1. 屈光参差与远视储备差异的基础认知与病理影响
1.1 核心概念界定
屈光参差（Anisometropia）是指双眼屈光度数存在差异的一种视力状况。具体而言，它表现为双眼的远视、近视或散光程度不同，或者一只眼为近视而另一只眼为远视（即对向性屈光参差，Antimetropia）1。在临床实践中，通常将双眼球镜度数或等效球镜度数（Spherical Equivalent, SE）差值达到或超过1.00屈光度（D）定义为屈光参差234。这种度数差异会导致双眼视网膜上成像的大小和清晰度不一致，进而影响视觉功能。
远视储备（Hyperopic Reserve）则指儿童在视觉发育过程中，眼睛所具有的生理性远视度数。新生儿通常处于远视状态，随着生长发育，眼球轴长逐渐增长，远视度数会逐渐减小，趋向于正视眼（Emmetropia）状态，这一过程称为“正视化”5。远视储备被认为是抵消眼轴增长、预防近视发生发展的重要“缓冲”机制。
远视储备差异加大，通常是指双眼远视度数存在显著不对称，或者一只眼的远视储备消耗速度远快于另一只眼。例如，当双眼等效球镜度数差异达到或超过1.00D时，即使两只眼均为远视，也可能被视为远视储备差异加大，这会增加弱视和斜视的风险367。在儿童视觉发育的动态过程中，远视储备的量会随年龄增长而自然减少5。如果远视储备过早或过快地消耗，尤其是在学龄前儿童，则预示着未来发生近视的风险增高8。例如，有研究指出，在快速城市化的地区，学龄前儿童的远视储备消耗加快，正视化过程提前8。因此，动态监测儿童的远视储备及其双眼差异，对于早期识别视觉发育异常并进行干预至关重要。
1.2 病理机制与潜在风险
屈光参差导致双眼物像不等（Aniseikonia），即双眼视网膜上形成的物像大小、形状或清晰度存在差异。当这种差异较大时，大脑难以将来自双眼的图像融合成一个清晰的、具有立体感的单一图像，从而引发一系列视觉功能障碍。
主要的病理机制之一是抑制机制。为了避免复视和视觉混淆，大脑会主动抑制来自模糊或度数较高眼的视觉信号，尤其是在儿童视觉系统发育的关键期（通常是7-8岁之前）9。这种长期抑制使得被抑制眼的视觉皮层通路发育不完善，即使后来屈光不正得到矫正，视力也可能无法达到正常水平，从而导致弱视（Amblyopia）1011。屈光参差性弱视是儿童弱视的常见类型之一，其发生率较高12。研究显示，约有半数到三分之二的弱视儿童伴有屈光参差，无论是否合并斜视12。在一些未进行早期干预的先天性内斜视病例中，113名8岁及以上患者中有16名（14.3%）发生弱视，其中10名（62.5%）存在屈光参差，提示屈光参差与弱视之间存在显著相关性13。值得注意的是，有研究发现，屈光参差性弱视患者的弱视眼（通常是度数较高的眼睛）的眼球，尤其是左眼，可能更容易受到影响，提示可能与微斜视、注视优势或眼球发育中的其他侧向性因素有关14。
远视储备的过度消耗，特别是双眼远视储备消耗速率的不一致，是导致屈光参差加剧并最终引发近视化的重要因素。当远视储备过早或过快地减少时，眼轴会相应增长。如果双眼消耗速度不一，例如一只眼加速近视化，另一只眼仍保持远视状态，则会形成或加重屈光参差。这种眼轴的异常增长，在生物学上可能与视网膜离焦、多巴胺分泌失衡以及巩膜重塑等机制相关15。有观点认为，周边视网膜的远视性离焦（即周边视网膜成像落在视网膜后方）可能刺激眼球的代偿性生长，导致眼轴增长，从而引发轴性近视16。
屈光参差和远视储备差异加大的长期风险包括：
- 屈光参差性弱视：如前所述，由于双眼物像不等导致大脑对一眼的抑制，弱视眼的视力发育受阻，可能出现视力下降、对比敏感度降低、拥挤现象等10。
- 斜视（Strabismus）：屈光参差可能导致眼位偏斜，尤其是一只眼睛清晰，另一只眼睛模糊时，大脑为了保持清晰视野可能会选择性使用清晰眼，导致模糊眼出现内斜或外斜。斜视性弱视也是弱视的一种重要类型910。
- 立体视功能障碍（Stereopsis Dysfunction）：正常的立体视需要双眼接收到略有差异但能够融合的图像。屈光参差破坏了这种平衡，使得双眼融合困难，从而导致缺乏深度知觉或立体盲17。立体视功能受损不仅影响空间感知能力，还可能对日常生活（如运动、驾驶）造成不便。
- 视疲劳与阅读困难：双眼持续地尝试调节和融合差异较大的图像，会导致眼部肌肉过度工作，引发视疲劳症状，如眼胀、头痛、阅读困难等，影响儿童的学习效率和生活质量。
- 近视风险增高：远视储备的不足或快速消耗，特别是与屈光参差并存时，极大地增加了儿童发展为近视的风险。早期屈光参差若未能及时干预，一只眼的近视度数可能迅速发展，进一步拉大双眼差距，形成高度近视。
总之，屈光参差与远视储备差异并非独立的视觉问题，它们相互关联，共同对儿童的视觉发育构成威胁。早期识别和干预这些问题对于保护儿童的视力健康至关重要。
2. 日常生活中的护眼核心策略与实施细节
2.1 环境与用眼习惯优化
优化环境和培养良好的用眼习惯是预防和管理儿童屈光参差及远视储备差异的重要基石。这些策略旨在减轻视觉压力，促进健康的视觉发育，并延缓近视的发生发展。
光照环境
适宜的光照对于儿童眼部健康至关重要。研究表明，不佳的照明条件会增加用眼负担。在进行阅读、写字或使用电子设备等近距离用眼活动时，应确保环境光线充足且分布均匀，避免眩光和阴影。
- 照度标准：理想的桌面照度应达到300-500勒克斯（lux），整个房间的背景照明也应达到足够的亮度，以减少眼睛在不同亮度区域频繁适应造成的疲劳。一项针对中国儿童青少年屏幕使用行为的研究发现，70.65%的参与者在白天使用平板电脑时的照度低于300 lux，而夜间有61.11%的参与者在低于100 lux的照度下使用屏幕，这表明普遍存在照明不足的情况 18。
- 色温：光线的色温也会影响眼睛舒适度。过高的色温（如超过4000K）可能导致蓝光暴露增加。研究显示，色温从1200K增加到6500K时，蓝光危害因子和昼夜节律因子显著增加，尤其对1岁儿童影响更大 19。因此，建议选择色温在4000K左右的柔和、自然光线，避免过高色温的灯光，尤其是在夜间。
用眼距离
保持正确的用眼距离是减少眼睛调节负担的关键。
- 读写距离：建议儿童在阅读或书写时，眼睛与书本的距离应保持在30-35厘米（即一尺），胸部与桌沿保持一拳距离，握笔手指与笔尖保持一寸距离。
- 屏幕用眼距离：使用电子屏幕时，应保持更远的距离。例如，观看电脑屏幕应保持50-70厘米，观看平板电脑或手机应保持30-40厘米 18。不当的观看距离和姿势是儿童用眼习惯中常见的问题。有研究指出，51.03%的参与者在使用平板电脑一小时内，平均观看距离小于50厘米 18。AI警报系统在纠正不正确的观看习惯方面表现出有效性，能够迅速纠正不正确的观看距离（65.49%）和观看姿势（86.48%）18。
连续用眼时间与20-20-20法则
长时间近距离用眼会导致眼睛疲劳，增加近视风险。
- 连续用眼时间：建议儿童每连续近距离用眼30-40分钟，就应休息10-15分钟。
- 20-20-20法则：这是一种简单有效的休息方法，即每近距离用眼20分钟，向20英尺（约6米）以外的远处看20秒。这种短时休息有助于放松眼睛的调节肌肉，缓解视觉疲劳，从而降低数字眼疲劳（Digital Eye Strain, DES）的风险 20。DES是一种由长时间使用电子设备引起的眼部和全身症状，包括干眼、视力模糊和头痛等 20。
电子屏幕使用的时长控制与内容选择
随着电子设备的普及，儿童屏幕时间过长已成为全球性的健康问题，与视力下降、认知和心理发展障碍、睡眠问题等多种负面影响相关 2122。
- 时长控制：世界卫生组织（WHO）建议对儿童每日屏幕时间进行限制。
- 内容选择：屏幕内容的选择同样重要。
- 动态/静态画面的差异：与被动观看电视节目等静态或无互动内容相比，参与互动性、教育性强的游戏或应用，并有成人共同参与（共同使用，co-use），可能对儿童发展更有益 27。一项系统综述和荟萃分析发现，程序观看（program viewing）和背景电视（background television）与认知结果呈负相关，而共同使用（co-use）则与认知结果呈正相关 27。
- 避免不适宜内容：应避免儿童接触暴力、快节奏或不适合其年龄的内容，这类内容可能激活多巴胺通路，导致行为问题和注意力缺陷多动障碍（ADHD）相关症状 28。研究表明，长时间使用屏幕，尤其是夜间使用和手机依赖，与抑郁症状和睡眠障碍有关 28。
- 关注蓝光：电子屏幕发出的蓝光可能对视网膜产生潜在危害，并影响昼夜节律 19。虽然目前关于防蓝光眼镜的有效性仍有争议，但控制屏幕使用时间和调整屏幕亮度、开启夜间模式（降低色温）是更直接有效的措施。
综上所述，通过优化光照环境、保持合理的用眼距离、控制用眼时长并选择适宜的屏幕内容，可以在日常生活中有效保护儿童的眼睛，为他们的视觉健康发育创造有利条件。
2.2 户外活动的科学干预
户外活动是公认的有效预防近视发生和延缓近视进展的非药物干预手段，尤其对于保护儿童远视储备具有关键作用。其核心机制主要围绕光照强度对眼球生物学调节的影响展开。
每日2小时以上户外活动的具体实施
多项研究证实，增加儿童户外活动时间可显著降低近视的发生率和进展速度。一项大规模荟萃分析表明，增加户外活动时间对近视的发生（临床试验：风险比=0.536；纵向队列研究：风险比=0.574）和屈光不正的近视漂移（近视和非近视人群的加权平均差=-0.30D）均有显著保护作用29。建议学龄儿童每天进行至少2小时的户外活动。
- 光照强度：户外光照强度是发挥近视保护作用的关键因素。即使在阴天或树荫下，户外光照强度也远高于室内环境。研究显示，与室内（通常低于500 lux）相比，户外光照强度可高达数万乃至十万lux。一项台湾的学校干预研究发现，每天增加户外活动时间（每周最多11小时），并暴露在1000 lux或更强的光照下，能显著减少近视进展和眼轴增长。该研究指出，即便在1000 lux以上的相对较低户外光照强度下，长时间户外活动也具有近视保护作用，如在走廊或树下活动30。另一项上海的随机对照试验也强调了户外活动时长和光照强度与近视发生率降低和近视漂移减缓之间的关联。该研究发现，每天户外活动120至150分钟，光照强度达到5000 lux/分钟或累积光照强度达到600,000至750,000 lux，可使近视发生率风险降低15%至24%31。此外，佩戴智能手表监测的证据表明，持续15分钟以上且光照强度不低于2000 lux的户外暴露模式，与较少的近视漂移相关32。这提示，户外活动不仅要强调时长，也要关注在光照强度相对较高（如2000 lux以上）的环境中进行。
- 时段选择：户外活动的最佳时段通常是上午10点至下午4点，此时阳光强度较高，但应注意避免在夏季正午时分过度暴露于强烈的直射阳光下，以防晒伤。在其他时段，只要是户外环境，其光照强度仍普遍高于室内，均能起到一定的保护作用。
- 活动形式：户外活动不应局限于体育运动，散步、玩耍、课间休息、户外用餐等多种形式都可计入户外时间。研究发现，更高水平的总户外时间，而非仅限于体育运动，与较少的近视发生率和更远视的屈光度相关33。户外玩耍不仅对视力有益，还有助于促进儿童的社会技能发展，与更高的表达和顺从能力评分呈正相关34。
延缓眼轴增长的生物学依据
户外活动通过多种生物学机制延缓眼轴增长，进而保护远视储备，预防近视。
- 多巴胺分泌：视网膜中的多巴胺是调节眼球生长的关键神经递质3536。强光刺激，特别是户外高强度光线，能促进视网膜多巴胺能无长突细胞（dopaminergic amacrine cells, DACs）释放多巴胺37。多巴胺通过抑制巩膜胶原重塑，从而减缓眼轴的异常增长。当视网膜接收到不清晰的图像信号（如远视离焦，近视发展的前兆）时，多巴胺分泌会减少，进而加速眼轴增长。户外强光通过增加多巴胺分泌，对抗这种近视诱导机制15。
- 瞳孔调节与视网膜离焦：户外活动时瞳孔会自然收缩，增加景深，减少周边视网膜的远视性离焦，而周边远视性离焦被认为是刺激眼轴增长的因素之一。此外，宽阔的视野和不断变化的视觉刺激，有助于锻炼眼睛的调节功能和双眼协调性。
- 褪黑素与昼夜节律：户外光照有助于调节人体的昼夜节律。规律的户外活动和暴露于自然光线，能使褪黑素分泌模式正常化，而褪黑素与眼轴增长也有一定的关联。紊乱的昼夜节律可能影响眼球的正常生长发育。
- 减少近距离用眼：户外活动意味着儿童有更少的时间进行近距离用眼（如阅读、使用电子设备），这直接减少了眼睛的调节负担和视觉疲劳，间接保护了远视储备。
年龄特异性
户外活动对近视的保护作用在不同年龄段的儿童中表现出一定的特异性。
- 学龄前儿童：对于学龄前儿童，户外活动的主要目的是维持充足的远视储备，预防近视的发生。在这个阶段，儿童的眼球发育处于快速变化中，对环境刺激的敏感性高。充足的户外时间可以有效促进正视化过程，减少未来近视的风险。儿童每天户外活动时间应至少达到2小时，并可根据自身情况适当延长。
- 学龄期儿童：学龄期儿童面临更重的学习负担和更多的近距离用眼时间，因此近视发生和进展的风险显著增加。对于他们而言，户外活动不仅是预防近视的手段，也是延缓已发生近视进展的有效策略。研究表明，在学校增加户外活动时间（如课间休息、体育课等），可以显著延缓近视的进展3031。例如，一项研究发现，每天增加2小时课外户外体育活动，不仅在学业成绩上不劣于对照组，且在体能改善上更优，提示户外活动与学业表现并非零和博弈38。然而，中国学龄儿童，特别是城市女童和高中生，户外时间普遍不足，有超过五分之一的儿童每天户外时间少于1小时，城市儿童平均每天户外时间比农村儿童少13分钟39。这提示需要针对性地鼓励学龄儿童，特别是城市地区儿童增加户外活动时间。
总而言之，科学地安排儿童每日2小时以上的户外活动，注重光照强度和时段，并结合儿童的年龄特点，是保护远视储备、预防和控制近视的重要且经济有效的策略。
2.3 营养与发育支持
均衡的营养摄入对儿童的整体发育至关重要，特别是对眼睛健康和视觉系统的正常发育具有不可替代的作用。多种维生素、矿物质和脂肪酸被认为与视网膜功能、眼轴稳定性和近视的发生发展密切相关。
关键营养素对视网膜发育的作用与补充方案
- 维生素A (Vitamin A)：
- 作用机制：维生素A是视网膜光感受器中视紫红质（Rhodopsin）的关键组成部分，对于暗视力（夜间视力）和维持视网膜正常功能至关重要 40。维生素A缺乏症（VAD）是全球儿童可预防性失明的主要原因，可导致干眼病（Xerophthalmia）、角膜软化症（Keratomalacia）甚至永久性失明 41424344。
- 膳食来源与补充方案：维生素A主要来源于动物肝脏、蛋黄、乳制品等。植物性食物中的β-胡萝卜素（如胡萝卜、菠菜、甘薯、南瓜等橙黄色和深绿色蔬菜）可在体内转化为维生素A。对于儿童，应确保日常饮食中富含这些食物。在发展中国家，维生素A缺乏症仍然是一个公共卫生问题，世界卫生组织（WHO）建议对存在维生素A缺乏风险的儿童进行补充 41。然而，过量摄入维生素A也可能引起毒性反应，因此在不缺乏的情况下，不建议常规补充大剂量维生素A制剂，应以均衡膳食为主 41。
- 叶黄素 (Lutein)：
- Omega-3脂肪酸 (Omega-3 Fatty Acids)，特别是DHA (Docosahexaenoic Acid)：
- 作用机制：DHA是视网膜光感受器细胞膜的重要结构成分，尤其在大脑和视网膜的发育过程中发挥关键作用 48。充足的DHA摄入对视网膜神经元的健康、视觉信号传导和视敏度的发展至关重要。研究表明，DHA有助于改善干眼症状，并可能在预防视网膜色素变性（Retinitis Pigmentosa）进展方面发挥作用，尽管证据等级仍需进一步确认 4950。
- 膳食来源与补充方案：Omega-3脂肪酸主要来源于深海鱼类（如鲑鱼、金枪鱼、沙丁鱼）、亚麻籽、核桃等。母乳也是婴儿DHA的重要来源，但肥胖母亲的母乳DHA浓度可能较低 45。因此，孕妇和哺乳期妇女补充DHA，以及儿童在日常饮食中增加富含DHA的食物摄入，对视力发育具有积极意义 4648。美国2020-2025膳食指南建议所有年龄段的人群增加海鲜摄入，尤其是孕妇和幼儿，每周至少两次 51。
微量元素与巩膜弹性、眼轴稳定性的关联
- 钙 (Calcium)：
- 作用机制：钙是骨骼和牙齿发育的重要组成部分，但其在眼球结构，特别是巩膜弹性方面的作用也日益受到关注。巩膜的生物力学特性与眼轴的稳定至关重要。虽然直接证据较少，但有理论认为，钙在维持巩膜胶原纤维的稳定性和弹性方面可能扮演角色，从而间接影响眼轴的增长。
- 膳食来源与补充方案：乳制品、豆制品、绿叶蔬菜等是钙的良好来源。确保儿童每日钙摄入充足，对于整体骨骼发育和可能对眼球结构的支持都是有益的。
- 锌 (Zinc)：
- 作用机制：锌是多种酶的组成部分，参与细胞生长、分化和代谢过程，对维持视网膜和视觉神经的正常功能至关重要。它是维生素A代谢的关键辅助因子，影响维生素A在视网膜中的利用。锌还参与抗氧化过程，有助于保护眼睛免受自由基损伤。
- 膳食来源与补充方案：富含锌的食物包括海鲜（尤其是牡蛎）、红肉、禽类、豆类和坚果。确保儿童日常饮食中锌的充足供应，对维持视网膜健康和整体视觉功能具有积极作用。
强调均衡饮食的重要性
任何单一营养素的补充都难以替代均衡膳食对眼睛健康的全面支持。儿童应养成不挑食、不偏食的习惯，保证摄入种类丰富、营养均衡的食物。
- 多样化食物：日常饮食应包含谷物、蔬菜、水果、肉类、蛋类、奶类、豆类等多种食物，以获取全面的营养素。
- 避免高糖、高脂食物：过量摄入高糖、高脂食物不仅可能导致肥胖，还可能影响体内多种营养素的吸收和利用，间接对眼睛健康造成负面影响。
- 规律进餐：保证三餐规律，避免暴饮暴食或长时间不进食。
- 饮水充足：充足的水分摄入对维持眼睛湿润、缓解眼疲劳也具有重要作用。
通过以上对关键营养素的理解和均衡饮食的实践，家长可以在儿童的日常生活中为他们的眼睛健康提供坚实的营养基础，支持视觉系统的正常发育，并协同其他护眼策略，共同保护儿童的远视储备和视力健康。
3. 临床治疗干预的分层与个性化方案
3.1 光学矫正的核心技术与选择
对于幼儿及儿童的屈光参差和远视储备差异，光学矫正仍是首要且基础的治疗手段。选择合适的光学矫正方式，不仅能提供清晰的视觉，更重要的是能促进双眼视功能发育，预防或治疗弱视、斜视等并发症，并延缓近视的进展。
3.1.1 框架眼镜
框架眼镜作为最常见的光学矫正工具，在儿童屈光参差的治疗中具有不可替代的作用。其核心在于矫正原则的选择，需根据儿童年龄、屈光度数、视功能状态等进行个性化判断。
- 屈光矫正原则（全矫/部分矫正的适应症）：
- 全矫（Full Correction）：通常指完全矫正患者的屈光不正度数，使其视网膜上形成清晰的物像。对于屈光参差的儿童，全矫的目的是使双眼视网膜上的成像大小差异最小化，从而促进双眼融合，减少抑制。对于年龄较小的儿童（特别是存在弱视风险的婴幼儿）以及中高度屈光参差，早期且完全的矫正是关键。全矫可有效提高视力，并为后续的弱视治疗（如遮盖）奠定基础。
- 部分矫正（Partial Correction）：在某些情况下，特别是高度屈光参差或首次配镜时，全矫可能因引起眩晕、视物变形或不适而难以耐受。此时可考虑部分矫正，即逐步增加度数，让儿童逐渐适应。然而，部分矫正需谨慎，尤其是在存在弱视风险的眼睛上，过度欠矫可能延误弱视的治疗时机。对于远视儿童，如果存在调节性内斜视，通常需要全矫远视度数以放松调节、矫正斜视。在远视储备过早消耗，有近视化趋势的儿童中，有时会考虑轻度欠矫远视以减少调节负担，但这需要严格的临床观察和判断。
- 屈光参差的矫正策略：在屈光参差中，双眼的全矫可能会导致较大的物像不等，若儿童无法耐受，可考虑以下策略：对于度数差异在2.00D以内，通常建议全矫或尽量接近全矫；对于度数差异超过2.00D的儿童，应个体化处理，可能需要逐步增加度数或考虑其他矫正方式（如接触镜），以平衡物像不等和视觉清晰度之间的关系。
- 棱镜补偿（针对斜视合并屈光参差）：当屈光参差合并斜视（特别是小角度斜视或融合功能障碍）时，棱镜可能被用于补偿眼位偏斜，帮助双眼更容易融合，改善双眼视功能。例如，对于伴有小角度内斜视和立体视功能不佳的屈光参差患者，研究表明，佩戴菲涅尔棱镜（Fresnel prism）可以改善非优势眼的视力和立体视锐度，即使在经过遮盖和屈光矫正后，仍可尝试使用棱镜进行管理 52。棱镜的处方需要精确验配，通常由经验丰富的眼科医生或视光师根据斜视的类型、角度和融合储备等进行评估。
- 防蓝光/防紫外线镜片的应用场景：
- 防蓝光镜片：鉴于电子屏幕的广泛使用，防蓝光镜片越来越受到关注。蓝光（特别是短波蓝光）被认为可能对视网膜造成光化学损伤，并影响睡眠节律。对于长时间使用电子设备的儿童，佩戴防蓝光镜片可以在一定程度上减少蓝光暴露，缓解视觉疲劳。然而，关于防蓝光镜片对近视进展的直接预防作用，目前尚缺乏强有力的临床证据支持。
- 防紫外线镜片：紫外线是眼睛健康的长期威胁，可导致白内障、翼状胬肉等眼部疾病。儿童户外活动较多，眼睛对紫外线更敏感。因此，所有儿童都应佩戴具有防紫外线功能的眼镜，无论是普通透明镜片还是太阳镜，以保护眼睛免受紫外线损伤。
3.1.2 角膜塑形镜（Ortho-k）
角膜塑形镜（Orthokeratology, Ortho-k），简称OK镜，是一种通过夜间佩戴、可逆性地改变角膜形态来暂时性矫正屈光不正的特殊硬性透气性接触镜（RGP镜）。近年来，其在儿童近视管理中显示出显著效果，对于屈光参差儿童的近视控制也具有独特优势 53。
- 夜间佩戴对角膜重塑的机制：OK镜通过其独特的反几何设计，在夜间睡眠时对角膜中央区域施加轻柔压力，使角膜中央变平，而角膜中周部相对隆起，从而暂时性降低角膜的屈光力。早晨取下镜片后，角膜在一定时间内保持矫正后的形态，使白天无需佩戴眼镜也能获得清晰视力 53。这种角膜形态的改变主要涉及角膜上皮层的重新分布，而非基质层，因此是可逆的。
- 在控制双眼屈光差异扩大、延缓眼轴增长中的有效性：OK镜在控制近视进展，特别是延缓眼轴增长方面表现出良好的效果。
- 近视控制机制：OK镜通过使角膜中央变平矫正近视，同时在角膜中周部形成相对性周边近视离焦，这种周边近视离焦被认为是抑制眼轴增长的关键机制。有研究指出，OK镜在一年内能显著减缓儿童眼轴增长0.16毫米，相较于其他治疗方式，效果更优 54。
- 屈光参差控制：对于屈光参差儿童，如果两眼都处于近视状态，但度数不同，或者一眼近视一眼远视，OK镜可以通过个体化验配，分别针对两眼进行矫正。对于近视的那只眼，OK镜可以有效地控制其度数增长和眼轴拉长，从而有助于稳定双眼屈光状态，减少屈光参差的进一步扩大。这种控制作用对于保护远视储备的眼睛也间接有利，因为它降低了近视眼与远视眼之间“争夺”清晰成像的压力。
- 不同年龄/屈光度数的效果对比：OK镜对不同年龄和屈光度数的儿童均显示出一定的近视控制效果。通常，越早开始佩戴OK镜，控制效果越好，但需结合儿童的依从性和卫生习惯。对于中低度近视（-0.75D至-6.00D）的儿童，OK镜通常能取得良好效果 54。高度近视儿童可能需要更长时间适应或无法达到完全矫正。
- 安全性管理（感染风险防控）：OK镜作为一种接触镜，其最主要的风险是角膜感染，特别是微生物性角膜炎。
- 感染风险：尽管OK镜的安全记录良好，但如果护理不当，感染风险会增加。研究显示，OK镜佩戴者出现不良事件（如感染）的风险比佩戴传统接触镜高3.79倍，但这一证据基础尚不完善，需要更多设计良好的研究来得出实质性结论 54。
- 防控措施：严格的卫生习惯和镜片护理是预防感染的关键。包括：
- 佩戴和摘取镜片前彻底洗净双手。
- 使用专用护理液浸泡、清洗和消毒镜片。
- 定期更换镜片盒。
- 避免用自来水冲洗镜片或镜片盒。
- 定期复查，由专业人士评估眼睛健康状况和镜片佩戴情况。
- 出现眼部不适（如红眼、疼痛、分泌物增多）应立即停戴并就医。
3.1.3 软性接触镜
软性接触镜，尤其是多焦点设计（Multifocal Contact Lenses），在儿童近视管理和屈光参差矫正方面展现出潜力。
- 多焦点设计（如双焦/环焦镜片）对周边离焦的控制作用：
- 机制：传统单焦点眼镜矫正中央视力，但可能导致周边视网膜形成远视性离焦，这被认为是刺激眼轴增长、促进近视进展的因素之一。多焦点软性接触镜，特别是具有中心近视、周边远视附加度数（Peripheral Add）设计的镜片，能够提供清晰的中央视力，同时在周边视网膜形成近视离焦，从而抑制眼轴增长，延缓近视进展。
- 有效性：多项研究和荟萃分析证实，周边附加度数多焦点软性接触镜能有效减缓近视进展。一项荟萃分析指出，周边附加度数多焦点软性接触镜组的屈光进展显著降低（平均差异为0.20D），眼轴增长也更少（平均差异为-0.08毫米），与单焦点对照组相比效果明显 55。另一项为期一年的随机对照试验也显示，多焦点软性接触镜在控制球镜等效屈光不正和眼轴增长方面，与市售的双焦点软性接触镜具有相似的近视控制效果 56。
- 在屈光参差儿童中的适配条件（如散光度数限制）：
- 屈光参差矫正：对于屈光参差儿童，特别是双眼近视度数不同或一眼近视一眼远视的情况，多焦点软性接触镜可以通过个体化验配不同度数，甚至不同设计的镜片，来矫正双眼屈光不正，同时提供近视控制效果。其物像不等效应通常小于框架眼镜，更易于儿童适应。
- 散光度数限制：目前，大多数多焦点软性接触镜主要针对球镜度数进行设计。对于合并较高散光（如超过-0.75D至-1.00D）的儿童，可能需要定制散光型多焦点软性接触镜，但这会增加成本和验配难度。对于不规则散光或高度散光，软性接触镜可能无法提供最佳的视觉质量，此时可能需要考虑RGP镜片或框架眼镜。
- 适配性与安全性：儿童佩戴软性接触镜需要良好的依从性和卫生习惯，以降低感染风险。对于年龄较小或依从性较差的儿童，可能不太适合。同时，部分多焦点软性接触镜可能会对低对比度视力产生轻微影响 55。因此，在选择软性接触镜时，需要综合评估儿童的年龄、屈光状态、视功能需求以及家长的依从性。
3.2 药物干预的应用与争议
药物干预，特别是低浓度阿托品眼药水，已成为儿童近视管理领域的重要组成部分，其在延缓远视储备消耗和控制近视进展方面展现出显著疗效。
低浓度阿托品（0.01%-0.05%）的作用机制
阿托品是一种非选择性M胆碱受体拮抗剂，主要通过以下机制发挥其在近视控制中的作用：
- 调节痉挛抑制：阿托品能够麻痹睫状肌，使其无法收缩，从而抑制调节（对焦）功能。高浓度的阿托品会导致明显的调节麻痹和瞳孔散大。而低浓度阿托品虽然也会产生一定程度的调节抑制，但其主要近视控制机制被认为并非单纯通过麻痹调节来减少近距离用眼引起的调节紧张。
- 脉络膜增厚与眼轴生长抑制：目前主流观点认为，低浓度阿托品主要是通过直接作用于视网膜和脉络膜中的M1和M4胆碱受体来发挥近视控制作用。它可以促进脉络膜增厚，并可能通过影响视网膜多巴胺的释放等机制，进而抑制巩膜重塑，从而减缓眼轴的异常增长 57。眼轴的过度增长是近视发生发展的关键因素，因此抑制眼轴增长是延缓远视储备消耗和近视进展的根本途径。
不同种族/年龄的临床研究数据及效果差异
全球多项随机对照临床试验（RCT）验证了低浓度阿托品在儿童近视控制中的有效性。
- LAMP研究（Low-Concentration Atropine for Myopia Progression）：这是一系列来自中国香港的研究，主要针对东亚儿童。
- LAMP第一阶段（1年期）：研究比较了0.05%、0.025%和0.01%阿托品与安慰剂的效果。结果显示，0.05%阿托品在控制等效球镜（SE）进展和眼轴（AL）增长方面最有效，其次是0.025%和0.01%阿托品，且所有浓度均优于安慰剂。1年时，0.05%阿托品组的平均SE进展为-0.27D，AL增长为0.20mm，显著优于安慰剂组的-0.81D和0.41mm 58。
- LAMP第二阶段（2年期）：进一步证实了0.05%阿托品在2年内的近视控制效果仍是最佳的。0.05%阿托品组的平均SE进展为0.55D，AL增长为0.39mm，是0.01%阿托品组效果的两倍 59。
- LAMP第三阶段（3年期）：发现持续使用阿托品比停药效果更好，且0.05%阿托品在3年内仍是最佳浓度 60。
- LAMP第四阶段（5年期）：长期随访结果表明，持续使用0.05%阿托品对近视控制具有良好的长期疗效。在停药后，大部分儿童需要重新开始治疗，而重新使用0.05%阿托品与持续治疗效果相似 61。
- LAMP2研究（针对近视发病率）：这项研究聚焦于预防近视的发生。对4-9岁非近视儿童的2年随访结果显示，0.05%阿托品显著降低了近视发生率（28.4%）和快速近视漂移的比例（25.0%），而0.01%阿托品与安慰剂组无显著差异 62。这表明0.05%阿托品不仅能控制近视进展，还能有效延迟近视的发生。
- ATOM2研究（Atropine for the Treatment of Myopia 2）：这是来自新加坡的研究，主要针对东亚儿童，比较了0.5%、0.1%和0.01%阿托品的效果。2年结果显示，0.01%阿托品在保留较好安全性的前提下，与高浓度阿托品具有相似的近视控制效果。5年随访结果进一步表明，0.01%阿托品在减缓近视进展和眼轴增长方面长期效果最佳，且副作用最小 6364。
- MOSAIC研究（Myopia Outcome Study of Atropine in Children）：这是一项在欧洲人群中进行的随机对照试验，主要针对白人儿童。研究结果显示，0.01%阿托品在2年内能够安全有效地减缓眼轴增长，但对SE进展的影响不显著 65。这提示，0.01%阿托品在白人儿童中的效果可能不如东亚儿童显著。
- 中国大陆儿童研究：一项针对中国大陆儿童的随机临床试验也证实，0.01%阿托品眼药水在1年内能有效减缓近视进展（相对减少34.2%）和眼轴增长（相对减少22.0%），且未报告严重不良事件 66。
种族差异：荟萃分析和系统综述指出，阿托品的疗效和副作用可能存在种族差异 67。东亚儿童对阿托品的反应可能更敏感，且低浓度阿托品在东亚人群中显示的近视控制效果通常优于白人人群 5765。这可能与不同种族眼球生物学特性、近视发生发展模式及环境因素的差异有关。
延缓远视储备消耗的效果
低浓度阿托品通过抑制眼轴增长，直接作用于延缓远视储备的消耗。对于尚未近视但远视储备不足或消耗过快的儿童，0.05%阿托品（如LAMP2研究所示）能够显著降低近视的发生率，从而有效延长其远视储备的维持时间，延缓近视的发生。
副作用（畏光、调节力下降）的应对策略
尽管低浓度阿托品相较于高浓度阿托品副作用显著减少，但仍可能出现一些常见不良反应：
- 畏光：阿托品会引起轻度瞳孔散大，导致进入眼睛的光线增多，从而产生畏光感。
- 应对策略：建议儿童在户外活动时佩戴帽子和太阳镜，以减少光线刺激。
- 调节力下降：即使是低浓度阿托品，也可能导致轻微的睫状肌麻痹，从而影响眼睛的调节能力，表现为看近模糊或近距离用眼时易疲劳。
- 应对策略：如果出现明显的近距离视物模糊，可以考虑配戴低度数的渐进多焦点眼镜或双焦点眼镜，以辅助近距离调节，减轻不适。通常，0.01%阿托品对调节力的影响较小，而0.05%阿托品的影响相对明显一些，但多数儿童仍能耐受 58。
- 其他副作用：少数儿童可能出现过敏反应（如眼部瘙痒、发红）或眼压升高。
- 应对策略：一旦出现过敏反应，应立即停药并咨询医生。对于有青光眼家族史或高眼压风险的儿童，应定期监测眼压。此外，有研究显示，阿托品对散光的影响不大，0.01%和0.02%阿托品在2年内对眼部和角膜散光没有临床显著影响 68。
临床应用总结
- 浓度选择：目前，0.05%阿托品被认为是综合疗效和安全性最佳的浓度，尤其对于近视进展较快或远视储备快速消耗的儿童。而0.01%阿托品在某些人群中（如欧洲白人儿童）效果可能不显著，或仅对眼轴增长有抑制作用，对屈光度进展效果不明显，但其副作用最小，更易于接受 5765。
