Training of vertical versus horizontal reading in patients with hemianopia - a randomized and controlled study.

HYPOTHESIS: Patients with hemianopic field defects (HFD) might benefit from reading text in vertical orientation if they place the text in the seeing hemifield along the vertical midline. METHODS: We assigned 21 patients with HFD randomly to either vertical or horizontal reading training. They trained reading single lines of texts from a computer screen at home for 2 × 30 min/day, 5 days/week, for 4 weeks. The main outcome variable was reading speed (RS) during reading standardized paragraphs of printed text (IReST) aloud. RS was assessed before training (T1), directly after training (T2) and 4 weeks later (T3). Quality of life (QoL) was assessed by Impact of Visual Impairment (IVI) questionnaire. RESULTS: Vertical training improved RS in the vertical direction significantly. Only patients with right HFD benefited. Horizontal training improved RS in horizontal diection significantly, but much more in patients with left than in those with right HFD. Both effects remained stable at T3. RS during training at the computer improved highly significantly and correlated strongly with RS of printed text (Pearson r= > 0.9). QoL: Vertical training showed a statistically significant improvement in the complete IVI-score, patients with right HFD in the emotional IVI-score. CONCLUSIONS: The improvements of RS were specific for the training. The stable effect indicates that the patients can apply the newly learned strategies to everyday life. The side of the HFD plays an essential role: Left-HFD patients benefitted from horizontal training, right-HFD patients from vertical training. However, the vertical RS did not reach the level of horizontal RS. The study was registered in the German Clinical Trials register (DRKS-ID: DRKS00018843).

Feasibility of Eye Movement Recordings with the SMI Tracking Bar in 10- to 11-Year-Old Children Performing a Reading Task.

INTRODUCTION: Eye movements during reading can be impaired in amblyopia, developmental dyslexia, reduced visual acuity, or visual field defects. To detect pathology, normative values are important for comparison. In healthy children, there is sparse data on eye movements during reading. Therefore, the aim of this study was to, in a first step, explore the feasibility of applying the SMI RED eye tracker bar to record eye movements in 10- and 11-year-old children while reading a text. MATERIALS AND METHODS: Thirty-three (19 aged 10 years, 14 aged 11 years) normally sighted children attending a primary school in Switzerland participated in our study. Visual acuity, the Lang test, and the cover test were performed as a screening for ophthalmologic pathology that might influence the results. Eye movements were recorded with the SMI RED eye tracker bar while the child read aloud two texts from the International Reading Speed Test (IReST), presented on a laptop. Both texts were in German with an equal level of difficulty and were presented in a randomized order. Reading speed (words/minute), number of saccades, number of fixations, and reading errors (mistakes in the reading) were evaluated. RESULTS: Screening did not reveal pathology other than refractive errors and children had full corrected visual acuity. Eye movements could be obtained in all but six children where the reflection of the glasses worn prevented a good pupil recording with the tracker. Younger children performed more saccades per word with a mean of 1.41 (SD 0.39) at 10 years of age versus 1.10 (SD 0.21) at 11 years of age. The number of fixations per word was also higher in younger children (mean: 1.63 [SD 0.37]) than in 11-year-old children (mean: 1.32 [SD 0.33]). Ten-year-old children seem to analyze a text in smaller units than 11-year-olds. Thus, 10-year-old children took more time to complete the reading task than the 11-year-olds (mean: 88.8 s [SD 24.1] versus 84.4 s [SD 15.1]). In addition, 10-year-old children made more reading errors compared to 11-year-olds (mean: 4.47 [SD 2.95] versus 2.28 [SD 1.72]). CONCLUSION: It is feasible to record eye movements in children aged 10 - 11, albeit this is more difficult when glasses are worn. As parameters change with age, further data is needed for a representative evaluation regarding eye movements during reading in children of different age groups. The information gained may offer help in recognizing reading difficulties and monitoring of treatment effects.

Effects of home reading training on reading and quality of life in AMD-a randomized and controlled study.

