Symposium Is it game over for the patching treatment? Dinsdag 12 september 2017 Hogeschool Utrecht Bolognalaan 101 3584 CJ Utrecht Accreditatie aangevraagd 21-07-17
P r o g r a m m a 18.30 Introductie 19.00 Background of behavioral treatments for amblyopia Sjoukje Loudon, oogarts, ErasmusMC 19:20 Overview of published study results: gaming as treatment for amblyopia Emily Tan, (research)orthoptiste, ErasmusMC 19:40 Our study-design: Is it game over for the patching treatment? Aveen Kadhum, promovenda, ErasmusMC 20.00 Interactief gedeelte, discussie 20:15 Pauze 20:30 Quality of life in amblyopia patients Gerdien Holtslag, orthoptiste & docente HU 20:45 Changes in the visual cortex after amblyopia treatment in adults using fmri technique Chris Klink, Matthew Self, postdoc onderzoekers, Nederlands Instituut voor Neurowetenschappen (NIN) 21:00 Interactief gedeelte, discussie 21:30 Einde
A b s t r a c t s 1. Background of behavioral treatments for amblyopia Dr. Sjoukje Loudon, oogarts Amblyopia affects approximately 3% of the children and is caused by strabismus, anisometropia or both. The standard treatment is glasses and patching therapy and is preferably commenced before the age of 8, as the visual cortex is still susceptible to change. From North-America, behavioral treatments have been developed over the past decades with the goal to improve visual acuity, stereo acuity and/or contrast sensitivity. They have become increasingly popular to treat amblyopia and also have reported a positive effect in adults who have always been thought to be beyond the sensitive period for treatment. These behavioral treatments include dichoptic training, perceptual learning and video gaming. Here, we report on the new behavioral methods. Dichoptic Training (i.e. using both eyes) originates from the idea that amblyopia is an inherently binocular disorder rooted in interocular suppression and that an effective treatment should engage both eyes. The original task was a motion coherence task, followed by a Tetris-based game in which the game pieces were presented dichoptically such that some of the blocks were seen only by the amblyopic eye, some only by the fellow eye and some by both eyes. By attenuating the contrast of the fellow eye blocks, the signals from the two eyes could be combined in order to play the game effectively. Perceptual Learning refers to the ability to improve performance on a sensory task by repeated practice (sometimes tens of thousands of trials) on a perceptual task with the fellow eye patched. Tasks include Vernier acuity tests; RSVP task with irrelevant features and Texture discrimination tasks. Video Gaming, played monocular or binocular, has been shown to improve certain visual functions in the normal visual system. The changes are similar to those seen in the perceptual learning: a reduction of noise and an increase in sampling efficiency. Purpose: In this study we use a new version of the dichoptic custommade Unreal Tournament video game developed by Levi s group combining the principle of all 3 behavioral treatments. The game is played under dichoptic viewing conditions using the Oculus Rift goggles and two joysticks that are easy to use for adults as well as children. The goggles use a pair of screens that displace the 2 images side by side, one with reduced luminance/contrast in an attempt to promote binocular fusion. A short demonstration of the video game will be given.
2. Overview of published study results: gaming as treatment for amblyopia Emily Tan, (research)orthoptiste The aforementioned principles of behavioral training have been studied in different treatment forms. Here we will give you an overview of the published studies concerning this subject. In a meta-analysis of Tsirlin et al. (2015) they investigated these new methods of treatment: they showed a mean improvement in visual acuity of 0.17 logmar, with 32% of the participants achieving gains 0.2 logmar. They concluded that participants may benefit from the new treatments, but more clinical trials are needed to confirm these findings. The improvement with the new treatment methods seems to be limited, while visual acuity improvement with patching therapy is up to 7 lines. Nevertheless, the speed of improvement is markedly quicker with gaming: 17 hours of gaming compared to 142 hours of patching is necessary to achieve one line of visual acuity improvement. As we have previously demonstrated the average level of compliance with patching therapy is only 50% and 9% of the children are not patched at all. Untill now there is no study, where the new treatment method and the standard patching are objectively compared (with compliance objectively monitored for both treatments). Because of a patent-issue we can only measure compliance electronically in Europe using the Occlusion Dose Monitor (ODM). It would have serious consequences if all newly diagnosed amblyopic children would receive gaming therapy whilst in the studies prescribed patching time was compared to realised game-time. Because of this, it is essential that this comparison is carried out correctly.
