Beyond the eye patch: binocular game therapy versus occlusion for amblyopia in children aged 3–17 years — a systematic review of visual acuity, treatment efficiency, and adherence

Background Amblyopia is the most common cause of monocular visual impairment in children. Patching the stronger eye has been the mainstay of treatment for decades, but it is burdensome and adherence is often poor. Binocular and dichoptic digital therapies have emerged as alternatives that engage both eyes simultaneously. This review compared binocular game therapy with patching for improving visual acuity in children with amblyopia. Methods We searched PubMed/MEDLINE, Cochrane Library, ScienceDirect, Web of Science, ClinicalTrials.gov, and the ISRCTN registry on 8 February 2025, with an updated search on 14 June 2026. Randomised controlled trials (RCTs) of children aged 3–17 years with amblyopia were eligible. Two reviewers screened records and extracted data independently using Rayyan and Zotero. Risk of bias was assessed with Cochrane RoB 2, and certainty of evidence with GRADE. Because of substantial clinical heterogeneity in treatment dose, duration, and outcome timing, we synthesised findings narratively rather than by meta-analysis. Results Seventeen RCTs involving 1,484 children were included. Visual acuity gains ranged from 0.074 to 0.33 logMAR for binocular games (2–24 weeks), 0.065 to 0.28 logMAR for patching (2–24 weeks), and 0.07 to 0.28 logMAR for passive dichoptic viewing (2–16 weeks). The largest single-device gains were with Occlu-tab (0.33 logMAR) and supervised virtual reality (0.30 logMAR). Most between-group differences were not statistically significant. Passive viewing and supervised platforms often matched patching with fewer treatment hours and higher adherence. Objective monitoring revealed that parental diaries overestimated patching adherence by up to 49%. Conclusions Binocular game therapy appears non-inferior to patching in the short term, with better adherence and greater treatment efficiency per hour. Passive dichoptic viewing may deliver early gains with less total treatment time. However, heterogeneity across devices, doses, and outcome measures, together with limited long-term follow-up, prevents firm conclusions. Larger, multicentre trials with standardised outcomes and extended follow-up are needed. Registration : Not registered.