BACKGROUND: Age-related macular degeneration (AMD) causes reading impairment, reduced quality of life (QoL), and secondary depression. We have shown that support with magnifying aids improved reading speed (RS), emotional and cognitive status, and QoL. The present study investigates whether additional reading training (RT) (after adapting to appropriate visual aids) can further improve vision rehabilitation. METHODS: Patients with dry AMD were randomly assigned to 2 groups. The primary RT group (P-RTG, n = 25) trained with sequentially presented text (RSVP), and the control group (CG, n = 12) performed placebo training (crossword puzzles) and later crossed over to RT, so that altogether 37 participants performed reading training. Patients trained at home on a PC for 6 weeks. RS was assessed during reading printed paragraphs of text aloud. Using a scanning laser ophthalmoscope, we examined fixation stability and preferred retinal locus (PRL) for fixating a cross, as well as PRL and eye movements during reading single words. We assessed emotional status by Montgomery-Åsberg Depression Rating Scale (MADRS), cognitive status by dementia detection test ( DemTect ) and QoL by Impact of Vision Impairment (IVI) profile. Visual acuity and magnification requirement were examined by standard procedures. All variables were measured before and after placebo training, before and after RT, and after 6 weeks without training (follow-up). RESULTS: RS improved significantly in the P-RTG during RT, but not in the CG during placebo training. The effect remained stable at follow-up. Fixation performance and eye movement variables did not change. Emotional status (MADRS) improved in P-RTG during RT and showed a significant difference of the change of scores between the 2 groups. Complete IVI scores improved significantly during RT and remained stable. CONCLUSION: The results indicate that patients with AMD, who already use magnifying aids, benefit from additional RT and that it can contribute in preventing depression and improve QoL. TRIAL REGISTRATION: The study was registered at the German Clinical Trials Register (DRKS00015609).

Vertical and horizontal reading training in patients with hemianopia and its effect on reading eye movements.

Vertical reading training (VRTr) increases reading speed (RS) significantly in patients with hemianopic field defects (HFD). We ask, how eye movements (EM) contribute to this improvement and whether EM-behavior is affected by the side of HFD. Twenty-one patients, randomly assigned to VRTr or horizontal RTr, trained reading single lines from a screen at home, for 4 weeks. In the clinic, we recorded EM while reading short sentences aloud from a screen before training (T1), directly (T2) and 4 weeks afterwards (T3). RS-screen was correlated with RS during reading printed paragraphs (RS-print) to assess the transfer to everyday life. RS-screen and RS-print correlated positively (horizontal: r > 0.8, vertical: r > 0.9) at all times. Vertical RS did not exceed horizontal RS. We found significant negative correlations of EM-variables and RS-print: in right-HFD with the number of forward saccades (T1: r = - 0.79, T2: r = - 0.94), in left-HFD with the steps during return sweeps (T1: r = - 0.83, T2: r = - 0.56). Training effects remained stable at T3. EM-improvement was specific for the RTr and the side of the HFD: in right-HFD fewer forward saccades after VRTr, in left-HFD fewer steps during return sweeps after HRTr. RTr on a screen transfers to reading printed text in real-life situations.Trial registration: The study was retrospectively registered in the German Clinical Trials register: DRKS-ID: DRKS00018843, March 13th, 2020.

[Rehabilitation of lesions in the visual pathways]. / Rehabilitation bei Sehbahnschäden.

This review considers diseases of the visual pathways at different levels, their consequences for relevant everyday functions and their rehabilitation. Infrachiasmatic lesions are mostly associated with central or ring scotomas causing reading problems. The use of an eccentric fixation locus in combination with text magnification often allows the patient to maintain reading ability. Chiasmatic lesions can cause orientation disability by bitemporal hemianopia and reading problems by slide phenomena along the vertical midline. Suprachiasmatic lesions lead to homonymous visual field defects. Regarding the hemianopic orientation disorder, there are two different training approaches, which have been discussed controversially: restitution of the visual field by visual stimulation versus compensation by explorative eye movements towards the hemianopic side. Previously described positive effects of exploration training were not entirely convincing due to the lack of control groups. A new randomised and controlled study has proved the effectiveness of exploration training and showed that the patients apply the improved exploration strategy to everyday life. In the control group, which received a visual field stimulation training--a potential restitution training--neither exploration nor visual fields changed. The hemianopic reading disorder depends on the distance of the field defect from the centre, i. e., the size of the reading visual field, the side of the field defect in regard to the reading direction and the presence of spontaneous adaptive strategies, such as eccentric fixation or predictive saccades. Specific reading training can be helpful. Cerebral visual impairments with visual field defects are often associated with disorders of information processing in higher cortical areas. These complex disorders usually require an interdisciplinary rehabilitation. Specific examination methods to assess functions of everyday relevance and their use as a basis for rehabilitation measures are discussed. Visual rehabilitation can be very successful in many cases and improves the patients' quality of life. One should expect that the demand for neuro-ophthalmological rehabilitation will increase, because the survival rate after severe cerebral lesions and the general lifespan are rising.

