Hyperbaric Oxygen Therapy Combined with Immunosuppression for Acute Macular Neuroretinopathy in Systemic Lupus Erythematosus.

PURPOSE: To describe the use of hyperbaric oxygen therapy (HBOT) in conjunction with immunosuppression for acute macular neuroretinopathy (AMN) in systemic lupus erythematosus (SLE). METHODS: Two known cases of SLE presented to us with blurred vision and paracentral scotomas due to AMN. Both cases reported worsening of their conditions despite the initiation of high-dose steroid therapy. HBOT was added on as a treatment modality to address vaso-occlusive ischemic injury. RESULTS: Both patients underwent a total of twelve cycles of HBOT. Functional and anatomical improvements were noted immediately after the initiation of therapy and were maintained over more than one year of follow-up. No significant retinal thinning was noted on optical coherence tomography on disease resolution, as has been noted previously. Visual field scotoma showed a complete resolution. CONCLUSION: Our cases suggest that HBOT may have a role in aiding functional and anatomical recovery in AMN associated with SLE.

Training to improve temporal processing of letters benefits reading speed for people with central vision loss.

Reading is slow and difficult for many people with central vision loss. A previous study showed that the temporal threshold for letter recognition is a major factor limiting reading speed for people with central vision loss. Here, we asked whether the temporal threshold for letter recognition for people with central vision loss could be improved through training and, if so, whether that would benefit reading. Training consisted of six sessions (3000 trials) of recognizing letter trigrams presented at fixation. Trigrams were initially presented at a baseline temporal threshold that was decreased by 0.1 log step when observers' letter recognition accuracies reached 80% or higher for four consecutive blocks. Before and after training, we measured observers' visual acuity, preferred retinal locus for fixation, fixation stability, reading speeds using the rapid serial visual presentation (RSVP) paradigm, the MNREAD Acuity Chart and 100-word passages, the baseline temporal threshold for letter recognition at 80% accuracy, and a visual-span profile. After training, the temporal threshold was decreased by 68%. This improvement was accompanied by a higher RSVP maximum reading speed (but no change in MNREAD and passage reading speeds) and a larger visual span. A mediation analysis showed that the relationship between the temporal threshold and RSVP maximum reading speed was mainly mediated by the information transfer rate (size of visual span/temporal duration). Our results showed that the temporal threshold for letter recognition is amenable to training and can improve RSVP reading speeds, offering a practical means to improve reading speed for people with central vision loss.

Effectiveness of Low Vision Rehabilitation Using Microperimetric Acoustic Biofeedback Training in Patients with Central Scotoma.

PURPOSE: To evaluate the efficacy of visual rehabilitation with microperimeter biofeedback in patients with central scotoma. MATERIALS AND METHODS: 35 consecutive patients with central scotoma (17 age-related macular degeneration (AMD), 14 Stargardt disease, and 4 cone dystrophy) were included in the study. Visual acuity, reading performance by Minnesota Low Vision Reading Test (MNREAD), quality of life by 25-item National Eye Institute Visual Function Questionnaire (NEI VFQ-25), and fixation analysis by MAIA microperimeter were evaluated before and 1 month after training. The rehabilitation program consisted of 10 training sessions of 10 minutes. RESULTS: The median best-corrected visual acuity (BCVA) was 0.80 logMAR (range 0.3 to 1.3 logMAR). Fifty-nine percent of patients with AMD developed a preferred retinal locus (PRL) nasal to the fovea, and 64% of the patients with Stargardt disease preferred a PRL superior to the fovea. The PRL location in 3 of 4 cone dystrophy patients was nasal to the fovea. The mean PRL distance from the fovea was 7.57 ± 3.61 degrees. Fixation stability improved with P1 values of 22.34 ± 11.81 versus 32.05 ± 18.79 (p = .003) and 95% bivariate contour ellipse area (BCEA) values of 41.6 versus 23.6 (p = .018) before and after training, respectively. There was a significant difference in reading acuity between before and after training (p = 0.008). The overall score and near activities score of NEI VFQ-25 were found to be increased at the end of the rehabilitation (p < 0.001). CONCLUSION: Rehabilitation with acoustic biofeedback in patients with central scotoma looks like a useful technique for improving fixation stability, reading performance and quality of life.

