New hope for adults with amblyopia (lazy eye)

By Professor Robert Hess

Robert F Hess ARTICLE IMAGE

Amblyopia is a visual developmental disorder in which the vision through one eye fails to develop properly in early childhood. The deficit is not in the eye itself but in the visual areas of the brain.

The disruption to early visual development can be due to a misaligned eye or an eye out of focus. Later, when the alignment is corrected by surgery or the focus corrected with lenses, the visual loss remains.

The treatment for the last 200 hundred years has involved patching of the fellow sighted eye, under the rationale of forcing the “lazy” eye to work.

Not too long ago, the patching was all day, but more recently, it has been restricted to 3-6 hrs a day.

In the majority of cases this does produce visual improvements, though there is a great deal of variability.

The cost in terms of inconvenience and psychological stress for the patient, usually a child at school age, is tremendous and the compliance is often low.

The end result after 6 months to 2 years of patching is certainly improved function in the majority of cases, but once the patch is removed the two eyes often don’t work together as they should, 3D vision is often not obtained and the fellow eye suppresses the amblyopic eye, which eventually leads to some reduction in acuity.

More significantly there is only a limited time-window in which the patching therapy works, kids are only patched up to the age of 12 years. There is no treatment offered to adults with amblyopia.

The current treatment approach is based on the assumption that amblyopia is the primary problem and the loss of binocular function is the secondary consequence.

The fact that reducing amblyopia with patching does not automatically lead to improved use of the two eyes together makes one question its validity.

There is reason to suspect the logic needs to be reversed, namely that the primary problem is that the two eyes, because of either an eye misalignment or an eye out of focus, stop working together with the secondary consequence being amblyopia. The link between disrupted binocular vision and amblyopia is suppression.

All amblyopes have some degree of suppression where the fellow sighted eye inhibits the functioning of the misaligned or out of focus eye to avoid the confusion resulting from a double or blurred image.

It seems perfectly feasible that over time this constant suppression leads to a more permanent loss of vision or amblyopia.

Recently we have developed tools for measuring suppression and shown that there is a direct relationship between suppression and amblyopia, consistent with the idea that the primary problem is the loss of binocular function with the secondary consequence the development of amblyopia.

This new way of thinking about the genesis of amblyopia leads one up a different treatment path, one that tackles the loss of binocular function as a first step with the expectation that the function through the amblyopic eye will improve as a consequence of the reduced suppression from the fellow eye.

With this new way of thinking about amblyopia in mind we developed a method of measuring the degree of suppression and arranging viewing conditions using dichoptic presentation (different images to each eye) where the suppression would be minimal.

Under these rather artificial (compared with natural viewing) viewing conditions we found that the two eyes were able to combine information normally. In other words, it was just the suppression that rendered that was a structurally intact binocular visual system into a functionally monocular one in amblyopic observers.

Furthermore, the more time the eyes worked together combining information (for the first time), the stronger their binocular capacity became and over time, the viewing conditions could be slowly moved in the direction of more normal viewing where both eyes sees the same images.

We (with my colleagues Drs Mansouri and Thompson) found that the binocular training only had to be done for 1 -2 hours a day for 4-6 weeks, after which the two eyes could work together under natural viewing conditions.

Once this was achieved we also showed that there were improvements in 3D vision, with some patients experiencing this for the first time.

The acuity of the amblyopic eye also improved as a result of eliminating the suppression from the fellow sighted eye. Even more remarkable all these results were obtained in adults, some of whom were middle aged, for whom there is no current treatment.

Robert F  Hess graphic

All of the above work was done in the laboratory using space consuming computer equipment. We then teamed up with our colleagues at McGill in Electrical Engineering (Drs Cooperstock, Long and Blum) and, using the same principle, converted it to a video game on an ipod. This introduced the first bit of fun into a treatment that has been anything but fun for the last 200years.

Tetris was used and it could only be played successfully if the amblyope truly combined the information from the two eyes because the information seen by each eye was different and both bits of information were used to play the game successfully.

We initially adjusted the dichoptic images for each patient to ensure that their suppression was minimal. As they successfully played the game, the viewing conditions were automatically adjusted in the direction towards normal viewing.