[Spectrum of ophthalmologic and social rehabilitation at the Tübinger Low-Vision Clinic : a retrospective analysis for 1999-2005]. / Ophthalmologische und soziale Rehabilitation sehbehinderter Patienten : Eine retrospektive Analyse an der Tübinger Sehbehindertenambulanz von 1999-2005.

BACKGROUND: In addition to medical care, the visual and social rehabilitation of low-vision patients is of increasing importance. The aim of our study was to evaluate the actual spectrum of patients concerning diagnoses and appropriate low-vision aids at a low-vision clinic. METHODS: In a retrospective study, the medical records of 4,711 patients treated at our low-vision clinic from January 1999 to December 2005 were reviewed and analyzed. The main outcome measurements were age, ophthalmologic diagnoses, magnification requirement, and prescribed low-vision aids, as well as social and professional rehabilitation measures. To evaluate the efficiency of visual rehabilitation, reading speed was measured in a subgroup of 930 patients before and after administration of low-vision aids. RESULTS: Age-related macular degeneration was, at 40%, the most frequent diagnosis. Other main diagnoses were tapetoretinal dystrophies, optic atrophy, and diabetic retinopathy. The median magnification need was 4x. A highly significant correlation existed between the measured magnification power and the magnification factor of the prescribed low-vision aids. Visual rehabilitation was frequently sufficient with simple optical low-vision aids such as high-plus reading additions and magnifiers. Closed-circuit television systems were necessary in 26%; however, 85% of these patients had a high magnification need of more than 6 x. For distance vision, a monocular telescope was the low-vision aid prescribed most often. A high proportion of patients needed more than two low-vision aids for different application areas. Forty percent of patients needed special social and professional rehabilitation measures. In a subgroup of 930 patients, the mean reading speed was 35+/-50 words/min before the use of low-vision aids, which increased significantly to 81+/-46 words/min with the use of such aids. Therefore, the reading speed essentially doubled following the use of low-vision aids. CONCLUSION: Our results provide actual, quantitative data about the need for and success of rehabilitation for visually impaired patients. A large number of patients suffer from age-related macular degeneration. Independent from the causal ophthalmologic diagnoses, most patients benefited greatly from the rehabilitation measures provided by the low-vision service and were thus able to improve their quality of life. In the face of the increasing number of visually impaired elderly patients, rehabilitation should start as early as possible.

[Current possibilities of visual rehabilitation]. / Aktuelle Möglichkeiten der visuellen Rehabilitation.

Diseases of the eyes and visual pathways can lead to different visual field defects, which limit the patients' abilities in everyday life in different ways. Central visual field defects cause mainly reading disorders and peripheral defects cause disorders of orientation and mobility. Rehabilitation measures have to be adapted specifically to the deficit and the individual needs of the patient. In central scotoma, reading ability can mostly be restored by magnifying visual aids. In reading disorders caused by insufficient size of the reading visual field, text magnification is contraindicated. In this case, contrast-enhancing or non-visual aids are applied. Modern electronic media are successfully used particularly by young people with visual impairments. Computer-based training programs are of increasing importance, especially saccadic training for orientation disorders due to concentric and homonymous visual field impairments.

New standardised texts for assessing reading performance in four European languages.

