Transcript Visual Anomalies from Brain Injury and Rehabilitation

Paul Koons, M.S., C.L.V.T., C.B.I.S., O&M Specialist
Background/Experience
O&M Specialist / Low Vision Therapist
NYC Lighthouse International
 State Blind Rehab agencies (Pa, CO, Ca, Va)
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Polytrauma Blind/Vision Rehabilitation (BROS)
2 of 5 Polytrauma Veterans Affairs Hospitals
Palo Alto Veterans Affairs
 Richmond (McGuire) Veterans Affairs
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Goals of Presentation
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Review Brain Injury information & modes of injury
Discuss general Brain Injury statistics
Identify types of visual deficits due to Brain Injury
Evaluating vision function & visual perceptual
deficits
Training strategies for neuro-visual deficits
Resources and materials for your “toolbox”
“Macular” or “Peripheral”
If time at end of presentation, explore some of the
BV devices, Assessments, Sunwear, etc.
Disclaimer statement
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This presenter has no financial interest
in any of the makes, models of rehab
equipment, devices, sunwear or
assessment tools
Audience Goal
 Networks
for addressing brain injury
and visual deficits
 Differentiate between brain or eyes?
Acronyms
TBI –Traumatic Brain Injury
 ABI – Acquired Brain Injury
 GCS – Glascow Coma Scale
 LOC – Loss of Consciousness
 PTA – Post Traumatic Amnesia
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1st Lady Visit to our Polytrauma
Rehab Unit 2012
Review of Brain Injury Info/Stats
Brain Injury:
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TBI – an acquired brain injury caused by an
external physical force, resulting in partial
functional disability or psychosocial impairment, or
both, adversely affecting educational performance.
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TBI – Traumatic Brain Injury (MVA, Fall, GSW, IED
blast)
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ABI – Acquired Brain Injury (Stroke, Brain Tumor,
Anoxia, Hypoxia, Seizures, Blood clots)
TBI Severity and Prognosis
Index
Mild
Moderate
Severe
GCS
13-15
9-12
<8
LOC
<30 min
<6 hours
>6 hours
Duration of 0-24 hours 1-7 days
PTA
Permanent Likely none Likely
neurologic
some but
& neuroare often
psychologi
quite
cal sequela
functional
>7 days
Likely to
have
severe
deficits
Severity of Brain Injury
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Mild TBI / Concussion – Loss of Consciousness less
than 30 minutes (or NO loss)
- Post Traumatic Amnesia/Post Concussion Symptoms for
less than 24 hours
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Moderate TBI – Coma more than 20-30 minutes, but
LESS than 24 hours.
- Some long term problems in one or more areas
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Severe TBI – Coma longer than 24 hours, often
lasting days or weeks, Longer term impairments
* According to Brain Injury Assoc of America
Estimates of TBI Severity
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Mild TBI / Concussion – up to 80% of all
cases
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Moderate TBI – 10-30%
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Severe TBI – 5-25%
*According to Brain Injury Assoc of America
Traumatic Brain Injury in America
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Not “just” a VA problem
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Polytrauma highlighted because of high
incidence of occurrence in Iraq/Afghanistan
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Relevance to community services
 1.4 – 1.7 million Americans sustain TBI annually
○ One every 21 seconds
 700,000 Americans experience stroke annually
○ One every 45 seconds
 235,000 hospitalizations
According to Brain injury Association of America
Annual incidence of TBI per Age group
0-4 years old (1121 per 100,000 cases)
 15-19 years old (814 per 100,000 cases)
 5-9 years old (659 per 100,000 cases)
 75 years and older (659 per 100,000 cases)
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‘Often times any brain injury during initial years
not tested until later years’
*According to Brain Injury Assoc of America
Highest incidence of death due to TBI
75 years and older (51 per 100,000)
 20-24 years old (28 per 100,000)
 15-19 years old (24 per 100,000)
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*According to Brain Injury Assoc of America
Multiple TBI Risk Factors
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After 1 TBI, the risk for a 2nd is 3x greater
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After 2 TBIs, the risk is 8x greater
Brain Injury Association of America
Polytrauma Definition
Polytrauma is currently defined as multiple
injuries of which one (or a combination) is life
threatening.
