Worldwide Argus II implantation: recommendations to optimize patient outcomes.

BACKGROUND: A position paper based on the collective experiences of Argus II Retinal Prosthesis System investigators to review strategies to optimize outcomes in patients with retinitis pigmentosa undergoing retinal prosthesis implantation. METHODS: Retinal surgeons, device programmers, and rehabilitation specialists from Europe, Canada, Middle East, and the United States were convened to the first international Argus II Investigator Meeting held in Ann Arbor, MI in March 2015. The recommendations from the collective experiences were collected. Factors associated with successful outcomes were determined. RESULTS: Factors leading to successful outcomes begin with appropriate patient selection, expectation counseling, and preoperative retinal assessment. Challenges to surgical implantation include presence of staphyloma and inadequate Tenon's capsule or conjunctiva. Modified surgical technique may reduce risks of complications such as hypotony and conjunctival erosion. Rehabilitation efforts and correlation with validated outcome measures following implantation are critical. CONCLUSIONS: Bringing together Argus II investigators allowed the identification of strategies to optimize patient outcomes. Establishing an on-line collaborative network will foster coordinated research efforts to advance outcome assessment and rehabilitation strategies.

Innovative vision rehabilitation method for hemianopsia: Comparing pre- and post audio-luminous biofeedback training for ocular motility improving visual functions and quality of life.

Background: Homonymous hemianopsia (HH) corresponds to vision loss in one hemi-field secondary to retro-chiasmal injury. Patients with HH experience difficulties in scanning and orientation in their environment. Near vision daily activities such as reading can also be impaired. There is an unmet need for standardized vision rehabilitation protocols for HH. We investigated the effectiveness of biofeedback training (BT), used for vision rehabilitation in patients with central vision loss, in individuals with HH. Methods: In this prospective pilot pre/post study, 12 participants, with HH consecutive to brain injury, performed 5 weekly BT sessions for 20 min each under supervision using the Macular Integrity Assessment microperimeter. BT consisted of relocation of the retinal locus 1-4° toward the blind hemi-field. Outcomes measured post-BT were paracentral retinal sensitivity, visual acuity (near vision), fixation stability, contrast sensitivity, reading speed, and visual functioning questionnaire. Statistical analysis was performed using Bayesian paired t-tests. Results: Paracentral retinal sensitivity significantly increased by 2.7 ± 0.9 dB in the treated eye in 9/11 of the participants. Significant improvements with medium-to-large effect size were observed for fixation stability (8/12 participants), contrast sensitivity (6/12 participants) and near vision visual acuity (10/12 participants). Reading speed increased by 32.5 ± 32.4 words per minute in 10/11 participants. Quality of vision scores improved significantly with large effect size for visual ability, visual information and mobility. Conclusion: BT led to encouraging improvements in visual functions and functional vision in individuals with HH. Further confirmation with larger trials is required.

Visual outcomes of audio-luminous biofeedback training for a child with idiopathic nystagmus.

Microperimetry biofeedback training is a vision rehabilitation method that involves the training of attention and oculomotor control, and the rehabilitation of poorly located and non-functional preferred retinal loci. It can significantly improve distance and near visual acuity in age-related macular degeneration. Previous studies have shown that biofeedback training using electrical nystagmography can reduce nystagmus amplitude and increase foveation time. However, these improvements have not been sustained following training sessions. We hereby report a pediatric case of idiopathic nystagmus in an 11-year old patient treated with microperimetric biofeedback to improve visual acuity and fixation stability. The training had a beneficial impact, positively affecting fixation stability as well as distance and near reading vision. Subjectively, improvement in quality of life was also reported. Conversely to previous studies, the positive effects in this case were maintained for as long as twelve months following therapy. To the best of our knowledge, this is the first case with long-term benefits to be reported in the literature.

Post audio-visual biofeedback training visual functions and quality of life in paediatric idiopathic infantile nystagmus: A pilot study.