Biofeedback fixation training method for improving eccentric vision in patients with loss of foveal function secondary to different maculopathies.

PURPOSE: Fixation stability (FS) of the preferred retinal locus (PRL) may be improved by biofeedback fixation training (BFT) with microperimetry. Such training can be done on the patient's PRL or in different retinal loci with better functional characteristics. We studied both options and compared the outcomes. METHODS: Sixty-seven consecutive patients with bilateral central vision loss, poor FS and visual acuity (VA) lower than 0.3 LogMAR were recruited for BFT with microperimeter. Patients were assigned into 2 groups. In group A, BFT was performed on the patient's spontaneous PRL. In group B, PRL was located between 2 adjacent loci with the highest light sensitivity and the lowest distance from the fovea. Two sets of 12 weekly BFT sessions were performed. Primary outcomes were: FS, VA and reading speed. RESULTS: Outcomes were statistically significantly better in group B. Mean percentage of FS at therapy end improved from 32 to 35% for group A and from 40 to 55% in group B. Mean VA improved from 1 to 0.86 in group A and from 1 to 0.84 in group B. Reading speed (wpm) improved from 56 to 58 in group A and from 63 to 89 in group B. CONCLUSIONS: This study describes a reliable methodology of improving eccentric fixation stability using BFT in microperimetry, when the fixation training locus is individualized as the retinal area with best functional characteristics. Further studies are needed to validate its value in a larger scale of patients, at different stages of the disease, and its persistence over time.

The effect of prism on preferred retinal locus.

BACKGROUND: Whether prism, especially base-up prism, affects the area of the retina used for fixation in a patient with central scotoma has been a controversial subject for 35 years. Our pilot study employed microperimetry to evaluate the effect of base-up prism on the fixation locus, or preferred retinal locus (PRL), in subjects with central scotoma. METHODS: We used a microperimeter to assess the PRL in 13 visually impaired subjects with central scotoma under four conditions: no lens, a lens with no prism (control lens), 6Δ base-up, and 10Δ base-up. The PRL was measured in degrees in horizontal and vertical co-ordinates from the centre of the optic disc using graphical analysis. RESULTS: The PRL with the control lens was not significantly different from the PRL with no lens. The preferred retinal loci with the two powers of prism were compared to the control lens and showed a superior shift in 22 of 26 cases (84.6 per cent). The amount of movement was significantly different from zero (p = 0.001 for 6Δ and p = 0.004 for 10Δ ). The vertical movement with the 10Δ prism (1.73 ± 1.73 degrees) was not significantly greater (p = 0.562) than with the 6Δ prism (1.37 ± 1.08 degrees). The shift was significantly less than the prism powers used (p < 0.001), and the amount of vertical relocation was not significantly different from the amount of horizontal movement. CONCLUSION: In our study, base-up prism appears to shift the PRL in the direction of the prism base most of the time, but our findings do not support the use of prism as a way of predictably relocating the PRL. More study is indicated to evaluate whether such a small shift is clinically or functionally significant.

Lack of Visual Field Improvement After Initiation of Intraocular Pressure Reducing Treatment in the Early Manifest Glaucoma Trial.

