Binocular Dig Rush Game Treatment for Amblyopia

Not Applicable

Completed

Conditions: Amblyopia

Interventions: Other: iPad®
Other: Spectacle correction

Registration Number: NCT02983552

Lead Sponsor: Jaeb Center for Health Research

Brief Summary: To compare the efficacy of 1 hour/day of binocular game play 5 days per week plus spectacle correction with spectacle correction only, for treatment of amblyopia in children 4 to \<13 years of age.

Detailed Description: The purpose of the study is to compare the efficacy of 1 hour/day of binocular game play 5 days per week plus spectacle correction with spectacle correction only, for treatment of amblyopia in children 4 to \<13 years of age.

Recruitment & Eligibility

Status: COMPLETED

Sex: All

Target Recruitment: 320

Inclusion Criteria

Age 4 to <13 years
Amblyopia associated with strabismus, anisometropia, or both (previously treated or untreated)
1. Criteria for strabismic amblyopia: At least one of the following must be met:
  - Presence of a heterotropia on examination at distance or near fixation (with or without optical correction, must be no more than 5pd by SPCT at near fixation (see #6 below)
  - Documented history of strabismus which is no longer present (which in the judgment of the investigator could have caused amblyopia)
2. Criteria for anisometropia: At least one of the following criteria must be met:
  - ≥1.00 D difference between eyes in spherical equivalent
  - ≥1.50 D difference in astigmatism between corresponding meridians in the two eyes
3. Criteria for combined-mechanism amblyopia: Both of the following criteria must be met:
  - Criteria for strabismus are met (see above)
  - ≥1.00 D difference between eyes in spherical equivalent OR ≥1.50 D difference in astigmatism between corresponding meridians in the two eyes
No amblyopia treatment other than optical correction in the past 2 weeks (patching, atropine, Bangerter, vision therapy, binocular treatment)
Requirements for required refractive error correction (based on a cycloplegic refraction completed within the last 7 months):
- Hypermetropia of 2.50 D or more by spherical equivalent (SE)
- Myopia of amblyopic eye of 0.50D or more SE
- Astigmatism of 1.00D or more
- Anisometropia of more than 0.50D SE
NOTE: Subjects with cycloplegic refractive errors that do not fall within the requirements above for spectacle correction may be given spectacles at investigator discretion but must follow the study-specified prescribing guidelines, as detailed below.
1. Spectacle prescribing instructions referenced to the cycloplegic refraction completed within the last 7 months:
  - SE must be within 0.50D of fully correcting the anisometropia.
  - SE must not be under corrected by more than 1.50D SE, and reduction in plus sphere must be symmetric in the two eyes.
  - Cylinder power in both eyes must be within 0.50D of fully correcting the astigmatism.
  - Axis must be within +/- 10 degrees if cylinder power is ≤1.00D, and within +/- 5 degrees if cylinder power is >1.00D.
  - Myopia must not be undercorrected by more than 0.25D or over corrected by more than 0.50D SE, and any change must be symmetrical in the two eyes.
2. Spectacle correction meeting the above criteria must be worn:
  - For at least 16 weeks OR until VA stability is documented (defined as <0.1 logMAR change by the same testing method measured on 2 consecutive exams at least 8 weeks apart).
  - For determining VA stability (non-improvement):
    - The first of two measurements may be made 1) in current spectacles, or 2) in trial frames with or without cycloplegia or 3) without correction (if new correction is prescribed),
    - The second measurement must be made without cycloplegia in the correct spectacles that have been worn for at least 8 weeks.
    - Note: since this determination is a pre-study procedure, the method of measuring VA is not mandated.
VA, measured in each eye without cycloplegia in current spectacle correction (if applicable) within 7 days prior to randomization using the ATS-HOTV VA protocol for children < 7 years and the E-ETDRS VA protocol for children ≥ 7 years on a study-approved device displaying single surrounded optotypes, as follows:
1. VA in the amblyopic eye 20/40 to 20/200 inclusive (ATS-HOTV) or 33 to 72 letters (E-ETDRS)
2. VA in the fellow eye 20/25 or better (ATS-HOTV) or ≥ 78 letters (E-ETDRS)
3. Interocular difference ≥ 3 logMAR lines (ATS-HOTV) or ≥ 15 letters (E-ETDRS)
Heterotropia with a near deviation of ≤ 5∆ (measured by SPCT) in habitual correction (Angles of ocular deviation >5∆ are not allowed because large magnitudes of the deviation would compromise successful playing of the game.)
Subject is able to play the Dig Rush game (at least level 3) on the study iPad under binocular conditions (with red-green glasses). Subject must be able to see both the red "diggers" and blue "gold carts" when contrast for the non-amblyopic eye is at 20%.
Investigator is willing to prescribe computer game play, or continued spectacle wear per protocol.
Parent understands the protocol and is willing to accept randomization.
Parent has phone (or access to phone) and is willing to be contacted by Jaeb Center staff or other study staff.
Relocation outside of area of an active PEDIG site for this study within the next 8 weeks is not anticipated.