PURPOSE: Biofeedback training (BT) was adapted to idiopathic infantile nystagmus syndrome (IINS) cases to enhance visual functions and quality of life (QoL). METHODS: 10 patients (age 9 ± 3.2 years) treated with the audio-visual BT module of the MAIA microperimeter (Centervue, Padova, Italy) were assessed in two baseline visits and 1week post-BT (BT 80 min in total). The outcomes were distance and near binocular best corrected visual acuity (BBCVA), fixation stability, reading speed, contrast sensitivity, stereopsis and Children's Visual Function Questionnaire. One-way repeated measured ANOVA and paired t-tests were used. RESULTS: Distance BBCVA improved from 0.46 ± 0.21 and 0.43 ± 0.18 pre-BT to 0.33 ± 0.2 logMAR post-BT (F (2,27) = 13.75, p = 0.0002). Post-BT was better than baseline (p = 0.0001) and pre-BT (p = 0.001). Near BBCVA improved from 0.23 ± 0.09 and 0.21 ± 0.14 pre-BT to 0.04 ± 0.08 post-BT (F (2,27) = 22.12, p = 0.000014), post-BT was better than baseline (p = 0.0001) and pre-BT (p = 0.0006). Stereopsis improved from 283 ± 338″ to 39 ± 32.2″ (p = 0.04), contrast sensitivity from 0.26 ± 0.17 to 0.08 ± 0.12 log units (p = 0.01), and reading speed improved from 74.7 ± 51.2 wpm to 104.7 ± 53.6 wpm (p = 0.0006). Fixation stability improved from 33.6 ± 28.1 to 14.3 ± 10.1 sq. QoL increased from 23.8 ± 2.2 to 26.3 ± 2.3 units (p = 0.001). CONCLUSION: BT benefited all visual functions and QoL in this pilot study, heralding a new possibility for Low Vision Rehabilitation in IINS.

Frequency and source of prescription eyewear insurance coverage in Ontario: a repeated population-based cross-sectional study using survey data.

BACKGROUND: Insurance coverage may reduce cost barriers to obtain vision correction. Our aim was to determine the frequency and source of prescription eyewear insurance to understand how Canadians finance optical correction. METHODS: We conducted a repeated population-based cross-sectional study using 2003, 2005 and 2013-2014 Canadian Community Health Survey data from respondents aged 12 years or older from Ontario, Canada. In this group, the cost of prescription eyewear is not covered by the government unless one is registered with a social assistance program or belongs to a specific population. We determined the frequency and source of insurance coverage for prescription eyewear in proportions. We used survey weights provided by Statistics Canada in all analyses to account for sample selection, a complex survey, and adjustments for seasonal effect, poststratification, nonresponse and calibration. We compared unadjusted proportions and adjusted prevalence ratios (PRs) of having insurance. RESULTS: Insurance covered all or part of the costs of prescription eyewear for 62% of Ontarians in all 3 survey years. Of those insured, 84.1%-86.0% had employer-sponsored coverage, 9.0%-10.3% had government-sponsored coverage, and 5.7%-6.8% had private plans. Employer-sponsored coverage remained constant for those in households with postsecondary graduation but decreased significantly for those in households with less than secondary school graduation, from 67.0% (95% confidence interval [CI] 63.2%-70.8%) (n = 175 000) in 2005 to 54.6% (95% CI 50.1%-59.2%) (n = 123 500) in 2013-2014. Government-sponsored coverage increased significantly for those in households with less than secondary school graduation, from 29.2% (95% CI 25.5%-32.9%) (n = 76 400) in 2005 to 41.7% (95% CI 37.2%-46.1%) (n = 93 900) in 2013-2014. In 2013-2014, Ontarians in households with less than secondary school graduation were less likely than those with secondary school graduation to report employer-sponsored coverage (adjusted PR 0.79, 95% CI 0.75-0.84) but were more likely to have government-sponsored coverage (adjusted PR 1.27, 95% CI 1.06-1.53). INTERPRETATION: Sixty-two percent of Ontarians had prescription eyewear insurance in 2003, 2005 and 2013-2014; the largest source of insurance was employers, primarily covering those with higher education levels, whereas government-sponsored insurance increased significantly among those with lower education levels. Further research is needed to elucidate barriers to obtaining prescription eyewear and the degree to which affordability impairs access to vision correction.

Rehabilitation with biofeedback training in age-related macular degeneration for improving distance vision.

OBJECTIVES: Biofeedback training (BT) is a modern method for enhancing the use of preferred retinal loci (PRL) retraining for new retinal loci (TRL), hence improving far and near vision. This article attempts to clarify the optimal methodology for BT and the types of patients who can benefit most from BT. METHODS: This is a retrospective review of cases who received BT with the macular integrity assessment (MAIA) microperimetre. Outcome measures selected for analysis were visual acuity, PRL location, fixation stability, fixation pattern orientation, reading acuity, critical print size, and reading speed. RESULTS: Out of 30 cases who received BT, only those with age-related macular degeneration and visual acuity of logMAR 0.8 (20/126) or poorer showed a visual acuity gain (statistically significant of 12 letters) after BT. Those with other diagnoses and those with residual Early Treatment Diabetic Retinopathy Study best-corrected visual acuity of logMAR of 0.7 (20/100) or better showed only positive trends for visual acuity and a negative trend for fixation stability. All subjects showed a shift in PRL location toward the superior quadrant of the retina (p < 0.02) in those who received BT. CONCLUSION: BT seems to offer patients a unique and efficient modality to improve distance vision outside of using optical devices.

