1. Homonymous Hemianopia:Rehabilitation with Scanning and Expansion Prism Therapy Kasey Suckow, OD Resident: Ocular Disease / Low Vision Rehab Hines & Jesse Brown VA ChicagoAAO Meeting Tampa 2007

2. Homonymous hemianopia Common etiologies • Stroke (most common1) • 8.1% over 652 • 20-30% with VF defects3 • Traumatic Brain Injury • Signature injury • Lesions along visual pathway 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 Therapy4. 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 Expansion4. Peli, Eli MSc, OD, FAAO. Optometry and Vision Science. Sept 2000 453-464.

10. Expansion Prism Therapy4. 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 EducationA.R. Bowers, et al. IVOS September 2006;47: E-Abstract 3489 • Viewing through carrier lens • Increasing peripheral awareness

12. Increased awareness

13. Prism AdaptationA.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. 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 Differences between Pts

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