No full-text available
To read the full-text of this research,
you can request a copy directly from the authors.
Lazy Eye Shooter: Making a Game Therapy for Visual Recovery in Adult Amblyopia Usable
Abstract
As many as three quarters of a million preschoolers are at risk for amblyopia in the United States, so appropriate screening and accessible treatment are very important. Recent studies have shown that playing action video games results in a range of improved spatial and temporal visual functions, including visual acuity. Lazy Eye Shooter is a game treatment that takes advantage of these findings in that the software contains a dichoptic display in a First Person Shooter (FPS) action video game. FPS games are unfortunately among the most difficult games to learn for naïve subjects. Given that the treatment requires over 40 hours of playtime, we wanted to make sure that subjects were successful at the game from the very beginning. We describe several methods we have used to make the overall experiences of subjects more positive and discuss current preliminary results from the use of Lazy Eye Shooter.
... For all other uses, contact the owner/author(s Other studies are so early in their development that they are still in the prototyping stage [18,5]. In terms of usability, the closest thing we found was a paper discussing the usability of a rehabilitative game they created [4]. This paper mostly talks about usability in terms of the physical system, like using 2 screens as opposed to 1, and it measures success in terms of vision tests. ...
... This paper mostly talks about usability in terms of the physical system, like using 2 screens as opposed to 1, and it measures success in terms of vision tests. However, they do mention two notable game design choices: users responded better to non-busy spaces, with non-textured foors and walls, and users did not have accurate mouse skills and kept trying to physically move the mouse [4]. ...
Amblyopia, or "lazy eye" is the world's most common neurological eye disorder. Yet, very little has been done looking into how to make virtual reality (VR) more usable for people with Amblyopia. Furthermore, a trend of using VR for Amblyopia therapy has arisen, making such a study more essential than ever. Our study asks our user base of people with Amblyopia questions through two surveys, verbal feedback, and interviews about their experience with our VR video game Amblyopia therapy. We found patterns encoded in this information, which we use to create preliminary hypotheses for making VR experiences as usable as possible for people with Amblyopia.
... Another example of a game used for rehabilitation is the game Lazy Eye Shooter [5]. This game is a first-person shooter used for the treatment of Amblyopia and has a traditional game structure (see Figure 1). ...
... In this way, the therapist can adapt the frequency of the feedback and task variables to the appropriate level to suit the client and their progress. As the game Lazy Eye Shooter shows [5], it is also possible to use dynamic difficulty adjustment with the therapist setting the initial difficulty and feedback structure. ...
In this paper we provide a rationale for using tabletop displays for the upper-limb movement rehabilitation of individuals with brain injury. We consider how computer game mechanics may leverage this technology to increase patient engagement and social interaction, and subsequently enhance prescribed training. In recent years there has been a growing interest among health professionals in the use of computer games and interactive technology for rehabilitation. Research indicates that games have the potential to stimulate a high level of interest and enjoyment in patients; enhance learning; provide safe task conditions; complement conventional therapy; and become intrinsically motivating. We explore how game mechanics that include reward structures, game challenges and augmented audiovisual feedback may enhance a goal-orientated rehabilitation learning space for individuals with brain injury. We pay particular attention to game design elements that support multiple players and show how these might be designed for interactive tabletop display systems in group rehabilitation.
... In the present study, we evaluate the potential benefits of combining PL, video game play and dichoptic presentation, by asking adults with amblyopia to play a dichoptic, custommade action videogame with an embedded, monocular PL task (see Bayliss et al., 2012Bayliss et al., , 2013 for 40 h. The dichoptic action game was designed to incorporate the benefits of action video game play, including an immersive and engaging game environment, with those of binocular dichoptic treatment, by using a split screen view that allows independent control of image luminance and contrast in each window. ...
... Specifically, the game is played under dichoptic viewing conditions in order to reduce suppression and promote fusion, while challenging the amblyopic eye with an embedded psychophysical resolution task. This custom-made game has five main innovative features ( Fig. 2; see Bayliss et al., 2012Bayliss et al., , 2013 for full details): a. The game presents a split screen view, allowing independent control of the images presented to the right and left eyes (which are viewed in a mirror stereoscope), and in particular their respective alpha level. ...
