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Amblyopia Video Game Treatments on the Horizon

In a recent blog post on new treatments for amblyopia (sometimes called “lazy laze”), I mentioned the Tetris study from a few years ago.* When this study was done, it was exciting because it was just a hint of the possibility of treatments that lay ahead.

Well, this morning I see in the Wall Street Journal “Digits” blog a story called “To Play Ubisoft’s ‘Dig Rush,’ You’ll Need a Prescription”. It reports about a new game from a major game company where thepoint of the game is to train the eyes to work together. This approach differs from the traditional treatment for amblyopia in which the stronger eye is patched in an effort to force the weaker eye to do more work. The blog also points out that figures from the National Eye Institute reveal that approximately two or three of every 100 kids may have amblyopia.

Here are some very compelling images from the game. As you can see this is the type of red/blue therapy where one eye sees the red images, one eye sees the blue images, and both eyes see the gray images. Optometists have used this for decades, but not with such fancy graphics.

amblyopia video game

amblyopia video game

I am also very interested in a therapy game for amblyopia and strabismus call “Diplopia“. It is based on the head-mounted virtual reality display Oculus Rift.  I do not know a great deal about, other than it is being studied for use in clinics and looks AWESOME! You can see it in action in this video here.

amblyopia video game

It will be quite some time before these types of amblyopia video games are available for mainstream treatment of patients, but I think you will agree that  they are pretty exciting!

-Dr. Nate


* Just for fun you can play a Magic Eye version of Tetris here. It is not the Tetris used in the study, but it is interesting.

Amblyopia Research Supports Treatment Without Patching

New amblyopia research shows that treatment with both eyes is better than patching alone!

eyepatch used in amblyopia researchFor ages, the majority of amblyopia research and treatment has focused on two areas: the use of glasses to provide the clearest vision possible and the use of an eye patch to force the amblyopic (weaker) eye to see.  Patching often worked well. But there are some reasons why patching alone often doesn’t work.

The problem is patching is two fold:

1) Patching is hard!  (It can be like a form of torture for some patients.) Cover up your good eye and see everything blurry for hours on end. You are forced to use an eye that you are not comfortable using, without having any idea how to intentionally move or change focus in that eye. You are just supposed to figure it out. Patients resist patching, avoid visually demanding activities, get frustrated more easily, and often “cheat” or “peek” from behind their patch.

As the American Optometric Association’s Amblyopia Patient Care Guideline says, “Noncompliance with occlusion represents a significant factor in occlusion failures, especially in patients over 8 years of age in whom up to 50 percent noncompliance is common.”

2)  Patching alone does not solve the underlying problem. Amblyopia is not a situation where one eye is normal and the other is lazy. Amblyopia is a situation where one eye is struggling to focus clearly or stay pointed in the right direction, and the other eye is a bully. Yes, literally. The bully eye steals the brain connections from the weaker eye and uses them for itself. So while patching helps the weaker eye reinforce brain connections and see more clearly, it does not teach the bully eye to be nice. It just means the weaker eye can stand up for itself.

For example, it is like taking a right-handed child and putting the right arm in a cast for 8 hours a day for a year or so. Without helping them learn to hold a pencil, button clothes, or eat with their left hand – what will they do? They will avoid activities that need them to use their hands because they are clumsy. And when the cast is off, the right hand still takes over. What about activities that use both hands together, like tying a shoe? They still haven’t really developed equal strength between both hands, fine motor control of the left hand, or any coordination with the right hand.

The same happens with binocular vision (using both eyes). Patients who only use patching, often find the amblyopia returns when the patching stops, because they never learned to use both eyes together. It’s easy for the eyes to slip back into old (bad) habits. More patching? Again? At some point, it would seem easier to just give up and accept less than ideal vision.

But there is good news! I have written about some exciting developments in amblyopia research before, such as the amblyopia Tetris study, which showed that amblyopic treatment not with patching, but by treating both eyes (binocular), improved amblyopia in adults.

amblyopia researchI am happy to report that there has been a recent spate of studies concerning the binocular treatment of amblyopia. Optometrists have felt for years that amblyopia was primarily a binocular phenomenon, and therefore required binocular solutions. We have anecdotally observed 1) faster treatment of amblyopia with binocular vision therapy and 2) greater regression with patching alone versus patching plus some form of binocular therapy. We are very excited to see excellent recent research that supports this view, mostly done by ophthalmologists and neuroscientists.

