Texas School for the Blind and Visually Impaired

Outreach Programs
www.tsbvi.edu !"#$%!%$&'(" "")) *. %!th St. +ustin, Texas -&-!'

#)"#$"( Texas .ocus Visual .ield /oss0 1auses, 2ffects, and Strategies

3arch (", #)"( ")0() +3 $"#0)) P3

Presented by 4r. 5ia 2ldred$3c6ee, O.4., Optometrist at the 3ichael 2. 4eBa7ey V+ 3edical 1enter in the VISO8 Program 7eldredmcgee9sbcglobal.net

4eveloped for Texas School for the Blind : Visually Impaired Outreach Programs

Visual Field Loss: Causes, Effects, and Strategies

5ia 2ldred, O4, .++O 4iplomate in /ow Vision, Staff Optometrist 3ichael 2. 4eBa7ey V+31, +d;unct Professor <=1O

.igure " Photo un7nown image.

Objectives
4iscuss functional implications of types of eye and neurological disease 4iscuss rehabilitation>learning strategies 4iscuss accommodations for reduced visual acuity, visual field or neurological dysfunction

The impact of living

1oloboma

ith a visual impairment

1ortical visual impairment 4iabetic retinopathy 6laucoma =istoplasmosis

=omonymous hemianopsia /eber?s 1ongenital +maurosis 3ultiple Sclerosis Optic atrophy 8etinal detachment 8etinitis pigmentosa 8etinopathy of prematurity

The !ealth" E"e

.igure # 4rawing of the structure of the eye.

+nterior segment o 1ornea o Iris>pupil o /ens o Trabecular meshwor7 o +@ueous

Posterior segment o 1iliary body

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o Vitreous o 8etina0 rods : cones o 3acula o 8etinal vasculature o Optic nerve head

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#osterior #ole

.igure ( Image of the retina

.ovea o "$#.!C radius o #)>#)$#)>%)

3acula o #.!$!C radius o #)>%)$#)>')

Paramacula o !$-.!C radius o #)>')$#)>&)

Perimacula o -.!$")C radius o #)>"))$#)>#))

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$etermining visual field

.igure % Photo of a young boy prepares for a visual field screening.

.igure ' Two pictures of devices for chec7ing visual fields. .igure ! Tangent screen

1onfrontation or

manual perimeter Tangent Screen 6oldmann +utomated perimeter o =umphrey is best for following disease The most useful functional test is 5inetic visual fields

Functional implications
If visual acuity loss or central scotomata A thin7 magnification If field loss A reading strategies, orientation and mobility If optic nerve damage A increase contrast, light sensitivity, color vision deficits If retinal damage A increase contrast, light sensitivity, possible color vision deficits, visual field deficits

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Vision Loss in Children in the %&S&

1ortical Visual Impairment $##D 8etinopathy of Prematurity A "%D Optic Eerve =ypoplasia A ")D 1oloboma A -D 1ataracts $'D +lbinism $ !D Optic +trophy $#D

Coloboma

.igure - Image of eye with coloboma

Inferior notch on iris 3ay also affect0 lens, choroid, OE=, and retina 1losure defect during embryonic stage Eystagmus

Coloboma: Functional involvement

Incomplete closure of the iris /ens notch>cataracts 8etinal coloboma
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3acular involvement OE= coloboma /ight scatter>/ight sensitivity 6lare Superior field loss 4ecreased visual acuity 2nlarged blind spot Slow dar7$adaptation

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Coloboma of 'etina

.igure & Two pictures showing coloboma of the retina

1oloboma of Optic Eerve =ead G/H vs Eormal Optic Eerve G8H

.igure F Two pictures of retina showing coloboma of optic nerve head G/H versus normal optic nerve head G8H.

C!(')E S"ndrome
1 A 1oloboma. 1left or failure to close the eyeball. GIris, Optic Eerve and 8etina can be affectedH. .unctional issues are field loss, light sensitivity, retinal detachment 1 A 1ranial Eerves A %)D of persons have a facial palsy G1E VIIH, at least ()D have swallowing problems G1E II>IH, and sensorineural hearing loss G1E VIIIH. Swallow problems can resolve by - or & years of age

.igure ") Image of retina in 1=+862 Syndrome.

