Harnessing Visual Neuroplasticity Through Auditory Biofeedback-Functional and Electrophysiological Gains Across Retinal, Optic-Nerve, and Cortical Visual Impairment: A Prospective Pilot Study.

Background: This prospective pilot study included four participants with chronic visual impairment and assessed functional and electrophysiological recovery following visual evoked potential (VEP)-guided auditory biofeedback across diverse etiologies. Low vision affects more than two billion people worldwide and imposes a sustained personal and socioeconomic burden. Conventional rehabilitation emphasizes optical aids and environmental modification without directly stimulating the visual pathway. Emerging evidence indicates that auditory biofeedback based on real-time cortical activity can leverage adult neuroplasticity. Methods: Four men (mean age 58 ± 12 years) with chronic visual impairment attributable to occipital stroke, stage IV macular hole, end-stage open-angle glaucoma, or diabetic maculopathy completed ten 10-min monocular sessions with the Retimax Vision Trainer over three weeks (15 Hz pattern reversal, 90% contrast). Primary end points were best corrected visual acuity (BCVA, ETDRS letters) and P100 amplitude/latency. Fixation stability was recorded with MAIA microperimetry when feasible. A focused PubMed review (2010-2025) mapped current evidence and research gaps. Results: Median BCVA improved by seven letters (IQR 0-15); three of eight eyes gained ≥ 10 letters and none lost vision. Mean P100 amplitude increased from 1.0 ± 1.2 µV to 3.0 ± 1.1 µV, while latency shortened by 3.9 ms. Electrophysiological improvement paralleled behavioural gain irrespective of lesion site. No adverse events occurred. Conclusions: A concise course of VEP-guided auditory biofeedback produced concordant functional and neurophysiological gains across retinal, optic nerve, and cortical pathologies. These pilot data support integration of closed-loop biofeedback into routine low vision care and justify larger sham-controlled trials.