- 个性化治疗：药物干预应结合儿童的年龄、近视进展速度、远视储备情况、是否存在屈光参差以及对副作用的耐受程度，由专业医生进行个体化评估和处方。
- 长期监测：使用低浓度阿托品期间，应定期进行眼科检查，包括视力、屈光度、眼轴长度、眼压、瞳孔大小和调节功能等，以便及时评估疗效和监测副作用。
总体而言，低浓度阿托品为儿童近视和远视储备管理提供了有效的药物干预手段，但其应用仍需在专业医生的指导下进行，并结合其他非药物干预措施，以实现最佳的近视控制效果。
3.3 弱视与并发症的针对性治疗
屈光参差是儿童弱视发生的重要原因之一。当双眼屈光度数差异较大时，大脑处理来自屈光不正程度较重眼（通常是视力较差的眼睛）的视觉输入会受到影响，导致该眼的视功能发育迟滞，形成屈光参差性弱视 2。弱视的治疗目标是提高弱视眼视力，改善双眼视觉功能（如融合功能和立体视），预防视力下降的长期影响。治疗方法需根据患儿年龄、弱视程度、屈光参差类型及并发症等因素进行个性化选择和调整。
3.3.1 遮盖疗法
遮盖疗法（Patching Therapy）是治疗弱视，特别是屈光参差性弱视的经典且最广泛使用的方法。其原理是通过遮盖健眼（或视力较好眼），强迫弱视眼工作，从而刺激弱视眼的视觉通路发育，改善其视力。
- 传统遮盖（Full-time Occlusion）vs. 部分时间遮盖（Part-time Occlusion）：
- 传统遮盖：指全天候（所有清醒时间）遮盖健眼 69。这种方法在早期弱视治疗中应用广泛。研究表明，全天遮盖对提高弱视眼视力非常有效，成功率可达96%，其中60%的患者能达到双眼视力相等 69。然而，长时间遮盖可能导致儿童不适、依从性差，甚至有诱发健眼弱视（Occlusion Amblyopia）的风险，尤其是在年龄较小的儿童中，健眼弱视的发生率可达25.8% 69。
- 部分时间遮盖：为了提高依从性并减少副作用，研究发现部分时间遮盖与全天遮盖在疗效上相似，且更受患儿及家长接受。例如，每日遮盖1-2小时的方案可能已足够，并且与更长时间的遮盖具有相似疗效 70。具体遮盖时间应根据弱视程度、患儿年龄和对遮盖的耐受性进行调整。一般来说，弱视程度越重、年龄越小，所需遮盖时间可能越长，但要密切监测健眼视力，防止发生遮盖性弱视。
- 适用年龄与强度调整：
- 适用年龄：遮盖疗法通常在儿童视觉发育关键期（0-7/8岁）内效果最佳 9。年龄越小，视力改善的潜力越大。
- 强度调整：遮盖强度（即每天遮盖时间）需根据弱视的初始视力、对治疗的反应以及患儿的依从性进行动态调整。通常在治疗初期，医生会根据弱视严重程度给出建议的遮盖时间，并定期复查（如每3-6个月一次），评估视力改善情况和是否存在副作用，然后调整遮盖方案。在视力稳定后，可能需要进行维持性遮盖，以巩固疗效，防止弱视反弹。
3.3.2 压抑疗法
压抑疗法（Penalization Therapy）是另一种治疗弱视的方法，通过药物或光学手段使健眼视力暂时性模糊，以达到强迫弱视眼工作、促进视力发育的目的。
- 光学压抑：
- 通过在健眼佩戴特殊镜片（如磨砂片、高屈光度数镜片）使其视物模糊，或在健眼眼镜中加入额外的正镜片（如+3.00D），使其在近距离看物模糊，从而促使弱视眼发挥作用。
- 药物压抑：
- 适用年龄与强度调整：
- 与遮盖疗法类似，压抑疗法在儿童视觉发育关键期效果更佳。
- 药物压抑的强度调整通常指阿托品的浓度和点药频率。医生会根据弱视程度和患儿反应进行个性化处方。光学压抑则通过调整镜片度数或类型来控制模糊程度。
3.3.3 新型数字疗法
近年来，随着技术发展，新型数字疗法（Digital Therapeutics, PDTs）为弱视治疗提供了新的思路和方法，尤其在提高患儿依从性和改善双眼融合功能方面展现出巨大潜力 7273。这些疗法通常基于双眼视觉（Dichoptic）原理，即通过特殊设计，同时向两眼呈现不同但又相互关联的图像，强迫两眼协同工作，从而克服抑制，改善双眼视觉功能。
- 双视刺激训练软件（Dichoptic Training Software）：
- 作用机制：这类软件通常利用游戏、电影或虚拟现实（VR）等互动形式，通过调整呈现给两眼的图像对比度、亮度或模糊度，使弱视眼接收到更清晰或对比度更高的图像，而健眼接收到的图像则被适当“弱化”。这种方法旨在平衡两眼输入，减少健眼对弱视眼的抑制，促进大脑皮层视觉通路的重塑和双眼协同工作能力的提高。
- 应用进展：
- Luminopia：一项针对4-7岁弱视儿童的随机对照试验显示，使用Luminopia数字疗法（每日1小时，每周6天）的儿童在12周后，弱视眼视力平均改善1.8行，显著优于仅佩戴眼镜的对照组（平均改善0.8行） 74。该研究因疗效显著而提前终止。
- CureSight：该疗法结合了色差眼镜和眼球追踪技术，通过在弱视眼观看视频内容时，实时地在健眼黄斑周围区域产生模糊，以达到双视刺激效果。一项针对4-9岁弱视儿童的临床试验发现，CureSight治疗（每日90分钟，每周5天，持续16周）在改善弱视眼视力方面不劣于传统遮盖疗法（每日2小时，每周7天），且患儿依从性更高（91% vs 83%） 75。此外，这种双眼治疗还显著改善了立体视和双眼视力 75。
- 对比度重新平衡电影：一项研究让4-10岁弱视儿童观看对比度重新平衡的双视电影（通过偏振眼镜），发现2周后弱视眼视力显著改善。这种被动观看的形式，也达到了与2周双视游戏治疗或3-4个月遮盖疗法相似的视力改善效果 76。
- VR双视训练：运动型虚拟现实（VR）双视训练App，如日本剑玉游戏，在健康成人中显示出良好的安全性，未引起显著的眼部不适或动晕症，提示其作为儿童弱视治疗手段的潜力 77。
- 优点：数字疗法因其互动性、趣味性、可在家中进行等特点，显著提高了患儿的治疗依从性，减轻了传统遮盖对儿童心理和社交方面的影响。此外，这类疗法不仅能提高弱视眼视力，还能有效改善双眼融合功能和立体视，甚至有研究表明双眼弱视治疗能够改善手部灵巧性（Manual Dexterity） 78。
- 局限性与展望：尽管数字疗法前景广阔，但其长期疗效、最佳治疗方案、不同年龄段和弱视类型儿童的适用性以及成本效益仍需更多研究验证 73。
综上所述，针对屈光参差继发的弱视及并发症，临床治疗应遵循个体化原则，从基础的光学矫正开始，结合遮盖或压抑疗法，并积极探索新型数字疗法的应用，以期达到最佳的视觉功能改善效果。
4. 视觉训练的阶段性目标与实施体系
视觉训练，又称视觉疗法或视功能训练，是一系列旨在改善视觉系统各项功能，包括调节、聚散、眼球运动、双眼协调和立体视等能力的非手术方法。对于幼儿及儿童，特别是存在屈光参差、远视储备差异或伴有弱视、斜视等问题的儿童，视觉训练具有极其重要的意义。它不仅能帮助儿童建立和巩固良好的视觉功能，弥补发育过程中的不足，还能通过针对性的练习，强化大脑对视觉信息的处理能力，最终提升整体视觉质量和生活质量。
本节将详细探讨视觉训练的阶段性目标与实施体系。我们将从基础视功能训练（针对3-6岁关键期）开始，逐步深入到高阶双眼协调训练（针对学龄期儿童），最后阐述训练效果的评估与动态调整策略。通过结构化的训练方案，旨在纠正因屈光参差导致的双眼不平衡，促进双眼视功能的协调发展，帮助儿童更好地利用其远视储备，并为后续的学习和生活奠定坚实的视觉基础。尽管有研究指出，目前关于计算机辅助视觉训练在特定发育性视觉障碍（如屈光不正、斜视）中的有效性的随机对照试验数据较少，且一些训练的临床相关性提升幅度可能较小 7980。例如，对于弱视，一些研究发现视觉训练（特别是近年发展的双视数字疗法）结合光学矫正和遮盖疗法，在改善弱视眼视力、提高融合功能和立体视方面显示出统计学上的显著差异，但这些差异通常较小，且大多低于临床相关性的阈值（例如-0.05 logMAR） 7980。然而，对于提升儿童的认知功能和视觉灵活性，以及纠正不良用眼习惯导致的视觉疲劳，视觉训练仍然是不可或缺的组成部分。
4.1 基础视功能训练（3-6岁关键期）
3-6岁是儿童视觉发育的关键时期，也是建立良好双眼视功能的重要窗口。在这一阶段，如果存在屈光参差、远视储备差异或早期弱视，应及时进行基础视功能训练。此阶段的训练目标主要集中于改善调节功能、促进双眼融合和建立立体视，为更复杂的视觉任务打下基础。
4.1.1 调节功能训练
调节功能是眼睛晶状体改变屈光力以看清不同距离物体的能力。对于远视储备不足或伴有调节滞后（accommodation lag）的儿童，调节功能训练尤为重要，有助于提升调节灵敏度与幅度，减少视疲劳。
- 反转拍（Flippers）：反转拍是一种用于训练调节灵敏度的常用工具。它通常包含两个不同度数的透镜（如±0.50D、±1.00D、±1.50D或±2.00D），患者通过快速翻转透镜，在不同屈光度数之间进行调节转换，从而训练眼睛快速准确地聚焦于远近目标的能力。
- 训练方案：儿童手持反转拍，注视前方33-40厘米处的视标（如字母卡、小图片）。在指导下，先用一眼看清视标，然后翻转反转拍，再看清视标，循环往复。训练时，要求儿童在每一次翻转后，都努力使视标瞬间变得清晰。训练强度（即反转拍的度数和持续时间）应根据儿童的年龄和调节能力逐步增加。例如，对于初学者可从±0.50D开始，每次训练5-10分钟，每日2-3次，逐渐增加至±1.00D或更高，并延长训练时间。
- 针对远视储备不足儿童的调节滞后问题：远视储备不足的儿童可能存在调节功能不足或调节滞后，表现为看近时调节反应不足，导致近距离视物模糊或视疲劳。反转拍训练通过强制性地刺激调节系统，可以有效改善调节灵敏度，减少调节滞后，从而提高看近的清晰度和舒适度，间接保护远视储备。
- 字母表/数字表调节训练：
- 训练方案：将不同大小的字母或数字表放置在不同距离（如近距离33-40厘米和远距离3-6米）或同一个视标上，通过远近视标的交替注视来训练调节功能。例如，让儿童先看清远处的字母表上指定字母，再迅速切换到近处的字母表上指定字母，并努力看清。此训练可增加调节幅度，提升远近视力转换的灵敏度。
- 阶梯式训练方案：对于调节功能较弱的儿童，可从较小的调节需求（即远近距离差异小）开始，逐步增加调节负荷。例如，先从1米和5米交替看视标开始，待适应后逐渐调整为33厘米和6米。同时，可结合视标的大小和清晰度要求，从大视标、低要求开始，逐步提高难度。
- 其他工具：还有一些其他工具如聚散球、调节仪等，也可用于调节功能训练。核心思想是提供多样化的视觉刺激，促使眼睛晶状体在不同距离间反复调节，从而锻炼其灵活性和准确性。
4.1.2 融合与立体视训练
屈光参差可能导致双眼物像不等，大脑为避免混淆而抑制一眼的视觉信息，最终导致融合功能障碍和立体视缺失。融合与立体视训练旨在打破抑制，重建双眼协同工作能力，使儿童能感知深度，形成三维视觉。
- 偏振片/红绿眼镜进行同时视、融合视训练：
- 同时视训练：通过佩戴红绿眼镜（或偏振眼镜），使左右眼分别接收到不同的图像信息。例如，在红绿底板上放置有红绿图案的训练图，让儿童用红绿眼镜观察。如果能同时看到所有图案，说明具备同时视功能。此训练旨在克服弱视眼的抑制，使两眼能够同时感知外界信息。
- 融合视训练：在同时视的基础上，通过提供部分重叠但有差异的图像，刺激大脑将两眼传入的信息融合成一个整体，并感知到深度。例如，使用融合训练卡或立体图，其中一眼看到的部分图像，另一眼看到另一部分图像，只有两眼融合后才能看到完整的图像。
- 训练方案：在专业指导下，儿童佩戴红绿眼镜或偏振眼镜，观察专用训练图卡或软件。训练从简单的同时视图案开始，逐渐过渡到复杂的高级融合图，并注意克服抑制。训练初期，弱视眼可能会出现明显的抑制，需要治疗师或家长指导儿童努力“看”到被抑制的图像。
- 结合立体图卡提升深度感知能力：
- 立体图卡：包括点状立体图（如随机点立体图，Random-Dot Stereogram，RSDS）和线条立体图等。这些图卡需要双眼具备良好的融合功能才能感知到隐藏的三维图像或深度效果。动态随机点立体图（DRDS）能有效地诱发大脑皮层，尤其是额叶的电活动，提示其在深度知觉处理中的重要性 81。一些自立体图（Autostereograms 或 SIRDS，Single Image Random-Dot Stereograms）也通过随机点原理，结合壁纸效应，可以无需借助辅助工具即可看到三维图像，有助于训练立体视 82。
- TNO立体视测试：TNO立体视测试是一种常用的临床立体视检测方法，然而，研究发现TNO立体视测试结果相较于其他临床立体视测试（如Randot Circles）可能高估立体阈值，这可能与测试协议、测试差异以及使用红绿滤镜而非偏振滤镜等因素有关 83。尽管如此，它仍是评估儿童立体视的重要手段。
- 训练方案：儿童在视光师指导下，通过观看不同难度的立体图卡，努力感知深度。从粗略立体视（大差异）开始，逐步训练精细立体视（小差异）。例如，使用不同立体锐度的点状立体图卡，训练儿童识别立体图形。立体视功能的重建对于改善因屈光参差导致的视觉障碍至关重要，特别是对于学龄前儿童，早期建立正常的立体视有助于提升空间感知能力和手眼协调能力。有研究指出，人类婴儿的立体视通常在3.5到6个月大时出现 84，并通过观察双眼融合模式，发现新生儿的视力并不会像叠加假设那样简单混合，而是随着立体视的出现才逐渐变得清晰的 85。这意味着立体视功能的建立是一个重要的视觉发育里程碑。
通过系统的调节功能训练和融合与立体视训练，3-6岁儿童可以有效改善其基础视功能，纠正屈光参差带来的双眼不平衡，并为未来的视觉学习和生活奠定坚实基础。这些训练应在专业人员的指导下进行，并结合儿童的兴趣和依从性，以游戏化、趣味化的方式开展。
4.2 高阶双眼协调训练（学龄期）
4.2.1 聚散功能训练
聚散功能是指双眼协调向内（集合）或向外（散开）转动，以使视轴汇聚于不同距离的物体上，从而维持双眼单视的能力。屈光参差或屈光储备差异可能导致双眼注视不平衡，进而引发聚散功能障碍，表现为集合不足、集合过量或散开不足等，这些问题常是学龄期儿童视疲劳和阅读困难的重要原因。
- 棱镜棒（Prism Bar）：棱镜棒是一种临床上常用的聚散功能训练工具，通过增加或减少眼睛所需的集合/散开量来锻炼眼外肌。
- 训练原理：棱镜能使光线偏折，从而改变物体成像在视网膜上的位置，刺激眼睛进行集合或散开运动以维持单视。
- 训练方案：儿童手持棱镜棒或将其置于试镜架中，注视远或近处的视标。治疗师或家长在视标与眼睛之间移动棱镜棒，从低度数棱镜开始逐渐增加度数，鼓励儿童努力维持视标的单视和清晰。例如，当佩戴基底向外的棱镜时，眼睛需要向内集合才能保持单眼注视；而佩戴基底向内的棱镜时，眼睛需要向外散开。训练的目的是提高集合和散开的幅度、速度和精确性，从而改善双眼的协调性和灵活性。
- 针对视疲劳的改善：集合不足是导致阅读时视疲劳的常见原因之一。通过棱镜棒训练可以增强集合功能，使儿童在长时间近距离用眼时，双眼更容易保持舒适的单视状态，从而减轻眼胀、头痛等视疲劳症状。
- 聚散球（Brock String）：聚散球是一种简便有效的家庭训练工具，通常由一条绳子和几个不同颜色的珠子组成。
- 训练原理：珠子在绳子上的位置可以调整，儿童通过观察珠子在视网膜上的成像位置，感知双眼集合的准确性。
- 训练方案：儿童将绳子的一端抵住鼻尖，另一端固定在远处，珠子沿绳子放置在不同距离。儿童需要注视某一个珠子，此时应看到一个珠子和两条绳子在珠子处交叉（形成“V”字或“X”字形）。如果看到两个珠子或绳子不交叉，则表明聚散功能异常或存在抑制。通过交替注视远近不同的珠子，训练眼睛的集合和散开能力，同时加强双眼对集合运动的自我感知和控制。
4.2.2 认知-视觉整合训练
学龄期儿童的学习任务日益复杂，阅读、书写等活动不仅要求眼睛能准确地接收视觉信息，还需要大脑高效地处理和整合这些信息。屈光参差可能导致双眼信息输入不对称，影响视觉信息的加工效率，进而引发阅读困难等问题。认知-视觉整合训练旨在提升复杂视觉场景下的双眼协同效率和信息处理能力。
- 视觉追踪训练（如眼动仪辅助）：
- 原理：视觉追踪是指眼睛跟随移动目标或在文本上平稳扫视的能力。对于阅读而言，平稳且准确的眼球运动至关重要。眼动不协调可能导致跳行、漏字或重复阅读，严重影响阅读流畅性。
- 训练方案：
- 传统方法：包括追踪移动的物体（如铅笔、球），或在特制追踪图表上进行视线移动练习。
- 眼动仪辅助训练：现代技术如眼动仪（Eye-tracker）可以精确记录儿童的眼球运动轨迹，并提供实时反馈。结合专门的训练软件，儿童可以在屏幕上进行视觉追踪练习，例如跟随光标移动、阅读动态文本或玩需要精确眼球运动的游戏。眼动仪能够量化训练前后眼球运动的改善情况（如扫视准确性、回溯次数、注视时间等），使训练更具针对性和客观性。
- 改善阅读困难：通过视觉追踪训练，可以提升儿童眼球运动的平稳性、准确性和灵活性，减少阅读中的跳行、漏字现象，从而提高阅读速度和理解力。有研究显示，未矫正的散光（即使是1.00DC）也会显著影响阅读流畅性，尤其是在小文本下，阅读速度可降低24% 86。因此，在确保屈光矫正的基础上进行视觉追踪训练，对改善阅读困难至关重要。
- 注意力分配训练：
- 原理：在复杂的视觉场景中，大脑需要高效地分配注意力，选择性地处理重要信息，抑制无关信息。屈光参差导致的双眼输入不平衡可能干扰这一过程。
- 训练方案：结合阅读、书写任务设计训练活动。例如，在包含干扰信息的文本中找出特定目标文字；在多任务情境下，要求儿童在完成主要视觉任务的同时，关注次要视觉线索。这些训练有助于提升儿童在视觉输入竞争性环境中筛选和处理信息的能力，增强视觉注意力的广度和持久性。
- 提升双眼协同效率：通过训练，儿童能够更好地将来自双眼的视觉信息进行整合和优先排序，减少因信息冲突或不对称造成的认知负荷，从而提高复杂视觉任务中的双眼协同效率，减少视觉疲劳。
高阶双眼协调训练的目标不仅是提高视功能参数，更重要的是将这些功能整合到实际的学习和生活中。这类训练通常需要更专业的设备和指导，尤其适合学龄期儿童，以应对日益增长的视觉挑战，保障其学习效率和生活质量。
4.3 训练效果评估与动态调整
视觉训练的有效性并非一劳永逸，它是一个动态、持续的过程，需要通过系统的评估来监测效果并适时调整方案。建立多维度评估体系和强调家庭-机构协同，是确保训练成功的关键。
建立多维度评估指标：
- 视力（Visual Acuity）：这是最直接的评估指标，包括裸眼视力（UCVA）和最佳矫正视力（BCVA）。在训练过程中，需定期测量并记录弱视眼和健眼的视力变化。对于弱视眼，主要观察其BCVA的提升程度；对于健眼，则需监测其视力是否因过度遮盖或压抑而下降。
- 屈光度（Refractive Error）：定期复查屈光度是评估屈光状态变化的重要手段，尤其对于屈光参差和远视储备差异的儿童。通过睫状肌麻痹验光获得的客观屈光度数，可以判断屈光参差是否改善或远视储备消耗的速度是否减缓。
- 眼轴长度（Axial Length）：眼轴长度是评估近视进展的金标准。利用生物测量仪（如IOLMaster, Lenstar）定期测量眼轴长度，可以精确监测眼球的生长情况。如果眼轴增长过快，提示训练或干预措施可能不足，需要调整。
- 调节幅度与灵敏度（Amplitude and Facility of Accommodation）：通过调节灵敏度测试（如反转拍测试）和调节幅度测量（如推近法），评估儿童调节功能的改善情况。调节功能障碍（如调节滞后）是视疲劳和近视发展的重要危险因素，训练后调节功能提高是衡量训练效果的重要指标。
- 立体视锐度（Stereoacuity）：立体视是双眼视觉功能的核心。通过立体图测试（如随机点立体图、TNO立体视图）评估立体视锐度的改善程度。立体视锐度的提高意味着双眼融合功能和深度感知能力的进步，对于屈光参差儿童尤其重要。研究表明，视觉感知学习系统对屈光不正性弱视儿童的治疗，可以提高最佳矫正视力并恢复立体视 87。
- 融合功能（Vergence Function）：通过棱镜融合范围、聚散力等指标，评估双眼维持单视和深度感知的能力。特别是对于有斜视风险或视疲劳的儿童，融合功能的改善是重要的训练目标。
- 眼球运动（Ocular Motility）：包括扫视、追随和固视等眼球运动功能。通过观察、眼动仪或其他工具评估眼球运动的平稳性、准确性和灵活性，特别是对阅读困难儿童的改善程度。
结合定期复查（每3-6个月）数据调整训练方案：
- 动态调整原则：视觉训练并非一成不变，应根据儿童的年龄、发育阶段、训练依从性以及各项评估指标的变化，每3-6个月进行一次全面的眼科检查和视功能评估。根据评估结果，专业人员将对训练项目、训练强度、训练频率、光学矫正方案（如眼镜度数、角膜塑形镜参数）甚至药物干预方案进行调整。
- 疗效阈值与进展管理：例如，如果弱视眼视力在训练一段时间后没有明显提高，或者屈光参差差异没有缩小，甚至眼轴长度仍在快速增长，则需要重新审视治疗方案，可能需要增加训练强度、更换训练方法、调整光学矫正，或考虑联合药物治疗。如果训练进展良好，则可以逐步提高训练难度，巩固疗效，并进入下一阶段的训练。
探讨家长/教师在训练监督中的角色，强调家庭-机构协同的重要性：
- 家长作为核心监督者：儿童视觉训练的大部分内容需要在家庭环境中完成。家长的积极参与是训练成功的最重要因素之一。家长需要：
- 理解训练目的和方法：通过医生的详细解释和指导，家长应充分理解训练的原理、目标和具体操作步骤。
- 确保训练依从性：每天监督儿童按时完成训练任务，并确保训练质量。一项针对家长对儿童屈光不正和眼镜佩戴的认知研究发现，许多家长对儿童视力保健的认识不足，这强调了加强家长教育的必要性 88。
- 观察儿童反应：密切关注儿童在训练过程中的情绪、合作度以及是否出现不适，及时向专业人员反馈。
- 营造支持性环境：鼓励儿童坚持训练，将训练融入游戏和日常生活中，使其更具趣味性。
- 教师作为辅助支持者：教师在学校环境中，能够协助观察儿童的用眼习惯、阅读表现以及是否存在视疲劳症状。教师应：
- 关注儿童在校表现：留意儿童在课堂上是否出现阅读困难、注意力不集中、频繁揉眼等视觉相关问题，并及时告知家长。
- 配合护眼措施：确保儿童在校期间有充足的户外活动时间，纠正不正确的坐姿和读写习惯。
- 理解训练需求：对于正在进行视觉训练的儿童，教师应理解其特殊需求，例如在阅读时可能需要更多休息。
- 家庭-机构协同的重要性：视觉训练是一个由专业机构（眼科医生、视光师、视觉训练师）制定方案、提供指导，并由家庭（家长）和学校（教师）共同监督和执行的系统工程。
- 定期沟通反馈：机构应与家长保持定期沟通，了解家庭训练的进展和遇到的问题，并给予及时指导。家长也应主动向机构反馈儿童的训练情况和身体反应。
- 专业指导与资源：机构应提供专业的训练设备、软件和指导，并定期组织家长培训，普及视觉健康知识。
- 建立完整档案：为儿童建立详细的视觉健康档案，记录每次评估和训练的详细数据，以便于长期管理和追踪。
- 家长作为核心监督者：儿童视觉训练的大部分内容需要在家庭环境中完成。家长的积极参与是训练成功的最重要因素之一。家长需要：
通过上述多维度的评估、动态调整策略以及家庭-机构的紧密协同，可以最大程度地发挥视觉训练的效果，帮助儿童克服屈光参差带来的视觉障碍，促进其视觉功能全面发展。
5. 长期管理与预后监测的关键要点
对幼儿及儿童屈光参差与远视储备差异的长期管理和预后监测，是确保儿童视觉健康发育、最大程度降低并发症风险的关键。这一过程涉及从学龄前到青春期的全周期监测、多学科协作、家庭支持以及对高风险人群的干预升级。
5.1 全周期监测体系构建
建立一个从学龄前到青春期的完整屈光发育档案，对儿童的视觉健康进行全周期跟踪，是早期发现问题、及时干预、评估效果的基础。
屈光发育档案：这份档案应系统地记录儿童在不同年龄阶段的各项眼部生物测量指标，包括：
- 屈光度（Refractive Error）：定期进行睫状肌麻痹下的验光检查，精确记录双眼的球镜度数、散光度数及轴向。这不仅能反映屈光参差的变化趋势，也能监测远视储备的消耗速度。
- 眼轴长度（Axial Length, AL）：眼轴长度是评估眼球生长和近视进展的金标准。通过光学生物测量仪（如IOLMaster, Lenstar）进行精确测量，有助于早期发现眼轴异常增长，预警近视的发生或进展。
- 角膜曲率（Corneal Curvature, K）：角膜曲率的变化会影响眼睛的屈光力。监测角膜曲率有助于评估角膜的形态稳定性，特别是对于角膜塑形镜佩戴者。
- 前房深度（Anterior Chamber Depth, ACD）：前房深度也是眼球生物测量的常规指标之一，可作为眼部结构发育的参考。
- 晶状体厚度（Lens Thickness, LT）：晶状体在调节功能和屈光度形成中扮演重要角色。
- 视力（Visual Acuity）：包括裸眼视力、最佳矫正视力以及双眼视力。
- 双眼视功能：如立体视、融合功能、调节功能等，这些指标能反映视觉系统整体的协调性。
- 家族史和用眼习惯：详细记录家族近视史、父母屈光状态、儿童户外活动时间、近距离用眼时长等环境和遗传因素，这些都是评估近视风险的重要依据 89。
远视储备消耗速率与屈光参差进展的动态阈值：
- 远视储备消耗速率（每年≥0.50D需预警）：在儿童的生长发育过程中，远视储备会逐渐减少，向正视化发展。但如果远视储备消耗过快，例如每年减少超过0.50D，则被视为近视的高风险信号。对于学龄前儿童，如果远视储备在6岁前低于+1.00D，则应引起高度警惕，因为他们面临较高的近视风险。
- 屈光参差进展（每年差异≥0.50D需干预）：对于已存在屈光参差的儿童，如果双眼屈光度差异每年扩大超过0.50D，则提示屈光参差正在加重，需要重新评估并可能调整干预策略，以避免弱视或双眼视功能障碍的进一步发展。例如，一项研究指出，单眼高度近视的儿童常常伴随弱视，如果不能及时干预，预后较差 90。
- 定期复查频率：通常建议对所有儿童进行定期眼科检查，学龄前儿童每6-12个月一次，学龄儿童每3-6个月一次，高风险儿童或正在接受治疗的儿童可能需要更频繁的随访。对于正在进行近视管理干预的儿童，建议每3个月进行一次眼轴测量，以更精准地监测进展并调整治疗方案。
5.2 多学科协作与家庭支持
儿童的视觉健康管理是一个复杂的系统工程，需要眼科医生、视光师、儿科医生以及家庭和学校的共同参与。
- 眼科医生、视光师、儿科医生的协作模式：
- 眼科医生：负责诊断屈光参差、弱视、斜视等眼部疾病，评估眼部结构健康，制定药物治疗（如低浓度阿托品）和手术干预方案。
- 视光师：负责精确验光、评估双眼视功能，制定光学矫正方案（框架眼镜、角膜塑形镜、软性接触镜），并提供视觉训练指导。视光师在近视管理和视觉功能康复中发挥核心作用。
- 儿科医生：负责儿童的全身健康评估，排除可能影响视觉发育的全身性疾病（如某些遗传综合征可能伴有屈光不正、斜视等眼部表现 919293），并提供全面的健康指导。儿科医生可作为视觉健康的初级筛查者，在儿童体检中发现视力异常时及时转诊。
- 联合评估与转诊：建立规范的联合评估和转诊机制，确保儿童能够获得最全面、最专业的诊疗服务。例如，在疑似存在遗传性眼病时，可进行基因检测和遗传咨询 94。
- 家长教育与学校支持：
- 家长教育：家长是儿童视觉健康的第一责任人。加强家长教育，普及屈光参差、远视储备、近视防控等知识至关重要。研究显示，家长对儿童眼保健知识和实践的认知水平普遍较低，存在诸多误解 95。因此，眼科专业人员应通过多种途径（如讲座、宣传资料、线上平台）向家长普及：
- 屈光知识科普：解释屈光参差和远视储备的含义，以及其对儿童视觉发育的潜在影响。
- 训练配合技巧：指导家长如何在家中监督和辅助儿童进行视觉训练，强调依从性和坚持性。
- 正确用眼习惯：指导家长营造良好的用眼环境，控制屏幕时间，鼓励户外活动。
- 定期检查的重要性：强调定期带儿童进行眼科检查，而不是等到出现问题才就医。
- 学校支持：学校在儿童视觉健康中扮演重要角色。
- 课桌椅调整：确保教室内的课桌椅高度适合儿童身高，保持正确的读写姿势。
- 眼保健操优化：科学指导和监督学生做眼保健操，缓解眼疲劳。
- 增加户外活动：学校应确保学生每天有充足的户外活动时间（至少2小时），包括课间休息和体育课。研究表明，增加学生户外活动时间是控制近视发生和进展的有效公共卫生干预措施 96。
- 视力筛查与转诊：学校应定期组织学生进行视力筛查，对发现视力异常的学生及时告知家长并建议就医。
- 家长教育：家长是儿童视觉健康的第一责任人。加强家长教育，普及屈光参差、远视储备、近视防控等知识至关重要。研究显示，家长对儿童眼保健知识和实践的认知水平普遍较低，存在诸多误解 95。因此，眼科专业人员应通过多种途径（如讲座、宣传资料、线上平台）向家长普及：
5.3 预后风险与干预升级
识别高风险人群并及时升级干预策略，对于预防高度近视及其并发症至关重要。
- 远视储备过早耗竭（<6岁储备<1.00D）与屈光参差持续扩大（≥2.00D）的高风险人群特征：
- 远视储备过早耗竭：学龄前儿童（特别是6岁以下）远视储备低于+1.00D被认为是未来发生近视的高风险信号。这类儿童应立即启动近视防控干预，如增加户外活动、考虑低浓度阿托品治疗等 97。
- 屈光参差持续扩大：如果双眼屈光度差异持续扩大，达到或超过2.00D，则弱视、斜视和立体视功能障碍的风险显著增加，需要更积极的干预。
- 其他高风险因素：包括父母高度近视、早期近视发病（如6岁前发生近视）、低龄远视度数快速下降、不健康的用眼习惯等。
- 联合干预策略（如光学矫正+药物+训练）：对于高风险人群或进展快速的儿童，单一的干预措施可能不足以控制病情，需要采取联合干预。
- 光学矫正：佩戴合适的框架眼镜或角膜塑形镜/多焦点软性接触镜来矫正屈光不正，并控制近视进展。
- 药物治疗：使用低浓度阿托品眼药水（如0.05%浓度）来延缓眼轴增长和近视进展，或预防近视发生。
- 视觉训练：针对弱视、双眼视功能障碍、调节功能不足等问题进行个性化的视觉训练。
- 户外活动：持续保障充足的户外活动时间。
- 个性化组合：根据儿童的具体情况，灵活组合上述干预手段。例如，对于一眼近视一眼远视的屈光参差，近视眼可佩戴角膜塑形镜控制近视，远视眼则需佩戴框架眼镜矫正，同时进行双眼视功能训练。
- 成年后可能的屈光手术（如ICL、LASIK）适应症与时机选择：
- 儿童期禁忌：屈光手术（如LASIK、PRK、ICL）在儿童期通常是禁忌的，因为儿童眼球仍在发育，屈光状态不稳定，且手术风险较高，长期效果不确定 98。
- 特殊适应症：极少数情况下，对于高度屈光参差且无法通过其他方式矫正的儿童，为挽救濒临失明的眼睛，屈光手术可能会在严格评估后被考虑，但这种情况非常罕见且需谨慎。
- 成年后考虑：当儿童发育成熟，屈光状态稳定（通常在18岁以后，屈光度数两年内变化不超过0.50D），且无其他眼部禁忌症时，可考虑屈光手术来永久性矫正屈光不正，摆脱眼镜或隐形眼镜的束缚。屈光手术种类包括激光角膜屈光手术（LASIK、PRK等）和晶体植入术（ICL）。具体选择哪种手术方式，需根据患者的屈光度数、角膜厚度、眼部健康状况等因素，在专业眼科医生的评估下决定。
通过构建全周期监测体系，整合多学科专业力量，并给予家庭和学校充分支持，同时对高风险儿童实施升级干预，才能全面、有效地管理儿童屈光参差和远视储备差异，为他们的视觉健康保驾护航。
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参考文献
1Progressive adult antimetropia.PubMed
Stephen J Vincent, Scott A Read
Clin Exp Optom. 2014 Jul;97(4):375-8. doi: 10.1111/cxo.12129. Epub 2014 Jan 20.
