Considerably diminished quality of life (QoL) is observed in patients with visual field defects after lesions affecting the visual pathway. But little is known to what extent vision- and health-related QoL impairments are associated with psychological distress. In 24 patients with chronic visual field defects (mean age=56.17±12.36) the National Eye Institute-visual functioning questionnaire (NEI-VFQ) for vision-related QoL, the Short Form Health Survey-36 (SF-36) for generic QoL and the revised Symptom-Checklist (SCL- 90-R) were administered. Cases with clinically relevant SCL-90-R symptoms were defined. Demographic, QoL and visual field parameters were correlated with SCL-90-R scales. About 40% of the investigated patients met the crite- ria for the definition of psychiatric caseness. 8/12 NEI-VFQ scales correlated significantly with SCL-90-R phobic anxiety (r-range -0.41 to -0.64, P<0.05), 5/12 NEI-VFQ scales correlated with SCL-90-R interpersonal sensitivity (-0.43 to -0.50), and 3/12 with SCL-90-R depression (-0.51 to -0.57) and obsessive-compulsiveness (-0.41 to -0.43). In contrast, only 1/8 SF-36 scales correlated significantly with SCL-90-R depression, phobic anxiety and interpersonal sensitivity (-0.41 to -0.54). No substantial correlations were observed between visual field parameters and SCL-90-R scales. Significant correlations of SCL-90-R with NEI-VFQ but not with SF-36 suggest that self-rated psychological distress is the result of diminished vision- related QoL as a consequence of visual field loss. The extent of visual field loss itself did not influence the rating of psychological distress directly, since SCL-90-R symptoms were only reported when diminished vision-related QoL was present. Patients with reduced vision-related QoL due to persisting visual field defects should therefore be offered additional neuropsychological rehabilitation and supportive psychotherapeutic interventions even years after the lesion.

OBJECTIVETo determine the relationship of objective and subjective outcome measures of Vision Restoration Training (VRT) for visual field recovery in partially blind patients. This is of interest because the patient's subjective improvement cannot be inferred from objective changes in visual field charts.DESIGNNineteen patients with visual system lesions underwent visual field tests (objective measure) before and after six months of VRT. Subjective outcome was determined by pre- and post-training interviews (open narration, questions on activities of daily living, ratings). Interview content was quantified by determining the response frequency for relevant content categories. Drawings of perceived visual field size were used as a subjective topographical measure. Subjective training results were compared to objective visual field size (perimetry).RESULTSVisual field size increased significantly over the training period. Patients' subjective evaluations depended on the size and location of regained areas, but also on specific evaluation of safe navigation, mobility, reading, and communication. Patients with objective increase of visual field size also reported subjective improvements in daily life.CONCLUSIONSComputer-based training can improve visual field size as well as subjective visual performance. The patients' subjective experience should be included in treatment evaluation to ensure the meaningfulness of training beyond perimetric measures.

Parallel interhemispheric processing is required to explore our visual environment and to integrate visual information from both hemifields simultaneously. Damage to the right temporo-parietal cortex can disrupt such parallel processes and result in neglect and visual extinction of stimuli in the left contralesional visual space. Neglected or extinguished stimuli can still be processed, yet without reaching the patient's awareness. Such unconscious processing has been attributed to structurally intact primary visual areas in neglect. To study whether unconscious parallel processing depends on visual functional integrity, we compared the performance of neglect patients with visual field defects (VFDs) (n=11) and hemianopic patients with partial or complete blindness of one visual hemifield (n=11) on redundant targets effects (RTE). The RTE manifests as faster reaction times to redundant paired (two stimuli, one in each hemifield) than single stimulation (in one hemifield). We found RTEs, i.e., unconscious processing, in neglect patients but not in hemianopic patients. Furthermore, neglect patients showed large crossed–uncrossed differences (CUDs), i.e., faster response times to ipsi- than contralesional hemifield stimulation, reflecting a difference in processing speed for single stimuli in the two hemispheres that were correlated with VFDs and visual extinction. The finding that extinction, but not RTE, was correlated with the CUD suggests that under competitive bilateral stimulus conditions the delayed contralesional visual field input may not be detected by the intact left hemisphere, which presumably mediates the task given the impairment of the right hemisphere. By contrast, unconscious parallel processing of contralesional stimuli (RTE) occurred even when contralesional visual field input is lacking (VFD) or delayed (CUD) and is possibly mediated via subcortical visual pathways.