Previous studies have employed different experimental approaches to enhance visual function in adults with amblyopia including perceptual learning, videogame play, and dichoptic training. Here, we evaluated the efficacy of a novel dichoptic action videogame combining all three approaches. This experimental intervention was compared to a conventional, yet unstudied method of supervised occlusion while watching movies. Adults with unilateral amblyopia were assigned to either playing the dichoptic action game (n=23; 'game' group), or to watching movies monocularly while the fellow eye was patched (n=15; 'movies' group) for a total of 40 hours. Following training, visual acuity (VA) improved on average by ≈ 0.14 LogMAR (≈ 27%) in the game group, with improvements noted in both anisometropic and strabismic patients. This improvement is similar to that described after perceptual learning, video game play or dichoptic training. Surprisingly, patients with anisometropic amblyopia in the movies group showed similar improvement, revealing a greater impact of supervised occlusion in adults than typically thought. Stereoacuity, reading speed, and contrast sensitivity improved more for game group participants compared with movies group participants. Most improvements were largely retained following a 2-month no-contact period. This novel video game, which combines action gaming, perceptual learning and dichoptic presentation, results in VA improvements equivalent to those previously documented with each of these techniques alone. Interestingly, however, our game intervention led to greater improvement than control training in a variety of visual functions, thus suggesting that this approach has promise for the treatment of adult amblyopia.
Copyright © 2015 Elsevier Ltd. All rights reserved.
... In the present study, we evaluate the potential benefits of combining PL, video game play and dichoptic presentation, by asking adults with amblyopia to play a dichoptic, custom-made action videogame with an embedded, monocular PL task (see Bayliss et al., 2012Bayliss et al., , 2013 for 40 hours. The dichoptic action game was designed to incorporate the benefits of action video game play, including an immersive and engaging game environment, with those of binocular dichoptic treatment, by using a split screen view that allows independent control of image luminance and contrast in each window. ...
... Specifically, the game is played under dichoptic viewing conditions in order to reduce suppression and promote fusion, while challenging the amblyopic eye with an embedded perceptual learning task. This custom-made game has five main innovative features ( Fig. 2; see Bayliss et al., 2012Bayliss et al., , 2013 for full details): ...
Amblyopia is a deficit in vision that arises from abnormal visual experience early in life. It was long thought to develop into a permanent deficit, unless properly treated before the end of the sensitive period for visual recovery. However, a number of studies now suggest that adults with long-standing amblyopia may at least partially recover visual acuity and stereopsis following perceptual training. Eliminating or reducing interocular suppression has been hypothesized to be at the root of these changes. Here we show that playing a novel dichoptic video game indeed results in reduced suppression, improved visual acuity and, in some cases, improved stereopsis. Our relatively large cohort of adults with amblyopia, allowed us, for the first time, to assess the link between visual function recovery and reduction in suppression. Surprisingly, no significant correlation was found between decreased suppression and improved visual function. This finding challenges the prevailing view and suggests that while dichoptic training improves visual acuity and stereopsis in adult amblyopia, reduced suppression is unlikely to be at the root of visual recovery. These results are discussed in the context of their implication on recovery of amblyopia in adults.
... A different approach, described in this issue (Bayliss, Vedamurthy, Bavelier, Nahum, & Levi, 2012;Bayliss, Vedamurthy, Nahum, Levi, & Bavelier, 2013;Vedamurthy, Bayliss, Knill, Bavelier, & Levi, 2012a;Vedamurthy, Nahum, Bavelier, & Levi, 2015;Vedamurthy et al., submitted for publication), uses a customized dichoptic action video game designed to reduce suppression, promote fusion and increase attention by the amblyopic eye under binocular conditions. The game, viewed in a stereoscope, presents identical images to the two eyes, with the luminance/contrast of the image seen by the strong eye decreased to perceptually match that of the weak (amblyopic) eye. ...
Amblyopia is a neuro-developmental disorder of the visual cortex that arises from abnormal visual experience early in life. Amblyopia is clinically important because it is a major cause of vision loss in infants and young children. Amblyopia is also of basic interest because it reflects the neural impairment that occurs when normal visual development is disrupted. Amblyopia provides an ideal model for understanding when and how brain plasticity may be harnessed for recovery of function. Over the past two decades there has been a rekindling of interest in developing more effective methods for treating amblyopia, and for extending the treatment beyond the critical period, as exemplified by new clinical trials and new basic research studies. The focus of this review is on stereopsis and its potential for recovery. Impaired stereoscopic depth perception is the most common deficit associated with amblyopia under ordinary (binocular) viewing conditions (Webber & Wood, 2005). Our review of the extant literature suggests that this impairment may have a substantial impact on visuomotor tasks, difficulties in playing sports in children and locomoting safely in older adults. Furthermore, impaired stereopsis may also limit career options for amblyopes. Finally, stereopsis is more impacted in strabismic than in anisometropic amblyopia. Our review of the various approaches to treating amblyopia (Patching, Perceptual Learning, Videogames) suggests that there are several promising new approaches to recovering stereopsis in both anisometropic and strabismic amblyopes. However, recovery of stereoacuity may require more active treatment in strabismic than in anisometropic amblyopia. Individuals with strabismic amblyopia have a very low probability of improvement with monocular training; however they fare better with dichoptic training than with monocular training, and even better with direct stereo training.