Antimetropia, a sub-classification of anisometropia, is a rare refractive condition in which one eye is myopic and the fellow eye is hyperopic. This case report describes the ocular characteristics and atypical refractive progression in an adult male with a moderate degree of non-amblyopic antimetropia over a 20-year period. The potential mechanisms underlying unilateral axial elongation, anisometropia and myopia progression in adulthood are discussed.
2Anisometropic amblyopia.PubMed
P J Kutschke, W E Scott, R V Keech
Ophthalmology. 1991 Feb;98(2):258-63. doi: 10.1016/s0161-6420(91)32307-8.
One hundred twenty-four patients with anisometropia of 1 diopter or greater and amblyopia were reviewed as to the type and amount of anisometropia, whether or not they had consulted with an ophthalmologist, visual acuity before and after treatment, and type of treatment. The patient population was divided into five groups according to the type of anisometropia. Eighty-two percent of all patients reached a visual acuity of 20/40 or better. Eighteen percent of all patients reached a visual acuity of 20/20. The best visual acuity obtained was not found to be related to the degree of anisometropia or the age at which treatment was begun. Patients with myopic and compound myopic astigmatism/mixed astigmatism anisometropia had poorer visual outcomes. There was a strong positive correlation between the initial visual acuity and the best visual acuity obtained (P = 0.0001).
3Anisometropia in Hispanic and african american infants and young children the multi-ethnic pediatric eye disease study.PubMed
Mark Borchert, Kristina Tarczy-Hornoch, Susan A Cotter, et al.
Ophthalmology. 2010 Jan;117(1):148-153.e1. doi: 10.1016/j.ophtha.2009.06.008. Epub 2009 Oct 8.
PURPOSE: To determine anisometropia prevalence and associated risk factors in Hispanic and African American preschoolers. DESIGN: Population-based, cross-sectional study. PARTICIPANTS: We included 3030 Hispanic and 2994 African American children aged 6 to 72 months from Inglewood, California. METHODS: Retinomax autorefraction was performed on all participants after cycloplegia. Anisometropia was defined by difference in spherical equivalent (SE), by difference in plus cylinder in any axis (cylindrical), and by difference in cylinder axis vectors (vertical Jackson cross cylinder vector [J0] and oblique Jackson cross cylinder vector [J45] between the eyes. Strabismus was determined by prism-cover testing. A parental questionnaire explored potential risk factors including developmental delay, prematurity, prenatal exposure, and family history. MAIN OUTCOME MEASURES: Anisometropia prevalence stratified by age, gender, and ethnicity. The association of anisometropia with strabismus and other biological risk factors was assessed. RESULTS: The prevalence of SE anisometropia > or =1.0 diopter (D) was 4.3% for Hispanics and 4.2% for African Americans. Prevalence of cylindrical anisometropia > or =1.0 D was 5.6% and 4.5%, respectively. Prevalence of cylindrical or SE anisometropia > or =3.0 D was < or =0.4% for both ethnic groups. Cylinder vector anisometropia > or =0.5 was twice as common as cylindrical anisometropia > or =1.0 D. The SE anisometropia decreased at age 1 year in Hispanics (P = 0.0016) but not African Americans. Cylindrical anisometropia decreased in the first year of life in both ethnic groups (P < or = 0.001). There was no trend in SE or cylindrical anisometropia beyond 1 year of age, but cylinder vector anisometropia steadily decreased beyond 1 year of age in both ethnic groups. Cylinder vector anisometropia was more prevalent among African Americans, but there was no difference in other measurements of anisometropia between ethnic groups. Anisometropia did not vary by gender. Strabismus was associated with all types of anisometropia. No association of anisometropia with gestational age, birth weight, cerebral palsy, family history, or prenatal exposure could be identified. CONCLUSIONS: Spherical and cylindrical anisometropia (> or =1.0 D) each affect 4% to 6% of Hispanic and African American preschoolers. Anisometropia > or =3.0 D is rare. Except for cylinder axis vector, the prevalence of anisometropia does not diminish beyond 1 year of age. Strabismus is associated with all forms of anisometropia. FINANCIAL DISCLOSURE(S): The authors have no proprietary or commercial interest in any of the materials discussed in this article.
4Prevalence and risk factors for anisometropia in the Tehran eye study, Iran.PubMed
Hassan Hashemi, Mehdi Khabazkhoob, Abbasali Yekta, et al.
Ophthalmic Epidemiol. 2011 Jun;18(3):122-8. doi: 10.3109/09286586.2011.574333.
PURPOSE: To determine the prevalence of anisometropia and its determinants in a population-based sample. METHODS: In a cross-sectional population-based study, stratified cluster sampling was carried out from the population of Tehran. Respondents were transferred to a clinic for an interview and ophthalmic examinations including tests for visual acuity with and without correction, cycloplegic refraction, the slit lamp examination, fundoscopy, and lensometry. Anisometropia was defined as unequal spherical equivalent cycloplegic refractions in the two eyes. RESULTS: Of 4565 participants, cycloplegic refraction was performed in both eyes of 3519 people. The mean age of the examinees was 31.5 ± 18.0 (range, 5-86) years. The mean anisometropia was 0.34 diopter (D) (95% Confidence Interval (CI): 0.31-0.37). The prevalence rates of anisometropia more than 0.5, 1.0, 1.5 and 2.0 D were 18.5% (95% CI: 17.0-19.9), 6.7% (95% CI: 5.8-7.7), 3.8% (95% CI: 3.1-4.5) and 2.6% (95% CI: 2.1-3.1). The inter-gender difference in the prevalence of anisometropia ≥ 1.0D was not statistically significant (P = 0.952). The prevalence of anisometropia increased after the age of 45 years. Overall, 15.7% of the examinees had anisomyopia and 4.7% had anisohypermetropia equal to or more than 1.0D. Anisometropia was more prevalent among patients with cataracts, amblyopia, and pseudophakia. The prevalence rates of spherical and cylindrical anisometropia in the studied sample were 8.0% and 7.1%, respectively. CONCLUSIONS: The prevalence of anisometropia in the population of Tehran is beyond negligible. It showed a significant increase with age. Results also indicate that myopic patients are more likely to have anisometropia.
5Refractive errors and risk factors for myopia in infants aged 1-18 months in Tianjin, China.PubMed
Lu Huo, Yuanyuan Qi, Shaozhen Zhao
BMC Ophthalmol. 2021 Nov 23;21(1):403. doi: 10.1186/s12886-021-02172-2.
BACKGROUND: Infancy is the of a child's visual development. Refractive errors, especially myopia, are a common vision disorder. Thus, the purpose of this study was to explore refractive errors and risk factors for myopia among infants aged 1-18 months in Tianjin, China. METHODS: A total of 583 infants aged 1-18 months participated in this cross-sectional study at Tianjin Women's and Children's Health Center in China from February 2019 to November 2020. Each infant received a complete ophthalmologic examination, and myopia-related risk factors were investigated using a questionnaire. RESULTS: A total of 583 eligible infants participated in this study, including 312 (53.5%) boys and 271 (46.5%) girls. There were 164 (28.1%) premature born infants. The mean age was 6.59 ± 4.84 months (range, 1-18 months). The mean spherical equivalent (MSE) for the right eye was 1.81 D ± 1.56 D, with no difference related to sex (P = 0.104). Refractive state showed an average hyperopia of +2.74 ± 1.74 D at early ages, followed by a trend toward less hyperopia, finally reaching +1.35 ± 1.44 D at the age of 18 months (P ≤0.001). The overall prevalence rates of myopia (MSE ≤ -0.50 D), emmetropia (-0.50 D<MSE<+0.50 D), hyperopia (MSE ≥ +2.00 D), and astigmatism (≥ 1.50 D) were 5.1%, 10.8%, 42.7%, and 49.9%, respectively. The chi-square tests showed that gender, gestational age ≥37 weeks, winter birth, prenatal exposure to environmental tobacco smoke, and parental history of high myopia were associated with children's myopia (P = 0.022, P = 0.023, P = 0.038, P = 0.015, P<0.001, respectively). CONCLUSIONS: Among Chinese infants in Tianjin, hyperopia and astigmatism were the most frequent refractive errors, and the diopter was lower in individuals with higher age. In a small number of infants with myopia, genetic factors and the prenatal environment were associated with the early onset of myopia.
6Anisometropia and binocularity.PubMed
S E Brooks, D Johnson, N Fischer
Ophthalmology. 1996 Jul;103(7):1139-43. doi: 10.1016/s0161-6420(96)30555-1.
PURPOSE: To determine the effects of experimentally induced anisometropia on binocular function in healthy adults as a means of assessing the potentially detrimental effects of uncorrected anisometropia on binocular development in childhood. METHODS: Nineteen adults with normal binocularity, ranging in age from 26 to 59 years, were studied. Unilateral myopia, hyperopia, or astigmatism (at 90 degrees or 45 degrees) was induced in each subject using trial lenses. Sensory status then was assessed by measuring stereoacuity, Worth four-dot fusion, and Bagolini lens response. RESULTS: All subjects showed a decline in binocular function with increasing levels of anisometropia. Foveal suppression was evident on the Worth four-dot test, and increased in proportion to the anisometropia. Stereoacuity was similarly degraded by the induced anisometropia, with some subjects showing significant loss of stereoacuity with as little as 1 diopter of spherical anisometropia. Bagolini lens responses were binocular in almost all patients, although occasional abnormalities were found. CONCLUSIONS: Relatively low degrees of anisometropia may cause significant abnormalities in high-grade binocular visual functions in adults. The potential effects of uncorrected anisometropia on binocularity in children require further investigation, but should be considered in developing guidelines for the empiric correction of refractive errors.
7Associations between hyperopia and other vision and refractive error characteristics.PubMed
Marjean Taylor Kulp, Gui-Shuang Ying, Jiayan Huang, et al.
Optom Vis Sci. 2014 Apr;91(4):383-9. doi: 10.1097/OPX.0000000000000223.
PURPOSE: To investigate the association of hyperopia greater than +3.25 diopters (D) with amblyopia, strabismus, anisometropia, astigmatism, and reduced stereoacuity in preschoolers. METHODS: Three- to five-year-old Head Start preschoolers (N = 4040) underwent vision examination including monocular visual acuity (VA), cover testing, and cycloplegic refraction during the Vision in Preschoolers Study. Visual acuity was tested with habitual correction and was retested with full cycloplegic correction when VA was reduced below age norms in the presence of significant refractive error. Stereoacuity testing (Stereo Smile II) was performed on 2898 children during study years 2 and 3. Hyperopia was classified into three levels of severity (based on the most positive meridian on cycloplegic refraction): group 1: greater than or equal to +5.00 D, group 2: greater than +3.25 D to less than +5.00 D with interocular difference in spherical equivalent greater than or equal to 0.50 D, and group 3: greater than +3.25 D to less than +5.00 D with interocular difference in spherical equivalent less than 0.50 D. "Without" hyperopia was defined as refractive error of +3.25 D or less in the most positive meridian in both eyes. Standard definitions were applied for amblyopia, strabismus, anisometropia, and astigmatism. RESULTS: Relative to children without hyperopia, children with hyperopia greater than +3.25 D (n = 472, groups 1, 2, and 3) had a higher proportion of amblyopia (34.5 vs. 2.8%, p < 0.0001) and strabismus (17.0 vs. 2.2%, p < 0.0001). More severe levels of hyperopia were associated with higher proportions of amblyopia (51.5% in group 1 vs. 13.2% in group 3) and strabismus (32.9% in group 1 vs. 8.4% in group 3; trend p < 0.0001 for both). The presence of hyperopia greater than +3.25 D was also associated with a higher proportion of anisometropia (26.9 vs. 5.1%, p < 0.0001) and astigmatism (29.4 vs. 10.3%, p < 0.0001). Median stereoacuity of nonstrabismic, nonamblyopic children with hyperopia (n = 206) (120 arcsec) was worse than that of children without hyperopia (60 arcsec) (p < 0.0001), and more severe levels of hyperopia were associated with worse stereoacuity (480 arcsec for group 1 and 120 arcsec for groups 2 and 3, p < 0.0001). CONCLUSIONS: The presence and magnitude of hyperopia among preschoolers were associated with higher proportions of amblyopia, strabismus, anisometropia, and astigmatism and with worse stereoacuity even among nonstrabismic, nonamblyopic children.
8Visual development cohort study on refractive parameters among preschool children in Sucheng district.PubMed
Yuqing Cui, Fan Yang, Qian Zhou, et al.
BMC Ophthalmol. 2025 Dec 1;26(1):5. doi: 10.1186/s12886-025-04535-5.
PURPOSE: To examine the dynamic changes in visual acuity and refractive parameters among preschool children in Sucheng District, Suqian City, addressing the lack of refractive development data for preschool-aged populations in rapidly urbanizing fourth-tier cities in China, and to offer a foundation for regional vision screening and intervention strategies. METHODS: A prospective longitudinal cohort study (2022-2024) was conducted. Utilizing stratified cluster sampling, 2,821 children (5,642 eyes) from 51 kindergartens in Sucheng District were selected and underwent three annual follow-ups. Non-cycloplegic refraction (Spot VS100 photorefractor(Welch Allyn, USA) and examinations using a standard logarithmic visual acuity chart were performed. Differences in visual impairment rates, refractive status distribution, spherical equivalent (SE), and other parameters by age and sex were analyzed. RESULTS: Visual impairment rates at baseline (2022), interim (2023), and final (2024) assessments were 6.45%, 5.17%, and 8.68%, respectively (χ²=28.20, P < 0.001), displaying a nonlinear U-shaped trajectory. At the final assessment, the impairment rate among girls (10.89%) was significantly higher than that of boys (6.52%) (χ²=16.88, P < 0.05). Astigmatism and SE values initially increased and then decreased over the three-year period (P < 0.001). With age, the proportion of pure hyperopia showed a significant decline (P < 0.001), while pure myopia proportions increased correspondingly (P < 0.001). CONCLUSIONS: Refractive development among preschool children in Sucheng District is significantly impacted by rapid urbanization, characterized by an accelerated depletion of hyperopic reserve and an earlier-than-expected emmetropization process. Girls and children aged 5-6 years (final assessment period) represent high-risk groups for visual impairment, underscoring the need for an annual kindergarten-based screening and early intervention system.
9Amblyopia.PubMed
Stephanie West, Cathy Williams
BMJ Clin Evid. 2011 Jun 30;2011:0709.
INTRODUCTION: Amblyopia is commonly associated with squint (strabismus) or refractive errors resulting in different visual inputs to each eye during the sensitive period of visual development (<7-8 years of age). The cumulative incidence is estimated at 2% to 4% in children aged up to 15 years. METHODS AND OUTCOMES: We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of interventions to detect amblyopia early? What are the effects of medical treatments for amblyopia? We searched: Medline, Embase, The Cochrane Library, and other important databases up to May 2010 (Clinical Evidence reviews are updated periodically; please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations, such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA). RESULTS: We found 33 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions. CONCLUSIONS: In this systematic review, we present information relating to the effectiveness and safety of the following interventions: active vision therapy; glasses alone or with occlusion; or penalisation to treat amblyopia; and screening to detect amblyopia early.
10[Functional amblyopia].PubMed
Elena Avram, Adriana Stănilă
Oftalmologia. 2013;57(4):3-8.
Amblyopia is a disorder of the visual system that represents unilateral or bi-lateral reduction of visual acuity in which an organic cause cannot be detected. The illness represents a syndrome of visual deficits, not only a deterioration of visual acuity. This syndrome includes: presence of crowding phenomena, contrast sensitivity deterioration, deficits in accommodation, deterioration of spatial orientation and ocular motility dysfunction. Depending on its etiology, amblyopia is classified into four main types: strabismic amblyopia, anisometropic amblyopia, isoametropic amblyopia and stimulus deprivation amblyopia. To successfully treat the "lazy eye" it is essential to remove the amblyopic factor with techniques addressing each disturbing factor. Techniques used for treating amblyopia include: occlusion, optical penalty or pharmacological, therapy with Levodopa and computer vision therapy. Amblyopia treatment is lengthy and it is very important to counsel not only the child but the whole family and to establish a relationship of trust between doctor and patient in order to get high treatment compliance and high child motivation.
11Amblyopia.PubMed
Nipa R Doshi, Maria Lourdes F Rodriguez
Am Fam Physician. 2007 Feb 1;75(3):361-7.
Amblyopia, a decrease in visual acuity, is a major public health problem with a prevalence of 1 to 4 percent in the United States. It is thought to develop early in life during the critical period of visual development. Early recognition of amblyogenic risk factors such as strabismus, refractive errors, and anatomic obstructions can facilitate early treatment and increase the chance for recovery of visual acuity. Multiple medical organizations endorse screening for visual abnormalities in children and young adults, yet only 20 percent of school-age children have routine vision screening examinations. Any child with a visual acuity in either eye of 20/40 or worse at age three to five years or 20/30 or worse at age six years or older, or a two-line difference in acuity between eyes, should be referred to an ophthalmologist for further evaluation and definitive therapy. Treatment is started at the time of diagnosis and depends on the etiology. Treatment options for children with strabismus include patching and atropine drops. Children with refractive errors should be prescribed corrective lenses. Corneal lesions, cataracts, and ptosis require surgery. The success of therapy is highly dependent on treatment compliance. Patients and their parents should be educated about the need for regular follow-up and the risk of permanent vision loss.
12The relationship between anisometropia and amblyopia.PubMed
Brendan T Barrett, Arthur Bradley, T Rowan Candy
Prog Retin Eye Res. 2013 Sep;36:120-58. doi: 10.1016/j.preteyeres.2013.05.001. Epub 2013 Jun 15.
This review aims to disentangle cause and effect in the relationship between anisometropia and amblyopia. Specifically, we examine the literature for evidence to support different possible developmental sequences that could ultimately lead to the presentation of both conditions. The prevalence of anisometropia is around 20% for an inter-ocular difference of 0.5D or greater in spherical equivalent refraction, falling to 2-3%, for an inter-ocular difference of 3D or above. Anisometropia prevalence is relatively high in the weeks following birth, in the teenage years coinciding with the onset of myopia and, most notably, in older adults starting after the onset of presbyopia. It has about one-third the prevalence of bilateral refractive errors of the same magnitude. Importantly, the prevalence of anisometropia is higher in highly ametropic groups, suggesting that emmetropization failures underlying ametropia and anisometropia may be similar. Amblyopia is present in 1-3% of humans and around one-half to two-thirds of amblyopes have anisometropia either alone or in combination with strabismus. The frequent co-existence of amblyopia and anisometropia at a child's first clinical examination promotes the belief that the anisometropia has caused the amblyopia, as has been demonstrated in animal models of the condition. In reviewing the human and monkey literature however it is clear that there are additional paths beyond this classic hypothesis to the co-occurrence of anisometropia and amblyopia. For example, after the emergence of amblyopia secondary to either deprivation or strabismus, anisometropia often follows. In cases of anisometropia with no apparent deprivation or strabismus, questions remain about the failure of the emmetropization mechanism that routinely eliminates infantile anisometropia. Also, the chronology of amblyopia development is poorly documented in cases of 'pure' anisometropic amblyopia. Although indirect, the therapeutic impact of refractive correction on anisometropic amblyopia provides strong support for the hypothesis that the anisometropia caused the amblyopia. Direct evidence for the aetiology of anisometropic amblyopia will require longitudinal tracking of at-risk infants, which poses numerous methodological and ethical challenges. However, if we are to prevent this condition, we must understand the factors that cause it to develop.
13Untreated essential infantile esotropia: factors affecting the development of amblyopia.PubMed
C Calcutt, A D Murray
Eye (Lond). 1998;12 ( Pt 2):167-72. doi: 10.1038/eye.1998.42.
PURPOSE: A concomitant esotropia, presenting within the first 6 months of life, associated with a high incidence of dissociated vertical deviation, manifest latent nystagmus and asymmetric optokinetic nystagmus is termed essential infantile esotropia. Most studies concern patients diagnosed in infancy and treated throughout childhood. This paper addresses the factors that may influence the development of amblyopia in patients who remain untreated until visual adulthood. METHODS: During a 3 year period 113 patients aged 8 years or more with a history of esotropia occurring within the first 6 months of life were examined for the study. All patients underwent full ocular motility assessment and cycloplegic refraction, and only those with one or more signs of essential infantile esotropia were included. RESULTS: Of the 113 patients, 16 (14.3%) had a difference of 2 or more lines in the visual acuity of the two eyes and were diagnosed as having amblyopia. Anisometropia was present in 10 of the 16 (62.5%). The correlation between anisometropia and amblyopia was statistically significant (p = 0.0001). CONCLUSIONS: Amblyopia following early surgical intervention in essential infantile exotropia is well documented, but the risk is outweighed by the chance of obtaining some form of binocular vision. However, where access to ongoing therapy is not available, patients with essential infantile esotropia, free alternation and no anisometropia have a significant chance of retaining good visual acuity in both eyes if surgery is delayed until visual adulthood.
14Laterality of amblyopia.PubMed
Michael Repka, Kurt Simons, Raymond Kraker, et al.
Am J Ophthalmol. 2010 Aug;150(2):270-4. doi: 10.1016/j.ajo.2010.01.040. Epub 2010 May 8.
PURPOSE: To determine the frequency of unilateral amblyopia in right versus left eyes among children younger than 18 years. DESIGN: Analysis of data collected in randomized clinical trials conducted by the Pediatric Eye Disease Investigator Group. METHODS: The laterality of the amblyopic eye was analyzed in 2635 subjects younger than 18 years who participated in 9 multicenter prospective, randomized treatment trials. Eligibility criteria for these clinical trials included unilateral amblyopia associated with strabismus, anisometropia, or both, with visual acuity between 20/40 and 20/400. Logistic regression was used to assess the association of baseline and demographic factors with the laterality of amblyopia. RESULTS: Among subjects with anisometropic amblyopia (with or without strabismus), amblyopia was present more often in left than right eyes, with a relative prevalence of 59% in left eyes (95% confidence interval, 57% to 62%; P < .001 from a test of proportion, 50%). However, among subjects with strabismic-only amblyopia, there was no laterality predilection (relative prevalence of 50% in left eyes; 95% confidence interval, 47% to 54%; P = .94). CONCLUSIONS: Anisometropic amblyopia, with or without strabismus, occurs more often in left eyes than right eyes. This finding of amblyopia laterality may be related to microtropia, sighting dominance, or other forms of ocular dominance; developmental or neurological factors; laterality in the development of refractive error; or a combination thereof.
15Melanopsin modulates refractive development and myopia.PubMed
Ranjay Chakraborty, Erica G Landis, Reece Mazade, et al.
Exp Eye Res. 2022 Jan;214:108866. doi: 10.1016/j.exer.2021.108866. Epub 2021 Nov 25.
Myopia, or nearsightedness, is the most common form of refractive abnormality and is characterized by excessive ocular elongation in relation to ocular power. Retinal neurotransmitter signaling, including dopamine, is implicated in myopic ocular growth, but the visual pathways that initiate and sustain myopia remain unclear. Melanopsin-expressing retinal ganglion cells (mRGCs), which detect light, are important for visual function, and have connections with retinal dopamine cells. Here, we investigated how mRGCs influence normal and myopic refractive development using two mutant mouse models: Opn4 mice that lack functional melanopsin photopigments and intrinsic mRGC responses but still receive other photoreceptor-mediated input to these cells; and Opn4 mice that lack intrinsic and photoreceptor-mediated mRGC responses due to mRGC cell death. In mice with intact vision or form-deprivation, we measured refractive error, ocular properties including axial length and corneal curvature, and the levels of retinal dopamine and its primary metabolite, L-3,4-dihydroxyphenylalanine (DOPAC). Myopia was measured as a myopic shift, or the difference in refractive error between the form-deprived and contralateral eyes. We found that Opn4 mice had altered normal refractive development compared to Opn4 wildtype mice, starting ∼4D more myopic but developing ∼2D greater hyperopia by 16 weeks of age. Consistent with hyperopia at older ages, 16 week-old Opn4 mice also had shorter eyes compared to Opn4 mice (3.34 vs 3.42 mm). Opn4 mice, however, were more hyperopic than both Opn4 and Opn4 mice across development ending with even shorter axial lengths. Despite these differences, both Opn4 and Opn4 mice had ∼2D greater myopic shifts in response to form-deprivation compared to Opn4 mice. Furthermore, when vision was intact, dopamine and DOPAC levels were similar between Opn4 and Opn4 mice, but higher in Opn4 mice, which differed with age. However, form-deprivation reduced retinal dopamine and DOAPC by ∼20% in Opn4 compared to Opn4 mice but did not affect retinal dopamine and DOPAC in Opn4 mice. Lastly, systemically treating Opn4 mice with the dopamine precursor L-DOPA reduced their form-deprivation myopia by half compared to non-treated mice. Collectively our findings show that disruption of retinal melanopsin signaling alters the rate and magnitude of normal refractive development, yields greater susceptibility to form-deprivation myopia, and changes dopamine signaling. Our results suggest that mRGCs participate in the eye's response to myopigenic stimuli, acting partly through dopaminergic mechanisms, and provide a potential therapeutic target underling myopia progression. We conclude that proper mRGC function is necessary for correct refractive development and protection from myopia progression.
16Aberrations and myopia.PubMed
W N Charman
Ophthalmic Physiol Opt. 2005 Jul;25(4):285-301. doi: 10.1111/j.1475-1313.2005.00297.x.
It has been suggested that high levels of axial aberration or specific patterns of peripheral refraction could play a role in myopia development. Possible mechanisms involving high levels of retinal image blur caused by axial aberrations include form deprivation through poor retinal image quality in distance vision, enhanced accommodative lags favouring compensatory eye growth, and an absence of adequate directional cues to guide emmetropization. In addition, in initially emmetropic eyes, hyperopia in the retinal periphery may result in local compensatory eye growth, which induces axial myopia. Evidence in support of these ideas is reviewed and it is concluded that, for any fixed pupil diameter, evidence for higher levels of axial aberration in myopes in comparison with other refractive groups is weak, making involvement of axial aberrations in myopization through image degradation at the fovea unlikely. If, however, some potential myopes had unusually large pupil diameters, their effective aberration levels and associated retinal blur would be larger than those of the rest of the population. There is stronger evidence in favour of differences in patterns of peripheral refraction in both potential and existing myopes, with myopes tending to show relative hyperopia in the periphery. These differences appear to be related to a more prolate eyeball shape. Longitudinal studies are required to confirm whether the retinal defocus associated with the peripheral hyperopia can cause patterns of eyeball growth which lead to axial myopia.
17Relating binocular and monocular vision in strabismic and anisometropic amblyopia.PubMed
Ritwick Agrawal, Ian P Conner, J V Odom, et al.
Arch Ophthalmol. 2006 Jun;124(6):844-50. doi: 10.1001/archopht.124.6.844.
