Download Resident`s Day at Academy 2012 Phoenix: Case Report Submission

Resident’s Day at Academy 2012 Phoenix: Case Report Submission
Ryan Johnson, OD
Binocular Vision Resident 2012-2013
University of California, Berkeley
Abstract:
This case report reviews management of a patient status post cardiovascular accident.
Emphasis is placed on the comparison of hemianopia versus neglect following stroke,
specifically investigating: incidence, pathophysiology, clinical features, detection, prognosis,
and treatment.
Case Outline:
- Case History
 Patient demographics:
o 77 year old Caucasian female presented to our clinic on July 6, 2012
o Retired book keeper, previously avid reader
 Chief complaint:
o Patient reports difficulty with reading following cardiovascular accident in
February 2012. The patient has difficulty maintaining single vision while
reading, often skips lines and misreads text located primarily on the left side of
the page. Additionally, the patient reports frontal headaches, asthenopia and
rapid fatigue when performing near tasks. Thus far the patient has found no
relief for her symptoms.
 Patient goals:
o Resume reading comfortably and, if possible, resume driving
 Ocular history significant for:
o Bilateral cataract extraction: 2008
o Left hemianopia diagnosed at last eye exam; April 2012
 Medical history
o Cardiovascular accident in the area of the posterior cerebral artery:
February 2012
o Probable TIA December 2011, diagnosed as viral infection
o Sinus congestion
o Asthma
o High cholesterol – Controlled with medication
o Hypertension – Controlled with medication
 Possible postural hypotension; primary care provider currently
modifying medications to manage patient symptoms
 Medications
o HCTZ
o Prilosec
o Simvastatin
o Norvasc
o Flovent
o Albuterol
o Symbalta
- Pertinent Findings
 Clinical
o Refraction: Astigmatism, presbyopia
 OD: Pl -2.25 x 030 20/20-2
 OS: PL -2.75 x 145 20/20 -2
OU: 20/20-1
 ADD: +2.75 OD: 0.4/0.5M (20/25)
OS: 0.4/0.6M (20/30)
OU: 0.4/0.5M (20/25)
o Pupillary Responses: Normal, no APD
o Color Vision: Normal OD & OS measured with F-2 plates and D15
o Contrast Sensitivity: Normal as measured with Cambridge
o Ocular Posture: Basic exophoria (4XP at distance, 5-6XP at near)
o Near Point of Convergence (NPC): Receded to 11cm, unable to maintain
o Vergence Ranges: In free space
 BI: Reduced at distance (X/6/2) & near (X/8/6)
 BO: Reduced at distance (X/8/2) & near (X/4/2)
o Ocular Motility
 Fixation: Unsteady, absence of nystagmus
 Pursuits: Saccadic intrusions in right, left, up, and down gaze
 Saccades: Hypometric in right, left, up, and down gaze
 Versions: Normal, absence of EOM underaction or cranial nerve palsies
 Ductions: Unrestricted
o Fusion (Worth Light)
 Momentary sensory fusion at all distances and in all lighting conditions
o Stereopsis: Negative with Randot stereo test and contour stereo test
o Visual Field: Goldmann – Three isopters
 Macula-sparing left hemianopia with a high degree of congruity with
absolute left superior quadranopia and relative left inferior quadranopia,
respecting vertical and horizontal midlines
o VANS: Left neglect observed with both line bisection and cancellation tasks
o TVAS: Spatial planning difficulties; kindergarten equivalent
o DEM: Type 4 behavior with significantly prolonged time, especially with the
horizontal task, suggesting challenges with spatial planning, tracking, and
ocular motor skills as well as with automaticity (visual processing speed and
rapid automatic naming).
