support the use of binocular treatment as a substitute for current therapies for amblyopia (including patching and optical treatment). Furthermore, 2 large randomized controlled trials showed inferior performance compared with standard patching treatment. On the basis of this review of the published literature, binocular therapy cannot be recommended as a replacement for standard amblyopia therapy. However, more research is needed to determine the potential benefits of proposed binocular treatments in the future.

An Assessment of Stereovision Acquired in Adulthood.

SIGNIFICANCE: Increasing evidence indicates that childhood binocular vision disorders that lead to stereodeficiency may be treated in adulthood. Reports of patients who gain stereopsis as adults indicate that this achievement provides for a qualitatively different and dramatically improved sense of space and depth. PURPOSE: Increasing evidence suggests that stereopsis can be achieved in adult patients despite long-standing binocular disorders. We polled individuals who gained stereopsis as adults to ascertain their initial binocular disorders, the length of time they were stereodeficient, effective treatments, and the nature of their recovered stereovision. METHODS: A questionnaire was posted online and announced in a brief article in the journal Vision Development and Rehabilitation. RESULTS: Of the 63 responders, 56 (89%) reported strabismus and/or amblyopia, and 55 (87%) indicated that they had been stereodeficient for as long as they could remember. All but seven participants (89%) achieved stereovision through vision training or a combination of surgery and vision training, and many reported vivid visual changes. CONCLUSIONS: Despite childhood binocular disorders, patients may be able to achieve stereopsis following interventions in adulthood. This achievement provides for a qualitatively different and dramatically improved sense of space and depth.

An Assessment of the Contrast Sensitivity in Patients with Ametropic and Anisometropic Amblyopia in Achieving the Corrected Visual Acuity of 1.0.

Both visual acuity (VA) and contrast sensitivity (CS) are important parameters for measuring visual function. In this research, we investigated the CS of patients with ametropic or anisometropic amblyopia, whose corrected visual acuity (CVA) recovered to 1.0. Fifty-five cases with amblyopia and 22 control cases with a normal visual acuity of 1.0 were enrolled. The CS of the patients whose ametropic amblyopia had recovered to a CVA of 1.0 at 18 cpd spatial frequency was still lower than that of the normal control group under both photopic and scotopic conditions (P = 0.001, 0.025), but there were no significant differences at low- and middle-spatial frequencies. The CS of amblyopic eyes of the patients with anisometropic amblyopia was lower than that of the normal control group at the 18 cpd spatial frequency under photopic conditions (P = 0.005), and at the 6 cpd, 12 cpd, and 18 cpd spatial frequencies under scotopic conditions (P = 0.008, <0.001, 0.004, respectively). The CS between the amblyopic eyes and the sound eyes of patients with anisometropic amblyopia presented significant differences at the 6 cpd, 12 cpd, and 18 cpd spatial frequencies under scotopic conditions (P = 0.025, 0.045, 0.019, respectively). We suggest that amblyopia treatment should involve not only the correction of VA but also the improvement of CS.

Socioeconomic status and utilization of amblyopia services at a tertiary pediatric hospital in Canada.

OBJECTIVE: To evaluate whether socioeconomic status is associated with equal utilization of amblyopia services at The Hospital for Sick Children (SickKids), a pediatric tertiary hospital in Canada. DESIGN: This is a retrospective, cross-sectional study. PARTICIPANTS: The medical records of children aged under 7 years diagnosed with amblyopia at SickKids from 2007 to 2009 were reviewed. METHODS: Socioeconomic status was derived from patients' residential postal codes through linking with income data in the 2006 Canadian census report. Patients were divided into 5 income quintiles to compare with amblyopia service utilization. The main outcome measure was the observed distribution of amblyopia patients by socioeconomic status versus the expected distribution of 20% for each quintile. RESULTS: The analyses included 336 patients. Children with amblyopia at SickKids were more likely to come from the richest neighbourhood (32.5%), whereas children from each of the 3 lowest quintiles (14.6%-15.5%) were less likely to present at SickKids. These results differed significantly from the expected 20% for each quintile (p < 0.0001). All types of amblyopia were significantly under-represented for children from the lower socioeconomic groups. When analyses were stratified by travel distance to the hospital, a significant inequality between the lower and higher income quintiles remained for nonmetropolitan Toronto patients, but not for metropolitan Toronto patients. CONCLUSION: Despite a publicly funded health-care system in Canada, children from lower socioeconomic neighbourhoods in distant areas utilize the amblyopia services in a tertiary pediatric centre less often than those from higher socioeconomic status.