OBJECTIVES: To examine deficits in monocular and binocular vision in adults with amblyopia and to test the following 2 hypotheses: (1) Regardless of clinical subtype, the degree of impairment in binocular integration predicts the pattern of monocular acuity deficits. (2) Subjects who lack binocular integration exhibit the most severe interocular suppression. METHODS: Seven subjects with anisometropia, 6 subjects with strabismus, and 7 control subjects were tested. Monocular tests included Snellen acuity, grating acuity, Vernier acuity, and contrast sensitivity. Binocular tests included Titmus stereo test, binocular motion integration, and dichoptic contrast masking. RESULTS: As expected, both groups showed deficits in monocular acuity, with subjects with strabismus showing greater deficits in Vernier acuity. Both amblyopic groups were then characterized according to the degree of residual stereoacuity and binocular motion integration ability, and 67% of subjects with strabismus compared with 29% of subjects with anisometropia were classified as having "nonbinocular" vision according to our criterion. For this nonbinocular group, Vernier acuity is most impaired. In addition, the nonbinocular group showed the most dichoptic contrast masking of the amblyopic eye and the least dichoptic contrast masking of the fellow eye. CONCLUSION: The degree of residual binocularity and interocular suppression predicts monocular acuity and may be a significant etiological mechanism of vision loss.
18Algorithmic and sensor-based research on Chinese children's and adolescents' screen use behavior and light environment.PubMed
Jifang Wang, Yang Shen, Jing Zhao, et al.
Front Public Health. 2024 Feb 22;12:1352759. doi: 10.3389/fpubh.2024.1352759. eCollection 2024.
BACKGROUND: Myopia poses a global health concern and is influenced by both genetic and environmental factors. The incidence of myopia tends to increase during infectious outbreaks, such as the COVID-19 pandemic. This study examined the screen-time behaviors among Chinese children and adolescents and investigated the efficacy of artificial intelligence (AI)-based alerts in modifying screen-time practices. METHODS: A cross-sectional analysis was performed using data from 6,716 children and adolescents with AI-enhanced tablets that monitored and recorded their behavior and environmental light during screen time. RESULTS: The median daily screen time of all participants was 58.82 min. Among all age groups, elementary-school students had the longest median daily screen time, which was 87.25 min and exceeded 4 h per week. Children younger than 2 years engaged with tablets for a median of 41.84 min per day. Learning accounted for 54.88% of participants' screen time, and 51.03% (3,390/6,643) of the participants used tablets for 1 h at an average distance <50 cm. The distance and posture alarms were triggered 807,355 and 509,199 times, respectively. In the study, 70.65% of the participants used the tablet under an illuminance of <300 lux during the day and 61.11% under an illuminance of <100 lux at night. The ambient light of 85.19% of the participants exceeded 4,000 K color temperature during night. Most incorrect viewing habits (65.49% in viewing distance; 86.48% in viewing posture) were rectified swiftly following AI notifications (all < 0.05). CONCLUSION: Young children are increasingly using digital screens, with school-age children and adolescents showing longer screen time than preschoolers. The study highlighted inadequate lighting conditions during screen use. AI alerts proved effective in prompting users to correct their screen-related behavior promptly.
19Change of blue light hazard and circadian effect of LED backlight displayer with color temperature and age.PubMed
Yang Chaopu, Fang Wenqing, Tang Jiancheng, et al.
Opt Express. 2018 Oct 15;26(21):27021-27032. doi: 10.1364/OE.26.027021.
In order to provide a theoretical reference for the personalized design and color temperature adjustment of LED backlight displayer, the spectral distribution of the LED backlight displayer at different color temperatures (1200-6500K) was measured. According to the transmittance of human eye at different ages (1-100 years old), the effective spectral distribution of the LED backlight displayer on the retina of the human eye at different ages was calculated. Based on the fitting of the response function of the human eye, the correlation studies on the changes of the blue light hazard factor, the proportion of blue light in the range of wavelength 400-500 nm, the circadian rhythm factor, and the proportion of blue light in the range of wavelength 446-477 nm with color temperature and age were conducted respectively. The results showed that the blue light hazard and circadian rhythm increased with the increase of the color temperature while decreased with the increase of age. For one-year-old infants, when the color temperature increased from 1200K to 6500K, the blue light hazard factor and circadian rhythm factor of the effective spectrum of the retina increased by 12.2 and 9.5 times respectively. For a 6500K LED backlight displayer, when the age increased from 1-year-old to 100 years old, the corresponding value of the two factors decreased by 0.2 and 0.3 times respectively. The proportion of blue light in the range of wavelength 400-500 nm can be used to approximately replace the blue light hazard factor to demonstrate the degree of blue light hazard. This conclusion can provide a certain theoretical reference for the personalized design and use of LED backlight displayer from the perspective of blue light hazard and circadian rhythm.
20Digital Eye Strain- A Comprehensive Review.PubMed
Kirandeep Kaur, Bharat Gurnani, Swatishree Nayak, et al.
Ophthalmol Ther. 2022 Oct;11(5):1655-1680. doi: 10.1007/s40123-022-00540-9. Epub 2022 Jul 9.
Digital eye strain (DES) is an entity encompassing visual and ocular symptoms arising due to the prolonged use of digital electronic devices. It is characterized by dry eyes, itching, foreign body sensation, watering, blurring of vision, and headache. Non-ocular symptoms associated with eye strain include stiff neck, general fatigue, headache, and backache. A variable prevalence ranging from 5 to 65% has been reported in the pre-COVID-19 era. With lockdown restrictions during the pandemic, outdoor activities were restricted for all age groups, and digital learning became the norm for almost 2 years. While the DES prevalence amongst children alone rose to 50-60%, the symptoms expanded to include recent onset esotropia and vergence abnormalities as part of the DES spectrum. New-onset myopia and increased progression of existing myopia became one of the most significant ocular health complications. Management options for DES include following correct ergonomics like reducing average daily screen time, frequent blinking, improving lighting, minimizing glare, taking regular breaks from the screen, changing focus to distance object intermittently, and following the 20-20-20 rule to reduce eye strain. Innovations in this field include high-resolution screens, inbuilt antireflective coating, matte-finished glass, edge-to-edge displays, and image smoothening graphic effects. Further explorations should focus on recommendations for digital screen optimization, novel spectacle lens technologies, and inbuilt filters to optimize visual comfort. A paradigm shift is required in our understanding of looking at DES from an etiological perspective, so that customized solutions can be explored accordingly. The aim of this review article is to understand the pathophysiology of varied manifestations, predisposing risk factors, varied management options, along with changing patterns of DES prevalence post COVID-19.
21Screen Time and Its Health Consequences in Children and Adolescents.PubMed
Nikos Priftis, Demosthenes Panagiotakos
Children (Basel). 2023 Oct 8;10(10):1665. doi: 10.3390/children10101665.
Nowadays, children and adolescents are exposed to digital media (DM) from an early age. Therefore, specific guidelines have been published by the World Health Organization, whose aim is to limit daily screen time (ST) viewing. However, during the COVID-19 pandemic, a rise in DM use, and consequently ST viewing, was observed. More and more aspects of modern life are thought to be affected by excessive ST viewing. Accordingly, the aim of this review is to document the health effects of excessive ST viewing on children and adolescents. A narrative review was performed in searchable databases. In total, 43 original articles were considered. Excessive ST viewing was correlated with increased risk for obesity and other cardiometabolic risk factors, mental health, unhealthy dietary habits and eating disorders, and problems in development and child-parent relationships. Sleep, physical activity, eyesight, headaches, and the musculoskeletal system were negatively affected as well. However, the effect of ST was weighted by the type of media used and the way types of media were used. Other confounding factors were reported. There is evidence to suggest a negative correlation between excessive ST and youth health exists. Nevertheless, more research is needed if this correlation is to be established.
22Increased Screen Time as a Cause of Declining Physical, Psychological Health, and Sleep Patterns: A Literary Review.PubMed
Vaishnavi S Nakshine, Preeti Thute, Mahalaqua Nazli Khatib, et al.
Cureus. 2022 Oct 8;14(10):e30051. doi: 10.7759/cureus.30051. eCollection 2022 Oct.
Dependency on digital devices resulting in an ever-increasing daily screen time has subsequently also been the cause of several adverse effects on physical and mental or psychological health. Constant exposure to devices like smartphones, personal computers, and television can severely affect mental health- increase stress and anxiety, for example, and cause various sleep issues in both children as well as adults. Risk factors for obesity and cardiovascular disorders, including hypertension, poor regulation of stress, low HDL cholesterol, and insulin resistance are among the physical health repercussions we see. The psychological health effects comprise suicidal tendencies and symptoms of depression which are associated with digital device dependency, screen-time-induced poor sleep quality, and content-influenced negativity. Oftentimes it can cause the induction of a state of hyper-arousal, increase stress hormones, desynchronize the body clock or the circadian cycle, alter brain chemistry and create a drag on mental energy and development. With a focus on brain development in children and detrimental effects in both adults and children, this research article goes on to explore the various aspects of screen addiction and excessive screen exposure.
23Association Between Screen Time Trajectory and Early Childhood Development in Children in China.PubMed
Jin Zhao, Zhangsheng Yu, Xiaoning Sun, et al.
JAMA Pediatr. 2022 Aug 1;176(8):768-775. doi: 10.1001/jamapediatrics.2022.1630.
IMPORTANCE: Screen time has become an integral part of children's daily lives. Nevertheless, the developmental consequences of screen exposure in young children remain unclear. OBJECTIVE: To investigate the screen time trajectory from 6 to 72 months of age and its association with children's development at age 72 months in a prospective birth cohort. DESIGN, SETTING, AND PARTICIPANTS: Women in Shanghai, China, who were at 34 to 36 gestational weeks and had an expected delivery date between May 2012 and July 2013 were recruited for this cohort study. Their children were followed up at 6, 9, 12, 18, 24, 36, 48, and 72 months of age. Children's screen time was classified into 3 groups at age 6 months: continued low (ie, stable amount of screen time), late increasing (ie, sharp increase in screen time at age 36 months), and early increasing (ie, large amount of screen time in early stages that remained stable after age 36 months). Cognitive development was assessed by specially trained research staff in a research clinic. Of 262 eligible mother-offspring pairs, 152 dyads had complete data regarding all variables of interest and were included in the analyses. Data were analyzed from September 2019 to November 2021. EXPOSURES: Mothers reported screen times of children at 6, 9, 12, 18, 24, 36, 48, and 72 months of age. MAIN OUTCOMES AND MEASURES: The cognitive development of children was evaluated using the Wechsler Intelligence Scale for Children, 4th edition, at age 72 months. Social-emotional development was measured by the Strengths and Difficulties Questionnaire, which was completed by the child's mother. The study described demographic characteristics, maternal mental health, child's temperament at age 6 months, and mental development at age 12 months by subgroups clustered by a group-based trajectory model. Group difference was examined by analysis of variance. RESULTS: A total of 152 mother-offspring dyads were included in this study, including 77 girls (50.7%) and 75 boys (49.3%) (mean [SD] age of the mothers was 29.7 [3.3] years). Children's screen time trajectory from age 6 to 72 months was classified into 3 groups: continued low (110 [72.4%]), late increasing (17 [11.2%]), and early increasing (25 [16.4%]). Compared with the continued low group, the late increasing group had lower scores on the Full-Scale Intelligence Quotient (β coefficient, -8.23; 95% CI, -15.16 to -1.30; P < .05) and the General Ability Index (β coefficient, -6.42; 95% CI, -13.70 to 0.86; P = .08); the early increasing group presented with lower scores on the Full-Scale Intelligence Quotient (β coefficient, -6.68; 95% CI, -12.35 to -1.02; P < .05) and the Cognitive Proficiency Index (β coefficient, -10.56; 95% CI, -17.23 to -3.90; P < .01) and a higher total difficulties score (β coefficient, 2.62; 95% CI, 0.49-4.76; P < .05). CONCLUSIONS AND RELEVANCE: This cohort study found that excessive screen time in early years was associated with poor cognitive and social-emotional development. This finding may be helpful in encouraging awareness among parents of the importance of onset and duration of children's screen time.
24Advances in myopia prevention strategies for school-aged children: a comprehensive review.PubMed
Farheen Tariq, Rabia Mobeen, Xinhai Wang, et al.
Front Public Health. 2023 Aug 15;11:1226438. doi: 10.3389/fpubh.2023.1226438. eCollection 2023.
Myopia has significantly risen in East and Southeast Asia, and the pathological outcomes of this condition, such as myopic maculopathy and optic neuropathy linked to high myopia, have emerged as leading causes of irreversible vision loss. Addressing this issue requires strategies to reduce myopia prevalence and prevent progression to high myopia. Encouraging outdoor activities for schoolchildren and reducing near-work and screen time can effectively prevent myopia development, offering a safe intervention that promotes healthier habits. Several clinical approaches can be employed to decelerate myopia progression, such as administering low-dose atropine eye drops (0.05%), utilizing orthokeratology lenses, implementing soft contact lenses equipped with myopia control features, and incorporating spectacle lenses with aspherical lenslets. When choosing an appropriate strategy, factors such as age, ethnicity, and the rate of myopia progression should be considered. However, some treatments may encounter obstacles such as adverse side effects, high costs, complex procedures, or limited effectiveness. Presently, low-dose atropine (0.05%), soft contact lenses with myopia control features, and orthokeratology lenses appear as promising options for managing myopia. The measures mentioned above are not necessarily mutually exclusive, and researchers are increasingly exploring their combined effects. By advocating for a personalized approach based on individual risk factors and the unique needs of each child, this review aims to contribute to the development of targeted and effective myopia prevention strategies, thereby minimizing the impact of myopia and its related complications among school-aged children in affected regions.
25Association Between Screen Time and Children's Performance on a Developmental Screening Test.PubMed
Sheri Madigan, Dillon Browne, Nicole Racine, et al.
JAMA Pediatr. 2019 Mar 1;173(3):244-250. doi: 10.1001/jamapediatrics.2018.5056.
IMPORTANCE: Excessive screen time is associated with delays in development; however, it is unclear if greater screen time predicts lower performance scores on developmental screening tests or if children with poor developmental performance receive added screen time as a way to modulate challenging behavior. OBJECTIVE: To assess the directional association between screen time and child development in a population of mothers and children. DESIGN, SETTING, AND PARTICIPANTS: This longitudinal cohort study used a 3-wave, cross-lagged panel model in 2441 mothers and children in Calgary, Alberta, Canada, drawn from the All Our Families study. Data were available when children were aged 24, 36, and 60 months. Data were collected between October 20, 2011, and October 6, 2016. Statistical analyses were conducted from July 31 to November 15, 2018. EXPOSURES: Media. MAIN OUTCOMES AND MEASURES: At age 24, 36, and 60 months, children's screen-time behavior (total hours per week) and developmental outcomes (Ages and Stages Questionnaire, Third Edition) were assessed via maternal report. RESULTS: Of the 2441 children included in the analysis, 1227 (50.2%) were boys. A random-intercepts, cross-lagged panel model revealed that higher levels of screen time at 24 and 36 months were significantly associated with poorer performance on developmental screening tests at 36 months (β, -0.06; 95% CI, -0.10 to -0.01) and 60 months (β, -0.08; 95% CI, -0.13 to -0.02), respectively. These within-person (time-varying) associations statistically controlled for between-person (stable) differences. CONCLUSIONS AND RELEVANCE: The results of this study support the directional association between screen time and child development. Recommendations include encouraging family media plans, as well as managing screen time, to offset the potential consequences of excess use.
26Screen Time at Age 1 Year and Communication and Problem-Solving Developmental Delay at 2 and 4 Years.PubMed
Ippei Takahashi, Taku Obara, Mami Ishikuro, et al.
JAMA Pediatr. 2023 Oct 1;177(10):1039-1046. doi: 10.1001/jamapediatrics.2023.3057.
IMPORTANCE: Whether some domains of child development are specifically associated with screen time and whether the association continues with age remain unknown. OBJECTIVE: To examine the association between screen time exposure among children aged 1 year and 5 domains of developmental delay (communication, gross motor, fine motor, problem-solving, and personal and social skills) at age 2 and 4 years. DESIGN, PARTICIPANTS, AND SETTING: This cohort study was conducted under the Tohoku Medical Megabank Project Birth and Three-Generation Cohort Study. Pregnant women at 50 obstetric clinics and hospitals in the Miyagi and Iwate prefectures in Japan were recruited into the study between July 2013 and March 2017. The information was collected prospectively, and 7097 mother-child pairs were included in the analysis. Data analysis was performed on March 20, 2023. EXPOSURE: Four categories of screen time exposure were identified for children aged 1 year (<1, 1 to <2, 2 to <4, or ≥4 h/d). MAIN OUTCOMES AND MEASURES: Developmental delays in the 5 domains for children aged 2 and 4 years were assessed using the Japanese version of the Ages & Stages Questionnaires, Third Edition. Each domain ranged from 0 to 60 points. Developmental delay was defined if the total score for each domain was less than 2 SDs from its mean score. RESULTS: Of the 7097 children in this study, 3674 were boys (51.8%) and 3423 were girls (48.2%). With regard to screen time exposure per day, 3440 children (48.5%) had less than 1 hour, 2095 (29.5%) had 1 to less than 2 hours, 1272 (17.9%) had 2 to less than 4 hours, and 290 (4.1%) had 4 or more hours. Children's screen time was associated with a higher risk of developmental delay at age 2 years in the communication (odds ratio [OR], 1.61 [95% CI, 1.23-2.10] for 1 to <2 h/d; 2.04 [1.52-2.74] for 2 to <4 h/d; 4.78 [3.24-7.06] for ≥4 vs <1 h/d), fine motor (1.74 [1.09-2.79] for ≥4 vs <1 h/d), problem-solving (1.40 [1.02-1.92] for 2 to <4 h/d; 2.67 [1.72-4.14] for ≥4 vs <1 h/d), and personal and social skills (2.10 [1.39-3.18] for ≥4 vs <1 h/d) domains. Regarding risk of developmental delay at age 4 years, associations were identified in the communication (OR, 1.64 [95% CI, 1.20-2.25] for 2 to <4 h/d; 2.68 [1.68-4.27] for ≥4 vs <1 h/d) and problem-solving (1.91 [1.17-3.14] for ≥4 vs <1 h/d) domains. CONCLUSIONS AND RELEVANCE: In this study, greater screen time for children aged 1 year was associated with developmental delays in communication and problem-solving at ages 2 and 4 years. These findings suggest that domains of developmental delay should be considered separately in future discussions on screen time and child development.
27Early Childhood Screen Use Contexts and Cognitive and Psychosocial Outcomes: A Systematic Review and Meta-analysis.PubMed
Sumudu Mallawaarachchi, Jade Burley, Myrto Mavilidi, et al.
JAMA Pediatr. 2024 Oct 1;178(10):1017-1026. doi: 10.1001/jamapediatrics.2024.2620.
IMPORTANCE: The multifaceted nature of screen use has been largely overlooked in favor of a simplistic unidimensional measure of overall screen time when evaluating the benefits and risks of screen use to early childhood development. OBJECTIVE: To conduct a systematic review and meta-analysis to examine associations of screen use contexts in early childhood with cognitive and psychosocial outcomes. DATA SOURCES: PsycINFO, Embase, MEDLINE Ovid, ProQuest, CINAHL, Web of Science, and Scopus were searched from inception to December 31, 2023. STUDY SELECTION: A total of 7441 studies were initially identified. Studies were included if they examined associations between a contextual factor of screen use among children aged 0 to 5.99 years and cognitive or psychosocial development. Observational, experimental, and randomized clinical trial study designs were included. DATA EXTRACTION AND SYNTHESIS: All studies were independently screened in duplicate following PRISMA guidelines. Effect sizes of associations (r) from observational studies were pooled using random-effects 3-level meta-analyses. The remaining study designs were narratively synthesized. MAIN OUTCOMES AND MEASURES: Screen use contexts included content (child directed and age inappropriate), type (program viewing and game or app use), co-use (or solo use), background television, caregiver screen use during child routines, and purpose. Outcomes were cognitive (executive functioning, language, and academic skills) or psychosocial (internalizing and externalizing behavior problems and socioemotional competence). RESULTS: Overall, 100 studies (176 742 participants) were included, and of these, 64 observational studies (pooled sample sizes ranging from 711 to 69 232) were included in meta-analyses. Program viewing (n = 14; k = 48; r, -0.16; 95% CI, -0.24 to -0.08) and background television (n = 8; k = 18; r, -0.10; 95% CI, -0.18 to -0.02) were negatively associated with cognitive outcomes, while program viewing (n = 6; k = 31; r, -0.04; 95% CI, -0.07 to -0.01), age-inappropriate content (n = 9; k = 36; r, -0.11; 95% CI, -0.17 to -0.04), and caregiver screen use during routines (n = 6; k = 14; r, -0.11; 95% CI, -0.20 to -0.03) were negatively associated with psychosocial outcomes. Co-use was positively associated with cognitive outcomes (n = 8; k = 28; r, 0.14; 95% CI, 0.03 to 0.25). CONCLUSIONS AND RELEVANCE: Findings show small to moderate effect sizes that highlight the need to consider screen use contexts when making recommendations for families, clinicians, and educators beyond screen time limits; including encouraging intentional and productive screen use, age-appropriate content, and co-use with caregivers.
28Adverse physiological and psychological effects of screen time on children and adolescents: Literature review and case study.PubMed
Gadi Lissak
Environ Res. 2018 Jul;164:149-157. doi: 10.1016/j.envres.2018.01.015. Epub 2018 Feb 27.
UNLABELLED: A growing body of literature is associating excessive and addictive use of digital media with physical, psychological, social and neurological adverse consequences. Research is focusing more on mobile devices use, and studies suggest that duration, content, after-dark-use, media type and the number of devices are key components determining screen time effects. Physical health effects: excessive screen time is associated with poor sleep and risk factors for cardiovascular diseases such as high blood pressure, obesity, low HDL cholesterol, poor stress regulation (high sympathetic arousal and cortisol dysregulation), and Insulin Resistance. Other physical health consequences include impaired vision and reduced bone density. Psychological effects: internalizing and externalizing behavior is related to poor sleep. Depressive symptoms and suicidal are associated to screen time induced poor sleep, digital device night use, and mobile phone dependency. ADHD-related behavior was linked to sleep problems, overall screen time, and violent and fast-paced content which activates dopamine and the reward pathways. Early and prolonged exposure to violent content is also linked to risk for antisocial behavior and decreased prosocial behavior. Psychoneurological effects: addictive screen time use decreases social coping and involves craving behavior which resembles substance dependence behavior. Brain structural changes related to cognitive control and emotional regulation are associated with digital media addictive behavior. A case study of a treatment of an ADHD diagnosed 9-year-old boy suggests screen time induced ADHD-related behavior could be inaccurately diagnosed as ADHD. Screen time reduction is effective in decreasing ADHD-related behavior. CONCLUSIONS: Components crucial for psychophysiological resilience are none-wandering mind (typical of ADHD-related behavior), good social coping and attachment, and good physical health. Excessive digital media use by children and adolescents appears as a major factor which may hamper the formation of sound psychophysiological resilience.
29Time spent in outdoor activities in relation to myopia prevention and control: a meta-analysis and systematic review.PubMed
Shuyu Xiong, Padmaja Sankaridurg, Thomas Naduvilath, et al.
Acta Ophthalmol. 2017 Sep;95(6):551-566. doi: 10.1111/aos.13403. Epub 2017 Mar 2.
Outdoor time is considered to reduce the risk of developing myopia. The purpose is to evaluate the evidence for association between time outdoors and (1) risk of onset of myopia (incident/prevalent myopia); (2) risk of a myopic shift in refractive error and c) risk of progression in myopes only. A systematic review followed by a meta-analysis and a dose-response analysis of relevant evidence from literature was conducted. PubMed, EMBASE and the Cochrane Library were searched for relevant papers. Of the 51 articles with relevant data, 25 were included in the meta-analysis and dose-response analysis. Twenty-three of the 25 articles involved children. Risk ratio (RR) for binary variables and weighted mean difference (WMD) for continuous variables were conducted. Mantel-Haenszel random-effects model was used to pool the data for meta-analysis. Statistical heterogeneity was assessed using the I test with I ≥ 50% considered to indicate high heterogeneity. Additionally, subgroup analyses (based on participant's age, prevalence of myopia and study type) and sensitivity analyses were conducted. A significant protective effect of outdoor time was found for incident myopia (clinical trials: risk ratio (RR) = 0.536, 95% confidence interval (CI) = 0.338 to 0.850; longitudinal cohort studies: RR = 0.574, 95% CI = 0.395 to 0.834) and prevalent myopia (cross-sectional studies: OR = 0.964, 95% CI = 0.945 to 0.982). With dose-response analysis, an inverse nonlinear relationship was found with increased time outdoors reducing the risk of incident myopia. Also, pooled results from clinical trials indicated that when outdoor time was used as an intervention, there was a reduced myopic shift of -0.30 D (in both myopes and nonmyopes) compared with the control group (WMD = -0.30, 95% CI = -0.18 to -0.41) after 3 years of follow-up. However, when only myopes were considered, dose-response analysis did not find a relationship between time outdoors and myopic progression (R = 0.00064). Increased time outdoors is effective in preventing the onset of myopia as well as in slowing the myopic shift in refractive error. But paradoxically, outdoor time was not effective in slowing progression in eyes that were already myopic. Further studies evaluating effect of outdoor in various doses and objective measurements of time outdoors may help improve our understanding of the role played by outdoors in onset and management of myopia.
30Myopia Prevention and Outdoor Light Intensity in a School-Based Cluster Randomized Trial.PubMed
Pei-Chang Wu, Chueh-Tan Chen, Ken-Kuo Lin, et al.
Ophthalmology. 2018 Aug;125(8):1239-1250. doi: 10.1016/j.ophtha.2017.12.011. Epub 2018 Jan 19.
PURPOSE: To investigate the effectiveness of a school-based program promoting outdoor activities in Taiwan for myopia prevention and to identify protective light intensities. DESIGN: Multi-area, cluster-randomized intervention controlled trial. PARTICIPANTS: A total 693 grade 1 schoolchildren in 16 schools participated. Two hundred sixty-seven schoolchildren were in the intervention group and 426 were in the control group. METHODS: Initially, 24 schools were randomized into the intervention and control groups, but 5 and 3 schools in the intervention and control groups, respectively, withdrew before enrollment. A school-based Recess Outside Classroom Trial was implemented in the intervention group, in which schoolchildren were encouraged to go outdoors for up to 11 hours weekly. Data collection included eye examinations, cycloplegic refraction, noncontact axial length measurements, light meter recorders, diary logs, and questionnaires. MAIN OUTCOME MEASURES: Change in spherical equivalent and axial length after 1 year and the intensity and duration of outdoor light exposures. RESULTS: The intervention group showed significantly less myopic shift and axial elongation compared with the control group (0.35 diopter [D] vs. 0.47 D; 0.28 vs. 0.33 mm; P = 0.002 and P = 0.003) and a 54% lower risk of rapid myopia progression (odds ratio, 0.46; 95% confidence interval [CI], 0.28-0.77; P = 0.003). The myopic protective effects were significant in both nonmyopic and myopic children compared with controls. Regarding spending outdoor time of at least 11 hours weekly with exposure to 1000 lux or more of light, the intervention group had significantly more participants compared with the control group (49.79% vs. 22.73%; P < 0.001). Schoolchildren with longer outdoor time in school (≥200 minutes) showed significantly less myopic shift (measured by light meters; ≥1000 lux: 0.14 D; 95% CI, 0.02-0.27; P = 0.02; ≥3000 lux: 0.16 D; 95% CI, 0.002-0.32; P = 0.048). CONCLUSIONS: The school-based outdoor promotion program effectively reduced the myopia change in both nonmyopic and myopic children. Outdoor activities with strong sunlight exposure may not be necessary for myopia prevention. Relatively lower outdoor light intensity activity with longer time outdoors, such as in hallways or under trees, also can be considered.
31Time Outdoors in Reducing Myopia: A School-Based Cluster Randomized Trial with Objective Monitoring of Outdoor Time and Light Intensity.PubMed
Xiangui He, Padmaja Sankaridurg, Jingjing Wang, et al.
Ophthalmology. 2022 Nov;129(11):1245-1254. doi: 10.1016/j.ophtha.2022.06.024. Epub 2022 Jun 30.
PURPOSE: To evaluate the efficacy of time outdoors per school day over 2 years on myopia onset and shift. DESIGN: A prospective, cluster-randomized, examiner-masked, 3-arm trial. PARTICIPANTS: A total of 6295 students aged 6 to 9 years from 24 primary schools in Shanghai, China, stratified and randomized by school in a 1:1:1 ratio to control (n = 2037), test I (n = 2329), or test II (n = 1929) group. METHODS: An additional 40 or 80 minutes of outdoor time was allocated to each school day for test I and II groups. Children in the control group continued their habitual outdoor time. Objective monitoring of outdoor and indoor time and light intensity each day was measured with a wrist-worn wearable during the second-year follow-up. MAIN OUTCOME MEASURES: The 2-year cumulative incidence of myopia (defined as cycloplegic spherical equivalent [SE] of ≤-0.5 diopters [D] in the right eye) among the students without myopia at baseline and changes in SE and axial length (AL) after 2 years. RESULTS: The unadjusted 2-year cumulative incidence of myopia was 24.9%, 20.6%, and 23.8% for control, test I, and II groups, respectively. The adjusted incidence decreased by 16% (incidence risk ratio [IRR], 0.84; 95% confidence interval [CI], 0.72-0.99; P = 0.035) in test I and 11% (IRR = 0.89; 95% CI, 0.79-0.99; P = 0.041) in test II when compared with the control group. The test groups showed less myopic shift and axial elongation compared with the control group (test I: -0.84 D and 0.55 mm, test II: -0.91 D and 0.57 mm, control: -1.04 D and 0.65 mm). There was no significant difference in the adjusted incidence of myopia and myopic shift between the 2 test groups. The test groups had similar outdoor time and light intensity (test I: 127 ± 30 minutes/day and 3557 ± 970 lux/minute; test II: 127 ± 26 minutes/day and 3662 ± 803 lux/minute) but significantly more outdoor time and higher light intensity compared with the control group (106 ± 27 minutes/day and 2984 ± 806 lux/minute). Daily outdoor time of 120 to 150 minutes at 5000 lux/minutes or cumulative outdoor light intensity of 600 000 to 750 000 lux significantly reduced the IRR by 15%～ 24%. CONCLUSIONS: Increasing outdoor time reduced the risk of myopia onset and myopic shifts, especially in nonmyopic children. The protective effect of outdoor time was related to the duration of exposure and light intensity. The dose-response effect between test I and test II was not observed probably because of insufficient outdoor time achieved in the test groups, which suggests that proper monitoring on the compliance on outdoor intervention is critical if one wants to see the protective effect.
32Smartwatch Measures of Outdoor Exposure and Myopia in Children.PubMed
Jun Chen, Jingjing Wang, Ziyi Qi, et al.
JAMA Netw Open. 2024 Aug 1;7(8):e2424595. doi: 10.1001/jamanetworkopen.2024.24595.
IMPORTANCE: Time spent outdoors has been proven effective in preventing myopia, but little is known about the association of outdoor exposure patterns with myopia. OBJECTIVE: To examine the association of outdoor exposure patterns with myopic shift in children. DESIGN, SETTING, AND PARTICIPANTS: This 1-year prospective cohort study from December 2017 to December 2018 was a secondary analysis of a cluster-randomized trial (Shanghai Time Outside to Reduce Myopia [STORM]). STORM was a school-based intervention study, recruiting 16 schools from 8 districts in Shanghai, from October 2016 to December 2018. Children without myopia at baseline who consistently wore a smartwatch for a minimum of 6 hours daily, sustained for at least 90 days, and who had complete information were included. Data analysis was performed from December 2017 to December 2018. EXPOSURES: The outdoor exposure pattern was defined as the episode of time outdoors and instant sunlight intensity over a continuous period. MAIN OUTCOMES AND MEASURES: Myopic shift was defined as the absolute change in refraction between the initial spherical equivalence and the follow-up spherical equivalence. RESULTS: This study included 2976 students (mean [SD] age, 7.2 [0.6] years; 1525 girls [51.2%]). The mean (SD) daily time outdoors was 90 (28) minutes, and the mean (SD) sunlight intensity was 2345 (486) lux. Of the 12 outdoor exposure patterns, the major outdoor exposure patterns were time outdoors with at least 15 minutes, accounting for 74.9% of minutes (33 677 584 of 45 016 800 minutes). Only patterns with at least 15 minutes accompanied with no less than 2000 lux were associated with less myopic shift in refraction (for ≥15 minutes and 2000 to 3999 lux, -0.007 diopter [D] [95% CI, -0.011 to -0.002 D]; for ≥15 minutes and ≥4000 lux, -0.006 D [95% CI, -0.010 to -0.002 D]). The isotemporal substitution of patterns with at least 15 minutes and 2000 lux for other outdoor exposure patterns was positively associated with less myopic shift. CONCLUSIONS AND RELEVANCE: In this 1-year prospective cohort study of children with smartwatches, continuous outdoor exposure with at least 15 minutes accompanied with no less than 2000 lux sunlight intensity was associated with less myopic shift. These findings suggest that future outdoor interventions should focus not only on the overall time outdoors but also on the effective outdoor exposure patterns, as a means to effectively prevent myopia in children.
