Neuro-rehabilitative Optometry Kevin E. Houston, O.D., FAAO Clinical Assistant Professor Vision Rehabilitation Services In...
Outline <ul><li>Neurorehabilitation Interdisciplinary Team </li></ul><ul><li>Prevalence of vision problems in ABI </li></u...
Rehab Multidisciplinary Team PM&R (Physiatry) Rehab Psychology  and  Neuropsychology Therapy Occupational Speech Physical ...
Management of Vision Services Rehab Optometrist OT-VRT CLVT O&M Vocational  Rehabilitation Adaptive  Technology CDRS
Visual Disturbances in ABI <ul><li>Hemispatial Neglect (HSN)  </li></ul><ul><li>Nerve Palsies </li></ul><ul><li>Homonymous...
Prevalence Studies <ul><li>Hines VA Study (n=103), 2009, TBI </li></ul><ul><ul><li>76% reported visual symptoms </li></ul>...
Prevalence Cont. <ul><li>Suchoff et al JAOA (2008), visual field defects in TBI (n=160) and CVA (n=60). </li></ul><ul><ul>...
60 minute TBI/Stroke Flowsheet <ul><li>Review prior reports, imaging, ect </li></ul><ul><li>Document Start Time for insura...
Visual Field Testing <ul><li>Confrontation </li></ul><ul><li>*Pearl:  -Move target from behind patient </li></ul><ul><li>E...
Left Occipital Cortex ICH
Left Parietal
Metastasis Left Occipital Cortex
Pituitary Adenoma
 
Visual Field testing See video
Plotting Foveal Field with Amsler X ●
Case CB:  Objective <ul><li>VA OD, 10/10, OS 10/10 -3.  </li></ul><ul><li>Confrontation: left superior absolute homonymous...
Ocular Motility Terminology <ul><li>Pursuits (Versions) </li></ul><ul><li>10 degrees/sec (Hz) </li></ul><ul><li>Levo, dext...
Ocular Motility See video file on visual field testing
Spontaneous Recovery Studies <ul><li>Homonymous field defects </li></ul><ul><li>Zhang et al.  Neurology (2006), n=254. </l...
Hemianopic Rehab  <ul><li>Hemianopsia is correlated with poor recovery from brain injury.  Ashley MJ, Krych DK.  Traumatic...
Key Questions for Rehab <ul><li>Are there therapies that promote recovery? </li></ul><ul><li>Can patients be trained to us...
Restorative Therapies, Hemianopia <ul><li>Hemianopsia </li></ul><ul><ul><li>Justification:  </li></ul></ul><ul><ul><ul><li...
Restorative Therapies <ul><li>Hemianopsia (cont’d) </li></ul><ul><ul><li>Procedures </li></ul></ul><ul><ul><ul><li>Visual ...
Other Restorative Therapies, Hemianopia <ul><li>Visual Restoration Therapy (VRT) </li></ul><ul><ul><li>NOVA vision </li></...
Compensatory Therapies Hemianopia <ul><li>Compensatory Training Technique: Systematic Visual Search </li></ul><ul><ul><li>...
Compensatory Therapies Hemianopia <ul><li>Other techniques </li></ul><ul><ul><li>Turn reading material sideways </li></ul>...
Restorative Therapies for Neglect <ul><li>Top Down (descending approach): </li></ul><ul><ul><li>Visual Scanning Training (...
<ul><li>Bottom-up </li></ul><ul><ul><li>Justification </li></ul></ul><ul><ul><ul><li>Caloric Stimulation  Rubens AB. Calor...
<ul><li>Anchoring </li></ul><ul><li>Systematic Visual Search Strategies </li></ul><ul><li>Cueing </li></ul><ul><li>Rotate ...
Restorative Therapies, BV <ul><li>Cranial Nerve Palsies </li></ul><ul><ul><li>Justification: Theory of Neuro-muscular Re-e...
Restorative Therapies, BV <ul><li>Accommodative Disorders </li></ul><ul><ul><li>Justification:  </li></ul></ul><ul><ul><ul...
Treating Convergence Insufficiency <ul><li>CITT:  First Randomized Double Blind Multicenter Study on Vision Therapy/Orthop...
Compensatory Treatments, BV <ul><li>Lenses, prisms </li></ul><ul><li>Patching </li></ul><ul><li>Large print </li></ul><ul>...
Restorative Therapies, AEL <ul><li>Disorders of Abnormal Egocentric Localization </li></ul><ul><ul><li>Justification:  </l...
Compensatory Treatments, AEL <ul><li>Disorders of Abnormal Egocentric Localization </li></ul><ul><ul><li>Full time wear yo...
Rehab Protocols <ul><li>See Files on teaching server->Low Vision Indy->training </li></ul><ul><li>Or </li></ul><ul><li>PDF...
Reporting and Plan Development <ul><li>Rehab OD primary responsibility is to oversee vision rehabilitative care </li></ul>...
Case L J:  HPI <ul><li>Aphasia and impairment of verbal reading </li></ul><ul><ul><li>Superior right quadranopsia and Wern...
Case L J:  Objective <ul><li>20/20 BCVA OD, OS </li></ul><ul><li>Confrontations:  Dense Right Homonymous Hemianopsia.  </l...
Case L J:  A&P <ul><li>Hemianopic Alexia </li></ul><ul><li>Dense Right Homonymous Hemianopsia </li></ul><ul><li>Impaired M...
Case L J:  Hemianopic Alexia <ul><li>Hemianopic alexia:  Recognize long words as quickly as short words, but have very slo...
A E U C G T O M A E U C G T O M H G N X Z J A L K J L D O W U O V R ◙   Case L J:  Eccentric Viewing
The first place that I can well remember was a large pleasant meadow with a pond of clear water in it. Some shady trees le...
Case KM:  OKN Therapy <ul><li>Fronto-Parietal Injury-Hit by car </li></ul><ul><li>Unable to read </li></ul><ul><li>Signifi...
Pre & Post Treatment Visigraph
Case L J:  Driver Rehab Protocol <ul><li>Evidence-based vision eval. </li></ul><ul><li>Assess Risk </li></ul><ul><li>Patie...
Case L J:  Evidence-Based eval for Driving <ul><li>Snellen VA OD, OS, OU [L J 20/20] </li></ul><ul><li>Mars-Perceptrix Con...
Case L J:  Assess Risk <ul><li>Assess Risk:  Review Snellen VA OD, OS, OU; Mars-Perceptrix Contrast Sensitivity OU; Visual...
Plan for Driver Rehabilitation <ul><li>Step 1:  Education and Demonstration Training </li></ul><ul><li>Step 2:  Fit Tempor...
Video: Training with the VFAS
Case L J:  Post Therapy Final Assessment <ul><li>Reading Speed:  50wpm to .4M CPS </li></ul><ul><li>Passed CDRS eval for d...
Case R C:  HPI <ul><li>S/P Right Frontal ICH, spontaneous on ASA </li></ul><ul><li>S/P Caniotomy for ICH </li></ul><ul><li...
Case R C:  Subjective <ul><li>Reports blur at distance when watching TV </li></ul><ul><li>Denies blind spots, double visio...
Case R C:  Objective <ul><li>BCVA 10/20 OD, OS;  Only reads right side </li></ul><ul><li>Confrontation:  LHH </li></ul><ul...
Case R C:  Objective
Case RC:  A & P <ul><li>Assessment </li></ul><ul><li>Viewer Centered Left Hemispatial Neglect with revisit targets and per...
Case RC: Before and After 4 sessions
Case RC:  Post-Therapy SOAP <ul><li>BCVA OD 10/20, OS 10/10 </li></ul><ul><li>Confrontations:  FTEF OD, OS </li></ul><ul><...
Rosetti Video
Subtypes of Negelct <ul><li>Sensory Neglect ( Stimulus Centered or Viewer Centered) :  Auditory, Visual, Tactile </li></ul...
Viewer-Centered Neglect <ul><li>Disorder of Egocentric Reference Frame </li></ul><ul><ul><li>Where am I.  Where is the cen...
Stimulus-Centered Neglect <ul><li>Patient neglects the left side of the stimulus, even if it is in the right hemispace.  <...
Behavioral Symptoms of Neglect <ul><li>Patient doesn’t respond to you when seated on their left.  </li></ul><ul><ul><li>Yo...
Corbetta’s Attentional Networks Nature Reviews Neuroscience   3 ; 201-215 (2002); doi:10.1038/nrn755 CONTROL OF GOAL-DIREC...
