YALE JOURNAL OF BIOLOGY AND MEDICINE 88 (2015), pp.

309-317

Video Game Use in the Treatment of

Amblyopia: Weighing the Risks of
Addiction
Chaoying S. Xu, Jessica S. Chen, and Ron A. Adelman*
Department of Ophthalmology and Visual Science, Yale School of
Medicine, New Haven, Connecticut
 INTRODUCTION
 Video games have surged in popularity due to their entertainment factor and,
with recent innovation, their use in health care. This review explores the
dual facets of video games in treating vision impairment in amblyopia as well
as their potential for overuse and addiction. Specifically, this review
examines video game addiction from a biopsychosocial perspective and
relates the addictive qualities of video games with their use as a therapeutic
treatment for amblyopia.
 Video games have increased in popularity since the early days of Atari® and
Pac-man® in the 1970s and 1980s. According to a 2014 report by the
Entertainment Software Association (ESA†), 59 percent of Americans play
video games
 Problematic video game use has become a global problem.
 As video games increase in popularity, innovative ways to use them for
productive purposes have arisen
VIDEO GAME ADDICTION: WORKING TOWARD
A CLINICAL DEFINITION
A GAP IN THERAPY FILLED BY VIDEO GAMES:
WHAT IS AMBLYOPIA?

 Amblyopia is a neurodevelopmental disease of the visual pathway that arises

when binocular visual experience is disrupted in early childhood.
 The process begins as one eye is weakened by factors that cause a mismatch
of images between the eyes such as
 Strabismus (“lazy eye”),
 anisometropia (unequal refractive power between eyes), cataract, or high
refractive error during the first few years of life
 If uncorrected, amblyopia can lead to irreversible vision loss, particularly
impaired visual acuity, and stereoscopic depth perception
 The current treatment for amblyopia centers primarily on
optic correction followed by occlusion of visual input from
the healthy fellow eye through the use of a patch.
 Contributing factors of the high failure rate include non-
compliance as well as a decrease in neuronal plasticity after
early childhood.
 Perceptual learning is an effective, alternative therapy to
patching for adults with amblyopia. Patients repeatedly
practice with a demanding visual task such as identifying
letters with difference sizes and contrast levels.
 However, this therapy is limited by boredom and a lack of
compliance
 Video games recently have emerged as an experimental
treatment modality for amblyopia
THE USE OF VIDEO GAMES: TREATMENT FOR
AMBLYOPIA

 The same aspects of video games that make them potentially addictive also
make them an ideal platform for a highly compliant treatment:
 attractive graphics requiring visual discrimination in the game play, varied visual task,
 immediate feedback, and reward for the visual task,
 among other appealing game characteristics
 Table 1 shows a summary of video games studied so far in the treatment for
amblyopia. In a study by Li et al., subjects played Medal of Honor® or Simcity®
for a total of 40 hours (2 hours per day) using the amblyopic eye while the fellow
eye was patched.
 Twenty patients (15 to 61 years of age) significantly improved their visual acuity
by a factor of 1.6, roughly two lines on the LogMAR letter chart
 In effect, such recovery rate is approximately five times faster than that
observed in children treated with conventional eye patching
 As binocular game play was shown to be superior to monocular
game play in visual acuity and stereopsis improvement,
researchers began to develop dichoptic games
 These games achieve their therapeutic effect by presenting a
different image to each eye, thus rewarding the patient when
both eyes work together to win the game.
 For instance, in the Tetris® game, some of the blocks seen by
the amblyopic eye are in high contrast, while other blocks in
lower contrast are seen by the healthy eye.
 The contrast level in these games can be modified based on
each patient’s burden of disease
Medal of Honor® Gameplay
Tetris® Gameplay
Simcity® Gameplay
DISCUSSION AND OUTLOOK
 Our review of the literature shows that video game consumption can
lead to an addiction, especially in the presence of certain risk factors.
However, the appealing features of video games also have been
channeled into creating an innovative therapy for amblyopia with
compliance
 More research is needed on the health benefits and harms of video
games.
 To investigate the full effect of video game in treating amblyopia, a
large-scale, randomized controlled trial is needed to confirm the
benefits of video game on vision in comparison to other visual
activities such as reading a book on the same electronic platform
 Ophthalmologists should weigh the risk of video addiction against the
benefits to vision when offering video game as a therapy and inform
patients and/or parents of the risks
 Unilateral or less commonly, bilateral reduction of
best corrected visual acuity that can not be
attributed directly to the effect of any structural
abnormality of the eye or the posterior visual
pathway.

