Levodopa for the Treatment of Residual Amblyopia (ATS17)

A Randomized Trial of Levodopa as Treatment for Residual Amblyopia (ATS 17)

The purpose of this study is to evaluate the efficacy and safety of oral levodopa and patching versus oral placebo and patching as treatment for residual amblyopia in children 7 to <13 years old with visual acuity of 20/50 to 20/400 in the amblyopic eye.

Study Overview

• Status: Completed
• Conditions: Amblyopia
• Intervention / Treatment: Drug: Levodopa/Carbidopa; Other: Patching; Drug: Placebo

Detailed Description

Amblyopia is the most common cause of monocular visual impairment in both children and young and middle-aged adults. Both patching and atropine are accepted treatment modalities for the management of moderate amblyopia in children. Despite best efforts with conventional amblyopia treatment, many older children and teenagers with amblyopia fail to achieve normal visual acuity in the amblyopic eye. In a previous PEDIG study where children 7 to 12 years old were treated with atropine and patching, only 36% of the children with moderate amblyopia and only 23% of the children with severe amblyopia achieved 20/40 or better acuity.

Many clinicians have recognized that conventional therapies with patching and atropine have not been universally successful and have sought alternatives. PEDIG has discussed for several years the problem of residual amblyopia and how the remaining visual acuity deficit could be reduced. A number of research groups have evaluated the short term use of oral levodopa-carbidopa as an adjunct to patching therapy for older children.

• Study Type: Interventional
• Enrollment (Actual): 139
• Phase: Phase 3

Contacts and Locations

Study Locations

• United States
  • Maryland
    • Baltimore, Maryland, United States, 21287
      • Wilmer Eye Institute

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 7 years to 12 years (CHILD)
• Accepts Healthy Volunteers: No
• Genders Eligible for Study: All

Description

Inclusion Criteria:

1. Age 7 to 12

2. Amblyopia associated with strabismus, anisometropia, or both

   • Criteria for strabismus: One of the following criteria must be met: Heterotropia at distance and/or near fixation on examination (with or without spectacles); History of strabismus surgery; Documented history of strabismus which is no longer present (which in the judgment of the investigator could have caused amblyopia)
   • Criteria for anisometropia: One of the following criteria must be met: ≥0.50 D difference between eyes in spherical equivalent; ≥1.50 D difference between eyes in astigmatism in any meridian

3. Visual acuity, measured in each eye (amblyopic eye without cycloplegia) within 7 days prior to enrollment using the E-ETDRS protocol by a study certified visual acuity tester as follows:

   • Visual acuity in the amblyopic eye 18 to 67 letters inclusive (20/50 to 20/400)
   • Visual acuity in the fellow eye ≥78 letters (20/25 or better)

4. Current amblyopia treatment (other than spectacles)

   • 12 weeks of at least 2 hours of occlusion per day prescribed for the fellow eye during the immediate pre-enrollment period.
   • While on current treatment, visual acuity has not improved one line (5 letters) or more since a non-study visit at least 6 weeks ago. Both acuity measurements to define no improvement must have been done using the same testing method.
   • Treatment with atropine at any time during this pre-enrollment period is not allowed.
   • Any treatment prior to the current patching episode with stable acuity is acceptable.

5. Spectacle correction (if applicable) for measurement of enrollment visual acuity must meet the following criteria and be based on a cycloplegic refraction that is no more than 6 months old:

   1. Requirements for spectacle correction:

      • Spherical equivalent must be within 0.50 D of fully correcting the anisometropia.
      • Hypermetropia of 3.00D or more must be corrected.
      • Hypermetropia must not be under corrected by more than 1.50 D spherical equivalent, and reduction in plus sphere must be symmetric in the two eyes.
      • Cylinder power in both eyes must be within 0.50 D of fully correcting the astigmatism.
      • Cylinder axis in both eyes is within 6 degrees of the axis in the spectacles when cylinder power is ≥1.00 D.
      • Myopia of amblyopic eye greater than 0.50 D by spherical equivalent must be corrected, and the glasses must not under correct the myopia by more than 0.25 D or overcorrect it by more than 0.50 D.
   2. Spectacles meeting above criteria must be worn :until visual acuity in amblyopic eye is stable (defined as 2 consecutive visual acuity measurements by the same testing method at least 4 weeks apart with no improvement of one line (5 letters) or more.
6. Eye examination within 6 months prior to enrollment
7. Parent available for at least one year of follow-up, has access to phone), and willing to be contacted by clinical site and Jaeb Center staff
8. In the investigator's judgment, the subject is likely to comply with prescribed treatment (e.g., no history of poor compliance with patching treatment) and unlikely to continue to improve by using 2 hours of patching per day alone.