Middle Cerebral Artery Infact Source: neuropathologyweb.org Source: www.psyweb.com/Brain/Bimages/blood2.gif
Comparisons of Treatments Arene NU, Hillis NE.  Rehabilitation of Unilateral Spatial Neglect and Neuroimaging.  Eura Medic...
Comparison of Treatments Viewer Centered Personal Anosognosia Representational Stimulus Centered Sensory Extinction Prism ...
History of Prism Adaptation <ul><li>First reference, Helmholtz 1908 </li></ul><ul><li>1950’s to study motor learning (Kohl...
Prism Adaptation Therapy(PA) <ul><li>Pubmed Search “Prism Adaptation and Neglect” </li></ul><ul><ul><li>60 citations since...
10 Original Studies Supporting PA for LHSN <ul><li>Keane S, Turner C, Sherrington C, Beard JR.  Use of fresnel prism glass...
Prismatic Lenses <ul><li>Base Direction Terminology </li></ul><ul><li>Diopters vs. Degrees of deviation </li></ul><ul><li>...
Perceptual Effects of Wedge Prism <ul><li>Visual-Proprioceptive Misalignment </li></ul><ul><ul><li>Vision is perturbed but...
Prism Adaptation Therapy(PA) <ul><li>Yves Rossetti, MD, Ph.D. at the Henry Gabrielle Rehabilitation Hospital in France  </...
Effects were increased 2hrs later Rossetti Y, Rode G, Pisella L, et al. Prism adaptation to a rightward optical deviation ...
Long Lasting Effects of PA <ul><li>In a 2002 article in March issue of Brain, Francesca Frassinetti and collegues studied ...
Results on BIT Effects of prism treatment on the patients’ performance (percentage of correct responses) in the BIT batter...
Comparison Between BIT Sessions <ul><li>Two-way ANOVA analysis based on correct responses </li></ul><ul><li>First session ...
Long Lasting Effects, Frassinetti et al <ul><li>The effects of PA last out to 5 weeks after 2 weeks of twice daily therapy...
Mechanism of Action of PA Therapy Pisella L, Rode G, Farnè A, Tilikete C, Rossetti Y. Prism adaptation in the rehabilitati...
Cerebellum’s Role in PA <ul><li>Visuomotor learning </li></ul><ul><li>Calibrates vision with motor system </li></ul><ul><l...
An Anatomo-Functional Model A visual error signal is created in the right hemifield… In the case of a rightward field shif...
Case Study C.L. <ul><li>Source: Cicero L.  What Owls Teach us About Stroke Rehabilitation.  Stanford Magazine, Nov/Dec 200...
Summary:  Take Home Points <ul><li>Rehab OD role overseeing vision rehab care </li></ul><ul><li>Evidence for Vision rehab ...
Upcoming SlideShare
Loading in …5
×

04 21 10 houston neurorehab

2,538 views

Published on

0 Comments
2 Likes
Statistics
Notes
  • Be the first to comment

No Downloads
Views
Total views
2,538
On SlideShare
0
From Embeds
0
Number of Embeds
56
Actions
Shares
0
Downloads
0
Comments
0
Likes
2
Embeds 0
No embeds

No notes for slide
  • Give you an idea of tests I do with these patients. HPI, get patient age, race, gender, handedness, date and location of stroke, visual symptoms noted by patient, sx noted by family/therapists. FODLAR out symptoms. Acuity: Trouble finding chart, trouble with VFG (isolate letters), Aphasia matching Lea, FC Teller, Pref Look, OKN drum. Functional Scan
  • This is a single field analysis plot from a 30 degree visual field. You are seeing plot for right eye left eye. It is best to look at the pattern standard deviation plot which is in the lower right. Where is the defect, left or right? Right Is it in both eyes on the same side, Homonymous? Yes Homonymous Is it a sector, quadrant, or hemi pattern? Hemianopsia Is it congrous (mostly identical) or incongrous different in each field? Congruous
  • Where is the defect, left or right? Right Is it in both eyes on the same side, Homonymous? Yes Homonymous Is it a sector, quadrant, or hemi pattern? Quadranopsia Is it congrous (mostly identical) or incongrous different in each field? Congruous You won’t know fovea for sure unless amsler grid is done.
  • Where is the defect, left or right? Left Is it in both eyes on the same side, Homonymous? Yes Homonymous Is it a sector, quadrant, or hemi pattern? Hemianopsia Is it congrous (mostly identical) or incongrous different in each field? Very Congruous
  • Where is the defect, left or right? Bitemporal Is it in both eyes? Yes Homonymous or Heteronymous? Heteronymous Is it a sector, quadrant, or hemi pattern? Hemianopsia Is it congrous (mostly identical) or incongrous different in each field? Congruous
  • Computerized visual field testers are nice and are the standard of care for optometry, but as SLP’s you are not likely to have access to one so I will demonstrate and easy and accurate way to get visual field information. The technique here is called confrontations.
  • Confrontation visual field testing is not sensitive enough to pick up central visual field loss. Our options are to run a separate 10 degree field, or even quicker and easier, run an Amsler grid test. This isn’t to scale here but you bring a small black target against the white target at the speed shown several times and mark the border of the defect. On the actual Amsler grid, each box is 1 degree at the 50cm standard working distance.
  • 1. Treatment focuses on the patient becoming aware of their condition Diller and Weinberg ([11], p. 67): This is particularly difficult in hemi-inattention since this failure in awareness appears to be at the heart of the patient’s difficulty’.
  • Rubens Proposed the subject felt as if they are constantly rotated toward the lesion side. Poured cold water into the neglect patient’s left ear, instantly produced a dramatic, although transient improvement of neglect.
  • Rubens Proposed the subject felt as if they are constantly rotated toward the lesion side. Poured cold water into the neglect patient’s left ear, instantly produced a dramatic, although transient improvement of neglect.
  • Scanning along a line of text is affected if the RHH encroaches to within 5 degrees of fixation, and most symptomatic patients have the central 2-3 degrees involved. As you can imagine, new glasses will not help, and instead eccentric viewing and visual scan therapy is indicated. You may have seen the glasses with a prism drilled in one corner known as the Gottlieb lens or VFAS, this is more for mobility and in my experience doesn’t help reading. Pure Alexia, characterized by an inability to recognize words, should be suspected in patients with reading speeds less than 40 wpm. In this condition the fusiform gyrus is damaged, remember the pink part of the brain from the other slide? These patients clue you into to their problem by spelling out their words letter-by-letter. Patients with hemianopic alexia might do this, but only occasionally. Sometimes it is hard to catch them in the act and simple flash cards without pictures presented quickly to prevent the letter by letter strategy will reveal the condition. It is important to note that the patient may not be aware that they are using a letter-by-letter strategy until the examiner proves it to them. When doing a literature review I ran across a technique where the patient is shown pictures with the word to try to access semantic stores through a pictorial route, which is theoretically intact and in the right hemisphere. Perhaps this will turn out to allow faster reading speeds in some of your patients with pure alexia.
  • Less
  • This is the protocol used in the IU school of optometry clinics. Scores on the vision evaluation are used to decide whether or not to proceed with training. If there are multiple high risk factors and a low chance for success, I let the patient know up front. I always warn them that even with training we may not be able to reach the goal of safe driving. We can use any treatments we want to help them compensate for deficits, but the final litmus test is always the same: Have to pass the on-the-road evaluation with the CDRS. During the evaluation and training period the patients are always educated on their risk and that I recommend not driving. In Indiana, unfortunately, I cannot report or request a courtesy drive without the patient’s signed consent. Different states have different rules, and in some States, reporting is required.
  • The evidence base evaluation is based on the SEE study and done at the beginning to assess risks, and the end to see how we improved.
  • Patients with any type of field defect cannont compensate for the defect if they don’t know where it is and understand that it moves when the eye moves. These patients are in denial that they miss things. They say “Oh I see it now” or “I just wasn’t ready”. They will deny it until you force them to recognize it. Most times they only report that they miss things or bump into things because they have been told repeately that they do this. Even still, they will often tell you the eye on the side of the defect is blind, or may even confuse which side the problem is on. The especially don’t realize that the blind spot moves with the eye, causing them to run into things directly in front of them if they are gazing away from the defect. The things must be demonstrated by a vision specialist who has measured and understands the location and depth of the hemi field defect.