 IEDs usually cause the most complicated
cases
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Co-Morbidities associated with TBI
 Vision, Hearing, Physical, Cognitive, Behavioral,
PTSD, Sleep, etc
Mechanism of Injury
Motor Vehicle Accident
 Sports Concussions
 Falls
 Physical Altercations
 Stroke, Brain Tumor
 Hypoxia/Anoxia
 Gun Shot
 IED Blast
 Penetrating vs. Non-Penetrating wounds
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PTRP Population (#s)
(Mechanism of Injury)
70
60
50
40
Blast/
Explosion
Vehicle
30
Bullet
20
Other
10
0
Injury Location for Veterans
Data Source: Richmond VAMC PTRP Tracking Log, October 2011-September 2012
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LOBES
Frontal - Problem solving, judgment, motor function, filter
Parietal – manage sensation, handwriting and body position in space
Temporal – memory and hearing
Occipital – Visual Processing Center
Brain’s Specialized areas working together
Cortex is outermost area of brain cells, thinking and voluntary movement
Brain Stem is between spinal cord and rest of brain, Basic functions like sleep
and breathing
Basal ganglia are a cluster of structures in centre of brain. Coordinate
messages throughout brain
Cerebellum is at base and back of the brain, coordination and balance
Brain’s Specialized areas working together
Cortex is outermost area of brain cells, thinking and voluntary movement
Brain Stem is between spinal cord and rest of brain,
- Basic functions like sleep and breathing
Basal ganglia -cluster of structures in centre of brain.
-Coordinate messages throughout brain
Cerebellum is at base and back of the brain, coordination and balance
Left vs Right Brain Functions
Left Brain Functions
uses logic
detail oriented
facts rule
words and language
present and past
math and science
can comprehend
knowing
acknowledges
order/pattern perception
knows object name
reality based
forms strategies
practical
safe
Right Brain Functions
uses feeling
"big picture" oriented
imagination rules
symbols and images
present and future
philosophy & religion
can "get it" (i.e. meaning)
believes
music
Facial recognition
spatial perception
knows object function
fantasy based
presents possibilities
risk taking
Visual Pathway numbers indicate how lesion affects visual field(s)
Red/Blue = image is seen
Gray = blind area
Most commonly reported visual
symptoms related to TBI
Diplopia or double vision
 Inability to focus
 Movement of print when reading
 Difficulty with tracking and fixations
 Photosensitivity (day/night/indoor glare)
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 Often associated with Headaches
Dry Eye
 Loss of place while reading / Saccadic
 Visual Fatigue
 Vertigo
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Asthenopia
Eye strain with nonspecific symptoms:
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pain in or around the eyes,
blurred vision,
Headache
fatigue
occasional double vision.
Symptoms often occur after reading, computer work, or when
concentrating on a visually intense task, causing ciliary
muscle tightening
Resolve: Giving the eyes a chance to focus on a distant object
at least once an hour usually alleviates the problem.