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C!(')E S"ndrome
= A =eart A +bout &)D of children are born with a heart defect. 3any are minor some can re@uire surgery. Some are serious A tetralogy of .allot heart defect + A +tresia of the choanae A 1hoanae are passages from the bac7 of the nose to the throat which ma7e it possible to breathe through the nose. +tresia is narrowing. Surgical intervention can be successful

C!(')E S"ndrome
8$ 8etarded 6rowth and 4evelopment A although most children are average siBe at birth many will lag in siBe due to nutrition problems, heart problems, or growth hormone deficiency. 3ost will be developmentally delayed due to medical issues, some will be 38

C!(')E S"ndrome
6 A 6enital and urinary abnormalities A many boys have small penis or undescended testes. 6irls have small labia. 3ay re@uire hormone therapy to achieve puberty. 5idney or urinary tract abnormalities, especially reflux

C!(')E S"ndrome
2$ 2ar abnormalities A <nusual external ears, including short, wide ears with little or no earlobe with a snipped off appearance to the helix Gouter fold of the earH. 3ay be soft due to floppy cartilage. =earing loss is present in &)$&!D of children with 1=+862 A ranging from mild to profound deafness. .re@uent ear infections as well.

C!(')E S"ndrome
Other birth defects include cleft lip and palate, tracheo$esophageal fistula or artresia, or poor immune response 3any have wea7 upper body strength.

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Cortical*Cerbral Visual +mpairment ,CV+-

.igure "" 4rawing of the brain showing visual pathway of light through to the visual cortex. The thalamus is also indicated.

4amage or disease affecting the occipital lobe or any part of the visual pathway. Ocular structures are normal

$emographics of Congenital Cortical*Cerebral Visual +mpairment

1ongenital cortical visual impairment is more common in wealthier nations. 1onsidered to constitute between ).)-D and ).##D of the total school population in the <S.

Cortical*Cerebral Visual +mpairment

1auses include0 Periventricular leu7omalacia Intraventricular hemorrhage Traumatic brain in;ury 3eningitis Shunt failure Severe seiBures 1ardiac arrest 1ES developmental delays

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Causes of CV+ . #eriventricular Leu/omalacia

.igure "# 4etailed drawing showing the impact to the brain in Periventricular /eu7omalacia..

#eriventricular Leu/omalacia

.igure "( Illustration of child with window into his upper s7ull showing the brain.

.igure "% Scan image of brain ventricles.

+ntraventricular !emorrhage

.igure "! 4rawing of brain showing intraventricular hemorrhage.

.igure "' Scan image of brain showing intraventricular hemorrhage.

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Optic $is/ Characteristics

ith #VL

It can be difficult to view the dis7 2arly PV/, before #& wee7s may be associated with small dis7s Eormal siBed dis7s with large cupping and a reduced neuro$retinal rim may be due to later lesions $ #& wee7s and later gestation. Spectrum of optic dis7 appearances

.igure "- Images of optic dis7s

$orsal Stream
8uns between occipital lobes and parietal lobes o Subserves the ability to process the whole visual scene and carry out visually guided movement Brings about accurate movement through visual space

Ventral Stream
8uns between the occipital lobes and temporal lobe tissue o Subserves visual recognition and memory Provides a conscious analysis and understanding of the visual world

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$orsal and Ventral Stream of Vision

.igure "& Illustration of dorsal and ventral stream of vision

$orsal Visual S"stems disrupted

ith CV+

4orsal Jwhere is it pathwayK associated with posterior parietal >occipital lobe lesions cause Visual motor disturbances o deficits in fixing direct visual attention to an ob;ect o shifting fixation and gaBe to new stimulus o fine motor tas7s such as copying and drawing Visual Spatial disturbances o localiBation of ob;ects o ;udgment of direction and distance ob;ects o orienting the body to the physical world

Visual Function
.unctional effects0 Visual acuity can vary from total blindness to wal7ing as if fully sightedL Visual field loss is varied and often difficult to assess, fre@uent loss of inferior visual field is cited Inability to cross a floor boundary without tactile exploration

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6E 4utton, + Saaed, B .ahad,8fraser,6 3c4aid, M 3c4ade, + 3ac7intosh, T 8ane and 5 Spowart +ssociation of binocular lower visual field impairment, impaired simultaneous perception, disordered visually guided motion and inaccurate saccades in children with cerebral visual dysfunction A a retrospective observational study. 2yeG#))%H"&,#-$(%

0ethods to evaluate function

Visual +cuity o Teller +cuity 1ards o 1ardiff 1ards o /ea 1ards 1onfrontation visual field testing o <sing various targets, most subtle to simulate real world testing