3. Our study-design: Is it game over for the patching treatment? Aveen Kadhum, promovenda Background: As explained before, new behavioral treatment methods for amblyopia are becoming increasingly popular. In our study we will objectively compare a dichoptic custom-made video game, developed by dr. Levi s group, with standard patching treatment. Purpose: To compare the effect (increase in visual acuity per time period) of gaming versus patching therapy, with compliance measured electronically, while taking into account the patient s preferences for both treatments and exploring changes in the visual cortex in adult cases after either treatment with fmri. Study design: This study will be a prospective randomised clinical trial. Newly diagnosed amblyopic children, who are eligible for the study will be randomised to either the standard patching therapy or the dichoptic video game. Visual acuity, stereo acuity and contrast sensitivity will be assessed by the research orthoptist who is blinded as to randomisation. The study will continue for 24 weeks. Children will be discharged to standard clinical care after the study. The children will be recruited from the School of Orthoptics and Optometry affiliated clinics in the Utrecht Area, the Netherlands. In the patching group the non-amblyopic eye will be patched several hours per day according to standard treatment. Compliance will be monitored electronically with the Occlusion Dose Monitor (ODM). In the video game group a custom-made dichoptic action video game for amblyopia treatment will be played. This will be played under dichoptic viewing conditions in order to reduce suppression and promote fusion through a special exercise session once every week, under direct supervision. Study parameters/ endpoints: Improvement of visual acuity (logmar units per time period) in the amblyopic eye after 24 weeks of patching therapy (actual dose received) compared to the gaming therapy in children and adults.
4. Quality of life in amblyopia patients Gerdien Holtslag, orthoptiste & docente During our study, questionnaires will be conducted, in order to collect information about the impact of the amblyopia and the treatment on vision-related quality of life. For the children the CVFQ and CAT-QoL will be conducted. The adult participants will also fill in questionnaires at three moments in time during the study. The aim is to have more insight in the patient preferences for both the treatments. But also, to know what kind of information the patient needs to make a well thought-out decision, if he/she could choose which treatment they want to undergo. Purpose: To evaluate the quality of life with amblyopia as well as the patient preferences and experiences for both interventions. Based on the outcome of the questionnaires a heterogenic sample of participants (e.g. various age, gender, visual acuity) will be selected for an additional interview about their experiences and perception of the amblyopia treatment. It will be mentioned in the information letter that participants may be asked to participate for this additional (in-depth) interview and that an additional signed informed consent is needed before the interview will take place. The data obtained from the Quality of Life questionnaires & in-depth-interviews will be analysed descriptively.
5. Changes in the visual cortex after amblyopia treatment in adults using fmri technique Dr. Chris Klink, dr. Matthew Self, post doc onderzoekers Functional MRI is a neuroimaging procedure using MRI technology that indirectly measures brain activity by detecting changes associated with blood oxygenation. This measure correlates well with the underlying neuronal activity and has been used in a multitude of studies to further our knowledge of brain function. In this study we are specifically interested in how video-game training / patching affects the basic neural representation of visual stimuli in the cortex. We will use both artificial stimuli, such as gratings, which can be well controlled, as well as naturalistic stimuli to study the daily visual experience of the patients. We will examine the fmri response to stimuli presented to either eye in isolation and the two eyes simultaneously before and after patching therapy / gaming. We are particularly interested in studying at which level in the cortical visual hierarchy therapy induced changes occur. Does video game training/patching lead to enhancements in low level visual areas only or are neural representations of visual stimuli in high-level visual areas also affected? To answer this question we will use state-of-the-art multi-voxel pattern classification techniques to decode which visual stimulus was presented and to which eye. As an input to the decoders we will use the fmri activity patterns from low-level or high-level visual areas. If video-game training / patching leads to strengthened or more reliable neural coding of the stimulus this should lead to better decoding. Furthermore, we aim to link the improvements in decoding accuracy observed in the fmri experiments with the clinically measured improvements in visual acuity. Purpose: Functional magnetic resonance imaging (fmri) scans will be conducted on 10 adult subjects, before and after either treatment. The scans will take place on a 3T scanner at the Netherlands Institute for Neuroscience in Amsterdam.
O n d e r z o e k s t e a m Dr. Sjoukje Loudon, oogarts Emily Tan, (research)orthoptiste Aveen Kadhum, promovenda Gerdien Holtslag, orthoptiste & docente HU Janna Bruijning, hoofddocent oogzorgopleidingen Jan Roelof Polling, orthoptist & hoofddocent oogzorgopleidingen Dr. Chris Klink, PhD, postdoc onderzoeker Dr. Matthew Self, PhD, postdoc onderzoeker