Exclusion Criteria

Prism in the spectacle correction at time of enrollment (eligible only if prism is discontinued 2 weeks prior to enrollment).
Myopia greater than -6.00D spherical equivalent in either eye.
Previous intraocular or refractive surgery.
Any treatment for amblyopia (patching, atropine, Bangerter filter, vision therapy or previous binocular treatment) during the past 2 weeks. Previous amblyopia therapy is allowed regardless of type, but must be discontinued at least 2 weeks prior to enrollment.
Ocular co-morbidity that may reduce VA determined by an ocular examination performed within the past 7 months (Note: nystagmus per se does not exclude the subject if the above VA criteria are met).
No Down syndrome or cerebral palsy
No severe developmental delay that would interfere with treatment or evaluation (in the opinion of the investigator). Subjects with mild speech delay or reading and/or learning disabilities are not excluded.
Subject has demonstrated previous low compliance with binocular treatment and/or spectacle treatment (as assessed informally by the investigator)

Study & Design

Study Type: INTERVENTIONAL

Study Design: PARALLEL

Arm && Interventions

Group	Intervention	Description
Binocular Computer Game Treatment	iPad®	Binocular computer game treatment is defined as playing a Dig Rush application on an iPad® 1 hour per day, 5 days per week for 8 weeks in addition to continued spectacle correction (if required)
Continued Spectacle Correction	Spectacle correction	Continued spectacle correction is defined as wearing appropriate spectacle correction (if required) for all waking hours, 7 days per week for 8 weeks.

