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Background Amblyopia (lazy eye) affects the vision of approximately 2% of all children. Traditional treatment consists of wearing a patch over their ‘good’ eye for a number of hours daily, over several months. This treatment is unpopular and compliance is often low. Therefore, results can be poor. I-BiT is a system, based on stereo technology using shutter glasses, designed to treat amblyopia using dichoptic stimulation. This trial uses a redesigned system for home use and includes eye-tracking capability. Methods/design This is a randomised controlled trial involving three groups of 40 patients each, aged between 3.5 and 12 years, with a diagnosis of (1) anisometropic amblyopia, (2) mixed or strabismic amblyopia prior to strabismic surgery and (3) mixed or strabismic amblyopia who have just undergone strabismus surgery. They will be randomised in a 1:1 ratio between I-BiT and control and will receive treatment, at home over a 6-week period. Their visual acuity will be assessed independently at baseline, mid-treatment (week 3), at the end of treatment (week 6) and, for those receiving the active I-BiT treatment, 4 weeks after completing treatment (week 10). The primary endpoint will be the change in visual acuity from baseline to the end of treatment. Secondary endpoints will be additional visual acuity measures, patient acceptability, compliance and the incidence of adverse events. Discussion This is a randomised controlled trial using the redesigned I-BiT™ system to determine if this is a feasible treatment strategy for the management of anisometropic, strabismic and mixed amblyopia. Trial registration ISRCTN Number/Clinical trials.gov, ID: NCT02810847 . Registered on 23 June 2016.

The ability to adapt is critical to survival and varies between individuals. Adaptation of one motor system may be related to the ability to adapt another. This study sought to determine whether phoria adaptation was correlated with the ability to modify the dynamics of disparity vergence. Eye movements from ten subjects were recorded during dynamic disparity vergence modification and phoria adaptation experiments. Two different convergent stimuli were presented during the dynamic vergence modification experiment: a test stimulus (4° step) and a conditioning stimulus (4° double step). Dynamic disparity vergence responses were quantified by measuring the peak velocity (°/s). Phoria adaptation experiments measured the changes in phoria over a 5-min period of sustained fixation. The maximum velocity of phoria adaptation was determined from an exponential fit of the phoria data points. Phoria and dynamic disparity vergence peak velocity were both significantly modified ( P  < 0.001). The maximum velocity of phoria adaptation was significantly correlated with the changes in convergence peak velocity ( r  > 0.89; P  < 0.001). There was a strong correlation between the ability to adaptively adjust two different oculomotor parameters: a tonic and dynamic component. Future studies should investigate additional interactions between these parameters, and the ability to adaptively change other oculomotor systems such as the saccadic or smooth pursuit system. Understanding the ability to modify phoria, dynamic disparity vergence, and other oculomotor parameters can yield insights into the plasticity of short-term adaptation mechanisms.

In this study, we propose a generative data augmentation technique to overcome the challenges of severely limited data when designing a deep learning-based automated strabismus diagnosis system. We implement a generative model based on the StyleGAN2-ADA model for system design and assess strabismus classification performance using two classifiers. We evaluate the capability of our proposed method against traditional data augmentation techniques and confirm a substantial enhancement in performance. Furthermore, we conduct experiments to explore the relationship between the diagnosis agreement among ophthalmologists and the generation performance of the generative model. Beyond FID, we validate the generative samples on the classifier to establish their practicality. Through these experiments, we demonstrate that the generative model-based data augmentation improves overall quantitative performance in scenarios of extreme data scarcity and effectively mitigates overfitting issues during deep learning model training.

Strabismus, or eye misalignment, is a common condition affecting individuals of all ages. Early detection and accurate classification are essential for proper treatment and avoiding long-term complications. This research presents a new deep-learning-based approach for automatically identifying and classifying strabismus from facial images. The proposed methodology leverages Convolutional Neural Networks (CNNs) to achieve high accuracy in both binary (strabismus vs. normal) and multi-class (eight-class deviation angle for esotropia and exotropia) classification tasks. The dataset for binary classification consisted of 4,257 facial images, including 1,599 normal cases and 2,658 strabismus cases, while the multi-class classification involved 480 strabismic and 142 non-strabismic images. These images were labeled based on ophthalmologist measurements using the Alternate Prism Cover Test (APCT) or the Modified Krimsky Test (MK). Five-fold cross-validation was employed, and performance was evaluated using sensitivity, accuracy, F1-score, and recall metrics. The proposed deep learning model achieved an accuracy of 86.38% for binary classification and 92.7% for multi-class classification. These results demonstrate the potential of our approach to assist healthcare professionals in early strabismus detection and treatment planning, ultimately improving patient outcomes.