33Outdoor activity reduces the prevalence of myopia in children.PubMed
Kathryn A Rose, Ian G Morgan, Jenny Ip, et al.
Ophthalmology. 2008 Aug;115(8):1279-85. doi: 10.1016/j.ophtha.2007.12.019. Epub 2008 Feb 21.
OBJECTIVE: To assess the relationship of near, midworking distance, and outdoor activities with prevalence of myopia in school-aged children. DESIGN: Cross-sectional study of 2 age samples from 51 Sydney schools, selected using a random cluster design. PARTICIPANTS: One thousand seven hundred sixty-five 6-year-olds (year 1) and 2367 12-year-olds (year 7) participated in the Sydney Myopia Study from 2003 to 2005. METHODS: Children had a comprehensive eye examination, including cycloplegic refraction. Parents and children completed detailed questionnaires on activity. MAIN OUTCOME MEASURES: Myopia prevalence and mean spherical equivalent (SE) in relation to patterns of near, midworking distance, and outdoor activities. Myopia was defined as SE refraction < or = -0.5 diopters (D). RESULTS: Higher levels of outdoor activity (sport and leisure activities) were associated with more hyperopic refractions and lower myopia prevalence in the 12-year-old students. Students who combined high levels of near work with low levels of outdoor activity had the least hyperopic mean refraction (+0.27 D; 95% confidence interval [CI], 0.02-0.52), whereas students who combined low levels of near work with high levels of outdoor activity had the most hyperopic mean refraction (+0.56 D; 95% CI, 0.38-0.75). Significant protective associations with increased outdoor activity were seen for the lowest (P = 0.04) and middle (P = 0.02) tertiles of near-work activity. The lowest odds ratios for myopia, after adjusting for confounders, were found in groups reporting the highest levels of outdoor activity. There were no associations between indoor sport and myopia. No consistent associations between refraction and measures of activity were seen in the 6-year-old sample. CONCLUSIONS: Higher levels of total time spent outdoors, rather than sport per se, were associated with less myopia and a more hyperopic mean refraction, after adjusting for near work, parental myopia, and ethnicity.
34Cross sectional associations of screen time and outdoor play with social skills in preschool children.PubMed
Trina Hinkley, Helen Brown, Valerie Carson, et al.
PLoS One. 2018 Apr 4;13(4):e0193700. doi: 10.1371/journal.pone.0193700. eCollection 2018.
Screen time and physical activity behaviours develop during the crucial early childhood period (0-5 years) and impact multiple health and developmental outcomes, including psychosocial wellbeing. Social skills, one component of psychosocial wellbeing, are vital for children's school readiness and future mental health. This study investigates potential associations of screen time and outdoor play (as a proxy for physical activity) with social skills. Cross sectional data were available for 575 mothers with a child (54% boys) aged 2-5 years. Mothers reported their child's screen time, outdoor play time and social skills (Adaptive Social Behavior Inventory; ASBI). Multiple linear regression analyses assessed associations of screen and outdoor play time (Model 1) and compliance with screen time and physical activity recommendations (Model 2) with three ASBI subscales. Boys and girls spent a mean of 2.0 and 2.2 hours per day in screen time, and 3.3 and 2.9 hours per day in outdoor play, respectively. Girls scores for express and comply skills were significantly higher than boys (p<0.005). After applying the Benjamini-Hochberg Procedure to adjust for multiple associations, children's television/DVD/video viewing was inversely associated with their compliant scores (B = -0.35 95% CI -0.26, -0.14; p = 0.001) and outdoor play time was positively associated with both expressive (B = 0.20 95% CI 0.07, 0.34; p = 0.004) and compliant (B = 0.22 95% CI 0.08, 0.36; p = 0.002) scores. Findings indicate that television/DVD/video viewing may be adversely, and outdoor play favourably, associated with preschool children's social skills. Future research is required to identify the direction of causation and explore potential mechanisms of association.
35Dopamine and retinal function.PubMed
Paul Witkovsky
Doc Ophthalmol. 2004 Jan;108(1):17-40. doi: 10.1023/b:doop.0000019487.88486.0a.
This review summarizes the experimental evidence in support of dopamine's role as a chemical messenger for light adaptation. Dopamine is released by a unique set of amacrine cells and activates D1 and D2 dopamine receptors distributed throughout the retina. Multiple dopamine-dependent physiological mechanisms result in an increased signal flow through cone circuits and a diminution of signal flow through rod circuits. Dopamine also has multiple trophic roles in retinal function related to circadian rhythmicity, cell survival and eye growth. In a reciprocal way, the health of the dopaminergic neurons depends on their receiving light-driven synaptic inputs. Dopamine neurons appear early in development, become functional in advance of the animal's onset of vision and begin to die in aging animals. Some diseases affecting photoreceptor function also diminish day/night differences in dopamine release and turnover. A reduction in retinal dopamine, as occurs in Parkinsonian patients, results in reduced visual contrast sensitivity.
36Advances in the study of the influence of photoreceptors on the development of myopia.PubMed
Kailei Wang, Guoge Han, Rui Hao
Exp Eye Res. 2024 Aug;245:109976. doi: 10.1016/j.exer.2024.109976. Epub 2024 Jun 17.
This review examines the pivotal role of photoreceptor cells in ocular refraction development, focusing on dopamine (DA) as a key neurotransmitter. Contrary to the earlier view favoring cone cells, recent studies have highlighted the substantial contributions of both rod and cone cells to the visual signaling pathways that influence ocular refractive development. Notably, rod cells appeared to play a central role. Photoreceptor cells interact intricately with circadian rhythms, color vision pathways, and other neurotransmitters, all of which are crucial for the complex mechanisms driving the development of myopia. This review emphasizes that ocular refractive development results from a coordinated interplay between diverse cell types, signaling pathways, and neurotransmitters. This perspective has significant implications for unraveling the complex mechanisms underlying myopia and aiding in the development of more effective prevention and treatment strategies.
37Modulating amacrine cell-derived dopamine signaling promotes optic nerve regeneration and preserves visual function.PubMed
Qi Zhang, Jingfei Xue, Jiahui Tang, et al.
Sci Adv. 2024 Aug 2;10(31):eado0866. doi: 10.1126/sciadv.ado0866.
As part of the central nervous system, the optic nerve, composed of axons from retinal ganglion cells (RGCs), generally fails to regenerate on its own when injured in adult mammals. An innovative approach to promoting optic nerve regeneration involves manipulating the interactions between amacrine cells (ACs) and RGCs. Here, we identified a unique AC subtype, dopaminergic ACs (DACs), that responded early after optic nerve crush by down-regulating neuronal activity and reducing retinal dopamine (DA) release. Activating DACs or augmenting DA release with levodopa demonstrated neuroprotective effects and modestly enhanced axon regeneration. Within this context, we pinpointed the DA receptor D1 (DRD1) as a critical mediator of DAC-derived DA and showed that RGC-specific overexpression effectively overcame subtype-specific barriers to regeneration. This strategy markedly boosted RGC survival and axon regeneration after crush and preserved vision in a glaucoma model. This study unveils the crucial role of DAC-derived DA signaling in optic nerve regeneration, holding promise for therapeutic insights into neural repair.
38Effect of Extracurricular After-School Physical Activities on Academic Performance of Schoolchildren: A Cluster Randomized Clinical Trial.PubMed
Decai Wang, Ruilin Xiong, Jiaqing Zhang, et al.
JAMA Pediatr. 2023 Nov 1;177(11):1141-1148. doi: 10.1001/jamapediatrics.2023.3615.
IMPORTANCE: The beneficial effects of increasing outdoor physical activity time on children's myopia onset and physical well-being are widely acknowledged. However, in countries with competitive educational systems, such as China, parents and school administrators may be relatively reluctant to increase the extracurricular physical activity time for children due to concerns that this action will compromise children's academic performance. OBJECTIVE: To investigate whether additional extracurricular physical activity time after school compromises the academic performance of schoolchildren. DESIGN, SETTING, AND PARTICIPANTS: This cluster randomized clinical trial was conducted from October 2020 to June 2021 in Yudu, Jiangxi, China. Eligible children in grades 3 and 4 from 24 elementary schools were randomized to the intervention or control group. Primary analysis was conducted in the full sample using the intention-to-treat principle. INTERVENTIONS: The intervention group received 2 hours of after-school physical activity time outdoors on school days. The control group was free to arrange their after-school activity. MAIN OUTCOMES AND MEASURES: The primary outcome was the between-group mean difference in mathematics test scores at the end of 1 academic year, with a noninferiority margin of -3.3 points. Standardized mathematics tests, physical fitness assessments (in reference to the 2018 National Physical Fitness Survey Monitoring Programme in China), and cycloplegic autorefraction were performed at baseline and the end of 1 academic year. Myopia was defined as a cycloplegic spherical equivalent refraction of -0.5 diopters or less in either eye. RESULTS: A total of 2032 children (mean [SD] age, 9.22 [0.62] years; 1040 girls [51.2%]) from 24 schools were randomized to the intervention group (12 schools; 1012 children) or control group (12 schools; 1020 children). The mean (SD) mathematics score at the end of 1 academic year was 78.01 (17.56) points in the intervention group and 77.70 (17.29) points in the control group. The adjusted between-group mean difference was 0.65 points (95% CI, -2.85 to 4.15). The adjusted between-group mean difference in physical fitness score was 4.95 points (95% CI, 3.56-6.34; P < .001) and -1.90% (95% CI, -18.72% to 14.91%; P > .99) in myopia incidence. CONCLUSIONS AND RELEVANCE: Results of this trial indicate that, compared with the control practice of free play after school, adding 2 hours of extracurricular physical activity outdoors after school was noninferior in academic performance and had superior efficacy in improving physical fitness. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT04587765.
39Distributions and determinants of time spent outdoors among school-age children in China.PubMed
Fei Gao, Qian Guo, Beibei Wang, et al.
J Expo Sci Environ Epidemiol. 2022 Mar;32(2):223-231. doi: 10.1038/s41370-021-00401-w. Epub 2022 Jan 4.
BACKGROUND: The outdoor time is a key factor that determines children's exposure to environmental contaminants. Meanwhile, children reap numerous physical and mental health benefits from playing outdoors. OBJECTIVE: This study aimed to characterize the distributions and identify determinants of the time spent outdoors among school-age children in China. METHODS: The study recruited 41,439 children aged 6-17 years in Mainland China using a multi-stage cluster random sampling method. This sample was nationally representative with sample weights created to account for the complex survey design. Information on time-activity patterns were collected with a standard questionnaire through face-to-face interviews. Frequency distributions of time outdoors were created by age group, gender, region, and other sociodemographic factors with sample weights. The key factors influencing time outdoors were identified using multivariable linear regression models. RESULTS: The grand mean (±standard deviation) time outdoors was 101 ± 51 min/day for all the study participants, 22.3% having <60 min/day. Children spent longer time outdoors in warm seasons and on weekends. Children's outdoor time was significantly influenced by gender, age, urbanicity, region, annual total household expenditure, building environment, and meteorological conditions (annual mean temperature, sunshine time, and precipitation). Girls, 15-17 year old, and urban children had 6 min/day, 8 min/day, and 13 min/day less outdoor time than boys, 6-8 year old, and rural children, respectively. Most significantly, urban girls and high school students had the shortest outdoor time. The cement ground was the most important type of ground for children playing outside. SIGNIFICANCE: This was the first national-scale study that characterized the time outdoors and where is it spent among school-age children in China. It revealed that one-fifth of Chinese children spent less than one hour outdoors every day, and urban girls had particular "indoor tendencies". The findings provide bases for future interventions and guidelines aimed at promoting children's physical activities.
40Mechanisms of vitamin A metabolism and deficiency in the mammalian and fly visual system.PubMed
Deepshe Dewett, Khanh Lam-Kamath, Clara Poupault, et al.
Dev Biol. 2021 Aug;476:68-78. doi: 10.1016/j.ydbio.2021.03.013. Epub 2021 Mar 25.
Vitamin A deficiency can cause human pathologies that range from blindness to embryonic malformations. This diversity is due to the lack of two major vitamin A metabolites with very different functions: the chromophore 11-cis-retinal (vitamin A aldehyde) is a critical component of the visual pigment that mediates phototransduction, while the signaling molecule all-trans-retinoic acid regulates the development of various tissues and is required for the function of the immune system. Since animals cannot synthesize vitamin A de novo, they must obtain it either as preformed vitamin A from animal products or as carotenoid precursors from plant sources. Due to its essential role in the visual system, acute vitamin A deprivation impairs photoreceptor function and causes night blindness (poor vision under dim light conditions), while chronic deprivation results in retinal dystrophies and photoreceptor cell death. Chronic vitamin A deficiency is the leading cause of preventable childhood blindness according to the World Health Organization. Due to the requirement of vitamin A for retinoic acid signaling in development and in the immune system, vitamin A deficiency also causes increased mortality in children and pregnant women in developing countries. Drosophila melanogaster is an excellent model to study the effects of vitamin A deprivation on the eye because vitamin A is not essential for Drosophila development and chronic deficiency does not cause lethality. Moreover, genetic screens in Drosophila have identified evolutionarily conserved factors that mediate the production of vitamin A and its cellular uptake. Here, we review our current knowledge about the role of vitamin A in the visual system of mammals and Drosophila melanogaster. We compare the molecular mechanisms that mediate the uptake of dietary vitamin A precursors and the metabolism of vitamin A, as well as the consequences of vitamin A deficiency for the structure and function of the eye.
41Vitamin A and Pregnancy: A Narrative Review.PubMed
Sabina Bastos Maia, Alex Sandro Rolland Souza, Maria de Fátima Costa Caminha, et al.
Nutrients. 2019 Mar 22;11(3):681. doi: 10.3390/nu11030681.
Vitamin A is a crucial micronutrient for pregnant women and their fetuses. In addition to being essential for morphological and functional development and for ocular integrity, vitamin A exerts systemic effects on several fetal organs and on the fetal skeleton. Vitamin A requirements during pregnancy are therefore greater. Vitamin A deficiency (VAD) remains the leading cause of preventable blindness in the world. VAD in pregnant women is a public health issue in most developing countries. In contrast, in some developed countries, excessive vitamin A intake during pregnancy can be a concern since, when in excess, this micronutrient may exert teratogenic effects in the first 60 days following conception. Routine prenatal vitamin A supplementation for the prevention of maternal and infant morbidity and mortality is not recommended; however, in regions where VAD is a public health issue, vitamin A supplementation is recommended to prevent night blindness. Given the importance of this topic and the lack of a complete, up-to-date review on vitamin A and pregnancy, an extensive review of the literature was conducted to identify conflicting or incomplete data on the topic as well as any gaps in existing data.
42Vitamin A deficiency disorders.PubMed
D S McLaren
J Indian Med Assoc. 1999 Aug;97(8):320-3.
The major cause of blindness in children worldwide is xerophthalmia caused by vitamin A deficiency. In addition it has other adverse effects, including increased mortality and the term vitamin A deficiency disorders (VADD) has been introduced to cover the whole clinical spectrum of disease. The ocular manifestations of xerophthalmia have been classified and a set of prevalence criteria for the detection of a problem of public health magnitude has been in use for more than two decades. The global prevalence of VADD is now well documented and World Health Organisation (WHO) receives information continuously for updating its data base on the subject. The pathogenesis of the disease is still imperfectly understood, it is not at all clear precisely why certain subjects in vulnerable communities develop xerophthalmia, while the majority are spared. A schedule for treatment of the established case has been available for a long time, but at both clinic and hospital level concentrated sources of vitamin A for treatment are frequently not available. More emphasis needs to be laid on prevention and a choice of methods consisting of large dose supplementation, fortification of food, control of precipitating infections and dietary improvement. The advantages and drawbacks of each are discussed.
43Measles & malnutrition.PubMed
P Bhaskaram
Indian J Med Res. 1995 Nov;102:195-9.
Measles is an important acute childhood viral infection having severe consequences on the nutritional status. The adverse nutritional effects of measles are experienced by both the well-nourished and the malnourished children. However, the severe nutritional deficiencies like kwashiorkor/marasmus are precipitated only in children who are already malnourished. As high as 3-4 per cent of children with measles suffered from these clinical nutritional syndromes in their post-measles period. Though malnutrition is widespread among Asian children also, measles appears to run a milder course with low mortality rates in developing Asian countries, as compared to African children. The associated secondary infections which apparently complicate the primary illness in malnourished children might be responsible for higher mortality and could be due to socioeconomic and environmental causes that are associated with poverty and malnutrition rather than due to malnutrition or measles per se. Measles related blindness is of multifactorial aetiology. While acute measles triggers corneal ulceration through viral proliferation in the cornea, nutritional keratomalacia is often the cause of blindness in the post-measles period. Measles vaccination is the major preventive measure. However, timely use of local antibiotic therapy to the eyes and administration of vitamin A supplements offer protection to the child who already has measles. Response of malnourished children to live attenuated measles vaccine has been found to be safe and effective. Neither malnutrition nor tuberculosis which are widespread among malnourished children of developing countries appear to be contraindications for measles vaccination. Thus, the beneficial effects of the measles vaccination should be fully exploited by adequate supply of potent vaccine and coverage of all susceptible children.
44Measles blindness.PubMed
Richard D Semba, Martin W Bloem
Surv Ophthalmol. 2004 Mar-Apr;49(2):243-55. doi: 10.1016/j.survophthal.2003.12.005.
Measles remains a major problem in developing countries, where it affects an estimated 30 million children a year and causes up to one million deaths annually. Measles blindness is the single leading cause of blindness among children in low income countries, accounting for an estimated 15,000 to 60,000 cases of blindness per year. There is a close synergism between measles and vitamin A deficiency that can result in xerophthalmia, with corneal ulceration, keratomalacia, and subsequent corneal scarring or phthisis bulbi. High-dose oral vitamin A supplementation is recommended for all children with measles in developing countries. Higher measles immunization coverage to interrupt measles transmission and interventions aimed at improving vitamin A nutriture of children are the main strategies to prevent measles blindness.
45Breastmilk from obese mothers has pro-inflammatory properties and decreased neuroprotective factors.PubMed
P G Panagos, R Vishwanathan, A Penfield-Cyr, et al.
J Perinatol. 2016 Apr;36(4):284-90. doi: 10.1038/jp.2015.199. Epub 2016 Jan 7.
OBJECTIVE: To determine the impact of maternal obesity on breastmilk composition. STUDY DESIGN: Breastmilk and food records from 21 lean and 21 obese women who delivered full-term infants were analyzed at 2 months post-partum. Infant growth and adiposity were measured at birth and 2 months of age. RESULT: Breastmilk from obese mothers had higher omega-6 to omega-3 fatty acid ratio and lower concentrations of docosahexaenoic acid, eicosapentaenoic acid, docasapentaenoic acid and lutein compared with lean mothers (P<0.05), which were strongly associated with maternal body mass index. Breastmilk saturated fatty acid and monounsaturated fatty acid concentrations were positively associated with maternal dietary inflammation, as measured by dietary inflammatory index. There were no differences in infant growth measurements. CONCLUSION: Breastmilk from obese mothers has a pro-inflammatory fatty acid profile and decreased concentrations of fatty acids and carotenoids that have been shown to have a critical role in early visual and neurodevelopment. Studies are needed to determine the link between these early-life influences and subsequent cardiometabolic and neurodevelopmental outcomes.
46Multiple Micronutrients, Lutein, and Docosahexaenoic Acid Supplementation during Lactation: A Randomized Controlled Trial.PubMed
Ella Schaefer, Hans Demmelmair, Jeannie Horak, et al.
Nutrients. 2020 Dec 16;12(12):3849. doi: 10.3390/nu12123849.
Breastfed infants require an adequate supply of critical nutrients for growth, tissue functions, and health. Recommended intakes for several nutrients are considerably higher in lactating than non-lactating women but are not always met with habitual diets. We report a randomized, double-blind clinical trial in 70 healthy lactating women in Germany evaluating the effects of supplementation with multiple micronutrients, lutein, and docosahexaenoic acid (DHA) compared to placebo on maternal nutrient status and milk composition. The primary endpoint was the effect on the change of human milk DHA content (as a proportion of total milk fatty acids) during 12 weeks of supplementation. Maternal blood and milk biomarkers were measured as secondary endpoints. Supplementation increased maternal milk DHA by 30% compared to a decline in the placebo group. Supplementation also increased maternal blood DHA (17%), eicosapentaenoic acid (4%), 25-OH-vitamin D (24%), vitamin B12 (12%), lutein (4%), and beta carotene (49%), while homocysteine decreased. No significant difference in the number of adverse events was observed between supplementation and placebo groups. In conclusion, multi-micronutrient supplementation was safe and increased maternal blood and milk concentrations of selected nutrients in healthy women.
47Synergistic Effects of Human Milk Nutrients in the Support of Infant Recognition Memory: An Observational Study.PubMed
Carol L Cheatham, Kelly Will Sheppard
Nutrients. 2015 Nov 3;7(11):9079-95. doi: 10.3390/nu7115452.
The aim was to explore the relation of human milk lutein; choline; and docosahexaenoic acid (DHA) with recognition memory abilities of six-month-olds. Milk samples obtained three to four months postpartum were analyzed for fatty acids, lutein, and choline. At six months, participants were invited to an electrophysiology session. Recognition memory was tested with a 70-30 oddball paradigm in a high-density 128-lead event-related potential (ERP) paradigm. Complete data were available for 55 participants. Data were averaged at six groupings (Frontal Right; Frontal Central; Frontal Left; Central; Midline; and Parietal) for latency to peak, peak amplitude, and mean amplitude. Difference scores were calculated as familiar minus novel. Final regression models revealed the lutein X free choline interaction was significant for the difference in latency scores at frontal and central areas (p < 0.05 and p < 0.001; respectively). Higher choline levels with higher lutein levels were related to better recognition memory. The DHA X free choline interaction was also significant for the difference in latency scores at frontal, central, and midline areas (p < 0.01; p < 0.001; p < 0.05 respectively). Higher choline with higher DHA was related to better recognition memory. Interactions between human milk nutrients appear important in predicting infant cognition, and there may be a benefit to specific nutrient combinations.
48Choline and DHA in Maternal and Infant Nutrition: Synergistic Implications in Brain and Eye Health.PubMed
Jonathan G Mun, LeeCole L Legette, Chioma J Ikonte, et al.
Nutrients. 2019 May 21;11(5):1125. doi: 10.3390/nu11051125.
The aim of this review is to highlight current insights into the roles of choline and docosahexaenoic acid (DHA) in maternal and infant nutrition, with special emphasis on dietary recommendations, gaps in dietary intake, and synergistic implications of both nutrients in infant brain and eye development. Adequate choline and DHA intakes are not being met by the vast majority of US adults, and even more so by women of child-bearing age. Choline and DHA play a significant role in infant brain and eye development, with inadequate intakes leading to visual and neurocognitive deficits. Emerging findings illustrate synergistic interactions between choline and DHA, indicating that insufficient intakes of one or both could have lifelong deleterious impacts on both maternal and infant health.
49The Role of Nutrition and Nutritional Supplements in Ocular Surface Diseases.PubMed
Marco Pellegrini, Carlotta Senni, Federico Bernabei, et al.
Nutrients. 2020 Mar 30;12(4):952. doi: 10.3390/nu12040952.
Dry eye disease (DED) is a multifactorial disease of the ocular surface system whose chore mechanisms are tear film instability, inflammation, tear hyperosmolarity and epithelial damage. In recent years, novel therapies specifically targeting inflammation and oxidative stress are being investigated and used in this field. Therefore, an increasing body of evidence supporting the possible role of different micronutrients and nutraceutical products for the treatment of ocular surface diseases is now available. In the present review, we analyzed in detail the effects on ocular surface of omega-3 fatty acids, vitamins A, B12, C, D, selenium, curcumin and flavonoids. Among these, the efficacy of omega-3 fatty acid supplementation in ameliorating DED signs and symptoms is supported by robust scientific evidence. Further long-term clinical trials are warranted to confirm the safety and efficacy of the supplementation of the other micronutrients and nutraceuticals.
50Vitamin A and fish oils for preventing the progression of retinitis pigmentosa.PubMed
Stephen G Schwartz, Xue Wang, Pamela Chavis, et al.
Cochrane Database Syst Rev. 2020 Jun 18;6(6):CD008428. doi: 10.1002/14651858.CD008428.pub3.
BACKGROUND: Retinitis pigmentosa (RP) comprises a group of hereditary eye diseases characterized by progressive degeneration of retinal photoreceptors. It results in severe visual loss that may lead to blindness. Symptoms may become manifest during childhood or adulthood which include poor night vision (nyctalopia) and constriction of peripheral vision (visual field loss). Visual field loss is progressive and affects central vision later in the disease course. The worldwide prevalence of RP is approximately 1 in 4000, with 100,000 individuals affected in the USA. At this time, there is no proven therapy for RP. OBJECTIVES: The objective of this review was to synthesize the best available evidence regarding the effectiveness and safety of vitamin A and fish oils (docosahexaenoic acid (DHA)) in preventing the progression of RP. SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL), which contains the Cochrane Eyes and Vision Trials Register (2020, Issue 2); Ovid MEDLINE; Embase.com; PubMed; Latin American and Caribbean Health Sciences Literature Database (LILACS); ClinicalTrials.gov; the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP); and OpenGrey. We did not use any date or language restrictions in the electronic searches for trials. We last searched the electronic databases on 7 February 2020. SELECTION CRITERIA: We included randomized controlled trials that enrolled participants of any age diagnosed with any degree of severity or type of RP, and evaluated the effectiveness of vitamin A, fish oils (DHA), or both compared to placebo, vitamins (other than vitamin A), or no therapy, as a treatment for RP. We excluded cluster-randomized trials and cross-over trials. DATA COLLECTION AND ANALYSIS: We prespecified the following outcomes: mean change from baseline visual field, mean change from baseline electroretinogram (ERG) amplitudes, and anatomic changes as measured by optical coherence tomography (OCT), at one-year follow-up, and mean change in visual acuity, at five-year follow-up. Two review authors independently extracted data and evaluated risk of bias for all included trials. We also contacted study investigators for further information when necessary. MAIN RESULTS: In addition to three trials from the previous version of this review, we included a total of four trials with 944 participants aged 4 to 55 years. Two trials included only participants with X-linked RP and the other two included participants with RP of all forms of genetic predisposition. Two trials evaluated the effect of DHA alone; one trial evaluated vitamin A alone; and one trial evaluated DHA and vitamin A versus vitamin A alone. Two trials recruited participants from the USA, and the other two recruited from the USA and Canada. All trials were at low risk of bias for most domains. We did not perform meta-analysis due to clinical heterogeneity. Four trials assessed visual field sensitivity. Investigators found no evidence of a difference in mean values between the groups. However, one trial found that the annual rate of change of visual field sensitivity over four years favored the DHA group in foveal (-0.02 ± 0.55 (standard error (SE)) dB versus -0.47 ± 0.03 dB, P = 0.039), macular (-0.42 ± 0.05 dB versus -0.85 ± 0.03 dB, P = 0.031), peripheral (-0.39 ± 0.02 versus -0.86 ± 0.02 dB, P < 0.001), and total visual field sensitivity (-0.39 ± 0.02 versus -0.86 ± 0.02 dB, P < 0.001). The certainty of the evidence was very low. The four trials evaluated visual acuity (LogMAR scale) at a follow-up of four to six years. In one trial (208 participants), investigators found no evidence of a difference between the two groups, as both groups lost 0.7 letters of the Early Treatment Diabetic Retinopathy Study (ETDRS) visual acuity per year. In another trial (41 participants), DHA showed no evidence of effect on visual acuity (mean difference -0.01 logMAR units (95% confidence interval -0.14 to 0.12; one letter difference between the two groups; very low-certainty evidence). In the third trial (60 participants), annual change in mean number of letters correct was -0.8 (DHA) and 1.4 letters (placebo), with no evidence of between-group difference. In the fourth trial (572 participants), which evaluated (vitamin A + vitamin E trace) compared with (vitamin A trace + vitamin E trace), decline in ETDRS visual acuity was 1.1 versus 0.9 letters per year, respectively. All four trials reported electroretinography (ERG). Investigators of two trials found no evidence of a difference between the DHA and placebo group in yearly rates of change in 31 Hz cone ERG amplitude (mean ± SE) (-0.028 ± 0.001 log μV versus -0.022 ± 0.002 log μV; P = 0.30); rod ERG amplitude (mean ± SE) (-0.010 ± 0.001 log μV versus -0.023 ± 0.001 log μV; P = 0.27); and maximal ERG amplitude (mean ± SE) (-0.042 ± 0.001 log μV versus -0.036 ± 0.001 log μV; P = 0.65). In another trial, a slight difference (6.1% versus 7.1%) in decline of ERG per year favored vitamin A (P = 0.01). The certainty of the evidence was very low. One trial (51 participants) that assessed optical coherence tomography found no evidence of a difference in ellipsoid zone constriction (P = 0.87) over two years, with very low-certainty evidence. The other three trials did not report this outcome. Only one trial reported adverse events, which found that 27/60 participants experienced 42 treatment-related emergent adverse events (22 in DHA group, 20 in placebo group). The certainty of evidence was very low. The rest of the trials reported no adverse events, and no study reported any evidence of benefit of vitamin supplementation on the progression of visual acuity loss. AUTHORS' CONCLUSIONS: Based on the results of four studies, it is uncertain if there is a benefit of treatment with vitamin A or DHA, or both for people with RP. Future trials should also take into account the changes observed in ERG amplitudes and other outcome measures from trials included in this review.
51Seafood and health: What you need to know?PubMed
Chengchu Liu, Nicholas V C Ralston
Adv Food Nutr Res. 2021;97:275-318. doi: 10.1016/bs.afnr.2021.04.001. Epub 2021 May 6.
Seafood, including fish and shellfish, provides an ideal package of nutrients and is an important part of a healthy diet. Strong evidence has shown that eating fish and other seafoods improve brain, eye, and heart health. The new 2020-2025 Dietary Guidelines for Americans (DGA) recommend that Americans of all ages should eat more seafood-at least twice a week-particularly pregnant women and young children. However, less than one in five Americans heed that advice. About one-third of Americans eat seafood once a week, while nearly half eat fish only occasionally or not at all. This calls for a drastic shift in the American diet to vary protein sources and include more seafood products in order to receive the most health benefits. This chapter covers (1) seafood nutrition and health benefits, (2) seafood's protective effects against mercury toxicity, (3) selenium health benefit values (HBVs), and (4) challenges and opportunities for seafood production, demand and sustainability. This chapter aims to convey recent advances in science-based information to increase public awareness of seafood safety, nutrition and health benefits of seafood as part of a healthy diet, and to advocate healthy eating with smart food choices by promoting two servings of seafood per week. This will support the healthy eating patterns and promotes a minimum two to three servings of seafood recommended by the current DGA.
52Management of patients with small-angle esotropia and subnormal stereopsis using Fresnel prism.PubMed
Haeng-Jin Lee, Seong-Joon Kim
Graefes Arch Clin Exp Ophthalmol. 2022 Jan;260(1):345-352. doi: 10.1007/s00417-021-05338-2. Epub 2021 Aug 18.