Depending on the patient and the degree of suppression, normal binocular function under normal everyday viewing conditions could be obtained within 4-6 weeks after 1 hrs of daily play.

The improvements in 3D vision and monocular acuity of the amblyopic eye were comparable to what we had found previously in the laboratory.

Initially we ran an in-office treatment study where we could ensure exact compliance and more recently we have run a take-home study and assessed compliance from the log files of the video game stored on the ipod. The compliance was excellent and the visual improvement comparable to our previous studies.

Very recently, we (Drs Li, Thompson, Chan, Yu and Hess) we assessed the current patching treatment with our dichoptic treatment. Amblyopic patients were divided into two comparable groups matched for the degree of amblyopia.

One group played tetris while being patched for 1 hrs a day for 2 weeks, the other group played tetris dichoptically (as described above) for 1 hrs a day for 2 weeks.

We measured 3D vision, degree of suppression and monocular vision. On all three measures, the dichoptic treatment was far superior to that of the monocular patching.

Furthermore, when the monocular patching group were crossed over to the dichoptic treatment, they too achieved comparable gains in each of these visual measures to that of the original dichoptic group, suggesting that the dichoptic approach, based on treating the binocular deficit, improves the function of the amblyopic eye more than the current patching approach.

Additionally, it does so with the extra benefit of having two eyes that work together that in turn ensures that any gains achieved in the function of the amblyopic eye will be maintained and not regress.

All of the above work was supported by a grant from the Canadian Institutes of Health (#53346) to RFH.

About Professor Robert Hess

Robert-F-Hess-250Professor Robert F. Hess is the Director of Research at the Department of Ophthalmology, McGill University, Canada, and founding Director of the McGill Vision Research Unit.

He is also an associate faculty member of McGill’s Departments of Psychology, and Neurology and Neurosurgery.

Prior to setting up the Unit in 1990, he was a Wellcome Senior Lecturer at the University of Cambridge’s Department of Physiology in the U.K. from 1982 to 1990, and a Meres Senior Fellow for Medical Research at St. John’s College, Cambridge, from 1977 to 1982.

Among Hess’ accolades are his winning of the Eldridge-Green Medal from the U.K.’s Royal College of Surgeons for his research in ophthalmology, and his invited deliveries of the prestigious Champness Lecture to the Worshipful Company of Spectacle Makers, the Clair Bobier Lecture in Vision at the University of Waterloo, Canada, and the Centenary Vision Lecture at Aston.

Aston also awarded Hess a DSc in 1998 in recognition of his outstanding contributions to vision science. He has published more than 320 peer-reviewed papers.

His broad research interests in normal visual processing include spatial, temporal, stereo, and motion processing, and he utilizes various techniques such as psychophysics, computational modeling, single-cell neurophysiology, evoked potentials, functional magnetic resonance imaging, transcranial magnetic stimulation, effective connectivity analysis and voxel-based morphometry.

Hess’ interests in clinical vision, centre on amblyopia, but he has expertise in the general area of low vision as well as normal visual function.

He has served on the editorial boards of renowned vision science journals, and was the founder and editor-in-chief of Clinical Vision Sciences in the 1990s.


Disclaimer: This article has not been subjected to peer review and is presented as the personal views of a qualified expert in the subject in accordance with the general terms and condition of use of the news-medical.net website.

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Comments
  1. Ángel Ferrero Ángel Ferrero Spain says:

    Hi there.
    I'm very interested in this treatment. I'm a 33yo amblyopic (weak left eye with 40% vision) and I'm from Spain.
    Here in Spain, amblyopia doesn't have any treatment at all, every single ophthalmologist says that amblyopia can only be treated before the age of 10 and the only therapy is patching the strong eye before the age comes.
    I don't know how can I get close to a treatment. I want to improve my visual acuity.
    Does anybody know how frustrating is it when your buddies talk about how amazing is Avatar in 3D and not really knowing WHAT does it mean... Or how frustrating is declining a movies evening because the movie you're going to watch is in 3D...
    How can I get to this treatment?
    I've been treated with Lasik in both eyes, this was good, but not enough.
    I'd appreciate any help.

