Feature Counting Under Dichoptic Viewing in Anisometropic and Strabismic Amblyopia

Attention deficits in Amblyopia: A narrative review

Amblyopia has effects on vision that extend from the processing of low-level visual features to higher level functions such as visual attention. In this narrative review, we focus on the impact of amblyopia on visual attention. A structured literature search revealed 28 articles reporting comparisons between amblyopia and normal vision control groups for a variety of visual attention tasks. Several of these articles also included neuroimaging measures. A review of these articles suggested that amblyopia does not affect behavioral performance of tasks with a low attentional load, such as cuing tasks, but deficits emerge for tasks with high demands on visual attention such as multiple object tracking. Deficits are not limited to the amblyopic eye but are also evident under fellow eye and binocular viewing conditions suggesting that abnormal early binocular visual experience can fundamentally alter the development of visual attention. Overall, the current literature suggests that amblyopia is associated with reduced visual attention resources. We raise the possibility that this attention resource deficit may be partially associated with an attentional demand for suppression of the amblyopic eye.

Structural and functional alterations in the brains of patients with anisometropic and strabismic amblyopia: a systematic review of magnetic resonance imaging studies

Amblyopia is the most common cause of vision loss in children and can persist into adulthood in the absence of effective intervention. Previous clinical and neuroimaging studies have suggested that the neural mechanisms underlying strabismic amblyopia and anisometropic amblyopia may be different. Therefore, we performed a systematic review of magnetic resonance imaging studies investigating brain alterations in patients with these two subtypes of amblyopia; this study is registered with PROSPERO (registration ID: CRD42022349191). We searched three online databases (PubMed, EMBASE, and Web of Science) from inception to April 1, 2022; 39 studies with 633 patients (324 patients with anisometropic amblyopia and 309 patients with strabismic amblyopia) and 580 healthy controls met the inclusion criteria (e.g., case-control designed, peer-reviewed articles) and were included in this review. These studies highlighted that both strabismic amblyopia and anisometropic amblyopia patients showed reduced activation and distorted topological cortical activated maps in the striate and extrastriate cortices during task-based functional magnetic resonance imaging with spatial-frequency stimulus and retinotopic representations, respectively; these may have arisen from abnormal visual experiences. Compensations for amblyopia that are reflected in enhanced spontaneous brain function have been reported in the early visual cortices in the resting state, as well as reduced functional connectivity in the dorsal pathway and structural connections in the ventral pathway in both anisometropic amblyopia and strabismic amblyopia patients. The shared dysfunction of anisometropic amblyopia and strabismic amblyopia patients, relative to controls, is also characterized by reduced spontaneous brain activity in the oculomotor cortex, mainly involving the frontal and parietal eye fields and the cerebellum; this may underlie the neural mechanisms of fixation instability and anomalous saccades in amblyopia. With regards to specific alterations of the two forms of amblyopia, anisometropic amblyopia patients suffer more microstructural impairments in the precortical pathway than strabismic amblyopia patients, as reflected by diffusion tensor imaging, and more significant dysfunction and structural loss in the ventral pathway. Strabismic amblyopia patients experience more attenuation of activation in the extrastriate cortex than in the striate cortex when compared to anisometropic amblyopia patients. Finally, brain structural magnetic resonance imaging alterations tend to be lateralized in the adult anisometropic amblyopia patients, and the patterns of brain alterations are more limited in amblyopic adults than in children. In conclusion, magnetic resonance imaging studies provide important insights into the brain alterations underlying the pathophysiology of amblyopia and demonstrate common and specific alterations in anisometropic amblyopia and strabismic amblyopia patients; these alterations may improve our understanding of the neural mechanisms underlying amblyopia.