Primary Outcome Measures

Name	Time	Method
Mean Change in Amblyopic-eye Visual Acuity (VA) Older Cohort	Baseline and 4 weeks	The primary objective is to compare the efficacy of 4 weeks of treatment with 1 hour/day of binocular game play 5 days per week plus spectacle correction to treatment with spectacle correction alone (control). Monocular distance visual acuity (VA) in current refractive correction (if required) in each eye by a certified examiner using the Electronic Early Treatment Diabetic Retinoscopy Study (E-ETDRS) visual acuity protocol for children ≥ 7 years on a study-certified acuity tester displaying single surrounded optotypes. For the analyses in the older cohort, the level of VA is measured as letter scores (approximate range: 0 to 97 letters, lower scores indicate poorer VA) and change in VA from baseline is measured in letters (positive values indicate improvement), defined as the difference in letter scores between enrollment and follow-up. Adjusted values have been adjusted for amblyopic-eye visual acuity at randomization.
Mean Visual Acuity (VA) in Amblyopic-eye (Older Cohort)	8 weeks	Monocular distance visual acuity (VA) in current refractive correction (if required) in each eye by a certified examiner using the Electronic Early Treatment Diabetic Retinoscopy Study (E-ETDRS) visual acuity protocol for children ≥ 7 years on a study-certified acuity tester displaying single surrounded optotypes. For the analyses in the older cohort, the level of VA is measured as letter scores (approximate range: 0 to 97 letters, lower scores indicate poorer VA) and change in VA from baseline is measured in letters (positive values indicate improvement), defined as the difference in letter scores between enrollment and follow-up.
Mean Change in Amblyopic-eye Visual Acuity (VA) in Older Cohort	Baseline and 8 weeks	Monocular distance visual acuity (VA) in current refractive correction (if required) in each eye by a certified examiner using the Electronic Early Treatment Diabetic Retinoscopy Study (E-ETDRS) visual acuity protocol for children ≥ 7 years on a study-certified acuity tester displaying single surrounded optotypes. For the analyses in the older cohort, the level of VA is measured as letter scores (approximate range: 0 to 97 letters, lower scores indicate poorer VA) and change in VA from baseline is measured in letters (positive values indicate improvement), defined as the difference in letter scores between enrollment and follow-up.
Mean Change in Amblyopic-eye Visual Acuity (VA) Younger Cohort	baseline and 4 weeks	The primary objective is to compare the efficacy of 4 weeks of treatment with 1 hour/day of binocular game play 5 days per week plus spectacle correction to treatment with spectacle correction alone (control). Monocular distance visual acuity (VA) in current refractive correction (if required) in each eye by a certified examiner using the Electronic Early Treatment Diabetic Retinoscopy Study (E-ETDRS) visual acuity protocol for children ≥ 7 years on a study-certified acuity tester displaying single surrounded optotypes. For the analyses in the younger cohort, the level of VA is measured in logMAR (approximate range: -0.2 to 1.2, lower scores indicate better VA) and change in VA from baseline is measured in logMAR lines (positive values indicate improvement), defined as 10 times the difference in logMAR between enrollment and follow-up. Adjusted values have been adjusted for amblyopic-eye visual acuity at randomization.
Mean Visual Acuity (VA) in Amblyopic-eye (Younger Cohort)	8 weeks	Monocular distance visual acuity (VA) in current refractive correction (if required) in each eye by a certified examiner using the Electronic Early Treatment Diabetic Retinoscopy Study (E-ETDRS) visual acuity protocol for children ≥ 7 years on a study-certified acuity tester displaying single surrounded optotypes. For the analyses in the younger cohort, the level of VA is measured in logMAR (approximate range: -0.2 to 1.2, lower scores indicate better VA) and change in VA from baseline is measured in logMAR lines (positive values indicate improvement), defined as 10 times the difference in logMAR between enrollment and follow-up.
Mean Change in Amblyopic-eye Visual Acuity (VA) in Younger Cohort	Baseline and 8 weeks	Monocular distance visual acuity (VA) in current refractive correction (if required) in each eye by a certified examiner using the Electronic Early Treatment Diabetic Retinoscopy Study (E-ETDRS) visual acuity protocol for children ≥ 7 years on a study-certified acuity tester displaying single surrounded optotypes. For the analyses in the younger cohort, the level of VA is measured in logMAR (approximate range: -0.2 to 1.2, lower scores indicate better VA) and change in VA from baseline is measured in logMAR lines (positive values indicate improvement), defined as 10 times the difference in logMAR between enrollment and follow-up.