Several visual field training programs have been designed to improve vision in patients with visual field loss due to cerebral lesion s. Using vision restoration training, several investigators studied pred ictors of training outcome. However, until now there are no studies testing whether these factors also predict the stability of the visual improvements after a long trainingfree interval. The aim of the present study was therefore to a nalyse whether predefined variables predict the success of vision restorat ion training and the stability of the outcome. The sample consisted of 23 patients with postchiasmatic lesions who participated in a six months visual training. Stability of visual fi eld improvements were tested in a follow-up session after a training-free per iod longer than three years. Visual field sizes were tested by suprathreshol d high-resolution perimetry (24°) and conventional automatic near-threshold perimetry (90°). Factors for therapy success and stability at follow-up were analysed using multiple linear regression. Overall, training-related improvements and their stabili ty were related to few variables. Similar to studies which measured the training o utcome immediately after training, in the present follow-up study the siz e of the transition zone between intact and defect areas of the visual field showe d the strongest correlation with training-induced improvement of the visu al field. Patients with high improvements of the number of detected stimuli immediately after training experienced also the greatest decrease of thei r detection rate after the training-free interval. Training results were stable i n those patients who had lower training success. Based on these observations we conclude that regular training sessions may be necessary for consolidati on especially in cases of large improvements of stimulus detection.

PURPOSE:Several studies have shown that computer-based visual stimulation improves detection performance in brain damaged patients with post-chiasmatic lesions after stroke or trauma. Because it is not known whether visual field defects after retinal lesions can also be modified by visual stimulation we explored if visual field enlargements are possible in patients with glaucoma.METHODS:Five patients with primary open angle glaucoma (POAG) performed Vision Restoration Training (VRT), a computer-based vision training for a total of 6 months in two 3-months blocks with a 3-months training-free interval between the two training periods. Perimetric testing was performed with High Resolution Perimetry (HRP) as well as with 30 degrees and 70 degrees white/white (W/W) and 30 degrees blue/yellow (B/Y) conventional automatic perimetry (Oculus Twinfield).RESULTS:After the first 3 months of training the average detection performance significantly increased in HRP (Z= -2.023, p<0.05) and in 30 degrees W/W perimetry (Z= -2.023, p<0.05), but not in B/Y perimetry (Z= -1.214, p=0.225) or in the 70 degrees W/W perimetry, which included more peripheral, non-trained areas (Z= -0.406, p=0.684). Visual improvements remained stable after the training-free interval. Measured by HRP after the second VRT period 3 patients achieved an increase in the ability to detect visual stimuli, however, this improvement did not reach significance (Z= -1.826, p=0.068).CONCLUSIONS:While a small patient sample does not permit general conclusions on visual field recovery after glaucoma, this pilot study suggests that visual field defects caused by retinal lesion may be improved by systematic vision stimulation. A larger sample, randomized clinical trial is now warranted.

PURPOSE:The aim of the study was to examine if improvements of stimulus detection performance in visual field tests after intensive visual training of the visual field border zone in patients with visual field defects are associated with changes in self-reported vision- and health-related quality of life (QoL).METHODS:We studied a clinical sample of 85 patients suffering from visual field loss after brain damage that underwent repetitive, daily light stimulation (vision restoration training, VRT) of the visual field border and the blind visual field for up to 75 hrs (N=16) or 150 hrs (N=69). Stimulus detection was quantified in the central visual field with a campimetric method before and after intervention. Health-related QoL was assessed by the Health-Survey SF-36 and vision-related QoL by the 39-item National Eye Institute Visual Function Questionnaire (NEI-VFQ).RESULTS:Both vision- and health-related QoL measures improved after VRT. Significant increases were found in 8 out of 12 NEI-VFQ and 3 out of 8 SF-36 subscales. Of the 85 participants 6% showed a decrease in stimulus detection performance, 42% showed an increase of less than 5% detected stimuli, 24% showed an increase of 5-10% detected stimuli and 28% of more than 10% detected stimuli. Changes in campimetric stimulus detection rates were related to NEI-VFQ subscales point differences general vision (3 points), difficulty with near vision activities (4 points), limitations in social functioning due to vision (4 points) and driving problems (12 points). There was no relation of visual field changes to changes in SF-36 component and subscale scores.CONCLUSIONS:The NEI-VFQ is a valuable measure of self-reported visual impairment in patients with visual field defects. Stimulation of the visual field by training may lead to improvements of vision-related QoL which were correlated with the extent of visual field enlargements.