    Thank you!

  2. Abdel wahab Abdel wahab Egypt says:

    Hello everyone , I'm from Egypt and I have an amblyopic eye ( right eye is 50 % ) and I wear glasses Frown I'm really interested in the treatment and I wish I would know anything about it .
    The doctors here would say even if your are 16 year-old-boy but the treatment is only for children under 9-10 years and that causes me depression  Frown( I wish to have a normal eye
    Can you help me please ?? Smile

  3. Margaret Moneys Margaret Moneys United Kingdom says:

    My 6 year old son suffers from a lazy eye, something I have had for 30 years but have had no option but to live with due to it not being picked up early enough.

    I really don't want my son to suffer due to this and after almost 2 years of wearing glasses and 3 monthly visits to the hospital he doesn't seem to be making any improvement and the next step is to wear a patch (something I would like to avoid if at all possible due to the psychological effects).

    How would I go about having my son involved in trials? The optician at the hospital isn't seem to be aware of this type of treatment in the UK.

    I would be grateful for any advice. Thanks

  4. Abhilasha Ahuja Abhilasha Ahuja Qatar says:

    Hi

    My name is Abhi and I am 45 years old.

    My right eye is Lazy from birth. My parents realized that I had a lazy eye when I was  16 years of age and going to the University. It was too late for the treatment the doctors said. The vision in the Lazy eye is 6/60 and the correct eye is 6/6.

    As it is very difficult to see with the lazy eye the thought of something happening to my good eye scares me a lot.I would really be interested in the treatment if possible in my case. Please advice weather this might work for me or not.

    thanks

  5. Aimee Henderson Aimee Henderson United Kingdom says:

    I remember having to be patched as a child. It really isn't what a young child needs in their day to day life. My right eye is still very weak, though the alignment was fixed at an early age. It would be great to see treatments like this available for adults. (Maybe I'll even be able to see a 3D film and see what all the fuss is about!)

  6. Brian Clancy Brian Clancy Ireland says:

    It's impossible to understand what this article is saying - typical of specialists.

  7. Will Do Will Do United States says:

    I have a lazy eye and something puzzling has occurred.   First a little history, I first noticed it when I was around 16.  I inquired about fixing it and I was told that I was too old.  To prevent squint, I tried to exercise my eye.  As the years went by I just adjusted to my lazy eye but I focused mainly out of my good eye.  I am 67 now and up until about 2 years ago I could not see anything clearly out of my lazy eye even with glasses.  For some reason the vision in my lazy eye improved.  The doctor said that I have cataracts so I decided to have them removed.  Before the cataract surgery the vision in my right eye was 20/80 with my glasses.  After the cataract surgery and implant my vision improved to 20/25.  I still cannot understand how my vision improved from being somewhat blind to 20/25.  My ophthalmologist was amazed at how much my vision had corrected.

  8. Richelle Danganan Richelle Danganan Philippines says:

    i have also a lazy eye on my left eye..i was 25 right now before i go to a doctor and they told me that i have a lazy eye..i cant read using my left eye and i only see a haft vision...and the doctor said that my optical nerve is damage and it can lead to total lost of vision..is it possible to correct my vision at my age..or to improved my vision..pls help...

  9. Ahmed Noman Ahmed Noman Islamic Republic of Pakistan says:

    hi, im 30 and from pakistan and i also have a lazy eye problem.. when i was a kid i remember doctors used to say i have a squint.. but just after recently when i read it on the web that its actually the lazy eye that im suffering from becomes really frustrating.. i couldnt see from one eye properly even though my eye sight is 6 by 6.. more frustrating is that the vision is reducing from the effected eye every year.. i can pray to God that everyone included myself who is suffering from this disease should get rid of it..
    plus i have been flying kites all my childhood but that couldnt help either. so i dont think playing games would work.. i think its all lies inside our brain and very much related with the nerves, we actually lack power and energy in our nerves attached to the effected eye...
    wish you all good health folks!
    regards,
    ahmed noman

  10. Tony Warren Tony Warren United States says:

    I'm 59 years old and as a child had two eye surgeries and did eye patching. Unfortunately my right eye is still suppressed. A possible treatment for adults with amblyopia would be amazing. Please sign me up even if it's just for a clinical trial.  Keep up the good work.

