Is virtual reality (VR) effective for treating amblyopia?

Virtual Reality for Amblyopia

The evidence remains insufficient to recommend virtual reality (VR) as a standard treatment for amblyopia, and traditional patching or atropine penalization should remain first-line therapy after refractive correction. 1

Current Evidence for VR-Based Dichoptic Therapy

The American Academy of Ophthalmology's 2023 Amblyopia Preferred Practice Pattern explicitly states that despite ongoing research and rapidly expanding technology, "the evidence remains limited to recommend binocular therapy for treatment of amblyopia." 1

What the Research Shows

One randomized clinical trial using VR headsets demonstrated modest benefit:

• Mean visual acuity improved by 1.8 lines in the VR treatment group compared to 0.8 lines in the continued glasses group at 12 weeks (P = 0.0011) 1
• This VR system delivered reduced contrast images to the nonamblyopic eye with masking of portions of the image visible to each eye while viewing web-based content 1

However, earlier binocular digital therapies failed to demonstrate efficacy:

• Three randomized trials failed to show that game play prescribed 1 hour per day was as good as patching prescribed 2 hours per day or better than placebo game play 1
• A trial in 7- to 12-year-olds comparing binocular therapy with continued glasses alone found no benefit 1
• A parallel trial in children 4 to 6 years of age found clinically important improvement at 4 weeks, but the benefit was not sustained at 8 weeks 1

Appropriate Patient Selection for VR (If Considering)

VR-based binocular therapy has only been studied in highly selected patients:

• Children with no strabismus or small-angle strabismus with some binocularity 1, 2
• Patients with demonstrable binocular potential 2

Do not use VR in:

• Children with moderate to large-angle strabismus 2
• Patients with poor binocular potential or suppression 2
• Children lacking binocularity 1

Recommended Treatment Algorithm

Step 1: Refractive Correction First

• Prescribe appropriate eyeglasses based on cycloplegic refraction 3
• Allow 8-18 weeks for adaptation before assessing need for additional treatment 3
• Refractive correction alone improves visual acuity in approximately one-fourth of children 3

Step 2: Initiate Proven Occlusion or Penalization Therapy

For moderate amblyopia (20/40 to 20/80):

• Prescribe 2 hours of daily patching of the nonamblyopic eye 3
• Combine with at least 1 hour of near-visual activities during patching 3
• Alternative: Atropine 1% ophthalmic solution to the nonamblyopic eye for children 3 years and older 3

For severe amblyopia (worse than 20/80):

• Prescribe 6 hours of daily patching, although 2 hours may be effective in some cases 3
• Direct adhesive patches applied to the skin are preferred over cloth patches mounted on eyeglass frames 3

Step 3: Follow-Up and Monitoring

• Schedule follow-up examination 2-3 months after initiating treatment 3
• If visual acuity improves and fellow eye is stable, continue the same treatment regimen 3
• If visual acuity is unchanged despite good adherence, consider increasing patching from 2 to 6 hours daily or switching to atropine 3

Critical Pitfalls to Avoid

Do not delay proven treatments in favor of experimental VR therapy:

• Patching and atropine remain the gold standard with robust evidence 4, 5, 6
• Treatment efficiency declines with age, making early intervention critical 5
• Best outcomes are achieved if amblyopia is treated before age 7 years 4

Do not use VR as monotherapy:

• The single positive VR trial showed only 1 additional line of improvement over glasses alone 1
• This modest benefit does not justify replacing established treatments with strong evidence 5, 7

Monitor for amblyopia recurrence:

• Amblyopia recurs in 25% of children, requiring continued surveillance 6
• Maintain consistent testing environment and visual acuity measurement methods across visits 3

When VR Might Be Considered (Experimental Context)

VR could potentially serve as an adjunct (not replacement) in:

• Children with documented poor compliance to patching or atropine 2
• Patients with small-angle strabismus and preserved binocularity who have failed standard therapy 1, 2
• Research settings with appropriate informed consent and continued monitoring 1

Even in these scenarios, do not abandon proven therapies:

• Continue refractive correction 3
• Maintain regular follow-up every 2-3 months 3
• Be prepared to return to patching or atropine if VR shows inadequate response 3