Uncorrected or undercorrected refractive errors affect 153 million individuals globally, leading to vision impairment and associated quality of life issues. Accurate measurement of refractive errors in children especially with strabismus is critical for effective management. This study evaluates the agreement between near retinoscopy (Mohindra retinoscopy) and cycloplegic autorefractometry in measuring refractive errors among children diagnosed with strabismus. Forty-three strabismic children (18 males, 25 females; ages 3-10 years; mean age 5.5 yo) underwent refractive error evaluations using both methods: Mohindra retinoscopy and cycloplegic autorefractometry. The study assessed spherical component, spherical equivalent, cylinder power, and cylinder vectors J0 and J45. Statistical analyses, including Wilcoxon test Student's t-test, Bland-Altman analysis, Intraclass Correlation Coefficient (ICC) analysis and correlations (supplementary analysis) evaluated differences, correlations and agreement between the two methods. The median spherical component of refractive error was almost equal for both methods used (+4.38 D vs. + 4.50, for Mohindra retinoscopy and cycloplegic autorefractometry, respectively; P = .54), as well as median spherical refractive equivalent (+4.25 for both methods; P = .29). Mean spherical components of refractive errors were nearly identical across both methods, showing Mohindra retinoscopy provided slightly higher hyperopic measurements (0.03 D more positive), whereas spherical equivalent of refractive error showed 0.07 D more positive results for Mohindra retinoscopy than cycloplegic autorefractometry. Median cylinder powers were the same for both methods (-0.50 D; P = .25). No differences were also found for J0 (P = .91) and J45 vectors (P = .88) between Mohindra retinoscopy and cycloplegic autorefractometry. Near retinoscopy demonstrates comparable accuracy to cycloplegic autorefractometry in children with strabismus. These findings suggest that Mohindra retinoscopy may be used effectively without the need for cycloplegic intervention during follow-up visits, though further research is warranted to confirm its applicability.

To develop and validate an artificial intelligence pipeline for binary screening of horizontal strabismus versus orthotropia using smartphone-acquired facial images and geometric landmark analysis. This two-stage system combines Real-Time Detection Transformer (RT-DETR) to localize nine ocular landmarks per eye across three gaze directions (left, center, right), and supervised machine learning classifiers. A feature set of five biometric ratios was derived from coordinates including the canthi, limbi, and corneal light reflexes. The model was trained on facial images from 150 participants (96 with strabismus and 54 controls). To address class imbalance and improve generalizability, Synthetic Minority Oversampling Technique (SMOTE) and 4-fold cross-validation were applied. RT-DETR achieved an intersection over union of 0.62 and a mean center-point error of 6.52 pixels in landmark localization. The Random Forest classifier achieved an accuracy of 0.95, sensitivity of 0.96, specificity of 0.94, positive predictive value of 0.97, and negative predictive value of 0.92. This study demonstrates the feasibility of combining transformer-based landmark detection with geometric ratios for strabismus screening. The framework shows high performance under controlled conditions. While the use of biometric ratios allows for feature-level inspection, further research is required to establish full clinical interpretability and performance in uncontrolled environments.

Previous neuroimaging studies demonstrated that patients with strabismus or amblyopia can show significant functional and anatomical changes in the brain, but alterations of interhemispheric functional connectivity (FC) have not been well studied in this population. The current study analyzed whole-brain changes of interhemispheric FC in children with strabismus and amblyopia (CSA) using voxel-mirrored homotopic connectivity (VMHC).A total of 24 CSA (16 males and 8 females) and 24 normal controls (NCs) consisting of 16 and 8 age-, sex, and education-matched males and females, respectively, underwent functional magnetic resonance imaging (fMRI) scans in the resting state. According to Gaussian random field theory, changes in the resting state FC (rsFC) between hemispheres were evaluated using the VMHC method. The relationships between mean VMHC values in multiple brain regions and behavioral performance were evaluated by Pearson correlation analysis. In contrast to NCs, the CSA group showed significantly decreased VMHC values in the bilateral cerebellum, bilateral frontal superior orbital (frontal sup orb), bilateral temporal inferior(temporal inf),and bilateral frontal superior(frontal sup). CSA have abnormal interhemispheric FC in many brain regions, which may reflect dysfunction of eye movements and visual fusion. These findings might provide insight into the underlying pathogenetic mechanisms of CSA.