Exclusion Criteria:

1. Myopia more than -6.00 D (spherical equivalent) in either eye.
2. Current vision therapy or orthoptics

3. Ocular cause for reduced visual acuity

   • nystagmus per se does not exclude the subject if the above visual acuity criteria are met
4. Prior intraocular or refractive surgery
5. History of narrow-angle glaucoma
6. Bronchial asthma or severe pulmonary disease
7. Strabismus surgery planned within 26 weeks
8. Known allergy to levodopa or carbidopa
9. History of dystonic reactions
10. Current use of oral iron supplements including multivitamins containing iron during treatment with levodopa-carbidopa
11. Current use of antihypertensive, anti-depressant medications, phenothiazines, butyrophenones, risperidone and isoniazid, non-specific monoamine oxidase inhibitors, or medication for the treatment of attention deficit hyperactivity disorder
12. Known liver disease
13. History of melanoma
14. Known psychological problems
15. Known skin reactions to patch or bandage adhesives
16. Prior levodopa treatment
17. Treatment with topical ophthalmic atropine within the past 12 weeks
18. A physician-prescribed diet high in protein

19. Females who are pregnant, lactating, or intend to become pregnant within the next 34 weeks.

    • A negative urine pregnancy test will be required for all females who have experienced menarche.
    • Requirements regarding pregnancy testing prior to enrollment may be further defined by each individual Institutional Review Board.

Study Plan

How is the study designed?

Design Details

• Primary Purpose: TREATMENT
• Allocation: RANDOMIZED
• Interventional Model: PARALLEL
• Masking: QUADRUPLE

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
ACTIVE_COMPARATOR: Levodopa/Carbidopa; Levodopa 0.76 mg/kg with Carbidopa 0.17 mg/kg tid	Drug: Levodopa/Carbidopa; Oral levodopa 0.76 mg/kg tid with carbidopa 0.17 mg/kg tid; Other: Patching; Two hours of daily patching
PLACEBO_COMPARATOR: Placebo; Oral placebo tid	Other: Patching; Two hours of daily patching; Drug: Placebo; Oral placebo tid

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Distribution of Amblyopic Eye Visual Acuity Change From Baseline	The primary outcome is the amblyopic eye visual acuity letter score measured at the 18-week primary outcome visit following a rapid taper of study medicine beginning at week 16. The primary analytic approach will be a treatment group comparison of the mean amblyopic eye visual acuity adjusted for baseline acuity. Visual acuity was measured in each eye (right eye first) by a study-certified VA tester using the Electronic Early Treatment of Diabetic Retinopathy Study (E-ETDRS©) visual acuity protocol. Five letters is equivalent to one logMAR line.	18 weeks after enrollment
Mean Amblyopic Eye Visual Acuity Change From Baseline	The primary outcome is the amblyopic eye visual acuity letter score measured at the 18-week primary outcome visit following a rapid taper of study medicine beginning at week 16. The primary analytic approach will be a treatment group comparison of the mean amblyopic eye visual acuity adjusted for baseline acuity. Visual acuity was measured in each eye (right eye first) by a study-certified VA tester using the Electronic Early Treatment of Diabetic Retinopathy Study (E-ETDRS©) visual acuity protocol. Five letters is equivalent to one logMAR line.	18 weeks after enrollment

