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

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: Zhang, Xiaojun MD, et al. J Neuro-Ophtho September 2006: Neyer, et al. Prevalence of Stroke JAMA. July 2007: 279– Rossi PW, et al Neurology 1990;40:1597-9

Therapy ► Therapy goals:  Increased Awareness  Increased Visual Field ► Therapy Options  Scanning Therapy  Prism Therapy ► Yoked prism ► Expansion prism

Scanning Therapy ► Never go where your eyes have not gone ► Critical for orientation and mobility ► Pt safety

Basic Movements ► Head Posture  Turn towards side of defect  Field shift ► Eye movements  Constant scanning  Systematic movements ► Walking

Scanning and Turns ► Turning into defect  Stopping in place  90 degree turn  Scan into defect  Looking up and down

Complex environments ► Combining all individual skills. ► Coordinated, intentional movements ► Encourage pt to take their time

Expansion Prism Therapy 4. Peli, Eli MSc, OD, FAAO. Optometry and Vision Science. Sept ► Increased field of view ► Peripheral prism  8 x 22mm segments  40 Diopter fresnel  Monocular fit  Superior and inferior ► Peripheral diplopia ► Clear single central vision

Field Expansion 4. Peli, Eli MSc, OD, FAAO. Optometry and Vision Science. Sept

Expansion Prism Therapy 4. Peli, Eli MSc, OD, FAAO. Optometry and Vision Science. Sept ► 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

Pt Education A.R. Bowers, et al. IVOS September 2006;47: E-Abstract 3489 ► Viewing through carrier lens ► Increasing peripheral awareness

Increased awareness

Prism Adaptation A.R. Bowers, et al. IVOS September 2006;47: E-Abstract 3489 ► Image jump  ~10-15 degrees ► Adaptation  75% acceptance rate

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

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.

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.

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.

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

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.

Acknowledgements ► Steve Rinne, MA Low vision research therapist ► Amy Wurf, MA Low vision therapist ► Joan Stelmack, OD MPH