Leveraging neural plasticity for the treatment of amblyopia.

Amblyopia is a form of visual cortical impairment that arises from abnormal visual experience early in life. Most often, amblyopia is a unilateral visual impairment that can develop as a result of strabismus, anisometropia, or a combination of these conditions that result in discordant binocular experience. Characterized by reduced visual acuity and impaired binocular function, amblyopia places a substantial burden on the developing child. Although frontline treatment with glasses and patching can improve visual acuity, residual amblyopia remains for most children. Newer binocular-based therapies can elicit rapid recovery of visual acuity and may also improve stereoacuity in some children. Nevertheless, for both treatment modalities full recovery is elusive, recurrence of amblyopia is common, and improvements are negligible when treatment is administered at older ages. Insights derived from animal models about the factors that govern neural plasticity have been leveraged to develop innovative treatments for amblyopia. These novel therapies exhibit efficacy to promote recovery, and some are effective even at ages when conventional treatments fail to yield benefit. Approaches for enhancing visual system plasticity and promoting recovery from amblyopia include altering the balance between excitatory and inhibitory mechanisms, reversing the accumulation of proteins that inhibit plasticity, and harnessing the principles of metaplasticity. Although these therapies have exhibited promising results in animal models, their safety and ability to remediate amblyopia need to be evaluated in humans.

Human deprivation amblyopia: treatment insights from animal models.

Amblyopia is a common visual impairment that develops during the early years of postnatal life. It emerges as a sequela to eye misalignment, an imbalanced refractive state, or obstruction to form vision. All of these conditions prevent normal vision and derail the typical development of neural connections within the visual system. Among the subtypes of amblyopia, the most debilitating and recalcitrant to treatment is deprivation amblyopia. Nevertheless, human studies focused on advancing the standard of care for amblyopia have largely avoided recruitment of patients with this rare but severe impairment subtype. In this review, we delineate characteristics of deprivation amblyopia and underscore the critical need for new and more effective therapy. Animal models offer a unique opportunity to address this unmet need by enabling the development of unconventional and potent amblyopia therapies that cannot be pioneered in humans. Insights derived from studies using animal models are discussed as potential therapeutic innovations for the remediation of deprivation amblyopia. Retinal inactivation is highlighted as an emerging therapy that exhibits efficacy against the effects of monocular deprivation at ages when conventional therapy is ineffective, and recovery occurs without apparent detriment to the treated eye.

Early monocular deprivation reduces the capacity for neural plasticity in the cat visual system.

Obstruction of vision to one eye during early postnatal development elicits neural modifications in the visual system that can last a lifetime. Research in rodents has revealed that an early and transient monocular deprivation (MD) can produce an enduring alteration to the framework of neural connections within visual cortex. This lasting trace of early MD enables an enhanced effect of a second MD imposed on the same eye in adulthood. In the current study, we examined whether the modification of plasticity potential was bidirectional by assessing whether the effect of early and brief MD attenuated the impact of a subsequent MD when applied to the fellow eye. Results were clear in showing that animals with an early MD exhibited a smaller response to later visual deprivation of the fellow eye. Compared to controls, animals with a history of MD exhibited less atrophy of neurons, and a smaller loss of neurofilament labeling within the dorsal lateral geniculate nucleus. The shift in cortical ocular dominance elicited by MD was also smaller in animals with a prior MD. These results indicate that early MD elicits abiding and eye-specific neural modifications that can selectively alter plasticity potential in the visual system.

Investigation of the efficacy and safety of retinal inactivation as a treatment for amblyopia in cats.

Introduction: Deprivation of normal vision early in postnatal development elicits modifications of neural circuitry within the primary visual pathway that can cause a severe and intractable vision impairment (amblyopia). In cats, amblyopia is often modeled with monocular deprivation (MD), a procedure that involves temporarily closing the lids of one eye. Following long-term MD, brief inactivation of the dominant eye's retina can promote recovery from the anatomical and physiological effects of MD. In consideration of retinal inactivation as a viable treatment for amblyopia it is imperative to compare its efficacy against conventional therapy, as well as assess the safety of its administration. Methods: In the current study we compared the respective efficacies of retinal inactivation and occlusion of the dominant eye (reverse occlusion) to elicit physiological recovery from a prior long-term MD in cats. Because deprivation of form vision has been associated with development of myopia, we also examined whether ocular axial length or refractive error were altered by a period of retinal inactivation. Results: The results of this study demonstrate that after a period of MD, inactivation of the dominant eye for up to 10 days elicited significant recovery of visually-evoked potentials that was superior to the recovery measured after a comparable duration of reverse occlusion. After monocular retinal inactivation, measurements of ocular axial length and refractive error were not significantly altered from their pre-inactivation values. The rate of body weight gain also was not changed during the period of inactivation, indicating that general well-being was not affected. Discussion: These results provide evidence that inactivation of the dominant eye after a period of amblyogenic rearing promotes better recovery than eye occlusion, and this recovery was achieved without development of form-deprivation myopia.

