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Background Traditional treatment of amblyopia involves either wearing a patch or atropine penalisation of the better eye. A new treatment is being developed on the basis of virtual reality technology allowing either DVD footage or computer games which present a common background to both eyes and the foreground, containing the imagery of interest, only to the amblyopic eye. Methods A randomised control trial was performed on patients with amblyopia aged 4–8 years with three arms. All three arms had dichoptic stimulation using shutter glass technology. One arm had DVD footage shown to the amblyopic eye and common background to both, the second used a modified shooter game, Nux, with sprite and targets presented to the amblyopic eye (and background to both) while the third arm had both background and foreground presented to both eyes (non-interactive binocular treatment (non-I-BiT) games). Results Seventy-five patients were randomised; 67 were residual amblyopes and 70 had an associated strabismus. The visual acuity improved in all three arms by approximately 0.07 logMAR in the amblyopic eye at 6 weeks. There was no difference between I-BiT DVD and non-I-BiT games compared with I-BiT games (stated primary outcome) in terms of gain in vision. Conclusions There was a modest vision improvement in all three arms. Treatment was well tolerated and safe. There was no difference between the three treatments in terms of primary stated outcomes but treatment duration was short and the high proportion of previously treated amblyopia and strabismic amblyopia disadvantaged dichoptic stimulation treatment.

Desktop Virtual Reality (VR) is an easy and affordable way to implement VR technology within an organisation. It provides an experience that can be shared by many people, and its 3D, interactive capability facilitates the communication of ideas not possible using other media formats. There are a number of software toolkits available for the building and programming of Virtual Environments (VEs), but very few resources that can help developers acquire the skills and techniques required to give their VEs utility and usability. This thesis reviews existing research into VE design with an emphasis on interactivity and usability, and then uses a case study based approach to conceptualise the VE development process and develop exemplar guidance tools. The first group of case studies date from the early 1990s, with an emphasis on finding ways to build VEs incorporating functionality. The experience gained through these case studies was used to discover the issues most relevant to the VE developer and report on the techniques used to resolve them. Several models are then presented to explain these techniques and relate them to the VE development context. For the second set of case studies the emphasis moves to finding ways of making VEs more usable. Several approaches are presented and further conceptualisation results in a decision table based guidance tool. The third set of case studies was carried out within the framework provided by the Virtual Environment Development Structure (VEDS), developed jointly by the author and other members of the Virtual Reality Applications Research Team (VIRART) at the University of Nottingham. In the light of this practical application of the framework and the experience gained throughout the case studies, changes are made to the structure to make it more accurately represent the actual process employed by VE developers. This version of VEDS is then used to more effectively define the areas where VE development guidance tools are needed.

Background Traditional treatment of amblyopia involves either wearing a patch or atropine penalisation of the better eye. A new treatment is being developed on the basis of virtual reality technology allowing either DVD footage or computer games which present a common background to both eyes and the foreground, containing the imagery of interest, only to the amblyopic eye. Methods A randomised control trial was performed on patients with amblyopia aged 4–8 years with three arms. All three arms had dichoptic stimulation using shutter glass technology. One arm had DVD footage shown to the amblyopic eye and common background to both, the second used a modified shooter game, Nux, with sprite and targets presented to the amblyopic eye (and background to both) while the third arm had both background and foreground presented to both eyes (non-interactive binocular treatment (non-I-BiT) games). Results Seventy-five patients were randomised; 67 were residual amblyopes and 70 had an associated strabismus. The visual acuity improved in all three arms by approximately 0.07 logMAR in the amblyopic eye at 6 weeks. There was no difference between I-BiT DVD and non-I-BiT games compared with I-BiT games (stated primary outcome) in terms of gain in vision. Conclusions There was a modest vision improvement in all three arms. Treatment was well tolerated and safe. There was no difference between the three treatments in terms of primary stated outcomes but treatment duration was short and the high proportion of previously treated amblyopia and strabismic amblyopia disadvantaged dichoptic stimulation treatment.