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Amblyopic Eye Visual Acuity Improvement Treatment Group Comparison at 18 Weeks	Treatment group comparisons of the proportion of subjects who have improved from baseline by 10 or more letters.	18 weeks after enrollment
Distribution of Amblyopic Eye Visual Acuity at 18 Weeks		18 weeks after enrollment
Mean Amblyopic Eye Visual Acuity at 18 Weeks	Visual acuity was measured in each eye (right eye first) by a study-certified VA tester using the Electronic Early Treatment of Diabetic Retinopathy Study (E-ETDRS©) visual acuity protocol. Five letters is equivalent to one logMAR line.	18 weeks after enrollment
Amblyopic Eye Visual Acuity Improvement Treatment Group Comparison at 4 Weeks	Treatment group comparisons adjusted for baseline acuity scores using logistic regression of the proportion of subjects who have improved from baseline by 10 or more letters.	4 weeks after enrollment
Amblyopic Eye Visual Acuity Improvement Treatment Group Comparison at 10 Weeks	Treatment group comparisons of the proportion of subjects who have improved from baseline by 10 or more letters.	10 weeks after enrollment
Amblyopic Eye Visual Acuity Improvement Treatment Group Comparison at 16 Weeks	Treatment group comparisons of the proportion of subjects who have improved from baseline by 10 or more letters.	16 weeks after enrollment
Amblyopic Eye Visual Acuity Improvement Treatment Group Comparison at 26 Weeks	Treatment group comparisons adjusted for baseline acuity scores using logistic regression of the proportion of subjects who have improved from baseline by 10 or more letters.	26 weeks after enrollment
Amblyopia Resolutionat 4 Weeks	Treatment group comparisons adjusted for baseline acuity scores using logistic regression of the proportion of subjects with 20/25 or better visual acuity.	4 weeks after enrollment
Amblyopia Resolution at 10 Weeks	Treatment group comparisons adjusted for baseline acuity scores using logistic regression of the proportion of subjects with 20/25 or better visual acuity.	10 weeks after enrollment
Amblyopia Resolution at 16 Weeks	Treatment group comparisons adjusted for baseline acuity scores using logistic regression of the proportion of subjects with 20/25 or better visual acuity.	16 weeks after enrollment
Amblyopia Resolution at 18 Weeks	Treatment group comparisons adjusted for baseline acuity scores using logistic regression of the proportion of subjects with 20/25 or better visual acuity.	18 weeks after enrollment
Amblyopia Resolution at 26 Weeks	Treatment group comparisons adjusted for baseline acuity scores using logistic regression of the proportion of subjects with 20/25 or better visual acuity.	26 weeks after enrollment
Distribution of Amblyopic Eye Visual Acuity Change From Baseline at 4 Weeks	Visual acuity was measured in each eye (right eye first) by a study-certified VA tester using the Electronic Early Treatment of Diabetic Retinopathy Study (E-ETDRS©) visual acuity protocol. Five letters is equivalent to one logMAR line.	4 weeks after enrollment
Mean Change in Amblyopic Eye Visual Acuity From Baseline at 4 Weeks	A treatment group comparison of the mean amblyopic eye visual acuity at 4 weeks after enrollment, adjusted for baseline acuity.	4 weeks after enrollment
Distribution of Amblyopic Eye Visual Acuity Change From Baseline at 10 Weeks	Visual acuity was measured in each eye (right eye first) by a study-certified VA tester using the Electronic Early Treatment of Diabetic Retinopathy Study (E-ETDRS©) visual acuity protocol. Five letters is equivalent to one logMAR line.	10 weeks after enrollment
Mean Change in Amblyopic Eye Visual Acuity From Baseline at 10 Weeks	A treatment group comparison of the mean amblyopic eye visual acuity at 10 weeks after enrollment, adjusted for baseline acuity. Visual acuity was measured in each eye (right eye first) by a study-certified VA tester using the Electronic Early Treatment of Diabetic Retinopathy Study (E-ETDRS©) visual acuity protocol. Five letters is equivalent to one logMAR line.	10 weeks after enrollment
Distribution of Amblyopic Eye Visual Acuity Change From Baseline at 16 Weeks	Visual acuity was measured in each eye (right eye first) by a study-certified VA tester using the Electronic Early Treatment of Diabetic Retinopathy Study (E-ETDRS©) visual acuity protocol. Five letters is equivalent to one logMAR line.	16 weeks after enrollment
Mean Change in Amblyopic Eye Visual Acuity From Baseline at 16 Weeks	A treatment group comparison of the mean amblyopic eye visual acuity at 16 weeks after enrollment, adjusted for baseline acuity. Visual acuity was measured in each eye (right eye first) by a study-certified VA tester using the Electronic Early Treatment of Diabetic Retinopathy Study (E-ETDRS©) visual acuity protocol. Five letters is equivalent to one logMAR line.	16 weeks after enrollment
Distribution of Amblyopic Eye Visual Acuity Change From Baseline at 26 Weeks	Visual acuity was measured in each eye (right eye first) by a study-certified VA tester using the Electronic Early Treatment of Diabetic Retinopathy Study (E-ETDRS©) visual acuity protocol. Five letters is equivalent to one logMAR line.	26 weeks after enrollment
Mean Change in Amblyopic Eye Visual Acuity From Baseline at 26 Weeks	A treatment group comparison of the mean amblyopic eye visual acuity at 26 weeks after enrollment, adjusted for baseline acuity. Visual acuity was measured in each eye (right eye first) by a study-certified VA tester using the Electronic Early Treatment of Diabetic Retinopathy Study (E-ETDRS©) visual acuity protocol. Five letters is equivalent to one logMAR line.	26 weeks after enrollment
Distribution of Fellow Eye Visual Acuity at 18 Weeks	Similar to the analysis for the amblyopic eye, the fellow eye visual acuity will be evaluated to determine if study treatment had an adverse effect on the occluded eye. The analysis will be a treatment group comparison of the mean fellow eye visual acuity at 18 weeks after enrollment, adjusted for baseline acuity.	18 weeks after enrollment
Mean Fellow Eye Visual Acuity at 18 Weeks	Visual acuity was measured in each eye (right eye first) by a study-certified VA tester using the Electronic Early Treatment of Diabetic Retinopathy Study (E-ETDRS©) visual acuity protocol. Five letters is equivalent to one logMAR line.	18 weeks after enrollment