Comparative analysis of structural modifications induced by monocular retinal inactivation and monocular deprivation in the developing cat lateral geniculate nucleus.

During a critical period of postnatal life, monocular deprivation (MD) by eyelid closure reduces the size of neurons in layers of the dorsal lateral geniculate nucleus (dLGN) connected to the deprived eye and shifts cortical ocular dominance in favor of the non-deprived eye. Temporary inactivation of the non-deprived eye can promote superior recovery from the effects of long-term MD compared to conventional occlusion therapy. In the current study, we assessed the modification of neuron size in the dLGN as a means of measuring the impact of a brief period of monocular inactivation (MI) imposed at different postnatal ages. The biggest impact of MI was observed when it occurred at the peak of the critical period. Unlike the effect of MD, structural plasticity following MI was observed in both the binocular and monocular segments of the dLGN. With increasing age, the capacity for inactivation to alter postsynaptic cell size diminished but was still significant beyond the critical period. In comparison to MD, inactivation produced effects that were about double in magnitude and exhibited efficacy at older ages. Notwithstanding the large neural alterations precipitated by MI, its effects were remediated with a short period of binocular experience, and vision through the previously inactivated eye fully recovered. These results demonstrate that MI is a potent means of modifying the visual pathway and does so at ages when occlusion is ineffective. The efficacy and longevity of inactivation to elicit plasticity highlight its potential to ameliorate disorders of the visual system such as amblyopia.

Documentation of the Development of Various Visuomotor Responses in Typically Reared Kittens and Those Reared With Early Selected Visual Exposure by Use of a New Procedure.

A new procedure was used to study the development of gaze (responses to moving targets or laser spots in normal kittens, those that had been reared in total darkness to 6 weeks of age, and others that received a period of monocular deprivation (MD). Gaze responses were observed to all stimuli in normal kittens at between 25-30 days of age and striking responses occurred on the same day or the next. Despite slow acquisition of spatial vision in the dark reared kittens over 3 months, they were able to follow and even strike at moving visual stimuli within a day of their initial exposure to light. By contrast, for a week following a period of MD, kittens showed no gaze or striking responses to moving stimuli when using their previously deprived eye. The very different profiles of acquisition of visuomotor skills and spatial vision in visually deprived kittens point to a dissociation between the neuronal populations that support these functions.

Correction of amblyopia in cats and mice after the critical period.

Monocular deprivation early in development causes amblyopia, a severe visual impairment. Prognosis is poor if therapy is initiated after an early critical period. However, clinical observations have shown that recovery from amblyopia can occur later in life when the non-deprived (fellow) eye is removed. The traditional interpretation of this finding is that vision is improved simply by the elimination of interocular suppression in primary visual cortex, revealing responses to previously subthreshold input. However, an alternative explanation is that silencing activity in the fellow eye establishes conditions in visual cortex that enable the weak connections from the amblyopic eye to gain strength, in which case the recovery would persist even if vision is restored in the fellow eye. Consistent with this idea, we show here in cats and mice that temporary inactivation of the fellow eye is sufficient to promote a full and enduring recovery from amblyopia at ages when conventional treatments fail. Thus, connections serving the amblyopic eye are capable of substantial plasticity beyond the critical period, and this potential is unleashed by reversibly silencing the fellow eye.

Development of parvalbumin neurons and perineuronal nets in the visual cortex of normal and dark-exposed cats.

