Health

These case studies are actual cases with some simplification in the clinical presentation and treatment plans to facilitate understanding. 

Case 1 (diplopia)

History:  This 22-year-old male patient had severe head trauma which resulted in a significant left eye outward turn (exotropia). The patient had no usable vision in the left eye, and the rehabilitation staff noted that his eye was constantly and significantly exotropic.

Examination:  Upon covering the right eye it was noted that the left eye remained out. The patient’s left eye remained looking off into space and he did not report seeing anything out of it. The left eye was “enticed” to a straight-ahead position by tapping on the patient’s temple with a finger. This tapping is thought to stimulate the visual pathway physically, like turning on a light switch. This was done repeatedly until the patient reported seeing out of both eyes, at which point a significant blur was reported out of that eye and also diplopia (double vision).

Treatment:  The initial treatment included a patch over the right with the patient’s glasses. The patch was a 20/100 translucent material (much like Scotch tape) which blurred the right eye but did not completely shut it off like a black patch would. This allowed the left eye to turn in without causing diplopia. Eventually the right eye patch was replaced with a “spot patch” (a piece of clear tape placed directly on the glasses in front of the patient’s pupil). This allows for peripheral vision in each eye while still helping the eye with the turn to stay straight and work. Eventually the patient was able to use both eyes together with the help of corrective prisms in his glasses. Without the prism glasses, there was still some outward eye turn and thus diplopia. At his last exam the vision was still reduced in his left eye, but his eyes appeared to be straight and no prism was necessary in his glasses.

Discussion: The patient would probably not have shown such dramatic improvement especially in a fairly short period of time (6 months), if he had been 40 years old or older. Neuroplasticity or the re-wiring of our brain certainly seems to be a benefit of youth. It is also difficult to say what would have become of his visual status if no intervention had been started; however, classic rehabilitation supports this sort of treatment and certainly no harm was done. The parents also reported seeing dramatic improvement as each successive stage of visual rehabilitation was started. 

Case 2 (Field Loss)

History:  This 41-year-old female patient suffered a significant stroke which resulted in a right complete visual field loss (homonymous hemianopsia). Along with the field loss there was a notable visual neglect which adds insult to injury. Neglect by definition is to ignore or disregard. In essence the patient was unable to see anything in her right visual field and also completely refused to acknowledge anything that was placed in that same field.

Examination:  A confrontational visual field confirmed the field loss. Questioning the rehabilitation staff also confirmed the right neglect. Visual acuities, eye movements and other health issues were normal.

Treatment:  The patient was asked to use a yoked prism (base of the prism in the same direction) correction, which essentially moves her visual field in the direction of the defect. This was to be worn during meals, mobility and related rehabilitation activities. The thought is to stimulate activity in the patient’s right visual field and thus make her aware of the missing area. The amount of prism correction was eventually reduced and the neglect significantly decreased. The visual field loss was then treated with a button prism correction on her lower right spectacle lens. This uses a glancing technique which does not restore her field but rather expands it.

Discussion:  Complete hemianopsias are usually permanent and have a poor prognosis of improvement with increasing age. Glancing prisms can be bulky, but press-on prisms are helpful in initially determining what, if any, benefit can be gained from an actual permanent prescription. The yoked prism prescription is a separate pair of glasses used in conjunction with the patient’s habitual prescription and is meant to be used only for therapy. This treatment can be very effective for neglect cases.

Case 3 (Spatial Awareness Disorder)

History:  This 26-year-old male was in a skiing accident and experienced problems keeping his balance, especially in crowded places. His job required him to frequently negotiate crowded high school hallways between class periods. He had a consistent bruise on the right side of his body due to misjudging corners and bumping into them. He also had a significant difference in pupil sizes due to the head trauma.

Examination:  When observing the patient walk down a hallway it was noted that he veered to the right side. He frequently used his right hand to help guide his way down the hall. He also complained of neck pain and upon observation had a noticeable right head tilt. Visual acuity, ocular motilities and general eye health was normal except for a significant difference in pupil size.

Treatment:  A small amount of yoked prism (base of the prisms in the same direction) was prescribed and the patient noted a significant subjective improvement with the prisms yoked with their base to the patient’s right. Objectively the patient was able to immediately negotiate the hallway without any lean or need to balance with the right hand.

Discussion:  Yoked prism therapy varies from person to person. Some people experience a great relief with these prism glasses while others see no benefit or even have negative effects from them.

Case 4 (Photophobia)

History:  This 36-year-old male was involved in a motor vehicle accident in which he experienced closed head trauma. He had multiple lacerations and internal injuries and reported that his eyes were extremely sensitive to fluorescent lights. He did have a history of unsuccessful contact lens wear but found glasses to be more tolerable.

Examination: A basic eye screening was performed without any significant problems noted. The patient did have a significant amount of redness in “the white of his eyes” and had a great deal of difficulty keeping his eyes open when any light was shined in his eyes.

Treatment:  The patient was placed on Restasis prescription eye drops twice daily in each eye. He was also instructed to use preservative free artificial tears four times per day. At his two-week recheck the patient was better but still light sensitive. At that visit a pair of punctal plugs was inserted.

Discussion:  This patient experienced a significant decrease in his photophobia almost immediately after the punctal plugs were inserted. He was able to function at work under fluorescents without a brimmed cap and reported discontinuing the Restasis without a problem. This case illustrates the link between dry eyes and photophobia.  

Case 5 (Eye Movement Disorder)

History:  This 62-year-old male patient had a cerebral vascular accident (CVA) that affected his ability to read. His wife stated that he read the paper cover to cover every day prior to his stroke. He tried on several occasions to read a book or the newspaper and reported that the words moved and he was unable to keep his place even with a “line guide.”

Examination:  His ocular motilities were full; however, significant jerks were noted. Hee was unable to follow a pencil tip through space with any accuracy. He was also unable to jump his eyes accurately from point to point or pencil tip to pencil tip accurately. This is referred to as a deficiency of pursuits and saccades. All other visual systems were normal.

Treatment:  The patient was prescribed several eye movement exercises. He was told to work on his smooth movements (pursuits) and also his jumping movements (saccades). These exercises were to be done for 15 minutes three times per day. He was also instructed to use large print versions of books and magazines where and when available and to get several books on tape and follow along with the reader while viewing the text.

Discussion:  Many patients in rehabilitation settings find reading to be either too difficult or too time consuming to fit into their schedule. They tend to prefer the TV and use it as company when they have down time. Age certainly plays into the prognosis for improvement, but even older patients should be encouraged to read at the earliest possible convenience. Even being read to can prove to be stimulating as the visual image that is formed can lead to a desire to pick up a book and restart the visual process necessary to enjoy printed material.