Be warned, gentle reader, the following are quotes directly from the published scientific papers on amblyopia research. I will summarize below each passage.  Emphasis mine.

Converging evidence points to the pivotal role of decorrelated binocular experience in the genesis of amblyopia and the associated residual deficits. These findings suggest that a new treatment approach designed to treat the binocular dysfunction as the primary deficit in amblyopia may be needed. Prog Retin Eye Res. 2013 Mar; 33: 67–84.

What this means: It turns out that amblyopia might be due to a problem of both eyes, not just the “lazy” one. We should find a way to treat both eyes together.

…dichoptic perceptual learning, designed to strengthen binocular combination by reducing suppression, improves both stereopsis and acuity in adults and children with amblyopia…. As a whole, these results lead us to question the prevalent view that amblyopia is primarily a disorder of monocular vision and should be treated accordingly with monocular occlusion. If we are open to the possibility that binocular interactions lie at the heart of amblyopia, then we could be at the threshold of a new age of therapeutic interventions that don’t involve patching the fellow fixing eye. Ophthalmic and Physiological Optics Volume 34, Issue 2, pages 146–162, March 2014 

What this means: Yep. Amblyopia is a problem of both eyes. And treating both eyes is better. And that means that hours of patching one eye might soon be a thing of the past. And vision therapy is the way of the future for patients of any age.

Update: You can see some examples of modern amblyopia video game treatment in this post.

If you want to read more about the amblyopia treatment that we offer go here. If you would like to make an appointment to have yourself or child evaluated go here or call 813-792-0637.

Onward and Upward!

Dr. Nate on amblyopia research

An Infographic About Amblyopia

There is a lot of discussion lately about amblyopia (AKA lazy eye), largely due to the recent news reports of adaptations of Tetris and other video games as treatments for amblyopia. As I described in my previous post, these new binocular techniques are definitely better than old-school patching. However, in there essence, these techniques are not new. In fact, optometrists have known for a long time that treating two eyes is better than one. That is the basis of what we do in the vision therapy room to help patients with amblyopia – play games with both eyes at the same time.

I’m very happy to share with you an infographic on amblyopia treatment from the VisionHelp blog.

Amblyopia Infographic

You can read the full story behind the origin of this excellent infographic here. I think it is fantastic!

If you and your child are struggling with patching – you don’t have to be! Not only is binocular therapy more effective than patching – it is way more fun! If you have questions about amblyopia, vision’s therapy, or children’s vision in general, do not hesitate to give us at call at 813-792-0637 or email me at Doc@BrightEyesTampa.com.

And please  – share, pin, tweet or photocopy this infographic!

Dr. Nate

By Nathan Bonilla-Warford, OD
Bright Eyes Family Vision Care
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Tetris therapy for amblyopia? Yes, please.

A new study, about amblyopia, has been published and it is really getting attention. From CBS news to Huffington Post to CNET, everyone is covering it, probably because they get to use the word “Tetris” in the title. Tetris, of course, is the hugely addictive block-stack game that, at least in my memory, was the first hand-held videogame blockbuster.

Amblyopia, known to many people as “lazy eye” is a visual adaptation to conditions that interfere with visual development. On a simple level, it means that even with the best glasses or contact lenses, the eye does not see and function as well as expected. It is not due to disease or injury, but rather a situation where the brain doesn’t communicate well with one eye and can’t use the eyes as a team.
Think of the brain being someone on the internet, and one eye is a friend with 14.4K dial up and the other has a 4G smart phone. Yes, you can communicate with both eyes, but you are going to prefer the 4G because it is faster and can do more things. Trying to use both eyes simultaneously as a team is hard because one is lagging behind and missing information.

I am extremely glad to see this study and I do have some thoughts on it:
First, do not get too excited about the Tetris part. While I really have no doubt that Tetris and similar games stimulate visual planning and cognitive development, I suspect that the main benefit of using Tetris in this study is that it is very engaging, requires attention to visual detail, and requires the  player to make decisions based on visual information. Basically this is true for most video games (and real world games, for that matter). So Tetris is not the magic here.

What IS a big deal about this study is the goggles – they required the eyes to work together to play the game. If you play, you can’t just shut off the amblyopic eye, or you’ll lose because you won’t see the falling blocks. And that isn’t motivating or good therapy.  It isn’t patching or covering the good eye because you won’t see the blocks on the bottom. You still won’t win. This is like conventional patching. You can stimulate the amblyopic eye (upgrading the modem), but that alone only helps somewhat.