The gold-standard treatment for childhood amblyopia remains patching or penalizing the fellow eye, resulting in an average of about a one line (0.1 logMAR) improvement in visual acuity following ≈ 120 hours of patching (Stewart, Moseley, Stephens, & Fielder, 2004; Stewart, Stephens, Fielder, Moseley, & Cooperative, 2007) in children 3 to 8 years old. However, compliance with patching and other treatment options is often poor. In contrast, fast-paced action video games can be highly engaging, and have been shown to yield broad-based improvements in vision and attention in adult amblyopia. Here, we pilot tested a custom-made action video game to treat children with amblyopia. Twenty-one (n=21) children (mean age 9.95 ± 3.14 [se]) with unilateral amblyopia (n=12 anisometropic and n=9 strabismic) completed 20 hours of game play either monocularly, with the fellow eye patched (n=11), or dichoptically, with reduced contrast to the fellow eye (n=10). Participants were assessed for visual acuity (VA), stereo acuity and reading speed at baseline, and following 10 and 20 hours of play. Additional exploratory analyses examined improvements after 6-10 weeks of completion of training (follow-up). Following 20 hours of training, VA improved on average by 0.14 logMAR (≈ 38%) for the dichoptic group and by 0.06 logMAR (≈ 15%) for the monocular group. Similarly, stereoacuity improved by 0.07 log arcsec (≈ 17%) following dichoptic training, and by 0.06 log arcsec (≈ 15%) following monocular training. Across both treatment groups, 7 of the 12 individuals with anisometropic amblyopia showed improvement in stereoacuity, while only 1 of the 9 strabismic individuals improved. Most improvements were largely retained at follow-up. Our feasibility study suggests that the action videogame approach may be used as an effective adjunct treatment for amblyopia in children, achieving results similar to those of the gold-standard treatment in shorter duration.
Abnormal visual experience during a sensitive period of development disrupts neuronal circuitry in the visual cortex and results in abnormal spatial vision or amblyopia. Here we examined whether playing video games can induce plasticity in the visual system of adults with amblyopia. Specifically 20 adults with amblyopia (age 15–61 y; visual acuity: 20/25–20/480, with no manifest ocular disease or nystagmus) were recruited and allocated into three intervention groups: action videogame group (n = 10), non-action videogame group (n = 3), and crossover control group (n = 7). Our experiments show that playing video games (both action and non-action games) for a short period of time (40–80 h, 2 h/d) using the amblyopic eye results in a substantial improvement in a wide range of fundamental visual functions, from low-level to high-level, including visual acuity (33%), positional acuity (16%), spatial attention (37%), and stereopsis (54%). Using a cross-over experimental design (first 20 h: occlusion therapy, and the next 40 h: videogame therapy), we can conclude that the improvement cannot be explained simply by eye patching alone. We quantified the limits and the time course of visual plasticity induced by video-game experience. The recovery in visual acuity that we observed is at least 5-fold faster than would be expected from occlusion therapy in childhood amblyopia. We used positional noise and modelling to reveal the neural mechanisms underlying the visual improvements in terms of decreased spatial distortion (7%) and increased processing efficiency (33%). Our study had several limitations: small sample size, lack of randomization, and differences in numbers between groups. A large-scale randomized clinical study is needed to confirm the therapeutic value of video-game treatment in clinical situations. Nonetheless, taken as a pilot study, this work suggests that video-game play may provide important principles for treating amblyopia, and perhaps other cortical dysfunctions.