AIMS: To develop standardised texts for assessing reading speed during repeated measurements and across languages for normal subjects and low vision patients. METHODS: 10 texts were designed by linguistic experts in English, Finnish, French, and German. The texts were at the level of a sixth grade reading material (reading ages 10-12 years) and were matched for length (830 (plus or minus 2) characters) and syntactic complexity, according to the syntactic prediction locality theory of Gibson. 100 normally sighted native speaking volunteers aged 18-35 years (25 per language) read each text aloud in randomised order. The newly designed text battery was then applied to test the reading performance of 100 normally sighted native speaking volunteers aged 60-85 years (25 per language). RESULTS: Reading speed was not significantly different with at least seven texts in all four languages. The maximum reading speed difference between texts, in the same language was 6.8% (Finnish). Average reading speeds (SD) in characters per minute are, for the young observer group: English 1234 (147), Finnish 1263 (142), French 1214 (152), German 1126 (105). The group of older readers showed statistically significant lower average reading speeds: English 951 (97), Finnish 1014 (179), French 1131 (160), German 934 (117). CONCLUSION: The authors have developed a set of standardised, homogeneous, and comparable texts in four European languages (English, Finnish, French, German). These texts will be a valuable tool for measuring reading speed in international studies in the field of reading and low vision research.

Does visual restitution training change absolute homonymous visual field defects? A fundus controlled study.

AIM: To examine whether visual restitution training (VRT) is able to change absolute homonymous field defect, assessed with fundus controlled microperimetry, in patients with hemianopia. METHODS: 17 patients with stable homonymous visual field defects before and after a 6 month VRT period were investigated with a specialised microperimetric method using a scanning laser ophthalmoscope (SLO). Fixation was controlled by SLO fundus monitoring. The size of the field defect was quantified by calculating the ratio of the number of absolute defects and the number of test points; the training effect E was defined as the difference between these two ratios before and after training. A shift of the entire vertical visual field border by 1 degrees would result in an E value of 0.14. RESULTS: The mean training effect of all right eyes was E = 0.025 (SD 0.052) and all left eyes E = 0.008 (SD 0.034). In one eye, a slight non-homonymous improvement along the horizontal meridian occurred. CONCLUSIONS: In one patient, a slight improvement along the horizontal meridian was found in one eye. In none of the patients was an explicit homonymous change of the absolute field defect border observed after training.

The vertical field border in hemianopia and its significance for fixation and reading.

PURPOSE: The existence of macular sparing, a central seeing area of several degrees within the hemianopic field defect, has been controversial for a long time, because inaccurate fixation during perimetry can produce ambiguous results. The visual field border in hemianopia was studied to examine whether a vertical strip of hemifield overlap described in monkeys exists in humans and whether additional macular sparing could be found. METHODS: Vertical triplets of dots were scanned on the retinas of eight patients (13 eyes) with hemianopia at different eccentricity from the vertical meridian during strict simultaneous fixation control using a scanning laser ophthalmoscope (SLO). Additionally, eye movements were measured by SLO and by an infrared reflection system while subjects read texts. RESULTS: Macular sparing of 2 degrees to 5 degrees and absence of sparing were observed. The presence and amount of sparing influenced fixation behavior, reading performance, and reliability of conventional perimetry. The smaller the macular sparing, the less stable the fixation. In the absence of sparing, either central unstable fixation with frequent saccades toward the hemianopic side or eccentric fixation occurred, resulting in a shift of the field defect toward the hemianopic side. A vertical strip of sometimes partial perception was found in 12 eyes at 0.5 degrees from the midline. CONCLUSIONS: Macular sparing and a slight vertical strip of hemifield overlap exists in humans. Adaptive strategies like eccentric fixation and predictive saccades improve reading performance and can augment rehabilitation.

Various stages of optic neuritis assessed by subjective brightness of flicker.

In the Aulhorn flicker test, the subjective brightness of a steady field is matched to that of a flickering field at 50 to 0 Hz. The test gives pathologic values only for active optic neuritis (ON) and gives normal results for normal eyes and eyes with subsided ON and other diagnoses, with a specificity of 98% and a sensitivity of 85.5%. Characteristic variations of the curves of subjective brightness during the course of ON allow a subtle assessment of five different disease stages, and there is a clear distinction between various disease patterns, ie, acute, chronic, recurrent, diminishing, and subsided ON. This distinction is impossible on the basis of visual evoked potentials. The test can be done easily and quickly without major technical equipment, even in an ophthalmologist's office.

The importance of sustained attention for patients with maculopathies.

Sustained attention enhances perception in eccentric positions in the visual field, which helps patients with foveal vision loss to develop a peripheral 'preferred retinal locus' (PRL). Besides central scotoma topography, local variations of attentional performance could influence the choice of PRL location. We tested sustained attention augmenting peripheral letter recognition in 23 maculopathy patients and 15 normally-sighted subjects (eight positions, 8 degrees eccentricity). Performance was shown to depend on tested location, which was the same in patients and normals. This indicates that the choice of the PRL location after foveal vision loss can be influenced by topographic features of sustained attention.

