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1. Active Vision Therapy in
Management of Amblyopia
Maharajgunj Medical
Campus, IOM, Nepal
Bikash Sapkota
B. Optometry
Final Year

2. Active Vision Therapy in Amblyopia
It is designed to improve visual performance by the
conscious involvement in a sequence of a specific,
controlled
visual task that provide feedback
i. Pleoptics
ii. Near activities
iii. Active stimulation therapy using CAM vision
iv. Syntonic phototherapy
v. Role of perceptual learning
vi. Binocular stimulation
vii. Software-based active treatments
viii. Exposure to dark
ix. Pharmacological Therapy

3. Pleoptics

4.  Pleoptics: Gr. meaning full vision
 Used for active stimulation of the fovea to overcome
eccentric fixation and improves the visual acuity
In this technique
- the peripheral retina is dazzled with an intense light
protecting
foveal area
- after the light source is turned off, the fovea functions
better
as the surrounding retinal area is in a state of hypofunction
- this can be followed by direct stimulation of fovea
by pleoptophore (Bangerter’s method)
or indirectly by producing after image (Cupper’s method)

5. Demerits
 The technique is complex and requires an absolute co-
operation of the pt. and intelligence to appreciate after-
images
 Daily sitting for a longer period of time is required
 Since occlusion of the dominant eye is a very successful
simple and inexpensive method of treating eccentric fixation,
so the use of pleoptics methods is abandoned
 Only indication is co-operative and intelligent child older than
6yrs having eccentric fixation

6. Pleoptics VS Occlusion of sound eye
 Visual acuity outcomes in children who have had
conventional occlusion are found to be better than in
those who have gone through pleoptic treatment (Verlee
DL, Iacobucci 1967)
 Visual acuity improvements are significantly greater in
the direct occlusion group than in the group
undergoing pleoptic therapy and inverse occlusion
(Veronneau T.S. et al 1974)

7. Treatment using grating stimuli
(Active stimulation therapy using CAM
vision stimulator)

8. Method
 Non amblyopic eye is occluded
 Amblyopic eye is stimulated for 7 mins by slowly rotating (at
about 1 revolution per min) high contrast square wave
grating of different spatial frequencies
 The treatment is carried out once in a week for 3 to 4 weeks
Advantages over the conventional occlusion therapy
o The sound eye remains open between the weekly treatment
sessions

9. Principle
 Assumption that rotating grating provides specific stimulation
for cortical neurons
Present status of CAM vision stimulator
 This technique is not as effective as conventional occlusion
therapy
 So it has failed to replace time tested conventional occlusion
therapy for the treatment of amblyopia
 Some workers use this technique as supplementary to
occlusion therapy in co-operative pts. with supportive
who can carry out the treatment at home

10.  Recently a new treatment has been described based on a
similar principle, namely, the use of grating stimuli to activate
certain cortical cells (Angelika Shanshinova et al, 2008)
 The treatment is computer-based and is intended to
supplement occlusion treatment, particularly in patients
beyond childhood
 The treatment comprises a computer game viewed on a
monitor against the background of a low spatial frequency
drifting sine wave grating

11.  The stimulus is a drifting sinusoidal grating of a spatial
frequency of 0.3 cyc/deg and a temporal frequency of 1
cyc/sec, reciprocally coordinated with each other to a drift of
0.33 deg/sec
 Based on the idea that stimulation of motion-sensitive cells
might help to improve function of form-sensitive cells by
synchronisation of responses
 Efficacy of treatment is higher for the computer based
method combined with occlusion than for occlusion only

12. Syntonic phototherapy in the
treatment of amblyopia

13.  Syntonics is the branch of ocular science dealing with the
application of selected visible light frequencies through the
eyes
 For the purposes of treatment, syntonic optometrists define
four syndromes as follows: acute, chronic, emotional fatigue
and lazy eye
 In lazy eye syndrome, amblyopia, strabismus, vergence
anomalies, suppression, ARC or visual field constrictions are
treated using red/orange filters

14.  It is based on work by Spitler, in which 2,791 of 3,067
individuals responded positively to syntonic phototherapy
 However, there is no published studies on the
effectiveness of this technique in amblyopia therapy
 In the absence of studies providing good quality evidence
that amblyopic patients will be helped by syntonic
phototherapy, there seems to be no basis for prescribing
this treatment
Wallace LB. The theory and practice of syntonic phototherapy 2009
Spitler HR. The Syntonic Principle. Pennsylvania: Science Press Printing
Company, 1941.