Secondary Outcome Measures

Name	Time	Method
VA Improvement at 4 Weeks Defined as a Binary Outcome	At 4 weeks	A secondary analysis will estimate the proportion of subjects with amblyopic-eye VA improvement of ≥ 2 logMAR lines (≥ 10 letters if E-ETDRS) at 4 weeks after baseline.
VA Improvement at 8 Weeks Defined as a Binary Outcome	At 8 weeks	A secondary analysis will estimate the proportion of subjects with amblyopic-eye VA improvement of ≥ 2 logMAR lines (≥ 10 letters if E-ETDRS) at 8 weeks after baseline.
Distribution of Stereoacuity Scores at 4 Weeks	4 weeks	Stereoacuity will be tested at near in current refractive correction using the Randot Butterfly and Randot Preschool stereoacuity tests. Stereoacuity scores (measure as seconds of arc) were calculated based on the Randot Butterfly (scores: 2000, Nil) and Randot Preschool stereoacuity (scores: 800, 400, 200, 100, 60 and 40) test methods. Lower scores indicate better stereoacuity. Results of the Randot Butterfly test were analyzed as 2000 seconds of arc (if correct response). Nil was assigned a score of 4000 seconds of arc and was defined as (1) an incorrect response on the butterfly in absence of a correct response on the 800 seconds of arc level of the Randot Preschool stereoacuity test or (2) an incorrect response on the 800 seconds of arc level if the butterfly was not attempted.
Distribution of Change in Stereoacuity Scores From Baseline	8 weeks	Stereoacuity was tested at near in current refractive correction. Stereoacuity scores (seconds of arc) were calculated based on the Randot Butterfly (scores: 2000, Nil) and Randot Preschool stereoacuity (scores: 800, 400, 200, 100, 60 and 40) test methods. Lower scores indicate better stereoacuity. Results of the Randot Butterfly test were analyzed as 2000 (if correct response). Nil (4000) was defined as (1) an incorrect response on the butterfly in absence of a correct response on the 800 seconds of arc level of the Randot Preschool stereoacuity test or (2) an incorrect response on the 800 seconds of arc level if the butterfly was not attempted. For each visit, stereoacuity scores were ordered and assigned a rank score. Change in stereoacuity was calculated as the difference in ranked score between the enrollment and 8-week stereoacuity scores.
Distribution of Stereoacuity Scores at 8 Weeks	8 weeks	Stereoacuity will be tested at near in current refractive correction using the Randot Butterfly and Randot Preschool stereoacuity tests. Stereoacuity scores (measure as seconds of arc) were calculated based on the Randot Butterfly (scores: 2000, Nil) and Randot Preschool stereoacuity (scores: 800, 400, 200, 100, 60 and 40) test methods. Lower scores indicate better stereoacuity. Results of the Randot Butterfly test were analyzed as 2000 seconds of arc (if correct response). Nil was assigned a score of 4000 seconds of arc and was defined as (1) an incorrect response on the butterfly in absence of a correct response on the 800 seconds of arc level of the Randot Preschool stereoacuity test or (2) an incorrect response on the 800 seconds of arc level if the butterfly was not attempted.
Distribution of Stereoacuity Scores (Participants With no History of Strabismus)	8 weeks	Stereoacuity was tested at near in current refractive correction. Stereoacuity scores (measure as seconds of arc) were calculated based on the Randot Butterfly (scores: 2000, Nil) and Randot Preschool stereoacuity (scores: 800, 400, 200, 100, 60 and 40) test methods. Lower scores indicate better stereoacuity. Results of the Randot Butterfly test were analyzed as 2000 seconds of arc (if correct response). Nil was assigned a score of 4000 seconds of arc and was defined as (1) an incorrect response on the butterfly in absence of a correct response on the 800 seconds of arc level of the Randot Preschool stereoacuity test or (2) an incorrect response on the 800 seconds of arc level if the butterfly was not attempted.