Brain injuries caused by stroke, trauma, or tumor often affect the visual system that leads to perceptual deficits. After intense visual stimulation of the damaged visual field or its border region, recovery may be achieved in some sectors of the visual field, but the extent of restoration is highly variable between patients and is not homogeneously distributed in the visual field. We now assess the visual field loss and its dynamics by perimetry, a standard diagnostic procedure in medicine, to measure the detectability of visual stimuli in the visual field. Subsequently, a treatment outcome prediction model (TOPM) has been developed, using features that were extracted from the baseline perimetric charts. The features in the TOPM were either empirically associated with treatment outcomes or were based on findings in the vision-restoration literature. Among other classifiers, the self-organizing map (SOM) was selected because it implicitly supports data exploration. Using a data pool of 52 patients with visual field defects, the TOPM was constructed to predict areas of improvement in the visual field topography. To evaluate the predictive validity of the TOPM, we propose a method to calculate the receiver operating characteristic graph, whereby the SOM is used in combination with a nearest neighbor classifier. We discuss issues relevant for medical TOPMs, such as appropriateness to the patient sample, clinical relevance, and incorporation of a priori knowledge.

PURPOSESystematic stimulation of the visual field border in patients with visual field loss after cerebral lesions improves visual function even years after the onset of partial blindness. However, computer-based training programs like Vision Restoration Training (VRT) are not equally effective in all patients. We therefore tested which factors determine training outcome and which visual and cognitive functions are changed by VRT.METHODSMultiple outcome measures were predicted using a multifactorial regression approach. Nineteen patients with post-geniculate visual system lesions performed six months of VRT and underwent extensive testing before and after treatment, including visual field measurements, attention functions, and subjective parameters.RESULTSVisual field size increased significantly during training, but a number of cognitive, especially attentional, variables also improved, as did subjective visual function. The size of areas of residual vision was the strongest predictor variable for visual field increase. Demographic and lesion-related variables had little influence on training success.CONCLUSIONSWith multivariate regression models, training outcome on different variables can be accurately predicted. Moreover, visual field increase is sufficiently predictable based on a set of variables readily available to the clinician: age of the patient, time since lesion, number of absolute perimetric defects, eccentricity of the visual field border, size of areas of residual vision, and average reaction time to perimetric stimuli.

Background. In patients with visual field defects, measurement of health-related quality of life (hQoL) and vision-related quality of life (vQoL) is an important adjunct to clinical measures such as perimetry. The purpose of this study was to describe hQoL and vQoL of patients with visual field defects after cerebral lesions such as infarction, traumatic brain injury, and tumor.Methods. The National Eye Institute - Visual Function Questionnaire (NEI-VFQ) for vQoL and the SF-36 Health Survey for hQoL were administered to 24 patients about 2 years after occurrence of the visual field defect. Visual fields were measured by standard perimetry and a near-threshold campimetric method. Visual acuity was measured by the Landolt-Ring-Test.Results. The NEI-VFQ scores - but not SF-36 scores - were not only lower than those of a disease-free group but also lower than those of patients with visual impairments not caused by cerebral damage. Rank correlations between the size of the visual field defect and NEI-VFQ subscales were significantly high or modest. With SF-36 scores these correlations were generally low and moderate at best.Conclusion. The NEI-VFQ is a valuable measure of self-reported visual impairment in patients with visual field defects after cerebral lesions. The measurement of unspecific hQoL is not sufficient to reflect the problems of patients with visual field defects.

This invention relates to novel di-quaternary ammonium salts of alpha -1,4-thiazine alkanephosphonic acids; the preparation thereof; and uses thereof.

Patienten mit visuellen Beeinträchtigungen werden nicht nur objektiv perimetrisch, sondern auch mit Fragebögen zur Lebensqualität untersucht. Die vorliegende Studie soll erstmalig allgemeine (health-related quality of life, hQoL) und sehspezifische Lebensqualität (vision-related quality of life, vQoL) in einer Stichprobe zerebral geschädigter Patienten mit Gesichtsfelddefekten beschreiben.

