Amblyopia is a developmental visual disorder of cortical origin, characterized by crowding and poor acuity in central vision of the affected eye. Crowding refers to the adverse effects of surrounding items on object identification, common only in normal peripheral but not central vision. We trained a group of adult human amblyopes on a crowded letter identification task to assess whether the crowding problem can be ameliorated. Letter size was fixed well above the acuity limit, and letter spacing was varied to obtain spacing thresholds for central target identification. Normally sighted observers practiced the same task in their lower peripheral visual field. Independent measures of acuity were taken in flanked and unflanked conditions before and after training to measure crowding ratios at three fixed letter separations. Practice improved the letter spacing thresholds of both groups on the training task, and crowding ratios were reduced after posttest. The reductions in crowding in amblyopes were associated with improvements in standard measures of visual acuity. Thus, perceptual learning reduced the deleterious effects of crowding in amblyopia and in the normal periphery. The results support the effectiveness of plasticity-based approaches for improving vision in adult amblyopes and suggest experience-dependent effects on the cortical substrates of crowding.

Background: Amblyopia presents early in childhood and affects approximately 3% of western populations. The monocular visual acuity loss is conventionally treated during the 'critical periods' of visual development by occluding or penalising the fellow eye to encourage use of the amblyopic eye. Despite the measurable success of this approach in many children, substantial numbers of people still suffer with amblyopia later in life because either they were never diagnosed in childhood, did not respond to the original treatment, the amblyopia was only partially remediated, or their acuity loss returned after cessation of treatment. Purpose: In this review, we consider whether the visual deficits of this largely overlooked amblyopic group are amenable to conventional and innovative therapeutic interventions later in life, well beyond the age at which treatment is thought to be effective. Recent findings: There is a considerable body of evidence that residual plasticity is present in the adult visual brain and this can be harnessed to improve function in adults with amblyopia. Perceptual training protocols have been developed to optimise visual gains in this clinical population. Results thus far are extremely encouraging; marked visual improvements have been demonstrated, the perceptual benefits transfer to new visual tasks and appear to be relatively enduring. The essential ingredients of perceptual training protocols are being incorporated into video game formats, facilitating home-based interventions. Summary: Many studies support perceptual training as a tool for improving vision in amblyopes beyond the critical period. Should this novel form of treatment stand up to the scrutiny of a randomised controlled trial, clinicians may need to re-evaluate their therapeutic approach to adults with amblyopia.

What determines how much an organism can learn? One possibility is that the neural factors that limit sensory performance prior to learning, place an upper limit on the amount of learning that can take place. We tested this idea by comparing learning on a sensory task where performance is limited by cortical mechanisms, at two retinal eccentricities. Prior to learning, visual performance at the two eccentricities was either unmatched or equated in two different ways (through spatial scaling or visual crowding). The magnitude of learning was equivalent when initial levels of performance were matched regardless of how performance was equated. The magnitude of learning was a constant proportion of initial performance. This Weber-like law for perceptual learning demonstrates that it should be possible to predict the degree of perceptual improvement and the final level of performance that can be achieved via sensory training, regardless of what cortical constraint limits performance.

Disruption of visual input to one eye during early development leads to marked functional impairments of vision, commonly referred to as amblyopia. A major consequence of amblyopia is the inability to encode binocular disparity information leading to impaired depth perception or stereo acuity. If amblyopia is treated early in life (before 4 years of age), then recovery of normal stereoscopic function is possible. Treatment is rarely undertaken later in life (adulthood) because declining levels of neural plasticity are thought to limit the effectiveness of standard treatments. Here, the authors show that a learning-based therapy, designed to exploit experience-dependent plastic mechanisms, can be used to recover stereoscopic visual function in adults with amblyopia. These cases challenge the long-held dogma that the critical period for visual development and the window for treating amblyopia are one and the same.

Mapping the pattern of learning onto the known deficit space for amblyopia enabled the identification of tasks and stimulus configurations that optimized learning, guiding further development of learning-based interventions in this clinical group.

The ability to identify a target is reduced by the presence of nearby objects, a phenomenon known as visual crowding. The extent to which crowding impairs our perception is generally governed by the degree of similarity between a target stimulus and its surrounding flankers. Here we investigated the influence of disparity differences between target and flankers on crowding. Orientation discrimination thresholds for a parafoveal target were first measured when the target and flankers were presented at the same depth to establish a flanker separation that induced a significant elevation in threshold for each individual. Flankers were subsequently fixed at this spatial separation while the disparity of the flankers relative to the target was altered. For all participants, thresholds showed a systematic decrease as flanker-target disparity increased. The resulting tuning function was asymmetric: Crowding was lower when the target was perceived to be in front of the flankers rather than behind. A series of control experiments confirmed that these effects were driven by disparity, as opposed to other factors such as flanker-target separation in three-dimensional (3-D) space or monocular positional offsets used to create disparity. When flankers were distributed over a range of crossed and uncrossed disparities, such that the mean was in the plane of the target, there was an equivalent or greater release of crowding compared to when all flankers were presented at the maximum disparity of that range. Overall, our results suggest that depth cues can reduce the effects of visual crowding, and that this reduction is unlikely to be caused by grouping of flankers or positional shifts in the monocular image.

It is now widely accepted that primary cortical areas of the brain that were once thought to be sensory-specific undergo significant functional reorganisation following sensory deprivation. For instance, loss of vision or audition leads to the brain areas normally associated with these senses being recruited by the remaining sensory modalities [1]. Despite this, little is known about the rules governing crossmodal plasticity in people who experience typical sensory development, or the potential behavioural consequences. Here, we used a novel perceptual learning paradigm to assess whether the benefits associated with training on a task in one sense transfer to another sense. Participants were randomly assigned to a spatial or temporal task that could be performed visually or aurally, which they practiced for five days; before and after training, we measured discrimination thresholds on all four conditions and calculated the extent of transfer between them. Our results show a clear transfer of learning between sensory modalities; however, generalisation was limited to particular conditions. Specifically, learned improvements on the spatial task transferred from the visual domain to the auditory domain, but not vice versa. Conversely, benefits derived from training on the temporal task transferred from the auditory domain to visual domain, but not vice versa. These results suggest a unidirectional transfer of perceptual learning from dominant to non-dominant sensory modalities and place important constraints on models of multisensory processing and plasticity.

Perceptual learning of visual tasks is emerging as a promising treatment for amblyopia, a developmental disorder of vision characterized by poor monocular visual acuity. The tasks tested thus far span the gamut from basic psychophysical discriminations to visually complex video games. One end of the spectrum offers precise control over stimulus parameters, whilst the other delivers the benefits of motivation and reward that sustain practice over long periods. Here, we combined the advantages of both approaches by developing a video game that trains contrast sensitivity, which in psychophysical experiments, is associated with significant improvements in visual acuity in amblyopia. Target contrast was varied adaptively in the game to derive a contrast threshold for each session. We tested the game on 20 amblyopic subjects (10 children and 10 adults), who played at home using their amblyopic eye for an average of 37 sessions (approximately 11 h). Contrast thresholds from the game improved reliably for adults but not for children. However, logMAR acuity improved for both groups (mean = 1.3 lines; range = 0–3.6 lines). We present the rationale leading to the development of the game and describe the challenges of incorporating psychophysical methods into game-like settings.