PURPOSE: We evaluate how visual fields are affected by the initiation of IOP-reducing therapy in previously untreated glaucoma individuals. METHODS: Qualifying individuals with newly diagnosed glaucoma having normal to moderately elevated IOP were prospectively randomized either to IOP-reducing therapy or to no treatment. Before randomization, individuals underwent repeatedly Standard Automated Perimetry (SAP) testing and Goldmann tonometry. Three months after randomization, patients again underwent SAP and tonometry. Changes between baseline and the 3-month follow-up visit in the perimetric summary index, mean deviation (MD), and total deviation values at significantly depressed test points were compared between the treated and untreated groups. RESULTS: Of 255 individuals studied, 129 were randomized to treatment and 126 to no treatment. Intraocular pressure decreased by an average of 24% among treated and by 0.6% in the untreated patients. Mean deviation deteriorated slightly in both groups; mean change was -0.15 and -0.44 dB in the treated and untreated groups, respectively; the difference was not statistically significant, (P = 0.16). No association was seen between IOP reduction and change in MD. Sensitivities decreased slightly in significantly depressed test points, mean change was -0.45 dB in the untreated and -0.38 dB in the treated groups (P = 0.88). CONCLUSIONS: Observed visual field changes among glaucoma patients receiving initial IOP-reducing therapy were not significantly different to changes seen in patients who received no treatment. Thus, our results did not support the idea that visual field status improves after initiation of IOP- reducing therapy in glaucoma individuals, at least not in individuals with initially normal to moderately elevated IOPs.

[Combination surgery for wet age-related macular degeneration and chronic peripheral uveitis].

AIM: To develop a combination surgery for wet age-related macular degeneration and concurrent chronic peripheral uveitis that would include intravitreal injection of Lucentis and cryocerclage of the peripheral retina. MATERIAL AND METHODS: A total of 75 patients were examined and divided into 2 groups: the main group (37 patients) and the controls (38 patients). Patients from the main group underwent the new combination surgery, while the controls received intravitreal Lucentis alone (peripheral uveitis was managed therapeutically). RESULTS: It has been found that the new combination method provides a significant and stable improvement in visual acuity (by a factor of 10) and a decrease in the area of central scotoma (by a factor of 2.95) in the postoperative period. The period needed for recovery in the central retinal thickness is also 1.6 times shorter. CONCLUSION: The new combination surgery for wet age-related macular degeneration and concurrent chronic peripheral uveitis provides rapid reduction of inflammation in the extreme periphery of the fundus and a 1.5 times faster (as compared to traditional methods) primary restoration of topographic anatomy of the retina in the macular region.

Expansion of Severely Constricted Visual Field Using Google Glass.

Google Glass (Google, Mountain View, CA) is a wearable technology with a computer and camera mounted on an eyeglass frame. The camera captures wide-angle video and projects it onto a prism located in the right superior temporal quadrant of the wearer's visual field. The authors present a case of an individual who used Google Glass' video projection feature to expand his severely constricted right visual field. This patient reported improved ambulatory navigation. Using Google Glass, the patient's peripheral vision, measured using Goldmann kinetic perimetry, expanded impressively. Based on these preliminary results, the authors propose further characterization on the potential utility of such head-mount display technology as a tool to improve the lives of patients with severely constricted visual fields. [Ophthalmic Surg Lasers Imaging Retina. 2016;47:486-489.].

The value of Tablets as reading aids for individuals with central visual field loss: an evaluation of eccentric reading with static and scrolling text.

PURPOSE: Technological devices such as smartphones and tablets are widely available and increasingly used as visual aids. This study evaluated the use of a novel app for tablets (MD_evReader) developed as a reading aid for individuals with a central field loss resulting from macular degeneration. The MD_evReader app scrolls text as single lines (similar to a news ticker) and is intended to enhance reading performance using the eccentric viewing technique by both reducing the demands on the eye movement system and minimising the deleterious effects of perceptual crowding. Reading performance with scrolling text was compared with reading static sentences, also presented on a tablet computer. METHODS: Twenty-six people with low vision (diagnosis of macular degeneration) read static or dynamic text (scrolled from right to left), presented as a single line at high contrast on a tablet device. Reading error rates and comprehension were recorded for both text formats, and the participant's subjective experience of reading with the app was assessed using a simple questionnaire. RESULTS: The average reading speed for static and dynamic text was not significantly different and equal to or greater than 85 words per minute. The comprehension scores for both text formats were also similar, equal to approximately 95% correct. However, reading error rates were significantly (p = 0.02) less for dynamic text than for static text. The participants' questionnaire ratings of their reading experience with the MD_evReader were highly positive and indicated a preference for reading with this app compared with their usual method. CONCLUSIONS: Our data show that reading performance with scrolling text is at least equal to that achieved with static text and in some respects (reading error rate) is better than static text. Bespoke apps informed by an understanding of the underlying sensorimotor processes involved in a cognitive task such as reading have excellent potential as aids for people with visual impairments.