During development, the visual system maintains a high capacity for modification by expressing characteristics permissive for plasticity, enabling neural circuits to be refined by visual experience to achieve their mature form. This period is followed by the emergence of characteristics that stabilize the brain to consolidate for lifetime connections that were informed by experience. Attenuation of plasticity potential is thought to derive from an accumulation of plasticity-inhibiting characteristics that appear at ages beyond the peak of plasticity. Perineuronal nets (PNNs) are molecular aggregations that primarily surround fast-spiking inhibitory neurons called parvalbumin (PV) cells, which exhibit properties congruent with a plasticity inhibitor. In this study, we examined the development of PNNs and PV cells in the primary visual cortex of a highly visual mammal, and assessed the impact that 10 days of darkness had on both characteristics. Here, we show that labeling for PV expression emerges earlier and reaches adult levels sooner than PNNs. We also demonstrate that darkness, a condition known to enhance plasticity, significantly reduces the density of PNNs and the size of PV cell somata but does not alter the number of PV cells in the visual cortex. The darkness-induced reduction of PV cell size occurred irrespective of whether neurons were surrounded by a PNN, suggesting that PNNs have a restricted capacity to inhibit plasticity. Finally, we show that PV cells surrounded by a PNN were significantly larger than those without one, supporting the view that PNNs may mediate trophic support to the cells they surround.

Retinal and Optic Nerve Integrity Following Monocular Inactivation for the Treatment of Amblyopia.

In animal models, monocular deprivation (MD) by lid closure mimics the effects of unilateral amblyopia in humans. Temporary inactivation of one or both eyes with intraocular administration of tetrodotoxin (TTX) has recently been shown to promote recovery from the anatomical effects of MD at post-critical period ages when standard recovery strategies fail. In the current study, the retinae and optic nerves of animals subjected to 10 days of monocular retinal inactivation were assessed for pathological changes as a means of assessing the viability of this potential new amblyopia therapy. Retinal sections from both eyes were subjected to hematoxylin and eosin staining and were then examined for cell density and soma size in the ganglion cell layer (GCL). Sections of the optic nerve from each eye were examined for neurofilament protein, myelin, glial cell density, and glial fibrillary acidic protein (GFAP). Our study revealed no evidence of gross histopathological abnormalities following inactivation for 10 days, nor was there evidence of degeneration of axons or loss of myelin in the optic nerve serving inactivated eyes. On all measurements, the inactivated eye was indistinguishable from the fellow eye, and both were comparable to normal controls. We confirmed that our inactivation protocol obliterated visually-evoked potentials for 10 consecutive days, but visual responses were restored to normal after the effects of inactivation wore off. Notwithstanding the critical need for further assessment of ocular and retinal health following inactivation, these results provide evidence that retinal inactivation as a treatment for amblyopia does not produce significant retinal damage or degeneration.

Modification of Peak Plasticity Induced by Brief Dark Exposure.

The capacity for neural plasticity in the mammalian central visual system adheres to a temporal profile in which plasticity peaks early in postnatal development and then declines to reach enduring negligible levels. Early studies to delineate the critical period in cats employed a fixed duration of monocular deprivation to measure the extent of ocular dominance changes induced at different ages. The largest deprivation effects were observed at about 4 weeks postnatal, with a steady decline in plasticity thereafter so that by about 16 weeks only small changes were measured. The capacity for plasticity is regulated by a changing landscape of molecules in the visual system across the lifespan. Studies in rodents and cats have demonstrated that the critical period can be altered by environmental or pharmacological manipulations that enhance plasticity at ages when it would normally be low. Immersion in complete darkness for long durations (dark rearing) has long been known to alter plasticity capacity by modifying plasticity-related molecules and slowing progress of the critical period. In this study, we investigated the possibility that brief darkness (dark exposure) imposed just prior to the critical period peak can enhance the level of plasticity beyond that observed naturally. We examined the level of plasticity by measuring two sensitive markers of monocular deprivation, namely, soma size of neurons and neurofilament labeling within the dorsal lateral geniculate nucleus. Significantly larger modification of soma size, but not neurofilament labeling, was observed at the critical period peak when dark exposure preceded monocular deprivation. This indicated that the natural plasticity ceiling is modifiable and also that brief darkness does not simply slow progress of the critical period. As an antecedent to traditional amblyopia treatment, darkness may increase treatment efficacy even at ages when plasticity is at its highest.

Fast Recovery of the Amblyopic Eye Acuity of Kittens following Brief Exposure to Total Darkness Depends on the Fellow Eye.