Distribution of Change in Stereoacuity Scores From Baseline (Participants With no History of Strabismus)	8 weeks	Stereoacuity was tested at near in current refractive correction. Stereoacuity scores (seconds of arc) were calculated based on the Randot Butterfly (scores: 2000, Nil) and Randot Preschool stereoacuity (scores: 800, 400, 200, 100, 60 and 40) test methods. Lower scores indicate better stereoacuity. Results of the Randot Butterfly test were analyzed as 2000 (if correct response). Nil (4000) was defined as (1) an incorrect response on the butterfly in absence of a correct response on the 800 seconds of arc level of the Randot Preschool stereoacuity test or (2) an incorrect response on the 800 seconds of arc level if the butterfly was not attempted. For each visit, stereoacuity scores were ordered and assigned a rank score. Change in stereoacuity was calculated as the difference in ranked score between the enrollment and 4-week stereoacuity scores.
Binocular Therapy: Treatment Compliance and Fellow-Eye Contrast	8 weeks	Data from the automated iPad log files will be used to assess game performance as measured by the fellow-eye contrast. The level and change in fellow-eye contrast will be computed for the initial 4 weeks of treatment for the binocular treatment group. Secondary analyses will evaluate the relationship between the change in fellow-eye contrast with (1) change in VA and (2) change in stereoacuity after the first 8 weeks of binocular treatment. Data from the automated iPad log files will also be used to assess game performance as measured by the fellow-eye contrast.
Treatment Compliance With Spectacle Wear	8 weeks	Parent-reported adherence with spectacle wear (excluding participants with reported compliance of 'N/A') across 8 weeks. Patient reported to have completed \>75% of spectacle wear at 8 weeks.
Mean Change in Fellow Eye Visual Acuity at 4 Weeks (Older Cohort)	Baseline and 4 weeks	The mean change in fellow-eye VA from baseline to 4 weeks will be calculated and compared between treatment groups using ANCOVA with adjustment for baseline VA.
Mean Change in Fellow Eye VA at 8 Weeks (Older Cohort)	Baseline and 8 weeks	The mean change in fellow-eye VA from baseline to 8 weeks will be calculated and compared between treatment groups using ANCOVA with adjustment for baseline VA.
Ocular Alignment at 4 Weeks	4 weeks	The proportion of subjects with development of new strabismus (no heterotropia at baseline and the presence of near and/or distance heterotropia at 4 weeks) or an increase from baseline ≥10∆ in a pre-existing strabismus at 4 weeks will be reported by treatment group and compared using Barnard's exact test. Ocular alignment will be assessed in current refractive correction by the cover/uncover test, simultaneous prism and cover test (SPCT), and prism and alternate cover test (PACT) in primary gaze at distance (3 meters) and at near (1/3 meter). Participants were classified according to whether they met the any of the following criteria at the 4-week visit: development of a new tropia (measured by SPCT) and/or worsening of a pre-existing deviation by 10 prism diopters (pd) measured by SPCT.
Ocular Alignment at 8 Weeks	8 weeks	The proportion of subjects with development of new strabismus (no heterotropia at baseline and the presence of near and/or distance heterotropia at 8 weeks) or an increase from baseline ≥10∆ in a pre-existing strabismus at 8 weeks will be reported by treatment group and compared using Barnard's exact test. Ocular alignment will be assessed in current refractive correction by the cover/uncover test, simultaneous prism and cover test (SPCT), and prism and alternate cover test (PACT) in primary gaze at distance (3 meters) and at near (1/3 meter). Participants were classified according to whether they met the any of the following criteria at the 8-week visit: development of a new tropia (measured by SPCT) and/or worsening of a pre-existing deviation by 10 prism diopters (pd) measured by SPCT.
Distribution of Diplopia Frequency at 4 Weeks (Participant-reported)	4 weeks	The proportion of subjects with each level of diplopia frequency will be reported by treatment group at 4 weeks. A standardized questionnaire was administered to participants and their parents to assess the presence and frequency of any diplopia since the last study visit.
Distribution of Diplopia Frequency at 8 Weeks (Participant-reported)	8 weeks	The proportion of subjects with each level of diplopia frequency will be reported by treatment group at 8 weeks. A standardized questionnaire was administered to participants and their parents to assess the presence and frequency of any diplopia since the last study visit.