'ecommendation for Function

The primary goal of most exams is to obtain more information for education and function. Very little information on this population. 5ey recommendations are to reduce visual clutter, determine appropriate near point siBe materials, use sound or color if possible, use of high contrast materials and placement of materials. Orientation can be a problem, may need a cane. 3ay need to use boo7s on tape, computers with speech, 11TV

'ecommendations for Function

+d;ust lighting for optimum performance 6ive child time to respond <se the same name for ob;ects consistently <se consistent visual cues A i.e. always use a red bowl at home and at school for meals Touch may be needed to be used with visual cues

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'ecommendations for Function

3oving ob;ects may assist the child?s attention The child may use peripheral rather than central vision The child may reach away after loo7ing at an ob;ect

$iabetic 'etinopath"

.igure "F Image of the retina in diabetic retinopathy

Vascular disease process Type I0 Muvenile, insulin dependent Type II0 ac@uired, non$insulin dependent

$iabetic retinopath"
/aser treatment options o Vascular photocoagulation o 8etinal photocoagulation .unctional deficits o 4ecreased V+ with macular hemorrhage o /ight sensitivity>glare o 4ecreased contrast sensitivity o Slow dar7$adaptation o 8efractive error fluctuation o Possible relative peripheral visual field loss
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)laucoma

.igure #) Image of retina in glaucoma

Types of glaucoma 1ongenital Primary open angle +ngle$closure /ow$tension glaucoma Traumatic 4rug$induced Pigmentary dispersion Eeovascular Gin diabetesH

)laucoma
3echanical vs. Vascular Theory Vascular Theory0 results from reduced blood flow to the optic nerve, this in turn causes slow, painless and irreversible loss of peripheral visual fields. 3echanical Theory0 results from the increased intraocular pressure compressing on the optic nerve head, and therefore, damaging the nerve which causes loss of peripheral visual fields.

Congenital )laucoma
8are, highly destructive

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o Signs include A tearing, photophobia, cloudy cornea, enlarged cornea, high IOP, cupping or asymmetry of nerves 3ay be present at birth or early infancy 1orneal enlargement if high IOP at birth to two years +lso syndromes A 8eiger?s syndrome, Peter?s anomaly, +niridia 2ven with aggressive intervention visual outcome is often poor with corneal scarring as well as nerve fiber loss with poor fields. Optical management includes glare control and devices

Congenital )laucoma

.igure #" Two photos0 child with glaucoma in left eye and close up of eyeball.

)laucoma: 1ilateral arcuate defect

.igure ## .ield test report showing images of left and right retina and visual field screening results.

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+mplications of )laucoma
Optic nerve head damage causes o .ield loss o 4ecreased contrast sensitivity o 6lare : slow in dar7$adapting o 4ecreased visual acuity .unctional loss due to OE= damage o Orientation : mobility o 6ood illumination : high contrast ob;ects o SpecialiBed filters to control light entering the eye o 3agnification

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!istoplasmosis

.igure #( Image of the retina in histoplasmosis

+ fungus causes retinal damage 1horoiditis due to presumed ocular histoplasmosis 1an affect central or peripheral vision /ight sensitivity is a common complaint

!omon"mous !emianopsia ,!!-

.igure #% Visual field test results for homonymous hemianopsia

Visual field defect resulting from 1V+ Gcerebrovascular accidentH or +BI /oss of the same half of the visual field in each eye. Eeglect may or may not be present.

Treatment options for !omon"mous !emianopsia

Teaching scanning s7ills and reading s7ills #"

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Incorporating sector or Peli prisms to enhance field 4ifficulty in reading varies depending on the hemi$field lost

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1asic revie

on prisms

.igure #! Photo showing how a prism magnifies and shifts the image of a pencil that is on a des7.

Image shift o Towards the apex

4isplacement in degrees is approx. half o #)N O ")P

2ote: 3 diopter 4 5&678

Concept of scanning s/ills

.igure #' Illustration of amplitude of scanning of dynamic field.