PURPOSE: Monofixation syndrome (MFS) is a specific subnormal binocular vision status, either with or without a small deviation. Patients with MFS have a tendency to maintain stable ocular alignment. Correction of refractive errors and occlusion are considered as treatment option for amblyopia, and the status of MFS could be changed with long-term follow-up. The purpose of this study is to evaluate whether a Fresnel prism affected the visual acuity, angle of deviation, and sensory status in small-angle esotropia with subnormal stereopsis presenting with MFS features. METHODS: Patients with small-angle esotropia within 8 prism diopters (PD) on the simultaneous prism and cover test from 2010 to 2019 were reviewed. Patients with subnormal stereopsis defined as more than 100 s of arc (arcsec) and with the central suppression with peripheral fusion were only included. A Fresnel prism was applied to the dominant eye, and the minimum follow-up period after Fresnel prism treatment was 24 months. We assessed patient clinical characteristics, course and response to therapy including visual acuity, angle of deviation, and stereopsis. RESULTS: Twenty patients with a mean age of 5.5 ± 1.4 years were included. The mean duration of Fresnel prism treatment was 15.3 ± 10.3 months. After 50.7 ± 17.2 months of follow-up, VA of the non-dominant eye was changed from 0.26 ± 0.20 logMAR to 0.07 ± 0.17 logMAR (P < .001). The initial stereoacuities were 3.54 ± 0.27 log arcsec, ranged from 6000 to 400 arcsec. After the treatment with Fresnel prism, the final stereoacuities were 3.09 ± 0.58 log arcsec, ranged from 6000 to 100 arcsec (P = .001); nine patients (45%) improved stereoacuity more than two octaves. No changes in the angle of deviation or a change of fixation were observed. CONCLUSIONS: After use of Fresnel prism, there was some improvement in visual acuity and stereopsis in patients with MFS features. Following occlusion and refractive correction, management using Fresnel prism could be attempted in small-angle esotropic patients with amblyopia or subnormal stereopsis.
53CLEAR - Orthokeratology.PubMed
Stephen J Vincent, Pauline Cho, Ka Yin Chan, et al.
Cont Lens Anterior Eye. 2021 Apr;44(2):240-269. doi: 10.1016/j.clae.2021.02.003. Epub 2021 Mar 25.
Orthokeratology (ortho-k) is the process of deliberately reshaping the anterior cornea by utilising specialty contact lenses to temporarily and reversibly reduce refractive error after lens removal. Modern ortho-k utilises reverse geometry lens designs, made with highly oxygen permeable rigid materials, worn overnight to reshape the anterior cornea and provide temporary correction of refractive error. More recently, ortho-k has been extensively used to slow the progression of myopia in children. This report reviews the practice of ortho-k, including its history, mechanisms of refractive and ocular changes, current use in the correction of myopia, astigmatism, hyperopia, and presbyopia, and standard of care. Suitable candidates for ortho-k are described, along with the fitting process, factors impacting success, and the potential options for using newer lens designs. Ocular changes associated with ortho-k, such as alterations in corneal thickness, development of microcysts, pigmented arcs, and fibrillary lines are reviewed. The safety of ortho-k is extensively reviewed, along with an overview of non-compliant behaviours and appropriate disinfection regimens. Finally, the role of ortho-k in myopia management for children is discussed in terms of efficacy, safety, and potential mechanisms of myopia control, including the impact of factors such as initial fitting age, baseline refractive error, the role of peripheral defocus, higher order aberrations, pupil size, and treatment zone size.
54Benefits and risks of orthokeratology treatment: a systematic review and meta-analysis.PubMed
Lauren Sartor, Damien S Hunter, Mai Linh Vo, et al.
Int Ophthalmol. 2024 Jun 21;44(1):239. doi: 10.1007/s10792-024-03175-w.
BACKGROUND: This meta-analysis reviews the evidence for the risks and benefits associated with orthokeratology (OK) treatment compared with other methods of myopia control in children and adults. METHODS: A systematic search of Cochrane Central Register of Controlled Trials, Pubmed, Embase and Ovid was conducted from database inception to 22nd August 2021. Studies that reported on risks, visual and ocular biometric effects of OK in patients > 5 years of age with myopia (- 0.75 to - 6.00D) were included. Main outcomes are change in axial length and any adverse event. RESULTS: Fourty-five papers were included in this systematic review and meta-analysis. The quality of data was variable and of moderate certainty, and selection bias likely skewed the results towards a relative benefit for OK. The rate of axial elongation in children was lower for OK treatment compared to other treatment modalities at one year (MD - 0.16 mm, 95% CI - 0.25 to - 0.07). Rate of change in axial length in children rebounded after OK discontinuation compared to participants who continued treatment (MD 0.10 mm, 95% CI 0.06 to 0.14). Adults and children wearing OK were up to 3.79 times more likely to experience an adverse event when compared with conventional contact lenses (OR 3.79, 95% CI 1.24 to ll.), though this evidence base is underdeveloped and requires additional well-designed studies for substantial conclusions to be drawn. CONCLUSIONS: OK arrests myopia progression while in use, however, there remain unanswered questions about the optimal duration of treatment, discontinuation effects and long-term risk for adverse events.
55Efficacy and adverse reactions of peripheral add multifocal soft contact lenses in childhood myopia: a meta-analysis.PubMed
Desheng Song, Wen Qiu, Ting Jiang, et al.
BMC Ophthalmol. 2024 Apr 16;24(1):173. doi: 10.1186/s12886-024-03408-7.
OBJECTIVES: This study aims to compare the efficacy of peripheral add multifocal soft contact lenses (SCLs) (excluding bifocal SCLs) with single vision contact lenses or spectacles in controlling myopia progression. METHOD: A comprehensive literature search was conducted in the Pubmed, EMBASE, Web of Science, and Cochrane Library databases until October 2023. The literature was thoroughly screened based on predetermined eligibility criteria. Pooled odds ratios (ORs) were calculated for dichotomous data and weighted mean differences (WMD) for continuous data. RESULTS: A total of 11 articles comprising 787 participants were included in this meta-analysis. Our pooled results demonstrated that the peripheral add multifocal SCLs groups exhibited significantly reduced refraction progression (MD = 0.20; 95%CI, 0.14 ∼ 0.27; P<0.001) and less axial length elongation (MD=-0.08; 95%CI, -0.09∼-0.08; P<0.001) compared to the control group. There was no significant difference in high-contrast logMAR distance visual acuity between the two groups (MD = 0.01; 95%CI, -0.00 ∼ 0.02; P = 0.19). However, the group using single-vision lenses had better low-contrast logMAR distance visual acuity compared to those using peripheral add multifocal SCLs (MD = 0.06; 95%CI, 0.02 ∼ 0.10; P = 0.004). Data synthesis using a random-effects model indicated an incidence of contact lens-related adverse events of 0.065 (95%CI, 0.048 ∼ 0.083). CONCLUSIONS: The present meta-analysis signifies that peripheral defocus modifying contact lenses are effective in slowing down the progression of myopia and reducing axial elongation.
56Soft peripheral contact lens for eye elongation control (SPACE): 1-year results of a double-blinded randomized controlled trial.PubMed
Shan-Chih Lee, Min-Yen Hsu, Shih-Chien Huang, et al.
Cont Lens Anterior Eye. 2024 Oct;47(5):102256. doi: 10.1016/j.clae.2024.102256. Epub 2024 Jul 3.
PURPOSE: To examine the safety and efficacy of soft multifocal contact lenses on slowing the rate of myopia progression. METHODS: A prospective, randomized, double-masked clinical trial was conducted including 115 children (55 boys and 60 girls) aged 8 to 15 years. Children were assigned to wear one of two daily disposable soft contact lens designs; a multifocal design (Pegavision) or a dual-focus design (MiSight, Coopervision) in both eyes for at least 8 h per day for one year. All contact lenses were replaced on a daily basis. Measurements were obtained using a logMAR vision meter, including objective refraction, handheld retinoscopy, high (96 %) and low (12 %) contrast sensitivity, and distance and near visual acuity. Axial length was measured every 6 months. RESULTS: After one year, the spherical equivalent refractive error and axial length of the experimental group (Pegavision) increased by -0.50 ± 0.48 D and 0.24 ± 0.16 mm, respectively, in the right eye and -0.47 ± 0.37 D and 0.23 ± 0.16 mm, respectively, in the left eye. The spherical equivalent refractive error and axial length of the control group (MiSight) increased by -0.48 ± 0.47 D and 0.22 ± 0.13 mm, respectively, in the right eye and by -0.50 ± 0.44 D and 0.23 ± 0.14 mm, respectively, in the left eye, with no significant differences observed between the two lens types. CONCLUSIONS: The one-year results from this clinical trial show that the multifocal soft contact lenses used in the experimental group have a similar myopia control efficacy with respect to spherical equivalent refraction and axial length elongation as a commercially available dual focus soft contact lens design.
57Advances in myopia control strategies for children.PubMed
Xiu Juan Zhang, Ebenezer Zaabaar, Amanda Nicole French, et al.
Br J Ophthalmol. 2025 Jan 28;109(2):165-176. doi: 10.1136/bjo-2023-323887.
Myopia has long been a global threat to public health. Timely interventions are likely to reduce the risk of vision-threatening complications. There are both established and rapidly evolving therapeutic approaches to slow myopia progression and/or delay its onset. The effective methods for slowing myopia progression include atropine eye-drops, defocus incorporated multiple segments (DIMS) spectacle lenses, spectacle lenses with highly aspherical lenslets target (HALT), diffusion optics technology (DOT) spectacle lenses, red light therapy (RLT), multifocal soft contact lenses and orthokeratology. Among these, 0.05% atropine, HALT lenses, RLT and +3.00 peripheral addition soft contact lenses yield over 60% reduction in myopia progression, whereas DIMS, DOT and MiSight contact lenses demonstrate at least 50% myopia control efficacy. 0.05% atropine demonstrates a more optimal balance of efficacy and safety than 0.01%. The efficacy of 0.01% atropine has not been consistent and requires further validation across diverse ethnicities. Combining atropine 0.01% with orthokeratology or DIMS spectacles yields better outcomes than using these interventions as monotherapies. Increased outdoor time is an effective public health strategy for myopia prevention while recent studies suggest that 0.05% low-concentration atropine and RLT therapy have promising potential as clinical myopia prevention interventions for high-risk groups. Myopia control spectacle lenses, being the least invasive, are safe for long-term use. However, when considering other approaches, it is essential to ensure proper instruction and regular follow-ups to maintain safety and monitor any potential complications. Ultimately, significant advances have been made in myopia control strategies, many of which have shown meaningful clinical outcomes. However, regular use and adequate safety monitoring over extended durations are imperative to foster confidence that can only come from extensive clinical experience.
58Low-Concentration Atropine for Myopia Progression (LAMP) Study: A Randomized, Double-Blinded, Placebo-Controlled Trial of 0.05%, 0.025%, and 0.01% Atropine Eye Drops in Myopia Control.PubMed
Jason C Yam, Yuning Jiang, Shu Min Tang, et al.
Ophthalmology. 2019 Jan;126(1):113-124. doi: 10.1016/j.ophtha.2018.05.029. Epub 2018 Jul 6.
PURPOSE: Low-concentration atropine is an emerging therapy for myopia progression, but its efficacy and optimal concentration remain uncertain. Our study aimed to evaluate the efficacy and safety of low-concentration atropine eye drops at 0.05%, 0.025%, and 0.01% compared with placebo over a 1-year period. DESIGN: Randomized, placebo-controlled, double-masked trial. PARTICIPANTS: A total of 438 children aged 4 to 12 years with myopia of at least -1.0 diopter (D) and astigmatism of -2.5 D or less. METHODS: Participants were randomly assigned in a 1:1:1:1 ratio to receive 0.05%, 0.025%, and 0.01% atropine eye drops, or placebo eye drop, respectively, once nightly to both eyes for 1 year. Cycloplegic refraction, axial length (AL), accommodation amplitude, pupil diameter, and best-corrected visual acuity were measured at baseline, 2 weeks, 4 months, 8 months, and 12 months. Visual Function Questionnaire was administered at the 1-year visit. MAIN OUTCOME MEASURES: Changes in spherical equivalent (SE) and AL were measured, and their differences among groups were compared using generalized estimating equation. RESULTS: After 1 year, the mean SE change was -0.27±0.61 D, -0.46±0.45 D, -0.59±0.61 D, and -0.81±0.53 D in the 0.05%, 0.025%, and 0.01% atropine groups, and placebo groups, respectively (P < 0.001), with a respective mean increase in AL of 0.20±0.25 mm, 0.29±0.20 mm, 0.36±0.29 mm, and 0.41±0.22 mm (P < 0.001). The accommodation amplitude was reduced by 1.98±2.82 D, 1.61±2.61 D, 0.26±3.04 D, and 0.32±2.91 D, respectively (P < 0.001). The pupil sizes under photopic and mesopic conditions were increased respectively by 1.03±1.02 mm and 0.58±0.63 mm in the 0.05% atropine group, 0.76±0.90 mm and 0.43±0.61 mm in the 0.025% atropine group, 0.49±0.80 mm and 0.23±0.46 mm in the 0.01% atropine group, and 0.13±1.07 mm and 0.02±0.55 mm in the placebo group (P < 0.001). Visual acuity and vision-related quality of life were not affected in each group. CONCLUSIONS: The 0.05%, 0.025%, and 0.01% atropine eye drops reduced myopia progression along a concentration-dependent response. All concentrations were well tolerated without an adverse effect on vision-related quality of life. Of the 3 concentrations used, 0.05% atropine was most effective in controlling SE progression and AL elongation over a period of 1 year.
59Two-Year Clinical Trial of the Low-Concentration Atropine for Myopia Progression (LAMP) Study: Phase 2 Report.PubMed
Jason C Yam, Fen Fen Li, Xiujuan Zhang, et al.
Ophthalmology. 2020 Jul;127(7):910-919. doi: 10.1016/j.ophtha.2019.12.011. Epub 2019 Dec 21.
PURPOSE: To evaluate the efficacy and safety of 0.05%, 0.025%, and 0.01% atropine eye drops over 2 years to determine which is the optimal concentration for longer-term myopia control. DESIGN: Randomized, double-masked trial extended from the Low-Concentration Atropine for Myopia Progression (LAMP) Study. PARTICIPANTS: Three hundred eighty-three of 438 children (87%) aged 4 to 12 years with myopia of at least -1.0 diopter (D) originally randomized to receive atropine 0.05%, 0.025%, 0.01%, or placebo once daily in both eyes in the LAMP phase 1 study were continued in this extended trial (phase 2). METHODS: Children in the placebo group (phase 1) were switched to receive 0.05% atropine from the beginning of the second-year follow-up, whereas those in the 0.05%, 0.025%, and 0.01% atropine groups continued with the same regimen. Cycloplegic refraction, axial length (AL), accommodation amplitude, photopic and mesopic pupil diameter, and best-corrected visual acuity were measured at 4-month intervals. MAIN OUTCOME MEASURES: Changes in spherical equivalent (SE) and AL and their differences between groups. RESULTS: Over the 2-year period, the mean SE progression was 0.55±0.86 D, 0.85±0.73 D, and 1.12±0.85 D in the 0.05%, 0.025%, and 0.01% atropine groups, respectively (P = 0.015, P < 0.001, and P = 0.02, respectively, for pairwise comparisons), with mean AL changes over 2 years of 0.39±0.35 mm, 0.50±0.33 mm, and 0.59±0.38 mm (P = 0.04, P < 0.001, and P = 0.10, respectively). Compared with the first year, the second-year efficacy of 0.05% and 0.025% atropine remained similar (P >0.1), but improved mildly in the 0.01% atropine group (P = 0.04). For the phase 1 placebo group, the myopia progression was reduced significantly after switching to 0.05% atropine (SE change, 0.18 D in second year vs. 0.82 D in first year [P < 0.001]; AL elongated 0.15 mm in second year vs. 0.43 mm in first year [P < 0.001]). Accommodation loss and change in pupil size in all concentrations remained similar to the first-year results and were well tolerated. Visual acuity and vision-related quality of life remained unaffected. CONCLUSIONS: Over 2 years, the efficacy of 0.05% atropine observed was double that observed with 0.01% atropine, and it remained the optimal concentration among the studied atropine concentrations in slowing myopia progression.
60Three-Year Clinical Trial of Low-Concentration Atropine for Myopia Progression (LAMP) Study: Continued Versus Washout: Phase 3 Report.PubMed
Jason C Yam, Xiu Juan Zhang, Yuzhou Zhang, et al.
Ophthalmology. 2022 Mar;129(3):308-321. doi: 10.1016/j.ophtha.2021.10.002. Epub 2021 Oct 7.
PURPOSE: (1) To compare the efficacy of continued and stopping treatment for 0.05%, 0.025%, and 0.01% atropine during the third year. (2) To evaluate the efficacy of continued treatment over 3 years. (3) To investigate the rebound phenomenon and its determinants after cessation of treatment. DESIGN: A randomized, double-masked extended trial. PARTICIPANTS: A total of 350 of 438 children aged 4 to 12 years originally recruited into the Low-Concentration Atropine for Myopia Progression (LAMP) study. METHODS: At the beginning of the third year, children in each group were randomized at a 1:1 ratio to continued treatment and washout subgroups. Cycloplegic spherical equivalent (SE) refraction and axial length (AL) were measured at 4-month intervals. MAIN OUTCOME MEASURES: Changes in SE and AL between groups. RESULTS: A total of 326 children completed 3 years of follow-up. During the third year, SE progression and AL elongation were faster in the washout subgroups than in the continued treatment groups across all concentrations: -0.68 ± 0.49 diopters (D) versus -0.28 ± 0.42 D (P < 0.001) and 0.33 ± 0.17 mm versus 0.17 ± 0.14 mm (P < 0.001) for the 0.05%; -0.57 ± 0.38 D versus -0.35 ± 0.37 D (P = 0.004) and 0.29 ± 0.14 mm versus 0.20 ± 0.15 mm (P = 0.001) for the 0.025%; -0.56 ± 0.40 D versus -0.38 ± 0.49 D (P = 0.04) and 0.29 ± 0.15 mm versus 0.24 ± 0.18 mm (P = 0.13) for the 0.01%. Over the 3-year period, SE progressions were -0.73 ± 1.04 D, -1.31 ± 0.92 D, and -1.60 ± 1.32 D (P = 0.001) for the 0.05%, 0.025%, and 0.01% groups in the continued treatment subgroups, respectively, and -1.15 ± 1.13 D, -1.47 ± 0.77 D, and -1.81 ± 1.10 D (P = 0.03), respectively, in the washout subgroup. The respective AL elongations were 0.50 ± 0.40 mm, 0.74 ± 0.41 mm, and 0.89 ± 0.53 mm (P < 0.001) for the continued treatment subgroups and 0.70 ± 0.47 mm, 0.82 ± 0.37 mm, and 0.98 ± 0.48 mm (P = 0.04) for the washout subgroup. The rebound SE progressions during washout were concentration dependent, but their differences were clinically small (P = 0.15). Older age and lower concentration were associated with smaller rebound effects in both SE progression (P < 0.001) and AL elongation (P < 0.001). CONCLUSIONS: During the third year, continued atropine treatment achieved a better effect across all concentrations compared with the washout regimen. 0.05% atropine remained the optimal concentration over 3 years in Chinese children. The differences in rebound effects were clinically small across all 3 studied atropine concentrations. Stopping treatment at an older age and lower concentration are associated with a smaller rebound.
61Five-Year Clinical Trial of the Low-Concentration Atropine for Myopia Progression (LAMP) Study: Phase 4 Report.PubMed
Xiu Juan Zhang, Yuzhou Zhang, Benjamin H K Yip, et al.
Ophthalmology. 2024 Sep;131(9):1011-1020. doi: 10.1016/j.ophtha.2024.03.013. Epub 2024 Mar 16.
PURPOSE: To evaluate (1) the long-term efficacy of low-concentration atropine over 5 years, (2) the proportion of children requiring re-treatment and associated factors, and (3) the efficacy of pro re nata (PRN) re-treatment using 0.05% atropine from years 3 to 5. DESIGN: Randomized, double-masked extended trial. PARTICIPANTS: Children 4 to 12 years of age originally from the Low-Concentration Atropine for Myopia Progression (LAMP) study. METHODS: Children 4 to 12 years of age originally from the LAMP study were followed up for 5 years. During the third year, children in each group originally receiving 0.05%, 0.025%, and 0.01% atropine were randomized to continued treatment and treatment cessation. During years 4 and 5, all continued treatment subgroups were switched to 0.05% atropine for continued treatment, whereas all treatment cessation subgroups followed a PRN re-treatment protocol to resume 0.05% atropine for children with myopic progressions of 0.5 diopter (D) or more over 1 year. Generalized estimating equations were used to compare the changes in spherical equivalent (SE) progression and axial length (AL) elongation among groups. MAIN OUTCOMES MEASURES: (1) Changes in SE and AL in different groups over 5 years, (2) the proportion of children who needed re-treatment, and (3) changes in SE and AL in the continued treatment and PRN re-treatment groups from years 3 to 5. RESULTS: Two hundred seventy (82.8%) of 326 children (82.5%) from the third year completed 5 years of follow-up. Over 5 years, the cumulative mean SE progressions were -1.34 ± 1.40 D, -1.97 ± 1.03 D, and -2.34 ± 1.71 D for the continued treatment groups with initial 0.05%, 0.025%, and 0.01% atropine, respectively (P = 0.02). Similar trends were observed in AL elongation (P = 0.01). Among the PRN re-treatment group, 87.9% of children (94/107) needed re-treatment. The proportion of re-treatment across all studied concentrations was similar (P = 0.76). The SE progressions for continued treatment and PRN re-treatment groups from years 3 to 5 were -0.97 ± 0.82 D and -1.00 ± 0.74 D (P = 0.55) and the AL elongations were 0.51 ± 0.34 mm and 0.49 ± 0.32 mm (P = 0.84), respectively. CONCLUSIONS: Over 5 years, the continued 0.05% atropine treatment demonstrated good efficacy for myopia control. Most children needed to restart treatment after atropine cessation at year 3. Restarted treatment with 0.05% atropine achieved similar efficacy as continued treatment. Children should be considered for re-treatment if myopia progresses after treatment cessation. FINANCIAL DISCLOSURE(S): The author(s) have no proprietary or commercial interest in any materials discussed in this article.
62Effect of Low-Concentration Atropine Eyedrops vs Placebo on Myopia Incidence in Children: The LAMP2 Randomized Clinical Trial.PubMed
Jason C Yam, Xiu Juan Zhang, Yuzhou Zhang, et al.
JAMA. 2023 Feb 14;329(6):472-481. doi: 10.1001/jama.2022.24162.
IMPORTANCE: Early onset of myopia is associated with high myopia later in life, and myopia is irreversible once developed. OBJECTIVE: To evaluate the efficacy of low-concentration atropine eyedrops at 0.05% and 0.01% concentration for delaying the onset of myopia. DESIGN, SETTING, AND PARTICIPANTS: This randomized, placebo-controlled, double-masked trial conducted at the Chinese University of Hong Kong Eye Centre enrolled 474 nonmyopic children aged 4 through 9 years with cycloplegic spherical equivalent between +1.00 D to 0.00 D and astigmatism less than -1.00 D. The first recruited participant started treatment on July 11, 2017, and the last participant was enrolled on June 4, 2020; the date of the final follow-up session was June 4, 2022. INTERVENTIONS: Participants were assigned at random to the 0.05% atropine (n = 160), 0.01% atropine (n = 159), and placebo (n = 155) groups and had eyedrops applied once nightly in both eyes over 2 years. MAIN OUTCOMES AND MEASURES: The primary outcomes were the 2-year cumulative incidence rate of myopia (cycloplegic spherical equivalent of at least -0.50 D in either eye) and the percentage of participants with fast myopic shift (spherical equivalent myopic shift of at least 1.00 D). RESULTS: Of the 474 randomized patients (mean age, 6.8 years; 50% female), 353 (74.5%) completed the trial. The 2-year cumulative incidence of myopia in the 0.05% atropine, 0.01% atropine, and placebo groups were 28.4% (33/116), 45.9% (56/122), and 53.0% (61/115), respectively, and the percentages of participants with fast myopic shift at 2 years were 25.0%, 45.1%, and 53.9%. Compared with the placebo group, the 0.05% atropine group had significantly lower 2-year cumulative myopia incidence (difference, 24.6% [95% CI, 12.0%-36.4%]) and percentage of patients with fast myopic shift (difference, 28.9% [95% CI, 16.5%-40.5%]). Compared with the 0.01% atropine group, the 0.05% atropine group had significantly lower 2-year cumulative myopia incidence (difference, 17.5% [95% CI, 5.2%-29.2%]) and percentage of patients with fast myopic shift (difference, 20.1% [95% CI, 8.0%-31.6%]). The 0.01% atropine and placebo groups were not significantly different in 2-year cumulative myopia incidence or percentage of patients with fast myopic shift. Photophobia was the most common adverse event and was reported by 12.9% of participants in the 0.05% atropine group, 18.9% in the 0.01% atropine group, and 12.2% in the placebo group in the second year. CONCLUSIONS AND RELEVANCE: Among children aged 4 to 9 years without myopia, nightly use of 0.05% atropine eyedrops compared with placebo resulted in a significantly lower incidence of myopia and lower percentage of participants with fast myopic shift at 2 years. There was no significant difference between 0.01% atropine and placebo. Further research is needed to replicate the findings, to understand whether this represents a delay or prevention of myopia, and to assess longer-term safety. TRIAL REGISTRATION: Chinese Clinical Trial Registry: ChiCTR-IPR-15006883.
63Atropine for the treatment of childhood myopia: safety and efficacy of 0.5%, 0.1%, and 0.01% doses (Atropine for the Treatment of Myopia 2).PubMed
Audrey Chia, Wei-Han Chua, Yin-Bun Cheung, et al.
Ophthalmology. 2012 Feb;119(2):347-54. doi: 10.1016/j.ophtha.2011.07.031. Epub 2011 Oct 2.
PURPOSE: Our previous study, Atropine for the Treatment of Myopia 1 (ATOM1), showed that atropine 1% eyedrops were effective in controlling myopic progression but with visual side effects resulting from cycloplegia and mydriasis. The aim of this study was to compare efficacy and visual side effects of 3 lower doses of atropine: 0.5%, 0.1%, and 0.01%. DESIGN: Single-center, double-masked, randomized study. PARTICIPANTS: A total of 400 children aged 6-12 years with myopia of at least -2.0 diopters (D) and astigmatism of -1.50 D or less. INTERVENTION: Children were randomly assigned in a 2:2:1 ratio to 0.5%, 0.1%, and 0.01% atropine to be administered once nightly to both eyes for 2 years. Cycloplegic refraction, axial length, accommodation amplitude, pupil diameter, and visual acuity were noted at baseline, 2 weeks, and then every 4 months for 2 years. MAIN OUTCOME MEASURES: Myopia progression at 2 years. Changes were noted and differences between groups were compared using the Huber-White robust standard error to allow for data clustering of 2 eyes per person. RESULTS: The mean myopia progression at 2 years was -0.30±0.60, -0.38±0.60, and -0.49±0.63 D in the atropine 0.5%, 0.1%, and 0.01% groups, respectively (P=0.02 between the 0.01% and 0.5% groups; between other concentrations P > 0.05). In comparison, myopia progression in ATOM1 was -1.20±0.69 D in the placebo group and -0.28±0.92 D in the atropine 1% group. The mean increase in axial length was 0.27±0.25, 0.28±0.28, and 0.41±0.32 mm in the 0.5%, 0.1%, and 0.01% groups, respectively (P < 0.01 between the 0.01% and 0.1% groups and between the 0.01% and 0.5% groups). However, differences in myopia progression (0.19 D) and axial length change (0.14 mm) between groups were small and clinically insignificant. Atropine 0.01% had a negligible effect on accommodation and pupil size, and no effect on near visual acuity. Allergic conjunctivitis and dermatitis were the most common adverse effect noted, with 16 cases in the 0.1% and 0.5% atropine groups, and no cases in the 0.01% group. CONCLUSIONS: Atropine 0.01% has minimal side effects compared with atropine at 0.1% and 0.5%, and retains comparable efficacy in controlling myopia progression.
64Five-Year Clinical Trial on Atropine for the Treatment of Myopia 2: Myopia Control with Atropine 0.01% Eyedrops.PubMed
Audrey Chia, Qing-Shu Lu, Donald Tan
Ophthalmology. 2016 Feb;123(2):391-399. doi: 10.1016/j.ophtha.2015.07.004. Epub 2015 Aug 11.
PURPOSE: To compare the safety and efficacy of different concentrations of atropine eyedrops in controlling myopia progression over 5 years. DESIGN: Randomized, double-masked clinical trial. PARTICIPANTS: A total of 400 children originally randomized to receive atropine 0.5%, 0.1%, or 0.01% once daily in both eyes in a 2:2:1 ratio. METHODS: Children received atropine for 24 months (phase 1), after which medication was stopped for 12 months (phase 2). Children who had myopia progression (≥-0.50 diopters [D] in at least 1 eye) during phase 2 were restarted on atropine 0.01% for a further 24 months (phase 3). MAIN OUTCOME MEASURES: Change in spherical equivalent and axial length over 5 years. RESULTS: There was a dose-related response in phase 1 with a greater effect in higher doses, but an inverse dose-related increase in myopia during phase 2 (washout), resulting in atropine 0.01% being most effective in reducing myopia progression at 3 years. Some 24%, 59%, and 68% of children originally in the atropine 0.01%, 0.1%, and 0.5% groups, respectively, who progressed in phase 2 were restarted on atropine 0.01%. Younger children and those with greater myopic progression in year 1 were more likely to require re-treatment. The lower myopia progression in the 0.01% group persisted during phase 3, with overall myopia progression and change in axial elongation at the end of 5 years being lowest in this group (-1.38±0.98 D; 0.75±0.48 mm) compared with the 0.1% (-1.83±1.16 D, P = 0.003; 0.85±0.53 mm, P = 0.144) and 0.5% (-1.98±1.10 D, P < 0.001; 0.87±0.49 mm, P = 0.075) groups. Atropine 0.01% also caused minimal pupil dilation (0.8 mm), minimal loss of accommodation (2-3 D), and no near visual loss compared with higher doses. CONCLUSIONS: Over 5 years, atropine 0.01% eyedrops were more effective in slowing myopia progression with less visual side effects compared with higher doses of atropine.
65Myopia outcome study of atropine in children: Two-year result of daily 0.01% atropine in a European population.PubMed
James Loughman, Emmanuel Kobia-Acquah, Gareth Lingham, et al.
Acta Ophthalmol. 2024 May;102(3):e245-e256. doi: 10.1111/aos.15761. Epub 2023 Sep 11.
PURPOSE: The Myopia Outcome Study of Atropine in Children (MOSAIC) is an investigator-led, double-masked, randomized controlled trial investigating the efficacy and safety of 0.01% atropine eye drops for managing myopia progression in a predominantly White, European population. METHODS: Children aged 6-16 years with myopia were randomly allocated 2:1 to nightly 0.01% atropine or placebo eye drops in both eyes for 2 years. The primary outcome was cycloplegic spherical equivalent (SE) progression at 24 months. Secondary outcomes included axial length (AL) change, safety and acceptability. Linear mixed models with random intercepts were used for statistical analyses. RESULTS: Of 250 participants enrolled, 204 (81.6%) completed the 24-month visit (136 (81.4%) treatment, 68 (81.9%) placebo). Baseline characteristics, drop-out and adverse event rates were similar between treatment and control groups. At 24 months, SE change was not significantly different between 0.01% atropine and placebo groups (effect = 0.10 D, p = 0.07), but AL growth was lower in the 0.01% atropine group, compared to the placebo group (-0.07 mm, p = 0.007). Significant treatment effects on SE (0.14 D, p = 0.049) and AL (-0.11 mm, p = 0.002) were observed in children of White, but not non-White (SE = 0.05 D, p = 0.89; AL = 0.008 mm, p = 0.93), ethnicity at 24 months. A larger treatment effect was observed in subjects least affected by COVID-19 restrictions (SE difference = 0.37 D, p = 0.005; AL difference = -0.17 mm, p = 0.001). CONCLUSIONS: Atropine 0.01% was safe, well-tolerated and effective in slowing axial elongation in this European population. Treatment efficacy varied by ethnicity and eye colour, and potentially by degree of COVID-19 public health restriction exposure during trial participation.
66Safety and Efficacy of Low-Dose Atropine Eyedrops for the Treatment of Myopia Progression in Chinese Children: A Randomized Clinical Trial.PubMed
Shifei Wei, Shi-Ming Li, Wenzai An, et al.
JAMA Ophthalmol. 2020 Nov 1;138(11):1178-1184. doi: 10.1001/jamaophthalmol.2020.3820.