[The influence of visual rehabilitation on secondary depressive disorders due to age-related macular degeneration. A randomized controlled pilot study]. / Einfluss visueller Rehabilitation auf sekundäre depressive Störungen bei altersabhängiger Makuladegeneration. Eine randomisierte kontrollierte Pilotstudie.

BACKGROUND: Age-related macular degeneration (AMD) often leads to visual impairment, loss of reading ability, reduced quality of life and secondary depression. The present study examined if visual rehabilitation has a preventive effect on secondary depression in these patients. MATERIAL AND METHODS: In a controlled pilot study 20 patients were randomized into 2 groups whereby 9 underwent visual rehabilitation at first examination and 11 received magnifying visual aids only after 3 months. Psychosocial status was assessed by the geriatric depression scale (GDS) and the German version of the Centre for Epidemiologic Studies depression (CES-D) scale (main outcome parameter), cognitive status by the dementia detection test (DemTecT), minimental status (MMS) and quality of life by the National Eye Institute visual function questionnaire (NEI-VFQ 25). Ophthalmological examination included reading speed measurement by standardized texts (International Reading Speed Texts; IReST). RESULTS: Parameters of the CES-D scale, DemTect and the subitem exercise of social roles of the NEI-VFQ 25 emerged in a divergent manner. Patients of the rehabilitation group became less depressive and improved in cognitive and social abilities and in the control group vice versa. The interactive effect of group and time was statistically significant for all three tests. CONCLUSIONS: Visual rehabilitation has a positive impact on depression as well as cognitive status and quality of life in patients with AMD. The effects have to be confirmed in future studies with more patients and a longer observation period.

[Visual rehabilitation training for homonymous field defects]. / Visuelles Rehabilitationstraining bei homonymen Gesichtsfeldausfällen.

Homonymous field defects cause reading and orientation disorders. The reading disorder depends on the size of the macular sparing, the side of the field defect (unfavorable in reading direction) and spontaneous adaptive mechanisms. Methods which support compensation strategies should be recommended as evidence-based training procedures: optokinetic training with scrolled text for reading disorders and saccade training for orientation disorders. By optimized utilization of the total field of gaze, general exploration of the environment, reaction times during search tasks and quality of life can be improved.

Comparing explorative saccade and flicker training in hemianopia: a randomized controlled study.

OBJECTIVE: Patients with homonymous hemianopia are disabled on everyday exploratory activities. We examined whether explorative saccade training (EST), compared with flicker-stimulation training (FT), would selectively improve saccadic behavior on the patients' blind side and benefit performance on natural exploratory tasks. METHODS: Twenty-eight hemianopic patients were randomly assigned to distinct groups performing for 6 weeks either EST (a digit-search task) or FT (blind-hemifield stimulation by flickering letters). Outcome variables (response times [RTs] during natural search, number of fixations during natural scene exploration, fixation stability, visual fields, and quality-of-life scores) were collected before, directly after, and 6 weeks after training. RESULTS: EST yielded a reduced (post/pre, 47%) digit-search RT for the blind side. Natural search RT decreased (post/pre, 23%) on the blind side but not on the seeing side. After FT, both sides' RT remained unchanged. Only with EST did the number of fixations during natural scene exploration increase toward the blind and decrease on the seeing side (follow-up/pre difference, 238%). Even with the target located on the seeing side, after EST more fixations occurred toward the blind side. The EST group showed decreased (post/pre, 43%) fixation stability and increased (post/pre, 482%) asymmetry of fixations toward the blind side. Visual field size remained constant after both treatments. EST patients reported improvements in social domain. CONCLUSIONS: Explorative saccade training selectively improves saccadic behavior, natural search, and scene exploration on the blind side. Flicker-stimulation training does not improve saccadic behavior or visual fields. The findings show substantial benefits of compensatory exploration training, including subjective improvements in mastering daily-life activities, in a randomized controlled trial.

Effect of visual restitution training on absolute homonymous scotomas.