  • Many subtypes of neglect have been defined over the years based on symptoms described. Work is underway in laboratories using fMRI and Transcranial magnetic stimulation (TMS) to better define the substrates related to the symptoms. Patients typically have multiple subtypes. Knowing which subtypes to expect based on the location of the injury is becoming more feasible and I will clue you in on what I know. Clearly I am more likley to pick up on the visual symptoms of neglect than other members of the rehab team. I have found it most useful in the clinic to take what has been documented in prior reports and add it to my diagnosis. For example, Patient AM was referred to me with symptoms of motor neglect as noted by the OT. A prior report by the neuropsychologist defined personal and peripersonal neglect. I found the patient had viewer centered neglect, only crossing out items to the right of midline on a line crossing test. They also re-cancelled many of the lines that had already been cancelled. My assessment included previous assessments as well as mine: Dense Viewer-centered personal and peripersonal neglect with bias for rightward stimuli and revisiting previously searched locations. In the next slide I will discuss what that means.
  • The subtype I see most commonly is viewer centered neglect. This is a condition of the patient’s egocentric reference frame, which is the part of the brain that monitors center of the body. This is a multmodal system of proprioception and vision. Patients with severe viewer centered neglect do not orient to sensory stimuli in the left hemifield. They may lean to the right and not fix and follow past midline. Even mild cases tend to have extinction of the left field. Viewer centered neglect patients are believed by researchers to have a corresponding injury to the Right Angular Gyrus (gold) and Intraparietal Sulcus (yellow line). The superior division of the MCA feeds this part of the cortex.
  • Stimulus Centered (patient neglects the left side of the stimulus, even if it is in the right hemispace): Right Superior Temporal Gyrus Visual Search: Right Superior Temporal Gyrus
  • This is the classic drawing a person with left neglect will exhibit. This is just a symptom of the condition. If a patient draws a picture like this, they definitely have neglect, but if they draw normally it doesn’t mean they don’t have neglect. You have probably also heard patients with neglect only eat food off one half of the plate. I am hear to tell you this is sometimes true, but more often not. In fact I have seen patients test out completely normal on paper and pencil tests and then seen them exhibit severe neglect behaviorally in a noisy lunch room. Perhaps we should start doing our test there.
  • 2 distinct attentional networks have been defined, a dorsal and a ventral. These should not be confused with the dorsal and ventral visual pathways, although they are similar in concept. The Dorsal stream, in blue, has not been correlated with neglect symptoms. It is involved in selective spatial attention during visual search tasks and eye hand coordination. The ventral attentional network is correlated with neglect. A balance is believed to exist between the 2 networks that is thrown out of whack when the ventral network is damaged. This contributes to symptoms of neglect that seem to be unrelated to the area injured. inferior parietal lobule [IPL; Mort et al., 2003;Vallar and Perani, 1987] superior temporal gyrus [STG;Karnath et al., 2001, 2004] subcortical nuclei [Karnath et al., 2002; Vallar and Perani, 1987] inferior frontal cortex [Husain and Kennard, 1996; Vallar and Perani,1987]
  • Treatments related to reflexive orienting do not involve learning, adaptive processes are not engaged.
  • Beginning with Herrmann von Helmholtz in the late 19 th century in Germany who viewed PA as illustrating his perceptual learning theory Ivo Kohler, Innsbruck Austria, systematically studied prism adaptation. Richard Held at MIT and Charlie Harris at Bell Labs conducted foundational research Gordon Redding at Illinois State and Ben Wallace at Cleveland State have researched this topic since the 1970’s and remain the leading experts on the mechanics of sensorimotor adaptation. Eve Ro’ss etti and collegues at the INSERM lab in Bron, France.
  • 04 21 10 houston neurorehab

    1. 1. Neuro-rehabilitative Optometry Kevin E. Houston, O.D., FAAO Clinical Assistant Professor Vision Rehabilitation Services Indiana University School of Optometry [email_address]
    2. 2. Outline <ul><li>Neurorehabilitation Interdisciplinary Team </li></ul><ul><li>Prevalence of vision problems in ABI </li></ul><ul><li>Functional and Neurological Assessment of the brain injured patient </li></ul><ul><li>Evidence for vision rehabilitation </li></ul><ul><li>Rehabilitation Protocols </li></ul><ul><li>Reporting and Rehab plan development </li></ul><ul><li>Case L J: Oligodendroglioma </li></ul><ul><li>Case RC: Intracerebral Hemorrhage </li></ul>
    3. 3. Rehab Multidisciplinary Team PM&R (Physiatry) Rehab Psychology and Neuropsychology Therapy Occupational Speech Physical Vision Therapeutic Rec Rehab Optometry Nursing Case Management
    4. 4. Management of Vision Services Rehab Optometrist OT-VRT CLVT O&M Vocational Rehabilitation Adaptive Technology CDRS
    5. 5. Visual Disturbances in ABI <ul><li>Hemispatial Neglect (HSN) </li></ul><ul><li>Nerve Palsies </li></ul><ul><li>Homonymous Field Defects (HFD) </li></ul><ul><li>Abnormal Egocentric Localization (AEL) </li></ul><ul><li>Convergence palsy and insufficiency </li></ul><ul><li>Deficiencies of visual pursuits and saccades </li></ul><ul><li>Accommodative dysfunction (paresis and psuedomyopia) </li></ul><ul><li>Cortical Visual Impairment and bilateral hemianopia </li></ul><ul><li>Vascular ocular health issues </li></ul><ul><li>Ocular trauma </li></ul><ul><li>Alexia/Dyslexia </li></ul>
    6. 6. Prevalence Studies <ul><li>Hines VA Study (n=103), 2009, TBI </li></ul><ul><ul><li>76% reported visual symptoms </li></ul></ul><ul><ul><li>Reading problem 50% </li></ul></ul><ul><ul><li>Accommodative problems 30% </li></ul></ul><ul><li>Ciuffreda et al JAOA 2007 Oculomotor dysfunctions, (n=220) </li></ul><ul><ul><li>90% TBI: Most commonly Accommodation and Vergence </li></ul></ul><ul><ul><li>86.7% CVA: Most commonly strabismus and CN palsy </li></ul></ul>
    7. 7. Prevalence Cont. <ul><li>Suchoff et al JAOA (2008), visual field defects in TBI (n=160) and CVA (n=60). </li></ul><ul><ul><li>Defects included hemineglect </li></ul></ul><ul><ul><li>TBI 38.75%, most commonly scattered </li></ul></ul><ul><ul><li>CVA 66.67%, most commonly homonymous </li></ul></ul><ul><li>Ringman et al. Neurology (2004) Left Neglect Prevalence: </li></ul><ul><ul><li>43% of acute right hemisphere CVA’s </li></ul></ul>
    8. 8. 60 minute TBI/Stroke Flowsheet <ul><li>Review prior reports, imaging, ect </li></ul><ul><li>Document Start Time for insurance billing purposes </li></ul><ul><li>HPI </li></ul><ul><li>Ocular history (TIDS) </li></ul><ul><li>Med Hx (Medications) </li></ul><ul><li>Ocular Family Hx </li></ul><ul><li>Social Hx </li></ul><ul><li>ROS </li></ul><ul><li>Acuities </li></ul><ul><li>Confrontations </li></ul><ul><li>Extinction of Fields </li></ul><ul><li>Monocular Ductions </li></ul><ul><li>Functional Scan </li></ul><ul><li>Amsler if suspect central field loss </li></ul><ul><li>Lensometry </li></ul><ul><li>Static 20ft Retinoscopy/Auto refractor </li></ul><ul><li>Subjective Refraction </li></ul><ul><li>Bell retinoscopy/MEM </li></ul><ul><li>Pursuits </li></ul><ul><li>Saccades </li></ul><ul><li>NPC/CT </li></ul><ul><li>MNread </li></ul><ul><li>Pupils/Angles </li></ul><ul><li>Pressures </li></ul><ul><li>Dilate </li></ul><ul><li>BIT (if neglect): Line Cancellation, Representational Drawing, Star Cancellation, Letter Cancellation, Line Bisection (as time allows). </li></ul><ul><li>Prism Adaptation Evaluation (if neglect present) </li></ul><ul><li>Repeat BIT (if time) </li></ul><ul><li>Check dilation </li></ul>
    9. 9. Visual Field Testing <ul><li>Confrontation </li></ul><ul><li>*Pearl: -Move target from behind patient </li></ul><ul><li>Extinction </li></ul><ul><li>* Pearl -Present bilaterally at a rate of ~0.5sec, present only to the seeing field. </li></ul><ul><li>Finger counting requires cognitive abilities that confrontation does not. </li></ul><ul><ul><li>Simultagnosia </li></ul></ul><ul><ul><li>Executive function </li></ul></ul><ul><ul><li>Aphasia </li></ul></ul><ul><ul><li>Anomia </li></ul></ul><ul><ul><li>Working Memory </li></ul></ul><ul><li>Amsler Grid </li></ul><ul><li>*Pearl: Move target perpendicular to edge of defect </li></ul><ul><li>Goldmann Bowl </li></ul><ul><li>* Pearl -1-2deg/sec, increase target size, repeat each line 2-3 times if variable. </li></ul><ul><li>HVF-30-2SF: Always set to Sita Fast </li></ul>
    10. 10. Left Occipital Cortex ICH
    11. 11. Left Parietal
    12. 12. Metastasis Left Occipital Cortex
    13. 13. Pituitary Adenoma
    14. 15. Visual Field testing See video
    15. 16. Plotting Foveal Field with Amsler X ●
    16. 17. Case CB: Objective <ul><li>VA OD, 10/10, OS 10/10 -3. </li></ul><ul><li>Confrontation: left superior absolute homonymous quadranopsia and a left inferior relative homonymous quadranopsia. </li></ul><ul><li>Unable to see any movement or light in the superior left quadrant. </li></ul><ul><li>Amsler: Macular sparing OS </li></ul><ul><li>MNread: Normal rate, normal return sweep, transposes words. (^) </li></ul>*Central field does not match peripheral field. Is the field defect causing the reading problem?