Long-Term Efficacy of the Combination of Active Vision Therapy and Occlusion in Children with Strabismic and Anisometropic Amblyopia

This retrospective study was conducted to evaluate the efficacy of the combined treatment of occlusion and active vision therapy in a total of 27 amblyopic children, including 14 strabismic and 13 anisometropic cases. For such purpose, changes in distance and near visual acuity as well as in the binocular function was evaluated during a two-year follow-up. In both amblyopia groups, significant improvements were found in distance and near visual acuity in the non-dominant eye (p < 0.001). In the strabismic amblyopia group, the percentage of patients with binocular function score (BF) > 3.3 decreased significantly from a baseline value of 64.3% to a two-year follow-up value of 7.1% (p < 0.001). In the anisometropic amblyopia group, this percentage also decreased significantly from a baseline value of 15.4% to a two-year follow-up value of 0.0% (p < 0.001). No recurrences were observed in the anisometropic amblyopia group, whereas recurrence occurred in two cases of the strabismic amblyopia group after finishing the vision rehabilitation process. In conclusion, the combined approach of the treatment evaluated is efficacious for providing an improvement in visual acuity and binocular function in both anisometropic and strabismic amblyopia, which was maintained over time.

Evaluation of the Efficacy of a New Dichoptic Digital Platform to Treat the Anisometropic and Isometropic Amblyopia

The aim of the current study was to evaluate the results of a novel dichoptic training program using an online platform in a group of subjects with refractive amblyopia, performing a comparative analysis of unilateral and bilateral amblyopic cases. For this purpose, a retrospective study analysis of data of 161 children (4−13 years) who underwent dichoptic treatment with the Bynocs® platform (Kanohi Eye Pvt. Ltd., Mumbai, India) was performed. In all cases, the therapy protocol consisted of sessions of training of 30 min daily 5 times a week for 6 weeks. Best corrected visual acuity (BCVA) in the non-dominant eye improved significantly with the treatment, with a mean change of 0.39 logMAR in the whole sample (p < 0.001). Regarding binocularity, the binocular function (BF) score also experienced a significant improvement (p < 0.001), with a mean change of 1.55 with therapy in the whole sample. The BCVA of the dominant eye only improved significantly (p < 0.001) in the isometropic amblyopic subgroup. In conclusion, the use of the dichoptic therapy with the digital platform evaluated allows an effective restoration of visual acuity and binocular function in children with anisometropic and isometropic amblyopia.

Perceptual learning with dichoptic attention tasks improves attentional modulation in V1 and IPS and reduces interocular suppression in human amblyopia

Long-term and chronic visual suppression to the non-preferred eye in early childhood is a key factor in developing amblyopia, as well as a critical barrier to treat amblyopia. To explore the relationship between selective visual attention and amblyopic suppression and its role in the success of amblyopic training, we used EEG source-imaging to show that training human adults with strabismic and anisometropic amblyopia with dichoptic attention tasks improved attentional modulation of neural populations in the primary visual cortex (V1) and intraparietal sulcus (IPS). We also used psychophysics to show that training reduced interocular suppression along with visual acuity and stereoacuity improvements. Importantly, our results revealed that the reduction of interocular suppression by training was significantly correlated with the improvement of selective visual attention in both training-related and -unrelated tasks in the amblyopic eye, relative to the fellow eye. These findings suggest a relation between interocular suppression and selective visual attention bias between eyes in amblyopic vision, and that dichoptic training with high-attention demand tasks in the amblyopic eye might be an effective way to treat amblyopia.

A novel method for utilizing dichoptic attention tasks in amblyopic training

There is converging evidence of attention deficits in individuals with amblyopia. It has been reported that selective visual attention is allocated preferentially toward the non-amblyopic fellow eye in strabismic ambloypes. This attention allocation bias between the eyes is found related to visual suppression in amblyopia. In this study, I introduced a novel method, which uses dichoptic attention tasks to train individuals with amblyopia and has been demonstrated alleviating visual suppression and improving visual functions while reducing interocular attention bias in adults with amblyopia. The method consists of the following components:•

The training tasks include three attention factors (searching, counting and cueing) to implement selective visual attention to the amblyopic eye dichoptically.

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With a dichoptic approach, the targets are presented to the amblyopic eye while the distractors are simultaneously presented to the fellow eye. The tasks are to search and count the targets that are presented to the cued eye among the distractors.

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The training stimuli avoid typical contrast sensitivity-based tasks, and the targets are highly visible allowing them to be seen by the amblyopic eye with poor visual acuity.