Change in Diplopia Frequency From Baseline to 4 Weeks (Participant-reported)	4 weeks	A standardized questionnaire was administered to participants and their parents to assess the presence and frequency of any diplopia since the last study visit. Change in diplopia frequency from baseline to 4 weeks was reported categorically.
Change in Diplopia Frequency From Baseline to 8 Weeks (Participant-reported)	8 weeks	A standardized questionnaire was administered to participants and their parents to assess the presence and frequency of any diplopia since the last study visit. Change in diplopia frequency from baseline to 8 weeks was reported categorically.
Distribution of Diplopia Frequency at 4 Weeks (Parent-reported)	4 weeks	The proportion of subjects with each level of diplopia frequency will be reported by treatment group at 4 weeks. A standardized questionnaire was administered to participants and their parents to assess the presence and frequency of any diplopia since the last study visit.
Distribution of Diplopia Frequency at 8 Weeks (Parent-reported)	8 weeks	The proportion of subjects with each level of diplopia frequency will be reported by treatment group at 8 weeks. A standardized questionnaire was administered to participants and their parents to assess the presence and frequency of any diplopia since the last study visit.
Change in Diplopia Frequency From Baseline to 4 Weeks (Parent-reported)	4 weeks	A standardized questionnaire was administered to participants and their parents to assess the presence and frequency of any diplopia since the last study visit. Change in diplopia frequency from baseline to 4 weeks was reported categorically.
Change in Diplopia Frequency From Baseline to 8 Weeks (Parent-reported)	8 weeks	A standardized questionnaire was administered to participants and their parents to assess the presence and frequency of any diplopia since the last study visit. Change in diplopia frequency from baseline to 8 weeks was reported categorically.
Frequency of Adverse Symptoms (Symptom Survey)	4 weeks	The child and parent(s) will complete a 5-item symptom survey regarding the presence of various ocular symptoms within the past 2 weeks at enrollment and at each visit. The distribution of scores on each symptom survey item will be described for the enrollment exam and the 4-week exam for each treatment group. The distribution of change in scores on each symptom survey item will also be described for each treatment group.
Frequency of Adverse Symptoms (Symptom Survey) at 8 Weeks	8 weeks	The child and parent(s) will complete a 5-item symptom survey regarding the presence of various ocular symptoms within the past 2 weeks at enrollment and at each visit. The distribution of scores on each symptom survey item will be described for the enrollment exam and the 4-week exam for each treatment group. The distribution of change in scores on each symptom survey item will also be described for each treatment group.
Distribution of Change in Adverse Symptom Frequency (Symptom Survey) From Baseline to 4 Weeks	4 weeks	The child and parent(s) will complete a 5-item symptom survey regarding the presence of various ocular symptoms within the past 2 weeks at enrollment and at each visit. The distribution of scores on each symptom survey item will be described for the enrollment exam and the 4-week exam for each treatment group. The distribution of change in scores on each symptom survey item will also be described for each treatment group.
Distribution of Change in Adverse Symptom Frequency (Symptom Survey) From Baseline to 8 Weeks	8 weeks	The child and parent(s) will complete a 5-item symptom survey regarding the presence of various ocular symptoms within the past 2 weeks at enrollment and at each visit. The distribution of scores on each symptom survey item will be described for the enrollment exam and the 8-week exam for each treatment group. The distribution of change in scores on each symptom survey item will also be described for each treatment group.
Mean Change in Fellow Eye Visual Acuity at 4 Weeks (Younger Cohort)	Baseline and 4 weeks	The mean change in fellow-eye VA from baseline to 4 weeks will be calculated and compared between treatment groups using ANCOVA with adjustment for baseline VA.
Mean Change in Fellow Eye VA at 8 Weeks (Younger Cohort)	baseline and 8 weeks	The mean change in fellow-eye VA from baseline to 8 weeks will be calculated and compared between treatment groups using ANCOVA with adjustment for baseline VA.