15. Role of perceptual learning in
amblyopia treatment

16. Perceptual Learning
 Any relatively permanent and consistent change in the
perception of stimulus array following practice or
experience with this array- Gibson (1963)
 No. of studies suggest that perceptual learning (PL) may
provide an important new method for treating amblyopia
Principle
 PL is reported to operate via a reduction of internal neural
noise and/ or through more efficient use of stimulus
information by returning weighting of the information

17.  PL employs repeatedly practicing a visual discrimination
task, e.g: positional acuity, contrast sensitivity,
stereo-acuity, etc
 Recommended period for PL: 2hrs/ day, 5 days/ week, for
a period of 9 months
 Significant improvements found in VA and CS (Chen P. et al
2008, Huang C. et al 2006)
 Role of PL is still controversial, but utility is reported in
adult amblyopes

18. Video Game Play & Brain Plasticity
 The intense sensory-motor interactions are immersed
video-game play
 This might push brain functions to the limit
 Enables the amblyopic visual system to learn, on the fly,
to recalibrate and adjust, providing the basis for
functional plasticity

19. Video Game Play & Brain Plasticity
 Game playing requires the allocation of spatial
detection, and localization of low contrast, fast moving
targets, and aiming
 Video games may include several essential elements for
active vision training to boost visual performance
 According to C. S. Green and co workers (2003) action
video game modifies visual selective attention
 Thus, it could potentially be useful in improving
amblyopic vision

20. Video-Game Play Induces Plasticity in the Visual
System of Adults with Amblyopia
(Roger W. Li1 et al, August 30 2011)
o 10 amblyopic adults: Action Video Game, 40 hrs,
2hrs/day
o 3 amblyopic adult: Non-action Video Game, 40 hrs, 2
hrs/ day
o Non-amblyopic eye: Occlusion
o Control Group 7 adults: Only patching
Action Game: Medal of Honor: Pacific AssaultNon-Action Game: SimCity Societies

24.  PL is an area with clear potential for treating amblyopia
 Significant improvements in vision can result from training
periods that are relatively short using tasks that are relatively
engaging, compared to conventional occlusion
 It is important to be aware that the way in which these
improvements arise is not yet fully understood
 Further research is needed before optimal training strategies
can be devised and before the way in which those strategies
modify visual function can be fully understood

25. Binocular stimulation in the
treatment of amblyopia

26.  During occlusion therapy, the non-amblyopic eye is
occluded i.e. binocular vision is not encouraged during
these periods
 It has been recognized that binocular stimulation may be
important in the treatment of amblyopia
 Animal research (Mitchell DE 2008) and recent studies (Baker
DH et al 2007, Mansauri et al 2007) indicate that binocular
stimulation encourages binocular cortical connections
during recovery from deprivation amblyopia
 Offers support for binocular stimulation when treating
amblyopia

27.  One existing approach to treating amblyopia that allows
binocular stimulation is the use of Bangerter foils (Baker and
colleagues 2007)
 Another long-standing and widely used approach is atropine
penalization
 In both cases, the image at the fovea of the non-amblyopic
eye is degraded (for near vision in the case of atropine), while
input to the amblyopic eye is not affected
 In these therapeutic scenarios, vision is binocular in the sense
that both eyes receive light stimulation and peripheral
resolution is not significantly impeded (Wang YZ et.al 1997)