  11. Kimberly Marie Kimberly Marie United States says:

    I am 38. I have had a lazy eye since I was a baby . My right eye. I had muscle surgery as a baby. I wore the patch for a while in elementary school. It is getting worse now. I'd like to try this treatment. I could never pass a depth perception test or enjoy a 3d movie. I'm tired of people noticing. I also passed it down genetically to my daughter. She is 16 and her issue seems slight. I'm sure it will get worse with time. Contact me please.

  12. Margaret Melfa Margaret Melfa United States says:

    I am 47...i was born with esotropia, and have had 3 surgeries to keep my left lazy eye aligned...most recent surgery in 2001. My parent patched the good eye when i was under 3 yrs of age, but nothing really helped permanently. When i'm tired my weak eye drifts more, and it is hard for me to keep it focused. I only have one "good eye"...when i cover it, i can't read past the first line on the eye chart. I would love info on any types of new treatment available!!!

  13. Christopher Pa Christopher Pa Germany says:

    I have a mild amblyopia in my left eye (80% vision) and alternating strabismus since I was a baby. Is there a danger of double images when the supression is reduced? Or is it possible to restore the binocular function that is currently not working?
    Thanks!

  14. Katja Korenjak Katja Korenjak Slovenia says:

    Hi. I am 33 from Slovenia and also suffering from amblyopia on my right eye. For now my left eye is completely healthy and my vision is 100%, but the thought of something happening scares me, since my right eye vision is very poor.
    I too am interested in this treatment.
    Regards, Katja

  15. Hiren Adesara Hiren Adesara United States says:

    I am 28, and I have amblyopia. And would be love to sign up if there is ANY treatment for amblyopia. I live in california.

  16. Emanuel Ortega Emanuel Ortega United States says:

    Hello!  

    I'm 32 and also suffering from Amblyopia on my right eye. I am interested in information and treatment.

    Thank you!

  17. Mike Perez Mike Perez United States says:

    Hello I am 22 and have had Amblyopia since birth in my right eye. I did the patching method and received surgery at an early age but neither worked. I am very interested in any information for a treatment you could share. My email is perez.michael@outlook.com
    Thank you very much.

  18. Enrique Acevedo Enrique Acevedo United States says:

    I am 46 and have been told that I could not even get Lasik on my good eye because their insurance would not cover the clinic if they screwed up and permanently damaged my good eye.  I thought I had no options until I read this article.  Did not get diagnosed early enough.  I would love to be a subject in your study.

  19. Israel Hlychho Israel Hlychho India says:

    Hi there, I'm 23 and I have amblyopic right eye. Doctors told me that the retina in my right eye is clouded by some white thing, which they are not sure of what it is. They told me that it could not be removed by surgery because there are so many risks in the process, and that the sight could be improved only upto 70%. So I am wondering if binocular training could bring me any improvement in my sights (of course for my right eye), because wearing glass tickles my face and does not work at all for my blurry vision, or any vision related problem in my right eye for that matter. I'd very much appreciate to receive your suggestions.

  20. Jo Carpenter Jo Carpenter je says:

    Hi, I am a 48 year old woman who has an amblyopic left eye. I went cross eyed at 2 and doctors removed a bit of muscle out of each eye. I was left with a lazy left eye. I was patched for a long time as a child and it was horrendous. Kept walking into things and it was so uncomfortable and very frustrating. Now that I am older, and I do a lot of computer work, my eyes get really tired but my poor lazy eye just closes now. It closes a lot, even in just a slight breeze too as it is so sensitive. I don't really understand the article as its written in doctor language, so I have emailed it to a doctor friend of mine to disseminate it for me. I would love to be part of a trial to see if your technique works. Please contact me if this would be at all possible. Many thanks and the best of luck to everyone out there, Jo

  21. Pam Newberg Pam Newberg United States says:

    Can you send me information as well?  We'd love to try this method for a 16 yr old.
    Thanks so much!

