Beyond monocular acuity: Resolving the amblyopia treatment paradox with mechanism-targeted outcomes and modern testing methods
- 1Eye Center of Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China; Zhejiang Provincial Key Laboratory of Ophthalmology, Zhejiang Provincial Clinical Research Center for Eye Diseases, Zhejiang Provincial Engineering Institute on Eye Diseases, Hangzhou, China
- 2Department of Psychology, Zhejiang Sci-Tech University, Hangzhou, China
- 3Eye Center of Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China; Zhejiang Provincial Key Laboratory of Ophthalmology, Zhejiang Provincial Clinical Research Center for Eye Diseases, Zhejiang Provincial Engineering Institute on Eye Diseases, Hangzhou, China; Corresponding author.
Abstract
Background: Amblyopia is a neurodevelopmental disorder affecting approximately 1%–5% of the population and has traditionally been treated based on reduced monocular visual acuity. However, growing evidence indicates that amblyopia involves broader deficits spanning low- and high-level visual processing, many of which persist even after successful acuity restoration and cannot be explained solely by acuity loss of the poor eye. Main text: Despite the expanded understanding and the development of binocular (dichoptic) therapies designed to rebalance interocular suppression, clinical trials over the past decade comparing binocular and occlusion therapies have remained largely focused on monocular visual acuity gains. Measures of binocular function were typically limited to coarse clinical stereoacuity tests, which lack the sensitivity needed to detect subtle yet meaningful functional improvements. This therapeutic paradox—targeting binocular mechanisms while evaluating outcomes mainly through monocular acuity—constrains our ability to properly assess emerging interventions. In this review, we summarize multilevel dysfunctions in amblyopia, evaluate outcome measures used in binocular therapy trials, and outline modern testing methods for rapid and clinically feasible assessment of binocular and higher-level visual functions. We propose a tiered framework for outcome selection that balances mechanistic relevance with feasibility by retaining visual acuity alongside at least one quantitative measure of binocular balance or suppression and one sensitive stereopsis assessment, with additional measures included when relevant to the intervention. We also highlight the need for open-source tools, standardized protocols, and reproducible research practices to improve accessibility and cross-study comparability of different testing methods for evaluating multi-level impairments in amblyopia. Conclusions: Advances in the understanding of amblyopia and the development of mechanism-targeted binocular therapies require a corresponding shift in how treatment outcomes are evaluated. Reliance on monocular acuity alone is insufficient to capture the broader functional deficits and recovery processes associated with amblyopia. A flexible, mechanism-driven, and clinically feasible testing strategy using a battery of tests is needed to align outcome measures with therapeutic targets and to better evaluate functional recovery across multiple domains of visual processing.
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BibTeX
@article{gong2026beyond,
title = {{Beyond monocular acuity: Resolving the amblyopia treatment paradox with mechanism-targeted outcomes and modern testing methods}},
author = {Ling Gong and Seung Hyun Min and Xiaoning Yu and Lixia Lou and Yidong Zhang and Zhaohui Sun and Xiajing Tang},
journal = {Advances in Ophthalmology Practice and Research},
year = {2026},
month = jun,
doi = {10.1016/j.aopr.2026.06.003},
url = {https://doi.org/10.1016/j.aopr.2026.06.003},
note = {CC BY-NC-ND 4.0},
}
RIS
TY - JOUR
TI - Beyond monocular acuity: Resolving the amblyopia treatment paradox with mechanism-targeted outcomes and modern testing methods
AU - Ling Gong
AU - Seung Hyun Min
AU - Xiaoning Yu
AU - Lixia Lou
AU - Yidong Zhang
AU - Zhaohui Sun
AU - Xiajing Tang
PY - 2026
DA - 2026/06/12
JO - Advances in Ophthalmology Practice and Research
DO - 10.1016/j.aopr.2026.06.003
UR - https://doi.org/10.1016/j.aopr.2026.06.003
AB - Background: Amblyopia is a neurodevelopmental disorder affecting approximately 1%–5% of the population and has traditionally been treated based on reduced monocular visual acuity. However, growing evidence indicates that amblyopia involves broader deficits spanning low- and high-level visual processing, many of which persist even after successful acuity restoration and cannot be explained solely by acuity loss of the poor eye. Main text: Despite the expanded understanding and the development of binocular (dichoptic) therapies designed to rebalance interocular suppression, clinical trials over the past decade comparing binocular and occlusion therapies have remained largely focused on monocular visual acuity gains. Measures of binocular function were typically limited to coarse clinical stereoacuity tests, which lack the sensitivity needed to detect subtle yet meaningful functional improvements. This therapeutic paradox—targeting binocular mechanisms while evaluating outcomes mainly through monocular acuity—constrains our ability to properly assess emerging interventions. In this review, we summarize multilevel dysfunctions in amblyopia, evaluate outcome measures used in binocular therapy trials, and outline modern testing methods for rapid and clinically feasible assessment of binocular and higher-level visual functions. We propose a tiered framework for outcome selection that balances mechanistic relevance with feasibility by retaining visual acuity alongside at least one quantitative measure of binocular balance or suppression and one sensitive stereopsis assessment, with additional measures included when relevant to the intervention. We also highlight the need for open-source tools, standardized protocols, and reproducible research practices to improve accessibility and cross-study comparability of different testing methods for evaluating multi-level impairments in amblyopia. Conclusions: Advances in the understanding of amblyopia and the development of mechanism-targeted binocular therapies require a corresponding shift in how treatment outcomes are evaluated. Reliance on monocular acuity alone is insufficient to capture the broader functional deficits and recovery processes associated with amblyopia. A flexible, mechanism-driven, and clinically feasible testing strategy using a battery of tests is needed to align outcome measures with therapeutic targets and to better evaluate functional recovery across multiple domains of visual processing.
SN - 2667-3762
ER -