- ICH GCP
- US Clinical Trials Registry
- Clinical Trial NCT03255707
A Comparative Study Between Dissociative Treatment and Binocular Interactive Treatment in Amblyopia
Amblyopia is a unilateral or, infrequently, a bilateral reduction of best corrected visual acuity which cannot be attributed to coexisting eye or visual pathway disease. Amblyopia can be due to eye-crossing occurring in early childhood or due to error of refraction whether a high difference between the two eyes or very high bilateral refractive errors.Another cause could be visual deprivation like the presence of congenital cataract.
The prevalence of amblyopia worldwide is approximately 1%-5% .In Egypt, a study that was held in Upper Egypt, found that the prevalence of amblyopia was 1.49%, which is higher in rural areas than in urban areas.
Several modalities of treatment for amblyopia are available, yet occlusion treatment is the gold standard involving covering the good eye with a patch for a prescribed period of time ranging from 10 minutes daily to all waking hours. However, its effectiveness decreases in older children and adults.
Disadvantages include prolonged treatment leading to poor compliance, patching related distress, relationship strain and stigma. In extreme cases, non-compliance with patching results in a costly hospital admission to supervise the patching treatment. In addition, wearing a patch eliminates any advantage of binocularity. Not to mention that not all patients respond to patching and of those who do, many have residual amblyopia after treatment is stopped regardless of compliance. More importantly, binocular vision is not automatically restored once the vision in the amblyopic eye has been improved. In fact, once the patch is removed after therapy, the amblyopic eye could be suppressed by the better seeing eye and can lose some of the gains achieved as a result of therapy.
Another modality of treatment is atropine eye drops and optical penalisation which are usually secondary treatments to failed patching but carrying the same disadvantages as the ordinary patching.
Advances in amblyopia treatment include dichoptic training, perceptual learning, and video gaming. These depend on the fact that the adult brain has been shown to be much more plastic than it was once believed to be and hence have the advantage of expanding the age of response in adults.
Perceptual learning approaches have the advantage of being a dichoptic (binocular treatment using both eyes) approach which is independent of age and type of amblyopia.
A step further to conventional treatment is the use of a home-based approach allowing remote internet monitoring of treatment between office visits and hence better compliance. In addition a video game version of the treatment is developed to make it more enjoyable for improving compliance.
Our goal is to compare the outcome between the gold standard occlusion therapy and one of the dichoptic treatments.
Study Overview
Status
Conditions
Intervention / Treatment
Detailed Description
Introduction Amblyopia is a unilateral or, infrequently, a bilateral reduction of best corrected visual acuity which cannot be attributed to coexisting eye or visual pathway disease. Amblyopic eyes may have decreased contrast sensitivity and accommodation deficit. The fellow eye is not often normal but has subtle deficits.This can be explained by interocular suppression, or inhibition of the amblyopic eye by the strong eye, with psychophysical and physiological evidence.
Amblyopia can be classified as follows: 1) Strabismic occurring in early childhood 2) Refractive: a) Anisometropic b) High bilateral refractive errors 3) Visual deprivation.
The prevalence of amblyopia worldwide is approximately 1%-5%. In Egypt, a study that was held in Upper Egypt, found that the prevalence of amblyopia was 1.49%, which is higher in rural areas than in urban areas.
Several modalities of treatment for amblyopia are available, yet occlusion treatment is the gold standard involving covering the good eye with a patch for a prescribed period of time ranging from 10 minutes daily to all waking hours. However, its effectiveness decreases in older children and adults.
Disadvantages include prolonged treatment leading to poor compliance, patching related distress, relationship strain and stigma. In extreme cases, non-compliance with patching results in a costly hospital admission to supervise the patching treatment. In addition, wearing a patch eliminates any advantage of binocularity. Not to mention that not all patients respond to patching and of those who do, many have residual amblyopia after treatment is stopped regardless of compliance. More importantly, binocular vision is not automatically restored once the vision in the amblyopic eye has been improved. In fact, once the patch is removed after therapy, the amblyopic eye could be suppressed by the better seeing eye and can lose some of the gains achieved as a result of therapy.
Another modality of treatment is atropine eye drops and optical penalisation which are usually secondary treatments to failed patching but carrying the same disadvantages as the ordinary patching.
Advances in amblyopia treatment include dichoptic training, perceptual learning, and video gaming. These depend on the fact that the adult brain has been shown to be much more plastic than it was once believed to be and hence have the advantage of expanding the age of response in adults.
Perceptual learning approaches have the advantage of being a dichoptic (binocular treatment) approach which is independent of age and type of amblyopia. Furthermore, it has been shown recently that therapy promotes binocular vision by strengthening stereopsis and reducing suppression.