Visual Inattention / Neglect
Decreased ability to attend to visual info on
the side opposite to the lesion/damage
 According to Wolter et al, 2006
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 Unilateral neglect is more commonly seen in R
hemisphere strokes (82%) than in L hemisphere
strokes (65%)
 Left hemisphere directs attention to R side visual
world
 Right hemisphere directs attention to both R and L
visual worlds
Visual Anomalies being addressed in
rehab program
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Photosensitivity / Photophobia
Convergence / Divergence Insufficiency
Saccadic / Pursuit Dysfunction (ocular motor)
Dry Eye
Accommodative issues (near focusing)
Tropia / Phoria / Strabismus (eye turns)
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Visual Field defects
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 Hemianopsia, Quadransopsia, general Field Constrictions
 Macular Sparing / Macular Splitting
*many of these overlap such as photosensitivity and accommodation
Possible Barriers to Intervention
Cognitive deficits (attention/concentration)
 Medical issues requiring medical intervention
 Anosagnosia – unawareness of deficit
 Low endurance / Decreased level of arousal
 Poor Initiation or Motivation
 Anxiety (PTSD) and / or Poor sleep patterns
 Sensorimotor deficits
 Memory
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 visual, auditory, recall, sequential, facial
 (Thurs a.m. Dr. Iskow, fellow Poly BROS at RIC
VAMC addressing memory deficits in RT strand)
RIC Eye/TBI Clinic n=100 (2007-2008)
Most Common Vision Disorders following TBI
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Photosensitivity
Convergence Insufficiency
Saccadic Dysfunction
Dry Eye
Accommodative issues
Tropia (Eye Turn)
Normal binocular findings
Visual Field defects
34%
31%
24%
23%
18%
13%
12%
10%
*research design was conservative as these are primary dx but many of these overlap
such as photosensitivity and accommodation
Ophthalmologic and Optometric
Interventions
Prescription of appropriate corrective
lenses
 Use of occlusion – complete or partial
 Prisms – yoked, Fresnel
 Medical and surgical intervention when
warranted (6 month window post injury)
 Optometric/vision therapy intervention
for ocular motor dysfunctions
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Scoring charts to monitor
improvement or decline in
task performance
* email me if you are interested in copies
[email protected]
Functional Autonomy Score (FAS)
 Based
on overall expected general
functional levels in areas of:
 self care, independent living skills,
mobility, communication, psycho social
adjustment, operational skills.
FAS scoring chart
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7. Complete Independence. Patient able to resume competitive employment, or if a homemaker,
resumes home management responsibilities. As a student, patient is prepared to return to school
with little adaptive needs. Patient able to perform skills necessary to live alone safely.
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6. Modified Independence. Patient may need adaptations to job/school (including adjusted
workload or assistive devices). May require vocational services to resume competitive
employment. If a homemaker or retired, able to arrange assistance for selected intermittent tasks
(eg. Shopping, transportation etc.) Patient has the ability to live alone, but may need brief
occasional visits (1-2 times per week).
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5. Supervision. Patient needs daily limited supervision/assistance (2-4 hours) to perform specific
functional tasks. May live alone, but needs job or school setting accommodations.
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4. Minimal Direction. Can be alone for extended periods of time (6-10 hours) when others in
household are absent. Needs supervision/assistance with several tasks for function in home. Can
participate in sheltered workshop. Needs a job coach. Could participate in work/school in
structured environment.
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3. Moderate Direction. Can be alone 2-4 hours. Unable to work or needs special education in
school. May need adapted mode of communication to access assistance.
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2. Maximal Direction. Patient requires 24 hour supervision/assist with someone present in the
home at least distant supervision.
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1. Total Direction. Patient needs 24 hour direct supervision/assist. Cannot be alone or perform
any activity without assistance or cues. May wander or engage in unsafe behaviors.