What this study shows is that only when both eyes can see and are given the opportunity to work together to achieve a common visual goal is there significant improvement in the amblyopic eye. In my internet analogy, this is not only giving the amblyopic eye a 4G smartphone but making sure it is net savvy. Both eyes are now friends on Facebook and Twitter so they can work together in real time to solve visual-spatial problems efficiently. (Just to be clear: the eyes do not use Facebook, and they do not communicate directly – all that happens in the brain).

So why is this so exciting? Because this is exactly what we do in vision therapy every day. We “upgrade” the eyes to work well individually (4G) but also “network” them to work together (Facebook, Twitter). We don’t use Tetris, but we do use paper & pens, balls, special glasses, computer programs, 3D art, optical illusions and lots of other fun tools to make it fun and productive.

It is great to see more research on this on adults with amblyopia. For too many years, patients have been told that after early childhood there is no hope of improving the vision in the amblyopic eye. It simply is not true. I did a blog post awhile back on the science behind amblyopia. You can see that here. For a great look at binocular treatment of amblyopia, see this recent post on the VisionHelp blog.

Dr. Nate

By Nathan Bonilla-Warford, OD
Bright Eyes Family Vision Care
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AOA School Readiness Summit: Focus on Vision

The American Optometric Association recently held a School Readiness Summit: Focus on Vision in which doctors, nurses, educators and advocates for children’s health gathered to examine learning-related vision issues that are keeping children from achieving in the classroom. This summit was created to address the concerns that our current system is flawed and a policy shift is needed. The problem is that currently, the U.S. educational system and some health care providers rely heavily on vision screenings to discover the kids that need comprehensive exams. These screenings do catch some types of vision problems but they can miss about 75% of those children that have learning-related vision problems. Detecting these vision problems is very important as “studies show that much of what children learn comes though vision, and undetected and untreated eye and vision disorders in children, such as amblyopia and strabismus, can result in vision loss, additional costly treatments, delayed reading and poorer outcomes in school.”

The take-home statement that the summit produced is that comprehensive eye exams must serve as the foundation to determine school readiness in school-aged children. Another important point established at this meeting is the establishment of the link between healthy vision and classroom learning.

This historic summit is an important step in ensuring that children receive the proper detection and treatment of vision problems before they become detrimental to their learning. Here at Bright Eyes Family Vision Care, we are excited to see these changes being made, since it has been our goal from the beginning to not only catch vision problems at an early stage, evidenced by the InfantSEE program that we offer that provides free eye exams to infants between the age of 6 months and 1 year of age, but to also treat certain types of problems through our extensive one-on-one vision therapy program.

If you have any questions regarding the InfantSEE program, vision therapy program, or would like to schedule a comprehensive eye exam for your child before they start school, give our office a call or come in to schedule.

All the best,

Justin Schoonover, CPO

Bright Eyes Family Vision Care
Located in the Westchase area of Tampa.
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Johnny Depp Can’t See 3D Movies – Maybe He Should See an Optometrist

It’s true! According to several recent entertainment stories such as this one from Engadget,  Johnny Depp is unable to see the 3-D effects in the very movies that he stars in. Specifically the upcoming  Pirates of the Caribbean: On Stranger Tides, which is to be released May 20th.

They way Depp described it, “I’m unable to see in 3D. My eyes don’t see in 3D. I have a weird eye… It just doesn’t work.”

While  all this may seem like a small bit of movie trivia to many people, this may remind a lot of folks of themselves… or their children.  We don’t know exactly what is weird about his “eye”, whether it is amblyopia (often called “lazy eye”) or some other condition. But we do know that many of the types of problems can be detected at a very early age. It is recommended that babies have their first eye exam at six months old. Treatment such as glasses or contacts or medical procedures to prevent further problems may allow the patient to have as normal vision as possible…. even normal 3-D vision. Also, vision therapy may be an option to give 3-D vision to patients,  young or old. The book “Fixing My Gaze”  by Dr. Susan Barry is an excellent example of this.

The recent news about Johnny Depp is just one more reminder that if you or anyone you know has trouble with 3-D movies you should see an optometrist.

Dr. Nate

Nathan Bonilla-Warford, OD
Bright Eyes Family Vision Care
Located in the Westchase area of Tampa.
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Acupuncture for Amblyopia (Lazy eye)?