A step further to conventional treatment is the use of a home-based approach allowing remote internet monitoring of treatment between office visits and hence better compliance. In addition a video game version of the treatment is developed to make it more enjoyable for improving compliance.
Aim of the work:
To compare the gold standard occlusion therapy alone with dichoptic therapy
Patients and Methods:
Design:
The study will be a prospective experimental controlled study.
Patients of the study:
From the vicinity of the ophthalmology outpatient clinic of Ain Shams University Hospital, 100 patients of both sexes with amblyopia will be enrolled to this study. Informed consents will be obtained from adult patients and children's parents.
Patients will be assigned randomly into two groups:
Group A: 50 patients will receive the gold standard occlusion therapy
Group B: 50 patients will receive dichoptic treatment in the form of playing a video game (Lazy Eye Blocks ®) while wearing a red/green goggle.
Each group will be subdivided according to age:
- From 4 to 7 years.
- From above 7 to 12 years.
- From above 12 to 30 years.
Hours of occlusion will be classified according to the degree of amblyopia:
- Mild to moderate amblyopia (Best corrected visual acuity (BCVA)< 0.2): 2-4 hours occlusion
- Severe (BCVA> 0.2): 4-6 hours occlusion
Hours of dichoptic treatment in group B will be classified according to the degree of amblyopia:
- Mild to moderate amblyopia (BCVA< 0.2): 2-4 hours of treatment
- Severe (BCVA> 0.2): 4-6 hours of treatment
Methods
All patients will undergo the following:
- Full medical and ophthalmic history
- Examination:
A) External Appearance:
Anomalous Head Position, globes (e.g., proptosis), lids (e.g. ptosis).
B) Refraction:
With and without cyclopegia
C) Visual acuity:
With and without correction using Snellen acuity chart and preferential looking test for non-verbal patients.
D) Motility:
Ductions and versions (9 positions of gaze) E) Angle of deviation if any
F) Fixation :
Fixation behavior (fixation preference) will be tested via base down 10 prism diopter fixation preference test.
G) Quantitative Binocular vision assessment H) Anterior segment examination. I) Posterior segment examination using indirect ophthalmoscopy with a 20 diopter lens through a dilated pupil.
All patients in Group A will receive the gold standard occlusion therapy. All patients in Group B will receive dichoptic treatment
Study Type
Enrollment (Actual)
Phase
- Not Applicable
Contacts and Locations
Study Locations
-
-
-
Cairo, Egypt
- Ain Shams University Hospitals (Demerdash)
-
-
Participation Criteria
Eligibility Criteria
Ages Eligible for Study
Accepts Healthy Volunteers
Genders Eligible for Study
Description
Inclusion Criteria:
- Any degree of amblyopia
- Orthotropia in primary position.
Exclusion Criteria:
- Any ocular disease affecting vision
- Angle of deviation in primary position (Heterotropia)
- Adult patients and children's parents unwilling to enter or complete the study
- Ignorance of patients to use the video game
Study Plan
How is the study designed?
Design Details
- Primary Purpose: Treatment
- Allocation: Randomized
- Interventional Model: Parallel Assignment
- Masking: None (Open Label)
Arms and Interventions
Participant Group / Arm |
Intervention / Treatment |
---|---|
Experimental: Group A
50 patients will receive the gold standard occlusion therapy
|
Occluding the better seeing eye for a given number of hours daily
|
Experimental: Group B
50 patients will receive dichoptic treatment in the form of playing a video game (Lazy Eye Blocks ®) while wearing a red/green goggle.
|
dichoptic treatment in the form of playing a video game (Lazy Eye Blocks ®) while wearing a red/green goggle.
|
What is the study measuring?
Primary Outcome Measures
Outcome Measure |
Measure Description |
Time Frame |
---|---|---|
visual acuity
Time Frame: 6 months
|
Best corrected visual acuity in the amblyopic eye
|
6 months
|
Secondary Outcome Measures
Outcome Measure |
Measure Description |
Time Frame |
---|---|---|
Compliance
Time Frame: 6 months
|
Compliance of the patient to treatment
|
6 months
|
crowding ratio
Time Frame: 6 months
|
crowded vs uncrowded visual acuity
|
6 months
|
Collaborators and Investigators
Sponsor
Investigators
- Study Chair: Hazem H Nouh, MD, Ophthalmology department, faculty of medicine, Ain Shams University
- Study Chair: Mohammad A Rashad, MD, Ophthalmology department, faculty of medicine, Ain Shams University
- Study Director: Walid M El-Zawahry, MD, Ophthalmology department, faculty of medicine, Ain Shams University
- Study Director: Ahmad T Ismail, MD, Ophthalmology department, faculty of medicine, Ain Shams University
- Principal Investigator: Suha A Hussein, M.Sc, Ophthalmology department, faculty of medicine, Ain Shams University
Publications and helpful links
General Publications
- Polat U, Ma-Naim T, Belkin M, Sagi D. Improving vision in adult amblyopia by perceptual learning. Proc Natl Acad Sci U S A. 2004 Apr 27;101(17):6692-7. doi: 10.1073/pnas.0401200101. Epub 2004 Apr 19.
