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PEDIG focusing on binocular activities for amblyopia


Group provides update on possible role of computer game rather than patching, eye drops

Michael Repka, MD, MBA, provided updates on the treatment of amblyopia with binocular activities on behalf of the Pediatric Eye Disease Investigator Group, a group of ophthalmologists and optometrists.

Reviewed by Michael Repka, MD, MBA

Focusing on the treatment of amblyopia with binocular activities, Michael Repka, MD, MBA, provided updates on behalf of the Pediatric Eye Disease Investigator Group (PEDIG). “Rather than doing patching or eye drops in an eye, the child might be able to play a computer game, and that is pretty exciting for kids and their parents to hear,” said Dr. Repka, past network chairman of PEDIG.

PEDIG is a group of ophthalmologists and optometrists who perform pediatric eye care. There are currently more than 100 sites in the network, with more than 300 pediatric ophthalmologists and pediatric optometrists in the United States, Canada, and the United Kingdom.

Supported by funding from the National Eye Institute, the investigators collaborate on developing and launching trials, and disseminating the results to the ophthalmology community.

Video game aid

Dr. Repka described a first-generation game, Hess Falling Blocks, a binocular video game similar to Tetris, where the child would watch the falling blocks through red-green glasses. By coloring the blocks, investigators could have the child see some blocks with the good eye, some with the bad eye, and some with both eyes. Contrast could be lowered in the good eye, so that the child would pay attention to those blocks seen by the bad eye, which remained at full contrast. 

The strategy was that by playing the game, the bad eye would be stimulated, and the visual acuity would improve. The contrast can be slowly raised in the better eye to the point where the child can see out of both eyes. This approach would only apply to children who have some degree of binocularity, both eyes working together. It cannot be used with strabismus larger than a microstrabismus.

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PEDIG investigators conducted two studies with Hess Falling Blocks, one with kids 5 to 12 years old, and one with kids 13 to 16 years old. Treatment was playing the game on a tablet for an hour a day for 16 weeks. A control group wore a patch over the stronger eye for two hours per day, so the trial compared conventional therapy with the new therapy.

The visual acuity outcome for both the younger group and the older group favored patching (the control group) slightly. The eyes of the children playing the game improved, but not by much, and they improved less than the eyes of the children in the patching control group.1,2 Investigators determined engagement was poor, leading to low compliance. In the older age group, only 13% reached 75% of the assigned time.

Researchers are now studying a game called Dig Rush, featuring underground miners digging for gold. For the randomly selected trial with this game, researchers had the children play the game for 8 weeks. The control group was not being patched or receiving any other treatment besides correct glasses, so researchers did not want to extend the treatment any longer. There was a safety outcome at 4 weeks. The study group was children 7 to 12 years old, and researchers looked to see if their vision improved.

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This game also did not work, even though compliance was better.3 Researchers are recruiting subjects 4 to 7 years old to participate in the Dig Rush study, following the theory that amblyopia should be easier to treat in a younger group. Dr. Repka also discussed a surgical trial on intermittent exotropia, where eyes occasionally drift out.

The study looked at two different approaches: surgery on both eyes, and surgery on just the eye that drifted out. The study group was followed for 3 years, and results were termed as a suboptimal surgical outcome. Researchers measured the outcomes over time, 12 months, 24 months, and 36 months, to see how the children did.

They found a difference in the two surgical approaches, although the children who had bilateral lateral rectus surgery did a little worse than children who had recess-resect surgery on only one eye. The difference was small and not statistically significant.

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Michael Repka, MD, MBA
E: mrepka@jhmi.edu
This article was adapted from Dr. Repka’s presentation at the 2018 Johns Hopkins Wilmer Eye Institute’s Current Concepts in Ophthalmology meeting in Baltimore. Dr. Repka has no financial interests to disclose.


1. Pediatric Eye Disease Investigator Group. Effect of a binocular iPad game versus part-time patching in children aged 5 to 12 with amblyopia: a randomized clinical trial. JAMA Ophthalmol. 2016;134(12).

2. Manh VM, Holmes JM, Lazar EL, Kraker RT, Wallace DK, Kulp MT, Galvin JA, Shah BK, Davis PL; Pediatric Eye Disease Investigator Group. A randomized trial of a binocular iPad game versus part-time patching In children 13 to 16 years of age with amblyopia. Am J Ophthalmol. 2018;186:104-115.

3. Holmes JM, Manny RE, Lazar EL, Birch EE, Kelly KR, Summers AI, Martinson SR, Raghuram A, Colburn JD, Law C, Marsh JD, Bitner DP, Kraker RT, Wallace DK, Pediatric Eye Disease Investigator Group. A randomized trial of binocular Dig Rush game treatment for amblyopia in children aged 7 to 12 Years. Ophthalmology. 2019;126:456-466. doi: 10.1016/j. ophtha.2018.10.032. Epub 2018 Oct 22.

4. Pediatric Eye Disease Investigator Group; Writing Committee, Donahue SP, Chandler DL, Holmes JM, Arthur BW, Paysse EA, Wallace DK, Petersen DB, Melia BM, Kraker RT, Miller AM. A randomized trial comparing bilateral lateral rectus recession versus unilateral recess and resect for basic-type intermittent exotropia. Ophthalmology. 2019;126:305-317. doi: 10.1016/j.ophtha.2018.08.034. Epub 2018 Sep 3.

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