Recent studies conducted on kittens have revealed that the reduced visual acuity of the deprived eye following a short period of monocular deprivation imposed in early life is reversed quickly following a 10-day period spent in total darkness. This study explored the contribution of the fellow eye to the darkness-induced recovery of the acuity of the deprived eye. Upon emergence of kittens from darkness, the fellow eye was occluded for different lengths of time in order to investigate its effects on either the speed or the extent of the recovery of acuity of the deprived eye. Occlusion of the fellow eye for even a day immediately following the period spent in darkness blocked any recovery of the acuity of the deprived eye. Moreover, occlusion of the fellow eye two days after the period of darkness blocked any further visual recovery beyond that achieved in the short period when both eyes were open. The results imply that the darkness-induced recovery of the acuity of the deprived eye depends upon, and is guided by, neural activity in the mature neural connections previously established by the fellow eye.

The critical period for darkness-induced recovery of the vision of the amblyopic eye following early monocular deprivation.

Exposure of kittens to complete darkness for 10 days has been shown (Duffy & Mitchell, 2013) to reverse the loss of visual acuity that follows a prior period of monocular deprivation (MD). In that study, recovery of acuity in the previously deprived eye was fast despite the fact that darkness was imposed 2 months after the period of MD when kittens were 3 months old. In a later study (Holman, Duffy, & Mitchell, 2018), it was demonstrated that the same period of darkness was ineffective when it was imposed on cats about 1 year old, suggesting that dark exposure may only promote recovery when applied within an early critical period. To determine the profile of this critical period, the identical period of darkness (10 days) was imposed on kittens at various ages that had all received the same 7-day period of MD from postnatal day 30 (P30). Recovery of the acuity of the deprived eye as measured by use of a jumping stand was complete when darkness was imposed prior to P186 days, but thereafter, darkness induced progressively smaller acuity improvements and was ineffective in kittens when it began at or beyond P191 days of age. These data indicate a critical period for darkness-induced recovery with an abrupt end over a 5-day period.

Short periods of darkness fail to restore visual or neural plasticity in adult cats.

It has been shown that the visual acuity loss experienced by the deprived eye of kittens following an early period of monocular deprivation (MD) can be alleviated rapidly following 10 days of complete darkness when imposed even as late as 14 weeks of age. To examine whether 10 days of darkness conferred benefits at any age, we measured the extent of recovery of the visual acuity of the deprived eye following the darkness imposed on adult cats that had received the same early period of MD as used in prior experiments conducted on kittens. Parallel studies conducted on different animals examined the extent to which darkness changed the magnitude of the MD-induced laminar differences of the cell soma size and immunoreactivity for the neurofilament (NF) protein in the dorsal lateral geniculate nucleus (dLGN). The results indicated that 10 days of darkness imposed at one year of age neither alleviated the acuity loss of the deprived eye induced by an earlier period of MD nor did it decrease the concurrent lamina differences of the soma size or NF loss in the dLGN.

Mapping of neuron soma size as an effective approach to delineate differences between neural populations.

BACKGROUND: A single histological marker applied to a slice of tissue often reveals myriad cytoarchitectonic characteristics that can obscure differences between neuron populations targeted for study. Isolation and measurement of a single feature from the tissue is possible through a variety of approaches, however, visualizing the data numerically or through graphs alone can preclude being able to identify important features and effects that are not obvious from direct observation of the tissue. NEW METHOD: We demonstrate an efficient, effective, and robust approach to quantify and visualize cytoarchitectural features in histologically prepared brain sections. We demonstrate that this approach is able to reveal small differences between populations of neurons that might otherwise have gone undiscovered. RESULTS & COMPARISON WITH EXISTING METHOD(S): We used stereological methods to record the cross-sectional soma area and in situ position of neurons within sections of the cat, monkey, and human visual system. The two-dimensional coordinate of every measured cell was used to produce a scatter plot that recapitulated the natural spatial distribution of cells, and each point in the plot was color-coded according to its respective soma area. The final graphic display was a multi-dimensional map of neuron soma size that revealed subtle differences across neuron aggregations, permitted delineation of regional boundaries, and identified small differences between populations of neurons modified by a period of sensory deprivation. CONCLUSIONS: This approach to collecting and displaying cytoarchitectonic data is simple, efficient, and provides a means of investigating small differences between neuron populations.