o PMA-PS: Visual processing speed at 19th percentile for 13yo (max age norm for
test)
o MVPT-3: Visual processing reduced to 19th percentile; response time index 510th percentile
o DDT: 12th grade equivalent, eidetic decoder and encoder
o Ocular Health
 Anterior Segment
 Bilateral: Lids, lashes, conjunctiva, cornea, anterior chamber, and
iris unremarkable




Bilateral reduced TBUT: OD 3 sec, OS 4 sec
Bilateral PCIOL well centered
Intraocular pressures measured with Goldmann applanation
tonometry
o OD: 16mmHg
o OS: 16mmHg
Posterior Segment observed with non-contact fundoscopy and binocular
indirect ophthalmoscopy
 Bilateral: Macula, optic nerve, posterior pole, vessels, periphery,
and vitreous unremarkable
- Differential Diagnosis for chief complaint of diplopia and difficulty with reading
 Hemianopia
 Left hemi-visual neglect
 Convergence palsy
 Convergence insufficiency
 Horizontal or vertical tropia
 Acquired cranial nerve palsies
 Decompensating phoria
 Age-related distance esotropia
 Uncorrected refractive error and anomalous refractive media findings
 Visual agnosia leading to difficulties with word recognition and comprehension
 Dry eye syndrome
- Diagnosis: Secondary to cardiovascular accident;
 Left superior quadranopia
o Determined by results of Goldmann visual field
 Left visual neglect; hemi-visual neglect, hemi-spatial neglect, left hemi-agnosia
o Determined by results of VANS testing
 Convergence Palsy
o Determined by normal adduction during ductions, diplopia during near tasks,
and receded NPC status post cardiovascular accident2
 Spatial planning difficulties
o Determined by results of DEM and TVAS
 Reduced processing speed
o Determined by results of PMA-PS and response time index of MVPT-3
 Dry eye syndrome
o Determined by reduced TBUT
- Treatment/Management
 Continue wearing current spectacle correction
 Begin vision therapy program emphasizing convergence, expanding vergence ranges,
and improving visual processing and tracking skills
 Artificial tears QID OU
- Progress Evaluation after 8 sessions of vision therapy (August 17, 2012)
 Assessment
o Progress with goals:
 Has resumed reading the newspaper, able to read entire article
 Reduced frequency of headaches and asthenopia
o Visual Field: Goldmann – Three isopters
 Stable with marginal improvement in the area of the inferior
quadranopia
 Presence Riddoch phenomenon (stato-kinetic dissociation present in left
eye)
o VANS: Stable left neglect observed
o DEM: Stable type 4 behavior
o Gross convergence insufficiency: Improved convergence ranges and NPC well
maintained for at least 10 seconds
o Stereo: 50 arc seconds with contour, absence of random dot stereo
 Plan
o Continue with vision therapy program emphasizing expansion of vergence
ranges, improving stability of fusion, and improving visual processing skills.
Discussion: Comparison of Hemianopia and visual neglect secondary to CVA
- Definition
 Hemianopia
o Impaired primary perception of visual information in the field contralateral to
damage to the optic tract and/or striate cortex7
 Visual Neglect
o Failure to report, respond, or orient to stimuli on the contra-lesional side of
space that cannot be accounted for by primary sensory or motor deficits4
- Epidemiology
 Some type of field defect seen in 67% of CVA patients10
 Hemianopia
o Most common type of visual field defect following cardiovascular accident
o Left more common than right hemianopia6,10
o Macular sparing hemianopia common following cortical lesions6
 Visual Neglect
o More common with right hemispheric CVA than left2
o Frequency and severity have positive association with age 2,3,11
 69.6% of subjects older than 65 years old compared to 49.4% of subjects
younger than 65 years old
 For every 10 years over 65, 1.83 times as likely to have neglect
 Scores on tests for visual neglect worsened as effect of age
 Percentage error during line bisection 3.8% higher for every 10 years of
age
- Pathophysiology
 Hemianopia

o Most often the result of a vascular lesion in the area of the posterior cerebral
artery or the middle cerebral artery6
o Can result from trauma, infection, or tumor6
o A result of damage to post-chiasmal visual pathways; the reticuo-geniculatestriate route, V1, or its post-chiasmal afferents6
o Hemianopia without neglect occurs due to infarction in the area of the PCA; the
inferior parietal and superior temporal lobes are unaffected7
Visual Neglect
o Lesions in different cerebral areas (central frontal, inferior parietal cortex, basal
ganglia3), superior temporal gyrus, perisylvian region, inferior parietal lobe4
o Lesion size influences the severity of visual neglect symptoms5
o Combination of dorsal and ventral pathways3
 Dorsal:
 Superior parietal lobe & frontal eye fields
 Goal-directed stimulus and response selection
 Ventral:
 Frontal cortex & temporo-parietal junction
 Novel and behaviorally relevant stimuli
o Left visual neglect observed following damage to the right parietal lobe3
o Right visual neglect is rarely observed due to redundant processing of the right
hemifield by both the right and left parietal lobes3
o Not a true sensory deficit, instead internal computation of one’s spatial
representation of the external world is disrupted11
o Infarct of middle cerebral artery4
- Clinical Features
 Hemianopia
o Visual field defect with sharp cutoff at vertical midline. With time the patient
will develop distorted perception at the edge of the hemianopia1,6.
