Innovative VA Program Improves Visual Functioning for Patients with Hemianopsia

By Mary D'Apice, VisionAware Peer Advisor

Purpose of the Western Blind Rehabilitation Center's Comprehensive Neurological Vision Rehabilitation Program

John Kingston works with veteran on the NVT system

Less than a decade ago, the typical patient at the Western Blind Rehabilitation Center (WBRC) at the Palo Alto Veteran's Affairs (VA) Medical Center, was an older gentlemen who had macular degeneration or other age-related visual impairments. With the onset of the wars in Iraq and Afghanistan, the WBRC began experiencing an influx of soldiers from the Polytrauma Rehabilitation Center who, after suffering serious blows to the head, were exhibiting signs of vision loss. Whether the cause was a car accident or a blast injury, soldiers with Traumatic Brain Injury (TBI) often reported having trouble reading, were bumping into things or experiencing objects just popping out of nowhere even though their eyes were completely unharmed. When vision loss occurs in the brain and not in the eye, typical adaptive techniques such as the use of magnification devices do not work. So, to better serve this growing population of veterans with brain-based visual impairments, WBRC founded the Comprehensive Neurological Vision Rehabilitation program in 2007.

Explanation of TBI's Effects

TBI can affect ocular motor function, the ability to move eyes fluidly, and make it difficult for a person to focus. Another very common occurrence is hemianopsia, a condition in which a person loses half of his field of view. Someone with a left hemianopsia for example, has damaged pathways on the right side of the brain and does not see objects or people on his left side when looking straight ahead. While hemianopsia can seriously compromise a persons ability to perform daily activities and move about freely and safely, learning to scan properly can improve visual functioning.

A Day of Observation of the Center's Comprehensive Neurological Vision Rehabilitation Program

I had the opportunity to visit the Western Blind Rehabilitation Center and spoke to John Kingston, Orientation and Mobility Supervisor and Acting Comprehensive Neurological Vision Rehabilitation (CNVR) Coordinator, to learn about an innovative therapy that was helping veterans adapt to hemianopsia. Kingston introduced me to a patient whom we'll call Mr. J., whose hemianopsia was a result of a stroke -another form of TBI. Mr. J. registered for the residential program at WBRC after his neighbor almost ran him over in the driveway. "He told me to swallow my pride and get some help...I would walk my dogs and run into trees."

Learning to Use Vision Effectively and Systematically

Although some doctors prescribe prism glasses that increase the field of view, Kingston finds that there is a simpler solution that is easier to master and less likely abandoned. He states, "Our goal is to teach people to use their vision more effectively and systematically." One might assume that it's instinctive for a person to turn his head towards his blind spot to bring what is unseen into view. But in the absence of visual stimulation in their peripheral fields, head or eye turning is not automatic. Illustrations often represent hemianopsia as black curtain over half the eye, but this is misleading. In fact, says, Kingston, "People don't see blackness or blurriness; the objects in the that field simply don't exist. A person with hemianopsia is literally not getting the whole picture, and may go for years completely unaware of it. Therefore, the first step in treating hemianopsia is to demonstrate that there is a visual field loss and to have the person experience what they are missing." Understanding the nature of one's vision loss can be a real revelation.

How Neuro Vision Technology Works

Kingston invited me to observe Mr. J. working with a device called the Neuro Vision Technology (NVT) system which is used at the WBRC to both assess field loss and provide practical exercises in scanning techniques. The NVT is a black plastic panel with two rows of colored lights approximately 5 foot long and 2 feet wide. Mr. J. was seated about a foot from the panel which Kingston adjusted to eye level. A person with a normal field of vision would be able to see all the lights on the panel when staring at a center dot but Mr. J. had previously discovered that he would miss lights illuminated on the left side. During today's training, the NVT is used to help Mr. J. perfect his scanning skills so as to bring the entire panel into view.

Kingston was seated to Mr. J's left with a laptop that operated a software program set to illuminate lights on the panel. As lights lit up in different patterns, Mr. J would point to their position and name the color. The challenge for Mr. J. was not to miss lights on his left side. In order to succeed, he needed to remember to bring his chin all the way over to his left shoulder before moving it back to midline. This pattern of looking first to the outside edge of the blind spot before scanning inward is critical. A person with hemianopsia will often stop looking towards his affected side when a single object stimulates his vision. For example, if Mr. J. were facing a park bench positioned off to his left, he might notice someone seated on the side of the bench closest to him but be completely unaware of the other two people seated next to that person.