- Levi DM, Li RW. Perceptual learning as a potential treatment for amblyopia: a mini-review. Vision Res. 2009 Oct;49(21):2535-49. doi: 10.1016/j.visres.2009.02.010. Epub 2009 Feb 27.
- Hess RF, Thompson B, Baker DH. Binocular vision in amblyopia: structure, suppression and plasticity. Ophthalmic Physiol Opt. 2014 Mar;34(2):146-62. doi: 10.1111/opo.12123.
- Hess RF, Babu RJ, Clavagnier S, Black J, Bobier W, Thompson B. The iPod binocular home-based treatment for amblyopia in adults: efficacy and compliance. Clin Exp Optom. 2014 Sep;97(5):389-98. doi: 10.1111/cxo.12192. Epub 2014 Aug 18.
- Aldebasi YH. Prevalence of amblyopia in primary school children in Qassim province, Kingdom of Saudi Arabia. Middle East Afr J Ophthalmol. 2015 Jan-Mar;22(1):86-91. doi: 10.4103/0974-9233.148355.
- Attebo K, Mitchell P, Cumming R, Smith W, Jolly N, Sparkes R. Prevalence and causes of amblyopia in an adult population. Ophthalmology. 1998 Jan;105(1):154-9. doi: 10.1016/s0161-6420(98)91862-0.
- Birch EE. Amblyopia and binocular vision. Prog Retin Eye Res. 2013 Mar;33:67-84. doi: 10.1016/j.preteyeres.2012.11.001. Epub 2012 Nov 29.
- Ding J, Klein SA, Levi DM. Binocular combination in abnormal binocular vision. J Vis. 2013 Feb 8;13(2):14. doi: 10.1167/13.2.14. Erratum In: J Vis. 2016 Nov 1;16(14 ):19.
- Ding J, Levi DM. Rebalancing binocular vision in amblyopia. Ophthalmic Physiol Opt. 2014 Mar;34(2):199-213. doi: 10.1111/opo.12115. Epub 2014 Jan 12.
- Dixon-Woods M, Awan M, Gottlob I. Why is compliance with occlusion therapy for amblyopia so hard? A qualitative study. Arch Dis Child. 2006 Jun;91(6):491-4. doi: 10.1136/adc.2005.090373. Epub 2006 Mar 10.
- Fu J, Li SM, Liu LR, Li JL, Li SY, Zhu BD, Li H, Yang Z, Li L, Wang NL; Anyang Childhood Eye Study Group. Prevalence of amblyopia and strabismus in a population of 7th-grade junior high school students in Central China: the Anyang Childhood Eye Study (ACES). Ophthalmic Epidemiol. 2014 Jun;21(3):197-203. doi: 10.3109/09286586.2014.904371. Epub 2014 Apr 17.
- Ganekal S, Jhanji V, Liang Y, Dorairaj S. Prevalence and etiology of amblyopia in Southern India: results from screening of school children aged 5-15 years. Ophthalmic Epidemiol. 2013 Aug;20(4):228-31. doi: 10.3109/09286586.2013.809772.
- He HY, Hodos W, Quinlan EM. Visual deprivation reactivates rapid ocular dominance plasticity in adult visual cortex. J Neurosci. 2006 Mar 15;26(11):2951-5. doi: 10.1523/JNEUROSCI.5554-05.2006.
- Hess RF, Mansouri B, Thompson B. Restoration of binocular vision in amblyopia. Strabismus. 2011 Sep;19(3):110-8. doi: 10.3109/09273972.2011.600418.
- Mansouri B, Thompson B, Hess RF. Measurement of suprathreshold binocular interactions in amblyopia. Vision Res. 2008 Dec;48(28):2775-84. doi: 10.1016/j.visres.2008.09.002. Epub 2008 Nov 1.
- Oscar A, Cherninkova S, Haykin V, Aroyo A, Levi A, Marinov N, Kostova S, Elenkov C, Veleva N, Chernodrinska V, Petkova I, Spitzer J. Amblyopia screening in Bulgaria. J Pediatr Ophthalmol Strabismus. 2014 Sep-Oct;51(5):284-8. doi: 10.3928/01913913-20140618-01. Epub 2014 Jun 25.