Distribution of Fellow Eye Visual Acuity Change From Baseline at 18 Weeks	Visual acuity was measured in each eye (right eye first) by a study-certified VA tester using the Electronic Early Treatment of Diabetic Retinopathy Study (E-ETDRS©) visual acuity protocol. Five letters is equivalent to one logMAR line.	18 weeks after enrollment
Mean Fellow Eye Visual Acuity Change From Baseline at 18 Weeks	Visual acuity was measured in each eye (right eye first) by a study-certified VA tester using the Electronic Early Treatment of Diabetic Retinopathy Study (E-ETDRS©) visual acuity protocol. Five letters is equivalent to one logMAR line.	18 weeks after enrollment
Mean Child Symptom Survey Score at Enrollment	A treatment group comparison of symptom survey scores at enrollment. The average of the overall item responses will be calculated and compared by treatment group with a t-test for difference in means. A higher number reflects a more negative response (5=always, 4=often, 3=sometimes, 2=rarely, 1=never).	At enrollment
Mean Child Symptom Survey Score at 4 Weeks	A treatment group comparison of symptom survey scores at the 4 week visit. The average of the overall item responses will be calculated and compared by treatment group with a t-test for difference in means. A higher number reflects a more negative response (5=always, 4=often, 3=sometimes, 2=rarely, 1=never).	4 weeks after enrollment
Mean Child Symptom Survey Score at 10 Weeks	A treatment group comparison of symptom survey scores at the 10 week visit. The average of the overall item responses will be calculated and compared by treatment group with a t-test for difference in means. A higher number reflects a more negative response (5=always, 4=often, 3=sometimes, 2=rarely, 1=never).	10 weeks after enrollment
Mean Child Symptom Survey Score at 16 Weeks	A treatment group comparison of symptom survey scores at the 16 week visit. The average of the overall item responses will be calculated and compared by treatment group with a t-test for difference in means. A higher number reflects a more negative response (5=always, 4=often, 3=sometimes, 2=rarely, 1=never).	16 weeks after enrollment
Mean Child Symptom Survey Score at 18 Weeks	A treatment group comparison of symptom survey scores at the primary outcome (18 week) visit. The average of the overall item responses will be calculated and compared by treatment group with a t-test for difference in means. A higher number reflects a more negative response (5=always, 4=often, 3=sometimes, 2=rarely, 1=never).	18 weeks after enrollment
Mean Child Symptom Survey Score at 26 Weeks	A treatment group comparison of symptom survey scores at the 26 week visit. The average of the overall item responses will be calculated and compared by treatment group with a t-test for difference in means. A higher number reflects a more negative response (5=always, 4=often, 3=sometimes, 2=rarely, 1=never).	26 weeks after enrollment
Mean Parent Symptom Survey Score at Enrollment	A treatment group comparison of symptom survey scores at enrollment. The average of the overall item responses will be calculated and compared by treatment group with a t-test for difference in means. A higher number reflects a more negative response (5=always, 4=often, 3=sometimes, 2=rarely, 1=never).	At enrollment
Mean Parent Symptom Survey Score at 4 Weeks	A treatment group comparison of symptom survey scores at the 4 week visit. The average of the overall item responses will be calculated and compared by treatment group with a t-test for difference in means. A higher number reflects a more negative response (5=always, 4=often, 3=sometimes, 2=rarely, 1=never).	4 weeks after enrollment
Mean Parent Symptom Survey Score at 10 Weeks	A treatment group comparison of symptom survey scores at the 10 week visit. The average of the overall item responses will be calculated and compared by treatment group with a t-test for difference in means. A higher number reflects a more negative response (5=always, 4=often, 3=sometimes, 2=rarely, 1=never).	10 weeks after enrollment
Mean Parent Symptom Survey Score at 16 Weeks	A treatment group comparison of symptom survey scores at the 16 week visit. The average of the overall item responses will be calculated and compared by treatment group with a t-test for difference in means. A higher number reflects a more negative response (5=always, 4=often, 3=sometimes, 2=rarely, 1=never).	16 weeks after enrollment
Mean Parent Symptom Survey Score at 18 Weeks	A treatment group comparison of symptom survey scores at the primary outcome (18 week) visit. The average of the overall item responses will be calculated and compared by treatment group with a t-test for difference in means. A higher number reflects a more negative response (5=always, 4=often, 3=sometimes, 2=rarely, 1=never).	18 weeks after enrollment
Mean Parent Symptom Survey Score at 26 Weeks	A treatment group comparison of symptom survey scores at the 26 week visit. The average of the overall item responses will be calculated and compared by treatment group with a t-test for difference in means. A higher number reflects a more negative response (5=always, 4=often, 3=sometimes, 2=rarely, 1=never).	26 weeks after enrollment
Mean Systemic Adverse Events		Enrollment through 26 weeks
Distribution of Fellow Eye Visual Acuity at 26 Weeks	Similar to the analysis for the amblyopic eye, the fellow eye visual acuity will be evaluated to determine if study treatment had an adverse effect on the occluded eye. The analysis will be a treatment group comparison of the mean fellow eye visual acuity at 26 weeks after enrollment, adjusted for baseline acuity.	26 weeks after enrollment
Mean Fellow Eye Visual Acuity at 26 Weeks	Visual acuity was measured in each eye (right eye first) by a study-certified VA tester using the Electronic Early Treatment of Diabetic Retinopathy Study (E-ETDRS©) visual acuity protocol. Five letters is equivalent to one logMAR line.	26 weeks after enrollment
Distribution of Fellow Eye Visual Acuity Change From Baseline at 26 Weeks	Visual acuity was measured in each eye (right eye first) by a study-certified VA tester using the Electronic Early Treatment of Diabetic Retinopathy Study (E-ETDRS©) visual acuity protocol. Five letters is equivalent to one logMAR line.	26 weeks after enrollment
Mean Fellow Eye Visual Acuity Change From Baseline at 26 Weeks	Visual acuity was measured in each eye (right eye first) by a study-certified VA tester using the Electronic Early Treatment of Diabetic Retinopathy Study (E-ETDRS©) visual acuity protocol. Five letters is equivalent to one logMAR line.	26 weeks after enrollment