o Compensatory mechanisms include: modified fixation and saccade patterns as a
compensatory mechanism6
 Visual Neglect
o Patients experience a gradient of visual unawareness of information in the left
field, rather than a sharp delineation between seeing and non-seeing areas of
vision1
o Neglect results in a number of abnormal visual functions including: fixation
patterns and saccades, reduced static and dynamic contrast, and difficulties
with visual processing (such as figure-ground)1,5
o Neglect can also impact auditory, somatosensory, and motor processing3
o Classification of neglect11
 Modality: Sensory or premotor
 Spatial Representation: Egocentric or allocentric
 Range of Space: Personal, peripersonal, or extrapersonal
- Detection/Testing



Subjective Straight Ahead Testing provides valuable information for both hemianopia
and neglect. Is not definitive for differentiating between hemianopia and neglect7
Hemianopia
o Visual field test: best way to detect
o Consider the characteristics of both the field defect and the patient’s processing
deficits (post-stroke) when choosing the appropriate instrument.
o Line bisection testing will show signs of hemianopia, however the influence of
hemianopia during line bisection tasks changes during the first month7
Visual Neglect
o Contained within the VANS, the three main types of testing used to identify
visual neglect are,3,4,7:
 Cancellation tests
 Line bisection tests
 Scene copying tests
- Treatment
 Hemianopia
o Treatment strategy can be viewed as either top-down or bottom-up.
 Top-Down: Purposeful modification of behavior to achieve a desired
outcome9
 Top-Down strategy has been shown to be effective when training
improvement of saccades6
 Bottom-Up: Desired outcome achieved through modification of
underlying systems that does not involve purposeful behavior
modification9
 Bottom-Up: principle is to act on the systems that produce ocular
movements (specifically saccades) via the sensory-motor system6
o Treatment type can be divided into 4 main categories6,7:
 Replacement or optical assistance: mirror or various types of prism used
to shift images from the damaged visual field into part of the intact field
 Restorative attempts of visual field expansion via vision therapy or
visual field restitution therapy (VRT)
 Stimulation or blind sight: areas within the field defect are stimulated in
an attempt to use the extrastriate visual pathways to repair visual
functioning
 Compensatory: one substitutes for the lost region through conscious
control of eye movements
 Visual Neglect
o Top-down (search instruction) approach has little impact on scanning behavior
or ipsilesional fixation bias5
o Bottom-Up: Dynamic cues with high contrast in contra-lesional hemifield are
attended to most often5
- Prognosis
 Hemianopia
o Studies have seen between 30 to 50% of patients show some degree of
recovery6

o Recovery dependent on underlying disease and lesion topography6
o A majority of recovery occurs in the first 3 months with minimal progress seen
after 8 months6
Visual Neglect
o Poor prognosis for functional independence or recovery, although 90% of
patients in one study showed favorable ADL outcome 6 months post stroke1,4
o Neuroimaging suggests the right superior parietal cortex as well as the
connectivity between the right and left superior parietal lobe play important
roles in recovery3
- Conclusions
 Based on the data from our evaluations, and taking into consideration the patient’s
pre-existing medical history, we concur with proposed diagnosis of a lesion in the postchiasmal area supplied by the posterior cerebral artery. Such a lesion will lead to both
a left hemianopia and left hemi-visual neglect, as confirmed with our testing.
 The patient’s recent episode of CVA lead to clinical presentations of convergence
insufficiency coupled with visual neglect and a left superior quadranopia
 The patient’s chief complaint of significant difficulties with reading could be attributed
to her left quadranopia, left hemi-neglect, convergence insufficiency, and visual
processing issues.