- Scheiman MM, Hertle RW, Beck RW, Edwards AR, Birch E, Cotter SA, Crouch ER Jr, Cruz OA, Davitt BV, Donahue S, Holmes JM, Lyon DW, Repka MX, Sala NA, Silbert DI, Suh DW, Tamkins SM; Pediatric Eye Disease Investigator Group. Randomized trial of treatment of amblyopia in children aged 7 to 17 years. Arch Ophthalmol. 2005 Apr;123(4):437-47. doi: 10.1001/archopht.123.4.437.
- Pizzorusso T, Medini P, Berardi N, Chierzi S, Fawcett JW, Maffei L. Reactivation of ocular dominance plasticity in the adult visual cortex. Science. 2002 Nov 8;298(5596):1248-51. doi: 10.1126/science.1072699.
- Stewart CE, Fielder AR, Stephens DA, Moseley MJ. Treatment of unilateral amblyopia: factors influencing visual outcome. Invest Ophthalmol Vis Sci. 2005 Sep;46(9):3152-60. doi: 10.1167/iovs.05-0357.
- VON NOORDEN G. Principles of surgical treatment. Binocular vision and ocular motility. 1985:440-79.
- Abdelrazik ST, Khalil MF. Prevalence of amblyopia among children attending primary schools during the amblyogenic period in Minia county. Journal of the Egyptian Ophthalmological Society. 2014 Oct 1;107(4):220.
- Baker DH, Meese TS, Hess RF. Contrast masking in strabismic amblyopia: attenuation, noise, interocular suppression and binocular summation. Vision Res. 2008 Jul;48(15):1625-40. doi: 10.1016/j.visres.2008.04.017. Epub 2008 Jun 10.
- Bi H, Zhang B, Tao X, Harwerth RS, Smith EL 3rd, Chino YM. Neuronal responses in visual area V2 (V2) of macaque monkeys with strabismic amblyopia. Cereb Cortex. 2011 Sep;21(9):2033-45. doi: 10.1093/cercor/bhq272. Epub 2011 Jan 24.
- Foss AJ, Gregson RM, MacKeith D, Herbison N, Ash IM, Cobb SV, Eastgate RM, Hepburn T, Vivian A, Moore D, Haworth SM; I-BiT Steering group. Evaluation and development of a novel binocular treatment (I-BiT) system using video clips and interactive games to improve vision in children with amblyopia ('lazy eye'): study protocol for a randomised controlled trial. Trials. 2013 May 20;14:145. doi: 10.1186/1745-6215-14-145.
- Hess RF, Mansouri B, Thompson B. A new binocular approach to the treatment of amblyopia in adults well beyond the critical period of visual development. Restor Neurol Neurosci. 2010;28(6):793-802. doi: 10.3233/RNN-2010-0550.
- Maehara G, Thompson B, Mansouri B, Farivar R, Hess RF. The perceptual consequences of interocular suppression in amblyopia. Invest Ophthalmol Vis Sci. 2011 Nov 21;52(12):9011-7. doi: 10.1167/iovs.11-7748.
- American Academy of Ophthalmology Basic and Clinical Science Course Subcommittee. Basic and Clinical Science Course. Pediatric Ophthalmology and Strabismus: Section 6. San Francisco, CA: American Academy of Ophthalmology. 2012.pp.61.
- Ophthalmology P. Strabismus Preferred Practice Pattern Panel. Amblyopia Preferred Practice Pattern Guidelines. San Francisco, CA: American Academy of Ophthamology. 2012
- Tsirlin I, Colpa L, Goltz HC, Wong AM. Behavioral Training as New Treatment for Adult Amblyopia: A Meta-Analysis and Systematic Review. Invest Ophthalmol Vis Sci. 2015 Jun;56(6):4061-75. doi: 10.1167/iovs.15-16583.
Study record dates
Study Major Dates
Study Start (Actual)
Primary Completion (Actual)
Study Completion (Actual)
Study Registration Dates
First Submitted
First Submitted That Met QC Criteria
First Posted (Actual)
Study Record Updates
Last Update Posted (Actual)
Last Update Submitted That Met QC Criteria
Last Verified
More Information
Terms related to this study
Additional Relevant MeSH Terms
Other Study ID Numbers
- FMASU MD 293/2016
Plan for Individual participant data (IPD)
Plan to Share Individual Participant Data (IPD)?
Drug and device information, study documents
Studies a U.S. FDA-regulated drug product
Studies a U.S. FDA-regulated device product
product manufactured in and exported from the U.S.
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