Background.Patients with brain injury secondary to stroke, surgery, or trauma frequently suffer from
homonymous hemianopia, defined as vision loss in one hemifield secondary to retro-
chiasmal lesion. About 45% of stroke survivors have homonymous hemianopia. A deficit in
vision and spatial perception can cause slowdown of the rehabilitation progress in
physiotherapy.
According to Kerkhoff 1patients face three main visual behavioral problems:
- (1) impaired
eye movements (including saccades) leading to defective visual and spatial exploration,
(2) hemianopic reading deficit (hemianopic alexia) because of the parafoveal field loss
and (3) deviated subjective midline.
Hemianopic dyslexia is not simply the product of the
visual field defect but is caused by a disorder of control of visual information
processing and eye movements in reading.
Most important, the capability to read is fundamental for daily living and an essential
prerequisite for education and success in our modern society, so this disorder can have a
profound effect on patients' lives. Patients with visual field loss usually fail to adapt
to their reading impairment (80% of cases). In these cases, word identification and the
abilities to plan and guide reading eye movements are disturbed.
In spite of these facts, visual rehabilitation program on a larger scale is still missing
in most rehabilitation centers and clinics. This is decurrent to the generalized belief
that lesions of the lateral geniculate nucleus and striate cortex lead to a permanent
loss of vision. According to scientific findings, this does not always have to be true.
Classic and effective saccadic compensatory training therapies are current.5 They aim to
reorganize the control of visual information processing and eye movements or, in other
words, to induce or improve oculomotor adaptation to visual field loss. Such therapies
involve the systematic and repetitive practice of specific eye movements for reading or
for visual exploration. Patients learn to intentionally shift their eyes and, thus, their
visual field border, into the area corresponding to their blind visual field. This shift
brings the visual information from the blind hemifield into the seeing hemifield for
further processing. Patients learn, therefore, to efficiently use their eyes "to keep the
'blind side' in sight". The training-induced, efficient oculomotor adaptation to visual
field loss becomes manifest as a change of reading (or visual exploration) eye-movement
patterns and indicates the functional reorganization of the control of visual information
processing and eye movements.6.Biofeedback training for active eye movement control was never used in hemianopia cases
before. Biofeedback training (BT) is the latest and newest technique for oculomotor
control training in cases with low vision when using available modules in the new
microperimetry instruments.7-9 Studies in the literature highlighted positive benefits
from using BT in a variety of central vision loss, nystagmus cases, and others.10-18 The
purpose of this study is to assess systematically the impact of BT in a series of cases
with hemianopia and formulate guidelines for further use of this intervention in vision
rehabilitation of hemianopia cases in general.
Rationale for the study.The deviation of the subjective midline in hemianopia cases brings visual perception from
a line of objects in the surrounds to be at a much higher-level of perception/cognition,
thus disturbing reading, gait and balance. Besides that, impaired saccades also cause
wrong exploration patterns and deteriorated visual search. It results in the prolonged
exploration time of a scene and can lead to significant problems in daily life such as
inability to navigate around various obstacles (cars, people and other objects). It also
causes a cognitive deficit while extracting information from a visual scene. 1 A
combination of factors such as reduced contrast sensitivity, impaired visual search and
inaccurate fixation contributes to the matter.
Visual information extraction from the parafoveal visual field provides the basis for
planning and guiding of reading eye movements. Therefore, patients with hemianopia have
difficulties in shifting their gaze systematically from left to right (in right-sided
field loss) or finding the beginning of a new line (in left sided field loss). Such eye
movements are optimized by visual feedback. BT promotes luminous and auditory
biofeedback, which potentializes its efficacy in vision rehabilitation.
BT in the microperimeter module provides the accurate and efficient oculomotor training
necessary to relocate the subjective midline to the seeing field in 1-20 or even more, as
needed. BT also improves dramatically fixation stability and saccades. The advantage of
this training method over classic training is potentially great. Firstly, the highest
retinal sensitivity convenient point can be identified considering the whole visual
field. The microperimeter provides real time scrutiny of ocular movements on a screen,
and the therapist is able to select precisely the trained retinal locus (FFT) to be used
by the patient on top of the microperimeter visual field. Finally, according to the
patients' response the FFT can be readjusted. Eight cases trained with BT for hemianopia
in our low vision rehabilitation (LVR) service had marked improvements in fixation
stability, and microperimeter fields.
Expansion of visual space in the direction of the blind field and compression of visual
space in the direction of the seeing field may be a contributory factor to the altered
perception of their egocentric directional sense and overall more veridical mapping of
their visual space, as well as the resultant shift in their positional centre of gravity.
We hypothesize that BT promotes this field relocation.
Conventional visual exploration training studies have confirmed that 10 to 25 training
sessions in a 6-week period can be effective for hemianopia patients to adopt these
strategies. BT is able to achieve significant results in 5 weekly sessions of 20 minutes
each, according to 8 cases treated in our service.
Study hypothesis.The visual and audio parts of the BT program improve in a synergistic way oculomotor
control through attention improvement and volitional eye movements towards pre-designated
targets. Improved oculomotor control results in better fixation stability of eyes. Better
fixation stability in turn results in better navigation for distance and near vision
reading. Dual sensory BT is a therapy used in low vision for more than ten years, showing
good results for near and distance vision in cases with macular degeneration and other
pathologies. The study hypothesis, never tested before, is that BT in cases with
hemianopia will impact positively oculomotor control and visual acuity as it was proven
to do in cases with macular degeneration.
Significance of the study.Vision is a major sensory input to the human brain. Half of the afferent neuronal fibers
projecting to the brain originate from the eyes. Intact visual abilities are an important
condition enabling us to orient ourselves in our world. Pambakian and Kennard 20 reported
that 50% of all neurological admissions into hospitals in the United Kingdom are due to a
stroke and 30% percent of them are reported to have hemianopia.
Numbers of hemianopic patients reported in the Czech Republic are similar and somewhat
lower due to differences in diagnostics and classification of nosological units.21 Visual
impairments are present in 20 to 40% of patients in neurological rehabilitation centers.
If brain visual plasticity is possible to be achieved from conventional vision training
methods, specialized training with BT needs to be investigated as a tool to improve
significantly a cortical visual disorder. There is need for simple and more effective
visual training which could be used in LVR in large scale for hemianopia cases.
Furthermore, BT needs to be evaluated in terms of quality of life (QoL) improvement to
the patients.
The objectives set for this trial is to verify if BT impacts on oculomotor control in
cases with hemianopia and results in better fixation stability, reading speed and QoL in
those trained with BT.