 In view of all clinical testing remaining stable, with the exception of significant
improvement with convergence and fusional convergence, we can draw the conclusion
that both convergence to near point and fusional convergence skills are important for
comfortable reading, sustained reading, scanning across the page, reading speed,
reading endurance, and meaningful enjoyment of reading
 Prognosis for the patient was guarded based on:
o Treatment took place within the first 6 months following the CVA, thus it was
more likely to see improvements in the visual field defect. Consistent with
literature, we did find marginal improvement in the patient’s visual field defect
during our follow-up assessment
o Prognosis for functional recovery is poor with visual neglect and consistent
with literature we found no improvement in left visual neglect during follow-up
assessment
 Partial relief of symptoms, primarily secondary to convergence palsy, was successfully
achieved through a vision therapy regimen that:
o Improved convergence ability and control though vergence therapy
o Improved reading fluency through a top-down approach to modified eye
movements and scanning techniques during reading
- Clinical Pearls
 Test for visual field defects in your post-CVA patients. Some type of visual field defect
is seen in 67% of CVA patients with hemianopia being the most common
 Identify visual neglect using the three main types of tests:
o Cancellation tests
o Line bisection tests
o Scene copying tests



Educate your patient that time is a crucial component of CVA recovery.
o 30-50% of patients with hemianopia show some degree of recovery within the
first 8 months
o A majority of patients with left visual neglect may show favorable ADL outcome
6 months post CVA
Select the best treatment options for your patient with hemianopia
o Replacement or optical assistance
o Restorative
o Stimulation or blind sight
o Compensatory
Consider visual dysfunctions in addition to hemianopia and left visual neglect when
assessing CVA patients
o Convergence insufficiency or palsy
o Accommodative insufficiency
Works Cited:
1. Gorgoraptis, N., and M. Husain. "Improving Visual Neglect after Right Hemisphere
Stroke." Journal of Neurology, Neurosurgery & Psychiatry 82.11 (2011): 1183-184.
Print.
2. Gottesman, R. F, Kleinman, J.T., Davis, C, “Unilateral Neglect is More Severe and
Common in Older Patients with Right Hemispheric Stroke.” Neurology 46 (2008):
1438-1444, Print.
3. Hassa, Thomas, Mircea A. Schoenfeld, and Christian Dettmers. "Neural Correlates of
Somatosensory Processing in Patients With Neglect." Restorative Neurology and
Neuroscience 29 (2011): 253-63. Print.
4. Kettunen, J. E., M. Nurmi, and P. Dastidar. "Recovery From Visual Neglect After Right
Hemisphere Stroke: Does Starting Point in Cancellation Tasks Change After 6 Months?"
The Clinical Neuropsychologist 26.2 (2012): 305-20. Print.
5. Machner, Bjorn, Michael Dorr, and Andreas Sprenger. "Impact of Dynamic Bottom-up
Features and Top-down Control on the Visual Exploration of Moving Real-World
Scenes in Hemispatial Neglect." Neuropsychologia 50 (2012): 2415-425. Print.
6. Pouget, M. C., D. Levy-Bencheton, and M. Prost. "Acquired Visual Field Defects
Rehabilitation: Critical Review and Perspectives." Annals of Physical and Rehabilitation
Medicine 55 (2012): 53-74. Print.
7. Saj, Arnaud, Jacques Honoré, Béranger Braem, Thérèse Bernati, and Marc Rousseaux.
"Time since Stroke Influences the Impact of Hemianopia and Spatial Neglect on Visualspatial Tasks." Neuropsychology 26.1 (2011): 37-44. Print.
8. Saj, A., J. Honoré, C. Richard, T. Bernati, and M. Rousseaux. "Hemianopia and Neglect
Influence on Straight-Ahead Perception." European Neurology 64.5 (2010): 297-303.
Print.
9. Sozzi, M., M. Balconi, and R. Arangio. "Top-Down Strategy in Rehabilitation of Spatial
Neglect: How About Age Effect?" Cognitive Processing (2012).
10. Suchoff, I., N. Kapoor, K. Ciuffreda, D. Rutner, E. Han, and S. Craig. "The Frequency of
Occurrence, Types, and Characteristics of Visual Field Defects in Acquired Brain Injury:
A Retrospective Analysis." Optometry - Journal of the American Optometric Association
79.5 (2008): 259-65. Print.
11. Ting, Darren S., MBChB, Alex Pollock, PhD, and Gordon N. Dutton, MD. "Visual Neglect
following Stroke: Current Concepts and Future Focus." Survey of Ophthalmology 56
(2011): 114-34. Print.
12. Umarova, R. M., D. Saur, C. P. Kaller, M.-S. Vry, V. Glauche, I. Mader, J. Hennig, and C.
Weiller. "Acute Visual Neglect and Extinction: Distinct Functional State of the
Visuospatial Attention System." Brain 134.11 (2011): 3310-325. Print.