The authors examined 16 patients with stable homonymous visual field defects (HVFDs) with static automated perimetry (SAP). Training effect E was defined as difference of the proportions of absolutely defective locations in all test locations, before and after visual restitution training (VRT). E was 0.05 +/- 0.05 (mean +/- SD). The authors observed a relevant training effect (E >or= 0.12) in two subjects, but only monocularly. VRT has little effect on absolute HVFDs in SAP.

[Significance of the flicker test for follow-up and prognosis in optic nerve neuritis]. / Die Bedeutung des Flimmertests für die Verlaufskontrolle und Prognose bei der Neuritis nervi optici.

In 105 eyes with florid optic neuritis (ON) the sensation of brightness lessened when the frequency of flickering light was reduced to between 5 and 10 Hz, but remained stable or increased in 239 healthy eyes, 106 eyes after an ON had subsided, and 117 eyes with other diagnoses. This Aulhorn Flicker Test is highly accurate (98%) and specific. It gives pathologic results only for florid ON, and yields normal results again after the inflammation has subsided, even though other visual functions may remain reduced. The Flicker Test therefore makes it possible to distinguish between acute, recidivous, chronic and subsided ON, a distinction which is clinically often ambiguous and cannot be made on the basis of visually evoked potentials. The fact that the Flicker Test reveals pathologic conditions even in abortive cases or when an Uhthoff phenomenon is present is of great diagnostic value. Five representative cases from the group of patients with ON are described in some detail to show how the test can be used to judge the course of the disease, course, to predict its prognosis and to distinguish various patterns of development.

The Aulhorn flicker test: possibilities and limits. Its use in optic neuritis for diagnosis, differential diagnosis, monitoring the course of the disease, and assessing the effect of oral prednisolone.

The Aulhorn flicker test, which measures subjective brightness in relation to flicker frequency, is of high specificity (98%) and sensitivity (85.5%) in active optic neuritis (ON). The test has proved to be valuable in the diagnosis and differential diagnosis of ON and in monitoring the course of the disease. The first part of this paper gives an overview based on more than 10 years of experience and on the evaluation of more than 1000 eyes, 250 of them with active ON. The possibilities and limits of the test are analyzed. The second part of the paper presents new results of a prospective, randomized, and controlled treatment study. The Aulhorn flicker test was used to determine whether a prednisolone effect would be assessable by means of this subtle parameter. A total of 50 patients were treated orally with either methylprednisolone (100 mg/day initially) or vitamin B1 (100 mg/day), 38 of them in a double-blind fashion. Although a trend toward faster recovery in favor of prednisolone treatment was noted, no long-term benefit was observed after 1 year.

[Examination strategies in simulation and functional vision disorders]. / Untersuchungsstrategien bei Simulation und funktionellen Sehstörungen.

The diagnosis of malingering and functional visual loss should be proven by specific tests-after the exclusion of differential diagnoses such as optical disturbances, amblyopia, early stages of macula and optic nerve disease and cortical lesions. Malingering and functional visual loss are based on different causes and pathogenetic mechanisms. However, they produce the same symptoms and can therefore be examined by the same methods. The strategy consists of three parts: 1) check the reproducibility of the results, 2) specific procedures: provocation of reflectory responses, deception, measurement of the same function with different methods and objective methods and 3) proof. In alleged bilateral blindness the provocation of reflexes and deceptive strategies are especially useful, in alleged bilateral reduction of visual acuity deceptive methods (related to the size of the optotype), the examination of central vision by other methods (equivalents to visual acuity) and objective methods are applied. In alleged monolateral blindness or reduction of visual acuity the binocular tests are valuable. Additionally, methods to provoke reflexes, especially pupil reaction, are used as well as the measure of equivalents to visual acuity. In alleged concentric constriction of the visual fields three strategies are mainly used: 1) check if visual field size is in accordance with the visual angle, 2) different methods to examine the isopters and 3) different perimetric methods. In case of an alleged hemianopic field defect the following methods are of special value: 1) binocular examination, 2) reading ability, 3) different perimetric methods and 4) half-field stimulation. After finishing the specific tests the diagnosis of malingering or functional visual loss should be unambiguous and the existing function should be determined. Strategies for further management are shown--dependent on the pathogenesis: the aim is to avoid repetition and to set the right course for the future. In case of malingering the reliable expert's report is helpful. In case of functional visual loss it is important to avoid unnecessary examinations and to offer specific aids.