    17. 18. Ocular Motility Terminology <ul><li>Pursuits (Versions) </li></ul><ul><li>10 degrees/sec (Hz) </li></ul><ul><li>Levo, dextro, supra, infraversion </li></ul><ul><li>Catch-up saccades </li></ul><ul><li>Saccadic Intrusions </li></ul><ul><li>Fix and Follow (^) </li></ul><ul><li>Ductions </li></ul><ul><li>AD, AB, supra, infraduction (monocular ROM) </li></ul><ul><li>Saccades </li></ul><ul><li>Normometric </li></ul><ul><li>Hypometric </li></ul><ul><li>Hypermetric </li></ul><ul><li>Latency </li></ul><ul><li>Velocity </li></ul><ul><li>Volitional </li></ul><ul><li>Antisaccade </li></ul><ul><li>Memory Guided </li></ul>What does it tell you if a person can’t Fix and Follow?
    18. 19. Ocular Motility See video file on visual field testing
    19. 20. Spontaneous Recovery Studies <ul><li>Homonymous field defects </li></ul><ul><li>Zhang et al. Neurology (2006), n=254. </li></ul><ul><li>50% of patients recover in first month without vision rehab. </li></ul><ul><li>In most cases, the improvement occurs within the first 3 months </li></ul><ul><li>Nerve Palsies </li></ul><ul><li>Tiffin et al, Eye (1996), n=165 </li></ul><ul><li>57% total recovery, median 3 months </li></ul><ul><li>80% made at least a partial recovery </li></ul><ul><li>*Clinical experience 9 month recovery period </li></ul><ul><li>Hemispatial Neglect </li></ul><ul><li>Cassidy TP et al, J Neurol Neurosurg Psychiatry (1998) </li></ul><ul><li>31% had persistent neglect past 3 months </li></ul>
    20. 21. Hemianopic Rehab <ul><li>Hemianopsia is correlated with poor recovery from brain injury. Ashley MJ, Krych DK. Traumatic Brain Injury Rehabilitation. CRC Press 1995. </li></ul><ul><li>Patients with hemianopic field defects who do not receive training do not tend to develop scanning strategies on their own. Kerkhoff, G, Munsinger U, Haaf E, Eberle-Strauss G, Stogerer E. Rehabilitation of homonymous scotomata in patients with postgeniculate damage of the visual system: Saccadic compensation training. Restor. Neurol. Neurosci, 4, 245, 1992. </li></ul><ul><li>Self report of 35 patients’s with persistent HH found 14 with slight functional impairment, 10 with moderate to severe impairment. Gassel MM, Williams D: Visual function in patients with homonymous hemianopia, III. The completion phenomenon, insight and attitude to the defect, and visual functional efficiency. Brain 1963, 86: 229-260. </li></ul><ul><li>35 patients with HH all showed “filling-in” effect with reduced awareness of the visual field defect. </li></ul><ul><li>Demonstrating the presence of defects to patient helped them compensate more efficiently. Safran A, Landis T. Plasticity in the adult visual cortex: implication for the diagnosis of visual field defects and visual rehabilitation. Current Opinion in Ophthalmology 1996, 7:53-64. </li></ul><ul><li>The potential of the adult brain for rapid functional reorganization could be exploited for therapeutic purposes. Safran A, Landis T. Plasticity in the adult visual cortex: implication for the diagnosis of visual field defects and visual rehabilitation. Current Opinion in Ophthalmology 1996, 7:53-64. </li></ul>
    21. 22. Key Questions for Rehab <ul><li>Are there therapies that promote recovery? </li></ul><ul><li>Can patients be trained to use compensatory strategies? </li></ul><ul><li>If so, what behaviors should we train and when? </li></ul><ul><li>Will the patient apply these strategies to their daily activities? </li></ul><ul><li>Will they continue to use these strategies over time? </li></ul><ul><li>Is it better to fit them with a device and not train them? </li></ul><ul><li>Is it best to do both? </li></ul>
    22. 23. Restorative Therapies, Hemianopia <ul><li>Hemianopsia </li></ul><ul><ul><li>Justification: </li></ul></ul><ul><ul><ul><li>Mohler and Wurtz in 1977 reported that if an animal is given training to respond to brief and small flashes of light in only one part of the blind field, that part recovers more than the remainder of the field. </li></ul></ul></ul><ul><ul><li> Mohler CW, Wurtz RH. Role of Striate Cortex and Superior Colliculus in Visual Guidance of Saccadic Eye Movements in Monkeys. J Neurophys. 40(1), Jan 1977. </li></ul></ul><ul><ul><ul><li>Kasten and Sabel in 1995 reported increased sensitivity in human subjects with repeated practice detecting a small light target at the border of the field defect. Kasten E. Sabel BA. Restor Neurol Neurosci 8:113-127 1995 </li></ul></ul></ul><ul><ul><li>Procedures (see next slide) </li></ul></ul>
    23. 24. Restorative Therapies <ul><li>Hemianopsia (cont’d) </li></ul><ul><ul><li>Procedures </li></ul></ul><ul><ul><ul><li>Visual Scan Therapy (VST) </li></ul></ul></ul><ul><ul><ul><li>Awareness Training: includes EV </li></ul></ul></ul><ul><ul><ul><li>Eye Lights (LED glasses to stimulate affected hemifield) </li></ul></ul></ul><ul><ul><ul><li>Sound field occlusion </li></ul></ul></ul><ul><ul><ul><li>Visual Restoration Therapy (NOVA vision) </li></ul></ul></ul>
    24. 25. Other Restorative Therapies, Hemianopia <ul><li>Visual Restoration Therapy (VRT) </li></ul><ul><ul><li>NOVA vision </li></ul></ul><ul><ul><li>Reinhard et al, Brit J Oph (2005), found no change in field when measured with microperimeter </li></ul></ul><ul><li>Syntonic Phototherapy </li></ul><ul><ul><li>Spitler HR. The syntonic principle its relation to health and ocular problems. 1941, College of Syntonic Optometry. </li></ul></ul>
    25. 26. Compensatory Therapies Hemianopia <ul><li>Compensatory Training Technique: Systematic Visual Search </li></ul><ul><ul><li>Justification: Study of natural strategy development teaches us patients initially show multiple step (3 or more) when searching into the blind field. Later they employ one large overshooting saccade to locate the target, then foveate. Meienberg O, Zangemeister WH, Rosenberg M, Hoyt WF, Stark L. Saccadic eye movement strategies in patient with homonymous hemianopia. Ann. Neurol 198, 9:537-544 </li></ul></ul><ul><ul><li>Goals: </li></ul></ul><ul><ul><ul><li>decrease problems locating items </li></ul></ul></ul><ul><ul><ul><li>Minimize visual omission of mobility hazards </li></ul></ul></ul><ul><ul><ul><ul><li>decrease fall risk </li></ul></ul></ul></ul><ul><ul><ul><li>May or may not decrease search times </li></ul></ul></ul><ul><ul><li>Technique: </li></ul></ul><ul><ul><ul><li>Anchoring: </li></ul></ul></ul><ul><ul><ul><ul><li>Def: A technique using a visual landmark </li></ul></ul></ul></ul><ul><ul><ul><ul><li>In HFD, anchor is placed on the side of the defect </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Results in patient overshooting the target </li></ul></ul></ul></ul><ul><ul><ul><li>Circular Scan Pattern </li></ul></ul></ul><ul><ul><ul><ul><li>Patient is trained to scan in clockwise pattern starting and ending at the anchor </li></ul></ul></ul></ul><ul><ul><li>Training tools </li></ul></ul><ul><ul><ul><li>Saccadic Fixator </li></ul></ul></ul><ul><ul><ul><li>Dynavision </li></ul></ul></ul><ul><ul><ul><li>Computer Orthoptics </li></ul></ul></ul><ul><ul><ul><li>ADL’s </li></ul></ul></ul>