Recovery from the anatomical effects of long-term monocular deprivation in cat lateral geniculate nucleus.

Monocular deprivation (MD) imposed early in postnatal life elicits profound structural and functional abnormalities throughout the primary visual pathway. The ability of MD to modify neurons within the visual system is restricted to a so-called critical period that, for cats, peaks at about one postnatal month and declines thereafter so that by about 3 months of age MD has little effect. Recovery from the consequences of MD likewise adheres to a critical period that ends by about 3 months of age, after which the effects of deprivation are thought to be permanent and without capacity for reversal. The attenuation of plasticity beyond early development is a formidable obstacle for conventional therapies to stimulate recovery from protracted visual deprivation. In the current study we examined the efficacy of dark exposure and retinal inactivation with tetrodotoxin to promote anatomical recovery in the dorsal lateral geniculate nuclues (dLGN) from long-term MD started at the peak of the critical period. Whereas 10 days of dark exposure or binocular retinal inactivation were not better at promoting recovery than conventional treatment with reverse occlusion, inactivation of only the non-deprived (fellow) eye for 10 days produced a complete restoration of neuron soma size, and also reversed the significant loss of neurofilament protein within originally deprived dLGN layers. These results reveal a capacity for neural plasticity and recovery that is larger than anything previously observed following protracted MD in cat, and they highlight a possibility for alternative therapies applied at ages thought to be recalcitrant to recovery.

Rapid recovery from the effects of early monocular deprivation is enabled by temporary inactivation of the retinas.

A half-century of research on the consequences of monocular deprivation (MD) in animals has revealed a great deal about the pathophysiology of amblyopia. MD initiates synaptic changes in the visual cortex that reduce acuity and binocular vision by causing neurons to lose responsiveness to the deprived eye. However, much less is known about how deprivation-induced synaptic modifications can be reversed to restore normal visual function. One theoretically motivated hypothesis is that a period of inactivity can reduce the threshold for synaptic potentiation such that subsequent visual experience promotes synaptic strengthening and increased responsiveness in the visual cortex. Here we have reduced this idea to practice in two species. In young mice, we show that the otherwise stable loss of cortical responsiveness caused by MD is reversed when binocular visual experience follows temporary anesthetic inactivation of the retinas. In 3-mo-old kittens, we show that a severe impairment of visual acuity is also fully reversed by binocular experience following treatment and, further, that prolonged retinal inactivation alone can erase anatomical consequences of MD. We conclude that temporary retinal inactivation represents a highly efficacious means to promote recovery of function.

Altered thalamocortical development in the SAP102 knockout model of intellectual disability.

Genetic mutations known to cause intellectual disabilities (IDs) are concentrated in specific sets of genes including both those encoding synaptic proteins and those expressed during early development. We have characterized the effect of genetic deletion of Dlg3, an ID-related gene encoding the synaptic NMDA-receptor interacting protein synapse-associated protein 102 (SAP102), on development of the mouse somatosensory cortex. SAP102 is the main representative of the PSD-95 family of postsynaptic MAGUK proteins during early development and is proposed to play a role in stabilizing receptors at immature synapses. Genetic deletion of SAP102 caused a reduction in the total number of thalamocortical (TC) axons innervating the somatosensory cortex, but did not affect the segregation of barrels. On a synaptic level SAP102 knockout mice display a transient speeding of NMDA receptor kinetics during the critical period for TC plasticity, despite no reduction in GluN2B-mediated component of synaptic transmission. These data indicated an interesting dissociation between receptor kinetics and NMDA subunit expression. Following the critical period NMDA receptor function was unaffected by loss of SAP102 but there was a reduction in the divergence of TC connectivity. These data suggest that changes in synaptic function early in development caused by mutations in SAP102 result in changes in network connectivity later in life.

Susceptibility to monocular deprivation following immersion in darkness either late into or beyond the critical period.