Trial Registration
ClinicalTrials.gov NCT01223716
It can be useful to present a different image to each of the two eyes while they cooperatively view the world. Such dichoptic presentation can occur in investigations of stereoscopic and binocular vision (e.g., strabismus, amblyopia) and vision rehabilitation in clinical and research settings. Various techniques have been used to construct dichoptic displays. The most common and most flexible modern technique uses liquid-crystal (LC) shutters. When used in combination with cathode ray tube (CRT) displays, there is often leakage of light from the image intended for one eye into the view of the other eye. Such interocular crosstalk is 14% even in our state of the art CRT-based dichoptic system. While such crosstalk may have minimal impact on stereo movie or video game experiences, it can defeat clinical and research investigations. We use micromirror digital light processing (DLP) technology to create a novel dichoptic visual display system with substantially lower interocular crosstalk (0.3%; remaining crosstalk comes from the LC shutters). The DLP system normally uses a color wheel to display color images. Our approach is to disable the color wheel, synchronize the display directly to the computer's sync signal, allocate each of the three (former) color presentations to one or both eyes, and open and close the LC shutters in synchrony with those color events.
The contrast sensitivity function (CSF) is routinely assessed in clinical evaluation of vision and is the primary limiting factor in how well one sees. CSF improvements are typically brought about by correction of the optics of the eye with eyeglasses, contact lenses or surgery. We found that the very act of action video game playing also enhanced contrast sensitivity, providing a complementary route to eyesight improvement.
Amblyopia is an example of abnormal visual development that is clinically defined as a reduction of best corrected Snellen acuity to less than 6/9 (20/30) in one eye or a two-line difference between the two eyes, with no visible signs of eye disease. We describe a sequential management program for anisometropic amblyopia that consists of four steps: (1) the full refractive correction, (2) added lenses or prism when needed to improve alignment of the visual axes, (3) 2 to 5 h/day of direct occlusion, and (4) active vision therapy to develop monocular acuity and improve binocular visual function. We examined records of 19 patients over 6 years of age who had been treated using this sequential management philosophy. After 15.2 (+/- 7.7) weeks of treatment the Amblyopia Success Index (ASI) documented an average improvement in visual acuity of 92.1% +/- 8.1 with a range from a low of 75% by a 49-year-old patient to a maximum of 100% achieved by 42.1% of the patients (8 of 19). Patients who had completed therapy 1 or more years ago (N = 4) maintained their acuity improvement. From these results we conclude that following a sequential management plan for treatment of anisometropic amblyopia can yield substantial long-lasting improvement in visual acuity and binocular function for patients of any age.
The purpose of the present study was to explore the potential for treating childhood amblyopia with a binocular stimulus designed to correlate the visual input from both eyes.
Eight strabismic, two anisometropic, and four strabismic and anisometropic amblyopes (mean age, 8.5 ± 2.6 years) undertook a dichoptic perceptual learning task for five sessions (each lasting 1 hour) over the course of a week. The training paradigm involved a simple computer game, which required the subject to use both eyes to perform the task.
A statistically significant improvement (t(₁₃) = 5.46; P = 0.0001) in the mean visual acuity (VA) of the amblyopic eye (AE) was demonstrated, from 0.51 ± 0.27 logMAR before training to 0.42 ± 0.28 logMAR after training with six subjects gaining 0.1 logMAR or more of improvement. Measurable stereofunction was established for the first time in three subjects with an overall significant mean improvement in stereoacuity after training (t(₁₃) =2.64; P = 0.02).
The dichoptic-based perceptual learning therapy employed in the present study improved both the monocular VA of the AE and stereofunction, verifying the feasibility of a binocular approach in the treatment of childhood amblyopia.
We have developed a prototype device for take-home use that can be used in the treatment of amblyopia. The therapeutic scenario we envision involves patients first visiting a clinic, where their vision parameters are assessed and suitable parameters are determined for therapy. Patients then proceed with the actual therapeutic treatment on their own, using our device, which consists of an Apple iPod Touch running a specially modified game application. Our rationale for choosing to develop the prototype around a game stems from multiple requirements that such an application satisfies. First, system operation must be sufficiently straightforward that ease-of-use is not an obstacle. Second, the application itself should be compelling and motivate use more so than a traditional therapeutic task if it is to be used regularly outside of the clinic. This is particularly relevant for children, as compliance is a major issue for current treatments of childhood amblyopia. However, despite the traditional opinion that treatment of amblyopia is only effective in children, our initial results add to the growing body of evidence that improvements in visual function can be achieved in adults with amblyopia.