    26. 27. Compensatory Therapies Hemianopia <ul><li>Other techniques </li></ul><ul><ul><li>Turn reading material sideways </li></ul></ul><ul><ul><li>Place items within the good field </li></ul></ul><ul><ul><li>Approach the patient from the good side </li></ul></ul><ul><ul><li>Long cane training </li></ul></ul><ul><ul><li>Walker for fall prevention </li></ul></ul><ul><ul><li>Screen readers and other speech enabled devices (in acquired dyslexia) </li></ul></ul><ul><li>Optical Aids </li></ul><ul><ul><li>EP Horizontal (Chadwick Optical) </li></ul></ul><ul><ul><li>Hemi lens, Chadwick Optical </li></ul></ul><ul><ul><li>Visual Field Awareness System, Daniel Gottlieb, OD Atlanta GA </li></ul></ul><ul><ul><ul><li>Prism Insert: Extreme Optics, Lithia Springs GA </li></ul></ul></ul><ul><ul><ul><li>Round prisms: Chadwick Optical </li></ul></ul></ul><ul><ul><li>Hemianopic mirrors </li></ul></ul><ul><ul><li>Reverse telescopes </li></ul></ul>
    27. 28. Restorative Therapies for Neglect <ul><li>Top Down (descending approach): </li></ul><ul><ul><li>Visual Scanning Training (VST) </li></ul></ul><ul><ul><li>Mental Imagery Training </li></ul></ul><ul><ul><li>Cueing </li></ul></ul><ul><li>These are the classical treatments in inpatient and early post-acute outpatient centers </li></ul><ul><li>Task specific, do not generalize to all tasks </li></ul><ul><li>Reduced effectiveness in anosognosia </li></ul>
    28. 29. <ul><li>Bottom-up </li></ul><ul><ul><li>Justification </li></ul></ul><ul><ul><ul><li>Caloric Stimulation Rubens AB. Caloric stimulation and unilateral visual neglect. Neurology 1985;35:1019–1024. </li></ul></ul></ul><ul><ul><ul><li>Optokinetic Therapies Kerkhoff G, Keller I, Ritter V, Marquardt C.Repetitive optokinetic stimulation induces lasting recovery from visual neglect.Restor Neurol Neurosci. 2006;24(4-6):357-69. </li></ul></ul></ul><ul><ul><ul><li>Limb Activation Active and passive activation of left limbs: influence on visual and sensory neglect. [Neuropsychologia. 1993] </li></ul></ul></ul><ul><ul><ul><li>Neck Vibration HO Karnath; K Christ; W Hartje. Brain : a journal of neurology, 1993 Apr; 116 ( Pt 2): 383-9. </li></ul></ul></ul><ul><ul><ul><li>Ocular Occlusion Barrett AM, Burkholder S.Monocular patching in subjects with right-hemisphere stroke affects perceptual-attentional bias.J Rehabil Res Dev. 2006 May-Jun;43(3):337-46. </li></ul></ul></ul><ul><ul><ul><li>Prism Adaptation Rossetti Y, Rode G, Pisella L, et al. Prism adaptation to a rightward optical deviation rehabilitates left hemispatial neglect. Nature 1998; 395:166–169. </li></ul></ul></ul><ul><li>Medicinal </li></ul><ul><ul><li>Bromocriptine and Methylphenidate (dopamine agonists) WS Fleet; E Valenstein; RT Watson; KM Heilman. Dopamine agonist therapy for neglect in humans. Neurology, 1987 Nov; 37(11): 1765-70 </li></ul></ul>Restorative Therapies for Neglect
    29. 30. <ul><li>Anchoring </li></ul><ul><li>Systematic Visual Search Strategies </li></ul><ul><li>Cueing </li></ul><ul><li>Rotate plate </li></ul><ul><li>Plate items on good side </li></ul><ul><li>Turn reading material sideways </li></ul><ul><li>Approach from good side </li></ul><ul><li>Walker </li></ul><ul><li>EP horizontal </li></ul>Compensatory Treatments for Neglect
    30. 31. Restorative Therapies, BV <ul><li>Cranial Nerve Palsies </li></ul><ul><ul><li>Justification: Theory of Neuro-muscular Re-education and aberrant regeneration </li></ul></ul><ul><ul><li>Procedures </li></ul></ul><ul><ul><ul><li>Ocular range of motion activities </li></ul></ul></ul><ul><ul><ul><li>Optokinetic therapy </li></ul></ul></ul><ul><ul><ul><li>Traditional orthoptic therapy </li></ul></ul></ul><ul><li>Convergence Disorders </li></ul><ul><ul><li>Justification: Convergence can be trained in neurologically intact children and adults (CITT study) </li></ul></ul><ul><ul><li>Procedures: Traditional orthoptic therapy </li></ul></ul><ul><ul><ul><li>Push-ups </li></ul></ul></ul><ul><ul><ul><li>Brock string with physical diplopia </li></ul></ul></ul><ul><ul><ul><li>Stereoscopes </li></ul></ul></ul><ul><ul><ul><li>Tranaglyphs </li></ul></ul></ul><ul><ul><ul><li>Computer programs </li></ul></ul></ul><ul><ul><ul><li>BI/BO flippers </li></ul></ul></ul>
    31. 32. Restorative Therapies, BV <ul><li>Accommodative Disorders </li></ul><ul><ul><li>Justification: </li></ul></ul><ul><ul><ul><li>Theory of Neuro-muscular Re-education and axonal remodeling. </li></ul></ul></ul><ul><ul><ul><li>No large multicenter trials have been performed </li></ul></ul></ul><ul><ul><li>Procedures </li></ul></ul><ul><ul><ul><li>Push up training </li></ul></ul></ul><ul><ul><ul><li>Near-Far rock </li></ul></ul></ul><ul><ul><ul><li>+/- flippers </li></ul></ul></ul><ul><ul><ul><li>Look hard/look soft (volitional proprioceptive control) </li></ul></ul></ul>
    32. 33. Treating Convergence Insufficiency <ul><li>CITT: First Randomized Double Blind Multicenter Study on Vision Therapy/Orthoptics. </li></ul><ul><li>42% reduction in symptoms with office-based vision therapy/orthoptics, 31% in office-based placebo vision therapy/orthoptics, and 20% in home-based pencil push-ups Scheiman M, Mitchell GL, Cotter S, Cooper J, Kulp M, Rouse M, Borsting E, London R, Wensveen J; Convergence Insufficiency Treatment Trial Study Group. A randomized clinical trial of treatments for convergence insufficiency in children. Arch Ophthalmol. 2005 Jan;123(1):14-24. </li></ul><ul><li>No large studies on convergence training for CI in TBI/Stroke. </li></ul>
    33. 34. Compensatory Treatments, BV <ul><li>Lenses, prisms </li></ul><ul><li>Patching </li></ul><ul><li>Large print </li></ul><ul><li>Magnifiers </li></ul>
    34. 35. Restorative Therapies, AEL <ul><li>Disorders of Abnormal Egocentric Localization </li></ul><ul><ul><li>Justification: </li></ul></ul><ul><ul><ul><li>Egocentric shift hypothesis of neglect S Chokron. Right parietal lesions, unilateral spatial neglect, and the egocentric frame of reference. NeuroImage, 2003 Nov; 20 Suppl 1: S75-81 </li></ul></ul></ul><ul><ul><ul><li>Theory of Motor learning </li></ul></ul></ul><ul><ul><ul><li>Prism Adaptation literature </li></ul></ul></ul><ul><ul><li>Procedures </li></ul></ul><ul><ul><ul><li>Eye hand coordination tasks </li></ul></ul></ul><ul><ul><ul><li>Reaching with and without visual control </li></ul></ul></ul><ul><ul><ul><li>Dynavision, saccadic fixator, visuo-motor tasks (VMT) </li></ul></ul></ul><ul><ul><ul><li>Prism Adaptation base opposite pointing error </li></ul></ul></ul>
    35. 36. Compensatory Treatments, AEL <ul><li>Disorders of Abnormal Egocentric Localization </li></ul><ul><ul><li>Full time wear yoked prism </li></ul></ul><ul><ul><li>Base towards the direction of misreaching </li></ul></ul>
    36. 37. Rehab Protocols <ul><li>See Files on teaching server->Low Vision Indy->training </li></ul><ul><li>Or </li></ul><ul><li>PDF files on oncourse </li></ul>
