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Homonymous Hemianopia: Rehabilitation with Scanning and Expansion Prism Therapy Kasey Suckow, OD Resident: Ocular Disease / Low Vision Rehab Hines & Jesse Brown VA Chicago AAO Meeting Tampa 2007
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Homonymous hemianopia Common etiologies Stroke (most common 1 ) ► 8.1% over 65 2 ► 20-30% with VF defects 3 Traumatic Brain Injury ► Signature injury Lesions along visual pathway Zhang, Xiaojun MD, et al. J Neuro-Ophtho September 2006: 180-183. 1. 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. 3. Rossi PW, et al Neurology 1990;40:1597-9
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Therapy ► Therapy goals: Increased Awareness Increased Visual Field ► Therapy Options Scanning Therapy Prism Therapy ► Yoked prism ► Expansion prism
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Scanning Therapy ► Never go where your eyes have not gone ► Critical for orientation and mobility ► Pt safety
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Basic Movements ► Head Posture Turn towards side of defect Field shift ► Eye movements Constant scanning Systematic movements ► Walking
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Scanning and Turns ► Turning into defect Stopping in place 90 degree turn Scan into defect Looking up and down
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Complex environments ► Combining all individual skills. ► Coordinated, intentional movements ► Encourage pt to take their time
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Expansion Prism Therapy 4. Peli, Eli MSc, OD, FAAO. Optometry and Vision Science. Sept 2000 453-464. ► Increased field of view ► Peripheral prism 8 x 22mm segments 40 Diopter fresnel Monocular fit Superior and inferior ► Peripheral diplopia ► Clear single central vision
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Field Expansion 4. Peli, Eli MSc, OD, FAAO. Optometry and Vision Science. Sept 2000 453-464.
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Expansion Prism Therapy 4. Peli, Eli MSc, OD, FAAO. Optometry and Vision Science. Sept 2000 453-464. ► Monocular fit (on side of VF defect) ► Upper segment first Demonstrate increased field Training Cleaning and care ► 2 wk adjustment ► Lower segment ► 2 wk adjustment ► Prism ground into lens
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Pt Education A.R. Bowers, et al. IVOS September 2006;47: E-Abstract 3489 ► Viewing through carrier lens ► Increasing peripheral awareness
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Increased awareness
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Prism Adaptation A.R. Bowers, et al. IVOS September 2006;47: E-Abstract 3489 ► Image jump ~10-15 degrees ► Adaptation 75% acceptance rate
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Case #1 ► 67 WM with hx of recent stroke ► HH confirmed with HVF ► VA: 20/25 OD, 20/20 OS ► No head turn/abnormal posture ► Functional complaints: Bumping into people/objects on his left Difficulty avoiding objects on left Problems shaving left side of face ► With actual act of shaving Difficulty cooking
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Therapy and Response ► Scanning therapy following previously listed steps shows increased performance and subjective improvement. ► Expansion Prism Therapy also has positive subjective results with both upper and lower prism. Pt notes increased awareness and avoidance of objects on left side.
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Case #2 ► 74 WM with history of head trauma (gunshot wound 50 yrs prior) ► HH confirmed with HVF ► VA: 20/40 OD, 20/32 OS ► Left head turn ► Significant fall history ► Functional complaints Pt did not have any complaints, but interested in prism therapy for increased left awareness.
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Therapy and Response ► Scanning therapy shows pt is proficient and has developed good compensating skills. ► Pt notes improved awareness of field, but not enough improvement to warrant permanent lenses, and preferred habitual Rx alone.
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Differences between Pts ► Case #1 ► Relatively recent loss ► No head turn ► Poor scanning strategies ► Several Functional complaints ► Case #2 ► Long term loss ► Left head turn ► Good scanning strategies ► Few functional complaints
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Conclusions ► Benefits of Scanning and Prism Therapy Safety ► Street crossing ► Fall prevention Orientation and Mobility ► Increased Confidence ► Each pt unique Consider patient goals and motivation Successful rehabilitation involves therapy with or without prism.
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Acknowledgements ► Steve Rinne, MA Low vision research therapist ► Amy Wurf, MA Low vision therapist ► Joan Stelmack, OD MPH
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