IMPORTANCE: Because studies have suggested that atropine might slow the progression of myopia in children, randomized clinical trials are warranted to understand this potential causal relationship. OBJECTIVE: To evaluate the efficacy and safety of atropine, 0.01%, eyedrops on slowing myopia progression and axial elongation in Chinese children. DESIGN, SETTING, AND PARTICIPANTS: This was a randomized, placebo-controlled, double-masked study. A total of 220 children aged 6 to 12 years with myopia of -1.00 D to -6.00 D in both eyes were enrolled between April 2018 and July 2018 at Beijing Tongren Hospital, Beijing, China. Cycloplegic refraction and axial length were measured at baseline, 6 months, and 12 months. Adverse events were also recorded. INTERVENTIONS: Patients were randomly assigned in a 1:1 ratio to atropine, 0.01%, or placebo groups to be administered once nightly to both eyes for 1 year. MAIN OUTCOMES AND MEASURES: Mean changes and percentage differences in myopia progression and axial elongation between atropine, 0.01%, or placebo groups. RESULTS: Of 220 participants, 103 were girls (46.8%), and the mean (SD) age was 9.64 (1.68) years. The mean (SD) baseline refractive error and axial length were -2.58 (1.39) D and 24.59 (0.87) mm. Follow-up at 1 year included 76 children (69%) and 83 children (75%) allocated into the atropine, 0.01%, and placebo groups, respectively, when mean myopia progression was -0.49 (0.42) D and -0.76 (0.50) D in the atropine, 0.01%, and placebo groups (mean difference, 0.26 D; 95% CI, 0.12-0.41 D; P < .001), with a relative reduction of 34.2% in myopia progression. The mean (SD) axial elongation in the atropine, 0.01%, group was 0.32 (0.19) mm compared with 0.41 (0.19) mm in the placebo group (mean difference, 0.09 mm; 95% CI, 0.03-0.15 mm; P = .004), with relative reduction of 22.0% in axial elongation. Fifty-one percent and 13.2% of children progressed by at least 0.50 D and 1.00 D in the atropine, 0.01%, group, compared with 69.9% and 34.9% in the placebo group. No serious adverse events related to atropine were reported. CONCLUSIONS AND RELEVANCE: While the clinical relevance of the results cannot be determined from this trial, these 1-year results, limited by approximately 70% follow-up, suggest that atropine, 0.01%, eyedrops can slow myopia progression and axial elongation in children and warrant future studies to determine longer-term results and potential effects on slowing sight-threatening pathologic changes later in life. TRIAL REGISTRATION: http://www.chictr.org.cn Identifier: ChiCTR-IOR-17013898.
67Topical Atropine for Myopia Control: A Review.PubMed
Navid Farassat
Klin Monbl Augenheilkd. 2024 Oct;241(10):1134-1139. doi: 10.1055/a-2307-0363. Epub 2024 May 27.
Over the past decade, atropine has emerged as an effective intervention for preventing myopia in children. Multiple randomized controlled trials, mainly from Asia, have demonstrated the safety and efficacy of topical atropine for myopia control. Both efficacy and side effects exhibit a positive dose-response relationship. This review focuses on new data from studies with predominantly white populations, ethnicity-dependent differences in efficacy and side effects, and primary prevention of incident myopia with atropine.
68Effect of 0.02% and 0.01% atropine on astigmatism: a two-year clinical trial.PubMed
Ming Wang, Can Cui, Yao Sui, et al.
BMC Ophthalmol. 2022 Apr 7;22(1):161. doi: 10.1186/s12886-022-02385-z.
BACKGROUND: To evaluate the effects of 0.02% and 0.01% atropine eye drops on ocular and corneal astigmatism over 2 years. METHODS: A prospective clinic-controlled trail. The cohort study assessed 400 myopic children and divided them into three groups: 138 and 142 children were randomized to use either 0.02% or 0.01% atropine eye drops, respectively. They wore single-vision (SV) spectacles, with one drop of atropine applied to both eyes once nightly. Control children (n = 120) only wore SV spectacles. Spherical equivalent refractive errors (SER) and corneal curvature were measured every 4 months. The SER and corneal curvature were assessed by cycloplegic autorefraction and IOLMaster. Ocular and corneal astigmatism were calculated by Thibos vector analysis and then split into its power vector components, J0 (with-the-rule astigmatism) and J45 (oblique). RESULTS: After 2 years, the ocular astigmatism increased by -0.38 ± 0.29 D, -0.47 ± 0.38 D, -0.41 ± 0.35 D in the 0.02%, 0.01% atropine groups and control group, respectively (p = 0.15). The corresponding corneal astigmatism increased by -0.20 ± 0.34 D, -0.28 ± 0.35 D and -0.26 ± 0.26 D (p = 0.18). The ocular astigmatism J0 increased by 0.19 ± 0.28 D, 0.22 ± 0.36 D, 0.18 ± 0.31 D in the 0.02% atropine, 0.01% atropine and control groups, respectively (p = 0.65). The corresponding corneal astigmatism J0 increased by -0.05 ± 0.34 D, -0.11 ± 0.37 D and -0.13 ± 0.30 D (p = 0.23). There was a small but significant increase in ocular astigmatism (including J0) (all P < 0.05), but there were no changes in the ocular astigmatism J45 and corneal astigmatism (including J0 and J45) in the three groups over time (all p > 0.05). However, there were no significant differences in the changes in ocular astigmatism (including J0) among the three groups. CONCLUSIONS: Treatment with 0.02% and 0.01% atropine had no clinically significant effect on ocular and corneal astigmatism over 2 years. TRIAL REGISTRATION: The First Affiliated Hospital of Zhengzhou University, ChiCTR-IPD-16008844 . Registered 14/07/2016.
69Amblyopia treatment outcomes.PubMed
William E Scott, Pamela J Kutschke, Ronald V Keech, et al.
J AAPOS. 2005 Apr;9(2):107-11. doi: 10.1016/j.jaapos.2004.12.003.
PURPOSE: To determine the effectiveness and side effects of full-time occlusion for the treatment of amblyopia. METHODS: Patients with unilateral amblyopia secondary to strabismus, anisometropia, or a combination of the two were retrospective reviewed. All patients had full-time occlusion encompassing 24 hours per day or all waking hours, followed to a defined endpoint. Success was defined as 20/30 or better or equal visual acuity by fixation pattern between the two eyes. The ultimate goal was equal visual acuity. RESULTS: Six hundred patients fit the inclusion criteria. Mean follow-up after the cessation of full-time patching was 7.2 years. Eighty-nine percent were followed for more than 1 year. Mean age at last follow-up visit was 10.82 years. Ninety-six percent of patients attained a successful visual result. Sixty percent attained equal visual acuity. Younger patients required less occlusion time to endpoint and had a better visual outcome ( P < 0.0001). Initial visual acuity was significantly related to best visual acuity attained ( P < 0.0001). The incidence of occlusion amblyopia was 25.8%. CONCLUSIONS: Full-time occlusion produces excellent visual acuity results. It was shown to be effective with no long-term complications if patients proceed as directed.
70Amblyopia.PubMed
Jonathan M Holmes, Michael P Clarke
Lancet. 2006 Apr 22;367(9519):1343-51. doi: 10.1016/S0140-6736(06)68581-4.
Results from recent randomised clinical trials in amblyopia should change our approach to screening for and treatment of amblyopia. Based on the current evidence, if one screening session is used, screening at school entry could be the most reasonable time. Clinicians should preferably use age-appropriate LogMAR acuity tests, and treatment should only be considered for children who are clearly not in the typical range for their age. Any substantial refractive error should be corrected before further treatment is considered and the child should be followed in spectacles until no further improvement is recorded, which can take up to 6 months. Parents and carers should then be offered an informed choice between patching and atropine drops. Successful patching regimens can last as little as 1 h or 2 h a day, and successful atropine regimens as little as one drop twice a week. Intense and extended regimens might not be needed in initial therapy.
71Full-time atropine, intermittent atropine, and optical penalization and binocular outcome in treatment of strabismic amblyopia.PubMed
K Simons, L Stein, E C Sener, et al.
Ophthalmology. 1997 Dec;104(12):2143-55. doi: 10.1016/s0161-6420(97)30048-7.
OBJECTIVE: The purpose of the study is to evaluate the monocular and binocular outcome of three types of "penalization" (blurring of the sound eye) treatment of amblyopia: traditional full-time atropine or optical penalization and a new intermittent atropine regimen involving atropine instillation 1 to 3 days a week. DESIGN: The study design was a retrospective study. PARTICIPANTS: A total of 163 patients with strabismic amblyopia treated by full-time atropine (n = 38), intermittent atropine (n = 73), or optical (n = 52) penalization participated. MAIN OUTCOME MEASURES: Logarithm of the minimum angle of resolution (logMAR) visual acuity, and binocularity index were determined. RESULTS: All three forms of penalization produced statistically significant mean reduction in amblyopia (1.7-2.7 logMAR lines) and mean improvement in binocularity by the end-of-treatment or long-term follow-up visit or both, with minimal mean loss after discontinuation or slight mean improvement on these measures at long-term mean follow-up of 1.9 to 4 years across groups. Few patients achieved high-grade stereoacuity. Compliance was high. Comparable efficacy was found for all three treatment groups after controlling for age, depth of amblyopia, and binocularity at the initial visit. Initial-visit amblyopia depth was strongly and significantly associated with amblyopia depth at both post-treatment visits. Pretreatment and post-treatment binocularity showed a similar strong relationship. Surprisingly, however, there was no consistent or significant association found between depth of amblyopia and binocularity in any visit combination. Post-treatment measures of these two variables also were not associated with initial-visit age or refractive error at any clinically significant level. Mean treatment duration was 1.1 to 2.9 years and was not found to be associated with visual outcome. Amblyopia reversal was found in one (full-time atropine) case at a clinically important level. CONCLUSIONS: The authors confirmed previous reports of penalization's efficacy as a primary treatment of moderate amblyopia (20/100 or better acuity) and, in some cases, relatively severe amblyopia (>20/100) and also confirmed its ability to significantly improve mean binocularity. Amblyopia and binocularity appear to respond to treatment independently and, within the postinfancy age range of the sample studied, the responses appear to be independent of initial-visit age. The high acceptability to patients and parents of atropine penalization, and particularly of the intermittent regimen introduced here, suggests the need for prospective-study-based re-evaluation of the relative merits of penalization and occlusion as the standard of care for mild-to-moderate amblyopia.
72When Software Becomes Medicine: Ignoring It May Soon Be Malpractice.PubMed
Shaheen E Lakhan
Cureus. 2025 Apr 22;17(4):e82793. doi: 10.7759/cureus.82793. eCollection 2025 Apr.
The convergence of mobile software, artificial intelligence, and biomedical science is ushering in a new era of precision medicine, defined not only by personalization but by real-time adaptability. This shift is exemplified by the evolution of Prescription Digital Therapeutics (PDTs): smartphone-based applications that treat a disease or condition and are regulated in the US by the FDA. Early PDTs (PDT 1.0) such as reSET for substance use disorder, reSET-O for opioid use disorder, and Somryst for chronic insomnia digitized cognitive behavioral therapy (CBT) into a smartphone app and laid the foundation for regulated digital interventions. Now in the era of PDT 2.0, we see greater personalization, multimodal approaches beyond CBT, robust clinical validation, and targeting drug-like endpoints with Rejoyn for major depressive disorder, CT-132 for episodic migraine prevention, Luminopia for amblyopia, and CT-155 in development for negative symptoms of schizophrenia. Despite promising results, widespread adoption remains limited by reimbursement, clinician and patient awareness, and integration into clinical workflows. On the horizon is smart medicine: a convergence of traditional pharmacotherapy with PDTs that work together to enhance overall effectiveness, safety and tolerability, and engagement, adherence, and personalization. These medicines optimize outcomes in ways conventional therapies cannot and, in true closed-loop principles, assess for disease and symptoms and modulate both the digital and drug interventions. Drawing from my work experience on multiple PDTs, this paper highlights how PDTs are transforming care. The FDA's Prescription Drug Use-Related Software (PDURS) guidance affirms the regulatory foundation for integrating PDTs and drugs. Meaningful therapeutic advancements now depend not only on the molecular design but also on the mechanisms, digital or otherwise, that support its success. I postulate that within the next five years, omitting digital interventions when indicated will not just be outdated, it may be malpractice.
73Emerging therapies for amblyopia.PubMed
Michelle M Falcone, David G Hunter, Eric D Gaier
Semin Ophthalmol. 2021 May 19;36(4):282-288. doi: 10.1080/08820538.2021.1893765. Epub 2021 Mar 3.
Traditional therapies to treat amblyopia, such as optical correction or occlusion/penalization of the non-amblyopic eye, are efficacious but are not without limitations such as poor adherence and decreased success with increasing age. Recently, there has been an interest in new amblyopia therapies, some using binocular techniques, through a variety of platforms including video games, movies, and virtual reality. Overall, available efficacy results for these treatments are highly variable.
74Randomized Controlled Trial of a Dichoptic Digital Therapeutic for Amblyopia.PubMed
Scott Xiao, Endri Angjeli, Hank C Wu, et al.
Ophthalmology. 2022 Jan;129(1):77-85. doi: 10.1016/j.ophtha.2021.09.001. Epub 2021 Sep 14.
PURPOSE: Digital therapeutics are a new class of interventions that are software driven and are intended to treat various conditions. We developed and evaluated a dichoptic digital therapeutic for amblyopia, a neurodevelopmental disorder for which current treatments may be limited by poor adherence and residual vision deficits. DESIGN: Randomized controlled trial. PARTICIPANTS: One hundred five children 4 to 7 years of age with amblyopia were enrolled at 21 academic and community sites in the United States. Participants were randomized 1:1 to the treatment or comparison group, stratified by site. METHODS: We conducted a phase 3 randomized controlled trial to evaluate the safety and efficacy of a dichoptic digital therapeutic for amblyopia. Participants in the treatment group used the therapeutic at home for 1 hour per day, 6 days per week and wore glasses full-time. Participants in the comparison group continued wearing glasses full-time alone. MAIN OUTCOME MEASURES: The primary efficacy outcome was change in amblyopic eye visual acuity (VA) from baseline at 12 weeks, and VA was measured by masked examiners. Safety was evaluated using the frequency and severity of study-related adverse events. Primary analyses were conducted using the intention-to-treat population. RESULTS: Between January 16, 2019, and January 15, 2020, 105 participants were enrolled; 51 were randomized to the treatment group and 54 were randomized to the comparison group. At 12 weeks, amblyopic eye VA improved by 1.8 lines (95% confidence interval [CI], 1.4-2.3 lines; n = 45) in the treatment group and by 0.8 lines (95% CI, 0.4-1.3 lines; n = 45) in the comparison group. At the planned interim analysis (adjusted α = 0.0193), the difference between groups was significant (1.0 lines; P = 0.0011; 96.14% CI, 0.33-1.63 lines) and the study was stopped early for success, according to the protocol. No serious adverse events were reported. CONCLUSIONS: Our findings support the value of the therapeutic in clinical practice as an effective treatment. Future studies should evaluate the therapeutic compared with other methods and in additional patient populations.
75An Eye-Tracking-Based Dichoptic Home Treatment for Amblyopia: A Multicenter Randomized Clinical Trial.PubMed
Tamara Wygnanski-Jaffe, Burton J Kushner, Avital Moshkovitz, et al.
Ophthalmology. 2023 Mar;130(3):274-285. doi: 10.1016/j.ophtha.2022.10.020. Epub 2022 Oct 26.
PURPOSE: Comparing visual outcomes after use of a novel binocular eye-tracking-based home treatment (CureSight; NovaSight, Ltd) with patching. DESIGN: Prospective, multicenter, randomized, masked, controlled, noninferiority pivotal trial. PARTICIPANTS: One hundred three children 4 to < 9 years with anisometropic, small-angle strabismic or mixed-mechanism amblyopia were randomized 1:1 to either CureSight treatment or patching. METHODS: The CureSight treatment uses combined anaglyph glasses and an eye tracker to induce real-time blur around the fellow eye fovea in dichoptic streamed video content. Participants used the device for 90 minutes/day, 5 days/week for 16 weeks (120 hours). The patching group received 2 hours of patching 7 days/week (224 hours). The prespecified noninferiority margin was 1 line. MAIN OUTCOME MEASURES: The primary outcome was the improvement in the amblyopic eye visual acuity (VA), modeled with a repeated measures analysis of covariance. Secondary outcomes included stereoacuity, binocular VA, and treatment adherence rates, analyzed by a 1-sample Wilcoxon test within each group and a 2-sample Wilcoxon test comparing groups. Safety outcomes included the frequency and severity of study-related adverse events (AEs). RESULTS: CureSight group VA improvement was found to be noninferior to patching group improvement (0.28 ± 0.13 logarithm of the minimum angle of resolution [logMAR] [P < 0.0001] and 0.23 ± 0.14 logMAR [P < 0.0001], respectively; 90% confidence interval [CI] of difference, -0.008 to 0.076). Stereoacuity improvement of 0.40 log arcseconds (P < 0.0001) and improved binocular VA (0.13 logMAR; P < 0.0001) were observed in the binocular treatment group, with similar improvements in the patching group in stereoacuity (0.40 log arcseconds; P < 0.0001) and binocular VA (0.09 logMAR; P < 0.0001), with no significant difference between improvements in the 2 groups in either stereoacuity (difference, 0; 95% CI, -0.27 to -0.27; P = 0.76) or binocular VA (difference, 0.041; 95% CI, -0.002 to 0.085; P = 0.07). The binocular treatment group had a significantly higher adherence than the patching group (91% vs. 83%; 95% CI, -4.0% to 21%; P = 0.011). No serious AEs were found. CONCLUSIONS: Binocular treatment was well tolerated and noninferior to patching in amblyopic children 4 to < 9 years of age. High adherence may provide an alternative treatment option for amblyopia. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found after the references.
76Binocular amblyopia treatment with contrast-rebalanced movies.PubMed
Eileen E Birch, Reed M Jost, Angie De La Cruz, et al.
J AAPOS. 2019 Jun;23(3):160.e1-160.e5. doi: 10.1016/j.jaapos.2019.02.007. Epub 2019 May 16.
BACKGROUND: Binocular amblyopia treatments promote visual acuity recovery and binocularity by rebalancing the signal strength of dichoptic images. Most require active participation by the amblyopic child to play a game or perform a repetitive visual task. The purpose of this study was to investigate a passive form of binocular treatment with contrast-rebalanced dichoptic movies. METHODS: A total of 27 amblyopic children, 4-10 years of age, wore polarized glasses to watch 6 contrast-rebalanced dichoptic movies on a passive 3D display during a 2-week period. Amblyopic eye contrast was 100%; fellow eye contrast was initially set to a lower level (20%-60%), which allowed the child to overcome suppression and use binocular vision. Fellow eye contrast was incremented by 10% for each subsequent movie. Best-corrected visual acuity, random dot stereoacuity, and interocular suppression were measured at baseline and at 2 weeks. RESULTS: Amblyopic eye best-corrected visual acuity improved from 0.57 ± 0.22 at baseline to 0.42 ± 0.23 logMAR (t = 8.09; P < 0.0001; 95% CI for improvement, 0.11-0.19 logMAR). Children aged 3-6 years had more improvement (0.21 ± 0.11 logMAR) than children aged 7-10 years (0.11 ± 0.06 logMAR; t = 3.05; P = 0.005). Children with severe amblyopia (≥0.7 logMAR) at baseline experienced greater improvement (0.24 ± 0.12 logMAR) than children with moderate amblyopia at baseline (0.12 ± 0.06 logMAR; t = 3.49; P = 0.002). CONCLUSIONS: In this cohort, passive viewing of contrast-rebalanced dichoptic movies effectively improved visual acuity in amblyopic subjects. The degree of improvement observed was similar to that previously reported for 2 weeks of binocular games treatment and with 3-4 months of occlusion therapy.
77Safety Evaluation in Healthy Adults of Motion-Based Virtual Reality Dichoptic Training for Pediatric Patients With Amblyopia: Prospective Intervention Study.PubMed
Masakazu Hirota, Yuichi Okumura, Ken Nagino, et al.
JMIR Form Res. 2025 Jun 17;9:e69801. doi: 10.2196/69801.
BACKGROUND: Amblyopia, a unilateral or bilateral visual disorder, affects up to 5% of the general population and is a leading cause of childhood visual impairment. Current treatments, such as patching therapy, aim to improve amblyopia by temporarily occluding the unaffected eye, thereby promoting the use of the amblyopic eye. However, adherence to patch therapy can be challenging, as the forced use of the amblyopic eye can be stressful for children. Moreover, despite improvements in visual acuity by patch therapy, children with amblyopia often face difficulties with hand-eye coordination; therefore, a treatment that reduces stress for them while simultaneously improving hand-eye coordination could address the limitations of existing amblyopia therapies. OBJECTIVE: This study investigated the safety of our motion-based virtual reality (VR) dichoptic training app using Japanese Kendama in healthy adult participants, which was designed to improve hand-eye coordination in pediatric patients with amblyopia. METHODS: This prospective intervention study involved 20 healthy young adults (median age 21, IQR 21-28.3 y), including 16 women. The participants played the motion-based VR dichoptic training app for 30 minutes and then completed a subjective symptom questionnaire, which comprised 9 questions (Q1-Q9) with each item scored on a 4-point scale, except Q9, which was assessed on a binary scale. Q1-Q3 focused on subjective eye symptoms, Q4-Q7 evaluated physical and mental discomfort, Q8 assessed the degree of VR session-induced arm fatigue, and Q9 assessed the severity of visually induced motion sickness. RESULTS: No significant differences were observed in the reported ocular symptoms before and after the VR session, including eye fatigue (mean before vs after: 1.25, SD 0.94 points vs 1.35, SD 0.85 points), blurred vision (0.55, SD 0.50 points vs 0.80, SD 0.40 points), eye dryness (0.95, SD 0.74 points vs 1.25, SD 0.83 points), and visually induced motion sickness (0.00, SD 0.00 points vs 0.05, SD 0.22 points). These results suggested that the motion-based VR dichoptic training did not induce significant adverse ocular effects. CONCLUSIONS: The motion-based VR dichoptic training app demonstrated minimal adverse ocular effects in healthy adult participants, suggesting that it is safe for use in this population. These findings demonstrate the feasibility and good tolerability of this VR-based intervention in healthy adults. Further studies, including clinical studies in adult and pediatric patients with amblyopia, are warranted to evaluate its applicability and therapeutic effects.
78Binocular amblyopia treatment improves manual dexterity.PubMed
Eileen E Birch, Sarah E Morale, Reed M Jost, et al.
J AAPOS. 2023 Feb;27(1):18.e1-18.e6. doi: 10.1016/j.jaapos.2022.10.006. Epub 2022 Dec 22.
PURPOSE: To determine whether deficits in manual dexterity in children with amblyopia improve after binocular amblyopia treatment and whether improvements are related to age at treatment, baseline sensory status, or amount of improvement in sensory status with treatment. METHODS: Manual dexterity (Movement Assessment Battery for Children-2), visual acuity, fusion, suppression, and stereoacuity were measured at baseline and after 4-8 weeks of binocular amblyopia in 134 children with amblyopia, including 75 children in the "younger group" (aged 3 to <7 years) and 59 in the "older group" (aged 7-10 years), and in 40 age-similar control children. RESULTS: Baseline manual dexterity standard scores of amblyopic children were significantly below those of controls in both the younger (8.81 ± 0.33 vs 11.80 ± 0.60 [P < 0.0001]) and older groups (7.19 ± 0.34 vs 9.75 ± 0.57 [P = 0.00013]). After 4-8 weeks of binocular amblyopia treatment, the younger group standard score improved to 9.85 ± 0.35 and the older group improved to 8.08 ± 0.39, but both groups remained significantly lower than controls (P = 0.03 and P = 0.01, resp.). Improvement in manual dexterity standard score was not associated with any baseline factors but was weakly correlated with the amount of visual acuity improvement (r = 0.26; 95% CI, 0.09-0.41) CONCLUSIONS: Manual dexterity impairments are common among children with amblyopia. In our study cohort, binocular amblyopia treatment improved visual acuity and manual dexterity.
79Computer-Assisted Visual Training in Children and Adolescents with Developmental Visual Disorders.PubMed
Christine Schmucker, Eberhard Thörel, Magdalena Flatscher-Thöni, et al.
Dtsch Arztebl Int. 2023 Nov 3;120(44):747-753. doi: 10.3238/arztebl.m2023.0191.
BACKGROUND: In this systematic review, we address the question whether children and adolescents with developmental visual disorders benefit from computer-assisted visual training. METHODS: Systematic literature searches were carried out in three bibliographic databases (initial search in October 2021) and trial registries. Included were randomized controlled trials that evaluated the efficacy of computer-assisted visual training in children and adolescents with developmental visual disorders in comparison to no training, sham training, or conservative treatment. RESULTS: The inclusion criteria were met by 17 trials (with a total of 1323 children and adolescents) focusing on binocular or monocular computer-assisted visual training for the treatment of amblyopia. In these trials, visual training was carried out for 2 to 24 weeks, either as "stand alone" therapy or in addition to occlusion therapy. Six trials showed a statistically significant difference in favor of the visual training for the outcome "best corrected visual acuity of the amblyopic eye." However, this difference was small and mostly below the threshold of clinical relevance of -0.05 logMAR (equivalent to an improvement of 0.5 lines on the eye chart, or 2.5 letters per line). Only few data were available for the outcomes "binocular vision" and "adverse events"; the differences between the groups were similarly small. CONCLUSION: The currently available data do not permit any firm conclusions regarding the efficacy of visual training in children and adolescents with amblyopia. Moreover, treatment adherence was often insufficient and the treatment durations in the trials was relatively short. No results from randomized trials have yet been published with respect to other developmental visual disorders (refractive errors, strabismus).
80PubMed
RESEARCH QUESTION OF THE HTA REPORT: The aims of this investigation are to: assess the benefit of treatment with active vision training versus treatment without active vision training in children and adolescents with deficits in visual developmental in terms of patient-relevant outcomes; determine the costs (intervention costs) and assess the cost-effectiveness of treatment with active vision training versus treatment without active vision training in children and adolescents with deficits in visual development as well as review ethical, social, legal, and organizational aspects associated with the medical intervention. CONCLUSION OF THE HTA REPORT: A total of 17 randomized trials evaluating active digital vision training in children and adolescents were included in the present health technology assessment (HTA). The identified studies focused on patients with amblyopia (from anisometropia and/or strabismus). To date, no results from randomized trials have been published on other relevant deficits in visual development (refractive anomalies or eye misalignment) or on vision training interventions which are not digitally delivered. Of the 17 included studies, 11 studies (with N = 1138 children and adolescents) evaluated the benefit of dichoptic (binocular) vision training, while 6 studies (with N = 165 children and adolescents) investigated the benefit of monocular vision training. Dichoptic training was compared with (A) no training, (B) sham training, or (C) conventional treatment (occlusion). Treatment was provided at home in all but 1 study, where children and adolescents attended an outpatient clinic. In total, 2 studies evaluated children with amblyopia induced exclusively by anisometropia (refractive amblyopia). The remaining studies included amblyopia from anisometropia and/or strabismus. The age of the children and adolescents in the 11 studies on dichoptic training ranged from 3 to 17 years, and the proportion of those who had received prior treatment ranged from 26% to 96%. In 10 studies, dichoptic training was performed using a video game (e.g. Tetris), while in 1 study, participants watched films or series. The image separation required during dichoptic training was achieved via anaglyph glasses (8 studies), shutter glasses (1 study), or virtual reality glasses (2 studies). Except in the 2 studies using virtual reality glasses, training was conducted on a computer or tablet. In total, 6 studies investigated the benefit of monocular vision training compared with (A) no training or (B) sham training. In 4 studies, monocular training, where the stronger eye is occluded, was performed on an outpatient basis. Two studies evaluated only refractive amblyopia, and 4 studies investigated only 2- to 10-year-old children who had received their initial diagnosis. While monocular training involved playing a video game on a computer or tablet in 5 studies, 1 study asked children and adolescents to trace images which were presented digitally. Three studies used special background stimulation (a moving sinusoidal grating for neural stimulation) during monocular training. The remaining 3 studies did not use this background stimulation. All studies reported data for the outcome “best-corrected visual acuity of the amblyopic eye". (A) Comparing active digital vision training with no training, significant effects were found in favour of active vision training — both dichoptic and monocular. The available study pool fails to show whether the additional occlusion treatment (which some studies used as add-on treatment in both intervention arms) enhances the effect of digital training. (B) When comparing vision training versus sham training, 1 of 6 studies described a statistically significant effect in favour of the investigated intervention. The missing effects in this comparison category could be due to the fact that the respective sham intervention (which was also based on vision training) showed the same effect as the experimental intervention. (C) Only studies on dichoptic training investigated digital vision training in the form of monotherapy versus occlusion treatment alone. Except for 1 study (with a treatment duration of only 2 weeks), no studies showed any statistically significant effects in favour of vision training – on the contrary, the effect estimators were in favour of occlusion treatment. Although isolated studies suggest a statistically significant effect in favour of active vision training compared to no training or sham training for the outcome “best-corrected visual acuity of the amblyopic eye”, the differences measured in these comparisons cannot be assumed to be clinically relevant. Most studies with statistically significant results do not meet a clinical relevance threshold of -0.05 logMAR (improvement by +0.5 lines) for the outcome “best-corrected visual acuity of the amblyopic eye”. Only in 1 study, which compared monocular vision training versus no training, was the clinical relevance threshold exceeded at 1 of 4 measurement time points: The upper and lower limits (95% CIs) of measured mean differences after 9 weeks of treatment were -0.24 logMAR (+2.4 lines) and -0.06 logMAR (+0.6 lines), respectively. In summary, for the outcome “best-corrected visual acuity of the amblyopic eye,” no hint of (greater) benefit of digital dichoptic or monocular vision training was found in any of the comparisons: neither compared to no training nor to sham training or occlusion treatment. For the patient-relevant outcome of binocular vision, none of the studies showed a hint of greater benefit of digital training – neither compared to no training nor to sham training or occlusion treatment. In the present study pool, the number of reported adverse events was rather low, and no study showed any hint of an increased risk of such events – neither with digital training nor in the control group. However, it must be noted that the rather small number of study participants precludes drawing a reliable conclusion with regard to adverse events. No data are available on other patient-relevant outcomes. In Germany, vision training is currently used only as an add-on to occlusion treatment. The average total costs per person for occlusion treatment in the 1 year of treatment are between €606 and €646, which is largely covered by the statutory health insurance (SHI); 2/3 of the costs are for the aids used in the treatment. In addition to these costs, 3 months of treatment with the monocular vision training offered in Germany by the company Caterna Vision GmbH would cost €380. Some health insurance funds cover the costs for the vision training within the framework of selective contracts. Apart from the costs presented for monocular visual training by Caterna Vision GmbH, no further data were available from which a reliable cost estimate for active vision training might be derived. In summary, for vision training to be cost-effective, the additional costs must be associated with either greater benefit (in the form of better treatment outcomes) or savings in conventional treatment (e.g. through reduced treatment times for the same benefit). Since neither of these conditions is currently met, the cost-effectiveness of active vision training in amblyopia cannot be conclusively assessed. Given that no studies were found on other relevant developmental vision impairments or on other non-digitally delivered vision training, extending the economic evaluations to other therapeutic indications or interventions was not deemed useful. When making decisions regarding digital training, the early and risk-associated access to digital media and the increased media consumption associated with such therapy must be considered critically from ethical and social perspectives. In terms of adherence to the prescribed therapy, study data additionally show that problems and treatment discontinuations repeatedly occur in practice. These are often due to a lack of understanding of the video game and/or patients being overchallenged (especially younger children) or underchallenged (especially older children and adolescents) because the ‘health games’ offered are typically video games with a simple design (e.g. Tetris). With regard to the home therapy concept, retaining attention therefore plays a critical role in active vision training. Overall, the available evidence does not allow drawing a final conclusion on the benefit of active vision training in children and adolescents with amblyopia. Alongside the frequent lack of treatment adherence, it is important to note that the studies’ treatment duration was set to only a few weeks, while amblyopia treatment is often required for many years. Furthermore, it was impossible to deduce from the heterogeneous study pool whether children with refractive amblyopia achieve better results than children with amblyopia from strabismus. Such results would be important for the benefit assessment of digital therapies, however, in order to better assess which patients benefit most from such therapy. In addition, further studies are needed to determine whether more interesting (possibly also non-digital) games or vision training interventions lead to better treatment adherence and possibly also show greater benefit with regard to patient-relevant outcomes – especially in older children. Overall, it can be concluded that the outcomes of the new therapies were not superior.