    37. 38. Reporting and Plan Development <ul><li>Rehab OD primary responsibility is to oversee vision rehabilitative care </li></ul><ul><li>Requires reporting and plan of care development </li></ul><ul><li>Follow-up monthly during treatment </li></ul><ul><li>Need close working relationship with therapists </li></ul><ul><li>Continues general care with PC OD </li></ul>
    38. 39. Case L J: HPI <ul><li>Aphasia and impairment of verbal reading </li></ul><ul><ul><li>Superior right quadranopsia and Wernike’s (receptive) and anomic aphasia </li></ul></ul><ul><ul><li>Superior and inferior quadranopsia in Broca’s (expressive) aphasia </li></ul></ul><ul><ul><ul><li>FEF can be affected resulting in leftward gaze deviation. </li></ul></ul></ul><ul><li>S/P left temporal lobe oligodendroglioma </li></ul><ul><li>Broca’s Aphasia </li></ul><ul><li>Can’t read </li></ul><ul><li>Contact lens wearer -3.00 N&D. </li></ul><ul><li>Goals: Return to work in sales, Drive, bowl </li></ul>
    39. 40. Case L J: Objective <ul><li>20/20 BCVA OD, OS </li></ul><ul><li>Confrontations: Dense Right Homonymous Hemianopsia. </li></ul><ul><li>Amsler: Foveal Splitting OD, OS </li></ul><ul><li>MNread: Dysfluent at all print sizes, 10wpm. </li></ul>
    40. 41. Case L J: A&P <ul><li>Hemianopic Alexia </li></ul><ul><li>Dense Right Homonymous Hemianopsia </li></ul><ul><li>Impaired Mobility and Ambulation </li></ul><ul><li>High risk for driving </li></ul><ul><li>Plan </li></ul><ul><li>Eccentric Viewing, Optokinetic Therapy, Typoscopes, Anchoring, Turn Material Sideways. </li></ul><ul><li>EP Horizontal Field Expander </li></ul><ul><li>Training with EP Horizontal, VST, and CDRS Eval and Training. </li></ul>
    41. 42. Case L J: Hemianopic Alexia <ul><li>Hemianopic alexia: Recognize long words as quickly as short words, but have very slow reading speeds (~100wpm). </li></ul><ul><ul><li>Amount of foveal sparing is exponentially and inversely correlated to reading speed. </li></ul></ul><ul><ul><li>Scotoma within 5 degrees of fixation will start to seriously affect reading. </li></ul></ul><ul><li>* Pearl: Teach rightward eccentric viewing, Optokinetic Therapy, turn reading material sideways, and/or use finger/lineguides/anchors. </li></ul><ul><li>Pure Alexia: Recognize letters, but not words. Essentially non-readers </li></ul><ul><ul><li>Have damage to the posterior fusiform gyrus of temporal lobe as well as occipital lobe (PCA territory). </li></ul></ul>
    42. 43. A E U C G T O M A E U C G T O M H G N X Z J A L K J L D O W U O V R ◙ Case L J: Eccentric Viewing
    43. 44. The first place that I can well remember was a large pleasant meadow with a pond of clear water in it. Some shady trees leaned over it, and rushes and water-lilies grew at the deep end. Case L J: Optokinetic Therapy l-opt-iuso eachingLOW VISION INDYJournal Articles-->Optokinetic Therapy Spitzyna GA, Wise RJ, McDonald SA, Plant GT, Kidd D, Crewes H, Leff AP. Optokinetic therapy improves text reading in patients with hemianopic alexia: a controlled trial. Neurology. 2007 May 29;68(22):1922-30.
    44. 45. Case KM: OKN Therapy <ul><li>Fronto-Parietal Injury-Hit by car </li></ul><ul><li>Unable to read </li></ul><ul><li>Significant aphasia </li></ul><ul><li>Initial Visigraph, 37wpm </li></ul><ul><li>Post Treatment Visigraph 61wpm </li></ul>
    45. 46. Pre & Post Treatment Visigraph
    46. 47. Case L J: Driver Rehab Protocol <ul><li>Evidence-based vision eval. </li></ul><ul><li>Assess Risk </li></ul><ul><li>Patient Education and Awareness Training </li></ul><ul><li>Fit Temporary Sector Prism (Fresnel) </li></ul><ul><li>Eccentric Viewing Training </li></ul><ul><li>Anchoring and Visual Scan Therapy (VST) </li></ul><ul><li>Prescribe refined sector prism </li></ul><ul><li>Repeat Evidenced-based vision eval. </li></ul><ul><li>Neuropsych referral if needed </li></ul><ul><li>On-the-road evaluation </li></ul>
    47. 48. Case L J: Evidence-Based eval for Driving <ul><li>Snellen VA OD, OS, OU [L J 20/20] </li></ul><ul><li>Mars-Perceptrix Contrast Sensitivity OU [L J 1.7] </li></ul><ul><li>Humphery Full-Field 81-pt OD, OS [L J: Already knew Risk] </li></ul><ul><li>Trail-making test part-B [L J 75sec] </li></ul><ul><li>How Many risk factors are there? </li></ul>
    48. 49. Case L J: Assess Risk <ul><li>Assess Risk: Review Snellen VA OD, OS, OU; Mars-Perceptrix Contrast Sensitivity OU; Visual Field; Cognitive Status. </li></ul><ul><li>Snellen acuity worse than 20/40 OU, </li></ul><ul><li>Contrast Sensitivity less than 1.6, </li></ul><ul><li>inferior absolute homonymous quadranopsia, </li></ul><ul><li>macular splitting, </li></ul><ul><li>homonymous hemianopsia, </li></ul><ul><li>significant cognitive impairment, </li></ul><ul><li>oculomotor or gaze palsy. </li></ul><ul><li>If 1 risk factor, good prognosis </li></ul><ul><li>If 2 risk factors, moderate prognosis </li></ul><ul><li>If 3 risk factors, guarded prognosis </li></ul><ul><li>If 4 risk factors, poor prognosis </li></ul><ul><li>If 5 risk factors, no driving rehab </li></ul><ul><li>How many risk factors for Mr. LJ? </li></ul><ul><li>Mr. L J had 2 risk factors </li></ul><ul><li>What’s your plan? </li></ul>
    49. 50. Plan for Driver Rehabilitation <ul><li>Step 1: Education and Demonstration Training </li></ul><ul><li>Step 2: Fit Temporary Sector Prism </li></ul><ul><li>Step 3: EV, Anchoring, and VST </li></ul><ul><li>Step 4: Driver Simulator </li></ul>
    50. 51. Video: Training with the VFAS
    51. 52. Case L J: Post Therapy Final Assessment <ul><li>Reading Speed: 50wpm to .4M CPS </li></ul><ul><li>Passed CDRS eval for driving. Cleared by all parties </li></ul><ul><li>Return to previous job in sales </li></ul><ul><li>Bowling (not professionally) </li></ul><ul><li>Stable MRI </li></ul><ul><li>Stable field (30-2SF) </li></ul>
    52. 53. Case R C: HPI <ul><li>S/P Right Frontal ICH, spontaneous on ASA </li></ul><ul><li>S/P Caniotomy for ICH </li></ul><ul><li>CV VII Palsy </li></ul><ul><li>TIA 2-3 yrs ago </li></ul><ul><li>Coronary Artery Disease </li></ul><ul><li>Bradycardia </li></ul><ul><li>BPH </li></ul><ul><li>Glaucoma, Cosopt BID </li></ul><ul><li>S/P ICCE </li></ul><ul><li>Reading Glasses </li></ul><ul><li>Therapist reports </li></ul><ul><ul><li>Left neglect </li></ul></ul><ul><ul><li>Problems keeping head midline </li></ul></ul><ul><ul><li>Reduced left scan </li></ul></ul><ul><li>Visual deficits affecting therapy </li></ul>
    53. 54. Case R C: Subjective <ul><li>Reports blur at distance when watching TV </li></ul><ul><li>Denies blind spots, double vision, or left visual problems. </li></ul><ul><li>*Anosognosia: Unawareness or denial of deficits due to brain injury </li></ul>
    54. 55. Case R C: Objective <ul><li>BCVA 10/20 OD, OS; Only reads right side </li></ul><ul><li>Confrontation: LHH </li></ul><ul><li>Amsler: Macular splitting OD 1°, OS 3 ° </li></ul><ul><li>Reduced levoversion (<2°/s) on fix & follow. </li></ul><ul><li>Normal dextroversion </li></ul><ul><li>Left gaze on command with coaxing </li></ul><ul><li>Hypometric leftward saccade /c inc. latency, & dec. velocity </li></ul><ul><li>MNread: Dysfluent, .8M @ 80wpm. Normal return sweep. </li></ul><ul><li>BIT: Positive for neglect </li></ul><ul><li>Normal visuomotor adaptation to 20PD base-left prism </li></ul>
