Eye disorders and vision problems are among the most common long-term medical conditions Australian children face.1 Amblyopia, or lazy eye, although treatable, remains the leading cause of monocular vision loss in children. Digital therapeutics based on a virtual reality (VR) headset and adapted video games, or TV shows could change the way eye care professionals determine treatment options.
Amblyopia affects the visual development of children. Commonly known as lazy eye, the condition develops when the cortical visual development of a child is disturbed. Amblyopia is more likely to affect one eye, although the condition can also occur bilaterally.
Recognising and treating this condition early is critical because how we see as infants and children determines how we see as adults.2 A delayed diagnosis or treatment that is ineffective could affect children well into adulthood. Even if kids are diagnosed early and current treatment protocols are well established, they are not always as effective as they could be. That is why we talked to patients and their families, ophthalmologists, and optometrists to learn what the future of amblyopia treatment could look like.
IMAGINING THE FUTURE OF AMBLYOPIA TREATMENT
Imagining the future of amblyopia treatment starts with looking at today’s treatment options and their limitations. Apart from refractive correction, eye patching or the application of atropine drops remain the gold standard of amblyopia treatment in Australia.
According to paediatric ophthalmologist Dr Rushmia Karim, the science behind today’s treatment protocols is strong.
“We have very robust results for both patching and atropine drops in clinical trials,” explains explains Dr Karim. “However, in practice, patient outcomes are not as robust as the science would suggest.”
So, if the science behind the treatments is strong, where is the disconnect between clinical trials and real-life applications? What is preventing or limiting treatment success?
BARRIERS TO TREATMENT
Dr Karim believes there are three main reasons for the gap between the success of treatment protocols in theory and practice:
- Educational and socioeconomic causes,
- Low compliance with treatment protocols, and
- The unkind and disruptive nature of the treatment itself.
“Essentially, interventions like having to wear an eye patch or being treated with atropine drops are unpleasant for the child,” says Dr Karim. “These treatments disrupt a child’s everyday routine. We’re asking them to complete a task and make an effort, both of which also put pressure on the parents and quickly lead to non-compliance.
“Parental motivation and compliance are also key to successful treatment. This starts with early education about, and understanding of, amblyopia. Discussions in the clinical setting take time, which can be difficult in a resource poor environment,” she says.
To transform the future of amblyopia treatment, parents and children need a solution that fits into the child’s daily lifestyle more seamlessly. New approaches like VR goggles have the potential to fill that void.
At the same time, every new treatment option that is based on technology raises questions about accessibility and funding. Paediatric ophthalmologists know that children from socially disadvantaged backgrounds have less access to eye screening and treatment, both in the public and the private system.
Geographic location also has a role to play. “In an urban area, children are likely to see an optometrist within days and a paediatric ophthalmologist within one or two months,” Dr Karim explains. Outside of Australia’s cities, wait times can be much longer, and parents may have to drive considerable distances to access treatment.
PUTTING PARENT AND PATIENT EXPERIENCE FIRST
Patient experience is critical to overcoming barriers to amblyopia treatment. Steven Wood’s daughter Maddie* was diagnosed with amblyopia when she was just one year old. “We noticed […] that one of her eyes was turning in a little,” Steven remembers.
While specialists agree that to be treated effectively, amblyopia needs to be caught early, there is no definition of the exact age range. Treatment should ideally start during the phase of maximum plasticity of a child’s visual development. Ophthalmologists and optometrists believe the optimal time for intervention is between the age of three visual development system loses some of its plasticity, and interventions tend to take longer to be effective. The therapies continue to work, but longer patching or atropine times may be necessary.
Maddie Wood’s amblyopia was diagnosed early, and her parents Steven and Sandy were offered the standard choices of atropine drops, eye patches, or glasses. They chose the drops initially, believing that this course of treatment would be more manageable than keeping patches or glasses on their one-year old. “Even so, putting drops in the eyes of a baby when they’re struggling or crying isn’t particularly easy,” Steven says.
“We moved to patches when Maddie got a little older. We started with sticky patches but soon moved to a cloth patch which fitted over her glasses’ lens. They were much more convenient, and by then she was more or less happily wearing her glasses.”
While cloth patches can be more convenient there is the risk that children can still peek through them under the glasses, so it is important to ensure the eye is fully covered by whatever means used.
Still, Steven and Sandy needed to apply a little creativity in the process: “We used to give her sultanas in her hands to distract her while we were putting the glasses and the patch on. Hopefully, her teeth haven’t suffered.”
Their experience resembles that of other parents in a similar situation, according to optometrist Peter Nixon. Mr Nixon is the owner of optometrists Pezzimenti Nixon and previously served as the Lead Optometrist of Children’s Services at the Australian College of Optometry. “Without a doubt, getting a child to wear their glasses on a full-time basis is battle number one,” Mr Nixon says.
