1. 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

2. 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

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

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

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

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

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

8. 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

9. Field Expansion 4. Peli, Eli MSc, OD, FAAO. Optometry and Vision Science. Sept 2000 453-464.

10. 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

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

12. Increased awareness

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

14. 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

15. 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.

16. 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.

17. 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.

18. 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

19. 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.

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