Collaborators and Investigators

• Sponsor: Jaeb Center for Health Research
• Collaborators: National Eye Institute (NEI)
• Investigators: Study Chair: Michael X Repka, MD, Jaeb Center for Health Research

Publications and helpful links

General Publications

• Pediatric Eye Disease Investigator Group; Repka MX, Kraker RT, Dean TW, Beck RW, Siatkowski RM, Holmes JM, Beauchamp CL, Golden RP, Miller AM, Verderber LC, Wallace DK. A randomized trial of levodopa as treatment for residual amblyopia in older children. Ophthalmology. 2015 May;122(5):874-81. doi: 10.1016/j.ophtha.2015.01.002. Epub 2015 Feb 9.

Helpful Links

• PubMed abstract
• PubMed Central HHS Public Access - Full Text

Study record dates

Study Major Dates

• Study Start: September 1, 2010
• Primary Completion (ACTUAL): January 1, 2014
• Study Completion (ACTUAL): April 1, 2014

Study Registration Dates

• First Submitted: August 17, 2010
• First Submitted That Met QC Criteria: August 27, 2010
• First Posted (ESTIMATE): August 30, 2010

Study Record Updates

• Last Update Posted (ESTIMATE): June 2, 2016
• Last Update Submitted That Met QC Criteria: May 3, 2016
• Last Verified: May 1, 2016

More Information

Terms related to this study

• Keywords: amblyopia, levodopa
• Additional Relevant MeSH Terms: Brain Diseases; Central Nervous System Diseases; Nervous System Diseases; Eye Diseases; Neurologic Manifestations; Sensation Disorders; Vision Disorders; Amblyopia; Physiological Effects of Drugs; Neurotransmitter Agents; Molecular Mechanisms of Pharmacological Action; Enzyme Inhibitors; Dopamine Agents; Antiparkinson Agents; Anti-Dyskinesia Agents; Aromatic Amino Acid Decarboxylase Inhibitors; Levodopa; Carbidopa
• Other Study ID Numbers: ATS 17; 2U10EY011751 (U.S. NIH Grant/Contract)

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: YES
• IPD Plan Description: A de-identified dataset is available on the PEDIG public website at http://pedig.jaeb.org/Studies.aspx?RecID=196