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      Efficacy of interventions for amblyopia: a systematic review and network meta-analysis

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          Abstract

          Background

          Many treatments are currently available for amblyopic patients; although, the comparative efficacy of these therapies is unclear. We conducted a systematic review and network meta-analysis (NMA) to establish the relative efficacy of these treatments for amblyopia.

          Methods

          Electronic databases (MEDLINE, EMBASE, Cochrane Library) were systematically searched from inception to Sep. 2019. Only Randomized clinical trials comparing any two or three of the following treatments were included: refractive correction (spectacles alone), patching of 2 h per day (patch 2H), patch 6H, patch 12H, patch 2H + near activities (N), patch 2H + distant activities (D), atropine (Atr) daily, Atr weekly, Atr weekly + plano lens over the sound eye (Plano), optical penalization and binocular therapy. The reviewers independently extracted the data according to the PRISMA guidelines; assessed study quality by Cochrane risk-of-bias tool for randomized trials. The primary outcome measure was the change in best-corrected visual acuity (BCVA) expressed as log MAR lines. Direct comparisons and a Bayesian meta-analysis were performed to synthesize data.

          Results

          Twenty-three studies with 3279 patients were included. In the network meta-analysis, optical penalization was the least effective of all the treatments for the change of visual acuity, spectacles (mean difference [MD], 2.9 Log MAR lines; 95% credibility interval [CrI], 1.8–4.0), patch 2H (MD, 3.3; 95% CrI, 2.3–4.3), patch 6H (MD, 3.6; 95% CrI, 2.6–4.6), patch 12H (MD, 3.4; 95% CrI, 2.3–4.5), patch 2H + N (MD, 3.7; 95% CrI, 2.5–5.0), patch 2H + D (MD, 3.5; 95% CrI, 2.1–5.0), Atr daily (MD, 3.2; 95% CrI, 2.2–4.3), Atr weekly (MD, 3.2; 95% CrI, 2.2–4.3), Atr weekly + Plano (MD, 3.7; 95% CrI, 2.7–4.7), binocular therapy (MD, 3.1; 95% CrI, 2.0–4.2). The patch 6H and patch 2H + N were better than spectacles ([MD, 0.73; 95% Crl, 0.10–1.40]; [MD, 0.84; 95% CrI, 0.19–1.50]).

          Conclusions

          The NMA indicated that the efficacy of the most of the examined treatment modalities for amblyopia were comparable, with no significant difference. Further high quality randomized controlled trials are required to determine their efficacy and acceptability.

          Systematic review registration

          CRD42019119843.

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          Most cited references 48

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          Amblyopia.

          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.
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            A computerized method of visual acuity testing: adaptation of the early treatment of diabetic retinopathy study testing protocol.

            To develop a computerized method of visual acuity testing for clinical research as an alternative to the standard Early Treatment for Diabetic Retinopathy Study (ETDRS) testing protocol, and to evaluate its test-retest reliability and concordance with standard ETDRS testing. Test-retest reliability study. Multicenter setting of a study population of 265 patients at three clinical sites. Visual acuity was measured with both the electronic visual acuity testing algorithm (E-ETDRS) and standard ETDRS protocol (S-ETDRS) twice on one eye of each patient. E-ETDRS testing was conducted using the electronic visual acuity tester (EVA), which utilizes a programmed Palm (Palm, Inc, Santa Clara, California, USA) hand-held device communicating with a personal computer and 17-inch monitor at a test distance of 3 meters. For the E-ETDRS protocol, test-retest reliability was high (r = 0.99; with 89% and 98% of retests within 0.1 logMAR and 0.2 logMAR of initial tests, respectively) and comparable with that of S-ETDRS testing (r = 0.99; with 87% and 98% of retests within 0.1 logMAR and 0.2 logMAR of initial test, respectively). The E-ETDRS and S-ETDRS scores were highly correlated (r = 0.96 for initial tests and r = 0.97 for repeat tests). Based on estimates of 95% confidence intervals, a change in visual acuity of 0.2 logMAR (10 letters) from a baseline level is unlikely to be related to measurement variability using either the E-ETDRS or the S-ETDRS visual acuity testing protocol. The E-ETDRS protocol has high test-retest reliability and good concordance with S-ETDRS testing. The computerized method has advantages over the S-ETDRS testing in electronically capturing the data for each tested letter, requiring only a single distance for testing from 20/12 to 20/800, potentially reducing testing time, and potentially decreasing technician-related bias.
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              Binocular iPad Game vs Patching for Treatment of Amblyopia in Children

              Fellow eye patching has long been the standard treatment for amblyopia, but it does not always restore 20/20 vision or teach the eyes to work together. Amblyopia can be treated with binocular games that rebalance contrast between the eyes so that a child may overcome suppression. However, it is unclear whether binocular treatment is comparable to patching in treating amblyopia.
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                Author and article information

                Contributors
                lijing68@hotmail.com
                Journal
                BMC Ophthalmol
                BMC Ophthalmol
                BMC Ophthalmology
                BioMed Central (London )
                1471-2415
                25 May 2020
                25 May 2020
                2020
                : 20
                Affiliations
                [1 ]GRID grid.13291.38, ISNI 0000 0001 0807 1581, Department of Evidence-Based Medicine and Clinical Epidemiology, West China Hospital, , Sichuan University, ; No.37 Guoxue Alley, Chengdu, 610041 China
                [2 ]GRID grid.412901.f, ISNI 0000 0004 1770 1022, Mental Health Center and Psychiatric Laboratory, the State Key Laboratory of Biotherapy, , West China Hospital of Sichuan University, ; No.37 Guoxue Alley, Chengdu, 610041 China
                [3 ]GRID grid.13291.38, ISNI 0000 0001 0807 1581, Department of Ophthalmology, West China Hospital, , Sichuan University, ; No.37 Guoxue Alley, Chengdu, 610041 China
                [4 ]GRID grid.13291.38, ISNI 0000 0001 0807 1581, Department of Clinical Research Management, West China Hospital, , Sichuan University, ; No.37 Guoxue Alley, Chengdu, 610041 China
                Article
                1442
                10.1186/s12886-020-01442-9
                7249307
                32450849
                © The Author(s) 2020

                Open AccessThis article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

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                © The Author(s) 2020

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