Trial Locations

Locations (62): University of Nebraska Medical Center
🇺🇸
Omaha, Nebraska, United States
Midwestern University Eye Institute
🇺🇸
Glendale, Arizona, United States
Mayo Clinic
🇺🇸
Rochester, Minnesota, United States
Concord Ophthalmologic Associates
🇺🇸
Concord, New Hampshire, United States
The Emory Eye Center
🇺🇸
Atlanta, Georgia, United States
St Luke's Hospital
🇺🇸
Boise, Idaho, United States
Greater Baltimore Medical Center
🇺🇸
Baltimore, Maryland, United States
Wilmer Eye Institute
🇺🇸
Baltimore, Maryland, United States
Pediatric Ophthalmology Associates, Inc.
🇺🇸
Columbus, Ohio, United States
Pediatric Eye Specialists
🇺🇸
Chattanooga, Tennessee, United States
University of Houston College of Optometry
🇺🇸
Houston, Texas, United States
Houston Eye Associates
🇺🇸
The Woodlands, Texas, United States
Western University College of Optometry
🇺🇸
Pomona, California, United States
Nova Southeastern University College of Optometry, The Eye Institute
🇺🇸
Fort Lauderdale, Florida, United States
University of Florida Shands Hospital
🇺🇸
Gainesville, Florida, United States
Ticho Eye Associates
🇺🇸
Chicago Ridge, Illinois, United States
Ann & Robert H. Lurie Children's Hospital of Chicago
🇺🇸
Chicago, Illinois, United States
Illinois College of Optometry
🇺🇸
Chicago, Illinois, United States
Progressive Eye Care
🇺🇸
Lisle, Illinois, United States
Pediatric Eye Associates
🇺🇸
Wilmette, Illinois, United States
Advanced Vision Center
🇺🇸
Schaumburg, Illinois, United States
Indiana School of Optometry
🇺🇸
Bloomington, Indiana, United States
University of Iowa Hospitals and Clinics
🇺🇸
Iowa City, Iowa, United States
Wolfe Eye Clinic
🇺🇸
West Des Moines, Iowa, United States
Children's Mercy Hospitals and Clinics
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Kansas City, Missouri, United States
Michigan College of Optometry at Ferris State Univ
🇺🇸
Big Rapids, Michigan, United States
Boston Children's Hospital
🇺🇸
Boston, Massachusetts, United States
Helen DeVos Children's Hospital Pediatric Ophthalmology
🇺🇸
Grand Rapids, Michigan, United States
Pediatric Ophthalmology, P.C.
🇺🇸
Grand Rapids, Michigan, United States
Saint Louis University Institute
🇺🇸
Saint Louis, Missouri, United States
U of MO St. Louis College of Optometry
🇺🇸
Saint Louis, Missouri, United States
St. Louis Children's Hospital Eye Center
🇺🇸
Saint Louis, Missouri, United States
Michael F. Gallaway, O.D., P.C.
🇺🇸
Marlton, New Jersey, United States
State University of New York, College of Optometry
🇺🇸
New York, New York, United States
Cincinnati Children's Hospital
🇺🇸
Cincinnati, Ohio, United States
University of North Carolina
🇺🇸
Chapel Hill, North Carolina, United States
The Ohio State University College of Optometry
🇺🇸
Columbus, Ohio, United States
Pacific University College of Optometry
🇺🇸
Portland, Oregon, United States
OHSU Casey Eye Institute
🇺🇸
Portland, Oregon, United States
Pediatric Ophthalmology of Erie
🇺🇸
Erie, Pennsylvania, United States
Conestoga Eye
🇺🇸
Lancaster, Pennsylvania, United States
Southern College of Optometry
🇺🇸
Memphis, Tennessee, United States
Texas Children's Hospital - Dept. Of Ophthalmology
🇺🇸
Houston, Texas, United States
Texas Tech University Health Science Center
🇺🇸
Lubbock, Texas, United States
Virginia Pediatric Eye Center
🇺🇸
Norfolk, Virginia, United States
Seattle Children's Hospital, University of Washington
🇺🇸
Seattle, Washington, United States
Northwest Pediatric Ophthalmology, P.S.
🇺🇸
Spokane, Washington, United States
Marshall University
🇺🇸
Huntington, West Virginia, United States
Spokane Eye Clinical Research
🇺🇸
Spokane, Washington, United States
University of Wisconsin, University Station
🇺🇸
Madison, Wisconsin, United States
Alberta Children's Hospital
🇨🇦
Calgary, Alberta, Canada
Snowy Range Vision Center
🇺🇸
Laramie, Wyoming, United States
University of Minnesota-Minnesota Lions Children's Eye Clinic
🇺🇸
Minneapolis, Minnesota, United States
Duke University Eye Center
🇺🇸
Durham, North Carolina, United States
Dean A. McGee Eye Institute, University of Oklahoma
🇺🇸
Oklahoma City, Oklahoma, United States
San Antonio Eye Center
🇺🇸
San Antonio, Texas, United States
University Eye Center at Ketchum Health
🇺🇸
Anaheim, California, United States
Loma Linda University Health Care, Dept. of Ophthalmology
🇺🇸
Loma Linda, California, United States
Saddleback Eye Medical Associates
🇺🇸
Mission Viejo, California, United States
UAB Pediatric Eye Care; Birmingham Health Care
🇺🇸
Birmingham, Alabama, United States
Yale University
🇺🇸
New Haven, Connecticut, United States
Eye Care Associates, Inc.
🇺🇸
Poland, Ohio, United States