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CURRENT STATUS of REHABILITATION for PATIENTS with HOMONYMOUS FIELD DEFECTS Susanne Trauzettel-Klosinski MD Center for Ophthalmology, University of Tuebingen Germany

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CURRENT STATUS of REHABILITATION for PATIENTS with HOMONYMOUS FIELD DEFECTS Susanne Trauzettel-Klosinski MD Center for Ophthalmology, University of Tuebingen Germany CURRENT STATUS OF REHABILITATION FOR PATIENTS WITH HOMONYMOUS FIELD DEFECTS Susanne Trauzettel-Klosinski MD Center for Ophthalmology, University of Tuebingen Germany LEARNING OBJECTIVES INTRODUCTION 1) The att endee will be able to describe the disabiliti es In pati ents with brain damage, oft en the hemianopic and handicaps in everyday life caused by hemianopia. fi eld defect is not diagnosed, because other neurological symptoms, such as hemiplegia, are predominant. The 2) The att endee will be able to explain the features of the mean ti me between the brain damage and the diagnosis reading disorder and its rehabilitati on opti ons. of the hemianopia was found to be 3 +/- 2 months (Zhang 3) The att endee will be able to understand what et al 2006). Additi onally, the pati ents oft en do not realize rehabilitati on approach to improve orientati on is the fi eld defect, even though they experience acti vity appropriate. limitati ons in their everyday life. The classifi cati on of the World Health Organizati on (WHO 2004) for Functi oning, Disability and Health (ICF) includes CME QUESTIONS three main aspects, which have to be considered in visual 1) Which spontaneous adapti ve strategies are favorable impairment: 1) impairment – related to the organ, 2) to improve orientati on? disability or acti vity limitati on – related to the person and 3) handicap or parti cipati on restricti on – related to the a) turning the head to the blind side society. b) saccades towards the blind side Homonymous fi eld defects cause two main disabiliti es/ c) shift ing att enti on to the blind side acti vity limitati ons: 2) The hemianopic reading disorder is caused by 1. reading disorder, if the central visual fi eld is involved a) low visual acuity 2. orientati on disorder (bumping into objects, problems b) fi xati on instability with way fi nding) c) limited size of the reading visual fi eld These disabiliti es cause major handicaps, which are listed in 3) Which rehabilitati on approach to improve the Table 1. hemianopic orientati on disorder is evidence-based? a) compensatory saccadic training Table 1: Handicaps resulti ng from hemianopia b) visual sti mulati on of the blind hemifi eld Reduced parti cipati on in society c) prisms mounted in the spectacles Missing spati al informati on No driving KEYWORDS Decreased acti viti es of daily living 1. Homonymous Hemianopia Impaired independence 2. Reading Reduced social contact 3. Orientati on Severe reducti on of quality of life! 4. Rehabilitati on 5. Training Because of these severe disabiliti es and handicaps, rehabilitati on is important and should be provided for these pati ents. 2011 Annual Meeting Syllabus | 91 General Aspects Of Rehabilitati on Fig. 1 A: Fixati onal eye movements during a strict fi xati on Three main aspects need to be considered: task. The fi xati onal eye movements are asymmetric towards the hemianopic side. B: By eccentric fi xati on and/ 1. Knowledge and potenti al uti lizati on of spontaneous or saccades towards the hemianopic side the verti cal adapti ve strategies visual fi eld border is shift ed towards the blind side, as well as the blind spot. The blind spot serves as a reference 2. Opti cal devices scotoma. This mechanism leads to a new perceptual along 3. Training the verti cal midline and is oft en misinterpreted as a real It is crucial for training studies to exclude spontaneous improvement of the visual fi eld. C top: With straight gaze, recovery. Additi onally, placebo eff ects have to be there is no informati on from the hemianopic side. C: ruled out by using a control group. Furthermore, it is With explorati ve saccades towards the hemianopic side necessary to defi ne appropriately, which improvement the visual fi eld defect is shift ed, resulti ng in a bett er use is clinically relevant and to assess the potenti al success of the fi eld of gaze. Obstacles, such as the suitcase and of a training by suitable methods. the person, can be detected in ti me. This strategy can be improved by saccadic training (Roth et al 2009) (modifi ed In principle, there are two approaches for training aft er Trauzett el-Klosinski 2010). methods: resti tuti on or compensati on (see below for details). THE HEMIANOPIC ORIENTATION DISORDER OPTICAL DEVICES FOR BETTER ORIENTATION Pati ents with homonymous hemianopia are oft en not Monocular prisms or mirrors can enlarge the binocular aware of their fi eld defect and are confused by unpleasant fi eld. A benefi t was described in 20% of the pati ents “events” such as bumping into objects or persons, as well (Hedges et al., 