A recent study came out yesterday that has a lot of people talking. Acupuncture may be as effective in treating amblyopia (lazy eye) as patching.

From the CNN story Needles trump patches in treating kids’ eye problem:

In the randomized trial, researchers compared the effectiveness of two hours of daily patching therapy with acupuncture for treating lazy eye in 88 children aged 7 to 12. All children had already worn glasses for at least 16 weeks. 43 of the children were randomly assigned to the acupuncture treatment group, receiving five treatments per week that targeted five needle insertion sites. 45 children in the patch group had their stronger eye patched for two hours per day and were instructed to do activities such as reading and typing, which helps to strengthen near vision in the weaker eye.

What do I think about this? I don’t know. I’m not highly educated in acupuncture. I do think it has it’s place. I do know that patching alone is not as effective as vision therapy because patching treats one eye and not both. (See this recent post by Dr. Len Press for additional info). So it is not compelling that acupuncture is better than patching.

I also know that amblyopia is much more than a visual acuity problem. It is a problem of many visual skills including focusing and perception. So much more extensive research needs to be done. But this is a good sign that ophthalmologists and visual scientists are looking into complex areas of vision and visual treatment.

Before anyone undertakes acupuncture for amblyopia, I do recommend a comprehensive visual and eye health evaluation by an optometrist who specializes in children’s vision. If you need to find one, COVD is a great place to start.

So that is my opinion. What do you think about acupuncture for amblyopia?

Nathan Bonilla-Warford, OD
Bright Eyes Family Vision Care
Located in the Westchase area of Tampa.

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The Science Behind Amblyopia Treatment

You may have a friend or family member who has had or is currently undergoing treatment for amblyopia. Even if you don’t know anyone with amblyopia, you likely have some idea that sometimes kids have to wear an eyepatch to improve the vision in their other eye. That treatment is indeed the time-honored, effective treatment of “lazy eye.”

But have we learned anything since the first patch was used? How many hours are you supposed to patch? Are there other options? Do they work? How do we know?

Fortunately, visual scientists have been hard at work the last few years, giving us valuable information that can help doctors guide their patients and parents towards the best, most effective, best tolerated treatment. I have selected a few research studies to cover here. If you want more detail, follow the links provided to obtain your own copy of the studies.

Of course, (and this goes without saying, but I must say it)  TALK TO YOUR DOCTOR before acting on anything written here or changing any part of your prescribed treatment. If you have questions about how this research affects your treatment, print out the study and take it with you to the next evaluation.

Now, on to the studies………

Continue reading

Ask Dr. Nate: Is Vision Therapy an Option at My Age?

I am a 36 year old male and have struggled with mild to moderate amblyopia most of my life. I am able to fuse close up and have very good hand eye coordination but at distance, such as driving, I am unable to fuse and the resulting strain  worsens the eye turn. Is vision therapy still a viable option at my age?

This is an impossible question to answer without the benefit for a full, thorough vision exam. This would show the cause and severity of the amblyopia, eye turn,  and other visual problems that you may have and identify areas of possible improvement.

But even without the particulars in your case, I can say a few things generally. Because the purpose of vision therapy is to help you develop visual skills that may be lacking, there is not point in life when it is not possible to receive some benefit from vision therapy. The real question is this: Are you bothered enough by your visual problem that you would like to take the steps to improve the situation. (Case in point, this video of a 101 year old vision therapy patient.)

But I don’t want to paint vision therapy as a panacea either, because some conditions are very complicated and can take a significant amount of time, effort, and expense to improve. Some conditions are best treated with a combination of vision therapy and other methods, such as special glasses or surgery. Yet other conditions are better left untreated.

I would recommend against any of the “improve your vision” ads on TV or the internet. Many of these have elements of legitimate therapy, but they tend to over-promise and do not match the person with the appropriate therapy. Instead, only pursue therapy from a doctor with specialized training in visual function and vision therapy.

Have you read Susan Barry’s book, “Fixing My Gaze“? I very highly recommend it. You may also find this blog interesting: http://seeing3d.blogspot.com/.

If you would like more information about the evaluation or vision therapy, please do not hesitate to call and speak to Edna or myself.

Best Wishes.
Dr. Nate

Nathan Bonilla-Warford, OD
Bright Eyes Family Vision Care
Located in the Westchase area of Tampa.

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