It is frequently stated that amblyopia is not correctable after the age of 6 years. Many practitioners report marked success for older patients. To evaluate these conflicting reports, we analyzed the results from 23 published amblyopia studies. Our analysis indicates that substantial numbers of patients over age 6 were successfully treated. Success rates under age 6 were not significantly better than those in older patients when the criterion for success was achievement of 20/30 acuity or better. When a criterion of 4 lines improvement was used, success rates at all ages under 16 were quite similar; in patients 16 and over, success by this criterion was significantly less frequent, but even in this group success was achieved by 42% of the patients.
To report successful therapy for anisometropic and strabismic amblyopia initiated after age 7 years.
A consecutive series of 36 compliant children older than 7 years (range, 7.0 to 10.3 years; mean, 8.2 years) at initiation of amblyopia therapy for anisometropic (19 patients; mean age, 8.3 years), strabismic (9 patients; mean age, 8.0 years), or anisometropic and strabismic (8 patients; mean age, 8.0 years) amblyopia was studied. Initial (worst) visual acuities were between 20/50 and 20/400 (log geometric mean, -0.83 [antilog, 20/134] for all patients; -0.88 [antilog, 20/151] for anisometropic patients; -0.70 [antilog, 20/100] for strabismic patients; and -0.88 [antilog, 20/151] for anisometropic and strabismic patients). Initial (worst) binocularity was absent or reduced in all cases. Therapy consisted of (1) full-time standard occlusion (21 patients; mean age, 8.0 years), (2) total penalization (7 patients; mean age, 7.8 years), or (3) full-time occlusive contact lenses (8 patients; mean age, 8.8 years).
Final (best) visual acuities were between 20/20 and 20/30 for all 36 patients. Final (best) binocularity was maintained or improved for 22 (61%) of 36 patients, including 16 anisometropic patients (84%), 2 strabismic patients (22%), and 4 anisometropic and strabismic patients (50%).
Given compliance, therapy for anisometropic and strabismic amblyopia can be successful even if initiated after age 7 years. Arch Ophthalmol. 2000;118:1535-1541
As video-game playing has become a ubiquitous activity in today's society, it is worth considering its potential consequences on perceptual and motor skills. It is well known that exposing an organism to an altered visual environment often results in modification of the visual system of the organism. The field of perceptual learning provides many examples of training-induced increases in performance. But perceptual learning, when it occurs, tends to be specific to the trained task; that is, generalization to new tasks is rarely found. Here we show, by contrast, that action-video-game playing is capable of altering a range of visual skills. Four experiments establish changes in different aspects of visual attention in habitual video-game players as compared with non-video-game players. In a fifth experiment, non-players trained on an action video game show marked improvement from their pre-training abilities, thereby establishing the role of playing in this effect.
To provide an overview of the current state of knowledge of amblyopia and highlight recent advances in diagnosis and treatment.
Review of literature and perspective.
MEDLINE search for amblyopia, with a review of all recent literature adding authors' personal perspectives on the findings.
Increased awareness of amblyopia and better screening techniques are required to identify children who are at risk for amblyopia at a younger age. Randomized, controlled trials have established atropine penalization as a viable alternative to occlusion therapy, have suggested that less treatment may be better tolerated and as effective as more traditionally used dosages, and have found no compelling evidence that treatment is beneficial clinically for older (over age 10) children with amblyopia.
Early detection and treatment of amblyopia can improve the chances for a successful visual outcome. Considering that the conditions that place a patient at risk for amblyopia can be identified, that amblyopia responds to treatment, and that well-tolerated treatments for the condition are now recognized, it is not unreasonable to imagine that, in the near future, severe amblyopia could be eliminated as a public health problem.
Playing Video Game Improves Visual Acuity and Visual Attention in Adult Amblyopia - A Potentially Useful Tool for Amblyopia Treatment
- R W Li
- C Ngo
- J Nguyen
- J Lam
- B Nia
- D Ren
- D M Levi
RW Li, C Ngo, J Nguyen, J Lam, B Nia, D Ren, and DM Levi. "Playing
Video Game Improves Visual Acuity and Visual Attention in Adult
Amblyopia -A Potentially Useful Tool for Amblyopia Treatment,"
Invest Ophthalmol Vis Sci. vol. 49, 2008.
A randomized pilot study of near activities versus non-near activities during patching therapy for amblyopia
Pediatric Eye Disease Investigator Group. "A randomized pilot study of
near activities versus non-near activities during patching therapy for
amblyopia", J AAPOS. Vol. 9, pp. 129-136, 2005.