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. A novel binocular treatment which uses 3D technology to present specially developed computer games and video footage (I-BiT™) has been studied in a small group of patients and has shown positive results over a short period of time. The system is therefore now being examined in a randomised clinical trial. Methods/design: Seventy-five patients aged between 4 and 8 years with a diagnosis of amblyopia will be randomised to one of three treatments with a ratio of 1:1:1 - I-BiT™ game, non-I-BiT™ game, and I-BiT™ DVD. They will be treated for 30 minutes once weekly for 6 weeks. Their visual acuity will be assessed independently at baseline, mid-treatment (week 3), at the end of treatment (week 6) and 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 the first randomised controlled trial using the I-BiT™ system. The results will determine if the I-BiT™ system is effective in the treatment of amblyopia and will also determine the optimal treatment for future development. Trial registration: ClinicalTrials.gov identifier: NCT01702727 Keywords: Amblyopia, I-BiT™, Randomised clinical trial, Lazy eye, Child, Visual acuity, Binocular

Desktop Virtual Reality (VR) is an easy and affordable way to implement VR technology within an organisation. It provides an experience that can be shared by many people, and its 3D, interactive capability facilitates the communication of ideas not possible using other media formats. There are a number of software toolkits available for the building and programming of Virtual Environments (VEs), but very few resources that can help developers acquire the skills and techniques required to give their VEs utility and usability. This thesis reviews existing research into VE design with an emphasis on interactivity and usability, and then uses a case study based approach to conceptualise the VE development process and develop exemplar guidance tools. The first group of case studies date from the early 1990s, with an emphasis on finding ways to build VEs incorporating functionality. The experience gained through these case studies was used to discover the issues most relevant to the VE developer and report on the techniques used to resolve them. Several models are then presented to explain these techniques and relate them to the VE development context. For the second set of case studies the emphasis moves to finding ways of making VEs more usable. Several approaches are presented and further conceptualisation results in a decision table based guidance tool. The third set of case studies was carried out within the framework provided by the Virtual Environment Development Structure (VEDS), developed jointly by the author and other members of the Virtual Reality Applications Research Team (VIRART) at the University of Nottingham. In the light of this practical application of the framework and the experience gained throughout the case studies, changes are made to the structure to make it more accurately represent the actual process employed by VE developers. This version of VEDS is then used to more effectively define the areas where VE development guidance tools are needed.

Desktop Virtual Reality (VR) is an easy and affordable way to implement VR technology within an organisation. It provides an experience that can be shared by many people, and its 3D, interactive capability facilitates the communication of ideas not possible using other media formats. There are a number of software toolkits available for the building and programming of Virtual Environments (VEs), but very few resources that can help developers acquire the skills and techniques required to give their VEs utility and usability. This thesis reviews existing research into VE design with an emphasis on interactivity and usability, and then uses a case study based approach to conceptualise the VE development process and develop exemplar guidance tools. The first group of case studies date from the early 1990s, with an emphasis on finding ways to build VEs incorporating functionality. The experience gained through these case studies was used to discover the issues most relevant to the VE developer and report on the techniques used to resolve them. Several models are then presented to explain these techniques and relate them to the VE development context. For the second set of case studies the emphasis moves to finding ways of making VEs more usable. Several approaches are presented and further conceptualisation results in a decision table based guidance tool. The third set of case studies was carried out within the framework provided by the Virtual Environment Development Structure (VEDS), developed jointly by the author and other members of the Virtual Reality Applications Research Team (VIRART) at the University of Nottingham. In the light of this practical application of the framework and the experience gained throughout the case studies, changes are made to the structure to make it more accurately represent the actual process employed by VE developers. This version of VEDS is then used to more effectively define the areas where VE development guidance tools are needed.

Desktop Virtual Reality (VR) is an easy and affordable way to implement VR technology within an organisation. It provides an experience that can be shared by many people, and its 3D, interactive capability facilitates the communication of ideas not possible using other media formats. There are a number of software toolkits available for the building and programming of Virtual Environments (VEs), but very few resources that can help developers acquire the skills and techniques required to give their VEs utility and usability. This thesis reviews existing research into VE design with an emphasis on interactivity and usability, and then uses a case study based approach to conceptualise the VE development process and develop exemplar guidance tools. The first group of case studies date from the early 1990s, with an emphasis on finding ways to build VEs incorporating functionality. The experience gained through these case studies was used to discover the issues most relevant to the VE developer and report on the techniques used to resolve them. Several models are then presented to explain these techniques and relate them to the VE development context. For the second set of case studies the emphasis moves to finding ways of making VEs more usable. Several approaches are presented and further conceptualisation results in a decision table based guidance tool. The third set of case studies was carried out within the framework provided by the Virtual Environment Development Structure (VEDS), developed jointly by the author and other members of the Virtual Reality Applications Research Team (VIRART) at the University of Nottingham. In the light of this practical application of the framework and the experience gained throughout the case studies, changes are made to the structure to make it more accurately represent the actual process employed by VE developers. This version of VEDS is then used to more effectively define the areas where VE development guidance tools are needed.