  22. Hi
    Oprea Stefan Oprea Stefan Romania says:

    Hello everyone, I am Oprea Stefan and I am 14 years old from Roumanian,Europe. Here we don t have a good tratament for amblyopia, my left eye is 50 with glasses, and my right eye is 100 (so he don t have problems) as I child I don t have money to do many things but I have a natural life style, I patched my eye 3 hours on day and I do exercices for my eyes, To be honest the result is very good I know I will have a normal eye, I think I see 3D, I mean when I was child my eye got patched too, I am sure I see 3D and I have a binocular vision too, but I want to be sure, so I will folow all natural trataments and I do what is in my power to see absoluty normaly, because I want to become a footballer and play in Europe. Hope all of you who see this comment will see normaly, I am sure you will. I am sorry for my bad english. Bye,bye!

  23. Dave S Dave S Canada says:

    Hi,
    I was born cross-eyed, had surgery to correct my eyes and wore a patch when I was very young. I hated the patch, and have been told I used to remove the patch often....
    I now have a lazy eye (right eye). I also have double-vision as a result of my eyes not working together. Not sure if other people here also have double-vision? It's something I've grown up (I'm 48). I'd like to have the correction done to my right eye (I am not so concerned about "better" vision in my right eye; I would like just to have my eyes aligned)... on a daily basis I get people turning their head to look behind them when I am talking to them (because they look at the lazy eye, which is pointing outward). I've tried to deal with this my entire life. My daughter (she's 5 1/2) will soon be asking why daddy's eyes aren't aligned. She'll probably turn her head too when I talk to her. I hate having to drive my vehicle when my wife is with me. Because I use my left eye for EVERYTHING, I tend to turn my head slightly to the right... so my left eye sees "Middle" (if that makes sense?). She has commented more times than I care to think about, "Keep your eyes on the road!". I have to then explain to her that I am. How embarrassing. Or when I turn to look at her, I have to turn my head far to the right (so I can see her with my left eye!) It makes me look as though I am peaking into the back seat!! Again.. how embarrassing. Or when I'm having a conversation with a co-worker... sometimes I can see the image from my right eye (double-vision, remember) and the eye is pointing outward... so not only do I see something off to the right, but my co-worker clearly sees my right eye off in la-la land. How embarrassing.
    I consider myself to be very thick-skinned... and I don't break down easily.. but talking about my lazy eye (and/or seeing somebody turn their head when I'm talking to them) can easily bring me to tears.

    During a recent visit to a NEW optometrist, she discussed the Prism fix for my eyes. Sadly, the glasses with the prism did nothing to bring in my right eye. He's a stubborn old cout...I'm staying out in Right Field!!!!!

    I was wearing a patch up to a while ago. It was just too difficult for me to go about my daily routine. So I stopped wearing the patch. Not to mention the wicked headaches I was getting.

    So let us rejoice all of us with lazy-eye!! Surely, if they can send men to outer space, they can find a cure/fix for lazy eye! Even when we are already into our adulthood.

    BTW: With contacts/glasses, I have 20/20 vision in my left eye and 20/200 in my right eye, so pretty much blind the right! Given the choice, I would rather have minimal vision in my eye versus being blind. I have never enjoyed a 3-D movie, and when my family and I visited Universal Studios, in California in 2012, I truly missed out experiencing the joy that my daughter was experiencing from the 3-D and 4-D movies! Literally everyone in the theatre would jump when things were "popping out of the screen", except for me.... I was left asking, "What happened?" How embarrassing.

    I'm not at a point in my life where I am considering having surgery to correct my lazy eye (for cosmetic reasons only.)

  24. Dave S Dave S Canada says:

    I'm interested!!!!!

  25. Lowell Thompson Lowell Thompson United States says:

    I am also interested in this treatment. I am 47 years old and have lived a great life in spite of my amblyopia. As I age my vision get worse (-7.50) in my good eye now. I was told I was about 20/400 in my right eye. If there is anything you could do for me I would greatly appreciate it.

The opinions expressed here are the views of the writer and do not necessarily reflect the views and opinions of News-Medical.Net.
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