4ynamic field Q Static field

Fresnel Sector #rism*#eli prism

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.igure #& Photo of .resnel Sector prism

.igure #- Photo of Peli prism

Eli #eli Sector #rism

.igure #F Photo of 2li Peli Sector prism

$"navision

.igure () *oman points to 4ynavision

Originally designed to improve visuomotor s7ills of athletes <sed to increase awareness of peripheral vision <se hand to stri7e point which is flashing Eumber of JhitsK are recorded at the end of the run .ully programmable for @uadrants, pace etc. 1enter fixation target with number for patient to call out to monitor fixation

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VF$ versus Visual +nattention*2eglect

=emi$inattention>neglect is often confused with visual field deficits $ distinctly different conditions. *hen a visual field deficit is present, the patient attempts to compensate for vision loss by engaging visual attention. *hen a hemi$inattention is present, the patient has lost the attentional mechanism that drives visual search for information on the left side and does not attempt to compensate. 1ombination of hemi$inattention and V.4 creates severe visual inattention, sometimes called visual neglect

*arren, 3. G#))'H. 2valuation and treatment of visual deficits following brain in;ury. In =.3. Pendleton, : *. SchultB$5rohn G2ds.H, Pedretti?s occupational therapy practice s7ills for physical dysfunction G'th ed., pp. !(#$!-(H. St. /ouis 3O0 3osby 2lsevier.

Leber9s Congenital (maurosis ,LC( /1+ is a group of disorders present at birth, autosomal recessive inheritance pattern 8esults in a reduction of visual acuity, color vision, and night blindness /1+ is one of the few causes of congenital blindness. 8etina appears intact, but 286 shows little activity 2arly adolescence retina appears li7e 8P changes

Leber9s Congenital (maurosis

Visual acuity range from #)>#)) to hand motion within the first year of life 8oving eye movements are common .unctional effects0 o Eight blindness o Poor light adaptation o Peripheral field loss
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o 6lare complaints

LC(: practical applications

2arly intervention for educational purposes +ppropriate blind s7ills needed o .rom Braille to cane$travel +ssociated with 7eratoconus and cataracts

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0ultiple Sclerosis ,0S 3S is a demyelinating disease ultimately affects the entire body. 3ay be accompanied o paresthesia of extremities o muscle spasticity o decreased sensitivity to touch, pain and temperature 3S is a progressive disease

Optic 2euritis

.igure (" Image of retina along with visual field screen in Optic Eeuritis.

Onset o =ard to predict o 1an be associated with 3S

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Progression o Stable once the cause is controlled

Type of field loss o Jswiss cheeseK

4ifficulty in mobility o varies

0S: Ocular involvement

V+0 ranges from normal$ severely impaired 4emyelination of the nerve fibers leads to optic neuritis o Optic nerve defects +ccomodative system is usually unstable Eystagmus and gaBe palsies A the world is moving +cuity can fluctuate significantly from day to day Visual field losses0 usually, li7e$Kswiss$cheeseK o 6lare complaints 8eading can be laborious even with good V+

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Optic (troph" ,O(-

.igure (# Image of retina with optic atrophy

+n irreversible, unhealthy>dysfunctional optic nerve causing0 8educed visual acuity 1ompromised visual fields>peripheral vision 8educed contrast sensitivity 1olor Vision deficits

Optic (troph" ,O(1ongenital causes include /eber?s hereditary optic neuropathy o +ffects young men o <nilateral vision lost at first with rapid progression +utosomal 4ominant A prevalence "0!),))) to "0"),))) o Onset is %$' years of age o #)>#) A #)>#)) in young adults o 1entral or paracentral scotomata +utosomal 8ecessive A rare o Vision loss in first year of life o Visual impairment is severe
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o Sensory nystagmus is present

Optic (troph"
Other congenital causes include Trauma Intrauterine teratogens G.etal +lcohol SyndromeH Perinatal ischemic event =ydrocephalus GpapilledemaH

Optic 2erve !"poplasia

.igure (( Image of optic nerve with peripapillary halo.

+ small optic nerve A less than the normal number of axons, usually bilateral, may be asymmetric Small gray or pale nerve surrounded by peripapillary halo. 3easure of the ratio of disc to macula distance compared to the disc diameter G43>44H Eormal is #." to (.# 44

Optic 2erve !"poplasia

Often associated with developmental central nervous syndrome of endocrine disorders. 1ognitive or multiple handicaps +ssociated with low maternal age, alcohol and drug use during pregnancy V+ varies from /ight Perception to normal Eystagmus is usually present ()

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Optic 2erve !"poplasia

Visual fields are reduced in various patterns depending on the area which is reduced in the optic nerve. 1an be reduced to hemianopic fields to constriction in the inferior field.

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Septo:optic d"splasia or $e0osier9s S"ndrome

.igure (% Image of brain without 1orpus 1allosum

8are, congenital disorder o Optic nerve hypoplasia o Thin or absent septum pellucidum and>or corpus callosum and pituitary dysfunction o 2ndocrine disorders Thyroid gland dysfunction, delayed of precocious puberty, reduced blood sugar, congenital architectural brain anomalies

o 1auses thought to be intrauterine infection, diabetes, antiseiBure meds, alcohol and drugs.