Changes in outer retinal microstructures during six month period in eyes with acute zonal occult outer retinopathy-complex.

PURPOSE: To study the changes in the outer retinal microstructures during a six month period after the onset of acute zonal occult outer retinopathy (AZOOR)-complex by spectral-domain optical coherence tomography (SD-OCT). METHODS: Seventeen eyes of 17 patients with the AZOOR-complex were studied. The integrity of the external limiting membrane (ELM), ellipsoid zone (EZ; also called the inner/outer segment junction), and interdigitation zone (IDZ; also called the cone outer segment tips) were evaluated in the SD-OCT images obtained at the initial visit and at six months. The three highly reflective bands were divided into three types; continuous, discontinuous, and absent. The integrity of the outer nuclear layer (ONL) was also assessed. RESULTS: Among the three highly reflective bands, the IDZ was most altered at the initial visit and least recovered at six months. Fifteen of 17 eyes (88%) had a recovery of at least one of the three bands at six months in the retinal area where the ONL was intact, and these areas showed an improvement of visual field. Three eyes (18%) had retinal areas where the ONL was absent at the initial visit, and there was no recovery in both the retinal structures and visual fields in these areas. CONCLUSIONS: Our results indicate that more than 85% eyes with AZOOR-complex show some recovery in the microstructures of the outer retina during a six month period if the ONL is intact. We conclude that SD-OCT is a useful method to monitor the changes of the outer retinal microstructure in eyes with the AZOOR-complex.

Efficacy of vision restoration therapy after optic neuritis (VISION study): study protocol for a randomized controlled trial.

BACKGROUND: Optic neuritis is a frequent manifestation of multiple sclerosis. Visual deficits range from a minor impairment of visual functions through to complete loss of vision. Although many patients recover almost completely, roughly 35% of patients remain visually impaired for years, and therapeutic options for those patients hardly exist. Vision restoration therapy is a software-based visual training program that has been shown to improve visual deficits after pre- and postchiasmatic injury. The aim of this pilot study is to evaluate whether residual visual deficits after past or recent optic neuritis can be reduced by means of vision restoration therapy. METHODS/DESIGN: A randomized, controlled, patient- and observer-blinded clinical pilot study (VISION study) was designed to evaluate the efficacy of vision restoration therapy in optic neuritis patients. Eighty patients with a residual visual deficit after optic neuritis (visual acuity ≤0.7 and/or scotoma) will be stratified according to the time of optic neuritis onset (manifestation more than 12 months ago (40 patients, fixed deficit) versus manifestation 2 to 6 months ago (40 patients, recent optic neuritis)), and randomized into vision restoration therapy arm or saccadic training arm (control intervention). Patients will be instructed to complete a computer-based visual training for approximately 30 minutes each day for a period of 6 months. Patients and evaluators remain blinded to the treatment allocation throughout the study. All endpoints will be analyzed and P-values < 0.05 will be considered statistically significant. The primary outcome parameter will be the expansion of the visual field after 3 and 6 months of treatment as determined by static visual field perimetry and high resolution perimetry. Secondary outcome variables will include visual acuity at both low and high contrast, glare contrast sensitivity, visually evoked potentials, optical coherence tomography and other functional tests of the visual system, alertness, health-related quality of life, fatigue, and depression. DISCUSSION: If vision restoration therapy is shown to improve visual function after optic neuritis, this method might be a first therapeutic option for patients with incomplete recovery from optic neuritis. TRIAL REGISTRATION: NCT01274702.