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 Resulting from one of following:

A. Strabismus - DEVIATION
B. Anisometropia or high bilateral refractive
error (Isoametropia) - DEFOCUS
C. Visual deprivation - DEPRIVATION

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 Prevalence: 2%-4%
 Commonly unilateral
 Nearly all amblyopic visual loss is preventable or
reversible with timely detection and appropriate
intervention.
 Children with amblyopia or at risk for amblyopia
should be identified at a young age when the
prognosis for successful treatment is best.
 Role of screening is important

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 Amblyopia is primarily a defect of central vision.
 There is a critical period for sensitivity in developing
amblyopia.
 The time necessary for amblyopia to occur during
critical period is shorter for stimulus deprivation
than for strabismus or anisometropia.

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Neurophysiology:

 Cells of the primary visual cortex can completely

lose their innate ability or show significant
functional deficiencies

 Abnormalities also occur in neurons in the lateral

geniculate body

 Evidence concerning involvement at the retinal level

remains inconclusive

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 Classification:

1. Strabismus Amblyopia :Deviation

2. Anisometropia Amblyopia : Defocuss
3. Amblyopia Due to bilateral high refractive
error (isometropic) : Defocuss
4. Deprivation Amblyopia : Deviation

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 Strabismus Amblyopia

 The most common form of amblyopia

 Strabismic amblyopia is thought to result
from competitive or inhibitory interaction
between neurons carrying the nonfusible
inputs from the two eyes.
 Which leads to domination of cortical vision
centers by the fixating eye and chronically
reduced responsiveness to the nonfixating
eye input.

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 Anisometropia Amblyopia

 Second in frequency
 It develops when unequal refractive error in the two
eyes causes the image on the one retina to be
chronically defocused.
 This condition is thought to result:
 Partly from the direct effect of image blur in the
development of visual acuity.
 Partly from intraocular competition or inhibition

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 Mild hyperopic or astigmatic anisometropia (1.5D)
 mild amblyopia
 Mild myopia anisometropia (less than -2.5D) usually
doesn't cause amblyopia
 unilateral high myopia (-6D)  sever amblyopia
visual loss.

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Amblyopia Due to bilateral high refractive
error (isometropia)

 isometropic amblyopia result from large,

approximately equal, uncorrected refractive error in
both eyes of a young child.
 Hyperopia exceeding 5D & myopia excess of 10 D 
risk bilateral amblyopia

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 Meridonial amblyopia:
 Uncorrected bilateral astigmatism in early
childhood may result in loss of resolving ability
limited to chronically blurred meridians.

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Deprivation Amblyopia

 It is usually caused by congenital or early acquired

media opacity.
 This form of amblyopia is the least common but most
damaging and difficult to treat.
 In bilateral cases acuity can be 20/200 or worse.

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 In children younger than 6 years, dense congenital
cataract that occupy the central 3 mm. or more of
the lens must be considered capable of causing sever
amblyopia.
 Similar lens opacities acquired after 6 years are
generally less harmful.

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 Small polar cataracts & lamellar cataracts may
cause mild to moderate amblyopia or may have no
effect on visual development.

 Occlusion amblyopia is a form of deprivation

caused by excessive therapeutic patching.

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Treatment

 Treatment of amblyopia involves the following

steps:
 Eliminating (if possible) any obstacle to vision such
as a cataract
 Correcting refractive error
 Forcing use of the poorer eye by limiting use of the
better eye.

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