28.  Comparisons between occlusion and atropine (LI T et al 2009)
or between occlusion and Bangerter foils (PEDIG 2010) as
treatments for amblyopia show no significant difference in
outcome
 Suggests that this type of binocular stimulation does not
offer significant advantages over the combination of
binocular and monocular vision allowed by periods of
occlusion

29. The ‘monocular fixation in a binocular field’ (MFBF)
technique
 Introduced with the intention of training the amblyopic visual
system to integrate information from both eyes (Cohen AH.
Monocular fixation in a binocular field. J Am Optom Assoc 1981)
 This technique involves the presentation of peripheral stimuli
to both eyes, while only the amblyopic eye is stimulated at
the fovea

30. The ‘monocular fixation in a binocular field’ (MFBF)
technique
 Applied in a range of paper-based formats.
E.g, pt. may be instructed to complete tasks such as
crossword
puzzles or placing dots in the ‘o’ letters in a text, using a
pen and wearing red-green glasses, with the red lens in
of the non-amblyopic eye (Wick B. et al 1992)

31. I-BiT™ Interactive Binocular Treatment for
Amblyopia
Concept
 Present separate images to each eye
 Dynamic visual scene
 Preferentially stimulating amblyopic eye
Patient motivation
 Interactive games and videos
 Encourage patient compliance
Shutter Glasses Technology
o Shutter glasses
o High definition screens
o Faster processing speeds

32. Adaptations for use with the I-BiT system
 Shutter glasses with I-BiT software is to change the ratio
of information presented to each eye in order to
stimulate one eye more than the other
 This creates a 2D view rather than the intended 3D
stereoscopic view
DVD Player
o Border with controls common
to both eyes
o Only amblyopic eye sees the
DVD
NUX Game

33. Evidence
 Six children treated with prototype and gained 2 lines of
vision (Waddingham et al Eye 2006)
 10 treated with I-BiT and improvement of 0.189 logMAR,
almost 2 lines (Herbison et al Eye 2013)
 Other groups: e.g. Hess’s group with the game Tetris in
adults (required a minimum of 6 hrs play before any effect is
discernible)

34. Fig: Visual acuity in LogMAR units for all patients
from baseline to week 10.
Herbison et al Eye 2013

35. Software-based active treatments for
amblyopia for use at home or in office

36. The AmbP iNet program for the treatment of Amblyopia
 Marketed by Home Therapy Solutions
 System features 12 treatment programs, 6 of which are
randomly assigned for completion by the patient each
5 days per week
 Involve activities like ‘letter jump’, among others
 The treatment involves visual search of certain target

37. The AmbP iNet program for the treatment of
Amblyopia
 Treatment system is designed to improve hand eye co-
ordination, VA, crowding effect and visual memory
 No published reports of clinical trials of this method, so it
is not possible to know whether the design is effective as
part of a treatment for amblyopia
 Thus, controlled trials of this treatment are needed
(Cooper J. et al 2007)

38. Not a "lazy" eye, but a "lazy" brain
 Amblyopia therapy is:
o Completed at home on a computer
o 2-3 times per week
o Each of the 40 sessions takes an average of 40 minutes
 Precise visual tasks consisting of patterned images with
subtle differences in orientation, size and contrast
 Through repetitive practice the brain is trained to be
efficient and to improve visual processing
 Specialized RevitalVision™ algorithms analyze

39. Binocular iPad Game VS Part-Time Patching
 2 studies (PEDIG 2016), (K.R. Kelly et al 2016) were done to
compare VA improvement in children with amblyopia treated
with a binocular iPad game vs part-time patching
Effect of a Binocular iPad Game vs Part-time Patching in Children Aged 5 to 12 Years
With Amblyopia A: Randomized Clinical Trial;Jonathan M. Holmes et; for the Pediatric
Eye Disease Investigator Group, JAMA Ophthalmology, November-3, 2016
Binocular iPad Game vs Patching for Treatment of Amblyopia in Children:A
Randomized Clinical Trial; Krista R. Kelly, PhD; Reed M. Jost, MS; Lori Dao, MD;
Cynthia L. Beauchamp, MD; Joel N. Leffler, MD; Eileen E. Birch, PhD, JAMA
Ophthalmology, December 2016