Optic 2europath"
Inflammation of the optic nerve anywhere along its course 3ay be caused by an infection, vaccination, meningitis, or autoimmune diseases such as multiple sclerosis 3ay have pain, nerve may appear swollen Vision may recover or remain impaired If it remains impaired the optic nerve will appear pale in color

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(nterior ischemic optic neuropath"

.igure (! Visual field test results

Onset o +dulthood

Progression o +cute

Type of field loss o +ltitudinal Gsuperior or inferiorH

4ifficulty in mobility o Inferior altitudinal defect

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'etinal $etachment

.igure (' Image of retina with detachment

Partial or total separation from the supporting structures. Sensory separation causes0 o .ield loss A if peripheral o +cuity loss A if central

+ssociated to0 o =igh myopes or myopic degeneration o 3arfan?s syndrome o Trauma o 8etinal tear>hole

'etinal $etachment

.igure (- Two image showing retina and 6oldman Visual .ield results pre$op.

Onset
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o Sudden Progression o Progressive if untreated Type of field loss o In the opposite location of the retinal damage 4ifficulty in mobility o varies

'etinal detachment: Functional deficits

Orientation : mobility is compromised depending on the extent of the detachment 4ar7$adaptation is very slow Severely glare complaint

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'etinitis #igmentosa

.igure (& Image of the retina in retinitis pigmentosa

+ diverse group of disorders in which the mechanism of retinal degeneration is un7nown. 1ommon signs and symptoms0 o Eight$blindness o /oss of peripheral vision o /oss of central vision Gend$stageH o 6lare complaint

'# related visual field

.igure (F 6oldman Visual .ield results for left and right eyes in 8P.

Functional implications of '#

Eight$blindness 1ane$travel with or without flashlight

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Peripheral field loss .ield enhancing devices through the patient?s eye$care professional 1ane$travel s7ills 6lare>decreased contrast sensitivity SpecialiBed filters for both out doors and in

Overall 0inification

.igure %) 4iagram showing overall minification

1ohen "FF#

'everse Telescope ,'TS-

.igure %" Image of par7ing lot and cars

4ecrease in V+ by the same about as the TS power o V+ R #)>(), thru the (x 8TS S #)>F)

Visual field increase by the same amount of the TS power o V. R -P, thru the (x 8TS S #)P

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'everse TS for peripheral field constriction in a bioptic

.igure %# *oman wearing a reverse telescope mounted on her glasses

Provides a miniaturiBed view of the world at a glance. .ast access to the information

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'etinopath" of #rematurit" ,'O# +ttributed to oxygen$therapy as well as elevated carbon dioxide levels, anemia, blood transfusions, IV=, BP4, hypoxia in utero, multiple spells of apnea or bradycardia, mechanical ventiliation, and seiBures /ow$birth weight is highly correlated to 8OP, more so then gestational period. =igher incidence if weighs less than %.%lbs, especially if under #.# lbs

0ost common signs in 'O#

.igure %( Image of retina with 8OP

4ragging of the macula 8etinal detachment .ailure to neovasculariBation of the peripheral retina Treatment includes A laser, cryotherapy A Stage (

'O#

.igure %% Image of premature infant having left eye examined.

.unctional changes
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4ecreased visual acuity 4ecreased peripheral visual field Eystagmus =igh myopia or asymmetric refractive errors +mbloyopia 6laucoma

To;oplasmosis

.igure %! Image of retina in toxoplasmosis

1aused by a parasite o Vitreous is rarely invaded, but the retina sustains ma;or damage

=ost of this parasite is primarily cats. 3ay lie dormant in tissue and reactivate when the host is immuno$compromised

Functional implication of to;oplasmosis

Visual function will depend on the location of the lesion. o 1entral macular lesions cause poor acuity o Peripheral lesions have minimal to no effect other than a peripheral blind spot

%nderstanding the patient9s diagnosis and the ocular structures involved can assist "ou in providing the /e" modifications to improve their <ualit" of life .

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Te;as School for the 1lind = Visuall" +mpaired Outreach #rograms

.igure " TSBVI logo.

TThis pro;ect is supported by the <.S. 4epartment of 2ducation, Office of Special 2ducation Programs GOS2PH. Opinions expressed herein are those of the authors and do not necessarily represent the position of the <.S. 4epartment of 2ducation.
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.igure # I42+ logo

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