Mastering Scanning Techniques

According to Kingston, the key to mastering scanning techniques is developing a muscle memory which serves as feedback for proper head and neck position. I watched as Kingston instructed Mr. J. to turn his head all the way to the left to look at the blue light the end of the panel and bring his vision back to midline. He repeated the movement with his eyes closed, tuning into the way a proper head turn should feel. Once his scanning technique became more accurate and automatic, he was ready to move from a static, clinical setting to a real world, dynamic setting.

Kingston had prepared for the next training exercise by attaching post-it note sized colored cards along the walls of the hallway at various heights. I followed Mr. J. down the hall as he scanned for targets, pointing them out as he passed. In subsequent lessons, Mr. J.'s Orientation and Mobility instructor would take him out into the community to apply his skills. One activity might include spotting shopping carts in a grocery store and another might be looking for signs or street addresses in a residential neighborhood. Eventually, he would work on crossing streets.

Helping Family Members Understand

A final piece of the CNVR Program is for veterans to learn to help their family and friends understand what they see and describe the adaptive techniques. Kingston spends time with his patients teaching them to understand their eye condition using drawings of the brain and simple models using tennis balls for eyes and a strings for fibers. Mr. J's wife frequently complained that he would lose her in the grocery store. With his training, now Mr. J can explain to his wife that she will "disappear" if she is standing to his left, particularly if he is looking right. The CNVR program tries to establish a partnership with families, so the skills learned at the center can be seamlessly transferred to the home.

During the observation, I asked Mr. J. if he would enlist the support of his wife of 35 years. Would she be willing to take on Kingston's role and remind him to turn his head? He laughed. "I think she'll love that!" Mr. J. feels ready to return home with his many new skills. He reflects on the supportive team at the CNVR who have been offering coaching and encouragement, allowing him to function at his best. He states emphatically, "This has been my Superbowl."

Suggestions on Learning Scanning Techniques Without the NVT Scanner

The concepts behind the CNVR can be useful to those in the general population who have experienced neurologically based vision loss. Not every center in America has the resources of the VA but the concepts can be taught without the high tech NVT scanner. Kingston stresses that "the light is just a stimuli," and that equally effective scanning exercises can be done with just a simple whiteboard with numbers printed across. The NVT is a useful tool but demonstrating field loss requires real world examples. For example, Kingston states that he often stands behind the patient seated in a chair and tells the patient to look straight ahead. He then tells the patient to speak up as soon as he sees Kingston pass him on the patient's affected side. Kingston reports that, typically, Kingston will already be standing right in front of the patient by the time he sees him. Veterans who suffer post traumatic stress disorder and are easily startled, see the value of turning their heads to prevent people and objects from suddenly popping up out of nowhere. Says Kingston, "Demonstrating field loss is motivating and is critical in establishing buy-in for all kinds of training, including learning to use the long, white cane to detect obstacles outside the field of view."

It's Never Too Late

Kingston also wants people to know that it is never too late to learn adaptive techniques. He says there are stories of people coming to the VA who have experienced years, even decades living with brain-related vision loss incurred in combat or in an accident and they can still learn to scan effectively.

Diagnosing Brain-Related Vision Loss

Administering the scanning training is a simpler piece of the puzzle. The greater challenge is catching people with brain-related vision loss because, being unaware of their vision loss, most people fail to report it. Kingston believes that the problem is that we don't ask the right questions when screening people following a stroke or other TBI. He states, "When people are asked if they have vision loss after a stroke or an injury, they frequently respond 'no.' But if you ask if they frequently bump into things or have trouble reading they will often respond 'yes.'" The VA is always the incubator for new ideas in the field of vision rehabilitation. It is hoped that in time improved screening techniques for brain-related vision loss and subsequent training in adaptive techniques will become standard.

You may also want to read I've Had a Concussion or Traumatic Brain Injury: What Do I Ask My Eye Doctor?

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