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CORE Metadata, citation and similar papers at core.ac.uk Provided by Elsevier - Publisher Connector Journal of Medical Hypotheses and Ideas (2015) 9,S8–S13 Available online at www.sciencedirect.com Journal of Medical Hypotheses and Ideas journal homepage: www.elsevier.com/locate/jmhi REGULAR ARTICLE Enhancing visual performance in individuals with cortical visual impairment (homonymous hemianopsia): Tapping into blindsight Faith A. Birnbaum a, Steven A. Hackley b, Lenworth N. Johnson a,* a Neuro-Ophthalmology Unit, Department of Ophthalmology, The Warren Alpert Medical School of Brown University/Lifespan/Rhode Island Hospital, Providence, RI, United States b Department of Psychological Sciences of the University of Missouri Columbia, Columbia, MO, United States Received 2 October 2015; revised 29 November 2015; accepted 15 December 2015 Available online 22 January 2016 KEYWORDS Abstract Homonymous hemianopsia is a type of cortical blindness in which vision is lost Blindsight; completely or partially in the left half or the right half of the field of vision. It is prevalent in Cortical blindness; approximately 12% of traumatic brain injury and 35% of strokes. Patients often experience Homonymous hemianopsia; difficulty with activities such as ambulating, eating, reading, and driving. Due to the high prevalence Augmented virtual reality; of homonymous hemianopsia and its associated difficulties, it is imperative to find methods for Vision restoration therapy visual rehabilitation in this condition. Traditional methods such as prism glasses can cause visual confusion and result in patient noncompliance. There is a large unmet medical need for improving this condition. In this article, we propose that modifying visual stimuli to activate non-cortical areas of visual processing, such as lateral geniculate nucleus and superior colliculus, may result in increased visual awareness. Presenting high contrast and low spatial frequency visual stimuli can increase visual detection in patients with cortical blindness, a phenomenon known as blindsight. Augmented virtual reality goggles have the potential to alter real-time visual input to high contrast and low spatial frequency images, possibly improving visual detection in the blind hemifield and providing an alternative therapy for homonymous hemianopsia. Ó 2016 Tehran University of Medical Sciences. Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). * Corresponding author at: Alpert Medical School of Brown University/Rhode Island Hospital, Neuro-Ophthalmology Unit, Department of Ophthalmology, 1 Hoppin Street, Suite 200, Providence, RI 02903, United States. Tel.: +1 401 444 6551; fax: +1 401 444 6587. E-mail address: [email protected] (L.N. Johnson). 2251-7294 Ó 2016 Tehran University of Medical Sciences. Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). URL: www.tums.ac.ir/english/ doi:http://dx.doi.org/10.1016/j.jmhi.2015.12.001 Restoring vision homonymous hemianopsia blindsight S9 Introduction quick eye movements in the direction of the blind hemifield, though there is not much evidence supporting efficacy [6]. Cortical visual impairment comprises a significant component Although these methods may provide some compensation for of strokes and traumatic brain injury. Cortical visual impair- the visual field loss, they do not restore the impaired visual field. ment includes homonymous hemianopsia, in which vision is Accordingly, other methods of improving vision are needed. lost completely or partially in the left half or the right half of Individuals with homonymous hemianopsia do not con- the field of vision. Homonymous hemianopsia is prevalent in sciously see vision in the blind hemifield. However, there is evi- approximately 12% of traumatic brain injury and 35% of dence of a ‘blindsight’ phenomenon, whereby some affected strokes [1–3]. Individuals with this vision loss usually have individuals can detect objects in their blind visual field, albeit difficulties with activities of daily living such as ambulating, without conscious awareness of being able to see the object. eating, reading, and driving [4,5]. Due to the high prevalence Functional magnetic resonance imaging (fMRI) studies have of homonymous hemianopsia and its associated difficulties, it indicated that visual processing occurs in other parts of the is imperative to find methods for visual rehabilitation in this brain, such as the lateral geniculate nucleus (LGN) and supe- condition. Traditional methods of visual rehabilitation for rior colliculus (SC) (Fig. 1). Visual processing in these regions homonymous hemianopsia include fitting spectacles with provides the neural network that enables patients with blind- prisms to shift