Background Traditional treatment of amblyopia involves either wearing a patch or atropine penalisation of the better eye. A new treatment is being developed on the basis of virtual reality technology allowing either DVD footage or computer games which present a common background to both eyes and the foreground, containing the imagery of interest, only to the amblyopic eye. Methods A randomised control trial was performed on patients with amblyopia aged 4–8 years with three arms. All three arms had dichoptic stimulation using shutter glass technology. One arm had DVD footage shown to the amblyopic eye and common background to both, the second used a modified shooter game, Nux, with sprite and targets presented to the amblyopic eye (and background to both) while the third arm had both background and foreground presented to both eyes (non-interactive binocular treatment (non-I-BiT) games). Results Seventy-five patients were randomised; 67 were residual amblyopes and 70 had an associated strabismus. The visual acuity improved in all three arms by approximately 0.07 logMAR in the amblyopic eye at 6 weeks. There was no difference between I-BiT DVD and non-I-BiT games compared with I-BiT games (stated primary outcome) in terms of gain in vision. Conclusions There was a modest vision improvement in all three arms. Treatment was well tolerated and safe. There was no difference between the three treatments in terms of primary stated outcomes but treatment duration was short and the high proportion of previously treated amblyopia and strabismic amblyopia disadvantaged dichoptic stimulation treatment.

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. A novel binocular treatment which uses 3D technology to present specially developed computer games and video footage (I-BiT™) has been studied in a small group of patients and has shown positive results over a short period of time. The system is therefore now being examined in a randomised clinical trial. Methods/design: Seventy-five patients aged between 4 and 8 years with a diagnosis of amblyopia will be randomised to one of three treatments with a ratio of 1:1:1 - I-BiT™ game, non-I-BiT™ game, and I-BiT™ DVD. They will be treated for 30 minutes once weekly for 6 weeks. Their visual acuity will be assessed independently at baseline, mid-treatment (week 3), at the end of treatment (week 6) and 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 the first randomised controlled trial using the I-BiT™ system. The results will determine if the I-BiT™ system is effective in the treatment of amblyopia and will also determine the optimal treatment for future development. Trial registration: ClinicalTrials.gov identifier: NCT01702727 Keywords: Amblyopia, I-BiT™, Randomised clinical trial, Lazy eye, Child, Visual acuity, Binocular

Desktop Virtual Reality (VR) is an easy and affordable way to implement VR technology within an organisation. It provides an experience that can be shared by many people, and its 3D, interactive capability facilitates the communication of ideas not possible using other media formats. There are a number of software toolkits available for the building and programming of Virtual Environments (VEs), but very few resources that can help developers acquire the skills and techniques required to give their VEs utility and usability. This thesis reviews existing research into VE design with an emphasis on interactivity and usability, and then uses a case study based approach to conceptualise the VE development process and develop exemplar guidance tools. The first group of case studies date from the early 1990s, with an emphasis on finding ways to build VEs incorporating functionality. The experience gained through these case studies was used to discover the issues most relevant to the VE developer and report on the techniques used to resolve them. Several models are then presented to explain these techniques and relate them to the VE development context. For the second set of case studies the emphasis moves to finding ways of making VEs more usable. Several approaches are presented and further conceptualisation results in a decision table based guidance tool. The third set of case studies was carried out within the framework provided by the Virtual Environment Development Structure (VEDS), developed jointly by the author and other members of the Virtual Reality Applications Research Team (VIRART) at the University of Nottingham. In the light of this practical application of the framework and the experience gained throughout the case studies, changes are made to the structure to make it more accurately represent the actual process employed by VE developers. This version of VEDS is then used to more effectively define the areas where VE development guidance tools are needed.