Visual field deficits in patients have long been considered to be nontreatable, but in previous studies we have found an enlargement of the intact visual field following vision restoration therapy ( VRT). In the present pilot study, we wished to determine whether a double-stimulation approach would facilitate visual field enlargements beyond those achieved by the single-stimulus paradigm used in standard VRT. This was motivated by the findings that following visual cortex injury in animals, the size of receptive fields could be enlarged by systematic costimulation, where two stimuli were used to excite visual cortex neurons ( Eysel, Eyding, & Schweigart, 1998). Patients ( n=23) with stable homonymous field deficits after trauma, cerebral ischemia, or hemorrhage ( lesion age >6 months) carried out either ( a) standard VRT with a single stimulation ( n=9), or vision therapy with (b) a parallel costimulation ( n=7) or ( c) a moving costimulation paradigm ( n=7). Training was carried out twice daily for 30 min over a 3-month period. Before and after therapy, visual fields were tested with 30 and 90 Tubinger automatic perimetry ( TAP) and with high-resolution perimetry ( HRP). Eye movements were recorded with an eye tracking system. When data of all three types of visual field training were pooled, we found significant improvements of stimulus detection in HRP ( 4.2%) and fewer misses within the central 30 perimetrically (-3.7% right eye, OD, or -4.4% left eye, OS). However, the type of training did not make any difference such that the three training groups profited equally. A more detailed analysis of trained versus untrained visual field areas in 16 patients revealed a superiority of the trained area of only 1.1% in HRP and between 3.5% ( OS) and 4.4% ( OD) in TAP. Spatial attention and alertness improved significantly in all three groups and correlated significantly with visual field enlargements. While vision training had no influence on the patient's testimonials concerning their visual abilities, the patients significantly improved in a practical paper-and-pencil number tracking task ( Zahlen-Verbindungs Test; ZVT). Visual field enlargement does not benefit from a double-stimulation paradigm, but visual attention seems to play an important role in vision restoration. The improvements in trained as well as in untrained areas are explained by top-down attentional control mechanisms interacting with local visual cortex plasticity.

Purpose: In small experimental trials, vision restoration therapy (VRT), a home-based rehabilitation method, has shown to enlarge the visual field and improve reaction times in patients with lesion involving the CNS. We now evaluated the outcome of VRT in a large sample of clinical patients and studied factors contributing to subjective and objective measures of visual field alterations. Methods: Clinical observational analysis of visual fields of 302 patients before and after being treated with computer-based vision restoration therapy for a period of 6 months at eight clinical centers in central Europe. The visual field defects were due to ischemia, hemorrhage, head trauma, tumor removal or anterior ischemic optic neuropathy. Primary outcome measure was a visual field assessment with super-threshold perimetry. Additionally, conventional near-threshold perimetry, eye movements and subjective reports of daily life activities were assessed in a subset of the patients. Results: VRT improved patients' ability to detect super-threshold stimuli in the previously deficient area of the visual field by 17.2% and these detection gains were not significantly correlated with eye movements. Notable improvements were seen in 70.9% of the patients. Efficacy was independent of lesion age and etiology, but patients with larger areas of residual vision at baseline and patients > 65 years old benefited most. Conventional perimetry validated visual field enlargements and patient testimonials confirmed the improvement in every day visual functions. Conclusions: VRT improves visual functions in a large clinical sample of patients with visual field defects involving the CNS, confirming former experimental studies.

Objective: To determine whether long-term vision restoration therapy (VRT) training has added benefit and whether visual field expansions are maintained for more than 23 months. Design: Before and after VRT, and again at follow-up, visual fields were examined. Follow-up examination was given after an average 46 months VRT-free interval (VRT-6: mean, 50mo, VRT-12: mean, 39mo). Participants: Patients with visual field defects caused by stroke or traumatic brain injury used VRT either for the standard 6-month period (n=15) or for 12 months (n=9). Intervention: VRT. Main Outcome Measures: Suprathreshold high-resolution perimetry and near-threshold perimetry. Results: In the total patient sample, stimulus detection increased in high-resolution perimetry from a mean ± SD of 53.73%±14.79% to 62.81%±17.08% (P<.001) after 6 months of VRT. Standard perimetry confirmed this, where the number of undetected stimuli significantly decreased in both eyes. Long-term VRT for 12 months led to no further improvements in high-resolution perimetry but there was a (nonsignificant) trend of improved perimetry performance, which, in a larger patient population, was significant. After the VRT-free interval, the visual field gains were stable and both groups, VRT-6 and VRT-12, showed similar long-term stability of the regained visual field. Conclusions: VRT-induced visual field enlargements are stable for more than 3.5 years. This does not depend on the duration of the therapy. Extension of VRT from 6 to 12 months did not improve suprathreshold performance but near-threshold performance showed a trend to increased performance above the 6-month results. This suggests that an additional 6 months training may be used to help patients further improve visual functions, but this needs confirmation with a larger patient sample.