81Electroencephalography Study of Frontal Lobe Evoked by Dynamic Random-Dot Stereogram.PubMed
Yueping Li, Lili Shen, Mingyang Sun
Invest Ophthalmol Vis Sci. 2022 May 2;63(5):7. doi: 10.1167/iovs.63.5.7.
PURPOSE: The purpose of this study was to investigate the cortical electrical activity and electroencephalography (EEG) features of the frontal lobe evoked by dynamic random dot stereogram (DRDS) and to probe the functional connectivity (FC) between the frontal lobe and occipital lobe when processing 3D perception based on the binocular disparity. METHODS: The EEG experiment involved 14 healthy adults with normal stereopsis (<60″) and normal corrected visual acuity (20/20). The Neuroscan system and 32-channel EEG cap were used to record EEG signals based on the DRDS stimuli. The maximum energies of 3 frequency bands (theta-/alpha- /beta-wave) from 13 interesting channels (FP1, FP2, F7, F3, FZ, F4, F8, FC3, FCZ, FC4, O1, OZ, and O2) located in the frontal and occipital lobes were calculated and analyzed. The FC between any two electrodes from the frontal and occipital lobes was calculated based on the Phase lag index (PLI). RESULTS: The maximum powers of theta- and alpha-waves in most channels of the frontal and occipital lobes were significantly increased (P < 0.05) when the depth perception was evoked by DRDS above the threshold, compared with that without stereo vision. The changes in the maximum powers of both theta- and alpha-waves were significantly different among the 13 electrodes (P = 0.0004 and 0.0015, respectively). Tukey's multiple comparisons showed that the changes in the maximum powers of theta-wave were significantly different in F8 vs. O1, F8 vs. OZ, and F4 vs. O1 (P = 0.0186, 0.0444, and 0.0412, respectively). Moreover, the changes in the maximum powers of alpha-waves were significantly different in FP1 vs. O1 (P = 0.0182). The FCs of theta-waves between the frontal channels and the occipital channels were significantly enhanced when processing the depth perception, compared with those without stereopsis. There was no significant change in the FCs of the alpha-waves when having 3D perception except for FC between F8 and O1 and FC between F8 and OZ. CONCLUSIONS: The cortical electrical activity in the frontal lobe and the functional connectivity between the frontal lobe and the occipital lobe increase when participating in the processing binocular disparity and obtaining 3D perception. Theta-waves in the frontal lobe may be crucial in the stereo vision.
82The science and craft of autostereograms.PubMed
Jacques Ninio
Spat Vis. 2007;21(1-2):185-200. doi: 10.1163/156856807782753912.
Autostereograms or SIRDS (Single Image Random-Dot Stereograms) are camouflaged stereograms which combine the Julesz random-dot stereogram principle with the wallpaper effect. They can represent any 3D shape on a single image having a quasi-periodic appearance. Rather large SIRDS can be interpreted in depth with unaided eyes. In the hands of computer graphic designers, SIRDS spread all over the world in 1992-1994, and these images, it was claimed, opened a new era of stereoscopic art. Some scientific, algorithmic and artistic aspects of these images are reviewed here. Scientifically, these images provide interesting cues on stereoscopic memory, and on the roles of monocular regions and texture boundaries in stereopsis. Algorithmically, problems arising with early SIRDS, such as internal texture repeats or ghost images are evoked. Algorithmic recommendations are made for gaining a better control on the construction of SIRDS. Problems of graphic quality (smoothness of the represented surfaces, or elimination of internal texture repeats) are discussed and possible solutions are proposed. Artistically, it is proposed that SIRDS should become less anecdotal, and more oriented towards simple geometric effects, which could be implemented on large panels in natural surrounds.
83Overestimation of stereo thresholds by the TNO stereotest is not due to global stereopsis.PubMed
Kathleen Vancleef, Jenny C A Read, William Herbert, et al.
Ophthalmic Physiol Opt. 2017 Jul;37(4):507-520. doi: 10.1111/opo.12371. Epub 2017 Mar 23.
PURPOSE: It has been repeatedly shown that the TNO stereotest overestimates stereo threshold compared to other clinical stereotests. In the current study, we test whether this overestimation can be attributed to a distinction between 'global' (or 'cyclopean') and 'local' (feature or contour-based) stereopsis. METHODS: We compared stereo thresholds of a global (TNO) and a local clinical stereotest (Randot Circles). In addition, a global and a local psychophysical stereotest were added to the design. One hundred and forty-nine children between 4 and 16 years old were included in the study. RESULTS: Stereo threshold estimates with TNO were a factor of two higher than with any of the other stereotests. No significant differences were found between the other tests. Bland-Altman analyses also indicated low agreement between TNO and the other stereotests, especially for higher stereo threshold estimates. Simulations indicated that the TNO test protocol and test disparities can account for part of this effect. DISCUSSION: The results indicate that the global - local distinction is an unlikely explanation for the overestimated thresholds of TNO. Test protocol and disparities are one contributing factor. Potential additional factors include the nature of the task (TNO requires depth discrimination rather than detection) and the use of anaglyph red/green 3D glasses rather than polarizing filters, which may reduce binocular fusion.
84Stereopsis in human infants.PubMed
R Fox, R N Aslin, S L Shea, et al.
Science. 1980 Jan 18;207(4428):323-4. doi: 10.1126/science.7350666.
Stereoscopic depth perception was tested in human infants by a new method based on attracting the infant's attention through movement of a stereoscopic contour formed from a dynamic random-element stereogram. The results reveal that stereopsis emerges at 3 1/2 to 6 months of age, an outcome consistent with evidence for rapid postnatal development of the visual system.
85Early binocular vision in human infants: limitations on the generality of the Superposition Hypothesis.PubMed
Angela M Brown, Jaime A Miracle
Vision Res. 2003 Jun;43(14):1563-74. doi: 10.1016/s0042-6989(03)00177-9.
The Superposition Hypothesis states that the binocular vision of newborn infants blends together the monocular visual responses of the two eyes, even when the visual stimulus evokes binocular rivalry in adults. According to the Superposition Hypothesis, this blending is replaced by binocular rivalry after the emergence of stereopsis [Neonate Cognition: Beyond the Blooming, Buzzing Confusion, Erlbaum, Hillsdale, NJ, 1985, p. 37; Early Visual Development Normal and Abnormal, Oxford University Press, New York, 1993, p. 201]. The main evidence for the Superposition Hypothesis is a preferential looking experiment [Vision Res., 26 (3) (1986) 501], in which 8-12-week-old infants fixated a rivalrous (for adults) dichoptic plaid, in preference over a fusible grating of parallel lines. This report describes our attempt to repeat that important experiment. Infant stereopsis emerged at 8.6 weeks under our conditions, but infants did not preferentially fixate the dichoptic plaid at any age between age 5 and 16 weeks. Control experiments showed that our result was not due to technical differences between their experiment and ours (red/green vs. polarizing glasses, the use of a fixation point, or the infant observation apparatus). Therefore, blending of the visual responses to rivalrous (for adults) stimuli is not a general feature of the pre-stereoptic infant visual system.
86Effect of simulated astigmatic refractive error on reading performance in the young.PubMed
Jocelyn Wills, Robyn Gillett, Emmeline Eastwell, et al.
Optom Vis Sci. 2012 Mar;89(3):271-6. doi: 10.1097/OPX.0b013e3182429c6b.
PURPOSE: Few studies have specifically investigated the functional effects of uncorrected astigmatism on measures of reading fluency. This information is important to provide evidence for the development of clinical guidelines for the correction of astigmatism. METHODS: Participants included 30 visually normal, young adults (mean age, 21.7 ± 3.4 years). Distance and near visual acuity and reading fluency were assessed with optimal spectacle correction (baseline) and for two levels of astigmatism, 1.00 diopter cylinder (DC) and 2.00 DC, at two axes (90 and 180°) to induce both against-the-rule (ATR) and with-the-rule (WTR) astigmatism. Reading and eye movement fluency were assessed using standardized clinical measures including the test of Discrete Reading Rate (DRR), the Developmental Eye Movement test (DEM), and by recording eye movement patterns with the Visagraph (III) during reading for comprehension. RESULTS: Both distance and near acuity were significantly decreased compared with baseline for all the astigmatic lens conditions (p < 0.001). Reading speed with the DRR for N16 print size was significantly reduced for the 2.00 DC ATR condition (a reduction of 10%), whereas for smaller text sizes, reading speed was reduced by up to 24% for the 1.00 DC ATR and 2.00 DC condition in both axis directions (p < 0.05). For the DEM, subtest completion speeds were significantly impaired, with the 2.00 DC condition affecting both vertical and horizontal times and the 1.00 DC ATR condition affecting only horizontal times (p < 0.05). Visagraph reading eye movements were not significantly affected by the induced astigmatism. CONCLUSIONS: Induced astigmatism impaired performance on selected tests of reading fluency, with ATR astigmatism having significantly greater effects on performance than did WTR, even for relatively small amounts of astigmatic blur of 1.00 DC. These findings have implications for the minimal prescribing criteria for astigmatic refractive errors.
87Evaluation of visual plasticity in patients with refractive amblyopia treated using a visual perceptual learning system.PubMed
Fang-Fang Lan, Wu-Xiao Zhao, Lu Gan
Technol Health Care. 2024;32(1):327-333. doi: 10.3233/THC-230183.
BACKGROUND: Amblyopia is a neurological deficit in binocular vision that affects 3% of the population and is the result of disruptions in early visual development. OBJECTIVE: In this study, we used a visual perceptual learning system for the short-term treatment of children with ametropic amblyopia and evaluated the clinical efficacy of this system in terms of visual plasticity. METHODS: We conducted a retrospective analysis of the clinical data of 114 children (228 eyes) with refractive amblyopia, who were aged 6.51 ± 1.51 years. Prior to the treatment, we evaluated all children with amblyopia using the visual information processing test. We determined the type of amblyopic defect according to the type of amblyopia, corrected visual acuity, and advanced visual function test results. Based on the type of defect, each child with amblyopia was given short-term visual perception training for 10 days. Finally, we compared the results of visual acuity and visual information processing tests before and after the treatment. RESULTS: The best-corrected visual acuity of patients was better after 10 days of visual training than that before training (P< 0.05). The perceptual eye position after training improved with statistically significant differences in horizontal and vertical perceptual eye position (both P< 0.05) compared to that before training. The number of amblyopic children without suppression in both eyes was 81 cases (71.1%) after training which was higher than that (65 cases, or 57.0%) before training, with a statistically significant difference (P< 0.05). Binocular fine stereopsis and dynamic stereopsis improved after training with a statistically significant difference (both P< 0.05). CONCLUSION: In this study, it was found that patients with amblyopia showed visual plasticity. Moreover, continuous visual perceptual learning improved the best-corrected visual acuity and recovered stereopsis in children with refractive amblyopia.
88Parents' Awareness of and Perspectives on Childhood Refractive Error and Spectacle Wear in Saudi Arabia.PubMed
Saif H Alrasheed, Waleed M Alghamdi
Sultan Qaboos Univ Med J. 2022 Nov;22(4):532-538. doi: 10.18295/squmj.10.2021.141. Epub 2022 Nov 7.
OBJECTIVES: This study aimed to assess parents' awareness of and perspectives on childhood refractive errors in Saudi Arabia. METHODS: This cross-sectional study was conducted between October and November 2020 in public schools across different regions of Saudi Arabia. Data were collected using an online questionnaire that assessed parents' knowledge and perceptions of childhood refractive errors and spectacle wear. RESULTS: A total of 358 parents from different regions of Saudi Arabia completed the questionnaire and were obtained in this study (response rate: 85%). Approximately one third (38.3%) of the parents reported that they had never heard of refractive errors and one-third (33.8%) mentioned that uncorrected refractive errors did not lead to visual impairment. The majority (74.0%) cited using eyeglasses as an effective way to manage childhood refractive errors. Two-thirds (63.7%) stated that they did not receive any information about paediatric eye care. Better knowledge was associated with a higher educational level, female gender and older age ( <0.001, = 0.008 and = 0.024, respectively). Regarding parents' perspective on spectacle wear, 13.7% felt that using eyeglasses affected their children's chances of learning. However, 82.7% supposed that eyeglasses did not affect their children's employment opportunities. Almost a quarter of the sample (22.1%) thought that using eyeglasses would decrease the eye's power, resulting in childhood visual impairment. CONCLUSION: The level of awareness and perceptions regarding childhood refractive errors and spectacle wear was low among parents. Therefore, a policy is needed to improve the awareness and perception of the key stakeholders in this issue, including parents and teachers.
89Development of a nomogram for predicting myopia risk among school-age children: a case-control study.PubMed
Jingfeng Mu, Haoxi Zhong, Mingjie Jiang, et al.
Ann Med. 2024 Dec;56(1):2331056. doi: 10.1080/07853890.2024.2331056. Epub 2024 Mar 20.
OBJECTIVES: To analyze the factors influencing myopia and construct a nomogram to forecast the risk of myopia among school-age children, providing a reference for identifying high-risk groups to aid prevention and control. METHODS: This case-control study enrolled 3512 students from three primary schools in Shenzhen using random cluster sampling for a questionnaire survey, myopia screening and ocular biometric parameter measurement. Logistic regression was used to analyze the influencing factors of myopia, and a nomogram was constructed to forecast myopia risk. Bootstrap resampling was used to verify the practicability of the nomogram. RESULTS: Older age (odds ratio[OR] = 1.164; 95% confidence interval [CI]: 1.111-1.219), female sex (OR = 2.405; 95% CI: 2.003-2.887), maternal myopia (OR = 1.331; 95% CI: 1.114-1.589), incorrect posture during reading and writing (OR = 1.283; 95% CI: 1.078-1.528) and axial length (OR = 7.708; 95% CI: 6.044-8.288) are risk factors for myopia, whereas an increase in corneal radius (OR = 0.036; 95% CI: 0.025-0.052) is a protective factor against myopia. The area under the receiver operating characteristic (ROC) curve of the nomogram was 0.857, and the net benefit was high when the risk threshold of the decision curve analyses (DCA) ranged from 0.20 to 1.00. The measured values were consistent with the prediction. CONCLUSION: The nomogram was accurate in predicting the risk of myopia among schoolchildren. This study provides a reference for screening high-risk students and for individualized myopia prevention and control.
90Clinical and genetic risk factors underlying severe consequence identified in 75 families with unilateral high myopia.PubMed
Yi Jiang, Xueshan Xiao, Wenmin Sun, et al.
J Transl Med. 2024 Jan 19;22(1):75. doi: 10.1186/s12967-024-04886-5.
BACKGROUNDS: Unilateral high myopia (uHM), commonly observed in patients with retinal diseases or only with high myopia, is frequently associated with amblyopia with poor prognosis. This study aims to reveal the clinical and genetic spectrum of uHM in a large Chinese cohort. METHODS: A total of 75 probands with simplex uHM were included in our Pediatric and Genetic Eye Clinic. Patients with significant posterior anomalies other than myopic fundus changes were excluded. Variants were detected by exome sequencing and then analyzed through multiple-step bioinformatic and co-segregation analysis and finally confirmed by Sanger sequencing. Genetic findings were correlated with associated clinical data for analysis. RESULTS: Among the 75 probands with a mean age of 6.21 ± 4.70 years at the presentation, myopic fundus of C1 and C2 was observed in 73 (97.3%) probands. Surprisingly, specific peripheral changes were identified in 63 eyes involving 36 (48.0%) probands after extensive examination, including peripheral retinal avascular zone (74.6%, 47/63 eyes), neovascularization (54.0%), fluorescein leakage (31.7%), peripheral pigmentary changes (31.7%), and others. Exome sequencing identified 21 potential pathogenic variants of 13 genes in 20 of 75 (26.7%) probands, including genes for Stickler syndrome (COL11A1 and COL2A1; 6/20), FEVR (FZD4, LRP5, and TSPAN12; 5/20), and others (FBN1, GPR179, ZEB2, PAX6, GPR143, OPN1LW, FRMD7, and CACNA1F; 9/20). For the peripheral retinal changes in the 20 probands, variants in Stickler syndrome-related genes were predominantly associated with retinal pigmentary changes, lattice degeneration, and retinal avascular region, while variants in genes related to FEVR were mainly associated with the avascular zone, neovascularization, and fluorescein leakage. CONCLUSIONS: Genetic defects were identified in about one-fourth of simplex uHM patients in which significant consequences may be hidden under a classic myopic fundus in up to half. To our knowledge, this is the first systematic genetic study on simplex uHM to date. In addition to routine care of strabismus and amblyopia, careful examination of the peripheral retina and genetic screening is warranted for patients with uHM in order to identify signs of risk for retinal detachment and other complications and provide meaningful genetic counseling.
91FOXP1 SyndromePubMed
Gudrun Rappold, Paige Siper, Ana Kostic, et al.
CLINICAL CHARACTERISTICS: FOXP1 syndrome is characterized by delays in early motor and language milestones, mild-to-severe intellectual deficits, speech and language impairment in all individuals regardless of level of cognitive abilities, and behavior abnormalities (including autism spectrum disorder or autistic features, attention-deficit/hyperactivity disorder, anxiety, repetitive behaviors, sleep disturbances, and sensory symptoms). Other common findings are oromotor dysfunction (contributing to speech and feeding difficulties), refractive errors, strabismus, cardiac abnormalities, renal abnormalities, cryptorchidism, hypertonia, hearing loss, and epilepsy. To date, more than 200 individuals have been identified with FOXP1 syndrome. DIAGNOSIS/TESTING: The diagnosis of FOXP1 syndrome is established in a proband with a heterozygous pathogenic variant in identified by molecular genetic testing and supportive clinical findings. MANAGEMENT: Supportive care to improve quality of life, maximize function, and reduce complications is recommended. This can include multidisciplinary care by specialists in pediatrics, developmental medicine or neurodevelopment, neurology, physiatry, occupational and physical therapy, speech-language pathology, psychiatry, psychology, ophthalmology, and medical genetics. Regular monitoring by the relevant specialists of existing manifestations, the individual's response to supportive care, and the emergence of new manifestations is recommended. GENETIC COUNSELING: FOXP1 syndrome is an autosomal dominant disorder typically caused by a pathogenic variant. To date, most probands with FOXP1 syndrome whose parents have undergone molecular genetic testing have the disorder as the result of a pathogenic variant. Rarely, a parent of an individual with FOXP1 syndrome has somatic and germline mosaicism for the pathogenic variant or a complex chromosome arrangement involving . Each child of an individual with FOXP1 syndrome has a 50% chance of inheriting the pathogenic variant. Risk to future offspring of the parents of the proband is presumed to be low, as the proband most likely has a pathogenic variant. There is, however, a recurrence risk (~1%) to sibs based on the possibility of parental germline mosaicism; given this risk, prenatal and preimplantation genetic testing may be considered.
92Aymé-Gripp SyndromePubMed
Shivarajan Manickavasagam Amudhavalli, Randi Gadea, Karen Gripp
CLINICAL CHARACTERISTICS: Aymé-Gripp syndrome is classically defined as the triad of bilateral early cataracts, sensorineural hearing loss, and characteristic facial features in combination with neurodevelopmental abnormalities. The facial features are often described as "Down syndrome-like" and include brachycephaly, flat facial appearance, short nose, long philtrum, narrow mouth, and low-set and posteriorly rotated ears. Hearing loss is often congenital. Other features may include postnatal short stature, seizure disorder, nonspecific brain abnormalities on head imaging, skeletal abnormalities, and joint limitations. A subset of individuals have been found to have pericarditis or pericardial effusion during the neonatal or infantile period. All affected individuals have had developmental delay, but the degree of cognitive impairment is extremely variable. Other features including gastrointestinal and endocrine abnormalities, ectodermal dysplasia (i.e., nail dystrophy and mammary gland hypoplasia), dental anomalies, and chronic glomerulopathy with proteinuria have been reported in rare affected individuals. DIAGNOSIS/TESTING: The diagnosis of Aymé-Gripp syndrome is established in a proband with cataracts, sensorineural hearing loss, and suggestive facial features and a heterozygous pathogenic variant in a specific region of identified by molecular genetic testing. MANAGEMENT: Treatment is symptomatic and ideally involves multidisciplinary care. Hearing aids or cochlear implant for sensorineural hearing loss; surgical intervention and eye glasses for cataracts and refractive errors, respectively; physical therapy for milder joint limitations; hip replacement for those with chondrolysis; standard therapy for developmental delay / cognitive impairment, seizure disorder, scoliosis, congenital heart defects / pericardial issues, oligodontia, and hypothyroidism. Dental evaluation every six months; assessment for new neurologic manifestations, progressive joint restriction in major joints, and developmental and educational needs at each visit; clinical examination for scoliosis at each visit until skeletal maturity; at least annual audiology and ophthalmology evaluations; assessment of thyroid function as clinically indicated. GENETIC COUNSELING: Aymé-Gripp syndrome is inherited in an autosomal dominant manner. Almost all individuals reported to date have been simplex cases (i.e., a single occurrence in a family) resulting from a pathogenic variant. Once the causative genetic alteration has been identified in the proband, parental testing may be offered. Each child of an individual with Aymé-Gripp syndrome has a 50% chance of inheriting the pathogenic variant. Prenatal diagnosis for pregnancies at increased risk is possible if the pathogenic variant in an affected family member is known.
93Blepharophimosis, Ptosis, and Epicanthus Inversus SyndromePubMed
Hannah Verdin, Charlotte Matton, Elfride De Baere
CLINICAL CHARACTERISTICS: lepharophimosis, tosis, and picanthus inversus yndrome (BPES) is defined by a complex eyelid malformation characterized by four major features, all present at birth: blepharophimosis, ptosis, epicanthus inversus, and telecanthus. BPES type I includes the four major features and primary ovarian insufficiency; BPES type II includes only the four major features. Other ophthalmic manifestations that can be associated with BPES include dysplastic eyelids, lacrimal duct anomalies, strabismus, refractive errors, and amblyopia. Other craniofacial features may include a broad nasal bridge and low-set ears. DIAGNOSIS/TESTING: The diagnosis of BPES is established in a proband with suggestive findings and a heterozygous pathogenic variant in or its regulatory domain identified by molecular genetic testing. MANAGEMENT: Management requires the input of a multidisciplinary team of specialists. Eyelid surgery traditionally involves a medial canthoplasty for correction of the blepharophimosis, epicanthus inversus, and telecanthus at age three to five years, typically followed a year later by ptosis correction. Primary ovarian insufficiency is managed by hormone replacement therapy; fertility is addressed with reproductive technologies such as embryo donation, egg donation, and cryopreservation strategies. Ophthalmic follow up depends on age, procedures performed in the past, and results of visual acuity testing. Endocrinologic and gynecologic follow up are advised for affected females. Psychological follow up is recommended. GENETIC COUNSELING: BPES is almost always inherited in an autosomal dominant manner. More than half of individuals diagnosed with BPES have the disorder as the result of a pathogenic variant inherited from an affected parent. Each child of an individual with BPES has a 50% chance of inheriting the pathogenic variant. Once the BPES-causing pathogenic variant has been identified in an affected family member, prenatal testing for a pregnancy at increased risk and preimplantation genetic testing for BPES are possible.
94Related RetinopathiesPubMed
Brittni A Scruggs, Madeline Q Reding, Lisa A Schimmenti
CLINICAL CHARACTERISTICS: -related retinopathies typically involve bilateral and symmetric fibrovascular changes of the retina that are evident at birth and usually progress through childhood or adolescence to cause varying degrees of visual impairment. The spectrum of -related retinopathies appears to be a continuum with considerable overlap, ranging from Norrie disease, -related persistent fetal vasculature, -related familial exudative vitreoretinopathy, -related advanced retinopathy of prematurity, and -related Coats disease. The eye findings of Norrie disease, the first described and best characterized of these disorders, are typically bilateral grayish-yellow, glistening, elevated retrolental masses composed of immature retinal cells usually visible through clear lenses; foveal development is always incomplete. In addition, Norrie disease is the only -related retinopathy with associated extraocular findings, which can variably include cognitive disability, mental health and behavior disorders, seizures, sensorineural hearing loss, and peripheral vascular disease. Rarely, females who are heterozygous for an pathogenic variant have clinical manifestations including retinal and extraocular features that may vary between other family members heterozygous for the same pathogenic variant. DIAGNOSIS/TESTING: The diagnosis of an -related retinopathy, an X-linked disorder, is established in a male proband with suggestive clinical findings by identification on molecular genetic testing of a hemizygous pathogenic variant in ; and in a female proband with suggestive clinical findings by identification of a heterozygous pathogenic variant in . MANAGEMENT: Based on a child's ocular findings, pediatric ophthalmologists and pediatric vitreoretinal surgeons individualize management to reduce increased intraocular pressure to decrease the risk of glaucoma; treat refractive errors and/or strabismus to optimize vision and ocular alignment; and discuss risks and benefits of possible vision-saving surgical intervention. Other issues are addressed by multidisciplinary specialists, typically: low-vision specialists, neurologists, pediatricians, developmental pediatricians, pediatric sleep specialists, mental health specialists, physiatrists, occupational and physical therapists, audiologists, and speech-language pathologists. Routine monitoring of: ophthalmologic manifestations and low vision needs; hearing; developmental progress and educational needs; neurologic and mental health manifestations; peripheral vascular disease; and response to treatment. Situations that could exacerbate hearing loss such as loud noises and use of listening devices that amplify sound. Clarify the genetic status of apparently asymptomatic older and younger at-risk female relatives so that those with the familial pathogenic have the option to undergo fluorescein angiography to detect peripheral retinal vascular changes that may require close monitoring and/or prophylactic laser photocoagulation to decrease the risk of neovascularization and vitreoretinal traction. GENETIC COUNSELING: -related retinopathies are inherited in an X-linked manner. The majority of affected males have the disorder as the result of an pathogenic variant inherited from their mother. If the mother of the proband has an pathogenic variant (i.e., is a carrier), the chance of transmitting it in each pregnancy is 50%: males who inherit the pathogenic variant will be affected; females who inherit the pathogenic variant will be heterozygous and may rarely have clinical manifestations. Affected males transmit the pathogenic variant to all of their daughters and none of their sons. Once the pathogenic variant has been identified in an affected family member, testing for females at risk of being carriers and prenatal and preimplantation genetic testing are possible.
95Parents' knowledge and practices of child eye health care: A scoping review.PubMed
Nor Diyana Hani Ghani, Norliza Mohamad Fadzil, Zainora Mohammed, et al.
PLoS One. 2024 Nov 14;19(11):e0313220. doi: 10.1371/journal.pone.0313220. eCollection 2024.
BACKGROUND: Treating children's eyes is not just a privilege for a child, it is an essential requirement for their visual health. Parents, as caregivers, have a paramount responsibility to make decisions regarding their children's eye health. Thus, this review aims to identify and summarise published information about parents' knowledge and practices on children's eye health care. METHODS: Relevant articles searches were performed through a systematic search of databases (EBSCOhost, PubMed, and Scopus) using the keywords 'knowledge', 'practice', 'parent', 'eye', 'problem', and 'children'. This review was conducted and reported in line with the PRISMA-ScR. The methodological quality of the listed studies was assessed using A Modified McMaster Critical Review form based on the total score. RESULT: From a total of 235 studies retrieved through literature review and pearling, 219 remained after removing duplicates. After screening titles and abstracts, 204 irrelevant studies were excluded, leaving 15. After a detailed full-text review, four studies were excluded due to not meeting inclusion criteria. Thus, this review includes the remaining 11 studies. All eleven studies (n = 11) show that parents's knowledge and practices vary. Some parents display good knowledge regarding children's eye health care, for example, understanding the importance of wearing spectacles, the significance of children having normal vision, and where to seek eye examinations. Five studies (n = 5) showed that parents have good practices such as consulting doctors and seeking eye examinations and treatment at the hospital. Six studies (n = 6) showed that parents have misconceptions regarding knowledge, practices, and treatment of children's eye health. CONCLUSION: This scoping review found that parents' knowledge and practices regarding children's eye health are poor. Parents' perceptions and practices about the cause and treatment of eye problems were tainted with misconceptions. Therefore, implementing structured programs to enhance awareness and promote the adoption of healthy practices for children's eye health is required.
96Review: Myopia control strategies recommendations from the 2018 WHO/IAPB/BHVI Meeting on Myopia.PubMed
Marcus Ang, Judith L Flanagan, Chee Wai Wong, et al.
Br J Ophthalmol. 2020 Nov;104(11):1482-1487. doi: 10.1136/bjophthalmol-2019-315575. Epub 2020 Feb 26.
Myopia is a major public health problem, particularly in East Asia. In this summary report, we present key findings and recommendations on strategies for myopia control discussed during the meeting jointly organised by the WHO Regional Office for the Western Pacific, the International Agency for the Prevention of Blindness and the Brien Holden Vision Institute. First, myopia prevalence was reported to be increasing, with up to 80% of junior school students with myopia in East Asia. However, common challenges in implementing myopia control strategies on a national level included lack of school screening programme, and paucity of accurate prevalence data. Second, there continues to be broad public misconception about myopia and myopia control, including lack of parental awareness and resistance to wearing spectacles. Third, best practices for myopia management were shared, and recommendations for policy implementation are presented in this review. Key recommendations from this meeting include increased public education to raise parent and teacher awareness; encouragement of increased outdoor time of 2-3 hours per day for schoolchildren-as a practical public health intervention that has been shown to potentially reduce onset and progression of myopia. Governments and non-governmental organisations are encouraged to collaborate, especially education and health ministries to develop national myopia prevention programme. Lastly, it is important to emphasise that the key recommendations, such as increasing outdoor time for schoolchildren, are specific for East Asian nations in the Western Pacific region and may not be entirely applicable for Western nations.
97Update in myopia and treatment strategy of atropine use in myopia control.PubMed
Pei-Chang Wu, Meng-Ni Chuang, Jessy Choi, et al.
Eye (Lond). 2019 Jan;33(1):3-13. doi: 10.1038/s41433-018-0139-7. Epub 2018 Jun 11.
The prevalence of myopia is increasing globally. Complications of myopia are associated with huge economic and social costs. It is believed that high myopia in adulthood can be traced back to school age onset myopia. Therefore, it is crucial and urgent to implement effective measures of myopia control, which may include preventing myopia onset as well as retarding myopia progression in school age children. The mechanism of myopia is still poorly understood. There are some evidences to suggest excessive expansion of Bruch's membrane, possibly in response to peripheral hyperopic defocus, and it may be one of the mechanisms leading to the uncontrolled axial elongation of the globe. Atropine is currently the most effective therapy for myopia control. Recent clinical trials demonstrated low-dose atropine eye drops such as 0.01% resulted in retardation of myopia progression, with significantly less side effects compared to higher concentration preparation. However, there remain a proportion of patients who are poor responders, in whom the optimal management remains unclear. Proposed strategies include stepwise increase of atropine dosing, and a combination of low-dose atropine with increase outdoor time. This review will focus on the current understanding of epidemiology, pathophysiology in myopia and highlight recent clinical trials using atropine in the school-aged children, as well as the treatment strategy in clinical implementation in hyperopic, pre-myopic and myopic children.
98Refractive surgery in children.PubMed
A V Drack, P Nucci
Ophthalmol Clin North Am. 2001 Sep;14(3):457-66. doi: 10.1016/s0896-1549(05)70244-3.
Refractive surgery techniques, especially those using laser ablation, have revolutionized the treatment of refractive errors. The short-term results have been well studied in adults, but long-term outcomes are not known. No good studies exist to tell us whether the pediatric eye responds the same as the adult eye to these techniques, but there is reason to believe that the pediatric eye will have many differences, both short- and long-term based on other similar surgeries adapted for pediatrics. These techniques have great potential to add to our armamentarium of treatments for frustrating problems such as unilateral high myopia with amblyopia, but they should be used with caution. The patients who are the most attractive to refractive surgeons, namely, teenagers with typical myopia who want to discard their spectacles, are the patients with potentially the most to lose from a procedure with unknown long-term results for a condition easily treated with other modalities. Those who need it most, namely infants and children with high anisometropia who cannot tolerate contact lenses or spectacles, are the least cooperative, the most difficult to treat postoperatively, and the least able to afford expensive treatments not covered by insurance, are therefore the least likely to be offered the procedure, or to have a study designed to evaluate their specific needs and concerns. It behooves ophthalmologists interested in pediatrics to carefully discuss and research the possible indications and theoretical concerns of these powerful techniques in pediatric eyes.