Objectives Considering the escalating incidence of strabismus and its consequential jeopardy to binocular vision, there is an imperative demand for expeditious and precise screening methods. This study was to develop an artificial intelligence (AI) platform in the form of an applet that facilitates the screening and management of strabismus on any mobile device. Methods The Visual Transformer (VIT_16_224) was developed using primary gaze photos from two datasets covering different ages. The AI model was evaluated by 5-fold cross-validation set and tested on an independent test set. The diagnostic performance of the AI model was assessed by calculating the Accuracy, Precision, Specificity, Sensitivity, F1-Score and Area Under the Curve (AUC). Results A total of 6194 photos with corneal light-reflection (with 2938 Exotropia, 1415 Esotropia, 739 Vertical Deviation and 1562 Orthotropy) were included. In the internal validation set, the AI model achieved an Accuracy of 0.980, Precision of 0.941, Specificity of 0.979, Sensitivity of 0.958, F1-Score of 0.951 and AUC of 0.994. In the independent test set, the AI model achieved an Accuracy of 0.967, Precision of 0.980, Specificity of 0.970, Sensitivity of 0.960, F1-Score of 0.975 and AUC of 0.993. Conclusions Our study presents an advanced AI model for strabismus screening which integrates electronic archives for comprehensive patient histories. Additionally, it includes a patient-physician interaction module for streamlined communication. This innovative platform offers a complete solution for strabismus care, from screening to long-term follow-up, advancing ophthalmology through AI technology for improved patient outcomes and eye care quality.

Purpose Our study presents a virtual reality-based tangent screen test (VTS) to measure subjective ocular deviations including torsion in nine directions of gaze. The test was compared to the analogous Harms tangent screen test (HTS). Methods We used an Oculus Go ® controller and head-mounted-display with rotation sensors to measure patient’s head orientation for the VTS. The software was developed with Unity ® . We assessed subjective squint angles of adult patients with eye motility disorders of different origin in nine positions of gaze by means of HTS and VTS. We calculated mean difference, 95% limits of agreement and intraclass correlations (ICC) for horizontal, vertical and torsional deviations. Results We included 85 patients. Measured horizontal and vertical deviations showed very good agreement between the two methods in all gaze directions (horizontal and vertical ICC: 0.93–0.98). Agreement was lower for torsional deviations (ICC: 0.79–0.93). The mean difference in primary position was 1.5° (95% limits of agreement -3.5° to 6.5°) for horizontal, 0° (-2,7° to 2,7°) for vertical, and 0.3° (-4.0° to 3.0°) for torsional deviations. The average examination time was 6 min with the VTS compared to 15 min with the HTS. Conclusions Vertical and horizontal deviations showed good agreement between both tests measuring a slightly higher esodeviation with VTS probably due to an increased vergence demand. Measurement of torsional misalignment would benefit from a controller with more holding stability, such as a PC-mouse with central wheel, facilitating fine adjustments. VTS allowed automatic documentation, required less time and was easier to use than HTS. Key messages What is known The incidence of neurogenic diplopia increases in the ageing population. The Harms tangent screen test (HTS) reliably measures subjective ocular deviations in patients with diplopia. The HTS requires staff well-trained in orthoptics limiting its use. What is new A novel virtual reality-based tangent screen test (VTS) enables measurement of horizontal, vertical and torsional ocular misalignment and shows a good comparability to the HTS. VTS uses commercially available head-mounted-display and controller, and specifically developed software, requires less time than HTS and allows automatic documentation. VTS administration does not require orthoptic training and can eventually be implemented in a clinical setting to provide a wider availability of subjective squint angle measurements.

PurposeTo describe the types of strabismus operated on, the surgical procedures performed, and the 2-year reoperation rate in France.MethodsEntire population 5-year cross-sectional analysis of a national medico-administrative database in France between January 2013 and December 2017 included all patients who underwent a first strabismus surgery, with a 2-year follow-up. Patient identification was based on the diagnostic codes of the 10th International Classification of Diseases and surgical procedures on the codes of the Common Classification of Medical Acts. A subgroup analysis comparing non-paralytic and paralytic strabismus was performed.ResultsAmong the 56,654 patients included (women: 50.8%), 26,892 (47.5%) patients were under 10 years old. Overall, 52,711 (93%) were diagnosed with non-paralytic strabismus and 3,943 (7%) with paralytic strabismus. Among the non-paralytics, the most frequent diagnosis was esotropia (21,282, 37.6%), followed by exotropia (14,392, 25.4%) and vertical strabismus (2,017, 3.6%). Among the paralytics, fourth cranial nerve palsy (1,499, 2.6%) was more frequent than sixth cranial nerve palsy (691, 1.2%) and third cranial nerve palsy (431, 0.8%). The 2-year reoperation rate was 7.7% (4,362 patients), the lowest for non-paralytic (7.4%) and the highest for paralytic (11.4%).ConclusionThis first French population-based study about strabismus will contribute to the evaluation of practices at a national level and permit comparisons between countries. Although the 2-year reoperation rate was found to be 1 out of 13 patients, it should be interpreted with caution. Long-term follow-up is still warranted due to considerable variability of the type and severity of strabismus as well as surgical practices.