    55. 56. Case R C: Objective
    56. 57. Case RC: A & P <ul><li>Assessment </li></ul><ul><li>Viewer Centered Left Hemispatial Neglect with revisit targets and perseveration. </li></ul><ul><li>Left Homonymous Heminanopsia </li></ul><ul><li>Macular Scotoma </li></ul><ul><li>Leftward Saccade and Pursuit deficiencies </li></ul><ul><li>Reading disorder </li></ul><ul><li>Plan </li></ul><ul><li>Prism Adaptation 3x’s/week x 2 weeks. </li></ul><ul><li>Trial EP Horizontal once functional and cognitive status improve </li></ul><ul><li>EV training as needed after discharge </li></ul>
    57. 58. Case RC: Before and After 4 sessions
    58. 59. Case RC: Post-Therapy SOAP <ul><li>BCVA OD 10/20, OS 10/10 </li></ul><ul><li>Confrontations: FTEF OD, OS </li></ul><ul><li>BIT: Rightward biases persist, much improved </li></ul><ul><li>MNread .5M, 120wpm-fluent </li></ul><ul><li>A: LHSN mostly resolved. LHH was largely attentional. </li></ul><ul><li>P: EP horizontal and EV training not needed. Threshold VF after D/C with PC OD to document and monitor field. RTC LV with any functional problems. </li></ul>
    59. 60. Rosetti Video
    60. 61. Subtypes of Negelct <ul><li>Sensory Neglect ( Stimulus Centered or Viewer Centered) : Auditory, Visual, Tactile </li></ul><ul><li>Motor (Intentional) Neglect: Don’t reach or look to the left </li></ul><ul><li>Representational Neglect: Imagery </li></ul><ul><ul><li>Bisiach and Luzzatti cathedral </li></ul></ul><ul><li>Personal Neglect: Failure to recognize body parts as own. </li></ul><ul><ul><li>Dress half the body </li></ul></ul><ul><li>Spatial Neglect </li></ul><ul><ul><li>Peripersonal: Within arms reach </li></ul></ul><ul><ul><li>Extrapersonal: Beyond arms reach </li></ul></ul><ul><li>* Pearl: Subtypes overlap and patient’s will have multiple subtypes </li></ul>
    61. 62. Viewer-Centered Neglect <ul><li>Disorder of Egocentric Reference Frame </li></ul><ul><ul><li>Where am I. Where is the center of my head in relation to my body. </li></ul></ul><ul><li>Do not orient or detect stimuli to the left of midline. </li></ul><ul><li>Visual tracking to the left is usually reduced. </li></ul><ul><li>Right Angular Gyrus (gold) and Intraparietal Suclus (yellow line). </li></ul><ul><li>Superior division of the MCA. </li></ul><ul><li>Frontal lobe involvement increases eye movement, working memory, and motor symptoms. </li></ul>
    62. 63. Stimulus-Centered Neglect <ul><li>Patient neglects the left side of the stimulus, even if it is in the right hemispace. </li></ul><ul><li>Right Superior Temporal Gyrus (orange) </li></ul><ul><li>Visual search is abnormal </li></ul><ul><li>Inferior division of the MCA </li></ul>
    63. 64. Behavioral Symptoms of Neglect <ul><li>Patient doesn’t respond to you when seated on their left. </li></ul><ul><ul><li>You speak and they still don’t respond. </li></ul></ul><ul><ul><li>You touch them on the left shoulder and they now notice you. </li></ul></ul><ul><ul><li>Therapist tells you patient is not dressing their left side . </li></ul></ul><ul><li>Patient touches their own left hand and they reply “oh, your hands are cold”. </li></ul><ul><li>Therapist tells you the patient doesn’t eat off the left side of the plate. </li></ul><ul><li>Patient extinguishes the left target on extinctions test. </li></ul><ul><li>Patient will not look past midline to the left on command. </li></ul><ul><li>Patient dresses themselves normally, but fails to write on the left side of the page. </li></ul>-> Visual Neglect -> Auditory Neglect -> No Tactile Neglect -> Personal Neglect -> Personal Neglect -> Visual Peripersonal Neglect -> Visual Neglect -> Viewer-centered Motor Neglect -> Peripersonal Neglect
    64. 65. Corbetta’s Attentional Networks Nature Reviews Neuroscience 3 ; 201-215 (2002); doi:10.1038/nrn755 CONTROL OF GOAL-DIRECTED AND STIMULUS-DRIVEN ATTENTION IN THE BRAIN BLUE=Dorsal Attention Network Red=Ventral Attentional Network Temporal Parietal Lobule and Superior Temporal Gyrus
    65. 66. Middle Cerebral Artery Infact Source: neuropathologyweb.org Source: www.psyweb.com/Brain/Bimages/blood2.gif
    66. 67. Comparisons of Treatments Arene NU, Hillis NE. Rehabilitation of Unilateral Spatial Neglect and Neuroimaging. Eura Medicophys 2007 43; 255-69 # of exposures Onset Success Rate (%) Degree of Improvement Duration of Improvement Generalization of Acquired Skills Prism Adaptation 1 immediate 100 significant At least up to 5 weeks with 2 weeks of tx Yes Visual Scan and perceptual training Several over 1-2 months Prolonged >90 significant 6-8 weeks Partial Optokinetic Training 1 immediate 100 partial Minutes No Vestibular Stimulation (caloric or glic 1 immediate 79-89 significant Minutes No Neck Vibration 1 immediate 93 significant At least 3 weeks with repeated tx. No Dopamine Agonists variable variable variable significant variable No
    67. 68. Comparison of Treatments Viewer Centered Personal Anosognosia Representational Stimulus Centered Sensory Extinction Prism Adaptation Yes Yes Yes Yes Vestibular Stimulation (caloric or glic Yes Yes Yes Yes Yes Optokinetic Training Yes Yes Yes Neck Vibration Yes Yes Yes Yes Visual Scan and perceptual training Yes
    68. 69. History of Prism Adaptation <ul><li>First reference, Helmholtz 1908 </li></ul><ul><li>1950’s to study motor learning (Kohler, Held and Harris) </li></ul><ul><li>Described in Optometric Literature since 1950’s and 60’s for therapeutic use. </li></ul><ul><li>Fad ended by the mid 1970’s and publications on the topic diminished. </li></ul><ul><li>Wallace and Redding continued systematic study 1970-present </li></ul><ul><li>Applied by Rossetti et al for Neglect, 1998 </li></ul>
    69. 70. Prism Adaptation Therapy(PA) <ul><li>Pubmed Search “Prism Adaptation and Neglect” </li></ul><ul><ul><li>60 citations since 1998 </li></ul></ul><ul><ul><li>All published after 2000 </li></ul></ul><ul><ul><li>“ Prism adaptation first among equals in alleviating left neglect” Luaute J, Halligan P, Rode G, Jacquin-Courtois S, Boisson D. Restor Neurol Neurosci. 2006;24(4-6):409-18. </li></ul></ul>