40. Fig: Visual Acuity (VA) in Amblyopic Eyes From Baseline to 16Weeks
(PEDIG 2016)
 VA improves with binocular game play and with
patching, particularly in younger children (age 5 to <7
years)
 VA improvement with this particular binocular iPad
treatment is not as good as with 2 hrs of prescribed daily

41. • High-contrast red elements (miners and fireball) are seen by the
amblyopic eye
• Low-contrast blue elements (gold and cart) are seen by the fellow
eye
• Gray elements (rocks and ground) are seen by both eyes
• Both eyes must see the game for successful play
Fig: Dig Rush Game
(K.R. Kelly et al 2016)

42. Fig: Best-Corrected Visual Acuity (BCVA) at Baseline, the 2-Week Visit, and the 4-
Week Visit
(K.R. Kelly et al 2016)
 Binocular iPad game is a successful treatment for childhood
amblyopia and is more effective than patching at the 2-week
visit

43. Exposure to Darkness

44.  Dark exposure promotes recovery from amblyopia
 It is based on Duffy and Mitchell (2013, current
biology) animal (kittens) experiments

45.  Three key parameters will have to be established first
o What is the minimum period of dark exposure needed to
trigger restoration of visual cortex plasticity?
o What is the age dependence of this effect?
o How absolute does the darkness have to be?
 The answers to these questions will ultimately determine
the utility of this approach to treating amblyopia

46. Pharmacological Therapy

47.  Levodopa & citicoline are the most extensively studied
drugs
 Plasticity of visual system during the sensitive period is
dependent on input from non-adrenergic neurons and thus
can be subjected to pharmacological manipulation
 Precursor for the catecholamine dopamine, a
neurotransmitter, known to influence visual system at retina
and cortical level
 It either extends or reactivates the visual system’s sensitive
period of neural plasticity
 Catecholamine based medical treatment has been
demonstrated to improve vision in amblyopic eyes.

48.  Leguire and co-workers (1993) found that 1 hr after
levodopa ingestion,VA, CS and PVEP temporarily improve
but starts to decrease 5 hrs after drug ingestion
 They concluded that combination of levodopa and
occlusion improves visual function more than levodopa-
carbidopa alone in amblyopic children
 Dadeya et al (2009) concluded that there is more than two
lines improvement in visual acuity, especially in children
younger than eight years of age

49.  Citicoline (cytidine 5’-diphosphocholine) used in a
dose of 1,000 mg I.M. for 15 days to patients aged 9–
37 yrs causes a temporary improvement in visual
acuity without any side effects (Campos et al 1995)
 Use of oral levodopa while continuing to patch 2 hrs
daily does not produce a clinically or statistically
meaningful improvement in VA compared with
patching (PEDIG 2015)

50. Advantages
o Augments conventional occlusion
o Speeds up recovery of visual functions
o Improves compliance
o Possibility for adult amblyopes
o Reduces cost and duration of treatment

51. Near activities used in the
treatment of amblyopia

52.  Active vision therapies for amblyopia involve paper-based
near activities such as reading, writing and word puzzles
 Von Noorden and associates (1970) found that minimal (1 hr
per day) occlusion combined with these exercises is
beneficial in the treatment of amblyopia for older children
 The latter studies (PEDIG 2005, 2008) provide high level
evidence that the use of near activities is not helpful in the
treatment of amblyopia
 In the absence of reliable evidence to the contrary, there is
not yet a sound basis for prescribing these tasks for pts.
undergoing treatment for amblyopia

53. Amblyopia is still an unsolved problem, the best
modality of treatment is still to be explored in
future
Thankyou