Download LV-10 Outline

Alexis Malkin, OD, FAAO, Tiffany L. Chan, O.D., F.A.A.O.
Clinical Strategies for Managing Patients with Hemifield Loss
Course Description
This course will provide a brief overview of the major causes of visual field loss. It
will be focused on providing an in depth look at management options for
optometrists who are caring for these patients. It will discuss an evidence-based
approach to developing in-clinic therapy and a patient home program.
Objectives:
1. To familiarize optometrists with the major causes of acquired hemifield loss
2. To fully explore rehabilitative options available to help patients maximize their
residual vision
3. To help optometrists develop strategies for clinical and in home therapy
programs to assist these patients
I. Introduction
- Introductory statistics on visual field loss with Acquired Brain Injury (ABI)
- Causes of Acquired Homonymous Hemianopia
o CVA
o TBI
o Brain tumor
o Craniotomy
o Aneurysm
o Inflammation
o Infection
-Congenital Hemianopsia may also occur
II. Implications for the patient with an acquired brain injury
- May have difficulty in any functional domain
o Reading: spot reading and continuous text reading
o Visual information/Seeing: television watching, identify faces
o Mobility – in the home and in the community
o Visual motor skills/ADLs – dressing/cooking/medication
management
o Driving
- Quality of life
- Cognition
- Speech
- Physical
- Consider role of comorbid conditions
- Consider other ocular conditions and refractive status
- Single vision lenses (as opposed to multifocal lenses) may be of benefit to
patients especially early in their rehabilitation process
III. Clinical Exam
Identify the visual problem
- Requires visual and cognitive skills
- Visual Field testing
o Confrontation Visual Field (CVF)
o Humphrey Visual Field (HVF)
o Goldmann Visual Field (GVF)
- Practical Testing (determining field loss vs. inattention vs. neglect)
o Line bisection
o Clock Drawing
o Letter cancellation
o Figure Copying (star, cube, daisy)
o Scanning Course (numbered sticky notes – time going down the
hallway)
o Simple reading paragraph
o Ability to look into the visual field defect
o Awareness of visual field loss
o Extinction Confrontation Fields
o General Scanning Skills:
 People with visual neglect will have disorganized and
abbreviated scanning pattern.
 People with visual field loss will miss their hemi-side, but will
have an organized scanning pattern and will check their
work.
- Rehabilitation potential
o Cognition
 Mini Mental State Exam (MMSE)
 Montreal Cognitive Assessment (MoCA)
o Ability to learn new material
o Awareness/ insight regarding visual field deficit
o Expectations of recovery
o Ability to sustain visual attention
o Support system -- to train strategies to apply when not in therapy
IV. Treatments
- Will focus on mobility, reading, and general cognition; some overlap with
the possible treatments and training strategies; patient may be receiving
other therapies in conjunction with vision specific treatment
o Occupational Therapy (OT)
o Physical Therapy (PT)
o Speech and Language Pathology (SLP)
o Recreational Therapy
- Scanning therapy
o Organized scanning techniques
o Z-pattern/Lighthouse/Clock Pattern
o General awareness of environment
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o Locating objects/items
o Avoid obstacles when walking in a static and dynamic environment
Prisms/field enhancement
o Dependent on awareness of visual field loss, saccades, cognition,
binocular vision
o Requires training
 OT
 O&M specialist
o Types
 Peli prisms
 Sector prisms
 Gottlieb Button prism
 All typically require single vision only RX
o Mirror
Visual skills:
o HART charts for saccades/tracking/visual awareness
o Websites with interactive games (Lumosity, Ping Pong, and others)
o Line cancellation exercises; word search/letter search activities
o Developing improved visual search
Role for white cane/mobility training in some cases
What does it mean for driving?
Reading
o High contrast borders
 Post-it notes
 Highlighter
o Line guide
 Ruler
 Finger
o Text-to-speech (read along)
o Holding text at 90 degree angle
Contrast enhancement
o Task lighting
o Glare
o E-reader with enhanced contrast or reverse polarity
Sight substitution
o Tactile
o Auditory
Driving
o States each have their own set of requirements
o Review of literature on hemianopic driving/safety (Peli, et al)
o Use Maryland as an example with modified driving program
Developing Your Therapy Packet
What to include?
o Word Search Puzzles with instructions
o Mock news articles with comprehension questions; also have
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patients search for words that start with certain letters
Home Hart Charts
Newspaper Ads and Food Packages to practice scanning patterns
and find relevant information
V. Conclusions
All optometrists will encounter patients with hemianopic vision loss during their
clinical practice. It is important to understand how these patients may be affected
and what the optometrist’s role can be. Many times these patients will be referred
to neurology or other rehabilitation therapies but the optometrist can play a
significant role through detailed refractions, prism application, and initiating home
exercises. Additionally, optometrists are in a unique position to discuss local
driving laws and to work in conjunction with a neurologist to assist patients as
they consider resuming driving. Using the above techniques, optometrists will be
able to develop a strategy and plan of care to help maximize the patient’s
residual visual after an acquired brain injury with visual field loss.