Orienting of covert attention by neutral and emotional gaze cues appears to be unaffected by mild to moderate amblyopia

Amblyopia is a developmental disorder of vision associated with higher-order visual attention deficits. We explored whether amblyopia affects the orienting of covert spatial attention by measuring the magnitude of the gaze cueing effect from emotional faces. Gaze and emotion cues are key components of social attention. Participants with normal vision (n = 30), anisometropic (n = 7) or strabismic/mixed (n = 5) amblyopia performed a cued peripheral target detection task under monocular and binocular viewing conditions. The cue consisted of a centrally presented face with left or right gaze (50% validity to target location) and a fearful, happy, or neutral expression. The magnitude of spatial cueing was computed as the reaction time difference between congruent and incongruent trials for each expression. Fearful facial expressions oriented spatial attention significantly more than happy or neutral expressions. The magnitude of the gaze cueing effect in our cohort of mild-to-moderate amblyopia was comparable to that in normal vision and was not correlated with the severity of amblyopia. There were no statistical group or amblyopia subtype differences for reaction time in any viewing condition. These results place constraints on the range of attentional mechanisms affected by amblyopia and possibly suggest normal covert processing of emotional face stimuli in mild and moderate amblyopia.

Feature Counting Is Impaired When Shifting Attention Between the Eyes in Adults With Amblyopia

BACKGROUND

Feature counting requires rapid shifts of attention in the visual field and reflects higher-level cortical functions. This process is drastically impaired in the amblyopic eye of strabismic amblyopes. In this study, we hypothesized that feature counting performance in anisometropic and strabismic amblyopes is further impaired when shifts in attention is required between the eyes.

MATERIALS AND METHODS

Through a mirror stereoscope, highly visible Gabor patches were presented to the same eye within a block or randomly presented to the left eye or to the right eye with an equal probability within a block. The task was to report the number of Gabors (3 to 9) as accurately as possible. Counting performance was compared between the amblyopes and the normal-vision observers and between the viewing conditions (shifting attention between the eyes versus maintaining attention in the same eye).

RESULTS

When attention was maintained in the same eye, the amblyopic eye of both anisometropic and strabismic groups undercounted the number of Gabors, but achieved near-perfect performance with their fellow eye, compared to normal-vision observers. In contrast, when shifting attention randomly to the left or to the right eye, the amblyopic eye further undercounted the number of Gabors. Undercounting was also found in the fellow eye of strabismic amblyopes, but was not in the fellow eye of anisometropic amblyopes. Performance in normal-vision observers did not differ between shifting attention between the eyes and maintaining attention in the same eye.

CONCLUSION

Our data showed that the amblyopic eye of both anisometropic and strabismic amblyopes further undercounted features when shifting attention between the eyes, compared to when maintaining attention in the same eye. This suggests that the ability to quickly redirect attention, particularly under interocular suppression, is impaired in amblyopia. The fellow eye of strabismic amblyopes also undercounted features when shifting attention between the eyes. However, such fellow eye abnormality was not found in anisometropic amblyopes, suggesting that different patterns of visual deficits are associated with amblyopia of different etiologies. The inability to count multiple features accurately reflects dysfunctions of high-level cortices in the amblyopic brain.

Rethinking amblyopia 2020

Recent work has transformed our ideas about the neural mechanisms, behavioral consequences and effective therapies for amblyopia. Since the 1700's, the clinical treatment for amblyopia has consisted of patching or penalizing the strong eye, to force the "lazy" amblyopic eye, to work. This treatment has generally been limited to infants and young children during a sensitive period of development. Over the last 20 years we have learned much about the nature and neural mechanisms underlying the loss of spatial and binocular vision in amblyopia, and that a degree of neural plasticity persists well beyond the sensitive period. Importantly, the last decade has seen a resurgence of research into new approaches to the treatment of amblyopia both in children and adults, which emphasize that monocular therapies may not be the most effective for the fundamentally binocular disorder that is amblyopia. These approaches include perceptual learning, video game play and binocular methods aimed at reducing inhibition of the amblyopic eye by the strong fellow eye, and enhancing binocular fusion and stereopsis. This review focuses on the what we've learned over the past 20 years or so, and will highlight both the successes of these new treatment approaches in labs around the world, and their failures in clinical trials. Reconciling these results raises important new questions that may help to focus future directions.