Childhood amblyopia: current management and new trends.

INTRODUCTION OR BACKGROUND: With a prevalence of 2-5%, amblyopia is the most common vision deficit in children in the UK and the second most common cause of functional low vision in children in low-income countries. SOURCES OF DATA: Pubmed, Cochrane library and clinical trial registries (clinicaltrials.gov, ISRCTN, UKCRN portfolio database). AREAS OF AGREEMENT: Screening and treatment at the age of 4-5 years are cost efficient and clinically effective. Optical treatment (glasses) alone can improve visual acuity, with residual amblyopia treated by part-time occlusion or pharmacological blurring of the better-seeing eye. Treatment after the end of the conventional 'critical period' can improve vision, but in strabismic amblyopia carries a low risk of double vision. AREAS OF CONTROVERSY: It is not clear whether earlier vision screening would be cost efficient and associated with better outcomes. Optimization of treatment by individualized patching regimes or early start of occlusion, and novel binocular treatment approaches may enhance adherence to treatment, provide better outcomes and shorten treatment duration. GROWING POINTS: Binocular treatments for amblyopia. AREAS TIMELY FOR DEVELOPING RESEARCH: Impact of amblyopia on education and quality of life; optimal screening timing and tests; optimal administration of conventional treatments; development of child-friendly, effective and safe binocular treatments.

Assessment of the Density of Suppression to Identify Risk of Intractable Diplopia in the United Kingdom.

BACKGROUND/AIMS: Occlusion used to treat amblyopia towards the end of the developmental component of the critical period gives a risk of inducing intractable diplopia. In the United Kingdom, the density of suppression is assessed via the Sbisa/Bagolini filter bar, but there is very little research evidence to guide clinical practice or interpretation of the tests used. The aims of this study were to determine current practice and estimate the incidence of intractable diplopia following amblyopia treatment. METHODS: Current practice and incidence of intractable diplopia following amblyopia were determined via a questionnaire distributed to head orthoptists in every eye department in the United Kingdom. The questionnaire explored testing and test conditions, interpretation of the test results, and cases of intractable diplopia over the last 5 years. RESULTS: There was considerable variation in clinical practice of the measurement of the density of suppression and interpretation of the results to guide the treatment of amblyopia. The minimum age of patients taking the test ranged from 2 to 8 years and the minimum filter considered still safe to continue treatment ranged from 4 to 17. It is estimated there were 24 cases of intractable diplopia over the last 5 years. CONCLUSION: The issue of intractable diplopia and amblyopia treatment is likely to become increasingly important as there appears to be greater plasticity and scope to treat amblyopia in teenagers and adults than was previously thought. Lack of knowledge of how to evaluate the risk may lead to more cases of intractable diplopia or alternatively treatment being withheld unnecessarily.

Sociocultural and psychological determinants in migrants for noncompliance with occlusion therapy for amblyopia.

BACKGROUND: Compliance with occlusion therapy for amblyopia in children is low when their parents have a low level of education, speak Dutch poorly, or originate from another country. We determined how sociocultural and psychological determinants affect compliance. METHODS: Included were amblyopic children between the ages of 3 and 6, living in low socio-economic status (SES) areas. Compliance with occlusion therapy was measured electronically. Their parents completed an oral questionnaire, based on the "Social Position & Use of Social Services by Migrants and Natives" questionnaire that included demographics and questions on issues like education, employment, religion and social contacts. Parental fluency in Dutch was rated on a five-point scale. Regression analysis was used to describe the relationship between the level of compliance and sociocultural and psychological determinants. RESULTS: Data from 45 children and their parents were analyzed. Mean electronically measured compliance was 56 ± 44 percent. Children whose parents had close contact with their neighbors or who were highly dependent on their family demonstrated low levels of compliance. Children of parents who were members of a club and who had positive conceptualizations of Dutch society showed high levels of compliance. Poor compliance was also associated with low income, depression, and when patching interfered with the child's outdoor activity. Religion was not associated with compliance. CONCLUSIONS: Poor compliance with occlusion therapy seems correlated with indicators of social cohesion. High social cohesion at micro level, i.e., family, neighbors and friends, and low social cohesion on macro level, i.e., Dutch society, are associated with noncompliance. However, such parents tend to speak Dutch poorly, so it is difficult to determine its actual cause.