Treatment Options

Visual Field Loss:  Because most field losses are permanent, it is necessary to train and rehabilitate with this in mind. Visual field loss can also have severe implications with driving, patient’s safety and the safety of others. For those who cannot drive, visual field loss can interfere with daily functioning and increase the risk of falls.

 

Prismatic field devices can be helpful in expanding peripheral vision. When these devices are placed on a patient’s glasses, he or she can be taught to glance into a small section of the glasses to gain back some of the lost field. This intervention requires an experienced clinician and extensive patient training on use of these devices.

 

As mentioned, field losses can be actual or due to neglect. In either case, retraining of the visual system may be necessary to teach the patient how to compensate for the missing field. The training can be as simple as placing food or other basic items in the missing field and working with the patient to learn to identify the necessary item. It is also possible to place items of interest such as the TV or family pictures in the missing field to encourage the patient to compensate by looking into the missing field to identify the object. Mobility and safety are of paramount interest to the rehabilitative specialist.

 

Another use of prism glasses is a pair in which objects below your gaze can be viewed without looking down. Since they keep a user from bending his head forward, these prism glasses can be particularly useful for patients in neck braces or with neck problems.

Diplopia:  Double vision can often be treated with prisms. These prisms can be applied to the patient’s glasses to eliminate the double vision. Because the eye turn is frequently different when the patient is looking at near versus far objects, it is often necessary to prescribe two pairs of glasses depending on the patient’s activity (i.e., driving or reading).

 

Diplopia can sometimes be successfully treated by using eye exercises. These are similar to exercises used to treat patients with neurological damage requiring strength training to rehabilitate arms and legs . A controlled and supervised treatment plan is necessary to ensure success. This should be under the direction of a trained eye care professional with knowledge in vision therapy.

 

The first step is to rule out damage that cannot be treated with exercise, such as severe cranial nerve injury. Cranial nerves come from the brainstem and travel into the brain and then to the muscles that control the eye. This condition does not improve with therapy because the nature of the damage is permanent and irreversible. Prisms also prove to be of little help because the deviation of eye turn is much different in all gazes.

 

Some cases of severe nerve palsy and some other select double vision cases need occlusion. The classic view of occlusion therapy is to use a patch over one eye. This conjures up visions of pirates. Very rarely is a black patch used anymore. One alternative is a press-on patch. These patches come in varying densities and reduce vision slightly to significantly depending on the level of occlusion desired to eliminate the diplopia. The patient must wear glasses to use the patches; Once applied, however, it is almost impossible to see the patch.

Another form of press-on patches is to use spot occlusion. This occlusive technique allows the patient to maintain peripheral vision while the central vision is being shut off. A modification of this is to place scotch tape in the gaze where the patient experiences double vision. In other words if the patient is double in left gaze, place a piece of tape on the outside part of their left lens and see if this helps to decrease the double vision.

 

Depending on the diagnosis, diplopia can either be one of the most rewarding or frustrating problems to treat. In any case, an extensive work-up is required, and treatment plans should have a prognosis tied to the diagnosis so the patient can have realistic expectations.

 

Spatial Awareness Disorder:  Treating balance and orientation disorders can prove to be both rewarding and frustrating to the physician. Distortion of space is sometimes referred to as a Visual Midline Shift (VMS). The patient’s perception of center does not correspond to the body’s actual center. Determining the patient’s perceived midline can be done by a simple pencil test. The practitioner asks the patient to identify when a moving pencil passes directly between the patient’s nose and the examiner’s nose. This test has some subjectivity naturally built into it, but the consistency of responses that most people demonstrate is surprising.

 

Another way to determine if a patient is suffering from midline shift is to simply watch him walk down a hall. Barring other physical problems, patients with visual spatial problems have a great deal of difficulty walking down a hallway without using the wall or other objects for support. Using balance beams, balance boards and walking straight lines can also be helpful in determining a patient’s midline deviation.

 

Treatment for midline shift tends to be through utilization of yoked (same direction) prisms. Prisms have a thick end and a thin end. Yoked prisms have the thick end pointing in the same direction (either both up, down, left or right). The prism is applied to make the patient’s perceived midline correspond to their actual midline. The use of vision therapy can also be helpful, as many patients with visual spatial issues also suffer from eye movement disorders.

 

Eye Movement Disorders:  Patients who are unable to keep their place when reading or who simply cannot maintain focus on printed material  may suffer from an eye movement disorder. Eye movement disorders can be a result of poor pursuits (smooth eye movements) or deficient saccades (jumping from one place to another with your eyes). Treatment of these disorders is fairly straightforward and very rewarding. The use of eye exercises can significantly improve the patient’s ability to read and thus function in society.

 

Eye movement exercises can be as simple as placing two photographs of the patient’s family members in different parts of the room or having the patient read. Reading may not be at the level they are used to, but starting easy and working up slowly is the key. There are also many exercises that can be prescribed in a logical order to help the patient’s visual motor system regain normal or near normal function.

 

Photophobia (light sensitivity) and Dry Eyes:  Many stroke, MS and brain injury patients experience light sensitivity. Treatment for dryness often produces a significant amount of relief for photophobia. However, the patient must always have an eye care professional rule out more significant and potentially sight-threatening problems causing the photophobia. A problem known as iritis (an inflammation if the iris) should be treated with strong medications to decrease any chance of sight-threatening problems.

 

Simple treatments for dry eye can often be overlooked and prove to be very rewarding for the patient’s eye discomfort and photophobia relief. A usually safe intervention is to instill over-the-counter eye drops specifically formulated for dryness. These come in a myriad of formulations; one that works for a particular patient may have little to no effect on another. Preservative-free formulas tend to be recommended by most eye care professionals, because preservatives can be irritating to an already dry eye. Preservative free are single dose and tend to be much more expensive. It should be noted that eye drops containing formulations that get the red out can do just that. In the long run, however, the patient’s eyes tend to be even redder than before because of a condition known as rebound redness.

 

Figure 6. The Lids and Puncta

 

Punctal occlusion is a technique that can be performed to plug off a patient’s drainage hole. Think of it as plugging the drain in a sink. The faucet is still on but the drain isplugged. Keep in mind that there are two holes responsible for tear drainage and usually only one is occluded.

Restasis is yet another form of dry eye treatment. This is a single dose prescription and is administered twice per day. The mechanism is not fully understood but an anti- inflammatory mechanism is thought to be at the heart of its success.

 

Any combination of the above treatments may also prove helpful. Some patients report that using a humidifier decreases symptoms. Other patients have noted relief by moving to a more humid environment. As this is often impractical, it may prove helpful in a differential diagnosis when visiting a humidity enriched climate and noting the eyes’ response in comfort and changes in photophobia.