Rehabilitation of reading skills in patients with age-related macular degeneration.

Reading is the most frequent clinical complaint and the primary goal for patients with macular degeneration seeking vision rehabilitation. The current prevalent methods for reading skills training across the globe are still magnification and basic scotoma awareness training. More recent studies showed that specific eccentric training, comprehension ability training, and specific oculomotor training are all beneficial to reading skills rehabilitation. In clinical practice, ophthalmologists should strive to implement reading skills methods that include assessment of cognitive skills, optimal eyewear, optimal reading material, PRL assessment, training of better oculomotor control, and efficient perceptual training.

Rehabilitation of lost functional vision with the Argus II retinal prosthesis.

The Argus II retinal prosthesis is the first commercially available device for restoration of vision in patients with Retinitis Pigmentosa or with similar retinal pathology who still have minimal residual native vision. The technology is able to restore vision with production of artificial visual percepts which usually are given adequate useful interpretation by the visual system in most implanted patients. The technology usually produces visual perception at the level of shape identification or better in some cases enabling in many less dependence on vision substitution devices and skills. There is no consensus among vision rehabilitation practitioners on single methods for assessments, outcome measures and training, yet there is constant progress in these areas of concern. Hence the current vision rehabilitation practice related to the implantation of the Argus II retinal prosthesis is a work in progress with many learning opportunities for all involved. All agree that implementation of this technology in clinical practice requires the combined work of a multi-disciplinary team which includes a specialized surgical team as well as a specialized rehabilitation team in order to obtain optimal results. Our own experience is presented in this paper and indicates so far that the Argus II technology is beneficial to patients and that it could be successfully managed within the Canadian heath care system.

The Toronto experience with the Argus II retinal prosthesis: new technology, new hope for patients.

Surgical restoration of vision with retinal prostheses is a new and developing technology currently available in a select group of countries, Canada among them. The Argus II retinal prosthesis is the first commercially available device for restoration of vision in patients with Retinitis Pigmentosa or with similar retinal pathology who still have minimal residual native vision. The surgery is complex and requires training however it is within the abilities of any experienced retina surgeon. Surgical experience builds up with each case and in our patients length of surgery constantly went down. Complications occurred however we experienced no catastrophic events. Most notable is that in our implanted cases the Argus II technology proved to be beneficial to most patients. In order to obtain optimal results with this surgical intervention it is absolutely required that the surgical work is complemented simultaneously with the work of a specialized rehabilitation team. A review of the technology, of our experience, comments and concerns is presented in this paper.

Occupational therapy interventions in low vision rehabilitation.

Low vision can significantly decrease a person's functional ability and independence. With the continuing rise in age of our population, the number of people with low vision will increase substantially. Restoring and maintaining their ability to function independently through the use of specific interventions is an intricate process that calls for the collaboration of various health care professionals. Occupational therapists (OTs) and occupational therapy assistants are essential members of the multidisciplinary rehabilitation team providing such interventions. OTs in low vision rehabilitation enhance performance for specific activities of daily living by training skills that are dependent on residual vision, such as reading and writing. OTs also conduct environmental assessments in the home and in the workplace or school to improve and promote a safe environment for patients with low vision. OTs may also assist in developing rehabilitation programs for orientation and mobility, driving, and vision rehabilitation therapy. To prepare for the future needs of the ageing Canadian population, more low vision rehabilitation practitioners and more funding for multidisciplinary rehabilitation programs are required.

Identification of preferred retinal loci with the Heidelberg Retina Tomograph II in patients with age-related macular degeneration.

BACKGROUND: To determine the suitability and accuracy of the Heidelberg Retina Tomograph II (HRT II) scanning laser ophthalmoscope for identification of preferred retinal loci (PRLs) in patients with age-related macular degeneration (AMD). METHODS: Fixation location was assessed prospectively in 9 eyes by 3 methods: the HRT II, a retinal camera equipped with a fixation target, and grid macular perimetry. Two testing protocols were also used: using an HRT protocol for disc location analysis and an HRT protocol for macular fixation analysis. RESULTS: Locations of PRLs on retinal quadrants identified by all 3 methods were identical in 7 of 9 (78%) cases (McNemar chi(2) test, p = 0.48, kappa = 0.78, at 95% confidence interval) with both testing protocols. Eccentric location coordinates for PRLs were not significantly different by testing modality when using either the disc location protocol (R = 0.47, p = 0.20 [t7 = 1.4], y = 0.29x + 3.29) or the macular fixation protocol (R = 0.44, p = 0.23 [t7 = 1.3], y = 0.31x + 3.23). INTERPRETATION: Eccentric locations of the optic disc on recorded video frames with the HRT II correspond to eccentric locations of PRLs in patients with AMD.