An extended duration of darkness starting near the time of birth preserves immature neuronal characteristics and prolongs the accentuated plasticity observed in young animals. Brief periods of complete darkness have emerged as an effective means of restoring a high capacity for neural plasticity and of promoting recovery from the effects of monocular deprivation (MD). We examined whether 10 days of darkness imposed in adulthood or beyond the peak of the critical period could rejuvenate the ability of MD to reduce the size of neuron somata within deprived layers of the cat dorsal lateral geniculate nucleus (dLGN). For adult cats subjected to 10 days of darkness before 7 days of MD, we observed no alteration in neuron size or neurofilament labeling within the dLGN. At 12 weeks of age, MD that followed immediately after 10 days of darkness produced an enhanced reduction of neuron soma size within deprived dLGN layers. For this age we observed that 10 days of darkness also enhanced the loss of neurofilament protein within deprived dLGN layers. These results indicate that, although 10 days of darkness in adulthood does not enhance the susceptibility to 7 days of MD, darkness imposed near the trailing edge of the critical period can restore a heightened susceptibility to MD more typical of an earlier developmental stage. The loss of neurofilament in juveniles exposed to darkness prior to MD suggests that the enhanced capacity for structural plasticity is partially rooted in the ability of darkness to modulate molecules that inhibit plasticity. J. Comp. Neurol. 524:2643-2653, 2016. © 2016 Wiley Periodicals, Inc.

Recovery of visual functions in amblyopic animals following brief exposure to total darkness.

KEY POINTS: Occlusion of one eye of kittens (monocular deprivation) results in a severe and permanent loss of visual acuity in that eye, which parallels closely the vision loss characteristic of human amblyopia. We extended earlier work to demonstrate that amblyopic vision loss can be either blocked or erased very fast by a 10 day period of total darkness following a period of monocular deprivation that begins near birth and extends to at least 8 weeks of age. The parameters of darkness were strict because no visual recovery was observed after 5 days of darkness. In addition, short periods of light introduced each day during an otherwise 10 day period of darkness obliterated the benefits. Despite recovery of normal visual acuity, only one-quarter of the animals showed evidence of having attained normal stereoscopic vision. A period of total darkness may catalyse and improve treatment outcomes in amblyopic children. A 10 day period of total darkness has been shown to either block or erase the severe effects on vision of a prior short period of monocular deprivation (MD) in kittens depending on whether darkness is contiguous or is delayed with respect to the period of MD. We have extended these earlier findings from kittens for which the period of MD began at 1 month and lasted for 1 week to more clinically relevant situations where MD began near birth and lasted for ≥ 6 weeks. Despite the far longer MD and the absence of prior binocular vision, all animals recovered normal visual acuity in the previously deprived eye. As before, when the period of darkness followed immediately after MD, the vision of both eyes was initially very poor but, subsequently, the acuity of each eye increased gradually and equally to attain normal levels in ∼ 7 weeks. By contrast, when darkness was introduced 8 weeks after MD, the visual acuity of the deprived eye recovered quickly to normal levels in just 1 week without any change in the vision of the fellow (non-deprived) eye. Short (15 or 30 min) periods of illumination each day during an otherwise 10 day period of darkness obliterated all the benefits for vision, and a 5 day period of darkness was also completely ineffective. Measurements of depth perception indicated that, despite possessing normal visual acuity in both eyes, only about one-quarter of the animals showed evidence of having attained normal stereoscopic vision.

Postnatal accumulation of intermediate filaments in the cat and human primary visual cortex.

A principal characteristic of the mammalian visual system is its high capacity for plasticity in early postnatal development during a time commonly referred to as the critical period. The progressive diminution of plasticity with age is linked to the emergence of a collection of molecules called molecular brakes that reduce plasticity and stabilize neural circuits modified by earlier visual experiences. Manipulation of braking molecules either pharmacologically or though experiential alteration enhances plasticity and promotes recovery from visual impairment. The stability of neural circuitry is increased by intermediate filamentous proteins of the cytoskeleton such as neurofilaments and α-internexin. We examined levels of these intermediate filaments within cat and human primary visual cortex (V1) across development to determine whether they accumulate following a time course consistent with a molecular brake. In both species, levels of intermediate filaments increased considerably throughout early postnatal life beginning shortly after the peak of the critical period, with the highest levels measured in adults. Neurofilament phosphorylation was also observed to increase throughout development, raising the possibility that posttranslational modification by phosphorylation reduces plasticity due to increased protein stability. Finally, an approach to scale developmental time points between species is presented that compares the developmental profiles of intermediate filaments between cats and humans. Although causality between intermediate filaments and plasticity was not directly tested in this study, their accumulation relative to the critical period indicates that they may contribute to the decline in plasticity with age, and may also constrain the success of treatments for visual disorders applied in adulthood.