BACKGROUND:Most rehabilitation studies on visual field deficits after stroke or trauma are conducted after completion of the spontaneous recovery phase. However, the question arises whether more extensive visual field improvements can be reached when the training starts very soon after the lesion.METHODS:In this study, the results of 26 patients who began visual restoration therapy within the first 12 months after the lesion were compared with an age-related group whose lesions were more than 1 year old.RESULTS:The early-onset group showed an improvement of 8% in computer campimetry and 10-15% in conventional automated perimetry. The late-onset group had 13.5% improvement in campimetry and 20% in perimetry.CONCLUSION:In contrast to our assumptions, there was no significant difference between the groups. Furthermore, the late-onset group showed considerably greater improvement than the early-onset group. It is proposed that pronounced attention deficits soon after brain damage may complicate the training.

Objectives: To analyze retrospectively the effects of vision restoration therapy (VRT) and to determine the role of eye movements in visual field restoration. Design: We replicated our earlier findings by using a larger patient population, and in a separate patient sample we checked the role of eye movements in this process. Setting: Retrospective data analysis and prospective small sample experiment. Participants: Sample of 302 patients. Interventions: Not applicable. Main Outcome Measures: Visual field charts generated by computer-based high-resolution perimetry (HRP) were obtained from 302 patients. HRP charts were compared before and after VRT, and stimulus detection and reaction times were quantified. Because eye movements might contribute to apparent visual improvements, we also measured visual fields in a separate small sample of 16 patients by using retina-adjusted perimetry (RAP). RAP uses eye-tracker technology to generate retina-stabilized visual field charts without interference by eye movements. Results: We confirmed that there are significant visual field enlargements in the sample of 302 patients. After VRT, there were highly significant improvements in the ability of patients to detect visual stimuli, and their reaction time improved significantly whereas fixation performance remained stable. RAP recordings before VRT confirmed the existence of areas of absolute blindness where none of the patients detected visual stimuli. However, after 6 months of VRT all patients were able to respond to numerous stimuli again within these previously blind regions. Conclusions: Restoration of vision after VRT was confirmed in a large patient sample. RAP recordings provide the final proof that visual field enlargements are not caused by eye movements but are the consequence of true restoration of vision.

Objectives: To analyze retrospectively the effects of vision restoration therapy (VRT) and to determine the role of eye movements in visual field restoration. Design: We replicated our earlier findings by using a larger patient population, and in a separate patient sample we checked the role of eye movements in this process. Setting: Retrospective data analysis and prospective small sample experiment. Participants: Sample of 302 patients. Interventions: Not applicable. Main Outcome Measures: Visual field charts generated by computer-based high-resolution perimetry (HRP) were obtained from 302 patients. HRP charts were compared before and after VRT, and stimulus detection and reaction times were quantified. Because eye movements might contribute to apparent visual improvements, we also measured visual fields in a separate small sample of 16 patients by using retina-adjusted perimetry (RAP). RAP uses eye-tracker technology to generate retina-stabilized visual field charts without interference by eye movements. Results: We confirmed that there are significant visual field enlargements in the sample of 302 patients. After VRT, there were highly significant improvements in the ability of patients to detect visual stimuli, and their reaction time improved significantly whereas fixation performance remained stable. RAP recordings before VRT confirmed the existence of areas of absolute blindness where none of the patients detected visual stimuli. However, after 6 months of VRT all patients were able to respond to numerous stimuli again within these previously blind regions. Conclusions: Restoration of vision after VRT was confirmed in a large patient sample. RAP recordings provide the final proof that visual field enlargements are not caused by eye movements but are the consequence of true restoration of vision.