MAYO Portland Inventory Scale (MPAI)
www.tbims.org/combi/mpai
Income / Outcome Scoring for 30 areas measuring:
Ability / Adjustment / Participation
0
No problems in this area
1 Mild problem but does
not interfere with activities; may use assistive
medication
2 Mild problem; interferes with activities
5 - 24% of the time
3
Moderate problem; interferes with activities
25 - 75% of the time
4 Severe problem; interferes with activities
device or
Priority Rating Scale - Student driven
Priority:
1= not a priority; 2 = low priority;
3 = medium priority; 4 = high priority;
5 = very high priority
Difficulty with task:
1= no difficulty; 2 = occasional;
3 = minimal; 4 = moderate; 5 =maximum
Break Rehab goals down
deficits into 3 paradigms
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Physical Function
 Cognitive
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Behavioral
Relevance of different visual abilities for four main types of activities (binocular
vision, reading, mobility, visual memory) in a neuro-rehabilitative context
Dr. Kerkhoff 2000 research article
3 Rehabilitation Strategies for Success
Intervention Strategies
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Use of sensory strategies:
a. Prisms – optometric intervention
b. Vibration to the neck muscles – used to
prime the system to attend and to improve
postural control
c. Limb activation
d. Trunk exercises
e. Vestibular stimulation
Intervention Strategies
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Manipulation of the environment
a. reduction of background pattern
b. use of adequate illumination
c. increase in background contrast
d. anchoring and boundary marking
strategies
 Recommendation on environmental
modification to improve awareness of
missing visual space
Screening and Assessment Process
Physician’s
Referral
Screening by
Vision
Specialist
Follow-up
by
Vision
Program
Referral to
Eye
Specialist
Definitive
Treatment
Vision
Program
F/U
OT/PT
Intervention
Optometry Glossary Review
 Accommodation
 Version
 Saccade
 Pursuit
 Photosensitivity
 Vergence
• Strabismus
 Visual
Fields
changizi.wordpress.com
Accommodation
Definition: ability to focus on different planes
 Practice with your pencil/pen print
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Optometric Visual Therapy
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Dysfunction: Accommodative
dysfunction
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Goal: Decrease blurry vision
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Technique: Exercise accommodation by
alternating near and far focus, increasing
the distance as able and focusing on the
most problematic distance or functional
task
Accommodation insufficiency
Rehabilitation strategies
Hart Chart Activities (Saccades
and Accommodation therapy)
Reading with +/- power flippers
can be performed monoc / binoc / bi-ocularly
Optometric Visual Therapy:
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Dysfunction: Deficits of pursuit (version)
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Ie.: Saccades and Pursuits
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Goal: move eyes conjugately and smoothly
with a target
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Technique: Move eyes smoothly and
accurately on targets in any direction and at
any distance from center based on
symptomatology
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Gradually increase target velocity
Saccades with Points of Fixation
- larger and smaller
NEAR SACCADIC EXERCISES
Pen and Paper tasks near visual
search
Indoor Saccades
Developmental Eye Movement (DEM)
Timed Reading Test A + B = C (time measured)
Saccadic work sheets
Reading with Right hemianopia
Reading with Left Hemianopia
Question for You ?
Does research show more reading
difficulty with Left or Right visual field
loss ?
Dr. Georg Kerkhoff,
J Neurol Neurosurg Psychiatry
2000;68:691-706
doi:10.1136/jnnp.68.6.691
 Review
 Neurovisual rehabilitation: recent
developments and future directions
 Georg Kerkhoff
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Bálint's (Holmes) syndrome
Acute onset of two or more strokes at @ the same place in
each hemisphere of brain
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Damage to temporal, occipital and sometimes parietal
lobes
Impairs visual and language functions
Uncommon and incompletely understood
 inability to perceive the visual field as a whole
 difficulty in fixating the eyes (ocular apraxia)
 inability to move the hand to a specific object by using vision
(optic ataxia)
 Reading difficulty / Poor depth perception
 Severe visual spatial disorders
*Per Dr. Kerkhoff - Estimated up to 30% of Alzheimers patients
show full range of these symptoms
Stats per Dr. Kerkhoff
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About 20-30% of all those in neuro rehab centers have
homonymous hemianopia visual field disorders
Of these, 70% show a visual field sparing of 5 degrees
or less
Partial recovery occurs in the first 2-3 months in 10%20% of the patients
After 3 months, visual field recovery ‘very rare’
Functional deficits due to Homonymous hemianopia
 Reading issues due to field loss and saccadic eye movement
 Spatially disorganized visual search patterns
-Per Dr. Kerkhoff
-Some 50%-90% of all patients with visual field disorders have hemianopic alexia,
resulting in loss of a “perceptual window” for reading & letter identification.
-In western societies this reading window extends 3–4 characters to the left of
fixation and
7–11 letter spaces to the right of it.