A congruous superior quadrantanopsia following a junctional scotoma induced by asperogillosis.

A 69-year old man presented to us with decreased vision in his right eye and a relative afferent pupillary defect. Under the presumption that he was suffering from retrobulbar optic neuritis or ischemic optic neuropathy, visual field tests were performed, revealing the presence of a junctional scotoma. Imaging studies revealed tumorous lesions extending from the sphenoid sinus at the right superior orbital fissure, with erosion of the right medial orbital wall and optic canal. Right optic nerve decompression was performed via an endoscopic sphenoidectomy, and histopathologic examination confirmed the presence of aspergillosis. The patient did not receive any postoperative antifungal treatment; however, his vision improved to 20 / 40, and his visual field developed a left congruous superior quadrantanopsia 18 months postoperatively. A junctional scotoma can be caused by aspergillosis, demonstrating the importance of examining the asymptomatic eye when a patient is experiencing a loss of vision in one eye. Furthermore, damage to the distal optic nerve adjacent to the proximal optic chiasm can induce unusual congruous superior quadrantanopsia.

Object detection in the ring scotoma of a monocular bioptic telescope.

OBJECTIVE: To evaluate the ability of the fellow eye to detect stimuli in the area corresponding to the ring scotoma (blind area) of a monocular bioptic telescope in simple conditions (conventional perimetry) and in more visually demanding conditions. METHODS: A computerized dichoptic perimeter enabled separate stimuli to be presented to each eye of 7 bioptic users and 7 nonusers. The bioptic ring scotoma was mapped by presenting the stimulus to the telescope eye only. Detection tests were then conducted under binocular viewing, with stimuli presented only to the fellow eye in a 2 × 2 × 2 design with or without telescope, on plain gray or patterned (spatial noise) background, and with passive (looking at cross) or active (reading letters) fixation task. RESULTS: No significant differences were noted in fellow-eye detection with (86%) and without (87%) a bioptic. The detection rate was significantly reduced on the patterned background and in the active fixation task. CONCLUSIONS: To our knowledge, this is the first study to demonstrate fellow-eye detection in the area of the ring scotoma with a monocular bioptic telescope under more realistic and visually demanding conditions than conventional perimetry. These results should ease the concern that the monocular ring scotoma might cause blindness to traffic outside the field of the telescope.

Acute zonal occult outer retinopathy.

Acute zonal occult outer retinopathy (AZOOR) is a rare unilateral or bilateral disease of unknown etiology characterized by focal degeneration of photoreceptors. A total of 131 cases of AZOOR (205 eyes), including the variant known as acute annular outer retinopathy, have been reported in the English language literature. In this group of predominantly white individuals, average age at presentation was 36.7 years, and the male:female ratio was 1:3.2. The majority of patients complained of the acute onset of a scotoma, which was associated with photopsia. Visual acuity was 20/40 or better in 74% of tested eyes, and fundus examination was unremarkable in 76% of eyes. Blind spot enlargement, with or without other field defects, was observed in 75% of the visual fields examined, and electroretinographic abnormalities were recorded in 99% of patients tested. Typically patients retained good visual acuity, although retinal pigment epithelial disturbances commonly developed over time. It was unusual for visual field loss to continue beyond six months. Various treatments have been attempted in patients with AZOOR--including systemic corticosteroids, other systemic immunosuppressive agents, and different antimicrobials--but none have been proven effective.

[Central scotoma and blurred vision in a patient with Crohn's disease]. / Zentralskotom und Verschwommensehen bei bekanntem Morbus Crohn.

A 42-year-old male patient was transferred as an emergency with suspected retrobulbar neuritis due to a central scotoma. He had suffered from reduced vision in the right eye in the past. The diagnosis was chronic recurrent retinopathy centralis serosa due to many years of corticosteroid intake for bronchial asthma and Crohn's disease. Photodynamic therapy was carried out on the right eye and the corticosteroids were discontinued.