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My remarks today are intended to put things in a clinical perspective after Dr. Polat’s presentation on NeuroVision. These are my opinions as an individual clinician, and not as a representative of COVD. When I was first exposed to this technology, I had already read something of it in the context of perceptual learning. In the jargon of rehabilitation, with Christopher Reeve has become a champion of people do not abandon hope for recovery of function, there is residual plasticity whether a system is malfunctioning from a developmental or acquired standpoint.

Residual plasticity implies that if you tend to master certain tasks in a repetitive framework, you can get improvement in function well beyond the age that improvement was thought possible. In the perceptual learning literature, I came across Uri Polat'trs work and the phenomenon of perceptual learning. Specifically, his application of Gabor patches, which has been used in vision science as early as 1946. It had not previously been applied very much in terms of in therapy or intervention as such. So when Jacob first approached me about this type of technology I said: Yes, I have been kind of intrigued by it.

In our area, and it may have happened in some other areas of the country, I was actually solicited by a pediatric ophthalmologist who was looking to recruit amblyopic patients for a study involving NeuroVision. I didn’t have that much of a reaction at first and I said hmm this is interesting --- there seems to be some collaboration between basic vision scientists and pediatric ophthalmologists. At first this seemed unlikely because ophthalmologists are not routinely interested in treating amblyopia beyond age seven or eight, and this treatment was earmarked for patients between age 9 and 55. Irrespective of what I thought of the ability to improve amblyopia beyond age nine, which all of you sitting in this room already know, now it seemed like the rest of the world had discovered what we have known all along. Or at least a whole new way of doing it in a more systematic fashion.

So we've all have our methodologies, but when I saw this technology to my office and I as it in action I said "wow!" Uri has mentioned that when treating amblyopia we think in different terms. Those of you who have read Ciuffreda, Levi and Selenow’s book on Amblyopia will be aware that a reduction in visual acuity is simply the tip of the iceberg. Actually, reduced acuity is what we measure all these other deficits that degrade the image becomes more obvious as the patient reads the eye chart. But what about all these underlying factors? We measure accommodation, eye movements, contrast sensitivity, spatial orientation and so forth but although we have the ability to measure things in a systematic fashion our treatment does not always follow such a sequential or systematic pattern. When you actually look at the training paradigm used here, it is obvious that training aspects of crowding, spatial frequency, interaction, excitation, inhibition and so on are factored in. We like to think that we are scientific and train our patients systematically. Yet we tend to be complacent because we are already doing so much more than simply patching any eye or using atropine penalization --- mainstays of amblyopia therapy certinaly in ophthalmology if not Optometry.

I began to look at NeuroVision as I do at many other things that I use in therapy. It appeared to be a significant tool that we could add to what we are already doing. Interestingly, as Uri has already said, the NeuroVision treatment does not directly address binocular therapy. In the beginning, the sessions last a bit longer as the visual system is actually learning in terms of the perceptual judgements it is capable of doing. The paradigm is to find the threshold of the amblyopic eye, and to keep working around this threshold. You are doing this about on an average 40 –45 minutes and ideally 2-3 times a week, and the patient is working the entire time. It is very intense, although you can take pauses and breaks. Realize that you are training things other than perceptual judgements. You are training sustained attention and fixation. Since this is being done with a filter over the good eye, it is a form of monocular fixation in a binocular field. And it is cumulative --- the better you do, the harder it gets

Another attractive feature of this technology is that there is someone monitoring the patient’s performance through the Internet. It’s as if there’s this little genie in the box who sends messages the next time you log on. Message like “nice work”; “keep going” etc. The patient is also encouraged to type in their comments at the end of every session, whether it was easy or difficult. I can guarantee that it is never going to be easy. There is always a warm up before every session to remind the patient of what the tasks are. There are a variety of tasks so that one may not remember exactly what to do if it has been awhile since the previous session.

The last thing that I want to mention is that, in Amblyopia, we know that the fellow eye is not entirely normal. During NeuroVision treatment, we measure visual acuity at the end of every five sessions in both eyes, and we are doing it on a Bailey Lovie (logMAR) chart which exposes the eyes to crowding. At the outset of therapy, you will usually see a crowding effect even in the non-amblyopic eye. This decreases even through therapy, even though you are not doing any direct work on the non amblyopic eye.

Evidently, with NeuroVision, there is some binocular facilitation despite the fact that we’re working primarily on the monocular aspects of the amblyopic eye. This is not shocking to us for the simple fact of what we already know: interocular transfer is always going on and perceptual learning is happening in the brain…. Perceptual learning is a paradigm that is useful in facilitating cooperation between the two eyes through interocular as well as interhemispheric transfer.