BARKEEPERS
B/ARK/EEPERS /
/ = fixation
/ = “perceptual window”
©2000 by BMJ Publishing Group Ltd
Kerkhoff G J Neurol Neurosurg Psychiatry 2000;68:691-706
Hemianopia and Reading Success
Dr. Poppelreuter, German Neurologist
 Brain injured Vets -- WWI (1917)
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Hemianopia and Reading Success
Dr. Poppelreuter, 1917 (early in century)
 Interested in studying reading deficits in R & L
hemianopic WW1 veterans
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 Left visual field loss handicaps return eye movement
to find beginning of a new line
 Right visual field loss handicaps eye movement to
next word/letter in sentence
 Right hemianopia more challenging since we read
left to right (trained to overshoot each word to
successfully read)
Visual Field Loss
Visual Pathway Review numbers indicate how lesion affects visual field(s)
Red/Blue = image is seen
Gray = blind area
Visual Field Loss assessment &
training strategies
Accurately Assess Visual Fields Monocularly
 Confrontation, Finger counting
 ARC Perimeter / Hand held disc perimeter
 Goldmann, Humphries, Octopus (eye clinic)
 Educate Patient and Family!
 Show best use of remaining field placement
 Establish full perimeter scan (overshoot) or
staircase visual search methods
 Increase complexity of environments, reducing
cues
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Visual Field Search training
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Goals: Increase awareness, establish
compensatory scanning pattern into the deficit
field which become automatic and accurate
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Technique: Start with a small number of
targets in the affected field and increase the
number as proficiency improves
• Continual verbal reinforcement to scan into the
affected field is required
• Field enhancing prisms may be used (OD)
White Board Scanning Training
(A to Z drill)
Scanning Training with Hemianopia
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Dr. Josef Zihl, 1988
 Trained 30 hemianopes (w/out inattention/neglect)
 Practice large saccades into blind field
 Visual search field increased 10-30 degrees
 4 – 8 sessions
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Kerkoff et al, 1992
 Validated similar results in 92 hemianopic patients & 30 with
additional inattention/neglect
 Following 6 weeks of scanning training (30 sessions)
 Hemianope group: Mean search field increased from 15
degrees to 35 degrees
 Additional Inattention/Neglect group; required 25% more
training over 2-3 months to achieve similar result
Brahm et al, 2009 & Dougherty
et al., 2010
 Visual field loss testing is recommended
for patients with a history of TBI
 Also discuss possible State DMV
requirements for visual field
documentation for TBI/ABI/Stroke, etc.
Types of visual search
strategies with Hemianopia
Staircase Strategy (general compensation
strategy without training)
Overshoot strategy:
place remaining visual into blind field further
than target expected (Right visual field loss)
X
Field Cut and Inattention/ Neglect
neuropolitics.org/hemineglect.gif
www.yvonnefoong.com/.../homonymoushemianopia.jpg
VISUAL INATTENTION / Neglect: Figure Copying –
What pieces of info is missed?
Describe room in balanced format?
‘Search for Sputnik’
circle one item and instruct student to circle all
others, give difft color pens
Visual Search & Scanning with Visual
Field Loss
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Chedru et al., 1973
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Ishiai, et al., 1987
○ Meienburg, et al., 1981
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Gassel et al., 1963
 Recorded eye movements & visual search in
TBI patients with hemianopia
 Patients paradoxically concentrated on the
blind side (compensation strategy)
 Patients with additional neglect/inattention
lacked this compensation strategy
Photosensitivity
day / night / indoor / screen
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Definition: Intolerance of light
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History: Patients complain they can’t transition quickly
I.e..: glare on floor, lights while driving, tearing, frequent
blinking, squinting, headaches, irritability with visual
activities
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Types: photophobia vs. photosensitivity
 Photosensitivity exists in the absence of true pain, distinct from the
photophobia seen in patients with inflammatory ocular disease
Skylight glare
Night Driving Glare
(simulate in dark office w/ flashlights)
Glare at night – trial 54% yellow tint
and 40% Plum tint to reduce “halo”