the visual field from the blind hemifield to the sight to see [7–11]. Blindsight has been manipulated in some intact visual field. This is accomplished by placing the base of individuals to enhance visual awareness. Sahraie et al. studied the prism in the blind hemifield, which shifts the image toward a patient with homonymous hemianopsia and well- the apex of the prism into the intact hemifield. Many patients documented blindsight over a long period of time [7]. The discontinue treatment with prisms because the prisms may patient reported increased awareness of visual stimuli in his induce visual confusion and double vision [1–4]. Another tech- blind visual field when the stimulus was presented with high nique used is to train individuals with hemianopsia to make contrast and low spatial frequency. Spatial frequency refers Figure 1 3-D representation of tracts overlaid on T1-weighted fMRI images between the lateral geniculate nucleus (LGN) and human motion complex (hMT+), adapted from Ajina and colleagues (eLife. 2015;4:e08935. doi: 10.7554/eLife.08935) [26]. (A) Dark green tracts are in the ipsilesional hemisphere, light green tracts are in the contralesional hemisphere and in controls. (B) Fractional anisotropy, reflecting neuronal damage, demonstrates increased impaired tissue microstructure in the ipsilesional tract in blindsight negative patients as compared with blindsight positive patients and controls. S10 F.A. Birnbaum et al. to the level of detail in an image appearing within a degree of may offer potential solutions to modify visual stimuli in such the visual field. Temporal frequency, the number of times a ways as to allow people with hemianopsia to improve visual stimulus is flashed within a second, also modulates detection. detection. This new technology which has been marketed Multiple studies have shown that within a temporal frequency toward business and gaming applications may be an ideal range of 5–20 Hz (cycles/s), detection of visual stimuli in a method for visual rehabilitation for individuals with homony- forced-choice test is significantly better than chance [7–11]. mous hemianopsia. Weiskrantz’s group at Oxford University The time of stimulus onset also affects the rate of detection. [8], Huxlin’s group at the University of Rochester [10], and Patients with parietal lobe injury often cannot detect a visual others have studied visual detection with Gabor patches and stimulus in the neglected hemifield when it is presented simul- checkerboard reversal in patients with homonymous hemi- taneously in the intact hemifield, but can detect the stimulus anopsia. To our knowledge, no one has published information when it is presented by itself in the neglected hemifield only, on the detection rate of real time video images, the logical next a phenomenon known as visual extinction [12,13]. It is thought steps. We expect the image detected in the blind hemifield will that visual extinction reflects an attentional deficit as opposed be rudimentary, but this would be the first time that a true to primarily a sensory deficit, although this remains an area of extension of vision in the blind hemifield will be documented active research [14]. Despite that visual extinction is primarily using blindsight (Fig. 3). studied in patients with hemi-neglect, patients with hemianop- sia also can have hemi-neglect from injury to both the occipital Evaluation of the hypothesis and parietal lobes [15]. Therefore, the relevant visual variables for increasing visual detection in hemianopsia are stimuli con- The following research directions are recommended for the trast, spatial frequency, temporal frequency and stimulus onset evaluation of our hypothesis: asynchrony. (1) Baseline studies of people affected by homonymous Hypothesis hemianopsia to assess the best spatial frequency, tempo- ral frequency, and stimulus onset asynchrony delay We propose that real-time visual input can be altered to have required for each individual for real visual stimuli high contrast, low spatial frequency, low temporal frequency, (Fig. 1). If necessary, this could be performed by dis- and appropriate stimulus onset asynchrony using augmented playing video clips on a computer screen before using virtual reality goggles (Fig. 2). Augmented virtual reality gog- augmented virtual reality goggles. Previously, temporal gles, which overlay real-world input with a virtual display, have frequencies of pattern-reversal at 10 Hz frequency have been developed in the past few years. Head-mounted displays been documented to produce the highest rates of detec- such as such as the Cast AR (http://technicalillusions.com/)or tion in hemianopsia [16–18]. A spatial frequency of 1 Daqri
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