Current Research Projects Gary S. Rubin, PhD Helen Keller Professor of Ophthalmology UCL Institute of Ophthalmology Low Vision Patient Day 7 June 2014

Topics Basic Research  Service Delivery New Devices  Training Two projects undertaken with colleagues from other parts of the University (Dept of Transportation Engineering)  and colleagues from other universities (School of Architecture, Kingston University

Is there Brain Remapping in Macular Disease? (Baseler, 2007) Specific areas of the brain process information from specific areas of the visual field AMD  central scotoma  silent areas of the brain Do these silent areas regain function? For vision – No For other senses – maybe Yes Response of Area V1 Silent brain areas before and after

Clinical Predictors of Reading Speed in AMD ( Rubin & Feely, 2009) Visual acuity does NOT predict reading speed in patients with AMD

Clinical Predictors of Reading Speed in AMD ( Rubin & Feely, 2009) Visual acuity does NOT predict reading speed in patients with AMD Fixation stability and size of forward saccades account for 74% of variance. Reading Speed (words/min)

Scanning Laser Ophthalmoscope

Scotoma Map

Replacing the SLO? Nidek MP-1

Compensation for Fixation Instability Improves Reading Speed (Macedo, 2013)

RSVP Reading Once

RSVP Reading upon

a RSVP Reading

time RSVP Reading

there RSVP Reading

lived RSVP Reading

upon a time there lived a RSVP Reading

Once a time there a vain RSVP Reading

Emperor. RSVP Reading

RSVP Improves reading Speed

Training Possibilities Eccentric Viewing Eye Movement Training Perceptual Learning

Electronic Head-Mounted Devices Portable Cosmetically acceptable Lightweight Multipurpose Affordable (good value for money) Commercial support The ultimate HMD

Electronic Magnification Devices: 1990 Low Vision Enhancement System - LVES

Electronic Magnification Devices: 2001 Jordy®

Reading Performance with Devices

The Demise of Jordy and His Friends

Portable Electronic Low Vision Aids

PELVAs Pros –Less expensive (<£400) –Smartphone platform –Battery powered –Light and compact Cons –Limited field of view –Limited magnification Studies in progress

Implantable Miniature Telescope (IMT)

UK Clinical Trial of IMT (Dunbar, 2010) Prospective open label trial of 3x IMT at 4 UK centers IMT implanted in better eye of 17 patients Followed by 12-week rehab course Results –3 line improvement in VA –Contrast sensitivity reduced by 0.4 logCS –Maximum reading rate improved by 10 words/min –Self-reported visual disability (Massof AI) improved by 0.6 logit (equiv to 4 lines of VA)

Retinal Prostheses – ‘Bionic Eye’ About 10 projects worldwide Mostly epi-retinal; some sub- retinal Well tolerated and apparently safe Also optic nerve and cortical prostheses Initially, low resolution –20 electrodes max due to safety concerns Winter, et al (2007)

Argus II – Second Sight (California)

Epi-retinal 60 electrode array Implanted in about two dozen patients worldwide (12 in UK; 8 Moorfields) Retinitis pigmentosa with light perception or worse Outcome measures –Grating acuity –Phosphene projection –Letter recognition –Mobility Follow a white line on a black background Find a white door on a black wall

A Sampler of Clinical Trials Underway Impact of LV rehab in patients with diabetic eye disease (Dunbar, ) Eccentric Fixation From Enhanced Clinical Training, (EFFECT): A Randomised Controlled Trial for Patients with AMD (Rubin, ) Depression in Visual Impairment Trial (DEPVIT; Margrain, ) The impact of timely emotional support on the quality of life of blind and partially sighted people (Afsani, )

Summary and Conclusions Substantial growth in low vision research during the past 10 years Shifting emphasis from head-mounted low vision magnifier to portable hand-held electronic magnifier New initiatives in service delivery showing great promise Profusion of new outcome measures Building momentum in establishing a sound evidence base for the effectiveness of low vision rehabilitation Still plenty of additional work to be done!

Acknowledgements Collaborators –Louise Culham - Moorfields Eye Hospital –Alan Bird - Moorfields Eye Hospital –Liz Pearce – Moorfields Eye Hospital –Peter Bex –Fred Fitzke Postdocs and Students –Michael Crossland –Stamatina Kabanarou –Caren Bellmann –Angela Rees –Thomas Butt –Radhika Gulati –Hannah Dunbar –Anthony Chabra Research Assistants –Eugeniu Dinu –Mary Feely –Hannah Roche Funding –Wellcome Trust –National Institute of Health Research –Guide Dogs for the Blind Association –Macular Disease Society –European Commission –Fight for Sight –Special Trustees of Moorfields Eye Hospital –Garfield Weston Foundation –Friends of Moorfields Eye Hospital