Background Traditional treatment of amblyopia involves either wearing a patch or atropine penalisation of the better eye. A new treatment is being developed on the basis of virtual reality technology allowing either DVD footage or computer games which present a common background to both eyes and the foreground, containing the imagery of interest, only to the amblyopic eye. Methods A randomised control trial was performed on patients with amblyopia aged 4–8 years with three arms. All three arms had dichoptic stimulation using shutter glass technology. One arm had DVD footage shown to the amblyopic eye and common background to both, the second used a modified shooter game, Nux, with sprite and targets presented to the amblyopic eye (and background to both) while the third arm had both background and foreground presented to both eyes (non-interactive binocular treatment (non-I-BiT) games). Results Seventy-five patients were randomised; 67 were residual amblyopes and 70 had an associated strabismus. The visual acuity improved in all three arms by approximately 0.07 logMAR in the amblyopic eye at 6 weeks. There was no difference between I-BiT DVD and non-I-BiT games compared with I-BiT games (stated primary outcome) in terms of gain in vision. Conclusions There was a modest vision improvement in all three arms. Treatment was well tolerated and safe. There was no difference between the three treatments in terms of primary stated outcomes but treatment duration was short and the high proportion of previously treated amblyopia and strabismic amblyopia disadvantaged dichoptic stimulation treatment.

Background Traditional treatment of amblyopia involves either wearing a patch or atropine penalisation of the better eye. A new treatment is being developed on the basis of virtual reality technology allowing either DVD footage or computer games which present a common background to both eyes and the foreground, containing the imagery of interest, only to the amblyopic eye. Methods A randomised control trial was performed on patients with amblyopia aged 4–8 years with three arms. All three arms had dichoptic stimulation using shutter glass technology. One arm had DVD footage shown to the amblyopic eye and common background to both, the second used a modified shooter game, Nux, with sprite and targets presented to the amblyopic eye (and background to both) while the third arm had both background and foreground presented to both eyes (non-interactive binocular treatment (non-I-BiT) games). Results Seventy-five patients were randomised; 67 were residual amblyopes and 70 had an associated strabismus. The visual acuity improved in all three arms by approximately 0.07 logMAR in the amblyopic eye at 6 weeks. There was no difference between I-BiT DVD and non-I-BiT games compared with I-BiT games (stated primary outcome) in terms of gain in vision. Conclusions There was a modest vision improvement in all three arms. Treatment was well tolerated and safe. There was no difference between the three treatments in terms of primary stated outcomes but treatment duration was short and the high proportion of previously treated amblyopia and strabismic amblyopia disadvantaged dichoptic stimulation treatment.

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. A novel binocular treatment which uses 3D technology to present specially developed computer games and video footage (I-BiT™) has been studied in a small group of patients and has shown positive results over a short period of time. The system is therefore now being examined in a randomised clinical trial. Methods/design: Seventy-five patients aged between 4 and 8 years with a diagnosis of amblyopia will be randomised to one of three treatments with a ratio of 1:1:1 - I-BiT™ game, non-I-BiT™ game, and I-BiT™ DVD. They will be treated for 30 minutes once weekly for 6 weeks. Their visual acuity will be assessed independently at baseline, mid-treatment (week 3), at the end of treatment (week 6) and 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 the first randomised controlled trial using the I-BiT™ system. The results will determine if the I-BiT™ system is effective in the treatment of amblyopia and will also determine the optimal treatment for future development. Trial registration: ClinicalTrials.gov identifier: NCT01702727 Keywords: Amblyopia, I-BiT™, Randomised clinical trial, Lazy eye, Child, Visual acuity, Binocular

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. A novel binocular treatment which uses 3D technology to present specially developed computer games and video footage (I-BiT™) has been studied in a small group of patients and has shown positive results over a short period of time. The system is therefore now being examined in a randomised clinical trial. Methods/design: Seventy-five patients aged between 4 and 8 years with a diagnosis of amblyopia will be randomised to one of three treatments with a ratio of 1:1:1 - I-BiT™ game, non-I-BiT™ game, and I-BiT™ DVD. They will be treated for 30 minutes once weekly for 6 weeks. Their visual acuity will be assessed independently at baseline, mid-treatment (week 3), at the end of treatment (week 6) and 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 the first randomised controlled trial using the I-BiT™ system. The results will determine if the I-BiT™ system is effective in the treatment of amblyopia and will also determine the optimal treatment for future development. Trial registration: ClinicalTrials.gov identifier: NCT01702727 Keywords: Amblyopia, I-BiT™, Randomised clinical trial, Lazy eye, Child, Visual acuity, Binocular