1988). However, the competi ti on between as problems with way fi nding. The pati ents oft en develop the seeing halves of the reti na leads to confusion and spontaneous adapti ve strategies: eye movements towards impairment of spati al orientati on. A newer method uses the blind side (Huber et al 1995, Pambakian et al 2000, monocular peripheral prisms, where the prisms are Trauzett el-Klosinski and Reinhard 1998, Reinhard et al 2005) located only in the peripheral part of the glasses in order that are small during fi xati on tasks (see Figure 1 A) and to avoid the central diplopia (Peli, 2006). This approach larger during explorati on tasks, where they allow a bett er has been described to be quite successful: 47% (20 of 32) use of the fi eld of gaze (Figure 1 C). Furthermore, pati ents of the pati ents where wearing the prisms aft er 12 months can develop an att enti onal shift towards the blind side. It is and reported benefi ts for obstacle avoidance (Bowers et known that att enti on improves sti mulus discriminati on (Pilz al., 2008). However, this study was not randomized and et al 2006). Some pati ents get accustomed to a head turn, controlled, and the success was mainly determined by the which is unfavorable. Interesti ngly, the eye movements subjecti ve report of the pati ents. during fi xa ti on are asymmetric towards the blind side, thus causing a shift of the visual fi eld border towards the blind Binocular prisms have been shown to be benefi cial in or side. Huber et al (1995) found in a SLO-perimetry study in pati ents with hemineglect (Rose tti et al 1998). all 15 pati ents with hemianopia fi xati onal shift s: 12 pati ents with 1-5°, 3 pati ents with 5-15°. This shift of the visual fi eld TRAINING border is oft en misinterpreted as an improvement of the There are two approaches to improve the hemianopic visual fi eld. The exact determinati on of the positi on of the orientati on disorder: blind spot helps to identi fy whether fi xati on is central or 1. Resti tuti on by visual sti mulati on of the blind eccentric or whether eye movements shift the fi eld defect hemifi eld. together with the blind spot (Figure 1B). 2. Compensati on by increasing the fi eld of gaze with explorati ve saccades. Previous studies performed visual sti mulati on using targets along the visual fi eld border. Zihl and von Cramon (1979) used targets at threshold and described an improvement of up to 40°. These results were not confi rmed by a later study by Balliet et al. (1985). Some years later, Kasten et al. (1998) used supra-threshold targets along the visual fi eld border and recorded an improvement of 5°. The eff ect of this “Vision Resti tuti on Training VRT” of 5° improvement along the verti cal fi eld border was not confi rmed by Reinhard et al. (2005) using SLO perimetry, where fi xati on was simultaneously 92 | North American Neuro-Ophthalmology Society controlled during sti mulus presentati on. The test point grid peripheral sti mulus might be safer regarding provocati on had a spati al resoluti on of 0.5° horizontally and 1° verti cally. of saccades, but it is not clear whether eye movement Also in conventi onal perimetry using a threshold oriented arti facts can be excluded. slightly supraliminal stati c grid procedure (Tuebingen Automated Perimetry) no relevant change in the fi elds The alleged eff ects of the above menti oned resti tuti on was found (Schreiber et al 2006; same pati ent group as in studies should be disti nguished from the “blindsight” Reinhard`s study, Reinhard et al 2005). The problem with phenomenon, which is an unconscious percepti on of visual conventi onal perimetry is insuffi cient fi xati on control and sti muli via the superior colliculus to extrastriate regions the provocati on of eye movement towards the sti mulus. without acti vati on of V1 (Pöppel et al., 1973; Vanni et al., Furthermore, light scatt er of a bright sti mulus near the fi eld 2001; Weiskrantz, 2004). It was shown recently that the border may interfere. Another problem in the studies by thalamic lateral geniculate nucleus has a causal role in V1- Kasten and Sabel`s group is the method used to assess the independent processing of visual informati on (Schmid et al visual fi eld. 2010). Whether blindsight training can improve this kind of residual vision to a level that is relevant for everyday life, is Kasten and Sabel (1998) reported especially on an open questi on (see also Schofi eld and Leff 2009). improvement along the verti cal fi eld border, where they reported that absolute fi eld defects changed to relati ve. COMPENSATING SACCADIC TRAINING However, we need to consider that the so-called high Several studies reported improvement of effi ciency of resoluti on perimetry HRP in their studies did not measure explorati on aft er compensati ng saccadic training (Kerkhoff relati ve fi eld defects, but rather how oft en a sti mulus is et al., 1992; Zihl, 1995; Nelles et al., 2001; Pambakian et al., seen or not seen.
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