Homonymous Homonymous Hemianopia:Hemianopia:

Rehabilitation with Scanning and Expansion Rehabilitation with Scanning and Expansion Prism TherapyPrism Therapy

Kasey Suckow, ODKasey Suckow, ODResident: Ocular Disease / Low Vision RehabResident: Ocular Disease / Low Vision Rehab

Hines & Jesse Brown VA ChicagoHines & Jesse Brown VA ChicagoAAO MeetingAAO MeetingTampa 2007Tampa 2007

Homonymous hemianopiaHomonymous hemianopia

Common etiologiesCommon etiologies Stroke (most Stroke (most

commoncommon11))►8.1% over 658.1% over 6522

►20-30% with VF 20-30% with VF defectsdefects33

Traumatic Brain Traumatic Brain InjuryInjury►Signature injurySignature injury

Lesions along visual Lesions along visual pathwaypathway1. Zhang, Xiaojun MD, et al. J Neuro-Ophtho September 2006: 180-183. Zhang, Xiaojun MD, et al. J Neuro-Ophtho September 2006: 180-183.

2. Neyer, et al. Prevalence of Stroke 2005. JAMA. July 2007: 279–281.2. Neyer, et al. Prevalence of Stroke 2005. JAMA. July 2007: 279–281.

3. Rossi PW, et al Neurology 1990;40:1597-93. Rossi PW, et al Neurology 1990;40:1597-9

TherapyTherapy

► Therapy goals:Therapy goals: Increased AwarenessIncreased Awareness Increased Visual Increased Visual

FieldField

► Therapy OptionsTherapy Options Scanning TherapyScanning Therapy Prism TherapyPrism Therapy

►Yoked prismYoked prism►Expansion prismExpansion prism

Scanning TherapyScanning Therapy

►Never go where Never go where your eyes have not your eyes have not gonegone

► Critical for Critical for orientation and orientation and mobilitymobility

► Pt safetyPt safety

Basic MovementsBasic Movements

►Head PostureHead Posture Turn towards side of Turn towards side of

defectdefect Field shiftField shift

► Eye movementsEye movements Constant scanningConstant scanning Systematic Systematic

movementsmovements

►WalkingWalking

Scanning and TurnsScanning and Turns

► Turning into defectTurning into defect Stopping in placeStopping in place 90 degree turn90 degree turn Scan into defectScan into defect Looking up and downLooking up and down

Complex environmentsComplex environments

► Combining all Combining all individual skills.individual skills.

► Coordinated, Coordinated, intentional intentional movementsmovements

► Encourage pt to Encourage pt to take their timetake their time

Expansion Prism TherapyExpansion Prism Therapy 4. Peli, Eli MSc, OD, FAAO. Optometry and Vision Science. Sept 2000 453-464.4. Peli, Eli MSc, OD, FAAO. Optometry and Vision Science. Sept 2000 453-464.

► Increased field of Increased field of viewview

► Peripheral prismPeripheral prism 8 x 22mm segments8 x 22mm segments 40 Diopter fresnel 40 Diopter fresnel Monocular fitMonocular fit Superior and inferiorSuperior and inferior

► Peripheral diplopiaPeripheral diplopia► Clear single central Clear single central

vision vision

Field ExpansionField Expansion 4. Peli, Eli MSc, OD, FAAO. Optometry and Vision Science. Sept 2000 453-464.4. Peli, Eli MSc, OD, FAAO. Optometry and Vision Science. Sept 2000 453-464.

Expansion Prism TherapyExpansion Prism Therapy 4. Peli, Eli MSc, OD, FAAO. Optometry and Vision Science. Sept 2000 453-464.4. Peli, Eli MSc, OD, FAAO. Optometry and Vision Science. Sept 2000 453-464.