Steven and Sandy’s raisin trick is not unique either, Nixon believes. “This [battle] involves a lot of work on the parents’ behalf and normally a lot of bribery until it becomes status quo. If amblyopia still exists after [that], the second battle is trying to get them to use a patch over their more functional eye.”
EXTERNAL REACTIONS CAN MAKE COMPLIANCE HARDER
Wearing eye patches in public does not go unnoticed, and Steven Wood remembers explaining amblyopia to strangers, telling them how covering the “good eye” encouraged the lazy eye’s visual pathway to develop.
In general, Steven believes that Maddie’s colourful patch would have led to lots of questions from other kids at her daycare and her school. He remembers most kids being simply inquisitive. But there were exceptions: “There was one incident we remember when she was bullied by some boys at the local swimming pool.”
Maddie’s treatment continued until she was 14 years old, by which time she was only wearing glasses. Her dad believes some aftereffects are lingering. “Maddie is still quite sensitive about [her treatment], so I imagine there has been some residual emotional effect from feeling different,” Steven explains. “She is quite self-conscious now, which may or may not be related to the treatment.”
Dr Karim is not surprised. “The interventions and treatment options we currently have are simply not pleasant,” she says.
Combined with the importance of compliance, this may explain the discrepancy between the potential of the treatment options as shown in clinical trials and actual patient outcomes.
“It is also worth noting that while treatment is not pleasant, it improves significantly as the weaker eye gains lines of visual acuity,” Dr Karim says.
“Compliance thus increases, and so does overall long-term vision.”
HOW TO IMPROVE AMBLYOPIA TREATMENT RIGHT NOW
Compliance remains the key to successful amblyopia treatment, but none of the currently available treatments make compliance easy.
Dr Karim believes that future treatments need to integrate into the patient’s lifestyle rather than disrupt it. She believes that incorporating virtual reality technology into amblyopia treatment has the potential to encourage excellent compliance if the content delivered via VR is engaging.
At the same time, she urges caution when it comes to the funding of technologybased solutions.
“I think we also need to be looking for a pretechnology solution that can help improve compliance with amblyopia treatment,” she says. “The initial education and discussion with parents, explaining what exactly amblyopia is and how the treatment can potentially improve their child’s vision is crucial to increase compliance and make the child and the parent feel engaged.”
For Mr Nixon, the future of amblyopia treatment lies in the teaching and exploration of binocularity, with technology playing a major role in helping to hold the patient’s attention while delivering visually challenging content.
VR-based tools may become an integral part of the treatment options available for amblyopia patients. Using game-based options like Vivid Vision3 or adapted movies like Luminopia One4 are more pleasant and potentially more likely to hold a patient’s attention. Mr Nixon believes in the efficiency of VR.
“My thoughts are that VR amblyopia therapy won’t replace conventional treatment,” he says. “But VR will be another amazing option to complement our patients’ therapy in the battle for great binocular vision.”
The Woods came across VR at a late stage of Maddie’s treatment and a very early stage of the technology. They made enquiries but ultimately decided against the option. “By then we were well into the routine of glasses and patching,” Steven says. “I think at that stage, to use the treatment we would have had to make an appointment and travel quite a distance, which wasn’t practical.”
However, if the family had to go through amblyopia treatment again, they would certainly consider it if a headset could be used at home.
“If it could be used as an alternative to screen time, we’d probably go with it instead of patching.
“This treatment would certainly be good for children who are very self-conscious about wearing glasses and patching.”
Innovative treatment approaches like VR headsets are almost guaranteed their place among amblyopia treatments of the future. Regardless, their availability does not take away from the importance of early screening reaching each Australian child and thorough diagnosis at the beginning of the treatment process. Based on that diagnosis, successful treatment will likely include traditional options like glasses,, patches, and atropine but also offer parents and patients additional digital treatment options.
To transform the future of amblyopia treatment, parents and children need a solution that fits into the child’s daily lifestyle more seamlessly
*Names of patients and family members have been changed to protect their privacy.
Yvonne Press is a writer with more than 15 years’ experience covering a variety of topics including healthcare.
- Australian Institute of Health and Welfare, Eye health among Australian Children (2008) https://www.aihw.gov. au/reports/children-youth/eye-health-australian-children/ summary [accessed 2 November 2022].
- Blair K., Cibis G., Gulani A.C., Amblyopia. [Updated 8 Aug 2022]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https:// www.ncbi.nlm.nih.gov/books/NBK430890/.
- https://mivision.com.au/2019/03/vivid-vision-partnerswith- acbo.