    70. 71. 10 Original Studies Supporting PA for LHSN <ul><li>Keane S, Turner C, Sherrington C, Beard JR. Use of fresnel prism glasses to treat stroke patients with hemispatial neglect. Arch Phys Med Rehabil. 2006 Dec;87(12):1668-72. </li></ul><ul><li>Neuropsychologia. 2006;44(12):2487-93. Epub 2006 May 18. Links </li></ul><ul><li>Prism adaptation improves spatial dysgraphia following right brain damage.Rode G, Pisella L, Marsal L, Mercier S, Rossetti Y, Boisson D. Neuropsychologia. 2006;44(12):2487-93. Epub 2006 May 18. </li></ul><ul><li>Dijkerman HC, Webeling M, ter Wal JM, Groet E, van Zandvoort MJ. A long-lasting improvement of somatosensory function after prism adaptation, a case study. Neuropsychologia. 2004;42(12):1697-702. </li></ul><ul><li>Berberovic N, Pisella L, Morris AP, Mattingley JB. Prismatic adaptation reduces biased temporal order judgements in spatial neglect. Neuroreport. 2004 May 19;15(7):1199-204. </li></ul><ul><li>Maravita A, McNeil J, Malhotra P, Greenwood R, Husain M, Driver J. Prism adaptation can improve contralesional tactile perception in neglect. Neurology. 2003 Jun 10;60(11):1829-31. </li></ul><ul><li>McIntosh RD, Rossetti Y, Milner AD. Prism adaptation improves chronic visual and haptic neglect: a single case study. Cortex. 2002 Jun;38(3):309-20. </li></ul><ul><li>Farne A, Rossetti Y, Toniolo S, Ladavas E. Ameliorating neglect with prism adaptation: visuo-manual and visuo-verbal measures. Neuropsychologia. 2002;40(7):718-29. </li></ul><ul><li>Frassinetti F, Angeli V, Meneghello F, Avanzi S, Ladavas E. Long-lasting amelioration of visuospatial neglect by prism adaptation. Brain. 2002 Mar;125(Pt 3):608-23. </li></ul><ul><li>Pisella L, Rode G, Farne A, Boisson D, Rossetti Y. Dissociated long lasting improvements of straight-ahead pointing and line bisection tasks in two hemineglect patients. Neuropsychologia. 2002;40(3):327-34. </li></ul>
    71. 72. Prismatic Lenses <ul><li>Base Direction Terminology </li></ul><ul><li>Diopters vs. Degrees of deviation </li></ul><ul><li>Wedge Prism = Yoked Prism </li></ul><ul><li>Perceived Midline is moved opposite the field shift toward the base of the prism </li></ul>
    72. 73. Perceptual Effects of Wedge Prism <ul><li>Visual-Proprioceptive Misalignment </li></ul><ul><ul><li>Vision is perturbed but proprioception is not </li></ul></ul><ul><ul><li>Think of it as moving the patient’s head left </li></ul></ul><ul><ul><li>Do not think of it as shifting the visual field </li></ul></ul><ul><li>Process of Realignment </li></ul><ul><ul><li>Performance Error </li></ul></ul><ul><ul><li>Conscious detection of misalignment (Recalibration) </li></ul></ul><ul><ul><li>Subconscious realignment of spatial maps </li></ul></ul>
    73. 74. Prism Adaptation Therapy(PA) <ul><li>Yves Rossetti, MD, Ph.D. at the Henry Gabrielle Rehabilitation Hospital in France </li></ul><ul><ul><li>First studied prism adaptation for HSN in 1998 </li></ul></ul><ul><ul><li>16 patients with HSN </li></ul></ul><ul><ul><li>10 degree shift of the visual field while making 50 pointing responses to visual targets (2-5min) </li></ul></ul><ul><ul><li>Line bisection, line cancellation, Gainotti test, flower from memory, reading task. </li></ul></ul><ul><ul><li>Prism patients showed a statistically significant improvement over the control group. </li></ul></ul>
    74. 75. Effects were increased 2hrs later Rossetti Y, Rode G, Pisella L, et al. Prism adaptation to a rightward optical deviation rehabilitates left hemispatial neglect. Nature 1998; 395:166–169.
    75. 76. Long Lasting Effects of PA <ul><li>In a 2002 article in March issue of Brain, Francesca Frassinetti and collegues studied the lasting effects of PA. </li></ul><ul><ul><li>13 Patients with LHSN, 4 also had hemianopsia </li></ul></ul><ul><ul><li>Control Groups recruited from other nearby hospitals </li></ul></ul>
    76. 77. Results on BIT Effects of prism treatment on the patients’ performance (percentage of correct responses) in the BIT battery (BIT-C = BIT conventional; BIT-B = BIT behavioural) for the experimental group (EG) and the control group (CG) as a function of time: before treatment (first session) and 2 days, 1 week and 5 weeks after treatment (second, third and fourth sessions, respectively).
    77. 78. Comparison Between BIT Sessions <ul><li>Two-way ANOVA analysis based on correct responses </li></ul><ul><li>First session (64%) </li></ul><ul><li>Second (80%, P < 0.0003) </li></ul><ul><li>Third (88%, P < 0.0002) </li></ul><ul><li>Fourth (90%, P < 0.0002) </li></ul><ul><li>All patients showed the effect </li></ul>
    78. 79. Long Lasting Effects, Frassinetti et al <ul><li>The effects of PA last out to 5 weeks after 2 weeks of twice daily therapy. Frassinetti F, Angeli V, Meneghello F, Avanzi S, Ladavas E. Long-lasting amelioration of visuospatial neglect by prism adaptation. Brain. 2002 Mar;125(Pt 3):608-23. </li></ul>
    79. 80. Mechanism of Action of PA Therapy Pisella L, Rode G, Farnè A, Tilikete C, Rossetti Y. Prism adaptation in the rehabilitation of patients with visuo-spatial cognitive disorders. Curr Opin Neurol. 2006 Dec;19(6):534-42. Right cerebellum and Left Hemisphere blood flow increase correlated with neglect score improvement
    80. 81. Cerebellum’s Role in PA <ul><li>Visuomotor learning </li></ul><ul><li>Calibrates vision with motor system </li></ul><ul><li>Unconscious system </li></ul><ul><li>Cannot adapt to prism after damage to the Vermis </li></ul>Pisella L, Rode G, Farnè A, Tilikete C, Rossetti Y. Prism adaptation in the rehabilitation of patients with visuo-spatial cognitive disorders. Curr Opin Neurol. 2006 Dec;19(6):534-42.
    81. 82. An Anatomo-Functional Model A visual error signal is created in the right hemifield… In the case of a rightward field shift, VES info is transferred to the vermis of the right cerebellum where realignment takes place. A separate network in the cerebellum contralateral to the hand being used is also activated allowing for the appropriate motor response. ..and travels to the left occipital cortex Temporal and frontal cortex and the PPC have been shown to be targets of output from the cerebellum via a neuronal loop also implicating the dentate nucleus and subcortical structures, such as the thalamus and the globus pallidus (GABA)
    82. 83. Case Study C.L. <ul><li>Source: Cicero L. What Owls Teach us About Stroke Rehabilitation. Stanford Magazine, Nov/Dec 2003 </li></ul><ul><li>DeBello WM , Feldman DE , Knudsen EI . Adaptive axonal remodeling in the midbrain auditory space map. J Neurosci. 2001 May 1;21(9):3161-74. </li></ul>
    83. 84. Summary: Take Home Points <ul><li>Rehab OD role overseeing vision rehab care </li></ul><ul><li>Evidence for Vision rehab </li></ul><ul><ul><li>High prevalence of vision disturbances </li></ul></ul><ul><ul><li>Small studies supporting restorative and compensatory therapies </li></ul></ul><ul><li>Rehab of Hemianopsia </li></ul><ul><ul><li>VST, Awareness </li></ul></ul><ul><ul><li>Visual Field Expanders, Anchoring and EV strategies </li></ul></ul><ul><li>Rehab of AEL </li></ul><ul><ul><li>VMT, Prism Adaptation </li></ul></ul><ul><ul><li>Full time wear yoked prism </li></ul></ul><ul><li>Rehab of USN </li></ul><ul><ul><li>Prism Adaptation Therapy, Cueing, VST, Neck Vibration, Sound field occ., Bromocriptine </li></ul></ul><ul><ul><li>Present from good side </li></ul></ul><ul><li>Convergence Insufficiency </li></ul><ul><ul><li>In-office Therapy </li></ul></ul><ul><li>Traumatic Strabismus </li></ul><ul><ul><li>ROM activities and Orthoptics </li></ul></ul><ul><ul><li>Prism/patching </li></ul></ul><ul><li>Accommodative Paresis </li></ul><ul><ul><li>N’VA not sufficient </li></ul></ul><ul><ul><li>+/- flippers, N’/F rock, push-up </li></ul></ul><ul><ul><li>Contacts, Glasses, Bifocal </li></ul></ul>

    ×