►Monocular fit (on side of VF defect)Monocular fit (on side of VF defect)► Upper segment firstUpper segment first

Demonstrate increased fieldDemonstrate increased field TrainingTraining Cleaning and careCleaning and care

► 2 wk adjustment2 wk adjustment► Lower segmentLower segment► 2 wk adjustment2 wk adjustment► Prism ground into lensPrism ground into lens

Pt EducationPt Education A.R. Bowers, et al. A.R. Bowers, et al. IVOS IVOS September 2006;47: E-Abstract 3489September 2006;47: E-Abstract 3489

► Viewing through Viewing through carrier lenscarrier lens

► Increasing Increasing peripheral peripheral awarenessawareness

Increased awarenessIncreased awareness

Prism AdaptationPrism Adaptation A.R. Bowers, et al. A.R. Bowers, et al. IVOS IVOS September 2006;47: E-Abstract 3489September 2006;47: E-Abstract 3489

► Image jump Image jump ~10-15 degrees~10-15 degrees

► AdaptationAdaptation 75% acceptance rate75% acceptance rate

Case #1Case #1

► 67 WM with hx of recent stroke67 WM with hx of recent stroke►HH confirmed with HVFHH confirmed with HVF► VA: 20/25 OD, 20/20 OSVA: 20/25 OD, 20/20 OS►No head turn/abnormal postureNo head turn/abnormal posture► Functional complaints:Functional complaints:

Bumping into people/objects on his leftBumping into people/objects on his left Difficulty avoiding objects on leftDifficulty avoiding objects on left Problems shaving left side of faceProblems shaving left side of face

►With actual act of shavingWith actual act of shaving Difficulty cookingDifficulty cooking

Therapy and ResponseTherapy and Response

►Scanning therapy following previously Scanning therapy following previously listed steps shows increased listed steps shows increased performance and subjective performance and subjective improvement. improvement.

►Expansion Prism Therapy also has Expansion Prism Therapy also has positive subjective results with both positive subjective results with both upper and lower prism.upper and lower prism. Pt notes increased awareness and Pt notes increased awareness and

avoidance of objects on left side.avoidance of objects on left side.

Case #2Case #2

►74 WM with history of head trauma 74 WM with history of head trauma (gunshot wound 50 yrs prior)(gunshot wound 50 yrs prior)

►HH confirmed with HVFHH confirmed with HVF►VA: 20/40 OD, 20/32 OSVA: 20/40 OD, 20/32 OS►Left head turnLeft head turn►Significant fall history Significant fall history ►Functional complaintsFunctional complaints

Pt did not have any complaints, but Pt did not have any complaints, but interested in prism therapy for increased left interested in prism therapy for increased left awareness.awareness.

Therapy and ResponseTherapy and Response

►Scanning therapy shows pt is Scanning therapy shows pt is proficient and has developed good proficient and has developed good compensating skills.compensating skills.

►Pt notes improved awareness of field, Pt notes improved awareness of field, but not enough improvement to but not enough improvement to warrant permanent lenses, and warrant permanent lenses, and preferred habitual Rx alone.preferred habitual Rx alone.

Differences between PtsDifferences between Pts

► Case #1Case #1► Relatively recent Relatively recent

lossloss►No head turnNo head turn► Poor scanning Poor scanning

strategiesstrategies► Several Functional Several Functional

complaintscomplaints

► Case #2Case #2► Long term lossLong term loss► Left head turnLeft head turn►Good scanning Good scanning

strategiesstrategies► Few functional Few functional

complaintscomplaints

ConclusionsConclusions

► Benefits of Scanning Benefits of Scanning and Prism Therapyand Prism Therapy Safety Safety

► Street crossingStreet crossing► Fall prevention Fall prevention

Orientation and MobilityOrientation and Mobility► Increased ConfidenceIncreased Confidence

► Each pt uniqueEach pt unique Consider patient goals Consider patient goals

and motivationand motivation

Successful rehabilitation Successful rehabilitation involves therapy with or involves therapy with or without prism.without prism.

AcknowledgementsAcknowledgements

►Steve Rinne, MA Low vision research Steve Rinne, MA Low vision research therapisttherapist

►Amy Wurf, MA Low vision therapistAmy Wurf, MA Low vision therapist► Joan Stelmack, OD MPHJoan Stelmack, OD MPH