Advances in behavioral vision training for the treatment of childhood amblyopia: a narrative review

Childhood amblyopia is a common neurodevelopmental disorder that impairs visual function and binocular integration. Traditional treatments, such as occlusion and pharmacological penalization, are often limited by poor adherence, incomplete restoration of binocular function, and variable response across patients. Behavioral vision training, grounded in principles of neural plasticity, has emerged as a promising alternative. This narrative review synthesizes the literature on behavioral vision training for pediatric amblyopia, focusing on its theoretical basis, main technical modalities, effects on multidimensional visual outcomes, comparison with traditional therapy, combination strategies, adherence, and influencing factors.

The PubMed and Web of Science databases were searched for literature published from January 1, 2015 to December 31, 2025. Search terms included combinations related to children, amblyopia, behavioral vision training, perceptual learning, dichoptic training, digital therapeutics, and virtual reality (VR). Studies were selected based on predefined inclusion and exclusion criteria, with data extraction and quality assessment performed independently by two reviewers. The heterogeneity of intervention protocols and outcome measures precluded quantitative synthesis, making a narrative review the appropriate approach.

A total of 100 original studies were included, comprising randomized controlled trials (RCTs), prospective and retrospective cohort studies, and single-arm interventional trials. The evidence base remains moderate in quality, with substantial heterogeneity in training protocols, outcome measures, and follow-up durations. Behavioral vision training encompasses monocular perceptual learning, dichoptic training, gamified digital therapeutics, and VR-based interventions. These approaches have demonstrated varying degrees of efficacy in improving best-corrected visual acuity (BCVA), stereopsis, contrast sensitivity (CS), and other visual functions. Direct comparisons with traditional occlusion therapy yield mixed results: some well-designed noninferiority trials show comparable or superior outcomes under specific conditions, while others report no advantage. Combination strategies integrating behavioral training with occlusion may provide synergistic benefits, particularly for children with suboptimal response to monotherapy. Adherence rates vary considerably (range 56-98%) and are influenced by training design, supervision, and delivery platform. Age, amblyopia subtype, and training dose appear to be important modifiers of treatment response. Key challenges include the lack of standardized protocols, insufficient long-term follow-up data, heterogeneity in study designs, and emerging safety considerations regarding ocular biometric changes.

Behavioral vision training represents a promising and evolving therapeutic approach for childhood amblyopia, offering the potential to address the limitations of traditional occlusion therapy through active, engaging, and mechanism-targeted interventions. The evidence supports its effectiveness in improving both monocular and binocular outcomes, but the field requires high-quality, long-term RCTs to establish standardized protocols, optimize patient selection, and clarify long-term safety profiles.