Visual outcomes of audio-luminous biofeedback training for a child with idiopathic nystagmus / Desfechos visuais de treinamento de biofeedback audioluminoso em criança com nistagmo idiopático

ABSTRACT Microperimetry biofeedback training is a vision rehabilitation method that involves the training of attention and oculomotor control, and the rehabilitation of poorly located and non-functional preferred retinal loci. It can significantly improve distance and near visual acuity in age-related macular degeneration. Previous studies have shown that biofeedback training using electrical nystagmography can reduce nystagmus amplitude and increase foveation time. However, these improvements have not been sustained following training sessions. We hereby report a pediatric case of idiopathic nystagmus in an 11-year old patient treated with microperimetric biofeedback to improve visual acuity and fixation stability. The training had a beneficial impact, positively affecting fixation stability as well as distance and near reading vision. Subjectively, improvement in quality of life was also reported. Conversely to previous studies, the positive effects in this case were maintained for as long as twelve months following therapy. To the best of our knowledge, this is the first case with long-term benefits to be reported in the literature.(AU)

RESUMO O treinamento de biofeedback por microperimetria é um método de reabilitação da visão que envolve treinamento de atenção, controle oculomotor e reabilitação do locus preferencial de fixação da retina. Esse treinamento pode melhorar significativamente a acuidade visual para longe e perto na degeneração macular relacionada à idade. Estudos anteriores mostraram que o treinamento de biofeedback usando a nistagmografia elétrica pode reduzir a amplitude do nistagmo e aumentar o período de foveação. Entretanto, os resultados não se mantiveram após o término das sessões. Aqui é relatado um caso de tratamento com biofeedback por microperimetria para melhorar a acuidade visual e a estabilidade de fixação em uma criança de 11 anos de idade. O treinamento teve impacto benéfico e afetou positivamente a estabilidade da fixação e a visão para longe, para perto e de leitura. Subjetivamente, foi relatada melhoria da qualidade de vida. Em contraste com estudos anteriores, os efeitos positivos foram mantidos até 12 meses após a terapia. Até onde sabemos, este é o primeiro caso na literatura que relata benefícios de longo prazo.(AU)

The multi-disciplinary nature of low vision rehabilitation--a case report.

This paper presents the case of a 47-year-old female with low vision secondary to high myopic macular degeneration who remains active in the work force as a spiritual and religious care coordinator for a large institution. An ophthalmologist with a specialty in low vision rehabilitation initially assessed the client. The ophthalmologist prescribed optical devices which used residual retinal vision available at preferred retinal loci. This availed better vision for viewing targets located at far, near and intermediate distances from the client. An optician provided and dispensed the devices prescribed to the client. Additionally, the ophthalmologist made a referral to an occupational therapist. The occupational therapist conducted a series of sessions to further enhance reading and writing skills and a work place assessment aimed at optimizing workplace conditions in order to achieve optimal functional vision. This case illustrates and emphasizes the multi-disciplinary nature of low vision rehabilitation, which involved in this case co-operation between ophthalmology, occupational therapy and opticianry.

Community integration status 4 years after traumatic brain injury: participant-proxy agreement.

OBJECTIVES: To measure the level of agreement on community integration outcomes 4 years after traumatic brain injury (TBI) in relation to injury severity, proxy-participant relationship, and type of question. PARTICIPANTS: Thirty-one survivors of TBI (14 with mild TBI and 17 with moderate-severe TBI) and 31 significant other proxies. MEASURES: General and leisure activity scales of the Katz Adjustment Scale (KAS). RESULTS: Agreement was highest between proxies and participants with mild versus moderate-severe TBIs, between spouse proxies and TBI participants compared to nonspouse proxies and on the more objective subscales (frequency of participation) compared to the expectation and satisfaction scales regardless of injury severity or proxy-participant relationship. CONCLUSIONS: For research purposes, proxy data are acceptable but clinicians should assess outcomes and set goals with input from both persons with TBIs and their proxies.